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Hopkins RE, Campbell G, Degenhardt L, Gisev N. 'We didn't cause the opioid epidemic': The experiences of Australians prescribed opioids for chronic non-cancer pain at a time of increasing restrictions. Drug Alcohol Rev 2024; 43:1625-1635. [PMID: 38803123 DOI: 10.1111/dar.13879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 04/11/2024] [Accepted: 05/09/2024] [Indexed: 05/29/2024]
Abstract
INTRODUCTION Many countries have implemented strategies to reduce opioid-related harms, including policies and prescribing restrictions. This study aimed to explore the lived experiences of Australians prescribed opioids for chronic non-cancer pain (CNCP) in the context of increasing restrictions for accessing opioids. METHODS Semi-structured interviews were conducted with 14 Australians (aged 24-65-years; 10 female/4 male) self-reporting regular use of prescribed opioids for CNCP. Participants were asked to describe their experiences using prescribed opioids, and perceived and actual changes in pain management including access to treatments. Using thematic analysis, four dominant themes were identified. RESULTS In 'On them for a reason': Opioids as a last resort, participants described the role of opioids as an important tool for pain management following unsuccessful treatment using other strategies. In 'You're problematic': Deepening stigma, participants described how increased attention and restrictions led to increasing stigma of opioid use and CNCP. In 'We didn't cause the opioid epidemic': Perceiving and redirecting blame, participants described feeling unfairly blamed for public health problems and an 'opioid epidemic' they described as 'imported' from America, drawing distinctions between legitimate and illegitimate opioid use. Finally, in 'Where do we go from here?': Fearing the future, participants described anticipating further restrictions and associating these with increased pain and disability. DISCUSSION AND CONCLUSIONS The experience of being prescribed opioids for CNCP in Australia in the context of increasing restrictions was characterised by stigma, blame and fear. There is a need to ensure people prescribed opioids for pain are considered when designing measures to reduce opioid-related harms.
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Affiliation(s)
- Ria E Hopkins
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Gabrielle Campbell
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
- School of Psychology, University of Queensland, Brisbane, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Natasa Gisev
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
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Amedi D, Gazerani P. Deprescribing NSAIDs: The Potential Role of Community Pharmacists. PHARMACY 2024; 12:116. [PMID: 39195845 PMCID: PMC11358956 DOI: 10.3390/pharmacy12040116] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Revised: 07/21/2024] [Accepted: 07/23/2024] [Indexed: 08/29/2024] Open
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are largely used for controlling various pain conditions and are widely available in community pharmacies, with and without prescription. Despite their effectiveness, NSAIDs can pose significant risks due to potential side effects and drug interactions, particularly in polypharmacy and comorbidity contexts and for vulnerable users. This study investigated whether and how NSAIDs deprescribing can be conducted at the community pharmacy level by assessing pharmacists' confidence, attitudes, and potential barriers and facilitators. Additionally, we aimed to identify any deprescribing guidelines that pharmacists could use. A literature search and a cross-sectional digital questionnaire targeting community pharmacists in Norway were conducted. Results showed that study participants (N = 73) feel confident in identifying needs for deprescribing NSAIDs but barriers such as time constraints, lack of financial compensation, and communication challenges were noted. Participants reported positive attitudes toward deprescribing but highlighted a need for better guidelines and training. This study highlights a gap in specific guidelines for deprescribing NSAIDs and a potential for enhancing pharmacists' roles in the deprescribing process, for example, through training and improved financial incentives. Further research is encouraged to develop concrete strategies for an effective implementation where community pharmacists can be involved in the deprescribing of NSAIDs.
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Affiliation(s)
- Delsher Amedi
- Department of Life Sciences and Health, Faculty of Health Sciences, Oslo Metropolitan University, 0130 Oslo, Norway
| | - Parisa Gazerani
- Department of Life Sciences and Health, Faculty of Health Sciences, Oslo Metropolitan University, 0130 Oslo, Norway
- Department of Health Science and Technology, Faculty of Medicine, Aalborg University, 9260 Gistrup, Denmark
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Yarborough BJH, Stumbo SP, Schneider JL, Ahmedani BK, Daida YG, Hooker SA, Lapham GT, Negriff S, Rossom RC. Patient Perspectives on Mental Health and Pain Management Support Needed Versus Received During Opioid Deprescribing. THE JOURNAL OF PAIN 2024; 25:104485. [PMID: 38311195 DOI: 10.1016/j.jpain.2024.01.350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/10/2024]
Abstract
Prescription opioid tapering has increased significantly over the last decade. Evidence suggests that tapering too quickly or without appropriate support may unintentionally harm patients. The aim of this analysis was to understand patients' experiences with opioid tapering, including support received or not received for pain control or mental health. Patients with evidence of opioid tapering from 6 health care systems participated in semi-structured, in-depth interviews; family members of suicide decedents with evidence of opioid tapering were also interviewed. Interviews were analyzed using thematic analysis. Participants included 176 patients and 16 family members. Results showed that 24% of the participants felt their clinicians checked in with them about their taper experiences while 41% reported their clinicians did not. A majority (68%) of individuals who experienced suicide behavior during tapering reported that clinicians did check in about mood and mental health changes specifically; however, 27% of that group reported no such check-in. More individuals reported negative experiences (than positive) with pain management clinics-where patients are often referred for tapering and pain management support. Patients reporting successful tapering experiences named shared decision-making and ability to adjust taper speed or pause tapering as helpful components of care. Fifty-six percent of patients reported needing more support during tapering, including more empathy and compassion (48%) and an individualized approach to tapering (41%). Patient-centered approaches to tapering include reaching out to monitor how patients are doing, involving patients in decision-making, supporting mental health changes, and allowing for flexibility in the tapering pace. PERSPECTIVE: Patients tapering prescription opioids desire more provider-initiated communication including checking in about pain, setting expectations for withdrawal and mental health-related changes, and providing support for mental health. Patients preferred opportunities to share decisions about taper speed and to have flexibility with pausing the taper as needed.
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Affiliation(s)
- Bobbi Jo H Yarborough
- Science Programs Department, Kaiser Permanente Northwest Center for Health Research, Portland, Oregon; Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Scott P Stumbo
- Science Programs Department, Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | - Jennifer L Schneider
- Science Programs Department, Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | - Brian K Ahmedani
- Center for Health Policy & Health Services Research, Henry Ford Health, Detroit, Michigan
| | - Yihe G Daida
- Center for Integrated Health Care Research, Kaiser Permanente Hawaii, Honolulu, Hawaii
| | - Stephanie A Hooker
- Research and Evaluation Division, HealthPartners Institute, Minneapolis, Minnesota
| | - Gwen T Lapham
- Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California; Research Department, Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Sonya Negriff
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Rebecca C Rossom
- Research and Evaluation Division, HealthPartners Institute, Minneapolis, Minnesota
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Meilhac M, Nesbit S, Bowman LA, Stewart RW. Know Your Guidelines Series: The CDC Clinical Practice Guideline for Prescribing Opioids for Pain. South Med J 2024; 117:371-373. [PMID: 38959965 DOI: 10.14423/smj.0000000000001703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Affiliation(s)
- Margaux Meilhac
- From the Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland
| | - Suzanne Nesbit
- From the Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland
| | - Lindsay A Bowman
- From the Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland
| | - Rosalyn W Stewart
- the Department of Medicine, Johns Hopkins University, Baltimore, Maryland
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Quinn PD, Mazurenko O, Meraz R, Chang Z, Pujol TA, Hirsh AT, Sjölander A, Kroenke K, D'Onofrio BM. Varying Definitions of Long-Term Opioid Therapy: Examining Prevalence, Prescription Patterns, and Substance-Related Adverse Outcomes. PAIN MEDICINE (MALDEN, MASS.) 2024:pnae051. [PMID: 38902945 DOI: 10.1093/pm/pnae051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 05/16/2024] [Accepted: 06/13/2024] [Indexed: 06/22/2024]
Affiliation(s)
- Patrick D Quinn
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington, Indiana
| | - Olena Mazurenko
- Department of Health Policy and Management, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana
| | - Richard Meraz
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, Indiana
| | - Zheng Chang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | | | - Adam T Hirsh
- Department of Psychology, Indiana University, Indianapolis, Indiana
| | - Arvid Sjölander
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Kurt Kroenke
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
- Regenstrief Institute, Indianapolis, Indiana
| | - Brian M D'Onofrio
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, Indiana
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Praeger VC, Frei MY, Pham D, Praeger AJ, Lubman DI, Arunogiri S. Rotation from methadone to buprenorphine using a micro-dosing regime in patients with opioid use disorder and serious mental illness: A case series. Drug Alcohol Rev 2024. [PMID: 38894653 DOI: 10.1111/dar.13885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 04/07/2024] [Accepted: 05/14/2024] [Indexed: 06/21/2024]
Abstract
INTRODUCTION Inducting buprenorphine from methadone has traditionally involved initial opioid withdrawal, with risk of mental state deterioration in patients with serious mental illness (SMI). Micro-dosing of buprenorphine, with small incremental doses, is a novel off-label approach to transitioning from methadone and does not require a period of methadone abstinence. Given the limited literature about buprenorphine microdosing, we aimed to evaluate the feasibility and safety of inducting buprenorphine in a series of patients on methadone with SMI. METHODS For this retrospective case series, we reviewed the records of 16 patients with SMI at a Melbourne addiction treatment centre, from January 2021 to July 2022, who transitioned via micro-dosing, from high-dose methadone (>30 mg) to buprenorphine and depot-buprenorphine. Psychiatric diagnoses, mental state, other substance withdrawal, transfer success, transition time, opioid withdrawal symptoms and overall patient experience were collected via objective and subjective reporting. RESULTS Methadone to buprenorphine transfer was completed by 88% of patients. Mental health measures remained stable with the exception of mildly increased anxiety. Median transfer time was 6.5 days for inpatients, 9 days for mixed setting and 10 days for outpatients. Most patients (93%) rated their experience 'manageable' reporting mild withdrawal symptoms. One patient met study criteria for precipitated withdrawal. DISCUSSION AND CONCLUSIONS This retrospective case series provides evidence that the use of a micro-dosing buprenorphine induction for methadone to buprenorphine transitions, including to depot-buprenorphine, has negligible risk, is tolerated by patients with SMI and is unlikely to precipitate an exacerbation of their mental illness.
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Affiliation(s)
| | - Matthew Y Frei
- Turning Point, Eastern Health, Melbourne, Victoria, Australia
| | - Dan Pham
- Turning Point, Eastern Health, Melbourne, Victoria, Australia
| | - Adrian J Praeger
- Department of Neurosurgery, Monash Hospital, Melbourne, Victoria, Australia
- Department of Surgery, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Dan I Lubman
- Turning Point, Eastern Health, Melbourne, Victoria, Australia
- Monash Addiction Research Centre, Eastern Health Clinical School, Faculty of Medicine, Nursing & Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Shalini Arunogiri
- Turning Point, Eastern Health, Melbourne, Victoria, Australia
- Monash Addiction Research Centre, Eastern Health Clinical School, Faculty of Medicine, Nursing & Health Sciences, Monash University, Melbourne, Victoria, Australia
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Hintz EA, Applequist J. "Saving us to Death": Ideology and Communicative (Dis)enfranchisement in Misapplications of the 2016 CDC Opioid Prescribing Guidelines. HEALTH COMMUNICATION 2024:1-11. [PMID: 38862411 DOI: 10.1080/10410236.2024.2363674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
Guided by the theory of communicative (dis)enfranchisement (TCD), this study interrogates how interactions in which chronic pain patients are force tapered from their prescribed opioids are constrained and afforded by the hegemonic ideologies. To interrogate the harms caused for chronic pain patients by ideological policies enacted by the Centers for Disease Control and Prevention and assess what communicative mechanisms reify and resist such ideologies, this research analyzes 238 posts authored by chronic pain patient Reddit users. Reflexive thematic analysis illuminated a hegemonic ideology of opiophobia, (im)material ramifications of (a) discrimination by doctors, and (b) political and legal interference; mechanisms of reification: (a) positioning suicide as a rational option, (b) advocating for the use of illicit substances, and (c) stopping opioids voluntarily; and mechanisms of resistance: (a) counter-organizing and (b) counter-generating knowledge. We offer theoretical implications for the TCD and practical implications for patients, providers, patient advocacy organizations, and policymakers.
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Affiliation(s)
| | - Janelle Applequist
- Zimmerman School of Advertising and Mass Communications, University of South Florida
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Pauly BB, Kurz M, Dale LM, Macevicius C, Kalicum J, Pérez DG, McCall J, Urbanoski K, Barker B, Slaunwhite A, Lindsay M, Nosyk B. Implementation of pharmaceutical alternatives to a toxic drug supply in British Columbia: A mixed methods study. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 161:209341. [PMID: 38490334 DOI: 10.1016/j.josat.2024.209341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 01/15/2024] [Accepted: 03/12/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND North America has been in an unrelenting overdose crisis for almost a decade. British Columbia (BC), Canada declared a public health emergency due to overdoses in 2016. Risk Mitigation Guidance (RMG) for prescribing pharmaceutical opioids, stimulants and benzodiazepine alternatives to the toxic drug supply ("safer supply") was implemented in March 2020 in an attempt to reduce harms of COVID-19 and overdose deaths in BC during dual declared public health emergencies. Our objective was to describe early implementation of RMG among prescribers in BC. METHODS We conducted a convergent mixed methods study drawing population-level linked administrative health data and qualitative interviews with 17 prescribers. The Consolidated Framework for Implementation Research (CFIR) informs our work. The study utilized seven linked databases, capturing the characteristics of prescribers for people with substance use disorder to describe the characteristics of those prescribing under the RMG using univariate summary statistics and logistic regression analysis. For the qualitative analysis, we drew on interpretative descriptive methodology to identify barriers and facilitators to implementation. RESULTS Analysis of administrative databases demonstrated limited uptake of the intervention outside large urban centres and a highly specific profile of urban prescribers, with larger and more complex caseloads associated with RMG prescribing. Nurse practitioners were three times more likely to prescribe than general practitioners. Qualitatively, the study identified five themes related to the five CFIR domains: 1) RMG is helpful but controversial; 2) Motivations and challenges to prescribing; 3) New options and opportunities for care but not enough to 'win the arms race'; 4) Lack of implementation support and resources; 5) Limited infrastructure. CONCLUSIONS BC's implementation of RMG was limited in scope, prescriber uptake and geographic scale up. Systemic, organizational and individual barriers and facilitators point to the importance of engaging professional regulatory colleges, implementation planning and organizational infrastructure to ensure effective implementation and adaptation to context.
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Affiliation(s)
- Bernadette Bernie Pauly
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC V8N 5M8, Canada; University of Victoria School of Nursing, Box 1700 Stn CSC, Victoria, BC 250, Canada.
| | - Megan Kurz
- Centre for Advancing Health Outcomes, Providence Health Care, 570-1081 Burrard Street, Vancouver, BC V6Z IY6b, Canada.
| | - Laura M Dale
- Centre for Advancing Health Outcomes, Providence Health Care, 570-1081 Burrard Street, Vancouver, BC V6Z IY6b, Canada.
| | - Celeste Macevicius
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC V8N 5M8, Canada; University of Victoria School of Public Health and Social Policy, PO Box 1700 STN CSC, Victoria, BC V8W 2Y2, Canada.
| | - Jeremy Kalicum
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC V8N 5M8, Canada; University of Victoria School of Public Health and Social Policy, PO Box 1700 STN CSC, Victoria, BC V8W 2Y2, Canada.
| | - Daniel Gudiño Pérez
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC V8N 5M8, Canada; University of Victoria School of Public Health and Social Policy, PO Box 1700 STN CSC, Victoria, BC V8W 2Y2, Canada.
| | - Jane McCall
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC V8N 5M8, Canada
| | - Karen Urbanoski
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC V8N 5M8, Canada; University of Victoria School of Public Health and Social Policy, PO Box 1700 STN CSC, Victoria, BC V8W 2Y2, Canada.
| | - Brittany Barker
- School of Public Health and Social Policy, University of Victoria, PO Box 1700 STN CSC, Victoria, BC V8W 2Y2, Canada; First Nations Health Authority, 501 - 100 Park Royal South, 170-6371 Crescent Road, Coast Salish Territory (West Vancouver), BC V7T 1A2, Canada; Faculty of Health Sciences, Simon Fraser University, Blusson Hall, Room 11300, 8888 University Drive, Burnaby, B.C. V5A 1S6, Canada.
| | - Amanda Slaunwhite
- BC Centre for Disease Control, 655 W 12th Ave, Vancouver, BC V5Z 4R4, Canada; School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC V6T 1Z3, Canada; Centre for Advancing Health Outcomes, 570-1081 Burrard Street, St. Paul's Hospital, Vancouver, BC V6Z1Y6, Canada.
| | - Morgan Lindsay
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC V8N 5M8, Canada.
| | - Bohdan Nosyk
- Faculty of Health Sciences, Simon Fraser University, Blusson Hall, Room 11300, 8888 University Drive, Burnaby, B.C. V5A 1S6, Canada; Centre for Advancing Health Outcomes, Providence Health Care, 570-1081 Burrard Street, St. Paul's Hospital, Vancouver, BC V6Z1Y6, Canada.
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Jung M, Xia T, Ilomäki J, Pearce C, Nielsen S. Opioid characteristics and nonopioid interventions associated with successful opioid taper in patients with chronic noncancer pain. Pain 2024; 165:1327-1335. [PMID: 38112755 PMCID: PMC11090027 DOI: 10.1097/j.pain.0000000000003133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 10/27/2023] [Accepted: 11/04/2023] [Indexed: 12/21/2023]
Abstract
ABSTRACT Current research indicates that tapering opioids may improve pain and function in patients with chronic noncancer pain. However, gaps in the literature remain regarding the choice of opioid and nonopioid interventions to support a successful taper. This study used an Australian primary care data set to identify a cohort of patients on long-term opioid therapy commencing opioid taper between January 2016 and September 2019. Using logistic regression analysis, we compared key clinical factors associated with differing taper outcomes. Of a total of 3371 patients who commenced taper, 1068 (31.7%) completed taper within 12 months. In the 3 months after commencement of taper, compared with those who did not complete taper, patients who successfully completed opioid taper were less likely to be prescribed buprenorphine (odds ratio [OR] 0.691; 95% CI: 0.530-0.901), fentanyl (OR, 0.429; 95% CI: 0.295-0.622), and long-acting (LA) opioids, including methadone (OR, 0.349; 95% CI: 0.157-0.774), oxycodone-naloxone (OR, 0.521; 95% CI: 0.407-0.669), and LA tapentadol (OR, 0.645; 95% CI: 0.461-0.902), but more likely to be prescribed codeine (OR, 1.308; 95% CI: 1.036-1.652). Compared with those who did not complete taper, patients who successfully tapered were less likely to be prescribed any formulations of oxycodone (short-acting [SA]: OR, 0.533; 95% CI: 0.422-0.672, LA: OR, 0.356; 95% CI: 0.240-0.530) and tramadol (SA: OR, 0.370; 95% CI: 0.218-0.628, LA: OR, 0.317; 95% CI: 0.234-0.428). The type of opioid prescribed in the months after commencement of taper seems to influence the taper outcomes. These findings may inform prospective studies on opioid taper.
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Affiliation(s)
- Monica Jung
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Australia
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Ting Xia
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Jenni Ilomäki
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Christopher Pearce
- Melbourne East General Practice Network (trading as Outcome Health), Surrey Hills, Australia
- Department of General Practice, School of Primary and Allied Health Care, Monash University, Notting Hill, Melbourne, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Australia
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Sabety AH, Neprash HT, Gaye M, Barnett ML. Clinical and healthcare use outcomes after cessation of long term opioid treatment due to prescriber workforce exit: quasi-experimental difference-in-differences study. BMJ 2024; 385:e076509. [PMID: 38754913 PMCID: PMC11096890 DOI: 10.1136/bmj-2023-076509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVE To examine the association between prescriber workforce exit, long term opioid treatment discontinuation, and clinical outcomes. DESIGN Quasi-experimental difference-in-differences study SETTING: 20% sample of US Medicare beneficiaries, 2011-18. PARTICIPANTS People receiving long term opioid treatment whose prescriber stopped providing office based patient care or exited the workforce, as in the case of retirement or death (n=48 079), and people whose prescriber did not exit the workforce (n=48 079). MAIN OUTCOMES Discontinuation from long term opioid treatment, drug overdose, mental health crises, admissions to hospital or emergency department visits, and death. Long term opioid treatment was defined as at least 60 days of opioids per quarter for four consecutive quarters, attributed to the plurality opioid prescriber. A difference-in-differences analysis was used to compare individuals who received long term opioid treatment and who had a prescriber leave the workforce to propensity-matched patients on long term opioid treatment who did not lose a prescriber, before and after prescriber exit. RESULTS Discontinuation of long term opioid treatment increased from 132 to 229 per 10 000 patients who had prescriber exit from the quarter before to the quarter after exit, compared with 97 to 100 for patients who had a continuation of prescriber (adjusted difference 1.22 percentage points, 95% confidence interval 1.02 to 1.42). In the first quarter after provider exit, when discontinuation rates were highest, a transient but significant elevation was noted between the two groups of patients in suicide attempts (adjusted difference 0.05 percentage points (95% confidence interval 0.01 to 0.09)), opioid or alcohol withdrawal (0.14 (0.01 to 0.27)), and admissions to hospital or emergency department visits (0.04 visits (0.01 to 0.06)). These differences receded after one to two quarters. No significant change in rates of overdose was noted. Across all four quarters after prescriber exit, an increase was reported in the rate of mental health crises (0.39 percentage points (95% confidence interval 0.08 to 0.69)) and opioid or alcohol withdrawal (0.31 (0.014 to 0.58)), but no change was seen for drug overdose (-0.12 (-0.41 to 0.18)). CONCLUSIONS The loss of a prescriber was associated with increased occurrences of discontinuation of long term opioid treatment and transient increases in adverse outcomes, such as suicide attempts, but not other outcomes, such as overdoses. Long term opioid treatment discontinuation may be associated with a temporary period of adverse health impacts after accounting for unobserved confounding.
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Affiliation(s)
- Adrienne H Sabety
- Department of Health Policy, Stanford University School of Medicine, Stanford, CA, USA
| | - Hannah T Neprash
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Marema Gaye
- Interfaculty Initiative in Health Policy, Harvard University, Cambridge, MA, USA
| | - Michael L Barnett
- Department of Health Policy and Management, Harvard T H Chan School of Public Health and Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital
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Solberg MA, Pasman E, O'Shay S, Friedrich F, Agius E, Resko SM. Public Perceptions of Opioid Use for Chronic Non-Cancer Pain. Subst Use Misuse 2024; 59:1416-1423. [PMID: 38733118 DOI: 10.1080/10826084.2024.2352619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/13/2024]
Abstract
Background: Chronic non-cancer pain affects 20% of Americans. This is significantly impacted by the ongoing opioid crisis and reduced opioid dispensing. Public perceptions additionally shape pain management strategies. Purpose: This study explores public attitudes toward prescription opioids for chronic non-cancer pain. We aim to understand how public attitudes are influenced by the evolving opioid crisis and shifting opioid use patterns. Methods: In Michigan, 823 adults participated in a Qualtrics survey on attitudes toward nonmedical and medical prescription opioid use. Multivariable logistic regression was performed to identify factors associated with beliefs that doctors prescribe opioids for too long (Model 1) and chronic pain patients should transition to alternative treatments (Model 2). Results: About half (49.4%) of respondents believed doctors keep patients on prescription opioids for too long, while two-thirds (65.7%) agreed chronic pain patients should be tapered off medications. Knowing someone who misused opioids and perceptions of substance use (e.g. perceived risk of prescription opioid misuse, stigma toward chronic pain patients, perceived prevalence of prescription opioid misuse, and awareness of fentanyl) were associated with greater odds of believing doctors keep patients on opioids too long. Demographics (age and education), substance use histories and perceptions (e.g. perceived risk and stigma) were associated with greater odds of believing patients should be tapered off their medication. Conclusions: These findings inform strategies to correct public misperceptions, emphasizing the importance of personal experience, perceived risks, and stigmatization of chronic pain patients. This insight can guide effective pain management for those with chronic non-cancer pain.
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Affiliation(s)
- Marvin A Solberg
- College of Nursing, Wayne State University, Detroit, Michigan, USA
- Institute for Social Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Emily Pasman
- Center for the Study of Drugs, Alcohol, Smoking, and Health, University of Michigan, School of Nursing, Ann Arbor, Michigan, USA
| | - Sydney O'Shay
- College of Humanities and Social Sciences, Utah State University, Logan, Utah, USA
| | | | - Elizabeth Agius
- School of Social Work, Wayne State University, Detroit, Michigan, USA
| | - Stella M Resko
- School of Social Work, Wayne State University, Detroit, Michigan, USA
- Merrill Palmer Skillman Institute, Wayne State University, Detroit, Michigan, USA
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Chang P, Amaral LJ, Asher A, Clauw D, Jones B, Thompson P, Warner AS. A perspective on a precision approach to pain in cancer; moving beyond opioid therapy. Disabil Rehabil 2024; 46:2174-2183. [PMID: 37194659 DOI: 10.1080/09638288.2023.2212916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 05/07/2023] [Indexed: 05/18/2023]
Abstract
PURPOSE Cancer-related pain is primarily treated with opioids which while effective can add significant patient burden due to side effects, associated stigma, and timely access. The purpose of this perspective discussion is to argue for a precision approach to pain in cancer based on a biopsychosocial and spiritual model which we argue can offer a higher quality of life while limiting opioid use. CONCLUSIONS Pain in cancer represents a heterogenous process with multiple contributing and modulating factors. Specific characterization of pain as either nociceptive, neuropathic, nociplastic, or mixed can allow for targeted treatments. Additional assessment of biopsychosocial and spiritual issues can elucidate further points of targeted intervention which can lead to overall greater pain control.
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Affiliation(s)
- Philip Chang
- Philip Chang - Cedars Sinai Medical Center, Los Angeles, CA
| | | | - Arash Asher
- Arash Asher - Cedars Sinai Medical Center, Los Angeles, CA
| | | | - Bronwen Jones
- Bronwen Jones - Cedars Sinai Medical Center, Los Angeles, CA
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13
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Sung ML, Eden SK, Becker WC, Crystal S, Duncan MS, Gordon KS, Kerns RD, Kundu S, Freiberg M, So-Armah KA, Edelman EJ. The Association of Prescribed Opioids and Incident Cardiovascular Disease. THE JOURNAL OF PAIN 2024; 25:104436. [PMID: 38029949 PMCID: PMC11058015 DOI: 10.1016/j.jpain.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 11/16/2023] [Accepted: 11/19/2023] [Indexed: 12/01/2023]
Abstract
Opioid prescribing remains common despite known overdose-related harms. Less is known about links to nonoverdose morbidity. We determined the association between prescribed opioid receipt with incident cardiovascular disease (CVD) using data from the Veterans Aging Cohort Study, a national prospective cohort of Veterans with/without Human Immunodeficiency Virus (HIV) receiving Veterans Health Administration care. Selected participants had no/minimal prior exposure to prescription opioids, no opioid use disorder, and no severe illness 1 year after the study start date (baseline period). We ascertained prescription opioid exposure over 3 years after the baseline period using outpatient pharmacy fill/refill data. Incident CVD ascertainment began at the end of the prescribed opioid exposure ascertainment period until the first incident CVD event, death, or September 30, 2015. We used adjusted Cox proportional hazards regression models with matching weights using propensity scores for opioid receipt to estimate CVD risk. Among 49,077 patients, 30% received opioids; the median age was 49 years, 97% were male, 49% were Black, and 47% were currently smoking. Prevalence of hypertension, diabetes, current smoking, alcohol and cocaine use disorder, and depression was higher in patients receiving opioids versus those not but were well-balanced by matching weights. Unadjusted CVD incidence rates per 1,000-person-years were higher among those receiving opioids versus those not: 17.4 (95% confidence interval [CI], 16.5-18.3) versus 14.7 (95% CI, 14.2-15.3). In adjusted analyses, those receiving opioids versus those not had an increased hazard of incident CVD (adjusted hazard ratio 1.16 [95% CI, 1.08-1.24]). Prescribed opioids were associated with increased CVD incidence, making opioids a potential modifiable CVD risk factor. PERSPECTIVE: In a propensity score weighted analysis of Veterans Administration data, prescribed opioids compared to no opioids were associated with an increased hazard of incident CVD. Higher opioid doses compared with lower doses were associated with increased hazard of incident CVD. Opioids are a potentially modifiable CVD risk factor.
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Affiliation(s)
- Minhee L Sung
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut; Department of Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut; Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Svetlana K Eden
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - William C Becker
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut; Department of Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut; Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut; Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Stephen Crystal
- Center for Health Services Research, Rutgers University, New Brunswick, New Jersey
| | - Meredith S Duncan
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Biostatistics, University of Kentucky, Lexington, Kentucky
| | - Kirsha S Gordon
- Department of Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut; Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Robert D Kerns
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut; Department of Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut; Departments of Psychiatry, Neurology and Psychology, Yale University, New Haven, Connecticut
| | - Suman Kundu
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew Freiberg
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kaku A So-Armah
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - E Jennifer Edelman
- Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut; Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut
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14
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Turner JP, Halme AS, Caetano P, Langford A, Tannenbaum C. Government Direct-to-Consumer Education to Reduce Prescription Opioid Use: A Cluster Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2413698. [PMID: 38809554 PMCID: PMC11137632 DOI: 10.1001/jamanetworkopen.2024.13698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 03/12/2024] [Indexed: 05/30/2024] Open
Abstract
Importance Direct-to-consumer education reduces chronic sedative use. The effectiveness of this approach for prescription opioids among patients with chronic noncancer pain remains untested. Objectives To evaluate the effectiveness of a government-led educational information brochure mailed to community-dwelling, long-term opioid consumers to reduce prescription opioid use compared with usual care. Design, Setting, and Participants This cluster randomized clinical trial was conducted from July 2018 to January 2019 in Manitoba, Canada. All adults with long-term opioid prescriptions were enrolled (n = 4225). Participants were identified via the Manitoba Drug Program Information Network. Individuals receiving palliative care or with a diagnosis of cancer or dementia were excluded. Data were analyzed from July 2019 to March 2020. Intervention Participants were clustered according to their primary care clinic and randomized to the intervention (a codesigned direct-to-consumer educational brochure sent by mail) or usual care (comparator group). Main Outcomes and Measures The main outcome was discontinuation of opioid prescriptions at the participant level after 6 months, ascertained by pharmacy drug claims. Secondary outcomes included dose reduction (in morphine milligram equivalents [MME]) and/or therapeutic switch. Reduction in opioid use was assessed using generalized estimating equations to account for clustering, with prespecified subgroup analyses by age and sex. Analysis was intention to treat. Results Of 4206 participants, 2409 (57.3%) were male; mean (SD) age was 60.0 (14.4) years. Mean (SD) baseline opioid use was comparable between groups (intervention, 157.7 [179.7] MME/d; control, 153.4 [181.8] MME/d). After 6 months, 235 of 2136 participants (11.0%) in 127 clusters in the intervention group no longer filled opioid prescriptions compared with 228 of 2070 (11.0%) in 124 clusters in the comparator group (difference, 0.0%; 95% CI, -1.9% to 1.9%). More participants in the intervention group than in the control group reduced their dose (1410 [66.0%] vs 1307 [63.1%]; difference, 2.8% [95% CI, 0.0%-5.7%]). Receipt of the brochure led to greater dose reductions for participants who were male (difference, 3.9%; 95% CI, 0.1%-7.7%), aged 18 to 64 years (difference, 3.7%; 95% CI, 0.2%-7.2%), or living in urban areas (difference, 5.9%; 95% CI, 1.9%-9.9%) compared with usual care. Conclusions and Relevance In this cluster randomized clinical trial, no significant difference in the prevalence of opioid cessation was observed after 6 months between the intervention and usual care groups; however, the intervention resulted in more adults reducing their opioid dose compared with usual care. Trial Registration ClinicalTrials.gov Identifier: NCT03400384.
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Affiliation(s)
- Justin P. Turner
- Centre for Medicine Use and Safety, Monash University, Parkville, Victoria, Australia
- Faculté de Pharmacie, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherche de l’Institut Universitaire de Gériatrie de Montréal, Montréal, Québec, Canada
| | - Alex S. Halme
- Département de Médecine Spécialisée, Centre Intégré de Santé et de Services Sociaux de la Gaspésie, Sainte-Anne-des-Monts, Québec, Canada
| | - Patricia Caetano
- Drug Data Services and Analytics, Canadian Agency for Drugs and Technologies in Health, Ontario, Canada
| | - Aili Langford
- Centre for Medicine Use and Safety, Monash University, Parkville, Victoria, Australia
| | - Cara Tannenbaum
- Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherche de l’Institut Universitaire de Gériatrie de Montréal, Montréal, Québec, Canada
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Spinella S, McCarthy R. Buprenorphine for Pain: A Narrative Review and Practical Applications. Am J Med 2024; 137:406-413. [PMID: 38340973 DOI: 10.1016/j.amjmed.2024.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 01/29/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024]
Abstract
Chronic noncancer pain affects about 20% of US adults and can significantly affect function and quality of life. Current guidelines recommend multimodal pain control. Despite risks associated with long-term opioid therapy, opioids are commonly prescribed. Buprenorphine is a partial opioid agonist with an improved safety profile compared to full agonists. Some formulations are approved for chronic pain and others for opioid use disorder. Buprenorphine is an option for patients who use chronic daily opioids for pain. This review summarizes the literature on buprenorphine's efficacy and safety for chronic pain and provides recommendations to generalists on initiation, titration, and monitoring of buprenorphine-based pain treatment. We also discuss a communication approach when considering buprenorphine for pain.
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Affiliation(s)
- Sara Spinella
- Department of Medicine, University of Pittsburgh School of Medicine and VA Pittsburgh Healthcare System, Pittsburgh, Pa.
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16
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Metz VE, Ray GT, Palzes V, Binswanger I, Altschuler A, Karmali RN, Ahmedani BK, Andrade SE, Boscarino JA, Clark RE, Haller IV, Hechter RC, Roblin DW, Sanchez K, Bailey SR, McCarty D, Stephens KA, Rosa CL, Rubinstein AL, Campbell CI. Prescription Opioid Dose Reductions and Potential Adverse Events: a Multi-site Observational Cohort Study in Diverse US Health Systems. J Gen Intern Med 2024; 39:1002-1009. [PMID: 37930512 PMCID: PMC11074095 DOI: 10.1007/s11606-023-08459-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 10/06/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND In response to the opioid crisis in the United States, population-level prescribing of opioids has been decreasing; there are concerns, however, that dose reductions are related to potential adverse events. OBJECTIVE Examine associations between opioid dose reductions and risk of 1-month potential adverse events (emergency department (ED) visits, opioid overdose, benzodiazepine prescription fill, all-cause mortality). DESIGN This observational cohort study used electronic health record and claims data from eight United States health systems in a prescription opioid registry (Clinical Trials Network-0084). All opioid fills (excluding buprenorphine) between 1/1/2012 and 12/31/2018 were used to identify baseline periods with mean morphine milligram equivalents daily dose of ≥ 50 during six consecutive months. PATIENTS We identified 60,040 non-cancer patients with ≥ one 2-month dose reduction period (600,234 unique dose reduction periods). MAIN MEASURES Analyses examined associations between dose reduction levels (1- < 15%, 15- < 30%, 30- < 100%, 100% over 2 months) and potential adverse events in the month following a dose reduction using logistic regression analysis, adjusting for patient characteristics. KEY RESULTS Overall, dose reduction periods involved mean reductions of 18.7%. Compared to reductions of 1- < 15%, dose reductions of 30- < 100% were associated with higher odds of ED visits (OR 1.14, 95% CI 1.10, 1.17), opioid overdose (OR 1.41, 95% CI 1.09-1.81), and all-cause mortality (OR 1.39, 95% CI 1.16-1.67), but lower odds of a benzodiazepine fill (OR 0.83, 95% CI 0.81-0.85). Dose reductions of 15- < 30%, compared to 1- < 15%, were associated with higher odds of ED visits (OR 1.08, 95% CI 1.05-1.11) and lower odds of a benzodiazepine fill (OR 0.93, 95% CI 0.92-0.95), but were not associated with opioid overdose and all-cause mortality. CONCLUSIONS Larger reductions for patients on opioid therapy may raise risk of potential adverse events in the month after reduction and should be carefully monitored.
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Affiliation(s)
- Verena E Metz
- Kaiser Permanente Northern California, Division of Research, Center for Addiction and Mental Health Research, Oakland, CA, USA.
| | - G Thomas Ray
- Kaiser Permanente Northern California, Division of Research, Center for Addiction and Mental Health Research, Oakland, CA, USA
| | - Vanessa Palzes
- Kaiser Permanente Northern California, Division of Research, Center for Addiction and Mental Health Research, Oakland, CA, USA
| | - Ingrid Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
- Colorado Permanente Medical Group, Denver, CO, USA
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Andrea Altschuler
- Kaiser Permanente Northern California, Division of Research, Center for Addiction and Mental Health Research, Oakland, CA, USA
| | | | - Brian K Ahmedani
- Center for Health Policy & Health Services Research, Henry Ford Health, Detroit, MI, USA
| | - Susan E Andrade
- Meyers Primary Care Institute, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Joseph A Boscarino
- Department of Population Health Sciences, Geisinger Clinic, Danville, PA, USA
| | - Robin E Clark
- Department of Family Medicine and Community Health, University of Massachusetts Chan School of Medicine, Worcester, MA, USA
| | | | - Rulin C Hechter
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Douglas W Roblin
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente, Rockville, MD, USA
| | - Katherine Sanchez
- Baylor Scott & White Research Institute, Dallas, TX, USA
- School of Social Work, University of Texas at Arlington, Arlington, TX, USA
| | - Steffani R Bailey
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Dennis McCarty
- OHSU-PSU School of Public Health, Portland, OR, USA
- Division of General and Internal Medicine, School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Kari A Stephens
- Department of Family Medicine, University of Washington, Seattle, WA, USA
| | - Carmen L Rosa
- Center for the Clinicals Trials Network, National Institute On Drug Abuse, National Institutes of Health, Bethesda, MD, USA
| | - Andrea L Rubinstein
- Department of Pain Medicine, The Permanente Medical Group, Santa Rosa, CA, USA
| | - Cynthia I Campbell
- Kaiser Permanente Northern California, Division of Research, Center for Addiction and Mental Health Research, Oakland, CA, USA
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, CA, USA
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17
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Fenton JJ, Magnan EM, Tancredi DJ, Tseregounis IE, Agnoli AL. Impact of overdose on health plan disenrollment among patients prescribed long-term opioids: Retrospective cohort study. Drug Alcohol Depend 2024; 258:111277. [PMID: 38581921 DOI: 10.1016/j.drugalcdep.2024.111277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 03/05/2024] [Accepted: 03/19/2024] [Indexed: 04/08/2024]
Abstract
CONTEXT Health plan disenrollment may disrupt chronic or preventive care for patients prescribed long-term opioid therapy (LTOT). PURPOSE To assess whether overdose events in patients prescribed LTOT are associated with subsequent health plan disenrollment. DESIGN Retrospective cohort study. SETTING AND DATASET Data from the Optum Labs Data Warehouse which includes de-identified medical and pharmacy claims and enrollment records for commercial and Medicare Advantage enrollees. The database contains longitudinal health information on patients, representing a mixture of ages and geographical regions across the United States. PATIENTS Adults prescribed stable opioid therapy (≥10 morphine milligram equivalents/day) for a 6-month baseline period prior to an index opioid prescription from January 1, 2018 to December 31, 2018. MAIN MEASURES Health plan disenrollment during follow-up. RESULTS The cohort comprised 404,151 patients who were followed up after 800,250 baseline periods of stable opioid dosing. During a mean follow-up of 9.1 months, unadjusted disenrollment rates among primary commercial beneficiaries and Medicare Advantage enrollees were 37.2 and 13.9 per 100 person-years, respectively. Incident overdoses were associated with subsequent health plan disenrollment with a statistically significantly stronger association among primary commercial insurance beneficiaries [adjusted incidence rate ratio (aIRR) 1.48 (95% CI: 1.33-1.64)] as compared to Medicare Advantage enrollees [aIRR 1.15 (95% CI: 1.07-1.23)]. CONCLUSIONS Among patients prescribed long-term opioids, overdose events were strongly associated with subsequent health plan disenrollment, especially among primary commercial insurance beneficiaries. These findings raise concerns about the social consequences of overdose, including potential health insurance loss, which may limit patient access to care at a time of heightened vulnerability.
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Affiliation(s)
- Joshua J Fenton
- Department of Family and Community Medicine, University of California, Davis, Sacramento, CA, USA; Center for Healthcare Policy and Research, University of California, Davis, Sacramento, CA, USA.
| | - Elizabeth M Magnan
- Department of Family and Community Medicine, University of California, Davis, Sacramento, CA, USA; Center for Healthcare Policy and Research, University of California, Davis, Sacramento, CA, USA
| | - Daniel J Tancredi
- Department of Pediatrics, University of California, Davis, Sacramento, CA, USA; Center for Healthcare Policy and Research, University of California, Davis, Sacramento, CA, USA
| | - Iraklis Erik Tseregounis
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA; Center for Healthcare Policy and Research, University of California, Davis, Sacramento, CA, USA
| | - Alicia L Agnoli
- Department of Family and Community Medicine, University of California, Davis, Sacramento, CA, USA; Center for Healthcare Policy and Research, University of California, Davis, Sacramento, CA, USA
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Riviere P, Morgan KM, Deshler LN, Huang X, Marienfeld C, Coyne CJ, Rose BS, Murphy JD. Opioid tapering in older cancer survivors does not increase psychiatric or drug hospitalization rates. J Natl Cancer Inst 2024; 116:606-612. [PMID: 37971959 PMCID: PMC10995846 DOI: 10.1093/jnci/djad241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 11/06/2023] [Accepted: 11/13/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Opioid tapering in the general population is linked to increases in hospitalizations or emergency department visits related to psychiatric or drug-related diagnoses. Cancer survivors represent a unique population with different opioid indications, prescription patterns, and more frequent follow-up care. This study sought to describe patterns of opioid tapering among older cancer survivors and to test the hypothesis of whether older cancer survivors face increased risks of adverse events with opioid tapering. METHODS Using the Surveillance, Epidemiology and End Results Medicare-linked database, we identified 15 002 Medicare-beneficiary cancer survivors diagnosed between 2010 and 2017 prescribed opioids consistently for at least 6 months after their cancer diagnosis. Tapering was defined as a binary time-varying event occurring with any monthly oral morphine equivalent reduction of 15% or more from the previous month. Primary diagnostic billing codes associated with emergency room or hospital admissions were used for the composite endpoint of psychiatric- or drug-related event(s). RESULTS There were 3.86 events per 100 patient-months, with 97.8% events being mental health emergencies, 1.91% events being overdose emergencies, and 0.25% involving both. Using a generalized estimating equation for repeated measure time-based analysis, opioid tapering was not statistically associated with acute events in the 3-month posttaper period (odds ratio [OR] = 1.02; P = .62) or at any point in the future (OR = 0.96; P = .46). CONCLUSIONS Opioid tapering in older cancer survivors does not appear to be linked to a higher risk of acute psychiatric- or drug-related events, in contrast to prior research in the general population.
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Affiliation(s)
- Paul Riviere
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
- Center for Health Equity and Education Research, University of California San Diego, La Jolla, CA, USA
| | - Kylie M Morgan
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
- Center for Health Equity and Education Research, University of California San Diego, La Jolla, CA, USA
| | - Leah N Deshler
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
- Center for Health Equity and Education Research, University of California San Diego, La Jolla, CA, USA
| | - Xinyi Huang
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
- Division of Biostatistics and Bioinformatics, Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA, USA
| | - Carla Marienfeld
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Christopher J Coyne
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
- Department of Emergency Medicine, University of California San Diego, La Jolla, CA, USA
| | - Brent S Rose
- Center for Health Equity and Education Research, University of California San Diego, La Jolla, CA, USA
| | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
- Center for Health Equity and Education Research, University of California San Diego, La Jolla, CA, USA
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19
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Jung M, Xia T, Ilomäki J, Pearce C, Nielsen S. Trajectories of prescription opioid tapering in patients with chronic non-cancer pain: a retrospective cohort study, 2015-2020. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:263-274. [PMID: 38191211 PMCID: PMC10988287 DOI: 10.1093/pm/pnae002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 11/30/2023] [Accepted: 12/16/2023] [Indexed: 01/10/2024]
Abstract
OBJECTIVE To identify common opioid tapering trajectories among patients commencing opioid taper from long-term opioid therapy for chronic non-cancer pain and to examine patient-level characteristics associated with these different trajectories. DESIGN A retrospective cohort study. SETTING Australian primary care. SUBJECTS Patients prescribed opioid analgesics between 2015 and 2020. METHODS Group-based trajectory modeling and multinomial logistic regression analysis were conducted to determine tapering trajectories and to examine demographic and clinical factors associated with the different trajectories. RESULTS A total of 3369 patients commenced a taper from long-term opioid therapy. Six distinct opioid tapering trajectories were identified: low dose / completed taper (12.9%), medium dose / faster taper (12.2%), medium dose / gradual taper (6.5%), low dose / noncompleted taper (21.3%), medium dose / noncompleted taper (30.4%), and high dose / noncompleted taper (16.7%). A completed tapering trajectory from a high opioid dose was not identified. Among patients prescribed medium opioid doses, those who completed their taper were more likely to have higher geographically derived socioeconomic status (relative risk ratio [RRR], 1.067; 95% confidence interval [CI], 1.001-1.137) and less likely to have sleep disorders (RRR, 0.661; 95% CI, 0.463-0.945) than were those who didn't complete their taper. Patients who didn't complete their taper were more likely to be prescribed strong opioids (eg, morphine, oxycodone), regardless of whether they were tapered from low (RRR, 1.444; 95% CI, 1.138-1.831) or high (RRR, 1.344; 95% CI, 1.027-1.760) doses. CONCLUSIONS Those prescribed strong opioids and high doses appear to be less likely to complete tapering. Further studies are needed to evaluate the clinical outcomes associated with the identified trajectories.
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Affiliation(s)
- Monica Jung
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, VIC 3199, Australia
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC 3052, Australia
| | - Ting Xia
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, VIC 3199, Australia
| | - Jenni Ilomäki
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC 3052, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Christopher Pearce
- Melbourne East General Practice Network (trading as Outcome Health), Surrey Hills, VIC 3127, Australia
- Department of General Practice, School of Primary and Allied Health Care, Monash University, Melbourne, VIC 3168, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, VIC 3199, Australia
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20
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Gholamrezaei A, Magee MR, McNeilage AG, Dwyer L, Sim A, Ferreira ML, Darnall BD, Brake T, Aggarwal A, Craigie M, Hollington I, Glare P, Ashton-James CE. A digital health intervention to support patients with chronic pain during prescription opioid tapering: a pilot randomised controlled trial. Pain Rep 2024; 9:e1128. [PMID: 38352024 PMCID: PMC10863948 DOI: 10.1097/pr9.0000000000001128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 09/02/2023] [Accepted: 12/03/2023] [Indexed: 02/16/2024] Open
Abstract
Introduction Recent changes in opioid prescribing guidelines have led to an increasing number of patients with chronic pain being recommended to taper. However, opioid tapering can be challenging, and many patients require support. Objectives We evaluated the feasibility, acceptability, and potential efficacy of a codesigned digital health intervention to support patients with chronic pain during voluntary prescription opioid tapering. Methods In a pilot randomised controlled trial, participants received a psychoeducational video and 28 days of text messages (2 SMS/day) in addition to their usual care (intervention) or usual care alone (control). The feasibility, acceptability, and potential efficacy of the intervention were evaluated. The primary outcome was opioid tapering self-efficacy. Secondary outcomes were pain intensity and interference, anxiety and depression symptom severity, pain catastrophising, and pain self-efficacy. Results Of 28 randomised participants, 26 completed the study (13 per group). Text message delivery was high (99.2%), but fidelity of video delivery was low (57.1%). Most participants rated the messages as useful, supportive, encouraging, and engaging; 78.5% would recommend the intervention to others; and 64.2% desired a longer intervention period. Tapering self-efficacy (Cohen d = 0.74) and pain self-efficacy (d = 0.41) were higher, and pain intensity (d = 0.65) and affective interference (d = 0.45) were lower in the intervention group at week 4. Conclusion First evidence supports the feasibility, acceptability, and potentially efficacy of a psychoeducational video and SMS text messaging intervention to support patients with chronic pain during voluntary prescription opioid tapering. Definitive trials with longer intervention duration are warranted.
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Affiliation(s)
- Ali Gholamrezaei
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Michael R. Magee
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Amy G. McNeilage
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Leah Dwyer
- Consumer Advisory Group, Painaustralia, Deakin, Victoria, Australia
| | - Alison Sim
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Manuela L. Ferreira
- Sydney Musculoskeletal Health, Kolling Institute, School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Beth D. Darnall
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Timothy Brake
- Pain Management Centre, Royal Prince Alfred Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Arun Aggarwal
- Pain Management Centre, Royal Prince Alfred Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Meredith Craigie
- Pain Management Unit, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia
| | - Irina Hollington
- Pain Management Unit, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia
| | - Paul Glare
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Claire E. Ashton-James
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, New South Wales, Australia
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21
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Yarborough BJH, Stumbo SP, Schneider JL, Ahmedani BK, Daida YG, Hooker SA, Negriff S, Rossom RC, Lapham G. Impact of Opioid Dose Reductions on Patient-Reported Mental Health and Suicide-Related Behavior and Relationship to Patient Choice in Tapering Decisions. THE JOURNAL OF PAIN 2024; 25:1094-1105. [PMID: 37952862 DOI: 10.1016/j.jpain.2023.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 11/01/2023] [Accepted: 11/05/2023] [Indexed: 11/14/2023]
Abstract
Mental health and suicide-related harms resulting from prescription opioid tapering are poorly documented and understood. Six health systems contributed opioid prescribing data from January 2016 to April 2020. Patients 18 to 70 years old with evidence of opioid tapering participated in semi-structured interviews. Individuals who experienced suicide attempts were oversampled. Family members of suicide decedents who had experienced opioid tapering were also interviewed. Interviews were analyzed using thematic analysis. The study participants included 176 patients and 16 family members. Patients were 68% female, 80% White, and 15% Hispanic, mean age 58. All family members were female spouses of White, non-Hispanic male decedents. Among the subgroup (n = 60) who experienced a documented suicide attempt, reported experiencing suicidal ideation during tapering, or were family members of suicide decedents, 40% reported that opioid tapering exacerbated previously recognized mental health issues, and 25% reported that tapering triggered new-onset mental health concerns. Among participants with suicide behavior, 47% directly attributed it to opioid tapering. Common precipitants included increased pain, reduced life engagement, sleep problems, withdrawal, relationship dissolution, and negative consequences of opioid substitution with other substances for pain relief. Most respondents reporting suicide behavior felt that the decision to taper was made by the health care system or a clinician (67%) whereas patients not reporting suicide behavior were more likely to report it was their own decision (42%). This study describes patient-reported mental health deterioration or suicide behavior while tapering prescription opioids. Clinicians should screen for, monitor, and treat suicide behavior while assisting patients in tapering opioids. PERSPECTIVE: This work describes changes in patient-reported mental health and suicide behavior while tapering prescription opioids. Recommendations for improving care include mental health and suicide risk screening during and following opioid tapering.
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Affiliation(s)
| | - Scott P Stumbo
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | | | | | | | | | - Sonya Negriff
- Kaiser Permanente Southern California, Pasadena, California
| | | | - Gwen Lapham
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
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22
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Rikard SM, Nataraj N, Zhang K, Strahan A, Mikosz CA, Guy GP. Reply to Chang et al. Pain 2024; 165:960. [PMID: 38501998 PMCID: PMC11009927 DOI: 10.1097/j.pain.0000000000003179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Affiliation(s)
- S. Michaela Rikard
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Nisha Nataraj
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Kun Zhang
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Andrea Strahan
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Christina A. Mikosz
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Gery P. Guy
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, United States
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23
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Fenton JJ. Centering the patient in decisions about opioid tapering. Expert Rev Clin Pharmacol 2024; 17:305-307. [PMID: 38349034 DOI: 10.1080/17512433.2024.2318470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 02/07/2024] [Indexed: 04/17/2024]
Affiliation(s)
- J J Fenton
- Department of Family and Community Medicine, University of California Davis School of Medicine Ringgold standard institution, Sacramento, CA, USA
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24
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Buonora MJ, Axson SA, Cohen SM, Becker WC. Paths Forward for Clinicians Amidst the Rise of Unregulated Clinical Decision Support Software: Our Perspective on NarxCare. J Gen Intern Med 2024; 39:858-862. [PMID: 37962733 PMCID: PMC11043299 DOI: 10.1007/s11606-023-08528-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/02/2023] [Indexed: 11/15/2023]
Abstract
Amidst the US overdose epidemic, policymakers, law enforcement agencies, and healthcare institutions have contributed to a decrease in opioid prescribing, assuming reduced mortality would result-an assumption we now understand was oversimplified. At this intersection between public health and public safety domains as they relate to opioid prescribing, unregulated and proprietary clinical decision support tools have emerged without rigorous external validation or public data sharing. In the following piece, we discuss challenges facing clinicians practicing medicine amidst unregulated clinical decision support tools, using the case of Bamboo Health's NarxCare-a prescription drug monitoring program-based analytics platform marketed as a clinical decision support tool-that is already positioned to impact over 1 billion patient encounters annually. We argue that sufficient evidence does not yet exist to support NarxCare's wide implementation, and that clinical decision support tools like NarxCare have flourished in recent years due to a lack of federal regulatory oversight and shielding by their proprietary formulas, which have facilitated their unchecked and outsized influence on patient care. Finally, we suggest specific actions by federal regulatory agencies, healthcare institutions, individual clinicians, and researchers, as well as academic journals, to mitigate potential harms associated with unregulated clinical decision support tools.
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Affiliation(s)
- Michele J Buonora
- National Clinician Scholars Program, Yale School of Medicine, New Haven, CT, USA.
- Department of Internal Medicine & Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, USA.
- General Internal Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA.
- Division of General Internal Medicine, Montefiore Medical Center, Bronx, NY, USA.
| | - Sydney A Axson
- National Clinician Scholars Program, Yale School of Medicine, New Haven, CT, USA
- General Internal Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Ross and Carol Nese College of Nursing and the Rock Ethics Institute, The Pennsylvania State University, University Park, PA, USA
| | - Shawn M Cohen
- Department of Internal Medicine & Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, USA
| | - William C Becker
- National Clinician Scholars Program, Yale School of Medicine, New Haven, CT, USA
- Department of Internal Medicine & Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, USA
- Pain Research, Informatics, Multimorbidities & Education Center of Innovation, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
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25
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Anderson TS, Wang BX, Lindenberg JH, Herzig SJ, Berens DM, Schonberg MA. Older Adult and Primary Care Practitioner Perspectives on Using, Prescribing, and Deprescribing Opioids for Chronic Pain. JAMA Netw Open 2024; 7:e241342. [PMID: 38446478 PMCID: PMC10918495 DOI: 10.1001/jamanetworkopen.2024.1342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/17/2024] [Indexed: 03/07/2024] Open
Abstract
Importance Guidelines recommend deprescribing opioids in older adults due to risk of adverse effects, yet little is known about patient-clinician opioid deprescribing conversations. Objective To understand the experiences of older adults and primary care practitioners (PCPs) with using opioids for chronic pain and discussing opioid deprescribing. Design, Setting, and Participants This qualitative study conducted semistructured individual qualitative interviews with 18 PCPs and 29 adults 65 years or older prescribed opioids between September 15, 2022, and April 26, 2023, at a Boston-based academic medical center. The PCPs were asked about their experiences prescribing and deprescribing opioids to older adults. Patients were asked about their experiences using and discussing opioid medications with PCPs. Main Outcome and Measures Shared and conflicting themes between patients and PCPs regarding perceptions of opioid prescribing and barriers to deprescribing. Results In total, 18 PCPs (12 [67%] younger that 50 years; 10 [56%] female; and 14 [78%] based at an academic practice) and 29 patients (mean [SD] age, 72 [5] years; 19 [66%] female) participated. Participants conveyed that conversations between PCPs and patients on opioid use for chronic pain were typically challenging and that conversations regarding opioid risks and deprescribing were uncommon. Three common themes related to experiences with opioids for chronic pain emerged in both patient and PCP interviews: opioids were used as a last resort, opioids were used to improve function and quality of life, and trust was vital in a clinician-patient relationship. Patients and PCPs expressed conflicting views on risks of opioids, with patients focusing on addiction and PCPs focusing on adverse drug events. Both groups felt deprescribing conversations were often unsuccessful but had conflicting views on barriers to successful conversations. Patients felt deprescribing was often unnecessary unless an adverse event occurred, and many patients had prior negative experiences tapering. The PCPs described gaps in knowledge on how to taper, a lack of clinical access to monitor patients during tapering, and concerns about patient resistance. Conclusions and Relevance In this qualitative study, PCPs and older adults receiving long-term opioid therapy viewed the use of opioids as a beneficial last resort for treating chronic pain but expressed dissonant views on the risks associated with opioids, which made deprescribing conversations challenging. Interventions, such as conversation aids, are needed to support collaborative discussion about deprescribing opioids.
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Affiliation(s)
- Timothy S. Anderson
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Pharmaceutical Policy and Prescribing, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Brianna X. Wang
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Julia H. Lindenberg
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Shoshana J. Herzig
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Dylan M. Berens
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Mara A. Schonberg
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Pogue J, Lau L, Boyer J. Data-Based Opioid Risk Review in Patients with Chronic Pain: A Retrospective Chart Review. J Pain Palliat Care Pharmacother 2024; 38:74-83. [PMID: 38019479 DOI: 10.1080/15360288.2023.2288109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/19/2023] [Indexed: 11/30/2023]
Abstract
A retrospective, cohort, single center, chart review was conducted to compare rates of opioid-associated serious adverse events (SAEs) in a patient cohort 6 months before and 6 months after data-based opioid risk review. The primary objective was the composite reduction in opioid-related SAEs including suicide-related events and opioid overdoses. The impact of the reviews was assessed via multivariate logistic regression and a McNemar's test to analyze difference in rates of opioid-associated SAEs. This study demonstrates that data-based opioid risk review can reduce opioid-related SAEs, opioid overdoses, and suicide-related events in the 6 months post-review. The primary outcome was not statistically significant with a p-value of 0.080. In the population that underwent opioid tapers, the hazard ratios (HR) for suicide-related events and opioid-related SAEs were 6.64 (1.09-40.53, p = 0.05) and 10.43 (0.48-226.80, p = 0.02) respectively when compared to non-tapered patients. The HR for suicide-related events and opioid-related SAEs when opioid therapy was discontinued were 9.95 (2.16-45.94, p = 0.009) and 15.64 (1.09-225.19, p = 0.001) respectively when compared to continuation of opioids. This study showed that data-based opioid risk review may reduce incidence of opioid-related SAEs in patients with chronic pain. Additionally, opioid tapers and discontinuations are significant risk factors for suicide-related events and opioid-related SAEs.
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Affiliation(s)
- Joshua Pogue
- Southern Arizona VA Healthcare System, Tucson, Arizona, USA
| | - Lily Lau
- Southern Arizona VA Healthcare System, Tucson, Arizona, USA
| | - Jeffrey Boyer
- Southern Arizona VA Healthcare System, Tucson, Arizona, USA
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Wei YJJ, Winterstein AG, Schmidt S, Fillingim RB, Schmidt S, Daniels MJ, DeKosky ST. Short- and long-term safety of discontinuing chronic opioid therapy among older adults with Alzheimer's disease and related dementia. Age Ageing 2024; 53:afae047. [PMID: 38497237 PMCID: PMC10945292 DOI: 10.1093/ageing/afae047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND Limited evidence exists on the short- and long-term safety of discontinuing versus continuing chronic opioid therapy (COT) among patients with Alzheimer's disease and related dementias (ADRD). METHODS This cohort study was conducted among 162,677 older residents with ADRD and receipt of COT using a 100% Medicare nursing home sample. Discontinuation of COT was defined as no opioid refills for ≥90 days. Primary outcomes were rates of pain-related hospitalisation, pain-related emergency department visit, injury, opioid use disorder (OUD) and opioid overdose (OD) measured by diagnosis codes at quarterly intervals during 1- and 2-year follow-ups. Poisson regression models were fit using generalised estimating equations with inverse probability of treatment weights to model quarterly outcome rates between residents who discontinued versus continued COT. RESULTS The study sample consisted of 218,040 resident episodes with COT; of these episodes, 180,916 residents (83%) continued COT, whereas 37,124 residents (17%) subsequently discontinued COT. Discontinuing (vs. continuing) COT was associated with higher rates of all outcomes in the first quarter, but these associations attenuated over time. The adjusted rates of injury, OUD and OD were 0, 69 and 60% lower at the 1-year follow-up and 11, 81 and 79% lower at the 2-year follow-up, respectively, for residents who discontinued versus continued COT, with no difference in the adjusted rates of pain-related hospitalisations or emergency department visits. CONCLUSIONS The rates of adverse outcomes were higher in the first quarter but lower or non-differential at 1-year and 2-year follow-ups between COT discontinuers versus continuers among older residents with ADRD.
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Affiliation(s)
- Yu-Jung Jenny Wei
- Division of Outcomes and Translational Sciences, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL 32610, USA
- Department of Epidemiology, Colleges of Medicine and Public Health and Health Professions, University of Florida, Gainesville, FL 32610, USA
| | - Siegfried Schmidt
- Department of Community Health and Family Medicine, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Roger B Fillingim
- Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, FL, USA
| | - Stephan Schmidt
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Michael J Daniels
- Department of Statistics, College of Liberal Arts and Sciences, University of Florida, Gainesville FL, 32610, USA
| | - Steven T DeKosky
- Department of Neurology, McKnight Brain Institute, University of Florida, Gainesville, FL 32610, USA
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28
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Appa A, McMahan VM, Long K, Shade SB, Coffin PO. Stimulant use and opioid-related harm in patients on long-term opioids for chronic pain. Drug Alcohol Depend 2024; 256:111065. [PMID: 38245963 PMCID: PMC10999379 DOI: 10.1016/j.drugalcdep.2023.111065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 12/08/2023] [Accepted: 12/15/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND There is lack of clarity regarding the impact of and optimal clinical response to stimulant use among people prescribed long-term opioid therapy (LTOT) for pain. OBJECTIVE To determine if a positive urine drug test (UDT) for stimulants was associated with subsequent opioid-related harm or discontinuation of LTOT. DESIGN Retrospective cohort study. PATIENTS People living with and without HIV living in a major metropolitan area with public insurance, prescribed LTOT for chronic, non-cancer pain (n=600). MAIN MEASURES UDT results from January 2012 to June 2019 were evaluated against 1) opioid-related emergency department (ED) visits (oversedation, constipation, infections associated with injecting opioids, and opioid seeking) or death in each 90-day period following a UDT, using logistic regression, and 2) LTOT discontinuation. RESULTS There were no opioid overdose deaths within 90 days following a stimulant-positive UDT. A stimulant-positive UDT was not statistically significantly associated with opioid-related ED visits within 90 days (adjusted odds ratio [aOR] 1.39; 95% CI=0.88-2.21). Stimulant-positive UDT was independently associated with subsequent discontinuation of LTOT within 90 days (aOR 2.96; 95% CI=2.13 - 4.12). Living with HIV was independently associated with decreased odds of LTOT discontinuation (aOR 0.65; 95% CI 0.43 - 0.99). CONCLUSIONS Despite no association between a stimulant-positive UDT and subsequent opioid-related harm, there was an association with subsequent LTOT discontinuation, with heterogeneity across clinical groups. Detection of stimulant use should result in a discussion of substance use and risk, rather than reflex LTOT discontinuation.
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Affiliation(s)
- Ayesha Appa
- University of California, San Francisco (UCSF), Division of HIV, Infectious Diseases & Global Medicine, Department of Medicine, 995 Potrero Ave, Box 0874, San Francisco, CA 94110, USA.
| | - Vanessa M McMahan
- San Francisco Department of Public Health, 25 Van Ness Avenue, San Francisco, CA 94102, USA
| | - Kyna Long
- San Francisco Department of Public Health, 25 Van Ness Avenue, San Francisco, CA 94102, USA
| | - Starley B Shade
- University of California San Francisco, Institute for Global Health Science, Division of Infectious Disease and Global Epidemiology, Department of Epidemiology and Biostatistics, 550 16th St, Box 0886, San Francisco, CA 94158, USA
| | - Phillip O Coffin
- San Francisco Department of Public Health, 25 Van Ness Avenue, San Francisco, CA 94102, USA
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Henry SG, Fang SY, Crawford AJ, Wintemute GJ, Tseregounis IE, Gasper JJ, Shev A, Cartus AR, Marshall BDL, Tancredi DJ, Cerdá M, Stewart SL. Impact of 30-day prescribed opioid dose trajectory on fatal overdose risk: A population-based, statewide cohort study. J Gen Intern Med 2024; 39:393-402. [PMID: 37794260 PMCID: PMC10897080 DOI: 10.1007/s11606-023-08419-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 09/07/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND Both increases and decreases in patients' prescribed daily opioid dose have been linked to increased overdose risk, but associations between 30-day dose trajectories and subsequent overdose risk have not been systematically examined. OBJECTIVE To examine the associations between 30-day prescribed opioid dose trajectories and fatal opioid overdose risk during the subsequent 15 days. DESIGN Statewide cohort study using linked prescription drug monitoring program and death certificate data. We constructed a multivariable Cox proportional hazards model that accounted for time-varying prescription-, prescriber-, and pharmacy-level factors. PARTICIPANTS All patients prescribed an opioid analgesic in California from March to December, 2013 (5,326,392 patients). MAIN MEASURES Dependent variable: fatal drug overdose involving opioids. Primary independent variable: a 16-level variable denoting all possible opioid dose trajectories using the following categories for current and 30-day previously prescribed daily dose: 0-29, 30-59, 60-89, or ≥90 milligram morphine equivalents (MME). KEY RESULTS Relative to patients prescribed a stable daily dose of 0-29 MME, large (≥2 categories) dose increases and having a previous or current dose ≥60 MME per day were associated with significantly greater 15-day overdose risk. Patients whose dose decreased from ≥90 to 0-29 MME per day had significantly greater overdose risk compared to both patients prescribed a stable daily dose of ≥90 MME (aHR 3.56, 95%CI 2.24-5.67) and to patients prescribed a stable daily dose of 0-29 MME (aHR 7.87, 95%CI 5.49-11.28). Patients prescribed benzodiazepines also had significantly greater overdose risk; being prescribed Z-drugs, carisoprodol, or psychostimulants was not associated with overdose risk. CONCLUSIONS Large (≥2 categories) 30-day dose increases and decreases were both associated with increased risk of fatal opioid overdose, particularly for patients taking ≥90 MME whose opioids were abruptly stopped. Results align with 2022 CDC guidelines that urge caution when reducing opioid doses for patients taking long-term opioid for chronic pain.
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Affiliation(s)
- Stephen G Henry
- University of California Davis Center for Healthcare Policy and Research; University of California, Davis, California, Sacramento, USA.
- Department of Internal Medicine, University of California, Davis, California, Sacramento, USA.
| | - Shao-You Fang
- University of California Davis Center for Healthcare Policy and Research; University of California, Davis, California, Sacramento, USA
| | - Andrew J Crawford
- Violence Prevention Research Program; University of California, Davis, California, Sacramento, USA
- Department of Emergency Medicine, University of California, Davis, California, Sacramento, USA
| | - Garen J Wintemute
- Violence Prevention Research Program; University of California, Davis, California, Sacramento, USA
- Department of Emergency Medicine, University of California, Davis, California, Sacramento, USA
| | - Iraklis Erik Tseregounis
- University of California Davis Center for Healthcare Policy and Research; University of California, Davis, California, Sacramento, USA
- Department of Internal Medicine, University of California, Davis, California, Sacramento, USA
| | - James J Gasper
- Department of Family and Community Medicine, University of California, San Francisco, California, San Francisco, USA
| | - Aaron Shev
- Violence Prevention Research Program; University of California, Davis, California, Sacramento, USA
- Department of Emergency Medicine, University of California, Davis, California, Sacramento, USA
| | - Abigail R Cartus
- Department of Epidemiology, Brown University School of Public Health, Rhode Island, Providence, USA
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, Rhode Island, Providence, USA
| | - Daniel J Tancredi
- University of California Davis Center for Healthcare Policy and Research; University of California, Davis, California, Sacramento, USA
- Department of Pediatrics, University of California, Davis, California, Sacramento, USA
| | - Magdalena Cerdá
- Department of Population Health, Center for Opioid Epidemiology and Policy; New York University Grossman School of Medicine, New York City, New York, USA
| | - Susan L Stewart
- Department of Public Health Sciences, University of California, Davis, California, Davis, USA
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30
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Wei YJ, Winterstein AG, Schmidt S, Fillingim RB, Daniels MJ, Solberg L, DeKosky ST. Pain intensity, physical function, and depressive symptoms associated with discontinuing long-term opioid therapy in older adults with Alzheimer's disease and related dementias. Alzheimers Dement 2024; 20:1026-1037. [PMID: 37855270 PMCID: PMC10916940 DOI: 10.1002/alz.13489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/31/2023] [Accepted: 09/02/2023] [Indexed: 10/20/2023]
Abstract
INTRODUCTION Limited evidence exists on the associations of discontinuing versus continuing long-term opioid therapy (LTOT) with pain intensity, physical function, and depression among patients with Alzheimer's disease and related dementias (ADRD). METHODS A cohort study among 138,059 older residents with mild-to-moderate ADRD and receipt of LTOT was conducted using a 100% Medicare nursing home sample. Discontinuation of LTOT was defined as no opioid refills for ≥ 60 days. Outcomes were worsening pain, physical function, and depression from baseline to quarterly assessments during 1- and 2-year follow-ups. RESULTS The adjusted odds of worsening pain and depressive symptoms were 29% and 5% lower at the 1-year follow-up and 35% and 9% lower at the 2-year follow-up for residents who discontinued versus continued LTOT, with no difference in physical function. DISCUSSION Discontinuing LTOT was associated with lower short- and long-term worsening pain and depressive symptoms than continuing LTOT among older residents with ADRD. HIGHLIGHTS Discontinuing long-term opioid therapy (LTOT) was associated with lower short- and long-term worsening pain. Discontinuing LTOT was related to lower short- and long-term worsening depression. Discontinuing LTOT was not associated with short- and long-term physical function.
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Affiliation(s)
- Yu‐Jung Jenny Wei
- Division of Outcomes and Translational SciencesCollege of PharmacyThe Ohio State UniversityColumbusOhioUSA
| | - Almut G. Winterstein
- Department of Pharmaceutical Outcomes and PolicyCollege of PharmacyUniversity of FloridaGainesvilleFloridaUSA
- Center for Drug Evaluation and SafetyUniversity of FloridaGainesvilleFloridaUSA
- Department of EpidemiologyColleges of Medicine and Public Health & Health ProfessionsUniversity of FloridaGainesvilleFloridaUSA
| | - Siegfried Schmidt
- Department of Community Health and Family MedicineCollege of MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Roger B. Fillingim
- Pain Research and Intervention Center of ExcellenceUniversity of FloridaGainesvilleFloridaUSA
| | - Michael J. Daniels
- Department of StatisticsCollege of Liberal Arts and SciencesUniversity of FloridaGainesvilleFloridaUSA
| | - Laurence Solberg
- North Florida/South Georgia Veterans Health SystemMalcom Randall Department of Veterans Affairs Medical CenterGeriatrics Research, Education, Clinical Center (GRECC)GainesvilleFloridaUSA
| | - Steven T. DeKosky
- Department of NeurologyMcKnight Brain InstituteUniversity of FloridaGainesvilleFloridaUSA
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31
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Schatman ME, Levin D. "Catastrophization", Its Weaponization, and Opiophobia: A Perfect Landscape for Unnecessary Harms, or "Catastrophization About Catastrophization"? J Pain Res 2024; 17:171-175. [PMID: 38204580 PMCID: PMC10778136 DOI: 10.2147/jpr.s453155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Affiliation(s)
- Michael E Schatman
- Department of Anesthesiology, Perioperative Care & Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA
- Department of Population Health - Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USA
| | - Danielle Levin
- Department of Anesthesiology, Perioperative Care & Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA
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Edmond SN, Wesolowicz DM, Snow JL, Currie S, Jankelovits A, Chhabra MS, Becker WC. Qualitative Analysis of Patient Perspectives of Buprenorphine After Transitioning From Long-Term, Full-Agonist Opioid Therapy Among Veterans With Chronic Pain. THE JOURNAL OF PAIN 2024; 25:132-141. [PMID: 37549775 DOI: 10.1016/j.jpain.2023.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 07/21/2023] [Accepted: 07/27/2023] [Indexed: 08/09/2023]
Abstract
Guidelines recommend consideration of modification, tapering, or discontinuation of long-term, full-agonist opioid therapy when harms outweigh benefits; one alternative to tapering or discontinuing full-agonist opioids for the management of chronic pain is switching to the partial agonist buprenorphine. As the use of buprenorphine for pain expands, understanding the patient experience during and after the transition to buprenorphine is critical. We conducted 45- to 60-minute semistructured qualitative interviews with 19 patients to understand the experiences of patients with chronic pain actively maintained on buprenorphine after previously receiving full-agonist, long-term opioid therapy. Patients were recruited from 2 medical centers via provider referral. Through thematic analysis, 5 overall themes were identified, including satisfaction with buprenorphine, the importance of preconceptions about buprenorphine, experiences with transitions, patient-provider communication, and potential contributions to racial disparities in pain care. While we heard a range of experiences, most patients were satisfied with buprenorphine, reporting either equivalent pain control to their previous regimens or reporting less analgesia but improved functioning due to a reduction in side effects (eg, mental clarity). Patients also emphasized the importance of a nonjudgmental, patient-centered approach, including education about the risks and benefits of buprenorphine. The few Black patients interviewed all reported limited access to pain care, which is consistent with the well-documented existence of racial disparities in access to pain treatment. As buprenorphine is used more frequently for pain management, provider education focused on pain treatment disparities, patient-centered approaches informed by motivational interviewing, and increasing acceptance of buprenorphine as an option for pain are needed. PERSPECTIVE: Qualitative analyses of patient experiences transitioning from full-agonist opioids to buprenorphine for chronic pain revealed general satisfaction. Patients reflected on functioning, tradeoffs between analgesia and side effects, patient-centered care, and access to treatment, highlighting how future research should focus on outcomes valued by patients.
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Affiliation(s)
- Sara N Edmond
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut; Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Danielle M Wesolowicz
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut; Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Jennifer L Snow
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | | | | | - Manik S Chhabra
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - William C Becker
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut; Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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Kollas CD, Ruiz K, Laughlin A. Effectiveness of Long-Term Opioid Therapy for Chronic Pain in an Outpatient Palliative Medicine Clinic. J Palliat Med 2024; 27:31-38. [PMID: 37552851 PMCID: PMC10790545 DOI: 10.1089/jpm.2023.0251] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2023] [Indexed: 08/10/2023] Open
Abstract
Background: Despite widespread use of opioid therapy in outpatient palliative medicine, there is limited evidence supporting its efficacy and safety in the long term. Objectives: We sought to improve overdose risk scores, maintain pain reduction, and preserve patient function in a cohort with severe chronic pain as we managed opioid therapy for a duration of four years in an outpatient palliative care clinic. Design: Over four years, we provided ongoing goal-concordant outpatient palliative care, including opioid therapy, using quarterly clinical encounters for a patient cohort with chronic pain. Setting/Subjects: The project took place in the outpatient palliative medicine clinic of a regional cancer center in Orlando, Florida (United States). The subjects were a cohort group who received palliative care during the time period between July 2018 and October 2022. Measurements: Key metrics included treatment-related reduction in pain intensity, performance scores, and overall overdose risk scores. Secondary metrics included cohort demographics, average daily opioid use in morphine milligram equivalents and categorization of type of pain. Results: In 97 patients, we observed a stable mean treatment-related reduction in pain intensity of 4.9 out of 10 points over four years. The cohort showed a 2-point (out of 100) improvement in performance scores and an 81-point (out of 999) reduction in mean overall overdose risk score. Conclusions: We present evidence that providing outpatient palliative care longitudinally over four years offered lasting treatment-related reductions in pain intensity, preservation of performance status, and reduction in overall overdose risk.
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Affiliation(s)
- Chad D. Kollas
- Supportive and Palliative Care, Orlando Health Cancer Institute, Orlando, Florida, USA
| | - Kevin Ruiz
- University of Central Florida College of Medicine, Orlando, Florida, USA
| | - Amy Laughlin
- Breast Medical Oncology and Cancer Genetics, Orlando Health Cancer Institute, Orlando, Florida, USA
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Nowels MA, Duberstein PR, Crystal S, Treitler P, Miles J, Olfson M, Samples H. Suicide within 1 year of non-fatal overdose: Risk factors and risk reduction with medications for opioid use disorder. Gen Hosp Psychiatry 2024; 86:24-32. [PMID: 38061284 PMCID: PMC10880030 DOI: 10.1016/j.genhosppsych.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/15/2023] [Accepted: 11/03/2023] [Indexed: 01/27/2024]
Abstract
OBJECTIVE Individuals with substance use disorders and overdoses have high risk of suicide death, but evidence is limited on the relationship between interventions following the initial overdose and subsequent suicide death. METHODS National Medicare data were used to identify Medicare disability beneficiaries (MDBs) with inpatient or emergency care for non-fatal opioid overdoses from 2008 to 2016. Data were linked with National Death Index (NDI) to obtain dates and causes of death for the sample. Cox proportional hazards models estimated the associations between exposure to interventions (mechanical ventilation, MOUD) and suicide death. RESULTS The sample (n = 81,654) had a suicide rate in the year following a non-fatal overdose of 566 per 100,000 person-years. Post-overdose MOUD was associated with an adjusted hazard ratio of 0.20 (95%CI: 0.05,0.85). Risk of suicide was elevated for those whose initial overdoses required mechanical ventilation as part of the treatment (aHR: 1.86, 95%CI:[1.48,2.34]). CONCLUSIONS The year following a non-fatal opioid overdose is a very high-risk period for suicide among MDBs. Those receiving MOUD had an 80% reduction in the hazards of suicide, while those whose overdose treatment involved mechanical ventilation had 86% higher hazards of death by suicide. Our findings highlight the importance of psychiatric intervention in this high-risk population. Efforts are needed to initiate and retain more patients in MOUD.
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Affiliation(s)
- Molly A Nowels
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, 683 Hoes Lane West, Piscataway, NJ 08854, USA; Institute for Health, Health Care Policy, and Aging Research, Rutgers University, 112 Paterson St, New Brunswick, NJ 08901, USA.
| | - Paul R Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, 683 Hoes Lane West, Piscataway, NJ 08854, USA
| | - Stephen Crystal
- Institute for Health, Health Care Policy, and Aging Research, Rutgers University, 112 Paterson St, New Brunswick, NJ 08901, USA
| | - Peter Treitler
- School of Social Work, Boston University, 264 Bay State Road, Boston, MA 02215, USA
| | - Jennifer Miles
- Institute for Health, Health Care Policy, and Aging Research, Rutgers University, 112 Paterson St, New Brunswick, NJ 08901, USA
| | - Mark Olfson
- New York Psychiatric Institute, Columbia University, 1051 Riverside Drive, New York, NY 10032, USA
| | - Hillary Samples
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, 683 Hoes Lane West, Piscataway, NJ 08854, USA; Institute for Health, Health Care Policy, and Aging Research, Rutgers University, 112 Paterson St, New Brunswick, NJ 08901, USA
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Xu S, Narwaney KJ, Nguyen AP, Binswanger IA, McClure DL, Glanz JM. An individual segmented trajectory approach for identifying opioid use patterns using longitudinal dispensing data. Pharmacoepidemiol Drug Saf 2024; 33:e5708. [PMID: 37814576 PMCID: PMC10841826 DOI: 10.1002/pds.5708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 10/11/2023]
Abstract
PURPOSE The aim of this study is to use electronic opioid dispensing data to develop an individual segmented trajectory approach for identifying opioid use patterns. The resulting opioid use patterns can be used for examining the association between opioid use and drug overdose. METHODS We retrospectively assembled a cohort of members on long-term opioid therapy (LTOT) between January 1, 2006 and June 30, 2019 who were 18 years and older and enrolled in one of three health care systems in the US. We have developed an individual segmented trajectory analysis for identifying various opioid use patterns by scanning over the follow-up and finding distinct opioid use patterns based on variability measured with coefficient of variation and trends of milligram morphine equivalents levels. RESULTS Among 31, 865 members who were on LTOT between January 1, 2006 and June 30, 2019, 58.3% were female, and the average age was 55.4 years (STD = 15.4). The study population had 152 557 person-years of follow-up, with an average follow-up of 4.4 years per enrollment per person (STD = 3.4). This novel approach identified up to 13 distinct patterns including 88 756 episodes of "stable" pattern (42.1%) with an average follow-up of 11.2 months, 29 140 episodes of "increasing" pattern (13.8%) with an average follow-up of 6.0 months, 13 201 episodes of ≤10% dose reduction (6.3%) with an average follow-up of 10.4 months, 7286 episodes of 11%-20% dose reduction (3.5%) with an average follow-up of 5.3 months, 4457 episodes of 21%-30% dose reduction (2.1%) with an average follow-up of 4.0 months, and 9903 episodes of >30% dose reduction (4.7%) with an average follow-up of 2.6 months. CONCLUSIONS A novel approach was developed to identify 13 distinct opioid use patterns using each individual's longitudinal dispensing data and these patterns can be used in examining overdose risk during the time that these patterns are ongoing.
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Affiliation(s)
- Stanley Xu
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Komal J Narwaney
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Anh P Nguyen
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Ingrid A Binswanger
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Chemical Dependency Treatment Services, Colorado Permanente Medical Group, Aurora, Colorado, USA
| | - David L McClure
- Center for Clinical Epidemiology and Population Health, Marshfield Clinic Research Institute, Marshfield, Wisconsin, USA
| | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
- Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado, USA
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Stewart SL, Crawford A, Shev AB, Wintemute G, Tseregounis IE, Henry SG. Comparison of record linkage software for deduplicating patient identities in California's Prescription Drug Monitoring Program. Pharmacoepidemiol Drug Saf 2024; 33:e5699. [PMID: 37779337 DOI: 10.1002/pds.5699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 08/24/2023] [Accepted: 09/11/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND To help prevent overdose deaths involving prescription drugs, accurate linkage of prescription drug monitoring program (PDMP) records for individual patients is essential. OBJECTIVES To compare the accuracy of the linkage program used by California's PDMP against various record linkage programs with respect to accuracy in deduplicating patient identities in the PDMP, with implications for identifying high-risk opioid use and outlier behaviors. RESEARCH DESIGN We evaluated California's program, Link Plus, LinkSolv, and The Link King on 557 861 PDMP identity records with addresses in two 3-digit zip code areas for patients who filled a controlled substance prescription in 2013. Manual review was performed on a stratified sample of 720 paired records identified as matches by at least one program. MEASURES We estimated sensitivity and positive predictive value, and computed PDMP patient alerts for the patient entities identified by each program. RESULTS Sensitivity was 95% for LinkSolv and The Link King, 84% for Link Plus, and 73% for California's program; positive predictive value was ≥93% for all programs. The number of patient entities prompting a PDMP alert was similar among the programs for all alerts except multiple provider episodes (obtaining prescriptions from ≥6 prescribers or ≥6 pharmacies in the last 6 months), which were 10.9%, 26.6%, and 16.9% greater using The Link King, Link Plus, and LinkSolv, respectively, compared to California's program. CONCLUSIONS PDMPs should assess the accuracy of record linkage algorithms and the impacts of these algorithms on patient safety alerts and develop national best practices for PDMP record linkage.
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Affiliation(s)
- Susan L Stewart
- Department of Public Health Sciences, University of California, Davis, Davis, California, USA
| | - Andrew Crawford
- Violence Prevention Research Program, Department of Emergency Medicine, University of California, Davis, Sacramento, California, USA
| | - Aaron B Shev
- Violence Prevention Research Program, Department of Emergency Medicine, University of California, Davis, Sacramento, California, USA
| | - Garen Wintemute
- Violence Prevention Research Program, Department of Emergency Medicine, University of California, Davis, Sacramento, California, USA
| | - Iraklis Erik Tseregounis
- Division of General Internal Medicine, University of California, Davis, Sacramento, California, USA
| | - Stephen G Henry
- Division of General Internal Medicine, University of California, Davis, Sacramento, California, USA
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Maharjan S, Ramachandran S, Bhattacharya K, Bentley JP, Eriator I, Yang Y. Opioid tapering and mental health crisis in older adults. Pharmacoepidemiol Drug Saf 2024; 33:e5698. [PMID: 37734725 PMCID: PMC10841175 DOI: 10.1002/pds.5698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 05/14/2023] [Accepted: 09/05/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Opioid tapering and discontinuation have increased in recent years with the implementation of national prescribing guidelines. This study aimed to examine the relationship between opioid tapering velocity and mental health crisis events in older Medicare beneficiaries. METHODS A nested case-control study was conducted using the 2012-2018, 5% national Medicare claims data. Older adults with chronic non-cancer pain (CNCP) who were receiving long-term opioid therapy (LTOT) were included in the study. Cases were defined as individuals experiencing mental health crisis events; controls were identified using incidence density sampling. The opioid tapering velocity was measured in the 120-day hazard period that yielded a monthly percentage of dose change. Conditional logistic regression was used to assess the relationship of interest. RESULTS A total of 42 091 older adults with CNCP were eligible for the study. Cases (n = 952) were matched with controls in a 1:2 ratio based on age (±1 year) and time of cohort entry (±30 days). A higher percentage of controls (67.65%) were on steady dose compared with cases (59.03%). In the adjusted model, tapering (aOR = 1.36; 95% CI: 1.02-1.83), rapid tapering (aOR = 1.45; 95% CI: 1.11-1.91), and dose escalation (aOR = 1.78; 95% CI: 1.32-2.39) were significantly associated with the mental health crisis, compared with steady dose. CONCLUSION Both opioid tapering and dose escalation are associated with mental health crisis events. Patient-driven and gradual dose tapering, as recommended by prescribing guidelines, should be promoted to prevent mental health crisis events among older adults on LTOT.
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Affiliation(s)
- Shishir Maharjan
- Department of Pharmacy Administration, University of Mississippi School of Pharmacy, University, MS 38677
- Center for Pharmaceutical Marketing & Management, University of Mississippi School of Pharmacy, University, MS 38677
| | - Sujith Ramachandran
- Department of Pharmacy Administration, University of Mississippi School of Pharmacy, University, MS 38677
- Center for Pharmaceutical Marketing & Management, University of Mississippi School of Pharmacy, University, MS 38677
| | - Kaustuv Bhattacharya
- Department of Pharmacy Administration, University of Mississippi School of Pharmacy, University, MS 38677
- Center for Pharmaceutical Marketing & Management, University of Mississippi School of Pharmacy, University, MS 38677
| | - John P. Bentley
- Department of Pharmacy Administration, University of Mississippi School of Pharmacy, University, MS 38677
- Center for Pharmaceutical Marketing & Management, University of Mississippi School of Pharmacy, University, MS 38677
| | - Ike Eriator
- Department of Anesthesiology, School of Medicine, University of Mississippi Medical Center, Jackson, MS 39216
| | - Yi Yang
- Department of Pharmacy Administration, University of Mississippi School of Pharmacy, University, MS 38677
- Center for Pharmaceutical Marketing & Management, University of Mississippi School of Pharmacy, University, MS 38677
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Manoharan D, Xie A, Hsu YJ, Flynn HK, Beiene Z, Giagtzis A, Shechter R, McDonald E, Marsteller J, Hanna M, Speed TJ. Patient Experiences and Clinical Outcomes in a Multidisciplinary Perioperative Transitional Pain Service. J Pers Med 2023; 14:31. [PMID: 38248732 PMCID: PMC10821325 DOI: 10.3390/jpm14010031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 01/23/2024] Open
Abstract
Siloed pain management across the perioperative period increases the risk of chronic opioid use and impedes postoperative recovery. Transitional perioperative pain services (TPSs) are innovative care models that coordinate multidisciplinary perioperative pain management to mitigate risks of chronic postoperative pain and opioid use. The objective of this study was to examine patients' experiences with and quality of recovery after participation in a TPS. Qualitative interviews were conducted with 26 patients from The Johns Hopkins Personalized Pain Program (PPP) an average of 33 months after their first PPP visit. A qualitative content analysis of the interview data showed that participants (1) valued pain expectation setting, individualized care, a trusting patient-physician relationship, and shared decision-making; (2) perceived psychiatric treatment of co-occurring depression, anxiety, and maladaptive behaviors as critical to recovery; and (3) successfully sustained opioid tapers and experienced improved functioning after PPP discharge. Areas for improved patient-centered care included increased patient education, specifically about the program, continuity of care with pain specialists while tapering opioids, and addressing the health determinants that impede access to pain care. The positive patient experiences and sustained clinical benefits for high-risk complex surgical patient support further efforts to implement and adapt similar models of perioperative pain care.
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Affiliation(s)
- Divya Manoharan
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (D.M.)
| | - Anping Xie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.X.); (Z.B.); (R.S.); (M.H.)
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD 21202, USA;
| | - Yea-Jen Hsu
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | - Hannah K. Flynn
- Loyola College of Arts & Sciences, Loyola University Maryland, Baltimore, MD 21210, USA
| | - Zodina Beiene
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.X.); (Z.B.); (R.S.); (M.H.)
| | - Alexandros Giagtzis
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (D.M.)
| | - Ronen Shechter
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.X.); (Z.B.); (R.S.); (M.H.)
| | - Eileen McDonald
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | - Jill Marsteller
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD 21202, USA;
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | - Marie Hanna
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.X.); (Z.B.); (R.S.); (M.H.)
| | - Traci J. Speed
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (D.M.)
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Zhang M, Zhang Y, Li J, Li J, Ji J, Wang Z. μ opioid receptor carboxyl terminal-derived peptide alleviates morphine tolerance by inhibiting β-arrestin2. Neuroreport 2023; 34:853-859. [PMID: 37942736 DOI: 10.1097/wnr.0000000000001963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
The interaction between the μ opioid receptor (MOR) and β-arrestin2 serves as a model for addressing morphine tolerance. A peptide was designed to alleviate morphine tolerance through interfering with the interaction of MOR and β-arrestin2. We developed a peptide derived from MOR. The MOR-TAT-pep peptide was expressed in E. coli Bl21(DE3) and purified. The effects of MOR-TAT-pep in alleviating morphine tolerance was examined through behavior tests. The potential mechanism was detected by Western blotting, Mammalian Two-Hybrid and other techniques. The pretreatment with MOR-TAT-pep prior to morphine usage led to an enhanced analgesic effectiveness of morphine and a significant reduction in the development of morphine tolerance. The peptide directly interacted with β-arrestin2 during morphine treatment and deceased the membrane recruitment of β-arrestin2. MOR-TAT-pep effectively suppressed the increase of β-arrestin2 induced by morphine. The MOR-TAT-pep could alleviate morphine tolerance through inhibition of β-arrestin2.
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Affiliation(s)
- Meng Zhang
- Department of Gynecology, Central Hospital of Xuzhou, Affiliated Hospital of Southeast University
| | - Yanling Zhang
- Department of Gynecology, Central Hospital of Xuzhou, Affiliated Hospital of Southeast University
| | - Jian Li
- Jiangsu Province Key Laboratory of Anesthesiology, Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Junliang Li
- Jiangsu Province Key Laboratory of Anesthesiology, Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Junwei Ji
- Jiangsu Province Key Laboratory of Anesthesiology, Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Zhongshan Wang
- Jiangsu Province Key Laboratory of Anesthesiology, Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou, Jiangsu, China
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Langford AV, Schneider CR, Lin CC, Bero L, Collins JC, Suckling B, Gnjidic D. Patient-targeted interventions for opioid deprescribing: An overview of systematic reviews. Basic Clin Pharmacol Toxicol 2023; 133:623-639. [PMID: 36808693 PMCID: PMC10953356 DOI: 10.1111/bcpt.13844] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 02/08/2023] [Accepted: 02/13/2023] [Indexed: 02/20/2023]
Abstract
BACKGROUND Deprescribing (reduction or cessation) of prescribed opioids can be challenging for both patients and healthcare professionals. OBJECTIVE To synthesize and evaluate evidence from systematic reviews examining the effectiveness and outcomes of patient-targeted opioid deprescribing interventions for all types of pain. METHODS Systematic searches were conducted in five databases with results screened against predetermined inclusion/exclusion criteria. Primary outcomes were (i) reduction in opioid dose, reported as change in oral Morphine Equivalent Daily Dose (oMEDD) and (ii) success of opioid deprescribing, reported as the proportion of the sample for which opioid use declined. Secondary outcomes included pain severity, physical function, quality of life and adverse events. The certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. FINDINGS Twelve reviews were eligible for inclusion. Interventions were heterogeneous in nature and included pharmacological (n = 4), physical (n = 3), procedural (n = 3), psychological or behavioural (n = 3) and mixed (n = 5) interventions. Multidisciplinary care programmes appeared to be the most effective intervention for opioid deprescribing; however, the certainty of evidence was low, with significant variability in opioid reduction across interventions. CONCLUSIONS Evidence is too uncertain to draw firm conclusions about specific populations who may derive the greatest benefit from opioid deprescribing, warranting further investigation.
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Affiliation(s)
- Aili V. Langford
- Centre for Medicine Use and SafetyMonash UniversityParkvilleVictoriaAustralia
- Faculty of Medicine and Health, School of PharmacyThe University of SydneySydneyNew South WalesAustralia
| | - Carl R. Schneider
- Faculty of Medicine and Health, School of PharmacyThe University of SydneySydneyNew South WalesAustralia
| | - Chung‐Wei Christine Lin
- Institute for Musculoskeletal Health, Faculty of Medicine and Health, School of Public HealthUniversity of SydneySydneyNew South WalesAustralia
- Sydney Musculoskeletal HealthThe University of SydneySydneyNew South WalesAustralia
| | - Lisa Bero
- School of Medicine, Colorado School of Public Health and Center for Bioethics and HumanitiesUniversity of Colorado Anschutz Medical CenterDenverColoradoUSA
| | - Jack C. Collins
- Faculty of Medicine and Health, School of PharmacyThe University of SydneySydneyNew South WalesAustralia
| | - Benita Suckling
- Faculty of Medicine and Health, School of PharmacyThe University of SydneySydneyNew South WalesAustralia
- Pharmacy DepartmentCaboolture Hospital, Queensland HealthBrisbaneAustralia
| | - Danijela Gnjidic
- Faculty of Medicine and Health, School of PharmacyThe University of SydneySydneyNew South WalesAustralia
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Rikard SM, Nataraj N, Zhang K, Strahan AE, Mikosz CA, Guy GP. Longitudinal dose patterns among patients newly initiated on long-term opioid therapy in the United States, 2018 to 2019: an observational cohort study and time-series cluster analysis. Pain 2023; 164:2675-2683. [PMID: 37498751 PMCID: PMC10694996 DOI: 10.1097/j.pain.0000000000002994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 06/05/2023] [Indexed: 07/29/2023]
Abstract
ABSTRACT Opioid prescribing varies widely, and prescribed opioid dosages for an individual can fluctuate over time. Patterns in daily opioid dosage among patients prescribed long-term opioid therapy have not been previously examined. This study uses a novel application of time-series cluster analysis to characterize and visualize daily opioid dosage trajectories and associated demographic characteristics of patients newly initiated on long-term opioid therapy. We used 2018 to 2019 data from the IQVIA Longitudinal Prescription (LRx) all-payer pharmacy database, which covers 92% of retail pharmacy prescriptions dispensed in the United States. We identified a cohort of 277,967 patients newly initiated on long-term opioid therapy during 2018. Patients were stratified into 4 categories based on their mean daily dosage during a 90-day baseline period (<50, 50-89, 90-149, and ≥150 morphine milligram equivalent [MME]) and followed for a 270-day follow-up period. Time-series cluster analysis identified 2 clusters for each of the 3 baseline dosage categories <150 MME and 3 clusters for the baseline dosage category ≥150 MME. One cluster in each baseline dosage category comprised opioid dosage trajectories with decreases in dosage at the end of the follow-up period (80.7%, 98.7%, 98.7%, and 99.0%, respectively), discontinuation (58.5%, 80.0%, 79.3%, and 81.7%, respectively), and rapid tapering (50.8%, 85.8%, 87.5%, and 92.9%, respectively). These findings indicate multiple clusters of patients newly initiated on long-term opioid therapy who experience discontinuation and rapid tapering and highlight potential areas for clinician training to advance evidence-based guideline-concordant opioid prescribing, including strategies to minimize sudden dosage changes, discontinuation, or rapid tapering, and the importance of shared decision-making.
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Affiliation(s)
- S. Michaela Rikard
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Nisha Nataraj
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Kun Zhang
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Andrea E. Strahan
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Christina A. Mikosz
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Gery P. Guy
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, United States
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Wartko PD, Krakauer C, Turner JA, Cook AJ, Boudreau DM, Sullivan MD. STRategies to Improve Pain and Enjoy life (STRIPE): results of a pragmatic randomized trial of pain coping skills training and opioid medication taper guidance for patients on long-term opioid therapy. Pain 2023; 164:2852-2864. [PMID: 37624901 PMCID: PMC10843637 DOI: 10.1097/j.pain.0000000000002982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 05/19/2023] [Indexed: 08/27/2023]
Abstract
ABSTRACT Because long-term opioid therapy (LtOT) for chronic pain has uncertain benefits and dose-dependent harms, safe and effective strategies for opioid tapering are needed. Adapting a promising pilot study intervention, we conducted the STRategies to Improve Pain and Enjoy life (STRIPE) pragmatic clinical trial. Patients in integrated health system on moderate-to-high dose of LtOT for chronic noncancer pain were randomized individually to usual care plus intervention (n = 79) or usual care only (n = 74). The intervention included pain coping skills training and optional support for opioid taper, delivered in 18 telephone sessions over a year, with pharmacologic guidance provided to participants' primary care providers by a pain physician. Coprimary outcomes were daily opioid dose (morphine milligram equivalent [MME]), calculated using pharmacy dispensing data, and the self-reported Pain, Enjoyment of Life and General Activity scale at 12 months (primary time point) and 6 months. Secondary outcomes included opioid misuse, opioid difficulties, opioid craving, pain self-efficacy, and global impression of change, depression, and anxiety. Only 41% randomized to the intervention completed all sessions. We did not observe significant differences between intervention and usual care for MME (adjusted mean difference: -2.3 MME; 95% confidence interval: -10.6, 5.9; P = 0.578), the Pain, Enjoyment of Life, General Activity scale (0.0 [95% confidence interval: -0.5, 0.5], P = 0.985), or most secondary outcomes. The intervention did not lower opioid dose or improve pain or functioning. Other strategies are needed to reduce opioid doses while improving pain and function for patients who have been on LtOT for years with high levels of medical, mental health, and substance use comorbidity.
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Affiliation(s)
- Paige D Wartko
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America (for Dr. Boudreau, affiliation at the time of the research, no longer affiliated)
| | - Chloe Krakauer
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America (for Dr. Boudreau, affiliation at the time of the research, no longer affiliated)
| | - Judith A. Turner
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, United States of America
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, United States of America
| | - Andrea J. Cook
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America (for Dr. Boudreau, affiliation at the time of the research, no longer affiliated)
- Department of Biostatistics, University of Washington, Seattle, WA, United States of America
| | - Denise M. Boudreau
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America (for Dr. Boudreau, affiliation at the time of the research, no longer affiliated)
- Genentech, Inc., South San Francisco, CA, United States of America (current primary affiliation)
| | - Mark D. Sullivan
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, United States of America
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Manhapra A, MacLean RR, Rosenheck R, Becker WC. Are opioids effective analgesics and is physiological opioid dependence benign? Revising current assumptions to effectively manage long-term opioid therapy and its deprescribing. Br J Clin Pharmacol 2023. [PMID: 37990580 DOI: 10.1111/bcp.15972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 11/10/2023] [Accepted: 11/14/2023] [Indexed: 11/23/2023] Open
Abstract
A re-examination of clinical principles of long-term opioid therapy (LTOT) for chronic pain is long overdue amid the ongoing opioid crisis. Most patients on LTOT report ineffectiveness (poor pain control, function and health) but still find deprescribing challenging. Although prescribed as analgesics, opioids more likely provide pain relief primarily through reward system actions (enhanced relief and motivation) and placebo effect and less through antinociceptive effects. The unavoidable physiologic LTOT dependence can automatically lead to a paradoxical worsening of pain, disability and medical instability (maladaptive opioid dependence) without addiction due to allostatic opponent neuroadaptations involving reward/antireward and nociceptive/antinociceptive systems. This opioid-induced chronic pain syndrome (OICP) can persist/progress whether LTOT dose is maintained at the same level, increased, decreased or discontinued. Current conceptualization of LTOT as a straightforward long-term analgesic therapy appears incongruous in view of the complex mechanisms of opioid action, LTOT dependence and OICP. LTOT can be more appropriately conceptualized as therapeutic induction and maintenance of an adaptive LTOT dependence for functional improvement irrespective of analgesic benefits. Adaptive LTOT dependence should be ideally used for a limited time to achieve maximum functional recovery and deprescribed while maintaining functional gains. Patients on LTOT should be regularly re-evaluated to identify if maladaptive LTOT dependence with OICP has diminished any functional gains or leads to ineffectiveness. Ineffective LTOT (with maladaptive LTOT dependence) should be modified to make it safer and more effective. An adequately functional life without opioids is the ideal healthy long-term goal for both LTOT initiation and LTOT modification.
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Affiliation(s)
- Ajay Manhapra
- Section of Pain Medicine, Department of Physical Medicine & Rehabilitation Sciences, Hampton VA Medical Center, Hampton, Virginia, USA
- New England Mental Illness Research Education and Clinical Center, West Haven, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
- Departments of Physical Medicine and Rehabilitation and Psychiatry, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - R Ross MacLean
- New England Mental Illness Research Education and Clinical Center, West Haven, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Robert Rosenheck
- New England Mental Illness Research Education and Clinical Center, West Haven, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - William C Becker
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Pain Research, Informatics, Multimorbidities & Education Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut, USA
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Liebschutz JM, Subramaniam GA, Stone R, Appleton N, Gelberg L, Lovejoy TI, Bunting AM, Cleland CM, Lasser KE, Beers D, Abrams C, McCormack J, Potter GE, Case A, Revoredo L, Jelstrom EM, Kline MM, Wu LT, McNeely J. Subthreshold opioid use disorder prevention (STOP) trial: a cluster randomized clinical trial: study design and methods. Addict Sci Clin Pract 2023; 18:70. [PMID: 37980494 PMCID: PMC10657560 DOI: 10.1186/s13722-023-00424-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 10/30/2023] [Indexed: 11/20/2023] Open
Abstract
BACKGROUND Preventing progression to moderate or severe opioid use disorder (OUD) among people who exhibit risky opioid use behavior that does not meet criteria for treatment with opioid agonists or antagonists (subthreshold OUD) is poorly understood. The Subthreshold Opioid Use Disorder Prevention (STOP) Trial is designed to study the efficacy of a collaborative care intervention to reduce risky opioid use and to prevent progression to moderate or severe OUD in adult primary care patients with subthreshold OUD. METHODS The STOP trial is a cluster randomized controlled trial, randomized at the PCP level, conducted in 5 distinct geographic sites. STOP tests the efficacy of the STOP intervention in comparison to enhanced usual care (EUC) in adult primary care patients with risky opioid use that does not meet criteria for moderate-severe OUD. The STOP intervention consists of (1) a practice-embedded nurse care manager (NCM) who provides patient participant education and supports primary care providers (PCPs) in engaging and monitoring patient-participants; (2) brief advice, delivered to patient participants by their PCP and/or prerecorded video message, about health risks of opioid misuse; and (3) up to 6 sessions of telephone health coaching to motivate and support behavior change. EUC consists of primary care treatment as usual, plus printed overdose prevention educational materials and an educational video on cancer screening. The primary outcome measure is self-reported number of days of risky (illicit or nonmedical) opioid use over 180 days, assessed monthly via text message using items from the Addiction Severity Index and the Current Opioid Misuse Measure. Secondary outcomes assess other substance use, mental health, quality of life, and healthcare utilization as well as PCP prescribing and monitoring behaviors. A mixed effects negative binomial model with a log link will be fit to estimate the difference in means between treatment and control groups using an intent-to-treat population. DISCUSSION Given a growing interest in interventions for the management of patients with risky opioid use, and the need for primary care-based interventions, this study potentially offers a blueprint for a feasible and effective approach to improving outcomes in this population. TRIAL REGISTRATION Clinicaltrials.gov, identifier NCT04218201, January 6, 2020.
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Affiliation(s)
- Jane M Liebschutz
- Division of General Internal Medicine, Center for Research On Health Care, University of Pittsburgh, 200 Lothrop Street, Suite 933W, Pittsburgh, PA, 15213, USA.
| | | | - Rebecca Stone
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Noa Appleton
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Lillian Gelberg
- David Geffen School of Medicine at UCLA, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Travis I Lovejoy
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA
| | - Amanda M Bunting
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Charles M Cleland
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Karen E Lasser
- Section of General Internal Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- School of Public Health, Boston University, Boston, MA, USA
| | - Donna Beers
- Section of General Internal Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | | | | | - Gail E Potter
- The Emmes Company, LLC, Rockville, MD, USA
- Biostatistics Research Branch, NIH/NIAID, Rockville, MD, USA
| | | | | | | | | | - Li-Tzy Wu
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Jennifer McNeely
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
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Castellanos S, Cooke A, Koenders S, Joshi N, Miaskowski C, Kushel M, Knight KR. Accounting for the interplay of interpersonal and structural trauma in the treatment of chronic non-cancer pain, opioid use disorder, and mental health in urban safety-net primary care clinics. SSM - MENTAL HEALTH 2023; 4:100243. [PMID: 38464953 PMCID: PMC10923552 DOI: 10.1016/j.ssmmh.2023.100243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024] Open
Abstract
While the epidemiological literature recognizes associations between chronic non-cancer pain (CNCP), opioid use disorder (OUD), and interpersonal trauma stemming from physical, emotional, sexual abuse or neglect, the complex etiologies and interplay between interpersonal and structural traumas in CNCP populations are underexamined. Research has documented the relationship between experiencing multiple adverse childhood experiences (ACEs) and the likelihood of developing an OUD as an adult. However, the ACEs framework is criticized for failing to name the social and structural contexts that shape ACE vulnerabilities in families. Social scientific theory and ethnographic methods offer useful approaches to explore how interpersonally- and structurally-produced traumas inform the experiences of co-occurring CNCP, substance use, and mental health. We report findings from a qualitative and ethnographic longitudinal cohort study of patients with CNCP (n = 48) who received care in safety-net settings and their primary care providers (n = 23). We conducted semi-structured interviews and clinical and home-based participant observation from 2018 to 2020. Here we focus our analyses on how patients and providers explained and situated the role of patient trauma in the larger clinical context of reductions in opioid prescribing to highlight the political landscape of the United States opioid overdose crisis and its impact on clinical interactions. Findings reveal the disproportionate burden structurally-produced, racialized trauma places on CNCP, substance use and mental health symptoms that shapes patients' embodied experiences of pain and substance use, as well as their emotional experiences with their providers. Experiences of trauma impacted clinical care trajectories, yet providers and patients expressed limited options for redress. We argue for an adaptation of trauma-informed care approaches that contextualize the structural determinants of trauma and their interplay with interpersonal experiences to improve clinical care outcomes.
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Affiliation(s)
- Stacy Castellanos
- Department of Humanities and Social Sciences, School of Medicine, University of California - San Francisco, 490 Illinois Street, 7th Floor, San Francisco, CA, 94143-0850, United States
| | - Alexis Cooke
- Department of Community Health Systems, School of Nursing, University of California - San Francisco, 2 Koret Way, N505, San Francisco, CA, 94143-0608, United States
| | - Sedona Koenders
- Department of Humanities and Social Sciences, School of Medicine, University of California - San Francisco, 490 Illinois Street, 7th Floor, San Francisco, CA, 94143-0850, United States
| | - Neena Joshi
- Department of Humanities and Social Sciences, School of Medicine, University of California - San Francisco, 490 Illinois Street, 7th Floor, San Francisco, CA, 94143-0850, United States
| | - Christine Miaskowski
- Department of Physiological Nursing, School of Nursing, University of California - San Francisco, 2 Koret Way, 631, San Francisco, CA, 94143-0610, United States
| | - Margot Kushel
- Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, Department of Medicine, School of Medicine, University of California -San Francisco, UCSF Box 1339, San Francisco, CA, 94143-0608, United States
| | - Kelly Ray Knight
- Department of Humanities and Social Sciences, School of Medicine, University of California - San Francisco, 490 Illinois Street, 7th Floor, San Francisco, CA, 94143-0850, United States
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Coleman C, Lennon RP, Garza RH, Veasley C, Kuchera J, Edwards R, Zgierska AE. Shifting quality chronic pain treatment measures from processes to outcomes. J Opioid Manag 2023; 19:83-94. [PMID: 37879663 DOI: 10.5055/jom.2023.0802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
OBJECTIVE Misapplication of the 2016 Centers for Disease Control (CDC) opioid prescribing guidelines has led to overem-phasis of morphineequivalent daily dose (MEDD) as a "metric of success" in chronic noncancer pain (CNCP), resulting in unintentional harms to patients. This article reviews CNCP-related guidelines and patient preferences in order to identify pragmatic, patient-centered metrics to assess treatment response and safety in opioid-treated CNCP. METHODS We reviewed the clinical (CDC), research (Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials), and implementability-related guidelines (GuideLine Implementability Appraisal), along with relevant patient-identified treatment goals. From these, we summarize a guideline-concordant, patient-centered, implementable set of measures to aid the clinical management of opioid-treated CNCP. RESULTS We identify metrics across three domains of care: (1) treatment response metrics, which align with the CNCP care goals (pain intensity, pain interference including function and quality of life, and global impression of change); (2) risk assessment ("safety") metrics, eg, MEDD, benzodiazepine-opioid or naloxone-opioid coprescribing, and severity of mental health disorders, which evaluate the risk-benefit profile of opioid therapy; and (3) adherence ("process") metrics, which assess clinician/patient adherence to the guideline-recommended opioid therapy monitoring practices, eg, the presence of completed treatment agreement or urine toxicology testing. All metrics should be informed by implementability principles, eg, be decidable, executable, and measurable. CONCLUSIONS This article summarizes guideline-concordant, patient-centered, implementable metrics for assessing treatment response, safety, and adherence in opioid-treated CNCP. Regardless of which specific treatment guidelines are applied, this approach could help conceptualize and standardize the collection and reporting of CNCP-relevant metrics, compare them across health systems, and optimize care and treatment outcomes in opioid-treated CNCP.
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Affiliation(s)
- Christa Coleman
- Departments of Psychiatry and Behavioral Health and Anesthesiology and Perioperative Medicine, Penn State College of Medicine, Hershey, Pennsylvania. ORCID: https://orcid.org/0000-0003-4255-5592
| | - Robert P Lennon
- Department of Family and Community Medicine, Penn State College of Medicine, Hershey; Affiliate Faculty, Penn State Law, University Park, Pennsylvania
| | - Rose Hennessy Garza
- Joseph J Zilber School of Public Health, University of Wisconsin - Milwaukee, Milwaukee, Wisconsin
| | | | - Jay Kuchera
- Specialized Opioid Support Services, Resolute Pain Solutions, Envision Physician Services, Port Saint Lucie, Florida
| | - Robert Edwards
- Department of Anesthesiology, Brigham & Women's Hospital, Harvard School of Medi-cine, Boston, Massachusetts
| | - Aleksandra E Zgierska
- Departments of Family and Community Medicine, Public Health Sciences, and Anes-thesiology and Perioperative Medicine, Penn State College of Medicine, Hershey, Pennsylvania
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Gholamrezaei A, Magee MR, McNeilage AG, Dwyer L, Jafari H, Sim AM, Ferreira ML, Darnall BD, Glare P, Ashton-James CE. Text messaging intervention to support patients with chronic pain during prescription opioid tapering: protocol for a double-blind randomised controlled trial. BMJ Open 2023; 13:e073297. [PMID: 37879692 PMCID: PMC10603486 DOI: 10.1136/bmjopen-2023-073297] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 10/03/2023] [Indexed: 10/27/2023] Open
Abstract
INTRODUCTION Increases in pain and interference with quality of life is a common concern among people with chronic non-cancer pain (CNCP) who are tapering opioid medications. Research indicates that access to social and psychological support for pain self-management may help people to reduce their opioid dose without increasing pain and interference. This study evaluates the efficacy of a text messaging intervention designed to provide people with CNCP with social and psychological support for pain self-management while tapering long-term opioid therapy (LTOT) under the guidance of their prescriber. METHODS AND ANALYSIS A double-blind randomised controlled trial will be conducted. Patients with CNCP (n=74) who are tapering LTOT will be enrolled from across Australia. Participants will continue with their usual care while tapering LTOT under the supervision of their prescribing physician. They will randomly receive either a psychoeducational video and supportive text messaging (two Short Message Service (SMS) per day) for 12 weeks or the video only. The primary outcome is the pain intensity and interference assessed by the Pain, Enjoyment of Life and General Activity scale. Secondary outcomes include mood, self-efficacy, pain cognitions, opioid dose reduction, withdrawal symptoms, and acceptability, feasibility, and safety of the intervention. Participants will complete questionnaires at baseline and then every 4 weeks for 12 weeks and will be interviewed at week 12. This trial will provide evidence for the efficacy of a text messaging intervention to support patients with CNCP who are tapering LTOT. If proven to be efficacious and safe, this low-cost intervention can be implemented at scale. ETHICS AND DISSEMINATION The study protocol was reviewed and approved by the Northern Sydney Local Health District (Australia). Study results will be published in peer-reviewed journals and presented at scientific and professional meetings. TRIAL REGISTRATION NUMBER ACTRN12622001423707.
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Affiliation(s)
- Ali Gholamrezaei
- Pain Management Research Institute, Kolling Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael Reece Magee
- Pain Management Research Institute, Kolling Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Amy Gray McNeilage
- Pain Management Research Institute, Kolling Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Leah Dwyer
- Consumer Advisory Group, Painaustralia, Deakin, Victoria, Australia
| | - Hassan Jafari
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Alison Michelle Sim
- Pain Management Research Institute, Kolling Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Manuela L Ferreira
- Sydney Musculoskeletal Health, Kolling Institute, The University of Sydney, Saint Leonards, New South Wales, Australia
| | - Beth D Darnall
- Department of Anaesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Paul Glare
- Pain Management Research Institute, Kolling Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Claire Elizabeth Ashton-James
- Pain Management Research Institute, Kolling Institute, The University of Sydney, Sydney, New South Wales, Australia
- Pain Management Research Institute, Kolling Institute, The University of Sydney, Sydney, New South Wales, Australia
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Wang L, Hong PJ, Jiang W, Rehman Y, Hong BY, Couban RJ, Wang C, Hayes CJ, Juurlink DN, Busse JW. Predictors of fatal and nonfatal overdose after prescription of opioids for chronic pain: a systematic review and meta-analysis of observational studies. CMAJ 2023; 195:E1399-E1411. [PMID: 37871953 PMCID: PMC10593195 DOI: 10.1503/cmaj.230459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND Higher doses of opioids, mental health comorbidities, co-prescription of sedatives, lower socioeconomic status and a history of opioid overdose have been reported as risk factors for opioid overdose; however, the magnitude of these associations and their credibility are unclear. We sought to identify predictors of fatal and nonfatal overdose from prescription opioids. METHODS We systematically searched MEDLINE, Embase, CINAHL, PsycINFO and Web of Science up to Oct. 30, 2022, for observational studies that explored predictors of opioid overdose after their prescription for chronic pain. We performed random-effects meta-analyses for all predictors reported by 2 or more studies using odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS Twenty-eight studies (23 963 716 patients) reported the association of 103 predictors with fatal or nonfatal opioid overdose. Moderate- to high-certainty evidence supported large relative associations with history of overdose (OR 5.85, 95% CI 3.78-9.04), higher opioid dose (OR 2.57, 95% CI 2.08-3.18 per 90-mg increment), 3 or more prescribers (OR 4.68, 95% CI 3.57-6.12), 4 or more dispensing pharmacies (OR 4.92, 95% CI 4.35-5.57), prescription of fentanyl (OR 2.80, 95% CI 2.30-3.41), current substance use disorder (OR 2.62, 95% CI 2.09-3.27), any mental health diagnosis (OR 2.12, 95% CI 1.73-2.61), depression (OR 2.22, 95% CI 1.57-3.14), bipolar disorder (OR 2.07, 95% CI 1.77-2.41) or pancreatitis (OR 2.00, 95% CI 1.52-2.64), with absolute risks among patients with the predictor ranging from 2-6 per 1000 for fatal overdose and 4-12 per 1000 for nonfatal overdose. INTERPRETATION We identified 10 predictors that were strongly associated with opioid overdose. Awareness of these predictors may facilitate shared decision-making regarding prescribing opioids for chronic pain and inform harm-reduction strategies SYSTEMATIC REVIEW REGISTRATION: Open Science Framework (https://osf.io/vznxj/).
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Affiliation(s)
- Li Wang
- Department of Anesthesia (L. Wang, Busse); The Michael G. DeGroote Institute for Pain Research and Care (L. Wang, Rehman, Couban, Busse); Department of Health Research Methods, Evidence & Impact (L. Wang, Rehman, Busse), McMaster University, Hamilton, Ont.; Department of Anesthesiology and Pain Medicine (P.J. Hong), University of Toronto, Toronto, Ont.; Faculty of Health Science (Jiang), McMaster University, Hamilton, Ont.; Division of Plastic Surgery, Department of Surgery (B.Y. Hong), University of Toronto, Toronto, Ont.; Guangdong Science and Technology Library (C. Wang), Institute of Information, Guangdong Academy of Sciences, Guangzhou, China; Department of Biomedical Informatics (Hayes), College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Ark.; Center for Mental Healthcare and Outcomes Research (Hayes), Central Arkansas Veterans Healthcare System, North Little Rock, Ark.; Sunnybrook Health Sciences Centre (Juurlink); Institute for Clinical Evaluative Sciences (Juurlink); Institute of Health Policy, Management, and Evaluation (Juurlink), University of Toronto, Toronto, Ont.
| | - Patrick J Hong
- Department of Anesthesia (L. Wang, Busse); The Michael G. DeGroote Institute for Pain Research and Care (L. Wang, Rehman, Couban, Busse); Department of Health Research Methods, Evidence & Impact (L. Wang, Rehman, Busse), McMaster University, Hamilton, Ont.; Department of Anesthesiology and Pain Medicine (P.J. Hong), University of Toronto, Toronto, Ont.; Faculty of Health Science (Jiang), McMaster University, Hamilton, Ont.; Division of Plastic Surgery, Department of Surgery (B.Y. Hong), University of Toronto, Toronto, Ont.; Guangdong Science and Technology Library (C. Wang), Institute of Information, Guangdong Academy of Sciences, Guangzhou, China; Department of Biomedical Informatics (Hayes), College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Ark.; Center for Mental Healthcare and Outcomes Research (Hayes), Central Arkansas Veterans Healthcare System, North Little Rock, Ark.; Sunnybrook Health Sciences Centre (Juurlink); Institute for Clinical Evaluative Sciences (Juurlink); Institute of Health Policy, Management, and Evaluation (Juurlink), University of Toronto, Toronto, Ont
| | - Wenjun Jiang
- Department of Anesthesia (L. Wang, Busse); The Michael G. DeGroote Institute for Pain Research and Care (L. Wang, Rehman, Couban, Busse); Department of Health Research Methods, Evidence & Impact (L. Wang, Rehman, Busse), McMaster University, Hamilton, Ont.; Department of Anesthesiology and Pain Medicine (P.J. Hong), University of Toronto, Toronto, Ont.; Faculty of Health Science (Jiang), McMaster University, Hamilton, Ont.; Division of Plastic Surgery, Department of Surgery (B.Y. Hong), University of Toronto, Toronto, Ont.; Guangdong Science and Technology Library (C. Wang), Institute of Information, Guangdong Academy of Sciences, Guangzhou, China; Department of Biomedical Informatics (Hayes), College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Ark.; Center for Mental Healthcare and Outcomes Research (Hayes), Central Arkansas Veterans Healthcare System, North Little Rock, Ark.; Sunnybrook Health Sciences Centre (Juurlink); Institute for Clinical Evaluative Sciences (Juurlink); Institute of Health Policy, Management, and Evaluation (Juurlink), University of Toronto, Toronto, Ont
| | - Yasir Rehman
- Department of Anesthesia (L. Wang, Busse); The Michael G. DeGroote Institute for Pain Research and Care (L. Wang, Rehman, Couban, Busse); Department of Health Research Methods, Evidence & Impact (L. Wang, Rehman, Busse), McMaster University, Hamilton, Ont.; Department of Anesthesiology and Pain Medicine (P.J. Hong), University of Toronto, Toronto, Ont.; Faculty of Health Science (Jiang), McMaster University, Hamilton, Ont.; Division of Plastic Surgery, Department of Surgery (B.Y. Hong), University of Toronto, Toronto, Ont.; Guangdong Science and Technology Library (C. Wang), Institute of Information, Guangdong Academy of Sciences, Guangzhou, China; Department of Biomedical Informatics (Hayes), College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Ark.; Center for Mental Healthcare and Outcomes Research (Hayes), Central Arkansas Veterans Healthcare System, North Little Rock, Ark.; Sunnybrook Health Sciences Centre (Juurlink); Institute for Clinical Evaluative Sciences (Juurlink); Institute of Health Policy, Management, and Evaluation (Juurlink), University of Toronto, Toronto, Ont
| | - Brian Y Hong
- Department of Anesthesia (L. Wang, Busse); The Michael G. DeGroote Institute for Pain Research and Care (L. Wang, Rehman, Couban, Busse); Department of Health Research Methods, Evidence & Impact (L. Wang, Rehman, Busse), McMaster University, Hamilton, Ont.; Department of Anesthesiology and Pain Medicine (P.J. Hong), University of Toronto, Toronto, Ont.; Faculty of Health Science (Jiang), McMaster University, Hamilton, Ont.; Division of Plastic Surgery, Department of Surgery (B.Y. Hong), University of Toronto, Toronto, Ont.; Guangdong Science and Technology Library (C. Wang), Institute of Information, Guangdong Academy of Sciences, Guangzhou, China; Department of Biomedical Informatics (Hayes), College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Ark.; Center for Mental Healthcare and Outcomes Research (Hayes), Central Arkansas Veterans Healthcare System, North Little Rock, Ark.; Sunnybrook Health Sciences Centre (Juurlink); Institute for Clinical Evaluative Sciences (Juurlink); Institute of Health Policy, Management, and Evaluation (Juurlink), University of Toronto, Toronto, Ont
| | - Rachel J Couban
- Department of Anesthesia (L. Wang, Busse); The Michael G. DeGroote Institute for Pain Research and Care (L. Wang, Rehman, Couban, Busse); Department of Health Research Methods, Evidence & Impact (L. Wang, Rehman, Busse), McMaster University, Hamilton, Ont.; Department of Anesthesiology and Pain Medicine (P.J. Hong), University of Toronto, Toronto, Ont.; Faculty of Health Science (Jiang), McMaster University, Hamilton, Ont.; Division of Plastic Surgery, Department of Surgery (B.Y. Hong), University of Toronto, Toronto, Ont.; Guangdong Science and Technology Library (C. Wang), Institute of Information, Guangdong Academy of Sciences, Guangzhou, China; Department of Biomedical Informatics (Hayes), College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Ark.; Center for Mental Healthcare and Outcomes Research (Hayes), Central Arkansas Veterans Healthcare System, North Little Rock, Ark.; Sunnybrook Health Sciences Centre (Juurlink); Institute for Clinical Evaluative Sciences (Juurlink); Institute of Health Policy, Management, and Evaluation (Juurlink), University of Toronto, Toronto, Ont
| | - Chunming Wang
- Department of Anesthesia (L. Wang, Busse); The Michael G. DeGroote Institute for Pain Research and Care (L. Wang, Rehman, Couban, Busse); Department of Health Research Methods, Evidence & Impact (L. Wang, Rehman, Busse), McMaster University, Hamilton, Ont.; Department of Anesthesiology and Pain Medicine (P.J. Hong), University of Toronto, Toronto, Ont.; Faculty of Health Science (Jiang), McMaster University, Hamilton, Ont.; Division of Plastic Surgery, Department of Surgery (B.Y. Hong), University of Toronto, Toronto, Ont.; Guangdong Science and Technology Library (C. Wang), Institute of Information, Guangdong Academy of Sciences, Guangzhou, China; Department of Biomedical Informatics (Hayes), College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Ark.; Center for Mental Healthcare and Outcomes Research (Hayes), Central Arkansas Veterans Healthcare System, North Little Rock, Ark.; Sunnybrook Health Sciences Centre (Juurlink); Institute for Clinical Evaluative Sciences (Juurlink); Institute of Health Policy, Management, and Evaluation (Juurlink), University of Toronto, Toronto, Ont
| | - Corey J Hayes
- Department of Anesthesia (L. Wang, Busse); The Michael G. DeGroote Institute for Pain Research and Care (L. Wang, Rehman, Couban, Busse); Department of Health Research Methods, Evidence & Impact (L. Wang, Rehman, Busse), McMaster University, Hamilton, Ont.; Department of Anesthesiology and Pain Medicine (P.J. Hong), University of Toronto, Toronto, Ont.; Faculty of Health Science (Jiang), McMaster University, Hamilton, Ont.; Division of Plastic Surgery, Department of Surgery (B.Y. Hong), University of Toronto, Toronto, Ont.; Guangdong Science and Technology Library (C. Wang), Institute of Information, Guangdong Academy of Sciences, Guangzhou, China; Department of Biomedical Informatics (Hayes), College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Ark.; Center for Mental Healthcare and Outcomes Research (Hayes), Central Arkansas Veterans Healthcare System, North Little Rock, Ark.; Sunnybrook Health Sciences Centre (Juurlink); Institute for Clinical Evaluative Sciences (Juurlink); Institute of Health Policy, Management, and Evaluation (Juurlink), University of Toronto, Toronto, Ont
| | - David N Juurlink
- Department of Anesthesia (L. Wang, Busse); The Michael G. DeGroote Institute for Pain Research and Care (L. Wang, Rehman, Couban, Busse); Department of Health Research Methods, Evidence & Impact (L. Wang, Rehman, Busse), McMaster University, Hamilton, Ont.; Department of Anesthesiology and Pain Medicine (P.J. Hong), University of Toronto, Toronto, Ont.; Faculty of Health Science (Jiang), McMaster University, Hamilton, Ont.; Division of Plastic Surgery, Department of Surgery (B.Y. Hong), University of Toronto, Toronto, Ont.; Guangdong Science and Technology Library (C. Wang), Institute of Information, Guangdong Academy of Sciences, Guangzhou, China; Department of Biomedical Informatics (Hayes), College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Ark.; Center for Mental Healthcare and Outcomes Research (Hayes), Central Arkansas Veterans Healthcare System, North Little Rock, Ark.; Sunnybrook Health Sciences Centre (Juurlink); Institute for Clinical Evaluative Sciences (Juurlink); Institute of Health Policy, Management, and Evaluation (Juurlink), University of Toronto, Toronto, Ont
| | - Jason W Busse
- Department of Anesthesia (L. Wang, Busse); The Michael G. DeGroote Institute for Pain Research and Care (L. Wang, Rehman, Couban, Busse); Department of Health Research Methods, Evidence & Impact (L. Wang, Rehman, Busse), McMaster University, Hamilton, Ont.; Department of Anesthesiology and Pain Medicine (P.J. Hong), University of Toronto, Toronto, Ont.; Faculty of Health Science (Jiang), McMaster University, Hamilton, Ont.; Division of Plastic Surgery, Department of Surgery (B.Y. Hong), University of Toronto, Toronto, Ont.; Guangdong Science and Technology Library (C. Wang), Institute of Information, Guangdong Academy of Sciences, Guangzhou, China; Department of Biomedical Informatics (Hayes), College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Ark.; Center for Mental Healthcare and Outcomes Research (Hayes), Central Arkansas Veterans Healthcare System, North Little Rock, Ark.; Sunnybrook Health Sciences Centre (Juurlink); Institute for Clinical Evaluative Sciences (Juurlink); Institute of Health Policy, Management, and Evaluation (Juurlink), University of Toronto, Toronto, Ont
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Brooke BS, Bayless K, Anderson Z, Holeman TA, Zhang C, Hales J, Buys MJ. Opioid tapering after surgery and its association with patient-reported outcomes and behavioral changes: a mixed-methods analysis. Reg Anesth Pain Med 2023:rapm-2023-104807. [PMID: 37865394 DOI: 10.1136/rapm-2023-104807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 10/02/2023] [Indexed: 10/23/2023]
Abstract
INTRODUCTION Opioid tapering after surgery is recommended among patients with chronic opioid use, but it is unclear how this process affects their quality of life. The objective of this study was to evaluate how opioid tapering following surgery was associated with patient-reported outcome measures related to pain control and behavioral changes that affect quality of life. METHODS We conducted an explanatory sequential mixed-methods study at a VA Medical Center among patients with chronic opioid use who underwent a spectrum of orthopedic, vascular, thoracic, urology, otolaryngology, and general surgery procedures between 2018 and 2020. Patients were stratified based on the extent that opioid tapering was successful (complete, partial, and no-taper) by 90 days after surgery, followed by qualitative interviews of 10 patients in each taper group. Longitudinal patient-reported outcome measures related to pain intensity, interference, and catastrophizing were compared using Kruskal Wallis tests over the 90-day period after surgery. Qualitative interviews were conducted among patients in each taper group to identify themes associated with the impact of opioid tapering after surgery on quality of life. RESULTS We identified 211 patients with chronic opioid use (92% male, median age 66 years) who underwent surgery during the time period, including 42 (20%) individuals with complete tapering, 48 (23%) patients with partial tapering, and 121 (57%) patients with no taper of opioids following surgery. Patients who did not taper were more likely to have a history of opioid use disorder (10%-partial, 2%-complete vs 17%-no taper, p<0.05) and be discharged on a higher median morphine equivalent daily dose (52-partial, 30-complete vs 60-no taper; p<0.05) than patients in the partial and complete taper groups. Pain interference (-7.2-partial taper and -9.8-complete taper vs -3.5-no taper) and pain catastrophizing (-21.4-partial taper and -16.5-complete taper vs -1.7-no taper) scores for partial and complete taper groups were significantly improved at 90 days relative to baseline when compared with patients in the no-taper group (p<0.05 for both comparisons), while pain intensity was similar between groups. Finally, patients achieving complete and partial opioid tapering were more likely to report improvements in activity, mood, thinking, and sleep following surgery as compared with patients who failed to taper. CONCLUSIONS Partial and complete opioid tapering within 90 days after surgery among patients with chronic opioid use was associated with improved patient-reported measures of pain control as well as behaviors that impact a patient's quality of life.
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Affiliation(s)
- Benjamin Sands Brooke
- Department of Surgery, University of Utah Health, Salt Lake City, Utah, USA
- IDEAS 2.0, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah, USA
| | - Kimberlee Bayless
- Anesthesiology, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Zachary Anderson
- Anesthesiology, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Teryn A Holeman
- Department of Surgery, University of Utah Health, Salt Lake City, Utah, USA
| | - Chong Zhang
- Internal Medicine-Epidemiology, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Julie Hales
- Department of Surgery, University of Utah Health, Salt Lake City, Utah, USA
- IDEAS 2.0, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah, USA
| | - Michael J Buys
- Anesthesiology, Salt Lake City VA Medical Center, Salt Lake City, Utah, USA
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50
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Xia T, Picco L, Lalic S, Buchbinder R, Bell JS, Andrew NE, Lubman DI, Pearce C, Nielsen S. Determining the Impact of Opioid Policy on Substance Use and Mental Health-Related Harms: Protocol for a Data Linkage Study. JMIR Res Protoc 2023; 12:e51825. [PMID: 37847553 PMCID: PMC10618880 DOI: 10.2196/51825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 08/21/2023] [Accepted: 08/21/2023] [Indexed: 10/18/2023] Open
Abstract
BACKGROUND Increasing harms related to prescription opioids over the past decade have led to the introduction of a range of key national and state policy initiatives across Australia. These include introducing a mandatory real-time prescription drug-monitoring program in the state of Victoria from April 2020 and a series of changes to subsidies for opioids on the Pharmaceutical Benefit Scheme from June 2020. Together, these changes aim to influence opioid supply and reduce harms related to prescription opioids, yet few studies have specifically explored how these policies have influenced opioid prescribing and related harms in Australia. OBJECTIVE The aim of this study is to examine the impact of a range of opioid-related policies on hospital admissions and emergency department (ED) presentations in Victoria, Australia. In particular, the study aims to understand the effect of various opioid policies and opioid-prescribing changes on (1) the number and rates of ED presentations and hospital admissions attributed to substance use (ie, opioid and nonopioid related) or mental ill-health (eg, suicide, self-harm, anxiety, and depression), (2) the association between differing opioid dose trajectories and the likelihood of ED presentations and hospital admissions related to substance use and mental ill-health, and (3) whether changes in an individual's opioid prescribing change the risk related to ED presentations and hospital admissions related to substance use and mental ill-health. METHODS We will conduct a population-level linked data study. General practice health records obtained from the Population Level Analysis and Reporting platform are linked with person-level data from 3 large hospital networks in Victoria, Australia. Interrupted time series analysis will be used to examine the impact of opioid policies on a range of harms, including the rates of presentations related to substance use (opioid and nonopioid) and mental ill-health among the primary care cohort. Group-based trajectory modeling and a case-crossover design will be used to further explore the impact of changes in opioid dosage and other covariates on opioid and nonopioid poisonings and mental ill-health-related presentations at the patient level. RESULTS Given that this paper serves as a protocol, there are currently no results available. The deidentified primary health data were sourced from electronic medical records of approximately 4,717,000 patients from 542 consenting general practices over a 6-year period (2017-2022). The submission of results for publication is planned for early 2024. CONCLUSIONS This study will add to the limited evidence base to help understand the impact of opioid policies in Australia, including whether intended or unintended outcomes are occurring as a result. TRIAL REGISTRATION EU PAS Register EUPAS104005; https://www.encepp.eu/encepp/viewResource.htm?id=104006. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/51825.
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Affiliation(s)
- Ting Xia
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Australia
| | - Louisa Picco
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Australia
| | - Samanta Lalic
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
- Pharmacy Department, Monash Health, Clayton, Australia
| | - Rachelle Buchbinder
- Musculoskeletal Health and Wiser Health Care Units, School of Public Health and Preventive Medicine, Monash University, St Kilda, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Nadine E Andrew
- Peninsula Clinical School, Central Clinical School, Peninsula Health, Monash University, Frankston, Australia
| | - Dan I Lubman
- Turning Point, Eastern Health, Richmond, Australia
| | | | - Suzanne Nielsen
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Australia
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