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Peiró AM, Grimby-Ekman A, Barrachina J, Escorial M, Margarit C, Selva-Sevilla C, Gerónimo-Pardo M. Health-Related Quality of Life in Chronic Pain Treated With Tapentadol Versus Oxycodone/Naloxone and Its Determinants: A Real-World, Single-Center Retrospective Cohort Study in Spain. Value Health Reg Issues 2024; 44:101013. [PMID: 38981175 DOI: 10.1016/j.vhri.2024.101013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 04/16/2024] [Accepted: 05/08/2024] [Indexed: 07/11/2024]
Abstract
OBJECTIVES A substantial proportion of patients with chronic noncancer pain (CNCP) are treated with tapentadol (TAP) or oxycodone/naloxone (OXN) to improve their perceived physical and mental health over time. METHODS A cross-sectional study was conducted in 135 CNCP outpatients with usual prescribing (TAP: n = 58, OXN: n = 77) at a tertiary-care Spanish Hospital to compare health-related quality-of-life (HRQoL) records. Health utility was derived from the EQ-5D-3L. Regression models were performed to search for other HRQoL determinants. Pain intensity, relief, analgesic prescription, adverse events, inpatient stays, emergency department visits, and change to painkiller prescriptions were registered from electronic records. RESULTS Health utility (0.43 ± 0.24 scores, from -0.654 to 1) was similar for both opioids, although TAP showed a significantly low daily opioid dose requirement, neuromodulators use, and constipation side effect compared with OXN. After multivariable adjustment, the significant predictors of impaired HRQoL were pain intensity (β = -0.227, 95% CI -0-035 to -0.005), number of adverse events (β = -0.201, 95% CI -0.024 to -0.004), and opioid daily dose (β = -0.175, 95% CI -0.097 to -0.012). Male sex (β = -0.044) and pain relief (β = 0.158) should be taken into account for future studies. CONCLUSIONS HRQoL was similar for TAP and OXN in real-world patients with CNCP, albeit with a TAP opioid-sparing effect. More work is needed to explore HRQoL determinants in relation to long-term opioid use in CNCP.
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Affiliation(s)
- Ana M Peiró
- Neuropharmacology Applied to Pain (NED), Clinical Pharmacology Department, Dr. Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain; Institute of Bioengineering, University Miguel Hernández, Avda. Elche, Spain.
| | - Anna Grimby-Ekman
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jordi Barrachina
- Neuropharmacology Applied to Pain (NED), Clinical Pharmacology Department, Dr. Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Mónica Escorial
- Neuropharmacology Applied to Pain (NED), Clinical Pharmacology Department, Dr. Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - César Margarit
- Neuropharmacology Applied to Pain (NED), Clinical Pharmacology Department, Dr. Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain; Pain Unit, Alicante Department of Health, General Hospital, Alicante, Spain
| | - Carmen Selva-Sevilla
- Department of Applied Economy, Faculty of Economic and Business Sciences, University of Castilla-La Mancha, Albacete, Spain
| | - Manuel Gerónimo-Pardo
- Department of Anesthesiology, Integrated Care Management of Albacete, Albacete, Spain
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Liu SX, Muelken P, Maxim ZL, Ramakrishnan A, Estill MS, LeSage MG, Smethells JR, Shen L, Tran PV, Harris AC, Gewirtz JC. Differential gene expression and chromatin accessibility in the medial prefrontal cortex associated with individual differences in rat behavioral models of opioid use disorder. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.02.29.582799. [PMID: 38979145 PMCID: PMC11230220 DOI: 10.1101/2024.02.29.582799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
Opioid use disorder (OUD) is a neuropsychological disease that has a devastating impact on public health. Substantial individual differences in vulnerability exist, the neurobiological substrates of which remain unclear. To address this question, we investigated genome-wide gene transcription (RNA-seq) and chromatin accessibility (ATAC-seq) in the medial prefrontal cortex (mPFC) of male and female rats exhibiting differential vulnerability in behavioral paradigms modeling different phases of OUD: Withdrawal-Induced Anhedonia (WIA), Demand, and Reinstatement. Ingenuity Pathway Analysis (IPA) of RNA-seq revealed greater changes in canonical pathways in Resilient (vs. Saline) rats in comparison to Vulnerable (vs. Saline) rats across 3 paradigms, suggesting brain adaptations that might contribute to resilience to OUD across its trajectory. Analyses of gene networks and upstream regulators implicated processes involved in oligodendrocyte maturation and myelination in WIA, neuroinflammation in Demand, and metabolism in Reinstatement. Motif analysis of ATAC-seq showed changes in chromatin accessibility to a small set of transcription factor (TF) binding sites as a function either of opioid exposure (i.e., morphine versus saline) generally or of individual vulnerability specifically. Some of these were shared across the 3 paradigms and others were unique to each. In conclusion, we have identified changes in biological pathways, TFs, and their binding motifs that vary with paradigm and OUD vulnerability. These findings point to the involvement of distinct transcriptional and epigenetic mechanisms in response to opioid exposure, vulnerability to OUD, and different stages of the disorder.
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Andonovic M, Shaw M, Quasim T, MacTavish P, McPeake J. Factors Associated With New Analgesic Requirements Following Critical Illness. J Intensive Care Med 2024; 39:550-557. [PMID: 38087427 PMCID: PMC11092297 DOI: 10.1177/08850666231219916] [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: 12/21/2023]
Abstract
BACKGROUND Chronic opioid use represents a significant burden to global healthcare with adverse long-term outcomes. Elevated patient reported pain levels and analgesic prescriptions have been reported following discharge from critical care. We describe analgesic requirements following discharge from hospital and identify if a critical care admission is a significant factor for stronger analgesic prescriptions. METHODS This retrospective observational cohort study identified patients in the UK Biobank with a registered admission to any UK hospital between January 1, 2010 and December 31, 2015 and information on prescriptions drawn both prior to and following hospital discharge. Two matched cohorts were created from the dataset: critical care patients and hospital patients admitted without a critical care encounter. Outcomes were analgesic requirements following hospital discharge and factors associated with increased analgesic prescriptions. Multivariable logistic regression was used to identify factors associated with prescriptions from higher steps on the World Health Organization (WHO) analgesic ladder. RESULTS In total, 660 formed the total study population. Strong opioid prescriptions following discharge were significantly higher in the critical care cohort (P value <.001). Critical care admission (OR = 1.45) and increasing Townsend deprivation (OR = 1.04) index were significantly associated with increasing strength of analgesic prescriptions following discharge. CONCLUSIONS Critical care patients require stronger analgesic prescriptions in the 12 months following hospital discharge. Patients from areas of high socioeconomic deprivation may also be associated with increased analgesic requirements. Multidisciplinary support is required for patients who may be at risk of chronic opioid use and could be delivered within critical care recovery programs.
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Affiliation(s)
- Mark Andonovic
- Academic Unit of Anaesthesia, Critical Care and Perioperative Medicine, University of Glasgow, Glasgow, UK
| | - Martin Shaw
- Academic Unit of Anaesthesia, Critical Care and Perioperative Medicine, University of Glasgow, Glasgow, UK
| | - Tara Quasim
- Academic Unit of Anaesthesia, Critical Care and Perioperative Medicine, University of Glasgow, Glasgow, UK
| | | | - Joanne McPeake
- The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, UK
- Healthcare Improvement Scotland, Edinburgh, UK
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Escorial M, Muriel J, Agulló L, Zandonai T, Margarit C, Morales D, Peiró AM. Clinical prediction of opioid use disorder in chronic pain patients: a cohort-retrospective study with a pharmacogenetic approach. Minerva Anestesiol 2024; 90:386-396. [PMID: 38619184 DOI: 10.23736/s0375-9393.24.17864-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
BACKGROUND Opioids are widely used in chronic non-cancer pain (CNCP) management. However, they remain controversial due to serious risk of causing opioid use disorder (OUD). Our main aim was to develop a predictive model for future clinical translation that include pharmacogenetic markers. METHODS An observational study was conducted in 806 pre-screened Spanish CNCP patients, under long-term use of opioids, to compare cases (with OUD, N.=137) with controls (without OUD, N.=669). Mu-opioid receptor 1 (OPRM1, A118G, rs1799971) and catechol-O-methyltransferase (COMT, G472A, rs4680) genetic variants plus cytochrome P450 2D6 (CYP2D6) liver enzyme phenotypes were analyzed. Socio-demographic, clinical and pharmacological outcomes were also registered. A logistic regression model was performed. The model performance and diagnostic accuracy were calculated. RESULTS OPRM1-AA genotype and CYP2D6 poor and ultrarapid metabolizers together with three other potential predictors: 1) age; 2) work disability; 3) oral morphine equivalent daily dose (MEDD), were selected with a satisfactory diagnostic accuracy (sensitivity: 0.82 and specificity: 0.85), goodness of fit (P=0.87) and discrimination (0.89). Cases were ten-year younger with lower incomes, more sleep disturbances, benzodiazepines use, and history of substance use disorder in front of controls. CONCLUSIONS Functional polymorphisms related to OPRM1 variant and CYP2D6 phenotypes may predict a higher OUD risk. Established risk factors such as young age, elevated MEDD and lower incomes were identified. A predictive model is expected to be implemented in clinical setting among CNCP patients under long-term opioids use.
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Affiliation(s)
- Mónica Escorial
- Unit of Pharmacogenetics, Department of Clinical Pharmacology, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
- Institute of Bioengineering, Miguel Hernández University, Elche, Spain
| | - Javier Muriel
- Unit of Pharmacogenetics, Department of Clinical Pharmacology, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Laura Agulló
- Unit of Pharmacogenetics, Department of Clinical Pharmacology, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
- Institute of Bioengineering, Miguel Hernández University, Elche, Spain
| | - Thomas Zandonai
- Unit of Pharmacogenetics, Department of Clinical Pharmacology, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
- Addiction Science Lab, Department of Psychology and Cognitive Science, University of Trento, Trento, Italy
| | - César Margarit
- Pain Unit, Dr. Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Domingo Morales
- Operations Research Center, Miguel Hernández University, Elche, Spain
| | - Ana M Peiró
- Unit of Pharmacogenetics, Department of Clinical Pharmacology, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain -
- Institute of Bioengineering, Miguel Hernández University, Elche, Spain
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Vinkers CH, Kupka RW, Penninx BW, Ruhé HG, van Gaalen JM, van Haaren PCF, Schellekens AFA, Jauhar S, Ramos-Quiroga JA, Vieta E, Tiihonen J, Veldman SE, Veling W, Vis R, de Wit LE, Luykx JJ. Discontinuation of psychotropic medication: a synthesis of evidence across medication classes. Mol Psychiatry 2024:10.1038/s41380-024-02445-4. [PMID: 38503923 DOI: 10.1038/s41380-024-02445-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 12/22/2023] [Accepted: 01/22/2024] [Indexed: 03/21/2024]
Abstract
Pharmacotherapy is an effective treatment modality across psychiatric disorders. Nevertheless, many patients discontinue their medication at some point. Evidence-based guidance for patients, clinicians, and policymakers on rational discontinuation strategies is vital to enable the best, personalized treatment for any given patient. Nonetheless, there is a scarcity of guidelines on discontinuation strategies. In this perspective, we therefore summarize and critically appraise the evidence on discontinuation of six major psychotropic medication classes: antidepressants, antipsychotics, benzodiazepines, mood stabilizers, opioids, and stimulants. For each medication class, a wide range of topics pertaining to each of the following questions are discussed: (1) Who can discontinue (e.g., what are risk factors for relapse?); (2) When to discontinue (e.g., after 1 year or several years of antidepressant use?); and (3) How to discontinue (e.g., what's the efficacy of dose reduction compared to full cessation and interventions to mitigate relapse risk?). We thus highlight how comparing the evidence across medication classes can identify knowledge gaps, which may pave the way for more integrated research on discontinuation.
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Affiliation(s)
- Christiaan H Vinkers
- Department of Psychiatry and Anatomy & Neurosciences, Amsterdam University Medical Center location Vrije Universiteit Amsterdam, 1081 HV, Amsterdam, The Netherlands.
- Amsterdam Public Health, Mental Health Program and Amsterdam Neuroscience, Mood, Anxiety, Psychosis, Sleep & Stress Program, Amsterdam, The Netherlands.
- GGZ inGeest Mental Health Care, Amsterdam, The Netherlands.
| | - Ralph W Kupka
- Department of Psychiatry, Amsterdam Neuroscience and Amsterdam Public Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Brenda W Penninx
- Department of Psychiatry, Amsterdam Neuroscience and Amsterdam Public Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Henricus G Ruhé
- Department of Psychiatry, Radboudumc, Radboud University, Nijmegen, The Netherlands
- Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen, The Netherlands
| | - Jakob M van Gaalen
- GGZ inGeest Mental Health Care, Amsterdam, The Netherlands
- Department of Psychiatry, Amsterdam Neuroscience and Amsterdam Public Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Paul C F van Haaren
- Department of Psychiatry, Radboudumc, Radboud University, Nijmegen, The Netherlands
- Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen, The Netherlands
| | - Arnt F A Schellekens
- Department of Psychiatry, Radboudumc, Radboud University, Nijmegen, The Netherlands
- Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen, The Netherlands
- Nijmegen Institute for Scientist Practitioners in Addiction (NISPA), Nijmegen, The Netherlands
| | - Sameer Jauhar
- Centre for Affective Disorders, Psychological Medicine, IoPPN, King's College, London, UK
| | - Josep A Ramos-Quiroga
- Department of Mental Health, Hospital Universitari Vall d'Hebron, Barcelona, Catalonia, Spain
- Group of Psychiatry, Mental Health and Addictions, Vall d'Hebron Research Institute (VHIR), Barcelona, Catalonia, Spain
- Biomedical Network Research Centre on Mental Health (CIBERSAM), Barcelona, Catalonia, Spain
- Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Eduard Vieta
- Bipolar and Depressive Disorders Unit, Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Jari Tiihonen
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland
- Department of Clinical Neuroscience, Karolinska Institutet, 11364, Stockholm, Sweden
- Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden
- Neuroscience Center, University of Helsinki, Helsinki, Finland
| | - Stijn E Veldman
- Department of Psychiatry, Radboudumc, Radboud University, Nijmegen, The Netherlands
- Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen, The Netherlands
- Nijmegen Institute for Scientist Practitioners in Addiction (NISPA), Nijmegen, The Netherlands
- Novadic-Kentron Addiction Care, Vught, The Netherlands
| | - Wim Veling
- Department of Psychiatry, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Roeland Vis
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein/Utrecht, The Netherlands
| | - Laura E de Wit
- Department of Psychiatry, St. Antonius Hospital, Nieuwegein/Utrecht, The Netherlands
| | - Jurjen J Luykx
- GGZ inGeest Mental Health Care, Amsterdam, The Netherlands
- Department of Psychiatry, Amsterdam Neuroscience and Amsterdam Public Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, The Netherlands
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Bao R, Zhang WS, Zha YF, Zhao ZZ, Huang J, Li JL, Wang T, Guo Y, Bian JJ, Wang JF. Effects of opioid-free anaesthesia compared with balanced general anaesthesia on nausea and vomiting after video-assisted thoracoscopic surgery: a single-centre randomised controlled trial. BMJ Open 2024; 14:e079544. [PMID: 38431299 PMCID: PMC10910406 DOI: 10.1136/bmjopen-2023-079544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 02/23/2024] [Indexed: 03/05/2024] Open
Abstract
OBJECTIVES Opioid-free anaesthesia (OFA) has emerged as a promising approach for mitigating the adverse effects associated with opioids. The objective of this study was to evaluate the impact of OFA on postoperative nausea and vomiting (PONV) following video-assisted thoracic surgery. DESIGN Single-centre randomised controlled trial. SETTING Tertiary hospital in Shanghai, China. PARTICIPANTS Patients undergoing video-assisted thoracic surgery were recruited from September 2021 to June 2022. INTERVENTION Patients were randomly allocated to OFA or traditional general anaesthesia with a 1:1 allocation ratio. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome measure was the incidence of PONV within 48 hours post-surgery, and the secondary outcomes included PONV severity, postoperative pain, haemodynamic changes during anaesthesia, and length of stay (LOS) in the recovery ward and hospital. RESULTS A total of 86 and 88 patients were included in the OFA and control groups, respectively. Two patients were excluded because of severe adverse events including extreme bradycardia and epilepsy-like convulsion. The incidence and severity of PONV did not significantly differ between the two groups (29 patients (33.0%) in the control group and 22 patients (25.6%) in the OFA group; relative risk 0.78, 95% CI 0.49 to 1.23; p=0.285). Notably, the OFA approach used was associated with an increase in heart rate (89±17 vs 77±15 beats/min, t-test: p<0.001; U test: p<0.001) and diastolic blood pressure (87±17 vs 80±13 mm Hg, t-test: p=0.003; U test: p=0.004) after trachea intubation. Conversely, the control group exhibited more median hypotensive events per patient (mean 0.5±0.8 vs 1.0±2.0, t-test: p=0.02; median 0 (0-4) vs 0 (0-15), U test: p=0.02) during surgery. Postoperative pain scores, and LOS in the recovery ward and hospital did not significantly differ between the two groups. CONCLUSIONS Our study findings suggest that the implementation of OFA does not effectively reduce the incidence of PONV following thoracic surgery when compared with traditional total intravenous anaesthesia. The opioid-free strategy used in our study may be associated with severe adverse cardiovascular events. TRIAL REGISTRATION NUMBER ChiCTR2100050738.
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Affiliation(s)
- Rui Bao
- Department of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Wei-Shi Zhang
- Department of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yi-Feng Zha
- Department of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhen-Zhen Zhao
- Department of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jie Huang
- Department of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jia-Lin Li
- Department of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Tong Wang
- Department of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yu Guo
- Department of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jin-Jun Bian
- Department of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jia-Feng Wang
- Department of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
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Konzelmann M, Vuistiner P, Burrus C, Luthi F, Léger B. Analgesic consumption in a large sample of people in musculoskeletal rehabilitation: A descriptive study. Ann Phys Rehabil Med 2024; 67:101776. [PMID: 38118341 DOI: 10.1016/j.rehab.2023.101776] [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: 10/26/2022] [Revised: 04/15/2023] [Accepted: 06/03/2023] [Indexed: 12/22/2023]
Abstract
BACKGROUND Consumption of opioids is increasing worldwide in people with chronic non-cancer pain, although their effectiveness is debated. OBJECTIVES The aim of the current study was to evaluate analgesic consumption and its association with different variables (demographic variables, pain, anxiety/depression, catastrophism, and kinesiophobia), in the field of musculoskeletal rehabilitation, where no data are available. METHODS This was a retrospective study over a period of 8 years on people hospitalised for rehabilitation after injury. Participants were classified into 3 categories: no analgesics (NA), non-opioid analgesics (NOA), and opioid analgesics (OPA). ANOVA or chi-squared tests were used to compare the 3 groups. RESULTS A total of 4,350 people (84% men; mean [SD] age, 44 [11] years) were included. In total, 20% were taking OPA, 40% NOA and 40% NA. In the OPA group, tramadol was mainly used, and the morphine equivalent median dose was 8.3 mg/day. In the NOA group, paracetamol and ibuprofen were mostly used. Symptoms increased progressively across the 3 groups (NA/NOA/OPA), with increased levels of pain severity/interference, anxiety/depression and catastrophizing, and a higher prevalence of neuropathic pain in the OPA group versus the others. CONCLUSIONS These results are consistent with those found in groups of people with chronic pain taking larger doses of opioids and following opioid reduction or cessation programs. Opioid prescription did not increase over the 8 years, which was reassuring. These factors are important to emphasise because they can be modified in the rehabilitation setting with interdisciplinary management. REGISTRATION Our database was registered on Mendeley Data.
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Affiliation(s)
- Michel Konzelmann
- Research service. Clinique Romande de réadaptation, Sion, Switzerland; Assessment and consultation service. Clinique Romande de réadaptation, Sion, Switzerland.
| | | | - Cyrille Burrus
- Research service. Clinique Romande de réadaptation, Sion, Switzerland; Rehabilitation of locomotor apparatus service. Clinique Romande de réadaptation, Sion, Switzerland
| | - François Luthi
- Rehabilitation of locomotor apparatus service. Clinique Romande de réadaptation, Sion, Switzerland; Department of locomotor apparatus. Hôpital Orthopédique, Lausanne. Switzerland
| | - Bertrand Léger
- Research service. Clinique Romande de réadaptation, Sion, Switzerland
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Nguyen AP, Palzes VA, Binswanger IA, Ahmedani BK, Altschuler A, Andrade SE, Bailey SR, Clark RE, Haller IV, Hechter RC, Karmali R, Metz VE, Poulsen MN, Roblin DW, Rosa CL, Rubinstein AL, Sanchez K, Stephens KA, Yarborough BJH, Campbell CI. Association of initial opioid prescription duration and an opioid refill by pain diagnosis: Evidence from outpatient settings in ten US health systems. Prev Med 2024; 179:107828. [PMID: 38110159 PMCID: PMC11046737 DOI: 10.1016/j.ypmed.2023.107828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/06/2023] [Accepted: 12/15/2023] [Indexed: 12/20/2023]
Abstract
OBJECTIVE The Centers for Disease Control and Prevention's 2022 Clinical Practice Guideline for Prescribing Opioids for Pain cautioned that inflexible opioid prescription duration limits may harm patients. Information about the relationship between initial opioid prescription duration and a subsequent refill could inform prescribing policies and practices to optimize patient outcomes. We assessed the association between initial opioid duration and an opioid refill prescription. METHODS We conducted a retrospective cohort study of adults ≥19 years of age in 10 US health systems between 2013 and 2018 from outpatient care with a diagnosis for back pain without radiculopathy, back pain with radiculopathy, neck pain, joint pain, tendonitis/bursitis, mild musculoskeletal pain, severe musculoskeletal pain, urinary calculus, or headache. Generalized additive models were used to estimate the association between opioid days' supply and a refill prescription. RESULTS Overall, 220,797 patients were prescribed opioid analgesics upon an outpatient visit for pain. Nearly a quarter (23.5%) of the cohort received an opioid refill prescription during follow-up. The likelihood of a refill generally increased with initial duration for most pain diagnoses. About 1 to 3 fewer patients would receive a refill within 3 months for every 100 patients initially prescribed 3 vs. 7 days of opioids for most pain diagnoses. The lowest likelihood of refill was for a 1-day supply for all pain diagnoses, except for severe musculoskeletal pain (9 days' supply) and headache (3-4 days' supply). CONCLUSIONS Long-term prescription opioid use increased modestly with initial opioid prescription duration for most but not all pain diagnoses examined.
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Affiliation(s)
- Anh P Nguyen
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, United States of America.
| | - Vanessa A Palzes
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States of America
| | - Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, United States of America; Colorado Permanente Medical Group, Denver, CO, United States of America; Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, United States of America; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States of America
| | - Brian K Ahmedani
- Center for Health Policy & Health Services Research, Henry Ford Health, Detroit, MI, United States of America
| | - Andrea Altschuler
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States of America
| | - Susan E Andrade
- Meyers Primary Care Health Institute/Fallon Health, Worcester, MA, United States of America
| | - Steffani R Bailey
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, United States of America
| | - Robin E Clark
- Department of Family Medicine and Community Health, University of Massachusetts Chan School of Medicine, Worcester, MA, United States of America
| | - Irina V Haller
- Essentia Institute of Rural Health, Duluth, MN, United States of America
| | - Rulin C Hechter
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States of America; Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States of America
| | | | - Verena E Metz
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States of America
| | - Melissa N Poulsen
- Department of Population Health Sciences, Geisinger, Danville, PA, United States of America
| | - Douglas W Roblin
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente, Rockville, MD, United States of America
| | - Carmen L Rosa
- Center for the Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD, United States of America
| | - Andrea L Rubinstein
- Department of Pain Medicine, The Permanente Medical Group, Santa Rosa, CA, United States of America
| | - Katherine Sanchez
- Baylor Scott & White Research Institute, Dallas, TX, United States of America; School of Social Work, University of Texas at Arlington, Arlington, TX, United States of America
| | - Kari A Stephens
- Department of Family Medicine, University of Washington, Seattle, WA, United States of America
| | - Bobbi Jo H Yarborough
- Kaiser Permanente Northwest Center for Health Research, Portland, OR, United States of America
| | - Cynthia I Campbell
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States of America; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States of America; Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, CA, United States of America
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9
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Montgomery C, Poole HM, Begley E, Abbasi Y. Taking the pain out of pain. Br J Pain 2023; 17:514-518. [PMID: 37969134 PMCID: PMC10642502 DOI: 10.1177/20494637231208167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023] Open
Affiliation(s)
| | - Helen M Poole
- School of Psychology, Liverpool John Moores University, Liverpool, UK
| | - Emma Begley
- School of Psychology, Aston University, Birmingham, UK
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10
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Kendler KS, Lönn SL, Ektor-Andersen J, Sundquist J, Sundquist K. Risk factors for the development of opioid use disorder after first opioid prescription: a Swedish national study. Psychol Med 2023; 53:6223-6231. [PMID: 36415073 PMCID: PMC10520598 DOI: 10.1017/s003329172200349x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 10/13/2022] [Accepted: 10/18/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND We need to better understand the frequency and predictors of opioid use disorder (OUD) after first opioid prescription (OP). METHODS We followed 1 516 392 individuals from the Swedish population born 1980-2000, from 1 July 2007, until 31 Dec 2017. We examined putative risk predictors with univariable and multivariable Cox Models and the potential causal effects of predictors by propensity score and co-sibling analyses. RESULT Of the individuals in our cohort, 24.8% (375 404) received a first OP, of whom 3034 (0.90%) developed a subsequent first OUD. The hazard ratio (HR) (± 95% CIs) for OUD after OP equaled 7.10 (6.75-7.46), with a mean time to onset of 3.41 (2.39) years. The strongest putative risk factors for development of OUD after OP were prior psychiatric and substance use disorders, criminal behavior, parental divorce/death, poor school performance, current community deprivation, divorce, and male sex. Few predictors differed across sexes. OP renewal was associated with a HR of 3.66 (3.41-3.93) for OUD. Co-sibling and propensity score analyses suggested that at least a moderate proportion of the risk factor-OUD association was likely causal. A risk score to predict OUD after OP had an AUC of 0.85, where nearly 60% of cases scoring in the top decile. CONCLUSIONS In a general population sample, an OP represents a substantial risk factor for subsequent OUD. Many of the risk factors for OUD after OP can be readily assessed at the time of potential OP, permitting clinicians to evaluate the risk of iatrogenic OUD.
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Affiliation(s)
- Kenneth S. Kendler
- Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University, Richmond, VA, USA
- Department of Psychiatry, Virginia Commonwealth University, Richmond, VA, USA
| | - Sara L. Lönn
- Center for Primary Health Care Research, Lund University, Malmö, Sweden
| | - John Ektor-Andersen
- Department of Family Medicine and Community Health, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Jan Sundquist
- Center for Primary Health Care Research, Lund University, Malmö, Sweden
- Department of Clinical Sciences Lund, Psychiatry, Faculty of Medicine, Lund University, Lund, Sweden and Addiction Center Malmö, Division of Psychiatry, Malmö, Sweden
| | - Kristina Sundquist
- Center for Primary Health Care Research, Lund University, Malmö, Sweden
- Department of Clinical Sciences Lund, Psychiatry, Faculty of Medicine, Lund University, Lund, Sweden and Addiction Center Malmö, Division of Psychiatry, Malmö, Sweden
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11
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Trujillo KA. Opiophobia and the tragedy of needless pain: A call for education and balance. Pharmacol Biochem Behav 2023; 230:173616. [PMID: 37572968 DOI: 10.1016/j.pbb.2023.173616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 08/02/2023] [Indexed: 08/14/2023]
Affiliation(s)
- Keith A Trujillo
- Department of Psychology, California State University, San Marcos, 333 S. Twin Oaks Valley Rd, San Marcos, CA 92096, USA.
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12
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Hall OT, Teater J, Entrup P, Deaner M, Bryan C, Harte SE, Kaplan CM, Phan KL, Clauw DJ. Fibromyalgia predicts increased odds of pain-related addiction exacerbation among individuals with pain and opioid use disorder. Pain 2023; 164:1801-1809. [PMID: 36921216 PMCID: PMC10348630 DOI: 10.1097/j.pain.0000000000002878] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/23/2023] [Accepted: 01/27/2023] [Indexed: 03/16/2023]
Abstract
ABSTRACT Fibromyalgia and opioid use disorder (OUD) are highly impactful chronic illnesses with substantially overlapping psychosocial, biological, and clinical features. Little previous research has examined interactions between fibromyalgia and OUD. Limiting such research has been the previous requirement of a clinical examination to diagnose fibromyalgia. The 2011 American College of Rheumatology Fibromyalgia Survey (ACR-FMS) is a validated self-report instrument with high sensitivity and specificity for fibromyalgia intended to enable fibromyalgia research in settings where a clinical examination is impractical. The present observational study uses the ACR-FMS to determine whether fibromyalgia affects odds of acknowledging pain-related OUD exacerbations among a sample of participants with pain and OUD. Participants with pain and OUD (n = 125) were recruited from an academic substance use treatment facility. The ACR-FMS, along with an original scale measuring pain-related OUD exacerbation-the Pain-related OUD Exacerbation Scale-was administered through an electronic survey. The factor structure, internal consistency, and construct validity of Pain-related OUD Exacerbation Scale were tested. In addition, descriptive analyses, multiple hierarchical linear regression, ordinal logistic regression, and multinomial logistic regression analyses were performed. Although all participants had pain, those with fibromyalgia demonstrated significantly greater odds of acknowledging pain-related OUD exacerbations. Pain-related OUD Exacerbation Scale was found to have a single-factor solution, strong internal consistency, and construct validity. This study provides first evidence of fibromyalgia as a risk factor for pain-related exacerbation of OUD and introduces a new scale with promising psychometric properties to measure pain-related OUD exacerbation.
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Affiliation(s)
- Orman Trent Hall
- Department of Psychiatry and Behavioral Health, Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Julie Teater
- Department of Psychiatry and Behavioral Health, Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Parker Entrup
- Department of Psychiatry and Behavioral Health, Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Megan Deaner
- Department of Psychiatry and Behavioral Health, Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Craig Bryan
- Department of Psychiatry and Behavioral Health, Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Steven E. Harte
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States
| | - Chelsea M. Kaplan
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States
| | - Kihn Luan Phan
- Department of Psychiatry and Behavioral Health, Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Daniel J. Clauw
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States
- Departments of Anesthesiology, Internal Medicine (Rheumatology) and Psychiatry, University of Michigan, Ann Arbor, MI, United States
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13
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Droog W, Walbeehm ET, Konijn JB, Lucas BMJ, Coert JH, Stolker RJ, Galvin EM. A Systematic Review on Long-Term Postsurgical Pain Outcomes; What Is the Effect of Upper Extremity Regional Anesthesia? Anesth Analg 2023; 137:365-374. [PMID: 37227939 DOI: 10.1213/ane.0000000000006529] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND Chronic pain is a recognized complication of surgery, and it has been hypothesized that regional anesthesia might reduce the risk of development of chronic pain after upper extremity surgery. METHODS A systematic literature review was performed to assess whether in patients undergoing elective upper extremity surgery (P), regional anesthesia (I), compared to general anesthesia (C), would result in lower long-term (>3 months) postoperative pain intensity (O). We included randomized and nonrandomized controlled trials (RCTs). Our primary outcome was numerical rating score or visual analogue scale for pain, at >3 months postoperatively. The Embase, Medline ALL, Web of Science Core Collections, Cochrane Central Register of Controlled Trials, and Google Scholar databases were searched for all reports assessing pain at >3 months after upper extremity surgery under general versus regional anesthesia. Secondary outcomes were: opioid prescription filling, complex regional pain syndrome (CRPS) incidence, the Mayo Wrist Score (MWS), and scores on the Disability of the Arm, Shoulder and Hand (DASH) questionnaire. Quality (or certainty) of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Risk-of-bias was assessed using the Cochrane tool for randomized trials (RoB 2.0) and nonrandomized trials (ROBINS-I). RESULTS This review included 14 studies, comprising 7 RCTs and 7 nonrandomized studies. Six of the 7 studies (4 RCTs, N = 273; 2 nonrandomized studies, N = 305) using a pain score, our primary outcome, report comparable long-term postoperative pain scores after regional and general anesthesia. Six of the 7 studies using our secondary outcomes report comparable long-term outcomes in terms of opioid prescription filling (2 retrospective cohort studies [RCSs], N = 89,256), CRPS incidence (1 RCT, N = 301), MWS (1 RCT and 1 RCS, N = 215), and DASH score (1 RCT, N = 36). Comparable outcomes were reported in all 7 RCTs (N = 778) and in 5 of the 7 nonrandomized studies, comprising 5 RCSs (N = 89,608). Two prospective observational studies (POSTs), comprising 279 patients, report a statistically significant difference in outcomes, with less pain and better DASH scores after brachial plexus anesthesia. All 14 studies provided moderate to very low certainty evidence, and there was a serious risk of bias due to confounding bias in 5 of the 7 nonrandomized studies (N = 631). CONCLUSIONS The results of this review indicate that upper extremity regional anesthesia, compared to general anesthesia, is unlikely to change pain intensity at >3 months postoperatively.
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Affiliation(s)
- Wouter Droog
- From the Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Erik T Walbeehm
- Department of Plastic Surgery, Lange Land Hospital, Zoetermeer, The Netherlandsand
| | - Julia B Konijn
- From the Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Benthe M J Lucas
- From the Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - J Henk Coert
- Department of Plastic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Robert Jan Stolker
- From the Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Eilish M Galvin
- From the Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
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14
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Ameiro RJ, Neves SS, Oliveira RP, Marques BB, Ferreira PRC. Perioperative Challenges of Heroin Addiction: A Case Report of Opioid-Free Anesthesia in Tongue Carcinoma Excision With Free-Flap Reconstruction. Cureus 2023; 15:e41195. [PMID: 37525785 PMCID: PMC10387187 DOI: 10.7759/cureus.41195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2023] [Indexed: 08/02/2023] Open
Abstract
Anesthesia for major head and neck surgery is historically heavily reliant on opioids with deleterious consequences. We reported a case of a patient with a history of heroin abuse submitted to a tongue carcinoma excision, followed by free-flap reconstruction under opioid-free anesthesia. We used a propofol total intravenous anesthesia and perfusions of ketamine, dexmedetomidine, lidocaine, and magnesium sulfate for analgesia, complemented by boluses of dexamethasone, acetaminophen, parecoxib, and metamizole. Hemodynamic needs of the procedure were addressed by titrating perfusions of sodium nitroprusside or dobutamine. The patient was weaned from the ventilator at the end of the surgery. Surgical outcomes were achieved and opioid-free analgesia allowed early reestablishment of bodily functions without compromise of adequate pain control. Anesthesia protocols for free-flap surgery still lack scientific evidence, especially in the context of substance abuse: opioid-sparing approaches seem a viable option, which requires further studies and familiarity by health care professionals.
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Affiliation(s)
- Roberto J Ameiro
- Department of Anaesthesiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, PRT
| | - Sara S Neves
- Department of Anaesthesiology, Centro Hospitalar Universitário de Santo António, Porto, PRT
| | - Rita P Oliveira
- Department of Anaesthesiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, PRT
| | - Beatriz B Marques
- Department of Anaesthesiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, PRT
| | - Paulo-Roberto C Ferreira
- Department of Anaesthesiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, PRT
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15
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Quinn PD, Chang Z, Pujol TA, Bair MJ, Gibbons RD, Kroenke K, D’Onofrio BM. Association between prescribed opioid dose and risk of motor vehicle crashes. Pain 2023; 164:e228-e236. [PMID: 36155384 PMCID: PMC11104685 DOI: 10.1097/j.pain.0000000000002790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 09/12/2022] [Indexed: 11/26/2022]
Abstract
ABSTRACT Opioid-involved motor vehicle traffic fatalities have increased over the past 2 decades. However, the extent to which prescribed opioids increase the risk of motor vehicle crashes remains uncertain. This study used real-world healthcare claims data to examine the association between prescription opioid dose and motor vehicle crash risk. Using nationwide US commercial insurance claims data for 2010 to 2018, we identified 772,404 adults who received incident, noncancer opioid therapy. We examined associations between daily prescription opioid dose, calculated in morphine milligram equivalents (MME) from filled prescription claims, and risk of motor vehicle crashes, assessed as diagnoses of motor vehicle injuries in claims for emergency visits, inpatient hospitalizations, and ambulance transportation. We estimated associations using a within-individual design, which ruled out all time-stable confounding. We complemented the design with time-varying statistical adjustment for other pharmacotherapies and a negative control pain pharmacotherapy analysis (with incident cyclic antidepressant prescriptions). During 2,150,009 person-years of follow-up, there were 12,123 motor vehicle crashes (5.64 crashes per 1000 person-years). In within-individual comparisons, crash risk was greater during opioid prescription periods involving doses ≤60 MME/day (odds ratio [OR], 3.86; 95% confidence interval [CI], 3.54, 4.21), >60 to 120 MME/day (OR, 5.46; 95% CI, 4.44, 6.73), and >120 MME/day (OR, 3.45; 95% CI, 2.31, 5.15) than during off-treatment periods. The negative control analysis supported the specificity of the results to opioids rather than to other processes associated with pharmacologic pain management. These findings suggest that the receipt of prescription opioids, even at doses ≤60 MME/day, is associated with an increased risk of motor vehicle crashes.
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Affiliation(s)
- Patrick D. Quinn
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington, Indiana
| | - Zheng Chang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | | | - Matthew J. Bair
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
- Regenstrief Institute, Indianapolis, Indiana
| | - Robert D. Gibbons
- Center for Health Statistics, University of Chicago, Chicago, Illinois
- Department of Medicine, University of Chicago, Chicago, Illinois
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
| | - Kurt Kroenke
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
- Regenstrief Institute, Indianapolis, Indiana
| | - Brian M. D’Onofrio
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, Indiana
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16
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The Impact of Provider Communication on Prescription Opioid Use: A Case Report. J Pain Palliat Care Pharmacother 2023; 37:78-81. [PMID: 36383736 DOI: 10.1080/15360288.2022.2144584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Over the past few decades, prescription opioids have greatly impacted our society, providing much needed relief for those in severe pain while simultaneously leading many to develop opioid use disorder. Although the scientific community has made great progress in combating this epidemic, there is still much work to be done. Physicians play a crucial role in this fight, as they are the ones in direct contact with patients. Proper and thorough communication is absolutely necessary when treating patients who are prescribed opioids. In this piece, we describe the case of a 62-year-old woman who experienced debilitating, cyclic opioid withdrawals after years of inappropriate prescription opioid use and how much of her suffering could have been avoided. Her case highlights the importance of patient-provider communication and the willingness of many patients to discontinue opioids.
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17
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Freiermuth CE, Kisor DF, Lambert J, Braun R, Frey JA, Bachmann DJ, Bischof JJ, Lyons MS, Pantalon MV, Punches BE, Ancona R, Sprague JE. Genetic Variants Associated with Opioid Use Disorder. Clin Pharmacol Ther 2023; 113:1089-1095. [PMID: 36744646 DOI: 10.1002/cpt.2864] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/29/2023] [Indexed: 02/07/2023]
Abstract
Genetics are presumed to contribute 30-40% to opioid use disorder (OUD), allowing for the possibility that genetic markers could be used to identify personal risk for developing OUD. We aimed to test the potential association among 180 candidate single nucleotide polymorphisms (SNPs), 120 of which were related to the dopamine reward pathway and 60 related to pharmacokinetics. Participants were randomly recruited in 2020-2021 in a cross-sectional genetic association study. Self-reported health history including Diagnostic and Statistical Manual of Mental Disorders (DSM-5) OUD criteria and buccal swabs were collected. A total of 1,301 participants were included in the analyses for this study. Of included participants, 250 met the DSM-5 criteria for ever having OUD. Logistic regression, adjusting for age and biologic sex, was used to characterize the association between each SNP and DSM-5 criteria consistent with OUD. Six SNPs found in 4 genes were associated with OUD: increased odds with CYP3A5 (rs15524 and rs776746) and DRD3 (rs324029 and rs2654754), and decreased odds with CYP3A4 (rs2740574) and CYP1A2 (rs2069514). Homozygotic CYP3A5 (rs15524 and rs776746) had the highest adjusted odds ratio of 2.812 (95% confidence interval (CI) 1.737, 4.798) and 2.495 (95% CI 1.670, 3.835), respectively. Variants within the dopamine reward and opioid metabolism pathways have significant positive (DRD3 and CYP3A5) and negative (CYP3A4 and CYP1A2) associations with OUD. Identification of these variants provides promising possibilities for genetic prognostic and therapeutic targets for future investigation.
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Affiliation(s)
| | - David F Kisor
- Department of Pharmaceutical Sciences and Pharmacogenomics, College of Pharmacy, Natural and Health Sciences, Manchester University, Fort Wayne, Indiana, USA
| | - Joshua Lambert
- College of Nursing, University of Cincinnati, Cincinnati, Ohio, USA
| | - Robert Braun
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jennifer A Frey
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Daniel J Bachmann
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Jason J Bischof
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Michael S Lyons
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Michael V Pantalon
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Brittany E Punches
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA.,College of Nursing, The Ohio State University, Columbus, Ohio, USA
| | - Rachel Ancona
- Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jon E Sprague
- The Ohio Attorney General's Center for the Future of Forensic Science, Bowling Green State University, Bowling Green, Ohio, USA
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18
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De A, Grasing KW. The antidepressant agomelatine attenuates morphine-induced reinstatement but not self-administration or precipitated withdrawal. Pharmacol Biochem Behav 2023; 223:173525. [PMID: 36758685 DOI: 10.1016/j.pbb.2023.173525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 02/05/2023] [Accepted: 02/06/2023] [Indexed: 02/10/2023]
Abstract
BACKGROUND Exogenous melatonin appears to have anti-addictive properties and was recently shown to improve mental health and metabolic measures in patients receiving chronic opioid maintenance therapy. Agomelatine is a marketed antidepressant which acts as a melatonin agonist. We evaluated its effects using a rat model of morphine-reinforced behavior. METHODS After pretreatment with noncontingent morphine, male Wistar rats were trained to self-administer intravenous morphine (1.0 mg/kg-injection) under a progressive-ratio schedule. Rats were pretreated with vehicle or agomelatine during extinction, reinstatement, and reacquisition of morphine-reinforced behavior. RESULTS Daily treatment with 10 mg/kg-day of agomelatine decreased the number of ratios completed and prolonged latency during morphine-induced reinstatement. There were no significant effects on cue-induced reinstatement, morphine self-administration, or naloxone-precipitated withdrawal. Treatment with 32 mg/kg-day of agomelatine caused postural changes. That dose prolonged withdrawal-induced loss of body weight and caused delayed reductions in food reinforcement. SUMMARY In addition to postural effects, high-dose agomelatine worsened the course of spontaneous withdrawal and produced nonspecific effects on food-reinforced behavior. When administered at a selective dose, agomelatine did not modify morphine self-administration or precipitated withdrawal, but decreased morphine-induced reinstatement. Our findings show potential detrimental effects of high-dose agomelatine, with reductions in opioid-seeking behavior after a lower, more selective dose.
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Affiliation(s)
- Alok De
- Substance Use Research Laboratory, Kansas City Veterans Affairs Medical Center, 4801 Linwood Boulevard, Kansas City, MO 64128, United States of America
| | - Ken W Grasing
- Substance Use Research Laboratory, Kansas City Veterans Affairs Medical Center, 4801 Linwood Boulevard, Kansas City, MO 64128, United States of America; Division of Clinical Pharmacology, Department of Medicine, University of Kansas School of Medicine, Kansas City, KS 66160, United States of America.
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19
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DeJesus J, Shah NR, Franco-Mesa C, Walters ET, Palackic A, Wolf SE. Risk factors for opioid use disorder after severe burns in adults. Am J Surg 2023; 225:400-407. [PMID: 36184330 DOI: 10.1016/j.amjsurg.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/09/2022] [Accepted: 09/18/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Risk factors for opioid dependence amongst burn patients have not been well-explored compared to other surgical fields. METHODS The TrinetX database was queried for patients diagnosed with opioid use disorder (OUD) after thermal or chemical burn. Propensity score matching was performed. Opioid and non-opioid analgesia use, ICU care, surgery, and comparative risks among common opiates were examined using descriptive and univariate regression models, including odds ratios. Subgroup analysis evaluated the impact of multimodal analgesia. RESULTS Odds of receiving IV opioids for acute analgesia (p = <0.0001, OR = 1.80, CI = 1.45-2.25), undergoing surgery (p = <0.0001, OR = 1.58, CI = 1.26-1.98), and ICU care (p = <0.0001, OR = 3.60, CI = 2.00-3.83) after burn injury were higher in patients who developed OUD. Patients receiving multimodal therapy within 24 hours of admission had lower odds of developing OUD (OR = 0.74, CI = 2.76-4.68, p = 0.0001) and chronic pain (OR = 0.89, CI = 0.78-1.00, p = 0.05) regardless of TBSA. CONCLUSION Patients who developed opioid use disorder following burn injury had higher odds of receiving opioid exclusive pain management, more frequent surgery, ICU care.
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Affiliation(s)
- Jana DeJesus
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555, USA.
| | - Nikhil R Shah
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555, USA.
| | - Camila Franco-Mesa
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555, USA.
| | - Elliot T Walters
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555, USA.
| | - Alen Palackic
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555, USA; Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, 8036, Austria.
| | - Steven E Wolf
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555, USA.
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20
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Quinlan J, Macintyre PE. The pitfalls of labelling opioids as weak or strong. Comment on Br J Anaesth 2022; 129: 137-42. Br J Anaesth 2022; 129:e150-e153. [PMID: 36182559 DOI: 10.1016/j.bja.2022.08.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/05/2022] [Accepted: 08/18/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
- Jane Quinlan
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Pamela E Macintyre
- Department of Anaesthesia, Pain Medicine and Hyperbaric Medicine, Royal Adelaide Hospital and University of Adelaide, Adelaide, Australia
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21
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Hébert HL, Morales DR, Torrance N, Smith BH, Colvin LA. Assessing the impact of a national clinical guideline for the management of chronic pain on opioid prescribing rates: a controlled interrupted time series analysis. Implement Sci 2022; 17:77. [PMID: 36419195 PMCID: PMC9682704 DOI: 10.1186/s13012-022-01251-2] [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: 05/23/2022] [Accepted: 11/09/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Opioids can be effective analgesics, but long-term use may be associated with harms. In 2013, the first national, comprehensive, evidence-based pain management guideline was published, from the Scottish Intercollegiate Guideline Network (SIGN 136: Management of Chronic Pain) with key recommendations on analgesic prescribing. This study aimed to examine the potential impact on national opioid prescribing rates in Scotland. METHODS Trends in national and regional community opioid prescribing data for Scotland were analysed from quarter one (Q1) 2005 to Q2 2020. Interrupted time series regression examined the association of SIGN 136 publication with prescribing rates for opioid-containing drugs. Gabapentinoid prescribing was used as a comparison drug. RESULTS After a positive prescribing trend pre-publication, the timing of SIGN 136 publication was associated with a negative change in the trend of opioid prescribing rates (-2.82 items per 1000 population per quarter [PTPPQ]; P < 0.01). By Q2 2020, the relative reduction in the opioid prescribing rate was -20.67% (95% CI: -23.61, -17.76). This persisted after correcting for gabapentinoid prescribing and was mainly driven by the reduction in weak opioids, whereas strong opioid prescribing rates continued to rise. Gabapentinoid prescribing showed a significant rise in level (8.00 items per 1000 population; P = 0.01) and trend (0.27 items PTPPQ; P = 0.01) following SIGN 136 publication. CONCLUSIONS The publication of SIGN 136 was associated with a reduction in opioid prescribing rates. This suggests that changes in clinical policy through evidence-based national clinical guidelines may affect community opioid prescribing, though this may be partially replaced by gabapentinoids, and other factors may also contribute.
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Affiliation(s)
- Harry L Hébert
- Division of Population Health and Genomics, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF, UK.
| | - Daniel R Morales
- Division of Population Health and Genomics, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF, UK
| | - Nicola Torrance
- School of Nursing, Midwifery & Paramedic Practice, Robert Gordon University, Aberdeen, UK
| | - Blair H Smith
- Division of Population Health and Genomics, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF, UK
| | - Lesley A Colvin
- Division of Population Health and Genomics, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF, UK
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22
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Mo KC, Sachdev R, Zhang B, Vadhera A, Ren M, Andrade NS, Kebaish KM, Skolasky RL, Neuman BJ. Preoperative duration of pain is associated with chronic opioid use after adult spinal deformity surgery. Spine Deform 2022; 10:1393-1397. [PMID: 35750987 DOI: 10.1007/s43390-022-00531-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 05/21/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Few studies have explored the association between preoperative patient-reported measures and chronic opioid use following adult spinal deformity (ASD) surgery. We sought to explore the association between preoperative duration of pain, as well as other patient-reported factors, and chronic opioid use after ASD surgery. METHODS We retrospectively reviewed our U.S. academic tertiary care hospital's database of ASD patients. We included patients 18 years or older who underwent arthrodesis of four or more spinal levels from January 2008 to February 2018, with 2-year follow-up. The primary outcome variable was chronic opioid use, defined as opioid use at both 1 and 2 years postoperatively. We analyzed patient characteristics; duration of preoperative pain (<4 years or ≥4 years); radiculopathy; preoperative Scoliosis Research Society-22r (SRS-22r) score; Oswestry Disability Index (ODI) value; and surgical characteristics. RESULTS Of 119 patients who met the inclusion criteria, 93 (78%) were women, and mean ± standard deviation age was 59 ± 13. Sixty patients (50%) reported preoperative opioid use, and 35 (29%) reported chronic opioid use. Preoperative opioid use was associated with higher odds of chronic use (adjusted odds ratio, 5.9; 95% confidence interval 1.6-21), as was preoperative pain duration of ≥4 years (adjusted odds ratio, 3.3; 95% confidence interval 1.1-9.8). Patient characteristics, surgical variables, ODI value, and SRS-22r score were not significantly associated with chronic postoperative opioid use. CONCLUSION Preoperative opioid use and duration of pain of ≥4 years were associated with higher odds of chronic opioid use after ASD surgery. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Kevin C Mo
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 5241, Baltimore, MD, 21287, USA
| | - Rahul Sachdev
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 5241, Baltimore, MD, 21287, USA
| | - Bo Zhang
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 5241, Baltimore, MD, 21287, USA
| | - Amar Vadhera
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 5241, Baltimore, MD, 21287, USA
| | - Mark Ren
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 5241, Baltimore, MD, 21287, USA
| | - Nicholas S Andrade
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 5241, Baltimore, MD, 21287, USA
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 5241, Baltimore, MD, 21287, USA
| | - Richard L Skolasky
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 5241, Baltimore, MD, 21287, USA
| | - Brian J Neuman
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 5241, Baltimore, MD, 21287, USA.
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23
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Hohmann LA, Fox BI, Garza KB, Wang CH, Correia C, Curran GM, Westrick SC. Impact of a Multicomponent Educational Intervention on Community Pharmacy-Based Naloxone Services Implementation: A Pragmatic Randomized Controlled Trial. Ann Pharmacother 2022; 57:677-695. [PMID: 36047381 DOI: 10.1177/10600280221120405] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Despite US naloxone access laws, community pharmacists lack training and confidence in providing naloxone. OBJECTIVE To assess the impact of the Empowering Community Pharmacists program on pharmacists' knowledge, perceived barriers, attitudes, confidence, and intentions regarding naloxone services implementation, as well as naloxone prescriptions dispensed. METHODS A 3-month pragmatic randomized controlled trial was conducted from December 2018 to March 2019. Alabama community pharmacists were recruited by mail, email, phone, and fax and randomized to intervention (monthly resources/reminders + educational webinar) or control (monthly reminders only). Outcome measures were assessed via online surveys at baseline (T1), immediately post-intervention (T2), and 3 months post-intervention (T3), including naloxone knowledge (%correct); perceived barriers, attitudes, confidence, and intention regarding naloxone services implementation (7-point Likert-type scale; 1 = strongly disagree, 7 = strongly agree); and number of naloxone prescriptions dispensed. Mean differences between control and intervention from T1 to T3 were assessed using 2-way mixed analysis of variance and adjusted analyses were conducted using generalized estimating equations with negative binomial distribution to assess associations between variables. RESULTS Of 55 participants (n = 27 intervention, n = 28 control), most were female (80.3%), white (80.6%), in independently owned pharmacies (39.1%). Increases in mean [SD] confidence (5.52 [1.03]-6.16 [0.74], P < 0.0005) and intention (5.35 [1.51]-6.10 [0.96], P = 0.023) occurred from pre- to post-program within the intervention group and were statistically significant compared with control (confidence P = 0.016, intention P = 0.014). Confidence (exp(β) = 1.46, P = 0.031) and perceived barriers (exp(β) = 0.75, P = 0.022) were associated with number of naloxone prescriptions dispensed. CONCLUSION AND RELEVANCE The Empowering Community Pharmacists program improved community pharmacists' confidence and intention regarding naloxone services implementation. Other states can adapt program elements according to their laws. CLINICALTRIALS.GOV IDENTIFIER NCT05093309.
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Affiliation(s)
- Lindsey A Hohmann
- Department of Pharmacy Practice, Auburn University Harrison College of Pharmacy, Auburn, AL, USA
| | - Brent I Fox
- Department of Health Outcomes Research and Policy, Auburn University Harrison College of Pharmacy, Auburn, AL, USA
| | - Kimberly B Garza
- Department of Health Outcomes Research and Policy, Auburn University Harrison College of Pharmacy, Auburn, AL, USA
| | - Chih-Hsuan Wang
- Department of Educational Foundations, Leadership, and Technology, Auburn University College of Education, Auburn, AL, USA
| | - Christopher Correia
- Department of Psychology, Auburn University College of Liberal Arts, Auburn, AL, USA
| | - Geoffrey M Curran
- Departments of Pharmacy Practice and Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Salisa C Westrick
- Department of Health Outcomes Research and Policy, Auburn University Harrison College of Pharmacy, Auburn, AL, USA
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24
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Maciel CB, Barlow B, Lucke-Wold B, Gobinathan A, Abu-Mowis Z, Peethala MM, Merck LH, Aspide R, Dickinson K, Miao G, Shan G, Bilotta F, Morris NA, Citerio G, Busl KM. Acute Headache Management for Patients with Subarachnoid Hemorrhage: An International Survey of Health Care Providers. Neurocrit Care 2022; 38:395-406. [PMID: 35915347 DOI: 10.1007/s12028-022-01571-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 07/05/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Severe headaches are common after subarachnoid hemorrhage. Guidelines recommend treatment with acetaminophen and opioids, but patient data show that headaches often persist despite multimodal treatment approaches. Considering an overall slim body of data for a common complaint affecting patients with SAH during their intensive care stay, we set out to assess practice patterns in headache management among clinicians who treat patients with SAH. METHODS We conducted an international cross-sectional study through a 37-question Web-based survey distributed to members of five professional societies relevant to intensive and neurocritical care from November 2021 to January 2022. Responses were characterized through descriptive analyses. Fisher's exact test was used to test associations. RESULTS Of 516 respondents, 329 of 497 (66%) were from North America and 121 of 497 (24%) from Europe. Of 435 respondents, 379 (87%) reported headache as a major management concern for patients with SAH. Intensive care teams were primarily responsible for analgesia during hospitalization (249 of 435, 57%), whereas responsibility shifted to neurosurgery at discharge (233 of 501, 47%). Most used medications were acetaminophen (90%), opioids (66%), corticosteroids (28%), and antiseizure medications (28%). Opioids or medication combinations including opioids were most frequently perceived as most effective by 169 of 433 respondents (39%, predominantly intensivists), followed by corticosteroids or combinations with corticosteroids (96 of 433, 22%, predominantly neurologists). Of medications prescribed at discharge, acetaminophen was most common (303 of 381, 80%), followed by opioids (175 of 381, 46%) and antiseizure medications (173 of 381, 45%). Opioids during hospitalization were significantly more prescribed by intensivists, by providers managing higher numbers of patients with SAH, and in Europe. At discharge, opioids were more frequently prescribed in North America. Of 435 respondents, 299 (69%) indicated no change in prescription practice of opioids with the opioid crisis. Additional differences in prescription patterns between continents and providers and while inpatient versus at discharge were found. CONCLUSIONS Post-SAH headache in the intensive care setting is a major clinical concern. Analgesia heavily relies on opioids both in use and in perception of efficacy, with no reported change in prescription patterns for opioids for most providers despite the significant drawbacks of opioids. Responsibility for analgesia shifts between hospitalization and discharge. International and provider-related differences are evident. Novel treatment strategies and alignment of prescription between providers are urgently needed.
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Affiliation(s)
- Carolina B Maciel
- Department of Neurology, College of Medicine, University of Florida, McKnight Brain Institute, L3-100, 1149 Newell Drive, Gainesville, FL, 32608, USA.,Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Brooke Barlow
- Department of Pharmacy, University of Florida Health Shands Hospital, Gainesville, FL, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Arravintha Gobinathan
- Departments of Microbiology and Anthropology, University of Florida, Gainesville, FL, USA
| | - Zaid Abu-Mowis
- Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA
| | - Mounika Mukherjee Peethala
- Department of Neurology, College of Medicine, University of Florida, McKnight Brain Institute, L3-100, 1149 Newell Drive, Gainesville, FL, 32608, USA
| | - Lisa H Merck
- Department of Emergency Medicine College of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Raffaele Aspide
- Anesthesia and Neurointensive Care Unit, Istituto delle Scienze Neurologiche di Bologna, Istituto di Ricovero e Cura a Carattere Scientifico, Bologna, Italy
| | - Katie Dickinson
- Department of Neurology, College of Medicine, University of Florida, McKnight Brain Institute, L3-100, 1149 Newell Drive, Gainesville, FL, 32608, USA
| | - Guanhong Miao
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Guogen Shan
- Department of Biostatistics, University of Florida, Gainesville, FL, USA.,Research Design and Data Coordinating Center, Clinical and Translational Science Institute, University of Florida, Gainesville, FL, USA
| | - Federico Bilotta
- Department of Anesthesiology, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Nicholas A Morris
- Department of Neurology, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Neurointensive Care Unit, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Katharina M Busl
- Department of Neurology, College of Medicine, University of Florida, McKnight Brain Institute, L3-100, 1149 Newell Drive, Gainesville, FL, 32608, USA. .,Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA.
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25
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Crush J, Levy N, Knaggs RD, Lobo DN. Misappropriation of the 1986 WHO analgesic ladder: the pitfalls of labelling opioids as weak or strong. Br J Anaesth 2022; 129:137-142. [PMID: 35397880 DOI: 10.1016/j.bja.2022.03.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 02/22/2022] [Accepted: 03/01/2022] [Indexed: 12/18/2022] Open
Abstract
Opioids have a vital role in alleviating pain from cancer and surgery. Despite good intentions, it is now recognised that the original WHO Cancer Pain Relief guidance from 1986, in which opioids were classified as either weak or strong, has been both inadvertently and purposefully misused, thereby contributing to harm from opioid use and misuse. However, the recommendation in the 2018 update of the WHO analgesic ladder that a combination of a high-potency opioid with simple analgesics is better than alternative analgesics for the maintenance of pain relief is also applicable to patients who require short-term opioids. Furthermore, because potential harm through opioid use and misuse is intrinsic to all opioids, whether weak or strong, we argue that the arbitrary classification of opioids either as weak or strong should be discontinued, as this description is not helpful to either prescribers or consumers.
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Affiliation(s)
- Jos Crush
- Department of Anaesthesia and Perioperative Medicine, West Suffolk Hospital NHS Foundation Trust, Bury St. Edmunds, UK
| | - Nicholas Levy
- Department of Anaesthesia and Perioperative Medicine, West Suffolk Hospital NHS Foundation Trust, Bury St. Edmunds, UK
| | - Roger D Knaggs
- Division of Pharmacy Practice and Policy, School of Pharmacy, UK; Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
| | - Dileep N Lobo
- Nottingham Digestive Diseases Centre, National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK.
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26
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Fugelstad A, Ågren G, Ramstedt M, Thiblin I, Hjelmström P. Oxycodone-related deaths in Sweden 2006-2018. Drug Alcohol Depend 2022; 234:109402. [PMID: 35306392 DOI: 10.1016/j.drugalcdep.2022.109402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 03/04/2022] [Accepted: 03/07/2022] [Indexed: 12/17/2022]
Abstract
AIM To identify and characterize oxycodone related deaths in Sweden from 2006 to 2018 and to compare them to other opioid-related deaths. METHODS To assess the factors contributing to the deaths, we used multinomial logistic regression to compare oxycodone-related deaths extracted from all forensic autopsy examinations and toxicology cases in the age groups 15-34 (reference group), 35-54 and 55-74 with regard to sex, presence of benzodiazepines and alcohol at the time of death, prescription of oxycodone, benzodiazepines and antidepressants, previous substance use-related (SUD) treatment, and manner of death. The oxycodone related deaths were compared with deaths with presence of other opioids. RESULT We identified 575 oxycodone-related deaths, and the rate increased during the study period from 0.10 to 1.12 per 100,000 in parallel with an increase of oxycodone prescriptions from 3.17 to 30.33 per 1000. Oxycodone-related deaths amounted to 10.0% of all opioid-related deaths. The deaths occurred mainly in older patients previously being prescribed oxycodone. Benzodiazepines were present at the time of death in 403 (70%) and alcohol in 259 (45%). Prescriptions of any opioid for pain (61%), oxycodone (50%), benzodiazepines (67%) and antidepressants (55%) were common. Only 15% had received treatment for SUD during the last year. CONCLUSION Oxycodone-related deaths increased in Sweden between 2006 and 2018 in parallel to an increase in oxycodone prescriptions. The increase occurred mainly in older patients being prescribed oxycodone for pain. There might be specific interventions needed to avoid oxycodone-related deaths compared to other opioid-related deaths associated with illicit opioid use.
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Affiliation(s)
- Anna Fugelstad
- Department of Clinical Neuroscience, Karolinska Institute, SE-17177 Stockholm, Sweden.
| | - Gunnar Ågren
- Former National Institute of Public Health, SE-11662 Stockholm, Sweden
| | - Mats Ramstedt
- Department of Clinical Neuroscience, Karolinska Institute, SE-17177 Stockholm, Sweden; Swedish Council for Information on Alcohol and Other Drugs (CAN), SE-11664 Stockholm, Sweden; Department of Public Health Sciences, Stockholm University, SE-10691 Stockholm, Sweden
| | - Ingmar Thiblin
- Department of Surgical Sciences, Section for Forensic Medicine, Uppsala University, SE-75140 Uppsala, Sweden
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27
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Broder JS, Oliveira J E Silva L, Bellolio F, Freiermuth CE, Griffey RT, Hooker E, Jang TB, Meltzer AC, Mills AM, Pepper JD, Prakken SD, Repplinger MD, Upadhye S, Carpenter CR. Guidelines for Reasonable and Appropriate Care in the Emergency Department 2 (GRACE-2): Low-risk, recurrent abdominal pain in the emergency department. Acad Emerg Med 2022; 29:526-560. [PMID: 35543712 DOI: 10.1111/acem.14495] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 03/18/2022] [Accepted: 03/19/2022] [Indexed: 02/07/2023]
Abstract
This second Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-2) from the Society for Academic Emergency Medicine is on the topic "low-risk, recurrent abdominal pain in the emergency department." The multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding four priority questions for adult emergency department patients with low-risk, recurrent, undifferentiated abdominal pain. The intended population includes adults with multiple similar presentations of abdominal signs and symptoms recurring over a period of months or years. The panel reached the following recommendations: (1) if a prior negative computed tomography of the abdomen and pelvis (CTAP) has been performed within 12 months, there is insufficient evidence to accurately identify populations in whom repeat CTAP imaging can be safely avoided or routinely recommended; (2) if CTAP with IV contrast is negative, we suggest against ultrasound unless there is concern for pelvic or biliary pathology; (3) we suggest that screening for depression and/or anxiety may be performed during the ED evaluation; and (4) we suggest an opioid-minimizing strategy for pain control. EXECUTIVE SUMMARY: The GRACE-2 writing group developed clinically relevant questions to address the care of adult patients with low-risk, recurrent, previously undifferentiated abdominal pain in the emergency department (ED). Four patient-intervention-comparison-outcome-time (PICOT) questions were developed by consensus of the writing group, who performed a systematic review of the literature and then synthesized direct and indirect evidence to formulate recommendations, following GRADE methodology. The writing group found that despite the commonality and relevance of these questions in emergency care, the quantity and quality of evidence were very limited, and even fundamental definitions of the population and outcomes of interest are lacking. Future research opportunities include developing precise and clinically relevant definitions of low-risk, recurrent, undifferentiated abdominal pain and determining the scope of the existing populations in terms of annual national ED visits for this complaint, costs of care, and patient and provider preferences.
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Affiliation(s)
- Joshua S Broder
- Department of Surgery, Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Caroline E Freiermuth
- Department of Emergency Medicine, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - Richard T Griffey
- Department of Emergency Medicine and Emergency Care Research Core, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Edmond Hooker
- Department of Health Services Administration, Xavier University, Cincinnati, Ohio, USA
| | - Timothy B Jang
- Department of Emergency Medicine, University of California Los Angeles, UCLA Santa Monica Medical Center, Torrance, California, USA
| | - Andrew C Meltzer
- Department of Emergency Medicine, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Angela M Mills
- Department of Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA.,Society for Academic Emergency Medicine, Des Plaines, Illinois, USA
| | | | | | - Michael D Repplinger
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Suneel Upadhye
- Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Christopher R Carpenter
- Department of Emergency Medicine and Emergency Care Research Core, Washington University School of Medicine, St. Louis, Missouri, USA.,Society for Academic Emergency Medicine, Des Plaines, Illinois, USA
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28
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Ballester P, Muriel J, Peiró AM. CYP2D6 phenotypes and opioid metabolism: the path to personalized analgesia. Expert Opin Drug Metab Toxicol 2022; 18:261-275. [PMID: 35649041 DOI: 10.1080/17425255.2022.2085552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Opioids play a fundamental role in chronic pain, especially considering when 1 of 5 Europeans adults, even more in older females, suffer from it. However, half of them do not reach an adequate pain relief. Could pharmacogenomics help to choose the most appropriate analgesic drug? AREAS COVERED The objective of the present narrative review was to assess the influence of cytochrome P450 2D6 (CYP2D6) phenotypes on pain relief, analgesic tolerability, and potential opioid misuse. Until December 2021, a literature search was conducted through the MEDLINE, PubMed database, including papers from the last 10 years. CYP2D6 plays a major role in metabolism that directly impacts on opioid (tramadol, codeine, or oxycodone) concentration with differences between sexes, with a female trend toward poorer pain control. In fact, CYP2D6 gene variants are the most actionable to be translated into clinical practice according to regulatory drug agencies and international guidelines. EXPERT OPINION CYP2D6 genotype can influence opioids' pharmacokinetics, effectiveness, side effects, and average opioid dose. This knowledge needs to be incorporated in pain management. Environmental factors, psychological together with genetic factors, under a sex perspective, must be considered when you are selecting the most personalized pain therapy for your patients.
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Affiliation(s)
- Pura Ballester
- Neuropharmacology on Pain (NED) group, Alicante Institute for Health and Biomedical Research (ISABIAL Foundation), Alicante, Spain
| | - Javier Muriel
- Neuropharmacology on Pain (NED) group, Alicante Institute for Health and Biomedical Research (ISABIAL Foundation), Alicante, Spain
| | - Ana M Peiró
- Neuropharmacology on Pain (NED) group, Alicante Institute for Health and Biomedical Research (ISABIAL Foundation), Alicante, Spain.,Clinical Pharmacology Unit, Department of Health of Alicante, General Hospital, Alicante, Spain
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29
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Quinn PD, Chang Z, Bair MJ, Rickert ME, Gibbons RD, Kroenke K, D’Onofrio BM. Associations of opioid prescription dose and discontinuation with risk of substance-related morbidity in long-term opioid therapy. Pain 2022; 163:e588-e595. [PMID: 34326295 PMCID: PMC8795234 DOI: 10.1097/j.pain.0000000000002415] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/28/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Efforts to reduce opioid-related harms have decreased opioid prescription but have provoked concerns about unintended consequences, particularly for long-term opioid therapy (LtOT) recipients. Research is needed to address the knowledge gap regarding how risk of substance-related morbidity changes across LtOT and its discontinuation. This study used nationwide commercial insurance claims data and a within-individual design to examine associations of LtOT dose and discontinuation with substance-related morbidity. We identified 194,839 adolescents and adults who initiated opioid prescription in 2010 to 2018 and subsequently received LtOT. The cohort was followed for a median of 965 days (interquartile range, 525-1550), of which a median of 176 days (119-332) were covered by opioid prescription. During follow-up, there were 17,582 acute substance-related morbidity events, defined as claims for emergency visits, inpatient hospitalizations, and ambulance transportation with substance use disorder or overdose diagnoses. Relative to initial treatment, risk was greater within individual during subsequent periods of >60 to 120 (adjusted odds ratio [OR], 1.29; 95% CI, 1.12 to 1.49) and >120 (OR, 1.48; 95% CI, 1.24-1.76) daily morphine milligram equivalents. Risk was also greater during days 1 to 30 after discontinuations than during initial treatment (OR, 1.19; 95% CI, 1.05-1.35). However, it was no greater than during the 30 days before discontinuations, indicating that the risk may not be wholly attributable to discontinuation itself. Results were supported by a negative control pharmacotherapy analysis and additional sensitivity analyses. They suggest that LtOT recipients may experience increased substance-related morbidity risk during treatment subsequent to initial opioid prescription, particularly in periods involving higher doses.
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Affiliation(s)
- Patrick D. Quinn
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington, Indiana
| | - Zheng Chang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Matthew J. Bair
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
- Regenstrief Institute, Indianapolis, Indiana
| | - Martin E. Rickert
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, Indiana
| | - Robert D. Gibbons
- Center for Health Statistics, University of Chicago, Chicago, Illinois
- Department of Medicine, University of Chicago, Chicago, Illinois
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
| | - Kurt Kroenke
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
- Regenstrief Institute, Indianapolis, Indiana
| | - Brian M. D’Onofrio
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, Indiana
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30
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Richards GC, Anwar S, Quinlan J. Averting a UK opioid crisis: getting the public health messages 'right'. J R Soc Med 2022; 115:161-164. [PMID: 35352589 DOI: 10.1177/01410768221089015] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Affiliation(s)
- Georgia C Richards
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, OX2 6GG, UK.,Global Centre on Healthcare and Urbanisation, Kellogg College, University of Oxford, Oxford, OX2 6PN, UK
| | - Sibtain Anwar
- Pain Medicine, Barts Heart Centre and St. Bartholomew's Hospital, EC1A 7BE, London, UK
| | - Jane Quinlan
- Nuffield Department of Anaesthetics, Oxford University Hospitals, NHS Foundation Trust, OX3 9DU, Oxford, UK
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31
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Mauer J, Bullok K, Watt S, Whalen E, Russo L, Junor R, Markman J, Hauber B, Tervonen T. Multi‐method quantitative benefit‐risk assessment of treatments for moderate‐to‐severe osteoarthritis. Br J Clin Pharmacol 2022; 88:3837-3846. [PMID: 35277997 PMCID: PMC9543715 DOI: 10.1111/bcp.15309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 02/23/2022] [Accepted: 03/03/2022] [Indexed: 11/30/2022] Open
Abstract
Objective Demonstrate how benefit‐risk profiles of systemic treatments for moderate‐to‐severe osteoarthritis (OA) can be compared using a quantitative approach accounting for patient preference. Study design and setting This study used a multimethod benefit‐risk modelling approach to quantifiably compare treatments of moderate‐to‐severe OA. In total four treatments and placebo were compared. Comparisons were based on four attributes identified as most important to patients. Patient Global Assessment of Osteoarthritis was included as a favourable effect. Unfavourable effects, or risks, included opioid dependence, nonfatal myocardial infarction and rapidly progressive OA leading to total joint replacement. Clinical data from randomized clinical trials, a meta‐analysis of opioid dependence and a long‐term study of celecoxib were mapped into value functions and weighted with patient preferences from a discrete choice experiment. Results Lower‐dose NGFi had the highest weighted net benefit‐risk score (0.901), followed by higher‐dose NGFi (0.889) and NSAIDs (0.852), and the lowest score was for opioids (0.762). Lower‐dose NGFi was the highest‐ranked treatment option even when assuming a low incidence (0.34% instead of 4.7%) of opioid dependence (ie, opioid benefit‐risk score 808) and accounting for both the uncertainty in clinical effect estimates (first rank probability 46% vs 20% for NSAIDs) and imprecision in patient preference estimates (predicted choice probability 0.26, 95% confidence interval [CI] 0.25‐0.28 vs 0.21, 95% CI 0.19‐0.23 for NSAIDs). Conclusion The multimethod approach to quantitative benefit‐risk modelling allowed the interpretation of clinical data from the patient perspective while accounting for uncertainties in the clinical effect estimates and imprecision in patient preferences.
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Affiliation(s)
| | - Kristin Bullok
- Eli Lilly & Co., Global Patient Safety Indianapolis IN USA
| | | | | | | | | | - John Markman
- Translational Pain Research Program, Department of Neurosurgery University of Rochester Rochester NY USA
| | - Brett Hauber
- Pfizer New York NY
- CHOICE Institute University of Washington School of Pharmacy Seattle WA USA
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Mayoral V. An overview of the use and misuse/abuse of opioid analgesics in different world regions and future perspectives. Pain Manag 2022; 12:535-555. [PMID: 35118876 DOI: 10.2217/pmt-2021-0094] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Opioids are an important therapeutic option for severe resistant chronic pain but, in the absence of proper oversight, their use has risks. The level of prescription opioid misuse/abuse differs among countries, due to differences in healthcare systems and pain management approaches. However, evaluating the true dimension of prescription opioid misuse/abuse is complicated by statistical reporting which often does not differentiate between prescription and illicit opioid use, or between prescription opioid use by patients and nonpatients, highlighting a need for greater uniformity. Parallel efforts to educate patients and the general public about opioid risks, facilitate appropriate analgesic prescribing and identify alternative formulations or options to use instead of or with opioids, may contribute to optimizing prescription opioid use for pain management.
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Affiliation(s)
- Victor Mayoral
- Pain Unit, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
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Heo KN, Ah YM, Lee JY. Risk factors of chronic opioid use after surgical procedures in noncancer patients: A nationwide case-control study. Eur J Anaesthesiol 2022; 39:161-169. [PMID: 33927106 DOI: 10.1097/eja.0000000000001528] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Surgery is an indication for opioid prescription in noncancer patients, and chronic use of opioids is associated with overdose and abuse. OBJECTIVES We aimed to evaluate the prevalence and risk factors associated with chronic opioid use (COU) following surgery among noncancer patients. DESIGN A nationwide case-control study. SETTING Retrospective analysis of the annual national patient sample data from 2012 to 2018 in South Korea. PATIENTS Adults without cancer who had undergone surgery and received noninjectable opioids during hospital stay. MAIN OUTCOME MEASURES COU during 3 months following surgery. RESULTS A total of 15 543 participants were included, and the prevalence overall and in opioid-naïve users was 8.1 and 5.7%, respectively. Prior exposure patterns of opioids [intermittent user, adjusted odds ratio (aOR) 2.35; 95% CI, 2.00 to 2.77, and continuous user, aOR 8.58; 95% CI, 6.54 to 11.24] and concomitant use of benzodiazepine (in continuous user, aOR 18.60; 95% CI 11.70 to 29.55) were strongly associated with COU compared with naïve users. Morphine milligram equivalent, type of opioid strength at discharge and prescription of nonopioid analgesics at discharge were also associated with COU. Compared with minor surgery, knee (aOR 1.49; 95% CI 1.17 to 1.89), spine (aOR 1.65; 95% CI 1.33 to 2.06) and shoulder (aOR 2.54; 95% CI 1.97 to 3.27) procedures showed a significantly positive association with COU. Sensitivity analysis in opioid-naïve patients showed similar results. CONCLUSION About 8.1% of noncancer patients who had undergone surgery and were prescribed noninjectable opioids became chronic opioid users in Korea. Identified risk factors could be used to derive strategies for safe opioid use in noncancer patients in the future.
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Affiliation(s)
- Kyu-Nam Heo
- From the College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul (KN-H, JY-L) and College of Pharmacy, Yeungnam University, Gyeongsan-si, Republic of Korea (YM-A)
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34
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Opioid Prescription Following Wrist and Ankle Fracture Fixation in Scotland—Tradition Prevails. J Clin Med 2022; 11:jcm11020468. [PMID: 35054162 PMCID: PMC8781195 DOI: 10.3390/jcm11020468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/22/2021] [Accepted: 01/10/2022] [Indexed: 12/10/2022] Open
Abstract
The American ‘opioid crisis’ is rapidly spreading internationally. Perioperative opioid use increases the risk of long-term opioid use. We review opioid use following wrist and ankle fracture fixation across Scotland, establishing prescribing patterns and associations with patient, injury, or perioperative factors. Six Scottish orthopedic units contributed. A total of 598 patients were included. Patient demographics were similar across all sites. There was variation in anesthetic practice, length of stay, and AO fracture type (p < 0.01). For wrist fractures, 85.6% of patients received a discharge opioid prescription; 5.0% contained a strong opioid. There was no significant variation across the six units in prescribing practice. For ankle fractures, 82.7% of patients received a discharge opioid prescription; 17% contained a strong opioid. Dundee and Edinburgh used more strong opioids; Inverness and Paisley gave the least opioids overall (p < 0.01). Younger patient age, location, and length of stay were independent predictors of increased prescription on binary regression. Despite variability in perioperative practices, discharge opioid analgesic prescription remains overwhelmingly consistent. We believe that the biggest influence lies with the prescriber-institutional ‘standard practice’. Education of these prescribing clinicians regarding the risk profile of opioids is key to reducing their use following surgery, thus lowering long-term opioid dependence.
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Farrar JT, Bilker WB, Cochetti PT, Argoff CE, Haythornthwaite J, Katz NP, Gilron I. Evaluating the stability of opioid efficacy over 12 months in patients with chronic noncancer pain who initially demonstrate benefit from extended release oxycodone or hydrocodone: harmonization of Food and Drug Administration patient-level drug safety study data. Pain 2022; 163:47-57. [PMID: 34261978 PMCID: PMC8675053 DOI: 10.1097/j.pain.0000000000002331] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 04/22/2021] [Accepted: 04/28/2021] [Indexed: 11/25/2022]
Abstract
ABSTRACT Opioids relieve acute pain, but there is little evidence to support the stability of the benefit over long-term treatment of chronic noncancer pain. Previous systematic reviews consider only group level published data which did not provide adequate detail. Our goal was to use patient-level data to explore the stability of pain, opioid dose, and either physical function or pain interference in patients treated for 12 months with abuse deterrent formulations of oxycodone and hydrocodone. All available studies in the Food and Drug Administration Document Archiving, Reporting, and Regulatory Tracking System were included. Patient-level demographics, baseline data, exposure, and outcomes were harmonized. Individual patient slopes were calculated from a linear model of pain, physical function, and pain interference to determine response over time. Opioid dose was summarized by change between baseline and the final month of observation. Patients with stable or less pain, stable or lower opioid dose, and stable or better physical function (where available) met our prespecified criteria for maintaining long-term benefit from chronic opioids. Of the complete data set of 3192 patients, 1422 (44.5%) maintained their pain level and opioid dose. In a secondary analysis of 985 patients with a measured physical function, 338 (34.3%) maintained their physical function in addition to pain and opioid dose. Of 2040 patients with pain interference measured, 788 (38.6%) met criteria in addition. In a carefully controlled environment, about one-third of patients successfully titrated on opioids to treat chronic noncancer pain demonstrated continued benefit for up to 12 months.
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Affiliation(s)
- John T. Farrar
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, United States
| | - Warren B. Bilker
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, United States
| | - Philip T. Cochetti
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, United States
| | - Charles E. Argoff
- Department of Neurology, Albany Medical Center, Albany, NY, United States
| | - Jennifer Haythornthwaite
- Department of Psychiatry & Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Nathaniel P. Katz
- Adjunct, Department of Anesthesia, Tufts University School of Medicine and Chief Science Officer, Analgesic Solutions, Boston, MA, United States
| | - Ian Gilron
- Department of Anesthesiology and Perioperative Medicine, Queens University School of Medicine, Kingston, ON, Canada
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Lavergne J, Debin M, Blanchon T, Colizza V, Dassieu L, Gimenez L, Kengne-Kuetche C, Lapeyre-Mestre M, Dupouy J. Perceived risk of opioid use disorder secondary to opioid analgesic medication use by the general population in France. Eur J Pain 2021; 26:729-739. [PMID: 34958720 DOI: 10.1002/ejp.1901] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 11/15/2021] [Accepted: 12/19/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND In Europe and France, the use of opioid analgesic drugs has become widespread as an option for pain management. However, their use can lead to nonmedical use and/or opioid use disorder (OUD). This work aimed to assess the perceived risk of OUD secondary to opioid analgesic drugs use by the general population. METHODS We conducted a cross-sectional observational study using the GrippeNet web-based cohort, comprising about 10,000 French volunteers from the general population, using a self-administered questionnaire. The main outcome was the perceived risk of OUD secondary to opioid analgesic drugs use, assessed by a 4-item scale and modeled using logistic regression (backward procedure). RESULTS Among 5,046 French respondents, after adjustment, 65% believed that the use of analgesic drugs could likely or very likely lead to OUD. Factors associated with perception of a higher risk were being over 50 and having heard about opioids in the media. Previous opioid use and a high level of education decreased the perception of the risk. Among those having used opioids in the past two years (N = 1770), 71.1% reported being not at all concerned by this risk. The majority of the sample perceived the risk of OUD but those having already used opioid analgesics drugs expressed no concern about this risk for themselves. CONCLUSIONS This finding highlight the need to reinforce warning on the package insert documents, therapeutic education and collaborative care between the prescribing general practitioners and pharmacists to increase awareness of opioid medications users on the risk of OUD.
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Affiliation(s)
- Justine Lavergne
- Département Universitaire de Médecine Générale, Université de Toulouse; Faculté de Médecine, 133 route de Narbonne, 31063, Toulouse, France
| | - Marion Debin
- Sorbonne Université, Inserm, Institut Pierre Louis d'Epidémiologie et de Santé Publique, IPLESP, F-75012, Paris, France
| | - Thierry Blanchon
- Sorbonne Université, Inserm, Institut Pierre Louis d'Epidémiologie et de Santé Publique, IPLESP, F-75012, Paris, France
| | - Vittoria Colizza
- Sorbonne Université, Inserm, Institut Pierre Louis d'Epidémiologie et de Santé Publique, IPLESP, F-75012, Paris, France
| | - Lise Dassieu
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, 850 rue Saint Denis, Montréal, QC, H2X0A9, Canada
| | - Laetitia Gimenez
- Département Universitaire de Médecine Générale, Université de Toulouse; Faculté de Médecine, 133 route de Narbonne, 31063, Toulouse, France.,CERPOP, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - Charly Kengne-Kuetche
- Sorbonne Université, Inserm, Institut Pierre Louis d'Epidémiologie et de Santé Publique, IPLESP, F-75012, Paris, France
| | - Maryse Lapeyre-Mestre
- CEIP-Addictovigilance, CIC 1436, Service de Pharmacologie Médicale et Clinique, Faculté de Médecine, 37 allées Jules Guesde, 31000, Toulouse, France
| | - Julie Dupouy
- Département Universitaire de Médecine Générale, Université de Toulouse; Faculté de Médecine, 133 route de Narbonne, 31063, Toulouse, France.,CERPOP, Université de Toulouse, Inserm, UPS, Toulouse, France
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Halsey E, Truoccolo DS. A Retrospective Comparison of Intravenous Opioid Use for Abdominal Pain in the Emergency Department After Implementation of Order Set Restriction. J Emerg Med 2021; 62:224-230. [PMID: 34893382 DOI: 10.1016/j.jemermed.2021.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/18/2021] [Accepted: 10/12/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study was developed to provide insight into the effects of an i.v. opioid order set on prescribing of i.v. opioids in the emergency department (ED) for nontraumatic, unspecified abdominal pain. Research is needed in this area to catalyze more consistent and evidence-based i.v. opioid prescribing. OBJECTIVE This study aimed to show the impact of an i.v. opioid order set restriction. Secondary objectives were the change in ED length of stay, change in pain score, total i.v. opioid morphine milligram equivalents, and number of i.v. opioid doses. METHODS Patients included in the study visited the ED with a relevant ICD-10-CM diagnosis code for nontraumatic, unspecified abdominal pain 3 months prior to or 3 months after the restriction. A sample size of 596 patients was calculated for 80% power to identify a 25% difference in the primary outcome. RESULTS There was a statistically significant decrease in i.v. opioid administration after the restriction (44.2% preintervention, 23.2% postintervention; p < 0.001). Mean length of stay decreased from 6.6 h to 6.2 h (p < 0.05). There was no statistically significant difference in pain scores. Oral opioid use increased significantly (20.5% preintervention, 31.7% postintervention; p < 0.001); therefore, combined i.v. and oral opioid use did not change significantly. CONCLUSIONS The restriction correlated with a decrease in i.v. opioids. Pain control was not diminished as a result of the restriction. The results of this study may be used to generate hypotheses for comparing different modes of pain management in the ED in this patient population and others. Future studies should continue to evaluate the impact of oral vs. i.v. opioids.
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Affiliation(s)
- Emily Halsey
- University of Virginia Health System, Charlottesville, Virginia
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38
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Mattia C, Luongo L, Innamorato M, Melis L, Sofia M, Zappi L, Puntillo F. An Italian Expert Consensus on the Use of Opioids for the Management of Chronic Non-Oncological Pain in Clinical Practice: Focus on Buprenorphine. J Pain Res 2021; 14:3193-3206. [PMID: 34675646 PMCID: PMC8519776 DOI: 10.2147/jpr.s314206] [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: 04/15/2021] [Accepted: 07/30/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose The aim of the present work was to evaluate the knowledge and prescriptive habits of clinicians involved in the management of chronic non cancer pain (CNCP), with a special focus on the use of opioids. Methods A Delphi method was used. A Board of specialists elaborated and discussed a series of statements, based on available literature and personal clinical expertise, about particularly controversial topics on pain pathophysiology and treatment. A Panel of experts in the field of pain management, selected by the Board, was invited to vote the proposed statements, indicating the level of agreement on a 5-point Likert scale (1: strongly disagree; 2: disagree; 3: partially agree; 4: agree; 5: strongly agree). The threshold for consensus was set at minimum 66.6% of the number of respondents with a level of agreement ≥4 (Agree or Strongly agree). Results The Board included 5 pain therapists, 1 pharmacologist and 1 methodology expert and drew up a total of 36 statements (for a total of 40 requested answers)”. A total of 100 clinicians were included in the Expert Panel. Respondents were 89 (89%). Consensus was achieved for 32 out of 40 answers. Most of the lack of consensus was recorded for statements regarding opioids use, and resulted from a low level of agreement (3 on the Likert scale), suggesting a neutral position deriving from a lack of knowledge rather than a strong contrary opinion. Conclusion Most of the proposed items reached consensus, suggesting a generally homogeneous approach to CNCP management. However, the lack of consensus recorded for several items regarding opioid use confirms the need to fill important gaps in the knowledge of available agents. A clear explanation of the peculiar pharmacological properties of drugs associated with potential clinical advantages (such as buprenorphine) will help optimize pain treatment in both primary care and hospital settings and improving pain control in CNCP patients.
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Affiliation(s)
- Consalvo Mattia
- Department of Medical and Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, "Sapienza" University of Rome, Rome, Italy.,Anesthesia, Intensive Care and Pain Unit, ICOT-Polo Pontino, Latina, Italy
| | - Livio Luongo
- Department of Experimental Medicine, Division of Pharmacology, University of Campania "L. Vanvitelli", Naples, Italy.,NEUROMED, Pozzilli, Italy
| | - Massimo Innamorato
- Pain Therapy Unit, AUSL Romagna, S.M.Croci Hospital Ravenna, Ravenna, Italy
| | | | - Michele Sofia
- Department of Palliative Care and Pain Therapy, ASST Rodhense, Garbagnate Milanese, Itlay
| | - Lucia Zappi
- UOC Antalgic Therapy, Emergency and Acceptance Department, San Martino Polyclinic Hospital, Genoa, Italy
| | - Filomena Puntillo
- Department of Interdisciplinary Medicine, "Aldo Moro" University of Bari, Bari, 70124, Italy.,Anesthesia, Intensive Care and Pain Unit, Policlinico Hospital of Bari, Bari, 70124, Italy
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Jin Z, Zhu M, Gupta A, Page C, Gan TJ, Bergese SD. Evaluating oliceridine as a treatment option for moderate to severe acute post-operative pain in adults. Expert Opin Pharmacother 2021; 23:9-17. [PMID: 34534033 DOI: 10.1080/14656566.2021.1982893] [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] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Despite the advances in regional anesthesia and non-opioid systemic analgesia, opioids remain the primary rescue analgesic for moderate to severe pain. However, the risks and side effects of opioid medications are well documented. Oliceridine is a novel opioid receptor agonist which is thought to have less risk of adverse events, such as postoperative nausea and vomiting (PONV) and respiratory depression. AREAS COVERED In this review, the authors discuss the limitations of the current opioid and non-opioid analgesic options. They also review the pharmacokinetics of oliceridine, its analgesic efficacy, and risk of adverse events; and its added clinical value in managing moderate to severe pain. EXPERT OPINION Despite the advances in regional anesthesia and multimodal systemic analgesia, opioid free analgesia is only feasible in selected procedures and patients. Oliceridine is effective in the management of moderate to severe pain and appears to be associated with lower risk of nausea and vomiting. The risk of sedation and respiratory depression associated with oliceridine will require further study. The availability of an opioid agonist with a better side effect profile could potentially change the current paradigm of opioid avoidance in postoperative pain management.
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Affiliation(s)
- Zhaosheng Jin
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY, USA
| | - Mingxi Zhu
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY, USA
| | - Abhishek Gupta
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY, USA
| | - Christopher Page
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY, USA
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY, USA
| | - Sergio D Bergese
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY, USA.,Department of Neurosurgery, Stony Brook University Health Science Center, Stony Brook, NY, USA
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Paljarvi T, Strang J, Quinn PD, Luciano S, Fazel S. Abuse-deterrent extended-release oxycodone and risk of opioid-related harm. Addiction 2021; 116:2409-2415. [PMID: 33394528 PMCID: PMC8363193 DOI: 10.1111/add.15392] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 08/05/2020] [Accepted: 12/23/2020] [Indexed: 01/05/2023]
Abstract
AIM To establish and quantify the association between abuse-deterrent formulation (ADF) oxycodone and 1-year risk of opioid-related harm. DESIGN Propensity score-matched cohort study of electronic medical records for years 2014-18, with patients followed up for 1 year after their index health-care visit. SETTING More than 70 million patients from 56 US health-care organizations. PARTICIPANTS Patients aged 18-64 years at index health-care visit with any indication for an oral opioid analgesic, with no past 12-month history of oral oxycodone use or substance use disorder, and who were alive at the end of the 1-year follow-up (new episode of prescription oral ADF oxycodone [OxyContin], n = 45 045; new episode of non-ADF oxycodone opioid preparation, n = 1 377 359). MEASUREMENTS International Classification of Diseases diagnoses of any opioid-related disorder or non-fatal opioid poisoning within 1 year of the index health-care visit. Pooled odds ratios (OR) with 95% confidence intervals (95% CI). FINDINGS After propensity score matching, 89 802 patients with a mean age of 44 [standard deviation (SD) = 11] years (62% women, 68% white) were included. During 1-year follow-up, 1445 diagnoses of opioid use disorder or opioid poisoning occurred in the ADF oxycodone cohort (34.8/1000 person-years) and 765 occurred in the non-ADF oxycodone cohort (18.2/1000 person-years). The odds of opioid-related adverse outcomes were increased in the ADF oxycodone cohort compared with the non-ADF oxycodone opioid cohort, including for opioid use disorders (OR = 2.02; 95% CI = 1.83, 2.23) and opioid poisoning (OR = 1.64 95% CI = 1.35, 1.99). CONCLUSIONS Patients with a new prescription of abuse-deterrent formulation oxycodone may be at increased risk of opioid-related harm.
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Affiliation(s)
- Tapio Paljarvi
- Department of Psychiatry, Oxford University, United Kingdom
| | - John Strang
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, United Kingdom
| | - Patrick D. Quinn
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington, USA
| | | | - Seena Fazel
- Department of Psychiatry, Oxford University, United Kingdom
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Beneficial Effects of Opioid Rotation to Buprenorphine/Naloxone on Opioid Misuse, Craving, Mental Health, and Pain Control in Chronic Non-Cancer Pain Patients with Opioid Use Disorder. J Clin Med 2021; 10:jcm10163727. [PMID: 34442024 PMCID: PMC8396821 DOI: 10.3390/jcm10163727] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/17/2021] [Accepted: 08/18/2021] [Indexed: 12/12/2022] Open
Abstract
Patients with chronic non-cancer pain (CNCP) often use opioids for long periods of time. This may lead to opioid use disorder (OUD) and psychiatric symptoms: mainly depression and anxiety. The current study investigated the effect of buprenorphine/naloxone (BuNa) rotation on opioid misuse, craving, psychiatric symptoms and pain in patients with CNCP and OUD. Forty-three participants with CNCP and OUD were converted from a full mu-receptor agonist opioid (mean morphine equivalent dose: 328.3 mg) to BuNa, in an inpatient setting. Opioid misuse, craving, co-occurring psychiatric symptoms, and pain perception were determined at baseline and after a two-month follow-up, using the following self-report questionnaires: Current Opioid Misuse Measurement (COMM), Visual Analog Scale (VAS-craving and VAS-pain) and Depression, Anxiety and Stress Scale (DASS), respectively. VAS-craving and VAS-pain were also determined immediately after conversion. A total of 37 participants completed the protocol. The mean COMM decreased from 17.1 to 6.7 (F = 36.5; p < 0.000), the mean VAS-craving decreased from 39.3 to 5.3 (−86.6%; F = 26.5, p < 0.000), the mean DASS decreased from 12.1 to 6.6 (F = 56.3, p < 0.000), and the mean VAS-pain decreased from 51.3 to 37.2 (−27.4%, F = 3.3; p = 0.043). Rotation to BuNa in patients with CNCP and OUD was accompanied by reductions in (i) opioid misuse, (ii) opioid craving, (iii) the severity of co-occurring psychiatric symptoms, and (iv) self-reported pain. BuNa as opioid agonist treatment may therefore be a beneficial strategy in CNCP patients with OUD. The limited sample size and the observational nature of this study underline the need for the replication of the current findings in large-scale, controlled studies.
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Nadeau SE, Wu JK, Lawhern RA. Opioids and Chronic Pain: An Analytic Review of the Clinical Evidence. FRONTIERS IN PAIN RESEARCH 2021; 2:721357. [PMID: 35295493 PMCID: PMC8915556 DOI: 10.3389/fpain.2021.721357] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 07/16/2021] [Indexed: 12/11/2022] Open
Abstract
We conducted an analytic review of the clinical scientific literature bearing on the use of opioids for treatment of chronic non-cancer pain in the United States. There is substantial, albeit not definitive, scientific evidence of the effectiveness of opioids in treating pain and of high variability in opioid dose requirements and side effects. The estimated risk of death from opioid treatment involving doses above 100 MMED is ~0.25%/year. Multiple large studies refute the concept that short-term use of opioids to treat acute pain predisposes to development of opioid use disorder. The prevalence of opioid use disorder associated with prescription opioids is likely <3%. Morbidity, mortality, and financial costs of inadequate treatment of the 18 million Americans with moderate to severe chronic pain are high. Because of the absence of comparative effectiveness studies, there are no scientific grounds for considering alternative non-pharmacologic treatments as an adequate substitute for opioid therapy but these treatments might serve to augment opioid therapy, thereby reducing dosage. There are reasons to question the ostensible risks of co-prescription of opioids and benzodiazepines. As the causes of the opioid crisis have come into focus, it has become clear that the crisis resides predominantly in the streets and that efforts to curtail it by constraining opioid treatment in the clinic are unlikely to succeed.
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Affiliation(s)
- Stephen E. Nadeau
- Research Service and the Brain Rehabilitation Research Center, Malcom Randall VA Medical Center and the Department of Neurology, University of Florida College of Medicine, Gainesville, FL, United States
- *Correspondence: Stephen E. Nadeau
| | | | - Richard A. Lawhern
- Independent Researcher and Patient Advocate, Fort Mill, SC, United States
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Bailey J, Nafees S, Jones L, Poole R. Rationalisation of long-term high-dose opioids for chronic pain: development of an intervention and conceptual framework. Br J Pain 2021; 15:326-334. [PMID: 34381614 PMCID: PMC8339941 DOI: 10.1177/2049463720958731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
There has been a large increase in the number of prescriptions for opioid drugs in the United Kingdom over the last 20 years or more and the prescribing of opioids in high doses continues to increase. Much opioid prescribing is for chronic non-cancer pain (CNCP) despite serious doubts about the long-term effectiveness of opioids for this indication. Clinical experience is that there are increasing numbers of patients who are on high dosages of opioid drugs over sustained periods which provide limited or no pain relief while having significant negative effects on functioning and quality of life. The aim of this article is to bring readers' attention to some clinical observations of the CNCP population with high doses and to describe an intervention to reduce these doses. Many of these patients have no clinical features of addiction; we suggest that those who show little or no substance misuse behaviours are best understood as a distinct clinical population who have different treatment needs. In order to understand and treat these patients, a model is required which, rather than seeing the problem as lying solely with the patient, focuses on the interaction between the individual and his or her environment and seeks a change in what the patient does every day, rather than a simple, and largely unattainable, goal of symptom elimination. The clinician authors worked together to develop an intervention based upon approaches taken from both pain management and psychiatric practice. A detailed description of this rapid opioid reduction intervention (RORI) is provided along with some preliminary outcome data.
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Affiliation(s)
- John Bailey
- Centre for Mental Health and
Society, Bangor University, Wrexham, UK
| | - Sadia Nafees
- Centre for Mental Health and
Society, Bangor University, Wrexham, UK
| | - Lucy Jones
- Betsi Cadwaladr University Health
Board, Wrexham, UK
| | - Rob Poole
- Centre for Mental Health and
Society, Bangor University, Wrexham, UK
- Betsi Cadwaladr University Health
Board, Wrexham, UK
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Worsham CM, Woo J, Jena AB, Barnett ML. Adverse Events And Emergency Department Opioid Prescriptions In Adolescents. Health Aff (Millwood) 2021; 40:970-978. [PMID: 34097510 DOI: 10.1377/hlthaff.2020.01762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Understanding the risks associated with opioid prescription in adolescents is critical for informing opioid policy, but the risks are challenging to quantify given the lack of randomized trial data. Using a regression discontinuity design, we exploited a discontinuous increase in opioid prescribing in the emergency department (ED) when adolescents transition from "child" to "adult" at age eighteen to estimate the effect of an ED opioid prescription on subsequent opioid-related adverse events. We found that adolescent patients just over age eighteen were similar to those just under age eighteen, but they were 9.7 percent more likely to be prescribed an opioid and 12.6 percent more likely to have an adverse opioid-related event, defined as overdose, diagnosis of opioid use disorder, or long-term opioid use, within one year. We estimated a 14.1 percent increased risk for an adverse outcome when "adults" just over age eighteen were prescribed opioids that would not have been prescribed if they were just under age eighteen and considered "children." Our results suggest that differences in care provided in pediatric versus adult care settings may be important to understanding prescribers' roles in the opioid epidemic.
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Affiliation(s)
- Christopher M Worsham
- Christopher M. Worsham is a clinical and research fellow in the Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, and the Department of Health Care Policy, Harvard Medical School, in Boston, Massachusetts
| | - Jaemin Woo
- Jaemin Woo is a research assistant in the Department of Health Care Policy, Harvard Medical School
| | - Anupam B Jena
- Anupam B. Jena is the Ruth L. Newhouse Associate Professor of Health Care Policy in the Department of Health Care Policy at Harvard Medical School and a scientific adviser at Precision Health Economics, Inc., in Los Angeles, California
| | - Michael L Barnett
- Michael L. Barnett is an assistant professor in the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, and an assistant professor of medicine at Harvard Medical School
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Nortriptyline for pain in knee osteoarthritis: a double-blind randomised controlled trial in New Zealand general practice. Br J Gen Pract 2021; 71:e538-e546. [PMID: 33571950 PMCID: PMC8177953 DOI: 10.3399/bjgp.2020.0797] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 01/10/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Osteoarthritis (OA) of the knee is a common cause of chronic pain. Analgesics that are currently available have limited efficacy and may be poorly tolerated. Tricyclic antidepressants are used as analgesics for other chronic conditions, but they have not been evaluated as analgesics in OA. AIM To investigate the analgesic efficacy of nortriptyline in people with knee OA. DESIGN AND SETTING A two-arm, parallel-group, 1:1, double-blind, randomised, placebo-controlled trial in Christchurch, New Zealand. METHOD Participants were recruited from orthopaedic outpatient clinics, primary care, and through public advertising. Adults with knee OA and a pain score of ≥20 points on the 50-point Western Ontario and McMaster University Osteoarthritis Index (WOMAC) pain subscale were randomised to receive either nortriptyline or identical placebo for 14 weeks. The primary outcome was knee pain at 14 weeks measured using the WOMAC pain subscale. Secondary outcomes included: function; stiffness; non-steroidal anti-inflammatory drug, opioid, and/or paracetamol use; each participant's global assessment; and adverse effects at 14 weeks. RESULTS Of the 205 randomised participants, 201 (98.0%) completed follow-up at 14 weeks. The baseline-adjusted mean WOMAC pain subscale score at week 14 was 6.2 points lower (95% confidence interval = -0.26 to 12.6, P = 0.06) in the nortriptyline arm versus the placebo arm. Differences in secondary outcomes generally favoured the nortriptyline arm, but were small and unlikely to be clinically relevant. However, the following were all more commonly reported by participants taking nortriptyline than those taking a placebo: dry mouth (86.9% versus 51.0%, respectively, P<0.001), constipation (58.6% versus 30.4%, respectively, P<0.001), and sweating (31.3% versus 20.6%, respectively, P = 0.033). CONCLUSION This study suggests nortriptyline does not significantly reduce pain in people with knee OA. The adverse effect profile was as expected.
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Omaki E, Castillo R, McDonald E, Eden K, Davis S, Frattaroli S, Rothman R, Shields W, Gielen A. A patient decision aid for prescribing pain medication: Results from a pilot test in two emergency departments. PATIENT EDUCATION AND COUNSELING 2021; 104:1304-1311. [PMID: 33280968 DOI: 10.1016/j.pec.2020.11.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 11/16/2020] [Accepted: 11/18/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE This study piloted a patient education and decision aid tool about prescription pain relievers to determine potential impact on: comfort receiving an opioid prescription; knowledge about opioids; decisional conflict about whether to take an opioid; and shared decision making with the prescribing physician. METHODS Patients with acute pain were recruited from two emergency departments (ED), and randomized to complete the tool (N = 65) or a time-matched control (N = 59) on a tablet. Data collection involved: a baseline survey; a post-test immediately following the assigned program; a discharge survey after seeing the physician; and a 6-week follow-up survey. RESULTS Knowledge increased and comfort receiving an opioid decreased as hypothesized, but did not reach statistical significance. Despite the lack of knowledge differences, the tool had significant positive impact on patients feeling more informed and experiencing less decisional conflict. Shared decision making with the prescribing physician was not impacted. CONCLUSION A patient decision aid can help ED patients feel more informed and less conflicted about prescription pain relievers but did not impact shared decision-making. PRACTICE IMPLICATIONS Patient education programs implemented in the ED should consider engaging physicians in the program to help to promote patient-centered approaches in the treatment of acute pain.
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Affiliation(s)
- Elise Omaki
- Johns Hopkins Center for Injury Research and Policy, Department of Health Policy & Management, Johns Hopkins School of Public Health, Baltimore, MD, 21205, United States.
| | - Renan Castillo
- Johns Hopkins Center for Injury Research and Policy, Department of Health Policy & Management, Johns Hopkins School of Public Health, Baltimore, MD, 21205, United States
| | - Eileen McDonald
- Johns Hopkins Center for Injury Research and Policy, Department of Health Policy & Management, Johns Hopkins School of Public Health, Baltimore, MD, 21205, United States
| | - Karen Eden
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, OR, 97239, United States
| | - Stephen Davis
- WVU Injury Control and Research Center, West Virginia University, Morgantown, WV, 26506, United States
| | - Shannon Frattaroli
- Johns Hopkins Center for Injury Research and Policy, Department of Health Policy & Management, Johns Hopkins School of Public Health, Baltimore, MD, 21205, United States
| | - Richard Rothman
- Johns Hopkins Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD, 21287, United States
| | - Wendy Shields
- Johns Hopkins Center for Injury Research and Policy, Department of Health Policy & Management, Johns Hopkins School of Public Health, Baltimore, MD, 21205, United States
| | - Andrea Gielen
- Johns Hopkins Center for Injury Research and Policy, Department of Health Policy & Management, Johns Hopkins School of Public Health, Baltimore, MD, 21205, United States
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Affiliation(s)
- Patrick D Quinn
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington
| | - Kurt Kroenke
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Brian M D'Onofrio
- Department of Psychological and Brain Sciences, Indiana University, Bloomington
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Larsson V, Nordenson C, Karling P. Long-term postoperative opioid prescription after cholecystectomy or gastric by-pass surgery: a retrospective observational study. Scand J Pain 2021; 21:569-576. [PMID: 33838096 DOI: 10.1515/sjpain-2020-0150] [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: 09/23/2020] [Accepted: 03/21/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Opioids are commonly prescribed post-surgery. We investigated the proportion of patients who were prescribed any opioids 6-12 months after two common surgeries - laparoscopic cholecystectomy and gastric by-pass (GBP) surgery. A secondary aim was to examine risk factors prior to surgery associated with the prescription of any opioids after surgery. METHODS We performed a retrospective observational study on data from medical records from patients who underwent cholecystectomy (n=297) or GBP (n=93) in 2018 in the Region of Västerbotten, Sweden. Data on prescriptions for opioids and other drugs were collected from the patients` medical records. RESULTS There were 109 patients (28%) who were prescribed opioids after discharge from surgery but only 20 patients (5%) who still received opioid prescriptions 6-12 months after surgery. All 20 of these patients had also been prescribed opioids within three months before surgery, most commonly for back and joint pain. Only 1 out of 56 patients who were prescribed opioids preoperatively due to gallbladder pain still received prescriptions for opioids 6-12 months after surgery. Although opioid use in the early postoperative period was more common among patients who underwent cholecystectomy, the patients who underwent GBP were more prone to be "long-term" users of opioids. In the patients who were prescribed opioids within three months prior to surgery, 8 out of 13 patients who underwent GBP and 12 of the 96 patients who underwent cholecystectomy were still prescribed opioids 6-12 months after surgery (OR 11.2; 95% CI 3.1-39.9, p=0,0002). Affective disorders were common among "long-term" users of opioids and prior benzodiazepine and amitriptyline use were significantly associated with "long-term" opioid use. CONCLUSIONS The proportion of patients that used opioids 6-12 months after cholecystectomy or GBP was low. Patients with preoperative opioid-use experienced a significantly higher risk of "long-term" opioid use when undergoing GBP compared to cholecystectomy. The indication for being prescribed opioids in the "long-term" were mostly unrelated to surgery. No patient who was naïve to opioids prior surgery was prescribed opioids 6-12 months after surgery. Although opioids are commonly prescribed in the preoperative and in the early postoperative period to patients with gallbladder disease, there is a low risk that these prescriptions will lead to long-term opioid use. The reasons for being prescribed opioids in the long-term are often due to causes not related to surgery.
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Affiliation(s)
- Viktoria Larsson
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Cecilia Nordenson
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Pontus Karling
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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Prescribing Patterns of Pain Medications in Unspecific Low Back Pain in Primary Care: A Retrospective Analysis. J Clin Med 2021; 10:jcm10071366. [PMID: 33810469 PMCID: PMC8036853 DOI: 10.3390/jcm10071366] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 03/23/2021] [Indexed: 12/02/2022] Open
Abstract
Acute low back pain (LBP) is one of the most prevalent diseases worldwide. Since there is evidence of excessive prescriptions of analgesics, i.e., opioids, the aim of this study was to describe the use of pain medications in patients with LBP in the Swiss primary care setting. A retrospective, observational study was performed using medical prescriptions of 180 general practitioners (GP) during years 2009–2020. Patterns of pain medications (nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol, and opioids) as well as co-medications were analyzed in patients with a LBP diagnosis. Univariable and multivariable regression analyses assessed GP and patient characteristics associated with the prescription of pain medication. Patients included were 10,331 (mean age 51.7 years, 51.2% female); 6449 (62.4%) received at least one pain medication and of these 86% receive NSAIDs and 22% opioids. GP characteristics (i.e., self-employment status) and patient characteristics (male gender and number of consultations) were associated with significantly higher odds of receiving any pain medication in multivariable analysis. 3719 patients (36%) received co-medications. Proton-pump-inhibitors and muscle relaxants were the most commonly used co-medications. In conclusion, two-thirds of LBP patients were treated with pain medications. Prescribing patterns were conservative, with little use of strong opioids and co-medications.
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Liu JY, Anderson JC, Franklin JS, Gesek FA, Soybel DI. Nudging patients and surgeons to change ambulatory surgery pain management: Results from an opioid buyback program. Surgery 2021; 170:485-492. [PMID: 33676733 DOI: 10.1016/j.surg.2021.01.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 12/18/2020] [Accepted: 01/14/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Optimal postoperative opioid stewardship combines adequate pain medication to control expected discomfort while avoiding abuse and community diversion of unused prescribed opioids. We hypothesized that an opioid buyback program would motivate patients to return unused opioids, and surgeons will use that data to calibrate prescribing. METHODS Prospective cohort study of postambulatory surgery pain management at a level II Veterans Affairs rural hospital (2017-2019). Eligible patients were offered $5/unused opioid pill ($50 limit) returned to our Veterans Affairs hospital for proper disposal. After 6 months, buyback data was shared with each surgical specialty. RESULTS Overall, 934 of 1,880 (49.7%) eligible ambulatory surgery patients were prescribed opioids and invited to participate in the opioid buyback. We had 281 patients (30%) return 3,165 unused opioid pills; this return rate remained constant over the study period. In 2017, 62.4% of patients were prescribed an opioid; after data was shared with providers, prescriptions for opioids were reduced to 50.7% and 38.3% of eligible patients in 2018 and 2019, respectively (P < .0001). The median morphine milligram equivalents prescribed also decreased from 108.8 morphine milligram equivalents in 2017 to 75.0 morphine milligram equivalents in 2018 and sustained at 75.0 morphine milligram equivalents in 2019 (P < .001). Surgical providers, surgeries performed, patient characteristics, and 30-day refill rates were similar throughout the study period. CONCLUSION A small financial incentive resulted in patients returning unused opioids after ambulatory surgery. Feedback to surgeons regarding opioids returned reduced the proportion of patients prescribed an opioid and the amount of opioid after ambulatory surgery without an increase in refills.
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Affiliation(s)
- Jean Y Liu
- VA Medical Center, White River Junction, VT; The Geisel School of Medicine at Dartmouth College, Hanover, NH.
| | - Joseph C Anderson
- VA Medical Center, White River Junction, VT; The Geisel School of Medicine at Dartmouth College, Hanover, NH; University of Connecticut School of Medicine, Farmington, CT
| | - Julie S Franklin
- VA Medical Center, White River Junction, VT; The Geisel School of Medicine at Dartmouth College, Hanover, NH. https://twitter.com/JulieFr87732501
| | - Frank A Gesek
- VA Medical Center, White River Junction, VT. https://twitter.com/FrankGesek
| | - David I Soybel
- VA Medical Center, White River Junction, VT; The Geisel School of Medicine at Dartmouth College, Hanover, NH. https://twitter.com/DSoybel
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