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Hadler RA, Klinedinst R, Jones CA, Bao Y, Pathak R, Zarrabi AJ, Rosa WE. Dangerous Variation or Patient-Centered Care? Palliative Care and Pain Providers' Comfort, Experiences, and Approaches when Treating Cancer Pain With Coexisting Aberrant Behaviors. Am J Hosp Palliat Care 2024:10499091241259034. [PMID: 38830349 DOI: 10.1177/10499091241259034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND Patients with cancer-related pain are at high risk for aberrant drug use behaviors (ADB), including self-escalation, diversion and concurrent illicit substance or opioid misuse; however, limited evidence is available to guide opioid prescribing for patients with life-limiting illness and concurrent or suspected ADB. We sought to characterize how specialists evaluate for and manage these high-risk behaviors in patients with cancer-related pain. METHODS We conducted telephonic semi-structured interviews with palliative care and pain medicine providers. Participants discussed their own comfort and experience level with identifying and managing ADB in patients with life-limiting illness. They were subsequently presented with a series of standardized scenarios and asked to describe their concerns and management strategies. RESULTS 95 interdisciplinary pain and palliative care specialists were contacted; 37 agreed to participate (38.9%). Analysis of interview contents revealed several central themes: (1) widespread discomfort and anxiety regarding safe and compassionate opioid prescribing for high-risk patients, (2) belief that widely used risk-mitigation tools such as opioid contracts and urine drug screens provided inadequate support for decision-making, and (3) lack of institutional and organizational support and guidance for safe prescribing strategies. Most clinicians reported self-education regarding addiction and alternative prescribing/pain management strategies. Providers varied widely in their willingness to discontinue opioid prescribing in a patient with aberrant behavior and pain associated with life-limiting illness. CONCLUSION Providers caring for patients demonstrating ADB and cancer-related pain struggle to balance safe prescribing with symptom management. Increased guidance is needed regarding opioid prescribing, monitoring, and discontinuation in high-risk patients.
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Affiliation(s)
- Rachel A Hadler
- Department of Anesthesiology, Emory University, Atlanta, GA, USA
- Emory Critical Care Center, Emory University, Atlanta, GA, USA
| | - Rachel Klinedinst
- Palliative Care Alliance, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Christopher A Jones
- Palliative Care Program, Department of Medicine, Duke University, Durham, NC, USA
| | - Yuhua Bao
- Department of Population Health Sciences, Weill-Cornell Medicine, New York, NY, USA
| | - Ravi Pathak
- Department of Anesthesiology, Emory University, Atlanta, GA, USA
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, Atlanta, GA, USA
| | - Ali J Zarrabi
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, Atlanta, GA, USA
| | - William E Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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Mishkin AD, Prince EJ, Leimbach EJ, Mapara MY, Carroll CP. Psychiatric comorbidities in adults with sickle cell disease: A narrative review. Br J Haematol 2023; 203:747-759. [PMID: 37455514 DOI: 10.1111/bjh.18981] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/21/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023]
Abstract
Although descriptions of quality of life and patient reports of mood in sickle cell disease (SCD) have become more common in the literature, less is known about psychiatric illness prevalence, presentation, and treatment, particularly for adults. We provide a narrative review of what is known about common and debilitating psychiatric conditions such as depression, anxiety, and cognitive impairment, specifically for adults with SCD. We discuss the limitations of the current evidence, make provisional recommendations, and identify opportunities for research and improved care.
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Affiliation(s)
- Adrienne D Mishkin
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York, USA
- Blood and Marrow Transplantation Program, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Elizabeth J Prince
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth J Leimbach
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York, USA
| | - Markus Y Mapara
- Blood and Marrow Transplantation Program, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - C Patrick Carroll
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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López-Arteaga T, Moreno-Rubio C, Mohedano-Moriano A. Risk factors for opioid addiction in chronic non-cancer pain. Heliyon 2023; 9:e19707. [PMID: 37809400 PMCID: PMC10558926 DOI: 10.1016/j.heliyon.2023.e19707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 07/17/2023] [Accepted: 08/30/2023] [Indexed: 10/10/2023] Open
Abstract
Opioids are very effective pain medications, but they are not without complications. Its use in chronic cancer pain is clearly established, but not in chronic non-cancer pain. Opioid use has increased in recent years, but at the same time, it has been accompanied by an increase in side effects and related complications, including abuse, abuse and opioid addiction. If we look in the literature on the subject there is a global concern to make an adequate therapy with risk reduction, but the samples studied make it difficult to extrapolate results to the general population and even more so if we take into account factors such as psychiatric comorbidity. This leads us to consider the need to study our own population, its characteristics and see how it is being treated, to refine as much as possible on an appropriate prescription. The authors have carried out a cross-sectional study on patients with non-cancer chronic pain referred to psychiatry and the presence of opioid use disorder. We found risk factors related to the biopsychosocial characteristics of the patients and the characteristics of pain and its treatment. Knowing the risk factors, we can avoid yatrogeny, implement primary and secondary prevention and, ultimately, improve the quality of patient care.
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Affiliation(s)
- Teresa López-Arteaga
- Médico Psiquiatra. Directora Médica Área Integrada de Talavera. Hospital General Universitario Ntra. Sra. Del Prado. Talavera de la Reina, Spain
| | - Carlos Moreno-Rubio
- Jefe de Servicio de Psiquiatría. Hospital General Universitario Ntra. Sra. Del Prado. Talavera de la Reina, Spain
| | - Alicia Mohedano-Moriano
- Titular de la Facultad de Ciencias de la Salud Talavera de la Reina. Universidad de Castilla-La Mancha, Spain
- Académica del Vicerrectorado de Ciencias de la Salud de la Universidad de Castilla-La Mancha, Spain
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Prince EJ, Pecker LH, Lanzkron S, Carroll CP. The Complex Association of Daily Opioid Dose with Visits for Pain in Sickle Cell Disease: Tolerance or Treatment-Refractory Pain? PAIN MEDICINE (MALDEN, MASS.) 2023; 24:703-712. [PMID: 36458906 PMCID: PMC10501470 DOI: 10.1093/pm/pnac187] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 11/25/2022] [Accepted: 11/29/2022] [Indexed: 12/03/2022]
Abstract
INTRODUCTION Opioids are used for acute and chronic pain in patients with sickle cell disease. How outpatient opioid regimens relate to acute care visits is of interest given the risks of high opioid doses and high hospital utilization. A prior study by our group suggested that outpatient opioid treatment for chronic pain could contribute to a vicious cycle of treatment-refractory acute pain, greater acute care utilization, and escalating opioid doses. The present larger naturalistic observational study was undertaken to determine whether the results were reliable across multiple acute care settings. METHODS One year of clinical data on patients (n = 291) followed in the Sickle Cell Center for Adults (August 2018 to July 2019) were extracted, including visits to the emergency department, visits to the infusion center, and inpatient admissions. Outpatient opioid dosage was used to predict acute care treatment in generalized linear models that were controlled for patient, disease, and treatment characteristics. RESULTS Outpatient opioid dosage predicted dosage during visits but did not predict visit length or pain relief. Higher outpatient opioid dosage was associated with greater number of visits. However, in post hoc analyses, this relationship was nonlinear, with a clear positive association only for those prescribed the lowest 50% of dosages. DISCUSSION Higher outpatient opioid dosage predicted higher dosages during acute care visits to achieve the same pain score improvement, which is more consistent with opioid tolerance than with treatment-refractory pain. The relationship of outpatient opioid dosage with number of acute care visits was more complex, which suggests that opioid consumption at lower levels is driven by intermittent acute pain and opioid consumption at higher levels is driven by chronic pain.
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Affiliation(s)
| | | | - Sophie Lanzkron
- Medicine and Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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5
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Vowles KE, Witkiewitz K, Clarke E, Schmidt Z, Borsari B, Edwards KE, Korecki JR, Moniz-Lewis DI, Bondzie JA, Mullins C, Thoreson CI, Delacruz J, Wilkins CH, Nelson S, Delventura J, Henderson R, Katz A, Hua W, Watson E, Baxley C, Canlas BR, Pendleton T, Herbst E, Batki S. Rationale and design of a multisite randomized clinical trial examining an integrated behavioral treatment for veterans with co-occurring chronic pain and opioid use disorder: The pain and opioids integrated treatment in veterans (POSITIVE) trial. Contemp Clin Trials 2023; 126:107096. [PMID: 36693589 DOI: 10.1016/j.cct.2023.107096] [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: 10/19/2022] [Revised: 01/13/2023] [Accepted: 01/18/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND Chronic pain and opioid use disorder (OUD) individually represent a risk to health and well-being. Concerningly, there is evidence that they are frequently co-morbid. While few treatments exist that simultaneously target both conditions, preliminary work has supported the feasibility of an integrated behavioral treatment targeting pain interference and opioid misuse. This treatment combined Acceptance and Commitment Therapy (ACT) and Mindfulness-Based Relapse Prevention (ACT+MBRP). This paper describes the protocol for the adequately powered efficacy study of this integrated treatment. METHODS A multisite randomized controlled trial will examine the efficacy of ACT+MBRP in comparison to a parallel education control condition, focusing on opioid safety and pain education. Participants include veterans (n = 160; 21-75 years old) recruited from three Veterans Administration (VA) Healthcare Systems with chronic pain who are on a stable dose of buprenorphine. Both conditions include twelve weekly 90 min group sessions delivered via telehealth. Primary outcomes include pain interference (Patient Reported Outcome Measurement Information System - Pain Interference) and hazardous opioid use (Current Opioid Misuse Measure), which will be examined at the end of the active treatment phase and through 12 months post-intervention. Secondary analyses will evaluate outcomes including pain intensity, depression, pain-related fear, and substance use, as well as treatment mechanisms. CONCLUSION This study will determine the efficacy of an integrated behavioral treatment program for pain interference and hazardous opioid use among veterans with chronic pain and OUD who are prescribed buprenorphine, addressing a critical need for more integrated treatments for chronic pain and OUD. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04648228.
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Affiliation(s)
- Kevin E Vowles
- School of Psychology, Queen's University Belfast, Belfast, Northern Ireland, UK.
| | - Katie Witkiewitz
- Department of Psychology, University of New Mexico, Albuquerque, NM, USA.
| | - Erik Clarke
- Puget Sound Veterans Affairs Healthcare Administration, Tacoma, WA, USA
| | - Zachary Schmidt
- Raymond G. Murphy Veterans Affairs Medical Center, New Mexico Veteran Affairs Healthcare System, Albuquerque, NM, USA
| | - Brian Borsari
- San Francisco Veteran Affairs Medical Center and University of California - San Francisco, San Francisco, CA, USA
| | - Karlyn E Edwards
- Department of Anesthesiology, Perioperative, and Pain Medicine, Division of Pain Medicine Stanford University, Palo Alto, CA, USA
| | - J Richard Korecki
- Department of Psychology, University of California, Los Angeles, Los Angeles, CA, USA
| | | | - Juliana A Bondzie
- Puget Sound Veterans Affairs Healthcare Administration, Tacoma, WA, USA
| | - Chloe Mullins
- Raymond G. Murphy Veterans Affairs Medical Center, New Mexico Veteran Affairs Healthcare System, Albuquerque, NM, USA
| | - Claire I Thoreson
- Puget Sound Veterans Affairs Healthcare Administration, Tacoma, WA, USA
| | - Joannalyn Delacruz
- San Francisco Veteran Affairs Medical Center and University of California - San Francisco, San Francisco, CA, USA
| | - Consuelo H Wilkins
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University, Nashville, TN, USA
| | - Sarah Nelson
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University, Nashville, TN, USA
| | | | - Ryan Henderson
- Puget Sound Veterans Affairs Healthcare Administration, Tacoma, WA, USA
| | - Andrea Katz
- Puget Sound Veterans Affairs Healthcare Administration, Tacoma, WA, USA
| | - William Hua
- San Francisco Veteran Affairs Medical Center and University of California - San Francisco, San Francisco, CA, USA
| | - Erin Watson
- San Francisco Veteran Affairs Medical Center and University of California - San Francisco, San Francisco, CA, USA
| | - Catherine Baxley
- San Francisco Veteran Affairs Medical Center and University of California - San Francisco, San Francisco, CA, USA
| | - Bernard R Canlas
- Puget Sound Veterans Affairs Healthcare Administration, Tacoma, WA, USA
| | - Tiffany Pendleton
- Raymond G. Murphy Veterans Affairs Medical Center, New Mexico Veteran Affairs Healthcare System, Albuquerque, NM, USA
| | - Ellen Herbst
- San Francisco Veteran Affairs Medical Center and University of California - San Francisco, San Francisco, CA, USA
| | - Steven Batki
- San Francisco Veteran Affairs Medical Center and University of California - San Francisco, San Francisco, CA, USA
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6
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Powell VD, Macleod C, Sussman J, Lin LA, Bohnert ASB, Lagisetty P. Variation in Clinical Characteristics and Longitudinal Outcomes in Individuals with Opioid Use Disorder Diagnosis Codes. J Gen Intern Med 2023; 38:699-706. [PMID: 35819683 PMCID: PMC9971398 DOI: 10.1007/s11606-022-07732-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 06/28/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Patterns of opioid use vary, including prescribed use without aberrancy, limited aberrant use, and potential opioid use disorder (OUD). In clinical practice, similar opioid-related International Classification of Disease (ICD) codes are applied across this spectrum, limiting understanding of how groups vary by sociodemographic factors, comorbidities, and long-term risks. OBJECTIVE (1) Examine how Veterans assigned opioid abuse/dependence ICD codes vary at diagnosis and with respect to long-term risks. (2) Determine whether those with limited aberrant use share more similarities to likely OUD vs those using opioids as prescribed. DESIGN Longitudinal observational cohort study. PARTICIPANTS National sample of Veterans categorized as having (1) likely OUD, (2) limited aberrant opioid use, or (3) prescribed, non-aberrant use based upon enhanced medical chart review. MAIN MEASURES Comparison of sociodemographic and clinical factors at diagnosis and rates of age-adjusted mortality, non-fatal opioid overdose, and hospitalization after diagnosis. An exploratory machine learning analysis investigated how closely those with limited aberrant use resembled those with likely OUD. KEY RESULTS Veterans (n = 483) were categorized as likely OUD (62.1%), limited aberrant use (17.8%), and prescribed, non-aberrant use (20.1%). Age, proportion experiencing homelessness, chronic pain, anxiety disorders, and non-opioid substance use disorders differed by group. All-cause mortality was high (44.2 per 1000 person-years (95% CI 33.9, 56.7)). Hospitalization rates per 1000 person-years were highest in the likely OUD group (831.5 (95% CI 771.0, 895.5)), compared to limited aberrant use (739.8 (95% CI 637.1, 854.4)) and prescribed, non-aberrant use (411.9 (95% CI 342.6, 490.4). The exploratory analysis reclassified 29.1% of those with limited aberrant use as having likely OUD with high confidence. CONCLUSIONS Veterans assigned opioid abuse/dependence ICD codes are heterogeneous and face variable long-term risks. Limited aberrant use confers increased risk compared to no aberrant use, and some may already have OUD. Findings warrant future investigation of this understudied population.
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Affiliation(s)
- Victoria D Powell
- Palliative Care Program, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, MI, USA.
- Geriatrics Research, Education, and Clinical Center, LTC Charles S. Kettles VA Medical Center, Ann Arbor, MI, USA.
| | - Colin Macleod
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jeremy Sussman
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Lewei A Lin
- VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Amy S B Bohnert
- VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Pooja Lagisetty
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Roberts RL, Garland EL. Association between opioid use disorder and blunted heart rate variability among opioid-treated chronic pain patients. Addict Biol 2022; 27:e13230. [PMID: 36301218 PMCID: PMC10234179 DOI: 10.1111/adb.13230] [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: 03/01/2022] [Revised: 08/14/2022] [Accepted: 08/21/2022] [Indexed: 01/24/2023]
Abstract
Given the severity of the ongoing opioid epidemic, it is essential to understand the mechanisms of risk for development and maintenance of opioid use disorder (OUD). The aim of the current large-scale psychophysiological investigation was to test whether patients with OUD had lower resting-state high-frequency heart rate variability (HF-HRV) than those without OUD, controlling for sociodemographic and clinical confounds. Additionally, we tested whether HF-HRV was associated with opioid craving in this population. Participants in this cross-sectional study were 490 chronic pain patients (50.4% female) treated with long-term opioid therapy. OUD diagnosis was determined by psychiatric interview. HF-HRV was measured at resting baseline. We computed the association between OUD and resting-state HF-HRV, controlling for age, gender, race, pain severity, emotional distress and opioid dose. Opioid craving was measured with visual analogue scales to assess whether HF-HRV was associated with craving. Results showed that resting HF-HRV was significantly lower for patients with OUD than for those without OUD (p < 0.001, d = 0.36), indicating deficits in autonomic flexibility. OUD diagnosis (p = 0.002) and OUD severity (p = 0.03) were associated with lower HF-HRV in regression models accounting for a range of confounders. Additionally, lower HF-HRV was significantly (but weakly) correlated with heightened opioid craving (r = -0.166, p < 0.001). Overall, findings suggest that resting-state HF-HRV may serve as a valid biomarker of addiction among people on long-term opioid therapy.
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Affiliation(s)
- R Lynae Roberts
- Center on Mindfulness and Integrative Health Intervention Development (C-MIIND), University of Utah, Salt Lake City, Utah, USA
- College of Social Work, University of Utah, Salt Lake City, Utah, USA
| | - Eric L Garland
- Center on Mindfulness and Integrative Health Intervention Development (C-MIIND), University of Utah, Salt Lake City, Utah, USA
- College of Social Work, University of Utah, Salt Lake City, Utah, USA
- Veterans Health Care Administration VISN 19 Whole Health, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
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Aiding the prescriber: developing a machine learning approach to personalized risk modeling for chronic opioid therapy amongst US Army soldiers. Health Care Manag Sci 2022; 25:649-665. [PMID: 35895214 DOI: 10.1007/s10729-022-09605-4] [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: 01/28/2021] [Accepted: 06/13/2022] [Indexed: 11/04/2022]
Abstract
The opioid epidemic is a major policy concern. The widespread availability of opioids, which is fueled by physician prescribing patterns, medication diversion, and the interaction with potential illicit opioid use, has been implicated as proximal cause for subsequent opioid dependence and mortality. Risk indicators related to chronic opioid therapy (COT) at the point of care may influence physicians' prescribing decisions, potentially reducing rates of dependency and abuse. In this paper, we investigate the performance of machine learning algorithms for predicting the risk of COT. Using data on over 12 million observations of active duty US Army soldiers, we apply machine learning models to predict the risk of COT in the initial months of prescription. We use the area under the curve (AUC) as an overall measure of model performance, and we focus on the positive predictive value (PPV), which reflects the models' ability to accurately target military members for intervention. Of the many models tested, AUC ranges between 0.83 and 0.87. When we focus on the top 1% of members at highest risk, we observe a PPV value of 8.4% and 20.3% for months 1 and 3, respectively. We further investigate the performance of sparse models that can be implemented in sparse data environments. We find that when the goal is to identify patients at the highest risk of chronic use, these sparse linear models achieve a performance similar to models trained on hundreds of variables. Our predictive models exhibit high accuracy and can alert prescribers to the risk of COT for the highest risk patients. Optimized sparse models identify a parsimonious set of factors to predict COT: initial supply of opioids, the supply of opioids in the month being studied, and the number of prescriptions for psychotropic medications. Future research should investigate the possible effects of these tools on prescriber behavior (e.g., the benefit of clinician nudging at the point of care in outpatient settings).
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Garland EL, Hanley AW, Nakamura Y, Barrett JW, Baker AK, Reese SE, Riquino MR, Froeliger B, Donaldson GW. Mindfulness-Oriented Recovery Enhancement vs Supportive Group Therapy for Co-occurring Opioid Misuse and Chronic Pain in Primary Care: A Randomized Clinical Trial. JAMA Intern Med 2022; 182:407-417. [PMID: 35226053 PMCID: PMC8886485 DOI: 10.1001/jamainternmed.2022.0033] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 01/07/2022] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Successful treatment of opioid misuse among people with chronic pain has proven elusive. Guidelines recommend nonopioid therapies, but the efficacy of mindfulness-based interventions for opioid misuse is uncertain. OBJECTIVE To evaluate the efficacy of Mindfulness-Oriented Recovery Enhancement (MORE) for the reduction of opioid misuse and chronic pain. DESIGN, SETTING, AND PARTICIPANTS This interviewer-blinded randomized clinical trial enrolled patients from primary care clinics in Utah between January 4, 2016, and January 16, 2020. The study included 250 adults with chronic pain receiving long-term opioid therapy who were misusing opioid medications. INTERVENTIONS Treatment with MORE (comprising training in mindfulness, reappraisal, and savoring positive experiences) or supportive group psychotherapy (control condition) across 8 weekly 2-hour group sessions. MAIN OUTCOMES AND MEASURES Primary outcomes were (1) opioid misuse assessed by the Drug Misuse Index (self-report, interview, and urine screen) and (2) pain severity and pain-related functional interference, assessed by subscale scores on the Brief Pain Inventory through 9 months of follow-up. Secondary outcomes were opioid dose, emotional distress, and ecological momentary assessments of opioid craving. The minimum intervention dose was defined as 4 or more completed sessions of MORE or supportive group psychotherapy. RESULTS Among 250 participants (159 women [63.6%]; mean [SD] age, 51.8 [11.9] years), 129 were randomized to the MORE group and 121 to the supportive psychotherapy group. Overall, 17 participants (6.8%) were Hispanic or Latino, 218 (87.2%) were White, and 15 (6.0%) were of other races and/or ethnicities (2 American Indian, 3 Asian, 1 Black, 2 Pacific Islander, and 7 did not specify). At baseline, the mean duration of pain was 14.7 years (range, 1-60 years), and the mean (SD) morphine-equivalent opioid dose was 101.0 (266.3) mg (IQR, 16.0-90.0 mg). A total of 203 participants (81.2%) received the minimum intervention dose (mean [SD], 5.7 [2.2] sessions); at 9 months, 92 of 250 participants (36.8%) discontinued the study. The overall odds ratio for reduction in opioid misuse through the 9-month follow-up period in the MORE group compared with the supportive psychotherapy group was 2.06 (95% CI, 1.17-3.61; P = .01). At 9 months, 36 of 80 participants (45.0%) in the MORE group were no longer misusing opioids compared with 19 of 78 participants (24.4%) in the supportive psychotherapy group. Mixed models demonstrated that MORE was superior to supportive psychotherapy through 9 months of follow-up for pain severity (between-group effect: 0.49; 95% CI, 0.17-0.81; P = .003) and pain-related functional interference (between-group effect: 1.07; 95% CI, 0.64-1.50; P < .001). Participants in the MORE group reduced their opioid dose to a greater extent than those in the supportive psychotherapy group. The MORE group also had lower emotional distress and opioid craving. CONCLUSIONS AND RELEVANCE In this randomized clinical trial, among adult participants in a primary care setting, the MORE intervention led to sustained improvements in opioid misuse and chronic pain symptoms and reductions in opioid dosing, emotional distress, and opioid craving compared with supportive group psychotherapy. Despite attrition caused by the COVID-19 pandemic and the vulnerability of the sample, MORE appeared to be efficacious for reducing opioid misuse among adults with chronic pain. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02602535.
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Affiliation(s)
- Eric L. Garland
- Center on Mindfulness and Integrative Health Intervention Development, College of Social Work, University of Utah, Salt Lake City
- Veterans Health Care Administration, Veterans Integrated Service Network 19 Whole Health Flagship Site, VA Salt Lake City Health Care System, Salt Lake City, Utah
| | - Adam W. Hanley
- Center on Mindfulness and Integrative Health Intervention Development, College of Social Work, University of Utah, Salt Lake City
| | - Yoshio Nakamura
- Pain Research Center, Division of Pain Medicine, Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City
| | - John W. Barrett
- Community Physicians Group, University of Utah School of Medicine, Salt Lake City
| | - Anne K. Baker
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | | | | | | | - Gary W. Donaldson
- Pain Research Center, Division of Pain Medicine, Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City
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Nelson EUE, Alichie BO. Chronic Pain and Prescription Opioid Use Among Socially Marginalized Nigerian Women: Exploring Supply Channels and Pathways to Misuse. JOURNAL OF DRUG ISSUES 2022. [DOI: 10.1177/00220426221083655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study explores pathways to prescription opioid misuse and supply channels based on in-depth interviews with 16 socially marginalized Nigerian women suffering chronic pain. The pathways identified were medical pain treatment, prior substance use and opioid use for recreation and coping with psychological distress. Facing barriers to prescription opioids due to prescribing restrictions and provider stigma, many resorted to unlicensed chemist stores and street drug dealers for opioid analgesics, including fake and potentially harmful products. Patterns of prescription opioid misuse were woven into multiple and overlapping dynamics of marginalization shaping the lives of these women, including homelessness, sex work, substance use and intimate partner violence. Findings show a need to improve access to prescription opioids and other evidence-based approaches, framed within a trauma-informed approach to pain management. Further, integrating substance abuse treatment and pain management could make services responsive to the inter-related problems of chronic pain and prescription opioid misuse.
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Affiliation(s)
- Ediomo-Ubong E. Nelson
- Global Drug Policy Observatory, Swansea University, Singleton Park, UK
- Centre for Research and Information on Substance Abuse, Uyo, Nigeria
| | - Bridget O. Alichie
- Department of Sociology, University of Alberta, Canada
- Department of Sociology and Anthropology, Nnamdi Azikiwe University, Awka, Nigeria
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Diagnostic and Predictive Capacity of the Spanish Versions of the Opioid Risk Tool and the Screener and Opioid Assessment for Patients with Pain-Revised: A Preliminary Investigation in a Sample of People with Noncancer Chronic Pain. Pain Ther 2022; 11:493-510. [PMID: 35128624 PMCID: PMC9098780 DOI: 10.1007/s40122-022-00356-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/17/2022] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Accurate assessment of the risk of opioid abuse and misuse in people with noncancer chronic pain is crucial for their prevention. This study aimed to provide preliminary evidence of the diagnostic and predictive capacity of the Spanish versions of the Opioid Risk Tool (ORT) and the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R). METHODS We used the Current Opioid Misuse Measure (COMM) as criterion measure to assess the capacity of each tool to identify patients misusing opioids at the time of the assessment. Eighteen months later, we used the COMM and the Drug Abuse Screening Test-10 (DAST-10) to assess their predictive capacity. In total, 147 people with noncancer chronic pain participated in the diagnostic study, and 42 in the predictive study. RESULTS Receiver operating curve analysis showed that the SOAPP-R had an excellent capacity to identify participants who were misusing opioids at the time of assessment (area under the curve [AUC] = 0.827). The diagnostic capacity of the ORT was close to acceptable (AUC = 0.649-0.669), whereas its predictive capacity was poor (AUC = 0.522-0.554). The predictive capacity of the SOAPP-R was close to acceptable regarding misuse (AUC = 0.672) and poor regarding abuse (AUC = 0.423). CONCLUSION In the setting of Spanish-speaking communities, clinicians should be cautious when using these instruments to make decisions on opioid administration. Further research is needed on the diagnostic and predictive capacity of the Spanish versions of both instruments.
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Ahrari M, Ali S, Hartling L, Dong K, Drendel AL, Klassen TP, Schreiner K, Dyson MP. Nonmedical Opioid Use After Short-term Therapeutic Exposure in Children: A Systematic Review. Pediatrics 2021; 148:183452. [PMID: 34816280 DOI: 10.1542/peds.2021-051927] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2021] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Opioid-related harms continue to rise for children and youth. Analgesic prescribing decisions are challenging because the risk for future nonmedical opioid use or disorder is unclear. OBJECTIVE To synthesize research examining the association between short-term therapeutic opioid exposure and future nonmedical opioid use or opioid use disorder and associated risk factors. DATA SOURCES We searched 11 electronic databases. STUDY SELECTION Two reviewers screened studies. Studies were included if: they were published in English or French, participants had short-term (≤14 days) or an unknown duration of therapeutic exposure to opioids before 18 years, and reported opioid use disorder or misuse. DATA EXTRACTION Data were extracted, and methodologic quality was assessed by 2 reviewers. Data were summarized narratively. RESULTS We included 21 observational studies (49 944 602 participants). One study demonstrated that short-term therapeutic exposure may be associated with opioid abuse; 4 showed an association between medical and nonmedical opioid use without specifying duration of exposure. Other studies reported on prevalence or incidence of nonmedical use after medical exposure to opioids. Risk factors were contradictory and remain unclear. LIMITATIONS Most studies did not specify duration of exposure and were of low methodologic quality, and participants might not have been opioid naïve. CONCLUSIONS Some studies suggest an association between lifetime therapeutic opioid use and nonmedical opioid use. Given the lack of clear evidence regarding short-term therapeutic exposure, health care providers should carefully evaluate pain management options and educate patients and caregivers about safe, judicious, and appropriate use of opioids and potential signs of misuse.
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Affiliation(s)
| | - Samina Ali
- Departments of Pediatrics.,Emergency Medicine.,Women and Children's Health Research Institute
| | | | | | - Amy L Drendel
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Terry P Klassen
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Kurt Schreiner
- Pediatric Parents' Advisory Group, University of Alberta, Edmonton, Alberta, Canada
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Smith MD, Emerick T, Brancolini S, Alter B. Clearing up the Confusion: What to Do with Ethanol and Ethanol Metabolites in Urine Drug Screens. PAIN MEDICINE 2021; 22:2401-2413. [PMID: 33595647 DOI: 10.1093/pm/pnab068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Michael D Smith
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Trent Emerick
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Scott Brancolini
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Benedict Alter
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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14
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Clinical Implications of Opioid Therapy. Cancer Treat Res 2021; 182:107-124. [PMID: 34542879 DOI: 10.1007/978-3-030-81526-4_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Although opioids are potent central acting broad-spectrum analgesics, their effectiveness is diminished by various factors pertaining to their metabolism, drug interactions, genetic issues, adverse/side effects, and potential for abuse. All these factors present potential barriers to effective analgesia requiring specific considerations in clinical practice, which include monitoring and case-based intervention.
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15
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Martel MO, Bruneau A, Edwards RR. Mind-body approaches targeting the psychological aspects of opioid use problems in patients with chronic pain: evidence and opportunities. Transl Res 2021; 234:114-128. [PMID: 33676035 DOI: 10.1016/j.trsl.2021.02.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 02/26/2021] [Accepted: 02/26/2021] [Indexed: 12/27/2022]
Abstract
Opioids are commonly prescribed for the management of patients with chronic noncancer pain. Despite the potential analgesic benefits of opioids, long-term opioid therapy (LTOT) may be accompanied by problems such as opioid misuse and opioid use disorder (OUD). In this review, we begin with a description of opioid misuse and OUD and the patient-specific factors associated with these problems among patients with chronic pain. We will focus primarily on highlighting the predominant role played by psychological factors in the occurrence of opioid misuse and OUD in these patients. Several psychological factors have been found to be associated with opioid use problems in patients with chronic pain, and evidence indicates that patients presenting with psychological disturbances are particularly at risk of transitioning to long-term opioid use, engaging in opioid misuse behaviors, and developing OUD. The biological factors that might underlie the association between psychological disturbances and opioid use problems in patients with chronic pain have yet to be fully elucidated, but a growing number of studies suggest that dysfunctions in reward, appetitive, autonomic, and neurocognitive systems might be involved. We end with an overview of specific types of psychological interventions that have been put forward to prevent or reduce the occurrence of opioid misuse and OUD in patients with chronic pain who are prescribed LTOT.
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Affiliation(s)
- Marc O Martel
- Faculty of Dentistry & Department of Anesthesiology, McGill University, Montreal, Canada; Division of Experimental Medicine, McGill University, Montreal, Canada
| | - Alice Bruneau
- Division of Experimental Medicine, McGill University, Montreal, Canada
| | - Robert R Edwards
- Department of Anesthesiology & Pain Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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16
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Ruiz-López D, Alonso-Babarro A. [Questionnaire made to understand the opioid analgesics prescription habits in the community of Madrid (Spain)]. Aten Primaria 2021; 53:102040. [PMID: 33857704 PMCID: PMC8065263 DOI: 10.1016/j.aprim.2021.102040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 12/29/2020] [Accepted: 01/21/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Pain is the fearest and disabling symptom for cancer patients. The cornerstone of treatment is opioid analgesics. The objective of this research was to relate the opioid consumption existing in the Community of Madrid (CM) with the prescription habits expressed by the Primary Care (PrC) and Palliative Care (PalC) physicians. DESIGN An opioid prescription habits questionnaire was designed. Sampling was consecutive non-probability. SITE: PrC and specific PalC resources in the CM. PARTICIPANTS The study population included all the family doctors who worked in PrC in the Madrid Public Health Service and all the physicians who worked in some specific PalC resources, both home-based teams and supportive hospital teams in the CM of the public and private/concerted health network services. MAIN MEASUREMENTS We asked about the strong and weak opioids most used in moderate-severe oncological and non-oncological pain, the preferred administration route, the safety in the use of opioids in the treatment of pain and the preferred clinical practice guidelines. RESULTS The questionnaire was answered by 840 PrC physicians (20%) and 56 PalC physicians (45%). For the treatment of moderate-severe cancer pain in both groups of professionals, the first choice was morphine; however, in non-cancer pain for PrC it was fentanyl and morphine for PalC professionals. Regarding the route of administration, 70% of family doctors and 87% of PalC physicians stated that the oral route was the first choice, compared to 27% in PrC and 5% in PalC who preferred the transdermal route. The PrC physicians rated their ability to use opioids as average (4-7/10), while the palliativists considered it as high (8-10/10). In PrC, they declared that they knew, above all, the European Association for Palliative Care (EAPC) and National Institute for Health and Care Excellence (NICE) guidelines, although the largest number answered that they trusted their experience. PalC physicians preferred to use the EAPC guide. CONCLUSIONS There is a clear disagreement between the actual consumption of opioids and the prescribing habits manifested by family doctors, as well as a false certainty in prescribing these drugs.
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Affiliation(s)
- Diego Ruiz-López
- Equipo de Soporte Paliativo Domiciliario (ESAPD), Centro de Salud Legazpi, Dirección Asistencial Noroeste de Atención Primaria, Servicio Madrileño de Salud, Madrid, España.
| | - Alberto Alonso-Babarro
- Unidad de Cuidados Paliativos, Hospital Universitario de La Paz, Servicio Madrileño de Salud, Madrid, España
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Firemark AJ, Schneider JL, Kuntz JL, Papajorgji-Taylor D, Dickerson JF, Thorsness LA, Reese KR, Sullivan MD, Debar LL, Smith DH. "We Need to Taper." Interviews with Clinicians and Pharmacists About Use of a Pharmacy-Led Opioid Tapering Program. PAIN MEDICINE 2021; 22:1213-1222. [PMID: 33616160 DOI: 10.1093/pm/pnaa442] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To identify factors that influence or interfere with referrals by primary care providers (PCPs) to a pharmacist-led telephone-based program to assist patients undergoing opioid tapering. The Support Team Onsite Resource for Management of Pain (STORM) program provides individualized patient care and supports PCPs in managing opioid tapers. DESIGN Qualitative interviews were conducted with referring PCPs and STORM staff. Interview guides addressed concepts from the RE-AIM framework, focusing on issues affecting referral to the STORM program. SETTING An integrated healthcare system (HCS) in the Northwest United States. SUBJECTS Thirty-five interviews were conducted with 20 PCPs and 15 STORM staff. METHODS Constant comparative analysis was used to identify key themes from interviews. A codebook was developed based on interview data and a qualitative software program was used for coding, iterative review, and content analysis. Representative quotes illustrate identified themes. RESULTS Use of the STORM opioid tapering program was influenced by PCP, patient, and HCS considerations. Factors motivating use of STORM included lack of PCP time to support chronic pain patients requiring opioid tapering and the perception that STORM is a valued partner in patient care. Impediments to referral included PCP confidence in managing opioid tapering, patient resistance to tapering, forgetting about program availability, and PCP resistance to evolving guidelines regarding opioid tapering goals. CONCLUSIONS PCPs recognized that STORM supported patient safety and reduced clinician burden. Utilization of the program could be improved through ongoing PCP education about the service and consistent co-location of STORM pharmacists within primary care clinics.
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Affiliation(s)
- Alison J Firemark
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon, USA
| | | | - Jennifer L Kuntz
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon, USA
| | | | - John F Dickerson
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon, USA
| | - Lou Ann Thorsness
- Kaiser Permanente Northwest Clinical Pharmacy Services, Portland, Oregon, USA
| | - Katherine R Reese
- Kaiser Permanente Northwest Clinical Pharmacy Services, Portland, Oregon, USA
| | - Mark D Sullivan
- Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
| | - Lynn L Debar
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - David H Smith
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon, USA
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Buonora M, Perez HR, Stumph J, Allen R, Nahvi S, Cunningham CO, Merlin JS, Starrels JL. Medical Record Documentation About Opioid Tapering: Examining Benefit-to-Harm Framework and Patient Engagement. PAIN MEDICINE 2021; 21:2574-2582. [PMID: 32142143 DOI: 10.1093/pm/pnz361] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Guidelines recommend that clinicians make decisions about opioid tapering for patients with chronic pain using a benefit-to-harm framework and engaging patients. Studies have not examined clinician documentation about opioid tapering using this framework. DESIGN AND SETTING Thematic and content analysis of clinician documentation about opioid tapering in patients' medical records in a large academic health system. METHODS Medical records were reviewed for patients aged 18 or older, without cancer, who were prescribed stable doses of long-term opioid therapy between 10/2015 and 10/2016 then experienced an opioid taper (dose reduction ≥30%) between 10/2016 and 10/2017. Inductive thematic analysis of clinician documentation within six months of taper initiation was conducted to understand rationale for taper, and deductive content analysis was conducted to determine the frequencies of a priori elements of a benefit-to-harm framework. RESULTS Thematic analysis of 39 patients' records revealed 1) documented rationale for tapering prominently cited potential harms of continuing opioids, rather than observed harms or lack of benefits; 2) patient engagement was variable and disagreement with tapering was prominent. Content analysis found no patients' records with explicit mention of benefit-to-harm assessments. Benefits of continuing opioids were mentioned in 56% of patients' records, observed harms were mentioned in 28%, and potential harms were mentioned in 90%. CONCLUSIONS In this study, documentation of opioid tapering focused on potential harms of continuing opioids, indicated variable patient engagement, and lacked a complete benefit-to-harm framework. Future initiatives should develop standardized ways of incorporating a benefit-to-harm framework and patient engagement into clinician decisions and documentation about opioid tapering.
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Affiliation(s)
- Michele Buonora
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York
| | - Hector R Perez
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York
| | - Jordan Stumph
- Department of Physical Medicine and Rehabilitation, New York-Presbyterian Columbia/Cornell, New York, New York
| | - Robert Allen
- Department of Emergency Medicine, SUNY Downstate Medical Center, Brooklyn, New York
| | - Shadi Nahvi
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York
| | - Chinazo O Cunningham
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York
| | - Jessica S Merlin
- Center for Research on Healthcare, Divisions of General Internal Medicine and Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Joanna L Starrels
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York
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Ramírez-Maestre C, López-Martínez AE, Esteve R. Predictive variables of prescription opioid misuse in patients with chronic noncancer pain. Development of a risk detection scale: A registered report protocol. PLoS One 2021; 16:e0251586. [PMID: 33984037 PMCID: PMC8118327 DOI: 10.1371/journal.pone.0251586] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 04/29/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Opioid therapy is utilized for a broad range of chronic pain conditions. Several studies have highlighted the adverse effects of opioid medication due to the misuse of these drugs. The gradual increase in the use of opioids has become a global phenomenon and is generating social concern. Several treatment guidelines have strongly recommended assessing the risks and benefits of pharmacological treatment with opioids. These guidelines also recommend the psychological assessment of patients with chronic noncancer pain in order to make informed decisions on the advisability of intervention with opioids. Some authors have emphasized the relevance of assessing the risk of opioid misuse in patients with noncancer chronic pain before initiating treatment. METHODS AND ANALYSIS Two studies will be conducted, each with a different primary objective. The primary objective of the first study (Study 1) will be to conduct a comprehensive investigation to identify the factors most closely associated with subsequent opioid misuse; and based on the results of Study 1, the primary objective of the second study (Study 2) will be to develop a brief, reliable, valid, and useful instrument that would enable health care providers to make decisions on opioid prescription and on the required level of monitoring and follow-up. These decisions would have positive consequences for patient wellbeing. Study 1 will include a logistic regression analysis to test the hypothetical model. Study 2 will have a longitudinal design and include three assessment sessions in order to develop a measure to assess the risk of prescribed opioid misuse and to analyse its reliability and validity. Participants will be individuals with chronic noncancer pain attending three Pain Units. These individuals will either be undergoing pharmacological treatment that includes opioid analgesics (Study 1, N = 400) or are going to commence such treatment (Study 2, N = 250).
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Affiliation(s)
- Carmen Ramírez-Maestre
- Universidad de Málaga, Facultad de Psicología, Andalucía Tech, Málaga, Spain
- Instituto de Investigación Biomédica de Málaga, Málaga, Spain
| | - Alicia E. López-Martínez
- Universidad de Málaga, Facultad de Psicología, Andalucía Tech, Málaga, Spain
- Instituto de Investigación Biomédica de Málaga, Málaga, Spain
| | - Rosa Esteve
- Universidad de Málaga, Facultad de Psicología, Andalucía Tech, Málaga, Spain
- Instituto de Investigación Biomédica de Málaga, Málaga, Spain
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20
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Vitzthum LK, Riviere P, Sheridan P, Nalawade V, Deka R, Furnish T, Mell LK, Rose B, Wallace M, Murphy JD. Predicting Persistent Opioid Use, Abuse, and Toxicity Among Cancer Survivors. J Natl Cancer Inst 2021; 112:720-727. [PMID: 31754696 DOI: 10.1093/jnci/djz200] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 09/08/2019] [Accepted: 09/27/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Although opioids play a critical role in the management of cancer pain, the ongoing opioid epidemic has raised concerns regarding their persistent use and abuse. We lack data-driven tools in oncology to understand the risk of adverse opioid-related outcomes. This project seeks to identify clinical risk factors and create a risk score to help identify patients at risk of persistent opioid use and abuse. METHODS Within a cohort of 106 732 military veteran cancer survivors diagnosed between 2000 and 2015, we determined rates of persistent posttreatment opioid use, diagnoses of opioid abuse or dependence, and admissions for opioid toxicity. A multivariable logistic regression model was used to identify patient, cancer, and treatment risk factors associated with adverse opioid-related outcomes. Predictive risk models were developed and validated using a least absolute shrinkage and selection operator regression technique. RESULTS The rate of persistent opioid use in cancer survivors was 8.3% (95% CI = 8.1% to 8.4%); the rate of opioid abuse or dependence was 2.9% (95% CI = 2.8% to 3.0%); and the rate of opioid-related admissions was 2.1% (95% CI = 2.0% to 2.2%). On multivariable analysis, several patient, demographic, and cancer and treatment factors were associated with risk of persistent opioid use. Predictive models showed a high level of discrimination when identifying individuals at risk of adverse opioid-related outcomes including persistent opioid use (area under the curve [AUC] = 0.85), future diagnoses of opioid abuse or dependence (AUC = 0.87), and admission for opioid abuse or toxicity (AUC = 0.78). CONCLUSION This study demonstrates the potential to predict adverse opioid-related outcomes among cancer survivors. With further validation, personalized risk-stratification approaches could guide management when prescribing opioids in cancer patients.
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Affiliation(s)
- Lucas K Vitzthum
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA.,Center for Precision Radiation Medicine, University of California San Diego, La Jolla, CA
| | - Paul Riviere
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Paige Sheridan
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Vinit Nalawade
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Rishi Deka
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Timothy Furnish
- Department of Family Medicine and Public Health and Division of Pain Medicine, Department of Internal Medicine, University of California San Diego, La Jolla, CA
| | - Loren K Mell
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA.,Center for Precision Radiation Medicine, University of California San Diego, La Jolla, CA
| | - Brent Rose
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA.,Center for Precision Radiation Medicine, University of California San Diego, La Jolla, CA
| | | | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA.,Center for Precision Radiation Medicine, University of California San Diego, La Jolla, CA
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Santana-Pineda MM, Vanlinthout LE, Santana-Ramírez S, Vanneste T, Van Zundert J, Novalbos-Ruiz JP. A Randomized Controlled Trial to Compare Analgesia and Functional Improvement After Continuous Neuroablative and Pulsed Neuromodulative Radiofrequency Treatment of the Genicular Nerves in Patients with Knee Osteoarthritis up to One Year After the Intervention. PAIN MEDICINE 2021; 22:637-652. [PMID: 33179073 DOI: 10.1093/pm/pnaa309] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To compare the analgesic and functional outcomes of continuous neuroablative radiofrequency (CNARF) and pulsed neuromodulative radiofrequency (PNMRF) treatment of genicular nerves up to 1 year after the intervention and to identify predictors associated with a successful outcome (defined as an at least 50% reduction in the pre-interventional visual analog scale [VAS] rating) after genicular radiofrequency treatment. DESIGN A prospective randomized controlled trial. SETTING The Pain Department of the Jerez de la Frontera University Hospital, Cadíz, Spain, from January 2018 until May 2019. SUBJECTS Patients with grade 3-4 gonarthritis suffering from knee pain, with a VAS score ≥5 for >6 months. METHODS Eligible participants were randomly assigned to receive either CNARF or PNMRF of the superior medial, superior lateral, and inferior medial genicular nerves. The VAS and Western Ontario and McMaster Universities Osteoarthritis (WOMAC) scores were assessed before and at 1, 6, and 12 months after treatment. Medication use was quantified before and at 6 months after the intervention. Potential characteristics associated with the efficacy of radiofrequency intervention were explored by using multivariable statistical models. RESULTS A total of 188 participants were included. The magnitude and duration of beneficial effect and reduction in analgesic use were significantly greater in the CNARF group. Success at 6 months after radiofrequency treatment decreased with grade 4 gonarthritis; higher pre-interventional VAS score; and concomitant depression, anxiety disorder, and diabetes mellitus. CONCLUSIONS Therapeutic efficacy and reduction in analgesic consumption were superior after CNARF. Treatment success at 6 months after radiofrequency intervention decreased with more severe gonarthritis; higher pre-interventional pain intensity; and concomitant depression, anxiety disorder, and diabetes mellitus.
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Affiliation(s)
- María M Santana-Pineda
- Department of Anesthesiology and Pain Medicine, University Hospital Campus Jerez de la Frontera, University of Cadíz, Cadíz, Spain
| | - Luc E Vanlinthout
- Department of Anesthesiology and Pain Medicine, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium.,Interuniversity Institute for Biostatistics and Statistical Bioinformatics (I-BIOSTAT), Universities of Leuven and Hasselt, Leuven and Diepenbeek, Belgium
| | - Samuel Santana-Ramírez
- Department of Orthopedics and Traumatology, University Hospital Campus Jerez de la Frontera, University of Cadíz, Cadíz, Spain
| | - Thibaut Vanneste
- Multidisciplinary Pain Centre at the Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Jan Van Zundert
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre, Maastricht, The Netherlands.,Multidisciplinary Pain Centre at the Ziekenhuis Oost-Limburg , Genk, Belgium
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Coyne KS, Barsdorf AI, Brooks A, Mazière JY, Pierson RF, Butler SF, Schnoll SH. Establishing the content validity of the Prescription Opioid Misuse and Abuse Questionnaire (POMAQ) among chronic pain patients. Curr Med Res Opin 2021; 37:505-514. [PMID: 33331184 DOI: 10.1080/03007995.2020.1865891] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Content validation is essential in the development of patient-reported instruments to ensure relevancy and understandability. The aim was to evaluate patient understanding of the Prescription Opioid Misuse and Abuse Questionnaire (POMAQ) using cognitive interviewing among adults with chronic moderate to severe pain. METHODS This qualitative study involved a one-time in-clinic visit to conduct one-on-one cognitive interviews among participants with chronic moderate to severe pain from four groups: (1) Known Opioid Abuse; (2) Known Abuse of Other Substances (e.g. alcohol, benzodiazepines); (3) Opioid Non-abuse; and (4) No Chronic Opioid Use. Patients were recruited from 6 US clinical centers. Concept elicitation questions regarding misuse and abuse were asked at interview start; the POMAQ was completed via a web interface followed by a cognitive interview regarding POMAQ items and response options. RESULTS 56 patients were enrolled. Mean age was 48.7 ± 12.3 years; 57% female; 80% Caucasian; mean duration of chronic pain was 11.2 ± 8.2 years with lower back pain predominating at 75%. Overall, the POMAQ was well-understood and received positive feedback. A few (n = 6, 11%) expressed concerns about completing the POMAQ using a secure internet site as they either indicated they were not computer savvy (n = 3, 5%) or were concerned about internet security (n = 3, 5%). Minor wording modifications were made to the POMAQ to enhance clarity and understanding of the POMAQ. CONCLUSIONS The POMAQ demonstrated content validity among patients with moderate to severe chronic pain and is undergoing psychometric evaluation among a larger cohort of patients.
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Affiliation(s)
- Karin S Coyne
- Patient-centered Research, Evidera, Bethesda, MD, USA
| | | | - Anne Brooks
- Patient-centered Research, Evidera, Bethesda, MD, USA
| | | | - Renee F Pierson
- Global Patient-Reported Outcomes, Janssen, Inc, Titusville, NJ, USA
| | | | - Sidney H Schnoll
- Pharmaceutical Risk Management Services, Pinney Associates, Inc, Bethesda, MD, USA
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23
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Furlan AD, Harvey AM, Chadha R. Warning from Canada: Latin America, South Africa and India may face an opioid epidemic in the coming years. J Glob Health 2021; 10:010324. [PMID: 32257147 PMCID: PMC7101494 DOI: 10.7189/jogh.10.010324] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Affiliation(s)
- Andrea D Furlan
- Institute for Work & Health, Toronto ON, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Alexandra M Harvey
- Munk School of Global Affairs, University of Toronto, Toronto, Ontario, Canada
| | - Rashmi Chadha
- Vancouver Coastal Health, Vancouver, British Columbia, Canada.,Department of Family Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Jantarada C, Silva C, Guimarães-Pereira L. Prevalence of Problematic Use of Opioids in Patients with Chronic Noncancer Pain: A Systematic Review with Meta-analysis. Pain Pract 2021; 21:715-729. [PMID: 33528858 DOI: 10.1111/papr.13001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 01/05/2021] [Accepted: 01/28/2021] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Cláudia Jantarada
- Department of Anesthesiology, Centro Hospitalar de São João, Porto, Portugal
| | - Catarina Silva
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Luís Guimarães-Pereira
- Department of Anesthesiology, Centro Hospitalar de São João, Porto, Portugal.,Faculty of Medicine, University of Porto, Porto, Portugal
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25
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Savaskan E, Fuchs A, Hemmeter U, Ibach B, Indermaur E, Klöppel S, Laimbacher S, Leyhe T, Lötscher C, Popp J, Stauch T, Wiesbeck G, Wopfner A, Zullino D. [Recommendations for the Prevention, Diagnostics and Therapy of Addiction Disorders in the Elderly]. PRAXIS 2021; 110:79-93. [PMID: 33530782 DOI: 10.1024/1661-8157/a003609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Recommendations for the Prevention, Diagnostics and Therapy of Addiction Disorders in the Elderly Abstract. Although the chronic consumption of alcohol and sedatives, and increasingly opioids, represents a major problem in old age with consequential damage for those affected, little attention has been paid to the substance abuse disorders in old age. The aim of the present recommendations, a collaboration work of the Swiss Society for Geriatric Psychiatry and Psychotherapy (SGAP), Swiss Nurses Association (SBK) and Swiss Society of Addiction Medicine (SSAM), is to summarize the current state of knowledge in prevention, diagnostics and therapy of substance abuse disorders in old age for an interprofessional clinical team. They are intended to help strengthen prevention and early diagnosis, and consciously emphasize psychotherapy and nursing intervention options.
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Affiliation(s)
- Egemen Savaskan
- Schweizerische Gesellschaft für Alterspsychiatrie und -psychotherapie (SGAP), Bern
- Klinik für Alterspsychiatrie, Psychiatrische Universitätsklinik Zürich
| | | | - Ulrich Hemmeter
- Schweizerische Gesellschaft für Alterspsychiatrie und -psychotherapie (SGAP), Bern
- Psychiatrie St. Gallen Nord, St. Gallen
| | - Bernd Ibach
- Zentrum für Alterspsychiatrie und Privé, Clienia Littenheid AG, Littenheid
| | - Esther Indermaur
- Schweizer Berufsverband für Pflegefachpersonal (SBK), Bern
- Spitex Zürich Limmat AG, Zürich
- Akademische Fachgesellschaft Psychiatrische Pflege und Gerontologie
| | - Stefan Klöppel
- Schweizerische Gesellschaft für Alterspsychiatrie und -psychotherapie (SGAP), Bern
- Universitätsklinik für Alterspsychiatrie und Psychotherapie, Universitäre Psychiatrische Dienste Bern
| | - Sabrina Laimbacher
- Schweizer Berufsverband für Pflegefachpersonal (SBK), Bern
- Berner Fachhochschule, Angewandte Forschung und Entwicklung Pflege
- Akademische Fachgesellschaft Psychiatrische Pflege und Gerontologie
| | - Thomas Leyhe
- Schweizerische Gesellschaft für Alterspsychiatrie und -psychotherapie (SGAP), Bern
- Zentrum für Alterspsychiatrie, Universitäre Psychiatrische Kliniken Basel und Alterspsychiatrie, Universitäre Altersmedizin, Felix Platter, Basel
| | - Claudia Lötscher
- Schweizer Berufsverband für Pflegefachpersonal (SBK), Bern
- Universitäre Psychiatrische Kliniken Basel
- Akademische Fachgesellschaft Psychiatrische Pflege und Gerontologie
| | - Julius Popp
- Klinik für Alterspsychiatrie, Psychiatrische Universitätsklinik Zürich
| | - Tilo Stauch
- Universitätsklinik für Alterspsychiatrie und Psychotherapie, Universitäre Psychiatrische Dienste Bern
| | - Gerhard Wiesbeck
- Schweizerische Gesellschaft für Suchtmedizin (SSAM), Bern
- Universitäre Psychiatrische Kliniken Basel
| | - Alexander Wopfner
- Schweizerische Gesellschaft für Suchtmedizin (SSAM), Bern
- Klinik Südhang, Kirchlindach
| | - Daniele Zullino
- Schweizerische Gesellschaft für Suchtmedizin (SSAM), Bern
- Service d'addictologie, Hôpitaux Universitaires de Genève, Genf
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26
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McMillin GA, Johnson-Davis KL, Kelly BN, Scott B, Yang YK. Impact of the Opioid Epidemic on Drug Testing. Ther Drug Monit 2021; 43:14-24. [PMID: 33230043 DOI: 10.1097/ftd.0000000000000841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 10/20/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND This review provides a description of how the opioid epidemic has impacted drug testing. METHODS Four major service areas of drug testing were considered, including emergency response, routine clinical care, routine forensics, and death investigations. RESULTS Several factors that the opioid epidemic has impacted in drug testing are discussed, including specimens, breadth of compounds recommended for testing, time to result required for specific applications, analytical approaches, interpretive support requirements, and examples of published practice guidelines. CONCLUSIONS Both clinical and forensic laboratories have adapted practices and developed new testing approaches to respond to the opioid epidemic. Such changes are likely to continue evolving in parallel with changes in both prescription and nonprescription opioid availability and use patterns, as well as emerging populations that are affected by the "waves" of the opioid epidemic.
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Affiliation(s)
| | | | - Brian N Kelly
- Department of Pathology, University of Utah and ARUP Laboratories; and
| | | | - Yifei K Yang
- Department of Pathology, University of Utah and ARUP Laboratories; and
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27
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Kuntz JL, Dickerson JF, Schneider JL, Firemark AJ, Papajorgji-Taylor D, Slaughter M, Reese KR, Thorsness LA, Sullivan MD, Debar LL, Smith DH. Factors associated with opioid-tapering success: A mixed methods study. J Am Pharm Assoc (2003) 2021; 61:248-257.e1. [PMID: 33485815 DOI: 10.1016/j.japh.2020.12.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/15/2020] [Accepted: 12/21/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Opioid tapering is recommended when risks of chronic opioid use outweigh benefits. Little is known about patient characteristics or factors related to tapering success. We sought to identify characteristics that predict a 50% reduction in opioid use and qualitatively characterize factors that impact tapering success. METHODS We used multilevel hierarchical modeling to identify predictors of a 50% reduction in opioid use among Kaiser Permanente Northwest patients who underwent pharmacist-led tapering between 2012 and 2017. We conducted qualitative interviews among patients and pharmacists to identify factors influencing tapering success. RESULTS We identified 1384 patients who, on average, were dispensed 207 milligram morphine equivalents per day at baseline. After 12 months, 56% of patients reduced their opioid use by 50%. Increased odds of 50% reduction were associated with younger age 21-49 years (Odds ratio [OR] 1.32, P = 0.004); previous surgery (OR 2.24, P < 0.001); increased number of Addiction Medicine encounters (OR 1.25, P = 0.011); substance use disorder (OR 1.62, P = 0.001); anxiety (OR 1.32, P = 0.003); non-narcotic analgesic (OR 1.22, P = 0.025) or antipsychotic medication use (OR 1.53, P = 0.006); and opioid days supplied in the previous year (OR 1.08, P < 0.001). Patients and pharmacists noted that success was influenced by patients' willingness or resistance to change opioid use, the level of patient engagement achieved through communication with their provider, aspects of the tapering process such as pace, and external factors including health issues or caregiving responsibilities. CONCLUSIONS Over one-half of patients who underwent tapering reduced their opioid use by 50%. Patient demographic and clinical characteristics were predictive of tapering success; however, patients and pharmacists noted that patient willingness, motivation, and personal circumstances also influence tapering outcome. Opioid tapering requires an individualized approach. Both clinical factors and personal circumstances should be considered when opioid tapering is being discussed as a possible solution for a patient.
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28
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Riviere P, Vitzthum LK, Nalawade V, Deka R, Furnish T, Mell LK, Rose BS, Wallace M, Murphy JD. Validation of an oncology-specific opioid risk calculator in cancer survivors. Cancer 2020; 127:1529-1535. [PMID: 33378556 DOI: 10.1002/cncr.33410] [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: 05/05/2020] [Revised: 10/19/2020] [Accepted: 11/25/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Clinical guidelines recommend that providers risk-stratify patients with cancer before prescribing opioids. Prior research has demonstrated that a simple cancer opioid risk score might help identify to patients with cancer at the time of diagnosis with a high likelihood of long-term posttreatment opioid use. This current project validates this cancer opioid risk score in a generalizable, population-based cohort of elderly cancer survivors. METHODS This study identified 44,932 Medicare beneficiaries with cancer who had received local therapy. Longitudinal opioid use was ascertained from Medicare Part D data. A risk score was calculated for each patient, and patients were categorized into low-, moderate-, and high-risk groups on the basis of the predicted probability of persistent opioid use. Model discrimination was assessed with receiver operating characteristic curves. RESULTS In the study cohort, 5.2% of the patients were chronic opioid users 1 to 2 years after the initiation of cancer treatment. The majority of the patients (64%) were at low risk and had a 1.2% probability of long-term opioid use. Moderate-risk patients (33% of the cohort) had a 5.6% probability of long-term opioid use. High-risk patients (3.5% of the cohort) had a 75% probability of long-term opioid use. The opioid risk score had an area under the receiver operating characteristic curve of 0.869. CONCLUSIONS This study found that a cancer opioid risk score could accurately identify individuals with a high likelihood of long-term opioid use in a large, generalizable cohort of cancer survivors. Future research should focus on the implementation of these scores into clinical practice and how this could affect prescriber behavior and patient outcomes. LAY SUMMARY A novel 5-question clinical decision tool allows physicians treating patients with cancer to accurately predict which patients will persistently be using opioid medications after completing therapy.
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Affiliation(s)
- Paul Riviere
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California
| | - Lucas K Vitzthum
- Department of Radiation Oncology, Stanford Medicine, Stanford, California
| | - Vinit Nalawade
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California
| | - Rishi Deka
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California
| | - Timothy Furnish
- Division of Pain Medicine, Department of Anesthesiology, University of California San Diego, La Jolla, California
| | - Loren K Mell
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California.,Center for Precision Radiation Medicine, University of California San Diego, La Jolla, California
| | - Brent S Rose
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California.,Center for Precision Radiation Medicine, University of California San Diego, La Jolla, California
| | - Mark Wallace
- Division of Pain Medicine, Department of Anesthesiology, University of California San Diego, La Jolla, California
| | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California.,Center for Precision Radiation Medicine, University of California San Diego, La Jolla, California
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29
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Smith RG. Mitigating the opioid crisis for the lower extremity provider opioid stewardship programs. Foot (Edinb) 2020; 45:101708. [PMID: 33049426 DOI: 10.1016/j.foot.2020.101708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 06/04/2019] [Accepted: 06/18/2020] [Indexed: 02/04/2023]
Abstract
Opioids are an effective form of analgesia for pain treatment. Over prescribing of opioids agents have becom;1;e detrimental to the United States' public health. One of the most difficult challenges for any prescriber is to balance the potential benefits versus the potential risks of opioid prescribing. Addressing the opioid crisis requires an interprofessional team approach. The utilization of an opioid stewardship program provides the necessary frame work to identify gaps in the in quality and development in the implementation of a change of long standing opioid culture and practice. These programs address opioid prescribing, treatment for opioid use disorder, educational initiatives, and the use of information technology. A few acronyms have been created to assist providers to guide them when prescribing opioids. The purpose of this article is to explore the central theme of responsible opioid pain management. It will introduce, define, and defend with clinical base evidence a proposed acronym "MORPHINE" to assist and help shape prescription opioid strategies used for lower extremity pain. Implications for practicing lower extremity providers need to acknowledge the potential harm that prescribing opioids may cause to their patients. Opioid stewardship principles should become a priority in podiatric medicine and podiatric surgery.
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Affiliation(s)
- Robert G Smith
- Shoe String Podiatry, 723 Lucerne Circle, Ormond Beach, Florida 32174, USA
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30
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Comerci G, Marr L, Finlay E. End Stage Chronic Pain (ESCP): Naming Complex Suffering in the Opioid Crisis Era. Am J Hosp Palliat Care 2020; 38:1078-1082. [PMID: 33124436 DOI: 10.1177/1049909120969623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The "opioid crisis" stemming from overprescribing of prescription opioids describes an iatrogenic situation which has resulted in a rise in opioid use disorder (OUD) and overdose deaths. Many of these patients suffer from chronic non-cancer pain syndromes (CNCP) who have been injudiciously treated with opioids. Some patients with CNCP are treated successfully with opioids in accordance with modern guidelines. There is a very complex, small group of patients with CNCP who require higher than recommended dosages of opioids when other modalities and treatments have failed. We describe such a patient and believe that there is a subset of patients with unremitting suffering from chronic pain which we have called end-stage chronic pain (ESCP). These patients, despite receiving expert chronic pain care, often require high doses of opioids and suffer a dramatic decline in quality of life (QOL), function and an increase in their suffering when their opioids are tapered or discontinued. We have responded to the treatment of this group of patients by critically examining our approach to the use of opioids for their pain and attempting to reconcile high dose opioids in the setting of the Center for Disease Control (CDC) guidelines. We describe a patient with severe chronic pain from congenital spinal disease who experienced increased pain and suffering when his opioids were tapered. We will discuss our approach to this patient and in doing so discuss the concept of ESCP and proposed criteria for the use of high dose opioids in such patients.
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Affiliation(s)
- George Comerci
- 1104University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Lisa Marr
- Division of Palliative Care, 1104University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Esme Finlay
- Division of Palliative Care, 1104University of New Mexico School of Medicine, Albuquerque, NM, USA
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31
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Telford A. Role of the nurse in supporting the safe use of opioids. Nurs Stand 2020; 35:77-82. [PMID: 32875753 DOI: 10.7748/ns.2020.e11534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2020] [Indexed: 06/11/2023]
Abstract
Opioids are powerful analgesics that are derived from the opium poppy plant. They are recognised as central in the management of acute pain and cancer pain, but concerns about long-term use have resulted in recommendations that they should be used with caution in the management of chronic pain. Opioids have associated side effects and risks, but these may be exaggerated and some healthcare professionals can be unnecessarily cautious and withhold the use of opioids, even in cases where these medicines may be beneficial. It is important that nurses understand the pharmacology, side effects and risks of opioids, so they can ensure these medicines are administered safely.
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Affiliation(s)
- Angela Telford
- Freeman Hospital, The Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, England
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32
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Buonora M, Perez HR, Heo M, Cunningham CO, Starrels JL. Race and Gender Are Associated with Opioid Dose Reduction Among Patients on Chronic Opioid Therapy. PAIN MEDICINE 2020; 20:1519-1527. [PMID: 30032197 DOI: 10.1093/pm/pny137] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Among patients with chronic pain, risk of opioid use is elevated with high opioid dose or concurrent benzodiazepine use. This study examined whether these clinical factors, or sociodemographic factors of race and gender, are associated with opioid dose reduction. DESIGN AND SETTING A retrospective cohort study of outpatients prescribed chronic opioid therapy between 2007 and 2012 within a large, academic health care system in Bronx, New York, using electronic medical record data. Included patients were prescribed a stable dose of chronic opioid therapy over a one-year "baseline period" and did not have cancer. METHODS The primary outcome was opioid dose reduction (≥30% reduction from baseline) within two years. Multivariable logistic regression tested the associations of two clinical variables (baseline daily opioid dose and concurrent benzodiazepine prescription) and two sociodemographic variables (race/ethnicity and gender) with opioid dose reduction. RESULTS Of 1,097 patients, 463 (42.2%) had opioid dose reduction. High opioid dose (≥100 morphine-milligram equivalents [MME]) was associated with lower odds of opioid dose reduction compared with an opioid dose <100 MME (adjusted odds ratio [AOR] = 0.69, 95% confidence interval [CI] = 0.54-0.89). Concurrent benzodiazepine prescription was not associated with opioid dose reduction. Black (vs white) race and female (vs male) gender were associated with greater odds of opioid dose reduction (AOR = 1.82, 95% CI = 1.22-2.70; and AOR = 1.43, 95% CI = 1.11-1.83, respectively). CONCLUSIONS Black race and female gender were associated with greater odds of opioid dose reduction, whereas clinical factors of high opioid dose and concurrent benzodiazepine prescription were not. Efforts to reduce opioid dose should target patients based on clinical factors and address potential biases in clinical decision-making.
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Affiliation(s)
| | - Hector R Perez
- Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
| | - Moonseong Heo
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Chinazo O Cunningham
- Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
| | - Joanna L Starrels
- Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
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Liberman JS, D'Agostino McGowan L, Greevy RA, Morrow JA, Griffin MR, Roumie CL, Grijalva CG. Mental health conditions and the risk of chronic opioid therapy among patients with rheumatoid arthritis: a retrospective veterans affairs cohort study. Clin Rheumatol 2020; 39:1793-1802. [PMID: 32036583 PMCID: PMC7337604 DOI: 10.1007/s10067-020-04955-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 01/12/2020] [Accepted: 01/22/2020] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Patients with rheumatoid arthritis (RA) often receive opioid analgesics for pain management. We examined the association between mental health conditions and the risk of chronic opioid therapy. METHODS A retrospective cohort of veterans with RA initiating opioid use was assembled using Veterans Health Administration databases (2001-2012). Mental health conditions included anxiety (N = 1108, 12.9%), depression (N = 1912, 22.2%), bipolar disease (N = 131, 1.5%), and post-traumatic stress disorder (N = 768, 8.9%) and were identified by ICD coded diagnoses and use of specific medications. Cohort members were followed from opioid initiation through chronic opioid therapy, defined as the continuous availability of opioids for at least 90 days. Multivariable Cox proportional hazard regression models assessed the association between mental health conditions and chronic opioid therapy accounting for relevant covariates. Subgroup analyses examined whether the strength of the observed association varied by the duration of the initial opioid prescription. RESULTS We identified 14,767 patients with RA with 22,452 episodes of opioid use initiation. Mental health conditions were identified in 8607 (38.3%) patients. Compared with patients without mental health conditions, patients with mental health conditions have a higher risk of developing chronic opioid therapy (469.3 vs 378.1 per 1000 person-years, adjusted hazard ratio [aHR] 1.18, 95% CI 1.09, 1.29). The increased risk was highest for those with a history of opioid use disorder (aHR 1.94, 95% CI 1.09, 3.46) and also elevated for those with other substance use disorders (aHR 1.35, 95% CI 1.05, 1.73). Duration of the initial opioid prescription was independently associated with chronic opioid therapy, regardless of the estimated opioid daily dose. CONCLUSIONS History of mental health conditions and duration of the initial opioid prescription were associated with an increased risk of chronic opioid therapy among patients with RA.Key Points• Approximately a third of patients with RA are exposed to opioid analgesics.• Patients with RA and history of mental health disease, especially substance use disorders, who initiate opioid use have an increased risk of chronic opioid therapy.• This study provides insight in an underrepresented population of mainly male patients with RA.
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Affiliation(s)
- Justin S Liberman
- Veteran Affairs Administration Tennessee Valley VA Health Care System Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA.
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Lucy D'Agostino McGowan
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Robert A Greevy
- Veteran Affairs Administration Tennessee Valley VA Health Care System Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - James A Morrow
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Marie R Griffin
- Veteran Affairs Administration Tennessee Valley VA Health Care System Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christianne L Roumie
- Veteran Affairs Administration Tennessee Valley VA Health Care System Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Carlos G Grijalva
- Veteran Affairs Administration Tennessee Valley VA Health Care System Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA
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Friedman BW, Ochoa LA, Naeem F, Perez HR, Starrels JL, Irizarry E, Chertoff A, Bijur PE, Gallagher EJ. Opioid Use During the Six Months After an Emergency Department Visit for Acute Pain: A Prospective Cohort Study. Ann Emerg Med 2020; 75:578-586. [PMID: 31685253 PMCID: PMC7188578 DOI: 10.1016/j.annemergmed.2019.08.446] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 08/16/2019] [Accepted: 08/22/2019] [Indexed: 10/25/2022]
Abstract
STUDY OBJECTIVE Despite the frequent use of opioids to treat acute pain, the long-term risks and analgesic benefits of an opioid prescription for an individual emergency department (ED) patient with acute pain are still poorly understood and inadequately quantified. Our objective was to determine the frequency of recurrent or persistent opioid use during the 6 months after the ED visit METHODS: This was a prospective, observational cohort study of opioid-naive patients presenting to 2 EDs for acute pain who were prescribed an opioid at discharge. Patients were followed by telephone 6 months after the ED visit. Additionally, we reviewed the statewide prescription monitoring program database. Outcomes included frequency of recurrent and persistent opioid use and frequency of persistent moderate or severe pain 6 months after the ED visit. Persistent opioid use was defined as filling greater than or equal to 6 prescriptions during the 6-month study period. RESULTS During 9 months beginning in November 2017, 733 patients were approached for participation. Four hundred eighty-four met inclusion criteria and consented to participate. Four hundred ten patients (85%) provided 6-month telephone data. The prescription monitoring database was reviewed for all 484 patients (100%). Most patients (317/484, 66%; 95% confidence interval 61% to 70%) filled only the initial prescription they received in the ED. One in 5 patients (102/484, 21%; 95% confidence interval 18% to 25%) filled at least 2 prescriptions within the 6-month period. Five patients (1%; 95% confidence interval 0% to 2%) met criteria for persistent opioid use. Of these 5 patients, all but 1 reported moderate or severe pain in the affected body part 6 months later. CONCLUSION Although 1 in 5 opioid-naive ED patients who received an opioid prescription for acute pain on ED discharge filled at least 2 opioid prescriptions in 6 months, only 1% had persistent opioid use. These patients with persistent opioid use were likely to report moderate or severe pain 6 months after the ED visit.
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Affiliation(s)
- Benjamin W Friedman
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY.
| | - Lorena Abril Ochoa
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Farnia Naeem
- Medical College, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Hector R Perez
- Division of General Internal Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Joanna L Starrels
- Division of General Internal Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Eddie Irizarry
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Andrew Chertoff
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - Polly E Bijur
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
| | - E John Gallagher
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
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35
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Carrell DS, Albertson-Junkans L, Ramaprasan A, Scull G, Mackwood M, Johnson E, Cronkite DJ, Baer A, Hansen K, Green CA, Hazlehurst BL, Janoff SL, Coplan PM, DeVeaugh-Geiss A, Grijalva CG, Liang C, Enger CL, Lange J, Shortreed SM, Von Korff M. Measuring problem prescription opioid use among patients receiving long-term opioid analgesic treatment: development and evaluation of an algorithm for use in EHR and claims data. J Drug Assess 2020; 9:97-105. [PMID: 32489718 PMCID: PMC7241518 DOI: 10.1080/21556660.2020.1750419] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 03/17/2020] [Indexed: 11/04/2022] Open
Abstract
Objective Opioid surveillance in response to the opioid epidemic will benefit from scalable, automated algorithms for identifying patients with clinically documented signs of problem prescription opioid use. Existing algorithms lack accuracy. We sought to develop a high-sensitivity, high-specificity classification algorithm based on widely available structured health data to identify patients receiving chronic extended-release/long-acting (ER/LA) therapy with evidence of problem use to support subsequent epidemiologic investigations. Methods Outpatient medical records of a probability sample of 2,000 Kaiser Permanente Washington patients receiving ≥60 days’ supply of ER/LA opioids in a 90-day period from 1 January 2006 to 30 June 2015 were manually reviewed to determine the presence of clinically documented signs of problem use and used as a reference standard for algorithm development. Using 1,400 patients as training data, we constructed candidate predictors from demographic, enrollment, encounter, diagnosis, procedure, and medication data extracted from medical claims records or the equivalent from electronic health record (EHR) systems, and we used adaptive least absolute shrinkage and selection operator (LASSO) regression to develop a model. We evaluated this model in a comparable 600-patient validation set. We compared this model to ICD-9 diagnostic codes for opioid abuse, dependence, and poisoning. This study was registered with ClinicalTrials.gov as study NCT02667262 on 28 January 2016. Results We operationalized 1,126 potential predictors characterizing patient demographics, procedures, diagnoses, timing, dose, and location of medication dispensing. The final model incorporating 53 predictors had a sensitivity of 0.582 at positive predictive value (PPV) of 0.572. ICD-9 codes for opioid abuse, dependence, and poisoning had a sensitivity of 0.390 at PPV of 0.599 in the same cohort. Conclusions Scalable methods using widely available structured EHR/claims data to accurately identify problem opioid use among patients receiving long-term ER/LA therapy were unsuccessful. This approach may be useful for identifying patients needing clinical evaluation.
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Affiliation(s)
- David S Carrell
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | - Arvind Ramaprasan
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Grant Scull
- Kaiser Permanente Washington, Seattle, WA, USA
| | | | - Eric Johnson
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - David J Cronkite
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | - Kris Hansen
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Carla A Green
- Kaiser Permanente Center for Health Research Northwest Region, Portland, OR, USA
| | - Brian L Hazlehurst
- Kaiser Permanente Center for Health Research Northwest Region, Portland, OR, USA
| | - Shannon L Janoff
- Kaiser Permanente Center for Health Research Northwest Region, Portland, OR, USA
| | | | | | | | | | | | - Jane Lange
- The Fred Hutchison Cancer Research Center, Seattle, WA, USA
| | - Susan M Shortreed
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Michael Von Korff
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
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Kuntz JL, Schneider JL, Firemark AJ, Dickerson JF, Papajorgji-Taylor D, Reese KR, Hamer TA, Marsh D, Thorsness LA, Sullivan MD, Debar LL, Smith DH. A Pharmacist-Led Program to Taper Opioid Use at Kaiser Permanente Northwest: Rationale, Design, and Evaluation. Perm J 2020; 24:19.216. [PMID: 33196429 DOI: 10.7812/tpp/19.216] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Primary care practitioners (PCPs) are concerned about adverse effects and poor outcomes of opioid use but may find opioid tapering difficult because of a lack of pain management training or time constraints limiting patient counseling. In 2010, Kaiser Permanente Northwest implemented a pharmacist-led opioid tapering program-Support Team Onsite Resource for Management of Pain (STORM)-to address high rates of opioid use, alleviate PCPs' workload demands, and improve patient outcomes. OBJECTIVE To describe the rationale, structure, and delivery of this unique pharmacist-led program, which partners with PCPs and provides individualized care to help patients reduce opioid use, and the Facilitating Lower Opioid Amounts through Tapering study, which examines the program's effectiveness, cost-effectiveness, and implementation. RESULTS The STORM program includes a pain medicine physician, a social worker or nurse, and pharmacists who have received specialized clinical and communications training. The program has a 2-fold role: 1) to provide PCP education about pain management and opioid use and 2) to offer clinician and patient support with opioid tapering and pain management. After program training, PCPs are equipped to discuss the need for tapering with a patient and to refer to the program. Program pharmacists provide a range of services, including opioid taper plans, nonopioid pain management recommendations, and taper-support outreach to patients. DISCUSSION The STORM program provides individualized care to assist patients with opioid tapering while reducing the burden on PCPs. CONCLUSION The STORM program may be a valuable addition to health care systems and settings seeking options to address their patients' opioid tapering needs.
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Affiliation(s)
- Jennifer L Kuntz
- Kaiser Permanente Northwest Center for Health Research, Portland, OR
| | | | - Alison J Firemark
- Kaiser Permanente Northwest Center for Health Research, Portland, OR
| | - John F Dickerson
- Kaiser Permanente Northwest Center for Health Research, Portland, OR
| | | | - Katherine R Reese
- Kaiser Permanente Northwest Clinical Pharmacy Services, Portland, OR
| | - Traci A Hamer
- Kaiser Permanente Northwest Clinical Pharmacy Services, Portland, OR
| | - Darlene Marsh
- Kaiser Permanente Northwest Clinical Pharmacy Services, Portland, OR
| | - Lou Ann Thorsness
- Kaiser Permanente Northwest Clinical Pharmacy Services, Portland, OR
| | - Mark D Sullivan
- Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA
| | - Lynn L Debar
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - David H Smith
- Kaiser Permanente Northwest Center for Health Research, Portland, OR
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Finkelman MD, Jamison RN, Kulich RJ, Butler SF, Smits N, Weiner SG. A Comparison of Short Forms of the Screener and Opioid Assessment for Patients With Pain – Revised (SOAPP-R). EUROPEAN JOURNAL OF PSYCHOLOGICAL ASSESSMENT 2020. [DOI: 10.1027/1015-5759/a000519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Abstract. The Screener and Opioid Assessment for Patients with Pain – Revised (SOAPP-R) is a 24-item self-report questionnaire that assesses risk of aberrant medication-related behavior among chronic pain patients. Recently, an 8-item version of the SOAPP-R that weights items differentially was proposed. However, no previous study had compared the 8-item form with other short versions of the SOAPP-R, including a static 12-item short form and computer-based versions customizing the test length to the individual respondent. Moreover, no prior research had investigated combining the 8-item short form with customized computer-based stopping rules to further enhance efficiency. The objectives of this study were to compare the 8-item version with previously recommended short forms of the SOAPP-R, and to develop and evaluate a new version of the SOAPP-R combining the 8-item version with computer-based stopping rules. Versions were compared via sensitivity, specificity, and mean test length using real-data simulation of three datasets. Although results varied across datasets, the 8-item SOAPP-R compared favorably to previously recommended forms. Combining the 8-item form with computer-based stopping rules reduced the mean test length without affecting sensitivity or specificity; thus, the combined approach is recommended. The methodology used to shorten questionnaires via computer-based testing can also be applied to other instruments.
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Affiliation(s)
- Matthew D. Finkelman
- Department of Public Health and Community Service, Tufts University School of Dental Medicine, Boston, MA, USA
| | - Robert N. Jamison
- Departments of Anesthesiology and Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Ronald J. Kulich
- Craniofacial Pain and Headache Center, Tufts University School of Dental Medicine, Boston, MA, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Niels Smits
- Department of Methods and Statistics, Research Institute of Child Development and Education, University of Amsterdam, The Netherlands
| | - Scott G. Weiner
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Patterns of Prescription Opioid Use in Women With Endometriosis: Evaluating Prolonged Use, Daily Dose, and Concomitant Use With Benzodiazepines. Obstet Gynecol 2020; 133:1120-1130. [PMID: 31135725 PMCID: PMC6553518 DOI: 10.1097/aog.0000000000003267] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To examine opioid use, opioid prescribing patterns, and timing of the first opioid prescription in endometriosis patients compared with matched women in the control group without endometriosis. METHODS We conducted a retrospective analysis of the Clinformatics Datamart database. Women diagnosed with endometriosis from January 2006 through December 2016 and aged 18-49 years were compared with women in the control group matched on age, region, race, insurance payer, and plan type. Key outcomes included: filled prescription for an opioid, multiple opioid prescriptions, number of days' supply, daily dose (morphine milligram equivalents), and concomitant opioid and benzodiazepine prescriptions. Cohorts were descriptively analyzed using t- and χ statistics and multivariable regression analyses yielded adjusted relative risk (RR) ratios and 95% CI. RESULTS The study sample included 53,847 endometriosis patients and 107,694 patients in the control group. The mean age was 38 years, 62.4% of patients were white, and 51.6% lived in the South. Women in the endometriosis case group, compared with women in the control group, were more likely to fill an opioid prescription (42,705 [79.3%] women in the case group vs 26,106 [24.2%] women in the control group; adjusted RR ratio 2.91; 2.87-2.94), had higher likelihood of filling prescriptions with a dose of 50 morphine milligram equivalents or more (24,544 [45.6%] vs 10,463 [9.7%]; adjusted RR ratio 4.07; 3.98-4.16) or 100 morphine milligram equivalents or more (8,013 [14.9%] vs 3,582 [3.3%]; adjusted RR ratio 3.56; 3.43-3.70). Women in the case group were more likely to have concomitant opioid and benzodiazepine prescriptions (5,453 [10.1%] vs 3,711 [3.5%]; adjusted RR ratio 1.95; 1.88-2.03) and to have used these drugs concurrently for at least 30 days (1,596 [3.0%] vs 1,265 [1.2%]; adjusted RR ratio 1.43; 1.34-1.52) or at least 90 days (875 [1.6%] vs 777 [0.7%]; adjusted RR ratio 1.27; 1.17-1.37). Similar results were obtained after excluding opioid prescriptions received during a 30-day postsurgery window. CONCLUSION Women with endometriosis had higher probabilities of prolonged use of opioids and concomitant use with benzodiazepines compared with women without this condition. FUNDING SOURCE This study was funded by AbbVie, Inc.
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Abstract
Urine drug test (UDT) is an effective tool used in chronic opioid therapy to ensure patient adherence to treatment and detect nonmedical opioid use. The two main types of UDT used in routine clinical practice are the screening tests or immunoassays and the confirmatory tests or laboratory-based specific drug identification tests such as gas chromatography-mass spectrometry, liquid chromatography-mass spectrometry, or tandem mass spectrometry. UDT produces objective data on some nonmedical opioid use that may otherwise go undetected, such as the use of undisclosed medications, the nonuse of prescribed medications, and the use of illegal drugs. It allows clinicians to initiate an open and effective conversation about nonmedical opioid use with their patients. However, the test has certain limitations that sometimes compromise its use. Its interpretation can be challenging to clinicians because of the complexity of the opioid metabolic pathways. Clear guidelines or recommendations regarding the use of UDT in cancer pain is limited. As a result, UDT appears to be underused among patients with cancer pain receiving opioid therapy. More studies are needed to help standardize the integration and use of UDT in routine cancer pain management. IMPLICATIONS FOR PRACTICE: Despite its potential benefits, urine drug testing (UDT) appears to be underused among patients with cancer pain receiving opioid therapy. This is partly because its interpretation can be challenging owing to the complexity of the opioid metabolic pathways. Information regarding the use of UDT in opioid therapy among patients with cancer is limited. This review article will improve clinician proficiency in UDT interpretation and assist oncologists in developing appropriate treatment plans during chronic opioid therapy.
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Affiliation(s)
- Joseph A. Arthur
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson CancerHoustonTexasUSA
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Opioid treatment for acute and chronic pain in patients with sickle cell disease. Neurosci Lett 2020; 714:134534. [DOI: 10.1016/j.neulet.2019.134534] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 09/13/2019] [Accepted: 10/01/2019] [Indexed: 12/24/2022]
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Edmonds KP, Saunders IM, Willeford A, Ajayi TA, Atayee RS. Emerging Challenges to the Safe and Effective Use of Methadone for Cancer-Related Pain in Paediatric and Adult Patient Populations. Drugs 2019; 80:115-130. [PMID: 31820362 DOI: 10.1007/s40265-019-01234-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Methadone continues to be an important medication for the treatment of paediatric and adult cancer-related pain. Appropriate patient selection to ensure safe and effective treatment by a team of clinicians who appreciate and are familiar with methadone and its unique pharmacology is crucial. Unlike morphine and other more common opioids, methadone is purported to have involvement with delta-opioid receptor and higher affinity as an N-methyl-D-aspartate-receptor antagonist. Clinically this gives it the advantage of being effective for both nociceptive and neuropathic pain, but also may be useful in the setting of tolerance to other opioids. Methadone also comes in multiple available formulations that can be administrated through a variety of routes beyond the oral route. Challenges with methadone in treating cancer-related pain include drug interactions specifically as it relates to new targeted cancer therapies. Recent guidelines recommend electrocardiogram monitoring with methadone and there is potential for additive cardiac toxicity in the oncology setting. Appropriate dosing of methadone for pain management given age, organ dysfunction, and patients who are on methadone maintenance therapy are also key factors. This article aims to provide clinicians with evidence and clinical practice guidelines for safe and appropriate use of methadone including indication, initiation, and monitoring given its complexity for management of pain in the dynamic oncology setting.
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Affiliation(s)
- Kyle P Edmonds
- Doris A. Howell Palliative Care Teams, University of California San Diego, La Jolla, CA, 92093, USA
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, 92093, USA
| | - Ila M Saunders
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, 92093, USA
- Department of Pharmacy, University of California San Diego Health, La Jolla, CA, USA
| | - Andrew Willeford
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, 92093, USA
- Department of Pharmacy, University of California San Diego Health, La Jolla, CA, USA
| | - Toluwalase A Ajayi
- Digital Medicine, Scripps Research Translational Institute, La Jolla, CA, 92037, USA
| | - Rabia S Atayee
- Doris A. Howell Palliative Care Teams, University of California San Diego, La Jolla, CA, 92093, USA.
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, 92093, USA.
- Department of Pharmacy, University of California San Diego Health, La Jolla, CA, USA.
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Nelson DA, Bjarnadóttir MV, Wolcott VL, Agarwal R. Stated Pain Levels, Opioid Prescription Volume, and Chronic Opioid Use Among United States Army Soldiers. Mil Med 2019; 183:e322-e329. [PMID: 29590410 DOI: 10.1093/milmed/usy026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 01/10/2018] [Accepted: 02/06/2018] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION The use of opioids has increased drastically over the past few years and decades. As a result, concerns have mounted over serious outcomes associated with chronic opioid use (COU), including dependency and death. A greater understanding of the factors that are associated with COU will be critical if prescribers are to navigate potentially competing objectives to provide compassionate care, while reducing the overall opioid use problem. In this study, we study pain levels and opioid prescription volumes and their effects on the risk of COU.This study leveraged passive data sources that support automated decision support systems (DSSs) currently employed in a large military population. The models presented compute monthly, person-specific, adjusted probability of subsequent COT and could potentially provide critical decision support for clinicians engaged in pain management. MATERIALS AND METHODS The study population included all outpatient presentations at military medical facilities worldwide among active duty United States Army soldiers during July 2011 to September 2014 (17,664,006 encounters; population N = 552,193). We conducted a retrospective cohort study of this population and employed longitudinal data and a discrete time multivariable logistic regression model to compute COT probability scores. The contribution of pain scores and opioid prescription quantities to the probability of COT represented analytic foci. RESULTS There were 13,891 subjects (2.5%) who experienced incident COT during the observed time period. Statistically significant interactions between pain scores and prescription quantity were present, in addition to effects of multiple other control variables. Counts of monthly opioid prescriptions and maximum stated pain scores per month were each positively associated with COT. A wide range in individual COT risk scores was evident. The effect of prescription volume on the COT risk was larger than the effect of the pain score, and the combined effect of larger pain scores and increased prescription quantity was moderated by the interaction term. CONCLUSIONS The results verified that passive data on the US Army can support a robust COT risk computation in this population. The individual, adjusted risk level requires statistical analyses to be fully understood. Because the same data sources drive current military DSSs, this work provides the potential basis for new, evidence-based decision support resources for military clinicians. The strong, independent impact of increasing opioid prescription counts on the COT risk reinforces the importance of exploring alternatives to opioids in pain management planning. It suggests that changing provider behavior through enhanced decision support could help reduce COT rates.
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Affiliation(s)
- D Alan Nelson
- Department of Medicine, Stanford University School of Medicine, 450 Serra Mall, Bldg 20, Stanford, CA
| | - Margrét V Bjarnadóttir
- Decision, Operations & Information Technologies, Robert H. Smith School of Business, University of Maryland, College Park, MD
| | - Vickee L Wolcott
- United Services Automobile Association (USAA), 10750 McDermott Fwy, San Antonio, TX.,Robert H. Smith School of Business, University of Maryland, College Park, MD
| | - Ritu Agarwal
- Robert H. Smith School of Business, University of Maryland, College Park, MD
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Acuña JP. RIESGO DE ADICCIÓN A ANALGÉSICOS OPIOIDES EN EL TRATAMIENTO DE DOLOR CRÓNICO NO ONCOLÓGICO. REVISTA MÉDICA CLÍNICA LAS CONDES 2019. [DOI: 10.1016/j.rmclc.2019.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Using Analgesics for Emotional Modulation is Associated With Increased Distress, Depression, and Risk of Opioid and Alcohol Misuse: Initial Evaluation and Component Analysis of the Reasons for Analgesic Use Measure (RAUM). Clin J Pain 2019; 34:975-982. [PMID: 29697475 DOI: 10.1097/ajp.0000000000000621] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES It is important to identify aspects of analgesic use that are associated with harm in chronic pain. Historically, the focus has been patterns of use (eg, overuse). This study evaluated another aspect of use-rather than evaluating how analgesics were being used, the primary interest was in why they were being used. METHODS In total, 334 analgesic using individuals with chronic pain responded to a pool of items assessing reasons for analgesic use. Measures of pain intensity, distress, depression, and opioid and alcohol misuse were also completed. RESULTS Exploratory factor analyses indicated 3 overarching reasons for use, including taking analgesics: (1) for pain reduction/functional improvement; (2) for emotional modulation/sedation; and (3) to be compliant with prescriber instructions. Correlation and regression analyses indicated that the second factor had the strongest relations with the other measures used, such that greater endorsement of analgesic use for emotional modulation was associated with greater distress, depression, and opioid and alcohol misuse. Using analgesics for pain reduction/functional improvement was associated with greater pain-related distress and depression. Using analgesics to be compliant was not associated with any measure. This pattern of results was generally replicated when a subsample of 131 individuals taking opioids was examined. DISCUSSION Results support the utility of examining reasons for analgesic use; use to achieve emotional modulation/sedation may be particularly associated with risk. The data also provide support for the questionnaire developed, the Reasons for Analgesic Use Measure.
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Singh S, Prasad S, Bhatnagar S, Lal R, Choudhary N, Sahi MS. A Cross-Sectional Web-Based Survey of Medical Practitioners in India to Assess their Knowledge, Attitude, Prescription Practices, and Barriers toward Opioid Analgesic Prescriptions. Indian J Palliat Care 2019; 25:567-574. [PMID: 31673214 PMCID: PMC6812418 DOI: 10.4103/ijpc.ijpc_83_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
CONTEXT Inadequate training of medical practitioners is a key factor responsible for inappropriate use of opioid analgesics. AIMS We assessed the current knowledge, attitude, prescribing practices, and barriers perceived by the Indian medical practitioners in three tertiary care hospitals toward the use of opioid analgesics. SUBJECTS AND METHODS Web-based survey of registered medical practitioner employed at three chosen tertiary health care institutions in New Delhi. STATISTICAL ANALYSIS USED Descriptive analysis of survey responses was carried out. Comparative analysis was done using Chi-square test, independent samples t-test, and Pearson correlation coefficient. RESULTS The response rate was 10.4% (n = 308). Two-thirds of the participants (61.7%) had never received formal pain management training, and 86.7% participants would like further training. Most participants (71.1%) agreed that opioids should be prescribed in cancer pain, while 26.3% agreed that opioids should be prescribed in noncancer pain. Half of the participants agreed that SOS (if necessary) dosing schedule (48.4%), low dosage (61.7%), and short duration of use (51.4%) could decrease the harmful effect of opioids. Lack of information about opioid-related policies and addiction potential were identified as the most common barriers to prescribing opioids. Those seeing more patients with chronic noncancer pain come across opioid misuse and diversion more often (P = 0.02). Those who understood addiction were more likely to agree that patients of chronic cancer pain with substance use disorders should be prescribed opioid analgesics (P < 0.01). CONCLUSIONS Indian medical practitioners felt the need for formal pain management training. There is a lack of consensus on how to manage the pain using opioid analgesics. Tough regulations on medical and scientific use of opioids are the most commonly reported barrier to prescribing them.
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Affiliation(s)
- Shalini Singh
- Department of Psychiatry, Institute of Liver and Biliary Sciences, Dr. B.R.A IRCH, AIIMS, New Delhi, India
| | - Shiv Prasad
- Department of Psychiatry, Lady Hardinge Medical College, Dr. B.R.A IRCH, AIIMS, New Delhi, India
| | - Sushma Bhatnagar
- Department of Onco-Anaesthesia and Palliative Medicine, Dr. B.R.A IRCH, AIIMS, New Delhi, India
| | - Rakesh Lal
- National Drug Dependence Treatment Centre, AIIMS, New Delhi, India
| | - Nandan Choudhary
- Department of Onco-Anaesthesia and Palliative Medicine, Dr. B.R.A IRCH, AIIMS, New Delhi, India
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Gardner RA, Brewer KL, Langston DB. Predicting opioid use disorder in patients with chronic pain who present to the emergency department. Inj Prev 2019; 25:386-391. [DOI: 10.1136/injuryprev-2018-042723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 03/20/2018] [Accepted: 03/25/2018] [Indexed: 11/03/2022]
Abstract
BackgroundEmergency department (ED) patients with chronic pain challenge providers to make quick and accurate assessments without an in-depth pain management consultation. Emergency physicians need reliable means to determine which patients may receive opioid therapy without exacerbating opioid use disorder (OUD).MethodsEighty-nine ED patients with a chief complaint of chronic pain were enrolled. Researchers administered questionnaires and reviewed medical and state prescription monitoring database information. Participants were classified as either OUD or non-OUD. Statistical analysis included a bivariate analysis comparing differences between groups and multivariate logistic regression evaluating ORs.ResultsThe 45 participants categorised as OUD had a higher proportion of documented or reported psychiatric diagnoses (p=0.049), preference of opioid treatment (p=0.005), current oxycodone prescription (p=0.043), borrowed pain medicine (p=0.004) and non-authorised dose increase (p<0.001). The state prescription monitoring database revealed the OUD group to have an increased number of opioid prescriptions (p=0.005) and pills (p=0.010). Participants who borrowed pain medicine and engaged in non-authorised dose increase were 5.2 (p=0.025, 95% CI 1.24 to 21.9) and 6.1 times (p=0.001, 95% CI 1.55 to 24.1) more likely to have OUD, respectively.LimitationsMajor limitations of our study include a small sample size, self-reported measures and convenience sample which may introduce selection bias.ConclusionPatients with chronic pain with OUD have distinguishable characteristics. Emergency physicians should consider such evidence-based variables prior to opioid therapy to ameliorate the opioid crisis and limit implicit bias.
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Bechara A, Berridge KC, Bickel WK, Morón JA, Williams SB, Stein JS. A Neurobehavioral Approach to Addiction: Implications for the Opioid Epidemic and the Psychology of Addiction. Psychol Sci Public Interest 2019; 20:96-127. [PMID: 31591935 PMCID: PMC7001788 DOI: 10.1177/1529100619860513] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Two major questions about addictive behaviors need to be explained by any worthwhile neurobiological theory. First, why do people seek drugs in the first place? Second, why do some people who use drugs seem to eventually become unable to resist drug temptation and so become "addicted"? We will review the theories of addiction that address negative-reinforcement views of drug use (i.e., taking opioids to alleviate distress or withdrawal), positive-reinforcement views (i.e., taking drugs for euphoria), habit views (i.e., growth of automatic drug-use routines), incentive-sensitization views (i.e., growth of excessive "wanting" to take drugs as a result of dopamine-related sensitization), and cognitive-dysfunction views (i.e., impaired prefrontal top-down control), including those involving competing neurobehavioral decision systems (CNDS), and the role of the insula in modulating addictive drug craving. In the special case of opioids, particular attention is paid to whether their analgesic effects overlap with their reinforcing effects and whether the perceived low risk of taking legal medicinal opioids, which are often prescribed by a health professional, could play a role in the decision to use. Specifically, we will address the issue of predisposition or vulnerability to becoming addicted to drugs (i.e., the question of why some people who experiment with drugs develop an addiction, while others do not). Finally, we review attempts to develop novel therapeutic strategies and policy ideas that could help prevent opioid and other substance abuse.
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Affiliation(s)
- Antoine Bechara
- Department of Psychology, University of Southern California
- Brain and Creativity Institute, University of Southern California
| | | | - Warren K. Bickel
- Addiction Recovery Research Center & Center for Transformational Research on Health Behaviors, Fralin Biomedical Research Institute at Virginia Tech Carilion, Roanoke, Virginia
| | - Jose A. Morón
- Department of Anesthesiology, Washington University School of Medicine
- Washington University Pain Center, Washington University School of Medicine
| | - Sidney B. Williams
- Department of Anesthesiology, Washington University School of Medicine
- Washington University Pain Center, Washington University School of Medicine
| | - Jeffrey S. Stein
- Addiction Recovery Research Center & Center for Transformational Research on Health Behaviors, Fralin Biomedical Research Institute at Virginia Tech Carilion, Roanoke, Virginia
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Ruiz-López D, Alonso-Babarro A. Consumo de opioides en la Comunidad de Madrid (España) entre 2004 y 2014. Rev Clin Esp 2019; 219:367-374. [DOI: 10.1016/j.rce.2019.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 02/06/2019] [Accepted: 02/09/2019] [Indexed: 10/27/2022]
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Witham G, Yarwood G, Wright S, Galvani S. An ethical exploration of the narratives surrounding substance use and pain management at the end of life: a discussion paper. Nurs Ethics 2019; 27:1344-1354. [PMID: 31526085 PMCID: PMC7406987 DOI: 10.1177/0969733019871685] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
This discussion article examines narrative positioning related to pain management for people who use substances at the end of life. We explore how dominant narrative genres associated with biomedicine, such as ‘restitution’ and narratives common within the context of drug services such as ‘recovery’ can hinder effective pain management within this population. We argue that these discourses can marginalise the ethical self-identity of patients who use substances at the end of life. It can also trouble health and social care professionals in supporting patients and generating counter-narratives that challenge those often associated with substance use. Stigma is a common experience for this population with stereotyping as ‘junkies’ and associated with criminality. They are positioned as drug-seeking, and this requires more surveillance at the end of life when opioid therapy is potentially more available and authorised. This can make it challenging to generate ‘companion’ stories that are positive and maintain moral adequacy. Dominant biomedical narrative genres often prevent the recognition of the fractured stories that people using substances can often present with. This can lead to narrative silencing and to the under treatment of pain. The person’s self-identity is invested in narratives of recovery, and opioid use symbolises their addicted past because for practitioners, this population is at clinical risk with the potential for drug seeking behaviours. Whilst not requiring formal ethical review this discussion paper was constructed in accordance with good scientific practice with the work of other researchers respected and cited appropriately.
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