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Williams EC, Frost MC, Lodi S, Forman LS, Lira MC, Tsui JI, Lunze K, Kim T, Liebschutz JM, Del Rio C, Samet JH. Influence of patient trust in provider and health literacy on receipt of guideline-concordant chronic opioid therapy in HIV care settings. J Opioid Manag 2023; 19:385-393. [PMID: 37968972 PMCID: PMC11037446 DOI: 10.5055/jom.0812] [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] [Indexed: 11/17/2023]
Abstract
OBJECTIVE Persons with HIV (PWH) frequently receive opioids for pain. Health literacy and trust in provider may impact patient-provider communication, and thus receipt of guideline-concordant opioid monitoring. We analyzed baseline data of HIV-positive patients on chronic opioid therapy (COT) in a trial to improve guideline-concordant COT in HIV clinics. DESIGN Retrospective cohort study. SETTING Two hospital-based safetynet HIV clinics in Boston and Atlanta. PATIENTS AND PARTICIPANTS A cohort of patients who were ≥18 years, HIV-positive, had received ≥ 3 opioid prescriptions from a study site ≥21 days apart within a 6-month period during the prior year and had ≥1 visit at the HIV clinic in the prior 18 months. MAIN OUTCOME MEASURES Adjusted logistic regression models examined whether health literacy and trust in provider (scale scored 11-55, higher indicates more trust) were associated with: (1) ≥ 2 urine drug tests (UDTs) and (2) presence of an opioid treatment agreement. RESULTS Among 166 PWH, mean trust in provider was 47.4 (SD 6.6); 117 (70 percent) had adequate health literacy. Fifty patients (30 percent) had ≥ 2 UDTs and 20 (12 percent) had a treatment agreement. The adjusted odds ratio (aOR) for a one-point increase in trust in provider was 0.97 for having ≥ 2 UDTs (95 percent CI 0.92-1.02) and 1.03 for opioid treatment agreement (95 percent CI 0.95-1.12). The aOR for adequate health literacy was 0.89 for having ≥ 2 UDTs (95 percent CI 0.42-1.88) and 1.66 for an opioid treatment agreement (95 percent CI 0.52-5.31). CONCLUSIONS Health literacy and trust in provider were not associated with chronic opioid therapy quality outcomes.
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Affiliation(s)
- Emily C. Williams
- University of Washington, Department of Health Systems and Population Health, Seattle, WA
- Veterans Health Administration (VA) Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA
| | - Madeline C. Frost
- University of Washington, Department of Health Systems and Population Health, Seattle, WA
- Veterans Health Administration (VA) Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA
| | - Sara Lodi
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Leah S. Forman
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA
| | - Marlene C. Lira
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Judith I. Tsui
- Section of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Karsten Lunze
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Theresa Kim
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Jane M. Liebschutz
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Carlos Del Rio
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
- Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Jeffrey H. Samet
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA
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Glanz JM, Xu S, Narwaney KJ, McClure DL, Rinehart DJ, Ford MA, Nguyen AP, Binswanger IA. Association Between Opioid Dose Reduction Rates and Overdose Among Patients Prescribed Long-Term Opioid Therapy. Subst Abus 2023; 44:209-219. [PMID: 37702046 DOI: 10.1177/08897077231186216] [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] [Indexed: 09/14/2023]
Abstract
BACKGROUND Tapering long-term opioid therapy is an increasingly common practice, yet rapid opioid dose reductions may increase the risk of overdose. The objective of this study was to compare overdose risk following opioid dose reduction rates of ≤10%, 11% to 20%, 21% to 30%, and >30% per month to stable dosing. METHODS We conducted a retrospective cohort study in three health systems in Colorado and Wisconsin. Participants were patients ≥18 years of age prescribed long-term opioid therapy between January 1, 2006, and June 30, 2019. Five opioid dosing patterns and drug overdoses (fatal and nonfatal) were identified using electronic health records, pharmacy records, and the National Death Index. Cox proportional hazard regression was conducted on a propensity score-weighted cohort to estimate adjusted hazard ratios (aHRs) for follow-up periods of 1, 3, 6, 9, and 12 months after a dose reduction. RESULTS In a cohort of 17 540 patients receiving long-term opioid therapy, 42.7% of patients experienced a dose reduction. Relative to stable dosing, a dose reduction rate of >30% was associated with an increased risk of overdose and the aHR estimates decreased as the follow-up increased; the aHRs for the 1-, 6- and 12-month follow-ups were 5.33 (95% CI, 1.98-14.34), 1.81 (95% CI,1.08-3.03), and 1.49 (95% CI, 0.97-2.27), respectively. The slower tapering rates were not associated with overdose risk. CONCLUSIONS Patients receiving long-term opioid therapy exposed to dose reduction rates of >30% per month had increased overdose risk relative to patients exposed to stable dosing. Results support the use of slow dose reductions to minimize the risk of overdose.
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Affiliation(s)
- Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
| | - Stanley Xu
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Komal J Narwaney
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - David L McClure
- Center for Clinical Epidemiology and Population Health, Marshfield Clinic Research Institute, Marshfield, WI, USA
| | - Deborah J Rinehart
- Center for Health Systems Research, Office of Research, Denver Health and Hospital Authority, Denver, CO, USA
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Morgan A Ford
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Anh P Nguyen
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Chemical Dependency Treatment Services, Colorado Permanente Medical Group, Aurora, CO, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
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DiPiro ND, Murday D, Krause JS. Assessment of high-risk opioid use metrics among individuals with spinal cord injury: A brief report. J Spinal Cord Med 2023; 46:687-691. [PMID: 37318872 PMCID: PMC10274556 DOI: 10.1080/10790268.2022.2084931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To examine high-risk opioid prescription metrics among individuals with chronic spinal cord injury (SCI) living in South Carolina. DESIGN Cohort Study. SETTING Two statewide population-based databases, an SCI Surveillance Registry and state prescription drug monitoring program (PDMP). PARTICIPANTS Linked data was obtained for 503 individuals with chronic (>1year-post injury) SCI who were injured in 2013 or 2014 and who survived at least 3 years post-injury. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE(S) Opioid prescription metrics were obtained from the PDMP. Fill data during the period between January 1, 2014 and December 31, 2017 were analyzed to assess high-risk opioid use. Outcomes included: percentage of individuals prescribed chronic opioids, high-dose chronic opioid therapy (daily morphine milligram equivalents (MME) ≥50 and ≥90), and chronic concurrent opioids and benzodiazepines, sedatives, or hypnotics (BSH). RESULTS Over half (53%) of the individuals filled an opioid in years 2-3 after injury. Of those, 38% had a concurrent BSH fill during the study period, 76% of which were for benzodiazepines. In any given quarter over the two-year timeframe, over half of the opioid prescriptions were for 60 days or more (chronic opioid prescriptions). Of those, roughly 40% of the individuals had high-dose chronic opioid prescriptions ≥50 MME/d and 25% were ≥90 MME/d. Over 33% had a concurrent BSH prescription for ≥60 days. CONCLUSIONS While the number of individuals receiving high-risk opioid prescriptions may not be large, it is a concerning number of prescriptions. The findings suggest a need for more cautious opioid prescribing and monitoring of high-risk use in adults with chronic SCI.
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Affiliation(s)
- Nicole D. DiPiro
- College of Health Professions, Medical University of South Carolina, Charleston, South Carolina, USA
| | - David Murday
- Arnold School of Public Health, University of South Carolina, ColumbiaSouth Carolina, USA
| | - James S. Krause
- College of Health Professions, Medical University of South Carolina, Charleston, South Carolina, USA
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Combined non-psychoactive Cannabis components cannabidiol and β-caryophyllene reduce chronic pain via CB1 interaction in a rat spinal cord injury model. PLoS One 2023; 18:e0282920. [PMID: 36913400 PMCID: PMC10010563 DOI: 10.1371/journal.pone.0282920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 02/27/2023] [Indexed: 03/14/2023] Open
Abstract
The most frequently reported use of medical marijuana is for pain relief. However, its psychoactive component Δ9-tetrahydrocannabinol (THC) causes significant side effects. Cannabidiol (CBD) and β-caryophyllene (BCP), two other cannabis constituents, possess more benign side effect profiles and are also reported to reduce neuropathic and inflammatory pain. We evaluated the analgesic potential of CBD and BCP individually and in combination in a rat spinal cord injury (SCI) clip compression chronic pain model. Individually, both phytocannabinoids produced dose-dependent reduction in tactile and cold hypersensitivity in male and female rats with SCI. When co-administered at fixed ratios based on individual A50s, CBD and BCP produced enhanced dose-dependent reduction in allodynic responses with synergistic effects observed for cold hypersensitivity in both sexes and additive effects for tactile hypersensitivity in males. Antinociceptive effects of both individual and combined treatment were generally less robust in females than males. CBD:BCP co-administration also partially reduced morphine-seeking behavior in a conditioned place preference (CPP) test. Minimal cannabinoidergic side effects were observed with high doses of the combination. The antinociceptive effects of the CBD:BCP co-administration were not altered by either CB2 or μ-opioid receptor antagonist pretreatment but, were nearly completely blocked by CB1 antagonist AM251. Since neither CBD or BCP are thought to mediate antinociception via CB1 activity, these findings suggest a novel CB1 interactive mechanism between these two phytocannabinoids in the SCI pain state. Together, these findings suggest that CBD:BCP co-administration may provide a safe and effective treatment option for the management of chronic SCI pain.
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Case AA, Davis MP. Mood Disturbances Associated with Long-Term Opioid Therapy #418. J Palliat Med 2021; 24:1102-1103. [PMID: 34128717 DOI: 10.1089/jpm.2021.0157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Agnoli A, Xing G, Tancredi DJ, Magnan E, Jerant A, Fenton JJ. Association of Dose Tapering With Overdose or Mental Health Crisis Among Patients Prescribed Long-term Opioids. JAMA 2021; 326:411-419. [PMID: 34342618 PMCID: PMC8335575 DOI: 10.1001/jama.2021.11013] [Citation(s) in RCA: 144] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 06/20/2021] [Indexed: 12/26/2022]
Abstract
Importance Opioid-related mortality and national prescribing guidelines have led to tapering of doses among patients prescribed long-term opioid therapy for chronic pain. There is limited information about risks related to tapering, including overdose and mental health crisis. Objective To assess whether there are associations between opioid dose tapering and rates of overdose and mental health crisis among patients prescribed stable, long-term, higher-dose opioids. Design, Setting, and Participants Retrospective cohort study using deidentified medical and pharmacy claims and enrollment data from the OptumLabs Data Warehouse from 2008 to 2019. Adults in the US prescribed stable higher doses (mean ≥50 morphine milligram equivalents/d) of opioids for a 12-month baseline period with at least 2 months of follow-up were eligible for inclusion. Exposures Opioid tapering, defined as at least 15% relative reduction in mean daily dose during any of 6 overlapping 60-day windows within a 7-month follow-up period. Maximum monthly dose reduction velocity was computed during the same period. Main Outcomes and Measures Emergency or hospital encounters for (1) drug overdose or withdrawal and (2) mental health crisis (depression, anxiety, suicide attempt) during up to 12 months of follow-up. Discrete time negative binomial regression models estimated adjusted incidence rate ratios (aIRRs) of outcomes as a function of tapering (vs no tapering) and dose reduction velocity. Results The final cohort included 113 618 patients after 203 920 stable baseline periods. Among the patients who underwent dose tapering, 54.3% were women (vs 53.2% among those who did not undergo dose tapering), the mean age was 57.7 years (vs 58.3 years), and 38.8% were commercially insured (vs 41.9%). Posttapering patient periods were associated with an adjusted incidence rate of 9.3 overdose events per 100 person-years compared with 5.5 events per 100 person-years in nontapered periods (adjusted incidence rate difference, 3.8 per 100 person-years [95% CI, 3.0-4.6]; aIRR, 1.68 [95% CI, 1.53-1.85]). Tapering was associated with an adjusted incidence rate of 7.6 mental health crisis events per 100 person-years compared with 3.3 events per 100 person-years among nontapered periods (adjusted incidence rate difference, 4.3 per 100 person-years [95% CI, 3.2-5.3]; aIRR, 2.28 [95% CI, 1.96-2.65]). Increasing maximum monthly dose reduction velocity by 10% was associated with an aIRR of 1.09 for overdose (95% CI, 1.07-1.11) and of 1.18 for mental health crisis (95% CI, 1.14-1.21). Conclusions and Relevance Among patients prescribed stable, long-term, higher-dose opioid therapy, tapering events were significantly associated with increased risk of overdose and mental health crisis. Although these findings raise questions about potential harms of tapering, interpretation is limited by the observational study design.
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Affiliation(s)
- Alicia Agnoli
- Department of Family and Community Medicine, University of California, Davis, Sacramento
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento
| | - Guibo Xing
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento
| | - Daniel J. Tancredi
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento
- Department of Pediatrics, University of California, Davis, Sacramento
| | - Elizabeth Magnan
- Department of Family and Community Medicine, University of California, Davis, Sacramento
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento
| | - Anthony Jerant
- Department of Family and Community Medicine, University of California, Davis, Sacramento
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento
| | - Joshua J. Fenton
- Department of Family and Community Medicine, University of California, Davis, Sacramento
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento
- OptumLabs Visiting Fellow, Eden Prairie, Minnesota
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Covington EC, Argoff CE, Ballantyne JC, Cowan P, Gazelka HM, Hooten WM, Kertesz SG, Manhapra A, Murphy JL, Stanos SP, Sullivan MD. Ensuring Patient Protections When Tapering Opioids: Consensus Panel Recommendations. Mayo Clin Proc 2020; 95:2155-2171. [PMID: 33012347 DOI: 10.1016/j.mayocp.2020.04.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 04/17/2020] [Accepted: 04/22/2020] [Indexed: 11/18/2022]
Abstract
Long-term opioid therapy has the potential for serious adverse outcomes and is often used in a vulnerable population. Because adverse effects or failure to maintain benefits is common with long-term use, opioid taper or discontinuation may be indicated in certain patients. Concerns about the adverse individual and population effects of opioids have led to numerous strategies aimed at reductions in prescribing. Although opioid reduction efforts have had generally beneficial effects, there have been unintended consequences. Abrupt reduction or discontinuation has been associated with harms that include serious withdrawal symptoms, psychological distress, self-medicating with illicit substances, uncontrolled pain, and suicide. Key questions remain about when and how to safely reduce or discontinue opioids in different patient populations. Thus, health care professionals who reduce or discontinue long-term opioid therapy require a clear understanding of the associated benefits and risks as well as guidance on the best practices for safe and effective opioid reduction. An interdisciplinary panel of pain clinicians and one patient advocate formulated recommendations on tapering methods and ongoing pain management in primary care with emphasis on patient-centered, integrated, comprehensive treatment models employing a biopsychosocial perspective.
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Affiliation(s)
- Edward C Covington
- Neurological Center for Pain (Emeritus), Cleveland Clinic, Cleveland, OH.
| | | | - Jane C Ballantyne
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle
| | | | - Halena M Gazelka
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - W Michael Hooten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Stefan G Kertesz
- Birmingham Veterans Affairs Medical Center and Division of Preventive Medicine, University of Alabama School of Medicine, Birmingham, AL
| | - Ajay Manhapra
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT; New England Mental Illness Research and Education Center, West Haven, CT; Advanced Pain Clinic, Hampton VA Medical Center, Hampton, VA
| | - Jennifer L Murphy
- James A. Haley Veterans Hospital and Department of Neurology, University of South Florida Morsani College of Medicine, Tampa
| | | | - Mark D Sullivan
- Department of Psychiatry and Behavioral Sciences, Department of Anesthesiology and Pain Medicine, and Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA
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Guilcher SJT, Hogan ME, Guan Q, McCormack D, Calzavara A, Patel T, Hitzig SL, Packer T, Lofters AK. Prevalence of Prescribed Opioid Claims Among Persons With Traumatic Spinal Cord Injury in Ontario, Canada: A Population-Based Retrospective Cohort Study. Arch Phys Med Rehabil 2020; 102:35-43. [PMID: 32891422 DOI: 10.1016/j.apmr.2020.06.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To examine prescription opioid claims among individuals with traumatic spinal cord injury (SCI) and to identify factors associated with both chronic opioid and chronic high-dose opioid use. DESIGN Retrospective cohort study using population-level administrative data. SETTING Ontario, Canada. PARTICIPANTS Individuals (N=1842) with traumatic SCI between April 1, 2004 and March 31, 2015. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Proportion of cohort with chronic opioid use (≥90d supply) and proportion with chronic high-dose opioid use (≥90d supply exceeding 90 mg morphine equivalent) between April 1, 2016 and March 31, 2017 (observation period). RESULTS A total of 1842 individuals with traumatic SCI were identified (74% men), with a median age of 51 years (interquartile range [IQR], 34-64y) and median duration of injury of 6 years (IQR, 4-9y). During the observation period, 35% were dispensed at least 1 opioid and 19.8% received chronic opioids, 39% of whom received more than 90 mg daily (chronic high dose). The median daily morphine equivalent dose was 212 mg morphine equivalent (IQR, 135.5-345.3 mg) for chronic high-dose users. Significant risk factors for chronic opioid use were male sex; age between 40 and 60 years; lower income; multimorbidity; thoracic, lumbar, or sacral level of injury; and having a previous diagnosis of osteoarthritis. Risk factors for chronic high-dose opioid use were an extended time since injury, age between 40 and 50 years, and increasing comorbidity. CONCLUSIONS A large proportion of individuals with traumatic SCI were dispensed an opioid in a recent 1-year period. A substantial proportion were dispensed more than 90 mg of morphine equivalents, which is the maximum recommended by the Canadian opioid guideline. Further research is needed to understand the risk factors associated with chronic, high-dose opioid use in this population.
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Affiliation(s)
- Sara J T Guilcher
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Mary-Ellen Hogan
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Qi Guan
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Tejal Patel
- University of Waterloo School of Pharmacy, Waterloo, Ontario, Canada; Schlegel - University of Waterloo Research Institute of Aging, Waterloo, Ontario, Canada; Waterloo Institute for Complexity and Innovation, Waterloo, Ontario, Canada
| | - Sander L Hitzig
- Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; St. John's Rehab Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tanya Packer
- Schools of Occupational Therapy and Health Administration, Dalhousie University, Halifax, Nova Scotia, Canada; Department of Rehabilitation, Radboud Medical University, Nijmegen, The Netherlands
| | - Aisha K Lofters
- ICES, Toronto, Ontario, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Women's College Research Institute, Toronto, Ontario, Canada
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Schatman ME, Vasciannie A, Kulich RJ. Opioid moderatism and the imperative of rapprochement in pain medicine. J Pain Res 2019; 12:649-657. [PMID: 30863137 PMCID: PMC6388760 DOI: 10.2147/jpr.s198849] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Michael E Schatman
- Research and Network Development, Boston PainCare, Waltham, MA, USA,
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA,
| | - Alexis Vasciannie
- Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA, USA
- Department of Biological Sciences, Northeastern University, Boston, MA, USA
| | - Ronald J Kulich
- Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA, USA
- Department of Anesthesia Critical Care and Pain Medicine, Harvard Medical School/Massachusetts General Hospital, Boston, MA, USA
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Severe chronic pain following spinal cord damage: a pragmatic perspective for prescribing opioids. Spinal Cord Ser Cases 2018; 4:65. [PMID: 30083394 DOI: 10.1038/s41394-018-0094-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 05/30/2018] [Accepted: 05/30/2018] [Indexed: 11/08/2022] Open
Abstract
The controversial issue of prescribing opioids to people with spinal cord damage who have severe pain is discussed in this paper. The reasons for concern regarding the increase in opioid prescription over recent years are outlined, along with a summary of the major potential adverse outcomes associated with opioids, such as falls, respiratory suppression, adverse endocrine effects, cognitive impairment, and the potential for opioid abuse, addiction and death. Situations when opioids are more appropriate are considered to be in the immediate post-trauma or post-operative periods. More controversial is the use of opioids in chronic non-cancer pain. A brief review of the evidence regarding opioids in chronic non-cancer pain is presented, and strategies outlined for reducing the risk of adverse consequences from opioid use in chronic non-cancer pain. These strategies include considerations before starting opioids, during initiation, monitoring activities and the cessation process. A vital consideration before starting opioids includes ensuring that all alternatives to opioids have been fully considered and trialled. Finally, some pragmatic proposals for prescribing opioids in people with SCD are suggested. It is recommended that before opioids are commenced, that the informed consent process should be complimented by a treatment agreement, with an initial 4-week trial period, and close monitoring of established goals.
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