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Bansal V, Lam L, Brown AV, Javed S. Prevalence of abnormal urine drug tests during COVID-19 pandemic in the cancer patient population: retrospective study. Pain Manag 2024; 14:129-138. [PMID: 38375593 PMCID: PMC11412139 DOI: 10.2217/pmt-2023-0122] [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: 11/09/2023] [Accepted: 02/06/2024] [Indexed: 02/21/2024] Open
Abstract
Background: Opioid misuse is a persistent concern, heightened by the COVID-19 pandemic. This study examines the risk factors contributing to elevated rates of abnormal urine drug tests (UDTs) in the cancer pain patient population during COVID-19. Materials & methods: A retrospective chart review of 500 patient encounters involving UDTs at a comprehensive cancer center. Results: Medication adherence rates increase when UDTs are incorporated into a chronic cancer pain management protocol. Higher positive tests for illicit or nonprescribed substances in patients with specific risk factors: current smokers (tobacco), no active cancer and concurrent benzodiazepine use. Conclusion: This research emphasizes the increased risk of opioid misuse during COVID-19 among cancer pain patients with specific risk factors outlined in the results.
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Affiliation(s)
- Vishal Bansal
- Department of Pain Medicine, Division of Anesthesiology, Critical Care Medicine & Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Loc Lam
- Department of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, TX 77030, USA
| | - Ashlyn Victoria Brown
- Department of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, TX 77030, USA
| | - Saba Javed
- Department of Pain Medicine, Division of Anesthesiology, Critical Care Medicine & Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Sandbrink F, Murphy JL, Johansson M, Olson JL, Edens E, Clinton-Lont J, Sall J, Spevak C. The Use of Opioids in the Management of Chronic Pain: Synopsis of the 2022 Updated U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline. Ann Intern Med 2023; 176:388-397. [PMID: 36780654 DOI: 10.7326/m22-2917] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2023] Open
Abstract
DESCRIPTION In May 2022, leadership within the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline for the use of opioids when managing chronic pain. This synopsis summarizes the recommendations that the authors believe are the most important to highlight. METHODS In December 2020, the VA/DoD Evidence-Based Practice Work Group assembled a team to update the 2017 VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain. The guideline development team included clinical stakeholders and conformed to the National Academy of Medicine's tenets for trustworthy clinical practice guidelines. The guideline team developed key questions to guide a systematic evidence review that was done by an independent third party and distilled 20 recommendations for care using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. The guideline team also created 3 one-page algorithms to help guide clinical decision making. This synopsis presents the recommendations and highlights selected recommendations on the basis of clinical relevance. RECOMMENDATIONS This guideline is intended for clinicians who may be considering opioid therapy to manage patients with chronic pain. This synopsis reviews updated recommendations for the initiation and continuation of opioid therapy; dose, duration, and taper of opioids; screening, assessment, and evaluation; and risk mitigation. New additions are highlighted, including recommendations about the use of buprenorphine instead of full agonist opioids; assessing for behavioral health conditions and factors associated with higher risk for harm, such as pain catastrophizing; and the use of pain and opioid education to reduce the risk for prolonged opioid use for postsurgical pain.
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Affiliation(s)
- Friedhelm Sandbrink
- National Pain Management, Opioid Safety, and Prescription Drug Monitoring Program, Veterans Health Administration, Washington DC VA Medical Center, and Department of Neurology, George Washington University, Washington, DC (F.S.)
| | - Jennifer L Murphy
- Pain Management, Opioid Safety, and Prescription Drug Monitoring Program, Veterans Health Administration, Washington, DC (J.L.M.)
| | - Melanie Johansson
- Walter Reed National Military Medical Center, Bethesda, Maryland (M.J.)
| | | | - Ellen Edens
- Opioid Reassessment Clinic, Yale Addiction Psychiatry Service, National TeleMental Health Center, VA Connecticut Healthcare System, West Haven, Connecticut (E.E.)
| | | | - James Sall
- Evidence Based Practice, Quality and Patient Safety, Veterans Health Administration, Washington, DC (J.S.)
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3
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Do Urine Drug Tests Reveal Substance Misuse Among Patients Prescribed Opioids for Chronic Pain? J Gen Intern Med 2022; 37:2365-2372. [PMID: 34405344 PMCID: PMC9360386 DOI: 10.1007/s11606-021-07095-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 07/30/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Urine drug testing (UDT) is a recommended risk mitigation strategy for patients prescribed opioids for chronic pain, but evidence that UDT supports identification of substance misuse is limited. OBJECTIVE Identify the prevalence of UDT results that may identify substance misuse, including diversion, among patients prescribed opioids for chronic pain. DESIGN Retrospective cohort study. SUBJECTS Patients (n=638) receiving opioids for chronic pain who had one or more UDTs, examining up to eight substances per sample, during a one 1-year period. MAIN MEASURES Experts adjudicated the clinical concern that UDT results suggest substance misuse or diversion as not concerning, uncertain, or concerning. KEY RESULTS Of 638 patients, 48% were female and 49% were over age 55 years. Patients had a median of three UDTs during the intervention year. We identified 37% of patients (235/638) with ≥1 concerning UDT and a further 35% (222/638) having ≥1 uncertain UDT. We found concerning UDTs due to non-detection of a prescribed substance in 24% (156/638) of patients and detection of a non-prescribed substance in 23% (147/638). Compared to patients over 65 years, those aged 18-34 years were more likely to have concerning UDT results with an adjusted odds ratio (AOR) of 4.8 (95% confidence interval [CI] 1.9-12.5). Patients with mental health diagnoses (AOR 1.6 [95% CI 1.1-2.3]) and substance use diagnoses (AOR 2.3 [95% CI 1.5-3.7]) were more likely to have a concerning UDT result. CONCLUSIONS Expert adjudication of UDT results identified clinical concern for substance misuse in 37% of patients receiving opioids for chronic pain. Further research is needed to determine if UDTs impact clinical practice or patient-related outcomes.
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Chen C, Lo-Ciganic WH, Winterstein AG, Tighe P, Wei YJJ. Concurrent Use of Prescription Opioids and Gabapentinoids in Older Adults. Am J Prev Med 2022; 62:519-528. [PMID: 34802816 PMCID: PMC9426287 DOI: 10.1016/j.amepre.2021.08.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Concurrent use of prescription opioids with gabapentinoids may pose risks of serious drug interactions. Yet, little is known about the trends in and patient characteristics associated with concurrent opioid-gabapentinoid use among older Medicare opioid users with chronic noncancer pain. METHODS A cross-sectional study was conducted among Medicare older beneficiaries (aged ≥65 years) with chronic noncancer pain who filled ≥1 opioid prescription within 3 months after a randomly selected chronic noncancer pain diagnosis (index date) in a calendar year between 2011 and 2018. Patient characteristics were measured in the 6-month baseline before the index date, and concurrent opioid-gabapentinoid use for ≥1 day was measured in the 3-month follow-up after the index date. Multivariable modified Poisson regression hwas used to assess the trends and characteristics of concurrent opioid-gabapentinoid use. Analyses were conducted from January to June 2021. RESULTS Among 464,721 eligible older beneficiaries with chronic noncancer pain and prescription opioids, the prevalence of concurrent opioid-gabapentinoid use increased from 17.0% in 2011 to 23.5% in 2018 (adjusted prevalence ratio=1.48, 95% CI=1.45, 1.53). Concurrent users versus opioid-only users tended to be non-Black, low-income subsidy recipients, and Southern residents. The clinical factors associated with concurrent opioid-gabapentinoid use included having a diagnosis of neuropathic pain, polypharmacy, and risk factors for opioid-related adverse events. CONCLUSIONS Concurrent opioid-gabapentinoid use among older Medicare beneficiaries with chronic noncancer pain and prescription opioids has increased significantly between 2011 and 2018. Future studies are warranted to investigate the impact of concurrent use on outcomes in older patients. Interventions that reduce inappropriate concurrent use may target older patients with identified characteristics.
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Affiliation(s)
- Cheng Chen
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida; Department of Epidemiology, College of Public Health and Health Professions & College of Medicine, University of Florida, Gainesville, Florida
| | - Patrick Tighe
- Department of Anesthesiology, College of Medicine, University of Florida, Gainesville, Florida
| | - Yu-Jung J Wei
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida.
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Bonifonte A, Merchant R, Deppen K. Morphine Equivalent Total Dosage as Predictor of Adverse Outcomes in Opioid Prescribing. PAIN MEDICINE 2021; 22:3062-3071. [PMID: 34373930 DOI: 10.1093/pm/pnab249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The objective of this work was to develop a risk prediction model of opioid overdoses and opioid use disorder for patients at first opioid prescription and compare the predictive accuracy of using morphine equivalent total dosage with daily dosage as predictors. DESIGN Records from patients aged 18-79 years with opioid prescriptions between January 1, 2016 and June 30, 2019, no prior history of adverse outcomes, and no malignant cancer diagnoses were collected from the electronic health records system of a medium-sized central Ohio health care system (n = 219,276). A Cox proportional hazards model was developed to predict the adverse outcomes of opioid overdoses and opioid use disorder from patient sociodemographic, pharmacological, and clinical diagnoses factors. RESULTS 573 patients experienced overdoses and 2,571 patients were diagnosed with OUD in the study time frame. Morphine equivalent total dosage of opioid prescriptions was identified as a stronger predictor of adverse outcomes (C = 0.797) than morphine equivalent daily dosage (C = 0.792), with best predictions from a model that includes both predictors (C = 0.803). In the model with both daily and total dosage predictors, patients receiving a high total/low daily dosage experienced a higher risk (HR = 2.17) than those receiving a low total/high daily dosage (HR = 2.02). Those receiving a high total/high daily dosage experienced the greatest risk of all (HR = 3.09). CONCLUSIONS These findings demonstrate the value of including morphine equivalent total dosage as a predictor of adverse opioid outcomes and suggest total dosage may be more strongly correlated with increased risk than daily dosage.
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Leap KE, Chen GH, Lee J, Tan KS, Malhotra V. Identifying Prevalence of and Risk Factors for Abnormal Urine Drug Tests in Cancer Pain Patients. J Pain Symptom Manage 2021; 62:355-363. [PMID: 33276043 PMCID: PMC9364695 DOI: 10.1016/j.jpainsymman.2020.11.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 11/24/2020] [Accepted: 11/25/2020] [Indexed: 11/30/2022]
Abstract
CONTEXT Opioids have become a mainstay treatment for severe cancer pain. Although opioid prescribing has decreased, opioid mortality continues to rise. Utilizing urine drug tests (UDT) can help monitor medication adherence and identify use of unprescribed or illicit substances. OBJECTIVES To identify the prevalence of abnormal UDT among oncologic pain patients, associated demographic and clinical factors, and the most common abnormal substances. METHODS A retrospective chart review of 2472 patients with a cancer diagnosis and documented UDT in a single center was conducted from January 1, 2018 to February 15, 2020. Multivariable analyses were conducted for 10 baseline patient factors on each of the two primary outcomes-illicit drugs excluding tetrahydrocannabinol and amphetamines and detected-not-prescribed. RESULTS Of the 2472 patients, 840 patients (34%) had abnormal results. For illicit drugs, the significant factors (incidence rate ratio [95% CI]) were age (45-54 vs. ≥ 65 years: 7.27 [2.27-23.23]), race (black vs. white: 2.99 [1.39-6.42]), smoking status (current vs. former: 2.63 [1.41-4.90]); never vs. former: 0.27 (0.10-0.76), and benzodiazepine use (use vs. no use: 2.06 [1.03-4.12]). For detected-not-prescribed, the significant factors (incidence rate ratio [95% CI]) were race (black vs. white: 1.37 [1.01-1.85]), smoking status (current vs. former: 1.27 [1.00-1.62]); never vs. former: 0.82 (0.67-1.00), log-transformed morphine milligram equivalence (1.04 [1.01-1.07]), and benzodiazepine use (use vs. no use: 1.64 [1.35-1.98]). CONCLUSIONS This study demonstrates that oncologic pain patients are not a risk-free population for abnormal UDT, thus recommends a UDT with initial opioid prescriptions and annually thereafter, with more frequent tests for patients suspected to be at higher risk for misuse.
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Affiliation(s)
- Kelly E Leap
- Department of Nursing, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
| | - Grant H Chen
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jasme Lee
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kay See Tan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Vivek Malhotra
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Martel MO, Bruneau A, Edwards RR. Mind-body approaches targeting the psychological aspects of opioid use problems in patients with chronic pain: evidence and opportunities. Transl Res 2021; 234:114-128. [PMID: 33676035 DOI: 10.1016/j.trsl.2021.02.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 02/26/2021] [Accepted: 02/26/2021] [Indexed: 12/27/2022]
Abstract
Opioids are commonly prescribed for the management of patients with chronic noncancer pain. Despite the potential analgesic benefits of opioids, long-term opioid therapy (LTOT) may be accompanied by problems such as opioid misuse and opioid use disorder (OUD). In this review, we begin with a description of opioid misuse and OUD and the patient-specific factors associated with these problems among patients with chronic pain. We will focus primarily on highlighting the predominant role played by psychological factors in the occurrence of opioid misuse and OUD in these patients. Several psychological factors have been found to be associated with opioid use problems in patients with chronic pain, and evidence indicates that patients presenting with psychological disturbances are particularly at risk of transitioning to long-term opioid use, engaging in opioid misuse behaviors, and developing OUD. The biological factors that might underlie the association between psychological disturbances and opioid use problems in patients with chronic pain have yet to be fully elucidated, but a growing number of studies suggest that dysfunctions in reward, appetitive, autonomic, and neurocognitive systems might be involved. We end with an overview of specific types of psychological interventions that have been put forward to prevent or reduce the occurrence of opioid misuse and OUD in patients with chronic pain who are prescribed LTOT.
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Affiliation(s)
- Marc O Martel
- Faculty of Dentistry & Department of Anesthesiology, McGill University, Montreal, Canada; Division of Experimental Medicine, McGill University, Montreal, Canada
| | - Alice Bruneau
- Division of Experimental Medicine, McGill University, Montreal, Canada
| | - Robert R Edwards
- Department of Anesthesiology & Pain Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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Taha SA, Westra JR, Raji MA, Kuo YF. Trends in Urine Drug Testing Among Long-term Opioid Users, 2012-2018. Am J Prev Med 2021; 60:546-551. [PMID: 33288392 PMCID: PMC8017600 DOI: 10.1016/j.amepre.2020.10.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 09/30/2020] [Accepted: 10/02/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Long-term opioid therapy increases the risk of opioid overdose death. Government agencies and medical societies, including the Center for Disease Control and Prevention and the American Society for Clinical Oncology, emphasized risk mitigation strategies, including urine drug testing, in published guidelines. Urine drug testing rates, time trends, and covariates among long-term opioid therapy users were examined to gauge guideline adherence. METHODS Using Optum's De-identified Clinformatics DataMart, an incidence cohort (n=28,790) and prevalence cohort (n=621,449) were created to measure baseline and annual urine drug testing, respectively, from 2012 to 2018. Urine drug testing time trends were evaluated by demographics, pain conditions, and Elixhauser comorbidity index. A multivariable generalized estimating model was developed in 2020 to examine the factors associated with urine drug testing. RESULTS Annual urine drug testing rates doubled from 25.6% in 2012 to 52.2% in 2018, whereas baseline urine drug testing also increased from 3.75% to 11.1%. Annual urine drug testing increased within each age group over time; however, older patients (OR=0.21, 95% CI=0.21, 0.22, aged >79 years) and patients with cancer (OR=0.82, 95% CI=0.80, 0.84) were less likely to receive urine drug testing. Patients residing in the South (OR=1.99, 95% CI=1.96, 2.01) and those with back pain (OR=2.04, 95% CI=2.02, 2.06) or with other chronic pain (OR=1.64, 95% CI=1.62, 1.66) were significantly more likely to be tested. Independent predictors of baseline urine drug testing were similar to predictors of annual urine drug testing. CONCLUSIONS Despite increasing urine drug testing trends from 2012 to 2018, annual and baseline urine drug testing remained low in 2018, relative to numerous guideline recommendations. Findings suggest a need for research on better guideline implementation strategies and the effectiveness of urine drug testing on patient outcomes.
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Affiliation(s)
- Shaden A Taha
- Department of Nutrition and Metabolism, University of Texas Medical Branch, Galveston, Texas; Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, Texas.
| | - Jordan R Westra
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, Texas; Office of Biostatistics, University of Texas Medical Branch, Galveston, Texas
| | - Mukaila A Raji
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas; Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas
| | - Yong F Kuo
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, Texas; Office of Biostatistics, University of Texas Medical Branch, Galveston, Texas; Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas; Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas
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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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Shen Y, Bhagwandass H, Branchcomb T, Galvez SA, Grande I, Lessing J, Mollanazar M, Ourhaan N, Oueini R, Sasser M, Valdes IL, Jadubans A, Hollmann J, Maguire M, Usmani S, Vouri SM, Hincapie-Castillo JM, Adkins LE, Goodin AJ. Chronic Opioid Therapy: A Scoping Literature Review on Evolving Clinical and Scientific Definitions. THE JOURNAL OF PAIN 2020; 22:246-262. [PMID: 33031943 DOI: 10.1016/j.jpain.2020.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/21/2020] [Accepted: 09/22/2020] [Indexed: 01/24/2023]
Abstract
The management of chronic noncancer pain (CNCP) with chronic opioid therapy (COT) is controversial. There is a lack of consensus on how COT is defined resulting in unclear clinical guidance. This scoping review identifies and evaluates evolving COT definitions throughout the published clinical and scientific literature. Databases searched included PubMed, Embase, and Web of Science. A total of 227 studies were identified from 8,866 studies published between January 2000 and July 2019. COT definitions were classified by pain population of application and specific dosage/duration definition parameters, with results reported according to PRISMA-ScR. Approximately half of studies defined COT as "days' supply duration >90 days" and 9.3% defined as ">120 days' supply," with other days' supply cut-off points (>30, >60, or >70) each appearing in <5% of total studies. COT was defined by number of prescriptions in 63 studies, with 16.3% and 11.0% using number of initiations or refills, respectively. Few studies explicitly distinguished acute treatment and COT. Episode duration/dosage criteria was used in 90 studies, with 7.5% by Morphine Milligram Equivalents + days' supply and 32.2% by other "episode" combination definitions. COT definitions were applied in musculoskeletal CNCP (60.8%) most often, and typically in adults aged 18 to 64 (69.6%). The usage of ">90 days' supply" COT definitions increased from 3.2 publications/year before 2016 to 20.7 publications/year after 2016. An increasing proportion of studies define COT as ">90 days' supply." The most recent literature trends toward shorter duration criteria, suggesting that contemporary COT definitions are increasingly conservative. PERSPECTIVE: This study summarized the most common, current definition criteria for chronic opioid therapy (COT) and recommends adoption of consistent definition criteria to be utilized in practice and research. The most recent literature trends toward shorter duration criteria overall, suggesting that COT definition criteria are increasingly stringent.
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Affiliation(s)
- Yun Shen
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida
| | - Hemita Bhagwandass
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Tychell Branchcomb
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Sophia A Galvez
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Ivanna Grande
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Julia Lessing
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Mikela Mollanazar
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Natalie Ourhaan
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Razanne Oueini
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Michael Sasser
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Ivelisse L Valdes
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Ashmita Jadubans
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Josef Hollmann
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Michael Maguire
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Silken Usmani
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Scott M Vouri
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida
| | - Juan M Hincapie-Castillo
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida; Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, Florida
| | - Lauren E Adkins
- University of Florida Health Science Center Libraries, Gainesville, Florida
| | - Amie J Goodin
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida.
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11
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Kapur BM, Aleksa K. What the lab can and cannot do: clinical interpretation of drug testing results. Crit Rev Clin Lab Sci 2020; 57:548-585. [PMID: 32609540 DOI: 10.1080/10408363.2020.1774493] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Urine drug testing is one of the objective tools available to assess adherence. To monitor adherence, quantitative urinary results can assist in differentiating "new" drug use from "previous" (historical) drug use. "Spikes" in urinary concentration can assist in identifying patterns of drug use. Coupled chromatographic-mass spectrometric methods are capable of identifying very small amounts of analyte and can make clinical interpretation rather challenging, specifically for drugs that have a longer half-life. Polypharmacy is common in treatment and rehabilitation programs because of co-morbidities. Medications prescribed for comorbidities can cause drug-drug interaction and phenoconversion of genotypic extensive metabolizers into phenotypic poor metabolizers of the treatment drug. This can have significant impact on both pharmacokinetic (PK) and pharmacodynamic properties of the treatment drug. Therapeutic drug monitoring (TDM) coupled with PKs can assist in interpreting the effects of phenoconversion. TDM-PKs reflects the cumulative effects of pathophysiological changes in the patient as well as drug-drug interactions and should be considered for treatment medications/drugs used to manage pain and treat substance abuse. Since only a few enzyme immunoassays for TDM are available, this is a unique opportunity for clinical laboratory scientists to develop TDM-PK protocols that can have a significant impact on patient care and personalized medicine. Interpretation of drug screening results should be done with caution while considering pharmacological properties and the presence or absence of the parent drug and its metabolites. The objective of this manuscript is to review and address the variables that influence interpretation of different drugs analyzed from a rehabilitation and treatment programs perspective.
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Affiliation(s)
- Bhushan M Kapur
- Clini Tox Inc., Oakville, Canada.,Seroclinix Corporation, Mississauga, Canada
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12
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Hosain F, Lee J, Ata A, Bhullar RK, Chang AK. Physician Renewal of Chronically Prescribed Controlled Substances Based on Urine Drug Test Results. J Prim Care Community Health 2020; 10:2150132719883632. [PMID: 31646927 PMCID: PMC6820170 DOI: 10.1177/2150132719883632] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective: The effect of specific urine drug testing (UDT) results on physician prescribing habits has not been well described. The primary objective was to report renewal rates of chronically prescribed controlled substances based on types of inconsistent UDT results. Methods: We conducted a retrospective chart review over a 5-month period comparing prescription renewals rates for patients with consistent versus inconsistent UDTs. Inconsistent UDTs were defined by prescribed drug not detected or the presence of heroin, cocaine, nonprescribed opioids, nonprescribed benzodiazepines, or marijuana. Results: Of the 474 UDTs reviewed, 214 (45.1%) were inconsistent. The most common findings among inconsistent UDTs, including overlapping results, were prescribed drug not detected (26.8%) and the presence of marijuana (20.7%), nonprescribed opioids (9.9%), and nonprescribed benzodiazepines (6.1%). In contrast, cocaine (5.5%) and heroin (0.4%) were less likely to be found on UDTs for this population. The relative risk (RR) of prescription renewal was 0.64 (95% CI 0.57-0.71) for inconsistent UDTs versus consistent UDTs. Within the inconsistent UDTs, the renewal rates when marijuana (79.6%) or nonprescribed opioids or benzodiazepines (63.6%) were present were much higher than when heroin or cocaine were present (0.0%; P < .001). Patients whose prescribed controlled substance was not detected had a 55.8% renewal rate. Conclusions: Prescription renewal rates were high when patient UDTs contained nonprescribed marijuana, opioids, and benzodiazepines, or when the prescribed drug was not detected. Prescription renewal rates were low when illicit drugs, such as heroin and cocaine, were detected.
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Affiliation(s)
| | | | - Ashar Ata
- Albany Medical Center, Albany, NY, USA
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13
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Chapman KB, Pas MM, Abrar D, Day W, Vissers KC, van Helmond N. Development and Performance of a Web-Based Tool to Adjust Urine Toxicology Testing Frequency: Retrospective Study. JMIR Med Inform 2020; 8:e16069. [PMID: 32319958 PMCID: PMC7203611 DOI: 10.2196/16069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 01/23/2020] [Accepted: 03/25/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Several pain management guidelines recommend regular urine drug testing (UDT) in patients who are being treated with chronic opioid analgesic therapy (COAT) to monitor compliance and improve safety. Guidelines also recommend more frequent testing in patients who are at high risk of adverse events related to COAT; however, there is no consensus on how to identify high-risk patients or on the testing frequency that should be used. Using previously described clinical risk factors for UDT results that are inconsistent with the prescribed COAT, we developed a web-based tool to adjust drug testing frequency in patients treated with COAT. OBJECTIVE The objective of this study was to evaluate a risk stratification tool, the UDT Randomizer, to adjust UDT frequency in patients treated with COAT. METHODS Patients were stratified using an algorithm based on readily available clinical risk factors into categories of presumed low, moderate, high, and high+ risk of presenting with UDT results inconsistent with the prescribed COAT. The algorithm was integrated in a website to facilitate adoption across practice sites. To test the performance of this algorithm, we performed a retrospective analysis of patients treated with COAT between June 2016 and June 2017. The primary outcome was compliance with the prescribed COAT as defined by UDT results consistent with the prescribed COAT. RESULTS 979 drug tests (867 UDT, 88.6%; 112 oral fluid testing, 11.4%) were performed in 320 patients. An inconsistent drug test result was registered in 76/979 tests (7.8%). The incidences of inconsistent test results across the risk tool categories were 7/160 (4.4%) in the low risk category, 32/349 (9.2%) in the moderate risk category, 28/338 (8.3%) in the high risk category, and 9/132 (6.8%) in the high+ risk category. Generalized estimating equation analysis demonstrated that the moderate risk (odds ratio (OR) 2.1, 95% CI 0.9-5.0; P=.10), high risk (OR 2.0, 95% CI 0.8-5.0; P=.14), and high risk+ (OR 2.0, 95% CI 0.7-5.6; P=.20) categories were associated with a nonsignificantly increased risk of inconsistency vs the low risk category. CONCLUSIONS The developed tool stratified patients during individual visits into risk categories of presenting with drug testing results inconsistent with the prescribed COAT; the higher risk categories showed nonsignificantly higher risk compared to the low risk category. Further development of the tool with additional risk factors in a larger cohort may further clarify and enhance its performance.
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Affiliation(s)
- Kenneth B Chapman
- Department of Anesthesiology, New York University Langone Medical Center, New York, NY, United States
- The Spine & Pain Institute of New York, New York, NY, United States
| | - Martijn M Pas
- The Spine & Pain Institute of New York, New York, NY, United States
- Radboud University Medical College, Nijmegen, Netherlands
| | - Diana Abrar
- The Spine & Pain Institute of New York, New York, NY, United States
- Radboud University Medical College, Nijmegen, Netherlands
| | - Wesley Day
- The Spine & Pain Institute of New York, New York, NY, United States
| | - Kris C Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Noud van Helmond
- The Spine & Pain Institute of New York, New York, NY, United States
- Department of Anesthesiology, Cooper Medical School of Rowan University, Cooper University Health Care, Camden, NJ, United States
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14
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D Sullivan M, Boudreau D, Ichikawa L, Cronkite D, Albertson-Junkans L, Salgado G, VonKorff M, Carrell DS. Primary Care Opioid Taper Plans Are Associated with Sustained Opioid Dose Reduction. J Gen Intern Med 2020; 35:687-695. [PMID: 31907789 PMCID: PMC7080895 DOI: 10.1007/s11606-019-05445-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 09/26/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Primary care providers prescribe most long-term opioid therapy and are increasingly asked to taper the opioid doses of these patients to safer levels. A recent systematic review suggests that multiple interventions may facilitate opioid taper, but many of these are not feasible within the usual primary care practice. OBJECTIVE To determine if opioid taper plans documented by primary care providers in the electronic health record are associated with significant and sustained opioid dose reductions among patients on long-term opioid therapy. DESIGN A nested case-control design was used to compare cases (patients with a sustained opioid taper defined as average daily opioid dose of ≤ 30 mg morphine equivalent (MME) or a 50% reduction in MME) to controls (patients matched to cases on year and quarter of cohort entry, sex, and age group, who had not achieved a sustained taper). Each case was matched with four controls. PARTICIPANTS Two thousand four hundred nine patients receiving a ≥ 60-day supply of opioids with an average daily dose of ≥ 50 MME during 2011-2015. MAIN MEASURES Opioid taper plans documented in prescription instructions or clinical notes within the electronic health record identified through natural language processing; opioid dosing, patient characteristics, and taper plan components also abstracted from the electronic health record. KEY RESULTS Primary care taper plans were associated with an increased likelihood of sustained opioid taper after adjusting for all patient covariates and near peak dose (OR = 3.63 [95% CI 2.96-4.46], p < 0.0001). Both taper plans in prescription instructions (OR = 4.03 [95% CI 3.19-5.09], p < 0.0001) and in clinical notes (OR = 2.82 [95% CI 2.00-3.99], p < 0.0001) were associated with sustained taper. CONCLUSIONS These results suggest that planning for opioid taper during primary care visits may facilitate significant and sustained opioid dose reduction.
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Affiliation(s)
| | - Denise Boudreau
- Kaiser Permanente Washington Research Institute, Seattle, WA, USA
| | - Laura Ichikawa
- Kaiser Permanente Washington Research Institute, Seattle, WA, USA
| | - David Cronkite
- Kaiser Permanente Washington Research Institute, Seattle, WA, USA
| | | | - Gladys Salgado
- Kaiser Permanente Washington Research Institute, Seattle, WA, USA
| | - Michael VonKorff
- Kaiser Permanente Washington Research Institute, Seattle, WA, USA
| | - David S Carrell
- Kaiser Permanente Washington Research Institute, Seattle, WA, USA
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15
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Chua I, Petrides AK, Schiff GD, Ransohoff JR, Kantartjis M, Streid J, Demetriou CA, Melanson SEF. Provider Misinterpretation, Documentation, and Follow-Up of Definitive Urine Drug Testing Results. J Gen Intern Med 2020; 35:283-290. [PMID: 31713040 PMCID: PMC6957646 DOI: 10.1007/s11606-019-05514-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 08/13/2019] [Accepted: 10/02/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Urine drug testing (UDT) is an essential tool to monitor opioid misuse among patients on chronic opioid therapy. Inaccurate interpretation of UDT can have deleterious consequences. Providers' ability to accurately interpret and document UDT, particularly definitive liquid chromatography-tandem mass spectrometry (LC-MS/MS) results, has not been widely studied. OBJECTIVE To examine whether providers correctly interpret, document, and communicate LC-MS/MS UDT results. DESIGN This is a retrospective chart review of 160 UDT results (80 aberrant; 80 non-aberrant) between August 2017 and February 2018 from 5 ambulatory clinics (3 primary care, 1 oncology, 1 pain management). Aberrant results were classified into one or more of the following categories: illicit drug use, simulated compliance, not taking prescribed medication, and taking a medication not prescribed. Accurate result interpretation was defined as concordance between the provider's documented interpretation and an expert laboratory toxicologist's interpretation. Outcome measures were concordance between provider and laboratory interpretation of UDT results, documentation of UDT results, results acknowledgement in the electronic health record, communication of results to the patient, and rate of prescription refills. KEY RESULTS Aberrant results were most frequently due to illicit drug use. Overall, only 88 of the 160 (55%) had any documented provider interpretations of which 25/88 (28%) were discordant with the laboratory toxicologist's interpretation. Thirty-six of the 160 (23%) documented communication of the results to the patient. Communicating results was more likely to be documented if the results were aberrant compared with non-aberrant (33/80 [41%] vs. 3/80 [4%], p < 0.001). In all cases where provider interpretations were discordant with the laboratory interpretation, prescriptions were refilled. CONCLUSIONS Erroneous provider interpretation of UDT results, infrequent documentation of interpretation, lack of communication of results to patients, and prescription refills despite inaccurate interpretations are common. Expert assistance with urine toxicology interpretations may be needed to improve provider accuracy when interpreting toxicology results.
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Affiliation(s)
- Isaac Chua
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Athena K Petrides
- Harvard Medical School, Boston, MA, USA
- Department of Pathology , Brigham and Women's Hospital, Boston, MA, USA
| | - Gordon D Schiff
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jaime R Ransohoff
- Department of Pathology , Brigham and Women's Hospital, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Michalis Kantartjis
- Department of Pathology , Brigham and Women's Hospital, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jocelyn Streid
- Harvard Medical School, Boston, MA, USA
- Harvard Kennedy School, Boston, MA, USA
| | - Christiana A Demetriou
- Department of Primary Care and Population Health, University of Nicosia Medical School, Nicosia, Cyprus
- The Cyprus School of Molecular Medicine, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Stacy E F Melanson
- Harvard Medical School, Boston, MA, USA.
- Department of Pathology , Brigham and Women's Hospital, Boston, MA, USA.
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16
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Dahlin JL, Palte MJ, LaMacchia J, Petrides AK. A Rapid Dilute-and-Shoot UPLC-MS/MS Assay to Simultaneously Measure 37 Drugs and Related Metabolites in Human Urine for Use in Clinical Pain Management. J Appl Lab Med 2019; 3:974-992. [DOI: 10.1373/jalm.2018.027342] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 10/01/2018] [Indexed: 11/06/2022]
Abstract
Abstract
Background
Monitoring of medication compliance and drug abuse is used by clinicians to increase patient prescription drug compliance and reduce illicit drug abuse and diversion. Despite available immunoassays, chromatography-mass spectrometry–based methods are considered the gold standard for urine drug monitoring owing to higher sensitivities and specificities. Herein, we report a fast, convenient ultraperformance liquid chromatography–tandem mass spectrometry (UPLC-MS/MS) assay to detect or quantify 37 clinically relevant prescription drugs, drugs of abuse, and related glucuronides and other metabolites in human urine by single diluted sample injection.
Methods
Analytes consisted of prescription and illicit opioids, benzodiazepines, and drugs of abuse, including parent compounds and glucuronidated and nonglucuronidated metabolites. Urine samples were diluted with water and supplemented with deuterated internal standards without enzymatic hydrolysis, analyte extraction, or sample purification. Analytes were separated by reversed-phase UPLC and quantified by positive-mode electrospray ionization and collision-induced dissociation MS. Assay validation followed Food and Drug Administration bioanalytical guidelines.
Results
Total analytical run time was 5.5 min. All analytes demonstrated acceptable inter- and intraassay accuracy, imprecision, and linearity throughout clinically relevant analytical ranges (1–2000 ng/mL, depending on analyte). All analytes demonstrated acceptable selectivity, stability, matrix effects, carryover, and performance compared to national reference laboratory or previously validated in-house methods. A total of 23 and 14 analytes were validated for quantitative and qualitative testing, respectively.
Conclusions
A convenient UPLC-MS/MS assay for simultaneously monitoring 37 analytes in human urine was validated for use in pain management testing. Advantages of this multiplex assay include facile sample preparation and higher-throughput definitive detection including glucuronide metabolite quantification.
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Affiliation(s)
- Jayme L Dahlin
- Department of Pathology, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Michael J Palte
- Department of Pathology, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - John LaMacchia
- Department of Pathology, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Athena K Petrides
- Department of Pathology, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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17
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Moses TEH, Greenwald MK. History of regular nonmedical sedative and/or alcohol use differentiates substance-use patterns and consequences among chronic heroin users. Addict Behav 2019; 97:14-19. [PMID: 31112911 PMCID: PMC6581601 DOI: 10.1016/j.addbeh.2019.05.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 05/15/2019] [Accepted: 05/15/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Concurrent use of sedating substances (e.g. alcohol or benzodiazepines) with opioids is associated with increased negative consequences of opioid use; however, few studies have attempted to differentiate effects of using sedating substances on heroin-use outcomes. This study examines differences between heroin users who use alcohol or misuse sedatives regularly and those who do not. METHODS Substance-use data were collected from 367 non-treatment seeking, chronic heroin-using, 18-to-55 year-old participants. We created 4 groups based on self-reported lifetime history of regular (at least weekly) substance use: heroin only (n = 95), heroin and sedatives (n = 21), heroin and alcohol (n = 151), and heroin, sedative, and alcohol (n = 100). Chi-square analyses and ANOVAs with Bonferroni post hoc tests were used to explore differences between these groups. RESULTS Heroin users who denied lifetime alcohol or nonmedical sedative use regularly endorsed fewer consequences associated with any substance they had used. Total adverse consequences of heroin use (e.g. health problems) were significantly higher among those who misused sedatives regularly, irrespective of alcohol use history (F(3,361) = 10.21; p < .001). Regular alcohol use did not independently impact heroin consequences but was associated with increased use of other substances. CONCLUSIONS Although polysubstance use is normative among heroin users, the risks depend on the substances used. Regular sedative use is associated with increased heroin consequences whereas regular alcohol use is not. This study refines the investigation of polysubstance use and highlights subgroup differences depending on types of substances used regularly. This knowledge is critical for understanding substance-use motivations and creating avenues for harm reduction.
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Affiliation(s)
- Tabitha E H Moses
- Department of Psychiatry and Behavioral Neurosciences, School of Medicine, Wayne State University, Detroit, MI 48201, USA
| | - Mark K Greenwald
- Department of Psychiatry and Behavioral Neurosciences, School of Medicine, Wayne State University, Detroit, MI 48201, USA; Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI 48201, USA.
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18
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DiBenedetto DJ, Weed VF, Wawrzyniak KM, Finkelman M, Paolini J, Schatman ME, Herrera D, Kulich RJ. The Association Between Cannabis Use and Aberrant Behaviors During Chronic Opioid Therapy for Chronic Pain. PAIN MEDICINE 2019; 19:1997-2008. [PMID: 29947796 DOI: 10.1093/pm/pnx222] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective Health care providers are likely to see an increase in the concomitant use of cannabis and opioids, particularly with the increased liberalization and ongoing research into the possible role of medical marijuana for chronic pain. Recent literature reports a prevalence of concurrent use ranging from 8.9% to 31.8%. The primary aim of this study was to determine the relationship between cannabis use and aberrant drug behaviors in noncancer pain patients receiving chronic opioid therapy. Design Retrospective chart review. Setting Community-based, interdisciplinary pain management center. Subjects Data from 209 patients who were evaluated for a medication management program between October 1, 2011, and January 1, 2014, and met inclusion criteria. Forty-four were positive for cannabis in their initial random urine drug toxicology. Methods Data from electronic health records, including demographics, urine drug toxicology, disability, opioid dose, opioid risk assessment data, and pain severity were analyzed to examine differences among cannabis users and noncannabis users. Results Subjects with cannabis in their initial urine drug toxicology were more likely to have a future occurrence of an opioid-related aberrancy (P < 0.001), be male (P = 0.047), have a history of substance abuse (P = 0.013), and be enrolled into a higher level of clinical monitoring of opioid medication use (P = 0.008). No other associations with demographic and clinical variables reached statistical significance. Conclusions Concurrent use of cannabis and opioids by patients with chronic pain appears to indicate higher risk for opioid misuse. Closer monitoring for opioid-related aberrancy is indicated for this group of patients.
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Affiliation(s)
- David J DiBenedetto
- Department of Diagnostic Sciences, Boston Pain Care, Tufts University School of Dental Medicine, Boston, Massachusetts
| | | | - Kelly M Wawrzyniak
- Department of Diagnostic Sciences, Boston Pain Care, Tufts University School of Dental Medicine, Boston, Massachusetts
| | - Matthew Finkelman
- Division of Biostatistics and Experimental Design, Tufts University School of Medicine, Boston, Massachusetts
| | | | - Michael E Schatman
- Department of Public Health and Community Medicine, Boston Pain Care, Tufts University School of Medicine, Boston, Massachusetts
| | | | - Ronald J Kulich
- Department of Diagnostic Sciences, Tufts University of School Dental Medicine, Boston, Massachusetts.,Department of Anesthesia Critical Care and Pain Medicine, Harvard Medical School/Massachusetts General Hospital Boston, Massachusetts, USA
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19
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Alzeer AH, Jones J, Bair MJ. Review of Factors, Methods, and Outcome Definition in Designing Opioid Abuse Predictive Models. PAIN MEDICINE 2019; 19:997-1009. [PMID: 29016966 DOI: 10.1093/pm/pnx149] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Objective Several opioid risk assessment tools are available to prescribers to evaluate opioid analgesic abuse among chronic patients. The objectives of this study are to 1) identify variables available in the literature to predict opioid abuse; 2) explore and compare methods (population, database, and analysis) used to develop statistical models that predict opioid abuse; and 3) understand how outcomes were defined in each statistical model predicting opioid abuse. Design The OVID database was searched for this study. The search was limited to articles written in English and published from January 1990 to April 2016. This search generated 1,409 articles. Only seven studies and nine models met our inclusion-exclusion criteria. Results We found nine models and identified 75 distinct variables. Three studies used administrative claims data, and four studies used electronic health record data. The majority, four out of seven articles (six out of nine models), were primarily dependent on the presence or absence of opioid abuse or dependence (ICD-9 diagnosis code) to define opioid abuse. However, two articles used a predefined list of opioid-related aberrant behaviors. Conclusions We identified variables used to predict opioid abuse from electronic health records and administrative data. Medication variables are the recurrent variables in the articles reviewed (33 variables). Age and gender are the most consistent demographic variables in predicting opioid abuse. Overall, there is similarity in the sampling method and inclusion/exclusion criteria (age, number of prescriptions, follow-up period, and data analysis methods). Intuitive research to utilize unstructured data may increase opioid abuse models' accuracy.
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Affiliation(s)
- Abdullah H Alzeer
- Indiana University School of Informatics and Computing, Indianapolis, Indiana
| | - Josette Jones
- Indiana University School of Informatics and Computing, Indianapolis, Indiana.,Regenstrief Institute, Indianapolis, Indiana.,Indiana University School of Nursing, Indianapolis, Indiana
| | - Matthew J Bair
- Regenstrief Institute, Indianapolis, Indiana.,Richard L. Roudebush VA Medical Center, Center for Health Information and Communication (CHIC), Indianapolis, Indiana.,Indiana University School of Medicine, Indianapolis, Indiana, USA
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20
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Rosenberg JM, Bilka BM, Wilson SM, Spevak C. Opioid Therapy for Chronic Pain: Overview of the 2017 US Department of Veterans Affairs and US Department of Defense Clinical Practice Guideline. PAIN MEDICINE 2019; 19:928-941. [PMID: 29025128 DOI: 10.1093/pm/pnx203] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Description The US Department of Veterans Affairs (VA) and US Department of Defense (DoD) revised the 2010 clinical practice guideline (CPG) for the management of opioid therapy for chronic pain, considering the specific needs of the VA and DoD and new evidence regarding prescribing opioid medication for non-end-of-life-related chronic pain. This paper summarizes the major recommendations and compares them with the US Centers for Disease Control and Prevention (CDC) guideline for prescribing opioids. Patient Population This Opioid Therapy CPG was developed for VA-DoD service members, veterans, and their families. Methods The VA/DoD Evidence-Based Practice Work Group convened a VA/DoD guideline renewal development effort and conformed to the guidelines established by the VA/DoD Joint Executive Council (JEC) and VA/DoD Health Executive Council (HEC). The panel developed questions, searched and evaluated the literature, developed recommendations using GRADE methodology, and developed algorithms. Passage of the CARA Act by Congress compelled consideration and comparison with the CDC opioid therapy guideline mid-development. Results There were 18 recommendations made. This article focuses on guideline development and key recommendations with CDC comparisons taken from four major areas, including: initiation and continuation of opioids;type, dose, follow-up, and taper of opioids;risk mitigation;acute pain. Conclusions Guideline development and recommendations are presented. There was substantial overlap with the CDC opioid guideline. Additionally, there were items particularly relevant to the VA-DoD, including risk mitigation, suicide prevention, and preventing opioid use disorder in young patients. Our guideline highlights avoiding opioid therapy longer than 90 days as a critical juncture.
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Affiliation(s)
- Jack M Rosenberg
- Department of Veterans Affairs, Physical Medicine and Rehabilitation, Ann Arbor, Michigan
| | - Brandon M Bilka
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Sara M Wilson
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
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21
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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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22
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Dixon RB. Treatment Compliance and Patient Management: The Use of Clinical Laboratory Data to Monitor Treatment Effectiveness. J Appl Lab Med 2018; 2:660-662. [PMID: 33636902 DOI: 10.1373/jalm.2017.024158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 08/14/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Robert B Dixon
- South Carolina Department of Health and Environmental Control, Public Health Laboratory, Columbia, SC
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Jannetto PJ, Bratanow NC, Clark WA, Hamill-Ruth RJ, Hammett-Stabler CA, Huestis MA, Kassed CA, McMillin GA, Melanson SE, Langman LJ. Executive Summary: American Association of Clinical Chemistry Laboratory Medicine Practice Guideline—Using Clinical Laboratory Tests to Monitor Drug Therapy in Pain Management Patients. ACTA ACUST UNITED AC 2017; 2:489-526. [DOI: 10.1373/jalm.2017.023341] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 10/12/2017] [Indexed: 11/06/2022]
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Abstract
While the evidence for urine drug testing for patients on chronic opioid therapy is weak, the guidelines created by numerous medical societies and state and federal regulatory agencies recommend that it be included as one of the tools used to monitor patients for compliance with chronic opioid therapy. To get the most comprehensive results, clinicians should order both an immunoassay screen and confirmatory urine drug test. The immunoassay screen, which can be performed as an in-office point-of-care test or as a laboratory-based test, is a cheap and convenient study to order. Limitations of an immunoassay screen, however, include having a high threshold of detectability and only providing qualitative information about a select number of drug classes. Because of these restrictions, clinicians should understand that immunoassay screens have high false-positive and false-negative rates. Despite these limitations, though, the results can assist the clinician with making preliminary treatment decisions. In comparison, a confirmatory urine drug test, which can only be performed as a laboratory-based test, has a lower threshold of detectability and provides both qualitative and quantitative information. A urine drug test's greater degree of specificity allows for a relatively low false-negative and false-positive rate in contrast to an immunoassay screen. Like any other diagnostic test, an immunoassay screen and a confirmatory urine drug test both possess limitations. Clinicians must keep this in mind when interpreting an unexpected test result and consult with their laboratory when in doubt about the meaning of the test result to avoid making erroneous decisions that negatively impact both the patient and clinician.
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25
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Enders JR, Reddy SG, Strickland EC, McIntire GL. Identification of metabolites of brexpiprazole in human urine for use in monitoring patient compliance. CLINICAL MASS SPECTROMETRY 2017. [DOI: 10.1016/j.clinms.2017.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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26
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Reasons for discontinuation of long-term opioid therapy in patients with and without substance use disorders. Pain 2017; 158:526-534. [PMID: 28192376 DOI: 10.1097/j.pain.0000000000000796] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Several factors may accelerate opioid discontinuation rates, including lack of information about the long-term effectiveness of opioids for chronic pain, heightened awareness about opioid-related adverse events, closer monitoring of patients for opioid-related aberrant behaviors, and greater restrictions around opioid prescribing. Rates of discontinuation may be most pronounced in patients deemed to be at "high risk." The purpose of this study was to compare reasons for discontinuation of long-term opioid therapy (LTOT) between patients with and without substance use disorder (SUD) diagnoses receiving care within a major U.S. health care system. This retrospective cohort study assembled a cohort of Veterans Health Administration patients prescribed opioid therapy for at least 12 consecutive months who subsequently discontinued opioid therapy for at least 12 months. From this cohort, we randomly selected 300 patients with SUD diagnoses and propensity score-matched 300 patients without SUD diagnoses. A comprehensive manual review of patients' medical records ascertained reasons for LTOT discontinuation. Most patients (85%) were discontinued as a result of clinician, rather than patient, decisions. For patients whose clinicians initiated discontinuation, 75% were discontinued because of opioid-related aberrant behaviors. Relative to patients without SUD diagnoses, those with SUD diagnoses were more likely to discontinue LTOT because of aberrant behaviors (81% vs 68%), most notably abuse of alcohol or other substances. This is the first study to document reasons for discontinuation of LTOT in a sample of patients with and without SUD diagnoses. Treatments that concurrently address SUD and chronic pain are needed for this high-risk population.
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Kwong TC, Magnani B, Moore C. Urine and oral fluid drug testing in support of pain management. Crit Rev Clin Lab Sci 2017; 54:433-445. [PMID: 28990451 DOI: 10.1080/10408363.2017.1385053] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
In recent years, the abuse of opioid drugs has resulted in greater prevalence of addiction, overdose, and deaths attributable to opioid abuse. The epidemic of opioid abuse has prompted professional and government agencies to issue practice guidelines for prescribing opioids to manage chronic pain. An important tool available to providers is the drug test for use in the initial assessment of patients for possible opioid therapy, subsequent monitoring of compliance, and documentation of suspected aberrant drug behaviors. This review discusses the issues that most affect the clinical utility of drug testing in chronic pain management with opioid therapy. It focuses on the two most commonly used specimen matrices in drug testing: urine and oral fluid. The advantages and disadvantages of urine and oral fluid in the entire testing process, from specimen collection and analytical methodologies to result interpretation are reviewed. The analytical sensitivity and specificity limitations of immunoassays used for testing are examined in detail to draw attention to how these shortcomings can affect result interpretation and influence clinical decision-making in pain management. The need for specific identification and quantitative measurement of the drugs and metabolites present to investigate suspected aberrant drug behavior or unexpected positive results is analyzed. Also presented are recent developments in optimization of test menus and testing strategies, such as the modification of the standard screen and reflexed-confirmation testing model by eliminating some of the initial immunoassay-based tests and proceeding directly to definitive testing by mass spectrometry assays.
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Affiliation(s)
- Tai C Kwong
- a Department of Pathology and Laboratory Medicine , University of Rochester Medical Center , Rochester , NY , USA
| | - Barbarajean Magnani
- b Department of Pathology and Laboratory Medicine , Tufts Medical Center , Boston , MA , USA
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Shortreed SM, Johnson E, Rutter CM, Kamineni A, Wernli KJ, Chubak J. Cohort restriction based on prior enrollment: Examining potential biases in estimating cancer and mortality risk. OBSERVATIONAL STUDIES 2016; 2:51-64. [PMID: 28530002 PMCID: PMC5435370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Electronic health records and administrative databases provide rich, longitudinal data for health-related research. These data cover large, diverse populations creating excellent research opportunities, but have limitations. In particular, information is available only for individuals who are enrolled in a particular health system; thus, studies often exclude individual's with short enrollment history. Such cohort restriction may cause selection bias in absolute risk estimates for the full enrollee population. We use hazard ratios (HRs) to estimate the association between length of prior enrollment and cancer and all-cause mortality risk. HRs different from one indicate restricted cohorts would produce biased risk estimates for the full enrollee population. Our study sample included 170,708 enrollees of a Western Washington healthcare delivery system. Unadjusted models found individuals with 10 or more years of prior enrollment had higher risk of cancer and death compared to those with less than 5 years prior enrollment (HRs ranged from 1.29 - 3.01). Age- and sex-adjusted models accounted for much of this difference (HRs: 0.93 - 1.24). Models adjusting for additional covariates had similar results (HRs: 0.91 - 1.14). After evaluating potential selection bias, we conclude that, in this setting, age- and sex-standardizing risk estimates can remove most of the bias due to lengthy, prior-enrollment cohort restrictions. Before generalizing estimates based on a selected sample of patients meeting prior enrollment criteria, researchers should assess the potential for selection bias.
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Affiliation(s)
- Susan M Shortreed
- Biostatistics Unit, Group Health Research Institute, Seattle, WA, U.S.A
| | - Eric Johnson
- Biostatistics Unit, Group Health Research Institute, Seattle, WA, U.S.A
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Carmichael AN, Morgan L, Del Fabbro E. Identifying and assessing the risk of opioid abuse in patients with cancer: an integrative review. Subst Abuse Rehabil 2016; 7:71-9. [PMID: 27330340 PMCID: PMC4898427 DOI: 10.2147/sar.s85409] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background The misuse and abuse of opioid medications in many developed nations is a health crisis, leading to increased health-system utilization, emergency department visits, and overdose deaths. There are also increasing concerns about opioid abuse and diversion in patients with cancer, even at the end of life. Aims To evaluate the current literature on opioid misuse and abuse, and more specifically the identification and assessment of opioid-abuse risk in patients with cancer. Our secondary aim is to offer the most current evidence of best clinical practice and suggest future directions for research. Materials and methods Our integrative review included a literature search using the key terms “identification and assessment of opioid abuse in cancer”, “advanced cancer and opioid abuse”, “hospice and opioid abuse”, and “palliative care and opioid abuse”. PubMed, PsycInfo, and Embase were supplemented by a manual search. Results We found 691 articles and eliminated 657, because they were predominantly non cancer populations or specifically excluded cancer patients. A total of 34 articles met our criteria, including case studies, case series, retrospective observational studies, and narrative reviews. The studies were categorized into screening questionnaires for opioid abuse or alcohol, urine drug screens to identify opioid misuse or abuse, prescription drug-monitoring programs, and the use of universal precautions. Conclusion Screening questionnaires and urine drug screens indicated at least one in five patients with cancer may be at risk of opioid-use disorder. Several studies demonstrated associations between high-risk patients and clinical outcomes, such as aberrant behavior, prolonged opioid use, higher morphine-equivalent daily dose, greater health care utilization, and symptom burden.
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Affiliation(s)
- Ashley-Nicole Carmichael
- School of Pharmacy, Oncology, and Palliative Care, Virginia Commonwealth University, Richmond, VA, USA
| | - Laura Morgan
- School of Pharmacy, Oncology, and Palliative Care, Virginia Commonwealth University, Richmond, VA, USA
| | - Egidio Del Fabbro
- Division of Hematology, Oncology, and Palliative Care, Virginia Commonwealth University, Richmond, VA, USA
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Capsule commentary on Turner et al., chronic opioid therapy urine drug testing in primary care: prevalence and predictors of aberrant results. J Gen Intern Med 2015; 30:241. [PMID: 25387440 PMCID: PMC4314479 DOI: 10.1007/s11606-014-3091-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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