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Garland EL, Jinpa T. Mindfulness-induced self-transcendence promotes universal love with consequent effects on opioid misuse. Behav Res Ther 2024; 175:104494. [PMID: 38395015 DOI: 10.1016/j.brat.2024.104494] [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] [Received: 09/19/2023] [Revised: 02/01/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024]
Abstract
In addition to its health benefits, mindfulness has been theorized in classical contemplative frameworks to elicit self-transcendent experiences as a means of promoting universal love and compassion. Increasing feelings of love may be especially clinically relevant for the treatment of opioid misuse, in that addictive use of opioids dysregulates neurobiological processes implicated in the experience of love. Here we tested these hypotheses in a secondary analysis (n = 187) of data from a randomized clinical trial of Mindfulness-Oriented Recovery Enhancement (MORE) versus supportive psychotherapy for comorbid opioid misuse and chronic pain. At pre- and post-treatment, participants completed a measure of state self-transcendence immediately following a laboratory-based mindfulness task. Through 9-month follow-up, we assessed changes in universal love and opioid misuse. Participants also completed ecological momentary assessments of opioid craving during the 8-week study interventions and for the following month. Compared to supportive psychotherapy, participants in MORE reported significantly greater increases in mindfulness-induced self-transcendence, which mediated the effect of MORE on increased feelings of universal love. In turn, increases in universal love significantly predicted decreased opioid craving and lower odds opioid misuse through 1- and 9-month follow-ups, respectively. Findings suggest mindfulness-induced self-transcendence may promote feelings of universal love, with possible downstream benefits on reducing addictive behavior.
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Affiliation(s)
- Eric L Garland
- Center on Mindfulness and Integrative Health Intervention Development, University of Utah, USA.
| | - Thupten Jinpa
- School of Religious Studies, McGill University, Canada
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Garland EL, Nakamura Y, Bryan CJ, Hanley AW, Parisi A, Froeliger B, Marchand WR, Donaldson GW. Mindfulness-Oriented Recovery Enhancement for Veterans and Military Personnel on Long-Term Opioid Therapy for Chronic Pain: A Randomized Clinical Trial. Am J Psychiatry 2024; 181:125-134. [PMID: 38196335 PMCID: PMC10976433 DOI: 10.1176/appi.ajp.20230272] [Citation(s) in RCA: 2] [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: 01/11/2024]
Abstract
OBJECTIVE This randomized clinical trial evaluated the efficacy of Mindfulness-Oriented Recovery Enhancement (MORE) among past and present U.S. military personnel with prescriptions for long-term opioid therapy for chronic pain. METHODS In this clinical trial, 230 past and present military personnel with prescriptions for long-term opioid therapy were randomized in a 1:1 ratio to MORE or supportive psychotherapy (initially delivered in person and then via videoconferencing after the onset of the COVID-19 pandemic). Primary outcomes were chronic pain, measured by the Brief Pain Inventory, and aberrant drug-related behaviors, measured by the Current Opioid Misuse Measure, through 8 months of follow-up. Opioid dose was a key secondary outcome. Other outcomes included psychiatric symptoms, catastrophizing, positive affect, ecological momentary assessments of opioid craving, and opioid attentional bias. RESULTS MORE was superior to supportive psychotherapy through the 8-month follow-up in reducing pain-related functional interference, pain severity, and opioid dose. MORE reduced daily opioid dose by 20.7%, compared with a dose reduction of 3.9% with supportive psychotherapy. Although there was no overall between-group difference in opioid misuse, the in-person MORE intervention outperformed supportive psychotherapy for reducing opioid misuse. MORE reduced anhedonia, pain catastrophizing, craving, and opioid attentional bias and increased positive affect to a greater extent than supportive psychotherapy. MORE also modulated therapeutic processes, including mindful reinterpretation of pain sensations, nonreactivity, savoring, positive attention, and reappraisal. CONCLUSIONS Among past and present U.S. military personnel, MORE led to sustained decreases in chronic pain, opioid use, craving, and opioid cue reactivity. MORE facilitated opioid dose reduction while preserving adequate pain control and preventing mood disturbances, suggesting its utility for safe opioid tapering.
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Affiliation(s)
- Eric L. Garland
- Center on Mindfulness and Integrative Health Intervention Development, University of Utah
- Veterans Health Care Administration VISN 19 Whole Health Flagship site located at the VA Salt Lake City Health Care System, Salt Lake City, Utah
| | - Yoshio Nakamura
- Center on Mindfulness and Integrative Health Intervention Development, University of Utah
- Department of Anesthesiology, Division of Pain Medicine, Pain Research Center, University of Utah School of Medicine
| | - Craig J. Bryan
- Department of Psychiatry and Behavioral Health, The Ohio State University
| | - Adam W. Hanley
- Center on Mindfulness and Integrative Health Intervention Development, University of Utah
| | - Anna Parisi
- Center on Mindfulness and Integrative Health Intervention Development, University of Utah
| | - Brett Froeliger
- Departments of Psychiatry & Psychological Sciences, University of Missouri, Columbia, MO
| | - William R. Marchand
- Veterans Health Care Administration VISN 19 Whole Health Flagship site located at the VA Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Psychiatry, University of Utah School of Medicine
| | - Gary W. Donaldson
- Department of Anesthesiology, Division of Pain Medicine, Pain Research Center, University of Utah School of Medicine
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Chatham AH, Bradley ED, Schirle L, Sanchez-Roige S, Samuels DC, Jeffery AD. Detecting Problematic Opioid Use in the Electronic Health Record: Automation of the Addiction Behaviors Checklist in a Chronic Pain Population. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.06.08.23290894. [PMID: 37398208 PMCID: PMC10312835 DOI: 10.1101/2023.06.08.23290894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Importance Individuals whose chronic pain is managed with opioids are at high risk of developing an opioid use disorder. Large data sets, such as electronic health records, are required for conducting studies that assist with identification and management of problematic opioid use. Objective Determine whether regular expressions, a highly interpretable natural language processing technique, could automate a validated clinical tool (Addiction Behaviors Checklist1) to expedite the identification of problematic opioid use in the electronic health record. Design This cross-sectional study reports on a retrospective cohort with data analyzed from 2021 through 2023. The approach was evaluated against a blinded, manually reviewed holdout test set of 100 patients. Setting The study used data from Vanderbilt University Medical Center's Synthetic Derivative, a de-identified version of the electronic health record for research purposes. Participants This cohort comprised 8,063 individuals with chronic pain. Chronic pain was defined by International Classification of Disease codes occurring on at least two different days.18 We collected demographic, billing code, and free-text notes from patients' electronic health records. Main Outcomes and Measures The primary outcome was the evaluation of the automated method in identifying patients demonstrating problematic opioid use and its comparison to opioid use disorder diagnostic codes. We evaluated the methods with F1 scores and areas under the curve - indicators of sensitivity, specificity, and positive and negative predictive value. Results The cohort comprised 8,063 individuals with chronic pain (mean [SD] age at earliest chronic pain diagnosis, 56.2 [16.3] years; 5081 [63.0%] females; 2982 [37.0%] male patients; 76 [1.0%] Asian, 1336 [16.6%] Black, 56 [1.0%] other, 30 [0.4%] unknown race patients, and 6499 [80.6%] White; 135 [1.7%] Hispanic/Latino, 7898 [98.0%] Non-Hispanic/Latino, and 30 [0.4%] unknown ethnicity patients). The automated approach identified individuals with problematic opioid use that were missed by diagnostic codes and outperformed diagnostic codes in F1 scores (0.74 vs. 0.08) and areas under the curve (0.82 vs 0.52). Conclusions and Relevance This automated data extraction technique can facilitate earlier identification of people at-risk for, and suffering from, problematic opioid use, and create new opportunities for studying long-term sequelae of opioid pain management.
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Affiliation(s)
| | - Eli D. Bradley
- Vanderbilt University School of Nursing, Nashville, TN, USA
| | - Lori Schirle
- Vanderbilt University School of Nursing, Nashville, TN, USA
- Department of Anesthesiology, School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Sandra Sanchez-Roige
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
- Department of Medicine, Division of Genetic Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David C. Samuels
- Department of Molecular Physiology and Biophysics, Vanderbilt Genetics Institute, Vanderbilt University, Nashville, TN, USA
| | - Alvin D. Jeffery
- Vanderbilt University School of Nursing, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
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Kim EJ, Hwang EJ, Yoo YM, Kim KH. Prevention, diagnosis, and treatment of opioid use disorder under the supervision of opioid stewardship programs: it's time to act now. Korean J Pain 2022; 35:361-382. [PMID: 36175336 PMCID: PMC9530691 DOI: 10.3344/kjp.2022.35.4.361] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 09/15/2022] [Accepted: 09/15/2022] [Indexed: 11/06/2022] Open
Abstract
The third opium war may have already started, not only due to illicit opioid trafficking from the Golden Crescent and Golden Triangle on the international front but also through indiscriminate opioid prescription and opioid diversion at home. Opioid use disorder (OUD), among unintentional injuries, has become one of the top 4 causes of death in the United States (U.S.). An OUD is defined as a problematic pattern of opioid use resulting in clinically significant impairment or distress, consisting of 2 or more of 11 problems within 1 year, as described by the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition. Observation of aberrant behaviors of OUD is also helpful for overworked clinicians. For the prevention of OUD, the Opioid Risk Tool and the Current Opioid Misuse Measure are appropriate screening tests before and during opioid administration, respectively. Treatment of OUD consists of 3 opioid-based U.S. Food and Drug Administration-approved medications, including methadone, buprenorphine, and naltrexone, and non-opioid-based symptomatic medications for reducing opioid withdrawal syndromes, such as α2 agonists, β-blockers, antidiarrheals, antiemetics, non-steroidal anti-inflammatory drugs, and benzodiazepines. There are at least 6 recommendable guidelines and essential terms related to OUD. Opioid stewardship programs are now critical to promoting appropriate use of opioid medications, improving patient outcomes, and reducing misuse of opioids, influenced by the successful implementation of antimicrobial stewardship programs. Despite the lack of previous motivation, now is the critical time for trying to reduce the risk of OUD.
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Affiliation(s)
- Eun-Ji Kim
- Department of Pharmacy, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Eun-Jung Hwang
- Department of Pharmacy, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Yeong-Min Yoo
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Kyung-Hoon Kim
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
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Takasusuki T, Hayashi S, Koretaka Y, Yamaguchi S. Prevalence of and Risk Factors for Prescription Opioid Misuse, Abuse, Diversion and Doctor Shopping in Japan: A Survey Study. Pain Ther 2022; 11:987-1009. [PMID: 35790601 PMCID: PMC9314531 DOI: 10.1007/s40122-022-00409-6] [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: 10/27/2021] [Accepted: 06/15/2022] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Opioid use disorder is a global problem. Although opioid analgesics are prescribed less frequently in Japan than in many other countries, the rate of aberrant prescription opioid-taking behaviors in Japan is unknown. METHODS An internet survey was conducted to estimate the prevalence of and risk factors for prescription opioid misuse, abuse, diversion and doctor shopping in Japanese subjects with chronic pain who had been prescribed opioid analgesics. RESULTS The proportion of respondents (n = 387) who reported opioid misuse was 45.5% (95% confidence interval [CI]: 40.4-50.6); rates were: 24.6% (95% CI: 20.3-29.2) for abuse; 15.0% (95% CI: 11.6-19.0) for diversion; and 10.6% (95% CI: 7.7-14.1) for doctor shopping. Aberrant prescription opioid-taking behaviors were higher in participants with chronic post-cancer treatment pain (misuse, 64.2%; abuse, 52.2%) or chronic cancer pain (misuse, 57.4%; abuse, 26.2%) than in those with chronic noncancer pain (misuse, 37.8%; abuse, 17.0%). Younger age, male sex, smoking, habitual drinking, diagnosis of psychiatric disease, use of opioids other than tramadol, and use of opioids for chronic post-cancer treatment pain and chronic cancer pain were identified as risk factors for aberrant prescription opioid-taking behaviors. CONCLUSION Even in Japan, which has not experienced the surge in opioid consumption documented in other countries, aberrant prescription opioid-taking behaviors were observed. When prescribing opioid analgesics, universal precautions should always be taken for both cancer and non-cancer patients. TRIAL REGISTRATION UMIN000041788.
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Affiliation(s)
- Toshifumi Takasusuki
- Department of Anesthesiology, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi, Japan
| | - Shinji Hayashi
- Integrated Disease Care Division, Shionogi & Co., Ltd., 1-8, Doshomachi 3-chome, Chuo-ku, Osaka, Japan
| | - Yuichi Koretaka
- DX Promotion Division, Shionogi & Co., Ltd., 1-8, Doshomachi 3-chome, Chuo-ku, Osaka, Japan
| | - Shigeki Yamaguchi
- Department of Anesthesiology, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi, Japan
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Garland EL, Hanley AW, Nakamura Y, Barrett JW, Baker AK, Reese SE, Riquino MR, Froeliger B, Donaldson GW. Mindfulness-Oriented Recovery Enhancement vs Supportive Group Therapy for Co-occurring Opioid Misuse and Chronic Pain in Primary Care: A Randomized Clinical Trial. JAMA Intern Med 2022; 182:407-417. [PMID: 35226053 PMCID: PMC8886485 DOI: 10.1001/jamainternmed.2022.0033] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 01/07/2022] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Successful treatment of opioid misuse among people with chronic pain has proven elusive. Guidelines recommend nonopioid therapies, but the efficacy of mindfulness-based interventions for opioid misuse is uncertain. OBJECTIVE To evaluate the efficacy of Mindfulness-Oriented Recovery Enhancement (MORE) for the reduction of opioid misuse and chronic pain. DESIGN, SETTING, AND PARTICIPANTS This interviewer-blinded randomized clinical trial enrolled patients from primary care clinics in Utah between January 4, 2016, and January 16, 2020. The study included 250 adults with chronic pain receiving long-term opioid therapy who were misusing opioid medications. INTERVENTIONS Treatment with MORE (comprising training in mindfulness, reappraisal, and savoring positive experiences) or supportive group psychotherapy (control condition) across 8 weekly 2-hour group sessions. MAIN OUTCOMES AND MEASURES Primary outcomes were (1) opioid misuse assessed by the Drug Misuse Index (self-report, interview, and urine screen) and (2) pain severity and pain-related functional interference, assessed by subscale scores on the Brief Pain Inventory through 9 months of follow-up. Secondary outcomes were opioid dose, emotional distress, and ecological momentary assessments of opioid craving. The minimum intervention dose was defined as 4 or more completed sessions of MORE or supportive group psychotherapy. RESULTS Among 250 participants (159 women [63.6%]; mean [SD] age, 51.8 [11.9] years), 129 were randomized to the MORE group and 121 to the supportive psychotherapy group. Overall, 17 participants (6.8%) were Hispanic or Latino, 218 (87.2%) were White, and 15 (6.0%) were of other races and/or ethnicities (2 American Indian, 3 Asian, 1 Black, 2 Pacific Islander, and 7 did not specify). At baseline, the mean duration of pain was 14.7 years (range, 1-60 years), and the mean (SD) morphine-equivalent opioid dose was 101.0 (266.3) mg (IQR, 16.0-90.0 mg). A total of 203 participants (81.2%) received the minimum intervention dose (mean [SD], 5.7 [2.2] sessions); at 9 months, 92 of 250 participants (36.8%) discontinued the study. The overall odds ratio for reduction in opioid misuse through the 9-month follow-up period in the MORE group compared with the supportive psychotherapy group was 2.06 (95% CI, 1.17-3.61; P = .01). At 9 months, 36 of 80 participants (45.0%) in the MORE group were no longer misusing opioids compared with 19 of 78 participants (24.4%) in the supportive psychotherapy group. Mixed models demonstrated that MORE was superior to supportive psychotherapy through 9 months of follow-up for pain severity (between-group effect: 0.49; 95% CI, 0.17-0.81; P = .003) and pain-related functional interference (between-group effect: 1.07; 95% CI, 0.64-1.50; P < .001). Participants in the MORE group reduced their opioid dose to a greater extent than those in the supportive psychotherapy group. The MORE group also had lower emotional distress and opioid craving. CONCLUSIONS AND RELEVANCE In this randomized clinical trial, among adult participants in a primary care setting, the MORE intervention led to sustained improvements in opioid misuse and chronic pain symptoms and reductions in opioid dosing, emotional distress, and opioid craving compared with supportive group psychotherapy. Despite attrition caused by the COVID-19 pandemic and the vulnerability of the sample, MORE appeared to be efficacious for reducing opioid misuse among adults with chronic pain. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02602535.
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Affiliation(s)
- Eric L. Garland
- Center on Mindfulness and Integrative Health Intervention Development, College of Social Work, University of Utah, Salt Lake City
- Veterans Health Care Administration, Veterans Integrated Service Network 19 Whole Health Flagship Site, VA Salt Lake City Health Care System, Salt Lake City, Utah
| | - Adam W. Hanley
- Center on Mindfulness and Integrative Health Intervention Development, College of Social Work, University of Utah, Salt Lake City
| | - Yoshio Nakamura
- Pain Research Center, Division of Pain Medicine, Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City
| | - John W. Barrett
- Community Physicians Group, University of Utah School of Medicine, Salt Lake City
| | - Anne K. Baker
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | | | | | | | - Gary W. Donaldson
- Pain Research Center, Division of Pain Medicine, Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City
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Turner HN, Oliver J, Compton P, Matteliano D, Sowicz TJ, Strobbe S, St Marie B, Wilson M. Pain Management and Risks Associated With Substance Use: Practice Recommendations. Pain Manag Nurs 2021; 23:91-108. [PMID: 34965906 DOI: 10.1016/j.pmn.2021.11.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 11/13/2021] [Indexed: 01/08/2023]
Abstract
Assessing and managing pain while evaluating risks associated with substance use and substance use disorders continues to be a challenge faced by health care clinicians. The American Society for Pain Management Nursing and the International Nurses Society on Addictions uphold the principle that all persons with co-occurring pain and substance use or substance use disorders have the right to be treated with dignity and respect, and receive evidence-based, high quality assessment, and management for both conditions. The American Society for Pain Management Nursing and International Nurses Society on Addictions have updated their 2012 position statement on this topic supporting an integrated, holistic, multidimensional approach, which includes nonopioid and nonpharmacological modalities. Opioid use disorder is used as an exemplar for substance use disorders and clinical recommendations are included with expanded attention to risk assessment and mitigation with interventions targeted to minimize the risk for relapse or escalation of substance use. Opioids should not be excluded for anyone when indicated for pain management. A team-based approach is critical, promotes the active involvement of the person with pain and their support systems, and includes pain and addiction specialists whenever possible. Health care systems should establish policies and procedures that facilitate and support the principles and recommendations put forth in this article.
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Affiliation(s)
| | - June Oliver
- Swedish Hospital, Northshore University Healthsystem, Chicago, IL.
| | | | | | | | | | - Barbara St Marie
- University of Iowa College of Nursing, Washington State University, College of Nursing
| | - Marian Wilson
- Oregon Health & Science University School of Nursing; Washington State University, College of Nursing
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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.
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Schirle L, Jeffery A, Yaqoob A, Sanchez-Roige S, Samuels DC. Two data-driven approaches to identifying the spectrum of problematic opioid use: A pilot study within a chronic pain cohort. Int J Med Inform 2021; 156:104621. [PMID: 34673309 PMCID: PMC8609775 DOI: 10.1016/j.ijmedinf.2021.104621] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/29/2021] [Accepted: 10/09/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Although electronic health records (EHR) have significant potential for the study of opioid use disorders (OUD), detecting OUD in clinical data is challenging. Models using EHR data to predict OUD often rely on case/control classifications focused on extreme opioid use. There is a need to expand this work to characterize the spectrum of problematic opioid use. METHODS Using a large academic medical center database, we developed 2 data-driven methods of OUD detection: (1) a Comorbidity Score developed from a Phenome-Wide Association Study of phenotypes associated with OUD and (2) a Text-based Score using natural language processing to identify OUD-related concepts in clinical notes. We evaluated the performance of both scores against a manual review with correlation coefficients, Wilcoxon rank sum tests, and area-under the receiver operating characteristic curves. Records with the highest Comorbidity and Text-based scores were re-evaluated by manual review to explore discrepancies. RESULTS Both the Comorbidity and Text-based OUD risk scores were significantly elevated in the patients judged as High Evidence for OUD in the manual review compared to those with No Evidence (p = 1.3E-5 and 1.3E-6, respectively). The risk scores were positively correlated with each other (rho = 0.52, p < 0.001). AUCs for the Comorbidity and Text-based scores were high (0.79 and 0.76, respectively). Follow-up manual review of discrepant findings revealed strengths of data-driven methods over manual review, and opportunities for improvement in risk assessment. CONCLUSION Risk scores comprising comorbidities and text offer differing but synergistic insights into characterizing problematic opioid use. This pilot project establishes a foundation for more robust work in the future.
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Affiliation(s)
- Lori Schirle
- Vanderbilt University School of Nursing, 461 21st Avenue South, Nashville, TN 37240, USA.
| | - Alvin Jeffery
- Vanderbilt University School of Nursing, 461 21st Avenue South, Nashville, TN 37240, USA; Vanderbilt University, Department of Biomedical Informatics, 2525 West End Ave #1475, Nashville, TN 37203, USA.
| | - Ali Yaqoob
- Vanderbilt University, Department of Biomedical Informatics, 2525 West End Ave #1475, Nashville, TN 37203, USA; Vanderbilt University, Data Science Institute, Sony Building, # 2000, 1400 18th Avenue South, Nashville, TN 37212, USA.
| | - Sandra Sanchez-Roige
- Vanderbilt University Medical Center, Division of Genetic Medicine, Robinson Research Building #536, 220 Pierce Avenue, Nashville, TN 37232, USA; University of California, Department of Psychiatry, 9500 Gilman Dr., LaJolla, CA 92093, USA.
| | - David C Samuels
- Vanderbilt University School of Medicine, Light Hall #507B, Department of Molecular Physiology and Biophysics, Vanderbilt Genetics Institute, 2215 Garland Avenue, Nashville, TN 37232, USA.
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Choudhary N, Singh S, Rathore P, Ambekar A, Bhatnagar S. Opioid Use Disorders among Patients on Long-Term Morphine for Management of Chronic Cancer Pain: A Pilot Study from a Tertiary Palliative Care Facility. Indian J Palliat Care 2021; 27:264-268. [PMID: 34511794 PMCID: PMC8428893 DOI: 10.25259/ijpc_358_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 10/18/2020] [Indexed: 11/21/2022] Open
Abstract
Objectives: Long-term opioid use can be associated with misuse and addiction. In the backdrop of increasing burden of cancer patients in India, it is important to assess the rate of opioid use disorders among those with chronic cancer pain. The objectives were to measure the rate of opioid use disorder in chronic cancer pain patients being managed with morphine and to assess its association with demographic and clinical characteristics. Materials and Methods: A cross-sectional study was conducted on chronic cancer pain patients who were prescribed morphine for ≥12 months, dosage of ≥60 mg/day. They were assessed using MINI version 7.0.0, WHO-ASSIST Hindi questionnaire, Addiction Behavior Checklist, and DSM-5 for opioid use disorder. Results: Forty patients who were treated with morphine for a total of 1479 months participated. The average morphine consumption was 159.50 ± 327.90 mg/day. Six (15%) showed possible inappropriate opioid analgesic use and none of the patients had opioid use disorder. Conclusion: This study reports the absence of opioid use disorder due to vigilant use of morphine in chronic cancer patients.
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Affiliation(s)
- Nandan Choudhary
- Department of Onco-Anesthesia and Palliative Medicine, IRCH, New Delhi, India
| | - Shalini Singh
- National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Puneet Rathore
- Department of Onco-Anesthesia and Palliative Medicine, IRCH, New Delhi, India
| | - Atul Ambekar
- National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Sushma Bhatnagar
- Department of Onco-Anesthesia and Palliative Medicine, IRCH, New Delhi, India
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Borsari B, Li Y, Tighe J, Manuel JK, Gökbayrak NS, Delucchi K, Morasco BJ, Abadjian L, Cohen BE, Baxley C, Seal KH. A pilot trial of collaborative care with motivational interviewing to reduce opioid risk and improve chronic pain management. Addiction 2021; 116:2387-2397. [PMID: 33405304 DOI: 10.1111/add.15401] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 07/20/2020] [Accepted: 12/23/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS Opioid use and chronic pain are prevalent in the veteran population. Collaborative care enhances coordination between patients and their care teams, and motivational interviewing (MI) is a communication style designed to facilitate behavior change. This study evaluated the use of collaborative care with MI (CCMI) with patients with chronic pain and high-risk prescription opioid use. DESIGN Small pilot study of a randomized controlled trial. SETTING An urban Veterans Affairs (VA) Medical Center in the United States. PARTICIPANTS One hundred adult veterans with chronic pain currently enrolled into primary care and receiving long-term opioid therapy. INTERVENTION AND COMPARATOR During an initial 1-hour visit with a study primary-care physician (PCP), all veterans (n = 100) developed a personalized pain care plan, after which they were randomized to receive four sessions (at 4, 6, 8 and 12 weeks) of either CCMI (n = 51) or attention control psychoeducation (ACP; n = 49). Subsequently, participants had 30-minute follow-up visits with study PCPs and post-treatment assessment at 12 weeks. MEASUREMENTS Co-primary outcomes measures assessed opioid risk and pain interference; secondary measures assessed pain severity, PCP rating of opioid risk and pain management goals. FINDINGS At 12 weeks, intent-to-treat (ITT) analyses using multivariate mixed-effects linear regression were inconclusive regarding the between-group differences in primary and secondary outcomes at post-intervention (12 weeks). Bayes factors for opioid risk, pain interference, pain severity and PCP ratings were 1.96, 1.36, 0.45 and 0.82, respectively. Veterans in the CCMI group reported implementing more complementary integrative health (CIH) goals (e.g. yoga) than did those in the ACP group (d = 0.54). CONCLUSIONS US veterans with chronic pain who received collaborative care with motivational interviewing reduced their high-risk opioid use and showed improved pain interference and severity after an intake with a primary-care provider involving shared decision-making and the creation of a personalized pain care plan.
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Affiliation(s)
- Brian Borsari
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA
| | - Yongmei Li
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Jennifer Tighe
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Jennifer K Manuel
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA
| | - N Simay Gökbayrak
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Kevin Delucchi
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA
| | - Benjamin J Morasco
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA.,Department of Psychiatry, Oregon Health and Science University, Portland, OR, USA
| | - Linda Abadjian
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Beth E Cohen
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Catherine Baxley
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA
| | - Karen H Seal
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA.,Department of Medicine, University of California, San Francisco, CA, USA
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12
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You DS, Mardian AS, Darnall BD, Chen CYA, De Bruyne K, Flood PD, Kao MC, Karnik AD, McNeely J, Porter JG, Schwartz RP, Stieg RL, Mackey SC. A Brief Screening Tool for Opioid Use Disorder: EMPOWER Study Expert Consensus Protocol. Front Med (Lausanne) 2021; 8:591201. [PMID: 33869240 PMCID: PMC8044786 DOI: 10.3389/fmed.2021.591201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 02/23/2021] [Indexed: 11/13/2022] Open
Abstract
Growing concerns about the safety of long-term opioid therapy and its uncertain efficacy for non-cancer pain have led to relatively rapid opioid deprescribing in chronic pain patients who have been taking opioid for years. To date, empirically supported processes for safe and effective opioid tapering are lacking. Opioid tapering programs have shown high rates of dropouts and increases in patient distress and suicidal ideation. Therefore, safe strategies for opioid deprescribing that are more likely to succeed are urgently needed. In response to this demand, the EMPOWER study has been launched to examine the effectiveness of behavioral medicine strategies within the context of patient-centered opioid tapering in outpatient settings (https://empower.stanford.edu/). The EMPOWER protocol requires an efficient process for ensuring that collaborative opioid tapering would be offered to the most appropriate patients while identifying patients who should be offered alternate treatment pathways. As a first step, clinicians need a screening tool to identify patients with Opioid Use Disorder (OUD) and to assess for OUD severity. Because such a tool is not available, the study team composed of eight chronic pain and/or addiction experts has extended a validated screening instrument to develop a brief and novel consensus screening tool to identify OUD and assess for OUD severity for treatment stratification. Our screening tool has the potential to assist busy outpatient clinicians to assess OUD among patients receiving long-term opioid therapy for chronic pain.
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Affiliation(s)
- Dokyoung S You
- Department Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Aram S Mardian
- Department of Family, Community and Preventive Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States.,Phoenix VA Health Care System, Phoenix, AZ, United States
| | - Beth D Darnall
- Department Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Chwen-Yuen A Chen
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Korina De Bruyne
- Division of Primary, Preventive, and Community Care, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Pamela D Flood
- Department Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Ming-Chih Kao
- Department Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Anita D Karnik
- Phoenix VA Health Care System, Department of Psychiatry, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States
| | - Jennifer McNeely
- Department of Population Health, Section on Tobacco, Alcohol, and Drug Use, New York University School of Medicine, New York, NY, United States
| | - Joel G Porter
- Intermountain Healthcare, Family Medicine, Layton, UT, United States
| | | | | | - Sean C Mackey
- Department Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
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13
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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.
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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
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14
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Parisi A, Pensieri MV, Cortellini A, D'Orazio C, Ficorella C, Verna L, Porzio G. Haloperidol for the treatment of opioid addiction in advanced cancer patients: a case series. J Addict Dis 2020; 38:229-234. [PMID: 32207385 DOI: 10.1080/10550887.2020.1742560] [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: 10/24/2022]
Abstract
Opioid addiction, if not well diagnosed and treated, can be a significant challenge for optimal pain management even in cancer patients. To date there is no definitive pharmacological standard of care for treating addiction, especially in this setting of patients. We present a clinical case series of three opioid-addicted advanced cancer patients, effectively treated with haloperidol, a well-known first-generation typical antipsychotic.
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Affiliation(s)
- Alessandro Parisi
- Medical Oncology, St. Salvatore Hospital, University of L'Aquila, L'Aquila, Italy.,Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Maria Vittoria Pensieri
- Medical Oncology, St. Salvatore Hospital, University of L'Aquila, L'Aquila, Italy.,Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Alessio Cortellini
- Medical Oncology, St. Salvatore Hospital, University of L'Aquila, L'Aquila, Italy.,Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Carla D'Orazio
- Medical Oncology, St. Salvatore Hospital, University of L'Aquila, L'Aquila, Italy.,Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Corrado Ficorella
- Medical Oncology, St. Salvatore Hospital, University of L'Aquila, L'Aquila, Italy.,Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Lucilla Verna
- Medical Oncology, St. Salvatore Hospital, University of L'Aquila, L'Aquila, Italy.,Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Giampiero Porzio
- Medical Oncology, St. Salvatore Hospital, University of L'Aquila, L'Aquila, Italy.,Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
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15
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Finkelman MD, Jamison RN, Kulich RJ, Butler SF, Smits N, Weiner SG. A Comparison of Short Forms of the Screener and Opioid Assessment for Patients With Pain – Revised (SOAPP-R). EUROPEAN JOURNAL OF PSYCHOLOGICAL ASSESSMENT 2020. [DOI: 10.1027/1015-5759/a000519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Abstract. The Screener and Opioid Assessment for Patients with Pain – Revised (SOAPP-R) is a 24-item self-report questionnaire that assesses risk of aberrant medication-related behavior among chronic pain patients. Recently, an 8-item version of the SOAPP-R that weights items differentially was proposed. However, no previous study had compared the 8-item form with other short versions of the SOAPP-R, including a static 12-item short form and computer-based versions customizing the test length to the individual respondent. Moreover, no prior research had investigated combining the 8-item short form with customized computer-based stopping rules to further enhance efficiency. The objectives of this study were to compare the 8-item version with previously recommended short forms of the SOAPP-R, and to develop and evaluate a new version of the SOAPP-R combining the 8-item version with computer-based stopping rules. Versions were compared via sensitivity, specificity, and mean test length using real-data simulation of three datasets. Although results varied across datasets, the 8-item SOAPP-R compared favorably to previously recommended forms. Combining the 8-item form with computer-based stopping rules reduced the mean test length without affecting sensitivity or specificity; thus, the combined approach is recommended. The methodology used to shorten questionnaires via computer-based testing can also be applied to other instruments.
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Affiliation(s)
- Matthew D. Finkelman
- Department of Public Health and Community Service, Tufts University School of Dental Medicine, Boston, MA, USA
| | - Robert N. Jamison
- Departments of Anesthesiology and Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Ronald J. Kulich
- Craniofacial Pain and Headache Center, Tufts University School of Dental Medicine, Boston, MA, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Niels Smits
- Department of Methods and Statistics, Research Institute of Child Development and Education, University of Amsterdam, The Netherlands
| | - Scott G. Weiner
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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16
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Moeller SJ, Hanley AW, Garland EL. Behavioral preference for viewing drug v. pleasant images predicts current and future opioid misuse among chronic pain patients. Psychol Med 2020; 50:644-652. [PMID: 30982480 PMCID: PMC7413318 DOI: 10.1017/s0033291719000461] [Citation(s) in RCA: 8] [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: 12/22/2022]
Abstract
BACKGROUND The USA is currently enduring an opioid crisis. Identifying cost-effective, easy-to-implement behavioral measures that predict treatment outcomes in opioid misusers is a crucial scientific, therapeutic, and epidemiological goal. METHODS The current study used a mixed cross-sectional and longitudinal design to test whether a behavioral choice task, previously validated in stimulant users, was associated with increased opioid misuse severity at baseline, and whether it predicted change in opioid misuse severity at follow-up. At baseline, data from 100 prescription opioid-treated chronic pain patients were analyzed; at follow-up, data were analyzed in 34 of these participants who were non-misusers at baseline. During the choice task, participants chose under probabilistic contingencies whether to view opioid-related images in comparison with affectively pleasant, unpleasant, and neutral images. Following previous procedures, we also assessed insight into choice behavior, operationalized as whether (yes/no) participants correctly self-reported the image category they chose most often. RESULTS At baseline, the higher choice for viewing opioid images in direct comparison with pleasant images was associated with opioid misuse and impaired insight into choice behavior; the combination of these produced especially elevated opioid-related choice behavior. In longitudinal analyses of individuals who were initially non-misusers, higher baseline opioid v. pleasant choice behavior predicted more opioid misuse behaviors at follow-up. CONCLUSIONS These results indicate that greater relative allocation of behavior toward opioid stimuli and away from stimuli depicting natural reinforcement is associated with concurrent opioid misuse and portends vulnerability toward future misuse. The choice task may provide important medical information to guide opioid-prescribing practices.
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Affiliation(s)
- Scott J. Moeller
- Department of Psychiatry, Stony Brook University School of Medicine
| | - Adam W. Hanley
- University of Utah Center on Mindfulness and Integrative Health Intervention Development
| | - Eric L. Garland
- University of Utah Center on Mindfulness and Integrative Health Intervention Development
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17
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Balhara YPS, Singh S, Kalra S. Pragmatic Opioid Use in Painful Diabetic Neuropathy. EUROPEAN ENDOCRINOLOGY 2020; 16:21-24. [PMID: 32595765 DOI: 10.17925/ee.2020.16.1.21] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 12/16/2019] [Indexed: 12/11/2022]
Abstract
The management of painful diabetic neuropathy poses a tough clinical challenge. Although opioid analgesics are considered as second- or third-line agents in the management of moderate-to-severe neuropathic pain, prescription of opioids for this indication is higher than expected. This narrative review is a recommendation on how to ensure pragmatic use of opioids for those with painful diabetic neuropathy while avoiding complications such as opioid overdose, opioid diversion and the development of opioid-use disorder. Risk mitigation strategies at the level of the clinician include periodic assessment and documentation of clinical details, treatment history and psychosocial status. Using a multimodal approach to pain management, medication counselling, adherence monitoring programmes, evidence-based opioid dosing strategies and empowering patients to make treatment decisions are effective strategies in reducing risk associated with prolonged opioid use. At the organisational and policy level, using prescription drug monitoring programmes, carrying out periodic opioid utilisation reviews and providing training to patients and physicians on safe opioid use are useful, implementable strategies.
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Affiliation(s)
- Yatan Pal Singh Balhara
- Department of Psychiatry, National Drug Dependence Treatment Center, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Shalini Singh
- Institute of Liver and Biliary Sciences (ILBS), New Delhi, India
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18
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Lee CS, Kim D, Park SY, Lee SC, Kim YC, Moon JY. Usefulness of the Korean Version of the CAGE-Adapted to Include Drugs Combined With Clinical Predictors to Screen for Opioid-Related Aberrant Behavior. Anesth Analg 2019; 129:864-873. [PMID: 31425231 DOI: 10.1213/ane.0000000000003580] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND As national opioid consumption in South Korea has soared, well-validated screening tools for opioid use disorder (OUD) have become indispensable. The aims of our study were to evaluate OUD using the Korean version of the CAGE-Adapted to Include Drugs (CAGE-AID) and the CAGE-Opioid (an alternative version of the CAGE-AID), and to investigate clinical predictors that might be useful to screen for OUD in conjunction with the CAGE-AID/Opioid questionnaires. METHODS A single-center, prospective, observational study was performed. After linguistic validation of the Korean version of the CAGE-AID/Opioid questionnaires, we assessed OUD in patients with chronic opioid treatment. Multivariable logistic models of the CAGE-AID/Opioid questionnaires combined with relevant clinical predictors were established. Then, the receiver operating characteristic curve analysis of the multivariable CAGE-AID/Opioid models was conducted to assess diagnostic accuracy to screen for OUD. Next, we calculated predicted probability with >85% sensitivity and >50% specificity in each CAGE-AID and CAGE-Opioid model. Using the optimal value of the predicted probability, a cutoff score of the CAGE-AID/Opioid questionnaires combined with the relevant clinical factors was suggested to screen for OUD. RESULTS Among 201 participants, 51 patients showed ≥1 OUDs. In the multivariable regression model, male sex, comorbid neuropsychiatric disorder, and current heavy drinking significantly remained as clinical variables to predict OUD combined with the scores of the Korean CAGE-AID/Opioid questionnaire. The area under the curve was 0.77 (95% confidence interval, 0.71-0.83) for the CAGE-AID model and 0.78 (95% confidence interval, 0.71-0.83) for the CAGE-Opioid model. The optimal predicted probability values to screen for OUD in the CAGE-AID/Opioid models were >0.135 (sensitivity, 0.86; specificity, 0.52) and >0.142 (sensitivity, 0.86; specificity, 0.53), respectively. When we used these predictive probabilities, the cutoff score of the CAGE-AID/Opioid questionnaires ranged from 0 to 3, which was dependent on the presence of the relevant clinical variables in each model. CONCLUSIONS In this study, one fourth of the total participants with chronic opioid treatment showed OUD in the Korean population. The multivariable models of the CAGE-AID/Opioid with sex, comorbid neuropsychiatric disorder, and current heavy drinking are valid parameters to screen for OUD, with the cutoff scores of the CAGE-AID/Opioid questionnaires ranging from 0 to 3 depending on the presence of the clinical variables.
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Affiliation(s)
- Chang-Soon Lee
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital College of Medicine, Seoul, Republic of Korea
| | - Daehyun Kim
- Department of Anesthesiology and Pain Medicine, National Cancer Center, Gwangju, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Sang-Yoen Park
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital College of Medicine, Seoul, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Sang Chul Lee
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital College of Medicine, Seoul, Republic of Korea
| | - Young-Chul Kim
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital College of Medicine, Seoul, Republic of Korea
| | - Jee Youn Moon
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital College of Medicine, Seoul, Republic of Korea
- Department of Integrated Cancer Care Center, Seoul National University Cancer Hospital, Seoul, Republic of Korea
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19
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Wisløff‐Aase K, Ræder J, Månum G, Løvstad M, Schanke A, Dyb G, Ekeberg Ø, Stanghelle JK. Chronic pain among the hospitalized patients after the 22 July 2011 terror attacks in Oslo and at Utøya Island. Acta Anaesthesiol Scand 2019; 63:913-922. [PMID: 30968401 DOI: 10.1111/aas.13373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 01/16/2019] [Accepted: 03/13/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND On 22 July 2011, 48 people were hospitalized due to physical injuries from gun shots or explosion, following 2 terror attacks in the Oslo area, Norway. In this study, we have investigated the occurrence of chronic pain, the severity and consequences of chronic pain in these patients, 3 to 4 years after the incidents. METHODS Totally 43 eligible terror trauma patients were invited to participate in the study, 30 patients were included. They underwent a consultation with a psychologist and a physician; containing psychological assessment, neuropsychological screening, a standardized clinical interview, medical examination, and a pain protocol. RESULTS In 18 (60%) the injury was severe, as defined by New Injury Severity Score > 15. Twenty-four patients (80%) reported injury-related chronic pain after the trauma, in 22 with consequences on daily life. Analgesics were used by 20 patients, including 5 in need of opioids. Ten patients had unmet needs of further specialist pain care. In 12 patients, the average pain score last week was above three on a 0-10 Numeric Rating Scale. In these patients, clinical signs of neuropathic pain were evident in 10, as tested by the Douleur Neuropathique score. There were significant correlations (P < 0.05) between severity of chronic pain and presence of post-traumatic stress symptoms, reduced quality of life, reduced psychosocial and physical function; but no correlation with pre-injury patient characteristics or the degree of physical injury. CONCLUSION Chronic pain was frequent and significant, irrespective of injury severity, in these patients who obtained their physical injuries under extreme psychological conditions.
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Affiliation(s)
- Kristin Wisløff‐Aase
- Department of Anaesthesiology Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine, Faculty of Medicine University of Oslo Oslo Norway
| | - Johan Ræder
- Department of Anaesthesiology Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine, Faculty of Medicine University of Oslo Oslo Norway
| | - Grethe Månum
- Institute of Clinical Medicine, Faculty of Medicine University of Oslo Oslo Norway
- Sunnaas Rehabilitation Hospital Nesodden Norway
| | - Marianne Løvstad
- Sunnaas Rehabilitation Hospital Nesodden Norway
- Department of Psychology University of Oslo Oslo Norway
| | - Anne‐Kristine Schanke
- Sunnaas Rehabilitation Hospital Nesodden Norway
- Department of Psychology University of Oslo Oslo Norway
| | - Grete Dyb
- Institute of Clinical Medicine, Faculty of Medicine University of Oslo Oslo Norway
- Norwegian Center for Violence and Traumatic Stress Studies Oslo Norway
| | - Øivind Ekeberg
- Division of Mental Health and Addiction Oslo University Hospital Oslo Norway
- Department of Behavioral Sciences in Medicine, Faculty of Medicine University of Oslo Oslo Norway
| | - Johan Kvalvik Stanghelle
- Institute of Clinical Medicine, Faculty of Medicine University of Oslo Oslo Norway
- Sunnaas Rehabilitation Hospital Nesodden Norway
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20
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Arthur J, Bruera E. Balancing opioid analgesia with the risk of nonmedical opioid use in patients with cancer. Nat Rev Clin Oncol 2019; 16:213-226. [PMID: 30514978 DOI: 10.1038/s41571-018-0143-7] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The current opioid crisis has brought renewed attention and scrutiny to opioid prescriptions. When patients receiving opioid therapy for pain engage in nonmedical opioid use (NMOU) or diversion, untoward consequences can occur. New evidence suggests that patients with cancer might be at a higher risk of NMOU than was previously thought, but clinical evidence still supports the use of opioid analgesics as the gold standard to treat cancer-related pain, creating a dilemma in patient management. Clinicians are encouraged to adopt a universal precautions approach to patients with cancer receiving opioids, which includes screening all patients; discussing the risks, benefits, adverse effects and alternatives of opioid therapy; and providing education on safe use, storage and disposal. Use of urine drug tests, prescription drug monitoring programmes and close observation of behaviours related to opioid use help to ensure treatment adherence, detect NMOU and support therapeutic decision-making. These measures can optimize the risk-benefit ratio while supporting safe opioid use. In this Review, we examine the role of opioids in cancer pain, the risk of substance use disorder and methods to achieve the right balance between the two in order to ensure safe opioid use.
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Affiliation(s)
- Joseph Arthur
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, TX, USA.
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21
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Abstract
Opioids are commonly prescribed in orthopaedics for acute or chronic pain for a variety of conditions, including injury, trauma, degenerative processes, and postsurgical. Patients who are taking opioids because of a substance use disorder (SUD) are also seen in orthopaedics. Patients who are prescribed opioids are at risk of developing an opioid use disorder (OUD). Ten percent of Americans will develop an SUD, which is considered a chronic medical condition that develops due to an imbalance in brain chemistry. In studies, orthopaedic surgeons have a high rate of prescribing opioids, but this rate is decreasing along with national average due to public and provider awareness of the opioid epidemic and professional recommendations. Despite the evidence of a neurobiological cause for SUDs, stigma toward patients with SUDs and a knowledge deficit are common among healthcare professionals, including orthopaedic nurses. A harm reduction approach when working with orthopaedic patients taking opioids either prescribed or used because of an OUD can be applied to reduce the problematic effects of opioids. Harm reduction strategies are supportive to the patient and include education and prevention, adopting evidence-based treatment and communication strategies, and the use of naloxone to prevent opioid overdose.
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22
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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.
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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
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Arthur J, Reddy A. Opioid Prescribing in an Opioid Crisis: What Basic Skills Should an Oncologist Have Regarding Opioid Therapy? Curr Treat Options Oncol 2019; 20:39. [PMID: 30937544 DOI: 10.1007/s11864-019-0636-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OPINION STATEMENT Although clinical evidence supports the use of opioids for cancer-related pain, doing so amidst the current opioid crisis remains a challenge. A proportion of opioid-related deaths in the USA are attributable to prescription opioids, which implicates health care providers as one of the major contributors. It is therefore even more important now for all clinicians to follow safe and effective opioid prescribing practices. Oncologists are often in the frontline of cancer pain management. They are encouraged to use validated tools to screen all patients receiving opioids for high risk behaviors. Those identified as high risk for potential abuse of opioids should be monitored closely. When aberrant behavior is detected, the clinician will need to openly discuss the issue and its possible implications. Oncologists may then implement measures such as limiting the dose and quantity of opioids prescribed, shortening interval between follow-ups for refills to allow for increased monitoring, setting boundaries/limitations, weaning off opioid analgesics, or/and referring to a pain or palliative medicine or drug addiction expert for co-management when necessary. These efforts may aid oncologists in safely managing cancer pain in the environment of national opioid crisis.
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Affiliation(s)
- Joseph Arthur
- Department of Palliative, Rehabilitation, & Integrative Medicine, The University of Texas MD Anderson Cancer, Unit 1414, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Akhila Reddy
- Department of Palliative, Rehabilitation, & Integrative Medicine, The University of Texas MD Anderson Cancer, Unit 1414, 1515 Holcombe Boulevard, Houston, TX, 77030, USA.
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Seal KH, Borsari B, Tighe J, Cohen BE, Delucchi K, Morasco BJ, Li Y, Sachs E, Abadjian L, Watson EC, Manuel JK, Vella L, Trafton J, Midboe A. Optimizing pain treatment interventions (OPTI): A pilot randomized controlled trial of collaborative care to improve chronic pain management and opioid safety-Rationale, methods, and lessons learned. Contemp Clin Trials 2019; 77:76-85. [PMID: 30572163 PMCID: PMC6392081 DOI: 10.1016/j.cct.2018.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 11/27/2018] [Accepted: 12/16/2018] [Indexed: 12/17/2022]
Abstract
Veterans seeking care in VA medical facilities have high rates of chronic pain, which often co-occur with mental health and substance use disorders, including prescription opioid misuse. The overall goal of the Optimizing Pain Treatment Interventions (OPTI) study was to pilot a 12-week Collaborative Care intervention to improve opioid safety, chronic pain disability, and use of non-pharmacological pain management strategies in veterans in VA primary care. Between November 2014 and January 2017, 100 veteran patients with chronic pain and high-risk prescription opioid use (e.g., high-dose therapy, early refills, etc.) were enrolled and completed an initial one-hour study visit with a primary care provider (PCP) within 4 weeks of enrollment. Study PCPs were guided by a web-based opioid management decision support program and templated notes in the VA electronic medical record. After assessment and education, study PCPs used Shared Decision-Making to formulate a Pain Care Plan aligned with a participant's personal values and goals. After the initial visit, patients randomized to Collaborative Care received one Motivational Interviewing (MI) session with a Care Manager followed by 3 Care Manager-delivered brief telephone MI sessions at 6, 8, and 12 weeks to reinforce Pain Care Plans; patients randomized to an Attention Control condition met with a Care Manager briefly, followed by 3 brief scripted telephone psychoeducation sessions at 6, 8, and 12 weeks. Masked evaluators assessed outcomes at baseline, end of intervention (12 weeks), and after eight weeks of no contact (20 weeks). We present study rationale, detailed methods, preliminary results and lessons learned.
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Affiliation(s)
- Karen H Seal
- San Francisco Veterans Affairs Health Care System, United States; University of California, San Francisco, San Francisco, CA, United States.
| | - Brian Borsari
- San Francisco Veterans Affairs Health Care System, United States; University of California, San Francisco, San Francisco, CA, United States
| | - Jennifer Tighe
- San Francisco Veterans Affairs Health Care System, United States
| | - Beth E Cohen
- San Francisco Veterans Affairs Health Care System, United States; University of California, San Francisco, San Francisco, CA, United States
| | - Kevin Delucchi
- University of California, San Francisco, San Francisco, CA, United States
| | - Benjamin J Morasco
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, United States; Department of Psychiatry, Oregon Health and Science University, United States
| | - Yongmei Li
- San Francisco Veterans Affairs Health Care System, United States
| | - Emily Sachs
- San Francisco Veterans Affairs Health Care System, United States
| | - Linda Abadjian
- San Francisco Veterans Affairs Health Care System, United States
| | - Erin C Watson
- San Francisco Veterans Affairs Health Care System, United States; University of California, San Francisco, San Francisco, CA, United States
| | - Jennifer K Manuel
- San Francisco Veterans Affairs Health Care System, United States; University of California, San Francisco, San Francisco, CA, United States
| | - Lea Vella
- San Francisco Veterans Affairs Health Care System, United States; University of California, San Francisco, San Francisco, CA, United States
| | - Jodie Trafton
- VA Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), United States; Program Evaluation and Resource Center (PERC), VA Office of Mental Health Operations, United States
| | - Amanda Midboe
- VA Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), United States
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Argoff CE, Alford DP, Fudin J, Adler JA, Bair MJ, Dart RC, Gandolfi R, McCarberg BH, Stanos SP, Gudin JA, Polomano RC, Webster LR. Rational Urine Drug Monitoring in Patients Receiving Opioids for Chronic Pain: Consensus Recommendations. PAIN MEDICINE 2019; 19:97-117. [PMID: 29206984 PMCID: PMC6516588 DOI: 10.1093/pm/pnx285] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objective To develop consensus recommendations on urine drug monitoring (UDM) in patients with chronic pain who are prescribed opioids. Methods An interdisciplinary group of clinicians with expertise in pain, substance use disorders, and primary care conducted virtual meetings to review relevant literature and existing guidelines and share their clinical experience in UDM before reaching consensus recommendations. Results Definitive (e.g., chromatography-based) testing is recommended as most clinically appropriate for UDM because of its accuracy; however, institutional or payer policies may require initial use of presumptive testing (i.e., immunoassay). The rational choice of substances to analyze for UDM involves considerations that are specific to each patient and related to illicit drug availability. Appropriate opioid risk stratification is based on patient history (especially psychiatric conditions or history of opioid or substance use disorder), prescription drug monitoring program data, results from validated risk assessment tools, and previous UDM. Urine drug monitoring is suggested to be performed at baseline for most patients prescribed opioids for chronic pain and at least annually for those at low risk, two or more times per year for those at moderate risk, and three or more times per year for those at high risk. Additional UDM should be performed as needed on the basis of clinical judgment. Conclusions Although evidence on the efficacy of UDM in preventing opioid use disorder, overdose, and diversion is limited, UDM is recommended by the panel as part of ongoing comprehensive risk monitoring in patients prescribed opioids for chronic pain.
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Affiliation(s)
- Charles E Argoff
- Department of Neurology, Albany Medical Center, Albany, New York
| | - Daniel P Alford
- Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Jeffrey Fudin
- Scientific and Clinical Affairs, Remitigate, LLC, Delmar, New York
| | - Jeremy A Adler
- Pacific Pain Medicine Consultants, Encinitas, California
| | - Matthew J Bair
- HSR&D Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indiana University School of Medicine, and Regenstrief Institute, Indianapolis, Indiana
| | | | | | - Bill H McCarberg
- Department of Family Medicine, University of California at San Diego School of Medicine, San Diego, California
| | - Steven P Stanos
- Swedish Pain Services, Swedish Health System, Seattle, Washington
| | - Jeffrey A Gudin
- Department of Pain Management and Palliative Care, Englewood Hospital and Medical Center, Englewood, New Jersey
| | - Rosemary C Polomano
- Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Lynn R Webster
- Scientific Affairs, PRA International, Salt Lake City, Utah, USA
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Substance-related disorders: A review of prevalence and correlates among patients with chronic pain. Prog Neuropsychopharmacol Biol Psychiatry 2018; 87:245-254. [PMID: 28669582 DOI: 10.1016/j.pnpbp.2017.06.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/26/2017] [Accepted: 06/27/2017] [Indexed: 01/25/2023]
Abstract
Over the past few decades, research has revealed high rates of substance-related disorders among patients with chronic pain. In addition to their potentially deleterious health consequences, substance-related disorders have consistently been associated with negative pain-related outcomes among patients with chronic pain. The goal of this narrative review was to provide an overview of studies that have examined the prevalence and correlates of substance-related disorders among patients with chronic pain. A particular focus was placed on opioids, sedatives/hypnotics, cannabis, tobacco, and alcohol given that these substances have received the bulk of research attention among patients with pain. Research conducted to date suggests that a host of biological and psychological factors are likely to contribute to the elevated rates of substance-related disorders among patients with chronic pain. In this review, in addition to reviewing the prevalence and correlates of substance-related disorders among patients with pain, we briefly discussed the changes that were recently made from the DSM-4 to the DSM-5 in the diagnostic criteria for substance-related disorders, and the implications of these changes for the assessment of patients with chronic pain. We also provided a brief overview of instruments that can be used for the assessment of these disorders in clinical and research settings.
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27
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Varney SM, Perez CA, Araña AA, Carey KR, Ganem VJ, Zarzabal LA, Ramos RG, Bebarta VS. Detecting aberrant opioid behavior in the emergency department: a prospective study using the screener and Opioid Assessment for Patients with Pain-Revised (SOAPP ®-R), Current Opioid Misuse Measure (COMM)™, and provider gestalt. Intern Emerg Med 2018; 13:1239-1247. [PMID: 29502329 DOI: 10.1007/s11739-018-1804-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 02/25/2018] [Indexed: 01/13/2023]
Abstract
Emergency department (ED) providers have limited time to evaluate patients at risk for opioid misuse. A validated tool to assess the risk for aberrant opioid behavior may mitigate adverse sequelae associated with prescription opioid misuse. We sought to determine if SOAPP-R, COMM, and provider gestalt were able to identify patients at risk for prescription opioid misuse as determined by pharmacy records at 12 months. We conducted a prospective observational study of adult patients in a high volume US ED. Patients completed the SOAPP-R and COMM, and treating EM providers evaluated patients' opioid misuse risk. We performed variable-centered, person-centered, and hierarchical cluster analyses to determine whether provider gestalt, SOAPP-R, or COMM, or a combination, predicted higher misuse risk. The primary outcome was the number of opioid prescriptions at 12 months according to pharmacy records. For 169 patients (mean age 43 years, 51% female, 73% white), correlation analysis showed a strong relationship between SOAPP-R and COMM with predicting the number of opioid prescriptions dispensed at 12 months. Provider scores estimating opioid misuse were not related to SOAPP-R and only weakly associated with COMM. In our adjusted regression models, provider gestalt and SOAPP-R uniquely predicted opioid prescriptions at 6 and 12 months. Using designated cutoff scores, only SOAPP-R detected a difference in the number of opioid prescriptions. Cluster analysis revealed that provider gestalt, SOAPP-R, and COMM scores jointly predicted opioid prescriptions. Provider gestalt and self-report instruments uniquely predicted the number of opioid prescriptions in ED patients. A combination of gestalt and self-assessment scores can be used to identify at-risk patients who otherwise miss the cutoff scores for SOAPP-R and COMM.
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Affiliation(s)
- Shawn M Varney
- University of Texas Health San Antonio, 7703 Floyd Curl Dr, San Antonio, TX, 78229-3900, USA.
| | - Crystal A Perez
- USAF En Route Care Research Center, U.S. Army Institute of Surgical Research, 3698 Chambers Pass STE B, JBSA Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Allyson A Araña
- USAF En Route Care Research Center, U.S. Army Institute of Surgical Research, 3698 Chambers Pass STE B, JBSA Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Katherine R Carey
- The Geneva Foundation, San Antonio Military Medical Center, 3551 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA
| | - Victoria J Ganem
- The Geneva Foundation, San Antonio Military Medical Center, 3551 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA
| | - Lee A Zarzabal
- STS Systems Integration, 1077 Central Pkwy S, San Antonio, TX, 78232, USA
| | - Rosemarie G Ramos
- University of Texas Health San Antonio, 7703 Floyd Curl Dr, San Antonio, TX, 78229-3900, USA
| | - Vikhyat S Bebarta
- University of Colorado-Denver-Anschutz Medical Campus, 13001 E 17th Place, Aurora, CO, 80045, USA
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Gabbard J, Jordan A, Mitchell J, Corbett M, White P, Childers J. Dying on Hospice in the Midst of an Opioid Crisis: What Should We Do Now? Am J Hosp Palliat Care 2018; 36:273-281. [DOI: 10.1177/1049909118806664] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
The current opioid crisis in the United States is a major problem facing health-care providers, even at the end of life. Opioids continue to be the mainstay treatment for pain at the end of life, with the prevalence of pain reported in up to 80% of patients and tends to increase as one gets closer toward the end of life. In the past year, 20.2 million Americans had a substance use disorder (SUD) and SUDs are disabling disorders that largely go untreated. In addition, the coexistence of both a mental health and SUD is very common with the use of opioids often as a means of chemical coping. Most hospice programs do not have standardized SUD policies/guidelines in place despite the increasing concerns about substance abuse within the United States. The goal of this article is to review the literature on this topic and offer strategies on how to manage pain in patients who have active SUD or who are at risk for developing SUD in those dying on hospice.
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Affiliation(s)
- Jennifer Gabbard
- Department of Internal Medicine, Internal Medicine Section of Gerontology and Geriatrics, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Allison Jordan
- Department of Palliative Medicine, Christian and Alton Memorial Hospitals, BJC Hospice, Washington University School of Medicine, St. Louis, MO, USA
| | - Julie Mitchell
- Department of Internal Medicine, Division of Hospital Medicine, Emory Palliative Care Center, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Patrick White
- Department of Internal Medicine, BJC Home Care, Washington University School of Medicine, St. Louis, MO, USA
| | - Julie Childers
- Section of Palliative Care and Medical Ethics and Section of Treatment, Research and Education in Addiction Medicine, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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29
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Pérez-Mañá C, Papaseit E, Fonseca F, Farré A, Torrens M, Farré M. Drug Interactions With New Synthetic Opioids. Front Pharmacol 2018; 9:1145. [PMID: 30364252 PMCID: PMC6193107 DOI: 10.3389/fphar.2018.01145] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 09/21/2018] [Indexed: 12/31/2022] Open
Abstract
Fentanyl, fentanyl analogs, and other new synthetic opioids (NSO) have burst onto the illegal drug market as new psychoactive substances (NPS). They are often sold as heroin to unsuspecting users and produce euphoria through their agonist action on μ- opioid receptors. Their high consumption, often combined with other substances, has led to multiple intoxications during recent years. In some countries, such as the United States, the consumption of opioids, whether for medical or recreational purposes, has become epidemic and is considered a public health problem. Fentanyl analogs are more potent than fentanyl which in turn is 50 times more potent than morphine. Furthermore, some fentanyl analogs have longer duration of action and therefore interactions with other substances and medicines can be more serious. This review is focused on the potentially most frequent interactions of opioid NPS taking into account the drugs present in the reported cases of poly-intoxication, including other illegal drugs of abuse and medication. Substances involved are mainly antidepressants, antihistamines, antipsychotics, benzodiazepines, analgesics, anesthetics, psychostimulants, other opioids, alcohol, and illegal drugs of abuse. The interactions can be produced due to pharmacokinetic and pharmacodynamic mechanisms. Naloxone can be used as an antidote, although required doses might be higher than for traditional opioid intoxications. It is crucial that doctors who habitually prescribe opioids, which are often misused by patients and NPS users, be aware of designer opioids' potentially life-threatening drug-drug interactions in order to prevent new cases of intoxication.
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Affiliation(s)
- Clara Pérez-Mañá
- Clinical Pharmacology Unit, Hospital Universitari Germans Trias i Pujol (HUGTP-IGTP), Badalona, Spain
- Department of Pharmacology, Therapeutics and Toxicology, Autonomous University of Barcelona, Barcelona, Spain
| | - Esther Papaseit
- Clinical Pharmacology Unit, Hospital Universitari Germans Trias i Pujol (HUGTP-IGTP), Badalona, Spain
- Department of Pharmacology, Therapeutics and Toxicology, Autonomous University of Barcelona, Barcelona, Spain
| | - Francina Fonseca
- Drug Addiction Unit, Institute of Neuropsychiatry and Addictions, Hospital del Mar Medical Research Institute, Barcelona, Spain
- Department of Psychiatry and Legal Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Adriana Farré
- Drug Addiction Unit, Institute of Neuropsychiatry and Addictions, Hospital del Mar Medical Research Institute, Barcelona, Spain
- Department of Psychiatry and Legal Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Marta Torrens
- Drug Addiction Unit, Institute of Neuropsychiatry and Addictions, Hospital del Mar Medical Research Institute, Barcelona, Spain
- Department of Psychiatry and Legal Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Magi Farré
- Clinical Pharmacology Unit, Hospital Universitari Germans Trias i Pujol (HUGTP-IGTP), Badalona, Spain
- Department of Pharmacology, Therapeutics and Toxicology, Autonomous University of Barcelona, Barcelona, Spain
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30
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Duber HC, Barata IA, Cioè-Peña E, Liang SY, Ketcham E, Macias-Konstantopoulos W, Ryan SA, Stavros M, Whiteside LK. Identification, Management, and Transition of Care for Patients With Opioid Use Disorder in the Emergency Department. Ann Emerg Med 2018; 72:420-431. [PMID: 29880438 PMCID: PMC6613583 DOI: 10.1016/j.annemergmed.2018.04.007] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 04/09/2018] [Accepted: 04/11/2018] [Indexed: 01/03/2023]
Abstract
Because of a soaring number of opioid-related deaths during the past decade, opioid use disorder has become a prominent issue in both the scientific literature and lay press. Although most of the focus within the emergency medicine community has been on opioid prescribing-specifically, on reducing the incidence of opioid prescribing and examining alternative pain treatment-interest is heightening in identifying and managing patients with opioid use disorder in an effective and evidence-based manner. In this clinical review article, we examine current strategies for identifying patients with opioid use disorder, the treatment of patients with acute opioid withdrawal syndrome, approaches to medication-assisted therapy, and the transition of patients with opioid use disorder from the emergency department to outpatient services.
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Affiliation(s)
- Herbert C Duber
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA.
| | - Isabel A Barata
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Eric Cioè-Peña
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Stephen Y Liang
- Divisions of Emergency Medicine and Infectious Diseases, Washington University School of Medicine, St. Louis, MO
| | - Eric Ketcham
- San Juan Regional Medical Center, Farmington, NM
| | | | - Shawn A Ryan
- Department of Emergency Medicine, University of Cincinnati, and BrightView, Cincinnati, OH
| | - Mark Stavros
- Department of Emergency Medicine, Florida State University, Tallahassee, FL
| | - Lauren K Whiteside
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA
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31
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Gómez-del Valle MC, Zertuche-Maldonado T, Bruera E. Compensación química y adicción a opioides: evidencia, valoración de riesgo y manejo en pacientes con cuidados paliativos. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/j.medipa.2016.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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32
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Núñez Olarte JM, Francisco López MDC, Conti Jiménez M, Sánchez Isac M, Pérez Aznar C, Solano Garzón ML, Guevara Méndez S. Manejo de conductas aberrantes inducidas por opioides en una consulta externa de «cuidados paliativos precoces». ACTA ACUST UNITED AC 2018. [DOI: 10.1016/j.medipa.2017.02.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Arthur J, Hui D. Safe Opioid Use: Management of Opioid-Related Adverse Effects and Aberrant Behaviors. Hematol Oncol Clin North Am 2018; 32:387-403. [PMID: 29729776 DOI: 10.1016/j.hoc.2018.01.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Opioids are highly effective for cancer pain but are associated with multiple adverse effects and risk of addiction. This article provides a synopsis on the management of various opioid-related adverse effects and strategies to minimize aberrant opioid use in patients who have cancer. Many adverse effects can be effectively managed. Some patients on chronic opioid therapy may demonstrate aberrant behaviors suggestive of opioid misuse or diversion. Through intensive education, longitudinal monitoring, early identification, and timely management, clinicians can optimize the risk to benefit ratio to support safe opioid use.
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Affiliation(s)
- Joseph Arthur
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Unit 1414, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Unit 1414, 1515 Holcombe Boulevard, Houston, TX 77030, USA; Department of General Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
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34
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Mosher H, Herzig SJ, Danovitch I, Boutsicaris C, Hassamal S, Wittnebel K, Dashti A, Nuckols T. The Evaluation of Medical Inpatients Who Are Admitted on Long-term Opioid Therapy for Chronic Pain. J Hosp Med 2018; 13:249-255. [PMID: 29240853 DOI: 10.12788/jhm.2889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Individuals who are on long-term opioid therapy (LTOT) for chronic noncancer pain are frequently admitted to the hospital with acute pain, exacerbations of chronic pain, or comorbidities. Consequently, hospitalists find themselves faced with complex treatment decisions in the context of uncertainty about the effectiveness of LTOT as well as concerns about risks of overdose, opioid use disorders, and adverse events. Our multidisciplinary team sought to synthesize guideline recommendations and primary literature relevant to assessing medical inpatients on LTOT, with the objective of assisting practitioners in balancing effective pain treatment and opioid risk reduction. We identified no primary studies or guidelines specific to assessing medical inpatients on LTOT. Recommendations from outpatient guidelines on LTOT and guidelines on pain management in acute-care settings include the following: evaluate both pain and functional status, differentiate acute from chronic pain, investigate the preadmission course of opioid therapy, obtain a psychosocial history, screen for mental health conditions, screen for substance use disorders, check state prescription drug monitoring databases, order urine drug immunoassays, detect use of sedative-hypnotics, and identify medical conditions associated with increased risk of overdose and adverse events. Although approaches to assessing medical inpatients on LTOT can be extrapolated from related guidelines, observational studies, and small studies in surgical populations, more work is needed to address these critical topics for inpatients on LTOT.
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Affiliation(s)
- Hilary Mosher
- Department of General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Iowa City VA Medical Center, Iowa City, Iowa, USA
| | - Shoshana J Herzig
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Itai Danovitch
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Christina Boutsicaris
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Sameer Hassamal
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Karl Wittnebel
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Azadeh Dashti
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Teryl Nuckols
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA.
- RAND Corporation, Santa Monica, California, USA
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Krebs EE, Gravely A, Nugent S, Jensen AC, DeRonne B, Goldsmith ES, Kroenke K, Bair MJ, Noorbaloochi S. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA 2018; 319:872-882. [PMID: 29509867 PMCID: PMC5885909 DOI: 10.1001/jama.2018.0899] [Citation(s) in RCA: 597] [Impact Index Per Article: 99.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 02/01/2018] [Indexed: 01/20/2023]
Abstract
Importance Limited evidence is available regarding long-term outcomes of opioids compared with nonopioid medications for chronic pain. Objective To compare opioid vs nonopioid medications over 12 months on pain-related function, pain intensity, and adverse effects. Design, Setting, and Participants Pragmatic, 12-month, randomized trial with masked outcome assessment. Patients were recruited from Veterans Affairs primary care clinics from June 2013 through December 2015; follow-up was completed December 2016. Eligible patients had moderate to severe chronic back pain or hip or knee osteoarthritis pain despite analgesic use. Of 265 patients enrolled, 25 withdrew prior to randomization and 240 were randomized. Interventions Both interventions (opioid and nonopioid medication therapy) followed a treat-to-target strategy aiming for improved pain and function. Each intervention had its own prescribing strategy that included multiple medication options in 3 steps. In the opioid group, the first step was immediate-release morphine, oxycodone, or hydrocodone/acetaminophen. For the nonopioid group, the first step was acetaminophen (paracetamol) or a nonsteroidal anti-inflammatory drug. Medications were changed, added, or adjusted within the assigned treatment group according to individual patient response. Main Outcomes and Measures The primary outcome was pain-related function (Brief Pain Inventory [BPI] interference scale) over 12 months and the main secondary outcome was pain intensity (BPI severity scale). For both BPI scales (range, 0-10; higher scores = worse function or pain intensity), a 1-point improvement was clinically important. The primary adverse outcome was medication-related symptoms (patient-reported checklist; range, 0-19). Results Among 240 randomized patients (mean age, 58.3 years; women, 32 [13.0%]), 234 (97.5%) completed the trial. Groups did not significantly differ on pain-related function over 12 months (overall P = .58); mean 12-month BPI interference was 3.4 for the opioid group and 3.3 for the nonopioid group (difference, 0.1 [95% CI, -0.5 to 0.7]). Pain intensity was significantly better in the nonopioid group over 12 months (overall P = .03); mean 12-month BPI severity was 4.0 for the opioid group and 3.5 for the nonopioid group (difference, 0.5 [95% CI, 0.0 to 1.0]). Adverse medication-related symptoms were significantly more common in the opioid group over 12 months (overall P = .03); mean medication-related symptoms at 12 months were 1.8 in the opioid group and 0.9 in the nonopioid group (difference, 0.9 [95% CI, 0.3 to 1.5]). Conclusions and Relevance Treatment with opioids was not superior to treatment with nonopioid medications for improving pain-related function over 12 months. Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain. Trial Registration clinicaltrials.gov Identifier: NCT01583985.
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MESH Headings
- Acetaminophen/therapeutic use
- Adult
- Aged
- Aged, 80 and over
- Analgesics, Non-Narcotic/adverse effects
- Analgesics, Non-Narcotic/therapeutic use
- Analgesics, Opioid/adverse effects
- Analgesics, Opioid/therapeutic use
- Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
- Back Pain/drug therapy
- Chronic Pain/drug therapy
- Chronic Pain/etiology
- Drug Therapy, Combination
- Female
- Humans
- Intention to Treat Analysis
- Male
- Middle Aged
- Osteoarthritis, Hip/complications
- Osteoarthritis, Hip/drug therapy
- Osteoarthritis, Knee/complications
- Osteoarthritis, Knee/drug therapy
- Pain Measurement
- Young Adult
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Affiliation(s)
- Erin E. Krebs
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota Medical School, Minneapolis
| | - Amy Gravely
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Sean Nugent
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Agnes C. Jensen
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Beth DeRonne
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Elizabeth S. Goldsmith
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
- Division of Epidemiology, University of Minnesota School of Public Health, Minneapolis, Minneapolis, Minnesota
| | - Kurt Kroenke
- Center for Health Information and Communication, Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis
- Regenstrief Institute, Indianapolis, Indiana
| | - Matthew J. Bair
- Center for Health Information and Communication, Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis
- Regenstrief Institute, Indianapolis, Indiana
| | - Siamak Noorbaloochi
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota Medical School, Minneapolis
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Ware MA, Martel MO, Jovey R, Lynch ME, Singer J. A prospective observational study of problematic oral cannabinoid use. Psychopharmacology (Berl) 2018; 235:409-417. [PMID: 29250737 DOI: 10.1007/s00213-017-4811-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 12/05/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Despite evidence supporting the benefits of cannabinoids for symptom control across a wide range of medical conditions, concerns have been raised regarding the potential misuse and/or problematic use of cannabinoids (CBs). OBJECTIVE The first objective of this study was to examine the incidence of problematic prescription cannabinoid use (PPCBU) over a 12-month period among patients initiating cannabinoid therapy. The second objective was to examine the factors associated with PPCBU. A total of 265 patients who were prescribed oral cannabinoid therapy as part of usual medical practice were enrolled into this prospective observational study. Patients first completed a series of baseline questionnaires assessing demographic, clinical, and substance use variables. Three measures designed to assess PPCBU were then administered at 3, 6, and 12 months after initiation of cannabinoid therapy. RESULTS At each of the follow-up assessment time points, a significantly greater number of patients scored below (vs above) cutoff scores on the three main PPCBU outcomes (all p's < .001). At any follow-up time point, a maximum of roughly 25% of patients demonstrated PPCBU. Heightened odds of PPCBU were observed among patients with a history of psychiatric problems, tobacco smokers, and recreational cannabis users (all p's < .05). Results indicated that past-year substance abuse, assessed using the DAST-20, was the strongest predictor of PPCBU (p < .005). CONCLUSION Findings from the present study could have implications for clinicians considering the use of cannabinoids for the management of patients with medical conditions. Although results indicated that the majority of patients included in this study did not reach cutoff scores on the three main PPCBU outcomes, our findings suggest that PPCBU should be routinely assessed and monitored over the course of cannabinoid therapy, particularly among patients with a history of psychiatric or substance use problems.
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Affiliation(s)
- Mark A Ware
- Department of Anesthesia, Faculty of Medicine, McGill University, Montreal, Canada. .,Department of Family Medicine, McGill University, Montreal, Canada. .,Alan Edwards Pain Management Unit, McGill University Health Centre, Montreal, Canada. .,Montreal General Hospital, A5.140, 1650 Cedar Avenue, Montreal, Quebec, H3G 1A4, Canada.
| | - Marc O Martel
- Department of Anesthesia, Faculty of Medicine, McGill University, Montreal, Canada.,Alan Edwards Pain Management Unit, McGill University Health Centre, Montreal, Canada.,Faculty of Dentistry, McGill University, Montreal, Canada
| | - Roman Jovey
- CPM Centres for Pain Management, Mississauga, Ontario, Canada
| | - Mary E Lynch
- Department of Anesthesia, Pain Medicine, and Perioperative Care, Dalhousie University, Halifax, Canada
| | - Joel Singer
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
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O'Brien T, Christrup LL, Drewes AM, Fallon MT, Kress HG, McQuay HJ, Mikus G, Morlion BJ, Perez-Cajaraville J, Pogatzki-Zahn E, Varrassi G, Wells JCD. European Pain Federation position paper on appropriate opioid use in chronic pain management. Eur J Pain 2018; 21:3-19. [PMID: 27991730 PMCID: PMC6680203 DOI: 10.1002/ejp.970] [Citation(s) in RCA: 135] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2016] [Indexed: 02/06/2023]
Abstract
Poorly controlled pain is a global public health issue. The personal, familial and societal costs are immeasurable. Only a minority of European patients have access to a comprehensive specialist pain clinic. More commonly the responsibility for chronic pain management and initiating opioid therapy rests with the primary care physician and other non‐specialist opioid prescribers. There is much confusing and conflicting information available to non‐specialist prescribers regarding opioid therapy and a great deal of unjustified fear is generated. Opioid therapy should only be initiated by competent clinicians as part of a multi‐faceted treatment programme in circumstances where more simple measures have failed. Throughout, all patients must be kept under close clinical surveillance. As with any other medical therapy, if the treatment fails to yield the desired results and/or the patient is additionally burdened by an unacceptable level of adverse effects, the overall management strategy must be reviewed and revised. No responsible clinician will wish to pursue a failed treatment strategy or persist with an ineffective and burdensome treatment. In a considered attempt to empower and inform non‐specialist opioid prescribers, EFIC convened a European group of experts, drawn from a diverse range of basic science and relevant clinical disciplines, to prepare a position paper on appropriate opioid use in chronic pain. The expert panel reviewed the available literature and harnessed the experience of many years of clinical practice to produce these series of recommendations. Its success will be judged on the extent to which it contributes to an improved pain management experience for chronic pain patients across Europe. Significance This position paper provides expert recommendations for primary care physicians and other non‐ specialist healthcare professionals in Europe, particularly those who do not have ready access to specialists in pain medicine, on the safe and appropriate use of opioid medications as part of a multi‐faceted approach to pain management, in properly selected and supervised patients.
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Affiliation(s)
- T O'Brien
- Marymount University Hospital & Hospice, Curraheen, Cork, Ireland.,Cork University Hospital, Wilton, Cork and College of Medicine and Health, University College, Cork, Ireland
| | - L L Christrup
- Department of Drug Design and Pharmacology, University of Copenhagen, Denmark
| | - A M Drewes
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Denmark
| | - M T Fallon
- Edinburgh Cancer Research Centre, University of Edinburgh, UK
| | - H G Kress
- Department of Special Anaesthesia and Pain Therapy, Medical University of Vienna/AKH, Austria
| | | | - G Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital, Heidelberg, Germany
| | - B J Morlion
- Leuven Centre for Algology & Pain Management, University Hospital Leuven, Belgium
| | | | - E Pogatzki-Zahn
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Müenster, Germany
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Kovatch M, Feingold D, Elkana O, Lev-Ran S. Evaluation and comparison of tools for diagnosing problematic prescription opioid use among chronic pain patients. Int J Methods Psychiatr Res 2017; 26:e1542. [PMID: 27774717 PMCID: PMC6877121 DOI: 10.1002/mpr.1542] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 07/10/2016] [Accepted: 08/24/2016] [Indexed: 11/09/2022] Open
Abstract
Prescription opioid medications are commonly used for the treatment of chronic pain. Assessments of problematic opioid use among pain patients are inconsistent across studies, partially due to differences between various measures. Therefore, the most appropriate measure to use is often unclear. In this study we assessed problematic opioid use in a sample of 551 individuals receiving treatment for chronic pain, using three questionnaires: the Alcohol Use Disorder and Associated Disabilities Interview Schedule - Fourth Edition (AUDADIS-IV), the Current Opioid Misuse Measure (COMM) questionnaire and Portenoy's criteria (PC). These questionnaires yielded discordant positive rates of problematic use: 52.6%, 28.7%, and 17.1%, respectively, which did not change substantially when excluding AUDADIS-IV criteria of physical symptoms of tolerance and withdrawal. Although these three questionnaires share some statistically correlated content-based congruent questions, positive response rates to them were significantly different based on construction features, including questionnaires' referred time-frame, wording of questions and response alternatives. The findings of the present study illustrate strengths and limitations of the AUDADIS-IV, COMM and PC in diagnosing problematic opioid use in a population of adults suffering from chronic pain, and highlight the importance of recognizing and addressing specific questionnaire and question-related differences when identifying problematic opioid use in this population.
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Affiliation(s)
- Merav Kovatch
- Behavioral Sciences, Academic College of Tel Aviv-Jaffa, Tel Aviv, Israel
| | - Daniel Feingold
- Ariel University, Ariel, Israel.,Addiction Medicine and Dual Diagnosis Services, Department of Psychiatry, Sheba Medical Center, Tel Hashomer, Israel
| | - Odelia Elkana
- Behavioral Sciences, Academic College of Tel Aviv-Jaffa, Tel Aviv, Israel
| | - Shaul Lev-Ran
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Addiction Medicine and Dual Diagnosis Services, Department of Psychiatry, Sheba Medical Center, Tel Hashomer, Israel
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Hande K. Pain Management: Strategies for Screening and Monitoring Patients Receiving Chronic Opioid Therapy
. Clin J Oncol Nurs 2017; 21:669-672. [PMID: 29149119 DOI: 10.1188/17.cjon.669-672] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The current state of pain management within the oncology setting, effectiveness of opioids for the relief of pain, and limited alternatives for chronic pain management have produced reliance on opioid medications with an inherent risk for aberrant behavior. Although standardization is lacking among prescribers who manage cancer-related pain, advanced practice RNs must act according to the available evidence that suggests assessing and monitoring for abuse and misuse.
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40
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Krebs EE, Jensen AC, Nugent S, DeRonne B, Rutks I, Leverty D, Gravely A, Noorbaloochi S, Bair MJ, Kroenke K. Design, recruitment outcomes, and sample characteristics of the Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) trial. Contemp Clin Trials 2017; 62:130-139. [PMID: 28893675 DOI: 10.1016/j.cct.2017.09.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 08/29/2017] [Accepted: 09/07/2017] [Indexed: 10/18/2022]
Abstract
This manuscript describes the study protocol, recruitment outcomes, and baseline participant characteristics for the Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) trial. SPACE is a pragmatic randomized comparative effectiveness trial conducted in multiple VA primary care clinics within one VA health care system. The objective was to compare benefits and harms of opioid therapy versus non-opioid medication therapy over 12months among patients with moderate-to-severe chronic back pain or hip/knee osteoarthritis pain despite analgesic therapy; patients already receiving regular opioid therapy were excluded. Key design features include comparing two clinically-relevant medication interventions, pragmatic eligibility criteria, and flexible treat-to-target interventions. Screening, recruitment and study enrollment were conducted over 31months. A total of 4491 patients were contacted for eligibility screening; 53.1% were ineligible, 41.0% refused, and 5.9% enrolled. The most common reasons for ineligibility were not meeting pain location and severity criteria. The most common study-specific reasons for refusal were preference for no opioid use and preference for no pain medications. Of 265 enrolled patients, 25 withdrew before randomization. Of 240 randomized patients, 87.9% were male, 84.1% were white, and age range was 21-80years. Past-year mental health diagnoses were 28.3% depression, 17% anxiety, 9.4% PTSD, 7.9% alcohol use disorder, and 2.6% drug use disorder. In conclusion, although recruitment for this trial was challenging, characteristics of enrolled participants suggest we were successful in recruiting patients similar to those prescribed opioid therapy in usual care.
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Affiliation(s)
- Erin E Krebs
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA; Department of Medicine, University of Minnesota Medical School, 420 Delaware Street SE MMC 194, Minneapolis, MN 55455, USA.
| | - Agnes C Jensen
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA
| | - Sean Nugent
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA
| | - Beth DeRonne
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA
| | - Indulis Rutks
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA
| | - David Leverty
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA
| | - Amy Gravely
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA
| | - Siamak Noorbaloochi
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA; Department of Medicine, University of Minnesota Medical School, 420 Delaware Street SE MMC 194, Minneapolis, MN 55455, USA
| | - Matthew J Bair
- Center for Health Information and Communication, Roudebush VA Medical Center, 1481 W. 10th St., Indianapolis, IN 46202, USA; Department of Medicine, Indiana University School of Medicine, 1110 W. Michigan Street Long Hall 417, Indianapolis, IN 46202, USA; Regenstrief Institute, Inc., Indianapolis, IN 46202, 1101 West 10th Street, USA
| | - Kurt Kroenke
- Center for Health Information and Communication, Roudebush VA Medical Center, 1481 W. 10th St., Indianapolis, IN 46202, USA; Department of Medicine, Indiana University School of Medicine, 1110 W. Michigan Street Long Hall 417, Indianapolis, IN 46202, USA; Regenstrief Institute, Inc., Indianapolis, IN 46202, 1101 West 10th Street, USA
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41
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Finkelman MD, Jamison RN, Kulich RJ, Butler SF, Jackson WC, Smits N, Weiner SG. Cross-validation of short forms of the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R). Drug Alcohol Depend 2017. [PMID: 28645065 DOI: 10.1016/j.drugalcdep.2017.04.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) is a 24-item assessment designed to assist in the prediction of aberrant drug-related behavior (ADB) among patients with chronic pain. Recent work has created shorter versions of the SOAPP-R, including a static 12-item short form and two computer-based methods (curtailment and stochastic curtailment) that monitor assessments in progress. The purpose of this study was to cross-validate these shorter versions in two new populations. METHODS This retrospective study used data from patients recruited from a hospital-based pain center (n=84) and pain patients followed and treated at primary care centers (n=110). Subjects had been administered the SOAPP-R and assessed for ADB. In real-data simulation, the sensitivity, specificity, and area under the curve (AUC) of each form were calculated, as was the mean test length using curtailment and stochastic curtailment. RESULTS Curtailment reduced the number of items administered by 30% to 34% while maintaining sensitivity and specificity identical to those of the full-length SOAPP-R. Stochastic curtailment reduced the number of items administered by 45% to 63% while maintaining sensitivity and specificity within 0.03 of those of the full-length SOAPP-R. The AUC of the 12-item form was equal to that of the 24-item form in both populations. CONCLUSIONS Curtailment, stochastic curtailment, and the 12-item short form have potential to enhance the efficiency of the SOAPP-R.
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Affiliation(s)
- Matthew D Finkelman
- Department of Public Health and Community Service, Tufts University School of Dental Medicine, 1 Kneeland St., Boston, MA 02111, USA.
| | - Robert N Jamison
- Departments of Anesthesiology and Psychiatry, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA.
| | - Ronald J Kulich
- Craniofacial Pain and Headache Center, Tufts University School of Dental Medicine, 1 Kneeland St., Boston, MA 02111, USA; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 15 Parkman St., Boston, MA 02114, USA.
| | - Stephen F Butler
- Inflexxion, Inc., 890 Winter St., Ste. 235, Waltham, MA 02451, USA.
| | - William C Jackson
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St. #148, Boston, MA 02114, USA.
| | - Niels Smits
- Department of Methods and Statistics, Research Institute of Child Development and Education, University of Amsterdam, Faculty of Social and Behavioural Sciences, Nieuwe Achtergracht 127, 1018 WS Amsterdam, The Netherland.
| | - Scott G Weiner
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, NH-226, Boston, MA 02115, USA.
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Muir H, Seymour F. Screening tools to assess risk of opioid abuse in the Canadian primary healthcare setting. Nurse Pract 2017; 42:45-50. [PMID: 28346282 DOI: 10.1097/01.npr.0000508172.41410.3b] [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: 06/06/2023]
Abstract
Opioid therapy for patients with chronic pain is increasing in frequency along with rates of opioid abuse. Many screening tools are available to assess for the risk of opioid abuse. NPs should use screening tools that are cross-validated for use in chronic pain patients in the Canadian primary healthcare setting.
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Affiliation(s)
- Hollie Muir
- Hollie Muir is an NP at the Oromocto Health Centre, Oromocto, N.B., Canada. Fran Seymour is a senior teaching associate and NP at the University of New Brunswick, Frederickton, N.B., Canada
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Setnik B, Roland CL, Barsdorf AI, Brooks A, Coyne KS. The content validation of the Self-Reported Misuse, Abuse and Diversion of Prescription Opioids (SR-MAD) instrument for use in patients with acute or chronic pain. Curr Med Res Opin 2017; 33:1067-1076. [PMID: 28277862 DOI: 10.1080/03007995.2017.1300142] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Establishing content validity is an essential component of instrument development. OBJECTIVE To assess the content validity and patient interpretation of the Self-Reported Misuse, Abuse and Diversion of Prescription Opioids (SR-MAD) instrument. METHODS A cross-sectional, qualitative study was conducted in patients with chronic or acute pain. Patients were recruited from three patient groups (opioid naïve, known opioid abusers, and chronic opioid non-abusers). After patients completed the SR-MAD, they participated in an in-person cognitive interview to assess the patient's understanding of the instrument. Descriptive statistics and content analysis were performed. RESULTS Fifty-seven patients (Wave 1: 20; Wave 2: 37) were enrolled and completed the SR-MAD and cognitive interview. Mean age was 54.5 ± 13.7 years (range 25-84) with 12.5 years of living with pain. The most common chronic pain conditions were back pain (68%), neck pain (32%), and osteoarthritis (25%). Overall, most patients understood the meaning of each question and were able to describe each item using their own words. Many patients reported that some questions were not applicable to them but understood the meaning of the questions as well as the need to ask questions about misuse, abuse, and diversion of opioid medications. Minor revisions to the SR-MAD wording, response options, recall period, and the definition of "opioid", were recommended by the patients in both waves. LIMITATIONS Given its qualitative design, this study has a small sample size. Additionally, quantitative validation of the SR-MAD is needed. CONCLUSION The SR-MAD, developed based on expert consensus and revised with patient input, is a 15-item self-report instrument that can be used to identify and monitor prescription opioid abuse, misuse, and diversion.
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Affiliation(s)
- Beatrice Setnik
- a INC Research , Raleigh , NC , USA
- b Department of Pharmacology and Toxicology , University of Toronto , Toronto , Ontario , Canada
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Measures That Identify Prescription Medication Misuse, Abuse, and Related Events in Clinical Trials: ACTTION Critique and Recommended Considerations. THE JOURNAL OF PAIN 2017; 18:1287-1294. [PMID: 28479207 DOI: 10.1016/j.jpain.2017.03.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 03/20/2017] [Accepted: 03/30/2017] [Indexed: 11/20/2022]
Abstract
Accurate assessment of inappropriate medication use events (ie, misuse, abuse, and related events) occurring in clinical trials is an important component in evaluating a medication's abuse potential. A meeting was convened to review all instruments measuring such events in clinical trials according to previously published standardized terminology and definitions. Only 2 approaches have been reported that are specifically designed to identify and classify misuse, abuse, and related events occurring in clinical trials, rather than to measure an individual's risk of using a medication inappropriately: the Self-Reported Misuse, Abuse, and Diversion (SR-MAD) instrument and the Misuse, Abuse, and Diversion Drug Event Reporting System (MADDERS). The conceptual basis, strengths, and limitations of these methods are discussed. To our knowledge, MADDERS is the only system available to comprehensively evaluate inappropriate medication use events prospectively to determine the underlying intent. MADDERS can also be applied retrospectively to completed trial data. SR-MAD can be used prospectively; additional development may be required to standardize its implementation and fully appraise the intent of inappropriate use events. Additional research is needed to further demonstrate the validity and utility of MADDERS as well as SR-MAD. PERSPECTIVE Identifying a medication's abuse potential requires assessing inappropriate medication use events in clinical trials on the basis of a standardized event classification system. The strengths and limitations of the 2 published methods designed to evaluate inappropriate medication use events are reviewed, with recommended considerations for further development and current implementation.
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45
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Olarte JMN. Breakthrough cancer pain and rational drug use. Support Care Cancer 2017; 25:11-17. [PMID: 28213817 PMCID: PMC5357276 DOI: 10.1007/s00520-017-3636-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 12/27/2016] [Indexed: 12/21/2022]
Abstract
Recent data indicate that there are large disparities in the use of opioid analgesics to control breakthrough cancer pain (BTcP) in Europe and worldwide. While it is clear that affordability is a key factor, it is certainly not the only one, and other factors, such as cultural differences and overall awareness, are undoubtedly responsible. More work remains to be done to overcome barriers in the use of these medications when warranted. When prescribing a medication for BTcP, it must be considered that its time profile is different from chronic persistent pain. The best control of background pain can best be achieved with a low dose of an extended opioid, and managing BTcP with a rapid-onset opioid, providing a good combination of overall pain control and lower opioid exposure. Notwithstanding their efficacy, greater attention needs to be paid to inappropriate use of opioids. It is important to evaluate patients for potential opioid misuse, including assessment of risk factors, and aberrant drug-taking behaviours must be investigated. In our institution, several measures have been adopted in this patient population in order to prevent aberrant opioid-induced behaviours. The adoption of some or all of these principles, depending on the individual patient and treatment setting, can undoubtedly help to reduce the risk of developing an aberrant behaviour related to opioid use as rescue medication for BTcP.
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Affiliation(s)
- Juan Manuel Núñez Olarte
- Palliative Care Unit, Hospital General Universitario Gregorio Marañón, c/Dr Esquerdo 46, 28007, Madrid, Spain.
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Nikulina V, Guarino H, Acosta MC, Marsch LA, Syckes C, Moore SK, Portenoy RK, Cruciani RA, Turk DC, Rosenblum A. Patient vs provider reports of aberrant medication-taking behavior among opioid-treated patients with chronic pain who report misusing opioid medication. Pain 2016; 157:1791-1798. [PMID: 27082008 PMCID: PMC4949142 DOI: 10.1097/j.pain.0000000000000583] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
During long-term opioid therapy for chronic noncancer pain, monitoring medication adherence of patients with a history of aberrant opioid medication-taking behaviors (AMTB) is an essential practice. There is limited research, however, into the concordance among existing monitoring tools of self-report, physician report, and biofluid screening. This study examined associations among patient and provider assessments of AMTB and urine drug screening using data from a randomized trial of a cognitive-behavioral intervention designed to improve medication adherence and pain-related outcomes among 110 opioid-treated patients with chronic pain who screened positive for AMTB and were enrolled in a pain program. Providers completed the Aberrant Behavior Checklist (ABC) and patients completed the Current Opioid Misuse Measure (COMM) and the Chemical Coping Inventory (CCI). In multivariate analyses, ABC scores were compared with COMM and CCI scores, while controlling for demographics and established risk factors for AMTB, such as pain severity. Based on clinical cutoffs, 84% of patients reported clinically significant levels of AMTB and providers rated 36% of patients at elevated levels. Provider reports of AMTB were not correlated with COMM or CCI scores. However, the ABC ratings of experienced providers (nurse practitioners/attending physicians) were higher than those of less experienced providers (fellows) and were correlated with CCI scores and risk factors for AMTB. Associations between patient- and provider-reported AMTB and urine drug screening results were low and largely nonsignificant. In conclusion, concordance between patient and provider reports of AMTB among patients with chronic pain prescribed opioid medication varied by provider level of training.
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Affiliation(s)
- Valentina Nikulina
- Queens College, CUNY; Department of Psychology, 6530 Kissena Boulevard, Flushing, NY 11367, T: (718) 997-3215; F: (718) 997-3257; http://www.qc.cuny.edu/Academics/Degrees/DMNS/Psychology/Pages/default.aspx
| | - Honoria Guarino
- National Development and Research Institutes, Inc., New York, NY
| | | | - Lisa A. Marsch
- Dartmouth Center for Technology and Behavioral Health, Lebanon, NH
| | - Cassandra Syckes
- National Development and Research Institutes, Inc., New York, NY
| | - Sarah K. Moore
- Dartmouth Center for Technology and Behavioral Health, Lebanon, NH
| | | | | | | | - Andrew Rosenblum
- National Development and Research Institutes, Inc., New York, NY
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Pombo N, Garcia N, Bousson K, Spinsante S, Chorbev I. Pain Assessment--Can it be Done with a Computerised System? A Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:415. [PMID: 27089351 PMCID: PMC4847077 DOI: 10.3390/ijerph13040415] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 03/29/2016] [Accepted: 04/07/2016] [Indexed: 01/17/2023]
Abstract
Background: Mobile and web technologies are becoming increasingly used to support the treatment of chronic pain conditions. However, the subjectivity of pain perception makes its management and evaluation very difficult. Pain treatment requires a multi-dimensional approach (e.g., sensory, affective, cognitive) whence the evidence of technology effects across dimensions is lacking. This study aims to describe computerised monitoring systems and to suggest a methodology, based on statistical analysis, to evaluate their effects on pain assessment. Methods: We conducted a review of the English-language literature about computerised systems related to chronic pain complaints that included data collected via mobile devices or Internet, published since 2000 in three relevant bibliographical databases such as BioMed Central, PubMed Central and ScienceDirect. The extracted data include: objective and duration of the study, age and condition of the participants, and type of collected information (e.g., questionnaires, scales). Results: Sixty-two studies were included, encompassing 13,338 participants. A total of 50 (81%) studies related to mobile systems, and 12 (19%) related to web-based systems. Technology and pen-and-paper approaches presented equivalent outcomes related with pain intensity. Conclusions: The adoption of technology was revealed as accurate and feasible as pen-and-paper methods. The proposed assessment model based on data fusion combined with a qualitative assessment method was revealed to be suitable. Data integration raises several concerns and challenges to the design, development and application of monitoring systems applied to pain.
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Affiliation(s)
- Nuno Pombo
- Instituto de Telecomunicações (Telecommunications Institute), University of Beira Interior, Covilhã 6200-001, Portugal.
- Department of Informatics, University of Beira Interior, Covilhã 6200-001, Portugal.
- ALLab-Assisted Living Computing and Telecommunications Laboratory, University of Beira Interior, Covilhã 6200-001, Portugal.
| | - Nuno Garcia
- Instituto de Telecomunicações (Telecommunications Institute), University of Beira Interior, Covilhã 6200-001, Portugal.
- Department of Informatics, University of Beira Interior, Covilhã 6200-001, Portugal.
- ALLab-Assisted Living Computing and Telecommunications Laboratory, University of Beira Interior, Covilhã 6200-001, Portugal.
| | - Kouamana Bousson
- Department of Aerospace Sciences, University of Beira Interior, Covilhã 6200-001, Portugal.
| | - Susanna Spinsante
- Dipartimento di Ingegneria dell'Informazione, Università Politecnica delle Marche, Ancona 60121, Italy.
| | - Ivan Chorbev
- Faculty of Computer Science and Engineering, Ss. Cyril and Methodius University Skopje, Skopje 1000, Macedonia.
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48
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McHugh RK, Weiss RD, Cornelius M, Martel MO, Jamison RN, Edwards RR. Distress Intolerance and Prescription Opioid Misuse Among Patients With Chronic Pain. THE JOURNAL OF PAIN 2016; 17:806-14. [PMID: 27058161 DOI: 10.1016/j.jpain.2016.03.004] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 02/23/2016] [Accepted: 03/18/2016] [Indexed: 02/03/2023]
Abstract
UNLABELLED The risk for misuse of opioid medications is a significant challenge in the management of chronic pain. The identification of those who may be at greater risk for misusing opioids is needed to facilitate closer monitoring of high-risk subgroups, and may help to identify therapeutic targets for mitigating this risk. The aim of this study was to examine whether distress intolerance-the perceived or actual inability to manage negative emotional and somatic states-was associated with opioid misuse in those with chronic pain. A sample of 51 participants prescribed opioid analgesics for chronic back or neck pain were recruited for a 1-time laboratory study. Participants completed measures of distress intolerance and opioid misuse, and a quantitative sensory testing battery. Results suggested that distress intolerance was associated with opioid misuse, even controlling for pain severity and negative affect. Distress intolerance was not associated with pain severity, threshold, or tolerance, but was associated with self-reported anxiety and stress after noxious stimuli. This study found robust differences in distress intolerance between adults with chronic pain with and without opioid medication misuse. Distress intolerance may be a relevant marker of risk for opioid misuse among those with chronic pain. PERSPECTIVE This study demonstrated that distress intolerance was associated with opioid misuse in adults with chronic pain who were prescribed opioids. Distress intolerance can be modified with treatment, and thus may be relevant not only for identification of risk for opioid misuse, but also for mitigation of this risk.
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Affiliation(s)
- R Kathryn McHugh
- Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts.
| | - Roger D Weiss
- Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Marise Cornelius
- Pain Management Center, Brigham and Women's Hospital, Chestnut Hill, Massachusetts
| | - Marc O Martel
- Pain Management Center, Brigham and Women's Hospital, Chestnut Hill, Massachusetts; Department of Anesthesiology, Harvard Medical School, Boston, Massachusetts
| | - Robert N Jamison
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts; Pain Management Center, Brigham and Women's Hospital, Chestnut Hill, Massachusetts; Department of Anesthesiology, Harvard Medical School, Boston, Massachusetts
| | - Robert R Edwards
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts; Pain Management Center, Brigham and Women's Hospital, Chestnut Hill, Massachusetts; Department of Anesthesiology, Harvard Medical School, Boston, Massachusetts
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49
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Efficacy of the Opioid Compliance Checklist to Monitor Chronic Pain Patients Receiving Opioid Therapy in Primary Care. THE JOURNAL OF PAIN 2016; 17:414-23. [DOI: 10.1016/j.jpain.2015.12.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 12/03/2015] [Accepted: 12/08/2015] [Indexed: 12/31/2022]
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50
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Pergolizzi JV, Zampogna G, Taylor R, Gonima E, Posada J, Raffa RB. A Guide for Pain Management in Low and Middle Income Communities. Managing the Risk of Opioid Abuse in Patients with Cancer Pain. Front Pharmacol 2016; 7:42. [PMID: 26973529 PMCID: PMC4771925 DOI: 10.3389/fphar.2016.00042] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 02/15/2016] [Indexed: 11/18/2022] Open
Abstract
Most patients who present with cancer have advanced disease and often suffer moderate to severe pain. Opioid therapy can be safe and effective for use in cancer patients with pain, but there are rightful concerns about inappropriate opioid use even in the cancer population. Since cancer patients live longer than ever before in history (and survivors may have long exposure times to opioid therapy), opioid misuse among cancer patients is an important topic worthy of deeper investigation. Cancer patients with pain must be evaluated for risk factors for potential opioid misuse and aberrant drug-taking behaviors assessed. A variety of validated screening tools should be used. Of particular importance is the fact that pain in cancer patients changes frequently, whether it is related to their underlying disease (progression or remission), pain related to treatment (such as painful chemotherapy-induced peripheral neuropathy), and concomitant pain unrelated to cancer (such as osteoarthritis, headache, or back pain). Fortunately, clinicians can use universal precautions to help reduce the risk of opioid misuse while still assuring that cancer patients get the pain therapy they need. Another important new “tool” in this regard is the emergence of abuse-deterrent opioid formulations.
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Affiliation(s)
- Joseph V Pergolizzi
- Department of Medicine, Johns Hopkins University School of MedicineBaltimore, MD, USA; Department of Anesthesiology, Georgetown University School of MedicineWashington, DC, USA; Department of Pharmacology, Temple University School of MedicinePhiladelphia, PA, USA
| | | | | | - Edmundo Gonima
- Anesthesiologist, Pain and Palliative Care, Pain Specialist in Hospital Militar Bogota, Colombia
| | - Jose Posada
- Psychiatry, Colombian National Board of Narcotics Bogota, Colombia
| | - Robert B Raffa
- Department of Pharmaceutical Sciences, Temple University School of Pharmacy Philadelphia, PA, USA
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