1
|
de Dios C, Suchting R, Green C, Klugh JM, Harvin JA, Webber HE, Schmitz JM, Lane SD, Yoon JH, Heads A, Motley K, Stotts A. An opioid-minimizing multimodal pain regimen reduces opioid exposure and pain in trauma-injured patients at high risk for opioid misuse: Secondary analysis from the mast trial. Surgery 2023; 174:1463-1470. [PMID: 37839970 PMCID: PMC10836717 DOI: 10.1016/j.surg.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 07/06/2023] [Accepted: 09/05/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Screening to identify patients at risk for opioid misuse after trauma is recommended but not commonly used to guide perioperative opioid management interventions. The Multimodal Analgesic Strategies for Trauma trial demonstrated that an opioid-minimizing multimodal pain regimen reduced opioid exposure in a heterogeneous trauma patient population. Here, we assess the efficacy of the Multimodal Analgesic Strategies for Trauma multimodal pain regimen in a critical patient subgroup who screened at high risk for opioid misuse. METHODS The Multimodal Analgesic Strategies for Trauma trial compared an opioid-minimizing multimodal pain regimen (oral acetaminophen, naproxen, gabapentin, lidocaine patch, as-needed opioid) against an original multimodal pain regimen (intravenous followed by oral acetaminophen, 48-hour celecoxib and pregabalin, followed by naproxen and gabapentin, scheduled tramadol, as-needed opioid), in a randomized trial conducted from April 2018 to March 2019. A total of 631 enrolled patients were classified either as low- or high-risk via the Opioid Risk Tool. Bayesian analyses evaluated the moderating influence of Opioid Risk Tool risk (high/low) on the effect of Multimodal Analgesic Strategies for Trauma multimodal pain regimen (versus original) on opioid exposure (morphine milligram equivalents/day), opioids prescribed at discharge, and pain scores. RESULTS Multimodal Analgesic Strategies for Trauma multimodal pain regimen effectively reduced morphine milligram equivalents/day in low- and high-Opioid Risk Tool risk groups. Moderation was observed for opioids at discharge and pain scores; Multimodal Analgesic Strategies for Trauma multimodal pain regimen was effective in the high-risk group only (opioids at discharge: 63% vs 77%, relative risk = 0.86, 95% Bayesian credible interval [0.66-1.08], posterior probability (relative risk <1) = 90%; pain scores: b = 3.8, 95% Bayesian credible interval [3.2-4.4] vs b = 4.0, 95% Bayesian credible interval [3.4-4.6], posterior probability (b <0) = 87%). CONCLUSION This study is the first to show the moderating influence of opioid misuse risk on the effectiveness of an opioid-minimizing multimodal pain regimen. The Opioid Risk Tool was useful in identifying high-risk patients for whom the Multimodal Analgesic Strategies for Trauma multimodal pain regimen is recommended for perioperative pain management.
Collapse
Affiliation(s)
- Constanza de Dios
- Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, TX.
| | - Robert Suchting
- Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, TX
| | - Charles Green
- Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, TX; Department of Pediatrics, Center for Clinical Research and Evidence-Based Medicine, UTHealth McGovern Medical School, University of Texas Health Science Center at Houston, TX
| | - James M Klugh
- Center for Translational Injury Research, Department of Surgery, University of Texas Health Science Center at Houston, TX
| | - John A Harvin
- Center for Translational Injury Research, Department of Surgery, University of Texas Health Science Center at Houston, TX
| | - Heather E Webber
- Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, TX
| | - Joy M Schmitz
- Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, TX
| | - Scott D Lane
- Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, TX
| | - Jin H Yoon
- Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, TX
| | - Angela Heads
- Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, TX
| | - Kandice Motley
- Center for Translational Injury Research, Department of Surgery, University of Texas Health Science Center at Houston, TX
| | - Angela Stotts
- Department of Family and Community Medicine, UTHealth McGovern Medical School, University of Texas Health Science Center at Houston, TX
| |
Collapse
|
2
|
Chamoun K, Mouawad J, Salameh P, Sacre H, Haddad R, Khabbaz LR, Megarbane B, Hajj A. Opioid use disorder in two samples of the Lebanese population: scale validation and correlation with sleep and mood disorders. BMC Psychiatry 2023; 23:797. [PMID: 37914993 PMCID: PMC10619223 DOI: 10.1186/s12888-023-05304-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 10/24/2023] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND The revised Opioid Risk Tool (ORT-OUD) is a brief, self-report scale designed to provide clinicians with a simple, validated method to screen for the risk of developing an Opioid Use Disorder (OUD) in patients without a prior history of substance abuse. This study aimed to translate and validate the Arabic version of ORT-OUD in the Lebanese population and assess its clinical validity in a sample of patients with OUD. METHODS This cross-sectional study in the Lebanese population used several validated scales to assess the risk of OUD, including the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). Other tools evaluated chronotype and sleep and mood disturbances. Principal component analysis with Varimax rotation was applied to assess ORT-OUD construct validity. Convergent validity with the Arabic version of ASSIST was evaluated. The ORT-OUD criterion validity was then assessed in a clinical sample of patients with OUD. RESULTS This study included 581 participants. The prevalence of the OUD risk in the Lebanese population using the ORT-OUD scale and the ASSIST-opioids scale was estimated at 14.5% and 6.54%, respectively. No items of the ORT-OUD were removed; all items converged over a solution of four factors with an eigenvalue > 1, explaining a total of 68.2% of the variance (Cronbach's alpha = 0.648). The correlation coefficients between the ORT-OUD total score and ASSIST subscales were as follows: ASSIST-opioids (r = 0.174; p = < 0.001), ASSIST-sedatives (r = 0.249; p < 0.001), and ASSIST-alcohol (r = 0.161; p = < 0.001). ORT-OUD clinical validation showed a correlation with ASSIST-opioids (r = 0.251; p = 0.093) and ASSIST-sedatives (r = 0.598; p < 0.001). Higher ORT-OUD scores were associated with a family and personal history of alcohol and substance consumption and higher insomnia and anxiety scores. CONCLUSIONS This study is the first to validate the Arabic version of ORT-OUD in the Lebanese population, an essential step towards improving the detection and management of OUD in this population.
Collapse
Affiliation(s)
- Karam Chamoun
- Faculty of Pharmacy, Saint Joseph University of Beirut, Beirut, Lebanon
- Laboratoire de Pharmacologie, Pharmacie Clinique et Contrôle de Qualité des Médicaments, Saint Joseph University of Beirut, Beirut, Lebanon
- Inserm, UMR-S1144, Université Paris Cité, Paris, France
| | - Joseph Mouawad
- Faculty of Pharmacy, Saint Joseph University of Beirut, Beirut, Lebanon
- Laboratoire de Pharmacologie, Pharmacie Clinique et Contrôle de Qualité des Médicaments, Saint Joseph University of Beirut, Beirut, Lebanon
| | - Pascale Salameh
- INSPECT-LB (Institut National de Santé Publique, d'Épidémiologie Clinique et de Toxicologie- Liban), Beirut, Lebanon
- School of Medicine, Lebanese American University, Byblos, Lebanon
- Faculty of Pharmacy, Lebanese University, Hadat, Lebanon
- Department of Primary Care and Population Health, University of Nicosia Medical School, Egkomi, Nicosia, 2417, Cyprus
| | - Hala Sacre
- INSPECT-LB (Institut National de Santé Publique, d'Épidémiologie Clinique et de Toxicologie- Liban), Beirut, Lebanon
| | - Ramzi Haddad
- Psychiatry Department, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
- Psychiatry Department, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Lydia Rabbaa Khabbaz
- Faculty of Pharmacy, Saint Joseph University of Beirut, Beirut, Lebanon
- Laboratoire de Pharmacologie, Pharmacie Clinique et Contrôle de Qualité des Médicaments, Saint Joseph University of Beirut, Beirut, Lebanon
| | - Bruno Megarbane
- Inserm, UMR-S1144, Université Paris Cité, Paris, France
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière-Fernand Widal Hospital, Paris, France
| | - Aline Hajj
- Faculty of Pharmacy, Saint Joseph University of Beirut, Beirut, Lebanon.
- Laboratoire de Pharmacologie, Pharmacie Clinique et Contrôle de Qualité des Médicaments, Saint Joseph University of Beirut, Beirut, Lebanon.
- Faculté de Pharmacie, Université Laval, Québec city, Québec, Canada.
- Oncology Division, CHU de Québec- Université Laval Research Center, Québec City, Québec, Canada.
| |
Collapse
|
3
|
Taylor EP, Vellozzi-Averhoff C, Vettese T. Care Throughout the Journey-The Interaction Between Primary Care and Palliative Care. Clin Geriatr Med 2023; 39:379-393. [PMID: 37385690 DOI: 10.1016/j.cger.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
Palliative care is no longer synonymous with end-of-life care, and because supply has been well outstripped by demand, much of the practice of palliative care early in a patient's illness journey will take place in the primary care clinic-referred to as primary palliative care. Referral to specialty palliative care for complex symptom management or clarification on decision-making is appropriate, and can facilitate hospice referral, if indicated and in line with patient/family goals.
Collapse
Affiliation(s)
- Emily Pinto Taylor
- Division of Hospice and Palliative Medicine, Department of Family and Preventative Medicine, Emory University School of Medicine, Atlanta, GA, USA; Division of General Internal Medicine, Department of Internal Medicine, Emory University School of Medicine, Atlanta, GA, USA.
| | - Cristina Vellozzi-Averhoff
- Division of Hospice and Palliative Medicine, Department of Family and Preventative Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Theresa Vettese
- Division of General Internal Medicine, Department of Internal Medicine, Emory University School of Medicine, Atlanta, GA, USA
| |
Collapse
|
4
|
Valdes EG, Reist C, Aamar R, Hallisey B, Stanton ES, Williams L, Andel R, Gorman J. Use of Predictive Analytics to Identify Unhealthy Opioid Use and Guide Intervention. Psychiatr Serv 2022:appips202200034. [PMID: 36545772 DOI: 10.1176/appi.ps.202200034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The authors aimed to use the newly developed Opioid Risk Stratification Tool to identify individuals who may be at risk for unhealthy opioid use and to examine the impact of applying a mailing and engagement intervention to this population and their prescribers, with the goal of reducing high-risk prescribing behaviors, opioid medication use, and mortality rates. METHODS A nonrandomized controlled study was conducted with members from two Medicaid managed care organizations. In both the intervention (N=131) and control (N=187) groups, an algorithm identified members at moderate to high risk for hazardous opioid use. Members at increased risk in the intervention group and their prescribers received a letter from the managed care organization, and members still at risk 3 months after the mailing were contacted by a care coordinator. Individuals in the control group were not contacted. Medicaid claims data were used to compare opioid use and prescribing practices between groups before and after the intervention. RESULTS Individuals in the intervention group were less likely to have any opioid prescription postintervention compared with those in the control group (OR=0.55, p<0.001), and the intervention group had a greater reduction in the number of individuals with concurrent opioid and benzodiazepine prescriptions (OR=0.49, p=0.042). Practices such as multiple opioid prescriptions and multiple prescribers of opioids were not affected by the intervention. CONCLUSIONS An intervention targeting individuals at risk for hazardous opioid use was associated with a reduction in some high-risk prescribing practices. Future research should determine the ideal mix of interventions to reduce as many risk factors as possible.
Collapse
Affiliation(s)
- Elise G Valdes
- Relias, Morrisville, North Carolina (Valdes, Reist, Aamar, Gorman); MindX Sciences, Indianapolis (Reist); Eastpointe Human Services, Beulaville, North Carolina (Hallisey); Partners Health Management, Gastonia, North Carolina (Stanton, Williams); Edson College of Nursing and Health Innovation, Arizona State University, Phoenix (Andel)
| | - Christopher Reist
- Relias, Morrisville, North Carolina (Valdes, Reist, Aamar, Gorman); MindX Sciences, Indianapolis (Reist); Eastpointe Human Services, Beulaville, North Carolina (Hallisey); Partners Health Management, Gastonia, North Carolina (Stanton, Williams); Edson College of Nursing and Health Innovation, Arizona State University, Phoenix (Andel)
| | - Rola Aamar
- Relias, Morrisville, North Carolina (Valdes, Reist, Aamar, Gorman); MindX Sciences, Indianapolis (Reist); Eastpointe Human Services, Beulaville, North Carolina (Hallisey); Partners Health Management, Gastonia, North Carolina (Stanton, Williams); Edson College of Nursing and Health Innovation, Arizona State University, Phoenix (Andel)
| | - Barbara Hallisey
- Relias, Morrisville, North Carolina (Valdes, Reist, Aamar, Gorman); MindX Sciences, Indianapolis (Reist); Eastpointe Human Services, Beulaville, North Carolina (Hallisey); Partners Health Management, Gastonia, North Carolina (Stanton, Williams); Edson College of Nursing and Health Innovation, Arizona State University, Phoenix (Andel)
| | - Elizabeth Shirley Stanton
- Relias, Morrisville, North Carolina (Valdes, Reist, Aamar, Gorman); MindX Sciences, Indianapolis (Reist); Eastpointe Human Services, Beulaville, North Carolina (Hallisey); Partners Health Management, Gastonia, North Carolina (Stanton, Williams); Edson College of Nursing and Health Innovation, Arizona State University, Phoenix (Andel)
| | - Leah Williams
- Relias, Morrisville, North Carolina (Valdes, Reist, Aamar, Gorman); MindX Sciences, Indianapolis (Reist); Eastpointe Human Services, Beulaville, North Carolina (Hallisey); Partners Health Management, Gastonia, North Carolina (Stanton, Williams); Edson College of Nursing and Health Innovation, Arizona State University, Phoenix (Andel)
| | - Ross Andel
- Relias, Morrisville, North Carolina (Valdes, Reist, Aamar, Gorman); MindX Sciences, Indianapolis (Reist); Eastpointe Human Services, Beulaville, North Carolina (Hallisey); Partners Health Management, Gastonia, North Carolina (Stanton, Williams); Edson College of Nursing and Health Innovation, Arizona State University, Phoenix (Andel)
| | - Jack Gorman
- Relias, Morrisville, North Carolina (Valdes, Reist, Aamar, Gorman); MindX Sciences, Indianapolis (Reist); Eastpointe Human Services, Beulaville, North Carolina (Hallisey); Partners Health Management, Gastonia, North Carolina (Stanton, Williams); Edson College of Nursing and Health Innovation, Arizona State University, Phoenix (Andel)
| |
Collapse
|
5
|
Kim SY, Park SY, Mathai B, Daheim J, France C, Delgado B. Cultural dimensions of individualism and collectivism and risk of opioid misuse: A test of Social Cognitive Theory. J Clin Psychol 2022; 78:2341-2356. [PMID: 35881671 PMCID: PMC9796527 DOI: 10.1002/jclp.23425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 07/08/2022] [Accepted: 07/17/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Despite the critical role social and cultural contexts play in pain experience, limited theoretical and empirical attention has been devoted to the interplay between social, cognitive, cultural, and psychological factors in chronic pain management and the risk of opioid misuse. METHODS Using structural equation modeling, the present study tested the Social Cognitive Theory (SCT) of chronic pain management and risk of opioid misuse in the context of intraindividual cultural dimensions of individualism and collectivism among 316 ethnically diverse adults with chronic pain in the United States. RESULTS Social cognitive predictors account for a significant amount of variance in pain dysfunction and risk of opioid misuse in adults with chronic pain. Satisfaction with pain support was positively associated with both greater pain acceptance and greater pain self-efficacy. Individualism was found to be positively associated with satisfaction with pain support, pain self-efficacy, and pain acceptance but negatively associated with the risk of opioid misuse. Collectivism was positively associated with the risk of opioid misuse. CONCLUSIONS The study findings not only empirically support using SCT for adults with chronic pain, but also provide a more thorough conceptual framework that highlights the intracultural diversity and interplay among social, cognitive, and psychological factors that affect pain experience and the risk of opioid misuse among adults with chronic pain.
Collapse
Affiliation(s)
- Shin Ye Kim
- Department of Counseling PsychologyUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Sung Yong Park
- Department of PsychologyKeimyung UniversityDaeguSouth Korea
| | - Babetta Mathai
- Department of Clinical and Health PsychologyUniversity of Florida Health Science CenterGainesvilleFloridaUSA
| | - Jacob Daheim
- Department of Psychological SciencesTexas Tech UniversityLubbockTexasUSA
| | | | - Betsaida Delgado
- Department of Psychological SciencesTexas Tech UniversityLubbockTexasUSA
| |
Collapse
|
6
|
Do U, El-Kefraoui C, Pook M, Balvardi S, Barone N, Nguyen-Powanda P, Lee L, Baldini G, Feldman LS, Fiore JF. Feasibility of Prospectively Comparing Opioid Analgesia With Opioid-Free Analgesia After Outpatient General Surgery: A Pilot Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2221430. [PMID: 35849399 PMCID: PMC9294998 DOI: 10.1001/jamanetworkopen.2022.21430] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE The overprescription of opioids to surgical patients is recognized as an important factor contributing to the opioid crisis. However, the value of prescribing opioid analgesia (OA) vs opioid-free analgesia (OFA) after postoperative discharge remains uncertain. OBJECTIVE To investigate the feasibility of conducting a full-scale randomized clinical trial (RCT) to assess the comparative effectiveness of OA vs OFA after outpatient general surgery. DESIGN, SETTING, AND PARTICIPANTS This parallel, 2-group, assessor-blind, pragmatic pilot RCT was conducted from January 29 to September 3, 2020 (last follow-up on October 2, 2020). at 2 university-affiliated hospitals in Montreal, Quebec, Canada. Participants were adult patients (aged ≥18 years) undergoing outpatient abdominal (ie, cholecystectomy, appendectomy, or hernia repair) or breast (ie, partial or total mastectomy) general surgical procedures. Exclusion criteria were contraindications to drugs used in the trial, preoperative opioid use, conditions that could affect assessment of outcomes, and intraoperative or early complications requiring hospitalization. INTERVENTIONS Patients were randomized 1:1 to receive OA (around-the-clock nonopioids and opioids for breakthrough pain) or OFA (around-the-clock nonopioids with increasing doses and/or addition of nonopioid medications for breakthrough pain) after postoperative discharge. MAIN OUTCOMES AND MEASURES Main outcomes were a priori RCT feasibility criteria (ie, rates of surgeon agreement, patient eligibility, patient consent, treatment adherence, loss to follow-up, and missing follow-up data). Secondary outcomes included pain intensity and interference, analgesic intake, 30-day unplanned health care use, and adverse events. Between-group comparison of outcomes followed the intention-to-treat principle. RESULTS A total of 15 surgeons were approached; all (100%; 95% CI, 78%-100%) agreed to have patients recruited and adhered to the study procedures. Rates of patient eligibility and consent were 73% (95% CI, 66%-78%) and 57% (95% CI, 49%-65%), respectively. Seventy-six patients were randomized (39 [51%] to OA and 37 [49%] to OFA) and included in the intention-to-treat analysis (mean [SD] age, 55.5 [14.5] years; 50 [66%] female); 40 (53%) underwent abdominal surgery, and 36 (47%) underwent breast surgery. Seventy-five patients (99%; 95% CI, 93%-100%) adhered to the allocated treatment; 1 patient randomly assigned to OFA received an opioid prescription. Seventeen patients (44%) randomly assigned to OA consumed opioids after discharge. Seventy-three patients (96%; 95% CI, 89%-99%) completed the 30-day follow-up. The rate of missing questionnaires was 37 of 3724 (1%; 95% CI, 0.7%-1.4%). All the a priori RCT feasibility criteria were fulfilled. CONCLUSIONS AND RELEVANCE The findings of this pilot RCT support the feasibility of conducting a robust, full-scale RCT to inform evidence-based prescribing of analgesia after outpatient general surgery. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04254679.
Collapse
Affiliation(s)
- Uyen Do
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | - Charbel El-Kefraoui
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | - Makena Pook
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | - Saba Balvardi
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Natasha Barone
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Philip Nguyen-Powanda
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | - Lawrence Lee
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Gabriele Baldini
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Anesthesia, McGill University, Montreal, Quebec, Canada
| | - Liane S. Feldman
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Julio F. Fiore
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | | |
Collapse
|
7
|
Mallery C, Paez K, Yang M, Lin A. Adapting the Current Opioid Misuse Measure (COMM) for People with Chronic Pain and Disability Due to Arthritis: The Development of the COMM 11-PWDA. Disabil Health J 2022; 15:101296. [DOI: 10.1016/j.dhjo.2022.101296] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 11/03/2021] [Accepted: 11/22/2021] [Indexed: 12/11/2022]
|
8
|
Salans M, Riviere P, Vitzthum LK, Nalawade V, Murphy JD. Temporal Trends and Predictors of Opioid Use Among Older Patients With Cancer. Am J Clin Oncol 2022; 45:74-80. [PMID: 35019879 DOI: 10.1097/coc.0000000000000888] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES While opioids represent a cornerstone of cancer pain management, the timing and patterns of opioid use in the cancer population have not been well studied. This study sought to explore longitudinal trends in opioid use among Medicare beneficiaries with nonmetastatic cancer. MATERIALS AND METHODS Within a cohort of 16,072 Medicare beneficiaries ≥66 years old diagnosed with nonmetastatic cancer between 2007 and 2013, we determined the likelihood of receiving a short-term (0 to 6 mo postdiagnosis), intermediate-term (6 to 12 mo postdiagnosis), long-term (1 to 2 y postdiagnosis), and high-risk (morphine equivalent dose ≥90 mg/day) opioid prescription after cancer diagnosis. Multivariable logistic regression models were used to identify patient and cancer risk factors associated with these opioid use endpoints. RESULTS During the study period, 74.6% of patients received an opioid prescription, while only 2.66% of patients received a high-risk prescription. Factors associated with use varied somewhat between short-term, intermediate-term, and long-term use, though in general, patients at higher risk of receiving an opioid prescription after their cancer diagnosis were younger, had higher stage disease, lived in regions of higher poverty, and had a history of prior opioid use. Prescriptions for high-risk opioids were associated with individuals living in regions with lower poverty. CONCLUSIONS Temporal trends in opioid use in cancer patients depend on patient, demographic, and tumor characteristics. Overall, understanding these correlations may help physicians better identify patient-specific risks of opioid use and could help better inform future evidence-based, cancer-specific opioid prescription guidelines.
Collapse
Affiliation(s)
- Mia Salans
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla
| | - Paul Riviere
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla
| | - Lucas K Vitzthum
- Department of Radiation Oncology, Stanford University, Stanford, CA
| | - Vinit Nalawade
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla
| | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla
| |
Collapse
|
9
|
Coughlin JM, Terranella SL, Ritz EM, Xu TQ, Tierney JF, Velasco JM, Myers JA. Understanding Opioid Prescribing Practices of Resident Physicians. Am Surg 2021:31348211060412. [PMID: 34971336 DOI: 10.1177/00031348211060412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND To compare opioid prescribing practices of resident physicians across a variety of surgical and nonsurgical specialties; to identify factors which influence prescribing practices; and to examine resident utilization of best practice supplemental resources. METHODS An anonymous survey which assessed prescribing practices was completed by residents from one of several different subspecialties, including internal medicine, obstetrics and gynecology, general surgery, neurosurgery, orthopedic surgery, and urology. Fisher's exact test assessed differences in prescribing practices between specialties. RESULTS Only 35% of residents reported receiving formal training in safe opioid prescribing. Overall, the most frequently reported influences on prescribing practices were the use of standardized order sets for specific procedures, attending preference, and patient's history of prescribed opioids. Resident physicians significantly underutilize best practice supplemental resources, such as counseling patients on pain expectations prior to prescribing opioid medication; contacting established pain specialists; screening patients for opioid abuse; referring to the Prescription Monitoring Program; and counseling patients on safe disposal of unused pills (P < .001). DISCUSSION The incorporation of comprehensive prescribing education into resident training and the utilization of standardized order sets can promote safe opioid prescribing.
Collapse
Affiliation(s)
- Julia M Coughlin
- Department of Surgery, 2468Rush University Medical Center, Chicago, IL, USA
| | | | - Ethan M Ritz
- Bioinformatics and Biostatistics Core, 2468Rush University Medical Center, Chicago, IL, USA
| | - Thomas Q Xu
- Department of Surgery, 2468Rush University Medical Center, Chicago, IL, USA
| | - John F Tierney
- Department of Surgery, 2468Rush University Medical Center, Chicago, IL, USA
| | - Jose M Velasco
- Department of Surgery, 2468Rush University Medical Center, Chicago, IL, USA
| | - Jonathan A Myers
- Department of Surgery, 2468Rush University Medical Center, Chicago, IL, USA
| |
Collapse
|
10
|
Gregorio SWD, Ehrman S, Bartle-Haring S, Polder J, Marks D, Probst DR, Hartman AD, Adolph M, Taylor R. Prospective Study of a Novel Risk Stratification Process for Opioid-Related Harm Reduction in Cancer Patients Seen in an Outpatient Palliative Care Clinic. J Palliat Med 2021; 25:783-792. [PMID: 34941451 DOI: 10.1089/jpm.2021.0332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Oncologists and palliative specialists prescribe opioids for millions of cancer patients despite limited research on effective screening and mitigation strategies to reduce risk of opioid-related harm in that population. Objective: To evaluate the efficacy of a novel opioid risk stratification process for predicting significant aberrant behaviors (SABs) related to prescribed opioid medications. Design and Setting/Subjects: This is a prospective, longitudinal study of 319 consecutive patients referred to an outpatient palliative care clinic between 2010 and 2012, a period during which prescription opioid-related deaths began to increase in the United States. Measures: Patients completed a psychodiagnostic/substance use risk assessment with a licensed clinical psychologist or social worker at the initial palliative clinic visit. Patients were assigned to Low-, Moderate-, or High-Risk groups based on predetermined stratification criteria and were managed via an opioid harm reduction approach. The primary dependent measure was the presence of at least one SAB after the initial visit. Results: Eighteen percent of patients (n = 56) demonstrated at least one major aberrant behavior. Odds of future aberrant behavior was 15 times greater in the High-Risk versus the Low-Risk category. Five risk factors significantly enhanced our risk model: age 18 to 45 years, job instability, history of bipolar diagnosis, history of substance abuse, and theft. Conclusion: Our risk stratification process provides a useful model for predicting those at greatest risk of future aberrant behaviors and most in need of comanagement. We recommend additional studies to test our proposed streamlined risk stratification tool.
Collapse
Affiliation(s)
- Sharla Wells-Di Gregorio
- Division of Palliative Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sarah Ehrman
- Division of Palliative Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | | | - Jason Polder
- Department of Interventional Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Donald Marks
- Department of Advanced Studies in Psychology, Kean University, Union, New Jersey, USA
| | - Danielle R Probst
- Division of Palliative Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Department of Veterans Affairs, Chalmers P. Wylie Veterans Affairs Ambulatory Care Center, Columbus, Ohio, USA
| | - Amber D Hartman
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Michael Adolph
- Division of Palliative Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Robert Taylor
- Division of Palliative Medicine, Department of Neurology and Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| |
Collapse
|
11
|
Abstract
Efforts to minimize the impact of prescribed opioids on future adverse outcomes are reliant on emergency care providers' ability to screen and detect opioid use disorder (OUD). Many prescriptions are initiated in the emergency department (ED) for acute pain; thus, validated measures are especially needed. Our systematic review describes the available opioid-related screening measures identified through search of the available literature. Measures were categorized by intent and applied clinical setting. We found 44 articles, identifying 15 screening measures. Of these, nine were developed to screen for current opioid misuse and five to screen for risk of future opioid misuse. None were created for use outside of a chronic pain setting. Many measures were applied differently from intended purpose. Although several measures are available, screening for adverse opioid outcomes in the ED is hampered by lack of validated instruments. Development of clarified conceptual models and ED-specific research is necessary to limit OUD.
Collapse
|
12
|
Impact of "race" as a social variable for screening for the risk of non-medical opioid use using nomogram. Palliat Support Care 2021; 19:638-639. [PMID: 34676811 DOI: 10.1017/s1478951521001358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
13
|
Manning K, Rogers AH, Shepherd JM, Matoska C, Ditre JW, Garey L, Kauffman BY, Zvolensky MJ. Fatigue Severity among Adults with Chronic Low Back Pain: Relations to Opioid Use and Hazardous Alcohol Use. FATIGUE : BIOMEDICINE, HEALTH & BEHAVIOR 2021; 9:148-158. [PMID: 34925967 PMCID: PMC8675936 DOI: 10.1080/21641846.2021.1966984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 08/09/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Chronic low back pain is the second leading cause of disability in the United States and is related to greater risk of opioid misuse. Research suggests that severe fatigue may be a relevant factor for better understanding the greater rates of opioid and misuse among adults with chronic low back pain. Therefore, the current study sought to examine differences in opioid misuse, risk for opioid use disorder, and hazardous alcohol use in two different groups: one group with clinically significant fatigue, and one group without clinically significant fatigue. METHODS Participants were recruited utilizing a validated online survey management system that yielded 1,681 adults (70.0% female, 81.1% White, M age = 44.5 years, SD = 11.88) with current mild to severe chronic low back pain. One-way analysis of covariance (ANCOVA) models were conducted to examine group differences. RESULTS Among adults with chronic low back pain, those with clinically significant fatigue reported significantly greater opioid misuse and risk for opioid use disorder compared to those without clinically significant fatigue. These results were evident after controlling for pain severity and interference. The results for hazardous alcohol use were not significantly different between groups. CONCLUSIONS Clinically significant fatigue is a distinguishing characteristic among adults with chronic low back pain in terms of opioid misuse and risk for opioid use disorder. Potential clinical implications of such findings suggest that it may be important for clinicians to assess fatigue levels to better manage opioid misuse potential among adults with chronic low back pain.
Collapse
Affiliation(s)
- Kara Manning
- Department of Psychology, University of Houston, Houston, TX, USA
| | - Andrew H. Rogers
- Department of Psychology, University of Houston, Houston, TX, USA
| | | | - Cameron Matoska
- Department of Psychology, University of Houston, Houston, TX, USA
| | - Joseph W. Ditre
- Department of Psychology, Syracuse University, Syracuse, NY, USA
| | - Lorra Garey
- Department of Psychology, University of Houston, Houston, TX, USA
| | | | - Michael J. Zvolensky
- Department of Psychology, University of Houston, Houston, TX, USA
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- HEALTH Institute, University of Houston, Houston, TX, USA
| |
Collapse
|
14
|
Hah J. Risk factors and screening for opioid misuse: current clinical implications for prescription opioid therapy. Pain Manag 2021; 11:625-630. [PMID: 34155912 DOI: 10.2217/pmt-2021-0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Jennifer Hah
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, & Pain Medicine, Stanford University, 1070 Arastradero Road, Suite 200, Palo Alto, CA 94304, USA
| |
Collapse
|
15
|
Kumar PS, Saphire ML, Grogan M, Benedict J, Janse S, Agne JL, Bertino EM, Presley CJ. Substance Abuse Risk and Medication Monitoring in Patients with Advanced Lung Cancer Receiving Palliative Care. J Pain Palliat Care Pharmacother 2021; 35:91-99. [PMID: 34010103 DOI: 10.1080/15360288.2021.1920545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Oncology and Palliative Medicine lack guidance on routine opioid risk screening and compliance monitoring. This study explored relationships among risk screening and aberrant medication related behaviors in patients with advanced lung cancer receiving embedded palliative care. This was a single center, prospective study and data was collected from December 2018 to March 2020. At the initial palliative visit, patients provided a baseline urine drug screen (UDS) test and completed the Screener and Opioid Assessment for Patients with Pain - Revised (SOAPP-R) self-assessment. Clinical pharmacists provided comprehensive review and interpretation of UDS results. Among 39 patients, 12 (30.8%) scored positive for risk of aberrant medication behaviors on the SOAPP-R. Only 34 of 39 patients provided a baseline UDS test and were included in further analysis. Prior to pharmacist review, 11/11 (100%) baseline UDS results in the positive-risk group and 13/23 (56.5%) in the negative-risk group appeared unexpected (p = 0.01). After pharmacist review, aberrant baseline UDS results were confirmed for 5/11 (45.5%) positive-risk and 4/23 (17.4%) negative-risk patients (p = 0.11). Overall, the SOAPP-R alone may be inadequate in this population and clinical pharmacists play an important role in comprehensive UDS result interpretation. Future studies are needed to validate this risk-screening tool in palliative cancer populations.
Collapse
Affiliation(s)
- Pooja S Kumar
- Pooja S. Kumar, PharmD, and Maureen L. Saphire, PharmD, are with the Department of Pharmacy, The Ohio State University, Columbus, Ohio, USA. Madison Grogan is with the Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, USA. Jason Benedict, MS, and Sarah Janse, PhD, are with the Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University, Columbus, Ohio, USA. Julia L. Agne, MD, is with the Department of Internal Medicine, Division of Palliative Medicine, The Ohio State University, Columbus, Ohio, USA. Erin M. Bertino, MD, and Carolyn J. Presley, MD, MHS, are with the Department of Internal Medicine, Division of Medical Oncology, The Ohio State University, Columbus, Ohio, USA
| | - Maureen L Saphire
- Pooja S. Kumar, PharmD, and Maureen L. Saphire, PharmD, are with the Department of Pharmacy, The Ohio State University, Columbus, Ohio, USA. Madison Grogan is with the Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, USA. Jason Benedict, MS, and Sarah Janse, PhD, are with the Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University, Columbus, Ohio, USA. Julia L. Agne, MD, is with the Department of Internal Medicine, Division of Palliative Medicine, The Ohio State University, Columbus, Ohio, USA. Erin M. Bertino, MD, and Carolyn J. Presley, MD, MHS, are with the Department of Internal Medicine, Division of Medical Oncology, The Ohio State University, Columbus, Ohio, USA
| | - Madison Grogan
- Pooja S. Kumar, PharmD, and Maureen L. Saphire, PharmD, are with the Department of Pharmacy, The Ohio State University, Columbus, Ohio, USA. Madison Grogan is with the Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, USA. Jason Benedict, MS, and Sarah Janse, PhD, are with the Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University, Columbus, Ohio, USA. Julia L. Agne, MD, is with the Department of Internal Medicine, Division of Palliative Medicine, The Ohio State University, Columbus, Ohio, USA. Erin M. Bertino, MD, and Carolyn J. Presley, MD, MHS, are with the Department of Internal Medicine, Division of Medical Oncology, The Ohio State University, Columbus, Ohio, USA
| | - Jason Benedict
- Pooja S. Kumar, PharmD, and Maureen L. Saphire, PharmD, are with the Department of Pharmacy, The Ohio State University, Columbus, Ohio, USA. Madison Grogan is with the Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, USA. Jason Benedict, MS, and Sarah Janse, PhD, are with the Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University, Columbus, Ohio, USA. Julia L. Agne, MD, is with the Department of Internal Medicine, Division of Palliative Medicine, The Ohio State University, Columbus, Ohio, USA. Erin M. Bertino, MD, and Carolyn J. Presley, MD, MHS, are with the Department of Internal Medicine, Division of Medical Oncology, The Ohio State University, Columbus, Ohio, USA
| | - Sarah Janse
- Pooja S. Kumar, PharmD, and Maureen L. Saphire, PharmD, are with the Department of Pharmacy, The Ohio State University, Columbus, Ohio, USA. Madison Grogan is with the Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, USA. Jason Benedict, MS, and Sarah Janse, PhD, are with the Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University, Columbus, Ohio, USA. Julia L. Agne, MD, is with the Department of Internal Medicine, Division of Palliative Medicine, The Ohio State University, Columbus, Ohio, USA. Erin M. Bertino, MD, and Carolyn J. Presley, MD, MHS, are with the Department of Internal Medicine, Division of Medical Oncology, The Ohio State University, Columbus, Ohio, USA
| | - Julia L Agne
- Pooja S. Kumar, PharmD, and Maureen L. Saphire, PharmD, are with the Department of Pharmacy, The Ohio State University, Columbus, Ohio, USA. Madison Grogan is with the Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, USA. Jason Benedict, MS, and Sarah Janse, PhD, are with the Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University, Columbus, Ohio, USA. Julia L. Agne, MD, is with the Department of Internal Medicine, Division of Palliative Medicine, The Ohio State University, Columbus, Ohio, USA. Erin M. Bertino, MD, and Carolyn J. Presley, MD, MHS, are with the Department of Internal Medicine, Division of Medical Oncology, The Ohio State University, Columbus, Ohio, USA
| | - Erin M Bertino
- Pooja S. Kumar, PharmD, and Maureen L. Saphire, PharmD, are with the Department of Pharmacy, The Ohio State University, Columbus, Ohio, USA. Madison Grogan is with the Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, USA. Jason Benedict, MS, and Sarah Janse, PhD, are with the Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University, Columbus, Ohio, USA. Julia L. Agne, MD, is with the Department of Internal Medicine, Division of Palliative Medicine, The Ohio State University, Columbus, Ohio, USA. Erin M. Bertino, MD, and Carolyn J. Presley, MD, MHS, are with the Department of Internal Medicine, Division of Medical Oncology, The Ohio State University, Columbus, Ohio, USA
| | - Carolyn J Presley
- Pooja S. Kumar, PharmD, and Maureen L. Saphire, PharmD, are with the Department of Pharmacy, The Ohio State University, Columbus, Ohio, USA. Madison Grogan is with the Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, USA. Jason Benedict, MS, and Sarah Janse, PhD, are with the Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University, Columbus, Ohio, USA. Julia L. Agne, MD, is with the Department of Internal Medicine, Division of Palliative Medicine, The Ohio State University, Columbus, Ohio, USA. Erin M. Bertino, MD, and Carolyn J. Presley, MD, MHS, are with the Department of Internal Medicine, Division of Medical Oncology, The Ohio State University, Columbus, Ohio, USA
| |
Collapse
|
16
|
Vitzthum LK, Riviere P, Sheridan P, Nalawade V, Deka R, Furnish T, Mell LK, Rose B, Wallace M, Murphy JD. Predicting Persistent Opioid Use, Abuse, and Toxicity Among Cancer Survivors. J Natl Cancer Inst 2021; 112:720-727. [PMID: 31754696 DOI: 10.1093/jnci/djz200] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 09/08/2019] [Accepted: 09/27/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Although opioids play a critical role in the management of cancer pain, the ongoing opioid epidemic has raised concerns regarding their persistent use and abuse. We lack data-driven tools in oncology to understand the risk of adverse opioid-related outcomes. This project seeks to identify clinical risk factors and create a risk score to help identify patients at risk of persistent opioid use and abuse. METHODS Within a cohort of 106 732 military veteran cancer survivors diagnosed between 2000 and 2015, we determined rates of persistent posttreatment opioid use, diagnoses of opioid abuse or dependence, and admissions for opioid toxicity. A multivariable logistic regression model was used to identify patient, cancer, and treatment risk factors associated with adverse opioid-related outcomes. Predictive risk models were developed and validated using a least absolute shrinkage and selection operator regression technique. RESULTS The rate of persistent opioid use in cancer survivors was 8.3% (95% CI = 8.1% to 8.4%); the rate of opioid abuse or dependence was 2.9% (95% CI = 2.8% to 3.0%); and the rate of opioid-related admissions was 2.1% (95% CI = 2.0% to 2.2%). On multivariable analysis, several patient, demographic, and cancer and treatment factors were associated with risk of persistent opioid use. Predictive models showed a high level of discrimination when identifying individuals at risk of adverse opioid-related outcomes including persistent opioid use (area under the curve [AUC] = 0.85), future diagnoses of opioid abuse or dependence (AUC = 0.87), and admission for opioid abuse or toxicity (AUC = 0.78). CONCLUSION This study demonstrates the potential to predict adverse opioid-related outcomes among cancer survivors. With further validation, personalized risk-stratification approaches could guide management when prescribing opioids in cancer patients.
Collapse
Affiliation(s)
- Lucas K Vitzthum
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA.,Center for Precision Radiation Medicine, University of California San Diego, La Jolla, CA
| | - Paul Riviere
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Paige Sheridan
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Vinit Nalawade
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Rishi Deka
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Timothy Furnish
- Department of Family Medicine and Public Health and Division of Pain Medicine, Department of Internal Medicine, University of California San Diego, La Jolla, CA
| | - Loren K Mell
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA.,Center for Precision Radiation Medicine, University of California San Diego, La Jolla, CA
| | - Brent Rose
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA.,Center for Precision Radiation Medicine, University of California San Diego, La Jolla, CA
| | | | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA.,Center for Precision Radiation Medicine, University of California San Diego, La Jolla, CA
| |
Collapse
|
17
|
Yennurajalingam S, Arthur J, Reddy S, Edwards T, Lu Z, Rozman de Moraes A, Wilson SM, Erdogan E, Joy MP, Ethridge SD, Kuriakose L, Malik JS, Najera JM, Rashid S, Qian Y, Kubiak MJ, Nguyen K, PharmD, Wu J, Hui D, Bruera E. Frequency of and Factors Associated With Nonmedical Opioid Use Behavior Among Patients With Cancer Receiving Opioids for Cancer Pain. JAMA Oncol 2021; 7:404-411. [PMID: 33410866 DOI: 10.1001/jamaoncol.2020.6789] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Importance One of the main aims of research on nonmedical opioid use (NMOU) is to reduce the frequency of NMOU behaviors through interventions such as universal screening, reduced opioid exposure, and more intense follow-up of patients with elevated risk. The absence of data on the frequency of NMOU behavior is the major barrier to conducting research on NMOU. Objective To determine the overall frequency of and the independent predictors for NMOU behavior. Design, Setting, and Participants In this prognostic study, 3615 patients with cancer were referred to the supportive care center at MD Anderson Cancer Center from March 18, 2016, to June 6, 2018. Patients were eligible for inclusion if they had cancer and were taking opioids for cancer pain for at least 1 week. Patients were excluded if they had no follow-up within 3 months of initial consultation, did not complete the appropriate questionnaire, or did not have scheduled opioid treatments. After exclusion, a total of 1554 consecutive patients were assessed for NMOU behavior using established diagnostic criteria. All patients were assessed using the Edmonton Symptom Assessment Scale, the Screener and Opioid Assessment for Patients with Pain (SOAPP), and the Cut Down, Annoyed, Guilty, Eye Opener-Adapted to Include Drugs (CAGE-AID) survey. Data were analyzed from January 6 to September 25, 2020. Results A total of 1554 patients (median [interquartile range (IQR)] age, 61 [IQR, 52-69] years; 816 women [52.5%]; 1124 White patients [72.3%]) were evaluable for the study, and 299 patients (19.2%) had 1 or more NMOU behaviors. The median (IQR) number of NMOU behaviors per patient was 1 (IQR, 1-3). A total of 576 of 745 NMOU behaviors (77%) occurred by the first 2 follow-up visits. The most frequent NMOU behavior was unscheduled clinic visits for inappropriate refills (218 of 745 [29%]). Eighty-eight of 299 patients (29.4%) scored 7 or higher on SOAPP, and 48 (16.6%) scored at least 2 out of 4 points on the CAGE-AID survey. Results from the multivariate model suggest that marital status (single, hazard ratio [HR], 1.58; 95% CI, 1.15-2.18; P = .005; divorced, HR, 1.43; 95% CI, 1.01-2.03; P = .04), SOAPP score (positive vs negative, HR, 1.35; 95% CI, 1.04-1.74; P = .02), morphine equivalent daily dose (MEDD) (HR, 1.003; 95% CI, 1.002-1.004; P < .001), and Edmonton Symptom Assessment Scale pain level (HR, 1.11; 95% CI, 1.06-1.16; P < .001) were independently associated with the presence of NMOU behavior. In recursive partition analysis, single marital status, MEDD greater than 50 mg, and SOAPP scores greater than 7 were associated with a higher risk (56%) for the presence of NMOU behavior. Conclusions and Relevance This prognostic study of patients with cancer taking opioids for cancer pain found that 19% of patients developed NMOU behavior within a median duration of 8 weeks after initial supportive care clinic consultation. Marital status (single or divorced), SOAPP score greater than 7, higher levels of pain severity, and MEDD level were independently associated with NMOU behavior. This information will assist clinicians and investigators designing clinical and research programs in this important field.
Collapse
Affiliation(s)
- Sriram Yennurajalingam
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Joseph Arthur
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Suresh Reddy
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Tonya Edwards
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Zhanni Lu
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Aline Rozman de Moraes
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Susamma M Wilson
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Elif Erdogan
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Manju P Joy
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Shirley Darlene Ethridge
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Leela Kuriakose
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Jimi S Malik
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - John M Najera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Saima Rashid
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Yu Qian
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Michal J Kubiak
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | | | - PharmD
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Jimin Wu
- Biostatistics, The University of Texas MD Anderson Cancer Center, Houston
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| |
Collapse
|
18
|
Yennurajalingam S, Edwards T, Arthur J, Lu Z, Erdogan E, Malik JS, Naqvi SMA, Wu J, Liu DD, Williams JL, Hui D, Reddy SK, Bruera E. The development of a nomogram to determine the frequency of elevated risk for non-medical opioid use in cancer patients. Palliat Support Care 2021; 19:3-10. [PMID: 32729447 DOI: 10.1017/s1478951520000322] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Non-medical opioid use (NMOU) is a growing crisis. Cancer patients at elevated risk of NMOU (+risk) are frequently underdiagnosed. The aim of this paper was to develop a nomogram to predict the probability of +risk among cancer patients receiving outpatient supportive care consultation at a comprehensive cancer center. METHOD 3,588 consecutive patients referred to a supportive care clinic were reviewed. All patients had a diagnosis of cancer and were on opioids for pain. All patients were assessed using the Edmonton Symptom Assessment Scale (ESAS), Screener and Opioid Assessment for Patients with Pain (SOAPP-14), and CAGE-AID (Cut Down-Annoyed-Guilty-Eye Opener) questionnaires. "+risk" was defined as an SOAPP-14 score of ≥7. A nomogram was devised based on the risk factors determined by the multivariate logistic regression model to estimate the probability of +risk. RESULTS 731/3,588 consults were +risk. +risk was significantly associated with gender, race, marital status, smoking status, depression, anxiety, financial distress, MEDD (morphine equivalent daily dose), and CAGE-AID score. The C-index was 0.8. A nomogram was developed and can be accessed at https://is.gd/soappnomogram. For example, for a male Hispanic patient, married, never smoked, with ESAS scores for depression = 3, anxiety = 3, financial distress = 7, a CAGE score of 0, and an MEDD score of 20, the total score is 9 + 9+0 + 0+6 + 10 + 23 + 0+1 = 58. A nomogram score of 58 indicates the probability of +risk of 0.1. SIGNIFICANCE OF RESULTS We established a practical nomogram to assess the +risk. The application of a nomogram based on routinely collected clinical data can help clinicians establish patients with +risk and positively impact care planning.
Collapse
Affiliation(s)
- Sriram Yennurajalingam
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Tonya Edwards
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Joseph Arthur
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Zhanni Lu
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elif Erdogan
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jimi S Malik
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Syed Mujtaba Ali Naqvi
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jimin Wu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Diane D Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Janet L Williams
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Suresh K Reddy
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| |
Collapse
|
19
|
Riviere P, Vitzthum LK, Nalawade V, Deka R, Furnish T, Mell LK, Rose BS, Wallace M, Murphy JD. Validation of an oncology-specific opioid risk calculator in cancer survivors. Cancer 2020; 127:1529-1535. [PMID: 33378556 DOI: 10.1002/cncr.33410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 10/19/2020] [Accepted: 11/25/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Clinical guidelines recommend that providers risk-stratify patients with cancer before prescribing opioids. Prior research has demonstrated that a simple cancer opioid risk score might help identify to patients with cancer at the time of diagnosis with a high likelihood of long-term posttreatment opioid use. This current project validates this cancer opioid risk score in a generalizable, population-based cohort of elderly cancer survivors. METHODS This study identified 44,932 Medicare beneficiaries with cancer who had received local therapy. Longitudinal opioid use was ascertained from Medicare Part D data. A risk score was calculated for each patient, and patients were categorized into low-, moderate-, and high-risk groups on the basis of the predicted probability of persistent opioid use. Model discrimination was assessed with receiver operating characteristic curves. RESULTS In the study cohort, 5.2% of the patients were chronic opioid users 1 to 2 years after the initiation of cancer treatment. The majority of the patients (64%) were at low risk and had a 1.2% probability of long-term opioid use. Moderate-risk patients (33% of the cohort) had a 5.6% probability of long-term opioid use. High-risk patients (3.5% of the cohort) had a 75% probability of long-term opioid use. The opioid risk score had an area under the receiver operating characteristic curve of 0.869. CONCLUSIONS This study found that a cancer opioid risk score could accurately identify individuals with a high likelihood of long-term opioid use in a large, generalizable cohort of cancer survivors. Future research should focus on the implementation of these scores into clinical practice and how this could affect prescriber behavior and patient outcomes. LAY SUMMARY A novel 5-question clinical decision tool allows physicians treating patients with cancer to accurately predict which patients will persistently be using opioid medications after completing therapy.
Collapse
Affiliation(s)
- Paul Riviere
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California
| | - Lucas K Vitzthum
- Department of Radiation Oncology, Stanford Medicine, Stanford, California
| | - Vinit Nalawade
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California
| | - Rishi Deka
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California
| | - Timothy Furnish
- Division of Pain Medicine, Department of Anesthesiology, University of California San Diego, La Jolla, California
| | - Loren K Mell
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California.,Center for Precision Radiation Medicine, University of California San Diego, La Jolla, California
| | - Brent S Rose
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California.,Center for Precision Radiation Medicine, University of California San Diego, La Jolla, California
| | - Mark Wallace
- Division of Pain Medicine, Department of Anesthesiology, University of California San Diego, La Jolla, California
| | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California.,Center for Precision Radiation Medicine, University of California San Diego, La Jolla, California
| |
Collapse
|
20
|
Patel JN, Salib M, Parala-Metz A. Best practices for opioid abuse screening in cancer patients. BMJ Support Palliat Care 2020; 10:306-309. [DOI: 10.1136/bmjspcare-2019-001950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 08/14/2019] [Indexed: 11/04/2022]
|
21
|
Anandarajah G, Mennillo HA, Rachu G, Harder T, Ghosh J. Lifestyle Medicine Interventions in Patients With Advanced Disease Receiving Palliative or Hospice Care. Am J Lifestyle Med 2020; 14:243-257. [PMID: 32477022 PMCID: PMC7232901 DOI: 10.1177/1559827619830049] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 01/18/2019] [Accepted: 01/21/2019] [Indexed: 01/01/2023] Open
Abstract
Background: Lifestyle medicine interventions have the potential to improve symptom management, daily function, and quality of life (QOL) in patients with advanced or terminal disease receiving palliative or hospice care. The goal of this review is to summarize the current state of the literature on this subject. Methods: The authors used a broad search strategy to identify relevant studies, reviews, and expert opinions, followed by narrative summary of available information. Results: Four main categories of lifestyle interventions feature prominently in the palliative care literature: exercise, nutrition, stress management, and substance use. High-quality studies in this vulnerable population are relatively sparse. Some interventions show promise. However, most show mixed results or inadequate evidence. For some interventions, risks in this generally frail population outweigh the benefits. Clinical decision making involves balancing research findings, including the risks and benefits of interventions, with a clear understanding of patients' prognosis, goals of care, and current physical, emotional, and spiritual state. Achieving optimum QOL, safety, and ethical care are emphasized. Conclusions: The use of lifestyle interventions in patients receiving palliative or hospice care is a complex undertaking, requiring tailoring recommendations to individual patients. There is potential for considerable benefits; however, more research is needed.
Collapse
Affiliation(s)
- Gowri Anandarajah
- Gowri Anandarajah, MD, Office of Medical Education, Warren Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI 02912; e-mail:
| | - Haran Asher Mennillo
- Warren Alpert Medical School of Brown University, Providence, Rhode Island (GA, HAM, JG)
- Hope Hospice and Palliative Care Rhode Island, Providence, Rhode Island (GA, GR)
- Brown University, Providence, Rhode Island (TH)
| | - Gregory Rachu
- Warren Alpert Medical School of Brown University, Providence, Rhode Island (GA, HAM, JG)
- Hope Hospice and Palliative Care Rhode Island, Providence, Rhode Island (GA, GR)
- Brown University, Providence, Rhode Island (TH)
| | - Tyler Harder
- Warren Alpert Medical School of Brown University, Providence, Rhode Island (GA, HAM, JG)
- Hope Hospice and Palliative Care Rhode Island, Providence, Rhode Island (GA, GR)
- Brown University, Providence, Rhode Island (TH)
| | - Jyotsna Ghosh
- Warren Alpert Medical School of Brown University, Providence, Rhode Island (GA, HAM, JG)
- Hope Hospice and Palliative Care Rhode Island, Providence, Rhode Island (GA, GR)
- Brown University, Providence, Rhode Island (TH)
| |
Collapse
|
22
|
Hooten WM. Opioid Management: Initiating, Monitoring, and Tapering. Phys Med Rehabil Clin N Am 2020; 31:265-277. [PMID: 32279729 PMCID: PMC7156434 DOI: 10.1016/j.pmr.2020.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Numerous guidelines targeting safe use of opioids for chronic pain have been published but substantial challenges persist in clinical application of best practice recommendations. This article describes a pragmatic approach to clinical care of adults with chronic pain receiving long-term opioid therapy. Three components of care are emphasized: (1) medical and mental health assessment before initiating opioid therapy, (2) clinical surveillance during the course of long-term opioid therapy, and (3) clinical considerations and strategies governing opioid tapering. A pressing need exists for ongoing research to further clarify the optimal role that long-term opioid therapy has in treatment of chronic pain.
Collapse
Affiliation(s)
- W Michael Hooten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Charlton 1-145, 200 First Street SW, Rochester, MN 55905, USA.
| |
Collapse
|
23
|
Hui D, Abdelghani E, Chen J, Dibaj S, Zhukovsky D, Dev R, Tanco K, Haider A, Azhar A, Reddy A, Epner D, Arthur J, Dalal S, Heung Y, Reddy S, De La Cruz M, Liu D, Bruera E. Chronic Non-Malignant Pain in Patients with Cancer Seen at a Timely Outpatient Palliative Care Clinic. Cancers (Basel) 2020; 12:cancers12010214. [PMID: 31952220 PMCID: PMC7016539 DOI: 10.3390/cancers12010214] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 01/08/2020] [Accepted: 01/09/2020] [Indexed: 12/16/2022] Open
Abstract
Palliative care is seeing cancer patients earlier in the disease trajectory with a multitude of chronic issues. Chronic non-malignant pain (CNMP) in cancer patients is under-studied. In this prospective study, we examined the prevalence and management of CNMP in cancer patients seen at our supportive care clinic for consultation. We systematically characterized each pain type with the Brief Pain Inventory (BPI) and documented current treatments. The attending physician made the pain diagnoses according to the International Association for the Study of Pain (IASP) task force classification. Among 200 patients (mean age 60 years, 69% metastatic disease, 1-year survival of 77%), the median number of pain diagnosis was 2 (IQR 1–2); 67 (34%, 95% CI 28–41%) had a diagnosis of CNMP; 133 (67%) had cancer-related pain; and 52 (26%) had treatment-related pain. In total, 12/31 (39%) patients with only CNMP and 21/36 (58%) patients with CNMP and other pain diagnoses were on opioids. There was a total of 94 CNMP diagnoses among 67 patients, including 37 (39%) osteoarthritis and 20 (21%) lower back pain; 30 (32%) were treated with opioids. In summary, CNMP was common in the timely palliative care setting and many patients were on opioids. Our findings highlight the need to develop clinical guidelines for CNMP in cancer patients to standardize its management.
Collapse
Affiliation(s)
- David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
- Correspondence: ; Tel.: +1-713-794-1803; Fax: +1-713-792-6092
| | - Eman Abdelghani
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| | - Joseph Chen
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| | - Shiva Dibaj
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| | - Donna Zhukovsky
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| | - Rony Dev
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| | - Kimberson Tanco
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| | - Ali Haider
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| | - Ahsan Azhar
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| | - Akhila Reddy
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| | - Daniel Epner
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| | - Joseph Arthur
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| | - Shalini Dalal
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| | - Yvonne Heung
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| | - Suresh Reddy
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| | - Maxine De La Cruz
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| | - Diane Liu
- Department of Biostatistics, MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| |
Collapse
|
24
|
Doan LV, Blitz J. Preoperative Assessment and Management of Patients with Pain and Anxiety Disorders. CURRENT ANESTHESIOLOGY REPORTS 2020; 10:28-34. [PMID: 32435161 PMCID: PMC7222996 DOI: 10.1007/s40140-020-00367-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Purpose of Review This review summarizes selected recent evidence on issues important for preoperative pain evaluation. Recent Findings Opioids, though a mainstay of postoperative pain management, are associated with both short and increasingly recognized long-term risks, including persistent opioid use. Risk factors for high levels of acute postoperative pain as well as chronic postsurgical pain may overlap, including psychological factors such as depression, anxiety, and catastrophizing. Tools to predict those at risk for poor postoperative pain outcomes are being studied. Summary Preoperative pain and psychological factors can affect postoperative pain outcomes. More work is needed in the future to develop practical interventions in the preoperative period to address these factors.
Collapse
Affiliation(s)
- Lisa V Doan
- 1Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University School of Medicine, New York, NY USA
| | - Jeanna Blitz
- 2Department of Anesthesiology, Duke University School of Medicine, Durham, NC USA
| |
Collapse
|
25
|
Miura M, Tsuruga K, Morimoto Y. A pediatric cancer patient with suspected chemical coping following high-dose opioid therapy: a case report. J Med Case Rep 2019; 13:353. [PMID: 31783905 PMCID: PMC6884815 DOI: 10.1186/s13256-019-2273-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 09/24/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chemical coping is an inappropriate method for dealing with stress through the use of opioids; it is considered the stage prior to abuse and dependence. In patients with cancer, it is important to evaluate the risk of chemical coping when using opioids. There are some pediatric opioid use-related tolerances and addictions; however, no mention of chemical coping has been found. CASE PRESENTATION We present a case of an 11-year-old Japanese boy with acute lymphocytic leukemia. After transplantation, he complained of abdominal and articular pain, which are considered as symptoms of graft-versus-host disease; thus, opioid therapy was initiated, and the dose was gradually increased for pain management, resulting in a high dose of 2700 μg/day of fentanyl (4200-4700 μg/day including the rescue dose). After switching from fentanyl to oxycodone injections, he continued to experience pain, and there was no change in the frequency of oxycodone rescue doses. Physically, his pain was considered to have alleviated; thus, there was the possibility of mental anxiety resulting in the lowering of pain threshold and the possibility of chemical coping. Mental anxiety and stress with progress through schooling was believed to have resulted in chemical coping; thus, efforts were made to reduce the boy's anxiety, and opioid education was provided. However, dose reduction was challenging. Ultimately, with guidance from medical care providers, the opioid dose was reduced, and the patient was successfully weaned off opioids. CONCLUSIONS When chemical coping is suspected in pediatric patients, after differentiating from pseudo-addiction, it might be necessary to restrict the prescription for appropriate use and to provide opioid education while taking into consideration the emotional background of the patient that led to chemical coping.
Collapse
Affiliation(s)
- Mototsugu Miura
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Hokkaido, Japan.
| | | | - Yuji Morimoto
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Hokkaido, Japan
| |
Collapse
|
26
|
Risk Factors for Misuse of Prescribed Opioids: A Systematic Review and Meta-Analysis. Ann Emerg Med 2019; 74:634-646. [DOI: 10.1016/j.annemergmed.2019.04.019] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 04/02/2019] [Accepted: 04/17/2019] [Indexed: 01/24/2023]
|
27
|
Gardner RA, Brewer KL, Langston DB. Predicting opioid use disorder in patients with chronic pain who present to the emergency department. Inj Prev 2019; 25:386-391. [DOI: 10.1136/injuryprev-2018-042723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 03/20/2018] [Accepted: 03/25/2018] [Indexed: 11/03/2022]
Abstract
BackgroundEmergency department (ED) patients with chronic pain challenge providers to make quick and accurate assessments without an in-depth pain management consultation. Emergency physicians need reliable means to determine which patients may receive opioid therapy without exacerbating opioid use disorder (OUD).MethodsEighty-nine ED patients with a chief complaint of chronic pain were enrolled. Researchers administered questionnaires and reviewed medical and state prescription monitoring database information. Participants were classified as either OUD or non-OUD. Statistical analysis included a bivariate analysis comparing differences between groups and multivariate logistic regression evaluating ORs.ResultsThe 45 participants categorised as OUD had a higher proportion of documented or reported psychiatric diagnoses (p=0.049), preference of opioid treatment (p=0.005), current oxycodone prescription (p=0.043), borrowed pain medicine (p=0.004) and non-authorised dose increase (p<0.001). The state prescription monitoring database revealed the OUD group to have an increased number of opioid prescriptions (p=0.005) and pills (p=0.010). Participants who borrowed pain medicine and engaged in non-authorised dose increase were 5.2 (p=0.025, 95% CI 1.24 to 21.9) and 6.1 times (p=0.001, 95% CI 1.55 to 24.1) more likely to have OUD, respectively.LimitationsMajor limitations of our study include a small sample size, self-reported measures and convenience sample which may introduce selection bias.ConclusionPatients with chronic pain with OUD have distinguishable characteristics. Emergency physicians should consider such evidence-based variables prior to opioid therapy to ameliorate the opioid crisis and limit implicit bias.
Collapse
|
28
|
Gregorian T, Alvarez N, Han K, Ayson M, Durham M. Tools for Community-Based Pharmacist Patient Care Services to Support Optimal Opioid Use. JOURNAL OF CONTEMPORARY PHARMACY PRACTICE 2019. [DOI: 10.37901/jcphp18-00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
|
29
|
Alzeer AH, Jones J, Bair MJ. Review of Factors, Methods, and Outcome Definition in Designing Opioid Abuse Predictive Models. PAIN MEDICINE 2019; 19:997-1009. [PMID: 29016966 DOI: 10.1093/pm/pnx149] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Objective Several opioid risk assessment tools are available to prescribers to evaluate opioid analgesic abuse among chronic patients. The objectives of this study are to 1) identify variables available in the literature to predict opioid abuse; 2) explore and compare methods (population, database, and analysis) used to develop statistical models that predict opioid abuse; and 3) understand how outcomes were defined in each statistical model predicting opioid abuse. Design The OVID database was searched for this study. The search was limited to articles written in English and published from January 1990 to April 2016. This search generated 1,409 articles. Only seven studies and nine models met our inclusion-exclusion criteria. Results We found nine models and identified 75 distinct variables. Three studies used administrative claims data, and four studies used electronic health record data. The majority, four out of seven articles (six out of nine models), were primarily dependent on the presence or absence of opioid abuse or dependence (ICD-9 diagnosis code) to define opioid abuse. However, two articles used a predefined list of opioid-related aberrant behaviors. Conclusions We identified variables used to predict opioid abuse from electronic health records and administrative data. Medication variables are the recurrent variables in the articles reviewed (33 variables). Age and gender are the most consistent demographic variables in predicting opioid abuse. Overall, there is similarity in the sampling method and inclusion/exclusion criteria (age, number of prescriptions, follow-up period, and data analysis methods). Intuitive research to utilize unstructured data may increase opioid abuse models' accuracy.
Collapse
Affiliation(s)
- Abdullah H Alzeer
- Indiana University School of Informatics and Computing, Indianapolis, Indiana
| | - Josette Jones
- Indiana University School of Informatics and Computing, Indianapolis, Indiana.,Regenstrief Institute, Indianapolis, Indiana.,Indiana University School of Nursing, Indianapolis, Indiana
| | - Matthew J Bair
- Regenstrief Institute, Indianapolis, Indiana.,Richard L. Roudebush VA Medical Center, Center for Health Information and Communication (CHIC), Indianapolis, Indiana.,Indiana University School of Medicine, Indianapolis, Indiana, USA
| |
Collapse
|
30
|
Klimas J, Gorfinkel L, Fairbairn N, Amato L, Ahamad K, Nolan S, Simel DL, Wood E. Strategies to Identify Patient Risks of Prescription Opioid Addiction When Initiating Opioids for Pain: A Systematic Review. JAMA Netw Open 2019; 2:e193365. [PMID: 31050783 PMCID: PMC6503484 DOI: 10.1001/jamanetworkopen.2019.3365] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 03/18/2019] [Indexed: 11/18/2022] Open
Abstract
Importance Although prescription opioid use disorder is associated with substantial harms, strategies to identify patients with pain among whom prescription opioids can be safely prescribed have not been systematically reviewed. Objective To review the evidence examining factors associated with opioid addiction and screening tools for identifying adult patients at high vs low risk of developing symptoms of prescription opioid addiction when initiating prescription opioids for pain. Data Sources MEDLINE and Embase (January 1946 to November 2018) were searched for articles investigating risks of prescription opioid addiction. Study Selection Original studies that were included compared symptoms, signs, risk factors, and screening tools among patients who developed prescription opioid addiction and those who did not. Data Extraction and Synthesis Two investigators independently assessed quality to exclude biased or unreliable study designs and extracted data from higher quality studies. The Preferred Reporting Items for Systematic Reviews and Meta-analyses of Diagnostic Accuracy Studies (PRISMA-DTA) reporting guideline was followed. Main Outcomes and Measures Likelihood ratios (LRs) for risk factors and screening tools were calculated. Results Of 1287 identified studies, 6 high-quality studies were included in the qualitative synthesis and 4 were included in the quantitative synthesis. The 4 high-quality studies included in the quantitative synthesis were all retrospective studies including a total of 2 888 346 patients with 4470 cases that met the authors' definitions of prescription opioid addiction. A history of opioid use disorder (LR range, 17-22) or other substance use disorder (LR range, 4.2-17), certain mental health diagnoses (eg, personality disorder: LR, 27; 95% CI, 18-41), and concomitant prescription of certain psychiatric medications (eg, atypical antipsychotics: LR, 17; 95% CI, 15-18) appeared useful for identifying patients at high risk of opioid addiction. Among individual findings, only the absence of a mood disorder (negative LR, 0.50; 95% CI, 0.45-0.52) was associated with a lower risk of opioid addiction. Despite their widespread use, most screening tools involving combinations of questions were based on low-quality studies or, when diagnostic performance was assessed among high-quality studies, demonstrated poor performance in helping to identify patients at high vs low risk. Conclusions and Relevance While a history of substance use disorder, certain mental health diagnoses, and concomitant prescription of certain psychiatric medications appeared useful for identifying patients at higher risk, few quality studies were available and no symptoms, signs, or screening tools were particularly useful for identifying those at lower risk.
Collapse
Affiliation(s)
- Jan Klimas
- School of Medicine, University College Dublin, Health Sciences Centre, Belfield, Dublin, Ireland
- Department of Medicine, University of British Columbia, St Paul’s Hospital, Vancouver, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Lauren Gorfinkel
- Mailman School of Public Health, Columbia University, New York, New York
| | - Nadia Fairbairn
- Department of Medicine, University of British Columbia, St Paul’s Hospital, Vancouver, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Laura Amato
- Department of Epidemiology, Lazio Regional Health Services, Rome, Italy
| | - Keith Ahamad
- Department of Medicine, University of British Columbia, St Paul’s Hospital, Vancouver, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Seonaid Nolan
- Department of Medicine, University of British Columbia, St Paul’s Hospital, Vancouver, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - David L. Simel
- Durham Veterans Affairs Medical Center, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
| | - Evan Wood
- Department of Medicine, University of British Columbia, St Paul’s Hospital, Vancouver, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| |
Collapse
|
31
|
Lawrence R, Mogford D, Colvin L. Systematic review to determine which validated measurement tools can be used to assess risk of problematic analgesic use in patients with chronic pain. Br J Anaesth 2019; 119:1092-1109. [PMID: 28981581 DOI: 10.1093/bja/aex316] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2017] [Indexed: 12/27/2022] Open
Abstract
Background Misuse of prescription opioids, and other drugs prescribed for chronic pain, has increased, with major concerns about harm. This review was undertaken to identify validated measurement tools for risk assessment and monitoring of chronic non-cancer pain patients being considered for, or currently prescribed, analgesic drugs with abuse potential. Methods Selected databases (Embase, Medline, Cochrane library/CENTRAL, PsycINFO, PubMed, CINAHL) were systematically searched for studies evaluating tools for risk of analgesic misuse, either before, or during, analgesic therapy for chronic pain, using predetermined inclusion/exclusion criteria. Two independent reviewers assessed abstracts, selected full texts, extracted data and assessed quality. Results 30 studies from 1844 met inclusion criteria, including three systematic reviews, with an additional four studies from bibliography review. The studies covered 14 tools pertaining to opioid use, with none for non-opioid analgesics. Conclusions For predicting prescription opioid misuse, the pain medication questionnaire (PMQ) and the screener and opioid assessment for patients with pain (SOAPP) had the best evidence; both developed and validated in five separate studies (four each of acceptable quality). The current opioid misuse measure (COMM) performed best screening for current misuse, developed and validated in three studies of acceptable quality. A small number of tools may accurately predict, or identify, opioid misuse. There are none for non-opioid analgesics, where there is a potential need.
Collapse
Affiliation(s)
- R Lawrence
- Ritson Clinic, Royal Edinburgh Hospital, Morningside Terrace, Edinburgh EH10 5HF, UK
| | - D Mogford
- Ritson Clinic, Royal Edinburgh Hospital, Morningside Terrace, Edinburgh EH10 5HF, UK
| | - L Colvin
- Department of Anaesthesia, Critical Care & Pain Medicine, University of Edinburgh, Western General Hospital, Crewe Rd, Edinburgh EH4 2XU, UK
| |
Collapse
|
32
|
Roughead EE, Lim R, Ramsay E, Moffat AK, Pratt NL. Persistence with opioids post discharge from hospitalisation for surgery in Australian adults: a retrospective cohort study. BMJ Open 2019; 9:e023990. [PMID: 30992289 PMCID: PMC6500207 DOI: 10.1136/bmjopen-2018-023990] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE To determine time to opioid cessation post discharge from hospital in persons who had been admitted to hospital for a surgical procedure and were previously naïve to opioids. DESIGN, SETTING AND PARTICIPANTS Retrospective cohort study using administrative health claims database from the Australian Government Department of Veterans' Affairs (DVA). DVA gold card holders aged between 18 and 100 years who were admitted to hospital for a surgical admission between 1 January 2014 and 30 December 2015 and naïve to opioid therapy prior to admission were included in the study. Gold card holders are eligible for all health services that DVA funds. MAIN OUTCOME MEASURES The outcome of interest was time to cessation of opioids, with follow-up occurring over 12 months. Cessation was defined as a period without an opioid prescription that was equivalent to three times the estimated supply duration. The proportion who became chronic opioid users was defined as those who continued taking opioids for greater than 90 days post discharge. Cumulative incidence function with death as a competing event was used to determine time to cessation of opioids post discharge. RESULTS In 2014-2015, 24 854 persons were admitted for a surgical admission. In total 3907 (15.7%) were discharged on opioids. In total 3.9% of those discharged on opioids became chronic users of opioids. The opioid that the patients were most frequently discharged with was oxycodone; oxycodone alone accounted for 43%, while oxycodone with naloxone accounted for 8%. CONCLUSIONS Opioid initiation post-surgical hospital admission leads to chronic use of opioids in a small percentage of the population. However, given the frequency at which surgical procedures occur, this means that a large number of people in the population may be affected. Post-discharge assessment and follow-up of at-risk patients is important, particularly where psychosocial elements such as anxiety and catastrophising are identified.
Collapse
Affiliation(s)
| | - Renly Lim
- Quality Use of Medicines and Pharmacy Research Centre, University of South Australia Division of Health Sciences, Adelaide, South Australia, Australia
| | | | | | | |
Collapse
|
33
|
Selecting the Appropriate Patient for Opioid Therapy: Risk Assessment and Treatment Strategies for Gynecologic Pain. Clin Obstet Gynecol 2019; 62:48-58. [DOI: 10.1097/grf.0000000000000411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
34
|
Salazar L, Findlay L. Implementation and Evaluation of an Opioid Risk Questionnaire in the Outpatient Plastic Surgery Setting. Plast Surg Nurs 2019; 39:136-141. [PMID: 31790042 DOI: 10.1097/psn.0000000000000278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Most patients undergoing plastic and cosmetic surgery are prescribed an opioid for postoperative pain control. With the advent of the opioid epidemic in our country, screening for opioid risk has become a topic of many health care discussions. However, there has been little mention of using an opioid risk questionnaire specific to the outpatient plastic surgery setting. This project consisted of distribution of an opioid risk questionnaire to adult patients undergoing outpatient plastic surgery. Data were collected at preoperative appointments from participating patients (n = 27). Although the sample size was small, two patients (7%) were identified as having a history of substance abuse, and both of those patients reported they had also received treatment for their substance abuse. In addition, six patients (22%) reported having a family history of substance abuse. Such findings suggest that clinicians working in outpatient plastic surgery should screen their patients for substance abuse and misuse.
Collapse
Affiliation(s)
- Leah Salazar
- Leah Salazar, DNP, APRN-BC, RN, is a board-certified family nurse practitioner working in outpatient plastic and cosmetic surgery in Reno, Nevada. Lillian Findlay, PhD, APRN, is a board-certified nurse practitioner and clinical nurse specialist in psychiatric mental health and a faculty member of the University of Alabama, Tuscaloosa
| | | |
Collapse
|
35
|
Black RA, McCaffrey SA, Villapiano AJ, Jamison RN, Butler SF. Development and Validation of an Eight-Item Brief Form of the SOAPP-R (SOAPP-8). PAIN MEDICINE 2018; 19:1982-1987. [PMID: 29024987 DOI: 10.1093/pm/pnx194] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective Although the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) has become a widely used screener for aberrant opioid-related behavior in adults, the length of the instrument may limit its utility. The purpose of the current study was to develop a short form of the SOAPP-R by retaining as few items as possible while maximizing predictive accuracy. Methods Participants (N = 555), recruited from pain clinics, completed the 24-item SOAPP-R and participated in a five-month follow-up visit to evaluate aberrant drug-related behaviors. Opioid aberrant-related behavior was determined through self-report, physician report, and urine toxicology screen. The optimal subset of SOAPP-R items to predict aberrant opioid-related behavior was identified empirically by employing the LASSO selection method and the leave-one-out cross-validation (LOOCV) method offered in the GLMSELECT procedure in SAS 9.4 in conjunction with content expertise. Results Eight items were identified before the selection method stopped. The receiver operating characteristic curve generated from the predicted probabilities from the model produced an area under the curve (AUC) value greater than the AUC value produced by the 24-item SOAPP-R total score and yielded a sensitivity of 0.74 and a specificity of 0.66. Conclusions These results provide strong preliminary support for the SOAPP-8 as a brief screening tool of aberrant opioid-related behavior in chronic pain patients.
Collapse
Affiliation(s)
| | | | | | - Robert N Jamison
- Anesthesia and Psychiatry, Brigham and Women's Hospital, Boston, MA
| | | |
Collapse
|
36
|
Bruce RD, Merlin J, Lum PJ, Ahmed E, Alexander C, Corbett AH, Foley K, Leonard K, Treisman GJ, Selwyn P. 2017 HIVMA of IDSA Clinical Practice Guideline for the Management of Chronic Pain in Patients Living With HIV. Clin Infect Dis 2018; 65:e1-e37. [PMID: 29020263 DOI: 10.1093/cid/cix636] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 07/19/2017] [Indexed: 12/27/2022] Open
Abstract
Pain has always been an important part of human immunodeficiency virus (HIV) disease and its experience for patients. In this guideline, we review the types of chronic pain commonly seen among persons living with HIV (PLWH) and review the limited evidence base for treatment of chronic noncancer pain in this population. We also review the management of chronic pain in special populations of PLWH, including persons with substance use and mental health disorders. Finally, a general review of possible pharmacokinetic interactions is included to assist the HIV clinician in the treatment of chronic pain in this population.It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. The Infectious Diseases Society of American considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.
Collapse
Affiliation(s)
- R Douglas Bruce
- Department of Medicine, Cornell Scott-Hill Health Center and Yale University, New Haven, Connecticut
| | - Jessica Merlin
- Divisions of Infectious Diseases and Gerontology, Geriatrics and Palliative Care, University of Alabama at Birmingham
| | - Paula J Lum
- Division of HIV, Infectious Disease, and Global Medicine, University of California San Francisco
| | - Ebtesam Ahmed
- St. Johns University College of Pharmacy and Health Sciences, Metropolitan Jewish Health System Institute for Innovation in Palliative Care, New York
| | - Carla Alexander
- University of Maryland School of Medicine, Institute of Human Virology, Baltimore
| | - Amanda H Corbett
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
| | - Kathleen Foley
- Attending Neurologist Emeritus, Memorial Sloan Kettering Cancer Center, New York
| | - Kate Leonard
- Division of Neuroscience and Clinical Pharmacology, Cornell University, New York, New York
| | | | - Peter Selwyn
- Department of Family and Social Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| |
Collapse
|
37
|
Calcaterra SL, Scarbro S, Hull ML, Forber AD, Binswanger IA, Colborn KL. Prediction of Future Chronic Opioid Use Among Hospitalized Patients. J Gen Intern Med 2018; 33:898-905. [PMID: 29404943 PMCID: PMC5975151 DOI: 10.1007/s11606-018-4335-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 11/07/2017] [Accepted: 01/17/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Opioids are commonly prescribed in the hospital; yet, little is known about which patients will progress to chronic opioid therapy (COT) following discharge. We defined COT as receipt of ≥ 90-day supply of opioids with < 30-day gap in supply over a 180-day period or receipt of ≥ 10 opioid prescriptions over 1 year. Predictive tools to identify hospitalized patients at risk for future chronic opioid use could have clinical utility to improve pain management strategies and patient education during hospitalization and discharge. OBJECTIVE The objective of this study was to identify a parsimonious statistical model for predicting future COT among hospitalized patients not on COT before hospitalization. DESIGN Retrospective analysis electronic health record (EHR) data from 2008 to 2014 using logistic regression. PATIENTS Hospitalized patients at an urban, safety net hospital. MAIN MEASUREMENTS Independent variables included medical and mental health diagnoses, substance and tobacco use disorder, chronic or acute pain, surgical intervention during hospitalization, past year receipt of opioid or non-opioid analgesics or benzodiazepines, opioid receipt at hospital discharge, milligrams of morphine equivalents prescribed per hospital day, and others. KEY RESULTS Model prediction performance was estimated using area under the receiver operator curve, accuracy, sensitivity, and specificity. A model with 13 covariates was chosen using stepwise logistic regression on a randomly down-sampled subset of the data. Sensitivity and specificity were optimized using the Youden's index. This model predicted correctly COT in 79% of the patients and no COT correctly in 78% of the patients. CONCLUSIONS Our model accessed EHR data to predict 79% of the future COT among hospitalized patients. Application of such a predictive model within the EHR could identify patients at high risk for future chronic opioid use to allow clinicians to provide early patient education about pain management strategies and, when able, to wean opioids prior to discharge while incorporating alternative therapies for pain into discharge planning.
Collapse
Affiliation(s)
- S L Calcaterra
- Hospital Medicine, Denver Health Medical Center, Denver, CO, USA. .,Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, USA.
| | - S Scarbro
- University of Colorado Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, CO, USA.,Rocky Mountain Prevention Research Center, Colorado School of Public Health, University of Colorado Denver, Aurora, CO, USA
| | - M L Hull
- Hospital Medicine, Denver Health Medical Center, Denver, CO, USA
| | - A D Forber
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - I A Binswanger
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, USA.,Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
| | - K L Colborn
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| |
Collapse
|
38
|
Eldrige JS, Rho RH, Martin JL, Murphy JB, Hooten WM. Opioids: Clinical Practice, Monitoring, and Medicolegal Considerations. J Appl Lab Med 2018; 2:573-586. [DOI: 10.1373/jalm.2017.024026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 10/11/2017] [Indexed: 11/06/2022]
Abstract
Abstract
Background
In the past decade, opioid use in the general population of the US has increased dramatically. Concomitantly, opioid-related morbidity and mortality have also risen steeply. The causes of opioid over-prescribing are multifactorial, with pressure from medical agencies, patients, aggressive patient-directed marketing, and use of patient surveys as an evaluation tool to unduly influence medical providers' decision-making. Providers also have significant concerns regarding scrutiny from their medical board and exposure to medicolegal liability.
Content
To provide the basis for best practice recommendations, several aspects of modern opioid prescribing practice require review. The practicing clinician should be aware of: (a) the pervasiveness of current opioid prescribing within the US; (b) the availability and applicability of clinical tools used to assess patient risk; (c) the new guidelines designed to facilitate appropriate and safe medical use of opioids; (d) the incorporation of clinical tools and best documentation practices to reduce medicolegal exposure.
Summary
On completion of this review, the reader should be able to recognize the magnitude of the problem of opioid over-prescribing in the US and identify several patient risk factors for opioid misuse, abuse, and/or diversion. Specifically, better familiarity with the recently published CDC guidelines for opioid prescribing will help ensure the adoption of best-use practices that maximize therapeutic efficacy while attenuating the possibility of harm to patients. A thorough review of the legal principles and risk-mitigation strategies relevant to opioid prescribing will also lessen the clinician's exposure to medicolegal liability.
Collapse
Affiliation(s)
- Jason S Eldrige
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic Foundation, Rochester, MN
| | - Richard H Rho
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic Foundation, Rochester, MN
| | | | | | - W Michael Hooten
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic Foundation, Rochester, MN
| |
Collapse
|
39
|
Pratt NL, Roughead EE. Can we reduce the prevalence of persistent opioid use after surgery by predicting the future? Anaesth Intensive Care 2017; 45:658-659. [PMID: 29137573 DOI: 10.1177/0310057x1704500602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
40
|
Pestka EL, Craner J, Evans M, Nash V, Kimondo N, Pestka D, Loukianova L, Sperry J. Impact of Family History of Substance Abuse on Admission Opioid Dose, Depressive Symptoms, and Pain Catastrophizing in Patients with Chronic Pain. Pain Manag Nurs 2017; 19:115-124. [PMID: 29153294 DOI: 10.1016/j.pmn.2017.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 09/22/2017] [Accepted: 09/30/2017] [Indexed: 10/18/2022]
Abstract
The objectives of this study were to examine association between a family history of substance abuse and admission morphine equivalent dose, depression and pain catastrophizing screening scores, as well as reported personal history of substance use. The retrospective research was completed in an interdisciplinary three-week pain rehabilitation center. The subject cohort included admissions from January through December 2014 with 351 datasets for family history of substance abuse and oral morphine equivalency and 341 for depression, pain catastrophizing and use of substances. Outcome measures included admission self-reported data on family history of substance abuse and past and current substance use, admission morphine equivalency dose, and scores on the Center for Epidemiologic Studies-Depression Scale and the Pain Catastrophizing Scale. One hundred forty-seven patients were using opioid medications on admission and those with a positive family history of substance abuse had an oral morphine equivalency (M = 92.12, SD = 95.32) compared to a negative history (M = 80.34, SD = 64.86); the difference was not statistically significant, t (120.01) =.87, p = .39. Patients with a positive family history reported higher levels of both depression, t (327.40) = 3.15, p = .002 and pain catastrophizing, t (338) = 2.76, p = .01. Those with a positive family history endorsed greater frequency of past alcohol use χ2 (1, N = 326) = 6.67, p = 0.1 and marijuana use χ2 (1, N = 341) = 4.23, p = .04 and past χ2 (1, N = 329) = 9.90, p = .002 and current tobacco use χ2 (1, N = 327) = 8.81, p = .003. Use of family history of substance abuse information may help provide data for multimodal treatments of chronic non-cancer-pain. The findings from this study can be used to guide future research.
Collapse
Affiliation(s)
| | - Julia Craner
- Department of Psychiatry and Behavioral Medicine, Spectrum Health System, Grand Rapids, Michigan
| | - Michele Evans
- Department of Psychiatry, Mayo Clinic, Rochester, Minnesota
| | - Virginia Nash
- Department of Psychiatry, Mayo Clinic, Rochester, Minnesota
| | - Njoki Kimondo
- Department of Psychiatry, Mayo Clinic, Rochester, Minnesota
| | - Deborah Pestka
- College of Pharmacy, University of Minnesota, Minneapolis, Minnesota
| | | | - Jeannie Sperry
- Department of Psychiatry, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
41
|
Bennett AS, Elliott L, Golub A, Wolfson-Stofko B, Guarino H. Opioid-Involved Overdose Among Male Afghanistan/Iraq-Era U.S. Military Veterans: A Multidimensional Perspective. Subst Use Misuse 2017; 52:1701-1711. [PMID: 28622067 PMCID: PMC5628147 DOI: 10.1080/10826084.2017.1306563] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Mirroring nationwide trends in a broad range of U.S. populations, an alarming number of Afghanistan/Iraq-era U.S. Military veterans have experienced opioid-related overdoses. A growing body of research has examined the proximal behaviors that can precipitate an overdose; considerably less is known about more distal physiological, psychosocial and structural influences on these risk behaviors. OBJECTIVES This study adopts a multidimensional approach to better understand opioid-related overdose among U.S. Military veterans, and seeks to explore not only the proximal behavioral precipitants of overdose events, but also the complex nexus of physiological, psychological, and sociological influences that undergird overdose events. METHODS This qualitative examination is based on interview data from 36 male veterans who were discharged from the military after September 2001 and experienced at least one opioid-related overdose during or after military service. Participants were recruited in New York City during 2014 to share narrative accounts of their overdoses. RESULTS Veterans' accounts indicate that background experiences, such as self-medication for social and psychological pain, trauma, social alienation and isolation, and histories of illicit drug use, precondition the more immediate factors and behaviors that precipitate overdose (including bingeing on drugs, mixing drugs, naiveté about dosage, and ambivalence about life/death). CONCLUSIONS Findings suggest the need for comprehensive drug safety and overdose education that is sensitive to veterans' physiological, psychological, and sociological conditions. A multidimensional understanding of the distal and proximal overdose risks faced by veterans and other vulnerable groups may help lay a foundation for more inclusive/holistic approaches to overdose prevention and education.
Collapse
Affiliation(s)
- Alex S. Bennett
- Center for Community and Health Disparities Research, National Development and Research Institutes, Inc., New York, NY, USA
- Center for Drug Use and HIV/HCV Research, New York University, New York, NY, USA
| | - Luther Elliott
- Center for Community and Health Disparities Research, National Development and Research Institutes, Inc., New York, NY, USA
- Center for Drug Use and HIV/HCV Research, New York University, New York, NY, USA
| | - Andrew Golub
- Center for Community and Health Disparities Research, National Development and Research Institutes, Inc., New York, NY, USA
| | - Brett Wolfson-Stofko
- Center for Community and Health Disparities Research, National Development and Research Institutes, Inc., New York, NY, USA
- Center for Drug Use and HIV/HCV Research, New York University, New York, NY, USA
| | - Honoria Guarino
- Center for Community and Health Disparities Research, National Development and Research Institutes, Inc., New York, NY, USA
- Center for Drug Use and HIV/HCV Research, New York University, New York, NY, USA
- Institute for Infectious Disease Research, National Development and Research Institutes, Inc., New York, NY, USA
| |
Collapse
|
42
|
Copenhaver DJ, Karvelas NB, Fishman SM. Risk Management for Opioid Prescribing in the Treatment of Patients With Pain From Cancer or Terminal Illness. Anesth Analg 2017; 125:1610-1615. [DOI: 10.1213/ane.0000000000002463] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
43
|
Stark N, Kerr S, Stevens J. Prevalence and Predictors of Persistent Post-Surgical Opioid Use: A Prospective Observational Cohort Study. Anaesth Intensive Care 2017; 45:700-706. [DOI: 10.1177/0310057x1704500609] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Post-surgical opioid prescribing intended for the short-term management of acute pain may lead to long-term opioid use. This study was undertaken to determine the prevalence of persistent post-surgical opioid use and patient-related factors associated with post-surgical opioid use. One thousand and thirteen opioid-naïve patients awaiting elective surgery in a tertiary private hospital in Sydney were enrolled. Preoperatively, patients completed a questionnaire comprising potential predictors of persistent post-surgical opioid use. Patients underwent surgery with routine perioperative care, and were followed up at 90 to 120 days after surgery to determine opioid use. Factors associated with opioid use were assessed with logistic regression. We had an overall response rate of 95.8% (n=970) of patients, of whom 10.5% (n=102) continued to use opioids at >90 days after surgery. On surgical subtype analysis, the prevalence of persistent opioid use was 23.6% after spinal surgery, and 13.7% after orthopaedic surgery. Four factors were independently associated with persistent post-surgical opioid use in a multivariate model: having orthopaedic (odds ratio [OR] 4.6, 95% confidence interval [CI] 2.0 to 10.8, P <0.001) or spinal surgery (OR 4.0, 95% CI 1.7 to 9.2, P <0.001), anxiety (OR 2.1, 95% CI 1.1 to 4.1, P=0.03), attending pre-admission clinic (OR 3.7, 95% CI 1.6 to 8.6, P=0.002), and higher self-reported pain score at >90 days after surgery (P <0.001). More than 10% of opioid-naïve patients undergoing elective surgery experience persistent post-surgical opioid use. Identification of factors associated with persistent post-surgical opioid use may allow development of a risk stratification tool to predict those at highest risk.
Collapse
Affiliation(s)
- N. Stark
- School of Medicine, University of Notre Dame Sydney, Sydney, New South Wales
| | - S. Kerr
- The Kirby Institute, University of New South Wales, Sydney, New South Wales
| | - J. Stevens
- Anaesthetist and Pain Medicine Specialist, Department of Anaesthetics, St Vincent's Private Hospital Sydney, Sydney, New South Wales
| |
Collapse
|
44
|
Abstract
Opioid analgesics are recognized as a legitimate medical therapy for selected patients with severe chronic pain that does not respond to other therapies. However, opioids are associated with risks for patients and society that include misuse, abuse, diversion, addiction, and overdose deaths. Therapeutic success depends on proper candidate selection, assessment before administering opioid therapy, and close monitoring throughout the course of treatment. Risk assessment and prevention include knowledge of patient factors that may contribute to misuse, abuse, addiction, suicide, and respiratory depression. Risk factors for opioid misuse or addiction include past or current substance abuse, untreated psychiatric disorders, younger age, and social or family environments that encourage misuse. Opioid mortality prevalence is higher in people who are middle aged and have substance abuse and psychiatric comorbidities. Suicides are probably undercounted or frequently misclassified in reports of opioid-related poisoning deaths. Greater understanding and better assessment are needed of the risk associated with suicide risk in patients with pain. Clinical tools and an evolving evidence base are available to assist clinicians with identifying patients whose risk factors put them at risk for adverse outcomes with opioids.
Collapse
|
45
|
Pouget ER, Bennett AS, Elliott L, Wolfson-Stofko B, Almeñana R, Britton PC, Rosenblum A. Development of an opioid-related Overdose Risk Behavior Scale (ORBS). Subst Abus 2017; 38:239-244. [PMID: 28113004 PMCID: PMC5522769 DOI: 10.1080/08897077.2017.1282914] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Drug overdose has emerged as the leading cause of injury-related death in the United States, driven by prescription opioid (PO) misuse, polysubstance use, and use of heroin. To better understand opioid-related overdose risks that may change over time and across populations, there is a need for a more comprehensive assessment of related risk behaviors. Drawing on existing research, formative interviews, and discussions with community and scientific advisors an opioid-related Overdose Risk Behavior Scale (ORBS) was developed. METHODS Military veterans reporting any use of heroin or POs in the past month were enrolled using venue-based and chain referral recruitment. The final scale consisted of 25 items grouped into 5 subscales eliciting the number of days in the past 30 during which the participant engaged in each behavior. Internal reliability, test-retest reliability and criterion validity were assessed using Cronbach's alpha, intraclass correlations (ICC) and Pearson's correlations with indicators of having overdosed during the past 30 days, respectivelyInternal reliability, test-retest reliability and criterion validity were assessed using Cronbach's alpha, intraclass correlations (ICC) and Pearson's correlations with indicators of having overdosed during the past 30 days, respectively. RESULTS Data for 220 veterans were analyzed. The 5 subscales-(A) Adherence to Opioid Dosage and Therapeutic Purposes; (B) Alternative Methods of Opioid Administration; (C) Solitary Opioid Use; (D) Use of Nonprescribed Overdose-associated Drugs; and (E) Concurrent Use of POs, Other Psychoactive Drugs and Alcohol-generally showed good internal reliability (alpha range = 0.61 to 0.88), test-retest reliability (ICC range = 0.81 to 0.90), and criterion validity (r range = 0.22 to 0.66). The subscales were internally consistent with each other (alpha = 0.84). The scale mean had an ICC value of 0.99, and correlations with validators ranged from 0.44 to 0.56. CONCLUSIONS These results constitute preliminary evidence for the reliability and validity of the new scale. If further validated, it could help improve overdose prevention and response research and could help improve the precision of overdose education and prevention efforts.
Collapse
Affiliation(s)
- Enrique R. Pouget
- National Development and Research Institutes, Inc., New York, New York, USA
| | - Alex S. Bennett
- National Development and Research Institutes, Inc., New York, New York, USA
| | - Luther Elliott
- National Development and Research Institutes, Inc., New York, New York, USA
| | | | - Ramona Almeñana
- National Development and Research Institutes, Inc., New York, New York, USA
| | - Peter C. Britton
- Canandaigua VA Medical Center, Center of Excellence for Suicide Prevention, Canandaigua, New York, USA
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
| | - Andrew Rosenblum
- National Development and Research Institutes, Inc., New York, New York, USA
| |
Collapse
|
46
|
Abstract
OBJECTIVE In light of the recent uptrend in the prescription of opioids, this study seeks to identify patterns of opioid misuse among orthopaedic postoperative patients and principal external sources in obtaining these medications. DESIGN Ten-month survey-based study. SETTING Two Level I trauma centers (urban and suburban). PATIENTS/PARTICIPANTS Two hundred seven patients between the ages of 18 and 89 years who underwent surgical fixation of fractures involving the pelvis, long bones, or periarticular regions of the knee, ankle, elbow, and wrist. MAIN OUTCOME MEASUREMENTS Patients who believed they were undermedicated, used prescribed opioids at higher than recommended doses, and took extra opioids in addition to their prescribed analgesics were analyzed by age, employment, income, education, controlled substance use, pain interference with activities of daily living, and anatomic surgical site. RESULTS One hundred eighty-two patients completed the survey; 19.2% of patients (n = 35) felt undermedicated [unemployed (P < 0.05), low income (P < 0.05), and self-reported controlled substance users (P < 0.05)]; 12.6% of patients (n = 23) admitted to using pain medications at a higher dose than prescribed [unemployed (P < 0.05), lower income (P < 0.05), nonhigh school graduates (P < 0.05), and previous controlled substance users (P < 0.05)]; 9.3% (n = 17) admitted to using external opioids [unemployed patients (P < 0.05) and self-reported controlled substance users (P < 0.05)]. Major sources of extraneous opioids include family/friends (n = 5) and other doctors (n = 4). CONCLUSION Unemployed and lower-income patients were significantly more likely to believe that their surgeon was not prescribing them enough pain medications as well as use their prescribed opioid medications at a higher than recommended dose compared with their employed counterparts with higher incomes. Unemployed patients were also significantly more likely to use additional opioid analgesics in addition to those prescribed to them by their primary surgeon. Surgeon awareness of a patient's socioeconomic background and associated risk of opioid misuse is crucial to prescribe the safest most effective pain regimen. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
47
|
Guerriero F, Bolier R, Van Cleave JH, Reid MC. Pharmacological Approaches for the Management of Persistent Pain in Older Adults: What Nurses Need to Know. J Gerontol Nurs 2016; 42:49-57. [PMID: 27898136 PMCID: PMC5472205 DOI: 10.3928/00989134-20161110-09] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 10/27/2016] [Indexed: 01/13/2023]
Abstract
HOW TO OBTAIN CONTACT HOURS BY READING THIS ARTICLE INSTRUCTIONS 1.4 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded once you register, pay the registration fee, and complete the evaluation form online at http://goo.gl/gMfXaf. To obtain contact hours you must: 1. Read the article, "Pharmacological Approaches for the Management of Persistent Pain in Older Adults: What Nurses Need to Know" found on pages 49-57, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz. 2. Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study. 3. Go to the Villanova website listed above to register for contact hour credit. You will be asked to provide your name; contact information; and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated. This activity is valid for continuing education credit until November 30, 2019. CONTACT HOURS This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated. Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. ACTIVITY OBJECTIVES 1. Describe age-related barriers to pain assessment and key aspects of the assessment process. 2. Identify benefits and risks associated with commonly prescribed analgesic medications for the treatment of later life pain. DISCLOSURE STATEMENT Neither the planners nor the authors have any conflicts of interest to disclose. The current article addresses pharmacological treatment issues regarding the management of persistent pain in later life, which is a worldwide problem associated with substantial disability. Recommendations from guidelines were reviewed and data are presented regarding the benefits and risks of commonly prescribed analgesic medications. The evidence base supports a stepwise approach with acetaminophen as first-line therapy for mild-to-moderate pain. Oral nonsteroidal anti-inflammatory drugs are not recommended for long-term use. In properly selected older patients, opioid drugs should be considered if pain is not adequately controlled. Careful surveillance to monitor for benefits and harms of therapy is critical, given that advancing age increases risk for adverse effects. Key aspects of the pain care process that nurses routinely engage in are covered, including conducting pain assessments prior to initiating therapy, addressing barriers to effective pain care, educating patients and family members about the importance of reducing pain, discussing treatment-related risks and benefits, and formulating strategies to monitor for treatment outcomes. Finally, a case is presented to illustrate issues that arise in the care of affected patients. [Journal of Gerontological Nursing, 42(12), 49-57.].
Collapse
|
48
|
|
49
|
Butler SF, Zacharoff KL, Charity S, Black RA, Chung E, Barreveld A, Clark MS, Jamison RN. Impact of an Electronic Pain and Opioid Risk Assessment Program: Are There Improvements in Patient Encounters and Clinic Notes? PAIN MEDICINE 2016; 17:2047-2060. [PMID: 27102526 DOI: 10.1093/pm/pnw033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE A comprehensive electronic self-report assessment, called PainCAS® (Clinical Assessment System), was developed and implemented in three clinics. PainCAS captures demographic information, pain assessment, quality-of-life variables, and contains validated, electronic versions of screeners for risk of aberrant opioid-related behaviors (the SOAPP and COMM). This investigation sought to determine the impact of PainCAS on documentation of pain and opioid risk evaluations. Exploratory hypotheses examined changes in the content of the patient-provider interaction and any impact on outcome. METHODS In study 1, chart reviews were conducted between pain patients who completed the electronic program (N = 89) and controls who represented standard of care (N = 120). In study 2, two groups of chronic pain patients (treatment-as-usual Control condition = 75, PainCAS Experimental condition = 72) were interviewed after completing their index clinic visit and completed mailed questionnaires 3 months later. RESULTS Results revealed significantly more key, pain-relevant chart elements documented in charts of patients who completed the PainCAS than those using a traditional paper questionnaire (Study 1; <0.001). In Study 2, the Experimental group reported more discussion about legal issues, substance use history, and medication safety compared with the Control group (p < 0.05). Satisfaction questionnaire responses supported provider and patient perceived benefit from using PainCAS. However, as expected, no differences were found between conditions on outcome measures of pain, mood, and function. CONCLUSIONS Results indicate that use of the PainCAS electronic pain assessment improves documentation of chart elements in clinic notes and is associated with increased discussion of key, pain-relevant topics during the clinical visit.
Collapse
Affiliation(s)
| | | | | | | | | | - Antje Barreveld
- Pain Management Center, Newton-Wellesley Hospital, Newton, Massachusetts
| | - Molly S Clark
- University of Mississippi Medical Center, Family Medicine, Jackson, Mississippi
| | - Robert N Jamison
- Pain Management Center, Brigham and Women's Hospital, Harvard Medical School, Chestnut Hill, Massachusetts, USA
| |
Collapse
|
50
|
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016. MMWR Recomm Rep 2016; 65:1-49. [PMID: 26987082 DOI: 10.15585/mmwr.rr6501e1] [Citation(s) in RCA: 1991] [Impact Index Per Article: 248.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
This guideline provides recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care. The guideline addresses 1) when to initiate or continue opioids for chronic pain; 2) opioid selection, dosage, duration, follow-up, and discontinuation; and 3) assessing risk and addressing harms of opioid use. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework, and recommendations are made on the basis of a systematic review of the scientific evidence while considering benefits and harms, values and preferences, and resource allocation. CDC obtained input from experts, stakeholders, the public, peer reviewers, and a federally chartered advisory committee. It is important that patients receive appropriate pain treatment with careful consideration of the benefits and risks of treatment options. This guideline is intended to improve communication between clinicians and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder, overdose, and death. CDC has provided a checklist for prescribing opioids for chronic pain (http://stacks.cdc.gov/view/cdc/38025) as well as a website (http://www.cdc.gov/drugoverdose/prescribingresources.html) with additional tools to guide clinicians in implementing the recommendations.
Collapse
Affiliation(s)
- Deborah Dowell
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC, Atlanta, Georgia
| | | | | |
Collapse
|