A chronic opioid therapy dose reduction policy in primary care

Sex differences in comorbid pain and opioid use disorder: A scoping review

Opioid use disorder (OUD) and chronic pain are commonly co-occurring disorders which can exacerbate each other. Sex/gender differences have been shown in aspects of the clinical course and biological underpinnings of both OUD and chronic pain. The purpose of this scoping review is to summarize literature which has addressed sex/gender differences in relation to the confluence of OUD and chronic pain. This review focused on peer-reviewed journal articles with human subjects and addressing (a) opioid misuse, chronic opioid use or opioid use disorder (OUD), (b) chronic or persistent pain and (c) sex/gender differences in relation to OUD and/or chronic pain. Of the 146 papers identified by the search strategy, 30 met the criteria for inclusion. Charting focused on a priori themes of chronic pain, opioid misuse/OUD and sex/gender in sample, predictor and outcome variables, and key study findings. The majority of research identified was cross-sectional in nature, and sex/gender differences and treatment effects were largely included as post-hoc analyses. Together, the results of this early work align with higher prevalence for OUD in men/males and chronic pain in women/females, while adding critical information with respect to potential sex/gender differences in the development and treatment of their co-occurrence across a range of biological and psychosocial factors. Findings underline the importance of considering sex and gender in the intersection of the development and treatment of OUD and chronic pain.

Government Direct-to-Consumer Education to Reduce Prescription Opioid Use: A Cluster Randomized Clinical Trial

Importance

Direct-to-consumer education reduces chronic sedative use. The effectiveness of this approach for prescription opioids among patients with chronic noncancer pain remains untested.

Objectives

To evaluate the effectiveness of a government-led educational information brochure mailed to community-dwelling, long-term opioid consumers to reduce prescription opioid use compared with usual care.

Design, Setting, and Participants

This cluster randomized clinical trial was conducted from July 2018 to January 2019 in Manitoba, Canada. All adults with long-term opioid prescriptions were enrolled (n = 4225). Participants were identified via the Manitoba Drug Program Information Network. Individuals receiving palliative care or with a diagnosis of cancer or dementia were excluded. Data were analyzed from July 2019 to March 2020.

Intervention

Participants were clustered according to their primary care clinic and randomized to the intervention (a codesigned direct-to-consumer educational brochure sent by mail) or usual care (comparator group).

Main Outcomes and Measures

The main outcome was discontinuation of opioid prescriptions at the participant level after 6 months, ascertained by pharmacy drug claims. Secondary outcomes included dose reduction (in morphine milligram equivalents [MME]) and/or therapeutic switch. Reduction in opioid use was assessed using generalized estimating equations to account for clustering, with prespecified subgroup analyses by age and sex. Analysis was intention to treat.

Results

Of 4206 participants, 2409 (57.3%) were male; mean (SD) age was 60.0 (14.4) years. Mean (SD) baseline opioid use was comparable between groups (intervention, 157.7 [179.7] MME/d; control, 153.4 [181.8] MME/d). After 6 months, 235 of 2136 participants (11.0%) in 127 clusters in the intervention group no longer filled opioid prescriptions compared with 228 of 2070 (11.0%) in 124 clusters in the comparator group (difference, 0.0%; 95% CI, -1.9% to 1.9%). More participants in the intervention group than in the control group reduced their dose (1410 [66.0%] vs 1307 [63.1%]; difference, 2.8% [95% CI, 0.0%-5.7%]). Receipt of the brochure led to greater dose reductions for participants who were male (difference, 3.9%; 95% CI, 0.1%-7.7%), aged 18 to 64 years (difference, 3.7%; 95% CI, 0.2%-7.2%), or living in urban areas (difference, 5.9%; 95% CI, 1.9%-9.9%) compared with usual care.

Conclusions and Relevance

In this cluster randomized clinical trial, no significant difference in the prevalence of opioid cessation was observed after 6 months between the intervention and usual care groups; however, the intervention resulted in more adults reducing their opioid dose compared with usual care.

Trial Registration

ClinicalTrials.gov Identifier: NCT03400384.

Opioid tapering and mental health crisis in older adults

BACKGROUND

Opioid tapering and discontinuation have increased in recent years with the implementation of national prescribing guidelines. This study aimed to examine the relationship between opioid tapering velocity and mental health crisis events in older Medicare beneficiaries.

METHODS

A nested case-control study was conducted using the 2012-2018, 5% national Medicare claims data. Older adults with chronic non-cancer pain (CNCP) who were receiving long-term opioid therapy (LTOT) were included in the study. Cases were defined as individuals experiencing mental health crisis events; controls were identified using incidence density sampling. The opioid tapering velocity was measured in the 120-day hazard period that yielded a monthly percentage of dose change. Conditional logistic regression was used to assess the relationship of interest.

RESULTS

A total of 42 091 older adults with CNCP were eligible for the study. Cases (n = 952) were matched with controls in a 1:2 ratio based on age (±1 year) and time of cohort entry (±30 days). A higher percentage of controls (67.65%) were on steady dose compared with cases (59.03%). In the adjusted model, tapering (aOR = 1.36; 95% CI: 1.02-1.83), rapid tapering (aOR = 1.45; 95% CI: 1.11-1.91), and dose escalation (aOR = 1.78; 95% CI: 1.32-2.39) were significantly associated with the mental health crisis, compared with steady dose.

CONCLUSION

Both opioid tapering and dose escalation are associated with mental health crisis events. Patient-driven and gradual dose tapering, as recommended by prescribing guidelines, should be promoted to prevent mental health crisis events among older adults on LTOT.

Comparative Effectiveness of Opioid Tapering or Abrupt Discontinuation vs No Dosage Change for Opioid Overdose or Suicide for Patients Receiving Stable Long-term Opioid Therapy

IMPORTANCE

Opioid dosage tapering has emerged as a strategy to reduce harms associated with long-term opioid therapy; however, evidence supporting this approach is limited.

OBJECTIVE

To identify the association of opioid tapering or abrupt discontinuation with opioid overdose and suicide events among patients receiving stable long-term opioid therapy without evidence of opioid misuse.

DESIGN, SETTING, AND PARTICIPANTS

This comparative effectiveness study with a trial emulation approach used a large US claims data set of individuals with commercial insurance or Medicare Advantage who were aged 18 years or older and receiving stable long-term opioid therapy without evidence of opioid misuse between January 1, 2010, and December 31, 2018. Statistical analysis was performed from January 17, 2020, through November 12, 2021.

INTERVENTIONS

Three opioid dosage strategies: stable dosage, tapering (dosage reduction ≥15%), or abrupt discontinuation.

MAIN OUTCOMES AND MEASURES

Time to opioid overdose or suicide event identified from International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes in medical claims over 11 months of follow-up. Inverse probability weighting was used to adjust for baseline confounders. The primary analysis used an intention-to-treat approach; follow-up after assignment regardless of changes in opioid dose was included. A per-protocol analysis was also conducted, in which episodes were censored for lack of adherence to assigned treatment.

RESULTS

A cohort of 199 836 individuals (45.1% men; mean [SD] age, 56.9 [12.4] years; and 57.6% aged 45-64 years) had 415 123 qualifying, long-term opioid therapy episodes; 87.1% of episodes were considered stable, 11.1% were considered a taper, and 1.8% were considered abrupt discontinuation. The adjusted cumulative incidence of opioid overdose or suicide events 11 months after baseline was 0.96% (95% CI, 0.92%-0.99%) with a stable dosage strategy, 1.10% (95% CI, 0.99%-1.22%) with a tapered dosage strategy, and 1.28% (95% CI, 0.93%-1.38%) with an abrupt discontinuation strategy. The risk difference between a taper and a stable dosage was 0.15% (95% CI, 0.03%-0.26%), and the risk difference between abrupt discontinuation and a stable dosage was 0.33% (95% CI, -0.03% to 0.74%). Results were similar using the per-protocol approach.

CONCLUSIONS AND RELEVANCE

This study identified a small absolute increase in risk of harms associated with opioid tapering compared with a stable opioid dosage. These results do not suggest that policies of mandatory dosage tapering for individuals receiving a stable long-term opioid dosage without evidence of opioid misuse will reduce short-term harm via suicide and overdose.

Randomised, pragmatic, waitlist controlled trial of cannabis added to prescription opioid support on opioid dose reduction and pain in adults with chronic non-cancer pain: study protocol

INTRODUCTION

Chronic, non-cancer pain impacts approximately 50 million adults in the USA (20%), approximately 25% of whom receive chronic prescription opioids for pain despite limited empirical efficacy data and strong dose-related risk for opioid use disorder and opioid overdose. Also despite lack of efficacy data, there are many reports of people using cannabis products to manage chronic pain and replace or reduce chronic opioids. Here we describe the protocol for a randomised trial of the effect of cannabis, when added to a behavioural pain management and prescription opioid taper support programme, on opioid utilisation, pain intensity and pain interference.

METHODS

This is a pragmatic, single-blind, randomised, wait-list controlled trial that aims to enrol 250 adults taking prescription opioids at stable doses of ≥25 morphine milligram equivalents per day for chronic non-cancer pain who express interest in using cannabis to reduce their pain, their opioid dose or both. All participants will be offered a weekly, 24-session Prescription Opioid Taper Support group behavioural pain management intervention. Participants will be randomly assigned in 1:1 ratio to use cannabis products, primarily from commercial cannabis dispensaries or to abstain from cannabis use for 6 months. Coprimary outcomes are change in prescription monitoring programme-verified opioid dose and change in Pain, Enjoyment, General Activity scale scores. Secondary outcomes include quality of life, depression, anxiety, self-reported opioid dose and opioid and cannabis use disorder symptoms. All other outcomes will be exploratory. We will record adverse events.

ETHICS AND DISSEMINATION

This study has ethical approval by the Massachusetts General Brigham Institutional Review Board (#2021P000871). Results will be published in peer-reviewed journals and presented at national conferences.

TRIAL REGISTRATION NUMBER

NCT04827992.

A review of trial and real-world data applying elements of a realist approach to identify behavioural mechanisms supporting practitioners to taper opioids

This evidence synthesis applying realist concepts and behavioural science aimed to identify behavioural mechanisms and contexts that facilitate prescribers tapering opioids. We identified relevant opioid‐tapering interventions and services from a 2018 international systematic review and a 2019 England‐wide survey, respectively. Interventions and services were eligible if they provided information about contexts and/or behavioural mechanisms influencing opioid‐tapering success. A stakeholder group (n = 23) generated draft programme theories based around the 14 domains of the Theoretical Domains Framework. We refined these using the trial and service data. From 71 articles and 21 survey responses, 56 and 16 respectively were included, representing primary care, hospital, specialist pain facilities and prison services. We identified 6 programme theories comprising 5 behavioural mechanisms: prescribers' knowledge about how to taper; build prescribers' beliefs about capabilities to initiate tapering discussions and manage psychological consequences of tapering; perceived professional role in tapering; the environmental context enabling referral to specialists; and facilitating positive social influence by aligning patient: prescriber expectations of tapering. No interventions are addressing all 6 mechanisms supportive of tapering. Work is required to operationalise programme theories according to organisational structures and resources. An example operationalisation is combining tapering guidelines with information about local excess opioid problems and endorsing these with organisational branding. Prescribers being given the skills and confidence to initiate tapering discussions by training them in cognitive‐based interventions and incorporating access to psychological and physical support in the patient pathway. Patients being provided with leaflets about the tapering process and informed about the patient pathway.

Efficacy of interventions to reduce long term opioid treatment for chronic non-cancer pain: systematic review and meta-analysis

OBJECTIVE

To review interventions to reduce long term opioid treatment in people with chronic non-cancer pain, considering efficacy on dose reduction and discontinuation, pain, function, quality of life, withdrawal symptoms, substance use, and adverse events.

DESIGN

Systematic review and meta-analysis of randomised controlled trials and non-randomised studies of interventions.

DATA SOURCES

Medline, Embase, PsycINFO, CINAHL, and the Cochrane Library searched from inception to July 2021. Reference lists and previous reviews were also searched and experts were contacted.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

Original research in English. Case reports and cross sectional studies were excluded.

DATA EXTRACTION AND SYNTHESIS

Two authors independently selected studies, extracted data, and used the Cochrane risk-of-bias tools for randomised and non-randomised studies (RoB 2 and ROBINS-I). Authors grouped interventions into five categories (pain self-management, complementary and alternative medicine, pharmacological and biomedical devices and interventions, opioid replacement treatment, and deprescription methods), estimated pooled effects using random effects meta-analytical models, and appraised the certainty of evidence using GRADE (grading of recommendations, assessment, development, and evaluation).

RESULTS

Of 166 studies meeting inclusion criteria, 130 (78%) were considered at critical risk of bias and were excluded from the evidence synthesis. Of the 36 included studies, few had comparable treatment arms and sample sizes were generally small. Consequently, the certainty of the evidence was low or very low for more than 90% (41/44) of GRADE outcomes, including for all non-opioid patient outcomes. Despite these limitations, evidence of moderate certainty indicated that interventions to support prescribers' adherence to guidelines increased the likelihood of patients discontinuing opioid treatment (adjusted odds ratio 1.5, 95% confidence interval 1.0 to 2.1), and that these prescriber interventions as well as pain self-management programmes reduced opioid dose more than controls (intervention v control, mean difference -6.8 mg (standard error 1.6) daily oral morphine equivalent, P<0.001; pain programme v control, -14.31 mg daily oral morphine equivalent, 95% confidence interval -21.57 to -7.05).

CONCLUSIONS

Evidence on the reduction of long term opioid treatment for chronic pain continues to be constrained by poor study methodology. Of particular concern is the lack of evidence relating to possible harms. Agreed standards for designing and reporting studies on the reduction of opioid treatment are urgently needed.

REVIEW REGISTRATION

PROSPERO CRD42020140943.

The protocol of the Application of Economics & Social psychology to improve Opioid Prescribing Safety trial 2 (AESOPS-2): Availability of opioid harm

BACKGROUND

High levels of opioid prescribing in the United States has resulted in an alarming trend in opioid-related harms. The objective of Trial 2 of the Application of Economics & Social psychology to improve Opioid Prescribing Safety (AESOPS-2) is to dampen the intensity and frequency of opioid prescribing in accordance with the Centers for Disease Control and Prevention recommendation to "go low and slow". We aim to accomplish this by notifying clinicians of harmful patient outcomes, which we expect to increase the mental availability of risks associated with opioid use.

METHODS

The trial is multi-site. Random assignment determines if prescribers to persons who suffer an opioid overdose (fatal or nonfatal) learn of this event (intervention) or practice usual care (control). Clinicians in the intervention group receive a letter notifying them of their patient's overdose. The primary outcome is the change in clinician weekly milligram morphine equivalent (MME) prescribed in a 6-month period before and after receiving the letter. Additional outcomes are the change in the proportion of patients prescribed at least 50 daily MME and in the proportion of patients referred to medication assisted treatment. Group differences in these outcomes will be compared using an intent-to-treat difference-in-differences framework with a mixed-effects regression model to estimate clinician MME.

DISCUSSION

The AESOPS-2 trial will provide new knowledge about whether increasing prescribers' awareness of patients' opioid-related overdoses leads to a reduction in opioid prescribing. Additionally, this trial may better inform how to reduce opioid use disorder and opioid overdoses by lowering population exposure to these drugs.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04758637.

Anxiety and Fear Avoidance Beliefs and Behavior May Be Significant Risk Factors for Chronic Opioid Analgesic Therapy Reliance for Patients with Chronic Pain-Results from a Preliminary Study

OBJECTIVE

To describe differences between patients with chronic, non-cancer pain (CNCP) who were successfully able to cease full mu agonist chronic opioid analgesic therapy (COAT), and those who exhibited refractory COAT reliance, among those who participated in a multidisciplinary program designed for COAT cessation.

DESIGN

A retrospective review of electronic medical records (EMR) data was organized for preliminary analysis.

SETTING

A multicenter private practice specializing in CNCP, which received patient referrals from the surrounding geographical area of primary and specialty care offices in Northern California.

SUBJECTS

Data from 109 patients with CNCP who participated in a multidisciplinary program to cease COAT between the dates of October 2017 to December 2019 were examined.

METHODS

EMR data, pre-COAT cessation, of oral morphine milligram equivalence (MME) and validated questionnaire responses assessing anxiety and fear-based beliefs and behavior, as well as opioid misuse, were extracted and compared between those who successfully ceased COAT and those who did not.

RESULTS

Patients who were unsuccessful at COAT cessation reported significantly higher Fear Avoidance Beliefs Questionnaire (FAB) scores. No significant differences were found based on incoming MME amounts, Current Opioid Misuse Measure (COMM) or Tampa Scale of Kinesiophobia (TSK) scores. Pain Catastrophizing Scale (PCS) scores showed a split pattern with unclear significance.

CONCLUSIONS

Results suggest that fear avoidance beliefs and behavior, as measured by the FAB, play a significant role in refractory COAT reliance for patients with CNCP.

Patterns of opioid analgesic use in the U.S., 2009 to 2018

ABSTRACT

Although overall outpatient dispensing of opioid analgesic prescriptions has declined, there may still be overprescribing. Understanding how many opioid analgesic units, primarily tablets, are dispensed with the intention of shorter-vs longer-term use can inform public health interventions. We used pharmacy prescription data to estimate the number of opioid analgesic tablets dispensed annually in the U.S. We studied patterns of new use of opioid analgesics by evaluating how many opioid analgesic prescriptions and tablets were dispensed to patients with no opioid analgesic prescriptions in the previous year. Estimated opioid analgesic tablets dispensed declined from a peak of 17.8 billion in 2012 to 11.1 billion in 2018. Patients newly starting opioid analgesics declined from 47.4 million patients in 2011 to 37.1 million patients in 2017. Approximately 40% fewer tablets were dispensed within a year to patients starting in 2017 (2.4 billion) compared with 2011 (4.0 billion). In 2011, patients with ≥5 opioid analgesic prescriptions within a year were dispensed 2.2 billion tablets (55% of all tablets in our study). This declined by 52% to 1.1 billion tablets (44% of all tablets) in 2017. Tablets dispensed within a year to patients with <5 opioid analgesic prescriptions declined by 26% from 2011 to 2017. Patients with ≥5 prescriptions comprised a small and decreasing proportion of all patients newly starting therapy. However, these patients received almost half of all tablets dispensed within a year to patients in our study, despite a larger decline than tablets dispensed to patients with <5 prescriptions within a year.

The protocol of the Application of Economics & Social psychology to improve Opioid Prescribing Safety Trial 1 (AESOPS-1): Electronic health record nudges

BACKGROUND

There is a lack of evidence that long-term opioid use offers benefit for noncancer pain and an abundance of evidence of harm. Despite clinical guidelines and education, prescribing continues at a higher rate than before the opioids crisis. The objective of trial 1 of the Application of Economics & Social psychology to improve Opioid Prescribing Safety (AESOPS-1) is to discourage unnecessary opioid prescribing in primary care by applying "behavioral insights"-empirically-tested social and psychological interventions that affect choice.

METHODS

AESOPS-1 randomizes primary care clinics in Illinois and California to behavioral intervention or control. Both arms receive opioid guideline education. Clinics randomized to the behavioral intervention arm receive nudges within the electronic health record (EHR) including: 1) an "accountable justification" entered in the chart, 2) a precommitment to address high-risk prescriptions, and 3) a "PainTracker" that broadens discussions about pain. The control arm receives no EHR-based intervention. The primary outcome is the change in weekly milligram morphine equivalents (MME) prescribed. The secondary outcome is the change in the proportion of patients prescribed at least 50 daily MME. To evaluate these outcomes, we will use a difference-in-differences mixed-effects regression model on clinician MME weekly or daily dose. The analysis will be "intent-to-treat." The intervention period is 18-months, with a 6-month follow-up period to measure persistence of effects.

DISCUSSION

The AESOPS-1 trial will evaluate the effect of EHR-based interventions in reducing noncancer opioid prescribing in primary care. AESOPS-1 may demonstrate practical and scalable strategies to lower unnecessary population exposure to opioids.

Mixed Methods Study of Patient and Primary Care Provider Perceptions of Chronic Pain Treatment

OBJECTIVE

A mixed-method study involving patient focus groups and survey of primary care providers (PCPs) sought to compare perspectives about chronic pain (CP) and its treatment. Our goal was to identify needs and barriers for facilitating patient-centered care.

METHODS

Two focus groups of CP patients from a single academic medical center explored interactions with PCPs and their understandings, experiences, and expectations of CP treatment. They were also asked their opinions about self-assessment/communication tools. We compared themes with survey data from two PCP research networks.

RESULTS

CP patients understand opioid risks and fear PCP judgement and condescension, while sensing PCP fear and avoidance of opioid prescribing. PCPs are dissatisfied with their ability to provide optimal CP care, despite feeling that patients are generally satisfied with their clinic visits. Evaluation tools, especially assessment of functional activities, are favorably viewed by all, but deemed time prohibitive.

CONCLUSION

Patients' understanding of opioid risks, desire for attention on functional goals and behavioral treatment may be greater than PCPs perceive. Such gaps in understanding and attitudes, if recognized, could support high-quality communication and interventional strategies.

PRACTICE IMPLICATIONS

These findings guide patient-PCP communication toward alignment of treatment goals and enhanced coordination of care.

The Effect of Opioid Stewardship Interventions on Key Outcomes: A Systematic Review

OBJECTIVES

We sought to identify potential patient safety practices to reduce high-risk opioid prescribing.

METHODS

We conducted a systematic review of the literature to identify opioid stewardship (OS) strategies implemented in primary care and other settings. Included studies evaluated an OS strategy or a multicomponent OS initiative to address potential harms of opioids and used experimental or quasi-experimental designs.

RESULTS

We identified 14 studies and 1 systematic review that met inclusion criteria. Most studies examined multicomponent OS interventions, which often consisted of guideline-recommended clinical interventions or care processes (e.g., use urine drug screening, check Prescription Drug Monitoring Program), as well as implementation strategies (e.g., dashboards, audit and feedback). Most studies examined the effect of OS interventions on reducing the potential risks of opioids with judicious prescribing and guideline-concordant care (e.g., reduce inappropriate high opioid dosages, avoid co-prescribing opioids and benzodiazepines, use urine drug screening, treatment agreements).

CONCLUSIONS

The strength of the evidence is low to moderate that OS efforts decrease numbers of opioid prescriptions, proportion of patients on long-term opioids, or days' supply. The strength of the evidence for OS initiatives producing significant reductions in opioid dosages was moderate. Future research is needed on the effectiveness of OS interventions, particularly studies with experimental designs and in diverse settings within the health care system.

Exploring Factors Associated With Long-Term Opioid Therapy in Cancer Survivors: An Integrative Review

CONTEXT

The prevalence of chronic pain in cancer survivors is double that of the general U.S.

POPULATION

Opioids have been the foundation of cancer pain management for decades; however, there is a paucity of literature on long-term opioid therapy (LTOT) in cancer survivors. An understanding of factors related to LTOT use in cancer survivors is needed to address chronic pain and balance opioid harms in the expanding population of cancer survivors.

OBJECTIVES

To analyze the research of LTOT utilization and factors associated with persistent opioid use in cancer survivors.

METHODS

A five-stage integrative review process was adapted from Whittemore and Knafl. Data sources searched included Web of Science, PubMed, Embase, Cochrane, and Google Scholar. Quantitative research studies from 2010 to present related to cancer survivors managed on LTOT were included. Editorials, reviews, or abstracts were excluded.

RESULTS

After reviewing 315 articles, 21 articles were included. We found that there were several definitions of LTOT in the reviewed studies, but the duration of opioid use (i.e., more than three months after completion of curative treatment) was the most common. The reviewed literature describes a relationship between LTOT and important biopsychosocial factors (cancer type, socioeconomic factors, and comorbidities).

CONCLUSION

The studies in this review shed light on the factors associated with LTOT in cancer survivors. LTOT was common in certain populations of cancer survivors and those with a collection of patient-specific characteristics. This review suggests that there is a critical need for specialized research on chronic cancer pain and opioid safety in cancer survivors.

Promoting Patient-Centeredness in Opioid Deprescribing: a Blueprint for De-implementation Science

A downward trend in opioid prescribing between 2011 and 2018 has brought per-capita opioid prescriptions below the levels of 2006, the earliest year for which the Centers for Disease Control and Prevention has published data. That trend has affected roughly ten million patients who previously received long-term opioid therapy. Any effort to reduce or replace a prior health practice is termed de-implementation. We suggest that the evaluation of opioid prescribing de-implementation has been misdirected, within US policy and health research, resulting in detrimental impacts on patients, their families and clinicians. Policymakers and implementation scientists can address these deficiencies in how we study and how we perform opioid de-implementation by applying an implementation science framework: the Consolidated Framework for Implementation Research. The Consolidated Framework lays out relevant domains of activity (internal, external, etc.) that influence implementation processes and outcomes. It can deepen our understanding of how policies are chosen, communicated, and carried out. Policymakers and researchers who embrace this framework will need a better approach to measuring success and failure in health care where both pain and opioids are concerned. This would involve shifting from a reductive focus on opioid prescription counts toward measures that are more effective, holistic, and patient-centered.

Benefits and Harms of Long-term Opioid Dose Reduction or Discontinuation in Patients with Chronic Pain: a Rapid Review

BACKGROUND

Many clinicians are reevaluating the use of long-term opioid therapy (LTOT) for chronic pain in response to the opioid crisis and calls from organizations including the Centers for Disease Control & Prevention to limit prescribing of high-dose opioids. However, this practice change is occurring largely in the absence of data regarding patient outcomes. A 2017 systematic review found inconclusive evidence on the impact of LTOT dose reduction and discontinuation on pain severity and function, quality of life, withdrawal symptoms, substance abuse, and adverse effects. This rapid systematic review provides an updated evidence synthesis of patient outcomes following LTOT dose reduction including serious harms such as overdose and suicide.

METHODS

We systematically searched numerous bibliographic databases from January 2017 (the end search date of the 2017 systematic review) through May 2020. One reviewer used prespecified criteria to assess articles for inclusion, evaluate study quality, abstract data, and grade strength of evidence, with a second reviewer checking.

RESULTS

We included 49 studies-1 systematic review, 34 studies included in that systematic review, and 14 new studies. We prioritized evidence synthesis of 19 studies with the most applicability to the Veteran population and outpatient settings. Among these studies, improvements in mean pain scores were common among patients tapering opioids while participating in intensive multimodal pain interventions and mostly unchanged with less intensive or nonspecific co-interventions. Our confidence in these findings is low due to methodological limitations of the studies. Observational data suggests that serious harms such as opioid overdose and suicidal ideation can occur following opioid dose reduction or discontinuation, but the incidence of these harms at the population level is unknown.

DISCUSSION

The net balance of benefits and harms of LTOT dose reduction for patients with chronic pain is unclear. Clinicians should closely monitor patients during the tapering process given the potential for harm.

End Stage Chronic Pain (ESCP): Naming Complex Suffering in the Opioid Crisis Era

The "opioid crisis" stemming from overprescribing of prescription opioids describes an iatrogenic situation which has resulted in a rise in opioid use disorder (OUD) and overdose deaths. Many of these patients suffer from chronic non-cancer pain syndromes (CNCP) who have been injudiciously treated with opioids. Some patients with CNCP are treated successfully with opioids in accordance with modern guidelines. There is a very complex, small group of patients with CNCP who require higher than recommended dosages of opioids when other modalities and treatments have failed. We describe such a patient and believe that there is a subset of patients with unremitting suffering from chronic pain which we have called end-stage chronic pain (ESCP). These patients, despite receiving expert chronic pain care, often require high doses of opioids and suffer a dramatic decline in quality of life (QOL), function and an increase in their suffering when their opioids are tapered or discontinued. We have responded to the treatment of this group of patients by critically examining our approach to the use of opioids for their pain and attempting to reconcile high dose opioids in the setting of the Center for Disease Control (CDC) guidelines. We describe a patient with severe chronic pain from congenital spinal disease who experienced increased pain and suffering when his opioids were tapered. We will discuss our approach to this patient and in doing so discuss the concept of ESCP and proposed criteria for the use of high dose opioids in such patients.

Deprescribing long-term opioid therapy in patients with chronic pain

Proposed regulatory changes will limit the access to opioids by Australian patients with chronic pain, many of whom are under the care of consultant physicians. This review summarises points of consensus on opioid deprescribing that emerged from the interaction of an expert panel and the audience at a symposium on the topic held in Sydney in 2019. Each of these consensus points speaks to the need for an individualised, patient-centred approach. In other words, 'treat the patient, not the pill count'.

Study protocol for evaluating Six Building Blocks for opioid management implementation in primary care practices

Background

The Six Building Blocks for improving opioid management (6BBs) is a program for improving the management of patients in primary care practices who are on long-term opioid therapy for chronic pain. The 6BBs include building leadership and consensus; aligning policies, patient agreements, and workflows; tracking and monitoring patient care; conducting planned, patient-centered visits; tailoring care for complex patients; and measuring success. The Agency for Healthcare Research and Quality funded the development of a 6BBs implementation guide: a step-by-step approach for independently implementing the 6BBs in a practice. This mixed-method study seeks to assess practices’ use of the implementation guide to implement the 6BBs and the effectiveness of 6BBs implementation on opioid management processes of care among practices using the implementation guide.

Methods

Data collection is guided by the Consolidated Framework for Implementation Research, Proctor’s taxonomy of implementation outcomes, and the Centers for Disease Control and Prevention’s Guideline for Prescribing Opioids for Chronic Pain. A diverse group of health care organizations with primary care clinics across the USA will participate in the study over 15 months. Qualitative data collection will include semi-structured interviews with stakeholders at each organization at two time points, notes from routine check-in calls, and document review. These data will be used to understand practices’ motivation for participation, history with opioid management efforts, barriers and facilitators to implementation, and implementation progress. Quantitative data collection will consist of a provider and staff survey, an implementation milestones assessment, and quarterly opioid prescribing quality measures. These data will supplement our understanding of implementation progress and will allow us to assess changes over time in providers’ opioid prescribing practices, prescribing self-efficacy, challenges to providing guideline-driven care, and practices’ opioid prescribing quality measures. Qualitative data will be coded and analyzed for emergent themes. Quantitative data will be analyzed using descriptive statistics and clustered multivariate regression.

Discussion

This study contributes to the knowledge of the implementation and effectiveness of a team-based approach to opioid management in primary care practices. Information gleaned from this study can be used to inform efforts to curtail opioid prescribing and assist primary care practices considering implementing the 6BBs.

Implementation and enforcement of state opioid prescribing laws

BACKGROUND

In response to the role overprescribing has played in the U.S. opioid crisis, in the past decade states have enacted four main types of laws to curb opioid prescribing: mandatory prescription drug monitoring program (PDMP) enrollment laws requiring clinicians to register with a PDMP; mandatory PDMP query laws requiring clinicians to check a PDMP prior to prescribing opioids; pill mill laws regulating pain management clinics; and opioid prescribing cap laws limiting the dose/duration of opioid prescriptions. While 47 states now have one or more of these laws in place, little is known about implementation and enforcement strategies, facilitators, and barriers.

METHODS

From November 2017 to February 2019, we interviewed 114 professionals involved in state opioid prescribing law implementation and enforcement in 20 states and identified common themes.

RESULTS

Implementation efforts focused on awareness campaigns and targeted training of key front-line implementers. Enforcement strategies included active, complaint-based, and automated strategies. Collaboration across agencies and stakeholders, particularly health agencies and law enforcement, was identified as an important facilitator of implementation and enforcement. Two key interrelated barriers were identified: the complexity of state opioid prescribing laws in terms of which providers, patients, and prescriptions they applied to, and IT infrastructure.

CONCLUSION

Despite differing approaches, our findings suggest similar barriers to implementation and enforcement across state opioid prescribing laws. Strategies are needed to ease implementation and enforcement of laws that apply only to specific sub-sets of providers, patients, or prescriptions and address issues of access and data utilization of the PDMP.

Transition to high-dose or strong opioids: a population-based study of people initiating opioids in Australia

BACKGROUND AND AIMS

Strong and high-dose opioids are associated with opioid overdose and death. The objective of this study was to determine the rate and predictors of transitioning to high-dose or strong opioids among people initiating opioids.

DESIGN

Retrospective cohort study.

SETTING

Australia.

PARTICIPANTS

People initiating opioid analgesics from July 2013 to January 2018 were identified from a random 10% sample of Australia's Pharmaceutical Benefits Scheme eligible population.

MEASUREMENTS

Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated for the predictors of escalating to ≥ 50 mg oral morphine equivalents (OMEs)/day (cohort 1); ≥ 90 mg OMEs/day (cohort 2) and transitioning from weak opioids to strong opioids (cohort 3) over 12 months of follow-up. Predictors included age, sex, number of comorbidities, history of depression, prior treatment for cancer and selected other medication use.

FINDINGS

In total, 861 691 people initiated opioids at average doses < 50 mg OMEs/day (cohort 1), 874 401 at < 90 mg OMEs/day (cohort 2) and 603 884 initiated weak opioids (cohort 3). Overall, 1.4% of people escalated to doses ≥ 50 mg OMEs/day, 0.8% to doses ≥ 90 mg OMEs/day and 7.3% transitioned to strong opioids. The strongest predictors of transitioning included prior treatment for cancer [cohort 1: HR = 3.19, 95% CI = 3.00-3.40; cohort 2: HR = 4.19, 95% CI = 3.90-4.51; cohort 3: HR = 2.07, 95% CI = 1.95-2.18] and age ≥ 75 years (cohort 1: HR = 3.04, 95% CI = 2.73-3.38; cohort 2: HR = 2.51, 95% CI = 2.17-2.89; cohort 3: HR = 1.88, 95% CI = 1.80-1.96). Females transitioned to high doses and strong opioids less rapidly than males (cohort 1: HR = 0.79, 95% CI = 0.76-0.82; cohort 2: HR = 0.70, 95% CI = 0.66-0.73; cohort 3: HR = 0.95, 95% CI = 0.93-0.96).

CONCLUSIONS

In Australia, more than one in every 13 people initiating weak opioids transition to strong opioids. By extrapolation, more than 26 000 Australian adults initiating opioids escalate to high doses each year. People with cancer treatment history, older people and males transition to strong and high-dose opioids more rapidly than others.

Evaluation of an Interdisciplinary Controlled Substance Review Committee on Opioid Prescribing in a Community Health Center

Objective

To describe recommendations made by an interdisciplinary controlled substance committee and acceptance by primary care providers.

Design

Retrospective cohort study.

Setting

Multisite federally qualified health center using an interdisciplinary committee to provide patient-specific recommendations to prescribers with patients using prescription opioids and other controlled substances.

Subjects

Patients prescribed long-term opioids.

Methods

We identified and characterized committee recommendations to prescribers between January 1, 2013, and December 31, 2016. We manually reviewed electronic medical records to determine if recommendations were accepted at eight months. The primary outcome was the overall acceptance rate of recommendations. Secondary outcomes were the acceptance of recommendations to reduce opioid doses and change in opioid dose from baseline.

Results

The committee made 337 recommendations for 94 patients. Of those, 169 recommendations (50.1%) were accepted within eight months. The most common recommendation was to change opioid prescribing (N = 53, 56.4%), but recommendations varied. For patients with a recommendation to change opioid prescribing, this was accepted in 31 of 53 patients (58.5%). Overall, opioid doses decreased from 60 morphine equivalents per day (interquartile range [IQR] = 27.5–135, range = 5–1,260) at baseline to 40 morphine equivalents per day (IQR = 15–105, range = 0–1,260) at eight months (P &lt; 0.001).

Conclusions

An interdisciplinary committee was well positioned to offer primary care providers with nonopioid options to manage chronic nonmalignant pain and provide support in reducing opioid doses. About half of recommendations were accepted by primary care providers. Future research should focus on strategies to improve the utility of this approach and its impact on clinical outcomes.

Primary Care Opioid Taper Plans Are Associated with Sustained Opioid Dose Reduction

BACKGROUND

Primary care providers prescribe most long-term opioid therapy and are increasingly asked to taper the opioid doses of these patients to safer levels. A recent systematic review suggests that multiple interventions may facilitate opioid taper, but many of these are not feasible within the usual primary care practice.

OBJECTIVE

To determine if opioid taper plans documented by primary care providers in the electronic health record are associated with significant and sustained opioid dose reductions among patients on long-term opioid therapy.

DESIGN

A nested case-control design was used to compare cases (patients with a sustained opioid taper defined as average daily opioid dose of ≤ 30 mg morphine equivalent (MME) or a 50% reduction in MME) to controls (patients matched to cases on year and quarter of cohort entry, sex, and age group, who had not achieved a sustained taper). Each case was matched with four controls.

PARTICIPANTS

Two thousand four hundred nine patients receiving a ≥ 60-day supply of opioids with an average daily dose of ≥ 50 MME during 2011-2015.

MAIN MEASURES

Opioid taper plans documented in prescription instructions or clinical notes within the electronic health record identified through natural language processing; opioid dosing, patient characteristics, and taper plan components also abstracted from the electronic health record.

KEY RESULTS

Primary care taper plans were associated with an increased likelihood of sustained opioid taper after adjusting for all patient covariates and near peak dose (OR = 3.63 [95% CI 2.96-4.46], p < 0.0001). Both taper plans in prescription instructions (OR = 4.03 [95% CI 3.19-5.09], p < 0.0001) and in clinical notes (OR = 2.82 [95% CI 2.00-3.99], p < 0.0001) were associated with sustained taper.

CONCLUSIONS

These results suggest that planning for opioid taper during primary care visits may facilitate significant and sustained opioid dose reduction.

Evidence for state, community and systems-level prevention strategies to address the opioid crisis

BACKGROUND

Practitioners and policy makers need evidence to facilitate the selection of effective prevention interventions that can address the ongoing opioid overdose epidemic in the United States.

METHODS

We conducted a systematic review of publications reporting on rigorous evaluations of systems-level interventions to address provider and patient/public behavior and prevent prescription and illicit opioid overdose. A total of 251 studies were reviewed. Interventions studied included 1) state legislation and regulation, 2) prescription drug monitoring programs (PDMPs), 3) insurance strategies, 4) clinical guideline implementation, 5) provider education, 6) health system interventions, 7) naloxone education and distribution, 8) safe storage and disposal, 9) public education, 10) community coalitions, and 11) interventions employing public safety and public health collaborations.

RESULTS

The quality of evidence supporting selected interventions was low to moderate. Interventions with the strongest evidence include PDMP and pain clinic legislation, insurance strategies, motivational interviewing in clinical settings, feedback to providers on opioid prescribing behavior, intensive school and family-based programs, and patient education in the clinical setting.

CONCLUSIONS

Although evidence is growing, further high-quality research is needed. Investigators should aim to identify strategies that can prevent overdose, as well as influence public, patient, and provider behavior. Identifying which strategies are most effective at addressing prescription compared to illicit opioid misuse and overdose could be fruitful, as well as investigating synergistic effects and unintended consequences.

Does Opioid Tapering in Chronic Pain Patients Result in Improved Pain or Same Pain vs Increased Pain at Taper Completion? A Structured Evidence-Based Systematic Review

Objective

To support or refute the hypothesis that opioid tapering in chronic pain patients (CPPs) improves pain or maintains the same pain level by taper completion but does not increase pain.

Methods

Of 364 references, 20 fulfilled inclusion/exclusion criteria. These studies were type 3 and 4 (not controlled) but reported pre/post-taper pain levels. Characteristics of the studies were abstracted into tabular form for numerical analysis. Studies were rated independently by two reviewers for quality. The percentage of studies supporting the above hypothesis was determined.

Results

No studies had a rejection quality score. Combining all studies, 2,109 CPPs were tapered. Eighty percent of the studies reported that by taper completion pain had improved. Of these, 81.25% demonstrated this statistically. In 15% of the studies, pain was the same by taper completion. One study reported that by taper completion, 97% of the CPPs had improved or the same pain, but CPPs had worse pain in 3%. As such, 100% of the studies supported the hypothesis. Applying the Agency for Health Care Policy and Research Levels of Evidence Guidelines to this result produced an A consistency rating.

Conclusions

There is consistent type 3 and 4 study evidence that opioid tapering in CPPs reduces pain or maintains the same level of pain. However, these studies represented lower levels of evidence and were not designed to test the hypothesis, with the evidence being marginal in quality with large amounts of missing data. These results then primarily reveal the need for controlled studies (type 2) to address this hypothesis.

Predictors of chronic prescription opioid use after orthopedic surgery: derivation of a clinical prediction rule

Background

Prescription opioid use at high doses or over extended periods of time is associated with adverse outcomes, including dependency and abuse. The aim of this study was to identify mediating variables that predict chronic opioid use, defined as three or more prescriptions after orthopedic surgery.

Methods

Individuals were ages between 18 and 50 years and undergoing arthroscopic hip surgery between 2004 and 2013. Two categories of chronic opioid use were calculated based on individuals (1) having three or more unique opioid prescriptions within 2 years and (2) still receiving opioid prescriptions > 1 year after surgery. Univariate elationships were identified for each predictor variable, then significant variables (P > 0.15) were entered into a multivariate logistic regression model to identify the most parsimonious group of predictor variables for each chronic opioid use classification. Likelihood ratios were derived from the most robust groups of variables.

Results

There were 1642 participants (mean age 32.5 years, SD 8.2, 54.1% male). Nine predictor variables met the criteria after bivariate analysis for potential inclusion in each multivariate model. Eight variables: socioeconomic status (from enlisted rank family), prior use of opioid medication, prior use of non-opioid pain medication, high health-seeking behavior before surgery, a preoperative diagnosis of insomnia, mental health disorder, or substance abuse were all predictive of chronic opioid use in the final model (seven variables for three or more opioid prescriptions; four variables for opioid use still at 1 year; all< 0.05). Post-test probability of having three or more opioid prescriptions was 93.7% if five of seven variables were present, and the probability of still using opioids after 1 year was 69.6% if three of four variables were present.

Conclusion

A combination of variables significantly predicted chronic opioid use in this cohort. Most of these variables were mediators, indicating that modifying them may be feasible, and the potential focus of interventions to decrease the risk of chronic opioid use, or at minimum better inform opioid prescribing decisions. This clinical prediction rule needs further validation.

Effect of a high dosage opioid prior authorization policy on prescription opioid use, misuse, and overdose outcomes

BACKGROUND

High dosage opioid use is a risk factor for opioid-related overdose commonly cited in guidelines, recommendations, and policies. In 2012, the Oregon Medicaid program developed a prior authorization policy for opioid prescriptions above 120 mg per day morphine equivalent dose (MED). This study aimed to evaluate the effects of that policy on utilization, prescribing patterns, and health outcomes.

METHODS

Using administrative claims data from Oregon and a control state (Colorado) between 2011 and 2013, we used difference-in-differences analyses to examine changes in utilization, measures of high risk opioid use, and overdose after introduction of the policy. We also evaluated opioid utilization in a cohort of individuals who were high dosage opioid users before the policy.

RESULTS

Following implementation of Oregon's high dosage policy, the monthly probability of an opioid fill over 120 mg MED declined significantly by 1.7 percentage points (95% confidence interval [CI]; -2.0% to -1.4%), whereas it increased significantly by 1.0 percentage points (95% CI 0.4% to 1.7%) for opioid fills &lt; 61 mg MED. Fills of medications used to treat neuropathic pain also increased by 1.2 percentage points (95% CI 0.7% to 1.8%). The monthly probability of multiple pharmacy use declined by 0.1 percentage points (-0.2% to -0.0) following the prior authorization, but there were no significant changes in ED encounters or hospitalizations for opioid overdose. Among individuals who were using a high dosage opioid before the policy, there was a 20.3 percentage point (95% CI -15.3% to -25.3%) decline in estimated probability of having a high dosage fill after the policy.

CONCLUSIONS

Oregon's prior authorization policy was effective at reducing high dosage opioid prescriptions. While multiple pharmacy use also declined, we found no impact on opioid overdose were observed.

The conundrum of opioid tapering in long-term opioid therapy for chronic pain: A commentary

BACKGROUND

In response to the opioid epidemic and new guidelines, many patients on high-dose long term opioid therapy (LTOT) for chronic pain are getting tapered off opioids. As a result, a unique clinical challenge is emerging: while many on LTOT have poor pain control, functional decline, psychiatric instability, aberrancies and misuse, these issues may often worsen with opioid tapering. Currently, a clear explanation and practical guidance on how to manage this perplexing clinical scenario is lacking.

METHODS

We offer a commentary with our perspective on possible mechanisms involved in this clinical phenomena and offer practical management guidance, supported by available evidence.

RESULTS

It is not well recognized that allostatic opponent process involved in development of opioid dependence can cause worsening pain, functional status, sleep and psychiatric symptoms over time, and significant fluctuation of pain and other affective symptoms due to their bidirectional dynamic interaction with opioid dependence ('affective dynamism'). These elements of complex persistent dependence (CPD), the grey area between simple dependence and addiction, can lead to escalating and labile opioid need, often generating aberrant behaviors. Opioid tapering, a seemingly logical intervention in this situation, may lead to worsening of pain, function and psychiatric symptoms due to development of protracted abstinence syndrome. We offer practicing clinicians management principles and practical guidance focused on management of CPD in addition to chronic pain in these difficult clinical scenarios.

CONCLUSION

Awareness of the science of the neuroplasticity effects of repeated use of opioids is necessary to better manage these patients with complex challenges.

Using opioids in general practice for chronic non-cancer pain: an overview of current evidence

Chronic non-cancer pain (lasting more than 3 months) is highly prevalent in Australia (17% of males and 20% of females) and its optimal management is crucial to the health and wellbeing of the community. For 5% of the population, such pain interferes markedly with daily function. Part of the treatment for acute non-cancer pain for many people will include opioid analgesics at least for days to weeks. However, as pain becomes chronic, evidence to support ongoing prescription of opioids is lacking. There is increasing pressure to ensure that prescribing opioid analgesics is minimised to reduce not only the risk of dependence and illicit diversion but also the potential harms associated with tolerance, side effects and complications. Frameworks for considering opioid prescribing include assessing suitability of the patient for opioids; initiating a trial of therapy; and monitoring long term use. There is limited evidence of the long term efficacy of opioids for chronic non-cancer pain, and documented clinical consequences beyond addiction include acceleration of loss of bone mineral density, hypogonadism and an association with increased risk of acute myocardial infarction. Careful clinical selection of patients can help optimise the evidence-based use of opioids for chronic non-cancer pain: only treat pain that has been as well defined as possible when non-opioid therapies have not been effective; consider referral to specialist services for assessment if doses are above 100 mg oral morphine equivalent per 24 hours or the duration of therapy is longer than 4 weeks; limit prescribing to only one practitioner; seek an agreement with the patient for the initiation and potential withdrawal of opioids if the therapeutic trial is not effective.