Long-term use of opioids in 210 officially registered patients with chronic noncancer pain in Taiwan: A cross-sectional study

Assessment of opioid knowledge and attitudes among senior medical students in Taiwan's pain education curriculum: A cross-sectional questionnaire survey

INTRODUCTION

While the opioid crisis has been a significant concern in North America, Taiwan has not encountered a similar crisis. This study investigated medical students' perceptions of opioid therapy for chronic pain management in Taiwan.

METHODS

A cross-sectional questionnaire survey was conducted among third- and fourth-year medical students who had completed an 18-hour pain medicine curriculum, in comparison with those who did not take the course in Mar 2022 and May 2023. The survey assessed their knowledge, attitude, and perceptions of the opioid crisis in the United States and Taiwan.

RESULTS

In total, 135 (88.2%) of 153 senior medical students who had completed the curriculum responded to the survey. They exhibited a better understanding of opioids (P < 0.001) and held a more negative attitude toward opioid use (P = 0.011) compared with 105 students who did not take the course. Additionally, out of 240 respondents, 177 (73.8%) acknowledged the ongoing opioid crisis in the United States, while only 70 (29.2%) disagreed with the notion of an ongoing opioid crisis in Taiwan. Furthermore, 90% of all students expressed agreement with the need for further education on chronic pain management after graduation.

CONCLUSION

Among senior medical students in Taiwan, those who completed an elective pain medicine curriculum demonstrated enhanced knowledge of opioids, a more cautious attitude toward opioid use, and a willingness to receive further education on chronic pain management. Over 70% of students remained uncertain or incorrectly believed that there was an opioid crisis in Taiwan.

Association Between Early Surgery and Postoperative Opioid Use in Patients With Lumbar Disc Herniation: A Propensity Score-Matching Analysis Using an Administrative Claims Database in Japan

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

This study aimed to investigate whether early surgery shortens the duration of opioid use in patients who underwent surgery with lumbar disc herniation.

METHODS

We extracted patients who underwent surgery at least 2 weeks after they were diagnosed with lumbar disc herniation between April 2014 and May 2021. Opioid use after surgery was compared between patients who underwent surgery within 90 days (early surgery group) and 90 days or later (late surgery group). Propensity-score-matching analysis and multivariable Cox hazard regression analysis with a restricted cubic spline model were conducted to evaluate the association between the timing of surgery and termination of opioid use after surgery.

RESULTS

A total of 1597 eligible patients were identified, with 807 (51%) in the early surgery group. In the propensity-score-matched cohort, the early surgery group had a significantly lower proportion of opioid use than the control group (28% vs 48%, percent difference -20%, P < .001). Multivariable Cox hazard regression analysis showed that early surgery was significantly associated with the earlier termination of opioid use (HR, 3.13; 95% CI, 1.97-4.97; P < .001). Restricted cubic spline model showed a monotonically decreased hazard ratio and decreased hazard ratio of .50 in patients who underwent surgery 111 days or later after the diagnosis.

CONCLUSIONS

Early surgery, especially within 90 days, was associated with earlier opioid use termination after surgery. Regarding the duration of opioid use following surgery, surgical treatment may be preferable to perform within around 4 months after the diagnosis.

Management of chronic pancreatitis: recent advances and future prospects

As a progressive fibroinflammatory disease, chronic pancreatitis (CP) often manifests as recurrent bouts of abdominal pain with or without complications, causing a heavy burden of health care. In recent years, some meaningful insights into the management of CP have been obtained from randomized controlled trials, systematic reviews, and meta-analyses, which were of great importance. Based on this research, it is shown that there are various treatments for CP. Therefore, it is of great importance to choose a suitable strategy for patients with CP individually. Relevant evidence on the management of CP was summarized in this review, including nutrition supplements, medication, endoscopy, surgery, exploration of novel therapies as well as evaluation and prediction of treatment response.

Machine Learning Algorithms Predict Long-Term Postoperative Opioid Misuse: A Systematic Review

INTRODUCTION

A steadily rising opioid pandemic has left the US suffering significant social, economic, and health crises. Machine learning (ML) domains have been utilized to predict prolonged postoperative opioid (PPO) use. This systematic review aims to compile all up-to-date studies addressing such algorithms' use in clinical practice.

METHODS

We searched PubMed/MEDLINE, EMBASE, CINAHL, and Web of Science using the keywords "machine learning," "opioid," and "prediction." The results were limited to human studies with full-text availability in English. We included all peer-reviewed journal articles that addressed an ML model to predict PPO use by adult patients.

RESULTS

Fifteen studies were included with a sample size ranging from 381 to 112898, primarily orthopedic-surgery-related. Most authors define a prolonged misuse of opioids if it extends beyond 90 days postoperatively. Input variables ranged from 9 to 23 and were primarily preoperative. Most studies developed and tested at least two algorithms and then enhanced the best-performing model for use retrospectively on electronic medical records. The best-performing models were decision-tree-based boosting algorithms in 5 studies with AUC ranging from .81 to .66 and Brier scores ranging from .073 to .13, followed second by logistic regression classifiers in 5 studies. The topmost contributing variable was preoperative opioid use, followed by depression and antidepressant use, age, and use of instrumentation.

CONCLUSIONS

ML algorithms have demonstrated promising potential as a decision-supportive tool in predicting prolonged opioid use in post-surgical patients. Further validation studies would allow for their confident incorporation into daily clinical practice.

External validation of machine learning algorithm predicting prolonged opioid prescriptions in opioid-naïve lumbar spine surgery patients using a Taiwanese cohort

BACKGROUND/PURPOSE

Identifying patients at risk of prolonged opioid use after surgery prompts appropriate prescription and personalized treatment plans. The Skeletal Oncology Research Group machine learning algorithm (SORG-MLA) was developed to predict the risk of prolonged opioid use in opioid-naive patients after lumbar spine surgery. However, its utility in a distinct country remains unknown.

METHODS

A Taiwanese cohort containing 2795 patients who were 20 years or older undergoing primary surgery for lumbar decompression from 2010 to 2018 were used to validate the SORG-MLA. Discrimination (area under receiver operating characteristic curve [AUROC] and area under precision-recall curve [AUPRC]), calibration, overall performance (Brier score), and decision curve analysis were applied.

RESULTS

Among 2795 patients, the prolonged opioid prescription rate was 5.2%. The validation cohort were older, more inpatient disposition, and more common pharmaceutical history of NSAIDs. Despite the differences, the SORG-MLA provided a good discriminative ability (AUROC of 0.71 and AURPC of 0.36), a good overall performance (Brier score of 0.044 compared to that of 0.039 in the developmental cohort). However, the probability of prolonged opioid prescription tended to be overestimated (calibration intercept of -0.07 and calibration slope of 1.45). Decision curve analysis suggested greater clinical net benefit in a wide range of clinical scenarios.

CONCLUSION

The SORG-MLA retained good discriminative abilities and overall performances in a geologically and medicolegally different region. It was suitable for predicting patients in risk of prolonged postoperative opioid use in Taiwan.

Prescription Opioid Use among Patients with Chronic Noncancer Pain before and after the COVID-19 Outbreak in Taiwan: A Multicenter Prospective Observational Study

BACKGROUND

The COVID-19 outbreak disrupted medical access for patients receiving chronic opioid therapy. This study investigated their prescription opioid dosages before and after the 2020 outbreak in Taiwan.

METHODS

A prospective questionnaire survey was conducted among registered outpatients receiving long-term opioids before July 2019 in Taiwan. The questionnaire included items from the Taiwanese Brief Pain Inventory and quality of life assessment. Follow-up surveys in outpatient departments through October 2020 were conducted to collect opioid prescription data.

RESULTS

After a mean of 531 days, the questionnaire responses of 103 of the initial 117 respondents were reviewed. Daily opioid doses decreased for 31 respondents (30.1%), remained roughly equivalent (defined as ±2.5%) for 27 (26.2%), and increased for 45 (43.7%) after the first wave of the pandemic. The use of strong opioids and nonopioid medications did not significantly differ among the three groups, but less fentanyl patch use was noted in the decreased-dose group after the outbreak. More than 70% of the patients received daily high-dose opioids (≥90 morphine milligram equivalents); moreover, 60% reported constipation. No deaths due to opioid overdose occurred during the study period.

CONCLUSIONS

The COVID-19 outbreak in 2020 did not interrupt access to long-term opioid prescriptions for most registered patients with chronic pain in Taiwan. Less fentanyl patch use was observed in participants whose opioid dose was tapering.

A machine learning algorithm for predicting prolonged postoperative opioid prescription after lumbar disc herniation surgery. An external validation study using 1,316 patients from a Taiwanese cohort

BACKGROUND CONTEXT

Preoperative prediction of prolonged postoperative opioid prescription helps identify patients for increased surveillance after surgery. The SORG machine learning model has been developed and successfully tested using 5,413 patients from the United States (US) to predict the risk of prolonged opioid prescription after surgery for lumbar disc herniation. However, external validation is an often-overlooked element in the process of incorporating prediction models in current clinical practice. This cannot be stressed enough in prediction models where medicolegal and cultural differences may play a major role.

PURPOSE

The authors aimed to investigate the generalizability of the US citizens prediction model SORG to a Taiwanese patient cohort.

STUDY DESIGN

Retrospective study at a large academic medical center in Taiwan.

PATIENT SAMPLE

Of 1,316 patients who were 20 years or older undergoing initial operative management for lumbar disc herniation between 2010 and 2018.

OUTCOME MEASURES

The primary outcome of interest was prolonged opioid prescription defined as continuing opioid prescription to at least 90 to 180 days after the first surgery for lumbar disc herniation at our institution.

METHODS

Baseline characteristics were compared between the external validation cohort and the original developmental cohorts. Discrimination (area under the receiver operating characteristic curve and the area under the precision-recall curve), calibration, overall performance (Brier score), and decision curve analysis were used to assess the performance of the SORG ML algorithm in the validation cohort. This study had no funding source or conflict of interests.

RESULTS

Overall, 1,316 patients were identified with sustained postoperative opioid prescription in 41 (3.1%) patients. The validation cohort differed from the development cohort on several variables including 93% of Taiwanese patients receiving NSAIDS preoperatively compared with 22% of US citizens patients, while 30% of Taiwanese patients received opioids versus 25% in the US. Despite these differences, the SORG prediction model retained good discrimination (area under the receiver operating characteristic curve of 0.76 and the area under the precision-recall curve of 0.33) and good overall performance (Brier score of 0.028 compared with null model Brier score of 0.030) while somewhat overestimating the chance of prolonged opioid use (calibration slope of 1.07 and calibration intercept of -0.87). Decision-curve analysis showed the SORG model was suitable for clinical use.

CONCLUSIONS

Despite differences at baseline and a very strict opioid policy, the SORG algorithm for prolonged opioid use after surgery for lumbar disc herniation has good discriminative abilities and good overall performance in a Han Chinese patient group in Taiwan. This freely available digital application can be used to identify high-risk patients and tailor prevention policies for these patients that may mitigate the long-term adverse consequence of opioid dependence: https://sorg-apps.shinyapps.io/lumbardiscopioid/.

Impact of expanded strong opioid availability on opioid prescription patterns in patients with cancer: A population-wide cohort study in Taiwan

Background One of the major barriers to adequate cancer pain management in Taiwan is the limited prescription options regarding strong opioids. Internationally recommended strong opioids, including oxycodone and hydromorphone, were not introduced in Taiwan until late 2014. We analysed the patterns in opioid prescription for cancer pain management, after the introduction of new opioid options. Methods All inpatient and outpatient clinical visits from January 1, 2012, to December 31, 2017, with the diagnosis of cancer and the analgesic prescriptions were collected from the database of National Health Insurance, Taiwan, and analysed. Opioids were grouped into strong opioids, weak opioids, and guideline non-recommended opioids. Findings A total of 1, 292, 905 patients with cancers were included. Approximately 50% of patients used analgesics, 50% of which were opioids; the proportions were stable during the study period. The annual cumulative opioid use per patient (defined daily dose, DDD) significantly decreased from 36•41±102•59 (Mean±SD) in 2012 to 32•42±100•99 in 2017 (p < •001). The annual cumulative strong opioid use per patient increased significantly from 17•54±89•23 in 2012 to 19•28±94•97 in 2017 (+9•90%, p < •001). In parallel, the annual cumulative weak opioids use per patient decreased from 18•64±40•81 in 2012 to 13•04±26•79 in 2017 (-30•04%, p < •001). Among extended-release strong opioids, the use of transdermal fentanyl significantly decreased after oxycodone and hydromorphone were introduced (p < •001). Interpretation Increased therapeutic options in strong opioid prescriptions led opioid prescription patterns to evolve towards international cancer pain management guidelines. In addition, increased accessibility to a wider range of different strong opioids may facilitate more efficient opioid titration and rotation - and thus decrease, not increase, the opioid usage. Funding This study was supported by Ministry of Science and Technology, Taiwan (MOST-106-2314-B-002-213 and MOST-108-2314-B-002-072-MY3), Ministry of Health and Welfare, Taiwan (MOHW109-TDU-B-211-114002), National Taiwan University Hospital, Taipei, Taiwan (NTUH-103-002314 and NTUH. 105-S2954), and National Center of Excellence for Clinical Trial & Research, National Taiwan University Hospital, Taipei, Taiwan (NCTRC201208 and NCTRC201603).

Gender Differences in Depression and Sex Hormones among Patients Receiving Long-Term Opioid Treatment for Chronic Noncancer Pain in Taiwan-A Multicenter Cross-Sectional Study

Background: Long-term use of opioids for chronic noncancer pain is associated with sex hormone disturbances. The interferences with sex hormones, sexual function, and depression were investigated in patients with chronic noncancer pain. Methods: A cross-sectional multicenter survey was conducted on 170 officially registered outpatients receiving long-term opioid treatment in nine medical centers in Taiwan between October 2018 and July 2019. Serum sex hormone levels were examined after the collection of self-administered questionnaires containing the Taiwanese version of the Brief Pain Inventory, depressive status, and sexual function interference. Results: Among 117 (68.8%) questionnaire responses from 170 enrolled outpatients, 38 women and 62 men completed the sex hormone tests, among whom only 23 (23%) had previously received blood hormone tests. Low serum total testosterone levels were detected in 34 (89.5%) women (<30 ng/dL) and 31 (50%) men (<300 ng/dL). Over 60% of women and men reported reduced sexual desire and function despite a nearly 50% reduction in pain intensity and daily function interference over the previous week after opioid treatment. Women generally had higher risks of a depression diagnosis (p = 0.034) and severe depressive symptoms (p = 0.003) and nonsignificantly lower opioid treatment duration (median 81 vs. 120 months) and morphine milligram equivalent (median 134 vs. 165 mg/day) compared with men. Conclusions: This survey demonstrated the high prevalence of depression diagnosis, low sex hormone levels, and reduced sexual function among Taiwanese patients with chronic noncancer pain receiving prolonged opioid therapy. Regular hypogonadal screenings are recommended for further management.

Progress in pharmacotherapy for alleviating pain of chronic pancreatitis

Pain is the main clinical symptom of chronic pancreatitis (CP), as well as the most common cause of patients' recurrent hospitalizations. The management regimen for CP pain needs to be formulated according to the patient's conditions. Lifestyle changes and drug treatment can usually be used as first-line therapy. Conventional analgesics, pancreatic enzymes, and antioxidants are commonly used in treating pain of CP. In recent years, the application of conventional analgesics has been further standardized. Besides, there have been more clinical studies on the treatment of CP pain with pancreatic enzymes or antioxidants. Traditional Chinese medicine has played an increasingly important role in the treatment of CP pain. New drugs such as camostat mesylate are expected to be used in CP pain, though more high-quality studies are still needed to confirm their safety and effectiveness.

Altered sensory nerve excitability in fibromyalgia

BACKGROUND/PURPOSE

To investigate nerve excitability changes in patients with fibromyalgia and the correlation with clinical severity.

METHODS

We enrolled 20 subjects with fibromyalgia and 22 sex and age-matched healthy subjects to receive nerve excitability test and nerve conduction study to evaluate the peripheral axonal function.

RESULTS

In the fibromyalgia cohort, the sensory axonal excitability test revealed increased superexcitability (%) (P = 0.029) compared to healthy control. Correlational study showed a negative correlation between increased subexcitability (%) (r = -0.534, P = 0.022) with fibromyalgia impact questionnaire (FIQ) score. Computer modeling confirmed that the sensory axon excitability pattern we observed in fibromyalgia cohort was best explained by increased Barrett-Barrett conductance, which was thought to be attributed to paranodal fast K⁺ channel dysfunction.

CONCLUSION

The present study revealed that paranodal sensory K⁺ conductance was altered in patients with fibromyalgia. The altered conductance indicated dysfunction of paranodal fast K⁺ channels, which is known to be associated with the generation of pain.

Knowledge, attitude, and barriers regarding prescribing long-term opioids among Taiwan physicians treating officially registered patients with chronic noncancer pain

BACKGROUND

Prescribing opioids for patients with chronic noncancer pain (CNCP) remains controversial. This study surveyed Taiwanese physicians who were clinically treating CNCP outpatients with long-term opioids.

METHODS

Anonymous questionnaires investigating the clinical practices, opioid knowledge, attitude, and barriers regarding the prescription of long-term opioids were delivered to 66 physicians treating CNCP outpatients who were officially registered and monitored by the Taiwan Food and Drug Administration in 2011.

RESULTS

All 66 (100%) physicians responded to the survey, comprising 41 (62%) board-certified pain specialists and 25 (38%) nonpain board-certified physicians. Pain specialists treated a greater number of CNCP outpatients and attended more CNCP training courses than nonpain board-certified physicians (97.6% vs. 56.0%, p < 0.001). Most of pain specialists stated that they were familiar with the Taiwan's narcotic regulations for CNCP patients (92.7% vs. 68.0%, p = 0.015). In addition, pain specialists were less likely to skip or reduce the dosage and duration of opioid prescriptions (22.0% vs. 36.0%, p < 0.001). By contrast, nonpain board-certified physicians had significantly less knowledge and a more negative attitude toward opioid prescription. The major perceived barriers were physician's reluctance to prescribe opioids (78% vs. 92%) and an inadequate knowledge of pain management (73% vs. 84%) among all physicians.

CONCLUSION

Among the Taiwanese physicians treating the officially registered CNCP patients, nonpain board-certified physicians had fewer patients, less knowledge, and an increased negative attitude toward long-term opioid prescriptions. Better education on chronic pain management is needed for improvement of clinical practice.

Endogenous opiates and behavior: 2017

This paper is the fortieth consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2017 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

Gender difference in long-term use of opioids among Taiwan officially registered patients with chronic noncancer pain

Research regarding sex or gender difference in chronic pain proliferated in this decade. This study was to analyze gender difference in Taiwan patients receiving long-term opioids for chronic noncancer pain.An observational cross-sectional survey was conducted among the registered outpatients by the Taiwan Food and Drug Administration. Participants completed a self-report questionnaire, including the Taiwanese version of Brief Pain Inventory and enquiry regarding sexual activities, depressive symptoms, and misuse behaviors.In total, 68 female and 142 male patients were analyzed. Both pain intensity and daily function interference reduced comparably (around 50%) between women and men after taking opioids in the past 1 week. The opioid-related adverse effects, including constipation, decreased sexual desire and satisfaction, and misuse behaviors were not significantly different. Women were exceedingly diagnosed with depression (67.7% vs 49.3%, P = .012) and had a higher mean depressive symptom score in the past 1 month, especially among those age <40 years (23.3 vs 11.9, P = .009), as compared with men. In addition, women had a lower mean self-rated health score (37.9 vs 44.3, P = .047). The mean morphine equivalent dose was significantly lower in women (131.6 vs 198.2 mg/day, P = .008), which was not correlated with their depressive scores.Gender differences in the effectiveness and adverse effects of long-term opioids were not found among Taiwan registered outpatients with chronic noncancer pain. However, more female patients inclined to have a coexisting depression diagnosis, depressive symptoms, and a lower perceived health score, needing regular screening and closer monitoring.

Medical Management of Pain in Chronic Pancreatitis

The medical management of pain in chronic pancreatitis continues to pose significant challenges for clinicians caring for these patients. There are increasing data, suggesting that pain in chronic pancreatitis is largely due to peripheral and central sensitization that evolves, over time, as a result of nociceptive afferent associated with chronic inflammation and fibrosis of the pancreas. In many instances, patients rapidly progress to requiring opioid analgesics for the adequate treatment of pain despite the unequivocal risks associated with the long-term use of these drugs. Centrally acting drugs, such as gabapentinoids, appear to be effective means of treating pain due to their inhibition of neurotransmitters involved in central sensitization, but side effects limit their use. The present review explores the evidence for various non-pharmacologic and pharmacologic treatments for pain in chronic pancreatitis.