European* clinical practice recommendations on opioids for chronic noncancer pain - Part 1: Role of opioids in the management of chronic noncancer pain

Updated guidelines for prescribing opioids to treat patients with chronic non-cancer pain in Korea: developed by committee on hospice and palliative care of the Korean Pain Society

There are growing concerns regarding the safety of long-term treatment with opioids of patients with chronic non-cancer pain. In 2017, the Korean Pain Society (KPS) developed guidelines for opioid prescriptions for chronic non-cancer pain to guide physicians to prescribe opioids effectively and safely. Since then, investigations have provided updated data regarding opioid therapy for chronic non-cancer pain and have focused on initial dosing schedules, reassessment follow-ups, recommended dosage thresholds considering the risk-benefit ratio, dose-reducing schedules for tapering and discontinuation, adverse effects, and inadvertent problems resulting from inappropriate application of the previous guidelines. Herein, we have updated the previous KPS guidelines based on a comprehensive literature review and consensus development following discussions among experts affiliated with the Committee on Hospice and Palliative Care in the KPS. These guidelines may assist physicians in prescribing opioids for chronic non-cancer pain in adult outpatient settings, but should not to be regarded as an inflexible standard. Clinical judgements by the attending physician and patient-centered decisions should always be prioritized.

Perceptions of Nurses Regarding Opioid Administration: A cross-sectional study

BACKGROUND

Opioids are important drugs used in pain management due to their strong analgesic effects. However, there is limited research on nurses' perceptions of administering opioids.

PURPOSE

This study aims to determine nurses' perceptions of administering opioids.

DESIGN

This study used a descriptive cross-sectional design.

SETTINGS

A university hospital located in the south of Turkey.

METHODS

A self-reporting survey was provided to a convenience sample of 190 nurses. The data were collected with the "Introductory Information Form," and the "Nurses' Perceptions on Opioid Medications Administration Questionnaire." Descriptive statistics were applied for data analysis.

RESULTS

The mean age of the nurses was 33.11 ± 7.82 and 86.3% were female. The majority of the nurses did not receive any training on opioid administration other than their undergraduate education. Among the nursing staff, 90.0% expressed the importance of having trust in the prescribing doctor for their comfort in administering opioids. Of the nurses, 30% were undecided about "Nurses associate opioids with drug abuse." and 78.9% disagreed with the statement "Nurses often associate giving opioids with helping patients to die."

CONCLUSIONS

The results of this study provided further insight into nurses' perceptions of administering opioids that potentially contribute to pain management. Nurses had information needs and some prejudices regarding opioid administration. Also, relying on the prescribing doctor was important, and problems with prescribing were an obstacle to pain control.

CLINICAL IMPLICATIONS

Determining the knowledge and needs of nurses regarding opioid administration and providing in-service training on this subject would positively affect their approach to opioids.

Opioid analgesics prescribing trends 2010-2019 in Slovenia: National database study

OBJECTIVE

Significant increases in global opioid use have been reported in recent decades. This study analyzed opioid utilization in outpatient care in Slovenia between 2010 and 2019.

METHODS

This retrospective cross-sectional study performed a nationwide database analysis of all outpatient opioid analgesic prescriptions based on Slovenian health insurance claims data. Prevalence was defined as the number of recipients prescribed at least one opioid per 1000 inhabitants. Opioid consumption was presented as the total number of dispensed prescriptions per 1000 inhabitants and dispensed defined daily doses (DDD) per 1000 inhabitants for each year analyzed.

RESULTS

The age-standardized prevalence of opioid recipients decreased by 21.5% during the study period. Total opioid consumption decreased both in the number of prescriptions (-9.2%) and DDD (-5.4%). Tramadol consumption decreased in terms of the number of prescriptions (-12.2%) and DDD (-2.7%), whereas prescriptions for strong opioids increased (10.2%) and DDDs decreased (-16.2%). The results suggest less intensive prescribing of strong opioids and more intensive prescribing for tramadol. The most frequently used strong opioids were fentanyl and oxycodone/naloxone.

CONCLUSIONS

The prevalence of opioid recipients and opioid consumption is decreasing in Slovenia. Further research is needed to understand whether this finding reflects safe use or underuse of these important analgesics.

Nociceptive, neuropathic, or nociplastic low back pain? The low back pain phenotyping (BACPAP) consortium's international and multidisciplinary consensus recommendations

The potential to classify low back pain as being characterised by dominant nociceptive, neuropathic, or nociplastic mechanisms is a clinically relevant issue. Preliminary evidence suggests that these low back pain phenotypes might respond differently to treatments; however, more research must be done before making specific recommendations. Accordingly, the low back pain phenotyping (BACPAP) consortium was established as a group of 36 clinicians and researchers from 13 countries (five continents) and 29 institutions, to apply a modified Nominal Group Technique methodology to develop international and multidisciplinary consensus recommendations to provide guidance for identifying the dominant pain phenotype in patients with low back pain, and potentially adapt pain management strategies. The BACPAP consortium's recommendations are also intended to provide direction for future clinical research by building on the established clinical criteria for neuropathic and nociplastic pain. The BACPAP consortium's consensus recommendations are a necessary early step in the process to determine if personalised pain medicine based on pain phenotypes is feasible for low back pain management. Therefore, these recommendations are not ready to be implemented in clinical practice until additional evidence is generated that is specific to these low back pain phenotypes.

How do opioids control pain circuits in the brainstem during opioid-induced disorders and in chronic pain? Implications for the treatment of chronic pain

ABSTRACT

Brainstem areas involved in descending pain modulation are crucial for the analgesic actions of opioids. However, the role of opioids in these areas during tolerance, opioid-induced hyperalgesia (OIH), and in chronic pain settings remains underappreciated. We conducted a revision of the recent studies performed in the main brainstem areas devoted to descending pain modulation with a special focus on the medullary dorsal reticular nucleus (DRt), as a distinctive pain facilitatory area and a key player in the diffuse noxious inhibitory control paradigm. We show that maladaptive processes within the signaling of the µ-opioid receptor (MOR), which entail desensitization and a switch to excitatory signaling, occur in the brainstem, contributing to tolerance and OIH. In the context of chronic pain, the alterations found are complex and depend on the area and model of chronic pain. For example, the downregulation of MOR and δ-opioid receptor (DOR) in some areas, including the DRt, during neuropathic pain likely contributes to the inefficacy of opioids. However, the upregulation of MOR and DOR, at the rostral ventromedial medulla, in inflammatory pain models, suggests therapeutic avenues to explore. Mechanistically, the rationale for the diversity and complexity of alterations in the brainstem is likely provided by the alternative splicing of opioid receptors and the heteromerization of MOR. In conclusion, this review emphasizes how important it is to consider the effects of opioids at these circuits when using opioids for the treatment of chronic pain and for the development of safer and effective opioids.

To Be Frail or Not to Be Frail: This Is the Question-A Critical Narrative Review of Frailty

Many factors have contributed to rendering frailty an emerging, relevant, and very popular concept. First, many pandemics that have affected humanity in history, including COVID-19, most recently, have had more severe effects on frail people compared to non-frail ones. Second, the increase in human life expectancy observed in many developed countries, including Italy has led to a rise in the percentage of the older population that is more likely to be frail, which is why frailty is much a more common concern among geriatricians compared to other the various health-care professionals. Third, the stratification of people according to the occurrence and the degree of frailty allows healthcare decision makers to adequately plan for the allocation of available human professional and economic resources. Since frailty is considered to be fully preventable, there are relevant consequences in terms of potential benefits both in terms of the clinical outcome and healthcare costs. Frailty is becoming a popular, pervasive, and almost omnipresent concept in many different contexts, including clinical medicine, physical health, lifestyle behavior, mental health, health policy, and socio-economic planning sciences. The emergence of the new "science of frailty" has been recently acknowledged. However, there is still debate on the exact definition of frailty, the pathogenic mechanisms involved, the most appropriate method to assess frailty, and consequently, who should be considered frail. This narrative review aims to analyze frailty from many different aspects and points of view, with a special focus on the proposed pathogenic mechanisms, the various factors that have been considered in the assessment of frailty, and the emerging role of biomarkers in the early recognition of frailty, particularly on the role of mitochondria. According to the extensive literature on this topic, it is clear that frailty is a very complex syndrome, involving many different domains and affecting multiple physiological systems. Therefore, its management should be directed towards a comprehensive and multifaceted holistic approach and a personalized intervention strategy to slow down its progression or even to completely reverse the course of this condition.

Opioid Treatment in Primary Care: Knowledge and Practical Use of Opioid Therapy

BACKGROUND

Primary care physicians play a key role in initiating opioid therapy. However, knowledge gaps in opioid use and pain management are significant barriers to providing optimal care. This research study aims to investigate the educational needs of primary care physicians regarding opioid therapy and opioid use in pain management.

METHODS

A computer-assisted web interview (CAWI) protocol was used to collect data from primary care physicians. Drug selection criteria, knowledge of opioid substitutes and dosage, and practical use of opioid therapy were evaluated.

RESULTS

While 84% of participating physicians (724 respondents) reported initiating opioid treatment, only a minority demonstrated accurate opioid dosage calculations. Significant discrepancies between physicians' self-perceived knowledge and their clinical skills in opioid prescribing and pain management were observed. In total, 41% of physicians incorrectly indicated dose conversion rates for tramadol (the most frequently used drug according to 65% of responders).

CONCLUSIONS

Targeted educational programs are essential to bridge the knowledge gap and increase physicians' competence in pain management. The proper self-assessment of one's own skills may be the key to improvement. Further research should focus on developing specialized educational courses and decision-support tools for primary care physicians and examining the impact of interprofessional pain management teams on patient outcomes.

Socioeconomic risk factors for long-term opioid use: A national registry-linkage study

BACKGROUND

Opioid use has increased substantially as a treatment for chronic pain, although harms from long-term opioid therapy outweigh the benefits. More knowledge about factors associated with long-term opioid use is needed. We aimed to investigate the association between socioeconomic status and long-term opioid use in the period 2010-2019.

METHODS

This was a nested case-control study in which the cases were all persons ≥18 years with long-term opioid use, that is use of opioids for more than 3 months (N = 215,642). Cases were matched on gender, age and index year (first long-term use period) with four controls who filled at least one opioid prescription, but never developed long-term opioid use in the study period (N = 862,568). We performed a logistic regression analysis adjusted for relevant confounders, stratified on age groups (18-67 years and 68 years and above).

RESULTS

In the younger age group, long-term opioid use was associated with low education (adjusted odds ratio, aOR = 1.54; 95% confidence interval, CI [1.51-1.57]), low income (1.33 [1.31-1.36]), being unemployed (1.40 [1.38-1.42]) and receiving disability pension (1.36 [1.33-1.38]). Weaker associations were found for living in a single-person household or in a dense geographical area. Similar associations were found for the older age group.

CONCLUSION

We found that low socioeconomic status was associated with long-term opioid use both among people in working age and older people. These results indicate a need for social and financial support for non-pharmacological treatment of chronic pain among people with lower socioeconomic status.

SIGNIFICANCE

This study shows that people with low socioeconomic status are at higher risk of developing long-term opioid use. In the clinical setting, physicians should consider socioeconomic status when prescribing opioids for chronic pain. Non-pharmacological treatment options funded by public health services should be prioritized to those with low socioeconomic status as long-term opioid use in chronic pain patients is not recommended.

Pragmatic Delphi study aimed at determining practical components for a tool designed to assist Dutch primary care-givers in opioid deprescribing for non-cancer pain

BACKGROUND

Over the past decades, opioid prescriptions have increased in the Netherlands. The Dutch general practitioners' guideline on pain was recently updated and now aims to reduce opioid prescriptions and high-risk opioid use for non-cancer pain. The guideline, however, lacks practical measures for implementation.

OBJECTIVE

This study aims to determine practical components for a tool that should assist Dutch primary care prescribers and implements the recently updated guideline to reduce opioid prescriptions and high-risk use.

METHODS

A modified Delphi approach was used. The practical components for the tool were identified based on systematic reviews, qualitative studies, and Dutch primary care guidelines. Suggested components were divided into Part A, containing components designed to reduce opioid initiation and stimulate short-term use, and Part B, containing components designed to reduce opioid use among patients on long-term opioid treatment. During three rounds, a multidisciplinary panel of 21 experts assessed the content, usability, and feasibility of these components by adding, deleting, and adapting components until consensus was reached on the outlines of an opioid reduction tool.

RESULTS

The resulting Part A consisted of six components, namely education, opioid decision tree, risk assessment, agreements on dosage and duration of use, guidance and follow-up, and interdisciplinary collaboration. The resulting Part B consisted of five components, namely education, patient identification, risk assessment, motivation, and tapering.

CONCLUSIONS

In this pragmatic Delphi study, components for an opioid reduction tool for Dutch primary care-givers are identified. These components need further development, and the final tool should be tested in an implementation study.

Treating persistent pain after breast cancer: practice gaps and future directions

This paper discusses the growing problem of persisting pain after successful treatment of breast cancer and presents recommendations for improving pain-related outcomes for this group. We discuss the dominant treatment approach for persisting pain post-breast cancer treatment and draw contrasts with contemporary treatment approaches to persistent pain in non-cancer-related populations. We discuss modern application of the biopsychosocial model of pain and the notion of variable sensitivity within the pain system, moment by moment and over time. We present the implications of increasing sensitivity over time for treatment selection and implementation. By drawing on transformative changes in treatment approaches to persistent non-cancer-related pain, we describe the potentially powerful role that an intervention called pain science education, which is now recommended in clinical guidelines for musculoskeletal pain, may play in improving pain and disability outcomes after successful breast cancer treatment. Finally, we present several research recommendations that centre around adaptation of the content and delivery models of contemporary pain science education, to the post-breast cancer context.

Opioids Prescribing Among Patients with Zoster-Related Pain in Real-Life: A Retrospective, Cohort Study Based on the Clinical Database

Purpose

The aim of this study was to analysis of the opioid use of opioid native zoster-related pain (ZRP) patients to evaluate the impact of opioid use on pain control and quality of life improvement based on the clinical database.

Patients and Methods

We conducted a retrospective cohort study to identify opioid native patients who were hospitalized in the pain department between May 1, 2020, and May 1, 2021. The primary outcomes were persistent opioid use after discharge, visual analogue scale (VAS) at the admission, VAS remission rate during hospitalization, VAS score and quality of life at follow-up. Then, we assessed patient-level risk factors for persistent opioid use after the discharge.

Results

A total of 350 patients met the inclusion criteria. Of those patients, 255 (72.9%) were administered with opioid during hospitalization, and 95 (27.1%) patients were not. Opioid prescription during hospitalization was independently associated with increased odds of persistent use after the discharge (adjusted odds ratio, 20.74; 95% CI, 4.504-95.474; P < 0.01). In the two groups, the VAS score at admission and the VAS score at follow-up were different. In the group with opioids during hospitalization, the persistent opioid use after discharge was more common (38% vs 2.1%) compared to patients without opioids, and VAS remission rate during hospitalization was less, restrictions on daily life, work or housework, and social activities were more common, and mood, diet and sleep were worse, respectively.

Conclusion

Opioids prescription during hospitalization might increase the risk of chronic opioid use in opioid native ZRP patients, and it has limited benefits in pain control and quality of life improvement. Even though PHN was painful and intractable, the use of opioids should also be more cautious, and strict follow-up, management in this population.

Simultaneous application of lidocaine and ketamine during ambulatory infusion therapy: a retrospective analysis

Background: Infusions with lidocaine or ketamine have been separately established in the treatment of chronic pain. This study aims to retrospectively evaluate the effect of combined infusions of lidocaine and ketamine. Materials & methods: Patient records were screened for receipt of combined ambulatory infusions of lidocaine and ketamine from 2012 through 2021. A scoring system was designed to assess pain response retrospectively. Results: A total of 319 patients were included. Median pain reduction in days was 10.00 (interquartile range: 13.25). Side effects were limited to the acute phase of infusions. A total of 41.4% of patients who received concomitant pain medication reported a dose reduction. Conclusion: Our data support combined infusions as a safe therapy option, with good short-, medium- and long-term reductions in pain and great heterogeneity in treatment response. Clinical trial registration: ClinicalTrials.gov (NCT05103319).

Recommendations for the management of opioid-induced constipation - how to improve usability in clinical practice

INTRODUCTION

Opioid-induced constipation remains undertreated despite effective and safe treatment options exists. Previous guidelines have only been partially effective in improving management, possibly due to their complexity, and studies suggest that a simple setup of concise and behaviorally-orientated steps improves usability.

AREAS COVERED

This article introduces the concept of opioid-induced constipation and provides an overview of existing guidelines in this field. We also propose simplified recommendations for managing opioid-induced constipation, derived from a synthesis of current guidelines and the principles of optimal guideline design theory.

EXPERT OPINION

Despite standard treatment with laxatives and fluid intake in patients with opioid-induced constipation, escalation of treatment is often needed where μ-opioid receptor antagonists or newer medications such as lubiprostone, linaclotide, or prucalopride are used. Previous guidelines have not been used sufficiently and thus management of the condition is often insufficient. We therefore propose simplified recommendations to management, which we believe can come into broader use. It was validated in primary care for credibility, clarity, relevance, usability, and overall benefit. We believe that this initiative can lead to better management of the substantial proportion of patients suffering from side effects of opioids.

Correlation Between Opioid Drug Prescription and Opioid-Related Mortality in Spain as a Surveillance Tool: Ecological Study

BACKGROUND

Opioid drug prescription (ODP) and opioid-related mortality (ORM) have increased in Spain. However, their relationship is complex, as ORM is registered without considering the type of opioid (legal or illegal).

OBJECTIVE

This ecological study aimed to examine the correlation between ODP and ORM in Spain and discuss their usefulness as a surveillance tool.

METHODS

This was an ecological descriptive study using retrospective annual data (2000-2019) from the Spanish general population. Data were collected from people of all ages. Information on ODP was obtained from the Spanish Medicines Agency in daily doses per 1000 inhabitants per day (DHD) for total ODP, total ODP excluding those with better safety protocols (codeine and tramadol), and each opioid drug separately. Rates of ORM (per 1,000,000 inhabitants) were calculated based on deaths registered (International Classification of Diseases, 10th Revision codes) as opioid poisoning by the National Statistics Institute, derived from the drug data recorded by medical examiners in death certificates. Opioid-related deaths were considered to be those that indicated opioid consumption (accidental, infringed, or self-inflicted) as the main cause of death: death due to accidental poisoning (X40-X44), intentional self-inflicted poisoning (X60-X64), drug-induced aggression (X85), and poisoning of undetermined intention (Y10-Y14). A descriptive analysis was carried out, and correlations between the annual rates of ORM and DHD of the prescribed opioid drugs globally, excluding medications of the least potential risk of overdose and lowest treatment tier, were analyzed using Pearson linear correlation coefficient. Their temporal evolution was analyzed using cross-correlations with 24 lags and the cross-correlation function. The analyses were carried out using Stata and StatGraphics Centurion 19.

RESULTS

The rate of ORM (2000-2019) ranged between 14 and 23 deaths per 1,000,000 inhabitants, with a minimum in 2006 and an increasing trend starting in 2010. The ODP ranged between 1.51 to 19.94 DHD. The rates of ORM were directly correlated with the DHD of total ODP (r=0.597; P=.006), total ODP without codeine and tramadol (r=0.934; P<.001), and every prescribed opioid except buprenorphine (P=.47). In the time analysis, correlations between DHD and ORM were observed in the same year, although not statistically significant (all P≥.05).

CONCLUSIONS

There is a correlation between greater availability of prescribed opioid drugs and an increase in opioid-related deaths. The correlation between ODP and ORM may be a useful tool in monitoring legal opiates and possible disturbances in the illegal market. The role of tramadol (an easily prescribed opioid) is important in this correlation, as is that of fentanyl (the strongest opioid). Measures stronger than recommendations need to be taken to reduce off-label prescribing. This study shows that not only is opioid use directly related to the prescribing of opioid drugs above what is desirable but also an increase in deaths.

Long-term deprescription in chronic pain and opioid use disorder patients: Pharmacogenetic and sex differences

More than half of patients with opioid use disorder for chronic non-cancer pain (CNCP) reduced their dose through a progressive opioid withdrawal supported by a rotation to buprenorphine and/or tramadol. The aim of this research is to analyse the long-term effectiveness of opioid deprescription taking into account the impact of sex and pharmacogenetics on the inter-individual variability. A cross-sectional study was carried out from October 2019 to June 2020 on CNCP patients who had previously undergone an opioid deprescription (n = 119 patients). Demographic, clinical (pain, relief and adverse events) and therapeutic (analgesic use) outcomes were collected. Effectiveness (< 50 mg per day of morphine equivalent daily dose without any aberrant opioid use behaviour) and safety (number of side-effects) were analysed in relation to sex differences and pharmacogenetic markers impact [OPRM1 genotype (rs1799971) and CYP2D6 phenotypes]. Long-term opioid deprescription was achieved in 49 % of the patients with an increase in pain relief and a reduction of adverse events. CYP2D6 poor metabolizers showed the lowest long-term opioid doses. Here, women showed a higher degree of opioid deprescription, but increased use of tramadol and neuromodulators, as well as an increased number of adverse events. Long-term deprescription was successful in half of the cases. Understanding sex and gender interaction plus a genetic impact could help to design more individualized strategies for opioid deprescription.

Pain assessment 3 × 3: a clinical reasoning framework for healthcare professionals

OBJECTIVES

To give an overview of central aspects of pain medicine-specific clinical reasoning when assessing a pain patient. Clinical reasoning is the thinking and decision-making processes associated with clinical practice.

METHODS

Three core pain assessment areas that are crucial for clinical reasoning in the field of pain medicine are discussed, each of them consisting of three points.

RESULTS

First, it is important to distinguish acute, chronic non-cancer, and cancer-related pain conditions. This classical and very simple trichotomy still has important implications treatment-wise, e.g., concerning the use of opioids. Second, the pain mechanism needs to be assessed. Is the pain nociceptive, neuropathic, or nociplastic? Simply put, nociceptive pain has to do with injury of non-neural tissue, neuropathic pain is caused by a disease or lesion of the somatosensory nervous system, and nociplastic pain is believed to be related to a sensitized nervous system (c.f. the concept of "central sensitization"). This also has implications concerning treatment. Some chronic pain conditions are nowadays viewed more as diseases rather than the pain being merely a symptom. In the new ICD-11 pain classification, this is conceptualized by the characterization of some chronic pains as "primary". Third, in addition to a conventional biomedical evaluation, psychosocial and behavioral aspects must also be assessed, the pain patient being viewed as an active agent and not merely as the passive recipient of an intervention. Hence, the importance of a dynamic bio-psycho-social perspective. The dynamic interplay of biological, psychological, and social aspects must be taken into account, putative behavioral "vicious circles" thereby being identified. Some core psycho-social concepts in pain medicine are mentioned.

CONCLUSIONS

The clinical applicability and clinical reasoning power of the 3 × 3 framework is illustrated by three short (albeit fictional) case descriptions.

Rationale and design of a multisite randomized clinical trial examining an integrated behavioral treatment for veterans with co-occurring chronic pain and opioid use disorder: The pain and opioids integrated treatment in veterans (POSITIVE) trial

BACKGROUND

Chronic pain and opioid use disorder (OUD) individually represent a risk to health and well-being. Concerningly, there is evidence that they are frequently co-morbid. While few treatments exist that simultaneously target both conditions, preliminary work has supported the feasibility of an integrated behavioral treatment targeting pain interference and opioid misuse. This treatment combined Acceptance and Commitment Therapy (ACT) and Mindfulness-Based Relapse Prevention (ACT+MBRP). This paper describes the protocol for the adequately powered efficacy study of this integrated treatment.

METHODS

A multisite randomized controlled trial will examine the efficacy of ACT+MBRP in comparison to a parallel education control condition, focusing on opioid safety and pain education. Participants include veterans (n = 160; 21-75 years old) recruited from three Veterans Administration (VA) Healthcare Systems with chronic pain who are on a stable dose of buprenorphine. Both conditions include twelve weekly 90 min group sessions delivered via telehealth. Primary outcomes include pain interference (Patient Reported Outcome Measurement Information System - Pain Interference) and hazardous opioid use (Current Opioid Misuse Measure), which will be examined at the end of the active treatment phase and through 12 months post-intervention. Secondary analyses will evaluate outcomes including pain intensity, depression, pain-related fear, and substance use, as well as treatment mechanisms.

CONCLUSION

This study will determine the efficacy of an integrated behavioral treatment program for pain interference and hazardous opioid use among veterans with chronic pain and OUD who are prescribed buprenorphine, addressing a critical need for more integrated treatments for chronic pain and OUD.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04648228.

Best clinical management of tenosynovial giant cell tumour (TGCT): A consensus paper from the community of experts

Tenosynovial giant cell tumour (TGCT) is a rare, locally aggressive, mesenchymal tumor arising from the joints, bursa and tendon sheaths. TGCT comprises a nodular- and a diffuse-type, with the former exhibiting mostly indolent course and the latter a locally aggressive behavior. Although usually not life-threatening, TGCT may cause chronic pain and adversely impact function and quality of life (QoL). CSFR1 inhibitors are effective with benefit on symptoms and QoL but are not available in most countries. The degree of uncertainty in selecting the most appropriate therapy and the lack of guidelines on the clinical management of TGCT make the adoption of new treatments inconsistent across the world, with suboptimal outcomes for patients. A global consensus meeting was organized in June 2022, involving experts from several disciplines and patient representatives from SPAGN to define the best evidence-based practice for the optimal approach to TGCT and generate the recommendations presented herein.

Appropriate use of tapentadol: focus on the optimal tapering strategy

OBJECTIVE

Due to its opioid and non-opioid mechanism of action, tapentadol is considered an atypical opioid with improved gastrointestinal tolerability versus traditional opioids. As for all opioid analgesics it is important to understand how to discontinue a treatment when it is not needed anymore. The aim of this article was to provide an overview of opioid therapy in non-cancer pain, with a specific focus on tapering of tapentadol in patients with chronic non-cancer pain, and suggestions on how to achieve tapering.

METHODS

Studies for this narrative review were identified via PubMed using a structured search strategy, focusing on management of chronic non-cancer pain with opioids, and the efficacy, tolerability, and pharmacology of tapentadol prolonged release. Publications were limited to English-language articles published within the last ∼10 years.

RESULTS

The review discusses the use and discontinuation of opioids in general, as well clinical data on discontinuation of tapentadol specifically. We provide a flow chart, which can be used by clinicians in the context of their own clinical experience to appropriately taper tapentadol in patients with chronic non-cancer pain. The flow chart can be easily tailored to individual patient characteristics, duration of tapentadol treatment, response to progressive dosage reduction, and likelihood of withdrawal symptom occurrence.

CONCLUSIONS

While tapentadol is associated with a low frequency of opioid withdrawal symptoms after abrupt discontinuation, use of a tapering strategy is prudent. Tapering strategies developed for opioids in general can potentially be safely individualized in tapentadol-treated patients, although research on tapering strategies for tapentadol is required.

Opioid-related adverse drug reactions in patients visiting the emergency division of a tertiary hospital

Opioid use and associated morbidity and mortality have increased in several countries during the past 20 years. We performed a study whose objective was to assess the frequency and causes of opioid-related emergency division (ED) visits in an adult tertiary Swiss University Hospital over 9 weeks in 2018. We primarily assessed opioid-related adverse drug reactions (ADR), secondary overdose, misuse, abuse, and insufficient pain relief. Current opioid use was identified in 1037 (8.3%) of the 12 470 included ED visits. In 64 opioid users, an ADR was identified as a contributing cause of the ED visit, representing 6.2% of opioid users, and 0.5% of the total ED visits. Moreover, we identified an overdose in 16 opioid users, misuse or abuse in 19 opioid users, and compatible withdrawal symptoms in 7 opioid users. After pooling all these events, we conclude that the ED visits could be related to opioid use in 10.2% of opioid users. Finally, in 201 opioid users, insufficient pain relief (pain not responding to the current pharmacological treatment) was identified as a contributing cause of ED visits. In these cases, other factors than simply pharmacological nonresponse may have been involved. In the context of an ever-increasing opioid use to better control chronic pain situations, these results should reinforce emergency network epidemiological surveillance studies at a national level.

Cross-sectional study of the prevalence of prescription opioids misuse in French patients with chronic non-cancer pain: An update with the French version of the POMI scale

Public health issues related to chronic pain management and the risks of opioid misuse and abuse remain a challenge for practitioners. Data on the prevalence of disorders related to the use of prescribed opioids in patients suffering from chronic pain remains rather patchy, in particular because of the absence of a gold standard for their clinical assessment. We estimated the prevalence of prescription opioid misuse (POM), using a specific and validated opioid misuse scale (POMI-5F scale), in adults with chronic non-cancer pain. Nine-hundred-fifty-one (951) patients with opioids prescription and followed-up in pain clinics and addictology centers for chronic non-cancer pain (CNCP) completed the survey interview. The results suggest that 44.4% of participants have POM, accompanied by overuse (42.5%), use of opioids for effects other than analgesia (30.9%), withdrawal syndrome (65.7%), and craving (6.9%). The motivations cited for POM, apart from pain relief, were to calm down, relax and improve mood. POM was shown to be related to male sex (OR 1.52), young age (OR 2.21) and the presence of nociplastic pain (OR 1.62) of severe intensity (OR 2.31), codeine use (OR 1.72) and co-prescription of benzodiazepines (OR 1.59). Finally, despite the presence of three subgroups of misusers, no factor was associated with the intensity of misuse, reinforcing the view that distinguishing between strong and weak opioids is not appropriate in the context of use disorder. Almost half of patients with CNCP misuse their prescribed opioid. Practitioners should be attentive of profiles of patients at risk of POM, such as young, male patients suffering from severe nociplastic pain, receiving prescription for codeine and a co-prescription for benzodiazepine. We encourage French-speaking practitioners to use the POMI-5F scale to assess the presence of POM in their patients receiving opioid-based therapy.

Clinical Trial Registrationclinicaltrials.gov, identifier NCT03195374

Trends in Opioid Utilisation in Hungary, 2006-2020: A Nationwide Retrospective Study with Multiple Metrics

BACKGROUND

Opioid use is well-documented in several countries: some countries struggle with overuse while others have almost no access to opioids. For Europe, limited data are available. This study analysed Hungarian opioid utilisation in ambulatory care between 2006 and 2020.

METHODS

We obtained national drug utilization data on reimbursed opioid analgesics (ATC code: N02A) from a national health insurance database for a 15-year period. We investigated utilisation trends, using three volume-based metrics (defined daily dose per 1000 inhabitants per day (DID), oral morphine equivalent per 1000 inhabitants per day, packages dispensed per 1000 inhabitants per year). We stratified data based on administration routes, analgesic potency and reimbursement categories.

RESULTS

Total opioid utilisation increased during the study period according to all three metrics (74% in DID) and reached 5.31 DID by 2020. Upward trends were driven by an increase both in weak and strong opioid use (79% vs. 53%). The most commonly used opioids were fentanyl (in the strong category; 0.76 DID in 2020) and tramadol (in the weak category; 2.62 DID in 2020). Overall, tramadol was also the most commonly used opioid throughout the study period. Oral administration of opioid medications was dominant. Based on reimbursement categories, musculoskeletal pain was becoming a more frequent indication for opioid use (1552% increase in DID), while opioid use for cancer pain declined significantly during the study period (-33% in DID).

CONCLUSIONS

Our low utilisation numbers might indicate underuse of opioid analgesia, especially for cancer pain.

Opioid and Alcohol Misuse in Veterans with Chronic Pain: A Risk Screening Study

In United States military veterans, chronic pain represents a risk factor for opioid and alcohol misuse, yet few studies have examined interactions among chronic pain, opioid prescription, and opioid and alcohol misuse. Previous work found substantial risk of co-morbid alcohol and opioid misuse in a community sample of opioid-prescribed individuals with chronic pain, a finding expanded upon here. Specifically, 211 veterans assessed within a chronic pain treatment service for opioid-prescribed individuals completed self-report measures of opioid misuse, alcohol misuse, pain intensity, depression, pain catastrophizing, and post-traumatic stress symptoms (PTS). Based on the substance misuse measures, 32% (n = 68) were misusing neither opioids nor alcohol, 23% (n = 48) were misusing both opioids and alcohol, 40% (n = 84) were misusing opioids alone, and 5% (n = 11) were misusing alcohol alone. Group comparisons indicated that individuals not misusing either substance were less distressed in comparison to those who were misusing opioids alone or both substances. The latter groups differed in PTS. Overall, misuse frequencies mirrored previous work, with approximately 1 of 3 misusing opioids and approximately 1 of 5 misusing both substances. There is a need for increased focus on both polysubstance misuse and the development of integrated treatment.

Opioid trends in Finland: a register-based nationwide follow-up study

The opioid epidemic in the U.S has gotten payers, prescribers, and policymakers alike interested in trends in opioid use. Despite no recognized opioid crisis in Europe, several countries have reported an increase in opioid-related deaths, which has further prompted discussion on the need of monitoring of opioid prescriptions. This study was conducted to offer information on opioid use during the escalation of the U.S. opioid epidemic in Finland, a Nordic country with universal tax-based health care. This is a nationwide retrospective register-based cohort study on all individuals in Finland who were dispensed opioids in 2009–2017 (n of unique patients = 1,761,584). By using the unique personal identification code assigned to every Finnish resident, we linked data from nationwide registers on dispensed drugs, medical history, and socio-demographic parameters. We report a wide set of patient demographics, dispensing trends for all opioid Anatomical Therapeutic Chemical (ATC) classes, and reasons for opioid initiation based on diagnostic coding for the most recent health care visit. For a cohort of incident opioid users with a four-year wash-out period (n = 1 370 057), we also present opioid use patterns in a three-year follow-up: the likelihood of becoming a persistent user or escalating from weak to strong opioids. A steady 7% of the Finnish population were dispensed opioids annually in 2009-2017. The mean annual quantity of dispensed opioids per opioid patient increased between 2009 and 2017 by 33%, reaching 2 583 oral morphine equivalent mg (OMEQ)/patient/year in 2017. The median quantity of dispensed opioids was lower: 315 OMEQ/year/patient. Depending on the opioid ATC class, there were either increasing or decreasing numbers of patients who had been dispensed said opioid class, and also in the mean quantity. The most common reason for opioid initiation was post-surgical pain (20%), followed by musculoskeletal pain (15%), injury (8.3%), and non-postsurgical dental pain (6.2%). 94% of new opioid initiators started with a weak opioid, i.e. codeine or tramadol. 85% of the patients who had been dispensed a weak opioid were not dispensed an opioid subsequently 3–6 months after the first one, and 95% of them had not escalated to a strong opioid in a 3-year follow-up. The number of patients dispensed opioids in Finland did not change during the escalation of the opioid epidemic in the U.S., but there were changes in the quantity of opioids dispensed per patient. Opioid therapy was typically initiated with weak opioid, the initial dispensed prescription was relatively small, and escalation to strong opioids was rare. A considerable share of patients had been prescribed opioids for chronic non-cancer pain - a type of pain where the risk-benefit ratio of opioids is controversial.

Oxycodone-related deaths in Sweden 2006-2018

AIM

To identify and characterize oxycodone related deaths in Sweden from 2006 to 2018 and to compare them to other opioid-related deaths.

METHODS

To assess the factors contributing to the deaths, we used multinomial logistic regression to compare oxycodone-related deaths extracted from all forensic autopsy examinations and toxicology cases in the age groups 15-34 (reference group), 35-54 and 55-74 with regard to sex, presence of benzodiazepines and alcohol at the time of death, prescription of oxycodone, benzodiazepines and antidepressants, previous substance use-related (SUD) treatment, and manner of death. The oxycodone related deaths were compared with deaths with presence of other opioids.

RESULT

We identified 575 oxycodone-related deaths, and the rate increased during the study period from 0.10 to 1.12 per 100,000 in parallel with an increase of oxycodone prescriptions from 3.17 to 30.33 per 1000. Oxycodone-related deaths amounted to 10.0% of all opioid-related deaths. The deaths occurred mainly in older patients previously being prescribed oxycodone. Benzodiazepines were present at the time of death in 403 (70%) and alcohol in 259 (45%). Prescriptions of any opioid for pain (61%), oxycodone (50%), benzodiazepines (67%) and antidepressants (55%) were common. Only 15% had received treatment for SUD during the last year.

CONCLUSION

Oxycodone-related deaths increased in Sweden between 2006 and 2018 in parallel to an increase in oxycodone prescriptions. The increase occurred mainly in older patients being prescribed oxycodone for pain. There might be specific interventions needed to avoid oxycodone-related deaths compared to other opioid-related deaths associated with illicit opioid use.

Screening, diagnosis and management of diabetic sensorimotor polyneuropathy in clinical practice: International expert consensus recommendations

Diabetic sensorimotor polyneuropathy (DSPN) affects around one third of people with diabetes and accounts for considerable morbidity, increased risk of mortality, reduced quality of life, and increased health care costs resulting particularly from neuropathic pain and foot ulcers. Painful DSPN is encountered in 13-26% of diabetes patients, while up to 50% of patients with DSPN may be asymptomatic. Unfortunately, DSPN still remains inadequately diagnosed and treated. Herein we provide international expert consensus recommendations and algorithms for screening, diagnosis, and treatment of DSPN in clinical practice derived from a Delphi process. Typical neuropathic symptoms include pain, paresthesias, and numbness particularly in the feet and calves. Clinical diagnosis of DSPN is based on neuropathic symptoms and signs (deficits). Management of DSPN includes three cornerstones: (1) lifestyle modification, optimal diabetes treatment aimed at near-normoglycemia, and multifactorial cardiovascular risk intervention, (2) pathogenetically oriented pharmacotherapy (e.g. α-lipoic acid and benfotiamine), and (3) symptomatic treatment of neuropathic pain including analgesic pharmacotherapy (antidepressants, anticonvulsants, opioids, capsaicin 8% patch and combinations, if required) and non-pharmacological options. Considering the individual risk profile, pain management should not only aim at pain relief, but also allow for improvement in quality of sleep, functionality, and general quality of life.

System-level policies on appropriate opioid use, a multi-stakeholder consensus

BACKGROUND

This consensus statement was developed because there are concerns about the appropriate use of opioids for acute pain management, with opposing views in the literature. Consensus statement on policies for system-level interventions may help inform organisations such as management structures, government agencies and funding bodies.

METHODS

We conducted a multi-stakeholder survey using a modified Delphi methodology focusing on policies, at the system level, rather than at the prescriber or patient level. We aimed to provide consensus statements for current developments and priorities for future developments.

RESULTS

Twenty-five experts from a variety of fields with experience in acute pain management were invited to join a review panel, of whom 23 completed a modified Delphi survey of policies designed to improve the safety and quality of opioids prescribing for acute pain in the secondary care setting. Strong agreement, defined as consistent among> 75% of panellists, was observed for ten statements.

CONCLUSIONS

Using a modified Delphi study, we found agreement among a multidisciplinary panel, including patient representation, on prioritisation of policies for system-level interventions, to improve governance, pain management, patient/consumers care, safety and engagement.

An overview of the use and misuse/abuse of opioid analgesics in different world regions and future perspectives

Opioids are an important therapeutic option for severe resistant chronic pain but, in the absence of proper oversight, their use has risks. The level of prescription opioid misuse/abuse differs among countries, due to differences in healthcare systems and pain management approaches. However, evaluating the true dimension of prescription opioid misuse/abuse is complicated by statistical reporting which often does not differentiate between prescription and illicit opioid use, or between prescription opioid use by patients and nonpatients, highlighting a need for greater uniformity. Parallel efforts to educate patients and the general public about opioid risks, facilitate appropriate analgesic prescribing and identify alternative formulations or options to use instead of or with opioids, may contribute to optimizing prescription opioid use for pain management.

Risk Prescriptions of Strong Opioids in the Treatment of Chronic Non-Cancer Pain by Primary Care Physicians in Catalonia: Opicat Padris Project

The prescription of strong opioids (SO) for chronic non-cancer pain (CNCP) is steadily increasing. This entails a high risk of adverse effects, a risk that increases with the concomitant prescription of SO with central nervous system depressant drugs and with the use of SO for non-recommended indications. In order to examine this concomitant risk prescription, we designed a descriptive, longitudinal, retrospective population-based study. Patients aged ≥15 years with a continued SO prescription for ≥3 months during 2013–2017 for CNCP were included. Of these, patients who had received concomitant prescriptions of SO and risk drugs (gabapentinoids, benzodiazepines and antidepressants) and those who had received immediate-release fentanyl (IRF) were selected. The study included 22,691 patients; 20,354 (89.7%) patients received concomitant risk prescriptions. Men and subjects with a higher socioeconomic status received fewer concomitant risk prescriptions. Benzodiazepines or Z-drugs were prescribed concomitantly with SO in 15,883 (70%) patients, antidepressants in 14,932 (65%) and gabapentinoids in 11,267 (49%), while 483 (21.32%) patients received IRF (2266 prescriptions in total) without a baseline SO. In conclusion, our study shows that a high percentage of patients prescribed SO for CNCP received concomitant prescriptions with known risks, as well as IRF for unauthorized indications.

Trends in the Prescription of Strong Opioids for Chronic Non-Cancer Pain in Primary Care in Catalonia: Opicat-Padris-Project

In chronic non-cancer pain (CNCP), evidence of the effectiveness of strong opioids (SO) is very limited. Despite this, their use is increasingly common. To examine SO prescriptions, we designed a descriptive, longitudinal, retrospective population-based study, including patients aged ≥15 years prescribed SO for ≥3 months continuously in 2013–2017 for CNCP in primary care in Catalonia. Of the 22,691 patients included, 17,509 (77.2%) were women, 10,585 (46.6%) were aged >80 years, and most had incomes of <€18,000 per year. The most common diagnoses were musculoskeletal diseases and psychiatric disorders. There was a predominance of transdermal fentanyl in the defined daily dose (DDD) per thousand inhabitants/day, with the greatest increase for tapentadol (312% increase). There was an increase of 66.89% in total DDD per thousand inhabitants/day for SO between 2013 (0.737) and 2017 (1.230). The mean daily oral morphine equivalent dose/day dispensed for all drugs was 83.09 mg. Transdermal fentanyl and immediate transmucosal release were the largest cost components. In conclusion, there was a sustained increase in the prescription of SO for CNCP, at high doses, and in mainly elderly patients, predominantly low-income women. The new SO are displacing other drugs.

Describing long-term opioid use utilizing Nordic Prescription Registers - A Norwegian example

Previous studies have defined long-term opioid use in varying ways, decreasing comparability, reproducibility, and clinical applicability of the research. Based on recommendations from recent systematic reviews, we aimed to develop a methodology to estimate the prevalence of use persisting more than three months utilizing one of the Nordic prescription registers. We used the Norwegian Prescription Register (NorPD) to extract data on all opioid dispensations between 1 January 2004 and 31 October 2019. New users of opioids (washout 365 days) were defined as long-term users if they fulfilled two criteria: 1) they had ≥2 dispensations of opioids, 91-180 days apart; 2) days 0-90 included ≥90 dispensed administration units (e.g., tablets) of opioids. Overall, there were 2,543,224 new users of opioids during the study period. Of these, 354,666 (13.9%) fulfilled the criteria for long-term opioid use at least once. Compared with those who did not fulfill the criteria (short-term users), long-term users were older, more likely women, and used tramadol, oxycodone, and buprenorphine more frequently as their first opioid. In conclusion, we found that 1/7 of opioid users continued use longer than 3 months. Future outcome research should identify the clinically most important dose requirements for long-term opioid use criteria.

Opioid reduction for patients with chronic pain in primary care: systematic review

BACKGROUND

Long-term opioid treatment in patients with chronic pain is often ineffective and possibly harmful. These patients are often managed by general practitioners, who are calling for a clear overview of effective opioid reduction strategies for primary care.

AIM

Evaluate effectiveness of opioid reduction strategies applicable in primary care for patients with chronic pain on long-term opioid treatment.

DESIGN

Systematic review of controlled trials and cohort studies. Method Literature search conducted in Embase, Medline, Web of Science, Cochrane CENTRAL register of trials, CINAHL, Google Scholar and PsychInfo. Studies evaluating opioid reduction interventions applicable in primary care among adults with long-term opioid treatment for chronic non-cancer pain were included. Risk of bias was assessed using Cochrane risk of bias (RoB) 2.0 tool or Risk-of-Bias in Non-randomized studies of Interventions (ROBINS-I) tool. Narrative synthesis was performed due to clinical heterogeneity in study designs and types of interventions.

RESULTS

Five RCTs and five cohort studies were included (total n= 1717, range 35-985) exploring various opioid reduction strategies. Six studies had high RoB, three moderate RoB, and one low RoB. Three cohort studies investigating a GP supervised opioid taper (critical ROBINS-I), an integrative pain treatment (moderate ROBINS-I) and group medical visits (critical ROBINS-I) demonstrated significant between-group opioid reduction.

CONCLUSION

Results carefully point in the direction of a GP supervised tapering and multidisciplinary group therapeutic sessions to reduce long term opioid treatment. However, due to high risk of bias and small sample sizes, no firm conclusions can be made demonstrating need for more high-quality research.

Cannabis-Based Medicines and Medical Cannabis for Chronic Neuropathic Pain

Neuropathic pain represents a broad category of pain syndromes that include a wide variety of peripheral and central disorders. The overall prevalence of neuropathic pain in the general population is reported to be between 7 and 10%. Management of neuropathic pain presents an unmet clinical need, with less than 50% of patients achieving substantial pain relief with medications currently recommended such as pregabalin, gabapentin, duloxetine and various tricyclic antidepressants. It has been suggested that cannabis-based medicines (CbMs) and medical cannabis (MC) may be a treatment option for those with chronic neuropathic pain. CbMs/MC are available in different forms: licensed medications or medical products (plant-derived and/or synthetic products such as tetrahydrocannabinol or cannabidiol); magistral preparations of cannabis plant derivatives with defined molecular content such as dronabinol (tetrahydrocannabinol); and herbal cannabis with a defined content of tetrahydrocannabinol and/or cannabidiol, together with other active ingredients (phytocannabinoids other than cannabidiol/tetrahydrocannabinol, terpenes and flavonoids). The availability of different types of CbMs/MC varies between countries worldwide. Systematic reviews of available randomised controlled trials have stated low-quality evidence for CbMs and MC for chronic neuropathic pain. Depending on the studies included in the various quantitative syntheses, authors have reached divergent conclusions on the efficacy of CbMs/MC for chronic neuropathic pain (from not effective to a clinically meaningful benefit). Clinically relevant side effects of CbMs/MC, especially for central nervous system and psychiatric disorders, have been reported by some systematic reviews. Recommendations for the use of CbMs/MC for chronic neuropathic pain by various medical associations also differ, from negative recommendations, no recommendation possible, recommended as third-line therapy, or recommended as an alternative in selected cases failing standard therapies within a multimodal concept. After reading this paper, readers are invited to formulate their own conclusions regarding the potential benefits and harms of CbMs/MC for the treatment of chronic neuropathic pain.

Impact and Consequences of Opioid-Induced Constipation: A Survey of Patients

INTRODUCTION

Opioids are a valuable tool to help achieve control of pain. However, opioid-induced constipation (OIC) is an important limitation of treatment with this class of drugs.

METHODS

To better understand the impact of OIC on patient-reported outcomes, we carried out a survey involving patients being treated with opioids. Both ad hoc questions and the PROMIS and PAC-SYM and PAC-QOL scores were used.

RESULTS

Of the 597 participants, 150 (25%) had cancer-related pain, and 447 (75%) had non-cancer pain; 66% experienced OIC. PROMIS pain interference questions indicated that pain is more likely to interfere with a patient's life when they have OIC. PAC-QOL and PAC-SYM revealed that 58% of patients with non-cancer pain and OIC reported at least one "severe" or "very severe" constipation symptom, compared to 83% with cancer-related pain. Younger age and less time on opioids were associated with greater impact of OIC on quality of life. Only 41% of patients were satisfied with how their constipation was managed. Over 50% of those with non-cancer pain said that they modified their opioid regimen due to constipation, vs. 6% of those with cancer pain. Constipation had been discussed with the healthcare provider (HCP) in 48% of non-cancer patients and in 73% of cancer patients. In those with chronic pain and OIC, 24% expressed varying degrees of dissatisfaction with the healthcare system, vs. 37% in those with cancer pain and OIC.

CONCLUSION

Our results provide additional evidence that management of OIC is inadequate in many cases. Moreover, they indicate that there is a definite need for better education about OIC among HCPs.

A pharmacist-led intervention to improve the management of opioids in a general practice: a qualitative evaluation of participant interviews

Background Opioid prescribing has escalated, particularly long-term in chronic noncancer pain. Innovative models of care have been recommended to augment regulatory and harm-minimisation strategies and to review the safety and benefits of opioids for the individual patient. Medication stewardship and pharmacist integration are evolving approaches for general practice. Aim To explore enablers, barriers, and outcomes of a pharmacist-led intervention to improve opioid management in general practice, from the perspectives of general practitioners (GPs) and practice personnel. Method The study was part of a mixed-methods investigation into a general practice pharmacist pilot. Qualitative data relevant to opioids were analysed. Data from 13 semi-structured interviews were coded, analysed iteratively and thematically, and interpreted conceptually through the framework of Opioid Stewardship fundamentals proposed by the National Quality Forum. Results Seven themes and 14 subthemes aligned with stewardship fundamentals. Participants considered organisational policy, supported by leadership and education, fostered collaboration and consistency and improved practice safety. Patient engagement with individualised resources, 'agreements' and 'having the conversation' with the pharmacist enabled person-centred opioid review and weaning. GPs reported greater accountability and reflection in their practices, in the broader context of opioid prescribing and dilemmas in managing patients transitioning through care. Receiving feedback on practice deprescribing outcomes encouraged participants' ongoing commitment. Patient communication was deemed an early barrier; however, learnings were applied when transferring the model to other high-risk medicines. Conclusion Improved opioid management was enabled through implementing pharmacist-led coordinated stewardship. The findings offer a practical application of guideline advice to individualise opioid deprescribing.

Pursuing the Recovery of Severe Chronic Musculoskeletal Pain in Italy: Clinical and Organizational Perspectives from a SIAARTI Survey

Background

Increased attention to the functional impact of chronic pain (CP), as highlighted by the 11th revision of the International Classification of Diseases (ICD-11) and advocated by the International Classification of Functioning, Disability and Health (ICF), is an important step forward for optimizing its management. Evidence about perspectives of Italian physicians on the relevance of musculoskeletal (MSK) pain care to improve patients’ functioning and Quality of Life is scant. The study aimed to investigate the physicians’ perception of the value of functional recovery in severe MSK pain patients, their attitude towards its assessment and achievement in Italy.

Methods

A survey was conducted in Italy between October 2020 and January 2021. Specialist centers members of the SIAARTI (n = 395) were sent an online questionnaire encompassing the Italian pain therapy network. Participants rated their agreement to questionnaire items according to a 5-point Likert-type scale.

Results

A total of 305 centers (77%) completed the survey. Most physicians rated the recovery of functioning as very relevant in MSK pain treatment and, when they assessed it, devoted great attention to the ability to perform daily activities, pain, ability to ambulate and sleep quality. Multidimensional questionnaires were less employed in favor of physical examination and pain intensity scales. Pharmacological therapy, rehabilitation and lifestyle changes and/or physical exercise were all rated optimal strategies to pursue the recovery of patients’ functioning. When considering pharmacological therapy, weak and strong opioids, either alone or combined with paracetamol, were the most frequently employed analgesics.

Conclusion

Clinicians seem to recognize the recovery of functioning as equally important as pain intensity reduction, but there is a need of streamlining available tools to effectively assess both across different MSK pain patients.

[Pain Management in Hospitals - Current Practice, Quality and Organisation in Non-surgical Medical Care]

For many years now, effective pharmacological and non-pharmacological treatment approaches for acute and chronic pain exist, as well as organisational strategies for their implementation in hospitals. Nevertheless, there remain considerable deficits in pain management and the portion of patients with severe or long-lasting pain in non-surgical units is often high. There is a considerable potential to improve quality and structures of pain mangement in non-surgical hospital settings in Germany. Recently, legal requirements to establish a structured perioperative pain management were introduced. This should not be seen as a signal that pain management is less important in non-surgical disciplines. On the contrary - it should raise awareness for more clinical and health services research to further develop and validate appropriate approaches and concepts to improve pain treatment in this field.

[Pain Management in Non-surgical Inpatients - Treatment Approaches and Competence for Pain Services]

The number of non-surgical patients in the hospital setting with pain due to medical conditions or comorbidities and/or invasive procedures or treatments is high. Compared to perioperative pain management, the portion of patients and/or conditions that require more than an approach focused on pharmacological treatment of nociceptive pain is considerably higher. Rather, treatment often requires the differentiated use of co-analgesics, non-pharmacological treatments, physiotherapy, occupational therapy, psychological assessment and interventsions and educational approaches, ideally in the form of closely coordinated interdisciplinary treatment. The assessment and treatment of acute and especially chronic pain should follow the biopsychosocial concept of pain, especially if risk factors for chronification have been identified, if patients receive high-dose therapy with analgesics or have preexisting a chronic pain disorder.

Is Europe also facing an opioid crisis?-A survey of European Pain Federation chapters

BACKGROUND

There is considerable public interest in whether Europe is facing an opioid crisis comparable to the one in the United States and the contribution of opioid prescriptions for pain to a potential opioid crisis.

METHODS

A task force of the European Pain Federation (EFIC) conducted a survey with its national chapter representatives on trends of opioid prescriptions and of drug-related emergency departments and substance use disorder treatment admissions and of deaths as proxies of opioid-related harms over the last 20 years.

RESULTS

Data from 25 European countries were received. In most European countries opioid prescriptions increased from 2004 to 2016. The levels of opioid consumption and their increase differed between countries. Some Eastern European countries still have a low opioid consumption. Opioids are mainly prescribed for acute pain and chronic noncancer pain in some Western and Northern European countries. There was a parallel increase in opioid prescriptions and some proxies of opioid-related harms in France, Finland and the Netherlands, but not in Germany, Spain and Norway. In United Kingdom, opioid overdose deaths, but not opioid prescriptions increased between 2016 and 2018. There are no robust data available on whether prescribed opioids for pain patients contributed to opioid-related harms.

CONCLUSIONS

There are marked differences between European countries in trends of opioid prescribing and of proxies for opioid-related harms. Europe as a whole is not facing an opioid crisis. Discussions on the potential harms of opioids should not obstruct their prescription for cancer pain and palliative care.

SIGNIFICANCE

Europe as a whole is not facing an opioid crisis. Some Eastern European countries have limited access to opioid medicines. Discussions on the potential harms of opioid medicines for noncancer pain should not obstruct opioid therapy for cancer therapy and palliative care.

European* clinical practice recommendations on opioids for chronic noncancer pain - Part 1: Role of opioids in the management of chronic noncancer pain

BACKGROUND

Opioid use for chronic non-cancer pain (CNCP) is complex. In the absence of pan-European guidance on this issue, a position paper was commissioned by the European Pain Federation (EFIC).

METHODS

The clinical practice recommendations were developed by eight scientific societies and one patient self-help organization under the coordination of EFIC. A systematic literature search in MEDLINE (up until January 2020) was performed. Two categories of guidance are given: Evidence-based recommendations (supported by evidence from systematic reviews of randomized controlled trials or of observational studies) and Good Clinical Practice (GCP) statements (supported either by indirect evidence or by case-series, case-control studies and clinical experience). The GRADE system was applied to move from evidence to recommendations. The recommendations and GCP statements were developed by a multiprofessional task force (including nursing, service users, physicians, physiotherapy and psychology) and formal multistep procedures to reach a set of consensus recommendations. The clinical practice recommendations were reviewed by five external reviewers from North America and Europe and were also posted for public comment.

RESULTS

The key clinical practice recommendations suggest: (a) first optimizing established non-pharmacological treatments and non-opioid analgesics and (b) considering opioid treatment if established non-pharmacological treatments or non-opioid analgesics are not effective and/or not tolerated and/or contraindicated. Evidence- and clinical consensus-based potential indications and contraindications for opioid treatment are presented. Eighteen GCP recommendations give guidance regarding clinical evaluation, as well as opioid treatment assessment, monitoring, continuation and discontinuation.

CONCLUSIONS

Opioids remain a treatment option for some selected patients with CNCP under careful surveillance.

SIGNIFICANCE

In chronic pain, opioids are neither a universal cure nor a universally dangerous weapon. They should only be used for some selected chronic noncancer pain syndromes if established non-pharmacological and pharmacological treatment options have failed in supervised pain patients as part of a comprehensive, multi-modal, multi-disciplinary approach to treatment. In this context alone, opioid therapy can be a useful tool in achieving and maintaining an optimal level of pain control in some patients.

European clinical practice recommendations on opioids for chronic noncancer pain - Part 2: Special situations

BACKGROUND

Opioid use for chronic non-cancer pain (CNCP) is under debate. In the absence of pan-European guidance on this issue, a position paper was commissioned by the European Pain Federation (EFIC).

METHODS

The clinical practice recommendations were developed by eight scientific societies and one patient self-help organization under the coordination of EFIC. A systematic literature search in MEDLINE (up until January 2020) was performed. Two categories of guidance are given: Evidence-based recommendations (supported by evidence from systematic reviews of randomized controlled trials or of observational studies) and Good Clinical Practice (GCP) statements (supported either by indirect evidence or by case-series, case-control studies and clinical experience). The GRADE system was applied to move from evidence to recommendations. The recommendations and GCP statements were developed by a multiprofessional task force (including nursing, service users, physicians, physiotherapy and psychology) and formal multistep procedures to reach a set of consensus recommendations. The clinical practice recommendations were reviewed by five external reviewers from North America and Europe and were also posted for public comment.

RESULTS

The European Clinical Practice Recommendations give guidance for combination with other medications, the management of frequent (e.g. nausea, constipation) and rare (e.g. hyperalgesia) side effects, for special clinical populations (e.g. children and adolescents, pregnancy) and for special situations (e.g. liver cirrhosis).

CONCLUSION

If a trial with opioids for chronic noncancer pain is conducted, detailed knowledge and experience are needed to adapt the opioid treatment to a special patient group and/or clinical situation and to manage side effects effectively.

SIGNIFICANCE

If a trial with opioids for chronic noncancer pain is conducted, detailed knowledge and experience are needed to adapt the opioid treatment to a special patient group and/or clinical situation and to manage side effects effectively. A collaboration of medical specialties and of all health care professionals is needed for some special populations and clinical situations.

Severe chronic low back pain: patient journey from onset of symptoms to strong opioid treatments in Europe

Aim: We report the first patient roadmap in severe chronic low back pain (cLBP) in Europe, assessing the views of cLBP patients and general practitioners (GPs) who treat cLBP with regard to current cLBP management. Methodology: Patient journey mapping was conducted in four European countries to assess the views of cLBP patients (n = 20) and GPs (n = 40). Results: Four broad phases of cLBP, subdivided into eight individual steps, were identified as part of the patient journey, showing a disconnect between patients' and physicians' treatment goals, and expectations regarding pain relief levels for some patients. Conclusion: Improved communication, with greater involvement of patients in multimodal management decisions, might benefit the GP-patient relationship and overall outcomes for cLBP patients.

Is opioid therapy for chronic non-cancer pain associated with a greater risk of all-cause mortality compared to non-opioid analgesics? A systematic review of propensity score matched observational studies

BACKGROUND

The many risks associated with opioid therapy for chronic non-cancer pain (CNCP) have led to questions about use. This is particularly relevant for risk of increased mortality. However, underlying medical conditions of those using opioids may influence mortality findings due to confounding by indication. Similarly, non-opioid analgesics are also associated with an increased risk of mortality, too.

METHODS

We have conducted a systematic review of propensity score matched observational studies comparing mortality associated with opioid use compared to non-opioid analgesics. Clinicaltrials.gov, Google Scholar, MEDLINE and Scopus were searched from inception to July 2020. Propensity score matched observational studies comparing opioids to non-opioid analgesics in real-world settings were analysed. Primary outcome was pooled adjusted hazard ratio (aHR) of all-cause death. Effects were summarized by a random effects model.

RESULTS

Four studies with seven study arms and 120,186 patients were analysed. Pooled aHR for all-cause death was 1.69 (95% confidence interval [CI] 1.47, 1.95). When mortality risk was confined to out-of-hospital deaths, the pooled aHR was 2.12 (95% CI 1.46, 3.09). The most frequent cause of death was cardiovascular death. Before matching, patients with opioids were older and had more somatic diseases than patients with non-opioids. Despite extensive propensity score matchings and sensitivity analyses, all studies could not fully exclude confounding by indication.

CONCLUSIONS

Possibly, opioids are associated with an increased all-cause mortality risk compared to non-opioid analgesics. When considering treatment options for patients with CNCP, the possible risk of increased all-cause mortality with opioids should be discussed.

SIGNIFICANCE

An increased all-cause mortality associated with opioid use compared to non-opioid analgesics for CNCP was identified by a systematic review of four propensity score matched cohort studies in real-world settings. The number needed to harm for an additional excess death per 10,000 person-years was 116. Despite extensive propensity score matchings and sensitivity analyses, all studies could not fully exclude confounding by indication. The potential risk of increased all-cause mortality with opioids should be discussed with patients when considering opioid treatment.