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Jung M, Xia T, Ilomäki J, Pearce C, Nielsen S. Opioid characteristics and nonopioid interventions associated with successful opioid taper in patients with chronic noncancer pain. Pain 2024; 165:1327-1335. [PMID: 38112755 PMCID: PMC11090027 DOI: 10.1097/j.pain.0000000000003133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 10/27/2023] [Accepted: 11/04/2023] [Indexed: 12/21/2023]
Abstract
ABSTRACT Current research indicates that tapering opioids may improve pain and function in patients with chronic noncancer pain. However, gaps in the literature remain regarding the choice of opioid and nonopioid interventions to support a successful taper. This study used an Australian primary care data set to identify a cohort of patients on long-term opioid therapy commencing opioid taper between January 2016 and September 2019. Using logistic regression analysis, we compared key clinical factors associated with differing taper outcomes. Of a total of 3371 patients who commenced taper, 1068 (31.7%) completed taper within 12 months. In the 3 months after commencement of taper, compared with those who did not complete taper, patients who successfully completed opioid taper were less likely to be prescribed buprenorphine (odds ratio [OR] 0.691; 95% CI: 0.530-0.901), fentanyl (OR, 0.429; 95% CI: 0.295-0.622), and long-acting (LA) opioids, including methadone (OR, 0.349; 95% CI: 0.157-0.774), oxycodone-naloxone (OR, 0.521; 95% CI: 0.407-0.669), and LA tapentadol (OR, 0.645; 95% CI: 0.461-0.902), but more likely to be prescribed codeine (OR, 1.308; 95% CI: 1.036-1.652). Compared with those who did not complete taper, patients who successfully tapered were less likely to be prescribed any formulations of oxycodone (short-acting [SA]: OR, 0.533; 95% CI: 0.422-0.672, LA: OR, 0.356; 95% CI: 0.240-0.530) and tramadol (SA: OR, 0.370; 95% CI: 0.218-0.628, LA: OR, 0.317; 95% CI: 0.234-0.428). The type of opioid prescribed in the months after commencement of taper seems to influence the taper outcomes. These findings may inform prospective studies on opioid taper.
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Affiliation(s)
- Monica Jung
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Australia
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Ting Xia
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Jenni Ilomäki
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Christopher Pearce
- Melbourne East General Practice Network (trading as Outcome Health), Surrey Hills, Australia
- Department of General Practice, School of Primary and Allied Health Care, Monash University, Notting Hill, Melbourne, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Australia
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2
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Spinella S, McCarthy R. Buprenorphine for Pain: A Narrative Review and Practical Applications. Am J Med 2024; 137:406-413. [PMID: 38340973 DOI: 10.1016/j.amjmed.2024.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 01/29/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024]
Abstract
Chronic noncancer pain affects about 20% of US adults and can significantly affect function and quality of life. Current guidelines recommend multimodal pain control. Despite risks associated with long-term opioid therapy, opioids are commonly prescribed. Buprenorphine is a partial opioid agonist with an improved safety profile compared to full agonists. Some formulations are approved for chronic pain and others for opioid use disorder. Buprenorphine is an option for patients who use chronic daily opioids for pain. This review summarizes the literature on buprenorphine's efficacy and safety for chronic pain and provides recommendations to generalists on initiation, titration, and monitoring of buprenorphine-based pain treatment. We also discuss a communication approach when considering buprenorphine for pain.
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Affiliation(s)
- Sara Spinella
- Department of Medicine, University of Pittsburgh School of Medicine and VA Pittsburgh Healthcare System, Pittsburgh, Pa.
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3
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Nunes JC, Costa GPA, Weleff J, Rogan M, Compton P, De Aquino JP. Assessing pain in persons with opioid use disorder: Approaches, techniques and special considerations. Br J Clin Pharmacol 2024. [PMID: 38556851 DOI: 10.1111/bcp.16055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 01/30/2024] [Accepted: 02/29/2024] [Indexed: 04/02/2024] Open
Abstract
Pain and opioid use disorder (OUD) are inextricably linked, as the former can be a risk factor for the development of the latter, and over a third of persons with OUD suffer concomitant chronic pain. Assessing pain among people with OUD is challenging, because ongoing opioid use brings changes in pain responses and most pain assessment tools have not been validated for this population. In this narrative review, we discuss the fundamentals of pain assessment for populations with OUD. First, we describe the biological, psychological and social aspects of the pain experience among people with OUD, as well as how opioid-related phenomena may contribute to the pain experience in this population. We then review methods to assess pain, including (1) traditional self-reported methods, such visual analogue scales and structured questionnaires; (2) behavioural observations and physiological indicators; (3) and laboratory-based approaches, such as quantitative sensory testing. These methods are considered from a perspective that encompasses both pain and OUD. Finally, we discuss strategies for improving pain assessment in persons with OUD and implications for future research, including educational strategies for multidisciplinary teams. We highlight the substantial gaps that persist in this literature, particularly regarding the applicability of current pain assessment methods to persons with OUD, as well as the generalizability of the existing results from adjacent populations on chronic opioid therapy but without OUD. As research linking pain and OUD evolves, considering the needs of diverse populations with complex psychosocial backgrounds, clinicians will be better equipped to reduce these gaps.
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Affiliation(s)
- Julio C Nunes
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Gabriel P A Costa
- Faculty of Medicine, University of Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Jeremy Weleff
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Michael Rogan
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Peggy Compton
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joao P De Aquino
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Clinical Neuroscience Research Unit, Connecticut Mental Health Center, New Haven, Connecticut, USA
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4
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Adler J, Mallick-Searle T, Garofoli M, Zimmerman A. Frontline Perspectives on Buprenorphine for the Management of Chronic Pain. J Multidiscip Healthc 2024; 17:1375-1383. [PMID: 38563040 PMCID: PMC10982663 DOI: 10.2147/jmdh.s449748] [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: 12/08/2023] [Accepted: 03/08/2024] [Indexed: 04/04/2024] Open
Abstract
Due to the prevalence of chronic pain and high-impact chronic pain in the US, a significant percentage of the population is prescribed opioids for pain management. However, opioid use disorder is associated with reduced quality of life, along with fatal opioid overdoses, and is a significant burden on the US economy. Considering the clinical needs of patients with intractable chronic pain and the potential harms associated with prescribed and illicit opioids in our communities, having a deep understanding of current treatment options, supporting evidence, and clinical practice guidelines is essential for optimizing treatment selections. Buprenorphine is a Schedule III opioid with a unique mechanism of action, allowing effective and long-lasting analgesia at microgram doses with fewer negative side effects and adverse events, including respiratory depression, when compared with other immediate-release, long-acting, and extended-release prescription opioids. Due to its relatively lower risk for overdose and misuse, buprenorphine was recently added to the Clinical Practice Guideline for the Use of Opioids in the Management of Chronic Pain as a first-line treatment for chronic pain managed by opioids by the US Departments of Defense and Veterans Affairs, and the Department of Health and Human Services recommends that buprenorphine be made available for the treatment of chronic pain. In this narrative review, we discuss the different buprenorphine formulations, clinical efficacy, advantages for older adults and other special populations, clinical practice guideline recommendations, and payer considerations of buprenorphine and suggest that buprenorphine products approved for chronic pain should be considered as a first-line treatment for this indication.
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Affiliation(s)
- Jeremy Adler
- Pacific Pain Medicine Consultants, Encinitas, CA, USA
| | | | - Mark Garofoli
- West Virginia University School of Pharmacy, Morgantown, WV, USA
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5
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Thompson MG, Kuriyama A, Yoshino T, Murphy MG, Jackson JL. Buprenorphine Use in the United States, 2010-2019. Am J Med 2024; 137:280-283. [PMID: 37984777 DOI: 10.1016/j.amjmed.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/01/2023] [Accepted: 11/07/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Buprenorphine is effective for the treatment of opioid use disorder and chronic pain, has a safer pharmacological profile than full mu-opioid agonists, and can now be prescribed by any US provider with a Drug Enforcement Administration license. This study aimed to examine a decade of buprenorphine prescribing patterns in the United States. METHODS We abstracted opioid and buprenorphine prescribing patterns, including patient characteristics, from the 2010-2019 National Ambulatory Medical Care Survey, a national probability sample of non-federal, ambulatory encounters. DISCUSSION Among 248,164 ambulatory encounters, opioids were prescribed 2.6%-4.3% of the time with a rate that peaked in 2013 and has been steadily declining. Buprenorphine was infrequently prescribed. Patients receiving buprenorphine were predominantly male (59%), white (70%), younger in age, and had higher rates of substance use disorder (72%). CONCLUSION Buprenorphine is infrequently used, despite being effective for pain and safer than full mu-opioid agonists. The Drug Enforcement Administration recently ended the requirement for prescribers to obtain an X-waiver, which may increase the rate of buprenorphine use among US practitioners.
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Affiliation(s)
| | - Akira Kuriyama
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Toru Yoshino
- Internal Medicine, Nakagami Hospital, Okinawa, Japan
| | | | - Jeffrey L Jackson
- Clement J Zablocki Wis Veteran Administration Medical Center, Milwaukee, Wis
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6
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Edmond SN, Wesolowicz DM, Snow JL, Currie S, Jankelovits A, Chhabra MS, Becker WC. Qualitative Analysis of Patient Perspectives of Buprenorphine After Transitioning From Long-Term, Full-Agonist Opioid Therapy Among Veterans With Chronic Pain. THE JOURNAL OF PAIN 2024; 25:132-141. [PMID: 37549775 DOI: 10.1016/j.jpain.2023.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 07/21/2023] [Accepted: 07/27/2023] [Indexed: 08/09/2023]
Abstract
Guidelines recommend consideration of modification, tapering, or discontinuation of long-term, full-agonist opioid therapy when harms outweigh benefits; one alternative to tapering or discontinuing full-agonist opioids for the management of chronic pain is switching to the partial agonist buprenorphine. As the use of buprenorphine for pain expands, understanding the patient experience during and after the transition to buprenorphine is critical. We conducted 45- to 60-minute semistructured qualitative interviews with 19 patients to understand the experiences of patients with chronic pain actively maintained on buprenorphine after previously receiving full-agonist, long-term opioid therapy. Patients were recruited from 2 medical centers via provider referral. Through thematic analysis, 5 overall themes were identified, including satisfaction with buprenorphine, the importance of preconceptions about buprenorphine, experiences with transitions, patient-provider communication, and potential contributions to racial disparities in pain care. While we heard a range of experiences, most patients were satisfied with buprenorphine, reporting either equivalent pain control to their previous regimens or reporting less analgesia but improved functioning due to a reduction in side effects (eg, mental clarity). Patients also emphasized the importance of a nonjudgmental, patient-centered approach, including education about the risks and benefits of buprenorphine. The few Black patients interviewed all reported limited access to pain care, which is consistent with the well-documented existence of racial disparities in access to pain treatment. As buprenorphine is used more frequently for pain management, provider education focused on pain treatment disparities, patient-centered approaches informed by motivational interviewing, and increasing acceptance of buprenorphine as an option for pain are needed. PERSPECTIVE: Qualitative analyses of patient experiences transitioning from full-agonist opioids to buprenorphine for chronic pain revealed general satisfaction. Patients reflected on functioning, tradeoffs between analgesia and side effects, patient-centered care, and access to treatment, highlighting how future research should focus on outcomes valued by patients.
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Affiliation(s)
- Sara N Edmond
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut; Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Danielle M Wesolowicz
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut; Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Jennifer L Snow
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | | | | | - Manik S Chhabra
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - William C Becker
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut; Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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7
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Chwistek M, Sherry D, Kinczewski L, Silveira MJ, Davis M. Should Buprenorphine Be Considered a First-Line Opioid for the Treatment of Moderate to Severe Cancer Pain? J Pain Symptom Manage 2023; 66:e638-e643. [PMID: 37343903 DOI: 10.1016/j.jpainsymman.2023.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/02/2023] [Accepted: 06/09/2023] [Indexed: 06/23/2023]
Abstract
Cancer pain remains a significant problem worldwide, affecting more than half of patients receiving anti-cancer treatment and most patients with advanced disease. Opioids remain the cornerstone of therapy, and morphine, given its availability, multiple formulations, price, and evidence base, is typically considered the first-line treatment for moderate to severe cancer pain. Buprenorphine has emerged in recent decades as an alternative opioid for treating chronic pain and substance use disorder (SUD). However, it remains controversial whether buprenorphine should be considered a first-line opioid for moderate to severe cancer pain. In this "Controversies in Palliative Care" article, three expert clinicians independently answer this question. Specifically, each group provides a synopsis of the key studies that inform their thought process, share practical advice on their clinical approach, and highlight the opportunities for future research. All three groups agree that there is a place for the use of buprenorphine as a first-line opioid in cancer pain. Specifically, they mention populations of elderly patients, patients with renal failure, and those with (SUD). They also underscore many unique and favorable characteristics of buprenorphine, such as the low risk for respiratory depression, lack of adverse effects on testosterone levels in men, no risk of serotonin syndrome when combined with antidepressants, and ease of use given its transdermal, transmucosal, and sublingual formulations. However, further studies are needed to guide the use of buprenorphine for cancer pain-primarily randomized clinical trials (RCTs) comparing buprenorphine with other opioids in various pain syndromes.
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Affiliation(s)
- Marcin Chwistek
- Department of Hematology and Oncology (M.C., D.S., L.K.), Fox Chase Cancer Center/Temple University Health System, Philadelphia, PA, USA.
| | - Dylan Sherry
- Department of Hematology and Oncology (M.C., D.S., L.K.), Fox Chase Cancer Center/Temple University Health System, Philadelphia, PA, USA
| | - Leigh Kinczewski
- Department of Hematology and Oncology (M.C., D.S., L.K.), Fox Chase Cancer Center/Temple University Health System, Philadelphia, PA, USA
| | - Maria J Silveira
- Division of Geriatric and Palliative Medicine (M.J.S.), University of Michigan & Geriatric Research Education and Clinical Center, Ann Arbor Veteran Administration Medical Center, Ann Arbor, MI, USA
| | - Mellar Davis
- Department of Palliative Care, Geisinger Medical Center, Geisinger Health Geisinger Commonwealth School of Medicine (M.D.), Danville, PA, USA
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8
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Abstract
In 2022, the CDC revised its and encourage clinicians to weight the risks versus harms of continued therapy and empathetically engage patients in patient-centered discussions around continued therapy while avoiding patient abandonment. This commentary discusses how the emphasis on "benefit" will almost always lead to discordance between the patient and provider since many clinicians find little benefit in opioid therapy for chronic pain with evidence questioning its efficacy for chronic pain. This disagreement between patients and providers has the potential to lead to unilateral tapers or patient abandonment and further increase patient harm. Considering this dilemma, we propose a revised framework that emphasizes weighing the harms of continuation of therapy against the harms of discontinuation of therapy when caring for patients on long-term opioid therapy. This revised harm-reductive decisional framework has the potential to retain patient-provider trust and increase opportunities for engagement in evidence-based multi-modal pain treatment, including non-opioid based treatment options.
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Affiliation(s)
- Pooja Lagisetty
- University of Michigan Medical School, Ann Arbor, MI, USA
- Ann Arbor Veterans Affairs, Ann Arbor, MI, USA
| | - Stefan Kertesz
- Birmingham VA Health Care system, Birmingham, AL, USA
- Heersink UAB School of Medicine, Birmingham, AL, USA
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9
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Stone AB, Zhong H, Poeran J, Liu J, Cozowicz C, Illescas A, Memtsoudis SG. Buprenorphine for chronic pain treatment and elective orthopaedic surgery: a US national database analysis. Br J Anaesth 2023; 130:e404-e406. [PMID: 36566125 DOI: 10.1016/j.bja.2022.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 10/16/2022] [Accepted: 11/05/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- Alexander B Stone
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiologist Critical Care and Perioperative Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| | - Haoyan Zhong
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Jashvant Poeran
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy/Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jiabin Liu
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Crispiana Cozowicz
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Alex Illescas
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria; Department of Health Policy and Research, Weill Cornell Medical College, New York, NY, USA
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10
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Powell VD, Macleod C, Sussman J, Lin LA, Bohnert ASB, Lagisetty P. Variation in Clinical Characteristics and Longitudinal Outcomes in Individuals with Opioid Use Disorder Diagnosis Codes. J Gen Intern Med 2023; 38:699-706. [PMID: 35819683 PMCID: PMC9971398 DOI: 10.1007/s11606-022-07732-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 06/28/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Patterns of opioid use vary, including prescribed use without aberrancy, limited aberrant use, and potential opioid use disorder (OUD). In clinical practice, similar opioid-related International Classification of Disease (ICD) codes are applied across this spectrum, limiting understanding of how groups vary by sociodemographic factors, comorbidities, and long-term risks. OBJECTIVE (1) Examine how Veterans assigned opioid abuse/dependence ICD codes vary at diagnosis and with respect to long-term risks. (2) Determine whether those with limited aberrant use share more similarities to likely OUD vs those using opioids as prescribed. DESIGN Longitudinal observational cohort study. PARTICIPANTS National sample of Veterans categorized as having (1) likely OUD, (2) limited aberrant opioid use, or (3) prescribed, non-aberrant use based upon enhanced medical chart review. MAIN MEASURES Comparison of sociodemographic and clinical factors at diagnosis and rates of age-adjusted mortality, non-fatal opioid overdose, and hospitalization after diagnosis. An exploratory machine learning analysis investigated how closely those with limited aberrant use resembled those with likely OUD. KEY RESULTS Veterans (n = 483) were categorized as likely OUD (62.1%), limited aberrant use (17.8%), and prescribed, non-aberrant use (20.1%). Age, proportion experiencing homelessness, chronic pain, anxiety disorders, and non-opioid substance use disorders differed by group. All-cause mortality was high (44.2 per 1000 person-years (95% CI 33.9, 56.7)). Hospitalization rates per 1000 person-years were highest in the likely OUD group (831.5 (95% CI 771.0, 895.5)), compared to limited aberrant use (739.8 (95% CI 637.1, 854.4)) and prescribed, non-aberrant use (411.9 (95% CI 342.6, 490.4). The exploratory analysis reclassified 29.1% of those with limited aberrant use as having likely OUD with high confidence. CONCLUSIONS Veterans assigned opioid abuse/dependence ICD codes are heterogeneous and face variable long-term risks. Limited aberrant use confers increased risk compared to no aberrant use, and some may already have OUD. Findings warrant future investigation of this understudied population.
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Affiliation(s)
- Victoria D Powell
- Palliative Care Program, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, MI, USA.
- Geriatrics Research, Education, and Clinical Center, LTC Charles S. Kettles VA Medical Center, Ann Arbor, MI, USA.
| | - Colin Macleod
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jeremy Sussman
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Lewei A Lin
- VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Amy S B Bohnert
- VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Pooja Lagisetty
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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11
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A Neuropharmacological Model to Explain Buprenorphine Induction Challenges. Ann Emerg Med 2022; 80:509-524. [DOI: 10.1016/j.annemergmed.2022.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/25/2022] [Accepted: 05/27/2022] [Indexed: 11/17/2022]
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12
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Bioequivalence, Drugs with Narrow Therapeutic Index and the Phenomenon of Biocreep: A Critical Analysis of the System for Generic Substitution. Healthcare (Basel) 2022; 10:healthcare10081392. [PMID: 35893214 PMCID: PMC9394341 DOI: 10.3390/healthcare10081392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/22/2022] [Accepted: 07/23/2022] [Indexed: 11/17/2022] Open
Abstract
The prescription of generic drugs represents one of the main cost-containment strategies of health systems, aimed at reducing pharmaceutical expenditure. In this context, most regulatory authorities encourage or obligate dispensing generic drugs because they are far less expensive than their brand-name alternatives. However, drug substitution can be critical in particular situations, such as the use of drugs with a narrow therapeutic index (NTI). Moreover, generics cannot automatically be considered bioequivalent with each other due to the biocreep phenomenon. In Italy, the regulatory authority has established the Transparency Lists which include the medications that will be automatically substituted for brand-name drugs, except in exceptional cases. This is a useful tool to guide prescribers and guarantee pharmaceutical sustainability, but it does not consider the biocreep phenomenon.
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13
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Fitzgerald Jones K, Khodyakov D, Arnold R, Bulls H, Dao E, Kapo J, Meier D, Paice J, Liebschutz J, Ritchie C, Merlin J. Consensus-Based Guidance on Opioid Management in Individuals With Advanced Cancer-Related Pain and Opioid Misuse or Use Disorder. JAMA Oncol 2022; 8:1107-1114. [PMID: 35771550 DOI: 10.1001/jamaoncol.2022.2191] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Opioid misuse and opioid use disorder (OUD) are important comorbidities in people with advanced cancer and cancer-related pain, but there is a lack of consensus on treatment. Objective To develop consensus among palliative care and addiction specialists on the appropriateness of various opioid management strategies in individuals with advanced cancer-related pain and opioid misuse or OUD. Design, Setting, and Participants For this qualitative study, using ExpertLens, an online platform and methodology for conducting modified Delphi panels, between August and October 2020, we conducted 2 modified Delphi panels to understand the perspectives of palliative and addiction clinicians on 3 common clinical scenarios varying by prognosis (weeks to months vs months to years). Of the 129 invited palliative or addiction medicine specialists, 120 participated in at least 1 round. A total of 84 participated in all 3 rounds. Main Outcomes and Measures Consensus was investigated for 3 clinical scenarios: (1) a patient with a history of an untreated opioid use disorder, (2) a patient taking more opioid than prescribed, and (3) a patient using nonprescribed benzodiazepines. Results Participants were mostly women (47 [62%]), White (94 (78 [65%]), and held MD/DO degrees (115 [96%]). For a patient with untreated OUD, regardless of prognosis, it was deemed appropriate to begin treatment with buprenorphine/naloxone and inappropriate to refer to a methadone clinic. Beginning split-dose methadone was deemed appropriate for patients with shorter prognoses and of uncertain appropriateness for those with longer prognoses. Beginning a full opioid agonist was deemed of uncertain appropriateness for those with a short prognosis and inappropriate for those with a longer prognosis. Regardless of prognosis, for a patient with no medical history of OUD taking more opioids than prescribed, it was deemed appropriate to increase monitoring, inappropriate to taper opioids, and of uncertain appropriateness to increase the patient's opioids or transition to buprenorphine/naloxone. For a patient with a urine drug test positive for non-prescribed benzodiazepines, regardless of prognosis, it was deemed appropriate to increase monitoring, inappropriate to taper opioids and prescribe buprenorphine/naloxone. Conclusions and Relevance The findings of this qualitative study provide urgently needed consensus-based guidance for clinicians and highlight critical research and policy gaps.
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Affiliation(s)
- Katie Fitzgerald Jones
- William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts.,VA Boston Healthcare System, Boston, Massachusetts
| | | | - Robert Arnold
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Hailey Bulls
- CHAllenges in Managing and Preventing Pain (CHAMPP) Clinical Research Center, Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Emily Dao
- RAND Corporation, Santa Monica, California
| | - Jennifer Kapo
- MSCE Palliative Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Diane Meier
- Department of Geriatrics and Palliative Medicine, Center to Advance Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Judith Paice
- RN Feinberg School of Medicine, Division of Hematology-Oncology, Northwestern University, Chicago, Illinois
| | - Jane Liebschutz
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christine Ritchie
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston
| | - Jessica Merlin
- CHAllenges in Managing and Preventing Pain (CHAMPP) Clinical Research Center, Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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14
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Spreen LA, Dittmar EN, Quirk KC, Smith MA. Buprenorphine initiation strategies for opioid use disorder and pain management: A systematic review. Pharmacotherapy 2022; 42:411-427. [PMID: 35302671 PMCID: PMC9310825 DOI: 10.1002/phar.2676] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 03/04/2022] [Accepted: 03/05/2022] [Indexed: 12/17/2022]
Abstract
Buprenorphine possesses many unique attributes that make it a practical agent for adults and adolescents with opioid use disorder (OUD) and/or acute or chronic pain. Sublingual buprenorphine has been the standard of care for treating OUD, but its use in pain management is not as clearly defined. Current practice guidelines recommend a period of mild‐to‐moderate withdrawal from opioids before transitioning to buprenorphine due to its ability to displace full agonists from the μ‐opioid receptor. However, this strategy can lead to negative physical and psychological outcomes for patients. Novel initiation strategies suggest that concomitant administration of small doses of buprenorphine with opioids can avoid the unwanted withdrawal associated with buprenorphine initiation. We aim to systematically review the buprenorphine initiation strategies that have emerged in the last decade. Embase, PubMed, and Cochrane Databases were searched for relevant literature. Studies were included if they were published in the English language and described the transition to buprenorphine from opioids. Data were collected from each study and synthesized using descriptive statistics. This review included 7 observational studies, 1 feasibility study, and 39 case reports/series which included 924 patients. The strategies utilized between the literature included traditional initiation (47.9%), microdosing with various buprenorphine formulations (16%), and miscellaneous methods (36.1%). Traditional initiation and microdosing initiation were compared in the data synthesis and analysis; miscellaneous methods were omitted given the high variability between methods. Overall, 95.6% of patients in the traditional initiation group and 96% of patients in the microdosing group successfully rotated to sublingual buprenorphine. Initiation regimens can vary widely depending on patient‐specific factors and buprenorphine formulation. A variety of buprenorphine transition strategies are published in the literature, many of which were effective for patients with OUD, pain, or both.
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Affiliation(s)
- Lauren A Spreen
- Department of Pharmacy Services, University of Michigan Health, Ann Arbor, Michigan, USA.,University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - Emma N Dittmar
- University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - Kyle C Quirk
- Department of Palliative Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Michael A Smith
- Department of Pharmacy Services, University of Michigan Health, Ann Arbor, Michigan, USA.,University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
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15
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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] [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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