Opioid use behaviors, mental health and pain--development of a typology of chronic pain patients

Intravenous Opioid Administration During Mechanical Ventilation and Use After Hospital Discharge

Importance

Guidelines recommend an analgesia-first strategy for sedation during mechanical ventilation, but associations between opioids provided during mechanical ventilation and posthospitalization opioid-related outcomes are unclear.

Objective

To evaluate associations between an intravenous opioid dose received during mechanical ventilation and postdischarge opioid-related outcomes in medical (nonsurgical) patients.

Design, Setting, and Participants

This retrospective cohort study evaluated adults receiving mechanical ventilation lasting 24 hours or more for acute respiratory failure and surviving hospitalization. Participants from 21 Kaiser Permanente Northern California hospitals from January 1, 2012, to December 31, 2019, were included. Data were analyzed from October 1, 2020, to October 31, 2023.

Exposures

Terciles of median daily intravenous fentanyl equivalents during mechanical ventilation.

Main Outcomes and Measures

The primary outcome was the first filled opioid prescription in 1 year after discharge. Secondary outcomes included persistent opioid use and opioid-associated complications. Secondary analyses tested for interaction between opioid doses during mechanical ventilation, prior opioid use, and posthospitalization opioid use. Estimates were based on multivariable-adjusted time-to-event analyses, with death as a competing risk, and censored for hospice or palliative care referral, rehospitalization with receipt of opioid, or loss of Kaiser Permanente plan membership.

Results

The study included 6746 patients across 21 hospitals (median age, 67 years [IQR, 57-76 years]; 53.0% male). Of the participants, 3114 (46.2%) filled an opioid prescription in the year prior to admission. The median daily fentanyl equivalent during mechanical ventilation was 200 μg (IQR, 40-1000 μg), with terciles of 0 to 67 μg, more than 67 to 700 μg, and more than 700 μg. Compared with patients who did not receive opioids during mechanical ventilation (n = 1013), a higher daily opioid dose was associated with opioid prescriptions in the year after discharge (n = 2942 outcomes; tercile 1: adjusted hazard ratio [AHR], 1.00 [95% CI, 0.85-1.17], tercile 2: AHR, 1.20 [95% CI, 1.03-1.40], and tercile 3: AHR, 1.25 [95% CI, 1.07-1.47]). Higher doses of opioids during mechanical ventilation were also associated with persistent opioid use after hospitalization (n = 1410 outcomes; tercile 3 vs no opioids: odds ratio, 1.44 [95% CI, 1.14-1.83]). No interaction was observed between opioid dose during mechanical ventilation, prior opioid use, and posthospitalization opioid use.

Conclusions and Relevance

In this retrospective cohort study of patients receiving mechanical ventilation, opioids administered during mechanical ventilation were associated with opioid prescriptions following hospital discharge. Additional studies to evaluate risks and benefits of strategies using lower opioid doses are warranted.

Developing a typology of interventions to support doctors' mental health and wellbeing

BACKGROUND

The problem of mental ill-health in doctors is complex, accentuated by the COVID-19 pandemic, and impacts on healthcare provision and broader organisational performance. There are many interventions to address the problem but currently no systematic way to categorise them, which makes it hard to describe and compare interventions. As a result, implementation tends to be unfocussed and fall short of the standards developed for implementing complex healthcare interventions. This study aims to develop: 1) a conceptual typology of workplace mental health and wellbeing interventions and 2) a mapping tool to apply the typology within research and practice.

METHODS

Typology development was based on iterative cycles of analysis of published and in-practice interventions, incorporation of relevant theories and frameworks, and team and stakeholder group discussions.

RESULTS

The newly developed typology and mapping tool enable interventions to be conceptualised and/or mapped into different categories, for example whether they are designed to be largely preventative (by either improving the workplace or increasing personal resources) or to resolve problems after they have arisen. Interventions may be mapped across more than one category to reflect the nuance and complexity in many mental health and wellbeing interventions. Mapping of interventions indicated that most publications have not clarified their underlying assumptions about what causes outcomes or the theoretical basis for the intervention.

CONCLUSION

The conceptual typology and mapping tool aims to raise the quality of future research and promote clear thinking about the nature and purpose of interventions, In doing so it aims to support future research and practice in planning interventions to improve the mental health and wellbeing of doctors.

Characteristics of patients with non-cancer pain and long-term prescription opioid use who have used medical versus recreational marijuana

OBJECTIVE

Marijuana use is increasingly common among patients with chronic non-cancer pain (CNCP) and long-term opioid therapy (LTOT). We determined if lifetime recreational and medical marijuana use were associated with more frequent and higher dose prescription opioid use.

DESIGN

Cross-sectional SUBJECTS: Eligible patients (n=1,037), who had a new period of prescription opioid use lasting 30-90 days, were recruited from two midwestern health care systems to a study of long-term prescription opioid use and mental health outcomes. The present cross-sectional analyses uses baseline data from this on-going cohort study.

METHODS

Primary exposures were participant reported lifetime recreational and medical marijuana use versus no lifetime marijuana use. Prescription opioid characteristics included daily versus non-daily opioid use and ≥50 morphine milligram equivalent (MME) dose per day vs. <50 MME. Multivariate, logistic regression models estimated the association between lifetime recreational and medical marijuana use vs. no use and odds of daily and higher dose prescription opioid use, before and after adjusting for confounding.

RESULTS

The sample was an average of 54.9 (SD±11.3) years of age, 57.3% identified as female gender, 75.2% identified as White, and 22.5% identified as Black race. Among all participants, 44.4% were never marijuana users, 21.3% were recreational only, 7.7% medical only and 26.6% were both recreational and medical marijuana users. After controlling for all confounders, lifetime recreational marijuana use, as compared to no use, was significantly associated with increased odds of daily prescription opioid use (OR=1.61; 95%CI:1.02-2.54). There was no association between lifetime recreational or medical marijuana use and daily opioid dose.

CONCLUSION

Lifetime medical marijuana use is not linked to current opioid dose, but lifetime recreational use is associated with more than a 60% odds of being a daily prescription opioid user. Screening for lifetime recreational marijuana use may identify patients with chronic pain who are vulnerable to daily opioid use which increases risk for adverse opioid outcomes. Prospective data is needed to determine how marijuana use influences the course of LTOT and vice versa.

Exploratory evaluation of spinal cord stimulation with dynamic pulse patterns: a promising approach to improve stimulation sensation, coverage of pain areas, and expected pain relief

Background

The societal burden of chronic pain and the contribution-in-part to the opioid crisis, is a strong motivation to improve and expand non-addictive treatments, including spinal cord stimulation (SCS). For several decades standard SCS has consisted in delivery of tonic pulses with static parameter settings in frequency, pulse width, and amplitude. These static parameters have limited ability to personalize the quality of paresthesia, the dermatomal coverage, and thus may affect SCS efficacy. Further, static settings may contribute to the build-up of tolerance or loss of efficacy of the therapy over time in some patients.

Methods

We conducted an acute exploratory study to evaluate the effects of SCS using time-dynamic pulses as compared to time-static (conventional tonic) stimulation pulses, with the hypotheses that dynamic pulse SCS may enable beneficial tailoring of the sensation and the patient's expectation for better pain relief with SCS. During a single clinic visit, consented subjects undergoing a standard SCS trial had their implanted leads temporarily connected to an investigational external stimulator capable of delivering time-static and six categories of time-dynamic pulse sequences, each characterized by continuously varying a stimulation parameter. Study subjects provided several assessments while blinded to the stimulation pattern, including: drawing of paresthesia maps, descriptions of sensation, and ratings for comfort and helpfulness to pain relief.

Results

Even without optimization of the field location, a majority of subjects rated sensations from dynamic stimulation as better or equal to that of static stimulation for comfortableness and for helpfulness to pain relief. The initial data showed a gender and/or pain dermatomal location related preference to a stimulation pattern. In particular, female subjects and subjects with pain at higher dermatomes tended to rank the sensation from dynamic stimulation better. Dynamic stimulation produced greater pain coverage without optimization; in 70% (9/13) of subjects, maximal pain coverage was achieved with a dynamic stimulation pattern. There was also greater variety in the words used by patients to describe stimulation sensation in the free text and free form verbal descriptions associated with dynamic stimulation.

Conclusions

With the same electrode configuration and comparable parameter settings, acute SCS using dynamic pulses produced more positive ratings, expanded paresthesia coverage, and greater variation in sensation as compared to SCS using static pulses, suggesting that dynamic stimulation has the potential to improve capabilities of SCS for the treatment of chronic pain. Further study is warranted.

Trial Registration

This study was registered at ClinicalTrials.gov under ID NCT02988713, November 2016 (URL: https://clinicaltrials.gov/ct2/show/NCT02988713).

Shifting quality chronic pain treatment measures from processes to outcomes

OBJECTIVE

Misapplication of the 2016 Centers for Disease Control (CDC) opioid prescribing guidelines has led to overem-phasis of morphineequivalent daily dose (MEDD) as a "metric of success" in chronic noncancer pain (CNCP), resulting in unintentional harms to patients. This article reviews CNCP-related guidelines and patient preferences in order to identify pragmatic, patient-centered metrics to assess treatment response and safety in opioid-treated CNCP.

METHODS

We reviewed the clinical (CDC), research (Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials), and implementability-related guidelines (GuideLine Implementability Appraisal), along with relevant patient-identified treatment goals. From these, we summarize a guideline-concordant, patient-centered, implementable set of measures to aid the clinical management of opioid-treated CNCP.

RESULTS

We identify metrics across three domains of care: (1) treatment response metrics, which align with the CNCP care goals (pain intensity, pain interference including function and quality of life, and global impression of change); (2) risk assessment ("safety") metrics, eg, MEDD, benzodiazepine-opioid or naloxone-opioid coprescribing, and severity of mental health disorders, which evaluate the risk-benefit profile of opioid therapy; and (3) adherence ("process") metrics, which assess clinician/patient adherence to the guideline-recommended opioid therapy monitoring practices, eg, the presence of completed treatment agreement or urine toxicology testing. All metrics should be informed by implementability principles, eg, be decidable, executable, and measurable.

CONCLUSIONS

This article summarizes guideline-concordant, patient-centered, implementable metrics for assessing treatment response, safety, and adherence in opioid-treated CNCP. Regardless of which specific treatment guidelines are applied, this approach could help conceptualize and standardize the collection and reporting of CNCP-relevant metrics, compare them across health systems, and optimize care and treatment outcomes in opioid-treated CNCP.

Sociocultural factors associated with persistent prescription opioid use (PPOU) among Puerto Rican adults in Massachusetts

BACKGROUND

Increasing numbers of opioid-overdose deaths have been witnessed among Hispanics and other underserved populations in Massachusetts. Puerto Rican adults (PRs) have a disproportionately higher prevalence of chronic diseases than non-Hispanic White adults-conditions linked to increased prescription opioid use and misuse. Stress indicators, including low acculturation, low social support, and perceived discrimination, have been recognized as correlates of chronic diseases. However, little research has been undertaken on how these socio-cultural factors relate to persistent prescription opioid use among PRs. This study evaluated the prevalence of prescription opioid use and socio-cultural factors associated with persistent prescription opioid use among PRs.

METHODS

Data from the prospective population-based Boston Puerto Rican Health Study, at baseline, ~2-year, and ~ 6-year follow-up, were used to estimate prescription opioid use prevalence and its associations with acculturation, social support, and perceived discrimination. Analyses were conducted using multivariable binary logistic regression modeling.

RESULTS

The study sample was comprised of 798 PRs (age 56.5 ± 7.5y) with data at all three-time points. A high prevalence of prescription opioid use was observed and was associated with lower household income. PRs with experiences of perceived discrimination had higher odds of persistent prescription opioid use (y/n; OR = 2.85, 95% CI: 1.46-5.58). No significant associations were found between acculturation, social support, and persistent prescription opioid use.

CONCLUSION

Our study reported a high prevalence of prescription opioid use in PRs, with persistent prescription opioid use significantly associated with perceived discrimination. Future programs to limit discrimination practices may reduce persistent prescription opioid use and opioid-related complications among PRs.

Between guidelines and clinical trials: evidence-based advice on the pharmacological management of non-specific chronic low back pain

The pharmacological management of nonspecific chronic low back pain (NCLBP) aims to restore patients' daily activities and improve their quality of life. The management of NCLBP is not well codified and extremely heterogeneous, and residual symptoms are common. Pharmacological management should be considered as co-adjuvant to non-pharmacological therapy, and should be guided by the symptoms reported by the patients. Depending on the individual severity of NCLPB, pharmacological management may range from nonopioid to opioid analgesics. It is important to identify patients with generalized sensory hypersensitivity, who may benefit from dedicated therapy. This article provides an evidence-based overview of the principles of pharmacological management of NCLPB.

Population- and individual-level trajectories of opioid prescription patterns among adults with cerebral palsy: a retrospective cohort study

BACKGROUND

There is little epidemiologic evidence on opioid prescription among adults with cerebral palsy (CP).

AIM

To describe the population- and individual-level opioid prescription patterns for adults with versus without CP.

METHOD

This retrospective cohort study used commercial claims (Optum's de-identified Clinformatics® Data Mart Database) from the USA from 01/01/2011-12/31/2017 from adults ≥ 18 years old with CP and matched adults without CP. For the population-level analysis, monthly estimates of opioid exposure were described for adults ≥ 18 years old with CP and matched adults without CP. For the individual-level analysis, group based trajectory modelling (GBTM) was used to identify groups of similar individual-level monthly opioid exposure patterns for adults with CP and matched adults without CP for 1-year starting from their first opioid exposure month.

RESULTS

For the population-level, adults with (n = 13,929) versus without (n = 278,538) CP had a higher prevalence of opioid exposure (~ 12%, ~ 8%) and days supplied (median, ~ 23, ~17) monthly over 7 years. For the individual-level, there were 6 trajectory groups for CP (n = 2099) and 5 for non-CP (n = 10,361). Notably, 14% of CP (comprising 4 distinct trajectory groups) and 8% (comprising 3 distinct groups) of non-CP had variably high monthly opioid volume for extended periods; exposure was higher for CP. The remaining had low/absent opioid exposure trajectories; for CP (non-CP), 55.7% (63.3%) had nearly absent exposure and 30.4% (28.9%) had consistently low exposure to opioids.

CONCLUSION

Adults with versus without CP were more likely to be exposed to opioids and for a longer duration, which may alter the risk-benefit balance of opioids.

The Use of Opioids in the Management of Chronic Pain: Synopsis of the 2022 Updated U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline

DESCRIPTION

In May 2022, leadership within the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline for the use of opioids when managing chronic pain. This synopsis summarizes the recommendations that the authors believe are the most important to highlight.

METHODS

In December 2020, the VA/DoD Evidence-Based Practice Work Group assembled a team to update the 2017 VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain. The guideline development team included clinical stakeholders and conformed to the National Academy of Medicine's tenets for trustworthy clinical practice guidelines. The guideline team developed key questions to guide a systematic evidence review that was done by an independent third party and distilled 20 recommendations for care using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. The guideline team also created 3 one-page algorithms to help guide clinical decision making. This synopsis presents the recommendations and highlights selected recommendations on the basis of clinical relevance.

RECOMMENDATIONS

This guideline is intended for clinicians who may be considering opioid therapy to manage patients with chronic pain. This synopsis reviews updated recommendations for the initiation and continuation of opioid therapy; dose, duration, and taper of opioids; screening, assessment, and evaluation; and risk mitigation. New additions are highlighted, including recommendations about the use of buprenorphine instead of full agonist opioids; assessing for behavioral health conditions and factors associated with higher risk for harm, such as pain catastrophizing; and the use of pain and opioid education to reduce the risk for prolonged opioid use for postsurgical pain.

Diagnosing Prescription Opioid Use Disorder in Patients Using Prescribed Opioids for Chronic Pain

OBJECTIVE

The diagnostic criteria for opioid use disorder, originally developed for heroin, did not anticipate the surge in prescription opioid use and the resulting complexities in diagnosing prescription opioid use disorder (POUD), including differentiation of pain relief (therapeutic intent) from more common drug use motives, such as to get high or to cope with negative affect. The authors examined the validity of the Psychiatric Research Interview for Substance and Mental Disorders, DSM-5 opioid version, an instrument designed to make this differentiation.

METHODS

Patients (N=606) from pain clinics and inpatient substance treatment who ever received a ≥30-day opioid prescription for chronic pain were evaluated for DSM-5 POUD (i.e., withdrawal and tolerance were not considered positive if patients used opioids only as prescribed, per DSM-5 guidelines) and pain-adjusted POUD (behavioral/subjective criteria were not considered positive if pain relief [therapeutic intent] was the sole motive). Bivariate correlated-outcome regression models indicated associations of 10 validators with DSM-5 and pain-adjusted POUD measures, using mean ratios for dimensional measures and odds ratios for binary measures.

RESULTS

The prevalences of DSM-5 and pain-adjusted POUD, respectively, were 44.4% and 30.4% at the ≥2-criteria threshold and 29.5% and 25.3% at the ≥4-criteria threshold. Pain adjustment had little effect on prevalence among substance treatment patients but resulted in substantially lower prevalence among pain treatment patients. All validators had significantly stronger associations with pain-adjusted than with DSM-5 dimensional POUD measures (ratios of mean ratios, 1.22-2.31). For most validators, pain-adjusted binary POUD had larger odds ratios than DSM-5 measures.

CONCLUSIONS

Adapting POUD measures for pain relief (therapeutic intent) improved validity. Studies should investigate the clinical utility of differentiating between therapeutic and nontherapeutic intent in evaluating POUD diagnostic criteria.

Trends in Opioid Prescribing Following Pennsylvania Statewide Implementation of a Prescription Drug Monitoring Program

Background: The opioid epidemic is a major public health crisis in the United States. Legislators have enacted various strategies to combat this crisis, including the implementation of statewide prescription drug monitoring programs (PDMP). These PDMPs are electronic databases that collect and analyze patient prescription data on controlled substances, allowing physicians to review prior prescriptions before prescribing. The objective of this study was to determine opioid prescribing patterns after the implementation of a statewide PDMP in Pennsylvania.

Methods: After IRB approval, PDMP data were obtained from the Pennsylvania Department of Health. Data obtained included: drug name, days supplied, refill count, and partially filled prescriptions. The study timeline was three years, from first quarter 2017 through first quarter 2020.

Results: Over the three years post-implementation of a PDMP, Pennsylvania saw a 33% decrease in the overall quantity of opioid pills prescribed (677,194 absolute reduction), a 9% decrease in partially filled prescriptions (5,821 absolute reduction), and an 18% decrease in authorized refills (525 absolute reduction). Opioid prescriptions for greater than seven days of supply decreased by a larger amount than prescriptions for less than seven days of supply (43% vs 27%). Similarly, prescriptions for more than 22 pills saw a greater decrease than prescriptions for less than 21 days (37% vs 21%). However, the rate of decrease in opioid pills prescribed lessened from 14% in the first two years post implementation, to 10% in the third year. The decrease in partially filled opioid prescriptions for the first two years averaged 14% per year, while it increased by 23% in the third year. An 8% average decrease occurred in the rate of refills for opioid prescriptions for the first two years post implementation, followed by a 3% reduction in the third year.

Conclusion: There was a 33% decrease in the overall quantity of opioid pills prescribed in the three years after the implementation of the PDMP. The first two years after implementation saw the largest decreases in prescribing habits, which slowed in the third year. More data are needed to show the long-term effects of implementing a statewide PDMP.

Differential Experience of Interdose Withdrawal During Long-Term Opioid Therapy and its Association With Patient and Treatment Characteristics: A Latent Class Analysis in Chronic Pain Population

Opioid withdrawal is characterized by a set of physical and psychological symptoms that depend on both opioid and patient specific characteristics. The present study aims to identify different latent classes of chronic pain patients according to the type of opioid withdrawal symptoms experienced, and to analyze the relationships between the classes and demographic, opioid therapy, psychological and substance use variables. This cross-sectional descriptive study included 391 chronic pain patients on long-term opioid therapy. A Latent Class Analysis (LCA) identified 3 classes (BIC = 7051.89, entropy = .87, LRTs P < .01). The mild withdrawal class showed low probabilities of presenting physical and psychological symptoms, the moderate withdrawal class was characterized by experiencing psychological symptoms, and the severe withdrawal class stood out for high probabilities of presenting both types of symptoms. The classes differed from each other, with higher rates of moderate-severe POUD, opioid misuse, anxiety, depression, and greater pain intensity and interference in more severe withdrawal classes (P < .05). The multinomial logistic regression showed that moderate-severe POUD and anxiety were the strongest variables related to moderate (OR_POUD = 3.34, OR_Anxiety = 2.58) and severe withdrawal classes (OR_POUD = 4.26, OR_Anxiety = 5.15). Considering that POUD and anxiety were strongly related to a more severe withdrawal syndrome, the inclusion of psychological interventions in pain management seems critical in this population. PERSPECTIVE: Although interdose opioid withdrawal is common in chronic pain patients, this study shows 3 different patterns in its experience (mild, moderate, and severe withdrawal). A more severe withdrawal may result in reduced effectiveness of opioids in relieving pain and increased negative consequences, such as higher risk of POUD. Findings that could help improve chronic pain management.

Protective and Risk Factors at the Intersection of Chronic Pain, Depression, Anxiety, and Somatic Amplification: A Latent Profile Approach

Objective

Research indicates a complex nexus between chronic pain, depression, anxiety, and somatic amplification (PDAS) symptoms, marked by high rates of co-morbidity and mutually maintaining mechanisms. Although recent frameworks have attempted to explain co-occurrence rates of pain and other comorbid disorders, the interrelations between PDAS and their impacts on pain outcomes have not been adequately examined with a person-centered approach. Using nationally representative data, this study assessed the heterogeneity in PDAS symptomatology and examined links among risk and protective factors in different profiles.

Methods

Data were derived from 1027 participants in the National Survey of Midlife Development in the United States (MIDUS) who completed telephone interviews or self-report measures that assessed PDAS, various sources of social supports (family, friends, spouses/partners, religion, coworkers, and supervisors), and the number of healthcare visits.

Results

We found heterogeneity in symptom severity rather than symptom type across classes over time. Regardless of comorbidity severity, people reported similar levels of somatic symptoms, which may help clinicians more effectively diagnose comorbidity issues among chronic pain patients. As PDAS symptomatology increased by group, the perceived levels of social support decreased. Membership in a higher symptom severity class was associated with being female, younger age, and an increase in medical, but not mental health visits.

Limitations

Limitations included the use of a cross-sectional design, reliance on self-report measures, and a sample largely comprised of Whites.

Conclusion

PDAS co-occurs across classes, which may relate to shared risk and protective factors. This study lays the foundation to investigate similar questions for overlapping symptoms that occur during the same period, which would shed light on whether—among middle to older age adults—these disorders are attributable to a common mechanism and if they may inform transdiagnostic treatments.

Opioid-related risk perceptions in chronic pain: influence of patient gender and previous misuse behaviors

ABSTRACT

Little is known about the factors that influence providers' perceptions of patient risk for aberrant opioid use. Patient gender may interact with previous opioid misuse to influence these perceptions. We asked 131 physicians to view videos and vignettes for 8 virtual patients with chronic pain. Gender (male/female) and previous prescription opioid misuse (present/absent) varied across patients; the vignettes were otherwise balanced on demographic and clinical characteristics. For each patient, providers assessed 4 risk domains: opioid-related adverse events, opioid misuse or abuse, opioid addiction, and opioid diversion. Results indicated a significant gender-by-misuse interaction for risk of opioid misuse orabuse. When previous misuse behaviors were absent, providers rated men at higher risk; there was no gender difference when previous misuse behaviors were present. A significant gender-by-misuse interaction was found for risk of opioid-related adverse events. Providers perceived men to be at higher risk when previous misuse behaviors were absent; there was no gender difference when previous misuse behaviors were present. A significant gender-by-misuse interaction was found for risk of opioid addiction. Providers rated women at higher risk when previous misuse behaviors were present and men at higher risk when previous misuse behaviors were absent. There were significant main effects of gender and misuse for risk of opioid diversion. Providers rated men and those with previous misuse behaviors at higher risk. These results demonstrate that patient gender and previous opioid misuse have unique and interactive effects on provider perceptions of prescription opioid-related risks. Studies are needed to identify the mechanisms underlying these effects, such as gender-based stereotypes about risk-taking and drug abuse.

Early Optimized Pharmacological Treatment in Patients With Depression and Chronic Pain

Major depressive disorder (MDD) is the leading cause of disability worldwide. Patients with MDD have high rates of comorbidity with mental and physical conditions, one of which is chronic pain. Chronic pain conditions themselves are also associated with significant disability, and the large number of patients with MDD who have chronic pain drives high levels of disability and compounds healthcare burden. The management of depression in patients who also have chronic pain can be particularly challenging due to underlying mechanisms that are common to both conditions, and because many patients with these conditions are already taking multiple medications. For these reasons, healthcare providers may be reluctant to treat such patients. The Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines provide evidence-based recommendations for the management of MDD and comorbid psychiatric and medical conditions such as anxiety, substance use disorder, and cardiovascular disease; however, comorbid chronic pain is not addressed. In this article, we provide an overview of the pathophysiological and clinical overlap between depression and chronic pain and review evidence-based pharmacological recommendations in current treatment guidelines for MDD and for chronic pain. Based on clinical experience with MDD patients with comorbid pain, we recommend rapidly and aggressively treating depression according to CANMAT treatment guidelines, using antidepressant medications with analgesic properties, while addressing pain with first-line pharmacotherapy as treatment for depression is optimized. We review options for treating pain symptoms that remain after response to antidepressant treatment is achieved.

Analgesic Effects of Oxycodone in Combination With Risperidone or Ziprasidone: Results From a Pilot Randomized Controlled Trial in Healthy Volunteers

Background and Objectives

Patients taking opioids are at risk of developing dependence and possibly abuse. Given the role of the mesolimbic dopamine system in opioid reward, blocking dopamine D2 receptors should limit the abuse liability of opioid analgesics. This pilot study evaluates the analgesic efficacy of oxycodone combined with an atypical antipsychotic (dopamine D2 receptor antagonist).

Methods

A randomized, double-blind, within-subjects, controlled trial in healthy volunteers was conducted at UT Health SA Pain Clinic. Fifteen volunteers with previous medical exposure to opioids were enrolled. Risperidone (2 mg) or ziprasidone (80 mg) in combination with oxycodone (5, 10, 15 mg) was administered. Pain intensity using the cold pressor test, Current Opioid Misuse Measure (COMM), Addiction Research Center Inventory (ARCI, opioid subscale), Drug likability with drug effects questionnaire (DEQ) were assessed.

Results

Oxycodone produced dose dependent increases in thermal analgesia on the cold pressor test that was significant at 10 and 15 mg (t = 3.087, P = 0.017). The combination did not significantly alter thermal analgesia. There was no significant effect of the combination on the ARCI or the POMS.

Discussion and Conclusion

The combination of an atypical antipsychotic with oxycodone does not alter analgesic response or increase the incidence of adverse effects when compared to oxycodone alone. Such information is critical for the development of drug combinations for the treatment of pain and provide the foundation for future studies of abuse potential in drug users.

Scientific Significance

This intervention in chronic pain patients is unique because it utilizes FDA approved drugs in combination to reduce abuse liability. The first step, and aim of this study, is to confirm the drug combination does not interfere with analgesic efficacy. The next step is to examine the combination in recreational drug users to assess the potential to block the euphoric effects of oxycodone. Ultimately, if this combination is effective, this approach could be beneficial in management of chronic pain.

Thirdhand smoke from tobacco, e-cigarettes, cannabis, methamphetamine and cocaine: Partitioning, reactive fate, and human exposure in indoor environments

A source of chemical exposure to humans, thirdhand smoke (THS) refers to the contamination that persists indoors following the cessation of a smoking event. The composition of thirdhand smoke depends on the type of substance from which it originates. Although past studies have investigated the effects of tobacco THS on indoor air quality and human health, few have focused on the chemical composition and health impacts of other sources and components of THS. Here we review the state of knowledge of the composition and partitioning behavior of various types of indoor THS, with a focus on THS from tobacco, e-cigarettes, cannabis, and illicit substances (methamphetamine and cocaine). The discussion is supplemented by estimates of human exposure to THS components made with a chemical fate and exposure model. The modeling results show that while very volatile THS compounds (i.e., aromatics) are likely to be taken up by inhalation, highly water-soluble compounds tended to be dermally absorbed. Conversely, minimally volatile THS compounds with low solubility are predicted to be ingested through hand-to-mouth and object-to-mouth contact.

Associations between elevated depressive symptoms and substance use, prescription opioid misuse, overdose history, pain, and general health among community pharmacy patients prescribed opioids

Background: Individuals with pain prescribed opioids experience high rates of comorbid depression. The aim of this study was to characterize pain, substance use, and health status as a function of depressive symptom level in individuals filling an opioid prescription at a community pharmacy. Methods: Participants (N = 1268) filling an opioid prescription enrolled in a study validating a prescription drug monitoring metric completed an online survey assessing sociodemographics, depressive symptoms, substance use, prescription opioid misuse, overdose history, general health, and pain severity and interference. Results: Approximately one-fifth (19.3%) had a positive depression screen result. In covariate-adjusted logistic regression analyses, individuals with a positive depression screen result were more likely to have moderate/high substance use risk scores for prescription opioids (adjusted odds ratio [AOR] = 2.06; 95% confidence interval [CI], 1.51-2.79); street opioids (AOR = 7.18; 95% CI, 2.57-20.01); cannabis (AOR = 2.00; 95% CI, 1.34-3.00); cocaine (AOR = 3.46; 95% CI, 1.46-8.22); tobacco (AOR = 1.59; 95% CI, 1.18-2.15); methamphetamine (AOR = 7.59; 95% CI, 2.58-22.35); prescription stimulants (AOR = 2.95; 95% CI, 1.59-5.49); and sedatives (AOR = 3.41; 95% CI, 2.43-4.79). Individuals with a positive depression screen were more likely to misuse prescription opioids (AOR = 3.46; 95% CI, 2.33-5.15), experience a prior overdose (AOR = 2.69; 95% CI, 1.76-4.11), report poorer general health (AOR = 0.25, 95% CI, 0.18-0.35), and report moderate/severe pain severity (AOR = 4.36, 95% CI, 2.80-6.77) and interference (AOR = 6.47, 95% CI, 4.08-10.26). Conclusions: Individuals prescribed opioids with heightened depression were more likely to report other substance use, prescription opioid misuse, prior overdose, greater pain, and poorer health.

Changes in Initial Opioid Prescribing Practices After the 2016 Release of the CDC Guideline for Prescribing Opioids for Chronic Pain

IMPORTANCE

The Centers for Disease Control and Prevention (CDC) released the "Guideline For Prescribing Opioids For Chronic Pain" (hereafter, CDC guideline) in 2016, but its association with prescribing practices for patients who are opioid naive is unknown.

OBJECTIVE

To estimate changes in initial prescribing rates, duration, and dosage practices to patients who are opioid naive after the release of the CDC guideline.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used 6 sequential cohorts to estimate preguideline trends in prescribing among patients who were opioid naive, project that trend forward, and compare it with postguideline prescribing practices. Participants included commercially insured adults without current cancer or hospice care diagnoses and with no past-year opioid claims in the US from 2011 to 2017. All adjusted models were controlled for patient demographics and state-fixed effects. Data were analyzed from January 2020 to May 2021.

EXPOSURES

The release of the CDC guideline.

MAIN OUTCOMES AND MEASURES

Indicators of any opioid prescription fills during a 9-month period, the number of days' supply of the initial prescription, and the binary indicator of whether the initial prescription was for 50 or more morphine milligram equivalents (MMEs) per day.

RESULTS

There were 12 870 612 eligible unique patients across cohorts (mean [SD] age in 2016, 51.2 [18.7] years; 6 553 458 [50.9%] women); and the mean (SD) age of the cohorts increased annually, from 48.7 (17.9) years in the April 2011 to December 2012 cohort to 51.9 (19.2) years in the April 2016 to December 2017 cohort. The postguideline prescribing prevalence was 532 962 of 5 834 088 individuals (9.1%), which exceeded that projected from the preguideline trend, estimated at 9.0% (95% CI, 9.0%-9.1%). Among patients receiving prescriptions during follow-up, adjusted mean days' supply was 4.7% (95% CI, 4.3%-5.1%) lower in the first year after release of the guideline and 9.8% (95% CI, 9.3%-10.3%) lower in the second year after release, compared with the expected rate from the preguideline trend. The adjusted odds of receiving a high-dose (ie, ≥50 MME/d) initial prescription were lower in the first year (odds ratio, 0.97; 95% CI, 0.96-0.98) and in the second year (odds ratio, 0.94; 95% CI, 0.93-0.96) after the release of the CDC guideline compared with the odds expected from the preguideline trend.

CONCLUSIONS AND RELEVANCE

This cohort study found that patients who were opioid naive continued to initiate opioid therapy after the release of opioid prescribing guidelines by the CDC, but trends in prescribing duration reversed and decreased, after increasing in each of 4 preguideline cohorts examined. High-dose prescribing rates were already decreasing, but those trends accelerated after the CDC guideline release. These results suggest that nonmandatory, evidence-based guidelines from trusted sources were associated with prescribing practices. Guideline-concordant care has potential to improve pain management and reduce opioid-related harms.

Prevalence of Problematic Use of Opioids in Patients with Chronic Noncancer Pain: A Systematic Review with Meta-analysis

BACKGROUND AND OBJECTIVE

Opioid prescription for chronic noncancer pain is associated with problematic use. We aimed to review and summarize the evidence on the prevalence of problematic use of opioids in adults with chronic noncancer pain and investigate whether the prevalence rates were changing over time.

DATABASES AND DATA TREATMENT

A systematic review of the literature was undertaken following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. We systematically searched the literature in the electronic databases MEDLINE, SCOPUS, and Web of Science and studies with adult participants with chronic noncancer pain using opioids with indication of one or more of the following terms about problematic opioid use: abuse, misuse, addiction, dependence, problematic use, and aberrant behavior/use were eligible for data extraction. Meta-analysis was performed to estimate the pooled prevalence rates using a random-effects model, and subanalysis was conducted.

RESULTS

Our search identified a total of 784 potentially relevant studies. After a thorough evaluation, 19 papers, mostly from the United States, were included in our qualitative and quantitative synthesis. The majority of the data came from speciality pain clinics. The estimated prevalence of problematic use of opioids in adults with chronic noncancer pain was 36.3% (95% confidence interval: 27.4 to 45.2%; I²  = 99.64%). Problematic opioid use was mostly identified using the questionnaire method. Thirteen studies (68%) presented a low risk of bias.

CONCLUSIONS

Our study presents an alarming estimate regarding the prevalence of problematic use of opioids among patients with noncancer pain. These results deserve special attention from health care professionals and health authorities.

Postpartum Analgesia in New Mothers (PAIN) Study: A Survey of Canadian Obstetricians' Post-Delivery Opioid-Prescribing Practices

OBJECTIVE

We aimed to describe opioid prescribing practices after obstetric delivery and to evaluate how these practices compare with national opioid prescribing guidelines.

METHODS

A closed survey was developed, evaluated for validity and reliability, and distributed by email to obstetrician members of the Society of Obstetricians and Gynaecologists of Canada (SOGC) in December 2018. Descriptive statistics were used to summarize respondent demographics, pharmaceutical pain management strategies, and opioid prescribing practices. Logistic regression was used to measure associations between respondent characteristics and high-risk opioid prescribing practices (e.g., prescribing >50 mg morphine equivalent dose per day, prescribing >5 days, not screening for substance/opioid use disorder before prescribing).

RESULTS

Our survey had high content validity (content validity index 0.89; 95% CI 0.78-1.00) and adequate reliability (Kappa 0.70; 95% CI 0.63-0.84 and intraclass correlation coefficient 0.70; 95% CI 0.67-0.81). Of the 1019 SOGC members reached, 243 initiated the survey (response rate, 24%). Among respondents, 235 (92%) completed the survey. Among opioid prescribers, 47% reported at least 1 high-risk opioid prescribing practice, the most frequent being a lack of substance/opioid use disorder screening. In the adjusted logistic regression model, being in practice more than 20 years (adjusted odds ratio [aOR] 0.53; 95% CI 0.29-0.93) and practising in a non-central area of Canada (aOR 0.49; 95% CI 0.28-0.84) reduced the odds of high-risk prescribing.

CONCLUSION

Further research on barriers to screening are needed to support and enhance safer opioid prescribing practices among Canadian obstetricians.

Anxiety sensitivity and pain intensity independently predict opioid misuse and dependence in chronic pain patients

The United States (US) population consumes an estimated 68% of the world's prescribed opioids each year, and over 2 million adults in the US suffer from an opioid use disorder. Although chronic pain populations are among the highest risk segments of the general population for opioid misuse and dependence, there is little understanding of individual risk characteristics that may contribute to greater risk for these outcomes among this group. The present investigation explored the concurrent role of anxiety sensitivity and pain intensity and their interaction in relation to opioid misuse and dependence among 429 adults with chronic pain (73.9% female, M_age = 38.32 years, SD = 11.07). Results revealed that both anxiety sensitivity and pain intensity were associated with opioid misuse and dependence. There was no evidence of an interaction for either outcome. Post-hoc analyses indicated that of the lower-order anxiety sensitivity facets, physical and mental incapacitation concerns contributed to variance in opioid misuse and only mental incapacitation concerns contributed to variance in opioid dependence. Overall, the current findings suggest the importance of assessing anxiety sensitivity in screening for opioid-related problems among persons with chronic pain, as it may represent a distinct pathway to poorer opioid-related outcomes among this group.

The relationship of opioid prescriptions and the educational performance of children

One of the more salient aspects of the opioid crisis in America has been the disparate impact it has had on communities. This paper considers the possibility that opioid abuse might have negative spillovers onto student performance in schools within the communities most affected. We use administrative data on individual children's test scores (grades 3 through 8) in South Carolina from the 2005-06 to 2016-17 academic years. These data are then linked to county-level changes in opioid prescriptions rates. Findings show that an increase in the opioid prescription rate in a county is associated with a statistically significant reduction in white student test scores, but no such decline was found among non-white students. This relationship is robust to controls for changing county-level economic conditions, time-varying controls for student-level poverty, county characteristics, and county time trends. Among white students, the association is strongest among rural students in households that are not receiving SNAP or TANF benefits. Given the importance of educational attainment, this reduction in test scores associated with high rates of opioid prescriptions may indicate that there will be long-lasting spillover effects of the opioid crisis.

The Moderating Role of Fatigue Sensitivity in the Relation between Depression and Alcohol and Opioid Misuse among Adults with Chronic Low Back Pain

OBJECTIVE

Chronic low back pain is the second leading cause of disability in the United States and is frequently related to increased risk of opioid and alcohol misuse. Depression is associated with poor substance use outcomes among persons with chronic low back pain. Theoretically, the influence of depression on opioid and alcohol misuse among those with chronic low back pain may vary as a function of fatigue sensitivity.

METHOD

To empirically test this theorized model, the current study examined fatigue sensitivity as a moderator for the relation between depression and opioid and alcohol misuse among 291 adults (69.1% female, M _age = 45.77 years, SD = 11.22) with chronic low back pain currently using opioids.

RESULTS

Results suggested that fatigue sensitivity moderated the effect of depression on opioid misuse (β=0.60, p= .001, 95%CI [0.02, 0.06]) and alcohol misuse (β=0.45, p= .025, 95%CI [0.002, 0.03]). Examination of simple slopes revealed that the association between depression and opioid and alcohol misuse was statistically significant for those with higher levels of fatigue sensitivity, but not lower levels of fatigue sensitivity.

CONCLUSIONS

Overall, the current investigation provides initial empirical support for the moderating role of fatigue sensitivity in the relation between depression and alcohol and opioid misuse among adults with chronic low back pain.

Using actor-partner interdependence modeling to understand recent illicit opioid use and injection drug use among men in community supervision and their female partners in New York City

BACKGROUND

The United States' opioid crisis disproportionately affects individuals in the criminal justice system. Intimate partners can be a source of social support that helps reduce substance use, or they can serve as a driver of continued or increased substance use. Better understanding of the association between intimate partner characteristics and illicit opioid use and injection drug use among individuals in community supervision could be vital to developing targeted interventions.

METHODS

Using actor-partner interdependence models, we examined individual and partner characteristics associated with recent illicit opioid use and injection drug use among males in community supervision settings in New York City (n = 229) and their female partners (n = 229).

RESULTS

Higher levels of depression (aOR 1.98, 95% CI [1.39-2.82], p ≤ 0.01) and anxiety (aOR 1.98, 95% CI [1.42-2.75], p ≤ 0.01) were associated with recent opioid use among males in community supervision. Females with a partner having higher levels of anxiety were more likely to have recently used opioids (aOR 1.52, 95% CI [1.06-2.16], p ≤ 0.05). Males with a female partner with higher levels of anxiety (aOR 2.16, 95% CI [1.31-3.56], p ≤ 0.01) or depression (aOR 1.70, 95% CI [1.01-2.86], p ≤ 0.05) were more likely to recently inject drugs. Women with a male partner who had been in prison were more likely to have recently injected drugs (aOR 3.71, 95% CI [1.14-12.12], p ≤ 0.05), but women who had a male partner who had been arrested in the past three months were less likely to have recently injected (aOR 0.08, 95% CI [0.02-0.46], p ≤ 0.01).

CONCLUSIONS

Results suggest that recent individual illicit opioid use and injection drug use is associated not only with individual-level factors, but also with partner factors, highlighting the need for couple-based approaches to address the opioid epidemic.

The Balanced Opioid Initiative: protocol for a clustered, sequential, multiple-assignment randomized trial to construct an adaptive implementation strategy to improve guideline-concordant opioid prescribing in primary care

BACKGROUND

Rates of opioid prescribing tripled in the USA between 1999 and 2015 and were associated with significant increases in opioid misuse and overdose death. Roughly half of all opioids are prescribed in primary care. Although clinical guidelines describe recommended opioid prescribing practices, implementing these guidelines in a way that balances safety and effectiveness vs. risk remains a challenge. The literature offers little help about which implementation strategies work best in different clinical settings or how strategies could be tailored to optimize their effectiveness in different contexts. Systems consultation consists of (1) educational/engagement meetings with audit and feedback reports, (2) practice facilitation, and (3) prescriber peer consulting. The study is designed to discover the most cost-effective sequence and combination of strategies for improving opioid prescribing practices in diverse primary care clinics.

METHODS/DESIGN

The study is a hybrid type 3 clustered, sequential, multiple-assignment randomized trial (SMART) that randomizes clinics from two health systems at two points, months 3 and 9, of a 21-month intervention. Clinics are provided one of four sequences of implementation strategies: a condition consisting of educational/engagement meetings and audit and feedback alone (EM/AF), EM/AF plus practice facilitation (PF), EM/AF + prescriber peer consulting (PPC), and EM/AF + PF + PPC. The study's primary outcome is morphine-milligram equivalent (MME) dose by prescribing clinicians within clinics. The study's primary aim is the comparison of EM/AF + PF + PPC versus EM/AF alone on change in MME from month 3 to month 21. The secondary aim is to derive cost estimates for each of the four sequences and compare them. The exploratory aim is to examine four tailoring variables that can be used to construct an adaptive implementation strategy to meet the needs of different primary care clinics.

DISCUSSION

Systems consultation is a practical blend of implementation strategies used in this case to improve opioid prescribing practices in primary care. The blend offers a range of strategies in sequences from minimally to substantially intensive. The results of this study promise to help us understand how to cost effectively improve the implementation of evidence-based practices.

TRIAL REGISTRATION

NCT04044521 (ClinicalTrials.gov). Registered 05 August 2019.

Parallel modeling of pain and depression in prediction of relapse during buprenorphine and naloxone treatment: A finite mixture model

BACKGROUND

Relapse is common in treatment for opioid use disorders (OUDs). Pain and depression often co-occur during OUD treatment, yet little is known about how they influence relapse among patients with a primary diagnosis of prescription opioid use disorder (POUD). Advanced statistical analyses that can simultaneously model these two conditions may lead to targeted clinical interventions.

METHOD

The objective of this study was to utilize a discrete survival analysis with a growth mixture model to test time to prescription opioid relapse, predicted by parallel growth trajectories of depression and pain, in a clinical sample of patients in buprenorphine/naloxone treatment. The latent class analysis characterized heterogeneity with data collected from the National Institute of Drug Abuse Clinical Trials Network project (CTN-0030).

RESULTS

Results suggested that a 4-class solution was the most parsimonious based on global fit indices and clinical relevance. The 4 classes identified were: 1) low relapse, 2) high depression and moderate pain, 3) high pain, and 4) high relapse. Odds ratios for time-to-first use indicated no statistically significant difference in time to relapse between the high pain and the high depression classes, but all other classes differed significantly.

CONCLUSION

This is the first longitudinal study to characterize the influence of pain, depression, and relapse in patients receiving buprenorphine and naloxone treatment. These results emphasize the need to monitor the influence of pain and depression during stabilization on buprenorphine and naloxone. Future work may identify appropriate interventions that can be introduced to extend time-to-first prescription opioid use among patients.

Patterns and Correlates of Prescription Opioid Receipt Among US Veterans: A National, 18-Year Observational Cohort Study

A better understanding of predisposition to transition to high-dose, long-term opioid therapy after initial opioid receipt could facilitate efforts to prevent opioid use disorder (OUD). We extracted data on 69,268 patients in the Veterans Aging Cohort Study who received any opioid prescription between 1998 and 2015. Using latent growth mixture modelling, we identified four distinguishable dose trajectories: low (53%), moderate (29%), escalating (13%), and rapidly escalating (5%). Compared to low dose trajectory, those in the rapidly escalating dose trajectory were proportionately more European-American (59% rapidly escalating vs. 38% low); had a higher prevalence of HIV (31% vs. 29%) and hepatitis C (18% vs. 12%); and during follow-up, had a higher incidence of OUD diagnoses (13% vs. 3%); were hospitalised more often [18.1/100 person-years (PYs) vs. 12.5/100 PY]; and had higher all-cause mortality (4.7/100 PY vs. 1.8/100 PY, all p < 0.0001). These measures can potentially be used in future prevention research, including genetic discovery.

Opioid use disorder and treatment: challenges and opportunities

BACKGROUND

Addiction health service researchers have focused efforts on opioid use disorder (OUD) and strategies to address the emerging public health threats associated with the epidemics of opioid use and opioid overdose. The increase in OUD is associated with widespread access to prescription opioid analgesics, enhanced purity of heroin, the introduction of potent illicit fentanyl compounds, and a rising tide of opioid overdose fatalities. These deaths have become the face of the opioid epidemic.

MAIN TEXT

OUD is a chronic disorder that usually requires both medications for opioid use disorder (MOUD) and psychosocial treatment and support. Research has found that MOUD with an opioid receptor agonist (methadone), partial agonist (buprenorphine), or opioid antagonist (extended-release naltrexone) can support recovery. Despite compelling evidence that MOUD are effective, they remain underutilized. More research is needed on these therapies to understand the feasibility of implementation in clinic settings.

CONCLUSION

This special issue focuses on how health services research has emerged as an important contributor to efforts to control the opioid epidemic in North America and Europe.

Trends and Rapidity of Dose Tapering Among Patients Prescribed Long-term Opioid Therapy, 2008-2017

Importance

A 2016 Centers for Disease Control and Prevention prescribing guideline cautioned against higher-dose long-term opioid therapy and recommended tapering daily opioid doses by approximately 10% per week if the risks outweigh the benefits. Warnings have since appeared regarding potential hazards of rapid opioid tapering.

Objectives

To characterize US trends in opioid dose tapering among patients prescribed long-term opioids from 2008 to 2017 and identify patient-level variables associated with tapering and a more rapid rate of tapering.

Design, Setting, and Participants

This retrospective cohort study used deidentified medical and pharmacy claims and enrollment records for 100 031 commercial insurance and Medicare Advantage enrollees, representing a diverse mixture of ages, races/ethnicities, and geographical regions across the United States. Adults with stable, higher-dosage (mean, ≥50 morphine milligram equivalents [MMEs]/d) opioid prescriptions for a 12-month baseline period and 2 or more months of follow-up from January 1, 2008, to December 31, 2017, were included in the study.

Main Outcomes and Measures

Tapering was defined as 15% or more relative reduction in mean daily MME during any of 6 overlapping 60-day windows within a 7-month follow-up period. The rate of tapering was computed as the maximum monthly percentage dose reduction.

Results

Among the 100 031 participants (53 452 [53.4%] women; mean [SD] age, 57.6 [11.8] years), from 2008 to 2015, the age- and sex-standardized percentage of patients tapering daily opioid doses increased from 10.5% to 13.7% (adjusted incidence rate ratio [aIRR] per year, 1.05 [95% CI, 1.05-1.06]) before increasing to 16.2% in 2016 and 22.4% in 2017 (aIRR in 2016-2017 vs 2008-2015, 1.20 [95% CI, 1.16-1.25]). Patient-level covariates associated with tapering included female sex (aIRR, 1.13 [95% CI, 1.10-1.15]) and higher baseline dose (aIRR for ≥300 MMEs/d vs 50-89 MMEs/d, 2.57 [95% CI, 2.48-2.65]). Among patients tapering daily opioid doses, the mean (SD) maximum dose reduction was 27.6% (17.0%) per month, and 18.8% of patients had a maximum tapering rate exceeding 40% per month (ie, faster than 10% per week). More rapid dose reduction was associated with 2016-2017 vs 2008-2015 (adjusted difference, 1.4% [95% CI, 0.8%-2.1%]) and higher baseline dose (adjusted difference, 2.7% [95% CI, 2.2%-3.3%] for 90-149 vs 50-89 MMEs/d).

Conclusions and Relevance

Patients using long-term opioid therapy are increasingly undergoing dose tapering, particularly women and those prescribed higher doses; in addition, dose tapering has become more common since 2016. Many patients undergoing tapering reduce daily doses at a rapid maximum rate.

Concerns and Help-Seeking Among Patients Using Opioids for Management of Chronic Noncancer Pain

BACKGROUND

The safety and efficacy of long-term opioid treatment for chronic noncancer pain (CNCP) remains controversial. This study examined whether patients who report problematic opioid use sought help and/or perceived barriers to help-seeking.

METHODS

Data were collected from 1,086 people prescribed opioids for CNCP via a large prospective cohort called the Pain and Opioids IN Treatment (POINT) study. Patients' characteristics and help-seeking were examined according to scores on the Prescribed Opioids Difficulties Scale (PODS).

RESULTS

Participants scoring "intermediate" (17%) or "high" (30%) on the PODS were younger and reported more complex pain presentations, higher opioid doses, poorer physical health, moderate to severe anxiety and depression, aberrant behavior, past month opioid use disorder and help-seeking (compared with the "low" PODS group, 53%). One-quarter (26%) had sought help, most commonly from a primary care physician, specialist pain clinic, family member/partner, counselor/psychologist, and the Internet. Participants in the "high" PODS group were more likely to have sought help from an alcohol or other drug service, addiction specialist, or drug information helpline. Common barriers to help-seeking were desire for self-management and concern that their opioid treatment may be discontinued. Although 35% met criteria for likely opioid use disorder, only 4.8% reported lifetime treatment with methadone or buprenorphine; participants' ratings indicated significant perceived stigma associated with these medications.

CONCLUSIONS

The PODS is effective in identifying patients who are concerned about their opioid use. Strategies to address stigma related to drug treatment, including better integration of primary health, specialist pain, and addiction services, are important in reducing opioid-related harm.

Iatrogenic opioid use disorder, chronic pain and psychiatric comorbidity: A systematic review

OBJECTIVE

A systematic review of the literature on the risks of developing iatrogenic opioid use disorders in chronic pain patients with psychiatric comorbidity.

METHODS

We conducted literature searches on Pubmed with key subjects: "chronic pain", "psychiatry", "opioids" and "opioid use disorder" and for original, English written articles published from 2000 until the first of September 2017. Final selection of the articles for review was made in a consensus between three reviewers.

RESULTS

Longitudinal studies showed a significant association between psychiatric comorbidity, especially depression and anxiety disorders and the development of problematic opioid use, more severe opioid craving and poor opioid treatment outcome (analgesia and side effects) in chronic pain patients. Cross-sectional studies showed a similar association between psychiatric disorders and problematic opioid use, where studies in specialized pain settings showed a higher prevalence of psychiatric disorders, compared to non-specialized settings.

CONCLUSIONS

This systematic review showed a significant association between psychiatric comorbidity, especially depression and anxiety disorders and the development of problematic opioid use in chronic pain patients. We therefore recommend psychiatric screening in chronic pain management. Chronic pain patients with comorbid psychiatric disorders need a multidisciplinary approach and monitoring opioid use is warranted in these patients.

Opioid Therapy for Chronic Pain: Overview of the 2017 US Department of Veterans Affairs and US Department of Defense Clinical Practice Guideline

Description

The US Department of Veterans Affairs (VA) and US Department of Defense (DoD) revised the 2010 clinical practice guideline (CPG) for the management of opioid therapy for chronic pain, considering the specific needs of the VA and DoD and new evidence regarding prescribing opioid medication for non-end-of-life-related chronic pain. This paper summarizes the major recommendations and compares them with the US Centers for Disease Control and Prevention (CDC) guideline for prescribing opioids.

Patient Population

This Opioid Therapy CPG was developed for VA-DoD service members, veterans, and their families.

Methods

The VA/DoD Evidence-Based Practice Work Group convened a VA/DoD guideline renewal development effort and conformed to the guidelines established by the VA/DoD Joint Executive Council (JEC) and VA/DoD Health Executive Council (HEC). The panel developed questions, searched and evaluated the literature, developed recommendations using GRADE methodology, and developed algorithms. Passage of the CARA Act by Congress compelled consideration and comparison with the CDC opioid therapy guideline mid-development.

Results

There were 18 recommendations made. This article focuses on guideline development and key recommendations with CDC comparisons taken from four major areas, including: initiation and continuation of opioids;type, dose, follow-up, and taper of opioids;risk mitigation;acute pain.

Conclusions

Guideline development and recommendations are presented. There was substantial overlap with the CDC opioid guideline. Additionally, there were items particularly relevant to the VA-DoD, including risk mitigation, suicide prevention, and preventing opioid use disorder in young patients. Our guideline highlights avoiding opioid therapy longer than 90 days as a critical juncture.

Use of the PROMIS-29® to identify subgroups of mothers with chronic pain

OBJECTIVE

Children of mothers with chronic pain are at increased risk for poor health, but few studies have examined what characteristics of maternal chronic pain may be associated with children's risk. This study identified subgroups of mothers based on patterns of pain, physical function, and emotional function on the 29-item Patient-Reported Outcomes Measurement Information System® (PROMIS-29®) and evaluated associations between maternal subgroups and children's pain and emotional functioning.

METHODS

Mothers with chronic pain (n = 334) completed the PROMIS-29® and reported on pain intensity, pain interference, physical functioning, anxiety, depression, fatigue, sleep disturbance, and participation in social activities. Mothers and their school-age children also completed measures of child pain and emotional functioning.

RESULTS

Latent profile analysis of PROMIS® domains indicated a 4-class solution (Group 1: 13.5%, Group 2: 9.9%, Group 3: 43.5%, and Group 4: 32.9%). Group 4 reported the most severe pain, psychological distress, and sleep disturbances and the lowest functioning. Group 1 reported the lowest pain, psychological distress, and sleep disturbances and the highest functioning, while Groups 2 and 3 represented moderate symptoms. Groups significantly differed on maternal reports of children's pain frequency, but not intensity, and children's self-reported somatic symptoms. Further, child depressive symptoms (mother-proxy and self-reported), anxiety (mother-proxy reported), and pain catastrophizing (self-reported) differed by maternal group.

CONCLUSIONS

Patterns of maternal symptoms and functioning were associated with pain frequency and emotional symptoms in children. Further examination of individual differences in mothers with chronic pain that may confer risk for chronic pain and psychological disorders in children is warranted. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The relationship between past 12-month suicidality and reasons for prescription opioid misuse

BACKGROUND

Understanding reasons for prescription opioid misuse can help elucidate suicide prevention efforts. The goal of the current study is to assess associations of reasons for prescription opioid misuse subtypes and suicide-related variables. We also assessed whether prescription opioid misuse differentiates ideators from those who attempt suicide.

METHODS

Using data from the 2015-2017 National Survey of Drug Use and Health (N = 45,074), prescription opioid misuse subtypes were grouped as follows: (a) Pain only, (b) Other reasons, and (c) Mixed reasons (i.e., pain and at least one other reason). Logistic regressions examined associations of misuse subtypes and past 12-month suicide-related variables (ideation, planning, attempts) relative to non-misusers. Logistic regression analyses were also conducted among the subset reporting ideation to assess whether prescription opioid misuse differentiated ideators with no attempt from ideators with an attempt.

RESULTS

In adjusted models, the Pain only and the Other reasons subtypes were associated with ideation and planning, but not attempts. The Mixed reasons subtype had higher odds of suicide ideation and planning compared to those not misusing prescription opioids and the Pain only misuse subtype. The Mixed reasons subtype had higher odds of a suicide attempt only when compared to those not misusing prescription opioids. Prescription opioid misuse was also associated with suicide attempts among the subset of ideators.

CONCLUSIONS

Findings indicate that people misuse prescription opioids for various reasons, and misuse subtypes are associated with past 12-month suicidality. Addressing pain and other reasons for misuse together through use of evidence-based treatments may help mitigate suicide risk.

Prescription opioids: Regional variation and socioeconomic status - evidence from primary care in England

BACKGROUND

This study aimed to quantify opioid prescriptions dispensed from primary care practices throughout England and investigate its association with socioeconomic status (SES).

METHODS

This cross-sectional study used publicly available data in 2015, including practice-level dispensing data and characteristics of registrants from the United Kingdom (UK) National Health Service Digital, and Index of Multiple Deprivation (IMD) data from Department of Communities and Local Government. Practices in England which issued opioid prescriptions that could be assigned a defined daily dose (DDD) in the claim-based dispensing database were included. The total amount of opioid prescriptions dispensed (DDD/1000 registrants/day) was calculated for each practice. The association between dispensed opioid prescriptions and IMD was analyzed by multi-level regression and adjusted for registrants' characteristics and the clustered effect of Clinical Commissioning Groups. Subgroup analysis was conducted for practices in London, Birmingham, Manchester and Newcastle.

RESULTS

Of the 7856 included practices in England, the median and interquartile range (IQR) of prescription opioids dispensed was 36.9 (IQR: 23.1, 52.5) DDD/1000 registrants/day. The median opioid utilization (DDD/1000 registrants/day) amongst practices varied between Manchester (53.1; IQR: 36.8, 71.4), Newcastle (48.9; IQR: 38.8, 60.1), Birmingham (35.3; IQR: 23.1, 49.4) and London (13.9; IQR: 8.1, 18.8). Lower SES, increased prevalence of patients aged more than 65 years, female gender, smoking, obesity and depression were significantly associated with increased opioid prescriptions. For every decrease in IMD decile (lower SES), there was a significant increase of opioid utilization by 1.0 (95% confidence interval: 0.89, 1.2, P < 0.001) DDD/1000 registrants/day.

CONCLUSION

There was substantial variation in opioid prescriptions among practices from Northern and Eastern England to Southern England. A significant association between increased opioid prescriptions and greater deprivation at a population level was observed. Further longitudinal studies using individual patient data are needed to validate this association and identify the potential mechanisms.

A crisis of opioids and the limits of prescription control: United States

A rise in addiction and overdose deaths involving opioids in the United States has spurred a series of initiatives focused on reducing opioid risks, including several related to prescription of opioids in care of pain. Policy analytical scholarship provides a conceptual framework to assist in understanding this response. Prior to 2011, a 'policy monopoly' of regulators and pharmaceutical manufacturers allowed and encouraged high levels of opioid prescribing. This permissive policy fell apart in the face of adverse outcomes brought to public attention by an 'advocacy coalition' consisting of officials, thought leaders, journalists and interest groups who shared common beliefs. This coalition has generated a more cautious prescribing regimen that has incentivized involuntary termination of opioids in otherwise stable patients, with resultant reports of harm. Its emphasis on dose reduction, regardless of outcomes, mirrors in some ways the prior focus on minimizing pain scores, regardless of outcomes. Central to the present analysis is that policies cannot be comprehensively rational; rather, they emerge from a range of actors and agencies constrained in their ability to assimilate complex data, evaluate the data objectively and to command necessary resources in an iterative, rapid response fashion. The imbalance between strong prescription control and weak pain and addiction treatment expansion exemplifies the policy scholar's notion of 'bounded rationality'. Results have been suboptimum: opioid prescriptions have fallen, but harms to pain patients and overdose deaths have risen. US policymakers could revise the course through a more thoroughgoing engagement with patients, families and communities now coping with both pain and addiction.

Trajectories of dispensed prescription opioids among beneficiaries enrolled in a Medicaid controlled substance "lock-in" program

PURPOSE

"Lock-in" programs (LIPs) are used by health insurers to address potential substance (eg, opioid) misuse among beneficiaries. We sought to (1) examine heterogeneity in trajectories of dispensed opioids (in average daily morphine milligram equivalents (MMEs)) over time: prior to, during, and following release from a LIP, and (2) assess associations between trajectory patterns and beneficiary characteristics.

METHODS

Medicaid claims were linked to Prescription Drug Monitoring Program records for a cohort of beneficiaries enrolled in the North Carolina Medicaid LIP (n = 2701). Using latent class growth analyses, we estimated trajectories of average daily MMEs of opioids dispensed to beneficiaries across specific time periods of interest.

RESULTS

Five trajectory patterns appeared to sufficiently describe underlying heterogeneity. Starting values and slopes varied across the 5 trajectory groups, which followed these overall patterns: (1) start at a high level of MMEs, end at a high level of MMEs (13.1% of cohort); (2) start medium, end medium (13.2%); (3) start medium, end low (21.5%); (4) start low, end medium (22.6%); and (5) start low, end low (29.6%). We observed strong associations between patterns and beneficiaries' demographics, substance use-related characteristics, comorbid conditions, and healthcare utilization.

CONCLUSIONS

In its current form, the Medicaid LIP appeared to have limited impact on beneficiaries' opioid trajectories. However, strong associations between trajectory patterns and beneficiary characteristics provide insight into potential LIP design modifications that might improve program impact (eg, LIP integration of substance use disorder assessment and referral to treatment, assessment and support for alternate pain therapies).

Substance-related disorders: A review of prevalence and correlates among patients with chronic pain

Over the past few decades, research has revealed high rates of substance-related disorders among patients with chronic pain. In addition to their potentially deleterious health consequences, substance-related disorders have consistently been associated with negative pain-related outcomes among patients with chronic pain. The goal of this narrative review was to provide an overview of studies that have examined the prevalence and correlates of substance-related disorders among patients with chronic pain. A particular focus was placed on opioids, sedatives/hypnotics, cannabis, tobacco, and alcohol given that these substances have received the bulk of research attention among patients with pain. Research conducted to date suggests that a host of biological and psychological factors are likely to contribute to the elevated rates of substance-related disorders among patients with chronic pain. In this review, in addition to reviewing the prevalence and correlates of substance-related disorders among patients with pain, we briefly discussed the changes that were recently made from the DSM-4 to the DSM-5 in the diagnostic criteria for substance-related disorders, and the implications of these changes for the assessment of patients with chronic pain. We also provided a brief overview of instruments that can be used for the assessment of these disorders in clinical and research settings.

Pharmacological Strategies for Decreasing Opioid Therapy and Management of Side Effects from Chronic Use

As awareness increases about the side effects of opioids and risks of misuse, opioid use and appropriate weaning of opioid therapies have become topics of significant clinical relevance among pediatric populations. Critically ill hospitalized neonates, children, and adolescents routinely receive opioids for analgesia and sedation as part of their hospitalization, for both acute and chronic illnesses. Opioids are frequently administered to manage pain symptoms, reduce anxiety and agitation, and diminish physiological stress responses. Opioids are also regularly prescribed to youth with chronic pain. These medications may be prescribed during the initial phase of a diagnostic workup, during an emergency room visit; as an inpatient, or on an outpatient basis. Following treatment for underlying pain conditions, it can be challenging to appropriately wean and discontinue opioid therapies. Weaning opioid therapy requires special expertise and care to avoid symptoms of increased pain, withdrawal, and agitation. To address this challenge, there have been enhanced efforts to implement opioid-reduction during pharmacological therapies for pediatric pain management. Effective pain management therapies and their outcomes in pediatrics are outside the scope of this paper. The aims of this paper were to: (1) Review the current practice of opioid-reduction during pharmacological therapies; and (2) highlight concrete opioid weaning strategies and management of opioid withdrawal.

The drive to taper opioids: mind the evidence, and the ethics

The high prevalence of pain in patients with spinal cord injury, coupled with a national recalibration of opioid prescribing, presents a challenge. Prescribers may attempt to taper opioids, where observable harms from the prescribed opioid appear to outweigh benefits, a stance endorsed by the 2016 Guideline for Prescribing Opioids for Chronic Pain, issued by the Centers for Disease Control and Prevention. Different considerations apply when clinicians wish to reduce doses in adherent and stable patients, absent their consent. In this perspective piece, we acknowledge the problematic nature of opioids as a treatment. However, forced tapers may destabilize patients and clinical evidence to support forced tapers is lacking. We favor an ethic of informed consent when proposing changes to care involve meaningful risk, and suggest alternative approaches to optimizing safety.

Pain and Addiction: An Integrative Therapeutic Approach

The current opioid crisis highlights an urgent need for better paradigms for prevention and treatment of chronic pain and addiction. Although many approach this complex clinical condition with the question, "Is this pain or is this addiction?," it is more than the sum of its parts. Chronic pain among those with dependence and addiction often evolves into a complex disabling condition with pain at multiple sites, psychosocial dysfunctions, medical and psychiatric disorders, polypharmacy, and polysubstance use, all interacting with each other in complex ways (multimorbidity). The authors offer an integrative therapeutic approach to manage this complex clinical scenario.

Methodologic limitations of prescription opioid safety research and recommendations for improving the evidence base

PURPOSE

The ongoing opioid epidemic has claimed more than a quarter million Americans' lives over the past 15 years. The epidemic began with an escalation of prescription opioid deaths and has now evolved to include secondary waves of illicit heroin and fentanyl deaths, while the deaths due to prescription opioid overdoses are still increasing. In response, the Centers for Disease Control and Prevention (CDC) moved to limit opioid prescribing with the release of opioid prescribing guidelines for chronic noncancer pain in March 2016. The guidelines represent a logical and timely federal response to this growing crisis. However, CDC acknowledged that the evidence base linking opioid prescribing to opioid use disorders and overdose was grades 3 and 4.

METHODS

Motivated by the need to strengthen the evidence base, this review details limitations of the opioid safety studies cited in the CDC guidelines with a focus on methodological limitations related to internal and external validity.

RESULTS

Internal validity concerns were related to poor confounding control, variable misclassification, selection bias, competing risks, and potential competing interventions. External validity concerns arose from the use of limited source populations, historical data (in a fast-changing epidemic), and issues with handling of cancer and acute pain patients' data. We provide a nonexhaustive list of 7 recommendations to address these limitations in future opioid safety studies.

CONCLUSION

Strengthening the opioid safety evidence base will aid any future revisions of the CDC guidelines and enhance their prevention impact.

Reducing Opioid Use for Patients With Chronic Pain: An Evidence-Based Perspective

The implementation of recent Centers for Disease Control and Prevention recommendations to move away from opioids and toward nonpharmacological therapies for the treatment of chronic pain could involve a difficult transition period for patients and practitioners. The focus of treatment should shift from eliminating pain completely to minimizing the impact of pain on quality of life. Many patients with chronic pain take opioids either because opioids were previously prescribed as a first-line treatment for chronic pain, on the basis of old standards of care, or because opioids were initially prescribed for acute pain. Patients currently taking opioids will need a tapering period during which they transition their pain management to interdisciplinary care and nonpharmacological treatments. To provide useful treatment options, physical therapists need to have a good understanding of the neuroscientific mechanisms of chronic pain, biopsychosocial components of chronic pain management, issues related to opioid use, and pain management strategies used by other health care professionals. Armed with knowledge and good communication skills, physical therapists can work within an interdisciplinary team to adapt care to each patient's needs and abilities. This perspective article provides guidance for physical therapists to effectively treat patients with chronic pain during the opioid tapering process. A framework has been created to help health care providers structure their reasoning as they collaborate to develop a unique approach for each patient.