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Nelson EUE. Addiction stigma and opioid use in chronic non-cancer pain management in Nigeria. SOCIOLOGY OF HEALTH & ILLNESS 2024; 46:457-472. [PMID: 37796514 DOI: 10.1111/1467-9566.13718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 09/18/2023] [Indexed: 10/06/2023]
Abstract
This study uses 26 in-depth interviews conducted with people who use drugs (PWUD) who had sought care for chronic non-cancer pain in public health facilities in Nigeria, to explore how drug consumption stigma constitutes patient legitimacy based on neoliberal ideals. It found drug consumption stigma to be salient and pervasive in PWUD health-care encounters, operating through interpersonal interactions and institutionalised policies and practices to shape access to care. Crucially, stigma emerged through disciplinary opioid prescribing and dispensing practices that defined, categorised and marginalised PWUD based on how their drug consumption disrupted normative values of rationality and responsibility. Accounts additionally revealed disengagement from biomedical care and reliance on alternative pain management approaches (e.g. herbal remedies and illegal drugs), which show how structural positions shape the exercise of choice and agency in socially marginalised populations. In conclusion, the study considers the need to improve the health-care experiences of PWUD as a strategy for enhancing health-care engagement and improving health outcomes. It called for interventions to address the structural factors and interactional dynamics that influence stigma in health-care settings as well as for a review of current guidelines and practices to improve access to opioids for chronic non-cancer pain management.
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Affiliation(s)
- Ediomo-Ubong E Nelson
- Global Drug Policy Observatory, Swansea University, Swansea, UK
- Centre for Research and Information on Substance Abuse, Uyo, Nigeria
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2
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Dickson-Gomez J, Krechel S, Spector A, Weeks M, Ohlrich J, Green Montaque HD, Li J. The effects of opioid policy changes on transitions from prescription opioids to heroin, fentanyl and injection drug use: a qualitative analysis. Subst Abuse Treat Prev Policy 2022; 17:55. [PMID: 35864522 PMCID: PMC9306091 DOI: 10.1186/s13011-022-00480-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Beginning in the 1990s, nonmedical use of prescription opioids (POs) became a major public health crisis. In response to rising rates of opioid dependence and fatal poisonings, measures were instituted to decrease the prescription, diversion, and nonmedical use of POs including prescription drug monitoring programs (PDMPs), pain clinic laws, prescription duration limits, disciplining doctors who prescribed an excessive number of POs, and the advent of abuse deterrent formulations of POs. This paper explores the unintended effects of these policies in the descriptions of why people who use opioids transitioned from PO to injection or heroin/fentanyl use. METHODS We conducted 148 in-depth-interviews with people who use prescription opioids nonmedically, fentanyl or heroin from a rural, urban and suburban area in three states, Connecticut, Kentucky and Wisconsin. Interviews with people who use opioids (PWUO) focused on how they initiated their opioid use and any transitions they made from PO use to heroin, fentanyl or injection drug use. RESULTS The majority of participants reported initiating use with POs, which they used for medical or nonmedical purposes. They described needing to take more POs or switched to heroin or fentanyl as their tolerance increased. As more policies were passed to limit opioid prescribing, participants noticed that doctors were less likely to prescribe or refill POs. This led to scarcity of POs on the street which accelerated the switch to heroin or fentanyl. These transitions likely increased risk of overdose and HIV/HCV infection. CONCLUSIONS A careful analysis of how and why people say they transitioned from PO to heroin or fentanyl reveals many unintended harms of policy changes to prevent overprescribing and diversion. Results highlight the importance of mitigating harms that resulted from policy changes.
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Affiliation(s)
- Julia Dickson-Gomez
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, USA.
| | - Sarah Krechel
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, USA
| | - Antoinette Spector
- Department of Rehabilitative Sciences and Technology, University of Wisconsin, Milwaukee, USA
| | | | - Jessica Ohlrich
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, USA
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3
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Hickey T, Abelleira A, Acampora G, Becker WC, Falker CG, Nazario M, Weimer MB. Perioperative Buprenorphine Management: A Multidisciplinary Approach. Med Clin North Am 2022; 106:169-185. [PMID: 34823729 DOI: 10.1016/j.mcna.2021.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Buprenorphine formulations (including buprenorphine/naloxone) are effective treatments of pain and opioid use disorder (OUD). Historically, perioperative management of patients prescribed buprenorphine involved abstinence from buprenorphine sufficient to allow for unrestricted mu-opioid receptor availability to full agonist opioid (FAO) treatment. Evidence is mounting that a multimodal analgesic strategy, including simultaneous administration of buprenorphine and FAO, nonopioid adjuncts such as acetaminophen and nonsteroidal anti-inflammatory drugs, and regional anesthesia, is a safe and effective perioperative strategy for the patient prescribed long-term buprenorphine treatment of OUD. This strategy will likely simplify management and more seamlessly provide continuous buprenorphine treatment of OUD after hospital discharge.
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MESH Headings
- Acetaminophen/administration & dosage
- Acetaminophen/therapeutic use
- Aged
- Analgesics, Non-Narcotic/administration & dosage
- Analgesics, Non-Narcotic/therapeutic use
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/pharmacology
- Analgesics, Opioid/therapeutic use
- Anti-Inflammatory Agents, Non-Steroidal/administration & dosage
- Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/methods
- Buprenorphine/administration & dosage
- Buprenorphine/pharmacology
- Buprenorphine/therapeutic use
- Combined Modality Therapy/methods
- Drug Compounding/methods
- Female
- Humans
- Interdisciplinary Communication
- Male
- Opiate Substitution Treatment/methods
- Opioid-Related Disorders/drug therapy
- Pain/drug therapy
- Pain Management/methods
- Pain, Postoperative/prevention & control
- Perioperative Care/methods
- Receptors, Opioid, mu/drug effects
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Affiliation(s)
- Thomas Hickey
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA; Department of Anesthesiology, Yale School of Medicine, 950 Campbell Avenue, West Haven, CT 06516, USA.
| | - Audrey Abelleira
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
| | - Gregory Acampora
- MGH/Harvard Center for Addiction Medicine, Pain Management Center at MGH, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - William C Becker
- Pain Research, Informatics, Multimorbidities and Education Center, VA Connecticut Healthcare System; Program in Addiction Medicine, Yale School of Medicine
| | - Caroline G Falker
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
| | - Mitchell Nazario
- National PBM Clinical Program Manager, VHA Pharmacy Benefits Management (12PBM), 1st Avenue - 1 Block North of Cermak (Building 37), Hines, IL 60141, USA
| | - Melissa B Weimer
- Program in Addiction Medicine, Yale School of Medicine; Yale School of Public Health
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4
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Management of Sedation and Analgesia in Critically Ill Patients Receiving Long-Acting Naltrexone Therapy for Opioid Use Disorder. Ann Am Thorac Soc 2021; 17:1352-1357. [PMID: 32866026 DOI: 10.1513/annalsats.202005-554cme] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The explosion of the opioid epidemic in the United States and across the world has been met with advances in pharmacologic therapy for the treatment of opioid use disorder. Long-acting naltrexone is a promising strategy, but its use has important implications for critical care, as it may interfere with or complicate sedation and analgesia. Currently, there are two available formulations of long-acting naltrexone, which are distinguished by different administration routes and distinct pharmacokinetics. The use of long-acting naltrexone may be identified through a variety of strategies (such as physical examination, laboratory testing, and medical record review), and is key to the safe provision of sedation and analgesia during critical illness. Perioperative experience caring for patients receiving long-acting naltrexone informs management in the intensive care unit. Important lessons include the use of multimodal analgesia strategies and anticipating patients' demonstrating variable sensitivity to opioids. For the critically ill patient, however, there are important distinctions to emphasize, including changes in drug metabolism and medication interactions. By compiling and incorporating the currently available literature, we provide critical care physicians with recommendations for the sedation and analgesia for critically ill patients receiving long-acting naltrexone therapy.
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Latif ZEH, Skjaervø I, Solli KK, Tanum L. Chronic Pain Among Patients With an Opioid Use Disorder. Am J Addict 2021; 30:366-375. [PMID: 33738870 DOI: 10.1111/ajad.13153] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 12/01/2020] [Accepted: 01/05/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Chronic pain is not well understood in opioid-dependent populations. We report the prevalence of chronic pain and pain characteristics in an opioid-dependent population by treatment type and gender. METHODS This cross-sectional study opportunistically recruited 569 patients (32% women) receiving treatment for opioid use disorder (DSM-5) in Norway during 2016-2018 (83% received opioid maintenance treatment, 17% received treatment without medication). We asked about chronic pain (≥3 months; ICD-11), pain severity (NRS-11), and other pain characteristics. RESULTS Overall, 55% reported chronic pain (≥3 months), with a higher prevalence among women (61% vs 52%, P = .041) and patients receiving methadone (66%) compared with buprenorphine or no medication (46% and 45%, P < .001). Chronic pain was associated with higher age (P < .001) and higher doses of methadone (P = .048). The average duration of pain was 11 years. The most frequently reported pain locations were the lower extremities (59%) and the back (54%), and 69% reported more than one pain location. Constant pain and migrating pain were significantly associated with both moderate (adjusted odds ratio [aOR]: 2.04, confidence interval [CI]: 1.12-3.74 and aOR: 2.44, CI: 1.09-5.43) and severe pain intensity (aOR: 2.08, CI: 1.14-3.80 and aOR: 2.46, CI: 1.10-5.47). Reporting no effect of analgesics was associated with severe pain intensity (aOR: 0.54, CI: 0.29-0.99). CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE Over half reported chronic pain, and rates were highest among women and patients receiving methadone. New contributions to the field are descriptions of pain characteristics by gender and pain severity, and interactions between medication type and age. (© 2021 The Authors. The American Journal on Addictions published by Wiley Periodicals LLC on behalf of The American Academy of Addiction Psychiatry). (Am J Addict 2021;00:00-00).
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Affiliation(s)
- Zill-E Huma Latif
- Department of Research and Development in Mental Health Service, Akershus University Hospital, Lørenskog, Norway
| | - Ingeborg Skjaervø
- Department of Research and Development in Mental Health Service, Akershus University Hospital, Lørenskog, Norway.,Norwegian Centre for Violence and Traumatic Stress Studies, Oslo, Norway
| | - Kristin K Solli
- Department of Research and Development in Mental Health Service, Akershus University Hospital, Lørenskog, Norway.,Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway.,Vestfold Hospital Trust, Tønsberg, Norway
| | - Lars Tanum
- Department of Research and Development in Mental Health Service, Akershus University Hospital, Lørenskog, Norway.,Faculty for Health Science, Oslo Metropolitan University, Oslo, Norway
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Mazanec P, Paice J, Campbell G, Ginex PK, Harris M, Matzo M. Managing pain in seriously ill patients with substance use disorders. Nursing 2021; 51:32-39. [PMID: 33346615 DOI: 10.1097/01.nurse.0000724344.85870.b2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
ABSTRACT Managing pain can be challenging, especially in patients with serious illnesses and a history of substance use disorders. This article discusses the challenges of addressing pain in these patients and offers perspectives regarding their clinical management.
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Affiliation(s)
- Polly Mazanec
- Polly Mazanec is a visiting associate professor at Case Western Reserve University in Cleveland, Ohio; Judy Paice is director of the cancer pain program at Northwestern University in Chicago, Ill.; Grace Campbell is an assistant professor at the University of Pittsburgh in Pittsburgh, Pa.; Pamela K. Ginex is a senior manager of evidence-based practice and inquiry at the Oncology Nursing Society in Pittsburgh, Pa.; Melodee Harris is an associate professor at the University of Arkansas in Little Rock, Ark.; and. Marianne Matzo is the former director of research at the Hospice and Palliative Nurses Association in Pittsburgh, Pa
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7
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Medication-Assisted Treatment for Opioid Use Disorder in Pregnancy: Practical Applications and Clinical Impact. Obstet Gynecol Surv 2020; 75:175-189. [PMID: 32232496 DOI: 10.1097/ogx.0000000000000744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Importance Opioid use disorder is increasingly common in the United States and affects many pregnancies. Given the rise in pregnancies complicated by opioid use, providers should understand the diagnosis and management of opioid use disorder in pregnancy. Objective This article focuses on screening for opioid misuse, selecting appropriate treatment for patients, initiating medication-assisted treatment in the inpatient setting, and providing appropriate peripartum care. Evidence Acquisition A PubMed search was undertaken using the following search terms: "opioid use disorder", "pregnancy," "medication assisted treatment," "buprenorphine," "methadone," "heroin," "addiction," "neonatal abstinence syndrome," and "detoxification." The search was limited to the English language publications, with most being published after 2000. Results All women should be screened for opioid use disorder during pregnancy. Opioid use has profound effects on the mother and infant. Medication-assisted treatment is the standard of care for pregnant women with opioid use disorder. Patients will require a multidisciplinary approach to management in the intrapartum and postpartum period. Conclusions Conclusions Opioid use disorder is a common, chronic condition with significant implications during pregnancy. Recognition and appropriate treatment of this disorder can optimize maternal and fetal outcomes. Conclusions Obstetricians are increasingly being challenged to manage pregnancies complicated by opioid use disorder and should be proficient in providing safe and effective care.
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Habib AM, Nagi K, Thillaiappan NB, Sukumaran V, Akhtar S. Vitamin D and Its Potential Interplay With Pain Signaling Pathways. Front Immunol 2020; 11:820. [PMID: 32547536 PMCID: PMC7270292 DOI: 10.3389/fimmu.2020.00820] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 04/09/2020] [Indexed: 12/12/2022] Open
Abstract
About 50 million of the U.S. adult population suffer from chronic pain. It is a complex disease in its own right for which currently available analgesics have been deemed woefully inadequate since ~20% of the sufferers derive no benefit. Vitamin D, known for its role in calcium homeostasis and bone metabolism, is thought to be of clinical benefit in treating chronic pain without the side-effects of currently available analgesics. A strong correlation between hypovitaminosis D and incidence of bone pain is known. However, the potential underlying mechanisms by which vitamin D might exert its analgesic effects are poorly understood. In this review, we discuss pathways involved in pain sensing and processing primarily at the level of dorsal root ganglion (DRG) neurons and the potential interplay between vitamin D, its receptor (VDR) and known specific pain signaling pathways including nerve growth factor (NGF), glial-derived neurotrophic factor (GDNF), epidermal growth factor receptor (EGFR), and opioid receptors. We also discuss how vitamin D/VDR might influence immune cells and pain sensitization as well as review the increasingly important topic of vitamin D toxicity. Further in vitro and in vivo experimental studies will be required to study these potential interactions specifically in pain models. Such studies could highlight the potential usefulness of vitamin D either alone or in combination with existing analgesics to better treat chronic pain.
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Affiliation(s)
| | | | | | | | - Saghir Akhtar
- College of Medicine, QU Health, Qatar University, Doha, Qatar
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9
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Painful lives: Chronic pain experience among people who use illicit drugs in Montreal (Canada). Soc Sci Med 2020; 246:112734. [DOI: 10.1016/j.socscimed.2019.112734] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 12/05/2019] [Accepted: 12/12/2019] [Indexed: 01/03/2023]
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10
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Martin CE, Terplan M, Krans EE. Pain, Opioids, and Pregnancy: Historical Context and Medical Management. Clin Perinatol 2019; 46:833-847. [PMID: 31653311 DOI: 10.1016/j.clp.2019.08.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Women are being disproportionately affected by the opioid crisis, including during pregnancy. Pain and other vulnerabilities to addiction differ between men and women. Management of opioid use disorder should be gender informed and accessible across the lifespan. During pregnancy, care teams should be multidisciplinary to include obstetrics, addiction, social work, anesthesia, pediatrics, and behavioral health. Pain management for women with opioid use disorder requires tailored approaches, including integration of trauma-informed care and addressing psychosocial needs. Thus, coordinated continued care by obstetric and addiction providers through pregnancy into postpartum is key to supporting women in recovery.
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Affiliation(s)
- Caitlin E Martin
- Department of Obstetrics and Gynecology, Virginia Commonwealth University, 1250 East Marshall Street, Richmond, VA 23298-0268, USA
| | - Mishka Terplan
- Friends Research Institute, 1040 Park Ave, Suite 103, Baltimore MD 21202, USA.
| | - Elizabeth E Krans
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Magee-Womens Research Institute, 300 Halket Street, Pittsburgh, PA 15213, USA
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11
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Dassieu L, Kaboré JL, Choinière M, Arruda N, Roy É. Understanding the link between substance use and chronic pain: A qualitative study among people who use illicit drugs in Montreal, Canada. Drug Alcohol Depend 2019; 202:50-55. [PMID: 31301552 DOI: 10.1016/j.drugalcdep.2019.07.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 06/26/2019] [Accepted: 07/02/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Lise Dassieu
- Université de Sherbrooke, Addiction Research and Study Program, Faculty of Medicine and Health Sciences, 150 Place Charles-Le Moyne, Longueuil, Québec, J4K 0A8, Canada; Research Center of the Centre Hospitalier de l'Université de Montréal (CRCHUM), Saint-Antoine Building, 850 Saint-Denis St, Montreal, Quebec, H2X 0A9, Canada.
| | - Jean-Luc Kaboré
- Research Center of the Centre Hospitalier de l'Université de Montréal (CRCHUM), Saint-Antoine Building, 850 Saint-Denis St, Montreal, Quebec, H2X 0A9, Canada; Université de Montréal, Faculty of Medicine, Department of Pharmacology and Physiology, Pavillon Roger-Gaudry, C.P. 6128, succursale Centre-ville, Montreal, Quebec, H3C 3J7, Canada
| | - Manon Choinière
- Research Center of the Centre Hospitalier de l'Université de Montréal (CRCHUM), Saint-Antoine Building, 850 Saint-Denis St, Montreal, Quebec, H2X 0A9, Canada; Université de Montréal, Faculty of Medicine, Department of Anesthesiology and Pain Medicine, Pavillon Roger-Gaudry, C.P. 6128, succursale Centre-ville, Montreal, Québec, H3C 3J7, Canada
| | - Nelson Arruda
- Université de Sherbrooke, Addiction Research and Study Program, Faculty of Medicine and Health Sciences, 150 Place Charles-Le Moyne, Longueuil, Québec, J4K 0A8, Canada
| | - Élise Roy
- Université de Sherbrooke, Addiction Research and Study Program, Faculty of Medicine and Health Sciences, 150 Place Charles-Le Moyne, Longueuil, Québec, J4K 0A8, Canada; Institut National de Santé Publique du Québec, 190 Crémazie Blvd. East, Montreal, Quebec, H2P 1E2, Canada
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Cornett EM, Kline RJ, Robichaux SL, Green JB, Anyama BC, Gennuso SA, Okereke EC, Kaye AD. Comprehensive Perioperative Management Considerations in Patients Taking Methadone. Curr Pain Headache Rep 2019; 23:49. [PMID: 31209656 DOI: 10.1007/s11916-019-0783-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE OF REVIEW Well-informed staff can help decrease risks and common misconceptions regarding opioid-tolerant patients, especially those taking methadone. RECENT FINDINGS In 2015, opioid pain relievers were the second most used drug at 3.8 million. Overdose death was three times greater in 2015 than in 2000. Medication-assisted treatment was sought by more than 2 million individuals with substance use disorder, one of which is methadone. Chronic pain affects millions of adults in the USA. Opioid therapy is widely used among these adults. Related to the risk of abuse and dependence, guidelines suggest that opioid therapy may not be considered first-line treatment. A multidisciplinary approach, including thorough preoperative evaluation, the utilization of multimodal pain management strategies, and opioid-sparing techniques in both the intraoperative and postoperative periods will allow for the best possible outcome.
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Affiliation(s)
- Elyse M Cornett
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Ryan J Kline
- Department of Anesthesiology, LSU Health Sciences Center New Orleans, Room 659, 1542 Tulane Ave, New Orleans, LA, 70112, USA
| | - Spencer L Robichaux
- Department of Anesthesiology, LSU Health Sciences Center, Room 656, 1542 Tulane Ave, New Orleans, LA, 70112, USA
| | - Jeremy B Green
- Department of Anesthesiology, LSU Health Sciences Center, Room 656, 1542 Tulane Ave, New Orleans, LA, 70112, USA
| | - Boris C Anyama
- Saint George's University School of Medicine, University Centre Grenada, West Indies, Grenada
| | - Sonja A Gennuso
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Eva C Okereke
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Alan D Kaye
- Department of Anesthesiology, LSU Health Sciences Center, Room 656, 1542 Tulane Ave, New Orleans, LA, 70112, USA
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13
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Dassieu L, Kaboré JL, Choinière M, Arruda N, Roy É. Chronic pain management among people who use drugs: A health policy challenge in the context of the opioid crisis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 71:150-156. [PMID: 30975594 DOI: 10.1016/j.drugpo.2019.03.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 02/04/2019] [Accepted: 03/01/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND In Canada, the rise in prescription opioid (PO) overdoses and addiction is a major public health concern. Various health authorities have recently recommended that physicians use caution when prescribing opioids, especially to people with histories of substance use. As a result, fewer therapeutic options are available for people who use drugs (PWUD) and suffer from chronic non-cancer pain (CNCP). This paper examines how PWUD describe their experiences with CNCP management in the context of the opioid crisis. METHODS This qualitative study is based on in-depth interviews with Montreal (Canada) PWUD experiencing CNCP for 3 months or more. RESULTS Most of the 25 participants (27-61 years; 10 women, 15 men) were polysubstance users (cocaine, opioids, amphetamine, etc.) suffering from CNCP for several years, with multiple additional health and social problems. The majority were unsatisfied with their CNCP management. They felt labelled as "addicts" and stigmatized within the healthcare system. Many participants had been denied PO, even those with severe CNCP and those who were not opioid-dependent. Participants expressed a desire to access non-pharmacological CNCP therapies, but these were often too expensive. Some PWUD were offered methadone to relieve CNCP and found this inappropriate. As a last resort several participants reported self-medicating CNCP with street drugs, increasingly known to be laced with fentanyl. CONCLUSION PWUD with CNCP are affected by two opioid crises: the PO crisis and the street-opioid crisis. The lack of a coherent policy that addresses their pain management produces reoccurring problems when seeking CNCP relief. Restrictive prescription measures implemented in response to the PO crisis may have consequences similar to prohibitionist policies: they heighten overdose risks for PWUD by increasing exposure to street drugs laced with fentanyl. Improving access to diverse CNCP management options for PWUD can help reduce harms related to street-opioid use.
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Affiliation(s)
- Lise Dassieu
- Université de Sherbrooke, Addiction Research and Study Program, Faculty of Medicine and Health Sciences, 150 Place Charles-Le Moyne, Longueuil, Québec, J4K 0A8, Canada.
| | - Jean-Luc Kaboré
- Research Centre, Centre Hospitalier de l'Université de Montréal (CRCHUM), Saint-Antoine Building, 850 Saint-Denis Street, Montreal, Quebec, H2X 0A9, Canada; Université de Montréal, Faculty of Medicine, Department of Pharmacology and Physiology, Pavillon Roger-Gaudry, C.P. 6128, Succursale Centre-ville, Montreal, Quebec, H3C 3J7, Canada
| | - Manon Choinière
- Research Centre, Centre Hospitalier de l'Université de Montréal (CRCHUM), Saint-Antoine Building, 850 Saint-Denis Street, Montreal, Quebec, H2X 0A9, Canada; Université de Montréal, Faculty of Medicine, Department of Anesthesiology and Pain Medicine, Pavillon Roger-Gaudry, C.P. 6128, Succursale Centre-ville, Montreal, Québec, H3C 3J7, Canada
| | - Nelson Arruda
- Université de Sherbrooke, Addiction Research and Study Program, Faculty of Medicine and Health Sciences, 150 Place Charles-Le Moyne, Longueuil, Québec, J4K 0A8, Canada
| | - Élise Roy
- Université de Sherbrooke, Addiction Research and Study Program, Faculty of Medicine and Health Sciences, 150 Place Charles-Le Moyne, Longueuil, Québec, J4K 0A8, Canada; Institut National de Santé Publique du Québec, 190 Crémazie Blvd. East, Montreal, Quebec, H2P 1E2, Canada
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Coloma-Carmona A, Carballo JL, Rodríguez-Marín J, Pérez-Carbonell A. Withdrawal symptoms predict prescription opioid dependence in chronic pain patients. Drug Alcohol Depend 2019; 195:27-32. [PMID: 30562677 DOI: 10.1016/j.drugalcdep.2018.11.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 11/12/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND The last version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes substantial changes for prescription opioid-use disorder (POUD). After its removal as a criterion, the goal of this study was to estimate the prevalence of withdrawal symptoms in long-term users of prescription opioids and its association with the new DSM-5 POUD classification. METHODS Data were collected from 215 long-term consumers of opioid medication who were chronic non-cancer pain patients. Participants completed sociodemographic, Adjective Rating Scale for Withdrawal (ARSW), opioid treatment characteristics, POUD criteria (DSM-5), and pain intensity measurements. RESULTS 26.6% of the participants were classified with moderate to severe POUD. Higher intensity of withdrawal symptoms was found in patients with moderate/severe POUD, younger age, and higher pain intensity (p < .01). Anxiolytics (p < .01) and antidepressants use (p < .05) and percentage of smokers (p < .05) were significantly higher in patients with severe withdrawal. Logistic regression analyses suggested moderate [odds ratio (OR) = 3.25] and severe (OR = 10.52) withdrawal as the strongest predictor of POUD. Age, anxiolytics use, and smoking were also associated with POUD, but multilevel analysis showed that these variables do not moderate the association between withdrawal intensity and POUD. CONCLUSION Escalation of withdrawal intensity during opioid treatment can be used to identify patients with POUD. Further studies are needed to assess the clinical implications of these findings during long-term opioid therapy for chronic pain.
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Affiliation(s)
- Ainhoa Coloma-Carmona
- Center for Applied Psychology, Miguel Hernández University, Avenida Universidad, s/n, 03202, Elche, Spain.
| | - José L Carballo
- Center for Applied Psychology, Miguel Hernández University, Avenida Universidad, s/n, 03202, Elche, Spain.
| | - Jesús Rodríguez-Marín
- Center for Applied Psychology, Miguel Hernández University, Avenida Universidad, s/n, 03202, Elche, Spain.
| | - Ana Pérez-Carbonell
- University General Hospital of Elche, Camino de la Almazara, 11, 03203, Elche, Spain.
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15
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Negative experiences of pain and withdrawal create barriers to abscess care for people who inject heroin. A mixed methods analysis. Drug Alcohol Depend 2018; 190:200-208. [PMID: 30055424 DOI: 10.1016/j.drugalcdep.2018.06.010] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 05/27/2018] [Accepted: 06/05/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Skin and soft tissue infections (SSTIs) are prevalent among people who inject heroin (PWIH). Delays in seeking health care lead to increased costs and potential mortality, yet the barriers to accessing care among PWIHs are poorly understood. METHODS We administered a quantitative survey (N = 145) and conducted qualitative interviews (N = 12) with PWIH seeking syringe exchange services in two U.S. cities. RESULTS 66% of participants had experienced at least one SSTI. 38% reported waiting two weeks or more to seek care, and 57% reported leaving the hospital against medical advice. 54% reported undergoing a drainage procedure performed by a non-medical professional, and 32% reported taking antibiotics that were not prescribed to them. Two of the most common reasons for these behaviors were fear of withdrawal symptoms and inadequate pain control, and these reasons emerged as prominent themes in the qualitative findings. These issues are often predicated on previous negative experiences and exacerbated by stigma and an asymmetrical power dynamic with providers, resulting in perceived barriers to seeking and completing care for SSTIs. CONCLUSIONS For PWIH, unaddressed pain and withdrawal symptoms contribute to profoundly negative health care experiences, which then generate motivation for delaying care SSTI seeking and for discharge against medical advice. Health care providers and hospitals should develop policies to improve pain control, manage opioid withdrawal, minimize prejudice and stigma, and optimize communication with PWIH. These barriers should also be addressed by providing medical care in accessible and acceptable venues, such as safe injection facilities, street outreach, and other harm reduction venues.
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16
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Klinge M, Coppler T, Liebschutz JM, Dugum M, Wassan A, DiMartini A, Rogal S. The assessment and management of pain in cirrhosis. ACTA ACUST UNITED AC 2018; 17:42-51. [PMID: 29552453 DOI: 10.1007/s11901-018-0389-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Purpose of review The treatment of pain in patients with cirrhosis is complicated by unpredictable hepatic drug metabolism and a higher risk of adverse drug reactions. We aimed to conduct a scoping review regarding pain management in cirrhosis. Recent findings Despite the high prevalence of pain in patients with cirrhosis, there is little literature to guide the management of pain in this population. Complex pain syndromes and disease-specific pain etiologies exist are common in patients with cirrhosis. There are numerous contraindications and limitations when considering pharmacotherapy for analgesia in cirrhosis, specifically with non-steroidal anti-inflammatory drugs (NSAIDS) and opioid medications. Non-pharmacologic therapies for pain have not been specifically assessed in this population. Summary As with other populations, a multi-dimensional treatment approach to pain with a focus on physical, behavioral, procedural and pharmacologic treatment is recommended when caring for patients with cirrhosis and pain. However, more research is needed to evaluate opioid-sparing and non-pharmacologic analgesia in this population.
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Affiliation(s)
- Matthew Klinge
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh
| | - Tami Coppler
- Division of Pharmacy, VA Pittsburgh Healthcare System
| | | | - Mohannad Dugum
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh
| | - Ajay Wassan
- Department of Anesthesiology, University of Pittsburgh
| | - Andrea DiMartini
- Department of Psychiatry, University of Pittsburgh.,Department of Surgery, University of Pittsburgh
| | - Shari Rogal
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh.,Department of Surgery, University of Pittsburgh.,Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System
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17
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Abstract
Supplemental Digital Content is Available in the Text. This descriptive case series among adults documents that pain can return temporarily at healed, previously pain-free injury sites during acute opioid withdrawal. Withdrawal pain can be a barrier to opioid cessation. Yet, little is known about old injury site pain in this context. We conducted an exploratory mixed-methods descriptive case series using a web-based survey and in-person interviews with adults recruited from pain and addiction treatment and research settings. We included individuals who self-reported a past significant injury that was healed and pain-free before the initiation of opioids, which then became temporarily painful upon opioid cessation—a phenomenon we have named withdrawal-associated injury site pain (WISP). Screening identified WISP in 47 people, of whom 34 (72%) completed the descriptive survey, including 21 who completed qualitative interviews. Recalled pain severity scores for WISP were typically high (median: 8/10; interquartile range [IQR]: 2), emotionally and physically aversive, and took approximately 2 weeks to resolve (median: 14; IQR: 24 days). Withdrawal-associated injury site pain intensity was typically slightly less than participants' original injury pain (median: 10/10; IQR: 3), and more painful than other generalized withdrawal symptoms which also lasted approximately 2 weeks (median: 13; IQR: 25 days). Fifteen surveyed participants (44%) reported returning to opioid use because of WISP in the past. Participants developed theories about the etiology of WISP, including that the pain is the brain's way of communicating a desire for opioids. This research represents the first known documentation that previously healed, and pain-free injury sites can temporarily become painful again during opioid withdrawal, an experience which may be a barrier to opioid cessation, and a contributor to opioid reinitiation.
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18
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Nordmann S, Vilotitch A, Lions C, Michel L, Mora M, Spire B, Maradan G, Bendiane MK, Morel A, Roux P, Carrieri P. Pain in methadone patients: Time to address undertreatment and suicide risk (ANRS-Methaville trial). PLoS One 2017; 12:e0176288. [PMID: 28520735 PMCID: PMC5435132 DOI: 10.1371/journal.pone.0176288] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 04/07/2017] [Indexed: 12/21/2022] Open
Abstract
Background Pain in opioid-dependent patients is common but data measuring the course of pain (and its correlates) using validated scales in patients initiating methadone treatment are sparse. We aimed to assess pain and its interference in daily life, associated correlates, and undertreatment before and during methadone treatment. Methods This is a secondary analysis using longitudinal data of a randomized trial comparing two methadone initiation models. We assessed the effect of methadone initiation and other correlates on pain intensity and interference (using the Brief Pain Inventory) at months 0, 6 and 12 using a mixed multinomial logistic regression model. Results The study group comprised 168 patients who had data for either pain intensity or interference for at least one visit. Moderate to severe pain was reported in 12.9% of patients at M0, 5.4% at M6 and 7.3% at M12. Substantial interference with daily functioning was reported in 36.0% at M0, 14.5% at M6 and 17.1% at M12. Of the 98 visits where patients reported moderate to severe pain or substantial interference, 55.1% reported no treatment for pain relief, non-opioid analgesics were reported by 34.7%, opioid analgesics by 3.1% and both opioid and non-opioid analgesics by 7.1%. Methadone was associated with decreased pain intensity at 6 months (OR = 0.29, p = 0.04) and 12 months (OR = 0.30, p = 0.05) of follow-up and tended to be associated with substantial pain interference. Suicide risk was associated with both pain intensity and pain interference. Conclusions Methadone in opioid-dependent patients can reduce pain. However, undertreatment of pain in methadone patients remains a major clinical concern. Patients with pain are at higher risk of suicide. Adequate screening and management of pain in this population is a priority and needs to be integrated into routine comprehensive care.
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Affiliation(s)
- Sandra Nordmann
- Aix Marseille Université, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, Marseille, France
- ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Marseille, France
| | - Antoine Vilotitch
- Aix Marseille Université, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, Marseille, France
- ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Marseille, France
| | - Caroline Lions
- Aix Marseille Université, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, Marseille, France
- ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Marseille, France
| | - Laurent Michel
- INSERM, UMR-S 669, Paris, France
- Université Paris-Sud and Université Paris Descartes, UMR-S 669, Paris, France
- Centre Pierre Nicole, Paris, France
| | - Marion Mora
- Aix Marseille Université, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, Marseille, France
- ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Marseille, France
| | - Bruno Spire
- Aix Marseille Université, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, Marseille, France
- ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Marseille, France
| | - Gwenaelle Maradan
- Aix Marseille Université, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, Marseille, France
- ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Marseille, France
| | - Marc-Karim Bendiane
- Aix Marseille Université, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, Marseille, France
- ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Marseille, France
| | | | - Perrine Roux
- Aix Marseille Université, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, Marseille, France
- ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Marseille, France
| | - Patrizia Carrieri
- Aix Marseille Université, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, Marseille, France
- ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Marseille, France
- * E-mail:
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Vadivelu N, Lumermann L, Zhu R, Kodumudi G, Elhassan AO, Kaye AD. Pain Control in the Presence of Drug Addiction. Curr Pain Headache Rep 2016; 20:35. [PMID: 27068665 DOI: 10.1007/s11916-016-0561-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Drug addiction is present in a significant proportion of the population in the USA and worldwide. Drug addiction can occur with the abuse of many types of substances including cocaine, marijuana, stimulants, alcohol, opioids, and tranquilizers. There is a high likelihood that clinicians will encounter patients with substance abuse disorders on a regular basis with the prevalence of the use of illicit substances and the high rate of abuse of prescription drugs. The use of abuse deterrent formulations of prescription opioid agents, pill counts, and urine drug abuse screenings are all useful strategies. Optimum pain management of patients with addiction in the outpatient and inpatient setting is essential to minimize pain states. Careful selection of medications and appropriate oversight, including drug agreements, can reduce drug-induced impairments, including sleep deficits and diminished physical, social, and sexual functioning. This review, therefore, discusses the prevalence of illicit and prescription drug addiction, the challenges of achieving optimum pain control, and the therapeutic approaches to be considered in this challenging population. More research is warranted to develop improved therapies and routes of treatments for optimum pain relief and to prevent the development of central sensitization, chronic pain, and impaired physical and social functioning in patients with drug addiction.
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Affiliation(s)
- Nalini Vadivelu
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, 06520, USA.
| | | | - Richard Zhu
- Yale University School of Medicine, New Haven, CT, 06520, USA
| | - Gopal Kodumudi
- California North State University College of Medicine, 9700 W Taron, Elk Grove, CA, 95757, USA
| | - Amir O Elhassan
- Department of Anesthesiology, LSU School of Medicine, New Orleans, LA, USA
| | - Alan David Kaye
- Department of Anesthesiology, LSU School of Medicine, New Orleans, LA, USA
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20
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Donroe JH, Holt SR, Tetrault JM. Caring for patients with opioid use disorder in the hospital. CMAJ 2016; 188:1232-1239. [PMID: 27647616 PMCID: PMC5135493 DOI: 10.1503/cmaj.160290] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Joseph H Donroe
- Department of General Internal Medicine, Yale University School of Medicine, New Haven, Conn.
| | - Stephen R Holt
- Department of General Internal Medicine, Yale University School of Medicine, New Haven, Conn
| | - Jeanette M Tetrault
- Department of General Internal Medicine, Yale University School of Medicine, New Haven, Conn
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21
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Dunn KE, Finan PH, Tompkins DA, Fingerhood M, Strain EC. Characterizing pain and associated coping strategies in methadone and buprenorphine-maintained patients. Drug Alcohol Depend 2015; 157:143-9. [PMID: 26518253 PMCID: PMC4663104 DOI: 10.1016/j.drugalcdep.2015.10.018] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 10/13/2015] [Accepted: 10/13/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Chronic pain is common among patients receiving opioid maintenance treatment (OMT) for opioid use disorder. To aid development of treatment recommendations for coexisting pain and opioid use disorder, it is necessary to characterize pain treatment needs and assess whether needs differ as a function of OMT medication. METHODS A point-prevalence survey assessing pain and engagement in coping strategies was administered to 179 methadone and buprenorphine-maintained patients. RESULTS Forty-two percent of participants were categorized as having chronic pain. Methadone patients had greater severity of pain relative to buprenorphine patients, though both groups reported high levels of interference with daily activities, and participants with pain attended the emergency room more frequently relative to participants without pain. Only 2 coping strategies were being utilized by more than 50% of participants (over-the-counter medication, prayer). CONCLUSIONS Results indicate that pain among OMT patients is common, severe, and of significant impairment. Methadone patients reported greater severity pain, particularly worse pain in the past 24h, though interference from pain in daily activities did not vary as a function of OMT. Most participants with pain were utilizing few evidenced-based pain coping strategies. Increasing OMT patient access to additional pain treatment strategies is an opportunity for immediate intervention, and similarities across OMT type suggest interventions do not need to be customized to methadone vs. buprenorphine patients.
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Affiliation(s)
- Kelly E Dunn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Patrick H Finan
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - D Andrew Tompkins
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Michael Fingerhood
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Eric C Strain
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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22
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Tsui JI, Lira MC, Cheng DM, Winter MR, Alford DP, Liebschutz JM, Mao J, Edwards RR, Samet JH. Hepatitis C virus infection and pain sensitivity in patients on methadone or buprenorphine maintenance therapy for opioid use disorders. Drug Alcohol Depend 2015; 153:286-92. [PMID: 26048638 PMCID: PMC4509826 DOI: 10.1016/j.drugalcdep.2015.05.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 05/02/2015] [Accepted: 05/04/2015] [Indexed: 01/17/2023]
Abstract
BACKGROUND Patients with opioid use disorders on opioid agonist therapy (OAT) have lower pain tolerance compared to controls. While chronic viral infections such as HCV and HIV have been associated with chronic pain in this population, no studies have examined their impact on pain sensitivity. METHODS We recruited 106 adults (41 uninfected controls; 40 HCV mono-infected; and 25 HCV/HIV co-infected) on buprenorphine or methadone to assess whether HCV infection (with or without HIV) was associated with increased experimental pain sensitivity and self-reported pain. The primary outcome was cold pain tolerance assessed by cold-pressor test. Secondary outcomes were cold pain thresholds, wind-up ratios to repetitive mechanical stimulation (i.e., temporal summation) and acute and chronic pain. Multivariable regression models evaluated associations between viral infection status and outcomes, adjusting for other factors. RESULTS No significant differences were detected across groups for primary or secondary outcomes. Adjusted mean cold pain tolerance was 25.7 (uninfected controls) vs. 26.8 (HCV mono-infection) vs. 25.3 (HCV/HIV co-infection) seconds (global p-value=0.93). Current pain appeared more prevalent among HCV mono-infected (93%) compared to HCV/HIV co-infected participants (76%) and uninfected controls (80%), as did chronic pain (77% vs. 64% vs. 61%, respectively). However, differences were not statistically significant in multivariable models. CONCLUSION This study did not detect an association between HCV infection and increased sensitivity to pain among adults with and without HIV who were treated with buprenorphine or methadone for opioid use disorders. Results reinforce that pain and hyperalgesia are common problems in this population.
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Affiliation(s)
- Judith I. Tsui
- Section of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, 325 9 Avenue Seattle, WA 98104
| | - Marlene C. Lira
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, 801 Massachusetts Ave., Second Floor, Boston, MA 02118
| | - Debbie M. Cheng
- Department of Biostatistics, Boston University School of Public Health, 801 Massachusetts Ave., Third Floor, Boston, MA 02118
| | - Michael R. Winter
- Data Coordinating Center, Boston University School of Public Health, 801 Massachusetts Ave., Third Floor, Boston, MA 02118
| | - Daniel P. Alford
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, 801 Massachusetts Ave., Second Floor, Boston, MA 02118,Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, 801 Massachusetts Ave., Second Floor, Boston, MA 02118
| | - Jane M. Liebschutz
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, 801 Massachusetts Ave., Second Floor, Boston, MA 02118,Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, 801 Massachusetts Ave., Second Floor, Boston, MA 02118
| | - Jianren Mao
- Department of Anesthesia, Massachusetts General Hospital, 101 Merrimac Street, Boston, MA 02110
| | - Robert R. Edwards
- Department of Anesthesia, Brigham and Women’s Hospital, Pain Management Center, 850 Boylston Street, Chestnut Hill, MA 02467
| | - Jeffrey H. Samet
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, 801 Massachusetts Ave., Second Floor, Boston, MA 02118,Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, 801 Massachusetts Ave., Second Floor, Boston, MA 02118,Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Ave., Second Floor, Boston, MA 02118
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23
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Chronic pain and depression among primary care patients treated with buprenorphine. J Gen Intern Med 2015; 30:935-41. [PMID: 25678375 PMCID: PMC4471032 DOI: 10.1007/s11606-015-3212-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 01/08/2015] [Accepted: 01/21/2015] [Indexed: 10/24/2022]
Abstract
BACKGROUND Pain and depression are each prevalent among opioid dependent patients receiving maintenance buprenorphine, but their interaction has not been studied in primary care patients. OBJECTIVE We set out to examine the relationship between chronic pain, depression, and ongoing substance use, among persons maintained on buprenorphine in primary care settings. DESIGN Between September 2012 and December 2013, we interviewed buprenorphine patients at three practice sites. PARTICIPANTS Opioid dependent persons at two private internal medicine offices and a federally qualified health center participated in the study. MAIN MEASURES Pain was measured in terms of chronicity, with chronic pain being defined as pain lasting at least 6 months; and in terms of severity, as measured by self-reported pain in the past week, measured on a 0-100 scale. We defined mild chronic pain as pain severity between 0 and 39 and lasting at least 6 months, and moderate/severe chronic pain as severity ≥ 40 and lasting at least 6 months. To assess depression, we used the Center for Epidemiologic Studies Depression (CESD) ten-item symptom scale and the two-item Patient Health Questionnaire (PHQ-2). KEY RESULTS Among 328 participants, 169 reported no chronic pain, 56 reported mild chronic pain, and 103 reported moderate/severe chronic pain. Participants with moderate/severe chronic pain commonly used non-opioid pain medications (56.3%) and antidepressants (44.7%), yet also used marijuana, alcohol, or cocaine (40.8%) to help relieve pain. Mean CESD scores were 7.1 (±6.8), 8.3 (±6.0), and 13.6 (±7.6) in the no chronic, mild, and moderate/severe pain groups, respectively. Controlling for covariates, higher CESD scores were associated with a higher likelihood of moderate/severe chronic pain relative to both no chronic pain (OR = 1.09, p < 0.001) and mild chronic pain (OR = 1.06, p = 0.04). CONCLUSION Many buprenorphine patients are receiving over-the-counter or prescribed pain medications, as well as antidepressants, and yet continue to have significant and disabling pain and depressive symptoms. There is a clear need to address the pain-depression nexus in novel ways.
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Dunn KE, Brooner RK, Clark MR. Severity and Interference of Chronic Pain in Methadone-Maintained Outpatients. PAIN MEDICINE 2014; 15:1540-8. [DOI: 10.1111/pme.12430] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Eyler ECH. Chronic and acute pain and pain management for patients in methadone maintenance treatment. Am J Addict 2014; 22:75-83. [PMID: 23398230 DOI: 10.1111/j.1521-0391.2013.00308.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Revised: 03/01/2012] [Accepted: 08/20/2012] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Many individuals receiving methadone maintenance treatment (MMT) for opioid addiction also require treatment for acute or chronic pain, and the presence of pain is known to have a negative impact on patient health and function. However, effective pain management in this population is complicated by many factors, including heightened pain sensitivity, high opioid tolerance, illicit substance use, and variable cross-tolerance to opioid pain medications. This article reviews the recent literature on acute and chronic pain among, and pain treatment of, patients receiving MMT for opioid addiction and discusses the implications for effective pain management. Acute pain management among women maintained on methadone during and after labor and delivery is also discussed, as well as common concerns held by patients and providers about appropriate pain management strategies in the context of methadone maintenance and addiction treatment. METHODS One hundred nine articles were identified in a PubMed/MEDLINE electronic database search using the following search terms: methadone, methadone maintenance, methadone addiction, pain, pain management, chronic pain, and acute pain. Abstracts were reviewed for relevance, and additional studies were extracted from the reference lists of articles identified in the original search. RESULTS The pain sensitivity and pain responses of MMT patients differ significantly from those of patients not maintained on opioids, and few data are available to guide patient care. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE Rigorous studies are needed to identify and evaluate effective pain management approaches for this unique patient population and to improve patient treatment outcomes.
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Affiliation(s)
- Elizabeth C H Eyler
- JBS International, Inc., 5515 Security Lane, Suite 800, North Bethesda, MD 20852, USA.
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Nosyk B, Fischer B, Sun H, Marsh DC, Kerr T, Rehm JT, Anis AH. High levels of opioid analgesic co-prescription among methadone maintenance treatment clients in British Columbia, Canada: results from a population-level retrospective cohort study. Am J Addict 2014; 23:257-64. [PMID: 24724883 PMCID: PMC4033518 DOI: 10.1111/j.1521-0391.2014.12091.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 04/22/2013] [Accepted: 06/01/2013] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The non-medical use of prescription opioids (PO) has increased dramatically in North America. Special consideration for PO prescription is required for individuals in methadone maintenance treatment (MMT). Our objective is to describe the prevalence and correlates of PO use among British Columbia (BC) MMT clients from 1996 to 2007. METHODS This study was based on a linked, population-level medication dispensation database. All individuals receiving 30 days of continuous MMT for opioid dependence were included in the study. Key measurements included the proportion of clients receiving >7 days of a PO other than methadone during MMT from 1996 to 2007. Factors independently associated with PO co-prescription during MMT were assessed using generalized linear mixed effects regression. RESULTS 16,248 individuals with 27,919 MMT episodes at least 30 days in duration were identified for the study period. Among them, 5,552 individuals (34.2%) received a total of 290,543 PO co-prescriptions during MMT. The majority (74.3%) of all PO dispensations >7 days originated from non-MMT physicians. The number of PO prescriptions per person-year nearly doubled between 1996 and 2006, driven by increases in morphine, hydromorphone and oxycodone dispensations. PO co-prescription was positively associated with female gender, older age, higher levels of medical co-morbidity as well as higher MMT dosage, adherence, and retention. CONCLUSION AND SCIENTIFIC SIGNIFICANCE A large proportion of MMT clients in BC received co-occurring PO prescriptions, often from physicians and pharmacies not delivering MMT. Experimental evidence for the treatment of pain in MMT clients is required to guide clinical practice.
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Affiliation(s)
- Bohdan Nosyk
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
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Tsui JI, Cheng DM, Coleman SM, Blokhina E, Bridden C, Krupitsky E, Samet JH. Pain is associated with heroin use over time in HIV-infected Russian drinkers. Addiction 2013; 108:1779-87. [PMID: 23773361 PMCID: PMC4012755 DOI: 10.1111/add.12274] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIMS To evaluate whether pain was associated with increased risk of using heroin, stimulants or cannabis among HIV-infected drinkers in Russia. DESIGN Secondary analysis of longitudinal data from the HERMITAGE study (HIV's Evolution in Russia-Mitigating Infection Transmission and Alcoholism in a Growing Epidemic), a behavioral randomized controlled trial, with data collected at baseline, 6-month and 12-month visits. SETTING Recruitment occurred at HIV and addiction treatment sites in St Petersburg, Russian Federation. PARTICIPANTS Six hundred and ninety-nine HIV-infected adult drinkers. MEASUREMENTS The primary outcome was past month illicit drug use; secondary outcomes examined each drug (heroin, stimulants and cannabis) separately. The main predictor was pain that interfered at least moderately with daily living. General estimating equations (GEE) logistic regression models were used to evaluate the association between pain and subsequent illicit drug use, adjusting for potential confounders. FINDINGS Participants reporting pain appeared to have higher odds of using illicit drugs, although the results did not reach statistical significance [adjusted odds ratio (OR) = 1.32; 95% confidence interval (CI) = 0.99, 1.76, P = 0.06]. There was a significant association between pain and heroin use (OR = 1.54; 95% CI = 1.11-2.15, P = 0.01) but not use of other drugs (OR = 0.75; 95% CI =0.40-1.40, P = 0.35 for stimulants and OR = 0.70; 95% CI = 0.45-1.07, P = 0.09 for cannabis). CONCLUSIONS HIV-infected Russian drinkers who report pain are more likely to use heroin over time than HIV-infected Russian drinkers who do not report pain. Pain may be an unrecognized risk factor for persistent heroin use with implications for HIV transmission in Russia.
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Affiliation(s)
- Judith I. Tsui
- Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education (CARE) Unit, Boston University School of Medicine/Boston Medical Center, 801 Massachusetts Ave., 2 Floor, Boston, MA 02118-2605, USA
| | - Debbie M. Cheng
- Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education (CARE) Unit, Boston University School of Medicine/Boston Medical Center, 801 Massachusetts Ave., 2 Floor, Boston, MA 02118-2605, USA,Department of Biostatistics, Boston University School of Public Health, 801 Massachusetts Ave., 3 Floor, Boston, MA 02118-2605, USA
| | - Sharon M. Coleman
- Data Coordinating Center, Boston University School of Public Health, 801 Massachusetts Ave., 3 Floor, Boston, MA 02118-2605, USA
| | - Elena Blokhina
- Institute of Pharmacology, St. Petersburg Pavlov State Medical University, Lev Tolstoy St. 6/8, St. Petersburg 197022, Russia
| | - Carly Bridden
- Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education (CARE) Unit, Boston University School of Medicine/Boston Medical Center, 801 Massachusetts Ave., 2 Floor, Boston, MA 02118-2605, USA
| | - Evgeny Krupitsky
- Laboratory of Clinical Pharmacology of Addictions, St. Petersburg Pavlov State Medical University, Lev Tolstoy St. 6/8, St. Petersburg 197022, Russia,Department of Addictions, Bekhterev Research Psychoneurological Institute, Bekhtereva St., 3, St. Petersburg 192019, Russia
| | - Jeffrey H. Samet
- Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education (CARE) Unit, Boston University School of Medicine/Boston Medical Center, 801 Massachusetts Ave., 2 Floor, Boston, MA 02118-2605, USA,Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118-2605, USA
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Abstract
AIM : To examine the prevalence and risk factors of low vitamin D status (vitamin D deficiency or insufficiency) among patients in a methadone maintenance treatment (MMT) program. DESIGN : Cross-sectional study of subjects recruited from an MMT program in a higher latitude (Boston, MA). MEASUREMENTS : Standardized survey and medical record review were used to assess patient characteristics. Serum was tested to determine vitamin D deficiency (25-hydroxyvitamin D <20 ng/mL) and insufficiency (25-hydroxyvitamin D between 20 and 30 ng/mL). Multivariable analyses were used to assess risk factors associated with vitamin D deficiency. FINDINGS : Low vitamin D status was found in 52% of the subjects (48 of 93), deficiency in 36%, and insufficiency in an additional 16%. Older age (OR = 3.47; 95% CI 1.31-9.22) and black or Hispanic race/ethnicity (OR 3.34; 95% CI 1.30-8.58) were significantly associated with higher risk of vitamin D deficiency. CONCLUSION : Low vitamin D status was present in a majority of patients recruited from an MMT program. This raises the question as to whether this is a generalizable phenomenon and whether these patients are at higher risk of complications of low vitamin D status including bone pain, periodontal disease, osteomalacia, and cardiovascular disease.
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Nosyk B, Fischer B, Sun H, Marsh DC, Kerr T, Rehm JT, Anis AH. High levels of opioid analgesic co-prescription among methadone maintenance treatment clients in British Columbia, Canada: Results from a population-level retrospective cohort study. Am J Addict 2013. [DOI: 10.1111/j.1521-0391.2013.12091.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
| | | | - Huiying Sun
- Centre for Health Evaluation & Outcome Sciences; Vancouver; British Columbia; Canada
| | - David C. Marsh
- Northern Ontario School of Medicine; Sudbury; Ontario; Canada
| | | | - Juergen T. Rehm
- Social and Epidemiological Research Department; Centre for Addiction and Mental Health (CAMH); Toronto; Ontario; Canada
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Counselors' Experiences Treating Methadone-maintained Patients with Chronic Pain: A Needs Assessment Study. J Addict Med 2013; 2:108-11. [PMID: 21768980 DOI: 10.1097/adm.0b013e31815ec240] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE : This study was designed to conduct a needs assessment concerning methadone counselors' experiences working with methadone-maintained patients with chronic pain and measure counselors' interest in receiving specialized training to treat such patients. METHODS : A survey, developed by the authors, was administered to 25 counselors with a combined caseload of 956 patients at 3 opioid agonist treatment programs. RESULTS : Patients with chronic pain comprised 27% of counselors' overall caseloads. Counselors believed that, on average, 46% of these patients' pain had a psychologic component and 56% exhibited continued drug use, which patients attributed to ongoing pain. Twenty-three counselors reported an interest in receiving specialized training in treating chronic pain. A variety of management issues, including monitoring the use of pain medications and providing pain management referrals, were reported. CONCLUSIONS : Findings from this needs assessment study suggest specific targets, which may be important to consider, in prospective specialized methadone maintenance treatment (MMT) counselor training and counseling for MMT patients with chronic pain.
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Keane H. Categorising methadone: Addiction and analgesia. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2013; 24:e18-24. [PMID: 23768774 DOI: 10.1016/j.drugpo.2013.05.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Revised: 05/10/2013] [Accepted: 05/14/2013] [Indexed: 12/31/2022]
Abstract
While methadone was first developed as an analgesic, and used for this purpose before it was adopted as a therapy for drug dependence, it is this latter use which has saturated its identity. Most of the literature and commentary on methadone discusses it in the context of methadone maintenance therapy (MMT). But one of the effects of the liberalization of opiate prescription for chronic pain which took place in the 1990s was the re-emergence of methadone as a painkiller. This article examines the relationship between methadone the painkiller and methadone the addiction treatment as it is constituted in recent medical research literature and treatment guidelines. It highlights the way medical discourse separates methadone into two substances with different effects depending on the problem that is being treated. Central to this separation is the classification of patients into addicts and non-addicts; and pain sufferers and non-pain sufferers. The article argues that despite this work of making and maintaining distinctions, the similarities in the way methadone is used and acts in these different medical contexts complicates these categories. The difficulties of keeping the 'two methadones' separate becomes most apparent in cases of MMT patients also being treated for chronic pain.
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Affiliation(s)
- Helen Keane
- School of Sociology, Research School of Social Sciences, Australian National University, Canberra ACT 0200, Australia.
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Arora S, Roxburgh A, Bruno R, Nielsen S, Burns L. A cross-sectional analysis of over-the-counter codeine use among an Australian sample of people who regularly inject drugs. Drug Alcohol Rev 2013; 32:574-81. [DOI: 10.1111/dar.12059] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 05/19/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Sheena Arora
- National Drug and Alcohol Research Centre; University of New South Wales; Sydney Australia
- Centre for Health Economics and Research Evaluation; University of Technology; Sydney Australia
| | - Amanda Roxburgh
- National Drug and Alcohol Research Centre; University of New South Wales; Sydney Australia
| | - Raimondo Bruno
- National Drug and Alcohol Research Centre; University of New South Wales; Sydney Australia
- School of Psychology; University of Tasmania; Hobart Australia
| | - Suzanne Nielsen
- Discipline of Addiction Medicine; Royal Prince Alfred Hospital; University of Sydney; Sydney Australia
| | - Lucy Burns
- National Drug and Alcohol Research Centre; University of New South Wales; Sydney Australia
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Pud D, Zlotnick C, Lawental E. Pain depression and sleep disorders among methadone maintenance treatment patients. Addict Behav 2012; 37:1205-10. [PMID: 22742985 DOI: 10.1016/j.addbeh.2012.05.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Revised: 04/25/2012] [Accepted: 05/31/2012] [Indexed: 11/15/2022]
Abstract
BACKGROUND The success of rehabilitation is not influenced solely by drug abstinence, but also by the state of general health and well-being, which for patients in methadone maintenance treatment (MMT) frequently is compromised by experiencing pain, depression and sleep disorders. Accordingly, this study sought to (1) characterize clusters of MMT patients who experienced different levels of these symptoms and (2) examine the association between these clusters and quality of life (QOL) measures. METHODS A convenience sample of MMT patients (n=73) completed surveys containing four scales (Numeric Rating Scale on Pain, Center for Epidemiological Studies-Depression Scale, General Sleep Disturbance Scale, and Short Form-36 QOL). Homogenous clusters based on the symptom severity of pain, depression and sleep disturbances were created using a two-stage process of: hierarchical clustering and K-means cluster analysis. RESULTS Based on the levels of symptoms, MMT patients were grouped as High (n=29), Moderate (n=26) or Low (n=18) symptom cluster members. The High symptom cluster group reported the highest severity levels of pain, depression and sleep disorders. Also, this group had the lowest scores on all QOL indices (p<0.05). Although pain, depression and sleep disorders effectively distinguish symptom clusters of MMT patients, pain was the single most important symptom differentiating MMT patients. CONCLUSIONS Successful rehabilitation will necessitate interventions that target MMT patients with high levels of pain, depression and sleep disorders. To the best of our knowledge this study was innovative in its approach to identify the presence of this high risk group by using cluster methodology in the MMT population.
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Affiliation(s)
- Dorit Pud
- The Cheryl Spencer Department of Nursing, Faculty of Welfare and Health Sciences, University of Haifa, Mt Carmel, Haifa Israel 31905.
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Attitudinal Barriers to Analgesic Use among Patients with Substance Use Disorders. PAIN RESEARCH AND TREATMENT 2012; 2012:167062. [PMID: 22685649 PMCID: PMC3352625 DOI: 10.1155/2012/167062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Revised: 02/29/2012] [Accepted: 03/02/2012] [Indexed: 11/19/2022]
Abstract
Attitudinal barriers towards analgesic use among primary care patients with chronic pain and substance use disorders (SUDs) are not well understood. We evaluated the prevalence of moderate to significant attitudinal barriers to analgesic use among 597 primary care patients with chronic pain and current analgesic use with 3 subscales from the Barriers Questionaire II: concern about side effects, fear of addiction, and worry about reporting pain to physicians. Concern about side effects was a greater barrier for those with opioid use disorders (OUDs) and non-opioid SUDs than for those with no SUD (OR (95% CI): 2.30 (1.44–3.68), P < 0.001 and 1.64 (1.02–2.65), P = 0.041, resp.). Fear of addiction was a greater barrier for those with OUDs as compared to those with non-opioid SUDs (OR (95% CI): 2.12 (1.04–4.30), P = 0.038) and no SUD (OR (95% CI): 2.69 (1.44–5.03), P = 0.002). Conversely, participants with non-opioid SUDs reported lower levels of worry about reporting pain to physicians than those with no SUD (OR (95% CI): 0.43 (0.24–0.76), P = 0.004). Participants with OUDs reported higher levels of worry about reporting pain than those with non-opioid SUDs (OR (95% CI): 1.91 (1.01–3.60), P = 0.045). Concerns about side effects and fear of addiction can be barriers to analgesic use, moreso for people with SUDs and OUDs.
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Fox AD, Sohler NL, Starrels JL, Ning Y, Giovanniello A, Cunningham CO. Pain is not associated with worse office-based buprenorphine treatment outcomes. Subst Abus 2012; 33:361-5. [PMID: 22989279 PMCID: PMC3447624 DOI: 10.1080/08897077.2011.638734] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Physical pain is common among individuals seeking treatment for opioid dependence. Pain may negatively impact addiction treatment. The authors prospectively studied opioid-dependent individuals initiating office-based buprenorphine treatment, comparing buprenorphine treatment outcomes (treatment retention and opioid use) among participants with and without pain (baseline pain or persistent pain). Among 82 participants, 60% reported baseline pain and 38% reported persistent pain. Overall, treatment retention was 56% and opioid use decreased from 89% to 26% over 6 months. In multivariable analyses, the authors found no association between pain and buprenorphine treatment outcomes. Opioid-dependent individuals with and without pain can achieve similar success with buprenorphine treatment.
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Affiliation(s)
- Aaron D Fox
- Albert Einstein College of Medicine, Bronx, New York 10467, USA.
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Treating Chronic Pain in Veterans Presenting to an Addictions Treatment Program. COGNITIVE AND BEHAVIORAL PRACTICE 2011. [DOI: 10.1016/j.cbpra.2010.05.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Winstock AR, Lintzeris N, Lea T. "Should I stay or should I go?" Coming off methadone and buprenorphine treatment. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2010; 22:77-81. [PMID: 20956077 DOI: 10.1016/j.drugpo.2010.08.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2009] [Revised: 07/26/2010] [Accepted: 08/17/2010] [Indexed: 11/25/2022]
Abstract
BACKGROUND This study aimed to investigate patient perspectives regarding coming off maintenance opioid substitution treatment (OST). The study explored previous experiences, current interest and concerns about stopping treatment, and perceptions of how and when coming off treatment should be supported. METHODS A cross-sectional survey was used. Participants were 145 patients receiving OST at public opioid treatment clinics in Sydney, Australia. RESULTS Sixty-two percent reported high interest in coming off treatment in the next 6 months. High interest was associated with having discussed coming off treatment with a greater number of categories of people (OR=1.72), not citing concern about heroin relapse (OR=3.18), and shorter duration of current treatment episode (OR=0.99). Seventy-one percent reported previous withdrawal attempts and 23% had achieved opioid abstinence for ≥3 months following a previous withdrawal attempt. Attempts most commonly involved jumping off (59%), and doctor-controlled (52%) or self-controlled (48%) gradual reduction. For future attempts respondents were most interested in doctor-controlled (68%) or self-controlled (41%) gradual reduction. Concerns regarding coming off treatment included withdrawal discomfort (68%), increased pain (50%), and relapse to heroin use (48%). CONCLUSION While some patients may require lifetime maintenance, the issue of coming off treatment is important to many patients and should be discussed regularly throughout treatment and where appropriate supported by a menu of clinical options.
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Affiliation(s)
- Adam R Winstock
- National Addiction Centre, Institute of Psychiatry, King's College London, 4 Windsor Walk, London, UK.
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Ilgen MA, Perron B, Czyz EK, McCammon RJ, Trafton J. The Timing of Onset of Pain and Substance Use Disorders. Am J Addict 2010; 19:409-15. [DOI: 10.1111/j.1521-0391.2010.00065.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Mark A. Ilgen
- VA Serious Mental Illness Treatment Research and Evaluation Center, Ann Arbor, Michigan
- University of Michigan Department of Psychiatry, Ann Arbor, Michigan
| | - Brian Perron
- VA Serious Mental Illness Treatment Research and Evaluation Center, Ann Arbor, Michigan
- University of Michigan School of Social Work, Ann Arbor, Michigan
| | - Ewa K. Czyz
- University of Michigan Department of Psychiatry, Ann Arbor, Michigan
| | - Ryan J. McCammon
- University of Michigan Department of Psychiatry, Ann Arbor, Michigan
| | - Jodie Trafton
- Department of Veterans Affairs Palo Alto Health Care System, Palo Alto, California
- Stanford University School of Medicine, Palo Alto, California
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Ilgen MA, McLouth C, Barry KL, Walton M, Cole PA, Dabrowski MP, Booth BM, Blow FC. Pain interference in individuals in driver intervention programs for driving under the influence offenders. Subst Use Misuse 2010; 45:1406-19. [PMID: 20509742 DOI: 10.3109/10826081003682818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Pain-related problems among individuals in court-mandated Driver Intervention Programs (DIPs) for "driving under the influence" (DUI) offenders have not been well studied. This project examines 3,189 individuals from a DIP in Dayton, Ohio. Over 11% of participants reported significant pain-related interference in the past 4 weeks. Pain was significantly more likely in those with depression, more childhood conduct problems, and recent use of multiple illicit drugs. Many individuals seen in court-mandated DIP programs for DUI offenders also report difficulties with pain. DIP programming should address pain in relation to substance use and mental health issues.
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Affiliation(s)
- Mark Andrew Ilgen
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan 48109, USA.
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40
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Alford DP. Opioids for chronic pain in patients with substance abuse: too much, too little or just right? Pain 2009; 145:267-268. [PMID: 19631467 DOI: 10.1016/j.pain.2009.06.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2009] [Accepted: 06/30/2009] [Indexed: 11/18/2022]
Affiliation(s)
- Daniel P Alford
- Boston University School of Medicine, Boston Medical Center, Boston, MA 02118, USA
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Faitot V, Simonpoli A, Keita H. [Anaesthetic and analgesic considerations in drug abusing pregnant women]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2009; 28:609-14. [PMID: 19520543 DOI: 10.1016/j.annfar.2009.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- V Faitot
- Service d'anesthésie, CHU Louis-Mourier, 178, rue des Renouillers, 92700 Colombes, France
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Berg KM, Arnsten JH, Sacajiu G, Karasz A. Providers' experiences treating chronic pain among opioid-dependent drug users. J Gen Intern Med 2009; 24:482-8. [PMID: 19189194 PMCID: PMC2659151 DOI: 10.1007/s11606-009-0908-x] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2008] [Revised: 11/19/2008] [Accepted: 01/05/2009] [Indexed: 10/21/2022]
Abstract
BACKGROUND Successful management of chronic pain with opioid medications requires balancing opioid dependence and addiction with pain relief and restoration of function. Evaluating these risks and benefits is difficult among patients with chronic pain and pre-existing addiction, and the ambiguity is increased for patients on methadone maintenance therapy for opioid dependence. Providers treating both chronic pain and addiction routinely make diagnostic and therapeutic decisions, but decision-making strategies in this context have not been well described. OBJECTIVE Our objective was twofold. We sought first to explore providers' perceptions of ambiguity, and then to examine their strategies for making diagnostic and treatment decisions to manage chronic pain among patients on methadone maintenance therapy. DESIGN Qualitative semi-structured interviews. SETTING AND PARTICIPANTS We interviewed health-care providers delivering integrated medical care and substance abuse treatment to patients in a methadone maintenance program. RESULTS Providers treating pain and co-morbid addiction described ambiguity in all diagnostic and therapeutic decisions. To cope with this inherent ambiguity, most providers adopted one of two decision-making frameworks, which determined clinical behavior. One framework prioritized addiction treatment by emphasizing the destructive consequences of abusing illicit drugs or prescription medications; the other prioritized pain management by focusing on the destructive consequences of untreated pain. Identification with a decision-making framework shaped providers' experiences, including their treatment goals, perceptions of treatment risks, pain management strategies, and tolerance of ambiguity. Adherence to one of these two frameworks led to wide variation in pain management practices, which created tension among providers. CONCLUSIONS Providers delivering integrated medical care and substance abuse treatment to patients in a methadone maintenance program found tremendous ambiguity in the management of chronic pain. Most providers adopted one of the two divergent heuristic frameworks we identified, which resulted in significant variations in pain management. To reduce variation and determine best practices, studies should examine clinically relevant endpoints, including pain, illicit drug use, prescription drug abuse, and functional status. Until then, providers managing chronic pain in patients with co-morbid addiction should attempt to reduce tension by acknowledging ambiguity and engaging in open discourse.
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Affiliation(s)
- Karina M Berg
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY 10467, USA.
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Sheu R, Lussier D, Rosenblum A, Fong C, Portenoy J, Joseph H, Portenoy RK. Prevalence and Characteristics of Chronic Pain in Patients Admitted to an Outpatient Drug and Alcohol Treatment Program. PAIN MEDICINE 2008; 9:911-7. [DOI: 10.1111/j.1526-4637.2008.00420.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Rosenblum A, Marsch LA, Joseph H, Portenoy RK. Opioids and the treatment of chronic pain: controversies, current status, and future directions. Exp Clin Psychopharmacol 2008; 16:405-16. [PMID: 18837637 PMCID: PMC2711509 DOI: 10.1037/a0013628] [Citation(s) in RCA: 397] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Opioids have been regarded for millennia as among the most effective drugs for the treatment of pain. Their use in the management of acute severe pain and chronic pain related to advanced medical illness is considered the standard of care in most of the world. In contrast, the long-term administration of an opioid for the treatment of chronic noncancer pain continues to be controversial. Concerns related to effectiveness, safety, and abuse liability have evolved over decades, sometimes driving a more restrictive perspective and sometimes leading to a greater willingness to endorse this treatment. The past several decades in the United States have been characterized by attitudes that have shifted repeatedly in response to clinical and epidemiological observations, and events in the legal and regulatory communities. The interface between the legitimate medical use of opioids to provide analgesia and the phenomena associated with abuse and addiction continues to challenge the clinical community, leading to uncertainty about the appropriate role of these drugs in the treatment of pain. This narrative review briefly describes the neurobiology of opioids and then focuses on the complex issues at this interface between analgesia and abuse, including terminology, clinical challenges, and the potential for new agents, such as buprenorphine, to influence practice.
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Affiliation(s)
- Andrew Rosenblum
- National Development and Research Institutes, New York, NY 10010, USA.
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Brooner RK. Advances in treating chronic nonmalignant pain and substance use disorders. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2008; 53:485-6. [PMID: 18801209 DOI: 10.1177/070674370805300802] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Robert K Brooner
- Professor of Medical Psychology and Psychiatry, Department of Psychiatry and Behavioral Science, Johns Hopkins University School of Medicine, Baltimore, MD
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Clark MR, Stoller KB, Brooner RK. Assessment and management of chronic pain in individuals seeking treatment for opioid dependence disorder. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2008; 53:496-508. [PMID: 18801211 DOI: 10.1177/070674370805300804] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To review the problem of chronic pain in patients with substance use disorders, focusing on the prevalence of chronic pain in patients with substance dependence disorders, especially prescription opioid dependence, associated comorbidities, and the impact on drug abuse treatment response. METHOD We identified relevant articles using PubMed from 1987 to 2008. Additional articles were obtained from the reference lists of key reviews of relevant topics. Studies were included if they investigated the relation between chronic pain and substance use disorders. Of particular interest were articles that proposed integrated treatment for both problems. RESULTS The high prevalence of chronic pain syndromes was only recently explored in patients seeking treatment for drug abuse. The presence of chronic pain increases the risk of poor response to substance abuse treatment and an increased likelihood of multiple comorbidities that further add to the negative impact experienced by patients with substance dependence disorders. Substance abuse treatment programs offering integrated medical and psychiatric care for these comorbidities improve outcomes, with stepped care approaches offering the best treatment by tailoring the level of care to the individual patient's needs. CONCLUSIONS Substance abuse treatment programs should expand their services to address the comorbidities likely to pose barriers to successful drug rehabilitation. Given the high prevalence and negative impact of chronic pain, new pain management services should be integrated within the drug treatment program and adapted as patients demonstrate the need for more intensive treatment. If applied to the problem of chronic pain, a model substance abuse treatment program of integrated stepped care would improve outcomes for patients with both devastating disorders.
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Affiliation(s)
- Michael R Clark
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA.
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Mitchell AM, Dewey CM. Chronic pain in patients with substance abuse disorder: general guidelines and an approach to treatment. Postgrad Med 2008; 120:75-9. [PMID: 18467812 DOI: 10.3810/pgm.2008.04.1763] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Treating pain may be difficult in patients with a coexisting substance abuse disorder. Opioids can be used successfully to control pain in such a patient population, but the physician must have a general understanding of addictive behavior and early signs of abuse. The challenge is not in treating pain, but identifying true pain from drug-seeking behaviors. Furthermore, several myths of opioid usage, such as iatrogenic addiction and risk of disciplinary action, may be unfounded. General guidelines and open communication between patient and physician may aid in controlling pain. With better understanding and a systematic treatment approach, patients with substance abuse disorders can receive adequate symptomatic pain relief.
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Affiliation(s)
- Adam M Mitchell
- Section of General Internal Medicine, Ben Taub General Hospital, Baylor College of Medicine, Houston, TX 77030, USA.
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Languages of Labor: Negotiating the “Real” and the Relational in Indo-Fijian Women's Expressions of Physical Pain. Med Anthropol Q 2007; 21:388-408. [DOI: 10.1525/maq.2007.21.4.388] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Morgan BD. Knowing How to Play the Game: Hospitalized Substance Abusers’ Strategies for Obtaining Pain Relief. Pain Manag Nurs 2006; 7:31-41. [PMID: 16490734 DOI: 10.1016/j.pmn.2005.12.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This study explored hospitalized substance abusers' perspectives about getting their pain adequately addressed in the hospital setting and their interactions with nurses about pain-management issues. The aim of the study was to generate theory that can contribute to a greater understanding of the problem of pain management with this population. A grounded theory approach was used to interview participants with a substance abuse problem who were hospitalized with a medical/surgical problem. Interviews were conducted using an interview guide; interviews were audiotaped and transcribed. In addition, a focus group of nurses who worked with this population met twice, once midway through the study, and before the final participant interview. The nurses commented on the fit of the developing model according to their experiences of working with the population described. Eighteen participants were interviewed for a total of 20 interviews (two participants were interviewed twice). All participants were polysubstance abusers and had a painful medical/surgical problem for which they were hospitalized. The Model of "Knowing How to Play the Game" was developed on the basis of participants' descriptions of their experiences and consisted of two core action categories "Feeling Respected/Not Respected" and " Strategizing to Get Pain Relief." Participants had many suggestions about nursing actions that were helpful or not helpful in assisting them to obtain pain relief. Nursing practice, education, research, and policy implications were discussed.
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Affiliation(s)
- Betty D Morgan
- University of Massachusetts Lowell School of Health and Environment, Department of Nursing, Lowell, Massachusetts 01854, USA.
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Bibliography. PROGRESS IN PALLIATIVE CARE 2005. [DOI: 10.1179/096992605x42396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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