Higher Prescription Opioid Dose is Associated With Worse Patient-Reported Pain Outcomes and More Health Care Utilization

Do veterans with risky substance use (RSU) use distinct pain treatment modalities?

BACKGROUND AND OBJECTIVES

Risky substance use (RSU) is common among people with chronic pain and is associated with worse pain treatment outcomes. Nonopioid treatment is recommended, but it is unknown whether people with RSU use different or fewer pain treatment modalities. This study describes use of different pain treatments by veterans with and without RSU and those receiving versus not receiving opioid medication.

METHODS

Veterans (N = 924) who filed service-connected disability claims related to musculoskeletal conditions and rated their pain four or higher on the Numeric Rating Scale, reported on 25 different pain services in the preceding 90 days. Recent RSU was identified via Alcohol, Smoking, and Substance Involvement Test (ASSIST) cutoffs and/or nail sample toxicology.

RESULTS

Overall, RSU was not associated with number of provider-delivered or self-delivered pain modalities. Over-the-counter medications (71%), self-structured exercise (69%), and nonopioid prescription medications (38%) were the most used modalities. Veterans receiving prescribed opioids (8.4%) were more likely to see primary care, receive injections, and attend exercise and/or meditation classes, compared to those without opioid prescriptions.

DISCUSSION AND CONCLUSIONS

Opioid and nonopioid pain treatment utilization did not differ based on RSU, and those prescribed opioids were more likely to engage in other nonopioid pain treatments. Regardless of RSU, veterans appear willing to try provider-delivered (58%) and self-delivered (79%) pain treatment.

SCIENTIFIC SIGNIFICANCE

In this first-ever evaluation of 25 different pain treatment modalities among veterans with and without RSU, people with RSU did not use less treatment modalities.

The Development of an Opioid Misuse Training Program for Physical Therapists: A Learning Community Approach

INTRODUCTION

Musculoskeletal pain and opioid misuse frequently co-occur.

REVIEW OF THE LITERATURE

The US Preventive Services Task Force calls for all health care providers to be trained to screen for misuse and/or opioid use disorder. The purpose of this study was to develop and implement an opioid misuse training program that could be used by physical therapists.

SUBJECTS

Thirteen practicing physical therapists were invited to participate in a curriculum development project.

METHODS

Using the Curriculum Framework, a collaborative learning approach was used to develop an opioid misuse training program and training manual for physical therapists. Four training sessions were provided virtually every 2 weeks. Topics included an introduction to the opioid crisis, screening, assessing, and communicating with patients and with the health care team about opioid misuse. Each didactic session was followed by a participant feedback session where participants provided recommendations on improving the training content and their impressions on the barriers and facilitators to incorporating the training into practice. A companion training manual was created and sent to participants for comment. Participants were asked over email to describe whether and how they incorporated training materials into clinical practice during the training curriculum.

RESULTS

All participants attended sessions 1-3. Twelve (92.3%) attended the fourth session. Based on the participants' feedback, training sessions were edited, and a companion training manual was finalized and distributed to each participant. After the fourth session, 9 participants (69.2%) reported using what they learned in the training. During the participant feedback sessions, participants regarded the training as important. Some participants expressed barriers to discussing opioids with patients and concerns about whether the training was within physical therapists' scope of practice.

DISCUSSION AND CONCLUSION

An iteratively developed training program for physical therapists to address opioid misuse was acceptable, feasible, and provided immediate practice change by most participants.

Opioid therapy trajectories of patients with chronic non-cancer pain over 1 year of follow-up after initiation of short-acting opioid formulations

OBJECTIVE

This study compared opioid utilization trajectories of persons initiating tramadol, short-acting hydrocodone, or short-acting oxycodone, and it characterized opioid dose trajectories and type of opioid in persistent opioid therapy subsamples.

METHODS

A retrospective cohort study of adults with chronic non-cancer pain who were initiating opioid therapy was conducted with the IQVIA PharMetrics® Plus for Academics data (2008-2018). Continuous enrollment was required for 6 months before ("baseline") and 12 months after ("follow-up") the first opioid prescription ("index date"). Opioid therapy measures were assessed every 7 days over follow-up. Group-based trajectory modeling (GBTM) was used to identify trajectories for any opioid and total morphine milligram equivalent measures, and longitudinal latent class analysis was used for opioid therapy type.

RESULTS

A total of 40 276 tramadol, 141 023 hydrocodone, and 45 221 oxycodone initiators were included. GBTM on any opioid therapy identified 3 latent trajectories: early discontinuers (tramadol 39.0%, hydrocodone 54.1%, oxycodone 61.4%), late discontinuers (tramadol 37.9%, hydrocodone 39.4%, oxycodone 33.3%), and persistent therapy (tramadol 6.7%, hydrocodone 6.5%, oxycodone 5.3%). An additional fourth trajectory, intermittent therapy (tramadol 16.4%), was identified for tramadol initiators. Of those on persistent therapy, 2687 individuals were on persistent therapy with tramadol, 9169 with hydrocodone, and 2377 with oxycodone. GBTM on opioid dose resulted in 6 similar trajectory groups in each persistent therapy group. Longitudinal latent class analysis on opioid therapy type identified 6 latent classes for tramadol and oxycodone and 7 classes for hydrocodone.

CONCLUSION

Opioid therapy patterns meaningfully differed by the initial opioid prescribed, notably the presence of intermittent therapy among tramadol initiators and higher morphine milligram equivalents and prescribing of long-acting opioids among oxycodone initiators.

Changes in Pain Among Housed and Unhoused U.S. Veterans After Receiving Battlefield Acupuncture at One Medical Center

This study reports on 54 homeless and 53 stably housed veterans who received battlefield acupuncture (BFA) between September 2018 and October 2022. Linear mixed-effects regressions were used to examine change in overall pain score and how pain impacted four areas: (1) activity, (2) sleep, (3) mood, and (4) stress over the course of 8 weeks from the baseline visit at one BFA clinic. Results indicated significant reductions in the impact of pain on activity, sleep, and stress among both homeless and housed veterans. Although overall pain levels were not significantly impacted, further research on the impact of BFA on homeless populations is warranted.

Pain medication misuse in the South African spinal cord injury context

Background

Pain after spinal cord injury (SCI) is debilitating and has been reported to be difficult to treat, despite pharmacological interventions. Pain medication misuse (PMM) and associated individual factors among people with spinal cord injury (PWSCI) are scarce.

Aim

To determine PMM and the associated factors in PWSCI.

Setting

Homes of community-dwelling manual wheelchair users with SCI in South Africa.

Methods

Community-dwelling PWSCI (n = 122) were consecutively sampled and the Pain Medication Questionnaire (PMQ) was used to determine PMM. Descriptive statistics, Fisher's exact test, independent t-tests, and simple linear regression tests were performed using SPSS v27. Testing was conducted at the 0.05 level of significance.

Results

Eighty-five per cent of the participants reported the presence of pain and 48.1% of them used pain medication. Forty-four percent of people who used pain medication scored ≥ 30, indicative of serious aberrant drug-taking behaviours. Opioids were mainly used for neuropathic pain and in combination with other types of medications such as anticonvulsants and non-steroidal anti-inflammatories (44.0%). Pain severity and the type of pain medication were found to be predictors of PMM (p < 0.01 respectively).

Conclusion

Pain relief after SCI remains difficult to achieve, with an evident high risk of PMM, which may lead to long-lasting side effects, dependency, or overdose.

Contribution

This study has shown the need for the assessment of the potential risk of dependency before prescribing pain medication, particularly opioids to PWSCI.

Adverse Events of the Long-Term Use of Opioids for Chronic Non-cancer Pain: A Narrative Review

BACKGROUND

The long-term use of opioids for chronic non-cancer pain (CNCP) has drawn more attention and debate. Although opioids are frequently used to treat chronic pain, their effectiveness and safety over extended periods are still unknown.

OBJECTIVES

The purpose of this review is to provide an overview of what is currently known about the adverse events of long-term use of opioids in CNCP. It also delivers patient-centered strategies designed to mitigate these risks.

METHODS

We conducted a literature search in PubMed, MEDLINE, EMBASE, and Web of Science databases. Search terms included CNCP, pain pathophysiology, opioid pharmacodynamics, opioid prescribing trends, guidelines for opioid use, and opioid side effects.  Results: Our review highlights that while opioids may provide short-term relief from CNCP, their effectiveness diminishes over time due to the development of opioid tolerance. This tolerance often leads to increased dosages, which can subsequently result in opioid dependence. Additionally, long-term opioid therapy is associated with a spectrum of adverse effects, including constipation, drowsiness, respiratory depression, and potential for drug interactions. Furthermore, our review indicates that alternative pain management strategies play a crucial role in controlling CNCP. They offer significant benefits with fewer adverse events. These strategies include non-opioid medications, physical therapy, cognitive-behavioral therapy (CBT), various interventional procedures, injection therapy, and acupuncture.

CONCLUSION

Using opioids to manage CNCP presents several challenges. Given these challenges, alternative treatments are being considered as viable options. Moreover, it is crucial to customize treatment plans to align with the patients' specific health requirements, existing conditions, and potential risks to ensure the best possible outcomes.

The Roles of Endogenous Opioids in Placebo and Nocebo Effects: From Pain to Performance to Prozac

Placebo and nocebo effects have been well documented for nearly two centuries. However, research has only relatively recently begun to explicate the neurobiological underpinnings of these phenomena. Similarly, research on the broader social implications of placebo/nocebo effects, especially within healthcare delivery settings, is in a nascent stage. Biological and psychosocial outcomes of placebo/nocebo effects are of equal relevance. A common pathway for such outcomes is the endogenous opioid system. This chapter describes the history of placebo/nocebo in medicine; delineates the current state of the literature related to placebo/nocebo in relation to pain modulation; summarizes research findings related to human performance in sports and exercise; discusses the implications of placebo/nocebo effects among diverse patient populations; and describes placebo/nocebo influences in research related to psychopharmacology, including the relevance of endogenous opioids to new lines of research on antidepressant pharmacotherapies.

Pain catastrophizing, pain anxiety, and substance use among Black individuals with chronic pain who use opioids

OBJECTIVE

Substance use is the leading cause of preventable deaths in the U.S. Chronic pain is associated with risky substance use. Black individuals experience substantial disparities in pain and substance use outcomes and treatment. Maladaptive psychological reactions to chronic pain, such as pain catastrophizing and pain anxiety, can increase substance use among White individuals. However, no research to date has tested this among Black individuals. This study is the first to test the relationships between pain catastrophizing, pain anxiety, and substance use among Black individuals with chronic pain who use opioid medications.

METHOD

Black adults with chronic pain who use opioids (N = 401) completed online measures of pain catastrophizing (Brief Pain Catastrophizing Scale); pain anxiety (Pain Anxiety Symptom Scale Short Form-20); risky use of alcohol, tobacco, e-cigarettes, cannabis and opioids (Alcohol, Smoking and Substance Involvement Screening Test); and opioid dependence (Severity of Dependence Scale). We conducted zero-inflated and hierarchical regressions to test associations between pain catastrophizing, pain anxiety and substance use (risky use; general use vs. nonuse) above that of demographics, pain intensity and pain interference.

RESULTS

Pain catastrophizing was uniquely associated with risky use of all substances (βs = .03-.09, ps < .001-.02), opioid dependence (β = .13, SE = .05, p = .01), and use (vs. nonuse) of tobacco, alcohol and opioids (βs = .07-.11, ps < .001-.02). Pain anxiety was uniquely associated with tobacco use (vs. nonuse; β = -.02, SE = .01, p = .04) and severity of opioid dependence (β = .21, SE = .01, p < .001).

CONCLUSION

Pain catastrophizing and, to a lesser degree, pain anxiety may be useful intervention targets for this underserved and understudied population. Addressing them may help reduce additional health complications and costs associated with substance use-related risk and dependence. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Dose Changes for Long-term Opioid Patients Following a State Opioid Prescribing Policy

BACKGROUND

In 2018, Nevada implemented opioid prescribing legislation (AB474) to support the uptake of CDC pain care guidelines. We studied the law's association with doses over threshold levels of morphine milligram equivalents (MMEs) and with time to dose increases and decreases, among long-term opioid patients.

METHODS

A difference-in-difference study examined dosing changes across opioid prescription episodes (ie, prescriptions within 30 day and within the same dosing threshold). Patients with at least 120 days supply over 6 months in Nevada and Colorado Medicaid pharmacy claims were included. Using a logistic regression model, we compare the predicted probabilities that opioid episodes exceeded 50 MME before and after implementation of the law, in both states. Adjusted hazard ratios (aHR) from a gap time survival model estimated time to escalate above 50 MME among low-dose episodes (<50 MME), and time to de-escalate below 50 MME among high-dose episodes (≥50 MME).

RESULTS

Among 453,577 episodes (74,292 patients), the Nevada law was associated with a 2.9% reduction in prescriptions over 50 MME (95% CI: -3.5, -2.3) compared with Colorado. While the law was also associated with slower escalation (Nevada: aHR = 0.75; 95% CI: 0.72, 0.77, Colorado: aHR = 1.04; 95% CI: 1.01, 1.06), it was also associated with slower de-escalation (Nevada: aHR = 0.87; 95% CI: 0.84, 0.89, Colorado: aHR = 0.97; 95% CI: 0.96, 0.99).

CONCLUSIONS

Slower dose escalations, rather than faster dose de-escalation, likely explain post-law reductions in doses over 50 MME. Slower dose de-escalations may be due to longer days supply post-policy.

The Effectiveness of a Mindfulness-Based Intervention Integrated with Physical Therapy (MIND-PT) for Postsurgical Rehabilitation After Lumbar Surgery: A Protocol for a Randomized Controlled Trial as Part of the Back Pain Consortium (BACPAC) Research Program

BACKGROUND

Improving pain management for persons with chronic low back pain (LBP) undergoing surgery is an important consideration in improving patient-centered outcomes and reducing the risk of persistent opioid use after surgery. Nonpharmacological treatments, including physical therapy and mindfulness, are beneficial for nonsurgical LBP through complementary biopsychosocial mechanisms, but their integration and application for persons undergoing surgery for LBP have not been examined. This study (MIND-PT) is a multisite randomized trial that compares an enriched pain management (EPM) pathway that integrates physical therapy and mindfulness vs usual-care pain management (UC) for persons undergoing surgery for LBP.

DESIGN

Participants from military treatment facilities will be enrolled before surgery and individually randomized to the EPM or UC pain management pathways. Participants assigned to EPM will receive presurgical biopsychosocial education and mindfulness instruction. After surgery, the EPM group will receive 10 sessions of physical therapy with integrated mindfulness techniques. Participants assigned to the UC group will receive usual pain management care after surgery. The primary outcome will be the pain impact, assessed with the Pain, Enjoyment, and General Activity (PEG) scale. Time to opioid discontinuation is the main secondary outcome.

SUMMARY

This trial is part of the National Institutes of Health Helping to End Addiction Long-term (HEAL) initiative, which is focused on providing scientific solutions to the opioid crisis. The MIND-PT study will examine an innovative program combining nonpharmacological treatments designed to improve outcomes and reduce opioid overreliance in persons undergoing lumbar surgery.

Changes in self-rated physical and mental health and life satisfaction associated with opioid and potentially inappropriate opioid prescribing in primary care older adults

OBJECTIVE

To examine changes in life satisfaction and physical and mental health associated with opioid and potentially inappropriate opioid prescribing (PIOP) among older adults.

METHODS

Secondary data analysis from the Étude sur la Santé des Aînés (ESA)-Services study. The sample consisted of 945 older adults recruited in primary care with available health survey information linked to administrative medical record data. The exposure of interest was categorized as no prescription, opioid prescription, and PIOP, defined using the Beers criteria. Outcomes were self-rated physical health, mental health, and life satisfaction measured at baseline and at a 3-year follow-up. Generalized estimating equations were used to examine 3-year changes in outcomes as a function of opioid prescribing. Analyses were adjusted for covariates relating to health, psychosocial, and sociodemographic factors as well as duration/frequency of opioid prescribing. Analyses were conducted in the overall sample and in non-cancer patients.

RESULTS

The sample had an average age of 73.1 years; the majority was Canadian-born (96.3%) while females made up over half (55.4%) the sample. Compared to not receiving an opioid prescription, PIOP was associated with a deterioration in physical health (ORadjusted = 0.65; 95%CI = 0.49, 0.86), but not mental health and life satisfaction. In non-cancer patients, PIOP was associated with poorer physical health (ORadjusted = 0.59; 95%CI = 0.40, 0.87) and opioid prescribing was marginally associated with improved life satisfaction (ORadjusted = 1.58; 95%CI = 0.96, 2.60).

CONCLUSION

PIOP was associated with a deterioration in physical health. Patient-centred chronic pain management and the effect on health and well-being require further study in older adults.

Treatment With Opioids Is Not Associated With Poor Outcomes Among Older Adults With Lumbar Spinal Stenosis Receiving Epidural Injections

STUDY DESIGN

Secondary analysis of a randomized controlled trial.

OBJECTIVE

To assess how baseline treatment with opioids is associated with pain and function in older adults with lumbar spinal stenosis who receive epidural injections.

SUMMARY OF BACKGROUND DATA

Data were obtained from the Lumbar Epidural Steroid injections for Spinal Stenosis trial, a double-blind, multisite, randomized controlled trial.

METHODS

Baseline treatment with opioids was assessed from electronic medical record prescription pharmacy data or from health utilization records collected from patients. We calculated adjusted changes in back pain numerical rating scale, leg pain numerical rating scale, and back-related disability (Roland Morris Disability Questionnaire scores) from baseline to three weeks and to six weeks among patients treated and not treated with opioids at baseline using generalized linear regression.

RESULTS

Baseline treatment with opioids was not significantly associated with back pain intensity (adjusted difference in means at three weeks of follow-up between patients treated with opioids at baseline versus not [±95% CI, 0.1 (-0.7, 0.7)], leg pain intensity [-0.2 (-0.9, 0.4)], or back-related function [-0.8 (-2.1, 0.4)]. We found similar results at six weeks of follow-up.

CONCLUSIONS

Among older adults with lumbar spinal stenosis who are receiving epidural injections, those treated with opioids at baseline had similar outcomes to those who were not.

High-dose opioids for chronic non-cancer pain: an overview of Cochrane Reviews

BACKGROUND

This overview was originally published in 2017, and is being updated in 2022.  Chronic pain is typically described as pain on most days for at least three months. Chronic non-cancer pain (CNCP) is any chronic pain that is not due to a malignancy. Chronic non-cancer pain in adults is a common and complex clinical issue, for which opioids are prescribed by some physicians for pain management. There are concerns that the use of high doses of opioids for CNCP lacks evidence of effectiveness, and may increase the risk of adverse events.

OBJECTIVES

To describe the evidence from Cochrane Reviews and overviews regarding the efficacy and safety of high-dose opioids (defined as 200 mg morphine equivalent or more per day) for CNCP.

METHODS

We identified Cochrane Reviews and overviews by searching the Cochrane Database of Systematic Reviews in The Cochrane Library. The date of the last search was 21 July 2022. Two overview authors independently assessed the search results. We planned to analyse data on any opioid agent used at a high dose for two weeks or more for the treatment of CNCP in adults.

MAIN RESULTS

We did not identify any reviews or overviews that met the inclusion criteria. The excluded reviews largely reflected low doses or titrated doses, where all doses were analysed as a single group; we were unable to extract any data for high-dose use only.

AUTHORS' CONCLUSIONS

There is a critical lack of high-quality evidence, in the form of Cochrane Reviews, about how well high-dose opioids work for the management of CNCP in adults, and regarding the presence and severity of adverse events.  No evidence-based argument can be made on the use of high-dose opioids, i.e. 200 mg morphine equivalent or more daily, in clinical practice. Considering that high-dose opioids have been, and are still being used in clinical practice to treat CNCP, knowing about the efficacy and safety of these higher doses is imperative.

Provider knowledge, beliefs, and self‐efficacy to deprescribe opioids and sedative‐hypnotics

BACKGROUND

While many studies have assessed and measured patient attitudes toward deprescribing, less quantitative research has addressed the provider perspective. We thus sought to describe provider knowledge, beliefs, and self-efficacy to deprescribe, with a focus on opioids and sedative-hypnotics.

METHODS

An electronic anonymous survey was distributed to primary care providers at Kaiser Permanente Washington. Two reminder emails were sent. The survey included 10 questions on general deprescribing, and six questions each specific to opioid and sedative-hypnotic deprescribing. Knowledge questions used a multiple-choice response option format. Questions addressing beliefs and self-efficacy (i.e., confidence) used a 0-10 Likert scale. Scales were dichotomized at ≥7 to define agreement (belief questions) or confidence (self-efficacy questions). We calculated descriptive statistics to summarize the responses.

RESULTS

Of 370 eligible primary care providers, 95 (26%) completed the survey. For general deprescribing questions, a majority believed that lack of patient willingness, withdrawal symptoms and fear of symptom return, and time constraints impeded deprescribing. Approximately half chose the correct answers about opioid deprescribing, 21% were confident that they could alleviate patient concerns about opioid tapering, and 32% were confident managing chronic non-cancer pain without opioids. For sedative-hypnotics, 64%-87% of respondents correctly answered questions about risks and the relative effectiveness of alternatives, but only one-third correctly answered a question about sedative-hypnotic tapering. Roughly half were confident in their ability to successfully engage patients in sedative deprescribing conversations and select alternatives. Only 54% and 34% were confident in writing a tapering protocol for opioids and sedative-hypnotics, respectively.

CONCLUSION

Results suggest that raising provider awareness of patient willingness to deprescribe, addressing knowledge gaps, and increasing self-efficacy for deprescribing are important targets for improving deprescribing. Support for writing tapering protocols and prescribing evidence-based drug and non-drug alternatives may be important to improve care.

The effect of long-term opioid use on back-specific disability and health-related quality of life in patients with chronic low back pain

CONTEXT

Opioids are commonly utilized for the treatment of chronic pain. However, research regarding the long-term (≥12 months) outcomes of opioid therapy remains sparse.

OBJECTIVES

This study aims to evaluate the effects of long-term opioid therapy on measures of back-specific disability and health-related quality of life in patients with chronic low back pain.

METHODS

In this retrospective cohort study, patients with chronic low back pain who reported consistent opioid use or abstinence for at least 12 months while enrolled in the Pain Registry for Epidemiological, Clinical, and Interventional Studies and Innovation Pain Research Registry were classified as long-term opioid users or nonusers, respectively. For comparison, intermediate-term and short-term opioid users and nonusers were also identified. Multiple linear regression analysis was performed to compare back-specific disability (Roland-Morris Disability Questionnaire [RMDQ]) and health-related quality of life (29-item Patient-Reported Outcomes Measurement Information System [PROMIS]) between opioid users and nonusers while controlling for pain intensity, depression, age, body mass index (BMI), and eight common comorbid conditions (herniated disc, sciatica, osteoporosis, osteoarthritis, heart disease, hypertension, diabetes, and asthma). Statistically significant findings were assessed for clinical relevance.

RESULTS

There were 96 long-term opioid users and 204 long-term opioid nonusers. After controlling for potential confounders, long-term opioid use was a predictor of worse back-specific disability (adjusted mean difference=2.85, p<0.001), physical function (adjusted mean difference=-2.90, p=0.001), fatigue (adjusted mean difference=4.32, p=0.001), participation in social roles (adjusted mean difference=-4.10, p<0.001), and pain interference (adjusted mean difference=3.88, p<0.001) outcomes. Intermediate-term opioid use was a predictor of worse back-specific disability (adjusted mean difference=2.41, p<0.001), physical function (adjusted mean difference=-2.26, p=0.003), fatigue (adjusted mean difference=3.70, p=0.002), and sleep disturbance outcomes (adjusted mean difference=3.03, p=0.004), whereas short-term opioid use was a predictor of worse back-specific disability (adjusted mean difference=2.42, p<0.001) and physical function outcomes (adjusted mean difference=-1.90, p<0.001).

CONCLUSIONS

The findings of this study are largely consistent with existing literature regarding the outcomes of long-term opioid therapy. Taken in conjunction with the well-established risks of opioid medications, these findings draw into question the utility of long-term opioid therapy for chronic low back pain.

An exploration of primary care healthcare professionals' understanding of pain and pain management following a brief pain science education

BACKGROUND

Persistent pain is a leading cause of disability worldwide yet implementation of clinical guidelines that recommend a biopsychosocial approach remains a challenge in clinical practise. Limited pain understanding amongst clinicians may be partly responsible for this.

PURPOSE OF THE STUDY

1) Qualitatively explore the experience of receiving PSE, understanding of PSE and operationalisation of PSE-related principles in routine clinical practice. 2) Quantitatively explore pain knowledge, attitudes, and behaviours of general practitioners (GPs) and nurse practitioners (NPs) before and after pain science education (PSE).

METHODS

An exploratory, single-site, mixed-methods study in north-east England. Fifteen NPs/GPs completed questionnaires and a case-vignette before and after a 70-min face-to-face PSE lecture. Qualitative data were thematically analysed from two focus groups after the intervention.

RESULTS

Clinicians' relatively high prior levels of knowledge, attitudes, and behaviour were similar after PSE. Qualitative themes described facilitation of self-reflection on pain management behaviours, and difficulties in operationalising PSE principles in practise including: limited patient rapport; short appointment times; patients' passive and often oppositional biomedical treatment expectations; and clinicians' lack of readily understandable language to communicate with patients.

CONCLUSION

The findings highlight the value of PSE perceived by these clinicians who were already favourably inclined towards biopsychosocial pain management. They sought more resources for their personal learning and for communication with patients. Even with such favourable disposition, the practicalities and environment of clinical practice impeded the operationalisation of PSE-related principles.

TRIAL REGISTRATION

This study was prospectively registered at ClinicalTrials.Gov ( NCT04587596 ) in October 2020.

Healthcare resource utilisation and cost analysis associated with opioid analgesic use for non-cancer pain: A case-control, retrospective study between 2005 and 2015

Objective

To examine differences in healthcare utilisation and costs associated with opioid prescriptions for non-cancer pain issued in primary care.

Method

A longitudinal, case-control study retrospectively examined Welsh healthcare data for the period 1 January 2005–31 December 2015. Data were extracted from the Secure Anonymised Information Linkage (SAIL) databank. Subjects, aged 18 years and over, were included if their primary care record contained at least one of six overarching pain diagnoses during the study period. Subjects were excluded if their record also contained a cancer diagnosis in that time or the year prior to the study period. Case subjects also received at least one prescription for an opioid analgesic. Controls were matched by gender, age, pain-diagnosis and socioeconomic deprivation. Healthcare use included primary care visits, emergency department (ED) and outpatient (OPD) attendances, inpatient (IP) admissions and length of stay. Cost analysis for healthcare utilisation used nationally derived unit costs for 2015. Differences between case and control subjects for resource use and costs were analysed and further stratified by gender, prescribing persistence (PP) and deprivation.

Results

Data from 3,286,215 individuals were examined with 657,243 receiving opioids. Case subjects averaged 5 times more primary care visits, 2.8 times more OPD attendances, 3 times more ED visits and twice as many IN admissions as controls. Prescription persistence over 6 months and greater deprivation were associated with significantly greater utilisation of healthcare resources. Opioid prescribing was associated with 69% greater average healthcare costs than in control subjects. National Health Service (NHS) healthcare service costs for people with common, pain-associated diagnoses, receiving opioid analgesics were estimated to be £0.9billion per year between 2005 and 2015.

Conclusion

Receipt of opioid prescriptions was associated with significantly greater healthcare utilisation and accompanying costs in all sectors. Extended prescribing durations are particularly important to address and should be considered at the point of initiation.

Association of chronic pain with comorbidities and health care utilization: a retrospective cohort study using health administrative data

ABSTRACT

Health administrative data provide a potentially robust information source regarding the substantial burden chronic pain exerts on individuals and the health care system. This study aimed to use health administrative data to estimate comorbidity prevalence and annual health care utilization associated with chronic pain in Newfoundland and Labrador, Canada. Applying the validated Chronic Pain Algorithm to provincial Fee-for-Service Physician Claims File data (1999-2009) established the Chronic Pain (n = 184,580) and No Chronic Pain (n = 320,113) comparator groups. Applying the Canadian Chronic Disease Surveillance System coding algorithms to Claims File and Provincial Discharge Abstract Data (1999-2009) determined the prevalence of 16 comorbidities. The 2009/2010 risk and person-year rate of physician and diagnostic imaging visits and hospital admissions were calculated and adjusted using the robust Poisson model with log link function (risks) and negative binomial model (rates). Results indicated a significantly higher prevalence of all comorbidities and up to 4 times the odds of multimorbidity in the Chronic Pain Group (P-value < 0.001). Chronic Pain Group members accounted for 58.8% of all physician visits, 57.6% of all diagnostic imaging visits, and 54.2% of all hospital admissions in 2009/2010, but only 12% to 16% of these were for pain-related conditions as per recorded diagnostic codes. The Chronic Pain Group had significantly higher rates of physician visits and high-cost hospital admission/diagnostic imaging visits (P-value < 0.001) when adjusted for demographics and comorbidities. Observations made using this methodology supported that people identified as having chronic pain have higher prevalence of comorbidities and use significantly more publicly funded health services.

The Right to Pain Relief: Its Origins in End-of-life Care and Extension to Chronic Pain Care

OBJECTIVES

The claim of a right to pain relief was made in recent decades by pain professionals, courts, and patient advocacy groups and likely contributed to increased opioid prescribing, overdose deaths, and addictions, but the origins and nature of this right have not been investigated.

MATERIALS AND METHODS

Relevant clinical, ethical, and legal literature concerning patient rights to pain care was reviewed.

RESULTS

The record describes the effort to improve end-of-life and cancer pain care in the 1980s and 1990s, which simultaneously legitimated pain relief as an independent goal of medical care and opioids as a safe and effective means to achieve this relief. In 1997, the US Supreme Court denied the right to assisted suicide but affirmed a right to palliative care to prevent dying in overwhelming pain. Other guidelines and regulations extended this right to pain relief from end-of-life care to chronic pain care, along with the titrate-to-effect principle, which specified that the correct opioid dose was the dose that relieved pain.

DISCUSSION

The most important consequence of combining the right to pain relief with the titrate-to-effect principle was the idea that a high pain score must not be ignored. This extension of the right to pain relief neglected important differences between end-of-life care and chronic pain care including: time frame, clinical setting and context, target of titration, and nature of iatrogenic harms. To help end our current opioid epidemic and prevent a future epidemic, we need to demedicalize pain and reintegrate it with the rest of human suffering as an experience connected to other personal behaviors and meanings.

Pain Medication Beliefs Mediate the Relationship Between Pain Catastrophizing and Opioid Prescription Use in Patients With Chronic Non-Cancer Pain

Little is known about the mechanisms by which pain catastrophizing may be associated with opioid use outcomes. This study aimed to investigate the potential mediating role of beliefs about the appropriateness of pain medicines for pain treatment on the association between pain catastrophizing and prescription opioid use in a community chronic non-cancer pain (CNCP) sample. Individuals (N = 420) diagnosed with CNCP participated in a cross-sectional online self-report study with validated measures of pain medication beliefs, pain catastrophizing, and current prescription opioid use. Two parallel multiple mediator analyses with percentile-based bootstrapping examined pathways to both prescription opioid use and high-dose use (≥ 100mg oral morphine equivalents/day), while controlling for pain intensity and other relevant covariates. Pain medication beliefs significantly mediated the association between pain catastrophizing and prescription opioid use (CI = 0.011, 0.033). A similar pattern of findings was found for high-dose opioid use, with pain medication beliefs significantly mediating the pain catastrophizing-high-dose use association (CI = 0.006, 0.050). Pain medication beliefs are a potentially modifiable psychological mechanism by which pain catastrophizing is associated with opioid use, including high-dose use. These findings have important implications for personalizing prevention and treatment programs.

Physical therapists should play a greater role in managing patients with opioid use and opioid misuse

The U.S. opioid crisis necessitates that health care providers of all types work collaboratively to manage patients taking prescription opioid medications and manage those who may be misusing prescription opioids. Musculoskeletal conditions are the most common diagnoses associated with an opioid prescription. Physical therapists commonly manage patients with musculoskeletal conditions and chronic pain. Some patients who attend physical therapy for pain management take prescription opioid medications for pain and some of these patients may be misusing prescription opioids. Physical therapists who manage patients with musculoskeletal conditions are well-positioned to help address the opioid crisis. Historically, physical therapists have not been adequately engaged in efforts to manage persons with co-occurring musculoskeletal pain and opioid misuse or OUD. The American Physical Therapy Association (APTA) has emphasized physical therapy over the use of prescription opioids for the management of painful conditions. The APTA, however, does not highlight the important role that physical therapists could play in monitoring opioid use among patients receiving treatment for pain, nor the role that physical therapists should play in screening for opioid misuse. Such screening could facilitate referral of patients suspected misuse to an appropriate provider for formal assessment and treatment. This commentary presents simulated musculoskeletal patient presentations depicting 2 common opioid use states; chronic opioid use and opioid misuse. The cases highlight and interactions that physical therapists could have with these patients and actions that the physical therapist could take when working inter-disciplinarily. Recommendations are provided that aim to increase physical therapists' knowledge and skills related to managing patients taking prescription opioid medications for pain.

The Relationship between Higher Chronic Opioid Therapy Dose and Specific Personality Traits in Individuals with Chronic Pain

Objective

To evaluate the relationship between opioid use and specific personality traits among individuals with chronic pain stratified by morphine equivalent doses (MEQ).

Design

Observational cohort study. Setting. Chronic pain outpatient clinic in Canada (2017-2019). Patients. Participants were included if they (1) were at least 18 years old, (2) had been diagnosed with chronic pain (pain >3 months), and (3) were able to read and write in English. Interventions. None. Main Outcome Measures. Completion of the following outcome measures: Acceptance and Action Questionnaire, Anxiety Sensitivity Index, Brief-Coping with Problems Experience 28-item, Brief Pain Inventory Short Form, CAGE-AID substance misuse screening tool, EuroQol-5D, Generalized Anxiety Disorder 7-item, and Patient Health Questionnaire 9-item. One-way analysis of variance compared outcomes between MEQ groups.

Results

215 individuals (64.2% female) were included with a mean age of 52.7 ± 11.7 years and time since pain onset of 14.1 ± 10.2 years (range 1-45). There were no significant differences between MEQ groups with respect to sociodemographic and clinical health variables except for gender and employment status and time since pain onset. After controlling for gender, time since pain onset, and average pain severity, patients with MEQ 90+ mg had significantly higher scores for experiential avoidance and anxiety sensitivity in addition to increased pain interference, greater depressive and anxiety symptoms, more dysfunctional coping, and poorer QoL than those with MEQ 1-89 mg or MEQ 0 mg.

Conclusions

Compared to individuals using no or lower-dose opioids to treat chronic pain, those using high-dose opioids had higher scores on two maladaptive personality traits (i.e., anxiety sensitivity and experiential avoidance) which was associated with poorer mood, greater pain interference, lower quality of life, and dysfunctional coping. These maladaptive personality traits may help to explain how individuals with chronic pain utilize higher doses of opioid analgesics.

Impact of opioid dose escalation on pain intensity: a retrospective cohort study

Prescribers are often confronted with the decision to escalate opioid doses to achieve adequate analgesia. Understanding the impact of dose escalation on pain intensity is warranted. Using a retrospective cohort study design, Veterans with chronic pain and chronic opioid therapy were identified. Opioid dose escalators (>20% increase in average morphine milligram equivalent daily dose) were compared with dose maintainers (±20% change in average morphine milligram equivalent daily dose) assessed over 2 consecutive 6-month windows. Pain intensity was measured by the Numeric Rating Scale. The primary analyses used linear repeated-measures models among a 1:1 matched sample of escalators and maintainers matched on propensity score and within ±180 days of the index date. Sensitivity analyses were conducted using adjusted linear repeated-measures models with and without incorporating stabilized inverse probability of treatment weighting. There were 32,420 dose maintainers and 20,767 dose escalators identified with 19,358 (93%) matched pairs. Pain scores were persistently higher among dose escalators at each 90-day period after the index date (0-90 days after index date: dose escalators: 4.68, 95% confidence interval [CI]: 4.64-4.72 dose maintainers: 4.32, 95% CI: 4.28-4.36, P < 0.0001; 91-180 days after index date: dose escalators: 4.53, 95% CI: 4.49-4.57; dose maintainers: 4.25, 95% CI: 4.22-4.29, P < 0.0001) but were not different in the 90 days before the index date (dose escalators: 4.64, 95% CI: 4.61-4.68; dose maintainers: 4.59, 95% CI: 4.55-4.63, P = 0.0551). Sensitivity analyses provided similar results as the primary analyses. Opioid dose escalation among patients with chronic pain is not associated with improvements in Numeric Rating Scale pain scores.

Pain Trends Among American Adults, 2002-2018: Patterns, Disparities, and Correlates

Determining long-term trends in chronic pain prevalence is critical for evaluating and shaping U.S. health policies, but little research has examined such trends. This study (1) provides estimates of pain trends among U.S. adults across major population groups; (2) tests whether sociodemographic disparities in pain have widened or narrowed over time; and (3) examines socioeconomic, behavioral, psychological, and medical correlates of pain trends. Regression and decomposition analyses of joint, low back, neck, facial/jaw pain, and headache/migraine using the 2002-2018 National Health Interview Survey for adults aged 25-84 (N  =  441,707) assess the trends and their correlates. We find extensive escalation of pain prevalence in all population subgroups: overall, reports of pain in at least one site increased by 10%, representing an additional 10.5 million adults experiencing pain. Socioeconomic disparities in pain are widening over time, and psychological distress and health behaviors are among the salient correlates of the trends. This study thus comprehensively documents rising pain prevalence among Americans across the adult life span and highlights socioeconomic, behavioral, and psychological factors as important correlates of the trends. Chronic pain is an important dimension of population health, and demographic research should include it when studying health and health disparities.

Pain Catastrophizing, Opioid Misuse, Opioid Use, and Opioid Dose in People With Chronic Musculoskeletal Pain: A Systematic Review

The objective of this study was to analyze the cross-sectional and longitudinal association between pain catastrophizing and opioid misuse, opioid use, and opioid dose in people with chronic musculoskeletal pain. For this systematic review, CINAHL, Embase, PsycINFO, PubMed, manual searches, and grey literature were searched from inception to May 2020. Observational studies were included if they evaluated the association between pain catastrophizing and opioid dose, opioid use, and/or opioid misuse in people with chronic musculoskeletal pain. Two reviewers independently performed the study selection, data extraction, risk of bias assessment, and the certainty of the evidence judgment. Seven observational studies (all cross-sectional designs) satisfied the eligibility criteria, with a total sample of 2,160 participants. Pain catastrophizing was associated with opioid misuse. The results were inconsistent regarding the association between pain catastrophizing and opioid use. A lack of association was found considering pain catastrophizing and the opioid dose. However, the presence of risk of bias and imprecision was serious across the included studies, and therefore, the overall certainty of the evidence was judged as very low for all the outcome measures. This report concludes that pain catastrophizing seem to be associated with opioid misuse in people with chronic musculoskeletal pain. However, the very low certainty of the current evidence confers to interpret the finding of this review as exclusively informative. PERSPECTIVE: This article shows that pain catastrophizing seem to be associated with opioid misuse in people with chronic musculoskeletal pain. The overall certainty of the evidence was judged to be very low, thus, these results should be interpreted with caution.

Prospective Investigation of Factors Associated with Prescription Opioid Dose Escalation among Patients in Integrated Health Systems

BACKGROUND

Prior research has identified factors associated with prescription opioid initiation, but little is known about the prevalence or predictors of dose escalation among patients already prescribed long-term opioid therapy (LTOT).

OBJECTIVE

This was a 2-year prospective cohort study to examine patient and clinician factors associated with opioid dose escalation.

DESIGN

A prospective cohort study. Participants were seen at baseline and every 6 months for a total of 2 years.

PARTICIPANTS

Patients prescribed a stable dose of LTOT for musculoskeletal pain were recruited from two integrated health systems (Kaiser Permanente and the Department of Veterans Affairs, respectively).

MAIN MEASURES

The prescription opioid dose was based on pharmacy records and self-report. Administrative data were gathered on characteristics of the opioid-prescribing clinician and healthcare utilization. Participants completed measures of pain, functioning, and quality of life.

KEY RESULTS

Of enrolled participants (n = 517), 19.5% had an opioid dose increase. In multivariate analyses, patient variables associated with dose escalation were lower opioid dose (hazard ratio [HR] = 0.86, 95% confidence interval [CI] = 0.79-0.94, for every 10-mg increase in baseline dose) and greater pain catastrophizing (HR = 1.03, 95% CI = 1.01-1.05). Other variables associated with dose escalation were as follows: receiving medications from a nurse practitioner primary care provider (HR = 2.10, 95% CI = 1.12-3.96) or specialty physician (HR = 3.18, 95% CI = 1.22-8.34), relative to a physician primary care provider, and having undergone surgery within the past 6 months (HR = 1.80, 95% CI = 1.10-2.94). Other variables, including pain intensity, pain disability, or depression, were not associated with dose escalation.

CONCLUSIONS

In this 2-year prospective cohort study, variables associated with opioid dose escalation were lower opioid dose, higher pain catastrophizing, receiving opioids from a medical specialist (rather than primary care clinician) or nurse practitioner, and having recently undergone surgery. Study findings highlight intervention points that may be helpful for reducing the likelihood of future prescription opioid dose escalation.

Examining opioid prescribing trends for non-cancer pain using an estimated oral morphine equivalence measure: a retrospective cohort study between 2005 and 2015

Background

Over the past 20 years prescription of opioid medicines has markedly increased in the UK, despite a lack of supporting evidence for use in commonly occurring, painful conditions. Prescribing is often monitored by counting numbers of prescriptions dispensed, but this may not provide an accurate picture of clinical practice.

Aim

To use an estimated oral morphine equivalent (OMEQ_e) dose to describe trends in opioid prescribing in non-cancer pain, and explore if opioid burden differed by deprivation status.

Design & setting

A retrospective cohort study using cross-sectional and longitudinal trend analyses of opioid prescribing data from Welsh Primary Care General Practices (PCGP) took place. Data were used from the Secure Anonymised Information Linkage (SAIL) databank.

Method

An OMEQ_e measure was developed and used to describe trends in opioid burden over the study period. OMEQ_e burden was stratified by eight drug groups, which was based on usage and deprivation.

Results

An estimated 643 436 843 milligrams (mg) OMEQ_e was issued during the study. Annual number of prescriptions increased 44% between 2005 and 2015, while total daily OMEQ_e per 1000 population increased by 95%. The most deprived areas of Wales had 100 711 696 mg more OMEQ_e prescribed than the least deprived over the study period.

Conclusion

Over the study period, OMEQ_e burden nearly doubled, with disproportionate OMEQ_e prescribed in the most deprived communities. Using OMEQ_e provides an alternative measure of prescribing and allows easier comparison of the contribution different drugs make to the overall opioid burden.

Opioid Pain Medication Prescription for Chronic Pain in Primary Care Centers: The Roles of Pain Acceptance, Pain Intensity, Depressive Symptoms, Pain Catastrophizing, Sex, and Age

Background: Psychological factors of patients may influence physicians’ decisions on prescribing opioid analgesics. However, few studies have sought to identify these factors. The present study had a double objective: (1) To identify the individual factors that differentiate patients who had been prescribed opioids for the management of chronic back pain from those who had not been prescribed opioids and (2) to determine which factors make significant and independent contributions to the prediction of opioid prescribing. Methods: A total of 675 patients from four primary care centers were included in the sample. Variables included sex, age, pain intensity, depressive symptoms, pain catastrophizing, and pain acceptance. Results: Although no differences were found between men and women, participants with chronic noncancer pain who were prescribed opioids were older, reported higher levels of pain intensity and depressive symptoms, and reported lower levels of pain-acceptance. An independent association was found between pain intensity and depressive symptoms and opioid prescribing. Conclusions: The findings suggest that patient factors influence physicians’ decisions on prescribing opioids. It may be useful for primary care physicians to be aware of the potential of these factors to bias their treatment decisions.

Fewer postoperative opioids are associated with decreased duration of stay for children with perforated appendicitis

BACKGROUND

The impact of postoperative opioid use on outcomes for children with perforated appendicitis is unknown.

METHODS

A retrospective cohort study was performed using the Pediatric Health Information System database from 2005 to 2015. Children 2 to 18 years with perforated appendicitis who underwent an appendectomy were identified. Postoperative day analgesic use was categorized as nonopioid analgesia alone, opioids (with or without nonopioid analgesia), or no analgesics. The impact of postoperative opioid use on postoperative duration of stay and 30-day readmission was evaluated using multivariable mixed-effects regression analysis.

RESULTS

Overall, 47,726 children with perforated appendicitis were identified. On postoperative day 1, 17.7% received nonopioid analgesia alone, 77.6% received opioids, and 4.7% received no analgesics. On adjusted analysis, postoperative day 1 opioid use was associated with a 0.75-day (95% confidence interval: 0.54-0.96) increased postoperative duration of stay. Starting opioids after postoperative day 1 was associated with 2.21 days (95% confidence interval: 1.90-2.51) longer postoperative duration of stay. Among children who received opioids on postoperative day 1, continued use of opioids after postoperative day 1 was associated with a 1.88 day (95% confidence interval: 1.77-1.98) longer postoperative duration of stay. Postoperative day 1 opioid use did not significantly affect 30-day readmission.

CONCLUSION

Early and continued postoperative opioid use is associated with prolonged postoperative duration of stay in children undergoing appendectomy for perforated appendicitis. Minimizing opioid use, even on postoperative day 2, may result in a decreased postoperative duration of stay.

Trends in Pain Prevalence among Adults Aged 50 and Older across Europe, 2004 to 2015

Objectives: We examine recent trends in pain prevalence among adults aged 50+ across Europe. Methods: Data for 15 countries from the Survey of Health, Ageing, and Retirement in Europe are examined for two periods: 2004-2011 and 2013-2015. Trends are shown descriptively, using a multilevel modeling strategy controlling for covariates, and modeled on a country-specific basis. Results: Population-level pain prevalence ranges from about 30% to about 60% depending on the country and year. Pain is more prevalent in women and generally increases with age. There is an increase in prevalence over time, net of age, and other predictors. Prevalence increased with an annual average of 2.2% between 2004 and 2011 and 5.8% between 2013 and 2015, in fully adjusted models. Discussion: Trends in pain prevalence have implications for disability, healthcare utilization, productivity, and population health. These findings are not optimistic but align with other population-wide studies, suggesting a global trend of rising pain prevalence.

Use and Opinions of Prescription Opioids Among Older American Adults: Sociodemographic Predictors

OBJECTIVES

This study identifies sociodemographic predictors of prescription opioid use among older adults (age 65+) during the peak decade of U.S. opioid prescription, and tests whether pain level and Medicaid coverage mediate the association between low wealth and opioid use. Predictors of prescription nonsteroidal anti-inflammatory drug (NSAID) use, and of opinions of both drug classes, are also examined.

METHOD

Regressions of opioid and NSAID use on sociodemographic characteristics, pain level, and insurance type were conducted using Health and Retirement Study 2004 core and 2005 Prescription Drug Study data (n = 3,721). Mediation analyses were conducted, and user opinions of drug importance, quality, and side effects were assessed.

RESULTS

Low wealth was a strong, consistent predictor of opioid use. Both pain level and Medicaid coverage significantly, but only partially, mediated this association. Net of wealth, there were no significant associations between education and use of, or opinions of, either class of drugs.

DISCUSSION

Among older American adults, the poorest are disproportionately likely to have been exposed to prescription opioid analgesics. Wealth, rather than education, drove social class differences in mid-2000s opioid use. Opioid-related policies should take into account socioeconomic contributors to opioid use, and the needs and treatment histories of chronic pain patients.

"It Sometimes Doesn't Even Work": Patient Opioid Assessments as Clues to Therapeutic Flexibility in Primary Care

BACKGROUND

Physicians' fear of difficult patient interactions is an important barrier to discontinuing long-term opioid therapy.

OBJECTIVE

To identify patient statements about opioids that indicate potential openness to tapering opioids or trying non-opioid pain treatments DESIGN: This is an observational study of regularly scheduled primary care visits involving discussion of chronic pain management. A coding system to characterize patient assessments about opioids, physician responses to assessments, and patient-endorsed opioid side effects was developed and applied to transcripts of video-recorded visits. All visits were independently coded by 2 authors.

PARTICIPANTS

Eighty-six established adult patients taking opioids for chronic pain; 49 physicians in 2 academic primary care clinics MAIN MEASURES: Frequency and topic of patients' opioid assessments; proportion of opioid assessments classified as clues (assessments indicating potential willingness to consider non-opioid pain treatments or lower opioid doses); physician responses to patient clues; frequency and type of patient-endorsed side effects KEY RESULTS: Patients made a mean of 3.2 opioid assessments (median 2) per visit. The most common assessment topics were pain relief (51%), effect on function (21%), and opioid safety (14%). Forty-seven percent of opioid assessments (mean 1.5 per visit) were classified as clues. Fifty-three percent of visits included ≥ 1 clue; 21% of visits contained ≥ 3 clues. Physicians responded to patient clues with no/minimal response 43% of the time, sympathetic/empathetic statements 14% of the time, and further explored clues 43% of the time. Fifty-eight percent of patients endorsed ≥ 1 opioid-related side effect; 10% endorsed ≥ 3 side effects. The most commonly endorsed side effects were constipation (15% of patients), sedation (15%), withdrawal symptoms (13%), and nausea (12%).

CONCLUSIONS

Patient statements suggesting openness to non-opioid pain treatments or lower opioid doses are common during routine primary care visits. Listening for and exploring these clues may be a patient-centered strategy for broaching difficult topics with patients on long-term opioid therapy.

Impact of opioid dose escalation on the development of substance use disorders, accidents, self-inflicted injuries, opioid overdoses and alcohol and non-opioid drug-related overdoses: a retrospective cohort study

AIM

To understand the potential harmful effects of dose escalation among patients with chronic, non-cancer pain (CNCP) on chronic opioid therapy.

DESIGN

Retrospective cohort study.

SETTING

United States Veterans Healthcare Administration.

PARTICIPANTS

Veterans with CNCP and on chronic opioid therapy were identified using data from fiscal years 2008-15. The Veteran sample was approximately 90% male and 70% white.

MEASUREMENTS

Dose escalators [increase of > 20% average morphine milligram equivalent (MME) daily dose] were compared with dose maintainers (change of ±20% average MME daily dose). A composite measure of subsequent substance use disorders (SUDs: opioid, non-opioid and alcohol use disorders) and opioid-related adverse outcomes (AOs: accidents resulting in wounds/injuries, opioid-related and alcohol and non-opioid medication-related accidents and overdoses, self-inflicted injuries) as well as the individual SUDs and AOs was examined. The primary analyses were conducted among a 1 : 1 matched sample of escalators and maintainers matched on propensity score and index date. Propensity scores were generated using demographic characteristics, medical comorbidities, medication and health-care utilization characteristics. Subgroup analyses were conducted by quartile of the propensity score. Sensitivity analyses were conducted using adjusted logistic regression, logistic regression using stabilized inverse probability of treatment weighting (SIPTW) and instrumental variable (IV) models using geographic variation in opioid dose escalation as the IV.

FINDINGS

There were 32 420 maintainers and 20 767 escalators resulting in 19 358 (93.2%) matched pairs. Composite AOs [odds ratio (OR) = 1.31, 95% confidence interval (CI) = 1.23, 1.40], composite SUDs (OR = 1.31, 95% CI = 1.22, 1.41) and individual SUD and AO subtypes were higher among dose escalators, except for opioid-related accidents and overdoses and violence-related injuries. Subgroup analyses within the propensity score quartiles found similar results. Sensitivity analyses with the adjusted and SIPTW logistic regressions found similar results to the primary analyses for all outcomes except for opioid-related accidents and overdoses, which were found to be significantly higher among escalators. Sensitivity analyses with IV models provided mixed results with SUDs and the individual types of AOs.

CONCLUSION

Escalating the opioid dose for those with chronic, non-cancer pain is associated with increased risks of substance use disorder and opioid-related adverse outcomes.

Pain rates in general population for the period 1991-2015 and 10-years prediction: results from a multi-continent age-period-cohort analysis

Background

Pain is a common symptom, often associated with neurological and musculoskeletal conditions, and experienced especially by females and by older people. The aims of this study are to evaluate the temporal variations of pain rates among general populations for the period 1991–2015 and to project 10-year pain rates.

Methods

We used the harmonized dataset of ATHLOS project, which included 660,028 valid observations in the period 1990–2015 and we applied Bayesian age–period–cohort modeling to perform projections up to 2025. The harmonized Pain variable covers the content “self-reported pain experienced at the time of the interview”, with a dichotomous (yes or no) modality.

Results

Pain rates were higher among females, older subjects, in recent periods, and among observations referred to cohorts of subjects born between the 20s and the 60s. The 10-year projections indicate a noteworthy increase in pain rates in both genders and particularly among subjects aged 66 or over, for whom a 10–20% increase in pain rate is foreseen; among females only, a 10–15% increase in pain rates is foreseen for those aged 36–50.

Conclusions

Projected increase in pain rates will require specific interventions by health and welfare systems, as pain is responsible for limited quality of subjective well-being, reduced employment rates and hampered work performance. Worksite and lifestyle interventions will therefore be needed to limit the impact of projected higher pain rates.

Correlates of Benzodiazepine Use and Adverse Outcomes Among Patients with Chronic Pain Prescribed Long-term Opioid Therapy

OBJECTIVE

To examine the correlates and odds of receiving overlapping benzodiazepine and opioid prescriptions and whether co-prescription was associated with greater odds of falling or visiting the emergency department.

DESIGN

Cross-sectional study.

SETTING

A large private integrated health system and a Veterans Health Administration integrated health system.

SUBJECTS

Five hundred seventeen adults with musculoskeletal pain and current prescriptions for long-term opioid therapy.

METHODS

A multivariate logistic regression model examined correlates of having overlapping benzodiazepine and opioid prescriptions in the year before enrollment in the cross-sectional study. Negative binomial models analyzed the number of falls in the past three months and past-year emergency department visits. In addition to propensity score adjustment, models controlled for demographic characteristics, psychiatric diagnoses, medications, overall comorbidity score, and opioid morphine equivalent dose.

RESULTS

Twenty-five percent (N = 127) of participants had co-occurring benzodiazepine and opioid prescriptions in the prior year. Odds of receiving a benzodiazepine prescription were significantly higher among patients with the following psychiatric diagnoses: anxiety disorder (adjusted odds ratio [AOR] = 4.71, 95% confidence interval [CI] = 2.67-8.32, P < 0.001), post-traumatic stress disorder (AOR = 2.24, 95% CI = 1.14-4.38, P = 0.019), and bipolar disorder (AOR = 3.82, 95% CI = 1.49-9.81, P = 0.005). Past-year overlapping benzodiazepine and opioid prescriptions were associated with adverse outcomes, including a greater number of falls (risk ratio [RR] = 3.27, 95% CI = 1.77-6.02, P = 0.001) and emergency department visits (RR = 1.66, 95% CI = 1.08-2.53, P = 0.0194).

CONCLUSIONS

Among patients with chronic pain prescribed long-term opioid therapy, one-quarter of patients had co-occurring prescriptions for benzodiazepines, and dual use was associated with increased odds of falls and emergency department visits.

The evaluating prescription opioid changes in veterans (EPOCH) study: Design, survey response, and baseline characteristics

In the United States (US), long-term opioid therapy has been commonly prescribed for chronic pain. Since recognition of the opioid overdose epidemic, clinical practice guidelines have recommended tapering long-term opioids to reduced doses or discontinuation. The Effects of Prescription Opioid Changes for veterans (EPOCH) study is a national population-based prospective observational study of US Veterans Health Administration primary care patients designed to assess effects of evolving opioid prescribing practice on patients treated with long-term opioids for chronic pain. A stratified random sampling design was used to identify a survey sample from the target population of patients treated with opioid analgesics for ≥ 6 months. Demographic, diagnostic, visit, and pharmacy dispensing data were extracted from existing datasets. A 2016 mixed-mode mail and telephone survey collected patient-reported data, including the main patient-reported outcomes of pain-related function (Brief Pain Inventory interference; BPI-I scores 0–10, higher scores = worse) and health-related quality of life. Data on survey participants and non-participants were analyzed to assess potential nonresponse bias. Weights were used to account for design. Linear regression models were used to assess cross-sectional associations of opioid treatment with patient-reported measures. Of 14,160 patients contacted, 9253 (65.4%) completed the survey. Participants were older than non-participants (63.9 ± 10.6 vs. 59.6 ± 13.0 years). The mean number of bothersome pain locations was 6.8 (SE 0.04). Effectiveness of pain treatment and quality of pain care were rated fair or poor by 56.1% and 45.3%, respectively. The opioid daily dosage range was 1.6 to 1038.2 mg, with mean = 50.6 mg (SE 1.1) and median = 30.9 mg (IQR 40.7). Among the 73.2% of patients who did not receive long-acting opioids, the mean daily dosage was 30.4 mg (SE 0.6) and mean BPI-I was 6.4 (SE 00.4). Among patients who received long-acting opioids, the mean daily dosage was 106.2 mg (SE 2.8) and mean BPI-I was 6.8 (SE 0.07). Higher daily dosage was associated with worse pain-related function and quality of life among patients without long-acting opioids, but not among patients with long-acting opioids. Future analyses will use follow-up data to examine effects of opioid dose reduction and discontinuation on patient outcomes.

Factors associated with the prescribing of high-dose opioids in primary care: a systematic review and meta-analysis

BACKGROUND

The risks of harms from opioids increase substantially at high doses, and high-dose prescribing has increased in primary care. However, little is known about what leads to high-dose prescribing, and studies exploring this have not been synthesized. We, therefore, systematically synthesized factors associated with the prescribing of high-dose opioids in primary care.

METHODS

We conducted a systematic review of observational studies in high-income countries that used patient-level primary care data and explored any factor(s) in people for whom opioids were prescribed, stratified by oral morphine equivalents (OME). We defined high doses as ≥ 90 OME mg/day. We searched MEDLINE, Embase, Web of Science, reference lists, forward citations, and conference proceedings from database inception to 5 April 2019. Two investigators independently screened studies, extracted data, and appraised the quality of included studies using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. We pooled data on factors using random effects meta-analyses and reported relative risks (RR) or mean differences with 95% confidence intervals (CI) where appropriate. We also performed a number needed to harm (NNT_H) calculation on factors when applicable.

RESULTS

We included six studies with a total of 4,248,119 participants taking opioids, of whom 3.64% (n = 154,749) were taking high doses. The majority of included studies (n = 4) were conducted in the USA, one in Australia and one in the UK. The largest study (n = 4,046,275) was from the USA. Included studies were graded as having fair to good quality evidence. The co-prescription of benzodiazepines (RR 3.27, 95% CI 1.32 to 8.13, I² = 99.9%), depression (RR 1.38, 95% CI 1.27 to 1.51, I² = 0%), emergency department visits (RR 1.53, 95% CI 1.46 to 1.61, I² = 0%, NNT_H 15, 95% CI 12 to 20), unemployment (RR 1.44, 95% CI 1.27 to 1.63, I² = 0%), and male gender (RR 1.21, 95% CI 1.14 to 1.28, I² = 78.6%) were significantly associated with the prescribing of high-dose opioids in primary care.

CONCLUSIONS

High doses of opioids are associated with greater risks of harms. Associated factors such as the co-prescription of benzodiazepines and depression identify priority areas that should be considered when selecting, identifying, and managing people taking high-dose opioids in primary care. Coordinated strategies and services that promote the safe prescribing of opioids are needed.

STUDY REGISTRATION

PROSPERO, CRD42018088057.

Clinician Response to Aberrant Urine Drug Test Results of Patients Prescribed Opioid Therapy for Chronic Pain

OBJECTIVE

Urine drug testing (UDT) is recommended for patients who are prescribed opioid medications, but little is known about the various strategies clinicians use to respond to aberrant UDT results. We sought to examine changes in opioid prescribing and implementation of other risk reduction activities following an aberrant UDT.

METHODS

In a national cohort of Veterans Affairs patients with new initiations of opioid therapy through 2013, we identified a random sample of 100 patients who had aberrant positive UDTs (results positive for nonprescribed/illicit substance), 100 who had aberrant negative UDTs (results negative for prescribed opioid), and 100 who had expected UDT results. We examined medical record data for opioid prescribing changes and risk reduction strategies in the 12 months following UDT.

RESULTS

Following an aberrant UDT, 17.5% of clinicians documented planning to discontinue or change the opioid dose and 52.5% initiated another strategy to reduce opioid-related risk. In multivariate analyses, variables associated with a planned change in opioid prescription status were having an aberrant positive UDT (odds ratio [OR], 30.77; 95% confidence interval [CI], 5.92-160.10) and higher prescription opioid dose (OR, 1.01; 95% CI, 1.01-1.02). The only variable associated with implementation of other risk reduction activities was having an aberrant positive UDT (OR, 0.29; 95% CI, 0.16-0.55).

DISCUSSION

The majority of clinicians enacted some type of opioid prescribing or other change to reduce risk following an aberrant UDT, and the action depended on whether the result was an aberrant positive or aberrant negative UDT. Experimental studies are needed to develop and test strategies for managing aberrant UDT results.

Research methods and baseline findings of the improving the safety of opioid therapy (ISOT) cluster-randomized trial

There are adverse effects associated with long-term opioid therapy (LTOT) for chronic pain and clinicians infrequently adhere to opioid treatment guideline recommendations for reducing risk and mitigating opioid-related harms. The primary goal of the Improving the Safety of Opioid Therapy (ISOT) intervention is to reduce harms related to prescription opioids. Secondary aims focus on enhancing the clinician-patient relationship and not having a negative impact on pain-related outcomes (to be examined through a non-inferiority analysis). The study is a cluster-randomized trial and the 44 primary care providers (PCPs) who enrolled were randomized to receive either (1) a two-hour educational workshop about a patient-centered approach to opioid therapy or (2) the educational workshop plus a collaborative care intervention delivered by a nurse care manager (NCM). Patients were assigned to the same condition as their treating PCP. ISOT was based on the chronic care model and includes patient and provider activation, outcomes monitoring, and feedback to the PCP over 12 months. The NCM conducted a baseline assessment with intervention patients, tracked opioid-related behaviors and outcomes, and provided decision support to the opioid-prescribing clinician about opioid safety. Between June 2016 and October 2018, 293 veterans who were prescribed LTOT for chronic pain were enrolled, completed a baseline assessment, and assigned to a treatment condition. Participants were enrolled for 12 months. Masked assessments were conducted with participants at baseline, 6-months, and 12-months. This manuscript describes study rationale, research methods, and baseline findings.

Opioid Prescriptions at Hospital Discharge Are Associated With More Postdischarge Healthcare Utilization

Background

Many patients use opioids for nonmalignant pain, and opioid use in the general population has been associated with poor long‐term outcomes. The use of high‐risk medications, including opioid analgesics, may increase the risk of unplanned healthcare utilization.

Methods and Results

We performed a nested evaluation in the VICS (Vanderbilt Inpatient Cohort Study) (N=3000) on patients with an admitting diagnosis of acute coronary syndrome and/or acute decompensated heart failure. Patient enrollment occurred from October 2011 until December 2015 and involved a single investigational site, Vanderbilt University Medical Center (Nashville, TN). Of the 2495 eligible patients, 501 (20%) were discharged with an opioid prescription and were predominantly white and men, with a median age of 59 (interquartile range, 53–67) years. Our primary outcome was unplanned healthcare utilization, which included emergency department presentation or readmission. Secondary outcomes included mortality and a composite of planned utilization behaviors: cardiac rehabilitation and provider follow‐up within 30 days. Cox proportional hazards models did not show a statistically significant association with increased unplanned utilization (adjusted hazard ratio, 1.06; 95% CI, 0.87–1.28) or mortality (adjusted hazard ratio, 1.08; 95% CI, 0.84–1.39), compared with those without opioids at discharge. Patients discharged with opioids were less likely to complete planned healthcare utilization (adjusted odds ratio, 0.69; 95% CI, 0.52–0.91).

Conclusions

There are decreased odds of planned healthcare utilization among patients with acute coronary syndrome and acute decompensated heart failure discharged with opioid medication. It is imperative to understand how opioid use can affect a patient's relationship with the healthcare system.

Endogenous opiates and behavior: 2017

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

Effectiveness of integrative medicine group visits in chronic pain and depressive symptoms: A randomized controlled trial

BACKGROUND

Current treatment options for chronic pain and depression are largely medication-based, which may cause adverse side effects. Integrative Medical Group Visits (IMGV) combines mindfulness techniques, evidence based integrative medicine, and medical group visits, and is a promising adjunct to medications, especially for diverse underserved patients who have limited access to non-pharmacological therapies.

OBJECTIVE

Determine the effectiveness of IMGV compared to a Primary Care Provider (PCP) visit in patients with chronic pain and depression.

DESIGN

9-week single-blind randomized control trial with a 12-week maintenance phase (intervention-medical groups; control-primary care provider visit).

SETTING

Academic tertiary safety-net hospital and 2 affiliated federally-qualified community health centers.

PARTICIPANTS

159 predominantly low income racially diverse adults with nonspecific chronic pain and depressive symptoms.

INTERVENTIONS

IMGV intervention- 9 weekly 2.5 hour in person IMGV sessions, 12 weeks on-line platform access followed by a final IMGV at 21 weeks.

MEASUREMENTS

Data collected at baseline, 9, and 21 weeks included primary outcomes depressive symptoms (Patient Health Questionnaire 9), pain (Brief Pain Inventory). Secondary outcomes included pain medication use and utilization.

RESULTS

There were no differences in pain or depression at any time point. At 9 weeks, the IMGV group had fewer emergency department visits (RR 0.32, 95% CI: 0.12, 0.83) compared to controls. At 21 weeks, the IMGV group reported reduction in pain medication use (Odds Ratio: 0.42, CI: 0.18-0.98) compared to controls.

LIMITATIONS

Absence of treatment assignment concealment for patients and disproportionate group attendance in IMGV.

CONCLUSION

Results demonstrate that low-income racially diverse patients will attend medical group visits that focus on non-pharmacological techniques, however, in the attention to treat analysis there was no difference in average pain levels between the intervention and the control group.

TRIAL REGISTRATION

clinicaltrials.gov NCT02262377.

High-Frequency Medical Cannabis Use Is Associated With Worse Pain Among Individuals With Chronic Pain

Cannabis is widely used for chronic pain. However, there is some evidence of an inverse dose-response relationship between cannabis effects and pain relief that may negatively affect analgesic outcomes. In this cross-sectional survey, we examined whether daily cannabis use frequency was associated with pain severity and interference, quality of life measures relevant to pain (eg, anxiety and depressive symptoms), and cannabis use preferences (administration routes and cannabinoid ratio). Our analysis included 989 adults who used cannabis every day for chronic pain. Participant use was designated as light, moderate, and heavy (1-2, 3-4, and 5 or more cannabis uses per day, respectively). The sample was also subgrouped by self-reported medical-only use (designated MED, n = 531, 54%) versus medical use concomitant with a past-year history of recreational use (designated MEDREC, n = 458, 46%). In the whole sample, increased frequency of use was significantly associated with worse pain intensity and interference, and worse negative affect, although high-frequency users also reported improved positive affect. Subgroup analyses showed that these effects were driven by MED participants. Heavy MED participant consumption patterns showed greater preference for smoking, vaporizing, and high tetrahydrocannabinol products. In contrast, light MED participants had greater preference for tinctures and high cannabidiol products. Selection bias, our focus on chronic pain, and our cross-sectional design likely limit the generalizability of our results. Our findings suggest that lower daily cannabis use frequency is associated with better clinical profile as well as lower risk cannabis use behaviors among MED participants. Future longitudinal studies are needed to examine how high frequency of cannabis use interacts with potential therapeutic benefits. PERSPECTIVE: Our findings suggest that lower daily cannabis use frequency is associated with better clinical profile as well as safer use behaviors (eg, preference for cannabidiol and noninhalation administration routes). These trends highlight the need for developing cannabis use guidelines for clinicians to better protect patients using cannabis.

Guideline-recommended vs high-dose long-term opioid therapy for chronic noncancer pain is associated with better health outcomes: data from a representative sample of the German population

Recent evidence-based guidelines for long-term opioid therapy (LTOT) for chronic noncancer pain (CNCP) have defined daily morphine equivalent doses (MEQ/d) that require particular caution. The recommendation for a threshold MEQ/d is based on North American studies that have demonstrated negative health outcomes associated with high-dose LTOT for CNCP. We have conducted a retrospective cross-sectional study using an anonymized German health claims database, including 4,028,618 persons insured by 69 German statutory health insurances, representative of age and sex for the German population in 2014. Those receiving German guideline-recommended opioid treatments (dose <120 mg MEQ/d) for CNCP were compared with those receiving high-dose LTOT (≥120 mg MEQ/d) for selected health outcomes (risky opioid prescribing; hospital admissions due to diagnoses indicative of abuse/addiction of prescribed opioids; and health costs). The prevalence of LTOT for CNCP was 0.8%, with 9.9% receiving high-dose LTOT. Those receiving German guideline-recommended opioid treatments vs those receiving high-dose LTOT differed for the following parameters: risky opioid prescribing (combination with tranquilizers) (11.1% vs 14.3%; P < 0.001), hospital admissions because of mental and behavioral disorders due to alcohol, opioids, tranquilizers, multiple substances and intoxication by narcotic agents (1.6% vs 2.9%; P < 0.001), and total health costs (7259 vs 10,732 Euro; P < 0.001). The difference in annual costs between the 2 groups was largely due to differences in pharmaceutical costs in the outpatient setting (2282 vs 5402 &OV0556;; P < 0.001). These data confirm recommendations for a threshold MEQ/d for CNCP as recommended by recent opioid prescribing guidelines for CNCP.

Changes in pain intensity after discontinuation of long-term opioid therapy for chronic noncancer pain

Little is known about changes in pain intensity that may occur after discontinuation of long-term opioid therapy (LTOT). The objective of this study was to characterize pain intensity after opioid discontinuation over 12 months. This retrospective U.S. Department of Veterans Affairs (VA) administrative data study identified N = 551 patients nationally who discontinued LTOT. Data over 24 months (12 months before and after discontinuation) were abstracted from VA administrative records. Random-effects regression analyses examined changes in 0 to 10 pain numeric rating scale scores over time, whereas growth mixture models delineated pain trajectory subgroups. Mean estimated pain at the time of opioid discontinuation was 4.9. Changes in pain after discontinuation were characterized by slight but statistically nonsignificant declines in pain intensity over 12 months after discontinuation (B = -0.20, P = 0.14). Follow-up growth mixture models identified 4 pain trajectory classes characterized by the following postdiscontinuation pain levels: no pain (average pain at discontinuation = 0.37), mild clinically significant pain (average pain = 3.90), moderate clinically significant pain (average pain = 6.33), and severe clinically significant pain (average pain = 8.23). Similar to the overall sample, pain trajectories in each of the 4 classes were characterized by slight reductions in pain over time, with patients in the mild and moderate pain trajectory categories experiencing the greatest pain reductions after discontinuation (B = -0.11, P = 0.05 and B = -0.11, P = 0.04, respectively). Pain intensity after discontinuation of LTOT does not, on average, worsen for patients and may slightly improve, particularly for patients with mild-to-moderate pain at the time of discontinuation. Clinicians should consider these findings when discussing risks of opioid therapy and potential benefits of opioid taper with patients.

Resilient to Pain: A Model of How Yoga May Decrease Interference Among People Experiencing Chronic Pain

Chronic musculoskeletal pain is the leading cause of disability globally, yet for the majority of people who experience chronic pain, it does not seriously disable them or interfere with their life. People who experience severe pain yet low disability display a resilient course of pain. Yoga has been shown to decrease disability among people with pain, but it is not known how. Because even the most basic yoga practices possess many of the components thought to be important in fostering resilience, yoga is a promising means of improving resilience and clinical outcomes for people with chronic pain. A validated conceptual model of how the experience of chronic pain is affected by yoga is needed to guide a future research agenda and identify potential targets for chronic pain intervention. Ultimately, an explanatory model could guide the optimization of yoga and other non-pharmacological therapies for the treatment of chronic pain. I present a testable model.

A Model of the Intersection of Pain and Opioid Misuse in Children and Adolescents

Despite being a significant public health concern, the role of opioid prescriptions in potentiating risk of opioid misuse in the context of pediatric pain has been under-investigated. To address this gap, the present review identifies theory-based hypotheses about these associations, reviews the extant literature on opioid prescriptions that supports these hypotheses, and provides routes for future empirical studies. A multi-level model of mechanisms through which opioid prescriptions may impact pain and other negative outcomes in youth, including risk for opioid misuse and related problems, is proposed with particular attention paid to the role that psychologists can play in informing policies and developing preventative interventions in healthcare settings.