Balancing the Risks and Benefits of Opioid Therapy: The Pill and the Pendulum

Attitudes and Beliefs Regarding Pain Medicine: Results of a National Palliative Physician Survey

CONTEXT

Pain is a prevalent symptom in patients with serious illness and often requires interventional approaches for adequate treatment. Little is known about referral patterns and collaborative attitudes of palliative physicians regarding pain management specialists.

OBJECTIVES

To evaluate referral rates, co-management strategies, and beliefs of palliative physicians about the value of Pain Medicine specialists in patients with serious illness.

METHODS

A 30-question survey with demographic, referral/practice, and attitudes/belief questions was mailed to 1000 AAHPM physician members. Responses were characterized with descriptive statistics and further analyzed for associations between training experiences, practice environment, and educational activities with collaborative practice patterns and beliefs.

RESULTS

The response rate was 52.6%. Most survey respondents had initial board certification primarily in internal medicine (n = 286, 56%) or family medicine (n = 144, 28%). A minority of respondents had completed a formal ABMS Hospice and Palliative Medicine fellowship (n = 178, 34%). Respondents had been in practice for a median of nine years, (range 1-38 years) primarily in community hospitals (n = 249, 47%) or academic hospitals (n = 202, 38%). The variables best associated with collaborative practices and attitudes was practice in an academic hospital setting and participation in regular joint academic conferences with pain medicine clinicians.

CONCLUSION

This study shows that Palliative Care physicians have highly positive attitudes toward Pain Medicine specialists, but referrals remain low. Facilitating professional collaboration via joint educational/clinical sessions is one possible solution to drive ongoing interprofessional care in patients with complex pain.

Pills and the damage done: the opioid epidemic as man-made crisis

The prescription opioid epidemic has slowly evolved over the past quarter century with increasingly detrimental consequences for public health. Man-made crises are often unforeseen and characterized by a situation without natural causes where - because of human intent, error, negligence, or the failure of manmade systems - the level of needs in the population exceeds available resources to counter the problem. This paper presents the prescription opioid epidemic as a man-made crisis and explores the public health impact of opioid manufacturers and other industries producing commodities with addictive potential as a shared vulnerability among countries. We examine this concept within the framework of the commercial determinants of health. We address three key aspects of the commercial determinants of health: (1) Cross-industry mechanisms, (2) policy inertia, and (3) the role of industry in science. Within cross-industry mechanisms, we explore parallels between prescription opioid epidemic and unhealthy commodity industries in terms of marketing, corporate use of misinformation, and diversionary tactics. Next, we examine how policy inertia has dominated the slow response to this man-made crisis. Lastly, we discuss how results from clinical trials are used as a key marketing strategy for drugs. The origins of the prescription opioid epidemic may be traced to innovations in drug development with the promise of improved pain management. However, through multiple factors, including fraudulent marketing from pharmaceutical industry and policy inertia, the resulting crisis represents a multi-system failure of regulation exploited by corporate greed.

Characteristics Associated with Self-Reported Exercise among US Adults Age ≥50 Years with Self-Reported Pain in the Past Four Weeks Who Used an Opioid

The number of older adults in the United States is growing, alongside the number of older adults experiencing some sort of pain and using opioids. Exercise is an important pain management and pain prevention strategy. However, little is known about the factors associated with exercise among United States adults ≥50 years old with pain who use opioids. This retrospective cross-sectional database study aimed to identify characteristics associated with self-reported frequent exercise (moderate- to vigorous-intensity exercise ≥30 min five times a week) in United States adults ≥50 years old with pain in the past four weeks who had also used an opioid. The study used 2020 Medical Expenditure Panel Survey data and logistic regression models. Analyses maintained the structure of the complex survey data and were weighted to obtain nationally representative estimates. Significantly associated variables with frequent exercise in the fully adjusted analysis included being aged 60-69 (versus ≥80 years, adjusted odds ratio [AOR] = 2.3, 95% confidence interval [CI] = [1.1-5.1]), having excellent/very good/good (versus fair/poor) self-perceived health (AOR = 2.4, 95% CI = [1.3-4.2]), normal/underweight (versus obese (AOR = 2.1, 95% CI = [1.1-3.9])), overweight (versus obese (AOR = 1.7, 95% CI = [1.0-2.9])), and having little (versus extreme) pain (AOR = 2.4, 95% CI = [1.0-5.7]). A secondary finding was that 35.7% considered themselves frequent exercisers, while the remaining 64.3% did not consider themselves frequent exercisers. In future, these findings can be used to personalize pain management strategies and encourage greater levels of exercise among this population.

Comparative Study of Opioid Initiation With Tramadol, Short-acting Hydrocodone, or Short-acting Oxycodone on Opioid-related Adverse Outcomes Among Chronic Noncancer Pain Patients

OBJECTIVE

To compare the safety profiles of low and high-dose tramadol, short-acting hydrocodone, and short-acting oxycodone therapies among chronic noncancer pain individuals.

MATERIALS AND METHODS

A retrospective cohort study of individuals with back/neck pain/osteoarthritis with an initial opioid prescription for tramadol, hydrocodone, or oxycodone was conducted using IQVIA PharMetrics Plus claims for Academics database (2006 to 2020). Two cohorts were created for separately studying opioid-related adverse events (overdoses, accidents, self-inflicted injuries, and violence-related injuries) and substance use disorders (opioid and nonopioid). Patients were followed from the index date until an outcome event, end of enrollment, or data end. Time-varying exposure groups were constructed and Cox regression models were estimated.

RESULTS

A total of 1,062,167 (tramadol [16.5%], hydrocodone [61.1%], and oxycodone [22.4%]) and 986,809 (tramadol [16.5%], hydrocodone [61.3%], and oxycodone [22.2%]) individuals were in the adverse event and substance use disorder cohorts. All high-dose groups had elevated risk of nearly all outcomes, compared with low-dose hydrocodone. Compared with low-dose hydrocodone, low-dose oxycodone was associated with a higher risk of opioid overdose (hazard ratio: 1.79 [1.37 to 2.33]). No difference in risk was observed between low-dose tramadol and low-dose hydrocodone (hazard ratio: 0.85 [0.64 to 1.13]). Low-dose oxycodone had higher risks of an opioid use disorder, and low-dose tramadol had a lower risk of accidents, self-inflicted injuries, and opioid use disorder compared with low-dose hydrocodone.

DISCUSSION

Low-dose oxycodone had a higher risk of opioid-related adverse outcomes compared with low-dose tramadol and hydrocodone. This should be interpreted in conjunction with the benefits of pain control and functioning associated with oxycodone use in future research.

Opioid: Plenitude versus pittance

The opioid crisis in the USA and in other developed countries can potentially affect low- and middle-income countries (LMICs). The licit medical use of opioids has two sides. The USA and high-income countries maintain abundant supply for medical prescription. Between 1990 and 2010, the use of opioids for cancer pain relief was overtaken by a dramatic rise in the opioid prescriptions for non-cancer acute or chronic pain. The surge led to the opioid epidemic, recognized as social catastrophe in the USA, Canada and in some countries in Europe. From 2016, the medical community, health policy regulators and law-makers have taken actions to tackle this opioid crisis. On the other side, formulary deficiency and low opioid availability exists for three-fourths of the global population living in LMICs. Physicians and nurses in Asia and Africa engaged in cancer pain relief and palliative care face a constant paucity of opioids. Millions of patients in LMICs, suffering from life-modifying cancer pain, do not have access to morphine and other essential opioids, due to restrictive opioid policies. Attention will be needed to improve opioid availability in large parts of the world, even though the opioid crisis has led to control the licit medical use in the USA.

Perceptions on wearable sensor-based interventions for monitoring of opioid therapy: A qualitative study

Prescription opioid use is a risk factor for the development of opioid use disorder. Digital solutions, including wearable sensors, represent a promising opportunity for health monitoring, risk stratification and harm reduction in this treatment space. However, data on their usability and acceptability in individuals using opioids is limited. To address this gap, factors that impact usability and acceptability of wearable sensor-based opioid detection were qualitatively studied in participants enrolled in a wearable sensor-based opioid monitoring research study. At the conclusion of the monitoring period, participants were invited to take part in semi-structured interviews developed based on the technology acceptance model. Thematic analysis was conducted first using deductive, then inductive coding strategies. Forty-four participants completed the interview; approximately half were female. Major emergent themes include sensor usability, change in behavior and thought process related to sensor use, perceived usefulness in sensor-based monitoring, and willingness to have opioid use patterns monitored. Overall acceptance for sensor-based monitoring was high. Aesthetics, simplicity, and seamless functioning were all reported as key to usability. Perceived behavior changes related to monitoring were infrequent while perceived usefulness in monitoring was frequently projected onto others, requiring careful consideration regarding intervention development and targeting. Specifically, care must be taken to avoid stigma associated with opioid use and implied misuse. The design of sensor systems targeted for opioid use must also consider the physical, social, and cognitive alterations inherent in the respective disease processes compared to routine daily life.

Practical recommendations for the management of the patient with chronic pain during the pandemic of COVID-19

SARS-CoV-2 infection has evolved into a pandemic and a Public Health Emergency of International Importance that has forced health organizations at the global, regional and local levels to adopt a series of measures to address to COVID-19 and try to reduce its impact, not only in the social sphere but also in the health sphere, modifying the guidelines for action in the health services. Within these recommendations that include the Pain Treatment Units, patients with suspected or confirmed SARS-CoV-2 infection may be waiting for medical consult or interventional procedures for the management of chronic pain refractory to other therapies. A series of guidelines aimed at reducing the risk of infection of health personnel, other patients and the community are included in this manuscript.

Chronic pain: an update on burden, best practices, and new advances

Chronic pain exerts an enormous personal and economic burden, affecting more than 30% of people worldwide according to some studies. Unlike acute pain, which carries survival value, chronic pain might be best considered to be a disease, with treatment (eg, to be active despite the pain) and psychological (eg, pain acceptance and optimism as goals) implications. Pain can be categorised as nociceptive (from tissue injury), neuropathic (from nerve injury), or nociplastic (from a sensitised nervous system), all of which affect work-up and treatment decisions at every level; however, in practice there is considerable overlap in the different types of pain mechanisms within and between patients, so many experts consider pain classification as a continuum. The biopsychosocial model of pain presents physical symptoms as the denouement of a dynamic interaction between biological, psychological, and social factors. Although it is widely known that pain can cause psychological distress and sleep problems, many medical practitioners do not realise that these associations are bidirectional. While predisposing factors and consequences of chronic pain are well known, the flipside is that factors promoting resilience, such as emotional support systems and good health, can promote healing and reduce pain chronification. Quality of life indicators and neuroplastic changes might also be reversible with adequate pain management. Clinical trials and guidelines typically recommend a personalised multimodal, interdisciplinary treatment approach, which might include pharmacotherapy, psychotherapy, integrative treatments, and invasive procedures.

Pain During COVID-19: A Comprehensive Review and Guide for the Interventionalist

BACKGROUND

Chronic pain, the leading cause of disability in the world, imposes limitations on activities of daily living and diminishes quality of life leading to unnecessary patient suffering. The personal and socioeconomic costs of chronic pain cannot be overstated. Physicians are at the crux of the pandemic and must attempt to limit the spread of the virus while maintaining their professional responsibility to their patients and staff members.

OBJECTIVE

The aim of this review is to analyze the existing literature to develop consensus recommendations for treating pain during the current COVID-19 pandemic.

METHODS

Relevant literature was located via computer-generated citations between the months of March and May of 2020. Online computer searches of multiple databases including Google Scholar, CINAHL, PubMed, and Cochrane Review were conducted in conjunction with a thorough review of local, state, national, and international governmental and organizational websites to locate research on the area of interest.

RESULTS

The guidelines in this review are meant to offer a framework to pain practitioners and organizations for providing highly effective, ethical, and safe care to patients while maintaining their commitment to mitigating the spread of the COVID-19 pandemic. Specific areas addressed include general and interventional-specific treatment and mitigation recommendations.

CONCLUSIONS

We believe that the recommendations in this review, if used in conjunction with evolving recommendations of Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), and federal, state, and local governing bodies, provides a path to not only mitigate the spread of the pandemic but also limit the adverse impact of pain and suffering in chronic pain patients.

Practical recommendations for the management of the patient with chronic pain during the pandemic of COVID-19

SARS-CoV-2 infection has evolved into a pandemic and a Public Health Emergency of International Importance that has forced health organizations at the global, regional and local levels to adopt a series of measures to address to COVID-19 and try to reduce its impact, not only in the social sphere but also in the health sphere, modifying the guidelines for action in the health services. Within these recommendations that include the Pain Treatment Units, patients with suspected or confirmed SARS-CoV-2 infection may be waiting for medical consult or interventional procedures for the management of chronic pain refractory to other therapies. A series of guidelines aimed at reducing the risk of infection of health personnel, other patients and the community are included in this manuscript.

Pain Management Best Practices from Multispecialty Organizations During the COVID-19 Pandemic and Public Health Crises

BACKGROUND

It is nearly impossible to overestimate the burden of chronic pain, which is associated with enormous personal and socioeconomic costs. Chronic pain is the leading cause of disability in the world, is associated with multiple psychiatric comorbidities, and has been causally linked to the opioid crisis. Access to pain treatment has been called a fundamental human right by numerous organizations. The current COVID-19 pandemic has strained medical resources, creating a dilemma for physicians charged with the responsibility to limit spread of the contagion and to treat the patients they are entrusted to care for.

METHODS

To address these issues, an expert panel was convened that included pain management experts from the military, Veterans Health Administration, and academia. Endorsement from stakeholder societies was sought upon completion of the document within a one-week period.

RESULTS

In these guidelines, we provide a framework for pain practitioners and institutions to balance the often-conflicting goals of risk mitigation for health care providers, risk mitigation for patients, conservation of resources, and access to pain management services. Specific issues discussed include general and intervention-specific risk mitigation, patient flow issues and staffing plans, telemedicine options, triaging recommendations, strategies to reduce psychological sequelae in health care providers, and resource utilization.

CONCLUSIONS

The COVID-19 public health crisis has strained health care systems, creating a conundrum for patients, pain medicine practitioners, hospital leaders, and regulatory officials. Although this document provides a framework for pain management services, systems-wide and individual decisions must take into account clinical considerations, regional health conditions, government and hospital directives, resource availability, and the welfare of health care providers.