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Yarborough BJH, Stumbo SP, Schneider JL, Ahmedani BK, Daida YG, Hooker SA, Lapham GT, Negriff S, Rossom RC. Patient Perspectives on Mental Health and Pain Management Support Needed Versus Received During Opioid Deprescribing. THE JOURNAL OF PAIN 2024; 25:104485. [PMID: 38311195 DOI: 10.1016/j.jpain.2024.01.350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/10/2024]
Abstract
Prescription opioid tapering has increased significantly over the last decade. Evidence suggests that tapering too quickly or without appropriate support may unintentionally harm patients. The aim of this analysis was to understand patients' experiences with opioid tapering, including support received or not received for pain control or mental health. Patients with evidence of opioid tapering from 6 health care systems participated in semi-structured, in-depth interviews; family members of suicide decedents with evidence of opioid tapering were also interviewed. Interviews were analyzed using thematic analysis. Participants included 176 patients and 16 family members. Results showed that 24% of the participants felt their clinicians checked in with them about their taper experiences while 41% reported their clinicians did not. A majority (68%) of individuals who experienced suicide behavior during tapering reported that clinicians did check in about mood and mental health changes specifically; however, 27% of that group reported no such check-in. More individuals reported negative experiences (than positive) with pain management clinics-where patients are often referred for tapering and pain management support. Patients reporting successful tapering experiences named shared decision-making and ability to adjust taper speed or pause tapering as helpful components of care. Fifty-six percent of patients reported needing more support during tapering, including more empathy and compassion (48%) and an individualized approach to tapering (41%). Patient-centered approaches to tapering include reaching out to monitor how patients are doing, involving patients in decision-making, supporting mental health changes, and allowing for flexibility in the tapering pace. PERSPECTIVE: Patients tapering prescription opioids desire more provider-initiated communication including checking in about pain, setting expectations for withdrawal and mental health-related changes, and providing support for mental health. Patients preferred opportunities to share decisions about taper speed and to have flexibility with pausing the taper as needed.
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Affiliation(s)
- Bobbi Jo H Yarborough
- Science Programs Department, Kaiser Permanente Northwest Center for Health Research, Portland, Oregon; Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Scott P Stumbo
- Science Programs Department, Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | - Jennifer L Schneider
- Science Programs Department, Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | - Brian K Ahmedani
- Center for Health Policy & Health Services Research, Henry Ford Health, Detroit, Michigan
| | - Yihe G Daida
- Center for Integrated Health Care Research, Kaiser Permanente Hawaii, Honolulu, Hawaii
| | - Stephanie A Hooker
- Research and Evaluation Division, HealthPartners Institute, Minneapolis, Minnesota
| | - Gwen T Lapham
- Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California; Research Department, Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Sonya Negriff
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Rebecca C Rossom
- Research and Evaluation Division, HealthPartners Institute, Minneapolis, Minnesota
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Yarborough BJH, Stumbo SP, Schneider JL, Ahmedani BK, Daida YG, Hooker SA, Negriff S, Rossom RC, Lapham G. Impact of Opioid Dose Reductions on Patient-Reported Mental Health and Suicide-Related Behavior and Relationship to Patient Choice in Tapering Decisions. THE JOURNAL OF PAIN 2024; 25:1094-1105. [PMID: 37952862 DOI: 10.1016/j.jpain.2023.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 11/01/2023] [Accepted: 11/05/2023] [Indexed: 11/14/2023]
Abstract
Mental health and suicide-related harms resulting from prescription opioid tapering are poorly documented and understood. Six health systems contributed opioid prescribing data from January 2016 to April 2020. Patients 18 to 70 years old with evidence of opioid tapering participated in semi-structured interviews. Individuals who experienced suicide attempts were oversampled. Family members of suicide decedents who had experienced opioid tapering were also interviewed. Interviews were analyzed using thematic analysis. The study participants included 176 patients and 16 family members. Patients were 68% female, 80% White, and 15% Hispanic, mean age 58. All family members were female spouses of White, non-Hispanic male decedents. Among the subgroup (n = 60) who experienced a documented suicide attempt, reported experiencing suicidal ideation during tapering, or were family members of suicide decedents, 40% reported that opioid tapering exacerbated previously recognized mental health issues, and 25% reported that tapering triggered new-onset mental health concerns. Among participants with suicide behavior, 47% directly attributed it to opioid tapering. Common precipitants included increased pain, reduced life engagement, sleep problems, withdrawal, relationship dissolution, and negative consequences of opioid substitution with other substances for pain relief. Most respondents reporting suicide behavior felt that the decision to taper was made by the health care system or a clinician (67%) whereas patients not reporting suicide behavior were more likely to report it was their own decision (42%). This study describes patient-reported mental health deterioration or suicide behavior while tapering prescription opioids. Clinicians should screen for, monitor, and treat suicide behavior while assisting patients in tapering opioids. PERSPECTIVE: This work describes changes in patient-reported mental health and suicide behavior while tapering prescription opioids. Recommendations for improving care include mental health and suicide risk screening during and following opioid tapering.
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Affiliation(s)
| | - Scott P Stumbo
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | | | | | | | | | - Sonya Negriff
- Kaiser Permanente Southern California, Pasadena, California
| | | | - Gwen Lapham
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
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Buonora MJ, Axson SA, Cohen SM, Becker WC. Paths Forward for Clinicians Amidst the Rise of Unregulated Clinical Decision Support Software: Our Perspective on NarxCare. J Gen Intern Med 2024; 39:858-862. [PMID: 37962733 PMCID: PMC11043299 DOI: 10.1007/s11606-023-08528-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/02/2023] [Indexed: 11/15/2023]
Abstract
Amidst the US overdose epidemic, policymakers, law enforcement agencies, and healthcare institutions have contributed to a decrease in opioid prescribing, assuming reduced mortality would result-an assumption we now understand was oversimplified. At this intersection between public health and public safety domains as they relate to opioid prescribing, unregulated and proprietary clinical decision support tools have emerged without rigorous external validation or public data sharing. In the following piece, we discuss challenges facing clinicians practicing medicine amidst unregulated clinical decision support tools, using the case of Bamboo Health's NarxCare-a prescription drug monitoring program-based analytics platform marketed as a clinical decision support tool-that is already positioned to impact over 1 billion patient encounters annually. We argue that sufficient evidence does not yet exist to support NarxCare's wide implementation, and that clinical decision support tools like NarxCare have flourished in recent years due to a lack of federal regulatory oversight and shielding by their proprietary formulas, which have facilitated their unchecked and outsized influence on patient care. Finally, we suggest specific actions by federal regulatory agencies, healthcare institutions, individual clinicians, and researchers, as well as academic journals, to mitigate potential harms associated with unregulated clinical decision support tools.
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Affiliation(s)
- Michele J Buonora
- National Clinician Scholars Program, Yale School of Medicine, New Haven, CT, USA.
- Department of Internal Medicine & Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, USA.
- General Internal Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA.
- Division of General Internal Medicine, Montefiore Medical Center, Bronx, NY, USA.
| | - Sydney A Axson
- National Clinician Scholars Program, Yale School of Medicine, New Haven, CT, USA
- General Internal Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Ross and Carol Nese College of Nursing and the Rock Ethics Institute, The Pennsylvania State University, University Park, PA, USA
| | - Shawn M Cohen
- Department of Internal Medicine & Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, USA
| | - William C Becker
- National Clinician Scholars Program, Yale School of Medicine, New Haven, CT, USA
- Department of Internal Medicine & Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, USA
- Pain Research, Informatics, Multimorbidities & Education Center of Innovation, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
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Ho HC, Wong SSC, Cheung CW. Individual-level and neighborhood-level shifts in mortality patterns among drug poisoning deaths in a high-density Asian city: a territory-wide, case-only analysis. Int Health 2023; 15:715-722. [PMID: 36916328 PMCID: PMC10629959 DOI: 10.1093/inthealth/ihad015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/27/2023] [Accepted: 02/14/2023] [Indexed: 03/15/2023] Open
Abstract
BACKGROUND The shifts in individual-level and neighborhood-level patterns of drug poisoning deaths in a high-density Asian city over time have been underestimated, although they provide essential information for community-based surveillance and interventions. METHODS A case-only analysis with a 16-y, territory-wide, population-based registry in Hong Kong was applied to compare drug poisoning deaths from 2001 to 2010 with 2011 to 2016. Drug poisoning deaths, deaths from heroin and deaths from other opioids (codeine or morphine) were extracted (ICD codes: T36-T50, T40.1, T40.2). Binomial regressions were used to estimate the shifts in mortality patterns. RESULTS Among 3069 drug poisoning deaths, a significant shift in mortality patterns was found despite a decreasing mortality trend in Hong Kong. Overall, drug poisoning deaths shifted towards middle-aged/young-old, widowed/divorced, economically active, white collar and non-local born. Since 2011, more deaths from heroin were in older ages and non-local born, but less were never married and economically inactive. More deaths from other opioids were middle-aged, young-old and divorced. In particular, most decedents shifted towards young-old, especially deaths from other opioids. Compared with deaths during 2001-2010, there were 3.72- and 6.50-fold more deaths from heroin and deaths from other opioids in those aged ≥60 y since 2021 (ORs: 3.72 [2.37, 5.86], 6.50 [3.97, 10.65]), respectively. Additionally, drug poisoning deaths shifted towards areas with less neighborhood deprivation (more high-education individuals and a mix of private/public housing residents), especially deaths from other opioids. CONCLUSION Misuse of registered drugs (e.g. opioid pain relievers) could be a rising trend among vulnerable subpopulations in Hong Kong other than illegal drug use (heroin). Health officials should provide more advice and support on drug information. Specifically, an improved health system with education regarding the appropriate use of registered drugs for medical treatments should be provided to mid-/high-income and local-born individuals.
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Affiliation(s)
- Hung Chak Ho
- Department of Anaesthesiology, School of Clinical Medicine, The University of Hong Kong, Hong Kong
| | - Stanley Sau-Ching Wong
- Department of Anaesthesiology, School of Clinical Medicine, The University of Hong Kong, Hong Kong
| | - Chi Wai Cheung
- Department of Anaesthesiology, School of Clinical Medicine, The University of Hong Kong, Hong Kong
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Sahebi-Fakhrabad A, Sadeghi AH, Kemahlioglu-Ziya E, Handfield R, Tohidi H, Vasheghani-Farahani I. The Impact of Opioid Prescribing Limits on Drug Usage in South Carolina: A Novel Geospatial and Time Series Data Analysis. Healthcare (Basel) 2023; 11:healthcare11081132. [PMID: 37107966 PMCID: PMC10137799 DOI: 10.3390/healthcare11081132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
The opioid crisis in the United States has had devastating effects on communities across the country, leading many states to pass legislation that limits the prescription of opioid medications in an effort to reduce the number of overdose deaths. This study investigates the impact of South Carolina's prescription limit law (S.C. Code Ann. 44-53-360), which aims to reduce opioid overdose deaths, on opioid prescription rates. The study utilizes South Carolina Reporting and Identification Prescription Tracking System (SCRIPTS) data and proposes a distance classification system to group records based on proximity and evaluates prescription volumes in each distance class. Prescription volumes were found to be highest in classes with pharmacies located further away from the patient. An Interrupted Time Series (ITS) model is utilized to assess the policy impact, with benzodiazepine prescriptions as a control group. The ITS models indicate an overall decrease in prescription volume, but with varying impacts across the different distance classes. While the policy effectively reduced opioid prescription volumes overall, an unintended consequence was observed as prescription volume increased in areas where prescribers were located at far distances from patients, highlighting the limitations of state-level policies on doctors. These findings contribute to the understanding of the effects of prescription limit laws on opioid prescription rates and the importance of considering location and distance in policy design and implementation.
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Affiliation(s)
- Amirreza Sahebi-Fakhrabad
- Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, NC 27606, USA
| | - Amir Hossein Sadeghi
- Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, NC 27606, USA
| | - Eda Kemahlioglu-Ziya
- Department of Business Management, Poole College of Management, North Carolina State University, Raleigh, NC 27695, USA
| | - Robert Handfield
- Department of Business Management, Poole College of Management, North Carolina State University, Raleigh, NC 27695, USA
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