Managing co-occurring substance use and pain disorders

Association of Opioid Use Disorder Diagnosis with Management of Acute Low Back Pain: A Medicare Retrospective Cohort Analysis

BACKGROUND

Practice guidelines recommend nonpharmacologic and nonopioid therapies as first-line pain treatment for acute pain. However, little is known about their utilization generally and among individuals with opioid use disorder (OUD) for whom opioid and other pharmacologic therapies carry greater risk of harm.

OBJECTIVE

To determine the association between a pre-existing OUD diagnosis and treatment of acute low back pain (aLBP).

DESIGN

Retrospective cohort study using 2016-2019 Medicare data.

PARTICIPANTS

Fee-for-service Medicare beneficiaries with a new episode of aLBP.

MAIN MEASURES

The main independent variable was OUD diagnosis measured prior to the first LBP claim (i.e., index date). Using multivariable logistic regressions, we assessed the following outcomes measured within 30 days of the index date: (1) nonpharmacologic therapies (physical therapy and/or chiropractic care), and (2) prescription opioids. Among opioid recipients, we further assessed opioid dose and co-prescription of gabapentin. Analyses were conducted overall and stratified by receipt of physical therapy, chiropractic care, opioid fills, or gabapentin fills during the 6 months before the index date.

KEY RESULTS

We identified 1,263,188 beneficiaries with aLBP, of whom 3.0% had OUD. Two-thirds (65.8%) did not receive pain treatments of interest at baseline. Overall, nonpharmacologic therapy receipt was less prevalent and opioid and nonopioid pharmacologic therapies were more common among beneficiaries with OUD than those without OUD. Beneficiaries with OUD had lower odds of receiving nonpharmacologic therapies (aOR = 0.62, 99%CI = 0.58-0.65) and higher odds of prescription opioid receipt (aOR = 2.24, 99%CI = 2.17-2.32). OUD also was significantly associated with increased odds of opioid doses ≥ 90 morphine milligram equivalents/day (aOR = 2.43, 99%CI = 2.30-2.56) and co-prescription of gabapentin (aOR = 1.15, 99%CI = 1.09-1.22). Similar associations were observed in stratified groups though magnitudes differed.

CONCLUSIONS

Medicare beneficiaries with aLBP and OUD underutilized nonpharmacologic pain therapies and commonly received opioids at high doses and with gabapentin. Complementing the promulgation of practice guidelines with implementation science could improve the uptake of evidence-based nonpharmacologic therapies for aLBP.

Opioids in the Management of Acute Pediatric Pain: An Update in a Time of Crisis

Management of acute pain in children is fundamental to our practice. Its myriad benefits include reduced suffering, improved patient satisfaction, more rapid recovery, and a reduced risk of developing postsurgical chronic pain. Although a multimodal analgesic approach is now routinely used, informed and judicious use of opioid receptor agonists remains crucial in this treatment paradigm, as long as the benefits and risks are fully understood. Further, an ongoing public health response to the current opioid crisis is required to help prevent new cases of opioid addiction, identify opioid-addicted individuals, and ensure access to effective opioid addiction treatment, while at the same time continuing to safely meet the needs of patients experiencing pain.

Beneficial opioid management strategies: A review of the evidence for the use of opioid treatment agreements

Background: The Centers for Disease Control and Prevention (CDC) and American Society of Interventional Pain Physicians (ASIPP) guidelines recommend opioid treatment agreements to reduce the misuse and abuse of opioids, but evidence of their effectiveness has not been well-established. This controversy has led to their varied use in primary care settings. The purpose of this review is to collect studies that assess the value of opioid treatment agreements and associated opioid misuse outcomes in patients with chronic non-cancer pain. Methods: This study used a modified preferred reporting items for systematic reviews and meta-analyses (PRISMA) approach which is organized by five distinct elements or steps: beginning with a clearly formulated question, using the question to develop clear inclusion criteria to identify relevant studies, using an approach to appraise the studies or a subset of the studies, summarizing the evidence using an explicit methodology, and interpreting the findings of the review. Results: Of 283 articles identified, six eligible studies were evaluated and assessed for quality. The study design, setting, and participants varied across the studies evaluated, and the methods of measuring primary and secondary outcomes were also diverse across all studies. One study was a randomized clinical trial (RCT), four studies were retrospective cohort studies (RCS), and one study was a prospective cohort study (PCS). The design, methods, and indication for misuse of these studies contributed to quality scores of very low for one study, low for four studies, and moderate for one study. Conclusion: This systematic review shows weak evidence to support the effectiveness of patient prescriber agreements in the reduction and mitigation of opioid misuse and abuse. Further research is needed to determine if these agreements are beneficial as an opioid management strategy.

A prospective, longitudinal study to evaluate the clinical utility of a predictive algorithm that detects risk of opioid use disorder

Purpose

The purpose of this study was to determine the clinical utility of an algorithm-based decision tool designed to assess risk associated with opioid use. Specifically, we sought to assess how physicians were using the profile in patient care and how its use affected patient outcomes.

Patients and methods

A prospective, longitudinal study was conducted to assess the utility of precision medicine testing in 5,397 patients across 100 clinics in the USA. Using a patent-protected, validated algorithm combining specific genetic risk factors with phenotypic traits, patients were categorized into low-, moderate-, and high-risk patients for opioid abuse. Physicians who ordered precision medicine testing were asked to complete patient evaluations and document their actions, decisions, and perceptions regarding the utility of the precision medicine tests. The patient outcomes associated with each treatment action were carefully documented.

Results

Physicians used the profile to guide treatment decisions for over half of the patients. Of those, guided treatment decisions for 24.5% of the patients were opioid related, including changing the opioid prescribed, starting an opioid, or titrating a patient off the opioid. Treatment guidance was strongly influenced by profile-predicted opioid use disorder (OUD) risk. Most importantly, patients whose physicians used the profile to guide opioid-related treatment decisions had improved clinical outcomes, including better pain management by medication adjustments, with an average pain decrease of 3.4 points on a scale of 1–10.

Conclusion

Patients whose physicians used the profile to guide opioid-related treatment decisions had improved clinical outcomes, as measured by decreased pain levels resulting from better pain management with prescribed medications. The clinical utility of the profile is twofold. It provides clinically actionable recommendations that can be used to 1) prevent OUD through limiting initial opioid prescriptions and 2) reduce pain in patients at low risk of developing OUD.

A Predictive Algorithm to Detect Opioid Use Disorder: What Is the Utility in a Primary Care Setting?

PURPOSE

The purpose of this study was to determine the clinical utility of an algorithm-based decision tool designed to assess risk associated with opioid use in the primary care setting.

METHODS

A prospective, longitudinal study was conducted to assess the utility of precision medicine testing in 1822 patients across 18 family medicine/primary care clinics in the United States. Using the profile, patients were categorized into low, moderate, and high risk for opioid use. Physicians who ordered testing were asked to complete patient evaluations and document their actions, decisions, and perceptions regarding the utility of the precision medicine tests.

RESULTS

Approximately 47% of primary care physicians surveyed used the profile to guide clinical decision-making. These physicians rated the benefit of the profile on patient care an average of 3.6 on a 5-point scale (1 indicating no benefit and 5 indicating significant benefit). Eighty-eight percent of all clinicians surveyed felt the test exhibited some benefit to their patient care. The most frequent utilization for the profile was to guide a change in opioid prescribed. Physicians reported greater benefit of profile utilization for minority patients. Patients whose treatment was guided by the profile had pain levels that were reduced, on average, 2.7 levels on the numeric rating scale.

CONCLUSIONS

The profile provided primary care physicians with a useful tool to stratify the risk of opioid use disorder and was rated as beneficial for decision-making and patient improvement by the majority of physicians surveyed. Physicians reported the profile resulted in greater clinical improvement for minorities, highlighting the objective use of this profile to guide judicial use of opioids in high-risk patients. Significantly, when physicians used the profile to guide treatment decisions, patient-reported pain was greatly reduced.

Opioid Prescribing for the Treatment of Acute Pain in Children on Hospital Discharge

BACKGROUND

The epidemic of nonmedical use of prescription opioids has been fueled by the availability of legitimately prescribed unconsumed opioids. The aim of this study was to better understand the contribution of prescriptions written for pediatric patients to this problem by quantifying how much opioid is dispensed and consumed to manage pain after hospital discharge, and whether leftover opioid is appropriately disposed of. Our secondary aim was to explore the association of patient factors with opioid dispensing, consumption, and medication remaining on completion of therapy.

METHODS

Using a scripted 10-minute interview, parents of 343 pediatric inpatients (98% postoperative) treated at a university children's hospital were questioned within 48 hours and 10 to 14 days after discharge to determine amount of opioid prescribed and consumed, duration of treatment, and disposition of unconsumed opioid. Multivariable linear regression was used to examine predictors of opioid prescribing, consumption, and doses remaining.

RESULTS

Median number of opioid doses dispensed was 43 (interquartile range, 30-85 doses), and median duration of therapy was 4 days (interquartile range, 1-8 days). Children who underwent orthopedic or Nuss surgery consumed 25.42 (95% confidence interval, 19.16-31.68) more doses than those who underwent other types of surgery (P < .001), and number of doses consumed was positively associated with higher discharge pain scores (P = .032). Overall, 58% (95% confidence interval, 54%-63%) of doses dispensed were not consumed, and the strongest predictor of number of doses remaining was doses dispensed (P < .001). Nineteen percent of families were informed how to dispose of leftover opioid, but only 4% (8 of 211) did so.

CONCLUSIONS

Pediatric providers frequently prescribed more opioid than needed to treat pain. This unconsumed opioid may contribute to the epidemic of nonmedical use of prescription opioids. Our findings underscore the need for further research to develop evidence-based opioid prescribing guidelines for physicians treating acute pain in children.

Benzodiazepine use in patients with chronic pain in an interdisciplinary pain rehabilitation program

Objectives

In the context of widespread opioid use, increased emphasis has been placed on the potentially deleterious effects of concurrent benzodiazepine (BZD) and opioid use. Although use of opioids in chronic pain has been a major focus, BZD use is equally concerning. Thus, the primary aim of this study was to determine the associations between BZD and opioid use in adults with chronic pain upon admission to an outpatient interdisciplinary pain rehabilitation (IPR) program.

Methods

The study cohort involved 847 consecutive patients admitted to a 3-week outpatient IPR program from January 2013 through December 2014. Study variables included baseline demographic and clinical characteristics, Center for Epidemiologic Studies-Depression Scale, Pain Catastrophizing Scale, and the pain severity subscale of the Multidimensional Pain Inventory.

Results

Upon admission, 248 (29%) patients were taking BZDs. Patients using BZDs were significantly more likely to use opioids and to be female. Additionally, patients using BZDs had significantly greater depression, pain catastrophizing, and pain severity scores. In univariable logistic regression analysis, opioid use, female sex, and greater scores of depression, pain catastrophizing, and pain severity were significantly associated with BZD use. In multivariable logistic regression analysis adjusted for age, sex, pain duration, opioid use, depression, pain catastrophizing, and pain severity, only female sex and greater depression scores were significantly associated with BZD use.

Discussion

Among patients participating in an outpatient IPR program, female sex and greater depression scores were associated with BZD use. Results identify a high prevalence of BZD use in patients with chronic pain and reinforce the need to weigh the risks versus benefits when prescribing in this patient population.

Pain Control in the Presence of Drug Addiction

Drug addiction is present in a significant proportion of the population in the USA and worldwide. Drug addiction can occur with the abuse of many types of substances including cocaine, marijuana, stimulants, alcohol, opioids, and tranquilizers. There is a high likelihood that clinicians will encounter patients with substance abuse disorders on a regular basis with the prevalence of the use of illicit substances and the high rate of abuse of prescription drugs. The use of abuse deterrent formulations of prescription opioid agents, pill counts, and urine drug abuse screenings are all useful strategies. Optimum pain management of patients with addiction in the outpatient and inpatient setting is essential to minimize pain states. Careful selection of medications and appropriate oversight, including drug agreements, can reduce drug-induced impairments, including sleep deficits and diminished physical, social, and sexual functioning. This review, therefore, discusses the prevalence of illicit and prescription drug addiction, the challenges of achieving optimum pain control, and the therapeutic approaches to be considered in this challenging population. More research is warranted to develop improved therapies and routes of treatments for optimum pain relief and to prevent the development of central sensitization, chronic pain, and impaired physical and social functioning in patients with drug addiction.

Increased Preoperative Narcotic Use and Its Association With Postoperative Complications and Length of Hospital Stay in Patients Undergoing Spine Surgery

STUDY DESIGN

Prospective cohort analysis.

OBJECTIVE

To assess the effect of preoperative narcotic use on the incidence of 30- and 90-day postoperative complications, as well as length of hospital stay (LOS) in patients undergoing spine surgery.

SUMMARY OF BACKGROUND DATA

Previous work has associated an increased incidence of complications and length of stay following surgery in patients with increased preoperative narcotic use. Despite this and recent national attention highlighting the negative effects of narcotics, they remain commonly used for the management of pain in patients undergoing spine surgery.

MATERIALS AND METHODS

A total of 583 patients undergoing spine surgery for a structural lesion were evaluated. Self-reported preoperative narcotic consumption was obtained and converted to morphine equivalents at the initial preoperative visit. LOS was recorded upon discharge and presence/type of a postoperative complication within 30/90 days was obtained. A multivariable logistic and linear regression analysis was performed for the incidence of complications and length of stay controlling for clinically important covariates.

RESULTS

Narcotic use was not associated with 30- or 90-day complications; however, smoking status was significantly associated with 30-day complications. Increased preoperative narcotic use was significantly associated with increased LOS, as was age, type of surgery, and depression.

CONCLUSIONS

Increased preoperative narcotic use and depression are associated with increased LOS in patients undergoing spine surgery. We calculated that for every 100 morphine equivalents a patient is taking preoperatively; their stay is extended 1.1 days. Narcotic use was not associated with 30- or 90-day postoperative complications. As reimbursement is bundled before surgery, providing interventions for patients with treatable causes for increased length of stay can save cost overall.

Managing Substance Use and Emotions in the Context of Trauma: A Case Study

The reciprocal interaction between substance use, trauma, and emotions is well documented. Trauma is associated with neuroendocrine and neurobiological dysfunction and the subsequent development of psychopathology in adults. Cumulative trauma triggers, aggravates, and increases the recurrence of psychiatric symptoms. Individuals suffering the psychiatric sequelae of cumulative trauma have a more complex clinical profile, ultimately resulting in worse treatment outcomes. Limited guidance exists in the form of treatment guidelines or clinical evidence on the management of substance use and emotions in the context of trauma. This article chronicles one patient's experience with cumulative trauma, depression, anxiety, and iatrogenic opioid dependence. The authors review the impact of trauma on brain function and discuss evidence and treatment strategies engaged in the management of this patient.

The Medicinal Cannabis Treatment Agreement: Providing Information to Chronic Pain Patients Through a Written Document

AIM

Pain practitioners would seem to have an obligation to understand and inform their patients on key issues of the evidence base on cannabinoid therapeutics. One way to fulfill this obligation might be to borrow from concepts developed in the prescription of opioids: the use of a written agreement to describe and minimize risks. Regrettably, the widespread adoption of opioids was undertaken while harmful effects were minimized; obviously, no one wants to repeat this misstep.

OBJECTIVE

This article describes a method of educating patients in a manner analogous to other treatment agreements.

BACKGROUND

Surveys have demonstrated that pain is the most common indication for medical use of cannabis. As more individuals gain access to this botanical product through state ballot initiatives and legislative mandate, the pain specialist is likely to be confronted by patients either seeking such treatment where permitted, or otherwise inquiring about its potential benefits and harms, and alternative pharmaceuticals containing cannabinoids.

METHODS

PubMed searches were conducted using the following keywords: cannabis guidelines, harmful effects of cannabis, medical marijuana, medicinal cannabis, opioid cannabis interaction, cannabis dependence and cannabis abuse

RESULTS

: The authors selected individual tenets a medicinal cannabis patient would be asked to review and acknowledge via signature.

CONCLUSIONS

Undoubtedly, the knowledge base concerning risks will be an iterative process as we learn more about the long-term use of medicinal cannabis. But we should start the process now so that patients may be instructed about our current conception of what the use of medicinal cannabis entails.

Self-management of pain among people who inject drugs in Vancouver

AIMS

To evaluate factors and methods associated with self-management of pain among people who inject drugs (IDUs) in Vancouver (Canada).

PATIENTS & METHODS

This cross-sectional study used bivariate statistics and multivariate logistic regression to analyze self-reported responses among 483 IDUs reporting moderate-to-extreme pain in two prospective cohort studies from 1 December 2012 to 31 May 2013.

RESULTS

Median age was 49.6 years (interquartile range: 43.9-54.6 years), 33.1% of IDUs were female and 97.5% reported self-management of pain. Variables independently and positively associated with self-managed pain included having been refused a prescription for pain medication (adjusted odds ratio: 7.83; 95% CI: 1.64-37.3) and having ever been homeless (adjusted odds ratio: 3.70; 95% CI: 1.00-13.7). Common methods of self-management of pain included injecting heroin (52.7%) and obtaining diverted prescription pain medication from the street (65.0%).

CONCLUSION

Self-management of pain was common among IDUs who reported moderate-to-extreme pain in this setting, particularly among those who had been refused a prescription for pain medication and those who had ever been homeless. These data highlight the challenges of adequate pain management among IDUs.

Costs and Consequences: A Review of Discharge Opioid Prescribing for ongoing Management of Acute Pain

Over recent years there has been a growing need for patients to be sent home from hospital with prescribed opioids for ongoing management of their acute pain. Increasingly complex surgery is being performed on a day-stay or 23-hour-stay basis and inpatients after major surgery and trauma are now discharged at a much earlier stage than in the past. However, prescription of opioids to be self-administered at home is not without risk. In addition to the potential for acute adverse effects, including opioid-induced ventilatory impairment and impairment of driving skills, a review of the literature shows that opioid use continues in some patients for some years after surgery. There are also indications that over-prescription of discharge opioids occur with a significant amount not consumed, resulting in a potentially large pool of unused opioid available for later use by either the patient or others in the community. Concerns about the potential for harm arising from prescription of opioids for ongoing acute pain management after discharge are relatively recent. However, at a time when serious problems resulting from the non-medical use of opioids have reached epidemic proportions in the community, all doctors must be aware of the potential risks and be able to identify and appropriately manage patients where there might be a risk of prolonged opioid use or misuse. Anaesthetists are ideally placed to exercise stewardship over the use of opioids, so that these drugs can maintain their rightful place in the post-discharge analgesic pharmacopoeia.

Rules and values: a coordinated regulatory and educational approach to the public health crises of chronic pain and addiction

Chronic pain and opioid addiction are 2 pressing public health problems, and prescribing clinicians often lack the skills necessary to manage these conditions. Our study sought to address the benefits of a coalition of an academic medical center pain faculty and government agencies in addressing the high unintentional overdose death rates in New Mexico. New Mexico's 2012-2013 mandated chronic pain and addiction education programs studied more than 1000 clinicians. Positive changes were noted in precourse and postcourse surveys of knowledge, self-efficacy, and attitudes. Controlled substance dispensing data from the New Mexico Board of Pharmacy also demonstrated safer prescribing. The total morphine and Valium milligram equivalents dispensed have decreased continually since 2011. There was also a concomitant decline in total drug overdose deaths.

Urine specimen detection of zolpidem use in patients with pain

This study examined zolpidem and concurrent opioid, benzodiazepine, other central nervous system (CNS) depressants, and alcohol use. Urine specimens were analyzed using liquid chromatography-mass spectrometry (LC-MS/MS). Specimens were tested for zolpidem (n = 71,919) and separated into a provider-reported medication list documenting (n = 5,257) or not documenting zolpidem use (n = 66,662). Zolpidem-positive specimens were further separated into reported and unreported use cohorts. The total number of zolpidem-positive specimens in the reported and unreported use cohorts was 3,391 and 3,190, respectively. Non-informed prescribers were 4.4% (3,190/71,919) among the general population and 48.5% (3,190/6,581) when only zolpidem users were considered. In the zolpidem user population, the most common concurrent opioids in both cohorts were hydrocodone and oxycodone. Alprazolam and clonazepam were higher in the unreported use cohort (P ≤ 0.05). The unreported use cohort also had a higher detection of zolpidem plus a benzodiazepine (49.7 vs. 46%; P ≤ 0.05), zolpidem plus an opioid and a benzodiazepine (40.8% vs. 37.4%; P ≤ 0.05) and zolpidem plus an opioid, a benzodiazepine, and an other CNS depressant (12.9 vs. 10.9%; P ≤ 0.05). Concurrent use of zolpidem, an opioid, a benzodiazepine and an other CNS depressant is prevalent in a pain patient population.

Fibromyalgia comorbid with anxiety disorders and depression: combined medical and psychological treatment

Fibromyalgia is associated with high level of pain and suffering. Lack of diagnosis leads to onerous indirect economic costs. Recent data indicate that fibromyalgia; anxiety disorders, and depression tend to occur as comorbid conditions. They also share some common neurochemical dysfunctions and central nervous system alterations such as hypofunctional serotonergic system and altered reactivity of the hypothalamic-pituitary-adrenal axis. Conversely, functional neuroimaging findings point to different patterns of altered pain processing mechanisms between fibromyalgia and depression. There is no cure for fibromyalgia, and treatment response effect size is usually small to moderate. Treatment should be based on drugs that also target the comorbid psychiatric condition. Combined pharmacotherapy and cognitive-behavior therapy should ideally be offered to all patients. Lifestyle changes, such as physical exercise should be encouraged. The message to patients should be that all forms of pain are true medical conditions and deserve proper care.

Preoperative narcotic use and its relation to depression and anxiety in patients undergoing spine surgery

STUDY DESIGN

Prospective review of registry data at a single institution from October 2010 to June 2012.

OBJECTIVE

To assess whether the amount of preoperative narcotic use is associated with preoperative depression and anxiety in patients undergoing spine surgery for a structural lesion.

SUMMARY OF BACKGROUND DATA

Previous work suggests that narcotic use and psychiatric comorbidities are significantly related. Among other psychological considerations, depression and anxiety may be associated with the amount of preoperative narcotic use in patients undergoing spine surgery.

METHODS

Five hundred eighty-three patients undergoing lumbar (60%), thoracolumbar (11%), or cervical spine (29%) were included. Self-reported preoperative narcotic consumption was obtained at the initial preoperative visit and converted to daily morphine equivalent amounts. Preoperative Zung Depression Scale (ZDS) and Modified Somatic Perception Questionnaire (MSPQ) scores were also obtained at the initial preoperative visit and recorded as measures of depression and anxiety, respectively. Resistant and robust bootstrapped multivariable linear regression analysis was performed to determine the association between ZDS and MSPQ scores and preoperative narcotics, controlling for clinically important covariates. Mann-Whitney U tests examined preoperative narcotic use in patients who were categorized as depressed (ZDS ≥ 33) or anxious (MSPQ ≥ 12).

RESULTS

Multivariable analysis controlling for age, sex, smoking status, preoperative employment status, and prior spinal surgery demonstrated that preoperative ZDS (P = 0.006), prior spine surgery (P = 0.007), and preoperative pain (0.014) were independent risk factors for preoperative narcotic use. Preoperative MSPQ (P = 0.083) was nearly a statistically significant risk factor. Patients who were categorized as depressed or anxious on the basis of ZDS and MSPQ scores also showed higher preoperative narcotic use than those who were not (P < 0.0001).

CONCLUSION

Depression and anxiety as assessed by ZDS and MSPQ scores were significantly associated with increased preoperative narcotic use, underscoring the importance of thorough psychological and substance use evaluation in patients being evaluated for spine surgery.