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Piret EM, Milloy MJ, Voon P, Choi J, DeBeck K, Hayashi K, Kerr T. Denial of prescription pain medication among people who use drugs in Vancouver, Canada. Harm Reduct J 2024; 21:72. [PMID: 38549113 PMCID: PMC10979632 DOI: 10.1186/s12954-024-00956-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 02/03/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND People who use drugs experience pain at two to three times the rate of the general population and yet continue to face substantial barriers to accessing appropriate and adequate treatment for pain. In light of the overdose crisis and revised opioid prescribing guidelines, we sought to identify factors associated with being denied pain medication and longitudinally investigate denial rates among people who use drugs. METHODS We used multivariable generalized estimating equations analyses to investigate factors associated with being denied pain medication among people who use drugs reporting pain in three prospective cohort studies in Vancouver, Canada. Analyses were restricted to study periods in which participants requested a prescription for pain from a healthcare provider. Descriptive statistics detail denial rates and actions taken by participants after being denied. RESULTS Among 1168 participants who requested a prescription for pain between December 2012 and March 2020, the median age was 47 years and 63.0% were male. Among 4,179 six-month observation periods, 907 (21.7%) included a report of being denied requested pain medication. In multivariable analyses, age was negatively associated with prescription denial (adjusted odds ratio [AOR] = 0.98, 95% confidence interval [CI]:0.97-0.99), while self-managing pain (AOR = 2.48, 95%CI:2.04-3.00), experiencing a non-fatal overdose (AOR = 1.51, 95%CI:1.22-1.88), engagement in opioid agonist therapy (AOR = 1.32, 95%CI:1.09-1.61), and daily use of heroin or other unregulated opioids (AOR = 1.32, 95%CI:1.05-1.66) were positively associated with being denied. Common actions taken (n = 895) after denial were accessing the unregulated drug supply (53.5%), doing nothing (30.6%), and going to a different doctor/emergency room (6.1%). The period following the introduction of new prescribing guidelines was not associated with a change in denial rates. CONCLUSIONS A substantial proportion of people who use drugs continue to be denied prescriptions for pain, with such denial associated with important substance use-related harms, including non-fatal overdose. Guidelines specific to the pharmaceutical management of pain among people who use drugs are needed.
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Affiliation(s)
- Evelyne Marie Piret
- British Columbia Centre On Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
- School of Population and Public Health, University of British Columbia, 5804 Fairview Avenue, Vancouver, BC, V6T 1Z3, Canada
| | - M-J Milloy
- British Columbia Centre On Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
- Division of Social Medicine, Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Pauline Voon
- British Columbia Centre On Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
| | - JinCheol Choi
- British Columbia Centre On Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
| | - Kora DeBeck
- British Columbia Centre On Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
- School of Public Policy, Simon Fraser University, 515 West Hastings St, Vancouver, BC, V6B 5K3, Canada
| | - Kanna Hayashi
- British Columbia Centre On Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
- Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada
| | - Thomas Kerr
- British Columbia Centre On Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.
- Division of Social Medicine, Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
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Pain, opioid use, depressive symptoms, and mortality in adults living in precarious housing or homelessness. Pain 2022; 163:2213-2223. [DOI: 10.1097/j.pain.0000000000002619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 02/15/2022] [Indexed: 11/26/2022]
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A cohort study examining the relationship among housing status, patient characteristics, and retention among individuals enrolled in low-barrier-to-treatment-access methadone maintenance treatment. J Subst Abuse Treat 2022; 138:108753. [DOI: 10.1016/j.jsat.2022.108753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 01/24/2022] [Accepted: 02/16/2022] [Indexed: 11/16/2022]
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Chahin M, Matosz S, Khalel I, Day S, Keruakous A. Pain Management in Oncology Patients Amidst the Opioid Epidemic: How To Minimize Non-Medical Opioid Use. Cureus 2021; 13:e19500. [PMID: 34912639 PMCID: PMC8666098 DOI: 10.7759/cureus.19500] [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] [Accepted: 11/11/2021] [Indexed: 11/05/2022] Open
Abstract
The opioid epidemic continues to be a significant public health concern. On the surface, it appears difficult to understate the profound consequences and unnecessary loss of life at the hands of the opioid crisis throughout the 2010s. This reality should not dissuade rigorous attention toward those who have suffered unnecessarily due to an overreaching backlash toward the opioid crisis. Oncology patients have been significantly impacted on both ends of the opioid crisis. Like other populations, cancer patients were first affected during the initial surge of opioid availability, prescription, and use at the beginning of the crisis, where opioid abuse and overdose negatively impacted cancer patient populations at similar rates as the general population. Yet, cancer patients were perhaps even more heavily affected during secondary events after the initial crisis, as opioid restrictions and the stigmatization, undoubtedly beneficial in many spaces, of opioid use became prevalent across the American society. During this second period of the opioid crisis (loosely from 2013 to the present day after the Veterans Health Administration Opioid Safety Initiative started), restrictions on opioids have significantly decreased the use and access of opioids for cancer patients. Management of pain, in general, is a complex topic, and cancer pain is no exception. Cancer patients may experience pain related to the disease itself, its treatment, or other comorbidities. This review aims to clarify the impact of reducing opioid use on cancer patients over the past eight years. We summarize the challenges facing providers as they attempt to manage cancer-related pain. Additionally, we propose tools for best practices to reduce the unnecessary suffering of cancer patients and protect against the overuse and abuse of opioids.
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Affiliation(s)
- Michael Chahin
- Department of Hematology and Oncology, Georgia Cancer Center at Augusta University, Augusta, USA
| | - Sabrina Matosz
- Department of Hematology and Oncology, Georgia Cancer Center at Augusta University, Augusta, USA
| | - Irene Khalel
- Internal Medicine, University of Alexandria, Faculty of Medicine, Alexandria, EGY
| | - Silas Day
- Hematology and Medical Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, USA
| | - Amany Keruakous
- Department of Hematology and Oncology, Georgia Cancer Center at Augusta University, Augusta, USA
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Zale EL, Powers JM, Ditre JW. Cognitive-Affective Transdiagnostic Factors Associated With Vulnerability to Alcohol and Prescription Opioid Use in the Context of Pain. Alcohol Res 2021; 41:08. [PMID: 34306903 PMCID: PMC8289456 DOI: 10.35946/arcr.v41.1.08] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The use of alcohol and prescription opioids is common among people in pain and poses significant public health burdens. This review identifies factors associated with motivation to use alcohol and prescription opioids in the context of pain. Pain-relevant, cognitive-affective, transdiagnostic vulnerability factors-expectancies/motives, pain catastrophizing, pain-related anxiety, distress intolerance, anxiety sensitivity, and perceived interrelations-were selected from theoretical conceptualizations of pain and substance use. Searches conducted in PubMed, PsycINFO, and Embase returned 25 studies that examined associations between identified variables of interest and the use of alcohol and prescription opioids in the context of pain. Consistent with a larger literature on pain and substance use, the studies included in this review demonstrated that people with chronic pain are motivated to use alcohol and opioids in response to negative affect and hold expectancies/motives for coping with pain. Vulnerabilities that engender difficulty managing aversive internal states (distress intolerance and anxiety sensitivity) and maladaptive responses to pain (pain-related anxiety and pain catastrophizing) also were implicated in motivation for alcohol and opioid use. Although one study found that pain-related anxiety was associated with co-use of alcohol and opioids, no studies examined simultaneous use. Future research directions that can explicate causal associations, identify patterns of alcohol and opioid co-use, clarify the role of pain in cessation processes, and inform treatment development are discussed.
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Affiliation(s)
- Emily L Zale
- Department of Psychology, Binghamton University, Binghamton, New York
| | - Jessica M Powers
- Department of Psychology, Syracuse University, Syracuse, New York
| | - Joseph W Ditre
- Department of Psychology, Syracuse University, Syracuse, New York
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De Aquino JP, Flores JM, Avila-Quintero VJ, Compton P, Sofuoglu M. Pharmacological treatment of pain among persons with opioid addiction: A systematic review and meta-analysis with implications for drug development. Addict Biol 2021; 26:e12964. [PMID: 32974993 DOI: 10.1111/adb.12964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 08/17/2020] [Accepted: 08/23/2020] [Indexed: 01/17/2023]
Abstract
The clinical features and neurobiology of pain and opioid use disorder (OUD) are inextricably linked. Despite emerging evidence supporting the negative impact of ongoing pain in the treatment of OUD, the pharmacological management of pain in the presence of OUD has received limited attention. We sought to systematically review the studies investigating pharmacotherapies for pain among persons with OUD. Eligible studies had participants with OUD and outcomes including evoked or spontaneous pain. We searched Scopus, Cochrane Database of Systematic Reviews, Medline, and Embase. Out of 1,097 studies that met the search criteria, 12 studies provided data relevant to the research question-five laboratory studies and seven clinical trials. Random effects pooled estimates suggested no significant difference between groups at baseline but a response favoring the active treatment group over placebo, with nonsignificant heterogeneity between studies. Findings from these studies provide preliminary evidence for analgesic and antihyperalgesic effects of gabapentin, GABA agonists, and NMDA antagonists among persons with OUD. To establish the tradeoffs between the analgesic effects and abuse liability of these compounds, further well-controlled clinical trials are required among persons with OUD. This review also underscores the need for methodological enhancement in drug development for pain in OUD. Future research should address the clinical and neurobiological overlap between pain- and addiction-related phenomena. Transdisciplinary approaches may identify biomarkers of these shared phenomena and their neural substrates. The development of novel therapeutics for pain in OUD may be accelerated by such integration of pain and addiction research.
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Affiliation(s)
- Joao P De Aquino
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
| | - José M Flores
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Peggy Compton
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mehmet Sofuoglu
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
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Tamarelli C, Hosanagar A. Phenibut Use in a Patient Prescribed Gabapentinoids. PAIN MEDICINE 2021; 22:761-762. [PMID: 32747958 DOI: 10.1093/pm/pnaa205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Carrie Tamarelli
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Avinash Hosanagar
- Department of Psychiatry, University of Michigan and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
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MacLean RR, Spinola S, Garcia-Vassallo G, Sofuoglu M. The Impact of Chronic Pain on Opioid Use Disorder Treatment Outcomes. CURRENT ADDICTION REPORTS 2021. [DOI: 10.1007/s40429-020-00352-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Buttram ME, Surratt HL. Factors Associated with Gabapentin Misuse among People Who Inject Drugs in Appalachian Kentucky. Subst Use Misuse 2020; 55:2364-2370. [PMID: 32917119 PMCID: PMC7643539 DOI: 10.1080/10826084.2020.1817082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Gabapentin is misused to potentiate the euphoric effects of opioids, self-treat physical pain, and moderate opioid withdrawal symptoms. Because examinations of gabapentin misuse among people who inject drugs (PWID) are scant, the aim of this study is to identify factors associated with gabapentin misuse among this population. Methods: Data are drawn from a study examining the uptake of syringe service programs (SSPs) in Appalachian Kentucky. The sample includes 324 PWID who were age 18 and over and reported past month drug injection. Logistic regression models were constructed to examine recent (past 90 days) gabapentin misuse. Results: Participants are female (50.0%); Hispanic (2.2%), Black (1.5%), white (90.7%), and other race/ethnicity (4.6%). Mean age is 37. Participants reporting gabapentin misuse had higher odds of reporting (mis)use of marijuana, cocaine, methamphetamine, prescription opioids, benzodiazepines, prescription stimulants, fentanyl, and buprenorphine (p < .042); severe substance use disorder (p < .000); and recent physical pain (p < .003). In multivariable models, findings related to misuse of prescription opioids and buprenorphine; severe substance use disorder; and recent physical pain or discomfort, remained significant (p < .042). Conclusions: This is one of the first studies to examine gabapentin misuse among PWID. It is possible that individuals reporting recent gabapentin misuse are attempting to self-treat physical pain when healthcare is limited. Gabapentin may also be misused to achieve desired central nervous system effects and to potentiate opioid highs. Syringe service programs can educate PWID about the potential dangers of polydrug use involving gabapentin and to connect PWID with needed healthcare services.
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Affiliation(s)
- Mance E Buttram
- Center for Applied Research on Substance Use and Health Disparities, Nova Southeastern University, Miami, Florida, USA
| | - Hilary L Surratt
- Department of Behavioral Science, College of Medicine, University of Kentucky, Lexington, Kentucky, USA
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