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Coates S, Bardhi K, Lazarus P. Cannabinoid-Induced Inhibition of Morphine Glucuronidation and the Potential for In Vivo Drug-Drug Interactions. Pharmaceutics 2024; 16:418. [PMID: 38543313 PMCID: PMC10975434 DOI: 10.3390/pharmaceutics16030418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 03/12/2024] [Accepted: 03/13/2024] [Indexed: 04/01/2024] Open
Abstract
Opioids are commonly prescribed for the treatment of chronic pain. Approximately 50% of adults who are prescribed opioids for pain co-use cannabis with their opioid treatment. Morphine is primarily metabolized by UDP-glucuronosyltransferase (UGT) 2B7 to an inactive metabolite, morphine-3-glucuronide (M3G), and an active metabolite, morphine-6-glucuronide (M6G). Previous studies have shown that major cannabis constituents including Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD) inhibit major UGT enzymes. To examine whether cannabinoids or their major metabolites inhibit morphine glucuronidation by UGT2B7, in vitro assays and mechanistic static modeling were performed with these cannabinoids and their major metabolites including 11-hydroxy-Δ9-tetrahydrocannabinol (11-OH-THC), 11-nor-9-carboxy-Δ9-tetrahydrocannabinol (11-COOH-THC), 7-hydroxy-cannabidiol (7-OH-CBD), and 7-carboxy-cannabidiol (7-COOH-CBD). In vitro assays with rUGT-overexpressing microsomes and human liver microsomes showed that THC and CBD and their metabolites inhibited UGT2B7-mediated morphine metabolism, with CBD and THC exhibiting the most potent Ki,u values (0.16 µM and 0.37 µM, respectively). Only 7-COOH-CBD exhibited no inhibitory activity against UGT2B7-mediated morphine metabolism. Static mechanistic modeling predicted an in vivo drug-drug interaction between morphine and THC after inhaled cannabis, and between THC, CBD, and 7-OH-CBD after oral consumption of cannabis. These data suggest that the co-use of these agents may lead to adverse drug events in humans.
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Affiliation(s)
| | | | - Philip Lazarus
- Department of Pharmaceutical Sciences, College of Pharmacy and Pharmaceutical Sciences, Washington State University, 412 E. Spokane Falls Blvd, Spokane, WA 99202, USA
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Rutkowski K, Wyszatycki M, Ejdys K, Hawryluk NM, Stompór M. Pain and Its Management in Patients Referred to a Geriatric Outpatient Clinic. J Pers Med 2023; 13:1366. [PMID: 37763134 PMCID: PMC10532457 DOI: 10.3390/jpm13091366] [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: 08/09/2023] [Revised: 08/29/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
(1) Background: A major problem affecting geriatric patients is pain. In addition to pain, a significant problem of old age is dementia and depression, which can hinder the diagnosis and treatment of pain. The aim of this study was to analyse the prevalence of pain in patients treated in a geriatric outpatient clinic and the treatment used. (2) Methods: The analysis was based on the records of 937 patients who visited the Geriatric Outpatient Clinic in Dobre Miasto between 2015 and 2020. Based on records containing data dating back to their first visit to the hospital, patients' experiences of pain, the presence of depressive symptoms and dementia, and the pharmacological treatment used for pain (analgesics and coanalgesics) were analysed. (3) Results: Pain complaints were reported by 311 patients (33.2% of the study group), 76% of the complaints were from females. The mean age of the patients was 78 years (SD = 8.45). At least one analgesic drug was taken by 107 patients (34.4%). The most commonly used analgesics were opioids (63 patients, 58.87%), especially tramadol. Of the potential coanalgesics, the largest number of patients used an antidepressant. (4) Conclusions: Despite the widespread prevalence of pain among the elderly, only about one-third of them were taking pain medication, mainly in the form of weak opioids. Patients with symptoms of dementia were found to report pain less frequently.
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Affiliation(s)
- Krzysztof Rutkowski
- The Nicolaus Copernicus Municipal Polyclinical Hospital in Olsztyn, 10-045 Olsztyn, Poland
| | - Mateusz Wyszatycki
- Marie Sklodowska-Curie Specialist Hospital in Zgierz, 95-100 Zgierz, Poland
| | - Krystian Ejdys
- Students’ Scientific Group, Department of Cardiology, Medical University of Bialystok, 15-089 Białystok, Poland
| | - Natalia Maria Hawryluk
- The Nicolaus Copernicus Municipal Polyclinical Hospital in Olsztyn, 10-045 Olsztyn, Poland
- Department of Family Medicine and Infectious Diseases, Medical Faculty, Collegium Medicum, University of Warmia and Mazury, 10-719 Olsztyn, Poland
| | - Małgorzata Stompór
- Department of Family Medicine and Infectious Diseases, Medical Faculty, Collegium Medicum, University of Warmia and Mazury, 10-719 Olsztyn, Poland
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3
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Vowles KE, Witkiewitz K, Clarke E, Schmidt Z, Borsari B, Edwards KE, Korecki JR, Moniz-Lewis DI, Bondzie JA, Mullins C, Thoreson CI, Delacruz J, Wilkins CH, Nelson S, Delventura J, Henderson R, Katz A, Hua W, Watson E, Baxley C, Canlas BR, Pendleton T, Herbst E, Batki S. Rationale and design of a multisite randomized clinical trial examining an integrated behavioral treatment for veterans with co-occurring chronic pain and opioid use disorder: The pain and opioids integrated treatment in veterans (POSITIVE) trial. Contemp Clin Trials 2023; 126:107096. [PMID: 36693589 DOI: 10.1016/j.cct.2023.107096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/13/2023] [Accepted: 01/18/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND Chronic pain and opioid use disorder (OUD) individually represent a risk to health and well-being. Concerningly, there is evidence that they are frequently co-morbid. While few treatments exist that simultaneously target both conditions, preliminary work has supported the feasibility of an integrated behavioral treatment targeting pain interference and opioid misuse. This treatment combined Acceptance and Commitment Therapy (ACT) and Mindfulness-Based Relapse Prevention (ACT+MBRP). This paper describes the protocol for the adequately powered efficacy study of this integrated treatment. METHODS A multisite randomized controlled trial will examine the efficacy of ACT+MBRP in comparison to a parallel education control condition, focusing on opioid safety and pain education. Participants include veterans (n = 160; 21-75 years old) recruited from three Veterans Administration (VA) Healthcare Systems with chronic pain who are on a stable dose of buprenorphine. Both conditions include twelve weekly 90 min group sessions delivered via telehealth. Primary outcomes include pain interference (Patient Reported Outcome Measurement Information System - Pain Interference) and hazardous opioid use (Current Opioid Misuse Measure), which will be examined at the end of the active treatment phase and through 12 months post-intervention. Secondary analyses will evaluate outcomes including pain intensity, depression, pain-related fear, and substance use, as well as treatment mechanisms. CONCLUSION This study will determine the efficacy of an integrated behavioral treatment program for pain interference and hazardous opioid use among veterans with chronic pain and OUD who are prescribed buprenorphine, addressing a critical need for more integrated treatments for chronic pain and OUD. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04648228.
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Affiliation(s)
- Kevin E Vowles
- School of Psychology, Queen's University Belfast, Belfast, Northern Ireland, UK.
| | - Katie Witkiewitz
- Department of Psychology, University of New Mexico, Albuquerque, NM, USA.
| | - Erik Clarke
- Puget Sound Veterans Affairs Healthcare Administration, Tacoma, WA, USA
| | - Zachary Schmidt
- Raymond G. Murphy Veterans Affairs Medical Center, New Mexico Veteran Affairs Healthcare System, Albuquerque, NM, USA
| | - Brian Borsari
- San Francisco Veteran Affairs Medical Center and University of California - San Francisco, San Francisco, CA, USA
| | - Karlyn E Edwards
- Department of Anesthesiology, Perioperative, and Pain Medicine, Division of Pain Medicine Stanford University, Palo Alto, CA, USA
| | - J Richard Korecki
- Department of Psychology, University of California, Los Angeles, Los Angeles, CA, USA
| | | | - Juliana A Bondzie
- Puget Sound Veterans Affairs Healthcare Administration, Tacoma, WA, USA
| | - Chloe Mullins
- Raymond G. Murphy Veterans Affairs Medical Center, New Mexico Veteran Affairs Healthcare System, Albuquerque, NM, USA
| | - Claire I Thoreson
- Puget Sound Veterans Affairs Healthcare Administration, Tacoma, WA, USA
| | - Joannalyn Delacruz
- San Francisco Veteran Affairs Medical Center and University of California - San Francisco, San Francisco, CA, USA
| | - Consuelo H Wilkins
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University, Nashville, TN, USA
| | - Sarah Nelson
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University, Nashville, TN, USA
| | | | - Ryan Henderson
- Puget Sound Veterans Affairs Healthcare Administration, Tacoma, WA, USA
| | - Andrea Katz
- Puget Sound Veterans Affairs Healthcare Administration, Tacoma, WA, USA
| | - William Hua
- San Francisco Veteran Affairs Medical Center and University of California - San Francisco, San Francisco, CA, USA
| | - Erin Watson
- San Francisco Veteran Affairs Medical Center and University of California - San Francisco, San Francisco, CA, USA
| | - Catherine Baxley
- San Francisco Veteran Affairs Medical Center and University of California - San Francisco, San Francisco, CA, USA
| | - Bernard R Canlas
- Puget Sound Veterans Affairs Healthcare Administration, Tacoma, WA, USA
| | - Tiffany Pendleton
- Raymond G. Murphy Veterans Affairs Medical Center, New Mexico Veteran Affairs Healthcare System, Albuquerque, NM, USA
| | - Ellen Herbst
- San Francisco Veteran Affairs Medical Center and University of California - San Francisco, San Francisco, CA, USA
| | - Steven Batki
- San Francisco Veteran Affairs Medical Center and University of California - San Francisco, San Francisco, CA, USA
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Molnar AO, Bota SE, Naylor K, Nash DM, Smith G, Suri RS, Sood MM, Gomes T, Garg AX. Opioid prescribing practices in chronic kidney disease: a population-based cohort study. Nephrol Dial Transplant 2022; 37:2408-2417. [PMID: 34888696 DOI: 10.1093/ndt/gfab343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Chronic pain is common, and its management is complex in patients with chronic kidney disease (CKD), but limited data are available on opioid prescribing. We examined opioid prescribing for non-cancer and non-end-of-life care in patients with CKD. METHODS This was a population-based retrospective cohort study using administrative databases in Ontario, Canada which included adults with CKD defined by an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 from 1 November 2012 to 31 December 2018 and estimated the proportion of opioid prescriptions (type, duration, dose, potentially inappropriate prescribing, etc.) within 1 year of cohort entry. Prescriptions had to precede dialysis, kidney transplant or death. RESULTS We included 680 445 adults with CKD, and 198 063 (29.1%) were prescribed opioids. Codeine (14.9%) and hydromorphone (7.2%) were the most common opioids. Among opioid users, 24.3% had repeated or long-term use, 26.1% were prescribed high doses and 56.8% were new users. Opioid users were more likely to be female, had cardiac disease or a mental health diagnosis, and had more healthcare visits. The proportions for potentially inappropriate prescribing indicators varied (e.g. 50.1% with eGFR <30 were prescribed codeine, and 20.6% of opioid users were concurrently prescribed benzodiazepines, while 7.2% with eGFR <30 mL/min/1.73 m2 were prescribed morphine, and 7.0% were received more than one opioid concurrently). Opioid prescriptions declined with time (2013 cohort: 31.1% versus 2018 cohort: 24.5%; p <0.0001), as did indicators of potentially inappropriate prescribing. CONCLUSIONS Opioid use was common in patients with CKD. While opioid prescriptions and potentially inappropriate prescribing have declined in recent years, interventions to improve pain management without the use of opioids and education on safer prescribing practices are needed.
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Affiliation(s)
- Amber O Molnar
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, ON, Canada.,ICES, ON, Canada
| | | | | | | | | | - Rita S Suri
- Research Institute of the McGill University Health Center (MUHC), and Division of Nephrology, Department of Medicine, MUHC, Montreal, QC, Canada.,Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Manish M Sood
- ICES, ON, Canada.,Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Tara Gomes
- ICES, ON, Canada.,Unity Health, Toronto, ON, Canada
| | - Amit X Garg
- ICES, ON, Canada.,Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
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5
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Avoundjian T, Troszak L, Cohen J, Foglia MB, Trafton J, Midboe A. Impact of Informed Consent and Education on Care Engagement After Opioid Initiation in the Veterans Health Administration. J Pain Res 2022; 15:1553-1562. [PMID: 35642185 PMCID: PMC9148610 DOI: 10.2147/jpr.s317183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 09/06/2021] [Indexed: 11/25/2022] Open
Abstract
Objective To ensure all patients receiving long-term opioid therapy (LTOT) understand the risks, benefits and treatment alternatives, the Veterans Health Administration (VHA) released a national policy in 2014 to standardize a signature informed consent (SIC) process. We evaluated the impact of this policy on medical follow-up after LTOT initiation, a guideline recommended practice. Methods Using VHA administrative data, we identified patients initiating LTOT between May 2013 and May 2016. We used an interrupted time series design to compare the monthly rates of medical follow-up within 30 days and primary care visits within 3 months after LTOT initiation across three periods: 12 months before the policy (Year 1); 12 months after policy release (Year 2); and 12-24 months after policy release, when the SIC process was mandatory (Year 3). Results Among the 409,895 patients who experienced 758,416 LTOT initiations, medical follow-up within 30 days and primary care engagement within 3 months increased by 4% between Year 1 and Year 3. Compared to Year 1, patients in Year 3 were 1.12 times more likely to have any medical follow-up (95% CI: 1.10, 1.13) and 1.13 times more likely to have a primary care visit (95% CI: 1.12, 1.15). Facilities with a greater proportion of patients receiving SIC had increased medical follow-up (RR: 1.04, 95% CI: 1.01, 1.07) and primary care engagement (RR: 1.06, 95% CI: 1.03, 1.10). Conclusion The VHA's SIC policy is associated with increased medical follow-up among patients initiating LTOT, which may result in improved patient safety and has implications for other healthcare settings.
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Affiliation(s)
- Tigran Avoundjian
- Center for Innovation to Implementation, Va Palo Alto Health Care System, Palo Alto, CA, USA
| | - Lara Troszak
- Center for Innovation to Implementation, Va Palo Alto Health Care System, Palo Alto, CA, USA
- School of Medicine, Stanford University, Stanford, CA, USA
| | - Jennifer Cohen
- National Center for Ethics in Health Care, Veterans Affairs, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Mary Beth Foglia
- National Center for Ethics in Health Care, Veterans Affairs, Seattle, WA, USA
- Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle, WA, USA
| | - Jodie Trafton
- Center for Innovation to Implementation, Va Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Stanford University, Stanford, CA, USA
- VA Office of Mental Health and Suicide Prevention, VA Palo Alto Healthcare System, Menlo Park, CA, USA
| | - Amanda Midboe
- Center for Innovation to Implementation, Va Palo Alto Health Care System, Palo Alto, CA, USA
- School of Medicine, Stanford University, Stanford, CA, USA
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6
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Berger AA, Syed Z, Ryan L, Lee C, Hasoon J, Urits I, Viswanath O, Cornett EM, Kaye AD, Eskander JP. Superior Block Length and Reduced Opioid Use with Dexmedetomidine and Dexamethasone regional block versus plain Ropivacaine: a retrospective trial. Orthop Rev (Pavia) 2022; 14:31921. [DOI: 10.52965/001c.31921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Amnon A Berger
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Zuby Syed
- Georgetown University School of Medicine, Washington DC
| | | | - Christopher Lee
- Creighton University School Of Medicine—Phoenix Regional Campus, Phoenix, AZ
| | - Jamal Hasoon
- Baylor College of Medicine, Department of Anesthesiology, Houston, TX
| | - Ivan Urits
- Louisiana State University Health Shreveport, Shreveport, LA
| | - Omar Viswanath
- Louisiana State University Health Shreveport, Shreveport, LA
| | - Elyse M Cornett
- Louisiana State University Health Shreveport, Shreveport, LA
| | - Alan D Kaye
- Louisiana State University Health Shreveport, Shreveport, LA
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7
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Su L, Bai X, Niu T, Zhuang X, Dong B, Wang G, Yu Y. P2Y1 purinergic receptor inhibition attenuated remifentanil-induced postoperative hyperalgesia via decreasing NMDA receptor phosphorylation in dorsal root ganglion. Brain Res Bull 2021; 177:352-362. [PMID: 34653560 DOI: 10.1016/j.brainresbull.2021.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 10/06/2021] [Accepted: 10/08/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Remifentanil-induced postoperative hyperalgesia is an intractable side effect of the clinical use of remifentanil, the mechanism of which remains obscure, especially in the peripheral nervous system. N-methyl-D-aspartate receptor (NMDAR) phosphorylation in dorsal root ganglion (DRG) plays a pronociceptive role in neuropathic pain. The contribution of the P2Y1 purinergic receptor (P2Y1R) in DRG to pain hypersensitivity derived from various origins and P2Y1R upregulation-induced NMDAR activation in neurons have also been uncovered. This study aimed to investigate whether P2Y1R participates in nociceptive processing in the DRG and spinal cord in remifentanil-induced postoperative hyperalgesia. METHODS Rats with remifentanil-induced postoperative hyperalgesia were intrathecally injected with NMDAR antagonist MK801 or P2Y1R antagonist MRS2179 at 10 min prior to remifentanil infusion. Mechanical allodynia, heat hyperalgesia, and cold hyperalgesia were measured at -24 h, 2 h, 6 h, 24 h, and 48 h following remifentanil infusion. The P2Y1R expression and NMDAR expression and phosphorylation in DRG ipsilateral to the incision were detected by Western blot and immunofluorescence. RESULTS Incision and remifentanil induced mechanical allodynia, heat hyperalgesia, and cold hyperalgesia accompanied by upregulated P2Y1R expression, increased NMDAR subunit NR1 expression and phosphorylation at Ser896, and NR2B expression and phosphorylation at Tyr1472 in DRG. Inhibition of NMDAR phosphorylation by MK801 effectively attenuated remifentanil-induced postoperative hyperalgesia. Furthermore, P2Y1R blockade by MRS2179 not only lessened remifentanil-evoked postoperative hypersensitivity to mechanical, heat, and cold stimuli, but also suppressed the increases in NR1 and NR2B expression and phosphorylation in DRG induced by incision and remifentanil. CONCLUSION The process by which P2Y1R mediates NMDAR expression and phosphorylation represents a mechanism of remifentanil-induced postoperative hyperalgesia in the DRG and/or spinal cord.
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Affiliation(s)
- Lin Su
- Department of Anesthesiology, Tianjin Medical University General Hospital, No. 154 Anshan Road, Heping District, Tianjin 300052, PR China; Tianjin Research Institute of Anesthesiology, No. 154 Anshan Road, Heping District, Tianjin 300052, PR China
| | - Xiaoqing Bai
- Department of Science and Education, Tianjin Beichen Hospital, No. 7 Beiyi Road, Beichen District, Tianjin 300400, PR China
| | - Tongxiang Niu
- Tianjin Research Institute of Anesthesiology, No. 154 Anshan Road, Heping District, Tianjin 300052, PR China; Department of Anesthesiology, Tianjin Jinnan Hospital, No. 120 Jingu Road, Jinnan District, Tianjin 300350, PR China
| | - Xinqi Zhuang
- Tianjin Research Institute of Anesthesiology, No. 154 Anshan Road, Heping District, Tianjin 300052, PR China; Department of Anesthesiology, Tianjin Medical University Second Hospital, No. 23 Pingjiang Road, Hexi District, Tianjin 300211, PR China
| | - Beibei Dong
- Department of Anesthesiology, Tianjin Medical University General Hospital, No. 154 Anshan Road, Heping District, Tianjin 300052, PR China; Tianjin Research Institute of Anesthesiology, No. 154 Anshan Road, Heping District, Tianjin 300052, PR China
| | - Guolin Wang
- Department of Anesthesiology, Tianjin Medical University General Hospital, No. 154 Anshan Road, Heping District, Tianjin 300052, PR China; Tianjin Research Institute of Anesthesiology, No. 154 Anshan Road, Heping District, Tianjin 300052, PR China
| | - Yonghao Yu
- Department of Anesthesiology, Tianjin Medical University General Hospital, No. 154 Anshan Road, Heping District, Tianjin 300052, PR China; Tianjin Research Institute of Anesthesiology, No. 154 Anshan Road, Heping District, Tianjin 300052, PR China.
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8
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Togun AT, Karaca-Mandic P, Wurtz R, Jeffrey M, Beebe T. Association of 3 CDC opioid prescription guidelines for chronic pain and 2 payer pharmacy coverage changes on opioid initiation practices. J Manag Care Spec Pharm 2021; 27:1352-1364. [PMID: 34595944 PMCID: PMC10391278 DOI: 10.18553/jmcp.2021.27.10.1352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Due to the US opioid epidemic, in March of 2016, the Centers for Disease Control and Prevention (CDC) published new guidelines for primary care providers on opioid prescribing for chronic pain. Payer coverage changes were also implemented to help modify opioid prescribing behavior. Whether these initiatives were associated with changes in opioid initiation patterns is unknown. OBJECTIVE: To assess the association between 3 of the 2016 CDC guidelines and 2 subsequent payer pharmacy coverage changes with changes in opioid initiation behavior across different provider specialties. METHODS: We conducted a real-world evidence study using claims data from OptumLabs Data Warehouse between January of 2014 and December of 2018. Subjects were continuously enrolled opioid naive patients, aged at least 18 years, who had at least 1 chronic pain diagnosis within 2 weeks before their first (first-time) opioid prescription. The study used multiple treatment period segmented regression analysis to evaluate the association, across different provider specialties, between the CDC guideline release and the payer pharmacy coverage changes with immediate change in level and overall change in the rate of first-time extended-release opioid prescriptions, firsttime opioid prescriptions at doses of at least 50 MME (morphine milligram equivalent) per day, and first-time opioid prescriptions with overlapping benzodiazepine prescription. RESULTS: The CDC guidelines were not associated with any change in the rate of first-time prescriptions of extended-release opioids. However, a January 2017 payer pharmacy coverage change was associated with a reduction over time in first-time extended-release opioid prescription rates by 22.15 in every 100,000 prescriptions (CI = -40.04 to -2.92, P = 0.013). The CDC guidelines were associated with an immediate decline in level of first-time opioid prescription at doses of at least 50 MME per day by 74.00 in every 10,000 prescriptions (CI = -124.86 to -23.13, P = 0.004) and an increased rate of decline over time by 13.64 in every 10,000 prescriptions (CI = -17.07 to -10.21, P < 0.001). These associations varied across provider types and specialties. The March 2018, payer coverage change was associated with an immediate reduction in level of first-time opioid prescriptions at doses of at least 50 MME per day across all specialties and an increased reduction over time among surgeons. The CDC guidelines were associated, respectively, with a reduction in the rate of overlapping first-time opioid prescriptions with benzodiazepines among family medicine, internal medicine, surgeons, emergency medicine providers, and providers with unknown specialty by 6.11, 5.10, 2.89, 11.43, and 9.11 in every 10,000 prescriptions monthly (CI = -9.48 to -2.73, -9.86 to -0.35, -5.40 to -0.38, -17.26 to -5.61 and -11.96 to -6.25, respectively, P < 0.001, P = 0.035, P = 0.024, P < 0.001 and P < 0.001). CONCLUSIONS: Some specialist providers also adopted the CDC guidelines, and the response to the guidelines differed across various provider specialties. Some CDC guidelines were associated with a reduction in high-risk first-time opioid prescriptions. Payer pharmacy coverage changes reinforced the guidelines both in situations where the CDC guidelines did and did not show any association. DISCLOSURE: This research was funded by Agency for Healthcare Research and Quality (R01 HS025164; PI: Karaca-Mandic). Karaca-Mandic reports grants from the American Cancer Society and Sempre Health, along with fees from Tactile Medical and Precision Health Economics, unrelated to this study. The other authors have nothing to disclose.
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Affiliation(s)
- Adeniyi T Togun
- Department of Health Services Research, School of Public Health, University of Minnesota Twin Cities, Minneapolis
| | - Pinar Karaca-Mandic
- OptumLabs Visiting Fellow, Carlson School of Management, Department of Finance, University of Minnesota, Minneapolis, and National Bureau of Economic Research, Cambridge, MA
| | - Rebecca Wurtz
- Division of Health Policy and Management, School of Public Health, University of Minnesota Twin Cities, Minneapolis
| | - Molly Jeffrey
- Department of Health Services Research, Mayo Clinic, Rochester, MN
| | - Timothy Beebe
- Division of Health Policy and Management, School of Public Health, University of Minnesota Twin Cities, Minneapolis
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9
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Belitskaya-Levy I, Clark JD, Shih MC, Bair MJ. Treatment Preferences for Chronic Low Back Pain: Views of Veterans and Their Providers. J Pain Res 2021; 14:161-171. [PMID: 33536780 PMCID: PMC7850463 DOI: 10.2147/jpr.s290400] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 12/15/2020] [Indexed: 12/29/2022] Open
Abstract
Purpose This study was conducted to characterize chronic low back pain (cLBP) and to identify treatment histories and preferences for cLBP management among Veterans and primary care providers within the Veterans Affairs (VA) healthcare system. Participants and Methods Veterans with cLBP from five geographically diverse VA medical centers were identified using International Classification of Diseases (ICD) 9 and 10 codes from VA administrative data as were primary care providers at these same sites. From these data, Veterans (200/per site) and providers (160/per site) were selected and mailed surveys. Open-ended interview data were collected from a subset of Veterans and providers. Results In total, 235 Veterans and 67 providers returned completed surveys. More than 80% of the Veteran respondents had daily back pain for more than 1 year. Most Veterans had tried several treatments for their pain with medications and physical therapy being the most commonly used. Veterans and providers had similar attitudes towards many cLBP treatments with the exception of psychological therapies that were more favored by providers. Open-ended interview data showed that Veterans and providers emphasized the need for multi-component approaches to treatment. Conclusion Among Veterans, cLBP is typically of sustained duration, is relatively severe, and also interferes significantly with normal functioning. Veterans are experienced with respect to treatments and had similar attitudes towards many cLBP treatments as their providers, especially tailored approaches.
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Affiliation(s)
- Ilana Belitskaya-Levy
- VA Cooperative Studies Program Coordinating Center - Mountain View Division, Palo Alto Healthcare System, Mountain View, CA, USA
| | - J David Clark
- Anesthesiology Service, VA Palo Alto Health Care System, Palo Alto, CA, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Mei-Chiung Shih
- VA Cooperative Studies Program Coordinating Center - Mountain View Division, Palo Alto Healthcare System, Mountain View, CA, USA
| | - Matthew J Bair
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, USA.,Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.,Regenstrief Institute, Inc., Indianapolis, IN, USA
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10
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Berger AA, Urits I, Hasoon J, Kaye AD, Viswanath O, Eskander J. Pain Alleviation and Opioid Weaning in an 80-Year-Old with Chronic Foot Pain Following Injection Therapy with Perineural Dexmedetomidine and Dexamethasone. Surg J (N Y) 2021; 7:e1-e2. [PMID: 33437869 PMCID: PMC7790527 DOI: 10.1055/s-0040-1722176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 09/22/2020] [Indexed: 12/03/2022] Open
Abstract
Opiates are routinely used for chronic pain patients, and up to 44% of them will have a prescription for an opiate medication for pain alleviation. However, of the 76 million adults prescribed opiates for pain management, about 12% report misuse, and a large number of these may find themselves addicted to opioid medications. Opioid addiction is an ongoing epidemic, costing many lives. Withdrawal is very difficult. This requires providers to consider alternative analgesic plans and minimize opiate use. Here we report the use of a dexamethasone-dexmedetomidine combination for a regional nerve block in an elderly woman chronically treated with opiate medications who had previously failed opiate weaning. Following her nerve block, she was able to completely wean off of opioids and continues having good pain control with an opioid-free regimen.
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Affiliation(s)
- Amnon A Berger
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ivan Urits
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jamal Hasoon
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, Louisiana
| | - Omar Viswanath
- Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, Arizona.,Department of Anesthesiology, University of Arizona College of Medicine - Phoenix, Phoenix, Arizona.,Department of Anesthesiology, Creighton University School of Medicine, Omaha, Nebraska
| | - Jonathan Eskander
- Anesthesiology and Pain Medicine, Portsmouth Anesthesia Associates, Portsmouth, Virginia
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11
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Galaj E, Xi ZX. Progress in opioid reward research: From a canonical two-neuron hypothesis to two neural circuits. Pharmacol Biochem Behav 2021; 200:173072. [PMID: 33227308 PMCID: PMC7796909 DOI: 10.1016/j.pbb.2020.173072] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/21/2020] [Accepted: 11/10/2020] [Indexed: 12/12/2022]
Abstract
Opioid abuse and related overdose deaths continue to rise in the United States, contributing to the national opioid crisis in the USA. The neural mechanisms underlying opioid abuse and addiction are still not fully understood. This review discusses recent progress in basic research dissecting receptor mechanisms and circuitries underlying opioid reward and addiction. We first review the canonical GABA-dopamine neuron hypothesis that was upheld for half a century, followed by major findings challenging this hypothesis. We then focus on recent progress in research evaluating the role of the mesolimbic and nigrostriatal dopamine circuitries in opioid reward and relapse. Based on recent findings that activation of dopamine neurons in the ventral tegmental area (VTA) and substantia nigra pars compacta (SNc) is equally rewarding and that GABA neurons in the rostromedial tegmental nucleus (RMTg) and the substantia nigra pars reticula (SNr) are rich in mu opioid receptors and directly synapse onto midbrain DA neurons, we proposed that the RTMg→VTA → ventrostriatal and SNr → SNc → dorsostriatal pathways may act as the two major neural substrates underlying opioid reward and abuse. Lastly, we discuss possible integrations of these two pathways during initial opioid use, development of opioid abuse and maintenance of compulsive opioid seeking.
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Affiliation(s)
- Ewa Galaj
- Addiction Biology Unit, Molecular Targets and Medications Discovery Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD, United States of America
| | - Zheng-Xiong Xi
- Addiction Biology Unit, Molecular Targets and Medications Discovery Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD, United States of America.
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12
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Wong KA, Goyal KS. Postoperative Pain Management of Non-"Opioid-Naive" Patients Undergoing Hand and Upper-Extremity Surgery. Hand (N Y) 2020; 15:651-658. [PMID: 30781996 PMCID: PMC7543219 DOI: 10.1177/1558944719828000] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Patients with prior opioid use are often difficult to manage postoperatively. We examined potential strategies for managing these patients: (1) prescribing a different opioid; and (2) encouraging the use of nonopioid analgesics over opioids. Methods: A pain control program was implemented at an outpatient hand and upper-extremity center. Patients were recruited before (n = 305) and after (n = 225) implementation. Seventy of them were taking opioids prior to surgery. Information about pain control satisfaction and opioid use was collected. The Fisher exact test was used to compare categorical variables with small expected frequencies. Wilcoxon rank sum test was used to compare nonnormally distributed continuous variables. Results: Opioid users used 28.8 ± 25.6 opioid pills; nonopioid users used 14.5 ± 21.5 pills. Furthermore, 41.4% of opioid users sought more pills after surgery compared with 14.0% among nonopioid users. The pain control program was more effective in reducing opioid consumption and waste and increasing nonopioid consumption for nonopioid users than for opioid users. Prior opioid users who were prescribed a different opioid after surgery used 24.6 ± 22.0 opioid pills. Patients prescribed the same opioid used 37.9 ± 30.8 pills. Conclusions: Patients taking opioids prior to hand and upper-extremity surgery use more opioid pills, seek more pills after surgery, and are less satisfied with their pain control than their nonopioid user counterparts. Furthermore, the comprehensive pain plan was less effective in this patient population. Prescribing a different opioid reduced medication requirements for these patients, but additional strategies are needed to address postoperative pain management.
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Affiliation(s)
- Kelvin A. Wong
- College of Medicine, The Ohio State University, Columbus, USA
| | - Kanu S. Goyal
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, USA
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13
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Kadado A, Slotkin S, Akioyamen NO, El-Alam A, North WT. Total Knee Arthroplasty: Opioid-Free Analgesia in a Patient with Opioid-Induced Hyperalgesia: A Case Report. JBJS Case Connect 2020; 10:e20.00024. [PMID: 32618610 DOI: 10.2106/jbjs.cc.20.00024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
CASE Pain control after total knee arthroplasty (TKA) remains a significant challenge, especially in the context of certain patient-specific factors. We present a case of a 59-year-old woman with opioid-induced hyperalgesia who was referred for left knee pain and end-stage tricompartmental degenerative joint disease after failure of conservative management. We outline an approach to control postoperative pain in patients undergoing TKA who have severe opioid contraindications. CONCLUSIONS TKA and rehabilitation with a 6-year follow-up period was accomplished using a multimodal nonopioid approach, consisting of a combination of gabapentin, acetaminophen, ketorolac, meloxicam, methocarbamol, a tunneled femoral nerve catheter, and periarticular injection.
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Affiliation(s)
- Allen Kadado
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Steven Slotkin
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Michigan
| | | | - Andrew El-Alam
- Wayne State University School of Medicine, Detroit, Michigan
| | - Wayne Trevor North
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Michigan
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14
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Mathieson S, Wertheimer G, Maher CG, Christine Lin CW, McLachlan AJ, Buchbinder R, Pearson SA, Underwood M. What proportion of patients with chronic noncancer pain are prescribed an opioid medicine? Systematic review and meta-regression of observational studies. J Intern Med 2020; 287:458-474. [PMID: 32100394 DOI: 10.1111/joim.13026] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 12/09/2019] [Accepted: 01/15/2020] [Indexed: 01/01/2023]
Abstract
Guidelines now discourage opioid analgesics for chronic noncancer pain because the benefits frequently do not outweigh the harms. We aimed to determine the proportion of patients with chronic noncancer pain who are prescribed an opioid, the types prescribed and factors associated with prescribing. Database searches were conducted from inception to 29 October 2018 without language restrictions. We included observational studies of adults with chronic noncancer pain measuring opioid prescribing. Opioids were categorized as weak (e.g. codeine) or strong (e.g. oxycodone). Study quality was assessed using a risk of bias tool designed for observational studies measuring prevalence. Individual study results were pooled using a random-effects model. Meta-regression investigated study-level factors associated with prescribing (e.g. sampling year, geographic region as per World Health Organization). The overall evidence quality was assessed using Grading of Recommendations Assessment, Development and Evaluation criteria. Of the 42 studies (5,059,098 participants) identified, the majority (n = 28) were from the United States of America. Eleven studies were at low risk of bias. The pooled estimate of the proportion of patients with chronic noncancer pain prescribed opioids was 30.7% (95% CI 28.7% to 32.7%, n = 42 studies, moderate-quality evidence). Strong opioids were more frequently prescribed than weak (18.4% (95% CI 16.0-21.0%, n = 15 studies, low-quality evidence), versus 8.5% (95% CI 7.2-9.9%, n = 15 studies, low-quality evidence)). Meta-regression determined that opioid prescribing was associated with year of sampling (more prescribing in recent years) (P = 0.014) and not geographic region (P = 0.056). Opioid prescribing for patients with chronic noncancer pain is common and has increased over time.
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Affiliation(s)
- S Mathieson
- From the, Institute for Musculoskeletal Health, Sydney, NSW, Australia.,Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - G Wertheimer
- School of Medicine, University of Notre Dame, Sydney, NSW, Australia
| | - C G Maher
- From the, Institute for Musculoskeletal Health, Sydney, NSW, Australia.,Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - C-W Christine Lin
- From the, Institute for Musculoskeletal Health, Sydney, NSW, Australia.,Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - A J McLachlan
- Faculty of Medicine and Health, Sydney Pharmacy School, The University of Sydney, Sydney, NSW, Australia
| | - R Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Institute, Malvern, Vic.,, Australia.,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia
| | - S-A Pearson
- Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - M Underwood
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK.,University Hospitals of Coventry and Warwickshire, Coventry, UK
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15
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Cleland CM, Bennett AS, Elliott L, Rosenblum A, Britton PC, Wolfson-Stofko B. Between- and within-person associations between opioid overdose risk and depression, suicidal ideation, pain severity, and pain interference. Drug Alcohol Depend 2020; 206:107734. [PMID: 31775106 PMCID: PMC6980716 DOI: 10.1016/j.drugalcdep.2019.107734] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 11/04/2019] [Accepted: 11/09/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND To better understand overdose (OD) risk and develop tailored overdose risk interventions, we surveyed 234 opioid-using veterans residing in New York City, 2014-2017. Our aim was to better understand how predictors of OD may be associated with physical and mental health challenges, including pain severity and interference, depression and suicidal ideation over time. METHODS Veterans completed monthly assessments of the Overdose Risk Behavior Scale (ORBS), pain severity and interference, suicidal ideation, and depression for up to two years and were assessed an average of 14 times over 611 days. To estimate between-person and within-person associations between time-varying covariates and opioid risk behavior, mixed-effects regression was used on the 145-person subsample of veterans completing the baseline and at least three follow-up assessments. RESULTS The level of each time-varying covariate at the average of study time (between-person effect) was positively related to ORBS for pain severity and interference, suicidal ideation, and depression. Deviations from individuals' personal trajectories (within-person effect) were positively related to ORBS for pain severity and interference, suicidal ideation, and depression. CONCLUSIONS US military veterans endure physical and mental health challenges elevating risk for opioid-related overdose. When pain severity, pain interference, suicidal ideation and depression were higher than usual, opioid risk behavior was higher. Conversely, when these health issues were less of a problem than usual, opioid risk behavior was lower. Assessing the physical and mental health of opioid-using veterans over time may support the development and implementation of interventions to reduce behaviors that increase the likelihood of overdose.
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Affiliation(s)
- Charles M. Cleland
- Center for Drug Use and HIV/HCV Research, College of Global
Public Health, New York University,665 Broadway, 11th Floor, New York,
NY, 10012,Department of Population Health, New York University School
of Medicine, 180 Madison Avenue, New York, NY, 10016
| | - Alex S. Bennett
- College of Global Public Health, New York University, 665
Broadway, 11th Floor, New York, NY, 10012,Center for Drug Use and HIV/HCV Research, College of Global
Public Health, New York University,665 Broadway, 11th Floor, New York,
NY, 10012
| | - Luther Elliott
- College of Global Public Health, New York University, 665
Broadway, 11th Floor, New York, NY, 10012,Center for Drug Use and HIV/HCV Research, College of Global
Public Health, New York University,665 Broadway, 11th Floor, New York,
NY, 10012
| | - Andrew Rosenblum
- National Development and Research Institutes/USA, New York,
NY, 10010
| | - Peter C. Britton
- VA Center of Excellence for Suicide Prevention, Canandaigua
VA Medical Center, 400 Fort Hill Avenue Canandaigua, NY, USA 14424,Department of Psychiatry, University of Rochester, USA
Rochester, NY
| | - Brett Wolfson-Stofko
- Center for Drug Use and HIV/HCV Research, College of Global
Public Health, New York University,665 Broadway, 11th Floor, New York,
NY, 10012
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16
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Bennett AS, Watford JA, Elliott L, Wolfson-Stofko B, Guarino H. Military veterans' overdose risk behavior: Demographic and biopsychosocial influences. Addict Behav 2019; 99:106036. [PMID: 31494452 DOI: 10.1016/j.addbeh.2019.106036] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 06/22/2019] [Accepted: 06/24/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND U.S. military veterans face many biopsychosocial (BPS) challenges post-service that may elevate risk for opioid-related overdose including physical pain, mental health concerns and social stressors. Some veterans use opioids to manage pain and cope with social readjustment. This study assessed associations between BPS factors and recent engagement in overdose risk behavior in a community sample of post-9/11 veterans who used opioids in New York City. METHODS Participants (n = 218) were recruited through convenience sampling and completed a baseline assessment including a validated Opioid Risk Behavior Scale (ORBS) that measured past-30-day engagement in 22 opioid-related overdose risk behaviors. Analyses examined associations between ORBS scores and hypothesized demographic, biological/physical, psychological and social predictors. Incident rate ratios estimated the expected relative difference in ORBS score associated with each predictor. RESULTS Participants reported an average of 4.72 overdose risk behaviors in the past 30 days. Significant independent predictors of higher ORBS score, after adjustment for demographics and current prescription medications, were past-30-day: depression symptoms; unsheltered or living in a homeless shelter (vs. private housing); history of mental health treatment; experiencing stressful life events; average pain severity; and pain interference. CONCLUSION Veterans face myriad BPS challenges and, while drug-related overdose risks are well understood, findings suggest that other factors-including mental health, pain and stressful life events-may also be associated with overdose risk among opioid-using veterans. The larger challenges veterans face should be considered in the context of BPS forms of pain management when tailoring and delivering overdose prevention interventions.
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17
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Integrated Behavioral Treatment for Veterans With Co-Morbid Chronic Pain and Hazardous Opioid Use: A Randomized Controlled Pilot Trial. THE JOURNAL OF PAIN 2019; 21:798-807. [PMID: 31760109 DOI: 10.1016/j.jpain.2019.11.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 11/07/2019] [Accepted: 11/17/2019] [Indexed: 11/21/2022]
Abstract
Opioid prescription in the treatment of chronic pain is frequent and carries a risk of increased morbidity and mortality in a clinically significant number of patients, particularly those who are using opioids in a hazardous manner. Few treatment options are available that target both pain-related interference and hazardous opioid use among patients with chronic pain. In military Veterans, this issue is of particular importance as numerous reports indicate continued high rates of opioid prescription for chronic pain, as well as significant opioid-related problems. The overall aim of the present study was to determine the feasibility of an integrated psychosocial treatment in Veterans with chronic pain, who also have evidence of hazardous opioid use. To examine this aim, a random design was used to assess the feasibility and initial efficacy of integrating 2 empirically supported interventions: Acceptance and Commitment Therapy for chronic pain and Mindfulness Based Relapse Prevention for opioid misuse. Half of participants were randomized to the integrated treatment group and all participants received usual care through a Veteran's Administration co-occurring disorders medical clinic to treat chronic pain and opioid misuse. In total, 37 participants were randomized and included in intent-to-treat analyses and 32 individuals were included in per protocol analyses with 6-month follow-up serving as the primary study endpoint. Feasibility indicators included recruitment, retention, and treatment completion rates. Recruitment fell short of targeted enrollment, although retention and completion were excellent. Primary outcome measures were opioid misuse, pain interference, and pain behavior. Simultaneous multiple regression analyses controlled for pain duration, baseline opioid dose, and baseline value for outcome measures. Results of both the intent-to-treat and per protocol indicated a significant effect in favor of the integrated intervention for opioid misuse, pain interference, and pain behavior. Results support the feasibility of providing an integrated treatment for both opioid risk and pain interference. PERSPECTIVE: Opioid misuse occurs in some opioid-prescribed individuals with chronic pain. Few treatment options exist that target both pain interference and opioid misuse. This study examined feasibility and initial efficacy of an integrated behavioral treatment for Veterans. Feasibility was supported, except recruitment. Efficacy was supported compared to usual care.
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18
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Wang W, Zeng F, Hu Y, Li X. A Mini-Review of the Role of Glutamate Transporter in Drug Addiction. Front Neurol 2019; 10:1123. [PMID: 31695674 PMCID: PMC6817614 DOI: 10.3389/fneur.2019.01123] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 10/08/2019] [Indexed: 12/29/2022] Open
Abstract
Goals: The development of new treatment for drug abuse requires identification of targetable molecular mechanisms. The pathology of glutamate neurotransmission system in the brain reward circuit is related to the relapse of multiple drugs. Glutamate transporter regulates glutamate signaling by removing excess glutamate from the synapse. And the mechanisms between glutamate transporter and drug addiction are still unclear. Methods: A systematic review of the literature searched in Pubmed and reporting drug addiction in relation to glutamate transporter. Studies were screened by title, abstract, and full text. Results: This review is to highlight the effects of drug addiction on glutamate transporter and glutamate uptake, and targeting glutamate transporter as an addictive drug addiction treatment. We focus on the roles of glutamate transporter in different brain regions in drug addiction. More importantly, we suggest the functional roles of glutamate transporter may prove beneficial in the treatment of drug addiction. Conclusion: Overall, understanding how glutamate transporter impacts central nervous system may provide a new insight for treatment of drug addiction.
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Affiliation(s)
- Wenjun Wang
- Institute for Cancer Medicine and School of Basic Medical Sciences, Southwest Medical University, Luzhou, China
| | - Fancai Zeng
- Department of Biochemistry and Molecular Biology, School of Basic Medical Science, Southwest Medical University, Luzhou, China
| | - Yingying Hu
- Department of Biochemistry and Molecular Biology, School of Basic Medical Science, Southwest Medical University, Luzhou, China
| | - Xiang Li
- Department of Biochemistry and Molecular Biology, School of Basic Medical Science, Southwest Medical University, Luzhou, China
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19
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Rodrigues P, Barbosa LB, Bianchini AE, Ferrari FT, Baldisserotto B, Heinzmann BM. Nociceptive-like behavior and analgesia in silver catfish (Rhamdia quelen). Physiol Behav 2019; 210:112648. [PMID: 31408639 DOI: 10.1016/j.physbeh.2019.112648] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 08/09/2019] [Accepted: 08/10/2019] [Indexed: 12/01/2022]
Abstract
Fish are useful animal models in research and have been employed in developing new pharmacological approaches. This study aimed to establish the use of silver catfish (Rhamdia quelen) as an animal model to evaluate antinociceptive activity. Initially, different concentrations of acetic acid (2.5-20%), formalin 1% (1-10 μL), menthol 0.5% (1-10 μL) or vehicle were injected in the lips to establish which concentration of each sample promotes nociceptive-like behavior in various parameters. The effect of morphine (0.5-10 mg/kg) on locomotion parameters was also evaluated for antinociceptive concentration determination. Morphine was administered intramuscularly immediately prior to algogen administration. The inhibition was evaluated with the antagonist naloxone (5 mg/kg), which was administered in the same way. Recording time varied according to the algogen used in each test and locomotor activity was evaluated by ANY-maze® software. Acid acetic at 15%, 10 μL of 1% formalin, and 1 μL of 0.5% menthol were chosen since they promoted nociceptive-like behavior in several parameters. Morphine (5 mg/kg) reversed the algogen-induced nociceptive-like behavior and naloxone inhibited this effect. Therefore, the proposed experimental model demonstrated specificity for nociception, since the reversion of the nociceptive-like behavior for a compound with well-described analgesic activity was observed. This new pharmacological model contributes to evaluating compounds with analgesic potential and developing new analgesic drugs, in addition to being a promising alternative to use with rodents.
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Affiliation(s)
- Patrícia Rodrigues
- Post-Graduation Program in Pharmacology, Federal University of Santa Maria, Santa Maria, RS, Brazil
| | | | - Adriane Erbice Bianchini
- Post-Graduation Program in Pharmacology, Federal University of Santa Maria, Santa Maria, RS, Brazil
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20
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Using Analgesics for Emotional Modulation is Associated With Increased Distress, Depression, and Risk of Opioid and Alcohol Misuse: Initial Evaluation and Component Analysis of the Reasons for Analgesic Use Measure (RAUM). Clin J Pain 2019; 34:975-982. [PMID: 29697475 DOI: 10.1097/ajp.0000000000000621] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES It is important to identify aspects of analgesic use that are associated with harm in chronic pain. Historically, the focus has been patterns of use (eg, overuse). This study evaluated another aspect of use-rather than evaluating how analgesics were being used, the primary interest was in why they were being used. METHODS In total, 334 analgesic using individuals with chronic pain responded to a pool of items assessing reasons for analgesic use. Measures of pain intensity, distress, depression, and opioid and alcohol misuse were also completed. RESULTS Exploratory factor analyses indicated 3 overarching reasons for use, including taking analgesics: (1) for pain reduction/functional improvement; (2) for emotional modulation/sedation; and (3) to be compliant with prescriber instructions. Correlation and regression analyses indicated that the second factor had the strongest relations with the other measures used, such that greater endorsement of analgesic use for emotional modulation was associated with greater distress, depression, and opioid and alcohol misuse. Using analgesics for pain reduction/functional improvement was associated with greater pain-related distress and depression. Using analgesics to be compliant was not associated with any measure. This pattern of results was generally replicated when a subsample of 131 individuals taking opioids was examined. DISCUSSION Results support the utility of examining reasons for analgesic use; use to achieve emotional modulation/sedation may be particularly associated with risk. The data also provide support for the questionnaire developed, the Reasons for Analgesic Use Measure.
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21
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Wyse JJ, Ganzini L, Dobscha SK, Krebs EE, Zamudio J, Morasco BJ. Clinical Strategies for the Treatment and Management of Patients Prescribed Long-term Opioid Therapy. PAIN MEDICINE 2019; 20:1737-1744. [PMID: 30388259 DOI: 10.1093/pm/pny211] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Across diverse health care systems, growing recognition of the harms associated with long-term opioid therapy (LTOT) for chronic pain has catalyzed substantial changes to policy and practice designed to promote safer prescribing and patient care. Although clear goals have been defined, how clinics and providers should most effectively implement these changes has been less well defined, and facilities and providers have had substantial flexibility to innovate. METHODS Qualitative interviews were conducted with 24 Department of Veterans Affairs (VA) clinicians across the United States who prescribe LTOT for chronic pain. Interviews probed the practices and initiatives providers utilized to meet opioid safety requirements and address common challenges in caring for patients prescribed LTOT. RESULTS Innovative strategies in the design and organization of clinical practice (urine drug testing, informed consent, limiting transfer requests, specialty patient panel) and resources utilized (engaged pharmacists, non-opioid pain treatments, intra-organizational collaborations) are described. CONCLUSIONS We conclude with recommendations designed to improve opioid prescribing practices, both within the VA and in other settings.
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Affiliation(s)
- Jessica J Wyse
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, Oregon.,Oregon Health Science University-Portland State University School of Public Health, Portland, Oregon
| | - Linda Ganzini
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, Oregon.,Department of Psychiatry, Oregon Health & Science University, Portland, Oregon
| | - Steven K Dobscha
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, Oregon.,Department of Psychiatry, Oregon Health & Science University, Portland, Oregon
| | - Erin E Krebs
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota.,Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Janet Zamudio
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, Oregon
| | - Benjamin J Morasco
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, Oregon.,Department of Psychiatry, Oregon Health & Science University, Portland, Oregon
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22
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Giannitrapani KF, Day RT, Azarfar A, Ahluwalia SC, Dobscha S, Lorenz KA. What Do Providers Want from a Pain Screening Measure Used in Daily Practice? PAIN MEDICINE 2019; 20:68-76. [PMID: 30085285 DOI: 10.1093/pm/pny135] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Objectives We aimed to understand providers' experiences and preferences regarding several brief pain screening measures. Methods We collected two waves of data for this analysis. Wave one: We conducted nine focus groups with multidisciplinary Department of Veterans Affairs (VA) providers. Wave two: To understand an emergent theme in wave one, we conducted 15 telephone interviews with prescribing providers where we used a semistructured guide comparing screening measures currently used in VA practices. Using content analysis of the wave two interviews, we evaluated providers' perceptions of important aspects of brief pain screening measures and reported emergent themes. Results Five emergent themes underlie providers' perceptions of the utility of brief pain screening measures: 1) item abstractness: how bounded and concrete a patient's interpretation of an individual item is; 2) item distinctness: belief in the patient's ability to differentiate between the meaning of various items in a pain measure; 3) item anchoring: presence of a description under each response option making the meaning explicit; 4) item look-back period: the period of time over which patients are asked to remember and comment on their pain; 5) parsimony: identifying the shortest and simplest approach possible to acquire desired information. Conclusions Overly complex or adaptive screening tools may include information that is ultimately not used by providers. Conversely, overly simplistic pain screening tools may omit information that helps providers understand the impact of pain on patients' lives. As pain is nuanced, complex, and subjective, all screening measures exhibit some limitations. No single pain measure serves all chronic pain patients, and specific contexts or settings may warrant additional specific items.
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Affiliation(s)
- Karleen F Giannitrapani
- VA Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), Menlo Park, California
| | - R Thomas Day
- VA Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), Menlo Park, California
| | - Azin Azarfar
- VA Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), Menlo Park, California
| | | | - Steven Dobscha
- VA Portland Health Care System, Center to Improve Veteran Involvement in Care (CIVIC), Portland, Oregon.,Department of Psychiatry, Oregon Health and Science University, Portland, Oregon
| | - Karl A Lorenz
- VA Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), Menlo Park, California.,RAND Corporation, Santa Monica, California.,Stanford University School of Medicine, Stanford, California, USA
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Taylor SL, Hoggatt KJ, Kligler B. Complementary and Integrated Health Approaches: What Do Veterans Use and Want. J Gen Intern Med 2019; 34:1192-1199. [PMID: 31011973 PMCID: PMC6614301 DOI: 10.1007/s11606-019-04862-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 11/06/2018] [Accepted: 01/09/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Non-pharmacological treatment options for common conditions such as chronic pain, anxiety, and depression are being given increased consideration in healthcare, especially given the recent emphasis to address the opioid crisis. One set of non-pharmacological treatment options are evidence-based complementary and integrative health (CIH) approaches, such as yoga, acupuncture, and meditation. The Veterans Health Administration (VHA), the nation's largest healthcare system, has been at the forefront of implementing CIH approaches, given their patients' high prevalence of pain, anxiety, and depression. We aimed to conduct the first national survey of veterans' interest in and use of CIH approaches. METHODS Using a large national convenience sample of veterans who regularly use the VHA, we conducted the first national survey of veterans' interest in, frequency of and reasons for use of, and satisfaction with 26 CIH approaches (n = 3346, 37% response rate) in July 2017. RESULTS In the past year, 52% used any CIH approach, with 44% using massage therapy, 37% using chiropractic, 34% using mindfulness, 24% using other meditation, and 25% using yoga. For nine CIH approaches, pain and stress reduction/relaxation were the two most frequent reasons veterans gave for using them. Overall, 84% said they were interested in trying/learning more about at least one CIH approach, with about half being interested in six individual CIH approaches (e.g., massage therapy, chiropractic, acupuncture, acupressure, reflexology, and progressive relaxation). Veterans appeared to be much more likely to use each CIH approach outside the VHA vs. within the VHA. CONCLUSIONS Veterans report relatively high past-year use of CIH approaches and many more report interest in CIH approaches. To address this gap between patients' level of interest in and use of CIH approaches, primary care providers might want to discuss evidence-based CIH options to their patients for relevant health conditions, given most CIH approaches are safe.
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Affiliation(s)
- Stephanie L. Taylor
- Center for the Study of Healthcare Innovation, Implementation and Policy, Greater Los Angeles VA Healthcare System, Los Angeles, CA USA
- Department of Health Policy and Management, UCLA School of Public Health, Los Angeles, CA USA
| | - Katherine J. Hoggatt
- Center for the Study of Healthcare Innovation, Implementation and Policy, Greater Los Angeles VA Healthcare System, Los Angeles, CA USA
- Department of Epidemiology, UCLA School of Public Health, Los Angeles, CA USA
| | - Benjamin Kligler
- Integrative Health Coordinating Center, VA Office of Patient Centered Care and Cultural Transformation, Los Angeles, CA USA
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Veiga DR, Monteiro-Soares M, Mendonça L, Sampaio R, Castro-Lopes JM, Azevedo LF. Effectiveness of Opioids for Chronic Noncancer Pain: A Two-Year Multicenter, Prospective Cohort Study With Propensity Score Matching. THE JOURNAL OF PAIN 2019; 20:706-715. [DOI: 10.1016/j.jpain.2018.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 12/19/2018] [Accepted: 12/19/2018] [Indexed: 10/27/2022]
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Plunkett AR, Peden RM. Opioid maintenance, weaning and detoxification techniques; where we have been, where we are now and what the future holds: an update. Pain Manag 2019; 9:297-306. [DOI: 10.2217/pmt-2018-0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
In 2017, the US Department of Health and Human Services declared a public health emergency on the opioid crisis. On average, 115 Americans die each day from an opioid overdose. The scope and breadth of this problem is continually evolving. In 2010, there was a shift in causes primarily due to the use of heroin, and currently the latest shift in opioid-related deaths involves a variety of synthetic opioids, particularly illicitly manufactured fentanyl. As the medical, sociological and political environments have drastically changed, especially in the USA, over the last 6 years with regard to opioid use and misuse, an updated review of the literature was necessary.
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Affiliation(s)
- Anthony R Plunkett
- Department of Anesthesia & Operative Services, Womack Army Medical Center Ft Bragg, NC 28310, USA
| | - Robert M Peden
- Department of Anesthesia & Operative Services, Womack Army Medical Center Ft Bragg, NC 28310, USA
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26
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Seckel E, Jorgenson T, McFarland S. Meeting the National Need for Expertise in Pain Management with Clinical Pharmacist Advanced Practice Providers. Jt Comm J Qual Patient Saf 2019; 45:387-392. [PMID: 30981644 DOI: 10.1016/j.jcjq.2019.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 01/23/2019] [Accepted: 01/24/2019] [Indexed: 11/28/2022]
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Shipton EE, Bate F, Garrick R, Steketee C, Shipton EA, Visser EJ. Systematic Review of Pain Medicine Content, Teaching, and Assessment in Medical School Curricula Internationally. Pain Ther 2018; 7:139-161. [PMID: 30058045 PMCID: PMC6251835 DOI: 10.1007/s40122-018-0103-z] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Indexed: 12/25/2022] Open
Abstract
Introduction Pain management is a major health care challenge in terms of the significant prevalence of pain and the negative consequences of poor management. Consequently, there have been international calls to improve pain medicine education for medical students. This systematic review examines the literature on pain medicine education at medical schools internationally, with a particular interest in studies that make reference to: a defined pain medicine curriculum, specific pain medicine learning objectives, dedicated pain education modules, core pain topics, medical specialties that teach pain medicine, elective study opportunities, hours allocated to teaching pain medicine during the curriculum, the status of pain medicine in the curriculum (compulsory or optional), as well as teaching, learning, and assessment methods. Methods A systematic review was undertaken of relevant studies on pain medicine education for medical students published between January 1987 and May 2018 using PubMed, Medline, Excerpta Medica database (EMBASE), Education Resources Information Center (ERIC), and Google Scholar, and Best Evidence Medical Education (BEME) data bases. Results Fourteen studies met the inclusion criteria. Evaluation of pain medicine curricula has been undertaken at 383 medical schools in Australia, New Zealand, the United States of America (USA), Canada, the United Kingdom (UK), and Europe. Pain medicine was mostly incorporated into medical courses such as anaesthesia or pharmacology, rather than presented as a dedicated pain medicine module. Ninety-six percent of medical schools in the UK and USA, and nearly 80% of medical schools in Europe had no compulsory dedicated teaching in pain medicine. On average, the median number of hours of pain content in the entire curriculum was 20 in Canada (2009), 20 in Australia and New Zealand (2018), 13 in the UK (2011), 12 in Europe (2012/2013), and 11 in the USA (2009). Neurophysiology and pharmacology pain topics were given priority by medical schools in all countries. Lectures, seminars, and case-based instruction were the teaching methods most commonly employed. When it was undertaken, medical schools mostly assessed student competency in pain medicine using written examinations rather than clinical assessments. Conclusions This systematic review has revealed that pain medicine education at medical schools internationally does not adequately respond to societal needs in terms of the prevalence and public health impact of inadequately managed pain. Electronic supplementary material The online version of this article (10.1007/s40122-018-0103-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Elspeth E Shipton
- School of Medicine, University of Notre Dame Australia, Fremantle, Australia
| | - Frank Bate
- School of Medicine, University of Notre Dame Australia, Fremantle, Australia
| | - Raymond Garrick
- School of Medicine, University of Notre Dame Australia, Fremantle, Australia
| | - Carole Steketee
- The Learning and Teaching Office, University of Notre Dame Australia, Fremantle, Australia
| | - Edward A Shipton
- Department of Anaesthesia, University of Otago Christchurch, Christchurch, New Zealand.
| | - Eric J Visser
- School of Medicine, University of Notre Dame Australia, Fremantle, Australia
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Fink DS, Schleimer JP, Sarvet A, Grover KK, Delcher C, Castillo-Carniglia A, Kim JH, Rivera-Aguirre AE, Henry SG, Martins SS, Cerdá M. Association Between Prescription Drug Monitoring Programs and Nonfatal and Fatal Drug Overdoses: A Systematic Review. Ann Intern Med 2018; 168:783-790. [PMID: 29801093 PMCID: PMC6015770 DOI: 10.7326/m17-3074] [Citation(s) in RCA: 144] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background Prescription drug monitoring programs (PDMPs) are a key component of the president's Prescription Drug Abuse Prevention Plan to prevent opioid overdoses in the United States. Purpose To examine whether PDMP implementation is associated with changes in nonfatal and fatal overdoses; identify features of programs differentially associated with those outcomes; and investigate any potential unintended consequences of the programs. Data Sources Eligible publications from MEDLINE, Current Contents Connect (Clarivate Analytics), Science Citation Index (Clarivate Analytics), Social Sciences Citation Index (Clarivate Analytics), and ProQuest Dissertations indexed through 27 December 2017 and additional studies from reference lists. Study Selection Observational studies (published in English) from U.S. states that examined an association between PDMP implementation and nonfatal or fatal overdoses. Data Extraction 2 investigators independently extracted data from and rated the risk of bias (ROB) of studies by using established criteria. Consensus determinations involving all investigators were used to grade strength of evidence for each intervention. Data Synthesis Of 2661 records, 17 articles met the inclusion criteria. These articles examined PDMP implementation only (n = 8), program features only (n = 2), PDMP implementation and program features (n = 5), PDMP implementation with mandated provider review combined with pain clinic laws (n = 1), and PDMP robustness (n = 1). Evidence from 3 studies was insufficient to draw conclusions regarding an association between PDMP implementation and nonfatal overdoses. Low-strength evidence from 10 studies suggested a reduction in fatal overdoses with PDMP implementation. Program features associated with a decrease in overdose deaths included mandatory provider review, provider authorization to access PDMP data, frequency of reports, and monitoring of nonscheduled drugs. Three of 6 studies found an increase in heroin overdoses after PDMP implementation. Limitation Few studies, high ROB, and heterogeneous analytic methods and outcome measurement. Conclusion Evidence that PDMP implementation either increases or decreases nonfatal or fatal overdoses is largely insufficient, as is evidence regarding positive associations between specific administrative features and successful programs. Some evidence showed unintended consequences. Research is needed to identify a set of "best practices" and complementary initiatives to address these consequences. Primary Funding Source National Institute on Drug Abuse and Bureau of Justice Assistance.
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Affiliation(s)
- David S Fink
- Columbia University, New York, New York (D.S.F., J.P.S., A.S., K.K.G., S.S.M.)
| | - Julia P Schleimer
- Columbia University, New York, New York (D.S.F., J.P.S., A.S., K.K.G., S.S.M.)
| | - Aaron Sarvet
- Columbia University, New York, New York (D.S.F., J.P.S., A.S., K.K.G., S.S.M.)
| | - Kiran K Grover
- Columbia University, New York, New York (D.S.F., J.P.S., A.S., K.K.G., S.S.M.)
| | | | | | - June H Kim
- New York University, New York, New York (J.H.K.)
| | | | - Stephen G Henry
- University of California, Davis, Sacramento, California (A.C., A.E.R., S.G.H., M.C.)
| | - Silvia S Martins
- Columbia University, New York, New York (D.S.F., J.P.S., A.S., K.K.G., S.S.M.)
| | - Magdalena Cerdá
- University of California, Davis, Sacramento, California (A.C., A.E.R., S.G.H., M.C.)
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Ondansetron Does Not Reduce Withdrawal in Patients With Physical Dependence on Chronic Opioid Therapy. J Addict Med 2018; 11:342-349. [PMID: 28514235 DOI: 10.1097/adm.0000000000000321] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Individuals taking opioids for an extended period of time may become physically dependent, and will therefore experience opioid withdrawal should they stop taking the medication. Previous work in animal and human models has shown that the serotonin (5-HT3) receptor may be implicated in opioid withdrawal. In this study, we investigated if ondansetron, a 5-HT3-receptor antagonist, could reduce the symptoms of opioid withdrawal after chronic opioid exposure in humans. METHODS In this double-blinded, randomized, crossover study, 33 chronic back pain patients (N = 33) were titrated onto sustained-release oral morphine for 30 days. After titration, participants attended 2 study sessions, 1 week apart, in which opioid withdrawal was induced with intravenous naloxone, with or without 8 mg intravenous ondansetron pretreatment. Opioid withdrawal symptoms were assessed by a blinded research assistant (objective opioid withdrawal score [OOWS]) and by the research participant (subjective opioid withdrawal score [SOWS]). RESULTS Clinically significant signs of withdrawal were observed during both the ondansetron (ΔOOWS = 3.58 ± 2.22, P < 0.0001; ΔSOWS = 12.48 ± 11.18, P < 0.0001) and placebo sessions (ΔOOWS = 3.55 ± 2.39, P < 0.0001; ΔSOWS = 12.21 ± 10.72, P < 0.0001), but no significant differences were seen between the treatment sessions in either the OOWS or SOWS scores. CONCLUSION We hypothesized that ondansetron would reduce opioid withdrawal symptoms in human subjects, but found no difference in withdrawal severity between ondansetron and placebo sessions. These findings suggest that more investigation may be necessary to determine if 5-HT3-receptor antagonists are suitable treatment options for opioid withdrawal.
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Shipton EE, Bate F, Garrick R, Steketee C, Visser EJ. Pain medicine content, teaching and assessment in medical school curricula in Australia and New Zealand. BMC MEDICAL EDUCATION 2018; 18:110. [PMID: 29751806 PMCID: PMC5948674 DOI: 10.1186/s12909-018-1204-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 04/20/2018] [Indexed: 05/03/2023]
Abstract
BACKGROUND The objective of pain medicine education is to provide medical students with opportunities to develop their knowledge, skills and professional attitudes that will lead to their becoming safe, capable, and compassionate medical practitioners who are able to meet the healthcare needs of persons in pain. This study was undertaken to identify and describe the delivery of pain medicine education at medical schools in Australia and New Zealand. METHOD All 23 medical schools in Australia and New Zealand in 2016 were included in this study. A structured curriculum audit tool was used to obtain information on pain medicine curricula including content, delivery, teaching and assessment methods. RESULTS Nineteen medical schools (83%) completed the curriculum audit. Neurophysiology, clinical assessment, analgesia use and multidimensional aspects of pain medicine were covered by most medical schools. Specific learning objectives for pain medicine were not identified by 42% of medical schools. One medical school offered a dedicated pain medicine module delivered over 1 week. Pain medicine teaching was delivered at all schools by a number of different departments throughout the curriculum. Interprofessional learning (IPL) in the context of pain medicine education was not specified by any of the medical schools. The mean time allocated for pain medicine teaching over the entire medical course was just under 20 h. The objective structured clinical examination (OSCE) was used by 32% of schools to assess knowledge and skills in pain medicine. 16% of schools were unsure of whether any assessment of pain medicine education took place. CONCLUSION This descriptive study provides important baseline information for pain medicine education at medical schools in Australia and New Zealand. Medical schools do not have well-documented or comprehensive pain curricula that are delivered and assessed using pedagogically-sound approaches considering the complexity of the topic, the prevalence and public health burden of pain.
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Affiliation(s)
- Elspeth Erica Shipton
- School of Medicine, University of Notre Dame Australia, UNDA, P O Box 1225, Fremantle, WA 6160 Australia
| | - Frank Bate
- School of Medicine, University of Notre Dame Australia, UNDA, P O Box 1225, Fremantle, WA 6160 Australia
| | - Raymond Garrick
- School of Medicine, University of Notre Dame Australia, UNDA, Sydney, Darlinghurst Campus, Darlinghurst, NSW 2000 Australia
| | - Carole Steketee
- The Learning and Teaching Office, University of Notre Dame Australia, UNDA, P O Box 1225, Fremantle, WA 6160 Australia
| | - Eric John Visser
- School of Medicine, University of Notre Dame Australia, UNDA, P O Box 1225, Fremantle, WA 6160 Australia
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Saqib A, Atif M, Scahill S. Drug utilization evaluation among an elderly population: a retrospective cross-sectional study in a tertiary care hospital in Pakistan. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2018. [DOI: 10.1111/jphs.12220] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Anum Saqib
- Department of Pharmacy; The Islamia University of Bahawalpur; Bahawalpur Pakistan
| | - Muhammad Atif
- Department of Pharmacy; The Islamia University of Bahawalpur; Bahawalpur Pakistan
| | - Shane Scahill
- School of Management; Massey University; Wellington New Zealand
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Higgins DM, Martin AM, Baker DG, Vasterling JJ, Risbrough V. The Relationship Between Chronic Pain and Neurocognitive Function: A Systematic Review. Clin J Pain 2018; 34:262-275. [PMID: 28719507 PMCID: PMC5771985 DOI: 10.1097/ajp.0000000000000536] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Understanding the relationship between chronic pain and neurocognition has important implications for the assessment and treatment of patient experiencing pain. This paper provides an overview of the current literature examining the neurocognition-chronic pain relationship and suggests future avenues of research, along with a discussion of clinical implications of the literature findings. Consideration of potential moderators and mediators of this relationship, as well as a brief discussion of the importance of future research in special populations at particular risk for these problems, are also a focus of this paper. METHODS This systematic review summarizes the findings of clinical studies in which neurocognitive performance was measured in chronic pain samples. A literature search led to the inclusion of 53 articles in the review. RESULTS Studies of neurocognitive performance in clinical chronic pain samples support a relationship between chronic pain and neurocognitive abnormalities, particularly on tests of memory, attention, and processing speed, with mixed data regarding executive functioning. DISCUSSION Several factors may moderate or mediate the relationship between chronic pain and neurocognitive functioning, including mood symptoms, medication side effects, and intensity and/or chronicity of pain. Limitations in the literature include a paucity of methodologically rigorous studies controlling for confounding variables (eg, opioid analgesia) and a limited number of studies examining the relationship between chronic pain and traumatic brain injury (a potential precipitant of both pain and neurocognitive impairment). Nonetheless, findings from the existing literature have significant clinical implications, including for populations with heightened risk of both pain and neurocognitive disorders.
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Affiliation(s)
- Diana M. Higgins
- VA Boston Healthcare System, Boston, MA
- Boston University School of Medicine, Boston, MA
| | | | - Dewleen G. Baker
- University of California San Diego, San Diego, CA
- VA Center of Excellence for Stress and Mental Health and San Diego Healthcare System, San Diego, CA
| | | | - Victoria Risbrough
- University of California San Diego, San Diego, CA
- VA Center of Excellence for Stress and Mental Health and San Diego Healthcare System, San Diego, CA
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Kelly MM, Reilly E, Quiñones T, Desai N, Rosenheck R. Long-acting intramuscular naltrexone for opioid use disorder: Utilization and association with multi-morbidity nationally in the Veterans Health Administration. Drug Alcohol Depend 2018; 183:111-117. [PMID: 29245103 DOI: 10.1016/j.drugalcdep.2017.10.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 09/01/2017] [Accepted: 10/11/2017] [Indexed: 01/14/2023]
Abstract
BACKGROUND Long acting intramuscular (IM) naltrexone is an effective treatment for opioid use disorder (OUD), but rates and correlates of its use have not been studied. METHODS National administrative from the Veterans Health Administration (VHA) from Fiscal Year 2012 identified only 16 VHA facilities that prescribed IM naltrexone to 5 or more veterans diagnosed with OUD. Data from these facilities were used to identify sociodemographic, diagnostic, and service use characteristics, including use of psychotropic medication, that were characteristic of veterans who filled prescriptions for IM naltrexone. This was in comparison to users of opiate agonist treatments (methadone or buprenorphine) or veterans with no pharmacologic treatment for OUD. Comparisons were made using both bi-variate analyses and multivariable logistic regression. RESULTS Only 179 of 16,402 veterans with OUD (1%) at these 16 facilities filled a prescription for IM naltrexone and only 256 of 99,394 (0.26%) nationally. These veterans were characterized by past homelessness, co-morbid alcohol use disorder, multiple psychiatric disorders, and a greater likelihood of psychiatric hospitalization, as well as mental health outpatient and antidepressant medication use. CONCLUSIONS IM naltrexone is rarely used for OUD and is primarily used for patients with multiple co-morbidities, especially alcohol use disorder and serious mental illness. The use of this treatment illustrates many of the principles identified by the emerging focus on multi-morbidity as a critical feature of clinical practice.
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Affiliation(s)
- Megan M Kelly
- VISN 1 VA New England Mental Illness Research, Education, and Clinical Center, USA; Social and Community Reintegration Research Program, Edith Nourse Rogers Memorial Veterans Hospital, 200 Springs Road, Bedford, MA 01730, USA; Edith Nourse Rogers Memorial Veterans Hospital, 200 Springs Road, Bedford, MA 01730, USA; University of Massachusetts Medical School, 55 Lake Ave North, Worcester, MA 01655, USA.
| | - Erin Reilly
- Social and Community Reintegration Research Program, Edith Nourse Rogers Memorial Veterans Hospital, 200 Springs Road, Bedford, MA 01730, USA; Edith Nourse Rogers Memorial Veterans Hospital, 200 Springs Road, Bedford, MA 01730, USA
| | - Timothy Quiñones
- Edith Nourse Rogers Memorial Veterans Hospital, 200 Springs Road, Bedford, MA 01730, USA
| | - Nitigna Desai
- VISN 1 VA New England Mental Illness Research, Education, and Clinical Center, USA; Edith Nourse Rogers Memorial Veterans Hospital, 200 Springs Road, Bedford, MA 01730, USA; University of Massachusetts Medical School, 55 Lake Ave North, Worcester, MA 01655, USA; Boston University School of Medicine,72 E. Concord Street, Boston, MA 02118, USA
| | - Robert Rosenheck
- VISN 1 VA New England Mental Illness Research, Education, and Clinical Center, USA; VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT 06516, USA; Yale University School of Medicine,333 Cedar Street, New Haven, CT 06510, USA
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Abstract
Pain is an increasing clinical challenge affecting about half the population, with a substantial number of people suffering daily intense pain. Such suffering can be linked to the dramatic rise in opioid use and associated deaths in the United States. There is a pressing need for new analgesics with limited side effects. Here, we summarize what we know about the genetics of pain and implications for drug development. We make the case that chronic pain is not one but a set of disease states, with peripheral drive a key element in most. We argue that understanding redundancy and plasticity, hallmarks of the nervous system, is critical in developing analgesic drug strategies. We describe the exploitation of monogenic pain syndromes and genetic association studies to define analgesic targets, as well as issues associated with animal models of pain. We appraise present-day screening technologies and describe recent approaches to pain treatment that hold promise.
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Affiliation(s)
- Jane E Sexton
- Molecular Nociception Group, Wolfson Institute for Biomedical Research, University College London, London WC1E 6BT, United Kingdom;
| | - James J Cox
- Molecular Nociception Group, Wolfson Institute for Biomedical Research, University College London, London WC1E 6BT, United Kingdom;
| | - Jing Zhao
- Molecular Nociception Group, Wolfson Institute for Biomedical Research, University College London, London WC1E 6BT, United Kingdom;
| | - John N Wood
- Molecular Nociception Group, Wolfson Institute for Biomedical Research, University College London, London WC1E 6BT, United Kingdom;
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Al-Zadjali N, Al-Khaldi S, Samir N, Rizvi S, Al-Zakwani I, Al-Mahrezi A. Characteristics of Chronic Pain Patients Attending a Primary Health Care Center in Oman. Oman Med J 2017; 32:461-466. [PMID: 29218121 DOI: 10.5001/omj.2017.89] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Objectives To determine the characteristics of patients presenting with chronic pain in a primary health care setting in Oman. Methods A retrospective cross-sectional study was carried out including all patients aged ≥ 18 years who attended Sultan Qaboos University Health Center during 2010. Patients were identified to have chronic pain if they were prescribed an analgesic medication for at least three months. Patients were compared to a control group which consisted of age- and gender-matched patients with no chronic pain. Results Out of 6 609 patients, 241 (3.6%) were found to have chronic pain. The mean age of patients with chronic pain was 54.0±13.0 years. The majority of patients were female (n = 174; 72.1%), and most were Omani (n = 201; 83.4%). The prevalence of chronic pain was found to be significantly higher among females compared to males (4.5% vs. 2.5%; p < 0.001) and also among Omani nationals to non-nationals (83.4% vs. 70.1%; p < 0.001). Chronic pain was significantly associated with the following comorbidities; diabetes (33.1% vs. 20.7%; p < 0.001), obesity (35.2% vs. 26.5%; p = 0.001), and hypertension (51.0% vs. 38.5%; p = 0.002). Osteoarthritis was the most common pain condition (n = 104; 43.1%). Diclofenac was the most commonly prescribed drug (n = 168; 69.7%). Conclusions The findings of our study point towards a higher prevalence of chronic pain in Omani females. These patients were also found to have a higher prevalence of other common comorbid conditions.
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Affiliation(s)
- Nasrin Al-Zadjali
- Directorate General of Primary Health Care, Ministry of Health, Muscat, Oman
| | - Samia Al-Khaldi
- Directorate General of Primary Health Care, Ministry of Health, Muscat, Oman
| | - Nafisa Samir
- Department of Family Medicine and Public Health, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
| | - Syed Rizvi
- Department of Family Medicine and Public Health, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
| | - Ibrahim Al-Zakwani
- Department of Pharmacology and Clinical Pharmacy, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat; Oman Gulf Health Research, Muscat, Oman
| | - Abdulaziz Al-Mahrezi
- Department of Family Medicine and Public Health, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
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Billet B, Wynendaele R, Vanquathem NE. A Novel Minimally Invasive Wireless Technology for Neuromodulation via Percutaneous Intercostal Nerve Stimulation for Post-Herpetic Neuralgia: A Case Report with Short-Term Follow-up. Pain Pract 2017. [DOI: 10.1111/papr.12607] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Sinnott PL, Dally SK, Trafton J, Goulet JL, Wagner TH. Trends in diagnosis of painful neck and back conditions, 2002 to 2011. Medicine (Baltimore) 2017; 96:e6691. [PMID: 28514286 PMCID: PMC5440123 DOI: 10.1097/md.0000000000006691] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Neck and back pain are pervasive problems. Some have suggested that rising incidence may be associated with the evidence of rising prevalence.To describe the trends in diagnosis of painful neck and back conditions in a large national healthcare system.A retrospective observational cohort study to describe the incidence and prevalence of diagnosis of neck and back pain in a national cohort.Patients were identified by International Classification of Diseases, 9 Revision (ICD-9) codes in Department of Veterans Affairs (VA) national utilization datasets in calendar years 2002 to 2011.Descriptive statistics were used to analyze the data. Prevalent cases were compared with all veterans who sought health care in each year. Incident cases were identified following a 2 years clean period in which the patient was enrolled and received care, but not services for any back or neck pain conditions.From 2004 to 2011, 3% to 4% of the population was diagnosed with incident back pain problems, the rate increasing on average, 1.75% per year. During the same period, 12.3% to 16.2% of the population was diagnosed with a prevalent back pain problem, the rate increasing on average 4.09% per year.In a national population, the prevalence rate for diagnosis of neck and back pain grew 1.8 to 2.3 times faster than the incidence rate. This suggests that the average duration of episodes of care is increasing. Additional research is needed to understand the influences on the differential rate of change and to develop efficient and effective care systems.
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Affiliation(s)
| | | | - Jodie Trafton
- Center for Innovation to Implementation and Program Evaluation and Resource Center
| | - Joseph L. Goulet
- The Pain Research, Informatics, Multimorbidities and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Todd H. Wagner
- Health Economics Resource Center (HERC) and Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, California
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The frequency of analgesic drug use and causes in 65 years old and above; A family medicine unit experience. JOURNAL OF SURGERY AND MEDICINE 2017. [DOI: 10.28982/josam.339263] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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A Double-Blind Placebo Randomized Controlled Trial of Minocycline to Reduce Pain After Carpal Tunnel and Trigger Finger Release. J Hand Surg Am 2017; 42:166-174. [PMID: 28259273 DOI: 10.1016/j.jhsa.2016.12.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 11/18/2016] [Accepted: 12/29/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE Minocycline is a microglial cell inhibitor and decreases pain behaviors in animal models. Minocycline might represent an intervention for reducing postoperative pain. This trial tested whether perioperative administration of minocycline reduced time to pain resolution (TPR) after standardized hand surgeries with known prolonged pain profiles: carpal tunnel release (CTR) and trigger finger release (TFR). METHODS This double-blinded randomized controlled trial included patients undergoing CTR or TFR under local anesthesia. Before surgery, participants recorded psychological and pain measures. Participants received oral minocycline, 200 mg, or placebo 2 hours prior to procedure, and then 100 mg of minocycline or placebo 2 times a day for 5 days. After surgery, participants were called daily assessing their pain. The primary end point of TPR was when participants had 3 consecutive days of 0 postsurgical pain. Futility analysis and Kaplan-Meier analyses were performed. RESULTS A total of 131 participants were randomized and 56 placebo and 58 controls were analyzed. Median TPR for CTR was 3 weeks, with 15% having pain more than 6 weeks. Median TPR for TFR was 2 weeks with 18% having pain more than 6 weeks. The overall median TPR for the placebo group was 2 weeks (10% pain > 6 weeks) versus 2.5 weeks (17% pain > 6 weeks) for the minocycline group. Futility analysis found that the likelihood of a true underlying clinically meaningful reduction in TPR owing to minocycline was only 3.5%. Survival analysis found minocycline did not reduce TPR. However, subgroup analysis of those with elevated posttraumatic distress scores found the minocycline group had longer TPR. CONCLUSIONS Oral administration of minocycline did not reduce TPR after minor hand surgery. There was evidence that minocycline might increase length of pain in those with increased posttraumatic stress disorder symptoms. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic I.
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Kostadinović S, Vasiljević J, Schumacher U. Pain therapy in patients with musculoskeletal disorders in outpatient setting: A cohort study. COGENT MEDICINE 2016. [DOI: 10.1080/2331205x.2016.1214337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
| | - Jovan Vasiljević
- School of Medicine, The Institute of Pathology, University of Belgrade, Belgrade, Serbia
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Lee J, Yoon JS, Lee JH, Chung SH, Lee KY, Kim YY, Kim JM, Kong MH, Kang UG, Park YS. Clinical Usefulness of Long-term Application of Fentanyl Matrix in Chronic Non-Cancer Pain: Improvement of Pain and Physical and Emotional Functions. Clin Orthop Surg 2016; 8:465-474. [PMID: 27904731 PMCID: PMC5114261 DOI: 10.4055/cios.2016.8.4.465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 06/13/2016] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Opioids are recently recommended for those who do not gain adequate pain relief from the use of acetaminophen or nonsteroidal anti-inflammatory drugs. Medical opioids are administered in various routes, and transdermal opioid products that can make up for the weaknesses of the oral or intravenous products have been developed. This study is to evaluate the clinical usefulness of fentanyl matrix in terms of the long-term improvement in pain and physical and mental functions. METHODS This was a multicenter, open, prospective, observational study that was conducted in 54 institutions in Korea. Patients with non-cancerous chronic pain completed questionnaires, and investigators also completed questionnaires. A total of 1,355 subjects participated in this study, and 639 subjects completed the study. Subjects received transdermal fentanyl matrix (12 µg/hr, 25 µg/hr, or 50 µg/hr depending on the patient's response and demand). Subjects visited at 29 ± 7 days, 85 ± 14 days, and 169 ± 14 days after administration, respectively, to receive drug titration and fill out the questionnaires. The results were analyzed using the intention-to-treat (ITT) analysis, full analysis set (FAS), and per-protocol (PP) analysis. The FAS analysis included only 451 participants; the PP analysis, 160 participants; and the ITT analysis, 1,355 participants. RESULTS The intensity of pain measured by the Numeric Rating Scale decreased from 7.07 ± 1.78 to 4.93 ± 2.42. The physical assessment score and mental assessment score of the Short-Form Health Survey 12 improved from 28.94 ± 7.23 to 35.90 ± 10.25 and from 35.80 ± 11.76 to 42.52 ± 10.58, respectively. These differences were significant, and all the other indicators also showed improvement. Adverse events with an incidence of ≥ 1% were nausea, dizziness, vomiting, and pruritus. CONCLUSIONS The long-term administration of fentanyl matrix in patients with non-cancerous pain can reduce the intensity of pain and significantly improves activities of daily living and physical and mental capabilities.
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Affiliation(s)
- Jaewon Lee
- Department of Orthopedic Surgery, Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Joon Shik Yoon
- Department of Physical Medicine and Rehabilitation, Korea University College of Medicine, Seoul, Korea
| | - Jae Hyup Lee
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - So-Hak Chung
- Department of Orthopedic Surgery, Kosin University Gospel Hospital, Kosin University School of Medicine, Busan, Korea
| | - Kyu-Yeol Lee
- Department of Orthopedic Surgery, Dong-A University College of Medicine, Busan, Korea
| | - Young Yul Kim
- Department of Orthopedic Surgery, Daejeon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Daejeon, Korea
| | - Jong Moon Kim
- Department of Rehabilitation, Konkuk University College of Medicine, Chungju, Korea
| | - Min Ho Kong
- Department of Neurosurgery, Seoul Medical Center, Seoul, Korea
| | - Ung Gu Kang
- Department of Psychiatry and Behavioral Science, Seoul National University College of Medicine, Seoul, Korea
| | - Ye-Soo Park
- Department of Orthopedic Surgery, Guri Hospital, Hanyang University College of Medicine, Guri, Korea
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Cheung CW, Choi SW, Wong SSC, Lee Y, Irwin MG. Changes in Prevalence, Outcomes, and Help-seeking Behavior of Chronic Pain in an Aging Population Over the Last Decade. Pain Pract 2016; 17:643-654. [PMID: 27735140 DOI: 10.1111/papr.12496] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 06/07/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND Chronic pain is expected to increase as the population ages. This study aimed to investigate the changes in prevalence, patterns, and help-seeking behavior of chronic pain and prevalence of neuropathic pain of an aging population in Hong Kong. METHODS A cross-sectional, telephone interview with a structured questionnaire was conducted in a randomly selected sample of adults with acute or chronic pain of any kind in the general population to estimate the prevalence of chronic and neuropathic pain, and to describe sociodemographics and help-seeking behavior. Results were compared with a similar study conducted in 1999. RESULTS Totally, 1,570 people were interviewed. Chronic pain was experienced by 28.7% of all respondents, compared to 10.8% in 1999. Joint (45.5%), muscle (27.1%), and back (25.2%) pain were the most common, similar to findings in 1999. Of those with chronic pain, 83.1% reported pain in more than one body site (63.4% in 1999, P = 0.0023). More respondents reported their average pain as being intense (51.57% vs. 33.0% in 2013 and 1999, respectively, P = 0.0098). A downward trend of respondents taking medications for chronic pain (34.9% in 2013 vs. 47.6% in 1999, P = 0.019) was seen. Neuropathic pain was present in 9.03% of the population and 14.7% of chronic pain sufferers. CONCLUSION The prevalence of neuropathic pain in Hong Kong is high and is described here for the first time. The number of chronic pain sufferers has tripled in the past decade. Significant changes in the patterns and help- seeking behavior of chronic pain sufferers are also seen.
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Affiliation(s)
- Chi Wai Cheung
- Laboratory and Clinical Research Institute for Pain, Department of Anaesthesiology, The University of Hong Kong, Hong Kong, China.,Department of Anaesthesiology, Queen Mary Hospital, Hong Kong, China.,Research Centre of Heart, Brain, Hormone & Healthy Aging, The University of Hong Kong, Hong Kong, China
| | - Siu Wai Choi
- Laboratory and Clinical Research Institute for Pain, Department of Anaesthesiology, The University of Hong Kong, Hong Kong, China
| | - Stanley Sau Ching Wong
- Laboratory and Clinical Research Institute for Pain, Department of Anaesthesiology, The University of Hong Kong, Hong Kong, China
| | - Yvonne Lee
- Laboratory and Clinical Research Institute for Pain, Department of Anaesthesiology, The University of Hong Kong, Hong Kong, China
| | - Michael Garnet Irwin
- Laboratory and Clinical Research Institute for Pain, Department of Anaesthesiology, The University of Hong Kong, Hong Kong, China.,Department of Anaesthesiology, Queen Mary Hospital, Hong Kong, China.,Research Centre of Heart, Brain, Hormone & Healthy Aging, The University of Hong Kong, Hong Kong, China
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Kim J, Ham S, Hong H, Moon C, Im HI. Brain Reward Circuits in Morphine Addiction. Mol Cells 2016; 39:645-53. [PMID: 27506251 PMCID: PMC5050528 DOI: 10.14348/molcells.2016.0137] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 07/18/2016] [Accepted: 07/20/2016] [Indexed: 12/30/2022] Open
Abstract
Morphine is the most potent analgesic for chronic pain, but its clinical use has been limited by the opiate's innate tendency to produce tolerance, severe withdrawal symptoms and rewarding properties with a high risk of relapse. To understand the addictive properties of morphine, past studies have focused on relevant molecular and cellular changes in the brain, highlighting the functional roles of reward-related brain regions. Given the accumulated findings, a recent, emerging trend in morphine research is that of examining the dynamics of neuronal interactions in brain reward circuits under the influence of morphine action. In this review, we highlight recent findings on the roles of several reward circuits involved in morphine addiction based on pharmacological, molecular and physiological evidences.
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Affiliation(s)
- Juhwan Kim
- Center for Neuroscience, Brain Science Institute, Seoul 02792,
Korea
- Convergence Research Center for Diagnosis, Treatment and Care System of Dementia, Korea Institute of Science and Technology (KIST), Seoul 02792,
Korea
- Department of Veterinary Anatomy, College of Veterinary Medicine and Animal Medical Institute, Chonnam National University, Gwangju 61186,
Korea
| | - Suji Ham
- Center for Neuroscience, Brain Science Institute, Seoul 02792,
Korea
- Convergence Research Center for Diagnosis, Treatment and Care System of Dementia, Korea Institute of Science and Technology (KIST), Seoul 02792,
Korea
- Department of Neuroscience, Korea University of Science and Technology (UST), Daejeon 34113,
Korea
| | - Heeok Hong
- Department of Medical Science, Konkuk University School of Medicine, Seoul 05029,
Korea
| | - Changjong Moon
- Department of Veterinary Anatomy, College of Veterinary Medicine and Animal Medical Institute, Chonnam National University, Gwangju 61186,
Korea
| | - Heh-In Im
- Center for Neuroscience, Brain Science Institute, Seoul 02792,
Korea
- Convergence Research Center for Diagnosis, Treatment and Care System of Dementia, Korea Institute of Science and Technology (KIST), Seoul 02792,
Korea
- Department of Neuroscience, Korea University of Science and Technology (UST), Daejeon 34113,
Korea
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Dorn S, Lembo A, Cremonini F. Opioid-induced bowel dysfunction: epidemiology, pathophysiology, diagnosis, and initial therapeutic approach. ACTA ACUST UNITED AC 2016; 2:31-7. [PMID: 25207610 DOI: 10.1038/ajgsup.2014.7] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Opioids affect motor and sensory function throughout the gastrointestinal tract, and are frequently associated with a number of gastrointestinal symptoms including constipation, which impairs the quality of life and may limit the dose of opioid or result in discontinuation altogether. Patients with opioid-induced constipation should be assessed by careful history and physical examination, and in some cases where the diagnosis is unclear with select diagnostic tests. Few clinical studies have been conducted to assess the efficacy of various treatments. However, it is generally recommended that first-line therapy begin with opioid rotation, as well as with low-cost and low-risk approaches such as lifestyle changes, consumption of fiber-rich food, stool softeners, and laxatives.
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Affiliation(s)
- Spencer Dorn
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Anthony Lembo
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Luchting B, Heyn J, Woehrle T, Rachinger-Adam B, Kreth S, Hinske LC, Azad SC. Differential expression of P2X7 receptor and IL-1β in nociceptive and neuropathic pain. J Neuroinflammation 2016; 13:100. [PMID: 27145808 PMCID: PMC4857287 DOI: 10.1186/s12974-016-0565-z] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 04/27/2016] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Despite substantial progress, pathogenesis and therapy of chronic pain are still the focus of many investigations. The ATP-gated P2X7 receptor (P2X7R) has previously been shown to play a central role in animal models of nociceptive inflammatory and neuropathic pain. Recently, we found that the adaptive immune system is involved in the pathophysiology of chronic nociceptive and neuropathic pain in humans. So far, data regarding P2X7R expression patterns on cells of the adaptive immune system of pain patients are scarce. We therefore analyzed the P2X7R expression on peripheral blood lymphocytes and monocytes, as well as serum levels of IL-1β in patients suffering from chronic nociceptive and neuropathic pain in comparison to healthy volunteers in order to identify individuals who might benefit from a P2X7R modulating therapy. METHODS P2X7R messenger RNA (mRNA) and protein expression were determined in patients with either chronic nociceptive low back pain (CLBP) or neuropathic pain (NeP), and in healthy volunteers by quantitative real-time PCR (qPCR) and by fluorescence-assisted cell-sorting (FACS), respectively. IL-1β serum levels were measured with a multiplex cytokine assay. RESULTS Compared to healthy volunteers, P2X7R mRNA (1.6-fold, p = 0.038) and protein levels were significantly increased on monocytes (NeP: 24.6 ± 6.2, healthy volunteers: 17.0 ± 5.4; p = 0.002) and lymphocytes (NeP: 21.8 ± 6.5, healthy volunteers: 15.6 ± 5.2; p = 0.009) of patients with NeP, but not in patients with CLBP. Similarly, IL-1β serum concentrations were significantly elevated only in NeP patients (1.4-fold, p = 0.04). CONCLUSIONS A significant upregulation of P2X7R and increased IL-1β release seems to be a particular phenomenon in patients with NeP. P2X7R inhibitors may therefore represent a potential option for the treatment of this frequently intractable type of pain. German Clinical Trial Register (DRKS): Registration Trial DRKS00005954.
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Affiliation(s)
- Benjamin Luchting
- Department of Anesthesiology and Pain Medicine, LMU-Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Jens Heyn
- Department of Anesthesiology and Pain Medicine, LMU-Munich, Marchioninistrasse 15, 81377, Munich, Germany.
| | - Tobias Woehrle
- Department of Anesthesiology and Pain Medicine, LMU-Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Banafscheh Rachinger-Adam
- Department of Anesthesiology and Pain Medicine, LMU-Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Simone Kreth
- Department of Anesthesiology and Pain Medicine, LMU-Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Ludwig C Hinske
- Department of Anesthesiology and Pain Medicine, LMU-Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Shahnaz C Azad
- Department of Anesthesiology and Pain Medicine, LMU-Munich, Marchioninistrasse 15, 81377, Munich, Germany
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Affiliation(s)
- Junad Khan
- Center for Temporomandibular Disorders and Orofacial Pain, Rutgers School of Dental Medicine, C 850, 07103, Newark, NJ, USA
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Dobscha SK, Lovejoy TI, Morasco BJ, Kovas AE, Peters DM, Hart K, Williams JL, McFarland BH. Predictors of Improvements in Pain Intensity in a National Cohort of Older Veterans With Chronic Pain. THE JOURNAL OF PAIN 2016; 17:824-35. [PMID: 27058162 DOI: 10.1016/j.jpain.2016.03.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 03/21/2016] [Accepted: 03/24/2016] [Indexed: 12/25/2022]
Abstract
UNLABELLED Little is known about the factors associated with pain-related outcomes in older adults. In this observational study, we sought to identify patient factors associated with improvements in pain intensity in a national cohort of older veterans with chronic pain. We included 12,924 veterans receiving treatment from the Veterans Health Administration with persistently elevated numeric rating scale scores in 2010 who had not been prescribed opioids in the previous 12 months. We examined: 1) percentage decrease over 12 months in average pain intensity scores relative to average baseline pain intensity score; and 2) time to sustained improvement in average pain intensity scores, defined as a 30% reduction in 3-month scores compared with baseline. Average relative improvement in pain intensity scores from baseline ranged from 25% to 29%; almost two-thirds met criteria for sustained improvement during the 12-month follow-up period. In models, higher baseline pain intensity and older age were associated with greater likelihood of improvement in pain intensity, whereas Veterans Affairs service-connected disability, mental health, and certain pain-related diagnoses were associated with lower likelihood of improvement. Opioid prescription initiation during follow-up was associated with lower likelihood of sustained improvement. The findings call for further characterization of heterogeneity in pain outcomes in older adults as well as further analysis of the relationship between prescription opioids and treatment outcomes. PERSPECTIVE This study identified factors associated with improvements in pain intensity in a national cohort of older veterans with chronic pain. We found that older veterans frequently show improvements in pain intensity over time, and that opioid prescriptions, mental health, and certain pain diagnoses are associated with lower likelihood of improvement.
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Affiliation(s)
- Steven K Dobscha
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon; Department of Psychiatry, Oregon Health and Science University, Portland, Oregon.
| | - Travis I Lovejoy
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon; Department of Psychiatry, Oregon Health and Science University, Portland, Oregon
| | - Benjamin J Morasco
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon; Department of Psychiatry, Oregon Health and Science University, Portland, Oregon
| | - Anne E Kovas
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Dawn M Peters
- Department of Public Health and Preventive Medicine, Oregon Health and Science University, Portland, Oregon
| | - Kyle Hart
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - J Lucas Williams
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Bentson H McFarland
- Department of Psychiatry, Oregon Health and Science University, Portland, Oregon; Department of Public Health and Preventive Medicine, Oregon Health and Science University, Portland, Oregon
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Carey EP, Frank JW, Kerns RD, Ho PM, Kirsh SR. Implementation of telementoring for pain management in Veterans Health Administration: Spatial analysis. ACTA ACUST UNITED AC 2016; 53:147-56. [DOI: 10.1682/jrrd.2014.10.0247] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 09/11/2015] [Indexed: 11/05/2022]
Affiliation(s)
- Evan P. Carey
- Department of Veterans Affairs (VA) Eastern Colorado Health Care System, Denver, CODepartment of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
| | - Joseph W. Frank
- Department of Veterans Affairs (VA) Eastern Colorado Health Care System, Denver, CODivision of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Robert D. Kerns
- VA Connecticut Healthcare System, West Haven, CT, and Yale School of Medicine, New Haven, CT
| | - P. Michael Ho
- Department of Veterans Affairs (VA) Eastern Colorado Health Care System, Denver, CODepartment of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Susan R. Kirsh
- Louis Stokes Cleveland VA Medical Center, Cleveland, OH, Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, OH, and Office of Specialty Care, Veterans Health Administration, Washington, DC
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Exposure to High-Risk Medications is Associated With Worse Outcomes in Older Veterans With Chronic Pain. Am J Med Sci 2015; 350:279-85. [PMID: 26418380 DOI: 10.1097/maj.0000000000000552] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Chronic pain is common, costly and leads to significant morbidity in older adults, yet there are limited data on medication safety. The authors sought to evaluate the association of incident high-risk medication in the elderly (HRME) with mortality, emergency department (ED) or hospital care among older adults with chronic pain. METHODS A retrospective Veterans Health Administration cohort study was conducted examining older veterans with chronic pain diagnoses and use of incident HRME (opioids, skeletal muscle relaxants, antihistamines and psychotropics). Outcomes evaluated included all-cause mortality, ED visits or inpatient hospital care. Descriptive statistics summarized variables for the overall cohort, the chronic pain cohort and those with and without HRME. Separate generalized linear mixed-effect regression models were used to examine the association of incident HRME on each outcome, controlling for potential confounders. RESULTS Among 1,807,404 veterans who received Department of Veterans Affairs care in 2005 to 2006, 584,066 (32.3%) had chronic pain; 45,945 veterans with chronic pain (7.9%) had incident HRME exposure. The strongest significant associations of incident HRME were for high-risk opioids with all-cause hospitalizations (odds ratio [OR] 2.08, 95% confidence interval [CI] 1.95-2.23), skeletal muscle relaxants with all-cause ED visits (OR 2.62, 95% CI 2.52-2.73) and mortality (OR 0.80, 95% CI 0.74-0.86), antihistamines with all-cause ED visits (OR 2.82 95% CI 2.72-2.95) and psychotropics with all-cause hospitalizations (OR 2.15, 95% CI 1.96-2.35). CONCLUSIONS Our data indicate that incident HRME is associated with clinically important adverse outcomes in older veterans with chronic pain and highlight the importance of being judicious with prescribing certain classes of drugs in this vulnerable population.
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Weimer MB, Hartung DM, Ahmed S, Nicolaidis C. A chronic opioid therapy dose reduction policy in primary care. Subst Abus 2015; 37:141-7. [DOI: 10.1080/08897077.2015.1129526] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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