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Richards N, Fried M, Svirsky L, Thomas N, Zettler PJ, Howard D. Clinician Perspectives on Opioid Treatment Agreements: A Qualitative Analysis of Focus Groups. AJOB Empir Bioeth 2023:1-12. [PMID: 37962913 DOI: 10.1080/23294515.2023.2274606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
BACKGROUND Patients with chronic pain face significant barriers in finding clinicians to manage long-term opioid therapy (LTOT). For patients on LTOT, it is increasingly common to have them sign opioid treatment agreements (OTAs). OTAs enumerate the risks of opioids, as informed consent documents would, but also the requirements that patients must meet to receive LTOT. While there has been an ongoing scholarly discussion about the practical and ethical implications of OTA use in the abstract, little is known about how clinicians use them and if OTAs themselves modify clinician prescribing practices. OBJECTIVE To determine how clinicians use OTAs and the potential impacts of OTAs on opioid prescribing. DESIGN We conducted qualitative analysis of four focus groups of clinicians from a large Midwestern academic medical center. Groups were organized according to self-identified prescribing patterns: two groups for clinicians who identified as prescribers of LTOT, and two who did not. PARTICIPANTS 17 clinicians from General Internal Medicine, Family Medicine, and Palliative Care were recruited using purposive, convenience sampling. APPROACH Discussions were recorded, transcribed, and analyzed for themes using reflexive thematic analysis by a multidisciplinary team. KEY RESULTS Our analysis identified three main themes: (1) OTAs did not influence clinicians' decisions whether to use LTOT generally but did shape clinical decision-making for individual patients; (2) clinicians feel OTAs intensify the power they have over patients, though this was not uniformly judged as harmful; (3) there is a potential misalignment between the intended purposes of OTAs and their implementation. CONCLUSION This study reveals a complicated relationship between OTAs and access to pain management. While OTAs seem not to impact the clinicians' decisions about whether to use LTOT generally, they do sometimes influence prescribing decisions for individual patients. Clinicians shared complex views about OTAs' purposes, which shows the need for more clarity about how OTAs could be used to promote shared decision-making, joint accountability, informed consent, and patient education.
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Affiliation(s)
- Nathan Richards
- English, Ohio State University College of Arts and Sciences, Columbus, Ohio, USA
| | - Martin Fried
- Division of General Internal Medicine, Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Larisa Svirsky
- Centre for Ethics, University of Toronto, Toronto, Ontario, Canada
| | - Nicole Thomas
- CATALYST, Ohio State University, Columbus, Ohio, USA
| | - Patricia J Zettler
- OSU Drug Enforcement and Policy Center and the OSU Comprehensive Cancer Center, Ohio State University College of Law, Columbus, Ohio, USA
| | - Dana Howard
- Department of Biomedical Education and Anatomy, Center for Bioethics and OSU College of Arts and Sciences, Philosophy, Ohio State University College of Medicine, Columbus, Ohio, USA
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Iroz CB, Schäfer WLA, Johnson JK, Ager MS, Huang R, Balbale SN, Stulberg JJ. The development of a safe opioid use agreement for surgical care using a modified Delphi method. PLoS One 2023; 18:e0291969. [PMID: 37751431 PMCID: PMC10522037 DOI: 10.1371/journal.pone.0291969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 09/08/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND Opioids prescribed to treat postsurgical pain have contributed to the ongoing opioid epidemic. While opioid prescribing practices have improved, most patients do not use all their pills and do not safely dispose of leftovers, which creates a risk for unsafe use and diversion. We aimed to generate consensus on the content of a "safe opioid use agreement" for the perioperative settings to improve patients' safe use, storage, and disposal of opioids. METHODS We conducted a modified three-round Delphi study with clinicians across surgical specialties, quality improvement (QI) experts, and patients. In Round 1, participants completed a survey rating the importance and comprehensibility of 10 items on a 5-point Likert scale and provided comments. In Round 2, a sub-sample of participants attended a focus group to discuss items with the lowest agreement. In Round 3, the survey was repeated with the updated items. Quantitative values from the Likert scale and qualitative responses were summarized. RESULTS Thirty-six experts (26 clinicians, seven patients/patient advocates, and three QI experts) participated in the study. In Round 1, >75% of respondents rated at least four out of five on the importance of nine items and on the comprehensibility of six items. In Round 2, participants provided feedback on the comprehensibility, formatting, importance, and purpose of the agreement, including a desire for more specificity and patient education. In Round 3, >75% of respondents rated at least four out of five for comprehensibility and importance of all 10 updated item. The final agreement included seven items on safe use, two items on safe storage, and one item on safe disposal. CONCLUSION The expert panel reached consensus on the importance and comprehensibility of the content for an opioid use agreement and identified additional patient education needs. The agreement should be used as a tool to supplement rather than replace existing, tailored education.
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Affiliation(s)
- Cassandra B. Iroz
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Willemijn L. A. Schäfer
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Julie K. Johnson
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Meagan S. Ager
- Mathematica Policy Research, Chicago, IL, United States of America
| | - Reiping Huang
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Salva N. Balbale
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, IL, United States of America
- Center of Innovation for Complex Chronic Healthcare, Health Services Research & Development, Edward Hines, Jr. VA Hospital, Hines, IL, United States of America
| | - Jonah J. Stulberg
- Department of Surgery, University of Texas McGovern Medical School, Houston, TX, United States of America
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Gonzalez K, Villasante-Tezanos A, Sharma G, Doulatram G, Williams SB, Hommel EL. Factors that impact initiation of pain management agreements for patients on chronic opioid therapy. J Opioid Manag 2023; 19:423-431. [PMID: 37968976 DOI: 10.5055/jom.0816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
OBJECTIVE This analysis seeks to understand variables within our institution that impact pain management agreement (PMA) utilization for chronic noncancer pain (CNCP). DESIGN Retrospective chart review. SETTING Public academic medical center. PATIENTS Adults prescribed an opioid for CNCP between July 2020 and October 2020. MAIN OUTCOME MEASURE We assessed the association between patient demographics, prescription factors, and prescriber factors with the presence of a PMA. Unadjusted rates and chi-square tests were generated for each predictor. Additionally, we performed two multivariable logistic regressions: one including all variables and another utilizing a stepwise forward variable selection process to further understand the relationships between predictors and the presence of a PMA. RESULTS 49.7 percent of patients who received an opioid for CNCP had a PMA on file. One significant predictor of the presence of PMA was prescriber specialty with anesthesia/pain medicine, demonstrating 88 percent compliance. Compared to anesthesia/pain medicine, patients receiving opioids from internal medicine had an odds ratio (OR) of 0.155 (95 percent confidence interval (CI), 0.109-0.220), while patients receiving opioids from family medicine had an OR of 0.122 (95 percent CI, 0.090-0.167). Additionally, patients who received schedule II opioids (as opposed to schedule III/IV opioids), patients with multiple opioid fills in 3 months, middle aged patients, and Black patients were more likely to have a PMA. CONCLUSIONS Compliance with PMA within our institution was only 49 percent despite an existing state law mandating use. Our analysis suggests quality improvement interventions should target patients on schedule III/IV opioids who receive their prescriptions from primary care providers.
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Affiliation(s)
- Katherine Gonzalez
- School of Medicine, The University of Texas Medical Branch, Galveston, Texas. ORCID: https://orcid.org/0000-0002-6458-2420
| | - Alejandro Villasante-Tezanos
- Department of Preventative Medicine and Population Health, The University of Texas Medical Branch, Galveston, Texas. ORCID: https://orcid.org/0000-0001-5108-8637
| | - Gulshan Sharma
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, The University of Texas Medical Branch, Galveston, Texas. ORCID: https://orcid.org/0000-0002-5339-0087
| | - Gulshan Doulatram
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, Texas. ORCID: https://orcid.org/0000-0002-7725-8574
| | - Stephen B Williams
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, Texas. ORCID: https://orcid.org/0000-0002-2683-2185
| | - Erin L Hommel
- Department of Internal Medicine, Division of Geriatrics and Palliative Medicine, The University of Texas Medical Branch, Galveston, Texas. ORCID: https://orcid.org/0000-0003-1975-4008
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McCloskey LJ, Dellabadia KA, Stickle DF. Receiver-operating characteristics of adjusted urine measurements of oxycodone plus metabolites to distinguish between three different rates of oxycodone administration. Clin Biochem 2012; 46:115-8. [PMID: 23010080 DOI: 10.1016/j.clinbiochem.2012.09.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Revised: 09/12/2012] [Accepted: 09/13/2012] [Indexed: 11/18/2022]
Abstract
OBJECTIVES In a study by Couto et al. (Use of an algorithm applied to urine drug screening to assess adherence to an oxycontin regimen. J Opioid Manag 2009;5:359-64), adjusted urine measurements of oxycodone plus metabolites noroxycodone and oxymorphone were determined among volunteer subjects in three groups according to oxycodone administration rates (A: 80 mg/day; B: 160 mg/day; C: 240 mg/day). We performed receiver-operating characteristic (ROC) analyses of the distribution data from this study to determine the ability to correctly categorize individual measurements with respect to each group. DESIGN AND METHODS For groups A-C, assumed reference ranges were defined as median-centered intervals encompassing a designated central percentage of the group's distribution. By varying assumed reference ranges across all possible reference ranges, ROC analyses of the ability of each group's reference ranges to appropriately include or exclude members of all groups were calculated. This generated six ROC curves (sensitivity vs. specificity): A vs. (B or C); B vs. (A or C); C vs. (A or B). RESULTS Overlaps of distributions A, B, and C were large, such that none of the ROC curves exceeded areas-under-curves of 0.8. The greatest sensitivity-specificity combination had a sensitivity of 74% for C with specificity of 75% for A, for which oxycodone administration rates were different by a factor of 3. CONCLUSIONS ROC analyses of data from a previous study demonstrated that, even under experimentally controlled conditions, adjusted urine drug measurements could not be used reliably to correctly categorize individual subjects' results according to their known oxycodone administration rates in the range of 80-240 mg/day. Misclassifications of results were 25% or greater.
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Affiliation(s)
- Laura J McCloskey
- Department of Pathology, Jefferson University Hospitals, Philadelphia, PA 19107, USA
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Clark MR, Galati SA. Opioids and psychological issues: A practical, patient-centered approach to a risk evaluation and mitigation strategy. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.eujps.2010.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Anderson E, Burris S. Opioid treatment agreements are the answer. What is the question? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2010; 10:15-17. [PMID: 21104548 DOI: 10.1080/15265161.2010.520583] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- Evan Anderson
- Temple University Beasley School of Law, Philadelphia, PA 19122, USA.
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Fishbain DA, Lewis JE, Gao J. Medical Malpractice Allegations of Iatrogenic Addiction in Chronic Opioid Analgesic Therapy: Forensic Case Reports. PAIN MEDICINE 2010; 11:1537-45. [DOI: 10.1111/j.1526-4637.2010.00938.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Barry DT, Irwin KS, Jones ES, Becker WC, Tetrault JM, Sullivan LE, Hansen H, O'Connor PG, Schottenfeld RS, Fiellin DA. Opioids, chronic pain, and addiction in primary care. THE JOURNAL OF PAIN 2010; 11:1442-50. [PMID: 20627817 DOI: 10.1016/j.jpain.2010.04.002] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Revised: 04/06/2010] [Accepted: 04/08/2010] [Indexed: 12/19/2022]
Abstract
UNLABELLED Research has largely ignored the systematic examination of physicians' attitudes towards providing care for patients with chronic noncancer pain. The objective of this study was to identify barriers and facilitators to opioid treatment of chronic noncancer pain patients by office-based medical providers. We used a qualitative study design using individual and group interviews. Participants were 23 office-based physicians in New England. Interviews were audiotaped, transcribed, and systematically coded by a multidisciplinary team using the constant comparative method. Physician barriers included absence of objective or physiological measures of pain; lack of expertise in the treatment of chronic pain and coexisting disorders, including addiction; lack of interest in pain management; patients' aberrant behaviors; and physicians' attitudes toward prescribing opioid analgesics. Physician facilitators included promoting continuity of patient care and the use of opioid agreements. Physicians' perceptions of patient-related barriers included lack of physician responsiveness to patients' pain reports, negative attitudes toward opioid analgesics, concerns about cost, and patients' low motivation for pain treatment. Perceived logistical barriers included lack of appropriate pain management and addiction referral options, limited information regarding diagnostic workup, limited insurance coverage for pain management services, limited ancillary support for physicians, and insufficient time. Addressing these barriers to pain treatment will be crucial to improving pain management service delivery. PERSPECTIVE This article demonstrates that perceived barriers to treating patients with chronic noncancer pain are common among office-based physicians. Addressing these barriers in physician training and in existing office-based programs might benefit both noncancer chronic pain patients and their medical providers.
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Affiliation(s)
- Declan T Barry
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA.
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Abstract
BACKGROUND Little is known about whether internal medicine residents find pain management agreements (PMAs) useful or whether PMA use is associated with more positive attitudes toward patients with chronic noncancer pain (CNCP). METHODS We surveyed all internal medicine residents at Rhode Island Hospital regarding whether they found PMAs useful, what percentage of their patients taking chronic opioids had a signed PMA, and their attitudes toward and experiences with managing CNCP. RESULTS Survey response rate was 89% (110/124). Ninety percent of respondents reported finding PMAs useful. A majority of respondents reported that PMAs were at least somewhat helpful for reducing multiple prescribers (76%), reducing requests for early refills (67%), reducing calls and pages from patients (57%), making it easier to discuss potential problems associated with chronic opioid use (73%), and making it easier to identify patients who are abusing pain medications (66%). Residents who reported greater use of PMAs reported a greater sense of preparation (r=0.20, P=0.04), greater confidence (r=0.18, P=0.06), and a greater sense of reward (r=0.24, P=0.02) for managing CNCP. In a multivariate analysis, PMA use was significantly associated with greater sense of preparation and greater sense of reward for managing CNCP. CONCLUSIONS Among internal medicine residents, PMA use was associated with more positive attitudes toward CNCP management.
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Boulanger A, Clark AJ, Squire P, Cui E, Horbay GLA. Chronic pain in Canada: have we improved our management of chronic noncancer pain? Pain Res Manag 2007; 12:39-47. [PMID: 17372633 PMCID: PMC2670724 DOI: 10.1155/2007/762180] [Citation(s) in RCA: 128] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Chronic noncancer pain (CNCP) is a global issue, not only affecting individual suffering, but also impacting the delivery of health care and the strength of local economies. OBJECTIVES The current study (the Canadian Chronic Pain Study II [CCPSII]) was designed to assess any changes in the prevalence and treatment of CNCP, as well as in attitudes toward the use of strong analgesics, compared with a 2001 study (the CCPSI), and to provide a snapshot of the current standards of care for pain management in Canada. METHODS Standard, computer-assisted telephone interview survey methodology was applied in two segments, ie, a general population survey and a survey targeting randomly selected primary care physicians (PCPs) who treat moderate to severe CNCP. RESULTS AND DISCUSSION The patient-reported prevalence of CNCP within Canada has not markedly changed since 2001 but the duration of suffering has decreased. There have been minor changes in regional distribution and generally more patients receive medical treatment, which includes prescription analgesics. Physicians continue to demonstrate opiophobia in their prescribing practices; however, although this is lessened relating to addiction, abuse remains an important concern to PCPs. Canadian PCPs, in general, are implementing standard assessments, treatment approaches, evaluation of treatment success and tools to prevent abuse and diversion, in accordance with guidelines from the Canadian Pain Society and other pain societies globally, although there remains room for improvement and standardization.
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Affiliation(s)
- Aline Boulanger
- Department of Anaesthesia, University of Montreal, Montreal, Quebec, Canada.
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Bosch-Capblanch X, Abba K, Prictor M, Garner P. Contracts between patients and healthcare practitioners for improving patients' adherence to treatment, prevention and health promotion activities. Cochrane Database Syst Rev 2007; 2007:CD004808. [PMID: 17443556 PMCID: PMC6464838 DOI: 10.1002/14651858.cd004808.pub3] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Contracts are a verbal or written agreement that a patient makes with themselves, with healthcare practitioners, or with carers, where participants commit to a set of behaviours related to the care of a patient. Contracts aim to improve the patients' adherence to treatment or health promotion programmes. OBJECTIVES To assess the effects of contracts between patients and healthcare practitioners on patients' adherence to treatment, prevention and health promotion activities, the stated health or behaviour aims in the contract, patient satisfaction or other relevant outcomes, including health practitioner behaviour and views, health status, reported harms, costs, or denial of treatment as a result of the contract. SEARCH STRATEGY We searched: the Cochrane Consumers and Communication Review Group's Specialised Register (in May 2004); the Cochrane Central Register of Controlled Trials (CENTRAL), (The Cochrane Library 2004, issue 1); MEDLINE 1966 to May 2004); EMBASE (1980 to May 2004); PsycINFO (1966 to May 2004); CINAHL (1982 to May 2004); Dissertation Abstracts. A: Humanities and Social Sciences (1966 to May 2004); Sociological Abstracts (1963 to May 2004); UK National Research Register (2000 to May 2004); and C2-SPECTR, Campbell Collaboration (1950 to May 2004). SELECTION CRITERIA We included randomised controlled trials comparing the effects of contracts between healthcare practitioners and patients or their carers on patient adherence, applied to diagnostic procedures, therapeutic regimens or any health promotion or illness prevention initiative for patients. Contracts had to specify at least one activity to be observed and a commitment of adherence to it. We included trials comparing contracts with routine care or any other intervention. DATA COLLECTION AND ANALYSIS Selection and quality assessment of trials were conducted independently by two review authors; single data extraction was checked by a statistician. We present the data as a narrative summary, given the wide range of interventions, participants, settings and outcomes, grouped by the health problem being addressed. MAIN RESULTS We included thirty trials, all conducted in high income countries, involving 4691 participants. Median sample size per group was 21. We examined the quality of each trial against eight standard criteria, and all trials were inadequate in relation to three or more of these standards. Trials evaluated contracts in addiction (10 trials), hypertension (4 trials), weight control (3 trials) and a variety of other areas (13 trials). Sixteen trials reported at least one outcome that showed statistically significant differences favouring the contracts group, five trials reported at least one outcome that showed differences favouring the control group and 26 trials reported at least one outcome without differences between groups. Effects on adherence were not detected when measured over longer periods. AUTHORS' CONCLUSIONS There is limited evidence that contracts can potentially contribute to improving adherence, but there is insufficient evidence from large, good quality studies to routinely recommend contracts for improving adherence to treatment or preventive health regimens.
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Affiliation(s)
- X Bosch-Capblanch
- International Health Research Group, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK L35QA.
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Bosch Capblanch X, Garner P. Contracts between patients and healthcare practitioners for improving patients' adherence to treatment, prevention and health promotion activities. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2006. [DOI: 10.1002/14651858.cd004808.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Nishimori M, Kulich RJ, Carwood CM, Okoye V, Kalso E, Ballantyne JC. Successful and unsuccessful outcomes with long-term opioid therapy: a survey of physicians' opinions. J Palliat Med 2006; 9:50-6. [PMID: 16430344 DOI: 10.1089/jpm.2006.9.50] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The attitudes, beliefs, and experience of physicians will influence how they view the use of opioids for chronic nonterminal pain. OBJECTIVE To survey pain specialists and primary care providers (PCPs) to obtain their opinion and attitude on aberrant drug-taking behaviors. DESIGN We surveyed three physician groups, mailing 250 surveys followed by two followups. The survey consisted of (1) questions about beliefs in the effectiveness of long-term opioid therapy and successful and unsuccessful outcomes and (2) a ratings section for possible indicators of unsuccessful long-term opioid treatment. RESULTS In total 147 questionnaires (82 PCPs, 65 pain specialists) were returned. Pain specialists reported a greater number of patients undergoing long-term opioid therapy compared to nonpain specialists. Opinion regarding the effectiveness of long-term opioid therapy among all physicians was mixed but there was no significant difference between pain specialists and PCPs. There was agreement among physicians with regard to highly aberrant behaviors being indicators of failed long-term opioid therapy. The ratings of the following indicators showed differences between each group: no improvement in pain control, not being able to return to work, and a deterioration in relationships with others. Physicians reported increases or decreases in function to be the most important successful or unsuccessful outcome, respectively. CONCLUSIONS This preliminary survey showed consensus among physicians that highly aberrant behaviors indicate a failure of chronic opioid therapy. However, when considering less egregious behaviors, it would appear a physician's experience and the number of patients they had taking opioids influenced their opinion.
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Affiliation(s)
- Mina Nishimori
- The MGH Pain Center, Department of Anesthesia and Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston Massachusetts 02114, USA.
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Sullivan MD, Leigh J, Gaster B. Brief report: Training internists in shared decision making about chronic opioid treatment for noncancer pain. J Gen Intern Med 2006; 21:360-2. [PMID: 16686813 PMCID: PMC1484730 DOI: 10.1111/j.1525-1497.2006.00352.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The use of chronic opioids for noncancer pain is an increasingly common and difficult problem in primary care. OBJECTIVE To test the effects on physicians' self-reported attitudes and behavior of a shared decision-making training for opioid treatment of chronic pain. DESIGN Randomized-controlled trial. PARTICIPANTS Internal Medicine residents (n=38) and attendings (n=7) were randomized to receive two 1-hour training sessions on a shared decision-making model for opioid treatment for chronic pain (intervention, n=22) or written educational materials (control, n=23). MEASUREMENTS Questionnaires assessing physician satisfaction, physician patient-centeredness, opioid prescribing practices, and completion rates of patient treatment agreements administered 2 months before and 3 months after training. RESULTS At follow-up, the intervention group reported significantly greater overall physician satisfaction (P=.002), including subscales on relationship quality (P=.03) and appropriate use of time (P=.02), self-reported completion rates of patient treatment agreements (P=.01), self-reported rates of methadone prescribing (P=.05), and self-reported change in care of patients with chronic pain (P=.01). CONCLUSIONS Training primary care physicians in the shared decision-making model improves physician satisfaction in caring for patients with chronic pain and promotes the use of patient treatment agreements. Further research is necessary to determine whether this training improves patient satisfaction and outcomes.
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Affiliation(s)
- Mark D Sullivan
- Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA 98195-6560, USA.
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Sullivan M, Ferrell B. Ethical challenges in the management of chronic nonmalignant pain: Negotiating through the cloud of doubt. THE JOURNAL OF PAIN 2005; 6:2-9. [PMID: 15629412 DOI: 10.1016/j.jpain.2004.10.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED After successful cancer pain initiatives, efforts have been recently made to liberalize the use of opioids for the treatment of chronic nonmalignant pain. However, the goals for this treatment and its place among other available treatments are still unclear. Cancer pain treatment is aimed at patient comfort and is validated by objective disease severity. For chronic nonmalignant pain, however, comfort alone is not an adequate treatment goal, and pain is not usually proportional to objective disease severity. Therefore, confusion about treatment goals and doubts about the reality of nonmalignant pain entangle therapeutic efforts. We present a case history to demonstrate that this lack of proportionality fosters fears about malingering, exaggeration, and psychogenic pain among providers. Doubt concerning the reality of patients' unrelieved chronic nonmalignant pain has allowed concerns about addiction to dominate discussions of treatment. We propose alternate patient-centered principles to guide efforts to relieve chronic nonmalignant pain, including accept all patient pain reports as valid but negotiate treatment goals early in care, avoid harming patients, and incorporate chronic opioids as one part of the treatment plan if they improve the patient's overall health-related quality of life. Although an outright ban on opioid use in chronic nonmalignant pain is no longer ethically acceptable, ensuring that opioids provide overall benefit to patients requires significant time and skill. Patients with chronic nonmalignant pain should be assessed and treated for concurrent psychiatric disorders, but those with disorders are entitled to equivalent efforts at pain relief. The essential question is not whether chronic nonmalignant pain is real or proportional to objective disease severity, but how it should be managed so that the patient's overall quality of life is optimized. PERSPECTIVE The management of chronic nonmalignant pain is moving from specialty settings into primary care. Primary care providers need an ethical framework within which to adopt the principles of palliative care to this population.
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Chen H, Lamer TJ, Rho RH, Marshall KA, Sitzman BT, Ghazi SM, Brewer RP. Contemporary management of neuropathic pain for the primary care physician. Mayo Clin Proc 2004; 79:1533-45. [PMID: 15595338 DOI: 10.4065/79.12.1533] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Neuropathic pain (NP), caused by a primary lesion or dysfunction in the nervous system, affects approximately 4 million people in the United States each year. It is associated with many diseases, including diabetic peripheral neuropathy, postherpetic neuralgia, human immunodeficiency virus-related disorders, and chronic radiculopathy. Major pathophysiological mechanisms include peripheral sensitization, sympathetic activation, disinhibition, and central sensitization. Unlike most acute pain conditions, NP is extremely difficult to treat successfully with conventional analgesics. This article introduces a contemporary management approach, that is, one that incorporates nonpharmacological, pharmacological, and interventional strategies. Some nonpharmacological management strategies include patient education, physical rehabilitation, psychological techniques, and complementary medicine. Pharmacological strategies include the use of first-line agents that have been supported by randomized controlled trials. Finally, referral to a pain specialist may be indicated for additional assessment, interventional techniques, and rehabilitation. Integrating a comprehensive approach to NP gives the primary care physician and patient the greatest chance for success.
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Affiliation(s)
- Hsiupei Chen
- Division of Pain Medicine, Duke University Medical Center, Durham, NC, USA.
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Abstract
Neuropathic pain is associated with numerous systemic illnesses, including HIV infection. The diagnosis and management of peripheral neuropathy presents diagnostic and therapeutic challenges. Among various forms of HIV-associated peripheral neuropathies, distal symmetrical polyneuropathy (DSP) is the most common. DSP may be caused or exacerbated by neurotoxic antiretrovirals, particularly the dideoxynucleoside analogues (d-drugs). Selection of appropriate pharmacologic intervention for peripheral neuropathy should be based on efficacy, safety, ease of administration, and cost. We review treatment options for painful HIV neuropathy, including experimental agents studied in recent and ongoing clinical trials.
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Affiliation(s)
- Susama Verma
- Department of Neurology, Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029, USA
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22
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Abstract
Neuropathic pain is associated with numerous systemic illnesses, including HIV infection. The diagnosis and management of peripheral neuropathy presents diagnostic and therapeutic challenges. Among various forms of HIV-associated peripheral neuropathies, distal symmetrical polyneuropathy (DSP) is the most common. DSP may be caused or exacerbated by neurotoxic antiretrovirals, particularly the dideoxynucleoside analogues (d-drugs). Selection of appropriate pharmacologic intervention for peripheral neuropathy should be based on efficacy, safety, ease of administration, and cost. We review treatment options for painful HIV neuropathy, including experimental agents studied in recent and ongoing clinical trials.
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Affiliation(s)
- Susama Verma
- Department of Neurology, Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029, USA.
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23
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Abstract
In the treatment of chronic benign pain, the administration of an intrathecal opioid produces a potent analgesia without interfering with the motor and sensory functions of the lower extremities. An intrathecal opioid should be considered only when pain control with conventional oral and systemic administration is inadequate or is associated with unmanageable side effects. A trial period and a psychological evaluation are mandatory prior to implantation of a permanent device. About 40% of the patients need surgical revision for various complications. Hormonal changes may influence sexual behaviour. Catheter granulomas can form with high concentrations of morphine. Adjuvant drugs such as bupivacaine, clonidine and ketamine might be necessary to deal with the development of tolerance to morphine. The sophistication of available technology for intrathecal infusion today far exceeds our knowledge of the potential neurological effects of this treatment modality.
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Affiliation(s)
- Helmut R Gerber
- Institut für Anästhesie, Kantonsspital, Ch 6000, Lucerne 16, Switzerland.
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24
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Abstract
Chronic pain is a symptom associated with ongoing physical or mental illness or a combination of both that may not have a clear, identifiable pathophysiology. Assessment of chronic pain varies in the clinical presentation related to age, gender, racial, and cultural differences. Headache, low back pain, musculoskeletal pain, and neuropathic pain are the most common types of chronic pain complaints by patients. Pharmacologic therapy is based on best practice standards, published clinical trials, and guidelines by professional organizations. Current medications reviewed include opioids, anticonvulsants, antidepressants, clonidine, local anesthetics, muscle relaxants, N-methyl-D-aspartate antagonists, and nonsteroidal anti-inflammatory drugs.
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Affiliation(s)
- Virginia L. Ghafoor
- Fairview Pain Management Center, University of Minnesota College of Pharmacy,
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25
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