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Elyn A, Roussin A, Lestrade C, Franchitto N, Jullian B, Cantagrel N. Low-dose ketamine infusion to facilitate opioid tapering in chronic non-cancer pain with opioid-use disorder: a historical cohort study. Reg Anesth Pain Med 2024:rapm-2023-105035. [PMID: 38499357 DOI: 10.1136/rapm-2023-105035] [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: 09/26/2023] [Accepted: 03/04/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Long-term opioid use is associated with pharmacological tolerance, a risk of misuse and hyperalgesia in patients with chronic pain (CP). Tapering is challenging in this context, particularly with comorbid opioid-use disorder (OUD). The antihyperalgesic effect of ketamine, through N-methyl-D-aspartate (NMDA) antagonism, could be useful. We aimed to describe the changes in the dose of opioids consumed over 1 year after a 5-day hospitalisation with ketamine infusion for CP patients with OUD. METHODS We performed a historical cohort study using a medical chart from 1 January 2014 to 31 December 2019. Patients were long-term opioid users with OUD and CP, followed by the Pain Center of the University Hospital of Toulouse, for which outpatient progressive tapering failed. Ketamine was administered at a low dose to initiate tapering during a 5-day hospitalisation. RESULTS 59 patients were included, with 64% of them female and a mean age of 48±10 years old. The most frequent CP aetiologies were back pain (53%) and fibromyalgia (17%). The baseline opioid daily dose was 207 mg (±128) morphine milligram equivalent (MME). It was lowered to 92±72 mg MME at discharge (p<0.001), 99±77 mg at 3 months (p<0.001) and 103±106 mg at 12 months. More than 50% tapering was achieved immediately for 40 patients (68%), with immediate cessation for seven patients (12%). 17 patients were lost to follow-up. CONCLUSIONS A 5-day hospitalisation with a low-dose ketamine infusion appeared useful to facilitate opioid tapering in long-term opioid users with CP and OUD. Ketamine was well tolerated, and patients did not present significant withdrawal symptoms. Prospective and comparative studies are needed to confirm our findings.
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Affiliation(s)
- Antoine Elyn
- Chronic Pain Center, University Hospital of Toulouse, Toulouse, France
- General and Family Medicine University Department, University of Toulouse III - Paul Sabatier, Toulouse, France
- RECaP F-CRIN - Réseau national de Recherche en Épidémiologie Clinique et en Santé Publique, Inserm, Toulouse, France
| | - Anne Roussin
- Clinical Pharmacology, University Hospital of Toulouse, Toulouse, France
- INSERM UMR1295, Pharmaco-épidémiologie, University of Toulouse III - Paul Sabatier, Toulouse, France
- University of Medicine, University of Toulouse III - Paul Sabatier, Toulouse, France
| | - Cécile Lestrade
- Chronic Pain Center, University Hospital of Toulouse, Toulouse, France
| | - Nicolas Franchitto
- University of Medicine, University of Toulouse III - Paul Sabatier, Toulouse, France
- Clinical Addictology Center, University Hospital of Toulouse, Toulouse, France
- INSERM UMR1295, EQUITY "Embodiment, social inequalities, lifecourse epidemiology, cancer and chronic diseases, interventions, methodology", University of Toulouse III - Paul Sabatier, Toulouse, France
| | - Bénédicte Jullian
- Clinical Addictology Center, University Hospital of Toulouse, Toulouse, France
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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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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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Mishkin AD, Prince EJ, Leimbach EJ, Mapara MY, Carroll CP. Psychiatric comorbidities in adults with sickle cell disease: A narrative review. Br J Haematol 2023; 203:747-759. [PMID: 37455514 DOI: 10.1111/bjh.18981] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/21/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023]
Abstract
Although descriptions of quality of life and patient reports of mood in sickle cell disease (SCD) have become more common in the literature, less is known about psychiatric illness prevalence, presentation, and treatment, particularly for adults. We provide a narrative review of what is known about common and debilitating psychiatric conditions such as depression, anxiety, and cognitive impairment, specifically for adults with SCD. We discuss the limitations of the current evidence, make provisional recommendations, and identify opportunities for research and improved care.
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Affiliation(s)
- Adrienne D Mishkin
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York, USA
- Blood and Marrow Transplantation Program, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Elizabeth J Prince
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth J Leimbach
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York, USA
| | - Markus Y Mapara
- Blood and Marrow Transplantation Program, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - C Patrick Carroll
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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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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Perry K, Ferron S, Norquist N, Mullen DM. A Pharmacist-Assisted Initiative to Improve Chronic Pain Management and Reduce Opioid Use in Primary Care. Innov Pharm 2023; 14:10.24926/iip.v14i1.5265. [PMID: 38035315 PMCID: PMC10686672 DOI: 10.24926/iip.v14i1.5265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023] Open
Abstract
Background- Since publication of the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain, there have been growing concerns that providers, including those in primary care, are tapering opioids too quickly and without concomitant use of non-opioid strategies for pain, leading to inadequate pain management. As a result, in November 2022 the CDC published Clinical Practice Guidelines for Prescribing Opioids for Pain, emphasizing the importance of creating comprehensive care plans for pain management and developing a consensual plan between provider and patient when tapering opioids. Objective-Determine the impact of a pharmacist-assisted approach aimed at helping primary care providers minimize opioid use while improving management of chronic, non-malignant pain (CNMP). Methods - This quality improvement project focused on one primary care provider partnering with a pharmacist to reassess the management of patients on long-term opioid therapy (LTOT) for CNMP. The intervention included a letter informing patients of the provider's intent, pharmacist outreach to intervention patients, and pharmacist development of a patient registry, updated regularly with clinical data, recommendations, and outcomes for the provider to reference throughout the project. The intervention group was compared to patients prescribed opioids for CNMP by the remaining providers at the clinic who did not engage in the quality initiative. Results - The intervention group had a mean effective daily morphine milligram equivalent (MME) reduction of 73.7% (17.2% control) after 18 months and 60% of patients discontinued opioids (14.3% control). In a subset of patients with functional assessment scores, 93.3% were either improved or unchanged, despite a 62.5% decrease in their mean effective daily MME. In both groups, one patient transferred care to a new provider. Conclusions - With targeted recommendations and assistance from a pharmacist, a primary care provider can make significant progress in improving management of CNMP while reducing opioid prescribing.
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Affiliation(s)
| | | | | | - Deborah M. Mullen
- The University of Tennessee at Chattanooga, Gary W. Rollins College of Business, Management Department, Chattanooga, TN
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8
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Newport KB, Webb JA. Innovations and Opportunities for the Integration of Palliative Care in Cancer Care. Curr Probl Cancer 2023; 47:101016. [PMID: 37806918 DOI: 10.1016/j.currproblcancer.2023.101016] [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: 08/25/2023] [Accepted: 08/30/2023] [Indexed: 10/10/2023]
Affiliation(s)
- Kristina B Newport
- Section of Palliative Care, Department of Medicine, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Jason A Webb
- Section of Palliative Care, Division of Hematology and Medical Oncology, Oregon Health and Science University, Portland, Oregon; Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon.
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9
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Li Y, Barr KD, Trafton JA, Oliva EM, Garrido MM, Frakt AB, Strombotne KL. Impact of Mandated Case Review Policy on Opioid Discontinuation and Mortality Among High-Risk Long-Term Opioid Therapy Patients: The STORM Stepped-Wedge Cluster Randomized Controlled Trial. Subst Abus 2023; 44:292-300. [PMID: 37830514 DOI: 10.1177/08897077231198299] [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] [Indexed: 10/14/2023]
Abstract
BACKGROUND Although long-term opioid therapy (LTOT) has its own risks, opioid discontinuation could pose harm for high-risk Veterans Health Administration (VHA) patients receiving LTOT. There is limited information on the impact of a mandate requiring providers to perform case reviews on high-risk patients with an active opioid prescription (ie, mandated case review policy) on opioid discontinuation and mortality. METHODS Our study is a secondary data analysis of a 23-month stepped-wedge cluster randomized controlled trial between April 2018 and March 2020. The study included 10 685 LTOT patients with a predicted risk of a serious adverse event between the top 1% to 5% nationally who entered the risk range between 4/18/2018 and 11/9/2019. We examined whether the mandated case review policy had an impact on opioid discontinuation and mortality for the patients. RESULTS Among 10 685 LTOT patients (88.2% male; mean [SD] age, 61.1 [11.7] years), 29.1% experienced discontinuation and the mortality rate was 9.5%. Patients under mandated case review had a decreased risk of opioid discontinuation (average marginal effect [AME], -11.16 [95% CI, -15.30 to -7.01] percentage points) and all-cause mortality (AME, -3.31 [95% CI, -5.63 to -1.00] percentage points), relative to patients who were not under the mandate. CONCLUSIONS The VHA mandated case review policy was associated with lower probability of discontinuation and all-cause mortality for high-risk patients receiving LTOT. Interventions that maintain care engagement while optimizing pain management for high-risk patients may be beneficial for minimizing mortality and other risks associated with discontinuation.
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Affiliation(s)
- Yufei Li
- Department of Health Law, Policy and Management, Boston University of Public Health, Boston, MA, USA
- Partnered Evidence-based Policy Resource Center, VA Boston Healthcare System, Boston, MA, USA
| | - Kyle D Barr
- Partnered Evidence-based Policy Resource Center, VA Boston Healthcare System, Boston, MA, USA
| | - Jodie A Trafton
- Program Evaluation and Resource Center, Office of Mental Health and Suicide Prevention, Veterans Health Administration, Menlo Park, CA, USA
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Veterans Health Administration, Menlo Park, CA, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University Medical School, Palo Alto, CA, USA
| | - Elizabeth M Oliva
- Program Evaluation and Resource Center, Office of Mental Health and Suicide Prevention, Veterans Health Administration, Menlo Park, CA, USA
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Veterans Health Administration, Menlo Park, CA, USA
| | - Melissa M Garrido
- Department of Health Law, Policy and Management, Boston University of Public Health, Boston, MA, USA
- Partnered Evidence-based Policy Resource Center, VA Boston Healthcare System, Boston, MA, USA
| | - Austin B Frakt
- Department of Health Law, Policy and Management, Boston University of Public Health, Boston, MA, USA
- Partnered Evidence-based Policy Resource Center, VA Boston Healthcare System, Boston, MA, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Cambridge, MA, USA
| | - Kiersten L Strombotne
- Department of Health Law, Policy and Management, Boston University of Public Health, Boston, MA, USA
- Partnered Evidence-based Policy Resource Center, VA Boston Healthcare System, Boston, MA, USA
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Pryce KD, Serafini RA, Ramakrishnan A, Nicolais A, Giosan IM, Polizu C, Torres-Berrío A, Vuppala S, Kronman H, Ruiz A, Gaspari S, Peña CJ, Sakloth F, Mitsi V, van Duzer J, Mazitschek R, Jarpe M, Shen L, Nestler EJ, Zachariou V. Oxycodone withdrawal induces HDAC1/HDAC2-dependent transcriptional maladaptations in the reward pathway in a mouse model of peripheral nerve injury. Nat Neurosci 2023; 26:1229-1244. [PMID: 37291337 PMCID: PMC10752505 DOI: 10.1038/s41593-023-01350-3] [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: 09/27/2021] [Accepted: 04/25/2023] [Indexed: 06/10/2023]
Abstract
The development of physical dependence and addiction disorders due to misuse of opioid analgesics is a major concern with pain therapeutics. We developed a mouse model of oxycodone exposure and subsequent withdrawal in the presence or absence of chronic neuropathic pain. Oxycodone withdrawal alone triggered robust gene expression adaptations in the nucleus accumbens, medial prefrontal cortex and ventral tegmental area, with numerous genes and pathways selectively affected by oxycodone withdrawal in mice with peripheral nerve injury. Pathway analysis predicted that histone deacetylase (HDAC) 1 is a top upstream regulator in opioid withdrawal in nucleus accumbens and medial prefrontal cortex. The novel HDAC1/HDAC2 inhibitor, Regenacy Brain Class I HDAC Inhibitor (RBC1HI), attenuated behavioral manifestations of oxycodone withdrawal, especially in mice with neuropathic pain. These findings suggest that inhibition of HDAC1/HDAC2 may provide an avenue for patients with chronic pain who are dependent on opioids to transition to non-opioid analgesics.
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Affiliation(s)
- Kerri D Pryce
- Nash Family Department of Neuroscience, Department of Pharmacological Sciences, and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Randal A Serafini
- Nash Family Department of Neuroscience, Department of Pharmacological Sciences, and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Aarthi Ramakrishnan
- Nash Family Department of Neuroscience, Department of Pharmacological Sciences, and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Andrew Nicolais
- Nash Family Department of Neuroscience, Department of Pharmacological Sciences, and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ilinca M Giosan
- Nash Family Department of Neuroscience, Department of Pharmacological Sciences, and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Claire Polizu
- Nash Family Department of Neuroscience, Department of Pharmacological Sciences, and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Angélica Torres-Berrío
- Nash Family Department of Neuroscience, Department of Pharmacological Sciences, and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sreeya Vuppala
- Nash Family Department of Neuroscience, Department of Pharmacological Sciences, and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hope Kronman
- Nash Family Department of Neuroscience, Department of Pharmacological Sciences, and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Anne Ruiz
- Nash Family Department of Neuroscience, Department of Pharmacological Sciences, and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sevasti Gaspari
- Nash Family Department of Neuroscience, Department of Pharmacological Sciences, and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Farhana Sakloth
- Nash Family Department of Neuroscience, Department of Pharmacological Sciences, and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Vasiliki Mitsi
- Nash Family Department of Neuroscience, Department of Pharmacological Sciences, and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Ralph Mazitschek
- Center for Systems Biology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Li Shen
- Nash Family Department of Neuroscience, Department of Pharmacological Sciences, and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eric J Nestler
- Nash Family Department of Neuroscience, Department of Pharmacological Sciences, and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Venetia Zachariou
- Nash Family Department of Neuroscience, Department of Pharmacological Sciences, and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA.
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11
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Kwon AH, Colloca L, Mackey SC. Blinded Pain Cocktails: A Reliable and Safe Opioid Weaning Method. Anesthesiol Clin 2023; 41:371-381. [PMID: 37245948 DOI: 10.1016/j.anclin.2023.03.006] [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] [Indexed: 05/30/2023]
Abstract
Weaning opioids in patients with noncancerous chronic pain often poses a challenge when psychosocial factors complicate the patient's chronic pain syndrome and opioid use. A blinded pain cocktail protocol used to wean opioid therapy has been described since the 1970s. At the Stanford Comprehensive Interdisciplinary Pain Program, a blinded pain cocktail remains a reliably effective medication-behavioral intervention. This review (1) outlines psychosocial factors that may complicate opioid weaning, (2) describes clinical goals and how to use blinded pain cocktails in opioid tapering, and (3) summarizes the mechanism of dose-extending placebos and ethical justification of its use in clinical practice.
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Affiliation(s)
- Albert Hyukjae Kwon
- Stanford University School of Medicine, 430 Broadway Street, Pavilion C, 3rd Floor, Redwood City, CA 94063, USA.
| | - Luana Colloca
- Pain and Translational Symptom Science, Placebo Beyond Opinions Center, School of Nursing, University of Maryland, Baltimore, 655 West Lombard Street, Room 729A, Baltimore, MD 21201, USA
| | - Sean C Mackey
- Stanford University School of Medicine, 1070 Arastradero Road, Suite 200, Palo Alto, CA 94304, USA
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12
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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. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.05.10.23289771. [PMID: 37214982 PMCID: PMC10197816 DOI: 10.1101/2023.05.10.23289771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
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 co-designed psycho-educational video and SMS text messaging intervention to support patients with chronic pain during prescription opioid tapering. Methods A pilot randomised controlled trial was conducted. In addition to their usual care, participants in the intervention group received a psycho-educational video and 28 days of text messages (two SMS/day). The control group received usual care. 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 in each group). Text message delivery was 99.2% successful. Most participants rated the messages as useful, supportive, encouraging, and engaging, 78.5% would recommend the intervention to others, and 64% desired a longer intervention period. Tapering self-efficacy (Cohen's d = 0.74) and pain self-efficacy (d = 0.41) were higher and pain intensity (d = 0.65) and affective interference (d = 0.45) lower in the intervention group at week 4. Conclusions It is feasible, acceptable, and potentially efficacious to support patients with chronic pain during prescription opioid tapering with a psycho-educational video and SMS text messaging intervention. A definitive trial has been initiated to test a 12-week intervention.
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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, California, 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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13
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Ukhanova M, Voss RW, Marino M, Huguet N, Bailey SR, Hartung DM, O'Malley J, Chamine I, Muench J. Chronic overlapping pain conditions and long-term opioid treatment. THE AMERICAN JOURNAL OF MANAGED CARE 2023; 29:233-239. [PMID: 37229782 PMCID: PMC10516299 DOI: 10.37765/ajmc.2023.89356] [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] [Indexed: 05/27/2023]
Abstract
OBJECTIVES One in 5 people in the United States lives with chronic pain. Many patients with chronic pain experience a subset of specific co-occurring pain conditions that may share a common pain mechanism and that have been designated as chronic overlapping pain conditions (COPCs). Little is known about chronic opioid prescribing patterns among patients with COPCs in primary care settings, especially among socioeconomically vulnerable patients. This study aims to evaluate opioid prescribing among patients with COPCs in US community health centers and to identify individual COPCs and their combinations that are associated with long-term opioid treatment (LOT). STUDY DESIGN Retrospective cohort study. METHODS We conducted analyses of more than 1 million patients 18 years and older based on electronic health record data from 449 US community health centers across 17 states between January 1, 2009, and December 31, 2018. Logistic regression models were used to assess the relationship between COPCs and LOT. RESULTS Individuals with COPCs were prescribed LOT 4 times more often than individuals without a COPC (16.9% vs 4.0%). The presence of chronic low back pain, migraine headache, fibromyalgia, or irritable bowel syndrome combined with any of the other COPCs increased the odds of LOT prescribing compared with the presence of a single COPC. CONCLUSIONS Although LOT prescribing has declined over time, it remains relatively high among patients with certain COPCs and for those with multiple COPCs. These study findings suggest target populations for future interventions to manage chronic pain among socioeconomically vulnerable patients.
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Affiliation(s)
- Maria Ukhanova
- Department of Family Medicine, Oregon Health & Science University, 3405 SW Perimeter Ct, Mail code: FM, Portland, OR 97239.
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14
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Wang Y, Wilson DL, Fernandes D, Adkins LE, Bantad A, Copacia C, Dharma N, Huang PL, Joseph A, Park TW, Budd J, Meenrajan S, Orlando FA, Pennington J, Schmidt S, Shorr R, Uphold CR, Lo-Ciganic WH. Deprescribing Strategies for Opioids and Benzodiazepines with Emphasis on Concurrent Use: A Scoping Review. J Clin Med 2023; 12:jcm12051788. [PMID: 36902574 PMCID: PMC10002935 DOI: 10.3390/jcm12051788] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/15/2023] [Accepted: 02/19/2023] [Indexed: 02/25/2023] Open
Abstract
While the Food and Drug Administration's black-box warnings caution against concurrent opioid and benzodiazepine (OPI-BZD) use, there is little guidance on how to deprescribe these medications. This scoping review analyzes the available opioid and/or benzodiazepine deprescribing strategies from the PubMed, EMBASE, Web of Science, Scopus, and Cochrane Library databases (01/1995-08/2020) and the gray literature. We identified 39 original research studies (opioids: n = 5, benzodiazepines: n = 31, concurrent use: n = 3) and 26 guidelines (opioids: n = 16, benzodiazepines: n = 11, concurrent use: n = 0). Among the three studies deprescribing concurrent use (success rates of 21-100%), two evaluated a 3-week rehabilitation program, and one assessed a 24-week primary care intervention for veterans. Initial opioid dose deprescribing rates ranged from (1) 10-20%/weekday followed by 2.5-10%/weekday over three weeks to (2) 10-25%/1-4 weeks. Initial benzodiazepine dose deprescribing rates ranged from (1) patient-specific reductions over three weeks to (2) 50% dose reduction for 2-4 weeks, followed by 2-8 weeks of dose maintenance and then a 25% reduction biweekly. Among the 26 guidelines identified, 22 highlighted the risks of co-prescribing OPI-BZD, and 4 provided conflicting recommendations on the OPI-BZD deprescribing sequence. Thirty-five states' websites provided resources for opioid deprescription and three states' websites had benzodiazepine deprescribing recommendations. Further studies are needed to better guide OPI-BZD deprescription.
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Affiliation(s)
- Yanning Wang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
- Department of Health Outcome and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Debbie L. Wilson
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Deanna Fernandes
- North Florida/South Georgia Veterans Health System Geriatric Research Education and Clinical Center, Gainesville, FL 32601, USA
| | - Lauren E. Adkins
- Health Science Center Libraries, University of Florida, Gainesville, FL 32610, USA
| | - Ashley Bantad
- College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Clint Copacia
- College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Nilay Dharma
- College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Pei-Lin Huang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Amanda Joseph
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Tae Woo Park
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Jeffrey Budd
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL 32611, USA
| | - Senthil Meenrajan
- Department of Medicine, College of Medicine, University of Florida, Gainesville, FL 32611, USA
| | - Frank A. Orlando
- Department of Community Heath and Family Medicine, College of Medicine, University of Florida, Gainesville, FL 32608, USA
| | - John Pennington
- Department of Community Heath and Family Medicine, College of Medicine, University of Florida, Gainesville, FL 32608, USA
| | - Siegfried Schmidt
- Department of Community Heath and Family Medicine, College of Medicine, University of Florida, Gainesville, FL 32608, USA
| | - Ronald Shorr
- North Florida/South Georgia Veterans Health System Geriatric Research Education and Clinical Center, Gainesville, FL 32601, USA
- Department of Epidemiology, College of Public Health and Health Professions & College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Constance R. Uphold
- North Florida/South Georgia Veterans Health System Geriatric Research Education and Clinical Center, Gainesville, FL 32601, USA
- Department of Physiology and Aging, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
- Center for Drug Evaluation and Safety (CoDES), College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
- Correspondence:
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Ashton-James CE, Anderson SR, Hirsh AT. Understanding the contribution of racially and ethnically discordant interactions to pain disparities: proximal mechanisms and potential solutions. Pain 2023; 164:223-229. [PMID: 35594518 PMCID: PMC9675882 DOI: 10.1097/j.pain.0000000000002698] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 05/12/2022] [Indexed: 02/06/2023]
Affiliation(s)
- Claire E Ashton-James
- Sydney Medical School, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Steven R Anderson
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Adam T Hirsh
- Department of Psychology, Indiana University-Purdue University Indianapolis, Indianapolis, IN, United States
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16
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Busse JW, Juurlink D, Buckley DN. Response to “Winner of the Ronald Melzack — Canadian Journal of Pain 2021 Paper of the Year Award”. Can J Pain 2022; 6:171-172. [PMID: 36118943 PMCID: PMC9481076 DOI: 10.1080/24740527.2022.2108775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Jason W. Busse
- Department of Anesthesia, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - David Juurlink
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Departments of Medicine and Paediatrics, University of Toronto, Toronto, ON, Canada
| | - D. Norman Buckley
- Department of Anesthesia, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
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17
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Nickerson K, Lieschke G, Rajappa H, Smith A, Inder KJ. A scoping review of outpatient interventions to support the reduction of prescription opioid medication for chronic non cancer pain. J Clin Nurs 2022; 31:3368-3389. [PMID: 35132707 PMCID: PMC9790561 DOI: 10.1111/jocn.16235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 12/27/2021] [Accepted: 01/14/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Prescription opioid use is a global health issue. Previous systematic reviews have not identified that any specific intervention supports prescription opioid reduction effectively. In keeping with the nature of a scoping review, this review details an overview of the existing literature on this topic, with quality of evidence being discussed rather than formally analysed. AIM This review aimed to examine and describe outpatient interventions that support the reduction of prescription opioid medication for chronic non cancer pain. ELIGIBILITY CRITERIA Abstracts were reviewed against the inclusion criteria of outpatient clinical interventions, for the purpose of prescription opioid dose reduction, offered to adults with CNCP. SOURCES OF EVIDENCE Following a structured review approach an electronic database search, of Medline, Embase, Cochrane, Cinahl, and Proquest and grey literature was undertaken. Search results were screened by title for relevance. CHARTING METHODS Two reviewers adhering to the PRISMA-ScR checklist charted and assessed studies for quality using Critical Appraisal Skills Programme checklist assessment tools. Extracted data were collated and synthesised for presentation as a tabular and narrative review. RESULTS From the initial search of 5089 papers, 19 underwent full-text review and quality appraisal. A variety of interventions were described to support reduction in prescription opioid use, however only one study of at least fair quality was able to demonstrate a demonstrated a statistically significant benefit in reducing measured opioid dose compared with a control group. Interventions were implemented in both specialist pain services and in primary care with multidisciplinary and interdisciplinary clinician care. Barriers and facilitators were observed in both settings. CONCLUSION AND IMPLICATIONS FOR CLINICAL PRACTICE Further rigorous research needs to be conducted to conclusively answer the question of what outpatient interventions support opioid reduction in chronic non cancer pain. This scoping review is the first step of inquiry in the development of a nursing intervention to support reduction of prescription opioids.
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Affiliation(s)
- Kathie Nickerson
- Hunter Integrated Pain ServiceHunter New England Local Health DistrictNew LambtonNew South WalesAustralia,School of Nursing and MidwiferyUniversity of NewcastleCallaghanNew South WalesAustralia
| | - Gena Lieschke
- Hunter Integrated Pain ServiceHunter New England Local Health DistrictNew LambtonNew South WalesAustralia,School of Nursing and MidwiferyUniversity of NewcastleCallaghanNew South WalesAustralia,Nursing and Midwifery Research CentreHunter New England Health Local Health DistrictNewcastleNew South WalesAustralia
| | - Hema Rajappa
- Hunter Integrated Pain ServiceHunter New England Local Health DistrictNew LambtonNew South WalesAustralia,School of Medicine and Public HealthUniversity of NewcastleCallaghanNew South WalesAustralia,Hunter Medical Research InstituteNew LambtonNew South WalesAustralia
| | - Angela Smith
- Hunter New England Health LibrariesNew LambtonNew South WalesAustralia
| | - Kerry Jill Inder
- School of Nursing and MidwiferyUniversity of NewcastleCallaghanNew South WalesAustralia,Hunter Medical Research InstituteNew LambtonNew South WalesAustralia
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Kelley AT, Incze MA, Baylis JD, Calder SG, Weiner SJ, Zickmund SL, Jones AL, Vanneman ME, Conroy MB, Gordon AJ, Bridges JF. Patient-centered quality measurement for opioid use disorder: Development of a taxonomy to address gaps in research and practice. Subst Abus 2022; 43:1286-1299. [PMID: 35849749 PMCID: PMC9703846 DOI: 10.1080/08897077.2022.2095082] [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] [Indexed: 10/17/2022]
Abstract
Background: Evidence-based treatment is provided infrequently and inconsistently to patients with opioid use disorder (OUD). Treatment guidelines call for high-quality, patient-centered care that meets individual preferences and needs, but it is unclear whether current quality measures address individualized aspects of care and whether measures of patient-centered OUD care are supported by evidence. Methods: We conducted an environmental scan of OUD care quality to (1) evaluate patient-centeredness in current OUD quality measures endorsed by national agencies and in national OUD treatment guidelines; and (2) review literature evidence for patient-centered care in OUD diagnosis and management, including gaps in current guidelines, performance data, and quality measures. We then synthesized these findings to develop a new quality measurement taxonomy that incorporates patient-centered aspects of care and identifies priority areas for future research and quality measure development. Results: Across 31 endorsed OUD quality measures, only two measures of patient experience incorporated patient preferences and needs, while national guidelines emphasized providing patient-centered care. Among 689 articles reviewed, evidence varied for practices of patient-centered care. Many practices were supported by guidelines and substantial evidence, while others lacked evidence despite guideline support. Our synthesis of findings resulted in EQuIITable Care, a taxonomy comprised of six classifications: (1) patient Experience and engagement, (2) Quality of life; (3) Identification of patient risks; (4) Interventions to mitigate patient risks; (5) Treatment; and (6) Care coordination and navigation. Conclusions: Current quality measurement for OUD lacks patient-centeredness. EQuIITable Care for OUD provides a roadmap to develop measures of patient-centered care for OUD.
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Affiliation(s)
- A. Taylor Kelley
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Vulnerable Veteran Innovative Patient-aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Michael A. Incze
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jacob D. Baylis
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Vulnerable Veteran Innovative Patient-aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Spencer G. Calder
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Vulnerable Veteran Innovative Patient-aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Saul J. Weiner
- Center of Innovation for Complex Chronic Healthcare, Jesse Brown VA Chicago Health Care System, Chicago, Illinois, USA
- Division of Academic Internal Medicine and Geriatrics, Department of Medicine, The University of Illinois College of Medicine at Chicago, Chicago, Illinois, USA
| | - Susan L. Zickmund
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Audrey L. Jones
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Vulnerable Veteran Innovative Patient-aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Megan E. Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Molly B. Conroy
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Adam J. Gordon
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Vulnerable Veteran Innovative Patient-aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - John F.P. Bridges
- Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022. MMWR Recomm Rep 2022; 71:1-95. [PMID: 36327391 PMCID: PMC9639433 DOI: 10.15585/mmwr.rr7103a1] [Citation(s) in RCA: 457] [Impact Index Per Article: 228.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
This guideline provides recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients aged ≥18 years. It updates the CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016 (MMWR Recomm Rep 2016;65[No. RR-1]:1-49) and includes recommendations for managing acute (duration of <1 month), subacute (duration of 1-3 months), and chronic (duration of >3 months) pain. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care. The guideline addresses the following four areas: 1) determining whether or not to initiate opioids for pain, 2) selecting opioids and determining opioid dosages, 3) deciding duration of initial opioid prescription and conducting follow-up, and 4) assessing risk and addressing potential harms of opioid use. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Recommendations are based on systematic reviews of the scientific evidence and reflect considerations of benefits and harms, patient and clinician values and preferences, and resource allocation. CDC obtained input from the Board of Scientific Counselors of the National Center for Injury Prevention and Control (a federally chartered advisory committee), the public, and peer reviewers. CDC recommends that persons with pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient's circumstances. Recommendations should not be applied as inflexible standards of care across patient populations. This clinical practice guideline is intended to improve communication between clinicians and patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death.
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20
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Strigo IA, Murphy E, Mitchell JM, Spadoni AD. Learning from addiction: Craving of prescription opioids in chronic pain sufferers. Neurosci Biobehav Rev 2022; 142:104904. [PMID: 36202255 PMCID: PMC10917419 DOI: 10.1016/j.neubiorev.2022.104904] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/30/2022] [Accepted: 10/01/2022] [Indexed: 01/19/2023]
Abstract
Prescription opioids are a primary driver of opioid-related deaths. Although craving is a substantial component of OUD, the degree to which craving leads to misuse among chronic pain patients on long-term prescription opioids is unknown. A clear understanding of the factors that lead to misuse in this vulnerable population is needed for the development of safe and effective practices for opioid taper. This narrative review summarizes the relevant literature on the role of craving in addiction and chronic pain through epidemiological and behavioral studies. The first part of this review examines the role of craving in predicting opioid use/misuse in individuals with chronic pain with and without OUD. The second part covers methods on how craving is evaluated experimentally using both subjective and objective measures and provides related findings. The overall goal of this review is to facilitate the development of a population-specific description of craving in those who use opioids to control chronic pain and to describe how it may be mechanistically linked to patterns of opioid (mis)use.
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Affiliation(s)
- Irina A Strigo
- Emotion and Pain Laboratory, San Francisco Veterans Affairs Healthcare Center, 4150 Clement Street, San Francisco, CA 94121, USA; Department of Psychiatry, University of California San Francisco, 401 Parnassus Ave, San Francisco, CA 94143, USA.
| | - Emily Murphy
- Emotion and Pain Laboratory, San Francisco Veterans Affairs Healthcare Center, 4150 Clement Street, San Francisco, CA 94121, USA
| | - Jennifer M Mitchell
- Department of Psychiatry, University of California San Francisco, 401 Parnassus Ave, San Francisco, CA 94143, USA; Department of Neurology, University of California San Francisco, 401 Parnassus Ave, San Francisco, CA 94143, USA
| | - Andrea D Spadoni
- San Diego Veterans Affairs Healthcare Center, 3350 La Jolla Village Drive, San Diego, CA 92121, USA; Department of Psychiatry, University of California San Diego, San Diego, CA 92300, USA
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21
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Xie A, Hsu YJ, Speed TJ, Villanueva M, Hanna I, Slupek DA, Nguyen J, Shechter R, Hanna MN. Patient engagement and prescription opioid use in perioperative pain management. J Opioid Manag 2022; 18:421-433. [PMID: 36226782 PMCID: PMC10698916 DOI: 10.5055/jom.2022.0736] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To examine (1) patient perceptions regarding their engagement and the engagement of their families in perioperative pain management, (2) demographic and clinical characteristics associated with perceived patient and family engagement, and (3) the association between perceived patient and family engagement and patient outcomes. DESIGN A prospective, observational study. SETTING The Personalized Pain Program (PPP) at the Johns Hopkins Hospital in Baltimore, Maryland. PARTICIPANTS Patients having more than one visit to the PPP. INTERVENTIONS n/a. MAIN OUTCOME MEASURES Since the inception of the PPP, patients were surveyed prior to each clinic visit to assess their pain severity and interference using the Brief Pain Inventory. Starting August 22, 2018, two additional questions were added to the survey to assess patient perceptions of their engagement and the engagement of their families in perioperative pain management. In addition, electronic medical records were reviewed to collect data on daily opioid consumption during the first and last PPP visits presurgery and post-surgery. RESULTS The final analysis included 511 survey responses from 155 patients. Perceived engagement of the patient in perioperative pain management improved over time (p < .001) and was significantly associated with reduction in prescription opioid consumption after surgery (coef = 12.7, SE = 5.8, p = .031). CONCLUSIONS Surgical patients and their family members should be actively engaged in perioperative pain management to improve prescription opioid use and the quality and safety of perioperative care.
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Affiliation(s)
- Anping Xie
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yea-Jen Hsu
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Traci J. Speed
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mariel Villanueva
- Helene Fuld Leadership Program, Johns Hopkins University School of Nursing, Baltimore, MD, USA
| | - Irini Hanna
- University of Maryland School of Dentistry, Baltimore, MD, USA
| | - David A. Slupek
- Kansas City University of Medicine and Biosciences, Kansas City, MO, USA
| | - Jaclyn Nguyen
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ronen Shechter
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marie N. Hanna
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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22
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Cen X, Jena AB, Mackey S, Sun EC. Surgeon Variation in Perioperative Opioid Prescribing and Medium- or Long-term Opioid Utilization after Total Knee Arthroplasty: A Cross-sectional Analysis. Anesthesiology 2022; 137:151-162. [PMID: 35503990 PMCID: PMC9991517 DOI: 10.1097/aln.0000000000004259] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Whether a particular surgeon's opioid prescribing behavior is associated with prolonged postoperative opioid use is unknown. This study tested the hypothesis that the patients of surgeons with a higher propensity to prescribe opioids are more likely to utilize opioids long-term postoperatively. METHODS The study identified 612,378 Medicare fee-for-service patients undergoing total knee arthroplasty between January 1, 2011, and December 31, 2016. "High-intensity" surgeons were defined as those whose patients were, on average, in the upper quartile of opioid utilization in the immediate perioperative period (preoperative day 7 to postoperative day 7). The study then estimated whether patients of high-intensity surgeons had higher opioid utilization in the midterm (postoperative days 8 to 90) and long-term (postoperative days 91 to 365), utilizing an instrumental variable approach to minimize confounding from unobservable factors. RESULTS In the final sample of 604,093 patients, the average age was 74 yr (SD 5), and there were 413,121 (68.4%) females. A total of 180,926 patients (30%) were treated by high-intensity surgeons. On average, patients receiving treatment from a high-intensity surgeon received 36.1 (SD 35.0) oral morphine equivalent (morphine milligram equivalents) per day during the immediate perioperative period compared to 17.3 morphine milligram equivalents (SD 23.1) per day for all other patients (+18.9 morphine milligram equivalents per day difference; 95% CI, 18.7 to 19.0; P < 0.001). After adjusting for confounders, receiving treatment from a high-intensity surgeon was associated with higher opioid utilization in the midterm opioid postoperative period (+2.4 morphine milligram equivalents per day difference; 95% CI, 1.7 to 3.2; P < 0.001 [11.4 morphine milligram equivalents per day vs. 9.0]) and lower opioid utilization in the long-term postoperative period (-1.0 morphine milligram equivalents per day difference; 95% CI, -1.4 to -0.6; P < 0.001 [2.8 morphine milligram equivalents per day vs. 3.8]). While statistically significant, these differences are clinically small. CONCLUSIONS Among Medicare fee-for-service patients undergoing total knee arthroplasty, surgeon-level variation in opioid utilization in the immediate perioperative period was associated with statistically significant but clinically insignificant differences in opioid utilization in the medium- and long-term postoperative periods. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Xi Cen
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Anupam B Jena
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts; Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; and National Bureau of Economic Research, Cambridge, Massachusetts
| | - Sean Mackey
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Eric C Sun
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
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23
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Edmond SN, Wesolowicz DM, Moore BA, Ibarra J, Chhabra M, Fraenkel L, Becker WC. Opioid tapering support using a web-based app: Development and protocol for a pilot randomized controlled trial. Contemp Clin Trials 2022; 119:106857. [PMID: 35863697 DOI: 10.1016/j.cct.2022.106857] [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: 04/19/2022] [Revised: 07/01/2022] [Accepted: 07/14/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Given limited efficacy and potential harms of long-term opioid therapy, it is patient-centered and guideline-concordant to offer patients the opportunity to engage in a supportive, patient-centered tapering program. The goal of this study was to develop and pilot an interactive web-based program designed to support patients willing to consider an opioid taper; this manuscript describes the development and the protocol for a pilot randomized trial of Summit. METHODS We used intervention mapping to develop the Summit program; during the development period we engaged multiple stakeholder groups and conducted usability testing to refine the interactive, theory-informed, multi-component mobile website program which includes education, video testimonials, self-management skills, and access to a peer specialist. We will evaluate the Summit program in a two-arm, 9 month randomized-controlled trial where 64 individuals will be assigned either to the Summit program or to a control group (pain tracking app). As a pilot trial, the primary outcomes are feasibility and acceptability; we will also measure patient-reported outcomes related to pain, quality of life, and opioid use. IMPLICATIONS We developed an interactive program; results of the pilot trial are pending. If shown to be effective, Summit would be useful both in augmenting care for patients who are engaged in a taper with primary care.
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Affiliation(s)
- Sara N Edmond
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, United States of America; Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America.
| | - Danielle M Wesolowicz
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, United States of America; Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America
| | - Brent A Moore
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, United States of America; Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America
| | - Jennifer Ibarra
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, United States of America
| | - Manik Chhabra
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States of America
| | - Liana Fraenkel
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States of America; Berkshire Medical Center, Pittsfield, MA, United States of America
| | - William C Becker
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, United States of America; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States of America
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Magee MR, Gholamrezaei A, McNeilage AG, Sim A, Dwyer L, Ferreira ML, Darnall BD, Glare P, Ashton-James CE. A DIGITAL VIDEO AND TEXT MESSAGING INTERVENTION TO SUPPORT PEOPLE WITH CHRONIC PAIN DURING OPIOID TAPERING: CONTENT DEVELOPMENT USING CO-DESIGN (Preprint). JMIR Form Res 2022; 6:e40507. [DOI: 10.2196/40507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 09/05/2022] [Accepted: 09/06/2022] [Indexed: 11/13/2022] Open
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25
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Darnall BD. Clarification of Conflict of Interest Disclosures. JAMA Intern Med 2022; 182:689-690. [PMID: 35435929 DOI: 10.1001/jamainternmed.2022.0809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Beth D Darnall
- Stanford Pain Relief Innovations Lab, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
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26
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Fenton JJ, Magnan E, Tseregounis IE, Xing G, Agnoli AL, Tancredi DJ. Long-term Risk of Overdose or Mental Health Crisis After Opioid Dose Tapering. JAMA Netw Open 2022; 5:e2216726. [PMID: 35696163 PMCID: PMC9194670 DOI: 10.1001/jamanetworkopen.2022.16726] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 04/26/2022] [Indexed: 01/24/2023] Open
Abstract
Importance Patients prescribed long-term opioid therapy are increasingly undergoing dose tapering. Recent studies suggest that tapering is associated with short-term risks of substance misuse, overdose, and mental health crisis, although lower opioid dose could reduce risks of adverse events over the longer term. Objective To assess the longer-term risks of overdose or mental health crisis associated with opioid dose tapering. Design, Setting, and Participants This is a cohort study using an exposure-crossover analysis. Data were obtained from the OptumLabs Data Warehouse, which includes deidentified medical and pharmacy claims and enrollment records for commercial insurance and Medicare Advantage enrollees, representing a diverse mixture of ages, races, ethnicities, and geographical regions across the US. Participants were US adults who underwent opioid dose tapering from 2008 to 2017 after a 12-month baseline period of stable daily dosing of 50 morphine milligram equivalents or higher and who had at least 1 month of long-term follow-up during a postinduction period beginning 12 months after taper initiation. Data analysis was performed from October 2021 to April 2022. Exposures Opioid tapering, defined as 15% or more relative reduction in mean daily dose during any of 6 overlapping 60-day windows within a 7-month follow-up period after the stable baseline period. Main Outcomes and Measures Emergency or hospital encounters for drug overdose or withdrawal and mental health crisis (depression, anxiety, or suicide attempt). Outcome counts were assessed in pretaper and postinduction periods (from 12 to 24 months after taper initiation). Results The study included 21 515 tapering events among 19 377 patients with a mean (SD) of 9.1 (2.7) months of postinduction follow-up per event (median [IQR], 10 [8-11] months). Patients had a mean (SD) age of 56.9 (11.2) years, 11 581 (53.8%) were female, and 8217 (38.2%) had commercial insurance (vs Medicare Advantage). In conditional negative binomial regression analyses, adjusted incidence rate ratios for the postinduction period compared with the pretaper period were 1.57 (95% CI, 1.42-1.74) for overdose or withdrawal and 1.52 (95% CI, 1.35-1.71) for mental health crisis. Conclusions and Relevance These findings suggest that opioid tapering was associated with increased rates of overdose, withdrawal, and mental health crisis extending up to 2 years after taper initiation.
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Affiliation(s)
- Joshua J. Fenton
- Department of Family and Community Medicine, University of California, Davis, Sacramento
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento
| | - Elizabeth Magnan
- Department of Family and Community Medicine, University of California, Davis, Sacramento
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento
| | | | - Guibo Xing
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento
| | - Alicia L. Agnoli
- Department of Family and Community Medicine, University of California, Davis, Sacramento
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento
| | - Daniel J. Tancredi
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento
- Department of Pediatrics, University of California, Davis, Sacramento
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Clarification of Conflict of Interest Disclosures. JAMA Intern Med 2022; 182:690. [PMID: 35435928 PMCID: PMC9016596 DOI: 10.1001/jamainternmed.2022.0813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Darnall BD, Fields HL. Clinical and neuroscience evidence supports the critical importance of patient expectations and agency in opioid tapering. Pain 2022; 163:824-826. [PMID: 34382602 PMCID: PMC9009317 DOI: 10.1097/j.pain.0000000000002443] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 07/29/2021] [Accepted: 08/04/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Beth D. Darnall
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Howard L. Fields
- Department of Neurology, University of California San Francisco, School of Medicine, Weill Institute for Neurosciences, San Francisco CA, United States
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29
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Affiliation(s)
- Howard L Fields
- Department of Neurology, School of Medicine, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, United States
| | - Beth D Darnall
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
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30
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Magee M, Gholamrezaei A, McNeilage AG, Dwyer L, Sim A, Ferreira M, Darnall B, Glare P, Ashton-James C. Evaluating acceptability and feasibility of a mobile health intervention to improve self-efficacy in prescription opioid tapering in patients with chronic pain: protocol for a pilot randomised, single-blind, controlled trial. BMJ Open 2022; 12:e057174. [PMID: 35473742 PMCID: PMC9045093 DOI: 10.1136/bmjopen-2021-057174] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Opioid medications are no longer recommended as long-term therapy for chronic non-cancer pain, and many patients are advised to reduce or discontinue opioid medications. Many patients report difficulties in tapering opioid medications, necessitating supporting interventions. This protocol describes a pilot randomised controlled trial (RCT) to investigate the acceptability, feasibility and potential efficacy of a mobile health intervention to improve the opioid tapering self-efficacy of patients with chronic non-cancer pain. METHODS AND ANALYSIS The trial will be a single-blind (clinician, data collector and statistician-blinded) pilot RCT with two parallel arms. Forty adult patients with chronic non-cancer pain who are voluntarily reducing their prescribed opioid medications under medical guidance will be recruited from two tertiary pain clinics (Start date 25 August 2021). Participants will be randomly assigned to an intervention or control group. Both groups will receive usual care, including multidisciplinary pain management. In addition to usual care, the intervention group will receive a short informational and testimonial video about opioid tapering and will receive two specifically text messages per day for 28 days. The intervention is codesigned with patients and clinicians to provide evidence-based informational, motivational and emotional support to patients with chronic pain to taper opioid medications. Feasibility of the intervention and a future definitive RCT will be evaluated by measuring patient acceptability, delivery of the intervention, rates and reasons of exclusions and drop-outs, completion rates and missing data in the study questionnaires, and obtaining estimates for sample size determination. Potential efficacy will be evaluated by comparing changes in opioid tapering self-efficacy between the two groups. 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 ACTRN12621000795897.
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Affiliation(s)
- Michael Magee
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Pain Management Research Institute, Kolling Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Ali Gholamrezaei
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Pain Management Research Institute, Kolling Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Amy Gray McNeilage
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Pain Management Research Institute, Kolling Institute, The 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, The University of Sydney, Sydney, New South Wales, Australia
- Pain Management Research Institute, Kolling Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Manuela Ferreira
- Pain Management Research Institute, Kolling Institute, The University of Sydney, Sydney, New South Wales, Australia
- School of Health Sciences, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Beth Darnall
- Department of Anesthesia, Perioperative and Pain Medicine, Stanford University, Stanford, California, USA
| | - Paul Glare
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Pain Management Research Institute, Kolling Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Claire Ashton-James
- Sydney Medical School, Faculty of Medicine and Health, 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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Manhapra A. Complex Persistent Opioid Dependence-an Opioid-induced Chronic Pain Syndrome. Curr Treat Options Oncol 2022; 23:921-935. [PMID: 35435616 DOI: 10.1007/s11864-022-00985-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2022] [Indexed: 11/03/2022]
Abstract
OPINION STATEMENT Long-term opioid therapy (LTOT) for chronic cancer and non-cancer pain is commonly ineffective in providing its stated goal of improving function through good control of pain. Opioid tapering (slow dose reduction and/or discontinuation), the logical solution, also appears to be ineffective among many patients on LTOT as it often leads to even worse pain control and function, leaving the patients and providers managing LTOT in a clinical conundrum with little treatment choices. Complex persistent opioid dependence (CPOD) was recently offered as a heuristic to explain this clinical conundrum exemplified by the ineffectiveness of both LTOT and opioid tapering. This manuscript provides a detailed description of the neurobehavioral underpinnings of CPOD, explaining how long-term opioid use can lead to more pain even while experiencing relief with each opioid dose. CPOD is characterized by the allostatic opponent mechanisms of neuroadaptations related to the progression of opioid dependence and tolerance involving nociceptive/anti-nociceptive brain systems causing opioid-induced hyperalgesia and reward/anti-reward systems causing hyperkatefia or suffering that induces pain experience through the cognitive/emotional component of pain mechanisms. "Opioid Induced Chronic Pain syndrome" (OICP) is offered as an alternate clinical diagnostic term instead of CPOD that has several limitations as a diagnosis term including poor patient acceptance due to stigma towards addiction and clinical confounding with opioid use disorder, a related but separate clinical entity. OICP with LTOT is conceptualized as a recoverable iatrogenic problem that can be managed by pain providers. Broad guidance on management of OICP is also provided.
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Affiliation(s)
- Ajay Manhapra
- Pain Medicine, Hampton VA Medical Center, 100 Emancipation Drive, Hampton, VA, 23667, USA. .,New England Mental Illness Research Education and Clinical Center (MIRECC), West Haven, CT, USA. .,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA. .,Departments of Physical Medicine and Rehabilitation and Psychiatry, Eastern Virginia Medical School, Norfolk, VA, USA.
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32
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Avery N, McNeilage AG, Stanaway F, Ashton-James CE, Blyth FM, Martin R, Gholamrezaei A, Glare P. Efficacy of interventions to reduce long term opioid treatment for chronic non-cancer pain: systematic review and meta-analysis. BMJ 2022; 377:e066375. [PMID: 35379650 PMCID: PMC8977989 DOI: 10.1136/bmj-2021-066375] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To review interventions to reduce long term opioid treatment in people with chronic non-cancer pain, considering efficacy on dose reduction and discontinuation, pain, function, quality of life, withdrawal symptoms, substance use, and adverse events. DESIGN Systematic review and meta-analysis of randomised controlled trials and non-randomised studies of interventions. DATA SOURCES Medline, Embase, PsycINFO, CINAHL, and the Cochrane Library searched from inception to July 2021. Reference lists and previous reviews were also searched and experts were contacted. ELIGIBILITY CRITERIA FOR STUDY SELECTION Original research in English. Case reports and cross sectional studies were excluded. DATA EXTRACTION AND SYNTHESIS Two authors independently selected studies, extracted data, and used the Cochrane risk-of-bias tools for randomised and non-randomised studies (RoB 2 and ROBINS-I). Authors grouped interventions into five categories (pain self-management, complementary and alternative medicine, pharmacological and biomedical devices and interventions, opioid replacement treatment, and deprescription methods), estimated pooled effects using random effects meta-analytical models, and appraised the certainty of evidence using GRADE (grading of recommendations, assessment, development, and evaluation). RESULTS Of 166 studies meeting inclusion criteria, 130 (78%) were considered at critical risk of bias and were excluded from the evidence synthesis. Of the 36 included studies, few had comparable treatment arms and sample sizes were generally small. Consequently, the certainty of the evidence was low or very low for more than 90% (41/44) of GRADE outcomes, including for all non-opioid patient outcomes. Despite these limitations, evidence of moderate certainty indicated that interventions to support prescribers' adherence to guidelines increased the likelihood of patients discontinuing opioid treatment (adjusted odds ratio 1.5, 95% confidence interval 1.0 to 2.1), and that these prescriber interventions as well as pain self-management programmes reduced opioid dose more than controls (intervention v control, mean difference -6.8 mg (standard error 1.6) daily oral morphine equivalent, P<0.001; pain programme v control, -14.31 mg daily oral morphine equivalent, 95% confidence interval -21.57 to -7.05). CONCLUSIONS Evidence on the reduction of long term opioid treatment for chronic pain continues to be constrained by poor study methodology. Of particular concern is the lack of evidence relating to possible harms. Agreed standards for designing and reporting studies on the reduction of opioid treatment are urgently needed. REVIEW REGISTRATION PROSPERO CRD42020140943.
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Affiliation(s)
- Nicholas Avery
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - Amy G McNeilage
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - Fiona Stanaway
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Claire E Ashton-James
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - Fiona M Blyth
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Rebecca Martin
- Michael J Cousins Pain Management and Research Centre, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Ali Gholamrezaei
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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Engagement in Prescription Opioid Tapering Research: the EMPOWER Study and a Coproduction Model of Success. J Gen Intern Med 2022; 37:113-117. [PMID: 34389937 PMCID: PMC8993995 DOI: 10.1007/s11606-021-07085-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 07/21/2021] [Indexed: 10/31/2022]
Abstract
Patients with chronic pain experience stigma within the healthcare system. This stigma is compounded for those taking long-term prescription opioids. Often, public messaging and organizational policies have telegraphed that opioid treatment is a problem to be solved by focusing only on medication reduction efforts. Lack of data has contributed to misperceptions and poor opioid policies. In part, data collection remains poor because patients feel fractured from systems of care and are often not interested in engaging with opioid reduction mandates and research. Similarly, clinicians may fail to engage with opioid stewardship and research due to complexities that exceed their training or capacities. The EMPOWER study applies a coproduction model that engages researchers, patients, clinicians, managers, and other health system users. Key stakeholders shaped the design of the study to best ensure acceptability and engagement of the "end users"-patients who enroll in the study and the clinicians who implement the opioid tapers. Targeting the needs of any stakeholder group in isolation is suboptimal. Accordingly, we detail the EMPOWER patient-centered opioid tapering clinical research framework and specific strategies to address stakeholder concerns. We also discuss how this framework may be applied to enhance engagement in healthcare research broadly.
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Abstract
This review summarizes current evidence related to perioperative opioid prescription fulfillment and use and discusses the role of personalized anesthesia care in mitigating opioid-related harms without compromising analgesia.
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Affiliation(s)
- Daniel B. Larach
- Department of Anesthesiology, Vanderbilt University Medical Center (Nashville, TN)
| | - Jennifer M. Hah
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine (Stanford, CA)
| | - Chad M. Brummett
- Department of Anesthesiology, University of Michigan Medical School (Ann Arbor, MI)
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35
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Kral LA, Bettinger JJ, Vartan CM, Hadlandsmyth K, Kullgren J, Smith MA. A Survey on Opioid Tapering Practices, Policies, and Perspectives by Pain and Palliative Care Pharmacists. J Pain Palliat Care Pharmacother 2022; 36:2-10. [PMID: 35254209 DOI: 10.1080/15360288.2022.2041147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Opioid tapering is an essential clinical tool to utilize for a variety of reasons, including safety and analgesic optimization. The need for individualized regimens reveals a corresponding need for healthcare providers who can actively manage patients throughout the process. Pharmacists have taken on an integral role for achieving success in opioid tapering. This survey was conducted to describe the current opioid tapering practices of pain and palliative care pharmacists. A Qualtrics survey was offered to the Society of Pain and Palliative Care Pharmacist members. The majority (87%) indicated they specialized in pain management. Almost all respondents (98%) reported providing tapering recommendations and 82% reported being involved with patient monitoring throughout the taper. The majority (multiple responses could be chosen) noted that the indication for initiating an opioid taper was due to abuse/misuse (91%), reduced overall efficacy (89%), and adverse drug reactions (78%). The most common follow-up intervals during tapering were weekly (15%), every 2 weeks (22%), and every 4 weeks (44%). This practice-based survey, though small, showed that pharmacists in pain management and palliative care are actively involved in opioid tapering. This survey will hopefully serve as a foundation for continuing research into opioid tapering and the pharmacist's role therein.
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36
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Keefe FJ. Managing Acute Pain With Opioids in the Emergency Department: A Teachable Moment? Am J Public Health 2022; 112:S9-S11. [PMID: 35143264 PMCID: PMC8842220 DOI: 10.2105/ajph.2022.306748] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Francis J. Keefe
- Francis J. Keefe is with the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Chapel Hill, NC
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37
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Bedford T, Kisaalita N, Haycock NR, Mullins CD, Wright T, Curatolo M, Hamlin L, Colloca L. Attitudes Toward a Pre-authorized Concealed Opioid Taper: A Qualitative Analysis of Patient and Clinician Perspectives. Front Psychiatry 2022; 13:820357. [PMID: 35401245 PMCID: PMC8987573 DOI: 10.3389/fpsyt.2022.820357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 02/23/2022] [Indexed: 11/18/2022] Open
Abstract
Standard opioid tapers tend to be associated with increased patient anxiety and higher pain ratings. Pre-authorized concealed opioid reductions may minimize expectations such as fear of increased pain due to the reduction of opioids and, prolong analgesic benefits in experimental settings. We recently observed that patients and clinicians are open to concealed opioid tapering. However, little is known about the "why" behind their attitudes. Based on this lack of data, we analyzed qualitative responses to survey questions on patients' and clinicians' acceptance of a concealed opioid reduction for chronic pain. Seventy-four patients with a history of high dose opioid therapy and 49 clinicians completed a web-based questionnaire with open-ended questions examining responses to two hypothetical clinical trials comparing a concealed opioid reduction pre-authorized by patients vs. standard tapering. We used content analysis based on qualitative descriptive methodology to analyze comments from the patients and clinicians. Five themes were identified: informed consent; anxiety; safety; support; and ignorance is bliss, or not. These themes highlight the overall positive attitudes toward concealed opioid tapers. Our findings reinforce the importance of patient-centered care and are expected to inform the design of clinical trials from both the patient and clinician perspective. This qualitative study presents patients' and clinicians' attitudes toward hypothetical scenarios for a trial of pre-authorized reduction of opioids. The findings indicate positive attitudes and the relevance of engaging patients with effective decision-making processes.
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Affiliation(s)
- Theresa Bedford
- 711 Human Performance Wing, En Route Care, Wright Patterson Air Force Base, OH, United States
| | - Nkaku Kisaalita
- Mental Health Service Line, Orlando Veterans Affairs Healthcare System, Orlando, FL, United States
| | - Nathaniel R Haycock
- Department of Pain and Translational Symptom Science, School of Nursing, University of Maryland, Baltimore, MD, United States
| | - C Daniel Mullins
- Department of Pharmaceutical Health Services Research, School of Pharmacy, University of Maryland, Baltimore, MD, United States
| | - Thelma Wright
- Department of Anesthesiology, School of Medicine, University of Maryland, Baltimore, MD, United States
| | - Michele Curatolo
- Department of Anesthesiology & Pain Medicine, School of Medicine, University of Washington, Seattle, WA, United States
| | - Lynette Hamlin
- Uniformed Services University of the Health Sciences, Graduate School of Nursing, Bethesda, MD, United States
| | - Luana Colloca
- Department of Pain and Translational Symptom Science, School of Nursing, University of Maryland, Baltimore, MD, United States.,Department of Anesthesiology, School of Medicine, University of Maryland, Baltimore, MD, United States.,Center to Advance Chronic Pain Research, University of Maryland, Baltimore, MD, United States
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38
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Emary PC, Oremus M, Mbuagbaw L, Busse JW. Association of chiropractic integration in an Ontario community health centre with prescription opioid use for chronic non-cancer pain: a mixed methods study protocol. BMJ Open 2021; 11:e051000. [PMID: 34732481 PMCID: PMC8572393 DOI: 10.1136/bmjopen-2021-051000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Emerging evidence from a number of primary care centres suggests that integration of chiropractic services into chronic pain management is associated with improved clinical outcomes and high patient satisfaction as well as with reductions in physician visits, specialist referrals use of advanced imaging and prescribing of analgesics. However, formal assessments of the integration of chiropractic services into primary care settings are sparse, and the impact of such integration on prescription opioid use in chronic pain management remains uncertain. To help address this knowledge gap, we will conduct a mixed methods health service evaluation of an integrated chiropractic back pain programme in an urban community health centre in Ontario, Canada. This centre provides services to vulnerable populations with high unemployment rates, multiple comorbidities and musculoskeletal disorders that are commonly managed with prescription opioids. METHODS AND ANALYSIS We will use a sequential explanatory mixed methods design, which consists of a quantitative phase followed by a qualitative phase. In the quantitative phase, we will conduct a retrospective chart review and evaluate whether receipt of chiropractic services is associated with reduced opioid use among patients already prescribed opioid therapy for chronic pain. We will measure opioid prescriptions (ie, opioid fills, number of refills and dosages) by reviewing electronic medical records of recipients and non-recipients of chiropractic services between 1 January 2014 and 31 December 2020 and use multivariable regression analysis to examine the association. In the qualitative phase, we will conduct in-depth, one-on-one interviews of patients and their general practitioners to explore perceptions of chiropractic integration and its impact on opioid use. ETHICS AND DISSEMINATION This study was approved by the Hamilton Integrated Research Ethics Board at McMaster University (approval number 2021-10930). The results will be disseminated via peer-reviewed publications, conference presentations and in-person or webinar presentations to community members and healthcare professionals.
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Affiliation(s)
- Peter C Emary
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Chiropractic, D'Youville College, Buffalo, New York, USA
- School of Public Health Sciences, Private Practice, Cambridge, Ontario, Canada
| | - Mark Oremus
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Lawrence Mbuagbaw
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St. Joseph's Healthcare, Hamilton, Ontario, Canada
- Centre for Development of Best Practices in Health (CDBPH), Yaoundé Central Hospital, Yaoundé, Cameroon
- Global Health, Stellenbosch University, Cape Town, South Africa
| | - Jason W Busse
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Anesthesia, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote National Pain Centre, McMaster University, Hamilton, Ontario, Canada
- Chronic Pain Centre of Excellence for Canadian Veterans, Hamilton, Ontario, Canada
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39
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Elphinston RA, Sullivan MJL, Sterling M, Connor JP, Baranoff JA, Tan D, Day MA. Pain Medication Beliefs Mediate the Relationship Between Pain Catastrophizing and Opioid Prescription Use in Patients With Chronic Non-Cancer Pain. THE JOURNAL OF PAIN 2021; 23:379-389. [PMID: 34662709 DOI: 10.1016/j.jpain.2021.08.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/16/2021] [Accepted: 08/24/2021] [Indexed: 10/20/2022]
Abstract
Little is known about the mechanisms by which pain catastrophizing may be associated with opioid use outcomes. This study aimed to investigate the potential mediating role of beliefs about the appropriateness of pain medicines for pain treatment on the association between pain catastrophizing and prescription opioid use in a community chronic non-cancer pain (CNCP) sample. Individuals (N = 420) diagnosed with CNCP participated in a cross-sectional online self-report study with validated measures of pain medication beliefs, pain catastrophizing, and current prescription opioid use. Two parallel multiple mediator analyses with percentile-based bootstrapping examined pathways to both prescription opioid use and high-dose use (≥ 100mg oral morphine equivalents/day), while controlling for pain intensity and other relevant covariates. Pain medication beliefs significantly mediated the association between pain catastrophizing and prescription opioid use (CI = 0.011, 0.033). A similar pattern of findings was found for high-dose opioid use, with pain medication beliefs significantly mediating the pain catastrophizing-high-dose use association (CI = 0.006, 0.050). Pain medication beliefs are a potentially modifiable psychological mechanism by which pain catastrophizing is associated with opioid use, including high-dose use. These findings have important implications for personalizing prevention and treatment programs.
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Affiliation(s)
- Rachel A Elphinston
- RECOVER Injury Research Centre, The University of Queensland, Brisbane, Australia; National Health and Medical Research Council Centre for Research Excellence in Road Traffic Injury Recovery, The University of Queensland, Brisbane, Australia; School of Psychology, The University of Queensland, Brisbane, Australia.
| | | | - Michele Sterling
- RECOVER Injury Research Centre, The University of Queensland, Brisbane, Australia; National Health and Medical Research Council Centre for Research Excellence in Road Traffic Injury Recovery, The University of Queensland, Brisbane, Australia
| | - Jason P Connor
- Discipline of Psychiatry, The University of Queensland, Brisbane, Australia; National Centre for Youth Substance Use Research, The University of Queensland, Brisbane, Australia
| | - John A Baranoff
- School of Psychology, The University of Queensland, Brisbane, Australia; Centre for Treatment of Anxiety and Depression, SA Health, Adelaide, South Australia
| | - Dylan Tan
- School of Psychology, The University of Queensland, Brisbane, Australia
| | - Melissa A Day
- School of Psychology, The University of Queensland, Brisbane, Australia; Department of Rehabilitation Medicine, The University of Washington, Washington
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40
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Bakshi N, Hart AL, Lee MC, Williams ACDC, Lackner JM, Norton C, Croft P. Chronic pain in patients with inflammatory bowel disease. Pain 2021; 162:2466-2471. [PMID: 34534174 PMCID: PMC8442739 DOI: 10.1097/j.pain.0000000000002304] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 03/19/2021] [Accepted: 03/31/2021] [Indexed: 12/19/2022]
Affiliation(s)
- Nikul Bakshi
- Research Department, Crohn's and Colitis UK, Hatfield, United Kingdom
| | | | - Michael C. Lee
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Amanda C de C. Williams
- Research Department of Clinical, Educational and Health Psychology, University College London, and Pain Management Centre, University College Hospitals NHS Foundation Trust, London, United Kingdom
| | - Jeffrey M. Lackner
- Division of Behavioral Medicine, Department of Medicine, University at Buffalo, SUNY, Buffalo, NY, United States
| | - Christine Norton
- Division of Care for Long-Term Conditions, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College, London, United Kingdom
| | - Peter Croft
- Primary Care Centre Versus Arthritis and Centre for Prognosis Research, Keele University, Keele, United Kingdom
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41
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Ballantyne JC, Koob GF. Allostasis theory in opioid tolerance. Pain 2021; 162:2315-2319. [PMID: 33769368 DOI: 10.1097/j.pain.0000000000002280] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 03/17/2021] [Indexed: 01/29/2023]
Affiliation(s)
- Jane C Ballantyne
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, United States
| | - George F Koob
- National Institute of Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD, United States
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42
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Fishbain DA. Opioid Tapering/Detoxification Protocols, A Compendium: Narrative Review. PAIN MEDICINE 2021; 22:1676-1697. [PMID: 33860319 DOI: 10.1093/pm/pnab019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES The opioid epidemic has put pressure on clinicians to taper their chronic pain patients (CPPs) from opioids. This has resulted in rapid or forced tapers and opioid discontinuation. Partially responsible is lack of information on how to taper (tapering protocols).The objectives of this narrative review were then the following: compile all the published opioid tapering/detoxification protocols from the pain/drug rehabilitation/psychiatric literature whether for inpatient or outpatient use; organize these into general types; compare the types for advantages/disadvantages for use by a clinician in an outpatient setting; and answer some commonly asked questions relating to opioid tapering. METHODS Relevant references were identified by a search strategy utilizing the terms tapering, tapering protocols, detoxification, detoxification protocols, withdrawal, dependence, addiction, and drug rehabilitation. These were explored with the term opioids. Identified abstract were reviewed for any study relating to the objectives of this review. Those studies were then included in this review. As this is a narrative review, no quality ratings of these references were performed. RESULTS Of 1,922 abstracts identified by this search strategy, 301 were reviewed in detail for potential inclusion. Of these, 104 were utilized in this review. Nine types of opioid tapering protocols were identified and compared in tabular form. Twenty-two questions in reference to opioid tapering were addressed. CONCLUSIONS Based on this review, the protocol utilizing the opioid of current use is the simplest to use as it requires no rotation to another opioid and thereby avoids rotation errors. It also has behavior advantages.
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Affiliation(s)
- David A Fishbain
- Departments of Psychiatry, Miller School of Medicine at the University of Miami, Miami, Florida, USA.,Neurological Surgery, Miller School of Medicine at the University of Miami, Miami, Florida, USA.,Anesthesiology, Miller School of Medicine at the University of Miami, Miami, Florida, USA
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43
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Martel MO, Bruneau A, Edwards RR. Mind-body approaches targeting the psychological aspects of opioid use problems in patients with chronic pain: evidence and opportunities. Transl Res 2021; 234:114-128. [PMID: 33676035 DOI: 10.1016/j.trsl.2021.02.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 02/26/2021] [Accepted: 02/26/2021] [Indexed: 12/27/2022]
Abstract
Opioids are commonly prescribed for the management of patients with chronic noncancer pain. Despite the potential analgesic benefits of opioids, long-term opioid therapy (LTOT) may be accompanied by problems such as opioid misuse and opioid use disorder (OUD). In this review, we begin with a description of opioid misuse and OUD and the patient-specific factors associated with these problems among patients with chronic pain. We will focus primarily on highlighting the predominant role played by psychological factors in the occurrence of opioid misuse and OUD in these patients. Several psychological factors have been found to be associated with opioid use problems in patients with chronic pain, and evidence indicates that patients presenting with psychological disturbances are particularly at risk of transitioning to long-term opioid use, engaging in opioid misuse behaviors, and developing OUD. The biological factors that might underlie the association between psychological disturbances and opioid use problems in patients with chronic pain have yet to be fully elucidated, but a growing number of studies suggest that dysfunctions in reward, appetitive, autonomic, and neurocognitive systems might be involved. We end with an overview of specific types of psychological interventions that have been put forward to prevent or reduce the occurrence of opioid misuse and OUD in patients with chronic pain who are prescribed LTOT.
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Affiliation(s)
- Marc O Martel
- Faculty of Dentistry & Department of Anesthesiology, McGill University, Montreal, Canada; Division of Experimental Medicine, McGill University, Montreal, Canada
| | - Alice Bruneau
- Division of Experimental Medicine, McGill University, Montreal, Canada
| | - Robert R Edwards
- Department of Anesthesiology & Pain Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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Goldstick JE, Guy GP, Losby JL, Baldwin G, Myers M, Bohnert ASB. Changes in Initial Opioid Prescribing Practices After the 2016 Release of the CDC Guideline for Prescribing Opioids for Chronic Pain. JAMA Netw Open 2021; 4:e2116860. [PMID: 34255047 PMCID: PMC8278262 DOI: 10.1001/jamanetworkopen.2021.16860] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The Centers for Disease Control and Prevention (CDC) released the "Guideline For Prescribing Opioids For Chronic Pain" (hereafter, CDC guideline) in 2016, but its association with prescribing practices for patients who are opioid naive is unknown. OBJECTIVE To estimate changes in initial prescribing rates, duration, and dosage practices to patients who are opioid naive after the release of the CDC guideline. DESIGN, SETTING, AND PARTICIPANTS This cohort study used 6 sequential cohorts to estimate preguideline trends in prescribing among patients who were opioid naive, project that trend forward, and compare it with postguideline prescribing practices. Participants included commercially insured adults without current cancer or hospice care diagnoses and with no past-year opioid claims in the US from 2011 to 2017. All adjusted models were controlled for patient demographics and state-fixed effects. Data were analyzed from January 2020 to May 2021. EXPOSURES The release of the CDC guideline. MAIN OUTCOMES AND MEASURES Indicators of any opioid prescription fills during a 9-month period, the number of days' supply of the initial prescription, and the binary indicator of whether the initial prescription was for 50 or more morphine milligram equivalents (MMEs) per day. RESULTS There were 12 870 612 eligible unique patients across cohorts (mean [SD] age in 2016, 51.2 [18.7] years; 6 553 458 [50.9%] women); and the mean (SD) age of the cohorts increased annually, from 48.7 (17.9) years in the April 2011 to December 2012 cohort to 51.9 (19.2) years in the April 2016 to December 2017 cohort. The postguideline prescribing prevalence was 532 962 of 5 834 088 individuals (9.1%), which exceeded that projected from the preguideline trend, estimated at 9.0% (95% CI, 9.0%-9.1%). Among patients receiving prescriptions during follow-up, adjusted mean days' supply was 4.7% (95% CI, 4.3%-5.1%) lower in the first year after release of the guideline and 9.8% (95% CI, 9.3%-10.3%) lower in the second year after release, compared with the expected rate from the preguideline trend. The adjusted odds of receiving a high-dose (ie, ≥50 MME/d) initial prescription were lower in the first year (odds ratio, 0.97; 95% CI, 0.96-0.98) and in the second year (odds ratio, 0.94; 95% CI, 0.93-0.96) after the release of the CDC guideline compared with the odds expected from the preguideline trend. CONCLUSIONS AND RELEVANCE This cohort study found that patients who were opioid naive continued to initiate opioid therapy after the release of opioid prescribing guidelines by the CDC, but trends in prescribing duration reversed and decreased, after increasing in each of 4 preguideline cohorts examined. High-dose prescribing rates were already decreasing, but those trends accelerated after the CDC guideline release. These results suggest that nonmandatory, evidence-based guidelines from trusted sources were associated with prescribing practices. Guideline-concordant care has potential to improve pain management and reduce opioid-related harms.
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Affiliation(s)
- Jason E. Goldstick
- Injury Prevention Center, University of Michigan, Ann Arbor
- Department of Emergency Medicine, University of Michigan, Ann Arbor
| | - Gery P. Guy
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jan L. Losby
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Grant Baldwin
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Matthew Myers
- Injury Prevention Center, University of Michigan, Ann Arbor
- Department of Emergency Medicine, University of Michigan, Ann Arbor
| | - Amy S. B. Bohnert
- Injury Prevention Center, University of Michigan, Ann Arbor
- Department of Anesthesiology, University of Michigan, Ann Arbor
- Department of Psychiatry, University of Michigan, Ann Arbor
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Ie K, Aoshima S, Yabuki T, Albert SM. A narrative review of evidence to guide deprescribing among older adults. J Gen Fam Med 2021; 22:182-196. [PMID: 34221792 PMCID: PMC8245739 DOI: 10.1002/jgf2.464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/24/2021] [Accepted: 05/09/2021] [Indexed: 11/30/2022] Open
Abstract
Potentially inappropriate prescription and polypharmacy are well‐known risk factors for morbidity and mortality among older adults. However, recent systematic reviews have failed to demonstrate the overall survival benefits of deprescribing. Thus, it is necessary to synthesize the current evidence to provide a practical direction for future research and clinical practice. This review summarizes the existing body of evidence regarding deprescribing to identify useful intervention elements. There is evidence that even simple interventions, such as direct deprescribing targeted at risky medications and explicit criteria‐based approaches, effectively reduce inappropriate prescribing. On the other hand, if the goal is to improve clinical outcomes such as hospitalization and emergency department visits, patient‐centered multimodal interventions such as a combination of medication review, multidisciplinary collaboration, and patient education are likely to be more effective. We also consider the opportunities and challenges for deprescribing within the Japanese healthcare system.
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Affiliation(s)
- Kenya Ie
- Division of General Internal Medicine Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan.,Division of General Internal Medicine Department of Internal Medicine Kawasaki Municipal Tama Hospital Kawasaki Japan.,Department of Behavioral and Community Health Sciences University of Pittsburgh Graduate School of Public Health Pittsburgh PA USA
| | | | - Taku Yabuki
- Department of Internal Medicine Tochigi Medical Center Tochigi Japan
| | - Steven M Albert
- Department of Behavioral and Community Health Sciences University of Pittsburgh Graduate School of Public Health Pittsburgh PA USA
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Magee MR, McNeilage AG, Avery N, Glare P, Ashton-James CE. mHealth Interventions to Support Prescription Opioid Tapering in Patients With Chronic Pain: Qualitative Study of Patients' Perspectives. JMIR Form Res 2021; 5:e25969. [PMID: 34003133 PMCID: PMC8170552 DOI: 10.2196/25969] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/29/2021] [Accepted: 04/06/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Patients with chronic pain who are tapering prescription opioids report a need for greater support for coping with symptoms of pain and withdrawal. Mobile health (mHealth) technologies (SMS text messaging- or app-based) have the potential to provide patients with educational, emotional, and motivational support for opioid tapering beyond what is offered by their health care provider. However, it is not known whether patients with chronic pain who are tapering opioids would be willing or able to engage with technology-based support. OBJECTIVE This study aims to examine patients' use of mobile technologies in health care, interest in using mHealth support, preferences for the form and content of mHealth support, and potential barriers to and facilitators of engagement with mHealth support for opioid tapering. METHODS A total of 21 patients (11 women and 10 men; age range 29-83 years) with chronic noncancer pain on long-term opioid therapy who had recently initiated a voluntary opioid taper were recruited from primary and tertiary care clinics in metropolitan and regional Australia for a larger study of patients' experiences of opioid tapering. Participants had been taking prescription opioids for a mean duration of 13 (SD 9.6; range 0.25-30) years at the time of the study. Survey items characterized participants' typical mobile phone use and level of interest in mobile technology-based support for opioid tapering. Semistructured interviews further explored patients' use of mobile technologies and their interest in, preferences for, and perspectives on potential barriers to and facilitators of engagement with mHealth support for opioid tapering. Two researchers collaborated to conduct a thematic analysis of the interview data. RESULTS All participants reported owning and using a mobile phone, and most (17/21, 81%) participants reported using mobile apps. The majority of participants expressed interest in SMS text messaging-based (17/21, 81%) and app-based (15/21, 71%) support for opioid tapering. Participants expected that messages delivering both informational and socioemotional support would be helpful. Participants expected that access to technology, mobile reception, internet connectivity, vision impairment, and low self-efficacy for using apps may be barriers to user engagement. Patients expected that continuity of care from their health care provider, flexible message dosing, responsivity, and familiarity with pain self-management strategies would increase user engagement. CONCLUSIONS The results of this study indicate that patients with chronic noncancer pain may be willing to engage with SMS text messaging-based and app-based mHealth interventions to support opioid tapering. However, the feasibility and acceptability of these interventions may depend on how patients' preferences for functionality, content, and design are addressed.
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Affiliation(s)
- Michael Reece Magee
- Pain Management Research Institute, Faculty of Medicine and Health, The University of Sydney, St Leonards, Australia
| | - Amy Gray McNeilage
- Pain Management Research Institute, Faculty of Medicine and Health, The University of Sydney, St Leonards, Australia
| | - Nicholas Avery
- Pain Management Research Institute, Faculty of Medicine and Health, The University of Sydney, St Leonards, Australia
| | - Paul Glare
- Pain Management Research Institute, Faculty of Medicine and Health, The University of Sydney, St Leonards, Australia
| | - Claire Elizabeth Ashton-James
- Pain Management Research Institute, Faculty of Medicine and Health, The University of Sydney, St Leonards, Australia
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Buonora M, Perez HR, Stumph J, Allen R, Nahvi S, Cunningham CO, Merlin JS, Starrels JL. Medical Record Documentation About Opioid Tapering: Examining Benefit-to-Harm Framework and Patient Engagement. PAIN MEDICINE 2021; 21:2574-2582. [PMID: 32142143 DOI: 10.1093/pm/pnz361] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Guidelines recommend that clinicians make decisions about opioid tapering for patients with chronic pain using a benefit-to-harm framework and engaging patients. Studies have not examined clinician documentation about opioid tapering using this framework. DESIGN AND SETTING Thematic and content analysis of clinician documentation about opioid tapering in patients' medical records in a large academic health system. METHODS Medical records were reviewed for patients aged 18 or older, without cancer, who were prescribed stable doses of long-term opioid therapy between 10/2015 and 10/2016 then experienced an opioid taper (dose reduction ≥30%) between 10/2016 and 10/2017. Inductive thematic analysis of clinician documentation within six months of taper initiation was conducted to understand rationale for taper, and deductive content analysis was conducted to determine the frequencies of a priori elements of a benefit-to-harm framework. RESULTS Thematic analysis of 39 patients' records revealed 1) documented rationale for tapering prominently cited potential harms of continuing opioids, rather than observed harms or lack of benefits; 2) patient engagement was variable and disagreement with tapering was prominent. Content analysis found no patients' records with explicit mention of benefit-to-harm assessments. Benefits of continuing opioids were mentioned in 56% of patients' records, observed harms were mentioned in 28%, and potential harms were mentioned in 90%. CONCLUSIONS In this study, documentation of opioid tapering focused on potential harms of continuing opioids, indicated variable patient engagement, and lacked a complete benefit-to-harm framework. Future initiatives should develop standardized ways of incorporating a benefit-to-harm framework and patient engagement into clinician decisions and documentation about opioid tapering.
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Affiliation(s)
- Michele Buonora
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York
| | - Hector R Perez
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York
| | - Jordan Stumph
- Department of Physical Medicine and Rehabilitation, New York-Presbyterian Columbia/Cornell, New York, New York
| | - Robert Allen
- Department of Emergency Medicine, SUNY Downstate Medical Center, Brooklyn, New York
| | - Shadi Nahvi
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York
| | - Chinazo O Cunningham
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York
| | - Jessica S Merlin
- Center for Research on Healthcare, Divisions of General Internal Medicine and Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Joanna L Starrels
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York
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Darnall BD, Mackey SC, Lorig K, Kao MC, Mardian A, Stieg R, Porter J, DeBruyne K, Murphy J, Perez L, Okvat H, Tian L, Flood P, McGovern M, Colloca L, King H, Van Dorsten B, Pun T, Cheung M. Comparative Effectiveness of Cognitive Behavioral Therapy for Chronic Pain and Chronic Pain Self-Management within the Context of Voluntary Patient-Centered Prescription Opioid Tapering: The EMPOWER Study Protocol. PAIN MEDICINE 2021; 21:1523-1531. [PMID: 31876947 PMCID: PMC7530567 DOI: 10.1093/pm/pnz285] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Objective. Evidence to date, while sparse, suggests that patients taking long-term opioids require special considerations and protections to prevent potential iatrogenic harms from opioid de-prescribing, such as increased pain or suffering. Following this study protocol, the EMPOWER study seeks to address multiple unmet needs of patients with chronic pain who desire to reduce long-term opioid therapy, and provide the clinical evidence on effective methodology. Methods. EMPOWER applies patient-centered methods for voluntary prescription opioid reduction conducted within a comprehensive, multi-state, 3-arm randomized controlled comparative effectiveness study of three study arms (1) group cognitive behavioral therapy for chronic pain; (2) group chronic pain self-management; and (3) usual care (taper only). Specialized electronic data capture systems collect patient reported symptoms and satisfaction data weekly and monthly during the taper, with real-time clinical alerts and electronic feedback loops informing, documenting, and steering needed care actions. Conclusion. The EMPOWER study seeks to provide granular evidence on patient response to voluntary opioid tapering, and will provide evidence to inform clinical systems changes, clinical care, patient satisfaction, and patient outcomes for opioid reduction.
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Affiliation(s)
- Beth D Darnall
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Sean C Mackey
- Division of Pain Medicine, Stanford Systems Neuroscience and Pain Lab, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Kate Lorig
- Stanford University School of Medicine, Palo Alto, California
| | - Ming-Chih Kao
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Aram Mardian
- Department of Family, Community, and Preventive Medicine, Phoenix VA Health Care System, Chronic Pain Wellness Center, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | | | - Joel Porter
- Department of Family Medicine, Intermountain Healthcare, Layton, Utah
| | - Korina DeBruyne
- Division of Primary, Preventive and, Community Care, Stanford School of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Jennifer Murphy
- James A. Haley Veterans' Hospital, University of South Florida School of Medicine, Tampa, Florida
| | - Luzmercy Perez
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Heather Okvat
- Department of Family, Community, and Preventive Medicine, Phoenix VA Health Care System, Chronic Pain Wellness Center, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | - Lu Tian
- Stanford University School of Medicine, Palo Alto, California
| | - Pamela Flood
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Mark McGovern
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California
| | - Luana Colloca
- University of Maryland School of Nursing, University of Maryland School of Medicine, Baltimore, Maryland
| | - Heather King
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | | | | | - Matthias Cheung
- Thomas J. Long School of Pharmacy, University of the Pacific, Stockton, California, USA
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American Society of Hematology 2020 guidelines for sickle cell disease: management of acute and chronic pain. Blood Adv 2021; 4:2656-2701. [PMID: 32559294 DOI: 10.1182/bloodadvances.2020001851] [Citation(s) in RCA: 176] [Impact Index Per Article: 58.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/09/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The management of acute and chronic pain for individuals living with sickle cell disease (SCD) is a clinical challenge. This reflects the paucity of clinical SCD pain research and limited understanding of the complex biological differences between acute and chronic pain. These issues collectively create barriers to effective, targeted interventions. Optimal pain management requires interdisciplinary care. OBJECTIVE These evidence-based guidelines developed by the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in pain management decisions for children and adults with SCD. METHODS ASH formed a multidisciplinary panel, including 2 patient representatives, that was thoroughly vetted to minimize bias from conflicts of interest. The Mayo Evidence-Based Practice Research Program supported the guideline development process, including updating or performing systematic reviews. Clinical questions and outcomes were prioritized according to importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used, including GRADE evidence-to-decision frameworks, to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel reached consensus on 18 recommendations specific to acute and chronic pain. The recommendations reflect a broad pain management approach, encompassing pharmacological and nonpharmacological interventions and analgesic delivery. CONCLUSIONS Because of low-certainty evidence and closely balanced benefits and harms, most recommendations are conditional. Patient preferences should drive clinical decisions. Policymaking, including that by payers, will require substantial debate and input from stakeholders. Randomized controlled trials and comparative-effectiveness studies are needed for chronic opioid therapy, nonopioid therapies, and nonpharmacological interventions.
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A qualitative trajectory analysis of patients' experiences tapering opioids for chronic pain. Pain 2021; 163:e246-e260. [PMID: 33990111 DOI: 10.1097/j.pain.0000000000002336] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 04/28/2021] [Indexed: 11/25/2022]
Abstract
ABSTRACT Tapering opioids for chronic pain can be challenging for both patients and prescribers, both of whom may be unsure of what to expect in terms of pain, distress, activity interference, and withdrawal symptoms over the first few weeks and months of the taper. To better prepare clinicians to provide patient-centred tapering support, the current research used prospective longitudinal qualitative methods to capture individual-level variation in patients' experience over the first few months of a voluntary physician-guided taper. The research aimed to identify patterns in individuals' experience of tapering and explore whether patient characteristics, readiness to taper, opioid tapering self-efficacy, or psychosocial context were related to tapering trajectory. Twenty-one patients with chronic noncancer pain commencing tapering of long-term opioid therapy were recruited from a metropolitan tertiary pain clinic (n = 13) and a regional primary care practice (n = 8). Semistructured phone interviews were conducted a mean of 8 times per participant over a mean duration of 12 weeks (N = 173). Four opioid-tapering trajectories were identified, which we characterised as thriving, resilient, surviving, and distressed. High and low readiness to taper was a defining characteristic of thriving and distressed trajectories, respectively. Life adversity was a prominent theme of resilient and distressed trajectories, with supportive relationships buffering the effects of adversity for those who followed a resilient trajectory. Discussion focuses on the implications of these findings for the preparation and support of patients with chronic pain who are commencing opioid tapering.
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