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Hadler RA, Klinedinst R, Jones CA, Bao Y, Pathak R, Zarrabi AJ, Rosa WE. Dangerous Variation or Patient-Centered Care? Palliative Care and Pain Providers' Comfort, Experiences, and Approaches when Treating Cancer Pain With Coexisting Aberrant Behaviors. Am J Hosp Palliat Care 2024:10499091241259034. [PMID: 38830349 DOI: 10.1177/10499091241259034] [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] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND Patients with cancer-related pain are at high risk for aberrant drug use behaviors (ADB), including self-escalation, diversion and concurrent illicit substance or opioid misuse; however, limited evidence is available to guide opioid prescribing for patients with life-limiting illness and concurrent or suspected ADB. We sought to characterize how specialists evaluate for and manage these high-risk behaviors in patients with cancer-related pain. METHODS We conducted telephonic semi-structured interviews with palliative care and pain medicine providers. Participants discussed their own comfort and experience level with identifying and managing ADB in patients with life-limiting illness. They were subsequently presented with a series of standardized scenarios and asked to describe their concerns and management strategies. RESULTS 95 interdisciplinary pain and palliative care specialists were contacted; 37 agreed to participate (38.9%). Analysis of interview contents revealed several central themes: (1) widespread discomfort and anxiety regarding safe and compassionate opioid prescribing for high-risk patients, (2) belief that widely used risk-mitigation tools such as opioid contracts and urine drug screens provided inadequate support for decision-making, and (3) lack of institutional and organizational support and guidance for safe prescribing strategies. Most clinicians reported self-education regarding addiction and alternative prescribing/pain management strategies. Providers varied widely in their willingness to discontinue opioid prescribing in a patient with aberrant behavior and pain associated with life-limiting illness. CONCLUSION Providers caring for patients demonstrating ADB and cancer-related pain struggle to balance safe prescribing with symptom management. Increased guidance is needed regarding opioid prescribing, monitoring, and discontinuation in high-risk patients.
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Affiliation(s)
- Rachel A Hadler
- Department of Anesthesiology, Emory University, Atlanta, GA, USA
- Emory Critical Care Center, Emory University, Atlanta, GA, USA
| | - Rachel Klinedinst
- Palliative Care Alliance, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Christopher A Jones
- Palliative Care Program, Department of Medicine, Duke University, Durham, NC, USA
| | - Yuhua Bao
- Department of Population Health Sciences, Weill-Cornell Medicine, New York, NY, USA
| | - Ravi Pathak
- Department of Anesthesiology, Emory University, Atlanta, GA, USA
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, Atlanta, GA, USA
| | - Ali J Zarrabi
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, Atlanta, GA, USA
| | - William E Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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Ramírez Medina CR, Feng M, Huang YT, Jenkins DA, Jani M. Machine learning identifies risk factors associated with long-term opioid use in fibromyalgia patients newly initiated on an opioid. RMD Open 2024; 10:e004232. [PMID: 38772680 DOI: 10.1136/rmdopen-2024-004232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 04/29/2024] [Indexed: 05/23/2024] Open
Abstract
OBJECTIVES Fibromyalgia is frequently treated with opioids due to limited therapeutic options. Long-term opioid use is associated with several adverse outcomes. Identifying factors associated with long-term opioid use is the first step in developing targeted interventions. The aim of this study was to evaluate risk factors in fibromyalgia patients newly initiated on opioids using machine learning. METHODS A retrospective cohort study was conducted using a nationally representative primary care dataset from the UK, from the Clinical Research Practice Datalink. Fibromyalgia patients without prior cancer who were new opioid users were included. Logistic regression, a random forest model and Boruta feature selection were used to identify risk factors related to long-term opioid use. Adjusted ORs (aORs) and feature importance scores were calculated to gauge the strength of these associations. RESULTS In this study, 28 552 fibromyalgia patients initiating opioids were identified of which 7369 patients (26%) had long-term opioid use. High initial opioid dose (aOR: 31.96, mean decrease accuracy (MDA) 135), history of self-harm (aOR: 2.01, MDA 44), obesity (aOR: 2.43, MDA 36), high deprivation (aOR: 2.00, MDA 31) and substance use disorder (aOR: 2.08, MDA 25) were the factors most strongly associated with long-term use. CONCLUSIONS High dose of initial opioid prescription, a history of self-harm, obesity, high deprivation, substance use disorder and age were associated with long-term opioid use. This study underscores the importance of recognising these individual risk factors in fibromyalgia patients to better navigate the complexities of opioid use and facilitate patient-centred care.
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Affiliation(s)
- Carlos Raúl Ramírez Medina
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
| | - Mengyu Feng
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
| | - Yun-Ting Huang
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
| | - David A Jenkins
- Division of Informatics, Imaging and Data Science, The University of Manchester, Manchester, UK
| | - Meghna Jani
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Department of Rheumatology, Salford Royal Hospital, Northern Care Alliance, Salford, UK
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Mohammad I, Alsomairy S, Mawari M, Elabdallah M, Elteriefi R, George J. Evaluation of Interprofessional Quality Improvement Interventions Led by an Ambulatory Care Pharmacist on Adherence to a Controlled Substance Agreement Policy. Innov Pharm 2023; 14:10.24926/iip.v14i2.5464. [PMID: 38025177 PMCID: PMC10653718 DOI: 10.24926/iip.v14i2.5464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
Background: A controlled substance agreement (CSA) is a risk mitigation strategy for patients managed on controlled substance medications such as opioids and benzodiazepines. Limited literature exists to describe the role of the clinic pharmacy team to promote adherence to CSA monitoring parameters. Objective: The objective of this study is to evaluate the impact of interprofessional educational and clinical interventions led by an ambulatory care pharmacist on adherence to monitoring parameters within a CSA policy. Methods: This retrospective observational study included patients on long-term controlled substances who had a clinic visit every 3 months during the study period. The primary outcomes were the proportion of patients with a signed CSA in the electronic medical record (EMR), urine drug screen (UDS) completion, and documentation of review of the statewide prescription drug monitoring program (PDMP) in the EMR 8 months prior to as compared to 8 months after implementation of pharmacist interventions. Results: Among 79 patients (mean age 55.7 years, 65.8% female, 54.4% African American), 8.9% pre- vs 88.6% post-interventions had a signed CSA (p<0.001), 35.4% pre- vs 65.8% post-interventions had a UDS completed (p<0.001), and 32.9% pre- vs 57% post-interventions had documentation of PDMP review (p=0.002). Conclusion: Adherence to monitoring parameters within a CSA policy significantly improved after educational and clinical interventions led by an ambulatory care pharmacist.
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Affiliation(s)
- Insaf Mohammad
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University
- Department of Pharmacy, Corewell Health - Dearborn Hospital
| | | | - Mona Mawari
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University
| | | | - Ruaa Elteriefi
- Department of Internal Medicine, Corewell Health - Dearborn Hospital
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Iroz CB, Schäfer WLA, Johnson JK, Ager MS, Huang R, Balbale SN, Stulberg JJ. The development of a safe opioid use agreement for surgical care using a modified Delphi method. PLoS One 2023; 18:e0291969. [PMID: 37751431 PMCID: PMC10522037 DOI: 10.1371/journal.pone.0291969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 09/08/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND Opioids prescribed to treat postsurgical pain have contributed to the ongoing opioid epidemic. While opioid prescribing practices have improved, most patients do not use all their pills and do not safely dispose of leftovers, which creates a risk for unsafe use and diversion. We aimed to generate consensus on the content of a "safe opioid use agreement" for the perioperative settings to improve patients' safe use, storage, and disposal of opioids. METHODS We conducted a modified three-round Delphi study with clinicians across surgical specialties, quality improvement (QI) experts, and patients. In Round 1, participants completed a survey rating the importance and comprehensibility of 10 items on a 5-point Likert scale and provided comments. In Round 2, a sub-sample of participants attended a focus group to discuss items with the lowest agreement. In Round 3, the survey was repeated with the updated items. Quantitative values from the Likert scale and qualitative responses were summarized. RESULTS Thirty-six experts (26 clinicians, seven patients/patient advocates, and three QI experts) participated in the study. In Round 1, >75% of respondents rated at least four out of five on the importance of nine items and on the comprehensibility of six items. In Round 2, participants provided feedback on the comprehensibility, formatting, importance, and purpose of the agreement, including a desire for more specificity and patient education. In Round 3, >75% of respondents rated at least four out of five for comprehensibility and importance of all 10 updated item. The final agreement included seven items on safe use, two items on safe storage, and one item on safe disposal. CONCLUSION The expert panel reached consensus on the importance and comprehensibility of the content for an opioid use agreement and identified additional patient education needs. The agreement should be used as a tool to supplement rather than replace existing, tailored education.
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Affiliation(s)
- Cassandra B. Iroz
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Willemijn L. A. Schäfer
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Julie K. Johnson
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Meagan S. Ager
- Mathematica Policy Research, Chicago, IL, United States of America
| | - Reiping Huang
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Salva N. Balbale
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, IL, United States of America
- Center of Innovation for Complex Chronic Healthcare, Health Services Research & Development, Edward Hines, Jr. VA Hospital, Hines, IL, United States of America
| | - Jonah J. Stulberg
- Department of Surgery, University of Texas McGovern Medical School, Houston, TX, United States of America
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Austin EJ, Briggs ES, Ferro L, Barry P, Heald A, Curran GM, Saxon AJ, Fortney J, Ratzliff AD, Williams EC. Integrating Routine Screening for Opioid Use Disorder into Primary Care Settings: Experiences from a National Cohort of Clinics. J Gen Intern Med 2023; 38:332-340. [PMID: 35614169 PMCID: PMC9132563 DOI: 10.1007/s11606-022-07675-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/11/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND The U.S. Preventive Services Task Force recommends routine population-based screening for drug use, yet screening for opioid use disorder (OUD) in primary care occurs rarely, and little is known about barriers primary care teams face. OBJECTIVE As part of a multisite randomized trial to provide OUD and behavioral health treatment using the Collaborative Care Model, we supported 10 primary care clinics in implementing routine OUD screening and conducted formative evaluation to characterize early implementation experiences. DESIGN Qualitative formative evaluation. APPROACH Formative evaluation included taking detailed observation notes at implementation meetings with individual clinics and debriefings with external facilitators. Observation notes were analyzed weekly using a Rapid Assessment Process guided by the Consolidated Framework for Implementation Research, with iterative feedback from the study team. After clinics launched OUD screening, we conducted structured fidelity assessments via group interviews with each site to evaluate clinic experiences with routine OUD screening. Data from observation and structured fidelity assessments were combined into a matrix to compare across clinics and identify cross-cutting barriers and promising implementation strategies. KEY RESULTS While all clinics had the goal of implementing population-based OUD screening, barriers were experienced across intervention, individual, and clinic setting domains, with compounding effects for telehealth visits. Seven themes emerged characterizing barriers, including (1) challenges identifying who to screen, (2) complexity of the screening tool, (3) staff discomfort and/or hesitancies, (4) workflow barriers that decreased screening follow-up, (5) staffing shortages and turnover, (6) discouragement from low screening yield, and (7) stigma. Promising implementation strategies included utilizing a more universal screening approach, health information technology (HIT), audit and feedback, and repeated staff trainings. CONCLUSIONS Integrating population-based OUD screening in primary care is challenging but may be made feasible via implementation strategies and tailored practice facilitation that standardize workflows via HIT, decrease stigma, and increase staff confidence regarding OUD.
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Affiliation(s)
- Elizabeth J Austin
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Box 351621, Seattle, WA, 98105, USA.
| | - Elsa S Briggs
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Box 351621, Seattle, WA, 98105, USA
| | - Lori Ferro
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Paul Barry
- Advancing Integrated Mental Health Solutions (AIMS) Center, University of Washington, Seattle, WA, USA
| | - Ashley Heald
- Advancing Integrated Mental Health Solutions (AIMS) Center, University of Washington, Seattle, WA, USA
| | - Geoffrey M Curran
- Departments of Pharmacy Practice and Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Central Arkansas Veterans Health Care System, Little Rock, AR, USA
| | - Andrew J Saxon
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound, Seattle, WA, USA
| | - John Fortney
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
- Advancing Integrated Mental Health Solutions (AIMS) Center, University of Washington, Seattle, WA, USA
- Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, VA Puget Sound, Seattle, WA, USA
| | - Anna D Ratzliff
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
- Advancing Integrated Mental Health Solutions (AIMS) Center, University of Washington, Seattle, WA, USA
| | - Emily C Williams
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Box 351621, Seattle, WA, 98105, USA
- Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, VA Puget Sound, Seattle, WA, USA
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Fiester A, Yuan C. Ethical Issues in Using Behavior Contracts to Manage the "Difficult" Patient and Family. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:50-60. [PMID: 34590938 DOI: 10.1080/15265161.2021.1974974] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Long used as a tool for medical compliance and adhering to treatment plans, behavior contracts have made their way into the in-patient healthcare setting as a way to manage the "difficult" patient and family. The use of this tool is even being adopted by healthcare ethics consultants (HECs) in US hospitals as part of their work in navigating conflict at the bedside. Anecdotal evidence of their increasing popularity among clinical ethicists, for example, can be found at professional bioethics meetings and conversations and idea-sharing among practitioners on HEC social media. While there are a handful of papers gesturing toward a bioethical critique of behavior contracts of various types, the use of behavior contracts in the context of interpersonal conflict has not been vetted by bioethicists to determine their ethical legitimacy or efficacy. In this paper, we highlight a set of ethical concerns that we believe must be addressed before continuing or widespread implementation of behavior contracts to manage the "difficult" patient or family.
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Gallagher E, Alvarez E, Jin L, Guenter D, Hatcher L, Furlan A. Patient contracts for chronic medical conditions: Scoping review. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2022; 68:e169-e177. [PMID: 35552216 PMCID: PMC9097748 DOI: 10.46747/cfp.6805e169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To describe how and why patient contracts are used for the management of chronic medical conditions. DATA SOURCES A scoping review was conducted in the following databases: MEDLINE, Embase, AMED, PsycInfo, Cochrane Library, CINAHL, and Nursing & Allied Health. Literature from 1997 to 2017 was included. STUDY SELECTION Articles were included if they were written in English and described the implementation of a patient contract by a health care provider for the management of a chronic condition. Articles had to present an outcome as a result of using the contract or an intervention that included the contract. SYNTHESIS Of the 7528 articles found in the original search, 76 met the inclusion criteria for the final review. Multiple study types were included. Extensive variety in contract elements, target populations, clinical settings, and cointerventions was found. Purposes for initiating contracts included behaviour change and skill development, including goal development and problem solving; altering beliefs and knowledge, including motivation and perceived self-efficacy; improving interpersonal relationships and role clarification; improving quality and process of chronic care; and altering objective and subjective health indices. How contracts were developed, implemented, and assessed was inconsistently described. CONCLUSION More research is required to determine whether the use of contracts is accomplishing their intended purposes. Questions remain regarding their rationale, development, and implementation.
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Affiliation(s)
- Erin Gallagher
- Assistant Professor in the Department of Family Medicine at McMaster University in Hamilton, Ont.
| | - Elizabeth Alvarez
- Assistant Professor in the Department of Health Research Methods, Evidence and Impact at McMaster University
| | - Lin Jin
- Master of public health candidate at McMaster University
| | - Dale Guenter
- Associate Professor in the Department of Family Medicine and the Department of Health Research Methods, Evidence and Impact at McMaster University
| | - Lydia Hatcher
- Associate Clinical Professor in the Department of Family Medicine at McMaster University
| | - Andrea Furlan
- Associate Professor in the Department of Medicine at the University of Toronto in Ontario
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Budge C, Taylor M, Mar M, Hansen C, Fai F. Chronic pain: good management of practical pain control strategies is associated with being older, more health activated and having better mental health. J Prim Health Care 2021; 12:225-234. [PMID: 32988444 DOI: 10.1071/hc19066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 12/08/2020] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Chronic pain affects a large proportion of the adult population and people in pain need to learn how to manage it in order to maintain quality of life. AIM This study aimed to examine how well people with long-term conditions make use of self-management strategies to control their pain, and to identify personal attributes associated with a higher degree of success. METHODS People with chronic pain who participated in the first phase of a longitudinal long-term conditions study in the MidCentral region made up the study sample (N=326, response rate 21%). They completed a questionnaire by mail or online, which included items on pain management, general health, patient activation, experiences with general practice and demographics. RESULTS Pain control strategies were managed fairly well overall. Taking pain medication and avoiding caffeine, alcohol, heavy meals and exercise before bed were managed best, whereas sleep, relaxation breathing and remaining socially active were managed least well. A multiple regression analysis found higher scores on patient activation, self-rated overall pain management at home, mental health and older age (≥75 years) to be associated with better management. DISCUSSION This study identified pain control strategies that are managed well, and less well, outside of a specific intervention. Results highlight topics for discussion in consultations and identify areas where general practice could provide better self-management support, such as sleep and exercise. Better overall pain control strategy management was most strongly associated with patient activation; that is, a combination of knowledge, skills and confidence to manage health and health care that is amenable to intervention. Improving the level of activation in people with long-term conditions may enhance their use of pain control strategies.
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Affiliation(s)
- Claire Budge
- THINK Hauora, 200 Broadway Avenue, Palmerston North 4410, New Zealand; and Corresponding author.
| | - Melanie Taylor
- THINK Hauora, 200 Broadway Avenue, Palmerston North 4410, New Zealand
| | - Materoa Mar
- Te Tihi o Ruahine Whanau Ora Alliance, 200 Broadway Avenue, Palmerston North 4410, New Zealand
| | - Chiquita Hansen
- THINK Hauora, 200 Broadway Avenue, Palmerston North 4410, New Zealand
| | - Folole Fai
- MidCentral DHB, PO Box 2075, Palmerston North 4410, New Zealand
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Keller MS, Jusufagic A, Nuckols T, Needleman J, Heilemann M. How Do Clinicians of Different Specialties Perceive and Use Opioid Risk Mitigation Strategies? A Qualitative Study. Subst Use Misuse 2021; 56:1352-1362. [PMID: 34027814 PMCID: PMC8667780 DOI: 10.1080/10826084.2021.1926514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND In response to the opioid crisis, states and health systems are encouraging clinicians to use risk mitigation strategies aimed at assessing a patient's risk for opioid misuse or abuse: opioid agreements, prescription drug monitoring programs (PDMPs), and urine drug tests (UDT). Objective: The objective of this qualitative study was to understand how clinicians perceived and used risk mitigation strategies for opioid abuse/misuse and identify barriers to implementation. Methods: We interviewed clinicians who prescribe opioid medications in the outpatient setting from 2016-2018 and analyzed the data using Constructivist Grounded Theory methodology. Results: We interviewed 21 primary care clinicians and 12 specialists. Nearly all clinicians reported using the PDMP. Some clinicians (adopters) found the opioid agreement and UDTs to be valuable, but most (non-adopters) did not. Adopters found the agreements and UDTs helpful in treating patients equitably, setting limits, and having objective evidence of misuse; protocols and workflows facilitated the use of the strategies. Non-adopters perceived the strategies as awkward, disruptive to the clinician-patient relationship, and introducing a power differential; they also cited lack of time and resources as barriers to use. Conclusions: Our study demonstrates that clinicians in certain settings have found effective ways to implement and use the PDMP, opioid agreements, and UDT but that other clinicians are less comfortable with their use. Administrators and policymakers should ensure that the strategies are designed in a way that strengthens the clinician-patient relationship while maximizing safety for patients and that clinicians are adequately trained and supported when introducing the strategies.
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Affiliation(s)
- Michelle S. Keller
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
- Division of Informatics, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California
| | - Alma Jusufagic
- Division of Health Services Research, Cedars-Sinai Medical Center, Los Angeles, California
| | - Teryl Nuckols
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jack Needleman
- Department of Health Policy and Management, Fielding School of Public Health, University of California-Los Angeles, Los Angeles, California
| | - MarySue Heilemann
- UCLA School of Nursing, University of California-Los Angeles, Los Angeles, California
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Starrels JL, Young SR, Azari SS, Becker WC, Jennifer Edelman E, Liebschutz JM, Pomeranz J, Roy P, Saini S, Merlin JS. Disagreement and Uncertainty Among Experts About how to Respond to Marijuana Use in Patients on Long-term Opioids for Chronic Pain: Results of a Delphi Study. PAIN MEDICINE 2021; 21:247-254. [PMID: 31393585 DOI: 10.1093/pm/pnz153] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Marijuana use is common among patients on long-term opioid therapy (LTOT) for chronic pain, but there is a lack of evidence to guide clinicians' response. OBJECTIVE To generate expert consensus about responding to marijuana use among patients on LTOT. DESIGN Analysis from an online Delphi study. SETTING/SUBJECTS Clinician experts in pain and opioid management across the United States. METHODS Participants generated management strategies in response to marijuana use without distinction between medical and nonmedical use, then rated the importance of each management strategy from 1 (not at all important) to 9 (extremely important). A priori rules for consensus were established, and disagreement was explored using cases. Thematic analysis of free-text responses examined factors that influenced participants' decision-making. RESULTS Of 42 participants, 64% were internal medicine physicians. There was consensus that it is not important to taper opioids as an initial response to marijuana use. There was disagreement about the importance of tapering opioids if there is a pattern of repeated marijuana use without clinical suspicion for a cannabis use disorder (CUD) and consensus that tapering is of uncertain importance if there is suspicion for CUD. Three themes influenced experts' perceptions of the importance of tapering: 1) benefits and harms of marijuana for the individual patient, 2) a spectrum of belief about the overall riskiness of marijuana use, and 3) variable state laws or practice policies. CONCLUSIONS Experts disagree and are uncertain about the importance of opioid tapering for patients with marijuana use. Experts were influenced by patient factors, provider beliefs, and marijuana policy, highlighting the need for further research.
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Affiliation(s)
- Joanna L Starrels
- Division of General Internal Medicine, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York
| | - Sarah R Young
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama.,Department of Social Work, College of Community and Public Affairs, Binghamton University, Binghamton, New York
| | - Soraya S Azari
- Division of General Internal Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California
| | - William C Becker
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut
| | - E Jennifer Edelman
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jane M Liebschutz
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jamie Pomeranz
- Department of Occupational Therapy, University of Florida, Gainesville, Florida
| | - Payel Roy
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Shalini Saini
- Department of Medicine, Information Technology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jessica S Merlin
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Colorafi K, Thomas A, Wilson M, Corbett CF. Perspectives of Aging Adults Who Frequently Seek Emergency Department Care. Pain Manag Nurs 2020; 22:184-190. [PMID: 33317936 DOI: 10.1016/j.pmn.2020.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/14/2020] [Accepted: 10/14/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The number of people managing chronic conditions is growing with the rapidly aging population. Visits to the emergency department are steadily rising, but little is known about the rationale of those seeking emergent care. AIMS The goal of this study was to better understand, from the patients' perspective, the reasons for seeking care in an emergency department setting. DESIGN A qualitative descriptive design was used to interview aging adults with at least two chronic conditions who made three or more visits to the emergency department within a year. PARTICIPANTS/SUBJECTS The eight-person sample was 88% female and 75% white, with an average age of 54 years. METHODS Participant interviews were conducted with a semistructured interview guide. Conventional content analysis was used to examine words and phrases in professionally transcribed documents. Qualitative methods for testing and confirming conclusions were performed. RESULTS We discovered that aging adults visit the emergency department to seek relief from unrelenting pain and to overcome barriers to receiving treatment for pain in ambulatory settings. Participants reported feeling judged when seeking emergency department care for pain management. CONCLUSIONS Participants described emergency department care as the only option in response to several barriers to healthcare access. Most commonly, emergency department care was sought when relief from persistent or acute pain was required. One way to reduce strain on EDs from pain-related visits is to manage patients with persistent pain more proactively in their community environment.
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Affiliation(s)
- Karen Colorafi
- School of Nursing and Human Physiology, Gonzaga University, Spokane, Washington; College of Nursing, Washington State University, Spokane, Washington.
| | - Amy Thomas
- College of Nursing, Washington State University, Spokane, Washington
| | - Marian Wilson
- College of Nursing, Washington State University, Spokane, Washington
| | - Cynthia F Corbett
- College of Nursing, Washington State University, Spokane, Washington; College of Nursing, University of South Carolina, Columbia, South Carolina
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12
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Interventions to optimize prescribed medicines and reduce their misuse in chronic non-malignant pain: a systematic review. Eur J Clin Pharmacol 2020; 77:467-490. [PMID: 33123784 PMCID: PMC7935820 DOI: 10.1007/s00228-020-03026-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 10/15/2020] [Indexed: 11/17/2022]
Abstract
Purpose Sub-optimal opioid prescribing and use is viewed as a major contributor to the growing opioid crisis. This study aims to systematically review the nature, process and outcomes of interventions to optimize prescribed medicines and reduce their misuse in chronic non-malignant pain (CNMP) with a particular focus on minimizing misuse of opiates. Methods A systematic review of literature was undertaken. Search of literature using Medline, EMBASE and CINAHL databases from 2000 onwards was conducted. Screening and selection, data extraction and risk of bias assessments were undertaken by two independent reviewers. Narrative synthesis of the data was conducted. Results A total of 21 studies were included in the review, of which three were RCTs. Interventions included clinical (e.g. urine drug testing, opioid treatment contract, pill count), behavioural (e.g. electrical diaries about craving), cognitive behavioural treatment and/or educational interventions for patients and healthcare providers delivered as a single or as a multi-component intervention. Medication optimization outcomes included aspects of misuse, abuse, aberrant drug behaviour, adherence and non-adherence. Although all evaluations showed improvement in medication optimization outcomes, multi-component interventions were more likely to consider and to have shown improvement in clinical outcomes such as pain intensity, quality of life, psychological states and functional improvement compared to single-component interventions. Conclusions A well-structured CNMP management programme to promote medicines optimization should include multi-component interventions delivered by a multidisciplinary team of healthcare professionals and target both healthcare professionals and patients. There was heterogeneity in definitions applied and interventions evaluated. There is a need for the development of clear and consistent terminology and measurement criteria to facilitate better comparisons of research evidence. Supplementary Information The online version of this article (10.1007/s00228-020-03026-4) contains supplementary material, which is available to authorized users.
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13
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Ghodke A, Ives TJ, Austin AE, Bennett WC, Patel NY, Eshet SA, Chelminski PR. Pain Agreements and Time-to-Event Analysis of Substance Misuse in a Primary Care Chronic Pain Program. PAIN MEDICINE 2020; 21:2154-2162. [PMID: 32186725 DOI: 10.1093/pm/pnaa033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Types and correlates of pain medication agreement (PMA) violations in the primary care setting have not been analyzed. METHODS A retrospective analysis was completed to examine patient characteristics and correlates of PMA violations, a proxy for substance misuse, over a 15-year period in an outpatient General Medicine Pain Service within the Division of General Medicine and Clinical Epidemiology, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill. Patients who signed the PMA were managed for chronic pain from 2002 through 2017 (N = 1,210). The incidence of PMA violations was measured over a 15-year span. Substance misuse was defined a priori in the study as urine toxicology screen positive for illicit or nonprescribed controlled substances, patient engagement in prescription alteration, doctor-shopping, or diversion. RESULTS Most patients received a prescription for a controlled substance (77.4%). During enrollment, 488 (40.3%) patients had one or more violations of their PMA. One-third (33.4%) of pain service patients had a violation within 365 days of signing the agreement. Active tobacco smokers had double the incidence of agreement violation within the first 30 days of enrollment. Almost one-half (49.8%) of violations were due to inconsistent use of controlled substances. Patients with any prior DWI/DUI or drug-related offense had a significantly increased rate of substance misuse (P < 0.0001). CONCLUSIONS PMA violations were common among a population of patients managed for chronic nonmalignant pain. Universal opioid prescribing precautions, including PMAs, require further investigation to assess their roles in mitigating the potential patient and societal harms associated with opioid prescribing.
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Affiliation(s)
- Ameer Ghodke
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Timothy J Ives
- Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anna E Austin
- Injury Prevention Research Center, Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - William C Bennett
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Naishal Y Patel
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Sharon A Eshet
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Paul R Chelminski
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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14
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Callahan A, Shah NH, Chen JH. Research and Reporting Considerations for Observational Studies Using Electronic Health Record Data. Ann Intern Med 2020; 172:S79-S84. [PMID: 32479175 PMCID: PMC7413106 DOI: 10.7326/m19-0873] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Electronic health records (EHRs) are an increasingly important source of real-world health care data for observational research. Analyses of data collected for purposes other than research require careful consideration of data quality as well as the general research and reporting principles relevant to observational studies. The core principles for observational research in general also apply to observational research using EHR data, and these are well addressed in prior literature and guidelines. This article provides additional recommendations for EHR-based research. Considerations unique to EHR-based studies include assessment of the accuracy of computer-executable cohort definitions that can incorporate unstructured data from clinical notes and management of data challenges, such as irregular sampling, missingness, and variation across time and place. Principled application of existing research and reporting guidelines alongside these additional considerations will improve the quality of EHR-based observational studies.
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Affiliation(s)
- Alison Callahan
- Center for Biomedical Informatics Research, School of Medicine, Stanford University (A.C., N.H.S.)
| | - Nigam H Shah
- Center for Biomedical Informatics Research, School of Medicine, Stanford University (A.C., N.H.S.)
| | - Jonathan H Chen
- Division of Hospital Medicine, School of Medicine, Stanford University (J.H.C.)
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15
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Kaye AD, Kandregula S, Kosty J, Sin A, Guthikonda B, Ghali GE, Craig MK, Pham AD, Reed DS, Gennuso SA, Reynolds RM, Ehrhardt KP, Cornett EM, Urman RD. Chronic pain and substance abuse disorders: Preoperative assessment and optimization strategies. Best Pract Res Clin Anaesthesiol 2020; 34:255-267. [PMID: 32711832 DOI: 10.1016/j.bpa.2020.04.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 04/24/2020] [Indexed: 01/26/2023]
Abstract
There is an ever-increasing number of opioid users among chronic pain patients and safely managing them can be challenging for surgeons, anesthesiologists, pain experts, and addiction specialists. Healthcare providers must be familiar with phenomena typical of opioid users and abusers, including tolerance, physical dependence, hyperalgesia, and addiction. Insufficient pain management is very common in these patients. Patient-centered preoperative communication is integral to setting realistic expectations for postoperative pain, developing successful nonopioid analgesic regimens, minimizing opioid consumption during the postoperative period, and decreasing the number of opioid pills at the risk of diversion. Preoperative evaluation should identify comorbidities and identify risk factors for substance abuse and withdrawal. Intraoperative and postoperative strategies can ensure safe and effective pain management and minimize the potential for morbidity and mortality in this high-risk patient population.
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Affiliation(s)
- Alan D Kaye
- Department of Anesthesiology and Pharmacology, Toxicology, and Neurosciences Provost, Chief Academic Officer, Vice Chancellor of Academic Affairs, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Sandeep Kandregula
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences (NIMHANS), Hosur Road, Bangalore, Karnataka, 560029, India.
| | - Jennifer Kosty
- Department of Neurosurgery, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Anthony Sin
- Department of Neurosurgery, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Bharat Guthikonda
- Department of Neurosurgery, LSU Health Shreveport, Shreveport, LA, USA.
| | - G E Ghali
- Department of Oral & Maxillofacial Surgery, Craniofacial Surgery/Head & Neck Surgery, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Madelyn K Craig
- Department of Anesthesiology, LSU Health Science Center New Orleans, 1542 Tulane Avenue, New Orleans, LA, 70112, USA.
| | - Alex D Pham
- Department of Anesthesiology, LSU Health New Orleans, 1542 Tulane Ave, Room 659, New Orleans, LA, 70112, USA.
| | - Devin S Reed
- Department of Anesthesiology, LSU Health Science Center New Orleans, 1542 Tulane Avenue, New Orleans, LA, 70112, USA.
| | - Sonja A Gennuso
- Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, USA.
| | | | - Ken Philip Ehrhardt
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA.
| | - Elyse M Cornett
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA.
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16
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Abstract
Urine drug test (UDT) is an effective tool used in chronic opioid therapy to ensure patient adherence to treatment and detect nonmedical opioid use. The two main types of UDT used in routine clinical practice are the screening tests or immunoassays and the confirmatory tests or laboratory-based specific drug identification tests such as gas chromatography-mass spectrometry, liquid chromatography-mass spectrometry, or tandem mass spectrometry. UDT produces objective data on some nonmedical opioid use that may otherwise go undetected, such as the use of undisclosed medications, the nonuse of prescribed medications, and the use of illegal drugs. It allows clinicians to initiate an open and effective conversation about nonmedical opioid use with their patients. However, the test has certain limitations that sometimes compromise its use. Its interpretation can be challenging to clinicians because of the complexity of the opioid metabolic pathways. Clear guidelines or recommendations regarding the use of UDT in cancer pain is limited. As a result, UDT appears to be underused among patients with cancer pain receiving opioid therapy. More studies are needed to help standardize the integration and use of UDT in routine cancer pain management. IMPLICATIONS FOR PRACTICE: Despite its potential benefits, urine drug testing (UDT) appears to be underused among patients with cancer pain receiving opioid therapy. This is partly because its interpretation can be challenging owing to the complexity of the opioid metabolic pathways. Information regarding the use of UDT in opioid therapy among patients with cancer is limited. This review article will improve clinician proficiency in UDT interpretation and assist oncologists in developing appropriate treatment plans during chronic opioid therapy.
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Affiliation(s)
- Joseph A. Arthur
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson CancerHoustonTexasUSA
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17
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Huang KTL, Blazey-Martin D, Chandler D, Wurcel A, Gillis J, Tishler J. A multicomponent intervention to improve adherence to opioid prescribing and monitoring guidelines in primary care. J Opioid Manag 2020; 15:445-453. [PMID: 31850506 DOI: 10.5055/jom.2019.0535] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Guidelines for appropriate management of chronic opioid therapy are underutilized by primary care physicians (PCPs). The authors hypothesized that developing a multicomponent, team-based opioid management system with electronic health record (EHR) support would allow our clinicians to improve adherence to chronic opioid prescribing and monitoring guidelines. DESIGN This was a retrospective pre-post study. SETTING The authors performed this intervention at our large, urban, academic primary care practice. PATIENTS, PARTICIPANTS All patients with the diagnosis of "chronic pain, opioid requiring (ICD-10 F11.20)" on their primary care EHR problem lists were included in this study. INTERVENTION The authors implemented a five-pronged strategy to improve our system of opioid prescribing, including (1) a patient registry with regular dissemination of reports to PCPs; (2) standardization of policies regarding opioid prescribing and monitoring; (3) development of a risk-assessment algorithm and riskstratified monitoring guidelines; (4) a team-based approach to care with physician assistant care managers; and (5) an EHR innovation to facilitate communication and guideline adherence. MAIN OUTCOME MEASURES The authors measured percent adherence to opioid prescribing guidelines, including annual patient-provider agreements, biannual urine drug screens (UDSs), and prescription monitoring program (PMP) verification. RESULTS Between September 2015 and September 2016, the percentage of patients on chronic opioid therapy with a signed controlled substances agreement within the preceding year increased from 46 to 76 percent (p < 0.0001), while the percentage of patients with a UDS done within the past 6 months rose from 23 to 79 percent (p < 0.0001). The percentage of patients whose state PMPs profile had been checked by a primary care team member in the past year rose from 45 to 97 percent (p < 0.0001). CONCLUSION A comprehensive strategy to standardize chronic opioid prescribing in our primary care practice coincided with an increase in adherence to opioid management guidelines.
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Affiliation(s)
- Kristin T L Huang
- Assistant Professor of Medicine, Division of Internal Medicine and Adult Primary Care, Tufts Medical Center, Boston, Massachusetts
| | - Deborah Blazey-Martin
- Assistant Professor of Medicine, Division of Internal Medicine and Adult Primary Care, Tufts Medical Center, Boston, Massachusetts
| | - Daniel Chandler
- Assistant Professor of Medicine, Division of Internal Medicine and Adult Primary Care, Tufts Medical Center, Boston, Massachusetts
| | - Alysse Wurcel
- Assistant Professor of Medicine, Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts
| | - Joseph Gillis
- Project Manager, Division of Internal Medicine and Adult Primary Care, Tufts Medical Center, Boston, Massachusetts
| | - Julie Tishler
- Assistant Professor of Medicine, Division of Internal Medicine and Adult Primary Care, Tufts Medical Center, Boston, Massachusetts
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18
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McAuliffe Staehler TM, Palombi LC. Beneficial opioid management strategies: A review of the evidence for the use of opioid treatment agreements. Subst Abus 2020; 41:208-215. [PMID: 31900073 DOI: 10.1080/08897077.2019.1692122] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background: The Centers for Disease Control and Prevention (CDC) and American Society of Interventional Pain Physicians (ASIPP) guidelines recommend opioid treatment agreements to reduce the misuse and abuse of opioids, but evidence of their effectiveness has not been well-established. This controversy has led to their varied use in primary care settings. The purpose of this review is to collect studies that assess the value of opioid treatment agreements and associated opioid misuse outcomes in patients with chronic non-cancer pain. Methods: This study used a modified preferred reporting items for systematic reviews and meta-analyses (PRISMA) approach which is organized by five distinct elements or steps: beginning with a clearly formulated question, using the question to develop clear inclusion criteria to identify relevant studies, using an approach to appraise the studies or a subset of the studies, summarizing the evidence using an explicit methodology, and interpreting the findings of the review. Results: Of 283 articles identified, six eligible studies were evaluated and assessed for quality. The study design, setting, and participants varied across the studies evaluated, and the methods of measuring primary and secondary outcomes were also diverse across all studies. One study was a randomized clinical trial (RCT), four studies were retrospective cohort studies (RCS), and one study was a prospective cohort study (PCS). The design, methods, and indication for misuse of these studies contributed to quality scores of very low for one study, low for four studies, and moderate for one study. Conclusion: This systematic review shows weak evidence to support the effectiveness of patient prescriber agreements in the reduction and mitigation of opioid misuse and abuse. Further research is needed to determine if these agreements are beneficial as an opioid management strategy.
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Affiliation(s)
- Tuesday M McAuliffe Staehler
- Department of Pharmacy Practice and Pharmaceutical Science, University of Minnesota, College of Pharmacy, Duluth, Minnesota, USA
| | - Laura C Palombi
- Department of Pharmacy Practice and Pharmaceutical Science, University of Minnesota, College of Pharmacy, Duluth, Minnesota, USA
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19
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Schatman ME, Vasciannie A, Kulich RJ. Opioid moderatism and the imperative of rapprochement in pain medicine. J Pain Res 2019; 12:649-657. [PMID: 30863137 PMCID: PMC6388760 DOI: 10.2147/jpr.s198849] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Michael E Schatman
- Research and Network Development, Boston PainCare, Waltham, MA, USA,
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA,
| | - Alexis Vasciannie
- Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA, USA
- Department of Biological Sciences, Northeastern University, Boston, MA, USA
| | - Ronald J Kulich
- Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA, USA
- Department of Anesthesia Critical Care and Pain Medicine, Harvard Medical School/Massachusetts General Hospital, Boston, MA, USA
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20
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Bargal B, Benneyan JC, Eisner J, Atalay AJ, Jacobson M, Singer SJ. Use of Systems-Theoretic Process Analysis to Design Safer Opioid Prescribing Processes. IISE Trans Occup Ergon Hum Factors 2018. [DOI: 10.1080/24725838.2018.1521887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Basma Bargal
- Healthcare Systems Engineering Institute, Northeastern University, Boston, MA, USA
| | - James C. Benneyan
- Healthcare Systems Engineering Institute, Northeastern University, Boston, MA, USA
- College of Engineering, Northeastern University, Boston, MA, USA
- Bouvé College of Health Sciences (JB), Northeastern University, Boston, MA, USA
| | - Joseph Eisner
- Healthcare Systems Engineering Institute, Northeastern University, Boston, MA, USA
| | - Alev J. Atalay
- Brigham and Women’s Hospital, Phyllis Jen Center for Primary Care (AA), Boston, MA, USA
| | - Margo Jacobson
- Healthcare Systems Engineering Institute, Northeastern University, Boston, MA, USA
| | - Sara J. Singer
- T.H. Chan Harvard School of Public Health (SS), Boston, MA, USA
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21
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Severe chronic pain following spinal cord damage: a pragmatic perspective for prescribing opioids. Spinal Cord Ser Cases 2018; 4:65. [PMID: 30083394 DOI: 10.1038/s41394-018-0094-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 05/30/2018] [Accepted: 05/30/2018] [Indexed: 11/08/2022] Open
Abstract
The controversial issue of prescribing opioids to people with spinal cord damage who have severe pain is discussed in this paper. The reasons for concern regarding the increase in opioid prescription over recent years are outlined, along with a summary of the major potential adverse outcomes associated with opioids, such as falls, respiratory suppression, adverse endocrine effects, cognitive impairment, and the potential for opioid abuse, addiction and death. Situations when opioids are more appropriate are considered to be in the immediate post-trauma or post-operative periods. More controversial is the use of opioids in chronic non-cancer pain. A brief review of the evidence regarding opioids in chronic non-cancer pain is presented, and strategies outlined for reducing the risk of adverse consequences from opioid use in chronic non-cancer pain. These strategies include considerations before starting opioids, during initiation, monitoring activities and the cessation process. A vital consideration before starting opioids includes ensuring that all alternatives to opioids have been fully considered and trialled. Finally, some pragmatic proposals for prescribing opioids in people with SCD are suggested. It is recommended that before opioids are commenced, that the informed consent process should be complimented by a treatment agreement, with an initial 4-week trial period, and close monitoring of established goals.
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22
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Elrashidi MY, Philpot LM, Ramar P, Leasure WB, Ebbert JO. Depression and Anxiety Among Patients on Chronic Opioid Therapy. Health Serv Res Manag Epidemiol 2018; 5:2333392818771243. [PMID: 29761131 PMCID: PMC5946357 DOI: 10.1177/2333392818771243] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 03/26/2018] [Indexed: 01/25/2023] Open
Abstract
Background: Chronic noncancer pain (CNCP) and chronic opioid therapy (COT) commonly coexist with comorbid depression and anxiety. We investigated the prevalence of depression and anxiety and their correlates at the time of controlled substance agreement (CSA) enrollment among patients with CNCP and a history of depression or anxiety on COT. Methods: Retrospective analysis of 1066 patients in a Midwest primary care practice enrolled in CSAs for COT between May 9, 2013, and August 15, 2016. Patients with self-reported symptoms or a clinical history of depression or anxiety were screened at CSA enrollment using the Patient Health Questionnaire–9 item scale and the Generalized Anxiety Disorder–7 item scale. Results: The percentage of patients screening positive for depression and anxiety at CSA enrollment was 15.4% and 14.4%, respectively. Patients screening positive for depression or anxiety were more likely to be younger, unmarried, unemployed, and live alone compared to patients not screening positive. Patients screening positive for depression or anxiety were more likely to smoke cigarettes and report concern from friends or relatives regarding alcohol consumption. Compared to patients screening negative, patients screening positive for depression had higher odds of receiving opioid doses of ≥50 morphine milligram equivalents per day (adjusted odds ratio: 1.62; 95% confidence interval: 1.01-2.58). Conclusion: Anxiety and depression are prevalent at enrollment in CSAs among patients receiving COT. Future research is needed to determine whether recognition of anxiety and depression leads to improved management and outcomes for this population.
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Affiliation(s)
- Muhamad Y Elrashidi
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Lindsey M Philpot
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Priya Ramar
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - William B Leasure
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Jon O Ebbert
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
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23
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Ferreira DH, Boland JW, Phillips JL, Lam L, Currow DC. The impact of therapeutic opioid agonists on driving-related psychomotor skills assessed by a driving simulator or an on-road driving task: A systematic review. Palliat Med 2018; 32:786-803. [PMID: 29299954 DOI: 10.1177/0269216317746583] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Driving cessation is associated with poor health-related outcomes. People with chronic diseases are often prescribed long-term opioid agonists that have the potential to impair driving. Studies evaluating the impact of opioids on driving-related psychomotor skills report contradictory results likely due to heterogeneous designs, assessment tools and study populations. A better understanding of the effects of regular therapeutic opioid agonists on driving can help to inform the balance between individual's independence and community safety. AIM To identify the literature assessing the impact of regular therapeutic opioid agonists on driving-related psychomotor skills for people with chronic pain or chronic breathlessness. DESIGN Systematic review reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis statement; PROSPERO Registration CRD42017055909. DATA SOURCES Six electronic databases and grey literature were systematically searched up to January, 2017. Inclusion criteria were as follows: (1) empirical studies reporting data on driving simulation, on-the-road driving tasks or driving outcomes; (2) people with chronic pain or chronic breathlessness; and (3) taking regular therapeutic opioid agonists. Critical appraisal used the National Institutes of Health's quality assessment tools. RESULTS From 3809 records screened, three studies matched the inclusion criteria. All reported data on people with chronic non-malignant pain. No significant impact of regular therapeutic opioid agonists on people's driving-related psychomotor skills was reported. One study reported more intense pain significantly worsened driving performance. CONCLUSION This systematic review does not identify impaired simulated driving performance when people take regular therapeutic opioid agonists for symptom control, although more prospective studies are needed.
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Affiliation(s)
- Diana H Ferreira
- 1 Discipline, Palliative and Supportive Services, Flinders University, Adelaide, SA, Australia
| | - Jason W Boland
- 2 Hull York Medical School, University of Hull, Hull, UK
| | - Jane L Phillips
- 3 IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Lawrence Lam
- 3 IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - David C Currow
- 1 Discipline, Palliative and Supportive Services, Flinders University, Adelaide, SA, Australia.,2 Hull York Medical School, University of Hull, Hull, UK.,3 IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.,4 Wolfson Centre for Palliative Care Research, Hull York Medical School, University of Hull, Hull, UK
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24
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Wiseman LK, Lynch ME. The utility of universal urinary drug screening in chronic pain management. Can J Pain 2018; 2:37-47. [PMID: 35005364 PMCID: PMC8730562 DOI: 10.1080/24740527.2018.1425980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 01/06/2018] [Accepted: 01/07/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND A recent systematic review found few studies that assessed the value of urinary drug screening (UDS) in the management of chronic pain. The Pain Management Unit in Halifax, Nova Scotia, has recently implemented tandem mass spectrometry (TMS) UDS for all new patients. AIMS To study the prevalence of unexpected TMS UDS results at a hospital-based chronic pain center, to assess which drugs are most likely to contribute to an unexpected result and to assess the clinical utilization of unexpected results by pain physicians. METHODS From June 2014 to June 2016, a total of 664 patients with chronic non-cancer pain (CNCP) were seen for initial consult. Charts were reviewed and used to create a database containing sex, age, UDS result, physician, and medication/illicit drug history. For all unexpected UDS results, an interview was conducted with the treating physician to determine its clinical implications. RESULTS For the general pain specialists, the overall percentage of patients with an unexpected UDS result was 16.67%. Excluding codeine, at most 4.47% of patients tested unexpectedly positive for a strong opioid. Although eight out of nine physicians found UDS helpful in general, only 29.58% of unexpected results were helpful in the management of their patients and directly influenced their care. CONCLUSIONS The prevalence of an unexpected UDS result in patients with CNCP is significant. Most physicians agree that UDS is helpful but in only a limited number of cases did the unexpected result provide helpful information that significantly influenced patient care.
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Affiliation(s)
- Luke K. Wiseman
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University and Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- Department of Pharmacology, Dalhousie University and Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- Department of Psychiatry, Dalhousie University and Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Mary E. Lynch
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University and Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- Department of Pharmacology, Dalhousie University and Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- Department of Psychiatry, Dalhousie University and Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
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25
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Philpot LM, Ramar P, Elrashidi MY, Mwangi R, North F, Ebbert JO. Controlled Substance Agreements for Opioids in a Primary Care Practice. J Pharm Policy Pract 2017; 10:29. [PMID: 28919978 PMCID: PMC5596855 DOI: 10.1186/s40545-017-0119-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/06/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Opioids are widely prescribed for chronic non cancer pain (CNCP). Controlled substance agreements (CSAs) are intended to increase adherence and mitigate risk with opioid prescribing. We evaluated the demographic characteristics of and opioid dosing for patients with CNCP enrolled in CSAs in a primary care practice. METHODS We conducted a retrospective cohort study of 1066 patients enrolled in CSAs between May 9, 2013 and August 15, 2016 for CNCP in a Midwest primary care practice. RESULTS Patients were prescribed an average of 40.8 (SD ± 57.0) morphine milligram equivalents per day (MME/day), and 21.5% of patients were receiving ≥50 MME/day and 9.7% were receiving ≥90 MME/day. Patients who were younger in age (≥ 65 vs. < 65 years, P < 0.0001), male gender (P = 0.0001), and used tobacco (P = 0.0002) received significantly higher MME/day. Patients with more co-morbidities (Charlson Comorbidity Index, CCI) received higher MME/day (CCI > 3 vs. CCI ≤ 3, P = 0.03), and reported higher average pain (CCI > 3 mean 5.8 [SD ± 2.1] vs. CCI ≤ 3 mean 5.3 [SD ± 2.0], P = 0.0011). Patients on an identified tapering plan (6.9%) had higher MME/day than patients not on a tapering plan (P = 0.0002). CONCLUSIONS CSAs present an opportunity to engage patients taking higher doses of opioids in discussions about opioid safety, appropriate dosing and tapering. CSAs could be leveraged to develop a population health management approach to the care of patients with CNCP.
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Affiliation(s)
- Lindsey M Philpot
- Robert D. and Patricia E. Kern Mayo Clinic Center for the Science of Health Care Delivery, Mayo Clinic College of Medicine, 200 1st Street SW, Rochester, MN 55905 USA
| | - Priya Ramar
- Robert D. and Patricia E. Kern Mayo Clinic Center for the Science of Health Care Delivery, Mayo Clinic College of Medicine, 200 1st Street SW, Rochester, MN 55905 USA
| | - Muhamad Y Elrashidi
- Robert D. and Patricia E. Kern Mayo Clinic Center for the Science of Health Care Delivery, Mayo Clinic College of Medicine, 200 1st Street SW, Rochester, MN 55905 USA.,Primary Care Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN USA
| | - Raphael Mwangi
- Robert D. and Patricia E. Kern Mayo Clinic Center for the Science of Health Care Delivery, Mayo Clinic College of Medicine, 200 1st Street SW, Rochester, MN 55905 USA
| | - Frederick North
- Primary Care Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN USA
| | - Jon O Ebbert
- Robert D. and Patricia E. Kern Mayo Clinic Center for the Science of Health Care Delivery, Mayo Clinic College of Medicine, 200 1st Street SW, Rochester, MN 55905 USA.,Primary Care Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN USA
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Prabhu M, Bortoletto P, Bateman BT. Perioperative pain management strategies among women having reproductive surgeries. Fertil Steril 2017; 108:200-206. [PMID: 28697915 PMCID: PMC5545053 DOI: 10.1016/j.fertnstert.2017.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 06/06/2017] [Indexed: 12/14/2022]
Abstract
This review presents opioid-sparing strategies for perioperative pain management among women undergoing reproductive surgeries and procedures. Recommendations are provided regarding the use of nonsteroidal anti-inflammatory drugs, acetaminophen, other adjunctive medications, and regional anesthetic blocks. Additional considerations for chronic opioid users or patients using opioid replacement or antagonist therapy are discussed.
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Affiliation(s)
- Malavika Prabhu
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Massachusetts General Hospital, 55 Fruit Street, Boston MA 02114,
| | - Pietro Bortoletto
- Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women’s Hospital, 75 Francis Street, Boston MA 02115,
| | - Brian T. Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, and Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, ., 617-529-7058
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Chaudhary S, Compton P. Use of risk mitigation practices by family nurse practitioners prescribing opioids for the management of chronic nonmalignant pain. Subst Abus 2016; 38:95-104. [DOI: 10.1080/08897077.2016.1265038] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Sahil Chaudhary
- Department of Health Systems Administration, Georgetown University, Washington, DC, USA
| | - Peggy Compton
- Department of Advanced Nursing Practice, Georgetown University, Washington, DC, USA
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Arthur JA, Edwards T, Lu Z, Reddy S, Hui D, Wu J, Liu D, Williams JL, Bruera E. Frequency, predictors, and outcomes of urine drug testing among patients with advanced cancer on chronic opioid therapy at an outpatient supportive care clinic. Cancer 2016; 122:3732-3739. [PMID: 27509305 DOI: 10.1002/cncr.30240] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 06/01/2016] [Accepted: 07/01/2016] [Indexed: 11/09/2022]
Abstract
BACKGROUND Data are limited on the use and outcomes of urine drug tests (UDTs) among patients with advanced cancer. The main objective of this study was to determine the factors associated with UDT ordering and results in outpatients with advanced cancer. METHODS A retrospective chart review was conducted of 1058 patients who attended an outpatient supportive care clinic from March 2014 to November 2015. Sixty-one patients who were receiving chronic opioid therapy and underwent UDTs were identified. A control group of 120 patients who did not undergo UDTs was selected for comparison. RESULTS Sixty-one of 1058 patients (6%) underwent UDTs, and 33 of 61 patients (54%) had abnormal results. Multivariate analysis indicated that the odds ratio for UDT ordering was 3.9 in patients who had positive Cut Down, Annoyed, Guilty, and Eye Opener (CAGE) questionnaire results (P = .002), 4.41 in patients aged < 45 years (P < .001), 5.58 in patients who had moderate-to-severe pain (Edmonton Symptom Assessment Scale pain scores ≥4; P < .001), 0.27 in patients with advanced-stage cancer, (P = .008), and 0.25 in patients who had moderate-to-severe fatigue (P = .001). Among 52 abnormal UDT results in 33 patients, the most common opioid findings were prescribed opioids absent in urine (14 of 52 tests; 27%) and unprescribed opioids in urine (13 of 52 tests; 25%). CONCLUSIONS UDTs were used infrequently among outpatients with advanced cancer who were receiving chronic opioid therapy. Younger age, positive CAGE questionnaire results, early stage cancer or no evidence of disease status, higher pain intensity, and lower fatigue scores were significant predictors of UDT ordering. More than 50% of UDT results were abnormal. More research is necessary to better characterize aberrant opioid use in patients with advanced cancer. Cancer 2016;122:3732-9. © 2016 American Cancer Society.
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Affiliation(s)
- Joseph A Arthur
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, Texas
| | - Tonya Edwards
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, Texas
| | - Zhanni Lu
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, Texas
| | - Suresh Reddy
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, Texas
| | - David Hui
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, Texas
| | - Jimin Wu
- Department of Quantitative Sciences, The University of Texas MD Anderson Cancer, Houston, Texas
| | - Diane Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer, Houston, Texas
| | - Janet L Williams
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, Texas
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, Texas
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Abstract
At least 100 million adults in the United States are afflicted with chronic pain. Nurse practitioners and other providers are often challenged by the complexity of chronic pain management. This article discusses systematic strategies to facilitate safe, efficient, satisfactory, and quality care of patients with chronic pain in primary care.
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Affiliation(s)
- Jennifer Kawi
- Jennifer Kawi is an assistant professor at the University of Nevada, Las Vegas School of Nursing, Las Vegas, Nev
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Song J, Foell J. An exploration of opioid medication management for non-malignant pain in primary care. Br J Pain 2015; 9:181-9. [PMID: 26516575 DOI: 10.1177/2049463715574111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The present study aimed to explore how prescription of opioid medication for chronic non-malignant pain (CNMP) is managed in primary care. We used audit as a research tool, and one general practitioner (GP) practice in West London acted as an exemplar. Of the practice population with CNMP, 1% had repeat prescription of at least 12 months duration for opioid analgesics at the time of data collection. These 1% are on highly controlled opioids. Our study showed the following: (1) long-term opioid prescription appears to follow a fluctuating course as opposed to staying the same; (2) we found that medication reviews were done in most cases (85.7%), but the quality of the process is difficult to assess and ascertain; and (3) we identified two incidences where opioid contract was implemented. In both cases, contracts were used as a last chance warning for patients who were already problematic, suggesting that opioid contracts served as a disciplinary tool rather than a preventative measure. Our findings highlight a need for a more structured and specific review of analgesic medication, and a need for a simple and effective way to identify patients at high risk of developing problematic use, to ensure better monitoring and early presentations.
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Affiliation(s)
- Jia Song
- Centre for Primary Care and Public Health, The Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK ; Richford Gate Medical Practice, London, UK
| | - Jens Foell
- Centre for Primary Care and Public Health, The Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK ; Richford Gate Medical Practice, London, UK
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Jurcik DC, Sundaram AH, Jamison RN. Chronic pain, negative affect, and prescription opioid abuse. Curr Opin Psychol 2015. [DOI: 10.1016/j.copsyc.2015.03.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Butler MM, Sansone RA, Opperman C. Resident and Patient Responses to the Institution of Required Narcotic Agreements in an Internal Medicine Outpatient Clinic. INNOVATIONS IN CLINICAL NEUROSCIENCE 2015; 12:12-13. [PMID: 26634175 PMCID: PMC4655893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Melissa M Butler
- Dr. Butler is Clinical Assistant Professor, Department of Internal Medicine, Wright State University School of Medicine, Dayton, Ohio, and Assistant Medical Director, Sycamore Primary Care Center, Miamisburg, Ohio; Dr. Sansone was Professor, Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education, Kettering Medical Center, Dayton, Ohio at the time of this study; Dr. Opperman is a resident in the Department of Internal Medicine, Kettering Medical Center, Dayton, Ohio
| | - Randy A Sansone
- Dr. Butler is Clinical Assistant Professor, Department of Internal Medicine, Wright State University School of Medicine, Dayton, Ohio, and Assistant Medical Director, Sycamore Primary Care Center, Miamisburg, Ohio; Dr. Sansone was Professor, Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education, Kettering Medical Center, Dayton, Ohio at the time of this study; Dr. Opperman is a resident in the Department of Internal Medicine, Kettering Medical Center, Dayton, Ohio
| | - Charles Opperman
- Dr. Butler is Clinical Assistant Professor, Department of Internal Medicine, Wright State University School of Medicine, Dayton, Ohio, and Assistant Medical Director, Sycamore Primary Care Center, Miamisburg, Ohio; Dr. Sansone was Professor, Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education, Kettering Medical Center, Dayton, Ohio at the time of this study; Dr. Opperman is a resident in the Department of Internal Medicine, Kettering Medical Center, Dayton, Ohio
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Lasser KE, Shanahan C, Parker V, Beers D, Xuan Z, Heymann O, Lange A, Liebschutz JM. A Multicomponent Intervention to Improve Primary Care Provider Adherence to Chronic Opioid Therapy Guidelines and Reduce Opioid Misuse: A Cluster Randomized Controlled Trial Protocol. J Subst Abuse Treat 2015; 60:101-9. [PMID: 26256769 DOI: 10.1016/j.jsat.2015.06.018] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 06/25/2015] [Accepted: 06/29/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Prescription opioid misuse is a significant public health problem as well as a patient safety concern. Primary care providers (PCPs) are the leading prescribers of opioids for chronic pain, yet few PCPs follow standard practice guidelines regarding assessment and monitoring. This cluster randomized controlled trial will determine whether four implementation strategies; nurse care management, use of a patient registry, academic detailing, and electronic tools, will increase PCP adherence to chronic opioid therapy guidelines and reduce opioid misuse among patients, relative to electronic tools alone. The implementation strategies and intervention content are based on the chronic care model. METHODS We include 53 PCPs from three Boston-area community health centers and one urban safety-net hospital-based primary care practice who have at least four patients meeting the following inclusion criteria: 1) age≥18; 2) one or more completed visits to the primary care practice in the past year; 3) long-term opioid treatment defined as three or more opioid prescriptions written at least 21days apart within 6months and 4) an inpatient or outpatient ICD-9-CM diagnosis for musculoskeletal or neuropathic pain. We consider PCPs to be study subjects, and obtained a waiver of informed consent for patients because the study is promoting an established standard of care. We enrolled participants (PCPs) from December 2012 through March 2015. PCPs were randomized to receive the intervention, which includes four components: 1) nurse care management, 2) use of a patient registry, 3) academic detailing, and 4) electronic tools, or a control condition, which includes only the use of the electronic tools. The intervention PCPs receive the services of a nurse-managed registry for planning individual patient care and conducting population-based care for patients receiving opioids for chronic pain. In academic detailing visits, trained co-investigators provide intervention PCPs with individualized education to change prescribing practice. Electronic tools, located on a web site external to the EMR, www.mytopcare.org, include validated instruments to assess patient status, and management resources to facilitate PCP adherence to suggested monitoring. Electronic tools are available to PCPs in both study arms. The primary outcomes are PCP adherence to chronic opioid therapy guidelines and patient opioid misuse. Secondary outcomes include measures of substance abuse, possible opioid diversion, and level of opioid risk among patients. We will follow PCPs and their estimated 1200 chronic pain patients for 1year after study enrollment. To determine whether the intervention condition achieves greater adherence to guidelines and reduced opioid misuse after 1year compared to the control condition, we will compare the baseline and follow-up measures of the individual patients, stratifying by intervention status and noting differences that are statistically significant at the p=0.05 level. Analyses will be based on intent-to-treat. RESULTS Randomization resulted in groups with similar baseline characteristics. The ages of PCPs are evenly distributed, with inclusion of both PCPs who have recently completed training and those who have been in practice for more than 20years. Two-thirds of enrolled PCPs are women, and one-third are non-white. DISCUSSION The study will determine the impact of this multicomponent intervention on improving PCP adherence to guidelines and reducing opioid misuse among patients.
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Affiliation(s)
- Karen E Lasser
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Boston Medical Center/Boston University School of Medicine, Boston, MA; Department of Community Health Sciences, Boston University School of Public Health.
| | - Christopher Shanahan
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Boston Medical Center/Boston University School of Medicine, Boston, MA
| | - Victoria Parker
- Department of Health Policy and Management, Boston University School of Public Health
| | - Donna Beers
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Boston Medical Center/Boston University School of Medicine, Boston, MA
| | - Ziming Xuan
- Department of Community Health Sciences, Boston University School of Public Health
| | - Orlaith Heymann
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Boston Medical Center/Boston University School of Medicine, Boston, MA
| | - Allison Lange
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Boston Medical Center/Boston University School of Medicine, Boston, MA
| | - Jane M Liebschutz
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Boston Medical Center/Boston University School of Medicine, Boston, MA
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Tournebize J, Gibaja V, Muszczak A, Kahn JP. Are Physicians Safely Prescribing Opioids for Chronic Noncancer Pain? A Systematic Review of Current Evidence. Pain Pract 2015; 16:370-83. [PMID: 25865462 DOI: 10.1111/papr.12289] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 11/14/2014] [Accepted: 12/27/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND With rising prescription of opioid medications for chronic noncancer pain (CNCP) in the past years, opioid abuse and overdose deaths have increased in parallel. To ensure adequate treatment outcomes and reduce the risks linked with the chronic use of opioids, practitioner's adherence to treatment guidelines is essential. This study summarizes published recommendations about the strategies to reduce the risks associated with the chronic use of opioids and evaluates the adherence of physicians to these recommendations. METHOD A systematic literature search was undertaken in May 2014 using major databases. Studies were included if they examined the adherence of practitioners with at least one form of opioid risk reduction strategy. Benchmark guidelines cited in these studies were also reviewed. RESULTS The search yielded 683 records, 14 of which were found to evaluate adherence of physicians to opioid risk reduction strategies. Nine benchmark guidelines were found. Almost all physicians consider opioid therapy only when other safer approaches have failed and do not prescribe opioids at doses greater than 200 mg/day of morphine equivalent. Unfortunately, less than 50% assess pain intensity using a pain scale; they often consider transdermal fentanyl safe for opioid-naïve patients and fail to discontinue opioids if they were ineffective in relieving patients' pain. CONCLUSIONS Substantial practice and knowledge gaps were identified, including the use of pain scales and prescription of transdermal fentanyl in opioid-naïve patients, which have important implications for patient's safety. Guidelines more practical to physicians' settings and further education of physicians are warranted.
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Affiliation(s)
- Juliana Tournebize
- Centre for Evaluation and Information on Pharmacodependence-Addictovigilance, 'Centre d'Evaluation et d'Information sur la Pharmacodépendance-Addictovigilance' (CEIP-A), Nancy University Medical Center, Nancy, France
| | - Valérie Gibaja
- Centre for Evaluation and Information on Pharmacodependence-Addictovigilance, 'Centre d'Evaluation et d'Information sur la Pharmacodépendance-Addictovigilance' (CEIP-A), Nancy University Medical Center, Nancy, France
| | - Amandine Muszczak
- Centre for Evaluation and Information on Pharmacodependence-Addictovigilance, 'Centre d'Evaluation et d'Information sur la Pharmacodépendance-Addictovigilance' (CEIP-A), Nancy University Medical Center, Nancy, France
| | - Jean-Pierre Kahn
- Centre for Evaluation and Information on Pharmacodependence-Addictovigilance, 'Centre d'Evaluation et d'Information sur la Pharmacodépendance-Addictovigilance' (CEIP-A), Nancy University Medical Center, Nancy, France.,Department of Psychiatry and Clinical Psychology, Nancy University Medical Center, Université de Lorraine, Lorraine, France
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Gudin JA. Clinical Strategies for the Primary Health Care Professional to Minimize Prescription Opioid Abuse. Postgrad Med 2015; 124:131-8. [DOI: 10.3810/pgm.2012.05.2556] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Degenhardt L, Blanch B, Gisev N, Larance B, Pearson S. The POPPY Research Programme protocol: investigating opioid utilisation, costs and patterns of extramedical use in Australia. BMJ Open 2015; 5:e007030. [PMID: 25631315 PMCID: PMC4316424 DOI: 10.1136/bmjopen-2014-007030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Opioid prescribing is increasing in many countries. In Australia, there is limited research on patterns of prescribing and access, or the outcomes associated with this use. The aim of this research programme is to use national dispensing data to estimate opioid use and costs, including problematic or extramedical use in the Australian population. METHODS AND ANALYSIS In a cohort of persons dispensed at least one opioid in 2013, we will estimate monthly utilisation and costs of prescribed opioids, overall and according to individual opioid formulations and strengths. In a cohort of new opioid users, commencing therapy between 1 July 2009 and 31 December 2013, we will examine patterns of opioid use including initiation of therapy, duration of treatment and concomitant use of opioids and other prescribed medicines. We will also examine patterns of extramedical opioid use based on indicators including excess dosing, use of more than one opioid concomitantly, doctor/pharmacy shopping and accelerated time to prescription refill. ETHICS AND DISSEMINATION This protocol was approved by the NSW Population and Health Services Ethics Committee (March 2014) and data access approved by the Department of Human Services External Review Evaluation Committee (June 2014). This will be one of the first comprehensive Australian studies with the capability to investigate individual patterns of use and track extramedical use. In the first instance our analysis will be based on 5 years of dispensing data but will be expanded with ongoing annual data updates. This research has the capability to contribute significantly to pharmaceutical policy within Australia and globally. In particular, the trajectory of extramedical prescription-opioid use has been the subject of limited research to date. The results of this research will be published widely in general medical, pharmacoepidemiology, addiction and psychiatry journals.
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Affiliation(s)
- Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Medicine, UNSW Australia, Sydney, New South Wales, Australia
| | - Bianca Blanch
- Faculty of Pharmacy, Pharmacoepidemiology and Pharmaceutical Policy Research Group, University of Sydney, Sydney, New South Wales, Australia
| | - Natasa Gisev
- National Drug and Alcohol Research Centre, UNSW Medicine, UNSW Australia, Sydney, New South Wales, Australia
| | - Briony Larance
- National Drug and Alcohol Research Centre, UNSW Medicine, UNSW Australia, Sydney, New South Wales, Australia
| | - Sallie Pearson
- Faculty of Pharmacy, Pharmacoepidemiology and Pharmaceutical Policy Research Group, University of Sydney, Sydney, New South Wales, Australia
- School of Public Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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McGee S, Silverman RD. Treatment Agreements, Informed Consent, and the Role of State Medical Boards in Opioid Prescribing. PAIN MEDICINE 2015; 16:25-9. [DOI: 10.1111/pme.12580] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Jamison RN, Martel MO, Edwards RR, Qian J, Sheehan KA, Ross EL. Validation of a brief Opioid Compliance Checklist for patients with chronic pain. THE JOURNAL OF PAIN 2014; 15:1092-1101. [PMID: 25092233 PMCID: PMC4253010 DOI: 10.1016/j.jpain.2014.07.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 07/05/2014] [Accepted: 07/21/2014] [Indexed: 01/22/2023]
Abstract
UNLABELLED There has been a need for a brief assessment tool to determine compliance with use of prescribed opioids for pain. The purpose of this study was to develop and begin the validation of a brief and simple compliance checklist (Opioid Compliance Checklist [OCC]) for chronic pain patients prescribed long-term opioid therapy. A review of the literature of opioid therapy agreements led to a 12-item OCC that was repeatedly administered to 157 patients who were taking opioids for chronic pain and followed for 6 months. Validation of the OCC was conducted by identifying those patients exhibiting aberrant drug-related behavior as determined by any of the following: positive urine toxicology screen, a positive score on the Prescription Drug Use Questionnaire interview or Current Opioid Misuse Measure, and/or ratings by staff on the Addiction Behavior Checklist. Of the original 12 items, 5 OCC items appeared to best predict subsequent aberrant behaviors based on multivariate logistic regression analyses (cross-validated area under the receiver operating characteristic curve = .67). Although further testing is needed, these results suggest that the OCC is an easy-to-use, promising measure in monitoring opioid adherence among persons with chronic pain. PERSPECTIVE This study presents validation of a brief 5-item compliance checklist for use with chronic pain patients prescribed long-term opioid therapy. This measure asks patients about aberrant drug-related behavior over the past month, and any positive response indicates problems with adherence with opioids. Further cross-validation testing is needed.
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Affiliation(s)
- Robert N Jamison
- Pain Management Center, Departments of Anesthesia and Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Marc O Martel
- Pain Management Center, Departments of Anesthesia and Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert R Edwards
- Pain Management Center, Departments of Anesthesia and Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jing Qian
- Division of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts, Amherst, Massachusetts
| | - Kerry Anne Sheehan
- Pain Management Center, Departments of Anesthesia and Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Edgar L Ross
- Pain Management Center, Departments of Anesthesia and Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Morris BJ, Zumsteg JW, Archer KR, Cash B, Mir HR. Narcotic Use and Postoperative Doctor Shopping in the Orthopaedic Trauma Population. J Bone Joint Surg Am 2014; 96:1257-1262. [PMID: 25100772 DOI: 10.2106/jbjs.m.01114] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The negative consequences of narcotic use and diversion for nonmedical use are on the rise. A growing number of narcotic abusers obtain narcotic prescriptions from multiple providers ("doctor shopping"). This study sought to determine the effects of multiple postoperative narcotic providers on the number of narcotic prescriptions, duration of narcotics, and morphine equivalent dose per day in the orthopaedic trauma population. METHODS Our prospective cohort study used the state-controlled substance monitoring database to identify all narcotic prescriptions filled three months prior to admission and six months following discharge for enrolled patients. Patients were assigned into two groups: a single narcotic provider group with prescriptions only from the treating surgeon (or extenders) or a multiple narcotic provider group with prescriptions from both the treating surgeon and an additional provider or providers. RESULTS Complete data were available for 130 of 151 eligible patients. Preoperative narcotic use, defined by three or more narcotic prescriptions within three months of admission, was noted in 8.5% of patients. Overall, 20.8% of patients sought multiple narcotic providers postoperatively. There were significant increases in postoperative narcotic prescriptions (p < 0.001) between the single narcotic provider group (two prescriptions) and the multiple narcotic provider group (seven prescriptions), in duration of postoperative narcotic use (p < 0.001) between the single narcotic provider group (twenty-eight days) and the multiple narcotic provider group (110 days), and in morphine equivalent dose per day (p = 0.002) between the single narcotic provider group (26 mg) and the multiple narcotic provider group (43 mg). Patients with a high school education or less were 3.2 times more likely to seek multiple providers (p = 0.02), and patients with a history of preoperative narcotic use were 4.5 times more likely to seek multiple providers (p < 0.001). CONCLUSIONS There is a 20.8% prevalence of postoperative doctor shopping in the orthopaedic trauma population. Patients with multiple postoperative narcotic providers had a significant increase in postoperative narcotic prescriptions, duration of narcotics, and morphine equivalent dose per day.
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Affiliation(s)
- Brent J Morris
- Division of Orthopaedic Trauma, Vanderbilt Orthopaedic Institute, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232. E-mail address for B.J. Morris:
| | - Justin W Zumsteg
- Division of Orthopaedic Trauma, Vanderbilt Orthopaedic Institute, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232. E-mail address for B.J. Morris:
| | - Kristin R Archer
- Division of Orthopaedic Trauma, Vanderbilt Orthopaedic Institute, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232. E-mail address for B.J. Morris:
| | - Brian Cash
- Division of Orthopaedic Trauma, Vanderbilt Orthopaedic Institute, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232. E-mail address for B.J. Morris:
| | - Hassan R Mir
- Division of Orthopaedic Trauma, Vanderbilt Orthopaedic Institute, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232. E-mail address for B.J. Morris:
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Hilario EY, Griffin ML, McHugh RK, McDermott KA, Connery HS, Fitzmaurice GM, Weiss RD. Denial of urinalysis-confirmed opioid use in prescription opioid dependence. J Subst Abuse Treat 2014; 48:85-90. [PMID: 25115135 DOI: 10.1016/j.jsat.2014.07.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 07/02/2014] [Accepted: 07/14/2014] [Indexed: 11/18/2022]
Abstract
Although research has generally supported the validity of substance use self-reports, some patients deny urine-verified substance use. We examined the prevalence and patterns of denying urinalysis-confirmed opioid use in a sample of prescription opioid dependent patients. We also identified characteristics associated with denial in this population of increasing public health concern. Opioid use self-reports were compared with weekly urinalysis results in a 12-week multi-site treatment study for prescription opioid dependence. Among those who used opioids during the trial (n=246/360), 44.3% (n=109) denied urinalysis-confirmed opioid use, although usually only once (78%). Overall, 22.9% of opioid-positive urine tests (149/650) were denied on self-report. Multivariable analysis found that initially using opioids to relieve pain was associated with denying opioid use. These findings support the use of both self-reports and urine testing in treating prescription opioid dependence.
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Affiliation(s)
- E Yvette Hilario
- Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, MA 02478, USA
| | - Margaret L Griffin
- Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, MA 02478, USA; Department of Psychiatry, Harvard Medical School, Boston, MA 02115, USA
| | - R Kathryn McHugh
- Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, MA 02478, USA; Department of Psychiatry, Harvard Medical School, Boston, MA 02115, USA
| | | | - Hilary S Connery
- Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, MA 02478, USA; Department of Psychiatry, Harvard Medical School, Boston, MA 02115, USA
| | - Garrett M Fitzmaurice
- Department of Psychiatry, Harvard Medical School, Boston, MA 02115, USA; Laboratory for Psychiatric Biostatistics, McLean Hospital, Belmont, MA 02478, USA; Department of Biostatistics, Harvard School of Public Health, Boston, MA 02115, USA
| | - Roger D Weiss
- Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, MA 02478, USA; Department of Psychiatry, Harvard Medical School, Boston, MA 02115, USA.
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Lakha SF, Louffat AF, Nicholson K, Deshpande A, Mailis-Gagnon A. Characteristics of chronic noncancer pain patients assessed with the opioid risk tool in a Canadian tertiary care pain clinic. PAIN MEDICINE 2014; 15:1743-9. [PMID: 24832821 DOI: 10.1111/pme.12465] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Opioid Risk Tool (ORT) is a screening instrument for assessing the risk of opioid-related aberrant behavior in chronic noncancer pain (CNCP) patients. OBJECTIVE This study aims to compare patient characteristics documented in the original ORT study with those identified in CNCP patients assessed using a physician-administered ORT in a tertiary care pain clinic in Toronto, Canada. METHODOLOGY This was a descriptive cross-sectional study of 322 consecutive new patients referred over 12 months. Data extraction included ORT scores, demographics, pain ratings, opioid, and other medication use at point of entry, diagnosis, and other variables. Characteristics were compared with those described in the original ORT study. RESULTS The total mean ORT scores of patients in this study were related to several demographic (gender, age, marital status, and country of birth) and nondemographic variables (employment status, cigarette smoking, and contribution of biomedical and/or psychological factors to presentation). Prevalence of characteristics noted in this patient sample differed substantially from that found in Webster and Webster as the basis for ORT scores. CONCLUSION Significant differences existed between this study population and the patient sample from which the ORT was derived. Limitations of this study are discussed. We concur with the authors of the original study that the ORT may not be applicable in different pain populations and settings. Based on our findings, we encourage caution in interpreting the ORT in general CNCP settings until further studies are performed.
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Affiliation(s)
- Shehnaz Fatima Lakha
- Comprehensive Pain Program (CPP), Toronto Western Hospital, Toronto, Ontario, Canada; Centre for the Study of Pain, University of Toronto, Toronto, Ontario, Canada
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Hoffelt C, Zwack A. Assessment and management of chronic pain in patients with depression and anxiety. Ment Health Clin 2014. [DOI: 10.9740/mhc.n198935] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This article will review the role of the pharmacist in the management of chronic pain in patients with comorbid mood disorders.
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Campbell G, Mattick R, Bruno R, Larance B, Nielsen S, Cohen M, Lintzeris N, Shand F, Hall WD, Hoban B, Kehler C, Farrell M, Degenhardt L. Cohort protocol paper: the Pain and Opioids In Treatment (POINT) study. BMC Pharmacol Toxicol 2014; 15:17. [PMID: 24646721 PMCID: PMC4000138 DOI: 10.1186/2050-6511-15-17] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 03/07/2014] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Internationally, there is concern about the increased prescribing of pharmaceutical opioids for chronic non-cancer pain (CNCP). In part, this is related to limited knowledge about the long-term benefits and outcomes of opioid use for CNCP. There has also been increased injection of some pharmaceutical opioids by people who inject drugs, and for some patients, the development of problematic and/or dependent use. To date, much of the research on the use of pharmaceutical opioids among people with CNCP, have been clinical trials that have excluded patients with complex needs, and have been of limited duration (i.e. fewer than 12 weeks). The Pain and Opioids In Treatment (POINT) study is unique study that aims to: 1) examine patterns of opioid use in a cohort of patients prescribed opioids for CNCP; 2) examine demographic and clinical predictors of adverse events, including opioid abuse or dependence, medication diversion, other drug use, and overdose; and 3) identify factors predicting poor pain relief and other outcomes. METHODS/DESIGN The POINT cohort comprises around 1,500 people across Australia prescribed pharmaceutical opioids for CNCP. Participants will be followed-up at four time points over a two year period. POINT will collect information on demographics, physical and medication use history, pain, mental health, drug and alcohol use, non-adherence, medication diversion, sleep, and quality of life. Data linkage will provide information on medications and services from Medicare (Australia's national health care scheme). Data on those who receive opioid substitution therapy, and on mortality, will be linked. DISCUSSION This study will rigorously examine prescription opioid use among CNCP patients, and examine its relationship to important health outcomes. The extent to which opioids for chronic pain is associated with pain reduction, quality of life, mental and physical health, aberrant medication behavior and substance use disorders will be extensively examined. Improved understanding of the longer-term outcomes of chronic opioid therapy will direct community-based interventions and health policy in Australia and internationally. The results of this study will assist clinicians to better identify those patients who are at risk of adverse outcomes and who therefore require alternative treatment strategies.
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Affiliation(s)
- Gabrielle Campbell
- National Drug and Alcohol Research Centre, UNSW, Sydney, NSW 2052, Australia
| | - Richard Mattick
- National Drug and Alcohol Research Centre, UNSW, Sydney, NSW 2052, Australia
| | - Raimondo Bruno
- National Drug and Alcohol Research Centre, UNSW, Sydney, NSW 2052, Australia
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Briony Larance
- National Drug and Alcohol Research Centre, UNSW, Sydney, NSW 2052, Australia
| | - Suzanne Nielsen
- National Drug and Alcohol Research Centre, UNSW, Sydney, NSW 2052, Australia
- Discipline of Addiction Medicine, The University of Sydney, Sydney, Australia
- The Langton Centre, South East Sydney Local Health District (SESLHD) Drug and Alcohol Services, Surry Hills, Australia
| | - Milton Cohen
- St Vincent’s Clinical School, UNSW Medicine, UNSW, Darlinghurst, Australia
| | - Nicholas Lintzeris
- Discipline of Addiction Medicine, The University of Sydney, Sydney, Australia
- The Langton Centre, South East Sydney Local Health District (SESLHD) Drug and Alcohol Services, Surry Hills, Australia
| | - Fiona Shand
- Black Dog Institute, UNSW, Randwick, Australia
| | - Wayne D Hall
- Centre for Youth Substance Abuse Research, University of Queensland, Queensland, Australia
- National Addiction Centre, Kings College, London, England
| | - Bianca Hoban
- National Drug and Alcohol Research Centre, UNSW, Sydney, NSW 2052, Australia
| | - Chyanne Kehler
- National Drug and Alcohol Research Centre, UNSW, Sydney, NSW 2052, Australia
| | - Michael Farrell
- National Drug and Alcohol Research Centre, UNSW, Sydney, NSW 2052, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW, Sydney, NSW 2052, Australia
- School of Population and Global Health, University of Melbourne, Melbourne, Australia
- Centre for Adolescent Health, Murdoch Children’s Research Institute, Melbourne, Australia
- Department of Global Health, School of Public Health, University of Washington, Seattle, USA
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Turner JA, Saunders K, Shortreed SM, Rapp SE, Thielke S, LeResche L, Riddell KM, Von Korff M. Chronic opioid therapy risk reduction initiative: impact on urine drug testing rates and results. J Gen Intern Med 2014; 29:305-11. [PMID: 24142119 PMCID: PMC3912304 DOI: 10.1007/s11606-013-2651-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 07/18/2013] [Accepted: 09/20/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND In response to epidemic levels of prescription opioid overdose, abuse, and diversion, routine urine drug tests (UDTs) are recommended for patients receiving chronic opioid therapy (COT) for chronic pain. However, UDT ordering for COT patients is inconsistent in primary care, and little is known about how to increase UDT ordering or the impact of increased testing on rates of aberrant results. OBJECTIVE To compare rates and results of UDTs for COT patients before versus after implementation of an opioid risk reduction initiative in a large healthcare system. DESIGN Pre-post observational study. PATIENTS Group Health patients on COT October 2008-September 2009 (N = 4,821), October 2009-September 2010 (N = 5,081), and October 2010-September 2011 (N = 5,498). INTERVENTION Multi-faceted opioid risk reduction initiative. MAIN MEASURES Annual rates of UDTs and UDT results. KEY RESULTS Half of COT patients received at least one UDT in the year after the initiative was implemented, compared to only 7 % 2 years prior. The adjusted odds of COT patients having at least one UDT in the first year of the opioid initiative were almost 16 times (adjusted OR = 15.79; 95 % CI: 13.96-17.87) those 2 years prior. The annual rate of UDT detection of marijuana and illicit drugs did not change (12.6 % after initiative implementation), and largely reflected marijuana use (detected in 11.1 % of all UDTs in the year after initiative implementation). In the year after initiative implementation, 10.7 % of UDTs were negative for opioids. CONCLUSIONS The initiative appeared to dramatically increase urine drug testing of COT patients in the healthcare system without impacting rates of aberrant results. The large majority of aberrant results reflected marijuana use or absence of opioids in the urine. The utility of increased urine drug testing for COT patient safety and prevention of diversion remains uncertain.
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Affiliation(s)
- Judith A Turner
- Department of Psychiatry and Behavioral Sciences, University of Washington, Box 356560, Seattle, WA, 98195-6560, USA,
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Sekhon R, Aminjavahery N, Davis CN, Roswarski MJ, Robinette C. Compliance with Opioid Treatment Guidelines for Chronic Non-Cancer Pain (CNCP) in Primary Care at a Veterans Affairs Medical Center (VAMC). PAIN MEDICINE 2013; 14:1548-56. [DOI: 10.1111/pme.12164] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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49
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Differentiating Medicinal from Illicit Use in Positive Methamphetamine Results in a Pain Population. J Anal Toxicol 2013; 37:83-9. [DOI: 10.1093/jat/bks096] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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50
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Cantrill SV, Brown MD, Carlisle RJ, Delaney KA, Hays DP, Nelson LS, O'Connor RE, Papa A, Sporer KA, Todd KH, Whitson RR. Clinical Policy: Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Department. Ann Emerg Med 2012; 60:499-525. [DOI: 10.1016/j.annemergmed.2012.06.013] [Citation(s) in RCA: 181] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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