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Holkenborg J, Frenken BA, Bon BVDKV, Vroegop MP, Van Meggelen MGM, Kramers C, Schellekens AFA, Kraaijvanger N. The prevalence of prescription opioid use and misuse among emergency department patients in The Netherlands. J Eval Clin Pract 2024; 30:473-480. [PMID: 38251860 DOI: 10.1111/jep.13965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 12/06/2023] [Accepted: 12/31/2023] [Indexed: 01/23/2024]
Abstract
RATIONALE Prescription opioid use and misuse have increased rapidly in many Western countries in the past decade. Patients (mis)using opioids are at risk of presenting to the emergency department (ED) with opioid-related problems. European data concerning prescription opioid (mis)use among the ED population is lacking. AIMS AND OBJECTIVES This study aims to determine prevalence of prescription opioid use, misuse, and opioid use disorder (OUD) among Dutch ED patients. Secondary objectives were to explore factors associated with prescription opioid misuse and the number of patients discharged with a new opioid prescription. METHODS In a cross-sectional multicenter study at three hospitals in the Netherlands, adult ED patients were screened for current prescription opioid use. Opioid users filled out questionnaires regarding opioid (mis)use, and underwent a structured interview to assess OUD criteria. The primary outcomes were prevalence rates of (1) current prescription opioid use, (2) prescription opioid misuse (based on a Current Opioid Misuse Measure [COMM] score > 8), (3) OUD, based on DSM-5 criteria. Independent T-tests, Pearson χ2 and Fisher's Exact tests were used to analyse differences in characteristics between groups. RESULTS A total of 997 patients were screened, of which 15% (n = 150) used prescription opioids. Out of 93 patients assessed, 22.6% (n = 21) showed signs of prescription opioid misuse, and 9.8% (n = 9, 95% CI: 4.5-17.8) fulfilled criteria for OUD. A medical history of psychiatric disorder was significantly more common in patients with prescription opioid misuse and OUD. CONCLUSION This study shows that prescription opioid use is relatively common in ED patients in the Netherlands, compared to the overall population. Over one fifth of these patients shows signs of opioid misuse or OUD. Awareness among ED personnel about the high prevalence of prescription opioid (mis)use in their population is critical for signalling opioid-related problems.
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Affiliation(s)
- Joris Holkenborg
- Emergency Department, Rijnstate Hospital, Arnhem, The Netherlands
| | | | | | - Maurice P Vroegop
- Emergency Department, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Cees Kramers
- Department of Pharmacology-Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Arnt F A Schellekens
- Nijmegen Institute for Science Practitioners in Addiction (NISPA), Nijmegen, The Netherlands
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands
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Chamoun K, Mouawad J, Salameh P, Sacre H, Haddad R, Khabbaz LR, Megarbane B, Hajj A. Opioid use disorder in two samples of the Lebanese population: scale validation and correlation with sleep and mood disorders. BMC Psychiatry 2023; 23:797. [PMID: 37914993 PMCID: PMC10619223 DOI: 10.1186/s12888-023-05304-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 10/24/2023] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND The revised Opioid Risk Tool (ORT-OUD) is a brief, self-report scale designed to provide clinicians with a simple, validated method to screen for the risk of developing an Opioid Use Disorder (OUD) in patients without a prior history of substance abuse. This study aimed to translate and validate the Arabic version of ORT-OUD in the Lebanese population and assess its clinical validity in a sample of patients with OUD. METHODS This cross-sectional study in the Lebanese population used several validated scales to assess the risk of OUD, including the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). Other tools evaluated chronotype and sleep and mood disturbances. Principal component analysis with Varimax rotation was applied to assess ORT-OUD construct validity. Convergent validity with the Arabic version of ASSIST was evaluated. The ORT-OUD criterion validity was then assessed in a clinical sample of patients with OUD. RESULTS This study included 581 participants. The prevalence of the OUD risk in the Lebanese population using the ORT-OUD scale and the ASSIST-opioids scale was estimated at 14.5% and 6.54%, respectively. No items of the ORT-OUD were removed; all items converged over a solution of four factors with an eigenvalue > 1, explaining a total of 68.2% of the variance (Cronbach's alpha = 0.648). The correlation coefficients between the ORT-OUD total score and ASSIST subscales were as follows: ASSIST-opioids (r = 0.174; p = < 0.001), ASSIST-sedatives (r = 0.249; p < 0.001), and ASSIST-alcohol (r = 0.161; p = < 0.001). ORT-OUD clinical validation showed a correlation with ASSIST-opioids (r = 0.251; p = 0.093) and ASSIST-sedatives (r = 0.598; p < 0.001). Higher ORT-OUD scores were associated with a family and personal history of alcohol and substance consumption and higher insomnia and anxiety scores. CONCLUSIONS This study is the first to validate the Arabic version of ORT-OUD in the Lebanese population, an essential step towards improving the detection and management of OUD in this population.
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Affiliation(s)
- Karam Chamoun
- Faculty of Pharmacy, Saint Joseph University of Beirut, Beirut, Lebanon
- Laboratoire de Pharmacologie, Pharmacie Clinique et Contrôle de Qualité des Médicaments, Saint Joseph University of Beirut, Beirut, Lebanon
- Inserm, UMR-S1144, Université Paris Cité, Paris, France
| | - Joseph Mouawad
- Faculty of Pharmacy, Saint Joseph University of Beirut, Beirut, Lebanon
- Laboratoire de Pharmacologie, Pharmacie Clinique et Contrôle de Qualité des Médicaments, Saint Joseph University of Beirut, Beirut, Lebanon
| | - Pascale Salameh
- INSPECT-LB (Institut National de Santé Publique, d'Épidémiologie Clinique et de Toxicologie- Liban), Beirut, Lebanon
- School of Medicine, Lebanese American University, Byblos, Lebanon
- Faculty of Pharmacy, Lebanese University, Hadat, Lebanon
- Department of Primary Care and Population Health, University of Nicosia Medical School, Egkomi, Nicosia, 2417, Cyprus
| | - Hala Sacre
- INSPECT-LB (Institut National de Santé Publique, d'Épidémiologie Clinique et de Toxicologie- Liban), Beirut, Lebanon
| | - Ramzi Haddad
- Psychiatry Department, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
- Psychiatry Department, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Lydia Rabbaa Khabbaz
- Faculty of Pharmacy, Saint Joseph University of Beirut, Beirut, Lebanon
- Laboratoire de Pharmacologie, Pharmacie Clinique et Contrôle de Qualité des Médicaments, Saint Joseph University of Beirut, Beirut, Lebanon
| | - Bruno Megarbane
- Inserm, UMR-S1144, Université Paris Cité, Paris, France
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière-Fernand Widal Hospital, Paris, France
| | - Aline Hajj
- Faculty of Pharmacy, Saint Joseph University of Beirut, Beirut, Lebanon.
- Laboratoire de Pharmacologie, Pharmacie Clinique et Contrôle de Qualité des Médicaments, Saint Joseph University of Beirut, Beirut, Lebanon.
- Faculté de Pharmacie, Université Laval, Québec city, Québec, Canada.
- Oncology Division, CHU de Québec- Université Laval Research Center, Québec City, Québec, Canada.
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Kravets V, McDonald M, DeRosa J, Hernandez-Irizarry R, Parker R, Lamis DA, Powers A, Schenker ML. Early Identification of Post-Traumatic Stress Disorder in Trauma Patients: Development of a Multivariable Risk Prediction Model. Am Surg 2023; 89:4542-4551. [PMID: 35981543 DOI: 10.1177/00031348221121549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The purpose of this study was to build a risk prediction model to identify trauma patients at the time of injury who are at high risk for post-traumatic stress disorder (PTSD) 1 year later. METHODS Patients 18+ with operative orthopedic trauma injuries were enrolled in prospective social determinants of health cohort. Data were collected through initial surveys, medical records at time of injury, and 1-year follow-up phone screenings. Univariate analysis examined associations between factors and PTSD at 1 year. The best fit multivariable logistic regression model led to a novel PTSD risk prediction tool based on weights assigned similar to the Charlson index methods. RESULTS Of 329 enrolled patients, 87 (26%) completed follow-up surveys; 58% screened positive for chronic PTSD. The best fit model predicting PTSD included age, insurance, violent mechanism, and 2 acute stress screening questions (AUC .89). Using these parameters, the maximum possible TIPPS index was 19. Those with PTSD at 1 year had a mean TIPPS index of 12.9 ± 4.0, compared to 5.9 ± 4.2 for those who did not (P < .001). DISCUSSION Traumatic injury often leads to PTSD, which can be predicted by a novel risk score incorporating age, insurance status, violent injury mechanism, and acute stress reaction symptoms. Stability in life and relationships with primary care physicians may be protective of PTSD. LEVEL OF EVIDENCE Diagnostic level II.
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Affiliation(s)
- Victoria Kravets
- Department of Orthopaedic Surgery, Emory University and Grady Memorial Hospital, Atlanta, GA, USA
| | - Michael McDonald
- Department of Orthopaedic Surgery, Emory University and Grady Memorial Hospital, Atlanta, GA, USA
| | - Joel DeRosa
- Department of Orthopaedic Surgery, Emory University and Grady Memorial Hospital, Atlanta, GA, USA
| | | | - Ruth Parker
- Department of Orthopaedic Surgery, Emory University and Grady Memorial Hospital, Atlanta, GA, USA
| | - Dorian A Lamis
- Department of Psychiatry and Behavioral Sciences, Emory University and Grady Memorial Hospital, Atlanta, GA, USA
| | - Abigail Powers
- Department of Psychiatry and Behavioral Sciences, Emory University and Grady Memorial Hospital, Atlanta, GA, USA
| | - Mara L Schenker
- Department of Orthopaedic Surgery, Emory University and Grady Memorial Hospital, Atlanta, GA, USA
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Grau-Sánchez J, Serrano A, Villoria J, Carnaval T, Porto MF, Zapata L, Flores-García M, Segura E, Garrido-Pedrosa J, Rodríguez-Fornells A, Fernández-Dueñas V, Videla S. Effect and safety of listening to music or audiobooks as a coadjuvant treatment for chronic pain patients under opioid treatment: a study protocol for an open-label, parallel-group, randomised, controlled, proof-of-concept clinical trial in a tertiary hospital in the Barcelona South Metropolitan area. BMJ Open 2023; 13:e074948. [PMID: 37696633 PMCID: PMC10496714 DOI: 10.1136/bmjopen-2023-074948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 08/21/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND Chronic non-cancer pain (CNCP) treatment's primary goal is to maintain physical and mental functioning while improving quality of life. Opioid use in CNCP patients has increased in recent years, and non-pharmacological interventions such as music listening have been proposed to counter it. Unlike other auditive stimuli, music can activate emotional-regulating and reward-regulating circuits, making it a potential tool to modulate attentional processes and regulate mood. This study's primary objective is to provide the first evidence on the distinct (separate) effects of music listening as a coadjuvant maintenance analgesic treatment in CNCP patients undergoing opioid analgesia. METHODS AND ANALYSIS This will be a single-centre, phase II, open-label, parallel-group, proof-of-concept randomised clinical trial with CNCP patients under a minimum 4-week regular opioid treatment. We plan to include 70 consecutive patients, which will be randomised (1:1) to either the experimental group (active music listening) or the control group (active audiobooks listening). During 28 days, both groups will listen daily (for at least 30 min and up to 1 hour) to preset playlists tailored to individual preferences.Pain intensity scores at each visit, the changes (differences) from baseline and the proportions of responders according to various definitions based on pain intensity differences will be described and compared between study arms. We will apply longitudinal data assessment methods (mixed generalised linear models) taking the patient as a cluster to assess and compare the endpoints' evolution. We will also use the mediation analysis framework to adjust for the effects of additional therapeutic measures and obtain estimates of effect with a causal interpretation. ETHICS AND DISSEMINATION The study protocol has been reviewed, and ethics approval has been obtained from the Bellvitge University Hospital Institutional Review Board, L'Hospitalet de Llobregat, Barcelona, Spain. The results from this study will be actively disseminated through manuscript publications and conference presentations. TRIAL REGISTRATION NUMBER NCT05726266.
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Affiliation(s)
- Jennifer Grau-Sánchez
- Research Group on Complex Health Diagnoses and Interventions from Occupation and Care (OCCARE), Department of Occupational Therapy, University School of Nursing and Occupational Therapy of Terrassa (EUIT), Autonomous University of Barcelona, Terrassa, Spain
| | - Ancor Serrano
- Pain Clinic, Department of Anaesthesia, Reanimation and Pain Management, Bellvitge University Hospital, Barcelona, Spain
| | - Jesús Villoria
- Neuropharmacology & Pain Group, Neuroscience Program, Bellvitge Institute for Biomedical Research, Barcelona, Spain
- Design and Biometrics Department, Medicxact, Madrid, Spain
| | - Thiago Carnaval
- Neuropharmacology & Pain Group, Neuroscience Program, Bellvitge Institute for Biomedical Research, Barcelona, Spain
- Design and Biometrics Department, Medicxact, Madrid, Spain
| | - María F Porto
- Cognition and Brain Plasticity Unit, Department of Cognition, Development and Educational Psychology, Faculty of Psychology, University of Barcelona and Bellvitge Institute for Biomedical Research (IDIBELL), Barcelona, Spain
| | - Lorena Zapata
- Pharmacology Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences, Institute of Neurosciences, Universitat de Barcelona, Barcelona, Spain
| | - Montse Flores-García
- Pharmacology Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences, Institute of Neurosciences, Universitat de Barcelona, Barcelona, Spain
| | - Emma Segura
- Cognition and Brain Plasticity Unit, Department of Cognition, Development and Educational Psychology, Faculty of Psychology, University of Barcelona and Bellvitge Institute for Biomedical Research (IDIBELL), Barcelona, Spain
| | - Jessica Garrido-Pedrosa
- Research Group on Complex Health Diagnoses and Interventions from Occupation and Care (OCCARE), Department of Occupational Therapy, University School of Nursing and Occupational Therapy of Terrassa (EUIT), Autonomous University of Barcelona, Terrassa, Spain
| | - Antoni Rodríguez-Fornells
- Cognition and Brain Plasticity Unit, Department of Cognition, Development and Educational Psychology, Faculty of Psychology, University of Barcelona and Bellvitge Institute for Biomedical Research (IDIBELL), Barcelona, Spain
- Catalan Institution for Research and Advanced Studies (ICREA), Barcelona, Spain
| | - Víctor Fernández-Dueñas
- Neuropharmacology & Pain Group, Neuroscience Program, Bellvitge Institute for Biomedical Research, Barcelona, Spain
- Pharmacology Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences, Institute of Neurosciences, Universitat de Barcelona, Barcelona, Spain
| | - Sebastian Videla
- Neuropharmacology & Pain Group, Neuroscience Program, Bellvitge Institute for Biomedical Research, Barcelona, Spain
- Pharmacology Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences, Institute of Neurosciences, Universitat de Barcelona, Barcelona, Spain
- Clinical Research Support Unit, Clinical Pharmacology Department, Bellvitge University Hospital, Barcelona, Spain
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Yang EC, Koenig NA, Gong M, Brotto LA, Barr AM, Lee T, Yong PJ, Geoffrion R. Cannabis use preferences in women with myofascial pelvic pain: A cross-sectional study. Eur J Obstet Gynecol Reprod Biol X 2023; 18:100192. [PMID: 37095765 PMCID: PMC10121619 DOI: 10.1016/j.eurox.2023.100192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 03/02/2023] [Accepted: 03/29/2023] [Indexed: 04/01/2023] Open
Abstract
Objective Myofascial tenderness is present in most chronic pelvic pain conditions and causes significant distress to patients. Treatment is challenging and often not curative. Cannabis is often used for self-management of chronic pelvic pain. However, we do not know which concentrations and routes of administration are most acceptable to users. We aimed to investigate patterns and willingness of cannabis product use among both habitual users and non-users with myofascial pelvic pain (MPP), to inform therapeutic development. Study design We conducted a cross-sectional study of questionnaire responses from female patients with MPP from two tertiary pelvic pain centers. We aimed for a convenience sample of 100 responses with representation from both centers. Inclusion criteria were age over 18 with pelvic floor muscle tenderness on standard gynecologic examination. We collected information on demographics, pelvic pain history, cannabis use status, cannabis use preferences, validated opioid misuse risk assessment, and interest in using gynecologic cannabis products and used descriptive analyses. Results 77/135 (57 %) questionnaire respondents were cannabis users and 58 (43 %) were non-users. Most users consume cannabis daily, (48.1 %) orally (66.2 %) or by smoking (60.7 %), and rated cannabis as effective at relieving pelvic pain. 37/58 (63.8 %) non-cannabis users responded that they would be willing to use cannabis for pelvic pain. Lack of information and potential adverse effects were the most common reasons for unwillingness to use. Approximately 3 of 4 respondents were willing to try vaginal or vulvar application of cannabis products for pelvic pain. Conclusions This cross-sectional study describes cannabis use patterns in MPP patients. Topical vulvar and vaginal cannabis products are of strong interest to both cannabis users and non-users and warrant further research.
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Affiliation(s)
- Emily C. Yang
- University of British Columbia, Vancouver, BC, Canada
- Correspondence to: St. Paul’s Hospital, Department of Obstetrics and Gynecology, Suite 930, 1125 Howe Street, Vancouver, BC, Canada V6Z 2K8.
| | | | - Merry Gong
- University of British Columbia, Vancouver, BC, Canada
| | | | | | - Terry Lee
- Centre for Health Evaluation & Outcome Sciences, Vancouver, BC, Canada
| | - Paul J. Yong
- University of British Columbia, Vancouver, BC, Canada
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Valdes EG, Reist C, Aamar R, Hallisey B, Stanton ES, Williams L, Andel R, Gorman J. Use of Predictive Analytics to Identify Unhealthy Opioid Use and Guide Intervention. Psychiatr Serv 2022:appips202200034. [PMID: 36545772 DOI: 10.1176/appi.ps.202200034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The authors aimed to use the newly developed Opioid Risk Stratification Tool to identify individuals who may be at risk for unhealthy opioid use and to examine the impact of applying a mailing and engagement intervention to this population and their prescribers, with the goal of reducing high-risk prescribing behaviors, opioid medication use, and mortality rates. METHODS A nonrandomized controlled study was conducted with members from two Medicaid managed care organizations. In both the intervention (N=131) and control (N=187) groups, an algorithm identified members at moderate to high risk for hazardous opioid use. Members at increased risk in the intervention group and their prescribers received a letter from the managed care organization, and members still at risk 3 months after the mailing were contacted by a care coordinator. Individuals in the control group were not contacted. Medicaid claims data were used to compare opioid use and prescribing practices between groups before and after the intervention. RESULTS Individuals in the intervention group were less likely to have any opioid prescription postintervention compared with those in the control group (OR=0.55, p<0.001), and the intervention group had a greater reduction in the number of individuals with concurrent opioid and benzodiazepine prescriptions (OR=0.49, p=0.042). Practices such as multiple opioid prescriptions and multiple prescribers of opioids were not affected by the intervention. CONCLUSIONS An intervention targeting individuals at risk for hazardous opioid use was associated with a reduction in some high-risk prescribing practices. Future research should determine the ideal mix of interventions to reduce as many risk factors as possible.
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Affiliation(s)
- Elise G Valdes
- Relias, Morrisville, North Carolina (Valdes, Reist, Aamar, Gorman); MindX Sciences, Indianapolis (Reist); Eastpointe Human Services, Beulaville, North Carolina (Hallisey); Partners Health Management, Gastonia, North Carolina (Stanton, Williams); Edson College of Nursing and Health Innovation, Arizona State University, Phoenix (Andel)
| | - Christopher Reist
- Relias, Morrisville, North Carolina (Valdes, Reist, Aamar, Gorman); MindX Sciences, Indianapolis (Reist); Eastpointe Human Services, Beulaville, North Carolina (Hallisey); Partners Health Management, Gastonia, North Carolina (Stanton, Williams); Edson College of Nursing and Health Innovation, Arizona State University, Phoenix (Andel)
| | - Rola Aamar
- Relias, Morrisville, North Carolina (Valdes, Reist, Aamar, Gorman); MindX Sciences, Indianapolis (Reist); Eastpointe Human Services, Beulaville, North Carolina (Hallisey); Partners Health Management, Gastonia, North Carolina (Stanton, Williams); Edson College of Nursing and Health Innovation, Arizona State University, Phoenix (Andel)
| | - Barbara Hallisey
- Relias, Morrisville, North Carolina (Valdes, Reist, Aamar, Gorman); MindX Sciences, Indianapolis (Reist); Eastpointe Human Services, Beulaville, North Carolina (Hallisey); Partners Health Management, Gastonia, North Carolina (Stanton, Williams); Edson College of Nursing and Health Innovation, Arizona State University, Phoenix (Andel)
| | - Elizabeth Shirley Stanton
- Relias, Morrisville, North Carolina (Valdes, Reist, Aamar, Gorman); MindX Sciences, Indianapolis (Reist); Eastpointe Human Services, Beulaville, North Carolina (Hallisey); Partners Health Management, Gastonia, North Carolina (Stanton, Williams); Edson College of Nursing and Health Innovation, Arizona State University, Phoenix (Andel)
| | - Leah Williams
- Relias, Morrisville, North Carolina (Valdes, Reist, Aamar, Gorman); MindX Sciences, Indianapolis (Reist); Eastpointe Human Services, Beulaville, North Carolina (Hallisey); Partners Health Management, Gastonia, North Carolina (Stanton, Williams); Edson College of Nursing and Health Innovation, Arizona State University, Phoenix (Andel)
| | - Ross Andel
- Relias, Morrisville, North Carolina (Valdes, Reist, Aamar, Gorman); MindX Sciences, Indianapolis (Reist); Eastpointe Human Services, Beulaville, North Carolina (Hallisey); Partners Health Management, Gastonia, North Carolina (Stanton, Williams); Edson College of Nursing and Health Innovation, Arizona State University, Phoenix (Andel)
| | - Jack Gorman
- Relias, Morrisville, North Carolina (Valdes, Reist, Aamar, Gorman); MindX Sciences, Indianapolis (Reist); Eastpointe Human Services, Beulaville, North Carolina (Hallisey); Partners Health Management, Gastonia, North Carolina (Stanton, Williams); Edson College of Nursing and Health Innovation, Arizona State University, Phoenix (Andel)
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Strigo IA, Murphy E, Mitchell JM, Spadoni AD. Learning from addiction: Craving of prescription opioids in chronic pain sufferers. Neurosci Biobehav Rev 2022; 142:104904. [PMID: 36202255 PMCID: PMC10917419 DOI: 10.1016/j.neubiorev.2022.104904] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/30/2022] [Accepted: 10/01/2022] [Indexed: 01/19/2023]
Abstract
Prescription opioids are a primary driver of opioid-related deaths. Although craving is a substantial component of OUD, the degree to which craving leads to misuse among chronic pain patients on long-term prescription opioids is unknown. A clear understanding of the factors that lead to misuse in this vulnerable population is needed for the development of safe and effective practices for opioid taper. This narrative review summarizes the relevant literature on the role of craving in addiction and chronic pain through epidemiological and behavioral studies. The first part of this review examines the role of craving in predicting opioid use/misuse in individuals with chronic pain with and without OUD. The second part covers methods on how craving is evaluated experimentally using both subjective and objective measures and provides related findings. The overall goal of this review is to facilitate the development of a population-specific description of craving in those who use opioids to control chronic pain and to describe how it may be mechanistically linked to patterns of opioid (mis)use.
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Affiliation(s)
- Irina A Strigo
- Emotion and Pain Laboratory, San Francisco Veterans Affairs Healthcare Center, 4150 Clement Street, San Francisco, CA 94121, USA; Department of Psychiatry, University of California San Francisco, 401 Parnassus Ave, San Francisco, CA 94143, USA.
| | - Emily Murphy
- Emotion and Pain Laboratory, San Francisco Veterans Affairs Healthcare Center, 4150 Clement Street, San Francisco, CA 94121, USA
| | - Jennifer M Mitchell
- Department of Psychiatry, University of California San Francisco, 401 Parnassus Ave, San Francisco, CA 94143, USA; Department of Neurology, University of California San Francisco, 401 Parnassus Ave, San Francisco, CA 94143, USA
| | - Andrea D Spadoni
- San Diego Veterans Affairs Healthcare Center, 3350 La Jolla Village Drive, San Diego, CA 92121, USA; Department of Psychiatry, University of California San Diego, San Diego, CA 92300, USA
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Higginbotham JA, Markovic T, Massaly N, Morón JA. Endogenous opioid systems alterations in pain and opioid use disorder. Front Syst Neurosci 2022; 16:1014768. [PMID: 36341476 PMCID: PMC9628214 DOI: 10.3389/fnsys.2022.1014768] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/26/2022] [Indexed: 11/25/2022] Open
Abstract
Decades of research advances have established a central role for endogenous opioid systems in regulating reward processing, mood, motivation, learning and memory, gastrointestinal function, and pain relief. Endogenous opioid systems are present ubiquitously throughout the central and peripheral nervous system. They are composed of four families, namely the μ (MOPR), κ (KOPR), δ (DOPR), and nociceptin/orphanin FQ (NOPR) opioid receptors systems. These receptors signal through the action of their endogenous opioid peptides β-endorphins, dynorphins, enkephalins, and nociceptins, respectfully, to maintain homeostasis under normal physiological states. Due to their prominent role in pain regulation, exogenous opioids-primarily targeting the MOPR, have been historically used in medicine as analgesics, but their ability to produce euphoric effects also present high risks for abuse. The ability of pain and opioid use to perturb endogenous opioid system function, particularly within the central nervous system, may increase the likelihood of developing opioid use disorder (OUD). Today, the opioid crisis represents a major social, economic, and public health concern. In this review, we summarize the current state of the literature on the function, expression, pharmacology, and regulation of endogenous opioid systems in pain. Additionally, we discuss the adaptations in the endogenous opioid systems upon use of exogenous opioids which contribute to the development of OUD. Finally, we describe the intricate relationship between pain, endogenous opioid systems, and the proclivity for opioid misuse, as well as potential advances in generating safer and more efficient pain therapies.
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Affiliation(s)
- Jessica A. Higginbotham
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, United States,Pain Center, Washington University in St. Louis, St. Louis, MO, United States,School of Medicine, Washington University in St. Louis, St. Louis, MO, United States,*Correspondence: Jessica A. Higginbotham,
| | - Tamara Markovic
- Nash Family Department of Neuroscience and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Nicolas Massaly
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, United States,Pain Center, Washington University in St. Louis, St. Louis, MO, United States,School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Jose A. Morón
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, United States,Pain Center, Washington University in St. Louis, St. Louis, MO, United States,School of Medicine, Washington University in St. Louis, St. Louis, MO, United States,Department of Neuroscience, Washington University in St. Louis, St. Louis, MO, United States,Department of Psychiatry, Washington University in St. Louis, St. Louis, MO, United States
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Arthur JA, Edwards T, Lu Z, Tang M, Amaram-Davila J, Reddy A, Hui D, Yennurajalingam S, Anderson AE, Jennings K, Reddy S, Bruera E. Interdisciplinary intervention for the management of nonmedical opioid use among patients with cancer pain. Cancer 2022; 128:3718-3726. [PMID: 35997289 PMCID: PMC10304363 DOI: 10.1002/cncr.34392] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/06/2022] [Accepted: 06/15/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Few studies have assessed interventions aimed at managing nonmedical opioid use (NMOU) behavior among patients with cancer. The authors developed the Compassionate High-Alert Team (CHAT) intervention to manage patients receiving opioids for cancer pain who demonstrate NMOU behavior. The objective of this study was to determine the change in frequency of NMOU behaviors, pain intensity, and opioid requirements among those who received the intervention. METHODS A total of 130 patients receiving opioids for cancer pain that had documented evidence of NMOU and received the CHAT intervention were reviewed. Demographic and clinical information such as NMOU behaviors, pain scores, and morphine equivalent daily dose at baseline, 3, and 6 months post-intervention was obtained. RESULTS NMOU behaviors significantly decreased from a median (interquartile range) of 2 (1-3) at baseline to 0 (0-1) at both 3 and 6 months post-intervention (p < .001). A total of 45 of 75 (60%) and 31 of 50 (62%) of CHAT recipients achieved complete response to the intervention at 3 and 6 months, respectively. Higher baseline number of NMOU behaviors was independently associated with patient response to the intervention (odds ratio [OR], 1.97; 95% confidence interval [CI],1.09-4.28, p = .049 at 3 months; OR, 2.5; 95% CI, 1.20-6.47, p = .03 at 6 months). The median pain score decreased from 7 at baseline to 6 at both 3 and 6 months (p = .01). Morphine equivalent daily dose did not significantly change during that same period (143 mg/day vs. 139 mg/day, p = .13). CONCLUSIONS Most patients who received the CHAT intervention improved in their NMOU behaviors and pain intensity scores 3 and 6 months post-intervention. These preliminary findings support the efficacy of CHAT in managing patients receiving opioids for cancer pain who demonstrate NMOU behavior.
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Affiliation(s)
- Joseph A. Arthur
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
| | - Tonya Edwards
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
| | - Zhanni Lu
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
| | - Michael Tang
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
| | - Jaya Amaram-Davila
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
| | - Akhila Reddy
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
| | - David Hui
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
| | - Sriram Yennurajalingam
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
| | - Aimee E. Anderson
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
| | - Kristofer Jennings
- Department of Biostatistics, The University of Texas MD
Anderson Cancer Center, Houston, Texas, USA
| | - Suresh Reddy
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation, and Integrative
Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA
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Can the Type of Subjective Response to First Opioid Exposure Predict the Risk of Opioid Use Disorder? A Scoping Review. Brain Res Bull 2022; 188:67-76. [PMID: 35901984 DOI: 10.1016/j.brainresbull.2022.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 07/07/2022] [Accepted: 07/24/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Effective identification of individuals at increased risk for developing opioid use disorder (OUD) could reduce the overdose fatalities and mitigate the harm of the opioid epidemic. Early evidence has linked certain subjective experiences during the first substance exposure to subsequent substance misuse. This is consistent with anecdotal evidence that "first response" to opioids may distinguish those who later develop OUD from those who do not, further suggesting individual differences in neural activity and responses to specific substances. OBJECTIVE The objective of this scoping review was to evaluate the evidence on the relationship between the subjective first response to opioids and the risk of developing OUD. METHODS Ovid MEDLINE search (through 1/29/2021), followed by the search for articles published by the first/senior authors (PubMed) and references citing (Web of Science Citing Reference) identified eligible publications, was focused on studies involving humans, published in English, and describing the initial subjective response to opioid exposure and its association with OUD development or its risk. Systematic data extraction was completed for each eligible study. RESULTS 3,364 title/abstracts and 48 full-text articles were reviewed. Four articles, describing six studies (526 adult participants) were eligible and included. These studies were methodologically heterogeneous, including 2 randomized controlled trials, and 1 case-control, and 3 cross-sectional studies, with small sample sizes, precluding data pooling and meta-analysis. Results suggested that individuals with OUD or at elevated risk for OUD (determined by the validated OUD risk assessment surveys) were more likely to report their "first opioid response" as euphoric compared to their counterparts. CONCLUSIONS Limited evidence suggests that subjectively-reported euphoric response to first opioid exposure could predict the OUD risk. Prospective studies are needed to evaluate the utility of assessing first response (e.g., via brief point-of-care screening surveys) for informing clinical decisions when prescribing opioids.
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11
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A systematic review of assessment approaches to predict opioid misuse in people with cancer. Support Care Cancer 2022; 30:5645-5658. [PMID: 35166898 PMCID: PMC9135805 DOI: 10.1007/s00520-022-06895-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 02/02/2022] [Indexed: 11/11/2022]
Abstract
Context Cancer prevalence is increasing, with many patients requiring opioid analgesia. Clinicians need to ensure patients receive adequate pain relief. However, opioid misuse is widespread, and cancer patients are at risk. Objectives This study aims (1) to identify screening approaches that have been used to assess and monitor risk of opioid misuse in patients with cancer; (2) to compare the prevalence of risk estimated by each of these screening approaches; and (3) to compare risk factors among demographic and clinical variables associated with a positive screen on each of the approaches. Methods Medline, Cochrane Controlled Trial Register, PubMed, PsycINFO, and Embase databases were searched for articles reporting opioid misuse screening in cancer patients, along with handsearching the reference list of included articles. Bias was assessed using tools from the Joanna Briggs Suite. Results Eighteen studies met the eligibility criteria, evaluating seven approaches: Urine Drug Test (UDT) (n = 8); the Screener and Opioid Assessment for Patients with Pain (SOAPP) and two variants, Revised and Short Form (n = 6); the Cut-down, Annoyed, Guilty, Eye-opener (CAGE) tool and one variant, Adapted to Include Drugs (n = 6); the Opioid Risk Tool (ORT) (n = 4); Prescription Monitoring Program (PMP) (n = 3); the Screen for Opioid-Associated Aberrant Behavior Risk (SOABR) (n = 1); and structured/specialist interviews (n = 1). Eight studies compared two or more approaches. The rates of risk of opioid misuse in the studied populations ranged from 6 to 65%, acknowledging that estimates are likely to have varied partly because of how specific to opioids the screening approaches were and whether a single or multi-step approach was used. UDT prompted by an intervention or observation of aberrant opioid behaviors (AOB) were conclusive of actual opioid misuse found to be 6.5–24%. Younger age, found in 8/10 studies; personal or family history of anxiety or other mental ill health, found in 6/8 studies; and history of illicit drug use, found in 4/6 studies, showed an increased risk of misuse. Conclusions Younger age, personal or familial mental health history, and history of illicit drug use consistently showed an increased risk of opioid misuse. Clinical suspicion of opioid misuse may be raised by data from PMP or any of the standardized list of AOBs. Clinicians may use SOAPP-R, CAGE-AID, or ORT to screen for increased risk and may use UDT to confirm suspicion of opioid misuse or monitor adherence. More research into this important area is required. Significance of results This systematic review summarized the literature on the use of opioid misuse risk approaches in people with cancer. The rates of reported risk range from 6 to 65%; however, true rate may be closer to 6.5–24%. Younger age, personal or familial mental health history, and history of illicit drug use consistently showed an increased risk of opioid misuse. Clinicians may choose from several approaches. Limited data are available on feasibility and patient experience. PROSPERO registration number. CRD42020163385.
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12
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Diagnostic and Predictive Capacity of the Spanish Versions of the Opioid Risk Tool and the Screener and Opioid Assessment for Patients with Pain-Revised: A Preliminary Investigation in a Sample of People with Noncancer Chronic Pain. Pain Ther 2022; 11:493-510. [PMID: 35128624 PMCID: PMC9098780 DOI: 10.1007/s40122-022-00356-2] [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: 11/23/2021] [Accepted: 01/17/2022] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Accurate assessment of the risk of opioid abuse and misuse in people with noncancer chronic pain is crucial for their prevention. This study aimed to provide preliminary evidence of the diagnostic and predictive capacity of the Spanish versions of the Opioid Risk Tool (ORT) and the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R). METHODS We used the Current Opioid Misuse Measure (COMM) as criterion measure to assess the capacity of each tool to identify patients misusing opioids at the time of the assessment. Eighteen months later, we used the COMM and the Drug Abuse Screening Test-10 (DAST-10) to assess their predictive capacity. In total, 147 people with noncancer chronic pain participated in the diagnostic study, and 42 in the predictive study. RESULTS Receiver operating curve analysis showed that the SOAPP-R had an excellent capacity to identify participants who were misusing opioids at the time of assessment (area under the curve [AUC] = 0.827). The diagnostic capacity of the ORT was close to acceptable (AUC = 0.649-0.669), whereas its predictive capacity was poor (AUC = 0.522-0.554). The predictive capacity of the SOAPP-R was close to acceptable regarding misuse (AUC = 0.672) and poor regarding abuse (AUC = 0.423). CONCLUSION In the setting of Spanish-speaking communities, clinicians should be cautious when using these instruments to make decisions on opioid administration. Further research is needed on the diagnostic and predictive capacity of the Spanish versions of both instruments.
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13
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Coughlin JM, Terranella SL, Ritz EM, Xu TQ, Tierney JF, Velasco JM, Myers JA. Understanding Opioid Prescribing Practices of Resident Physicians. Am Surg 2021:31348211060412. [PMID: 34971336 DOI: 10.1177/00031348211060412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND To compare opioid prescribing practices of resident physicians across a variety of surgical and nonsurgical specialties; to identify factors which influence prescribing practices; and to examine resident utilization of best practice supplemental resources. METHODS An anonymous survey which assessed prescribing practices was completed by residents from one of several different subspecialties, including internal medicine, obstetrics and gynecology, general surgery, neurosurgery, orthopedic surgery, and urology. Fisher's exact test assessed differences in prescribing practices between specialties. RESULTS Only 35% of residents reported receiving formal training in safe opioid prescribing. Overall, the most frequently reported influences on prescribing practices were the use of standardized order sets for specific procedures, attending preference, and patient's history of prescribed opioids. Resident physicians significantly underutilize best practice supplemental resources, such as counseling patients on pain expectations prior to prescribing opioid medication; contacting established pain specialists; screening patients for opioid abuse; referring to the Prescription Monitoring Program; and counseling patients on safe disposal of unused pills (P < .001). DISCUSSION The incorporation of comprehensive prescribing education into resident training and the utilization of standardized order sets can promote safe opioid prescribing.
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Affiliation(s)
- Julia M Coughlin
- Department of Surgery, 2468Rush University Medical Center, Chicago, IL, USA
| | | | - Ethan M Ritz
- Bioinformatics and Biostatistics Core, 2468Rush University Medical Center, Chicago, IL, USA
| | - Thomas Q Xu
- Department of Surgery, 2468Rush University Medical Center, Chicago, IL, USA
| | - John F Tierney
- Department of Surgery, 2468Rush University Medical Center, Chicago, IL, USA
| | - Jose M Velasco
- Department of Surgery, 2468Rush University Medical Center, Chicago, IL, USA
| | - Jonathan A Myers
- Department of Surgery, 2468Rush University Medical Center, Chicago, IL, USA
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14
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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: 2] [Impact Index Per Article: 0.7] [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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15
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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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16
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Psychological Flexibility, Pain Characteristics and Risk of Opioid Misuse in Noncancerous Chronic Pain Patients. J Clin Psychol Med Settings 2021; 28:405-417. [PMID: 32519037 DOI: 10.1007/s10880-020-09729-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Chronic pain has an estimated annual prevalence rate between 10 and 35%. In the US, first-line treatment for chronic pain is often opioids. OBJECTIVE To our knowledge, this is the first study exploring psychological flexibility and its association with pain severity, pain interference and risk of opioid misuse in chronic pain patients. METHODS Data were collected at two outpatient pain clinics in the northeastern United States. Adults (N = 99) completed a cross-sectional survey with validated measures. Pain severity and pain interference were hypothesized to uniquely predict the risk of opioid misuse. Pain severity was hypothesized to predict pain interference. Finally, psychological flexibility was hypothesized as an indirect effect in these relationships. RESULTS Main findings suggest that pain severity predicts risk of opioid misuse, mediated by psychological flexibly. Pain interference also predicts risk of opioid misuse, mediated by psychological flexibility. Finally, results suggest pain severity predicts pain interference, mediated by psychological flexibility. DISCUSSION Implications of findings are discussed in terms of future psychological and medical assessments and interventions for chronic pain patients seeking prescription opioids.
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17
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Ferreira-Chamorro P, Redondo A, Riego G, Pol O. Treatment with 5-fluoro-2-oxindole Increases the Antinociceptive Effects of Morphine and Inhibits Neuropathic Pain. Cell Mol Neurobiol 2021; 41:995-1008. [PMID: 32880099 DOI: 10.1007/s10571-020-00952-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 08/20/2020] [Indexed: 02/08/2023]
Abstract
The efficacy of µ-opioid receptors (MOR) in neuropathic pain is low and with numerous side effects that limited their use. Chronic neuropathic pain is also linked with emotional disorders that aggravate the sensation of pain and which treatment has not been resolved. This study investigates whether the administration of an oxindole, 5-fluoro-2-oxindole, could inhibit the nociceptive and emotional behaviors and increase the effectiveness of morphine via modulating the microglia and activating the nuclear factor erythroid-2 related factor 2 (Nrf2) signaling pathway and MOR expression. In C57BL/6 mice with neuropathic pain provoked by the total constriction of sciatic nerve we studied the effects of 10 mg/kg 5-fluoro-2-oxindole in: (i) the allodynia and hyperalgesia caused by the injury; (ii) the anxiety- and depressive-like behaviors; (iii) the local antinociceptive actions of morphine; (iv) the expression of CD11b/c (a microglial marker), the antioxidant and detoxificant enzymes Nrf2, heme oxygenase 1 (HO-1) and NAD(P)H:quinone oxidoreductase-1 (NQO1), and of MOR in the spinal cord and hippocampus. Results showed that the inhibition of the main nociceptive symptoms and the anxiety- and depressive-like behaviors induced by 5-fluoro-2-oxindole were accompanied with the suppression of microglial activation and the activation of Nrf2/HO-1/NQO1 signaling pathway in the spinal cord and/or hippocampus. This treatment also potentiated the pain-relieving activities of morphine by normalizing the reduced MOR expression. This work demonstrates the antinociceptive, anxiolytic and antidepressant effects of 5-fluoro-2-oxindole, suggests a new strategy to enhance the antinociceptive actions of morphine and proposes a new mechanism of action of oxindoles during chronic neuropathic pain.
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Affiliation(s)
- Pablo Ferreira-Chamorro
- Grup de Neurofarmacologia Molecular, Institut D'Investigació Biomèdica Sant Pau, 08041, Barcelona, Spain
- Grup de Neurofarmacologia Molecular, Institut de Neurociències, Universitat Autònoma de Barcelona, 08193, Barcelona, Spain
| | - Alejandro Redondo
- Grup de Neurofarmacologia Molecular, Institut D'Investigació Biomèdica Sant Pau, 08041, Barcelona, Spain
- Grup de Neurofarmacologia Molecular, Institut de Neurociències, Universitat Autònoma de Barcelona, 08193, Barcelona, Spain
| | - Gabriela Riego
- Grup de Neurofarmacologia Molecular, Institut D'Investigació Biomèdica Sant Pau, 08041, Barcelona, Spain
- Grup de Neurofarmacologia Molecular, Institut de Neurociències, Universitat Autònoma de Barcelona, 08193, Barcelona, Spain
| | - Olga Pol
- Grup de Neurofarmacologia Molecular, Institut D'Investigació Biomèdica Sant Pau, 08041, Barcelona, Spain.
- Grup de Neurofarmacologia Molecular, Institut de Neurociències, Universitat Autònoma de Barcelona, 08193, Barcelona, Spain.
- Grup de Neurofarmacologia Molecular, Institut D'Investigació Biomèdica Sant Pau & Institut de Neurociències, Facultat de Medicina. Edifici M2, Universitat Autònoma de Barcelona, Bellaterra, 08193, Barcelona, Spain.
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18
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Lau J, Mazzotta P, Fazelzad R, Ryan S, Tedesco A, Smith AJ, Sud A, Furlan AD, Zimmermann C. Assessment tools for problematic opioid use in palliative care: A scoping review. Palliat Med 2021; 35:1295-1322. [PMID: 34000897 PMCID: PMC8267087 DOI: 10.1177/02692163211015567] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Screening for problematic opioid use is increasingly recommended in patients receiving palliative care. AIM To identify tools used to assess for the presence or risk of problematic opioid use in palliative care. DESIGN Scoping review. DATA SOURCES Bibliographic databases (inception to January 31, 2020), reference lists, and grey literature were searched to find primary studies reporting on adults receiving palliative care and prescription opioids to manage symptoms from advanced cancer, neurodegenerative diseases, or end-stage organ diseases; and included tools to assess for problematic opioid use. There were no restrictions based on study design, location, or language. RESULTS We identified 42 observational studies (total 14,431 participants) published between 2009 and 2020 that used questionnaires (n = 32) and urine drug tests (n = 21) to assess for problematic opioid use in palliative care, primarily in US (n = 38) and outpatient palliative care settings (n = 36). The questionnaires were Cut down, Annoyed, Guilty, and Eye-opener (CAGE, n = 8), CAGE-Adapted to Include Drugs (CAGE-AID, n = 6), Opioid Risk Tool (n = 9), Screener and Opioid Assessment for Patients with Pain (SOAPP; n = 3), SOAPP-Revised (n = 2), and SOAPP-Short Form (n = 5). Only two studies' primary objectives were to evaluate a questionnaire's psychometric properties in patients receiving palliative care. There was wide variation in how urine drug tests were incorporated into palliative care; frequency of abnormal urine drug test results ranged from 8.6% to 70%. CONCLUSION Given the dearth of studies using tools developed or validated specifically for patients receiving palliative care, further research is needed to inform clinical practice and policy regarding problematic opioid use in palliative care.
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Affiliation(s)
- Jenny Lau
- Division of Palliative Care, University of Toronto, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Paolo Mazzotta
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, ON, Canada
| | - Rouhi Fazelzad
- UHN Library and Information Services, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Suzanne Ryan
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Division of Palliative Medicine, University of Toronto, Toronto, ON, Canada
| | - Alissa Tedesco
- Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, ON, Canada
| | - Andrew J Smith
- Addictions Division, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Abhimanyu Sud
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Medical Psychiatry Alliance, Toronto, ON, Canada
| | - Andrea D Furlan
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada.,Institute for Work and Health, Toronto, ON, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Division of Palliative Medicine, University of Toronto, Toronto, ON, Canada.,Division of Medical Oncology, University of Toronto, Toronto, ON, Canada
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19
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Hah J. Risk factors and screening for opioid misuse: current clinical implications for prescription opioid therapy. Pain Manag 2021; 11:625-630. [PMID: 34155912 DOI: 10.2217/pmt-2021-0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Jennifer Hah
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, & Pain Medicine, Stanford University, 1070 Arastradero Road, Suite 200, Palo Alto, CA 94304, USA
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20
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Shah I, Sheth SG, Kothari DJ. Pain management in chronic pancreatitis incorporating safe opioid practices: Challenge accepted. World J Gastroenterol 2021; 27:3142-3147. [PMID: 34163102 PMCID: PMC8218357 DOI: 10.3748/wjg.v27.i23.3142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/15/2021] [Accepted: 05/21/2021] [Indexed: 02/06/2023] Open
Abstract
Patients with chronic pancreatitis often experience severe, unrelenting abdominal pain, which can significantly impact their quality of life. Pain control, therefore, remains central to the overall management of chronic pancreatitis. Most of the strategies aimed at treating the pain of chronic pancreatitis are based on expert opinion and vary from one institution to another, as there are no uniform guidelines to direct a stepwise approach towards achieving this goal. In this editorial, we comment on best practice strategies targeted towards pain control in chronic pancreatitis, specifically highlighting the use of opioid medications in this patient population. We discuss various safe and efficacious prescription monitoring practices in this article.
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Affiliation(s)
- Ishani Shah
- Department of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Sunil G Sheth
- Department of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Darshan J Kothari
- Department of Gastroenterology, Duke University Medical Center, Durham, NC 27710, United States
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21
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Colasanti JA, Vettese T, Samet JH. Improving Outpatient Management of Patients On Chronic Opioid Therapy. Infect Dis Clin North Am 2021; 34:621-635. [PMID: 32782105 DOI: 10.1016/j.idc.2020.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Managing patients with chronic pain on chronic opioid therapy (COT) can be challenging if done mainly by an individual clinician. A stepwise, systematic approach to managing patients on COT includes centering the discussion around safety for the patient. Treatment agreements and monitoring plans are important to safe prescribing. With a team-based care approach programs can be implemented, which optimize the benefits of opioid therapy and mitigate the risk. In these settings COT can be prescribed adhering to current guidelines in order to help achieve pain management, optimize function, and advance the patients' quality of life goals.
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Affiliation(s)
- Jonathan A Colasanti
- Department of Medicine, Division of Infectious Diseases, Emory University, 341 Ponce de Leon Avenue, Atlanta, GA 30308, USA.
| | - Theresa Vettese
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Emory University, 49 Jesse Hill Drive SE #40, Atlanta, GA 30303, USA. https://twitter.com/tracyvettese
| | - Jeffrey H Samet
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center; 801 Massachusetts Avenue, CT 2, Boston, MA 02118, USA; Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Avenue, CT 2, Boston, MA 02118, USA
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Arthur JA, Tang M, Lu Z, Hui D, Nguyen K, Rodriguez EM, Edwards T, Yennurajalingam S, Dalal S, Dev R, Reddy A, Tanco K, Haider A, Liu DD, Bruera E. Random urine drug testing among patients receiving opioid therapy for cancer pain. Cancer 2021; 127:968-975. [PMID: 33231885 PMCID: PMC10015495 DOI: 10.1002/cncr.33326] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/24/2020] [Accepted: 10/06/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND There is limited information regarding the true frequency of nonmedical opioid use (NMOU) among patients receiving opioid therapy for cancer pain. Data to guide patient selection for urine drug testing (UDT) as well as the timing and frequency of ordering UDT are insufficient. This study examined the frequency of abnormal UDT among patients with cancer who underwent random UDT and their characteristics. METHODS Demographic and clinical information for patients with cancer who underwent random UDT were retrospectively reviewed and compared with a historical cohort that underwent targeted UDT. Random UDT was ordered regardless of a patient's risk potential for NMOU. Targeted UDT was ordered on the basis of a physician's estimation of a patient's risk for NMOU. RESULTS In all, 552 of 573 eligible patients (96%) underwent random UDT. Among these patients, 130 (24%) had 1 or more abnormal results; 38 of the 88 patients (43%) who underwent targeted UDT had 1 or more abnormal results. When marijuana was excluded, 15% of the random group and 37% of the targeted group had abnormal UDT findings (P < .001). It took a shorter time from the initial consultation to detect 1 or more abnormalities with the random test than the targeted test (median, 130 vs 274 days; P = .02). Abnormal random UDT was independently associated with younger age (P < .0001), male sex (P = .03), Cut Down, Annoyed, Guilty, and Eye Opener-Adapted to Include Drugs positivity (P = .001), and higher Edmonton Symptom Assessment System anxiety (P = .01). CONCLUSIONS Approximately 1 in 4 patients receiving opioids for cancer pain at a supportive care clinic who underwent random UDT had 1 or more abnormalities. Random UDT detected abnormalities earlier than the targeted test. These findings suggest that random UDT is justified among patients with cancer pain.
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Affiliation(s)
- Joseph A Arthur
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael Tang
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Zhanni Lu
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David Hui
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kristy Nguyen
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eden Mae Rodriguez
- Pharmacy Services, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Tonya Edwards
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sriram Yennurajalingam
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shalini Dalal
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rony Dev
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Akhila Reddy
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kimberson Tanco
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ali Haider
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Diane D Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Yennurajalingam S, Arthur J, Reddy S, Edwards T, Lu Z, Rozman de Moraes A, Wilson SM, Erdogan E, Joy MP, Ethridge SD, Kuriakose L, Malik JS, Najera JM, Rashid S, Qian Y, Kubiak MJ, Nguyen K, PharmD, Wu J, Hui D, Bruera E. Frequency of and Factors Associated With Nonmedical Opioid Use Behavior Among Patients With Cancer Receiving Opioids for Cancer Pain. JAMA Oncol 2021; 7:404-411. [PMID: 33410866 DOI: 10.1001/jamaoncol.2020.6789] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Importance One of the main aims of research on nonmedical opioid use (NMOU) is to reduce the frequency of NMOU behaviors through interventions such as universal screening, reduced opioid exposure, and more intense follow-up of patients with elevated risk. The absence of data on the frequency of NMOU behavior is the major barrier to conducting research on NMOU. Objective To determine the overall frequency of and the independent predictors for NMOU behavior. Design, Setting, and Participants In this prognostic study, 3615 patients with cancer were referred to the supportive care center at MD Anderson Cancer Center from March 18, 2016, to June 6, 2018. Patients were eligible for inclusion if they had cancer and were taking opioids for cancer pain for at least 1 week. Patients were excluded if they had no follow-up within 3 months of initial consultation, did not complete the appropriate questionnaire, or did not have scheduled opioid treatments. After exclusion, a total of 1554 consecutive patients were assessed for NMOU behavior using established diagnostic criteria. All patients were assessed using the Edmonton Symptom Assessment Scale, the Screener and Opioid Assessment for Patients with Pain (SOAPP), and the Cut Down, Annoyed, Guilty, Eye Opener-Adapted to Include Drugs (CAGE-AID) survey. Data were analyzed from January 6 to September 25, 2020. Results A total of 1554 patients (median [interquartile range (IQR)] age, 61 [IQR, 52-69] years; 816 women [52.5%]; 1124 White patients [72.3%]) were evaluable for the study, and 299 patients (19.2%) had 1 or more NMOU behaviors. The median (IQR) number of NMOU behaviors per patient was 1 (IQR, 1-3). A total of 576 of 745 NMOU behaviors (77%) occurred by the first 2 follow-up visits. The most frequent NMOU behavior was unscheduled clinic visits for inappropriate refills (218 of 745 [29%]). Eighty-eight of 299 patients (29.4%) scored 7 or higher on SOAPP, and 48 (16.6%) scored at least 2 out of 4 points on the CAGE-AID survey. Results from the multivariate model suggest that marital status (single, hazard ratio [HR], 1.58; 95% CI, 1.15-2.18; P = .005; divorced, HR, 1.43; 95% CI, 1.01-2.03; P = .04), SOAPP score (positive vs negative, HR, 1.35; 95% CI, 1.04-1.74; P = .02), morphine equivalent daily dose (MEDD) (HR, 1.003; 95% CI, 1.002-1.004; P < .001), and Edmonton Symptom Assessment Scale pain level (HR, 1.11; 95% CI, 1.06-1.16; P < .001) were independently associated with the presence of NMOU behavior. In recursive partition analysis, single marital status, MEDD greater than 50 mg, and SOAPP scores greater than 7 were associated with a higher risk (56%) for the presence of NMOU behavior. Conclusions and Relevance This prognostic study of patients with cancer taking opioids for cancer pain found that 19% of patients developed NMOU behavior within a median duration of 8 weeks after initial supportive care clinic consultation. Marital status (single or divorced), SOAPP score greater than 7, higher levels of pain severity, and MEDD level were independently associated with NMOU behavior. This information will assist clinicians and investigators designing clinical and research programs in this important field.
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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
| | - Joseph Arthur
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Suresh Reddy
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Tonya Edwards
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Zhanni Lu
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Aline Rozman de Moraes
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Susamma M Wilson
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Elif Erdogan
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Manju P Joy
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Shirley Darlene Ethridge
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Leela Kuriakose
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Jimi S Malik
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - John M Najera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Saima Rashid
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Yu Qian
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Michal J Kubiak
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | | | - PharmD
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Jimin Wu
- Biostatistics, The University of Texas MD Anderson Cancer Center, Houston
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
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Romman A, Doulatram G, Doctor N, Krishnamurthy P. Sensitivity and specificity of SOAPP-SF questionnaire for predicting aberrant urine drug screen. Reg Anesth Pain Med 2020; 45:763-764. [DOI: 10.1136/rapm-2019-101179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 01/30/2020] [Accepted: 02/04/2020] [Indexed: 11/04/2022]
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Hirsh AT, Anastas TM, Miller MM, Quinn PD, Kroenke K. Patient race and opioid misuse history influence provider risk perceptions for future opioid-related problems. AMERICAN PSYCHOLOGIST 2020; 75:784-795. [PMID: 32915023 PMCID: PMC7490831 DOI: 10.1037/amp0000636] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In response to the dual public health crises of chronic pain and opioid use, providers have become more vigilant about assessing patients for risk of opioid-related problems. Little is known about how providers are making these risk assessments. Given previous studies indicating that Black patients are at increased risk for suboptimal pain care, which may be related to stereotypes about drug abuse, the current study examined how patient race and previous opioid misuse behaviors impact providers' risk assessments for future prescription opioid-related problems. Physician residents and fellows (N = 135) viewed videos and read vignettes about 8 virtual patients with chronic pain who varied by race (Black/White) and history of prescription opioid misuse (absent/present). Providers rated patients' risk for future prescription opioid-related adverse events, misuse/abuse, addiction, and diversion, and also completed measures of implicit racial attitudes and explicit beliefs about race differences in pain. Two significant interactions emerged indicating that Black patients were perceived to be at greater risk for future adverse events (when previous misuse was absent) and diversion (when previous misuse was present). Significant main effects indicated that Black patients and patients with previous misuse were perceived to be at greater risk for future misuse/abuse of prescription opioids, and that patients with previous misuse were perceived to be at greater risk of addiction. These findings suggest that racial minorities and patients with a history of prescription opioid misuse are particularly vulnerable to any unintended consequences of efforts to stem the dual public health crises of chronic pain and opioid use. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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Affiliation(s)
- Adam T. Hirsh
- Department of Psychology, Indiana University – Purdue University Indianapolis
| | - Tracy M. Anastas
- Department of Psychology, Indiana University – Purdue University Indianapolis
| | - Megan M. Miller
- Department of Psychology, Indiana University – Purdue University Indianapolis
| | - Patrick D. Quinn
- Department of Applied Health Science, Indiana University, Bloomington
| | - Kurt Kroenke
- Department of Medicine, Indiana University School of Medicine
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26
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Abstract
Opioid use disorder and opioid misuse continue to increase rapidly in prevalence in North America. Nurses play a critical role in managing pain in patients who are at risk for opioid use disorder. The interplay of pain and opioid use disorder provides nurses with an opportunity to address urgent needs while treating patients across the continuum of care. This article reviews strategies for assessing risk for opioid use disorder while treating patients with pain. Implementing these approaches into daily nursing practice may improve patient care and help reduce the incidence of opioid use disorder.
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Affiliation(s)
- Barbara St Marie
- Barbara St. Marie is Assistant Professor, College of Nursing, University of Iowa, 50 Newton Road, Iowa City, IA
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27
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Chapman KB, Pas MM, Abrar D, Day W, Vissers KC, van Helmond N. Development and Performance of a Web-Based Tool to Adjust Urine Toxicology Testing Frequency: Retrospective Study. JMIR Med Inform 2020; 8:e16069. [PMID: 32319958 PMCID: PMC7203611 DOI: 10.2196/16069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 01/23/2020] [Accepted: 03/25/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Several pain management guidelines recommend regular urine drug testing (UDT) in patients who are being treated with chronic opioid analgesic therapy (COAT) to monitor compliance and improve safety. Guidelines also recommend more frequent testing in patients who are at high risk of adverse events related to COAT; however, there is no consensus on how to identify high-risk patients or on the testing frequency that should be used. Using previously described clinical risk factors for UDT results that are inconsistent with the prescribed COAT, we developed a web-based tool to adjust drug testing frequency in patients treated with COAT. OBJECTIVE The objective of this study was to evaluate a risk stratification tool, the UDT Randomizer, to adjust UDT frequency in patients treated with COAT. METHODS Patients were stratified using an algorithm based on readily available clinical risk factors into categories of presumed low, moderate, high, and high+ risk of presenting with UDT results inconsistent with the prescribed COAT. The algorithm was integrated in a website to facilitate adoption across practice sites. To test the performance of this algorithm, we performed a retrospective analysis of patients treated with COAT between June 2016 and June 2017. The primary outcome was compliance with the prescribed COAT as defined by UDT results consistent with the prescribed COAT. RESULTS 979 drug tests (867 UDT, 88.6%; 112 oral fluid testing, 11.4%) were performed in 320 patients. An inconsistent drug test result was registered in 76/979 tests (7.8%). The incidences of inconsistent test results across the risk tool categories were 7/160 (4.4%) in the low risk category, 32/349 (9.2%) in the moderate risk category, 28/338 (8.3%) in the high risk category, and 9/132 (6.8%) in the high+ risk category. Generalized estimating equation analysis demonstrated that the moderate risk (odds ratio (OR) 2.1, 95% CI 0.9-5.0; P=.10), high risk (OR 2.0, 95% CI 0.8-5.0; P=.14), and high risk+ (OR 2.0, 95% CI 0.7-5.6; P=.20) categories were associated with a nonsignificantly increased risk of inconsistency vs the low risk category. CONCLUSIONS The developed tool stratified patients during individual visits into risk categories of presenting with drug testing results inconsistent with the prescribed COAT; the higher risk categories showed nonsignificantly higher risk compared to the low risk category. Further development of the tool with additional risk factors in a larger cohort may further clarify and enhance its performance.
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Affiliation(s)
- Kenneth B Chapman
- Department of Anesthesiology, New York University Langone Medical Center, New York, NY, United States
- The Spine & Pain Institute of New York, New York, NY, United States
| | - Martijn M Pas
- The Spine & Pain Institute of New York, New York, NY, United States
- Radboud University Medical College, Nijmegen, Netherlands
| | - Diana Abrar
- The Spine & Pain Institute of New York, New York, NY, United States
- Radboud University Medical College, Nijmegen, Netherlands
| | - Wesley Day
- The Spine & Pain Institute of New York, New York, NY, United States
| | - Kris C Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Noud van Helmond
- The Spine & Pain Institute of New York, New York, NY, United States
- Department of Anesthesiology, Cooper Medical School of Rowan University, Cooper University Health Care, Camden, NJ, United States
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28
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Nielsen S, Picco L, Campbell G, Lintzeris N, Larance B, Farrell M, Degenhardt L, Bruno R. Development of a Brief Patient-Administered Screening Tool for Prescription Opioid Dependence for Primary Care Settings. PAIN MEDICINE (MALDEN, MASS.) 2020; 21:e79-e88. [PMID: 31591644 PMCID: PMC8204889 DOI: 10.1093/pm/pnz213] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To develop a short, patient-administered screening tool that will allow for earlier assessment of prescription opioid dependence (often referred to as addiction) in primary care settings. DESIGN AND SETTING Cross-sectional analysis (N = 1,134) from the two-year time point of the Pain and Opioids IN Treatment (POINT) cohort was used in the scale development. SUBJECTS Participants who completed two-year interviews in the POINT study, a prospective cohort study that followed people with chronic noncancer pain over a five-year period, and who were prescribed strong opioids for a minimum of six weeks at baseline. METHODS An advisory committee provided advice on wording and content for screening in primary care settings. Univariate logistic regression identified individual items that were significantly associated with meeting ICD-11 criteria for prescription opioid dependence. Exploratory and confirmatory factor analysis (EFA and CFA) were conducted, and items were reduced to identify a small item set that were discriminative and shared a simple underlying structure. RESULTS Sixty-four variables associated with ICD-11 criteria for prescription opioid dependence were initially identified. Four rounds of EFA were performed, resulting in five items remaining. CFA identified two possible four-item combinations, with the final combination chosen based on greater item endorsement and the results of goodness-of-fit indices. CONCLUSIONS Addressing prescription opioid dependence is an important part of the global public health challenge surrounding rising opioid-related harm. This study addresses an important initial requisite step to develop a brief screening tool. Further studies are required to validate the tool in clinical settings.
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Affiliation(s)
- Suzanne Nielsen
- National Drug and Alcohol Research Centre, University of New South Wales Sydney, Sydney, New South Wales, Australia
- Monash Addiction Research Centre, Monash University Peninsula Campus, Frankston, Victoria, Australia
| | - Louisa Picco
- Monash Addiction Research Centre, Monash University Peninsula Campus, Frankston, Victoria, Australia
| | - Gabrielle Campbell
- National Drug and Alcohol Research Centre, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | - Nicholas Lintzeris
- Discipline of Addiction Medicine, University of Sydney, Sydney, New South Wales, Australia
- The Langton Centre, South East Sydney Local Health District (SESLHD) Drug and Alcohol Services, Sydney, New South Wales, Australia
| | - Briony Larance
- National Drug and Alcohol Research Centre, University of New South Wales Sydney, Sydney, New South Wales, Australia
- School of Psychology, University of Wollongong, Wollongong, New South Wales, Australia
| | - Michael Farrell
- National Drug and Alcohol Research Centre, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales Sydney, Sydney, New South Wales, Australia
- School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Raimondo Bruno
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
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29
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Hui D, Abdelghani E, Chen J, Dibaj S, Zhukovsky D, Dev R, Tanco K, Haider A, Azhar A, Reddy A, Epner D, Arthur J, Dalal S, Heung Y, Reddy S, De La Cruz M, Liu D, Bruera E. Chronic Non-Malignant Pain in Patients with Cancer Seen at a Timely Outpatient Palliative Care Clinic. Cancers (Basel) 2020; 12:cancers12010214. [PMID: 31952220 PMCID: PMC7016539 DOI: 10.3390/cancers12010214] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 01/08/2020] [Accepted: 01/09/2020] [Indexed: 12/16/2022] Open
Abstract
Palliative care is seeing cancer patients earlier in the disease trajectory with a multitude of chronic issues. Chronic non-malignant pain (CNMP) in cancer patients is under-studied. In this prospective study, we examined the prevalence and management of CNMP in cancer patients seen at our supportive care clinic for consultation. We systematically characterized each pain type with the Brief Pain Inventory (BPI) and documented current treatments. The attending physician made the pain diagnoses according to the International Association for the Study of Pain (IASP) task force classification. Among 200 patients (mean age 60 years, 69% metastatic disease, 1-year survival of 77%), the median number of pain diagnosis was 2 (IQR 1–2); 67 (34%, 95% CI 28–41%) had a diagnosis of CNMP; 133 (67%) had cancer-related pain; and 52 (26%) had treatment-related pain. In total, 12/31 (39%) patients with only CNMP and 21/36 (58%) patients with CNMP and other pain diagnoses were on opioids. There was a total of 94 CNMP diagnoses among 67 patients, including 37 (39%) osteoarthritis and 20 (21%) lower back pain; 30 (32%) were treated with opioids. In summary, CNMP was common in the timely palliative care setting and many patients were on opioids. Our findings highlight the need to develop clinical guidelines for CNMP in cancer patients to standardize its management.
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Affiliation(s)
- David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
- Correspondence: ; Tel.: +1-713-794-1803; Fax: +1-713-792-6092
| | - Eman Abdelghani
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| | - Joseph Chen
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| | - Shiva Dibaj
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| | - Donna Zhukovsky
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| | - Rony Dev
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| | - Kimberson Tanco
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| | - Ali Haider
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| | - Ahsan Azhar
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| | - Akhila Reddy
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| | - Daniel Epner
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| | - Joseph Arthur
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| | - Shalini Dalal
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| | - Yvonne Heung
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| | - Suresh Reddy
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| | - Maxine De La Cruz
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
| | - Diane Liu
- Department of Biostatistics, MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA; (E.A.); (J.C.); (S.D.); (D.Z.); (R.D.); (K.T.); (A.H.); (A.A.); (A.R.); (D.E.); (J.A.); (S.D.); (Y.H.); (S.R.); (M.D.L.C.); (E.B.)
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Adopting Graduate Competencies in Opioid Prescribing for Massachusetts Physician Assistant Programs: A Statewide Public Health Response. J Physician Assist Educ 2019; 30:207-213. [PMID: 31664008 DOI: 10.1097/jpa.0000000000000276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Opioid addiction has become a national epidemic. Morbidity and mortality from prescription and synthetic opioid use and abuse have increased at an alarming rate in recent years. Ensuring that physician assistant (PA) graduates have the knowledge to become safe prescribers of medications, including opiates, is a goal of PA training programs. Achieving that goal requires fostering PA student competence regarding current issues in pain control, drug use and misuse, polypharmacy, diversion, self-medication, and substance use disorder. We present a public health approach to addressing that need. Our approach involved developing consensus among the 9 PA programs in Massachusetts concerning the adoption and implementation of statewide, graduate core competencies for the prevention and management of prescription drug misuse. The process implemented in Massachusetts could be used as a model in other states and might be relevant to addressing other public health crises. We present the adopted competencies as well as individual PA programs' curricular approaches.
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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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DiBenedetto DJ, Weed VF, Wawrzyniak KM, Finkelman M, Paolini J, Schatman ME, Herrera D, Kulich RJ. The Association Between Cannabis Use and Aberrant Behaviors During Chronic Opioid Therapy for Chronic Pain. PAIN MEDICINE 2019; 19:1997-2008. [PMID: 29947796 DOI: 10.1093/pm/pnx222] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective Health care providers are likely to see an increase in the concomitant use of cannabis and opioids, particularly with the increased liberalization and ongoing research into the possible role of medical marijuana for chronic pain. Recent literature reports a prevalence of concurrent use ranging from 8.9% to 31.8%. The primary aim of this study was to determine the relationship between cannabis use and aberrant drug behaviors in noncancer pain patients receiving chronic opioid therapy. Design Retrospective chart review. Setting Community-based, interdisciplinary pain management center. Subjects Data from 209 patients who were evaluated for a medication management program between October 1, 2011, and January 1, 2014, and met inclusion criteria. Forty-four were positive for cannabis in their initial random urine drug toxicology. Methods Data from electronic health records, including demographics, urine drug toxicology, disability, opioid dose, opioid risk assessment data, and pain severity were analyzed to examine differences among cannabis users and noncannabis users. Results Subjects with cannabis in their initial urine drug toxicology were more likely to have a future occurrence of an opioid-related aberrancy (P < 0.001), be male (P = 0.047), have a history of substance abuse (P = 0.013), and be enrolled into a higher level of clinical monitoring of opioid medication use (P = 0.008). No other associations with demographic and clinical variables reached statistical significance. Conclusions Concurrent use of cannabis and opioids by patients with chronic pain appears to indicate higher risk for opioid misuse. Closer monitoring for opioid-related aberrancy is indicated for this group of patients.
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Affiliation(s)
- David J DiBenedetto
- Department of Diagnostic Sciences, Boston Pain Care, Tufts University School of Dental Medicine, Boston, Massachusetts
| | | | - Kelly M Wawrzyniak
- Department of Diagnostic Sciences, Boston Pain Care, Tufts University School of Dental Medicine, Boston, Massachusetts
| | - Matthew Finkelman
- Division of Biostatistics and Experimental Design, Tufts University School of Medicine, Boston, Massachusetts
| | | | - Michael E Schatman
- Department of Public Health and Community Medicine, Boston Pain Care, Tufts University School of Medicine, Boston, Massachusetts
| | | | - Ronald J Kulich
- Department of Diagnostic Sciences, Tufts University of School Dental Medicine, Boston, Massachusetts.,Department of Anesthesia Critical Care and Pain Medicine, Harvard Medical School/Massachusetts General Hospital Boston, Massachusetts, USA
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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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Wawrzyniak KM, Finkelman M, Schatman ME, Kulich RJ, Weed VF, Myrta E, DiBenedetto DJ. The World Health Organization Disability Assessment Schedule-2.0 (WHODAS 2.0) in a chronic pain population being considered for chronic opioid therapy. J Pain Res 2019; 12:1855-1862. [PMID: 31354334 PMCID: PMC6573777 DOI: 10.2147/jpr.s207870] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 05/23/2019] [Indexed: 12/17/2022] Open
Abstract
Purpose To examine the validity of the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) for the assessment of function in a community-based sample of patients with chronic pain conditions undergoing evaluation for chronic opioid therapy. Patients and methods One hundred nine of 124 patients were evaluated for a chronic opioid therapy program between December 1, 2014 and April 10, 2015, inclusive, at one community-based interdisciplinary pain management practice. Measures included: demographic data; the WHODAS 2.0; a modified version of the Roland Morris Disability Questionnaire (RMDQ-m); the Patient Health Questionnaire-9 item (PHQ-9); the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R); the Current Opioid Misuse Measure (COMM), the Opioid Risk Tool (ORT); opioid dose. These data were collected as part of routine care, and this retrospective chart review study examined the data from this convenience sample, comparing the results of each assessment tool to the results of the WHODAS 2.0. Results Median score on the WHODAS 2.0 was 25.69 (IQR=16.01 to 35.28). WHODAS 2.0 score was significantly correlated with the RMDQ-m (rs=0.69, p<0.001), the PHQ-9 (rs=0.68, p<0.001), the COMM (rs=0.52, p<0.001) and the SOAPP-R (rs=0.51, p<0.001). There was no significant correlation between the WHODAS 2.0 and the ORT (rs=0.14, p=0.12) or opioid dose (rs=0.07, p=0.47). Conclusions The WHODAS 2.0 was significantly positively correlated with other measures, including measures of disability, risk of opioid misuse, and depression among patients being evaluated for chronic opioid therapy. The WHODAS 2.0 may be a useful measure of disability across a number of important domains when discussing expectations of both patients and providers at initiation of opioid therapy for chronic pain management. This assessment and discussion is crucial, particularly given the focus on function, rather than analgesia alone, when evaluating the effectiveness of opioid treatment.
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Affiliation(s)
- Kelly M Wawrzyniak
- Boston PainCare Center, Waltham, MA 02451, USA.,Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA 02111, USA
| | - Matthew Finkelman
- Division of Biostatistics and Experimental Design, Tufts University School of Dental Medicine, Boston, MA 02111, USA
| | - Michael E Schatman
- Boston PainCare Center, Waltham, MA 02451, USA.,Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA 02111, USA
| | - Ronald J Kulich
- Boston PainCare Center, Waltham, MA 02451, USA.,Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA 02111, USA
| | - Valerie F Weed
- Primary Care Psychology Associates, LLC, Northbrook, IL 60062, USA
| | - Eura Myrta
- Boston PainCare Center, Waltham, MA 02451, USA
| | - David J DiBenedetto
- Boston PainCare Center, Waltham, MA 02451, USA.,Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA 02111, USA
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Chow RM, Marascalchi B, Abrams WB, Peiris NA, Odonkor CA, Cohen SP. Driving Under the Influence of Cannabis: A Framework for Future Policy. Anesth Analg 2019; 128:1300-1308. [PMID: 31094805 DOI: 10.1213/ane.0000000000003575] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Marijuana is the most widely consumed illicit substance in the United States, and an increasing number of states have legalized it for both medicinal and recreational purposes. As it becomes more readily available, there will be a concurrent rise in the number of users and, consequently, the number of motor vehicle operators driving under the influence. This article examines the cognitive and psychomotor effects of cannabis, as well as current policy concerning driving under the influence of drugs. The authors performed a MEDLINE search on the epidemiology of cannabis use, its cognitive and psychomotor effects, and policies regarding driving under the influence of drugs. Twenty-eight epidemiological studies, 16 acute cognitive and psychomotor studies, 8 chronic cognitive and psychomotor studies, and pertinent state and federal laws and policies were reviewed. These search results revealed that marijuana use is associated with significant cognitive and psychomotor effects. In addition, the legalization of marijuana varies from state to state, as do the laws pertaining to driving under the influence of drugs. Marijuana is a commonly found illicit substance in motor vehicle operators driving under the influence of drugs. Current evidence shows that blood levels of tetrahydrocannabinol do not correlate well with the level of impairment. In addition, although acute infrequent use of cannabis typically leads to cognitive and psychomotor impairment, this is not consistently the case for chronic heavy use. To establish the framework for driving under the influence of cannabis policy, we must review the current published evidence and examine existing policy at state and federal levels.
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Affiliation(s)
- Robert M Chow
- From the Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
| | | | - Winfred B Abrams
- Physical Medicine & Rehabilitation, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Nathalie A Peiris
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Charles A Odonkor
- Physical Medicine & Rehabilitation, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Steven P Cohen
- Department of Anesthesiology, Neurology and Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, Maryland
- Department of Anesthesiology and Physical Medicine & Rehabilitation, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Alzeer AH, Jones J, Bair MJ. Review of Factors, Methods, and Outcome Definition in Designing Opioid Abuse Predictive Models. PAIN MEDICINE 2019; 19:997-1009. [PMID: 29016966 DOI: 10.1093/pm/pnx149] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Objective Several opioid risk assessment tools are available to prescribers to evaluate opioid analgesic abuse among chronic patients. The objectives of this study are to 1) identify variables available in the literature to predict opioid abuse; 2) explore and compare methods (population, database, and analysis) used to develop statistical models that predict opioid abuse; and 3) understand how outcomes were defined in each statistical model predicting opioid abuse. Design The OVID database was searched for this study. The search was limited to articles written in English and published from January 1990 to April 2016. This search generated 1,409 articles. Only seven studies and nine models met our inclusion-exclusion criteria. Results We found nine models and identified 75 distinct variables. Three studies used administrative claims data, and four studies used electronic health record data. The majority, four out of seven articles (six out of nine models), were primarily dependent on the presence or absence of opioid abuse or dependence (ICD-9 diagnosis code) to define opioid abuse. However, two articles used a predefined list of opioid-related aberrant behaviors. Conclusions We identified variables used to predict opioid abuse from electronic health records and administrative data. Medication variables are the recurrent variables in the articles reviewed (33 variables). Age and gender are the most consistent demographic variables in predicting opioid abuse. Overall, there is similarity in the sampling method and inclusion/exclusion criteria (age, number of prescriptions, follow-up period, and data analysis methods). Intuitive research to utilize unstructured data may increase opioid abuse models' accuracy.
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Affiliation(s)
- Abdullah H Alzeer
- Indiana University School of Informatics and Computing, Indianapolis, Indiana
| | - Josette Jones
- Indiana University School of Informatics and Computing, Indianapolis, Indiana.,Regenstrief Institute, Indianapolis, Indiana.,Indiana University School of Nursing, Indianapolis, Indiana
| | - Matthew J Bair
- Regenstrief Institute, Indianapolis, Indiana.,Richard L. Roudebush VA Medical Center, Center for Health Information and Communication (CHIC), Indianapolis, Indiana.,Indiana University School of Medicine, Indianapolis, Indiana, USA
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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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Selecting the Appropriate Patient for Opioid Therapy: Risk Assessment and Treatment Strategies for Gynecologic Pain. Clin Obstet Gynecol 2019; 62:48-58. [DOI: 10.1097/grf.0000000000000411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cheatle MD, Compton PA, Dhingra L, Wasser TE, O'Brien CP. Development of the Revised Opioid Risk Tool to Predict Opioid Use Disorder in Patients with Chronic Nonmalignant Pain. THE JOURNAL OF PAIN 2019; 20:842-851. [PMID: 30690168 DOI: 10.1016/j.jpain.2019.01.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 11/20/2018] [Accepted: 01/22/2019] [Indexed: 12/18/2022]
Abstract
The Opioid Risk Tool (ORT) is a commonly used measure of risk of aberrant drug-related behaviors in patients with chronic pain prescribed opioid therapy. In this study, the discriminant predictive validity of the ORT was evaluated in a unique cohort of patients with chronic nonmalignant pain (CNMP) on long-term opioid therapy who displayed no evidence of developing an opioid use disorder (OUD) and a sample of patients with CNMP who developed an OUD after commencing opioid therapy. Results revealed that the original ORT was able to discriminate between patients with and without OUDs (odds ratio = 1.624; 95% confidence interval [CI] = 1.539-1.715, P < .001). A weighted ORT eliminating the gender-specific history of preadolescent sexual abuse item revealed comparable results (odds ratio = 1.648, 95% CI = 1.539-1.742, P < .001). A revised unweighted ORT removing the history of preadolescent sexual abuse item was notably superior in predicting the development of OUD in patients with CNMP on long-term opioid therapy (odds ratio = 3.085; 95% CI = 2.725-3.493; P < .001) with high specificity (.851; 95% CI = .811-.885), sensitivity (.854; 95% CI = .799-.898), positive predictive value (.757; 95% CI = .709-.799), and negative predictive value (.914; 95% CI = .885-.937). Perspective: The revised ORT is the first tool developed on a unique cohort to predict the risk of developing an OUD in patients with CNMP receiving opioid therapy, as opposed to aberrant drug-related behaviors that can reflect a number of other issues. The revised ORT has clinical usefulness in providing clinicians a simple, validated method to rapidly screen for the risk of developing OUD in patients on or being considered for opioid therapy.
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Affiliation(s)
- Martin D Cheatle
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Peggy A Compton
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lara Dhingra
- MJHS Institute for Innovation in Palliative Care, New York, New York; Albert Einstein College of Medicine, Bronx, New York
| | - Thomas E Wasser
- Consult-Stat: Complete Statistical Services, Macungie, Pennsylvania
| | - Charles P O'Brien
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Binswanger IA, Joseph N, Hanratty R, Gardner EM, Durfee J, Narwaney KJ, Breslin K, Mueller SR, Glanz JM. Novel Opioid Safety Clinic Initiative to Deliver Guideline-Concordant Chronic Opioid Therapy in Primary Care. Mayo Clin Proc Innov Qual Outcomes 2018; 2:309-316. [PMID: 30560232 PMCID: PMC6260499 DOI: 10.1016/j.mayocpiqo.2018.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 09/17/2018] [Accepted: 09/27/2018] [Indexed: 11/16/2022] Open
Abstract
Objective To develop and evaluate a novel Opioid Safety Clinic (OSC) initiative to enhance adherence to guidelines on the assessment and monitoring of patients prescribed chronic opioid therapy (COT). Patients and Methods The OSC was developed at an urban Federally Qualified Health Center to provide guideline-concordant care for COT, standardize workflows, and efficiently use clinic staff. We evaluated the OSC using a matched cohort study. Five hundred thirty-nine patients participated in the clinic between July 1, 2014, and March 31, 2016. Of these, 472 clinic participants were matched to 472 nonparticipants by sex and age on the date of the OSC visit. The OSC was evaluated by its completion rates of standardized pain assessments, urine toxicology, and naloxone dispensings. We conducted logistic regression comparing OSC participants to OSC nonparticipants. Results A total of 539 patients attended an OSC visit, representing approximately 53% of patients in the chronic opioid registry. The OSC participants were more likely than nonparticipants to have completed a pain assessment (adjusted odds ratio [aOR], 169.8; 95% CI, 98.3-293.5), completed a urine toxicology (aOR, 46.1; 95% CI, 30.4-69.9), or had naloxone dispensed (aOR, 2.8; 95% CI, 1.9-4.3) over 12 months of follow-up. Conclusion The OSC model improved adherence to guideline-concordant COT in primary care. Future research is needed to assess the impact of these interventions on pain, quality of life, and adverse events from opioid analgesics.
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Affiliation(s)
- Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO.,Colorado Permanente Medical Group, Denver, CO.,Division of General Internal Medicine, University of Colorado School of Medicine, Denver, CO.,Denver Health and Hospital Authority, Denver, CO
| | - Nicole Joseph
- Division of General Internal Medicine, University of Colorado School of Medicine, Denver, CO.,Denver Health and Hospital Authority, Denver, CO
| | - Rebecca Hanratty
- Division of General Internal Medicine, University of Colorado School of Medicine, Denver, CO.,Denver Health and Hospital Authority, Denver, CO
| | - Edward M Gardner
- Denver Health and Hospital Authority, Denver, CO.,Denver Public Health, Denver, CO
| | - Josh Durfee
- Denver Health and Hospital Authority, Denver, CO
| | - Komal J Narwaney
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
| | - Kristin Breslin
- Denver Health and Hospital Authority, Denver, CO.,Denver Public Health, Denver, CO
| | - Shane R Mueller
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
| | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO.,Department of Epidemiology, Colorado School of Public Health, Denver, CO
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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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Peck KR, Harman JL, Anghelescu DL. Provision of Adequate Pain Management to a Young Adult Oncology Patient Presenting with Aberrant Opioid-Associated Behavior: A Case Study. J Adolesc Young Adult Oncol 2018; 8:221-224. [PMID: 30335554 DOI: 10.1089/jayao.2018.0093] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Pain and emotional distress are relevant risk factors as clinicians assess for aberrant opioid-associated behavior and provide adequate and responsible pain relief to patients who engage in behaviors that may be interpreted as drug seeking in nature. The present case illustrates how undertreated pain and treatment-related anxiety affected the opioid use of a young adult with cancer. Because these risk factors were identified during the initial consult, the treatment team was able to implement a multimodal and multidisciplinary treatment approach that provided the patient with better analgesia and coping skills for anxiety.
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Affiliation(s)
- Kelly R Peck
- 1 Department of Psychology, University of Mississippi , University, Mississippi.,2 Vermont Center on Behavior and Health, University of Vermont , Burlington, Vermont
| | - Jennifer L Harman
- 3 Department of Psychology, St. Jude Children's Research Hospital , Memphis, Tennessee
| | - Doralina L Anghelescu
- 4 Division of Anesthesiology, Department of Pediatric Medicine, St. Jude Children's Research Hospital , Memphis, Tennessee
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A Biopsychosocial Approach to Managing HIV-Related Pain and Associated Substance Abuse in Older Adults: a Review. AGEING INTERNATIONAL 2018. [DOI: 10.1007/s12126-018-9333-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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45
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Black RA, McCaffrey SA, Villapiano AJ, Jamison RN, Butler SF. Development and Validation of an Eight-Item Brief Form of the SOAPP-R (SOAPP-8). PAIN MEDICINE 2018; 19:1982-1987. [PMID: 29024987 DOI: 10.1093/pm/pnx194] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective Although the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) has become a widely used screener for aberrant opioid-related behavior in adults, the length of the instrument may limit its utility. The purpose of the current study was to develop a short form of the SOAPP-R by retaining as few items as possible while maximizing predictive accuracy. Methods Participants (N = 555), recruited from pain clinics, completed the 24-item SOAPP-R and participated in a five-month follow-up visit to evaluate aberrant drug-related behaviors. Opioid aberrant-related behavior was determined through self-report, physician report, and urine toxicology screen. The optimal subset of SOAPP-R items to predict aberrant opioid-related behavior was identified empirically by employing the LASSO selection method and the leave-one-out cross-validation (LOOCV) method offered in the GLMSELECT procedure in SAS 9.4 in conjunction with content expertise. Results Eight items were identified before the selection method stopped. The receiver operating characteristic curve generated from the predicted probabilities from the model produced an area under the curve (AUC) value greater than the AUC value produced by the 24-item SOAPP-R total score and yielded a sensitivity of 0.74 and a specificity of 0.66. Conclusions These results provide strong preliminary support for the SOAPP-8 as a brief screening tool of aberrant opioid-related behavior in chronic pain patients.
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Affiliation(s)
| | | | | | - Robert N Jamison
- Anesthesia and Psychiatry, Brigham and Women's Hospital, Boston, MA
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Yennurajalingam S, Edwards T, Arthur JA, Lu Z, Najera J, Nguyen K, Manju J, Kuriakose L, Wu J, Liu D, Williams JL, Reddy SK, Bruera E. Predicting the risk for aberrant opioid use behavior in patients receiving outpatient supportive care consultation at a comprehensive cancer center. Cancer 2018; 124:3942-3949. [DOI: 10.1002/cncr.31670] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 04/04/2018] [Accepted: 06/11/2018] [Indexed: 01/18/2023]
Affiliation(s)
- Sriram Yennurajalingam
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Tonya Edwards
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Joseph A. Arthur
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Zhanni Lu
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - John Najera
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Kristy Nguyen
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Joy Manju
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Leela Kuriakose
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Jimin Wu
- Department of Quantitative Sciences; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Diane Liu
- Department of Biostatistics; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Janet L. Williams
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Suresh K. Reddy
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation, and Integrative Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas
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47
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Peglow SL, Binswanger IA. Preventing Opioid Overdose in the Clinic and Hospital: Analgesia and Opioid Antagonists. Med Clin North Am 2018; 102:621-634. [PMID: 29933819 PMCID: PMC6029888 DOI: 10.1016/j.mcna.2018.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Drawing from existing opioid prescribing guidelines, this article describes how medical providers can reduce the risk of overdose. Through primary prevention, providers can prevent initial exposure and associated risks by educating patients, using risk stratification, minimizing opioid dose and duration, and avoiding coprescribing with sedatives. Secondary prevention efforts include monitoring patients with urine toxicology and prescription monitoring programs, and screening for opioid use disorders. Tertiary prevention includes treating opioid use disorders and providing naloxone to prevent overdose death. Specific preventive strategies may be required for those with psychiatric disorders or substance use disorders, adolescents, the elderly, and pregnant women.
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Affiliation(s)
- Stephanie Lee Peglow
- Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, 825 Fairfax Avenue Suite 710, Norfolk, VA 23507, USA.
| | - Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, 2550 South Parker Road, Suite 200, Aurora, CO 80014, USA; Division of General Internal Medicine, Department of Medicine, University of Colorado, 12631 East 17th Avenue, Academic Office One, Campus Box B180, Aurora, CO 80045, USA
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48
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Whiteside LK, Goldstick J, Dora-Laskey A, Thomas L, Walton M, Cunningham R, Bohnert AS. Patient Preference for Pain Medication in the Emergency Department Is Associated with Non-fatal Overdose History. West J Emerg Med 2018; 19:722-730. [PMID: 30013710 PMCID: PMC6040914 DOI: 10.5811/westjem.2018.4.37019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 03/06/2018] [Accepted: 04/09/2018] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Opioid overdose is a major public health problem. Emergency physicians need information to better assess a patient's risk for overdose or opioid-related harms. The purpose of this study was to determine if patient-reported preference for specific pain medications was associated with a history of lifetime overdose among patients seeking care in the emergency department (ED). METHODS ED patients (18-60 years) completed a screening survey that included questions on overdose history, ED utilization, opioid misuse behaviors as measured by the Current Opioid Misuse Measure (COMM), and analgesic medication preferences for previous ED visits for pain with specific responses for preference for hydromorphone (Dilaudid®), morphine, ketorolac (Toradol®), "no preference" or "never visited the ED for pain." We compared individuals who reported a lifetime history of overdose descriptively to those without a lifetime history of overdose. Logistic regression was used to determine factors associated with a history of overdose. RESULTS We included 2,233 adults in the analysis (71.5% response rate of patients approached) with 532 reporting at least one lifetime overdose. In the univariate analysis, medication preference was significantly associated with overdose history (p < .001); more patients in the overdose group reported preferring morphine and hydromorphone and those without a history of overdose were more likely to have no preference or say they had never visited the ED for pain. In the logistic regression analysis, patients with higher odds of overdose included those of Caucasian race, participants with a higher COMM score, preference for ketorolac, morphine or hydromorphone. Those who were younger, female and reported never having visited the ED for pain had lower odds of reporting a lifetime overdose. Having "any preference" corresponded to 48% higher odds of lifetime overdose. CONCLUSION Patients with a pain medication preference have higher odds of having a lifetime overdose compared to patients without a specific pain medication preference, even after accounting for level of opioid misuse. This patient-reported preference could cue emergency physicians to identifying high-risk patients for overdose and other substance-related harms.
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Affiliation(s)
- Lauren K. Whiteside
- University of Washington, Department of Emergency Medicine, Seattle, Washington
| | - Jason Goldstick
- University of Michigan Medical School, University of Michigan Injury Center, Ann Arbor, Michigan
| | - Aaron Dora-Laskey
- University of Michigan Medical School, University of Michigan Injury Center, Ann Arbor, Michigan
- University of Michigan Medical School, Department of Emergency Medicine, Ann Arbor, Michigan
| | - Laura Thomas
- University of Michigan Medical School, Addiction Center and Department of Psychiatry, Ann Arbor, Michigan
- VA Center for Clinical Management Research, Department of Veterans Affairs Healthcare System, Ann Arbor, Michigan
| | - Maureen Walton
- University of Michigan Medical School, University of Michigan Injury Center, Ann Arbor, Michigan
- University of Michigan Medical School, Addiction Center and Department of Psychiatry, Ann Arbor, Michigan
| | - Rebecca Cunningham
- University of Michigan Medical School, University of Michigan Injury Center, Ann Arbor, Michigan
- University of Michigan Medical School, Department of Emergency Medicine, Ann Arbor, Michigan
| | - Amy S.B. Bohnert
- University of Michigan Medical School, University of Michigan Injury Center, Ann Arbor, Michigan
- University of Michigan Medical School, Addiction Center and Department of Psychiatry, Ann Arbor, Michigan
- VA Center for Clinical Management Research, Department of Veterans Affairs Healthcare System, Ann Arbor, Michigan
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49
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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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50
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Pilkonis PA, Yu L, Dodds NE, Johnston KL, Lawrence SM, Hilton TF, Daley DC, Patkar AA, McCarty D. An Item Bank for Abuse of Prescription Pain Medication from the Patient-Reported Outcomes Measurement Information System (PROMIS®). PAIN MEDICINE 2018; 18:1516-1527. [PMID: 28339555 DOI: 10.1093/pm/pnw233] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objective There is a need to monitor patients receiving prescription opioids to detect possible signs of abuse. To address this need, we developed and calibrated an item bank for severity of abuse of prescription pain medication as part of the Patient-Reported Outcomes Measurement Information System (PROMIS ® ). Methods Comprehensive literature searches yielded an initial bank of 5,310 items relevant to substance use and abuse, including abuse of prescription pain medication, from over 80 unique instruments. After qualitative item analysis (i.e., focus groups, cognitive interviewing, expert review, and item revision), 25 items for abuse of prescribed pain medication were included in field testing. Items were written in a first-person, past-tense format, with a three-month time frame and five response options reflecting frequency or severity. The calibration sample included 448 respondents, 367 from the general population (ascertained through an internet panel) and 81 from community treatment programs participating in the National Drug Abuse Treatment Clinical Trials Network. Results A final bank of 22 items was calibrated using the two-parameter graded response model from item response theory. A seven-item static short form was also developed. The test information curve showed that the PROMIS ® item bank for abuse of prescription pain medication provided substantial information in a broad range of severity. Conclusion The initial psychometric characteristics of the item bank support its use as a computerized adaptive test or short form, with either version providing a brief, precise, and efficient measure relevant to both clinical and community samples.
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Affiliation(s)
| | - Lan Yu
- Departments of Psychiatry.,Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | | | | | - Thomas F Hilton
- National Institute on Drug Abuse, Indian Harbour Beach, Florida
| | | | - Ashwin A Patkar
- Department of Psychiatry, Duke University School of Medicine, Durham, North Carolina.,Department of Community and Family Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Dennis McCarty
- School of Public Health, Oregon Health and Science University and Portland State University, Portland, Oregon, USA
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