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Mukhida K, Sedighi S, Hart C. Popcorn in the pain clinic: A content analysis of the depiction of patients with chronic pain and their management in motion pictures. Can J Pain 2022; 6:195-210. [PMID: 36324369 PMCID: PMC9620999 DOI: 10.1080/24740527.2022.2123308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 09/03/2022] [Accepted: 09/07/2022] [Indexed: 11/11/2022]
Abstract
The watching of films is popular and accessible to broad segments of the population. The depiction of medical conditions in films has the potential to affect the public's perception of them and contribute to stereotypes and stigma. We investigated how patients with chronic pain and their management are depicted in feature films. Films that contained characters with or references to chronic pain were searched for using databases such as the International Movie Database. Themes that emerged from the content analysis revolved around the films' depictions of characters with pain, their health care providers, and therapies for pain management. Patients with chronic pain were depicted in various ways, including in manners that could elicit empathy from audiences or that might contribute to the development of negative stereotypes about them. The attitudes of health care professionals toward patients with chronic pain ranged from compassionate to dispassionate. Pain management was typically depicted as lacking in breadth or using multidisciplinary approaches with a focus on pharmacological management. The variety of topics related to chronic pain depicted in feature films lends to their use in medical education strategies to better inform health care professions trainees about chronic pain management.
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Affiliation(s)
- Karim Mukhida
- Department of Anesthesiology, Pain Management and Perioperative Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sina Sedighi
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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Seangrung R, Tempeetikul T, Pannarunothai S, Sakdanuwatwong S. Perspectives of pain specialists, patients, and family members on long-term opioid use for chronic non-cancer pain: a qualitative study. BMC Anesthesiol 2021; 21:275. [PMID: 34753421 PMCID: PMC8576950 DOI: 10.1186/s12871-021-01501-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 10/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Opioids are currently prescribed for chronic non-cancer pain (CNCP), and some patients use opioids continuously for long-term treatment. Stakeholders' awareness about long-term opioid therapy is essential for improving the safety and effectiveness of pain treatment. The purpose of this study is to explore the perspectives of pain specialists, patients, and family caregivers about long-term opioid use in CNCP management. METHODS This study was a qualitative study and adhered to the COREQ guidelines. Pain specialists (n = 12), patients (n = 14), and family members (n = 9) were recruited to the study by purposive sampling at the Pain Clinic of Ramathibodi Hospital. Semi-structured interviews were recorded, verbatim transcribed, conceptually coded, and analyzed using Atlas.ti 8.0. RESULTS All groups of participants described opioids as non-first-line drugs for pain management. Opioids should be prescribed only for severe pain, when non-opioid pharmacotherapy and non-pharmacological therapies are not effective. Patients reported that the benefits of opioids were for pain relief, while physicians and most family members highlighted that opioid use should improve functional outcomes. Physicians and family members expressed concerns about opioid-related side effects, harm, and adverse events, while patients did not. Patients confirmed that they would continue using opioids for pain management under supervision. However, physicians stated that they would taper off or discontinue opioid therapy if patients' pain relief or functional improvement was not achieved. Both patients and family members were willing to consider non-pharmacological therapies if potential benefits existed. Patient education, doctor-patient/family relationships, and opioid prescription policies were proposed to enhance CNCP management. CONCLUSION Long-term opioid therapy for CNCP may be beneficial in patients who have established realistic treatment goals (for both pain relief and functional improvement) with their physicians. Regular monitoring and evaluation of the risks and benefits, adverse events, and drug-related aberrant behaviors are necessary. Integrated multimodal multidisciplinary therapies and family member collaborations are also important for improving CNCP management.
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Affiliation(s)
- Rattaphol Seangrung
- Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400 Thailand
| | - Thongchai Tempeetikul
- Department of Anesthesiology, Maharat Nakhon Ratchasima Hospital, 49 Changpueak Road, Amphoe Mueang, Nakhon Ratchasima, 30000 Thailand
| | - Supasit Pannarunothai
- Center for Health Equity Monitoring Foundation, 173/113, Moo 7, Phitsanulok-Nakhon Sawan Road, Thapho, Mueang District, Phitsanulok, 65000 Thailand
| | - Supalak Sakdanuwatwong
- Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400 Thailand
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Keller MS, Jusufagic A, Nuckols TK, Needleman J, Heilemann M. Understanding Clinicians' Decisions to Assume Prescriptions for Inherited Patients on Long-term Opioid Therapy: A Qualitative Study. PAIN MEDICINE (MALDEN, MASS.) 2020; 21:3187-3198. [PMID: 32186728 PMCID: PMC8453626 DOI: 10.1093/pm/pnaa045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Given the changing political and social climate around opioids, we examined how clinicians in the outpatient setting made decisions about managing opioid prescriptions for new patients already on long-term opioid therapy. METHODS We conducted in-depth interviews with 32 clinicians in Southern California who prescribed opioid medications in the outpatient setting for chronic pain. The study design, interview guides, and coding for this qualitative study were guided by constructivist grounded theory methodology. RESULTS We identified three approaches to assuming a new patient's opioid prescriptions. Staunch Opposers, mostly clinicians with specialized training in pain medicine, were averse to continuing opioid prescriptions for new patients and often screened outpatients seeking opioids. Cautious and Conflicted Prescribers were wary about prescribing opioids but were willing to refill prescriptions if they perceived the patient as trustworthy and the medication fell within their comfort zone. Clinicians in the first two groups felt resentful about other clinicians "dumping" patients on opioids on them. Rapport Builders, mostly primary care physicians, were the most willing to assume opioid prescriptions and were strategic in their approach to transitioning patients to safer doses. CONCLUSIONS Clinicians with the most training in pain management were the least willing to assume responsibility for opioid prescriptions for patients already on long-term opioid therapy. In contrast, primary care clinicians were the most willing to assume this responsibility. However, primary care clinicians face barriers to providing high-quality care for patients with complex pain conditions, such as short visit times and less specialized training.
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Affiliation(s)
- Michelle S Keller
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Teryl K Nuckols
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jack Needleman
- Department of Health Policy and Management, UCLA Fielding School of Public Health, University of California-Los Angeles, Los Angeles, California
| | - MarySue Heilemann
- UCLA School of Nursing, University of California-Los Angeles, Los Angeles, California, USA
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Cataldo J, Collins S, Mckinnies RC, Nichols J, Shaw TA. Addressing the Opioid Epidemic: Recommended Solutions from Physicians. QUALITATIVE RESEARCH IN MEDICINE & HEALTHCARE 2020. [DOI: 10.4081/qrmh.2020.8619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The purpose of this study was to assess physicians’ accounts related to the current opioid epidemic and to identify solutions that they feel would be most successful in addressing opioid misuse and overuse. A survey was administered a group of physicians obtained from a nationwide database. Nearly all physicians surveyed believed there was a current opioid crisis in the United States and that physicians should take an active role in addressing opioid use in patients. Four key themes emerged regarding solutions to the opioid crisis: i) policy change, ii) improve treatment, iii) education, and iv) alternative treatment. The diversity of responses highlighted the need for a multifaceted approach to address opioid misuse and abuse.
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Prathivadi P, Barton C, Mazza D. Qualitative insights into the opioid prescribing practices of Australian GP. Fam Pract 2020; 37:412-417. [PMID: 31768532 DOI: 10.1093/fampra/cmz083] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Over the last three decades, Australian opioid-prescribing rates and related morbidity and mortality have dramatically increased. Opioids are frequently prescribed by general practitioners (GPs) to manage chronic non-cancer pain, despite evidence-based recommendations from the Centre for Disease Control, National Institute for Health and Care Excellence and World Health Organization widely cautioning their use. Little is known about the factors influencing the opioid prescribing decisions of Australian GPs, especially when not evidence based. OBJECTIVE To explore the opioid prescribing knowledge, attitudes and practices of Australian GPs. METHODS Semi-structured interviews with 20 GPs recruited from the Monash University practice-based research network in metropolitan, southeastern Melbourne. Thematic analysis was used to identify emergent themes. Data were managed using QSR NVivo. Ethics approval was granted by Monash University. RESULTS Three key themes emerged. GP attitudes towards opioid use for chronic pain varied by age of patient and goals for therapy. Use of opioids for elderly patients was positively perceived. GPs were reluctant to use opioids in younger patients due to fears of addiction and difficulty weaning. GPs felt obliged to prescribe opioids recommended by specialists, even if they believed the opioids were unsafe. CONCLUSION This study identified and described the patient-centred nature of GP opioid prescribing decisions. Patient age and perceived age-related opioid harm were important factors influencing prescribing decisions. Future work should inform interventions that value GP autonomy while still encouraging a collaborative inter-speciality approach to managing chronic pain patients with opioids.
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Affiliation(s)
- Pallavi Prathivadi
- Department of General Practice, Monash University, Notting Hill, Australia
| | - Chris Barton
- Department of General Practice, Monash University, Notting Hill, Australia
| | - Danielle Mazza
- Department of General Practice, Monash University, Notting Hill, Australia
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Kosik KB, Hoch MC, Villasante‐Tezanos AG, Gribble PA. Visit Characteristics Associated With Opioids Administered or Prescribed During Emergency Department Visits for Ankle Sprain Between 2010 and 2015. PM R 2020; 12:647-654. [DOI: 10.1002/pmrj.12326] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 01/08/2020] [Indexed: 12/18/2022]
Affiliation(s)
- Kyle B. Kosik
- Department of Rehabilitation Sciences, Division of Athletic TrainingUniversity of Kentucky Lexington KY
| | - Matthew C. Hoch
- Department of Rehabilitation Sciences, Division of Athletic TrainingUniversity of Kentucky Lexington KY
| | | | - Phillip A. Gribble
- Department of Rehabilitation Sciences, Division of Athletic TrainingUniversity of Kentucky Lexington KY
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Singh S, Prasad S, Bhatnagar S, Lal R, Choudhary N, Sahi MS. A Cross-Sectional Web-Based Survey of Medical Practitioners in India to Assess their Knowledge, Attitude, Prescription Practices, and Barriers toward Opioid Analgesic Prescriptions. Indian J Palliat Care 2019; 25:567-574. [PMID: 31673214 PMCID: PMC6812418 DOI: 10.4103/ijpc.ijpc_83_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
CONTEXT Inadequate training of medical practitioners is a key factor responsible for inappropriate use of opioid analgesics. AIMS We assessed the current knowledge, attitude, prescribing practices, and barriers perceived by the Indian medical practitioners in three tertiary care hospitals toward the use of opioid analgesics. SUBJECTS AND METHODS Web-based survey of registered medical practitioner employed at three chosen tertiary health care institutions in New Delhi. STATISTICAL ANALYSIS USED Descriptive analysis of survey responses was carried out. Comparative analysis was done using Chi-square test, independent samples t-test, and Pearson correlation coefficient. RESULTS The response rate was 10.4% (n = 308). Two-thirds of the participants (61.7%) had never received formal pain management training, and 86.7% participants would like further training. Most participants (71.1%) agreed that opioids should be prescribed in cancer pain, while 26.3% agreed that opioids should be prescribed in noncancer pain. Half of the participants agreed that SOS (if necessary) dosing schedule (48.4%), low dosage (61.7%), and short duration of use (51.4%) could decrease the harmful effect of opioids. Lack of information about opioid-related policies and addiction potential were identified as the most common barriers to prescribing opioids. Those seeing more patients with chronic noncancer pain come across opioid misuse and diversion more often (P = 0.02). Those who understood addiction were more likely to agree that patients of chronic cancer pain with substance use disorders should be prescribed opioid analgesics (P < 0.01). CONCLUSIONS Indian medical practitioners felt the need for formal pain management training. There is a lack of consensus on how to manage the pain using opioid analgesics. Tough regulations on medical and scientific use of opioids are the most commonly reported barrier to prescribing them.
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Affiliation(s)
- Shalini Singh
- Department of Psychiatry, Institute of Liver and Biliary Sciences, Dr. B.R.A IRCH, AIIMS, New Delhi, India
| | - Shiv Prasad
- Department of Psychiatry, Lady Hardinge Medical College, Dr. B.R.A IRCH, AIIMS, New Delhi, India
| | - Sushma Bhatnagar
- Department of Onco-Anaesthesia and Palliative Medicine, Dr. B.R.A IRCH, AIIMS, New Delhi, India
| | - Rakesh Lal
- National Drug Dependence Treatment Centre, AIIMS, New Delhi, India
| | - Nandan Choudhary
- Department of Onco-Anaesthesia and Palliative Medicine, Dr. B.R.A IRCH, AIIMS, New Delhi, India
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Fleming ML, Driver L, Sansgiry SS, Abughosh SM, Wanat MA, Varisco TJ, Pickard T, Reeve K, Todd KH. Drug Enforcement Administration Rescheduling of Hydrocodone Combination Products Is Associated With Changes in Physician Pain Management Prescribing Preferences. J Pain Palliat Care Pharmacother 2019; 33:22-31. [DOI: 10.1080/15360288.2019.1615027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Taha S, Maloney-Hall B, Buxton J. Lessons learned from the opioid crisis across the pillars of the Canadian drugs and substances strategy. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2019; 14:32. [PMID: 31426814 PMCID: PMC6700784 DOI: 10.1186/s13011-019-0220-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 08/07/2019] [Indexed: 01/19/2023]
Abstract
Background Canada is facing an urgent challenge to reduce the harms associated with opioids: from January 2016 to December of 2018, more than 11,500 individuals lost their lives due to opioid related harms. This review examines responses to the opioid crisis thus far, the lessons learned from these initiatives and the knowledge gaps that still need to be addressed across the four pillar model adopted by the CDSS. Methods A search of peer-reviewed literature was conducted in PubMed and PsycNet, and grey literature was retrieved from reputable substance use and health organizations to determine responses to the opioid crisis and related outcomes between 2013 and 2019. Findings related to actions, outcomes and unintended consequences across the categories of prevention, treatment, harm reduction, enforcement and the evidence base were included and synthesized into a narrative review on lessons learned. Results The opioid crisis is a result of multiple, complex interrelated factors. Many physicians may not feel competent to appropriately treat pain and/or addiction. Pushes for opioid deprescribing have resulted in some individuals using illicit opioids as treatment. A range of effective and accessible pharmacological and psychological treatments are still required. When regulations are barriers, unsanctioned actions, such as overdose prevention sites, may be enacted by individuals to respond to urgent public health needs. A nimble response with evolving enforcement perspectives can aid individuals experiencing harms from opioid use. Conclusions There is no one size fits all response to this crisis, and consideration should be given to the unique needs of different communities and populations, as well as the broader impact of harms on families, communities, and society. A situation so multifaceted requires both immediate and long-term strategies implemented concurrently in order to address the differing and on-going needs of Canadians experiencing opioid harms. The expertise of individuals and families affected by the opioid crisis must be included in consultations and decisions related to different strategies, to ensure responses are not stigmatizing, that they will be effective and acceptable and that unintended consequences are quickly recognized and mitigated.
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Affiliation(s)
- Sheena Taha
- Canadian Centre on Substance Use and Addiction, 500-75 Albert Street, Ottawa, ON, K1P 5E7, Canada.
| | - Bridget Maloney-Hall
- Canadian Centre on Substance Use and Addiction, 500-75 Albert Street, Ottawa, ON, K1P 5E7, Canada
| | - Jane Buxton
- British Columbia Centre for Disease Control, 655 W 12th Avenue, Vancouver, British Columbia, V5Z 4R4, Canada
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Hooten WM, Dvorkin J, Warner NS, Pearson AC, Murad MH, Warner DO. Characteristics of physicians who prescribe opioids for chronic pain: a meta-narrative systematic review. J Pain Res 2019; 12:2261-2289. [PMID: 31413625 PMCID: PMC6662164 DOI: 10.2147/jpr.s202376] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 06/25/2019] [Indexed: 01/19/2023] Open
Abstract
Background: The primary objective of this systematic review was to identify the characteristics of physicians who prescribe opioids to adults with chronic pain. This review was limited to studies examining fully-trained physicians, as relevant characteristics of resident physicians and non-physician clinicians may differ. Methods: A comprehensive search of databases from January 1, 1980 to December 5, 2017 was conducted. Eligible study designs included (1) randomized trials; (2) nonrandomized prospective and retrospective studies; and (3) cross-sectional observational studies. The risk of bias in the included studies was assessed using an adapted version of the Newcastle-Ottawa Scale for cross-sectional studies. A total of 2508 records were screened and 22 studies met inclusion criteria. The majority of studies were cross-sectional (n=20) and the total number of participants was 8433. Results: The risk of bias was high overall. The majority of physicians were confident managing and prescribing opioids for chronic pain but had high levels of dissatisfaction. Physicians reported high awareness of the potential for opioid misuse and were concerned about inadequate prior training in pain management. The majority of physicians were less likely to prescribe for patients with a history of substance abuse and reported major concerns about regulatory scrutiny. Conclusion: This systematic review provides the foundation for the development of prospective studies aimed at further elucidating the constellation of mechanisms that influence physicians who manage pain and prescribe opioids.
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Affiliation(s)
- W Michael Hooten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Jodie Dvorkin
- Institute for Clinical Systems Improvement , Minneapolis, MN, USA
| | - Nafisseh S Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Amy Cs Pearson
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - M Hassan Murad
- Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - David O Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
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Gilmore-Bykovskyi AL, Block L, Hovanes M, Mirr J, Kolanowski A. Analgesic Use Patterns Among Patients With Dementia During Transitions From Hospitals to Skilled Nursing Facilities. Res Gerontol Nurs 2019; 12:61-69. [PMID: 30703217 DOI: 10.3928/19404921-20190122-01] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 11/28/2018] [Indexed: 01/09/2023]
Abstract
Gaps in pain management, including discontinuity in analgesic medication prescribing, frequently complicate transitions from hospital to skilled nursing facilities (SNFs) for patients with dementia. The objective of the current study was to examine analgesic medication use and prescribing patterns in the last 48 hours of hospitalization and upon discharge to SNF among stroke and hip fracture patients with dementia. Of 318 patients who received an analgesic medication within the last 48 hours of hospitalization, 23% experienced potentially abrupt discontinuations upon discharge. These rates varied by medication, with acetaminophen with codeine (27%), hydromorphone (19%), and acetaminophen with hydrocodone (19%) having the highest rates of potentially abrupt discontinuations. Conversely, 38% of patients experienced potentially abrupt additions of an analgesic medication upon discharge. Findings suggest that changes to analgesic regimens prior to and upon discharge may be common practice, potentially hindering care continuity and pain control during transitions. [Res Gerontol Nurs. 2019; 12(2):61-69.].
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Opioid use and the presence of Alzheimer's disease and related dementias among elderly Medicare beneficiaries diagnosed with chronic pain conditions. ALZHEIMERS & DEMENTIA-TRANSLATIONAL RESEARCH & CLINICAL INTERVENTIONS 2018; 4:661-668. [PMID: 30560199 PMCID: PMC6288458 DOI: 10.1016/j.trci.2018.10.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Introduction There is scant literature on the use of opioids among community-dwelling elderly with Alzheimer's disease and related dementias (ADRD). Methods We adopted a retrospective, cross-sectional study design using Medicare Current Beneficiary Survey data from 2006 to 2013. The study sample included elderly community-dwelling Medicare beneficiaries who were diagnosed with chronic pain conditions and had Medicare fee-for-service plans for the entire year. We conducted bivariate χ2 test and multivariate logistic regression to examine the relationship between opioid use and ADRD status. Results The study sample included 19,347 Medicare beneficiaries; 7.7% of them had ADRD. We found no statistically significant difference in opioid use by ADRD status in the unadjusted analysis; however, controlling for various factors, those with ADRD had lower odds of opioid use (adjusted odds ratio = 0.81, 95% confidence interval = 0.71, 0.93) than those without ADRD. Discussion This population-based study suggests that elderly Medicare beneficiaries with ADRD and chronic pain conditions may have undertreatment of pain.
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Curran GM, Freeman PR, Martin BC, Teeter BS, Drummond KL, Bradley K, Thannisch MM, Mosley CL, Schoenberg N, Edlund M. Communication between pharmacists and primary care physicians in the midst of a U.S. opioid crisis. Res Social Adm Pharm 2018; 15:974-985. [PMID: 30170901 DOI: 10.1016/j.sapharm.2018.08.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 07/11/2018] [Accepted: 08/09/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Effective communication between prescribers of opioids and community pharmacists can contribute to maximizing appropriate pain management and reducing opioid misuse and diversion. While much of the education and training available on reducing opioid misuse and diversion stresses the importance of interprofessional communication between prescribers and pharmacists, few studies have been explored those communication patterns directly. OBJECTIVE The objectives of this manuscript are to present and explore key emergent themes from a qualitative study around the nature, frequency, and content of communication between primary care physicians (PCPs) and pharmacists focusing on opioids. METHODS Interviews were conducted with 48 PCPs and 60 community pharmacists across four states in the U.S.: Washington, Idaho, Kentucky and Arkansas. RESULTS Convergent results from both samples indicated that the content of communication usually centers on questions of dosing, timing of the prescription, and/or evidence of potential misuse/diversion. When communication was focused on relaying information about a patient and/or clarifying questions around the prescription, it appeared positive for both parties. Results also indicated that close physical proximity between PCPs and dispensing pharmacists contributed to more positive and useful communication, especially when the clinics and pharmacies were part of the same healthcare system. Many pharmacists reported hesitancy in "questioning" a physician's judgement, which appeared related to commonly held beliefs of both pharmacists and physicians about the respective roles of each in providing patient care. Pharmacists reported difficulty in reaching PCPs for discussion, while PCPs reported it was easy to reach pharmacists. CONCLUSIONS Physician and pharmacist communication around opioids can be mutually beneficial. When prescribers and pharmacists are co-located, higher levels of trust and teamwork are reported, which in turn seems to be related to more open and positive communication. Additional research is needed to identify interventions to increase mutually-valued communication that improves the quality of decision-making around opioids.
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Affiliation(s)
- Geoffrey M Curran
- University of Arkansas for Medical Sciences, 4301 West Markham St., #522-4, Little Rock, AR, 72205-7199, United States; Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR, 72114, United States.
| | - Patricia R Freeman
- University of Kentucky, College of Pharmacy, 789 South Limestone Street, Lexington, KY, 40536, United States
| | - Bradley C Martin
- University of Arkansas for Medical Sciences, 4301 West Markham St., #522-4, Little Rock, AR, 72205-7199, United States
| | - Benjamin S Teeter
- University of Arkansas for Medical Sciences, 4301 West Markham St., #522-4, Little Rock, AR, 72205-7199, United States
| | - Karen L Drummond
- University of Arkansas for Medical Sciences, 4301 West Markham St., #522-4, Little Rock, AR, 72205-7199, United States; Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR, 72114, United States
| | - Katharine Bradley
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101-1466, United States
| | - Mary M Thannisch
- University of Arkansas for Medical Sciences, 4301 West Markham St., #522-4, Little Rock, AR, 72205-7199, United States
| | - Cynthia L Mosley
- University of Arkansas for Medical Sciences, 4301 West Markham St., #522-4, Little Rock, AR, 72205-7199, United States
| | - Nancy Schoenberg
- University of Kentucky, College of Pharmacy, 789 South Limestone Street, Lexington, KY, 40536, United States
| | - Mark Edlund
- RTI International, 3040 East Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC, 27709-2194, United States
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Lee C, Sharma M, Kantorovich S, Brenton A. A Predictive Algorithm to Detect Opioid Use Disorder: What Is the Utility in a Primary Care Setting? Health Serv Res Manag Epidemiol 2018; 5:2333392817747467. [PMID: 29383324 PMCID: PMC5784544 DOI: 10.1177/2333392817747467] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 07/17/2017] [Indexed: 11/21/2022] Open
Abstract
PURPOSE The purpose of this study was to determine the clinical utility of an algorithm-based decision tool designed to assess risk associated with opioid use in the primary care setting. METHODS A prospective, longitudinal study was conducted to assess the utility of precision medicine testing in 1822 patients across 18 family medicine/primary care clinics in the United States. Using the profile, patients were categorized into low, moderate, and high risk for opioid use. Physicians who ordered testing were asked to complete patient evaluations and document their actions, decisions, and perceptions regarding the utility of the precision medicine tests. RESULTS Approximately 47% of primary care physicians surveyed used the profile to guide clinical decision-making. These physicians rated the benefit of the profile on patient care an average of 3.6 on a 5-point scale (1 indicating no benefit and 5 indicating significant benefit). Eighty-eight percent of all clinicians surveyed felt the test exhibited some benefit to their patient care. The most frequent utilization for the profile was to guide a change in opioid prescribed. Physicians reported greater benefit of profile utilization for minority patients. Patients whose treatment was guided by the profile had pain levels that were reduced, on average, 2.7 levels on the numeric rating scale. CONCLUSIONS The profile provided primary care physicians with a useful tool to stratify the risk of opioid use disorder and was rated as beneficial for decision-making and patient improvement by the majority of physicians surveyed. Physicians reported the profile resulted in greater clinical improvement for minorities, highlighting the objective use of this profile to guide judicial use of opioids in high-risk patients. Significantly, when physicians used the profile to guide treatment decisions, patient-reported pain was greatly reduced.
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Affiliation(s)
- Chee Lee
- Proove Biosciences Inc, Irvine, CA, USA
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Tompkins DA, Huhn AS, Johnson PS, Smith MT, Strain EC, Edwards RR, Johnson MW. To take or not to take: the association between perceived addiction risk, expected analgesic response and likelihood of trying novel pain relievers in self-identified chronic pain patients. Addiction 2018; 113:67-79. [PMID: 28645137 PMCID: PMC5725253 DOI: 10.1111/add.13922] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 03/31/2017] [Accepted: 06/19/2017] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND AIMS Probability discounting refers to the effect of outcome uncertainty on decision making. Using probability discounting, we examined the degree to which self-identified chronic pain patients (CPP) were likely to try a novel analgesic medication given increasing addiction risk. We postulated that propensity for opioid misuse, trait impulsivity and previous opioid experience would be associated positively with likelihood of risky medication use. DESIGN This cross-sectional on-line study determined state/trait associations with addiction-related medication decisions in CPP. SETTING US-based CPP participated via Amazon Mechanical Turk; data were collected and analyzed in Baltimore, Maryland. PARTICIPANTS A total of 263 CPP (70.6% female) participated in the study from 12-13 December 2014. MEASUREMENTS CPP responded to the Benefit versus Addiction Risk Questionnaire (BARQ) assessing likelihood of taking a hypothetical once-daily oral analgesic medication as a function of two factors: risk of addiction (0-50%) and duration of expected complete pain relief (3, 30 or 365 days). The primary outcome was the BARQ, quantified as area under the curve (AUC). Grouping of CPP at high or low risk for opioid misuse was based on the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R). Predictors included previous experience with opioids, as well as various measures of chronic pain and mental health. FINDINGS Across hypothetical addiction risk assessed in the BARQ, the likelihood of taking a novel analgesic medication was elevated significantly in patients with high (≥18; n = 137) versus low (<18; n = 126) SOAPP-R scores [P < 0.001; 3-day: Cohen's d = 0.66, 95% confidence interval (CI) = 0.63, 0.69; 30-day: d = 0.74, 95% CI = 0.71, 0.78; 365-day: d = 0.75, 95% CI = 0.72, 0.79]. CONCLUSIONS In the United States, self-identified chronic pain patients (CPP) at higher risk for opioid misuse were more likely to report willingness to try a novel analgesic despite increasing addiction risk than CPP with low risk of opioid misuse.
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Affiliation(s)
- D. Andrew Tompkins
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andrew S. Huhn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Patrick S. Johnson
- Department of Psychology, California State University - Chico, Chico, CA, USA
| | - Michael T. Smith
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Eric C. Strain
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert R. Edwards
- Department of Anesthesiology, Perioperative, and Pain Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, USA
| | - Matthew W. Johnson
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Hooten WM, Brummett CM, Sullivan MD, Goesling J, Tilburt JC, Merlin JS, St Sauver JL, Wasan AD, Clauw DJ, Warner DO. A Conceptual Framework for Understanding Unintended Prolonged Opioid Use. Mayo Clin Proc 2017; 92:1822-1830. [PMID: 29108841 DOI: 10.1016/j.mayocp.2017.10.010] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 09/22/2017] [Accepted: 10/09/2017] [Indexed: 12/12/2022]
Abstract
An urgent need exists to better understand the transition from short-term opioid use to unintended prolonged opioid use (UPOU). The purpose of this work is to propose a conceptual framework for understanding UPOU that posits the influence of 3 principal domains that include the characteristics of (1) individual patients, (2) the practice environment, and (3) opioid prescribers. Although no standardized method exists for developing a conceptual framework, the process often involves identifying corroborative evidence, leveraging expert opinion to identify factors for inclusion in the framework, and developing a graphic depiction of the relationships between the various factors and the clinical problem of interest. Key patient characteristics potentially associated with UPOU include (1) medical and mental health conditions; (2) pain etiology; (3) individual affective, behavioral, and neurophysiologic reactions to pain and opioids; and (4) sociodemographic factors. Also, UPOU could be influenced by structural and health care policy factors: (1) the practice environment, including the roles of prescribing clinicians, adoption of relevant practice guidelines, and clinician incentives or disincentives, and (2) the regulatory environment. Finally, characteristics inherent to clinicians that could influence prescribing practices include (1) training in pain management and opioid use; (2) personal attitudes, knowledge, and beliefs regarding the risks and benefits of opioids; and (3) professionalism. As the gatekeeper to opioid access, the behavior of prescribing clinicians directly mediates UPOU, with the 3 domains interacting to determine this behavior. This proposed conceptual framework could guide future research on the topic and allow plausible hypothesis-based interventions to reduce UPOU.
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Affiliation(s)
- W Michael Hooten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN.
| | - Chad M Brummett
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Mark D Sullivan
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
| | - Jenna Goesling
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Jon C Tilburt
- Department of General Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Jessica S Merlin
- Division of Infectious Diseases, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham
| | - Jennifer L St Sauver
- Division of Epidemiology, Department of Health Science Research, Mayo Clinic College of Medicine, Rochester, MN
| | - Ajay D Wasan
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, PA
| | - Daniel J Clauw
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - David O Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN
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Suleiman ZA, Wahab KW, Kolawole IK. Opioid prescribing habits of physicians in Kwara State, Nigeria. Ghana Med J 2016; 50:63-7. [PMID: 27635092 DOI: 10.4314/gmj.v50i2.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Although opioid analgesics are effective in the treatment of moderate to severe acute, cancer and chronic non-malignant pains, they are under-prescribed in Nigeria. The objective of this study was to assess the prescription pattern of opioids among physicians in a north central State, Nigeria.. DESIGN This was a descriptive cross sectional study. SETTING The study was conducted at the International Association for the Study of Pain (IASP)-sponsored workshops on pain and palliative care at the University of Ilorin Teaching Hospital, Ilorin, Nigeria. PARTICIPANTS These were physicians at the monthly workshops organized by the Pain and Palliative Care Unit of the hospital between August 2011 and July, 2012. INTERVENTIONS Pre-tested semi-structured questionnaires were used to obtain responses to questions on pain management including opioids utilization in the various hospitals of the 114 participants. MAIN OUTCOME MEASURES The main outcome measure was opioid prescription by the participants. RESULTS Out of the 114 questionnaires distributed, 113 were returned with complete information giving a response rate of 99.1%. The mean age of the respondents was 42.0±10.8 years. Although 97.3% of the respondents reported that pain was a frequent complaint in their practice, 69.5% of those who reported seeing patients with moderate to severe pain on a daily basis rarely or never prescribed opioid analgesics. The reasons given for poor opioid prescription were fear of respiratory depression (86.8%), fear of addiction (85.1%) and non-availability (28.9%). CONCLUSION Opioid prescription rate for patients with moderate-severe pain is low possibly due to myths and misconceptions about their adverse effects. FUNDING International Association for the Study of Pain (IASP) Initiative for Improving Pain Education Grant awarded to Dr. K.W. Wahab in 2011.
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Affiliation(s)
- Zakari A Suleiman
- Department of Anaesthesia, Faculty of Clinical Sciences, University of Ilorin, Ilorin, Nigeria
| | - Kolawole W Wahab
- Department of Medicine, Faculty of Clinical Sciences, University of Ilorin, Ilorin, Nigeria
| | - Israel K Kolawole
- Department of Anaesthesia, Faculty of Clinical Sciences, University of Ilorin, Ilorin, Nigeria
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Calcaterra SL, Drabkin AD, Leslie SE, Doyle R, Koester S, Frank JW, Reich JA, Binswanger IA. The hospitalist perspective on opioid prescribing: A qualitative analysis. J Hosp Med 2016; 11:536-42. [PMID: 27157317 PMCID: PMC4970927 DOI: 10.1002/jhm.2602] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 03/07/2016] [Accepted: 03/15/2016] [Indexed: 11/08/2022]
Abstract
BACKGROUND Pain is a frequent symptom among patients in the hospital. Pain management is a key quality indicator for hospitals, and hospitalists are encouraged to frequently assess and treat pain. Optimal opioid prescribing, described as safe, patient-centered, and informed opioid prescribing, may be at odds with the priorities of current hospital care, which focuses on patient-reported pain control rather than the potential long-term consequences of opioid use. OBJECTIVE We aimed to understand physicians' attitudes, beliefs, and practices toward opioid prescribing during hospitalization and discharge. DESIGN In-depth, semistructured interviews. SETTING Two university hospitals, a safety-net hospital, a Veterans Affairs hospital, and a private hospital located in Denver, Colorado or Charleston, South Carolina. PARTICIPANTS Hospitalists (N = 25). MEASUREMENTS We systematically analyzed transcribed interviews and identified emerging themes using a team-based mixed inductive and deductive approach. RESULTS Although hospitalists felt confident in their ability to control acute pain using opioid medications, they perceived limited success and satisfaction when managing acute exacerbations of chronic pain with opioids. Hospitalists recounted negative sentinel events that altered opioid prescribing practices in both the hospital setting and at the time of hospital discharge. Hospitalists described prescribing opioids as a pragmatic tool to facilitate hospital discharges or prevent readmissions. At times, this left them feeling conflicted about how this practice could impact the patient over the long term. CONCLUSIONS Strategies to provide adequate pain relief to hospitalized patients, which allow hospitalists to safely and optimally prescribe opioids while maintaining current standards of efficiency, are urgently needed. Journal of Hospital Medicine 2016;11:536-542. © 2016 Society of Hospital Medicine.
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Affiliation(s)
- Susan L Calcaterra
- Department of Hospital Medicine, Denver Health Medical Center, Denver, Colorado
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Anne D Drabkin
- Department of Hospital Medicine, Denver Health Medical Center, Denver, Colorado
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Sarah E Leslie
- Center for Health Systems Research, Denver Health Medical Center, Denver, Colorado
| | - Reina Doyle
- Center for Health Systems Research, Denver Health Medical Center, Denver, Colorado
| | - Stephen Koester
- Department of Anthropology, University of Colorado, Denver, Colorado
- Department of Health and Behavioral Sciences, University of Colorado Denver, Denver, Colorado
| | - Joseph W Frank
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
- VA Eastern Colorado Health Care System, Denver, Colorado
| | - Jennifer A Reich
- Department of Sociology, University of Colorado, Denver, Colorado
| | - Ingrid A Binswanger
- Department of Hospital Medicine, Denver Health Medical Center, Denver, Colorado
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
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Fleming ML, Driver L, Sansgiry SS, Abughosh SM, Wanat M, Sawant RV, Ferries E, Reeve K, Todd KH. Physicians' intention to prescribe hydrocodone combination products after rescheduling: A theory of reasoned action approach. Res Social Adm Pharm 2016; 13:503-512. [PMID: 27567741 DOI: 10.1016/j.sapharm.2016.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 07/16/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND The U.S. Drug Enforcement Administration (DEA) rescheduled hydrocodone combination products (HCPs) in an attempt to mitigate the prescription opioid epidemic. Many in the medical and pharmacy community expressed concerns of unintended consequences as a result of rescheduling. OBJECTIVES This study examined physicians' intentions to prescribe HCPs after rescheduling using the framework of the theory of reasoned action (TRA). METHODS A cover letter containing a link to the online questionnaire was sent to physicians of the Texas Medical Association who were likely to prescribe opioids. The questionnaire assessed physicians' intentions to prescribe HCPs after rescheduling. Predictor variables included attitude toward rescheduling, subjective norm toward HCP prescribing, and past prescribing behavior of schedule II prescriptions. All variables were measured on a 7-point, Likert-type scale. Intention to prescribe as a dependent variable was regressed over TRA variables and respondent characteristics. RESULTS A total of 1176 usable responses were obtained, yielding a response rate of 13.3%. Mean (M) age was 53.07 ± 11 and most respondents were male (70%) and Caucasian (75%). Physicians held a moderately positive intention to prescribe HCPs (M = 4.36 ± 2.08), held a moderately negative attitude towards rescheduling, M = 4.68 ± 1.51 (reverse coded). Subjective norm was moderately low, M = 3.06 ± 1.78, and past prescribing behavior M = 2.43 ± 1.21. The linear regression analysis indicated that attitude (β = 0.10; P = 0.006), subjective norm (β = 0.35; P < 0.0001) and past prescribing behavior (β = 0.59; P < 0.0001) were significant predictors of intention to prescribe HCPs after rescheduling. CONCLUSIONS TRA was shown to be a predictive model of physicians' intentions to prescribe HCPs after rescheduling. Overall, physicians held a moderately positive intention to prescribe HCPs. Past behavior concerning schedule II prescribing was found to be the most significant predictor of intention. Understanding the impact of federal rule changes on pain management care and patient satisfaction is necessary to determine whether this change has produced the intended consequences without harming patients in need of HCPs.
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Affiliation(s)
- Marc L Fleming
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston, College of Pharmacy, Texas Medical Center Campus, 1441 Moursund St, Houston, TX 77030, USA.
| | - Larry Driver
- Department of Pain Medicine, Division of Anesthesiology and Critical Care, The University of Texas-MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Sujit S Sansgiry
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston, College of Pharmacy, Texas Medical Center Campus, 1441 Moursund St, Houston, TX 77030, USA
| | - Susan M Abughosh
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston, College of Pharmacy, Texas Medical Center Campus, 1441 Moursund St, Houston, TX 77030, USA
| | - Matthew Wanat
- Department of Pharmacy Practice and Translational Research, University of Houston, College of Pharmacy, Texas Medical Center Campus, 1441 Moursund St, Houston, TX 77030, USA
| | - Ruta V Sawant
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston, College of Pharmacy, Texas Medical Center Campus, 1441 Moursund St, Houston, TX 77030, USA
| | - Erin Ferries
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston, College of Pharmacy, Texas Medical Center Campus, 1441 Moursund St, Houston, TX 77030, USA
| | - Kathleen Reeve
- School of Nursing, University of Houston, 14000 University Blvd., Sugar Land, TX 77479, USA
| | - Knox H Todd
- The University of Texas-MD Anderson Cancer Center, Unit 1468, 1515 Holcombe Blvd., Houston, TX 77030, USA
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20
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Primary Care Physicians’ Knowledge And Attitudes Regarding Prescription Opioid Abuse and Diversion. Clin J Pain 2016; 32:279-84. [DOI: 10.1097/ajp.0000000000000268] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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21
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Pearson AC, Eldrige JS, Moeschler SM, Hooten WM. Opioids for chronic pain: a knowledge assessment of nonpain specialty providers. J Pain Res 2016; 9:129-35. [PMID: 27022300 PMCID: PMC4790520 DOI: 10.2147/jpr.s98273] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Although the majority of opioids in the US are prescribed by nonpain specialists, these providers often report inadequate training in chronic pain management and opioid prescribing. The extent of health care providers’ knowledge of opioid prescribing for chronic pain has not been well established. The purpose of this study was to assess knowledge about the use of opioids for chronic pain among health care providers seeking pain-focused continuing medical education. Materials and methods The study participants (n=131) were recruited at a pain-focused continuing medical education conference for nonpain specialists. Upon commencement of the conference, the KnowPain-50 survey was completed. The survey comprised 50 questions, and 18 questions were related to opioid management. The focus of each opioid question was further categorized as either medicolegal (n=7) or clinical (n=11). Results The majority of study participants were male physicians with a mean age of 51.8 years. The proportion of correct responses to the 50-item survey was 72%. The proportion of correct responses to the 32 nonopioid questions was 74%, and the proportion of correct responses to the 18 opioid questions was 69% (P<0.001). Similarly, the proportion of correct responses to the seven medicolegal opioid questions was 74%, and the proportion of correct responses to the eleven clinical opioid questions was 67% (P<0.001). Conclusion Health care providers demonstrated gaps in knowledge about the use of opioids for chronic pain. Lower scores on clinically based opioid questions may indicate an opportunity to provide focused educational content about this area of practice. This information could be helpful in designing future educational modules for nonpain providers.
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Affiliation(s)
- Amy Cs Pearson
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - Jason S Eldrige
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
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Khan S, Mascarenhas A, Moore JE, Knowles S, Gomes T. Access to Triptans for Acute Episodic Migraine: A Qualitative Study. Headache 2015; 55 Suppl 4:199-211. [PMID: 26178420 DOI: 10.1111/head.12593] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Our study aims to examine factors related to access of triptans among multiple stakeholder groups. BACKGROUND Triptans are a cornerstone of pain management for the acute treatment of migraine, but actual utilization of triptans is lower than ideal. Initial and continued access to triptans may be an important clinical issue in the acute treatment of migraines, but factors affecting access at the patient, provider, and health-care system levels have not been comprehensively explored. METHODS A qualitative study was conducted in Ontario, Canada, between August 2013 and January 2014. Three participant groups were recruited to the qualitative study: (1) migraineurs who have experience accessing triptans; (2) physicians, including primary care physicians (PCPs) and neurologists, who have prescribed triptans; and (3) pharmacists who have dispensed triptans. Qualitative data were collected through one-on-one, semi-structured telephone interviews. The framework approach was used for data collection and analysis. RESULTS Data collected from 19 migraineurs, 6 physicians, and 8 pharmacists were included in the analysis. Study participants discussed various factors that facilitate or hinder access to triptans, which were synthesized into four themes that emerged at the patient, provider, and health-care systems levels: (1) awareness; (2) apathy; (3) advocacy; and (4) affordability. Across all participant groups, awareness of available treatments and coverage policies for those treatments were potential factors relating to timely drug provision. Participants describe apathy in terms of patients' health-seeking behaviors and physicians' lack of concern toward migraine, which were seen as factors that could delay diagnosis and provision of appropriate treatment. Patients engaging in self-advocacy enhanced their ability to seek timely and appropriate provision of triptans at the patient level. At the health-care provider level, pharmacists were identified by patients as advocates for receiving more effective treatments for their migraines; pharmacists also self-identified with the advocate role. The affordability of triptans was a key concern impacting access at the systems level, but coverage limitations (eg, quantity limits) were also described to influence the appropriateness of prescribed migraine treatment. CONCLUSION This study fills a gap in knowledge about access to triptans and how this may be impacted by patient, provider, and health-care systems barriers. Overall, our study sheds light on the experiences of prescribing, dispensing, and accessing triptans for migraine treatment, and unveils important information that can impact how patients access these drugs.
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Affiliation(s)
- Sobia Khan
- Li KaShing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | | | - Julia E Moore
- Li KaShing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Sandra Knowles
- Li KaShing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Tara Gomes
- Li KaShing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Ontario Drug Policy Research Network, The Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
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23
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Gudin JA. Clinical Strategies for the Primary Health Care Professional to Minimize Prescription Opioid Abuse. Postgrad Med 2015; 124:131-8. [DOI: 10.3810/pgm.2012.05.2556] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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McCarberg BH. Pain Management in Primary Care: Strategies to Mitigate Opioid Misuse, Abuse, and Diversion. Postgrad Med 2015; 123:119-30. [DOI: 10.3810/pgm.2011.03.2270] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
People with chronic noncancer pain who rely on prescription opioid painkillers for treatment experience stigmatization, both within and outside of the health care system, which hinders their ability to achieve adequate pain relief. This barrier to appropriate treatment affects not only individual patients but their families as well. In this article, I provide an autoethnographic account of my experience as the daughter of a mother with severe chronic pain who manages her condition with prescription opioid painkillers. Through personal narrative, I explore how I, and members of my family, experience and interpret barriers my mom faces in accessing effective treatment, and how even now, over a decade after my mom’s pain started, the stigma surrounding prescription opioids continues to permeate every facet of our lives.
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Affiliation(s)
- Loren E. Wilbers
- Department of Sociology, University of South Florida, Tampa, FL, USA
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26
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Smith CD. A curriculum to address family medicine residents' skills in treating patients with chronic pain. Int J Psychiatry Med 2014; 47:327-36. [PMID: 25084855 DOI: 10.2190/pm.47.4.g] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Chronic pain is a challenging condition, both for the patient, who is coping with constant pain and limitations in functionality, and for the treating physician. Narcotic medications, often used for the treatment of chronic pain, can be addictive and rates of overdose deaths associated with their use have increased significantly in the last 10 years [1]. Behavioral and physician faculty at the Lincoln Family Medicine Center developed a curriculum to improve family medicine residents' skills in the treatment of patients with chronic pain. The experience includes education in pain physiology and assessment, administration of medications, adjunctive treatments, and interactions with difficult patients. Two cohorts of residents have participated in the curriculum with positive results. The curriculum may be helpful for primary care providers with privileges to prescribe narcotic medications and is targeted towards resident physicians.
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27
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Preferences, Experience, and Attitudes in the Management of Chronic Pain and Depression. Clin J Pain 2014; 30:766-74. [DOI: 10.1097/ajp.0000000000000035] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Jeevanjee S, Penko J, Guzman D, Miaskowski C, Bangsberg DR, Kushel MB. Opioid analgesic misuse is associated with incomplete antiretroviral adherence in a cohort of HIV-infected indigent adults in San Francisco. AIDS Behav 2014; 18:1352-8. [PMID: 24077929 DOI: 10.1007/s10461-013-0619-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
There is little or no data examining the association between either pain or the use or misuse of opioid analgesic with adherence to antiretroviral medications (ARVs) among HIV-infected adults. We interviewed a community-based cohort of HIV-infected indigent adults prescribed antiretroviral medications (ARVs) quarterly to examine the association between (1) pain, (2) receipt of opioid analgesics, and (3) opioid analgesic misuse with self-reported ARV adherence. Of 281 participants, most (82.5 %) reported severe or moderate pain, half (52.4 %) received a prescription for opioids, and one quarter (24.6 %) misused opioid analgesics. Most (71.9 %) reported >90 % ARV adherence. In a GEE model, neither pain (unadjusted OR 1.14, CI 0.90–1.45) nor prescription of opioid analgesics (unadjusted OR 1.11, CI 0.84–1.49) were significantly associated with ARV adherence. Misuse of opioid analgesics was associated with incomplete adherence (AOR 1.42, CI 1.09–1.86). Individuals who misuse opioid analgesics, like those who use illicit substances, may have difficulty adhering to medication regimens.
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29
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Trends in Ambulatory Physician Opioid Prescription in the United States, 1997-2009. PM R 2014; 6:575-82.e4. [DOI: 10.1016/j.pmrj.2013.12.015] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 12/29/2013] [Accepted: 12/31/2013] [Indexed: 11/19/2022]
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Wallace LS, Wexler RK, McDougle L, Miser WF, Haddox JD. Voices that may not otherwise be heard: a qualitative exploration into the perspectives of primary care patients living with chronic pain. J Pain Res 2014; 7:291-9. [PMID: 24940079 PMCID: PMC4051730 DOI: 10.2147/jpr.s62317] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Although psychometrically sound pain assessment tools are available, there is a paucity of research that comprehensively defines chronic pain from the perspective of patients. The purpose of this study was to examine the utility of a combination of qualitative methods (Photovoice, one-on-one interviews, and focus groups) in examining the daily experiences of primary care patients living with chronic pain. Methods A sample of English-speaking primary care patients aged 30 years or older, who had been prescribed an opioid for long-term, noncancer pain management, participated in the study. Each patient took photographs that best reflected both his/her experiences with chronic pain and what he/she would like his/her life to be without chronic pain. Results Patients submitted an average of 20.2±3.1 photographs (range =8–27 photographs). Analysis of one-on-one interviews illuminated five dominant themes: daily need for multiple medications, including opioids; difficulties climbing a flight of stairs; struggling to get out of bed in the morning; extreme challenges with participating in day-to-day life activities; and experiencing feelings of hopelessness and helplessness on a regular basis. Seven themes emerged from the focus groups: undesired effects/burdens of medications, loss of/striving for independence, effect on social interactions/relationships, pain effect on activities of daily living, constant search for convenience/a better situation, interactions with physicians, and frustration/depression with pain. Conclusion The qualitative methods employed in this study provide deep insight into perceptions and experiences of patients living with chronic pain that is vital for informing future clinical interventions.
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Affiliation(s)
- Lorraine S Wallace
- Department of Family Medicine, the Ohio State University, Columbus, OH, USA
| | - Randell K Wexler
- Department of Family Medicine, the Ohio State University, Columbus, OH, USA
| | - Leon McDougle
- Department of Family Medicine, the Ohio State University, Columbus, OH, USA
| | - W Frederick Miser
- Department of Family Medicine, the Ohio State University, Columbus, OH, USA
| | - J David Haddox
- Health Policy, Purdue Pharma L.P., Stamford, CT, USA ; Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
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Differential prescribing of opioid analgesics according to physician specialty for Medicaid patients with chronic noncancer pain diagnoses. Pain Res Manag 2014; 19:179-85. [PMID: 24809067 DOI: 10.1155/2014/857952] [Citation(s) in RCA: 124] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Despite >20 years of studies investigating the characteristics of patients seeking or receiving opioid analgesics, research characterizing factors associated with physicians' opioid prescribing practices has been inconclusive, and the role of practitioner specialty in opioid prescribing practices remains largely unknown. OBJECTIVE To examine the relationships between physicians' and other providers' primary specialties and their opioid prescribing practices among patients with chronic noncancer pain (CNCP). METHODS Prescriptions for opioids filled by 81,459 Medicaid patients with CNCP in North Carolina (USA), 18 to 64 years of age, enrolled at any point during a one-year study period were examined. χ<span style="vertical-align: super">2<⁄span> statistics were used to examine bivariate differences in prescribing practices according to specialty. For multivariable analyses, maximum-likelihood logistic regression models were used to examine the effect of specialty on prescribing practices, controlling for patients' pain diagnoses and demographic characteristics. RESULTS Of prescriptions filled by patients with CNCP, who constituted 6.4% of the total sample of 1.28 million individuals, 12.0% were for opioids. General practitioner⁄family medicine specialists and internists were least likely to prescribe opioids, and orthopedists were most likely. Across specialties, men were more likely to receive opioids than women, as were white individuals relative to other races⁄ethnicities. In multivariate analyses, all specialties except internal medicine had higher odds of prescribing an opioid than general practitioners: orthopedists, OR 7.1 (95% CI 6.7 to 7.5); dentists, OR 3.5 (95% CI 3.3 to 3.6); and emergency medicine physicians, OR 2.7 (95% CI 2.6 to 2.8). CONCLUSIONS Significant differences in opioid prescribing practices across prescriber specialties may be reflective of differing norms concerning the appropriateness of opioids for the control of chronic pain. If so, sharing these norms across specialties may improve the care of patients with CNCP.
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Müller-Schwefe GHH, Wimmer AM, Dejonckheere J, Eggers A, Vellucci R. Patients' and physicians' perspectives on opioid therapy for chronic cancer and musculoskeletal pain in Germany, Italy, and Turkey: PAin RESearch (PARES) survey. Curr Med Res Opin 2014; 30:339-47. [PMID: 24224687 DOI: 10.1185/03007995.2013.861349] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Under-treatment or lack of appropriate treatment for chronic pain remains an ongoing major healthcare problem. Opioids are being increasingly recognized as an effective option for chronic pain management. The objective of this survey was to understand the perspective of patients treated with opioids on quality of treatment, preferences, and possibilities to improve treatment and communication between patients and physicians. RESEARCH DESIGN A large-scale PAin RESearch (PARES) survey of 2860 patients (Germany, Italy, and Turkey) with chronic cancer or musculoskeletal pain prescribed opioid therapy was conducted to assess various factors such as ease of use and compliance, sleep, quality-of-life, and polymedication. A physician component was also included. Relationships between variables and differences between groups were tested using Spearman and Wilcoxon signed-rank tests, respectively. RESULTS Of the patients surveyed, 61% received strong opioids (WHO III) and 39% weak opioids (WHO II). Nearly 65% of the patients were currently on a twice daily or more dosing schedule; however, 61.5% of the patients responded that they considered once-daily dosing to be the most convenient schedule. Patients' responses indicated that different dosing schedules significantly influenced the occurrence of end-of-dose pain, feeling limited by the remaining level of pain, problems in falling asleep, and episodes of waking up at night or early in the morning. Physicians' responses showed that they were not surprised by 68.5% of patient responses; they also felt the need to change some aspect of pain treatment for a third of the patients, the commonest being pain medication (52.4%). CONCLUSIONS The results of the survey suggest that patients prefer a convenient dosing scheme, which may have a positive impact on compliance. Physicians may have to communicate more closely with patients about their needs.
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Ferreira M, Verloo H, Mabire C, Vieira MMS, Marques-Vidal P. Psychometric evaluation of the French version of the questionnaire attitudes towards morphine use; a cross-sectional study in Valais, Switzerland. BMC Nurs 2014; 13:1. [PMID: 24406097 PMCID: PMC4029768 DOI: 10.1186/1472-6955-13-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Accepted: 01/06/2014] [Indexed: 12/02/2022] Open
Abstract
Background In Switzerland, nurses are allowed to prescribe and administer morphine in emergency situations without a doctor. Still, nurses and other health professionals are often reluctant to prescribe and administer morphine for pain management in patients. No valid French-speaking instrument is available in Switzerland to assess the attitudes of nurses and other health professionals towards the prescription and administration of morphine. In this study, we evaluated the psychometric properties of the French version of the questionnaire “Attitudes towards morphine use”. Methods The instrument was derived from an Italian version. Forward and back translations of the questionnaire were performed. Item analysis and construct validity were assessed between April and December 2010 in a cross sectional study including five Swiss hospitals in a sample of 588 health professionals (533 nurses, mean age 38.3 ± 10.2 years). Thirty subjects participated in test-retest reliability. Results The time to complete the instrument ranged between 12 and 15 minutes and neither floor nor ceiling effect were found. The initial 24-item instrument showed an intraclass correlation (ICC) of 0.69 (95% CI: 0.64 to 0.73, P < 0.001), and a Cronbach’s α of 0.700. Factor analysis led to a six-component solution explaining 52.4% of the total variance. After excluding five items, the shortened version showed an ICC of 0.74 (95% CI, 0.70 to 0.77, P < 0.001) and a Cronbach’s α of 0.741. Factor analysis led to a five-component solution explaining 54.3% of the total variance. The five components were named “risk of addiction/dependence”; “operational reasons for not using morphine”; “risk of escalation”; “other (non-dependence) risks” and “external (non-operational) reasons”. In test-retest, the shortened instrument showed an ICC of 0.797 (95% CI, 0.630 to 0.911, P < 0.001) and a Cronbach’s α of 0.797. Conclusions The 19-item shortened instrument assessing attitudes towards the prescription and administration of morphine showed adequate content and construct validity.
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Affiliation(s)
- Maria Ferreira
- Hôpital de Sion, Avenue Grand-Champsec 80, Case Postale 736, Sion, 1951, Switzerland.
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Seamark D, Seamark C, Greaves C, Blake S. GPs prescribing of strong opioid drugs for patients with chronic non-cancer pain: a qualitative study. Br J Gen Pract 2013; 63:e821-8. [PMID: 24351498 PMCID: PMC3839391 DOI: 10.3399/bjgp13x675403] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Revised: 07/03/2013] [Accepted: 08/06/2013] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Chronic non-cancer pain (CNCP) is common in the UK. GPs manage most patients with such pain. Previous research has suggested that prescribing is influenced by patient and doctor factors, but less is known about the decision- making process involved in prescribing opioid drugs for CNCP. AIM To describe the factors influencing GPs' prescribing of strong opioid drugs for CNCP. Design and setting Semi-structured interviews and a focus group of a purposive sample of GPs from a range of practice settings including male and female GPs with experience of prescribing strong opioids. METHOD Transcripts of interviews and a focus group were analysed using qualitative research methodology (thematic analysis). RESULTS GPs described prescribing opioid drugs for patients with CNCP as being different from treating cancer related pain. GPs followed accepted stepwise approaches in their prescribing for CNCP. They reported difficulty in assessing the level of pain and concern over duration of use of strong opioids and their possible side effects, tolerance, and addiction. Variation in reported practice was observed, which may be linked to experience and significant events. CONCLUSION GPs in this study demonstrated a thoughtful attitude towards prescribing strong opioids for CNCP. They were aware of the difficulties of long-term strong opioid prescription. Only a few GPs had had specific training in chronic pain management and this may explain some of the variation in practice reported. GPs may benefit from training in pain assessment and long-term management of patients with CNCP.
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Affiliation(s)
| | | | - Colin Greaves
- University of Exeter medical School (Primary Care), Exeter, UK
| | - Susan Blake
- Honiton Research Practice, Honiton, Devon, UK
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Becker WC, Fraenkel L, Kerns RD, Fiellin DA. A research agenda for enhancing appropriate opioid prescribing in primary care. J Gen Intern Med 2013; 28:1364-7. [PMID: 23568187 PMCID: PMC3785661 DOI: 10.1007/s11606-013-2422-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Revised: 02/13/2013] [Accepted: 03/13/2013] [Indexed: 11/30/2022]
Abstract
The challenges facing patients and providers in managing ongoing opioid analgesic therapy for chronic pain are complex. Benefit of long-term opioid therapy, for which there are scant data, must be balanced against myriad potential undesired outcomes, including safety problems, ranging from mild toxicities to overdose and death; inadequate efficacy, which may mean continued patient suffering and unwarranted exposure to toxicities; and misuse of these potent medications. To help patients and providers navigate these challenges and optimize therapy, we present a research agenda in which we first characterize appropriate ongoing opioid prescribing and then describe three areas where quality improvement work is needed: 1) developing brief validated measures of patient-reported safety, efficacy, and misuse that improve outcomes; 2) designing evidence-based algorithms to guide changes in therapy when issues related to safety, efficacy or misuse are identified; and 3) promoting use of patient-centered, multi-modal treatment plans.
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Affiliation(s)
- William C Becker
- VA Connecticut Healthcare System, 151B, 950 Campbell Avenue, West Haven, CT, 06516, USA,
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Gupta A, Weber N, Duwell M. Implementing a public health approach to the management of chronic pain in the USA. Pain Manag 2013; 3:315-9. [DOI: 10.2217/pmt.13.23] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Chronic pain represents a staggering public health burden. Despite research and technologic advances in pain management, chronic pain is grossly undertreated in the USA. Many pain patients are dissatisfied with their treatment regimens, and disparities exist in pain treatment for minorities and for socioeconomically disadvantaged and elderly patients. Many doctors feel inadequately trained to treat chronic pain. Therapeutic opioid use for chronic pain is a particularly challenging issue for both physicians and patients. Strategies for addressing chronic pain from a public health perspective include increased education of physicians and the public, improved integration of pain management across disciplines, and improved systems for monitoring prescription opioids.
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Affiliation(s)
- Anita Gupta
- University Pain Institute, Division of Pain Medicine & Regional Anesthesiology, Department of Anesthesiology & Perioperative Medicine, Drexel University College of Medicine, 245 North 15th Street, New College Building, Room 7328, MS 310, Philadelphia, PA 19102, USA.
| | - Nicholas Weber
- University Pain Institute, Division of Pain Medicine & Regional Anesthesiology, Department of Anesthesiology & Perioperative Medicine, Drexel University College of Medicine, 245 North 15th Street, New College Building, Room 7328, MS 310, Philadelphia, PA 19102, USA
| | - Monique Duwell
- Department of Medicine, George Washington University, 2150 Pennsylvania Avenue NW, Washington DC 20037, USA
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Wilson HD, Dansie EJ, Kim MS, Moskovitz BL, Chow W, Turk DC. Clinicians' Attitudes and Beliefs About Opioids Survey (CAOS): Instrument Development and Results of a National Physician Survey. THE JOURNAL OF PAIN 2013; 14:613-27. [DOI: 10.1016/j.jpain.2013.01.769] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Revised: 12/27/2012] [Accepted: 01/22/2013] [Indexed: 11/17/2022]
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Self-reported practices in opioid management of chronic noncancer pain: a survey of Canadian family physicians. Pain Res Manag 2013; 18:177-84. [PMID: 23717824 DOI: 10.1155/2013/528645] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND In May 2010, a new Canadian guideline on prescribing opioids for chronic noncancer pain (CNCP) was released. To assess changes in family physicians' (FPs) prescribing of opioids following the release of the guideline, it is necessary to know their practices before the guideline was widely disseminated. OBJECTIVES To determine FPs' practices and knowledge in prescribing opioids for CNCP in relation to the Canadian guideline, and to determine factors that hinder or enable FPs in prescribing opioids for CNCP. METHODS An online survey was developed and FPs who manage CNCP were electronically contacted through the College of Family Physicians of Canada, university continuing medical education offices and provincial regulatory colleges. RESULTS A total of 710 responses were received. FPs followed a precautionary approach to prescribing opioids and already practiced in accordance with Canadian guideline recommendations by discussing adverse effects, monitoring for aberrant drug-related behaviour and advising caution when driving. However, FPs seldom discontinued opioids even if they were ineffective and were unaware of the 'watchful dose' of opioids, the daily dose at which patients may need reassessment or closer monitoring. Only two of nine knowledge questions were answered correctly by more than 40% of FPs. The main enabler to optimal opioid prescribing was having access to a patient's opioid history from a provincial prescription monitoring program. The main barriers to optimal prescribing were concerns about addiction and misuse. CONCLUSIONS While FPs follow a precautionary approach to prescribing opioids for CNCP, there are substantial practice and knowledge gaps, with implications for patient safety and costs.
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Johnson M, Collett B, Castro-Lopes JM. The challenges of pain management in primary care: a pan-European survey. J Pain Res 2013; 6:393-401. [PMID: 23723719 PMCID: PMC3666876 DOI: 10.2147/jpr.s41883] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The OPENMinds Primary Care group is a group of European primary care physicians (PCPs) with an interest in pain management, formed to improve the understanding and management of chronic pain in primary care. OBJECTIVE A survey was conducted to assess the challenges of chronic nonmalignant pain (CNMP) management in primary care in Europe, focusing particularly on pain assessment, opioid therapy, and educational needs. METHODS A questionnaire was developed for online use by PCPs in 13 European countries (Belgium, Denmark, France, Germany, Ireland, Italy, the Netherlands, Norway, Poland, Portugal, Spain, Sweden, and the UK). RESULTS A total of 1309 PCPs completed the questionnaire, approximately 100 from each country. Most PCPs (84%) perceived CNMP to be one of the most challenging conditions to treat, yet a low priority within healthcare systems. Only 48% of PCPs used pain assessment tools, and 81% considered chronic pain and its impact on quality of life to be underassessed in primary care. PCPs were less confident about prescribing strong opioids for CNMP than for use in cancer pain. Most PCPs (84%) considered their initial training on CNMP was not comprehensive, with 89% recognizing a need for more education on the topic. CONCLUSION These findings reveal that PCPs in Europe find CNMP a challenge to treat. Areas to address with training include underuse of pain assessment tools and lack of confidence in use of opioid therapy. Guidelines on CNMP management in primary care would be welcomed. The insights gained should provide the basis for future initiatives to support primary care management of chronic pain.
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Affiliation(s)
- Martin Johnson
- Community Pain Medicine, Cardiff University, Cardiff, UK
| | - Beverly Collett
- Pain Management Service, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - José M Castro-Lopes
- Department of Experimental Biology, Faculty of Medicine of the University of Porto, Porto, Portugal
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Thompson LA, Meinert E, Baker K, Knapp C. Chronic pain management as a barrier to pediatric palliative care. Am J Hosp Palliat Care 2013; 30:764-7. [PMID: 23329083 DOI: 10.1177/1049909112473632] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Pain is common as a presenting complaint to outpatient and emergency departments for children, yet pain management represents one of the children's largest unmet needs. A child may present with acute pain for an intermittent issue or may have acute or chronic pain in the setting of chronic illness. The mainstay of treatment for pain uses a stepwise approach for pain management, such as set up by the World Health Organization. For children with life-limiting illnesses, the Institute of Medicine guidelines recommends referral upon diagnosis for palliative care, meaning that the child receives comprehensive services that include pain control in coordination with curative therapies; yet barriers remain. From the provider perspective, pain can be better addressed through a careful assessment of one's own knowledge, skills, and attitudes. The key components of pain management in children are multimodal, regardless of the cause of the pain.
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Affiliation(s)
- Lindsay A Thompson
- 1Departments of Pediatrics and Epidemiology and Health Policy Research, College of Medicine, University of Florida, Gainesville, FL, USA
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Benzon HT, Kendall MC, Katz JA, Benzon HA, Malik K, Cox P, Dean K, Avram MJ. Prescription Patterns of Pain Medicine Physicians. Pain Pract 2012; 13:440-50. [DOI: 10.1111/papr.12011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Accepted: 09/18/2012] [Indexed: 12/26/2022]
Affiliation(s)
- Honorio T. Benzon
- Department of Anesthesiology; Northwestern University Feinberg School of Medicine; Chicago; Illinois; U.S.A
| | - Mark C. Kendall
- Department of Anesthesiology; Northwestern University Feinberg School of Medicine; Chicago; Illinois; U.S.A
| | - Jeffrey A. Katz
- Department of Anesthesiology; Northwestern University Feinberg School of Medicine; Chicago; Illinois; U.S.A
| | - Hubert A. Benzon
- Department of Anesthesiology; Boston Children's Hospital; Boston; Massachusetts; U.S.A
| | - Khalid Malik
- Department of Anesthesiology; Northwestern University Feinberg School of Medicine; Chicago; Illinois; U.S.A
| | - Paul Cox
- Temecula Valley Anesthesiologist; Temecula; California; U.S.A
| | - Kathryn Dean
- Transitional Year; Department of Medicine; North Shore Hospital; University of Chicago; Evanston; Illinois; U.S.A
| | - Michael J. Avram
- Department of Anesthesiology; Northwestern University Feinberg School of Medicine; Chicago; Illinois; U.S.A
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Abstract
BACKGROUND Primary care physicians, nurse practitioners, and nurses are often the first to evaluate patients with pain and many patients depend on these clinicians for pain relief. The growing evidence supporting use of opioids for appropriately selected patients means that primary care practitioners must be knowledgeable regarding ever-evolving pain-management strategies. SCOPE This review summarizes core considerations in opioid prescribing in the primary care setting, the risks of undertreatment of pain, the challenges and barriers associated with prescribing opioids, identifying risk factors that may predict problematic use, and emerging formulation technologies expected to assist clinicians in better achieving effective pain control while minimizing risks for misuse or diversion. RESULTS Primary care physicians face considerable challenges in optimizing pain management while minimizing potential for misuse, abuse and diversion. Opioid treatment decisions are based not only on the type of pain but also the patient's psychosocial history, including a screening for predicting aberrant behaviors and, in some patients, substance abuse. New opioid formulations are available to assist clinicians in achieving adequate patient relief while reducing risk of tampering and abuse. Primary care practitioners need to be aware of these new options and integrate them into clinical treatment decisions. CONCLUSIONS The strategic use of new opioid formulations and better patient assessment may lead to more successful use of opioids in the management of pain, while limiting or lowering the risk of the development of an addiction problem, abuse or diversion.
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Affiliation(s)
- Steven Stanos
- Center for Pain Management, Rehabilitation Institute of Chicago, Chicago, IL 60611, USA.
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Vijayaraghavan M, Penko J, Guzman D, Miaskowski C, Kushel MB. Primary care providers' views on chronic pain management among high-risk patients in safety net settings. PAIN MEDICINE 2012; 13:1141-8. [PMID: 22846057 DOI: 10.1111/j.1526-4637.2012.01443.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE We examined chronic pain management practices and confidence and satisfaction levels in treating chronic pain among primary care providers (PCPs) who cared for high-risk patients in safety net health settings. DESIGN We recruited PCPs (N = 61) through their HIV-infected patients who were enrolled in a longitudinal study on pain, use, and misuse of opioid analgesics (Pain Study). We asked PCPs to complete a questionnaire about all of their patients in their practice on the prevalence of chronic pain and illicit substance use, use of opioid analgesics, confidence and satisfaction levels in treating chronic pain, and likelihood of prescribing opioid analgesics in response to clinical vignettes. RESULTS All PCPs cared for at least some patients with chronic pain, and the majority prescribed opioid analgesics for its treatment. All PCPs cared for at least some patients who used illicit substances. PCPs reported low confidence and satisfaction levels in treating chronic pain. The majority (73.8%) of PCPs were highly likely to prescribe opioid analgesics to a patient without a history of substance use who had chronic pain. The majority (88.5%) were somewhat to highly likely to prescribe opioid analgesics to a patient with a prior history of substance use but not active use. Most (67.2%) were somewhat to highly likely to prescribe opioids to a patient with active substance use. CONCLUSION In order to improve PCPs' confidence and satisfaction in managing chronic pain, further work should explore the root causes of low confidence and satisfaction and also explore possible remedies.
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Affiliation(s)
- Maya Vijayaraghavan
- Division of General Internal Medicine/San Francisco General Hospital, San Francisco, CA 94143-1364, USA
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Hansen L, Penko J, Guzman D, Bangsberg DR, Miaskowski C, Kushel MB. Aberrant behaviors with prescription opioids and problem drug use history in a community-based cohort of HIV-infected individuals. J Pain Symptom Manage 2011; 42:893-902. [PMID: 21802896 PMCID: PMC3230691 DOI: 10.1016/j.jpainsymman.2011.02.026] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2010] [Revised: 02/16/2011] [Accepted: 02/22/2011] [Indexed: 11/17/2022]
Abstract
CONTEXT The treatment of pain in patients with substance use disorders creates tensions for clinicians between undertreating pain and enabling opioid analgesic misuse. OBJECTIVES To characterize prevalence and factors associated with aberrant opioid analgesic behaviors in a cohort of HIV-infected individuals who are at high risk for opioid analgesic misuse. METHODS We assessed pain and substance use disorders in a cross-sectional study that enrolled 296 participants from the Research on Access to Care in the Homeless cohort, a community-based sample of indigent HIV-infected adults. We measured aberrant opioid behaviors, defined as major or minor depending on level of risk of harm to patients, using Audio Computer-Assisted Self-Interview technology. RESULTS Most participants (91.2%) reported pain in the week before interview, with the majority of these experiencing severe pain (53.7%). More than two-thirds (69.2%) of the participants met criteria for a lifetime history of cocaine, amphetamine, or heroin/opioid use disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition). More than one-third of the sample (37.4%) had a history of aberrant opioid behavior within 90 days of interview. One-fifth (18.5%) had a history of "major" aberrant behaviors. CONCLUSION In this high-risk population, severe pain is common and aberrant opioid behaviors are prevalent but not universal. As recommended by American Pain Society and American Academy of Pain Medicine guidelines, when prescribing opioid analgesics, clinicians must consider variation in the severity of aberrant behaviors, particularly aberrant behaviors that may represent undertreatment of pain.
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Affiliation(s)
- Luke Hansen
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA.
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Spitz A, Moore AA, Papaleontiou M, Granieri E, Turner BJ, Reid MC. Primary care providers' perspective on prescribing opioids to older adults with chronic non-cancer pain: a qualitative study. BMC Geriatr 2011; 11:35. [PMID: 21752299 PMCID: PMC3212901 DOI: 10.1186/1471-2318-11-35] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Accepted: 07/14/2011] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The use of opioid medications as treatment for chronic non-cancer pain remains controversial. Little information is currently available regarding healthcare providers' attitudes and beliefs about this practice among older adults. This study aimed to describe primary care providers' experiences and attitudes towards, as well as perceived barriers and facilitators to prescribing opioids as a treatment for chronic pain among older adults. METHODS Six focus groups were conducted with a total of 23 physicians and three nurse practitioners from two academically affiliated primary care practices and three community health centers located in New York City. Focus groups were audiotape recorded and transcribed. The data were analyzed using directed content analysis; NVivo software was used to assist in the quantification of identified themes. RESULTS Most participants (96%) employed opioids as therapy for some of their older patients with chronic pain, although not as first-line therapy. Providers cited multiple barriers, including fear of causing harm, the subjectivity of pain, lack of education, problems converting between opioids, and stigma. New barriers included patient/family member reluctance to try an opioid and concerns about opioid abuse by family members/caregivers. Studies confirming treatment benefit, validated tools for assessing risk and/or dosing for comorbidities, improved conversion methods, patient education, and peer support could facilitate opioid prescribing. Participants voiced greater comfort using opioids in the setting of delivering palliative or hospice care versus care of patients with chronic pain, and expressed substantial frustration managing chronic pain. CONCLUSIONS Providers perceive multiple barriers to prescribing opioids to older adults with chronic pain, and use these medications cautiously. Establishing the long-term safety and efficacy of these medications, generating improved prescribing methods, and implementing provider and patient educational interventions could help to improve the management of chronic pain in later life.
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Affiliation(s)
- Aerin Spitz
- Department of Internal Medicine, Virginia Mason Medical Center, Seattle, WA, USA
| | - Alison A Moore
- Division of Geriatrics, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Maria Papaleontiou
- Division of Endocrinology, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Evelyn Granieri
- Division of Geriatric Medicine and Aging, Columbia University, New York, NY, USA
| | - Barbara J Turner
- Department of Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - M Carrington Reid
- Division of Geriatrics and Gerontology, Weill Cornell Medical College, New York, NY, USA
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Corrigan C, Desnick L, Marshall S, Bentov N, Rosenblatt RA. What can we learn from first-year medical students' perceptions of pain in the primary care setting? PAIN MEDICINE 2011; 12:1216-22. [PMID: 21668747 DOI: 10.1111/j.1526-4637.2011.01150.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Pain concerns are one of the leading causes of visits to primary care. However, practicing physicians find managing pain frustrating and complex. There is little information about how undergraduate medical students approach pain and its management. This study aimed to explore first-year medical students' perceptions of pain-related patient encounters in the primary care setting. DESIGN Qualitative analysis was used to explore first-year students' reflective journals written during an early clinical experience in primary care. Using iterative process for text analysis, entries referencing pain-related encounters were coded by two independent researchers with 94% inter-rater reliability. Themes and categories were sought by immersion crystallization. RESULTS Three themes emerged from the students' journals: positive, negative, and neutral perceptions of pain-related encounters. With further analysis of the journals, acute, chronic, end-of-life, iatrogenic, and emotional pain categories also emerged. Most journal entries were negative, and chronic pain generated the most negativity. CONCLUSIONS First-year medical students identified pain as a major concern in their early clinical experience. Students' perceptions of pain-related encounters can inform curriculum design and may ultimately benefit both physicians and the patients.
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Affiliation(s)
- Corinne Corrigan
- Department of Family Medicine, University of Washington School of Medicine, Seattle, Washington 98195-6390, USA.
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Nicolaidis C. Police officer, deal-maker, or health care provider? Moving to a patient-centered framework for chronic opioid management. PAIN MEDICINE (MALDEN, MASS.) 2011; 12:890-7. [PMID: 21539703 PMCID: PMC4841254 DOI: 10.1111/j.1526-4637.2011.01117.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
How we frame our thoughts about chronic opioid therapy greatly influences our ability to practice patient-centered care. Even providers who strive to be nonjudgmental may approach clinical decision-making about opioids by considering if the pain is real or they can trust the patient. Not only does this framework potentially lead to poor or unshared decision-making, it likely adds to provider and patient discomfort by placing the provider in the position of a police officer or a judge. Similarly, providers often find themselves making deals with patients using a positional bargaining approach. Even if a compromise is reached, this framework can potentially inadvertently weaken the therapeutic relationship by encouraging the idea that the patient and provider have opposing goals. Reframing the issue can allow the provider to be in a more therapeutic role. As recommended in the American Pain Society/American Academy of Pain Medicine guidelines, providers should decide whether the benefits of opioid therapy are likely to outweigh the harms for a specific patient (or sometimes, for society) at a specific time. This article discusses how providers can use a benefit-to-harm framework to make and communicate decisions about the initiation, continuation, and discontinuation of opioids for managing chronic nonmalignant pain. Such an approach focuses decisions and discussions on judging the treatment, not the patient. It allows the provider and the patient to ally together and make shared decisions regarding a common goal. Moving to a risk-benefit framework may allow providers to provide more patient-centered care, while also increasing provider and patient comfort with adequately monitoring for harm.
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Affiliation(s)
- Christina Nicolaidis
- Department of Medicine and Public Health and Preventive Medicine, Oregon Health and Science University, Portland, Oregon 97239, USA.
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Rosser BA, McCracken LM, Velleman SC, Boichat C, Eccleston C. Concerns about medication and medication adherence in patients with chronic pain recruited from general practice. Pain 2011; 152:1201-1205. [PMID: 21376463 DOI: 10.1016/j.pain.2011.01.053] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2010] [Revised: 01/26/2011] [Accepted: 01/27/2011] [Indexed: 11/17/2022]
Abstract
This study examines the concerns and beliefs about medication reported by patients with nonmalignant chronic pain encountered within general practice. Two hundred thirty-nine patients with chronic pain took part in this research. Patients completed the Pain Medication Attitudes Questionnaire, a measure of patient concerns and beliefs relating to addiction, withdrawal, side effects, mistrust in doctors, perceived need of medication, scrutiny from others, and tolerance. The data revealed that patient concerns and beliefs predicted general medication nonadherence. In addition, concerns were related to the direction of nonadherence: overuse of medication was related to increased perceived need for medication and greater concern over side effects; underuse was related to decreased concerns over withdrawal and increased mistrust in the prescribing doctor. Analyses also indicated that patient attitudes and concerns about medication were more predictive of nonadherence than both level of pain and the reported frequency of experienced side effects. This research contributes to the increasing evidence that patient attitudes and beliefs about pain medication are associated with adherence behavior. Training general practitioners to identify and address these concerns may reduce concerns, improve adherence, and facilitate the doctor-patient relationship.
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Affiliation(s)
- Benjamin A Rosser
- Bath Centre for Pain Research, University of Bath, Bath, UK Bath Centre for Pain Services, Royal National Hospital for Rheumatic Diseases, Bath, UK
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49
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Limitations of Pharmacologic Pain Management. Pain Manag 2011. [DOI: 10.1016/b978-1-4377-0721-2.00128-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Gore M, Tai KS, Sadosky A, Leslie D, Stacey BR. Clinical comorbidities, treatment patterns, and direct medical costs of patients with osteoarthritis in usual care: a retrospective claims database analysis. J Med Econ 2011; 14:497-507. [PMID: 21682606 DOI: 10.3111/13696998.2011.594347] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Comorbidities and resource utilization among patients with osteoarthritis (OA) in clinical practice have been infrequently characterized. The purpose of this study was to examine comorbidities, pain-related pharmacotherapy, and direct medical costs of patients with OA in clinical practice. METHOD This retrospective cohort analysis used medical and pharmacy claims data from the LifeLink™ Database. OA patients (ICD-9-CM codes 715.XX) were matched (age, gender, and region) with individuals without OA. Comorbidities, pain-related pharmacotherapy, and direct medical costs (pharmacy, outpatient, inpatient, total) were examined for the calendar year 2008. RESULTS The sample consisted of 112,951 OA patients and 112,951 controls (mean age: 56.9 [SD=9.5] years; 62% female). Relative to controls, OA patients were significantly more likely (p<0.0001) to have comorbidities, including musculoskeletal (84.3 vs. 37.1%) and neuropathic pain (22.0 vs. 6.1%) conditions, depression (12.4 vs. 6.4%), anxiety (6.6 vs. 3.5%), and sleep disorders (11.9 vs. 4.2%). OA patients were significantly more likely (p<0.0001) to receive pain-related medications, including opioids (40.7 vs. 17.1%), NSAIDs (37.1 vs. 11.5%), tramadol (9.8 vs. 1.8%), and adjunctive medications for treating depression, anxiety, and insomnia. Mean [SD] total direct medical costs were more than two times higher among OA patients ($12,905 [$21,884] vs. $5099 [$13,855]; p<0.001) and median costs were more than three times higher ($6188 vs. $1879; p<0.0001). Study limitations include potential errors in coding and recording; overestimation of the comorbidity burden; inability to link condition of interest, OA, with prescribed medications; and possible underestimation of the true costs of OA, because indirect costs were not considered and the direct costs were from a third party payer (commercial insurance) perspective. CONCLUSION The patient burden of OA was characterized by a high prevalence of comorbidities. The payer burden was also substantial, with significantly greater use of pain-related and adjunctive medications, and higher direct medical costs.
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Affiliation(s)
- Mugdha Gore
- Avalon Health Solutions, Inc., 1518 Walnut Steeet, Philadelphia, PA 19102, USA.
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