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Yarborough BJH, Stumbo SP, Schneider JL, Ahmedani BK, Daida YG, Hooker SA, Lapham GT, Negriff S, Rossom RC. Patient Perspectives on Mental Health and Pain Management Support Needed Versus Received During Opioid Deprescribing. THE JOURNAL OF PAIN 2024; 25:104485. [PMID: 38311195 DOI: 10.1016/j.jpain.2024.01.350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/10/2024]
Abstract
Prescription opioid tapering has increased significantly over the last decade. Evidence suggests that tapering too quickly or without appropriate support may unintentionally harm patients. The aim of this analysis was to understand patients' experiences with opioid tapering, including support received or not received for pain control or mental health. Patients with evidence of opioid tapering from 6 health care systems participated in semi-structured, in-depth interviews; family members of suicide decedents with evidence of opioid tapering were also interviewed. Interviews were analyzed using thematic analysis. Participants included 176 patients and 16 family members. Results showed that 24% of the participants felt their clinicians checked in with them about their taper experiences while 41% reported their clinicians did not. A majority (68%) of individuals who experienced suicide behavior during tapering reported that clinicians did check in about mood and mental health changes specifically; however, 27% of that group reported no such check-in. More individuals reported negative experiences (than positive) with pain management clinics-where patients are often referred for tapering and pain management support. Patients reporting successful tapering experiences named shared decision-making and ability to adjust taper speed or pause tapering as helpful components of care. Fifty-six percent of patients reported needing more support during tapering, including more empathy and compassion (48%) and an individualized approach to tapering (41%). Patient-centered approaches to tapering include reaching out to monitor how patients are doing, involving patients in decision-making, supporting mental health changes, and allowing for flexibility in the tapering pace. PERSPECTIVE: Patients tapering prescription opioids desire more provider-initiated communication including checking in about pain, setting expectations for withdrawal and mental health-related changes, and providing support for mental health. Patients preferred opportunities to share decisions about taper speed and to have flexibility with pausing the taper as needed.
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Affiliation(s)
- Bobbi Jo H Yarborough
- Science Programs Department, Kaiser Permanente Northwest Center for Health Research, Portland, Oregon; Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Scott P Stumbo
- Science Programs Department, Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | - Jennifer L Schneider
- Science Programs Department, Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | - Brian K Ahmedani
- Center for Health Policy & Health Services Research, Henry Ford Health, Detroit, Michigan
| | - Yihe G Daida
- Center for Integrated Health Care Research, Kaiser Permanente Hawaii, Honolulu, Hawaii
| | - Stephanie A Hooker
- Research and Evaluation Division, HealthPartners Institute, Minneapolis, Minnesota
| | - Gwen T Lapham
- Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California; Research Department, Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Sonya Negriff
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Rebecca C Rossom
- Research and Evaluation Division, HealthPartners Institute, Minneapolis, Minnesota
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Rikard SM, Nataraj N, Zhang K, Strahan A, Mikosz CA, Guy GP. Reply to Chang et al. Pain 2024; 165:960. [PMID: 38501998 PMCID: PMC11009927 DOI: 10.1097/j.pain.0000000000003179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Affiliation(s)
- S. Michaela Rikard
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Nisha Nataraj
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Kun Zhang
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Andrea Strahan
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Christina A. Mikosz
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Gery P. Guy
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, United States
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Rikard SM, Nataraj N, Zhang K, Strahan AE, Mikosz CA, Guy GP. Longitudinal dose patterns among patients newly initiated on long-term opioid therapy in the United States, 2018 to 2019: an observational cohort study and time-series cluster analysis. Pain 2023; 164:2675-2683. [PMID: 37498751 PMCID: PMC10694996 DOI: 10.1097/j.pain.0000000000002994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 06/05/2023] [Indexed: 07/29/2023]
Abstract
ABSTRACT Opioid prescribing varies widely, and prescribed opioid dosages for an individual can fluctuate over time. Patterns in daily opioid dosage among patients prescribed long-term opioid therapy have not been previously examined. This study uses a novel application of time-series cluster analysis to characterize and visualize daily opioid dosage trajectories and associated demographic characteristics of patients newly initiated on long-term opioid therapy. We used 2018 to 2019 data from the IQVIA Longitudinal Prescription (LRx) all-payer pharmacy database, which covers 92% of retail pharmacy prescriptions dispensed in the United States. We identified a cohort of 277,967 patients newly initiated on long-term opioid therapy during 2018. Patients were stratified into 4 categories based on their mean daily dosage during a 90-day baseline period (<50, 50-89, 90-149, and ≥150 morphine milligram equivalent [MME]) and followed for a 270-day follow-up period. Time-series cluster analysis identified 2 clusters for each of the 3 baseline dosage categories <150 MME and 3 clusters for the baseline dosage category ≥150 MME. One cluster in each baseline dosage category comprised opioid dosage trajectories with decreases in dosage at the end of the follow-up period (80.7%, 98.7%, 98.7%, and 99.0%, respectively), discontinuation (58.5%, 80.0%, 79.3%, and 81.7%, respectively), and rapid tapering (50.8%, 85.8%, 87.5%, and 92.9%, respectively). These findings indicate multiple clusters of patients newly initiated on long-term opioid therapy who experience discontinuation and rapid tapering and highlight potential areas for clinician training to advance evidence-based guideline-concordant opioid prescribing, including strategies to minimize sudden dosage changes, discontinuation, or rapid tapering, and the importance of shared decision-making.
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Affiliation(s)
- S. Michaela Rikard
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Nisha Nataraj
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Kun Zhang
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Andrea E. Strahan
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Christina A. Mikosz
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Gery P. Guy
- Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, United States
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Vivas-Valencia C, Dong H, Stringfellow EJ, Russell WA, Morgan JR, Tadrous M, Jalali MS. Factors Associated With Abrupt Discontinuation of Long-Term High-Dose Opioid Treatment. JAMA Netw Open 2023; 6:e2341416. [PMID: 37921772 PMCID: PMC10625034 DOI: 10.1001/jamanetworkopen.2023.41416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 09/24/2023] [Indexed: 11/04/2023] Open
Abstract
This cohort study investigates factors associated with abrupt discontinuation of long-term high-dose opioid treatment at the national level and across US states.
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Affiliation(s)
- Carolina Vivas-Valencia
- Department of Biomedical Engineering and Chemical Engineering, The University of Texas, San Antonio
| | - Huiru Dong
- Massachusetts General Hospital, Harvard Medical School, Boston
| | | | - W. Alton Russell
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Jake R. Morgan
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston
| | - Mina Tadrous
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
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Li Y, Barr KD, Trafton JA, Oliva EM, Garrido MM, Frakt AB, Strombotne KL. Impact of Mandated Case Review Policy on Opioid Discontinuation and Mortality Among High-Risk Long-Term Opioid Therapy Patients: The STORM Stepped-Wedge Cluster Randomized Controlled Trial. Subst Abus 2023; 44:292-300. [PMID: 37830514 DOI: 10.1177/08897077231198299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
BACKGROUND Although long-term opioid therapy (LTOT) has its own risks, opioid discontinuation could pose harm for high-risk Veterans Health Administration (VHA) patients receiving LTOT. There is limited information on the impact of a mandate requiring providers to perform case reviews on high-risk patients with an active opioid prescription (ie, mandated case review policy) on opioid discontinuation and mortality. METHODS Our study is a secondary data analysis of a 23-month stepped-wedge cluster randomized controlled trial between April 2018 and March 2020. The study included 10 685 LTOT patients with a predicted risk of a serious adverse event between the top 1% to 5% nationally who entered the risk range between 4/18/2018 and 11/9/2019. We examined whether the mandated case review policy had an impact on opioid discontinuation and mortality for the patients. RESULTS Among 10 685 LTOT patients (88.2% male; mean [SD] age, 61.1 [11.7] years), 29.1% experienced discontinuation and the mortality rate was 9.5%. Patients under mandated case review had a decreased risk of opioid discontinuation (average marginal effect [AME], -11.16 [95% CI, -15.30 to -7.01] percentage points) and all-cause mortality (AME, -3.31 [95% CI, -5.63 to -1.00] percentage points), relative to patients who were not under the mandate. CONCLUSIONS The VHA mandated case review policy was associated with lower probability of discontinuation and all-cause mortality for high-risk patients receiving LTOT. Interventions that maintain care engagement while optimizing pain management for high-risk patients may be beneficial for minimizing mortality and other risks associated with discontinuation.
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Affiliation(s)
- Yufei Li
- Department of Health Law, Policy and Management, Boston University of Public Health, Boston, MA, USA
- Partnered Evidence-based Policy Resource Center, VA Boston Healthcare System, Boston, MA, USA
| | - Kyle D Barr
- Partnered Evidence-based Policy Resource Center, VA Boston Healthcare System, Boston, MA, USA
| | - Jodie A Trafton
- Program Evaluation and Resource Center, Office of Mental Health and Suicide Prevention, Veterans Health Administration, Menlo Park, CA, USA
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Veterans Health Administration, Menlo Park, CA, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University Medical School, Palo Alto, CA, USA
| | - Elizabeth M Oliva
- Program Evaluation and Resource Center, Office of Mental Health and Suicide Prevention, Veterans Health Administration, Menlo Park, CA, USA
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Veterans Health Administration, Menlo Park, CA, USA
| | - Melissa M Garrido
- Department of Health Law, Policy and Management, Boston University of Public Health, Boston, MA, USA
- Partnered Evidence-based Policy Resource Center, VA Boston Healthcare System, Boston, MA, USA
| | - Austin B Frakt
- Department of Health Law, Policy and Management, Boston University of Public Health, Boston, MA, USA
- Partnered Evidence-based Policy Resource Center, VA Boston Healthcare System, Boston, MA, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Cambridge, MA, USA
| | - Kiersten L Strombotne
- Department of Health Law, Policy and Management, Boston University of Public Health, Boston, MA, USA
- Partnered Evidence-based Policy Resource Center, VA Boston Healthcare System, Boston, MA, USA
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Schulson LB, Dick A, Sheng F, Stein BD. An Exploratory Analysis of Differential Prescribing of High-Risk Opioids by Insurance Type Among Patients Seen by the Same Clinician. J Gen Intern Med 2023; 38:1681-1688. [PMID: 36745303 DOI: 10.1007/s11606-023-08025-6] [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: 06/23/2022] [Accepted: 12/30/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Insurance status may influence quality of opioid analgesic (OA) prescribing among patients seen by the same clinician. OBJECTIVE To explore how high-risk OA prescribing varies by payer type among patients seeing the same prescriber and identify clinician characteristics associated with variable prescribing DESIGN: Retrospective cohort study using the 2016-2018 IQVIA Real World Data - Longitudinal Prescription PARTICIPANTS: New OA treatment episodes for individuals ≥ 12 years, categorized by payer and prescriber. We created three dyads: prescribers with ≥ 10 commercial insurance episodes and ≥ 10 Medicaid episodes; ≥ 10 commercial insurance episodes and ≥ 10 self-pay episodes; and ≥ 10 Medicaid episodes and ≥ 10 self-pay episodes. MAIN OUTCOME(S) AND MEASURE(S) Rates of high-risk episodes (initial opioid episodes with > 7-days' supply or prescriptions with a morphine milliequivalent daily dose >90) and odds of being an unbalanced prescriber (prescribers with significantly higher percentage of high-risk episodes paid by one payer vs. the other payer) KEY RESULTS: There were 88,352 prescribers in the Medicaid/self-pay dyad, 172,392 in the Medicaid/commercial dyad, and 122,748 in the self-pay/commercial dyad. In the Medicaid/self-pay and the commercial-self-pay dyads, self-pay episodes had higher high-risk episode rates than Medicaid (16.1% and 18.4%) or commercial (22.7% vs. 22.4%). In the Medicaid/commercial dyad, Medicaid had higher high-risk episode rates (21.1% vs. 20.4%). The proportion of unbalanced prescribers was 11-12% across dyads. In adjusted analyses, surgeons and pain specialists were more likely to be unbalanced prescribers than adult primary care physicians (PCPs) in the Medicaid/self-paydyad (aOR 1.2, 95% CI 1.16-1.34 and aOR 1.2, 95% CI 1.03-1.34). For Medicaid/commercial and self-pay/commercial dyads, surgeons had lower odds of being unbalanced compared to PCPs (aOR 0.6, 95% CI 0.57-0.66 and aOR 0.6, 95% CI 0.61-0.68). CONCLUSIONS Clinicians prescribe high-risk OAs differently based on insurance type. The relationship between insurance and opioid prescribing quality goes beyond where patients receive care.
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Affiliation(s)
- Lucy B Schulson
- RAND Corporation, Boston, MA, USA. .,Boston University Aram V. Chobanian & Edward Avedisian School of Medicine, Boston, MA, USA.
| | - Andrew Dick
- RAND Corporation, Boston, MA, USA.,Columbia University School of Nursing, New York, NY, USA
| | | | - Bradley D Stein
- RAND Corporation, Pittsburgh, PA, USA.,Medicine, University of Pittsburgh, Pittburgh, PA, USA
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Poole HM, Frank B, Begley E, Woods A, Ramos-Silva A, Merriman M, McCulough R, Montgomery C. Feasibility study of a Behavioural Intervention for Opioid Reduction (BIOR) for patients with chronic non-cancer pain in primary care: a protocol. BMJ Open 2023; 13:e065646. [PMID: 36657771 PMCID: PMC9853248 DOI: 10.1136/bmjopen-2022-065646] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 06/13/2022] [Accepted: 12/28/2022] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Around 30%-50% of adults suffer moderate to severe chronic pain not caused by cancer. Significant numbers are treated with opioids which over time may cease to be effective and produce side effects (eg, nausea, drowsiness and constipation). Stopping taking opioids abruptly can cause unpleasant withdrawal effects. Tapering in small steps is recommended, though some patients might struggle and need support, particularly if they have limited access to pain management alternatives. Awareness of the potential risks as well as benefits of tapering should be explored with patients. METHODS AND ANALYSIS A randomised controlled pilot feasibility study to investigate the effectiveness and feasibility of reducing high doses of opioids through a tapering protocol, education and support in primary care. Working with NHS Knowsley Place, we will identify patients taking 50 mg or above morphine equivalent dose of opioids per day to be randomly allocated to either the tapering group or tapering with support group. At an initial joint appointment with a pain consultant and General Practitioner (GP) GP tapering will be discussed and negotiated. Both groups will have their opioid reduced by 10% per week. The taper with support group will have access to additional support, including motivational counselling, realistic goal setting and a toolkit of resources to promote self-management. Some patients will successfully reduce their dose each week. For others, this may be more difficult, and the tapering reduction will be adjusted to 10% per fortnight. We assess opioid use, pain and quality of life in both groups at the start and end of the study to determine which intervention works best to support people with chronic pain who wish to stop taking opioids. ETHICS AND DISSEMINATION The Behavioural Intervention for Opioid Reduction feasibility study has been granted full approval by Liverpool Central Research Ethics Committee on 7 April 2022 (22/NW/0047). The current protocol version is V.1.1, date 6 July 2022. Results will be published in peer-reviewed journals and disseminated to patient stakeholders in a lay summary report available on the project website and in participating GP surgeries. TRIAL REGISTRATION NUMBER ISRCTN 30201337.
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Affiliation(s)
- Helen M Poole
- School of Psychology, Liverpool John Moores University, Liverpool, UK
- Pain Research Institute, Liverpool, UK
| | - Bernhard Frank
- Pain Research Institute, Liverpool, UK
- The Walton Centre NHS Foundation Trust, Liverpool, UK
| | | | - Aimee Woods
- School of Psychology, Liverpool John Moores University, Liverpool, UK
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Avery N, McNeilage AG, Stanaway F, Ashton-James CE, Blyth FM, Martin R, Gholamrezaei A, Glare P. Efficacy of interventions to reduce long term opioid treatment for chronic non-cancer pain: systematic review and meta-analysis. BMJ 2022; 377:e066375. [PMID: 35379650 PMCID: PMC8977989 DOI: 10.1136/bmj-2021-066375] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To review interventions to reduce long term opioid treatment in people with chronic non-cancer pain, considering efficacy on dose reduction and discontinuation, pain, function, quality of life, withdrawal symptoms, substance use, and adverse events. DESIGN Systematic review and meta-analysis of randomised controlled trials and non-randomised studies of interventions. DATA SOURCES Medline, Embase, PsycINFO, CINAHL, and the Cochrane Library searched from inception to July 2021. Reference lists and previous reviews were also searched and experts were contacted. ELIGIBILITY CRITERIA FOR STUDY SELECTION Original research in English. Case reports and cross sectional studies were excluded. DATA EXTRACTION AND SYNTHESIS Two authors independently selected studies, extracted data, and used the Cochrane risk-of-bias tools for randomised and non-randomised studies (RoB 2 and ROBINS-I). Authors grouped interventions into five categories (pain self-management, complementary and alternative medicine, pharmacological and biomedical devices and interventions, opioid replacement treatment, and deprescription methods), estimated pooled effects using random effects meta-analytical models, and appraised the certainty of evidence using GRADE (grading of recommendations, assessment, development, and evaluation). RESULTS Of 166 studies meeting inclusion criteria, 130 (78%) were considered at critical risk of bias and were excluded from the evidence synthesis. Of the 36 included studies, few had comparable treatment arms and sample sizes were generally small. Consequently, the certainty of the evidence was low or very low for more than 90% (41/44) of GRADE outcomes, including for all non-opioid patient outcomes. Despite these limitations, evidence of moderate certainty indicated that interventions to support prescribers' adherence to guidelines increased the likelihood of patients discontinuing opioid treatment (adjusted odds ratio 1.5, 95% confidence interval 1.0 to 2.1), and that these prescriber interventions as well as pain self-management programmes reduced opioid dose more than controls (intervention v control, mean difference -6.8 mg (standard error 1.6) daily oral morphine equivalent, P<0.001; pain programme v control, -14.31 mg daily oral morphine equivalent, 95% confidence interval -21.57 to -7.05). CONCLUSIONS Evidence on the reduction of long term opioid treatment for chronic pain continues to be constrained by poor study methodology. Of particular concern is the lack of evidence relating to possible harms. Agreed standards for designing and reporting studies on the reduction of opioid treatment are urgently needed. REVIEW REGISTRATION PROSPERO CRD42020140943.
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Affiliation(s)
- Nicholas Avery
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - Amy G McNeilage
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - Fiona Stanaway
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Claire E Ashton-James
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - Fiona M Blyth
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Rebecca Martin
- Michael J Cousins Pain Management and Research Centre, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Ali Gholamrezaei
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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