Successful and unsuccessful outcomes with long-term opioid therapy: a survey of physicians' opinions

Prospective Investigation of Factors Associated with Prescription Opioid Dose Escalation among Patients in Integrated Health Systems

BACKGROUND

Prior research has identified factors associated with prescription opioid initiation, but little is known about the prevalence or predictors of dose escalation among patients already prescribed long-term opioid therapy (LTOT).

OBJECTIVE

This was a 2-year prospective cohort study to examine patient and clinician factors associated with opioid dose escalation.

DESIGN

A prospective cohort study. Participants were seen at baseline and every 6 months for a total of 2 years.

PARTICIPANTS

Patients prescribed a stable dose of LTOT for musculoskeletal pain were recruited from two integrated health systems (Kaiser Permanente and the Department of Veterans Affairs, respectively).

MAIN MEASURES

The prescription opioid dose was based on pharmacy records and self-report. Administrative data were gathered on characteristics of the opioid-prescribing clinician and healthcare utilization. Participants completed measures of pain, functioning, and quality of life.

KEY RESULTS

Of enrolled participants (n = 517), 19.5% had an opioid dose increase. In multivariate analyses, patient variables associated with dose escalation were lower opioid dose (hazard ratio [HR] = 0.86, 95% confidence interval [CI] = 0.79-0.94, for every 10-mg increase in baseline dose) and greater pain catastrophizing (HR = 1.03, 95% CI = 1.01-1.05). Other variables associated with dose escalation were as follows: receiving medications from a nurse practitioner primary care provider (HR = 2.10, 95% CI = 1.12-3.96) or specialty physician (HR = 3.18, 95% CI = 1.22-8.34), relative to a physician primary care provider, and having undergone surgery within the past 6 months (HR = 1.80, 95% CI = 1.10-2.94). Other variables, including pain intensity, pain disability, or depression, were not associated with dose escalation.

CONCLUSIONS

In this 2-year prospective cohort study, variables associated with opioid dose escalation were lower opioid dose, higher pain catastrophizing, receiving opioids from a medical specialist (rather than primary care clinician) or nurse practitioner, and having recently undergone surgery. Study findings highlight intervention points that may be helpful for reducing the likelihood of future prescription opioid dose escalation.

Characteristics of physicians who prescribe opioids for chronic pain: a meta-narrative systematic review

Background: The primary objective of this systematic review was to identify the characteristics of physicians who prescribe opioids to adults with chronic pain. This review was limited to studies examining fully-trained physicians, as relevant characteristics of resident physicians and non-physician clinicians may differ.

Methods: A comprehensive search of databases from January 1, 1980 to December 5, 2017 was conducted. Eligible study designs included (1) randomized trials; (2) nonrandomized prospective and retrospective studies; and (3) cross-sectional observational studies. The risk of bias in the included studies was assessed using an adapted version of the Newcastle-Ottawa Scale for cross-sectional studies. A total of 2508 records were screened and 22 studies met inclusion criteria. The majority of studies were cross-sectional (n=20) and the total number of participants was 8433.

Results: The risk of bias was high overall. The majority of physicians were confident managing and prescribing opioids for chronic pain but had high levels of dissatisfaction. Physicians reported high awareness of the potential for opioid misuse and were concerned about inadequate prior training in pain management. The majority of physicians were less likely to prescribe for patients with a history of substance abuse and reported major concerns about regulatory scrutiny.

Conclusion: This systematic review provides the foundation for the development of prospective studies aimed at further elucidating the constellation of mechanisms that influence physicians who manage pain and prescribe opioids.

A Two-Year Prospective Multicenter Study of Opioid Therapy for Chronic Noncancer Pain: Prescription Trends and Predictors

Objectives

Opioid use in chronic pain has increased worldwide in recent years. The aims of this study were to describe the trends and patterns of opioid therapy over two years of follow-up in a cohort of chronic noncancer pain (CNCP) patients and to assess predictors of long-term opioid use and clinical outcomes.

Methods

A prospective cohort study with two years of follow-up was undertaken in four multidisciplinary chronic pain clinics. Demographic data, pain characteristics, and opioid prescriptions were recorded at baseline, three, six, 12, and 24 months.

Results

Six hundred seventy-four CNCP patients were recruited. The prevalence of opioid prescriptions at baseline was 59.6% (N = 402), and 13% (N = 86) were strong opioid prescriptions. At 24 months, opioid prescription prevalence was as high as 74.3% (N = 501), and strong opioid prescription was 31% (N = 207). Most opioid users (71%, N = 479) maintained their prescription during the two years of follow-up. Our opioid discontinuation was very low (1%, N = 5). Opioid users reported higher severity and interference pain scores, both at baseline and after two years of follow-up. Opioid use was independently associated with continuous pain, pain location in the lower limbs, and higher pain interference scores.

Conclusions

This study describes a pattern of increasing opioid prescription in chronic pain patients. Despite the limited improvement of clinical outcomes, most patients keep their long-term opioid prescriptions. Our results underscore the need for changes in clinical practice and further research into the effectiveness and safety of chronic opioid therapy for CNPC.

Comparing chronic pain treatment seekers in primary care versus tertiary care settings

BACKGROUND

Patients frequently seek treatment for chronic nonmalignant pain in primary care settings. Compared with physicians who have completed extensive specialization (eg, fellowships) in pain management, primary care physicians receive much less formal training in managing chronic pain. While chronic pain represents a complicated condition in its own right, the recent increase in opioid prescriptions further muddles treatment. It is unknown whether patients with chronic pain seeking treatment in primary care differ from those seeking treatment in tertiary care settings. This study sought to determine whether patients with chronic pain in primary care reported less pain, fewer psychological variables related to pain, and lower risk of medication misuse/abuse compared with those in tertiary care.

METHODS

Data collected from patients with chronic pain in primary care settings and tertiary care settings were analyzed for significant differences using Wilcoxon rank sum tests, Fisher exact tests, and linear regression. A host of variables among populations, including demographics, self-reported pain severity, psychological variables related to pain, and risk for opioid misuse and abuse, were compared.

RESULTS

Findings suggest that primary care patients with chronic pain were similar to those in tertiary care on a host of indices and reported more severe pain. There were no significant group differences for risk of medication misuse or abuse.

CONCLUSION

It seems that primary care physicians care for a complicated group of patients with chronic pain that rivals the complexity of those seen in specialized tertiary care pain management facilities.

Prevalence and characteristics of hospitalized adults on chronic opioid therapy

BACKGROUND

As chronic opioid therapy (COT) becomes more common, complexity of pain management in the inpatient setting increases; little is known about medical inpatients on COT.

OBJECTIVE

To determine the prevalence of COT among hospitalized patients and to compare outcomes among these patients relative to those not receiving COT.

DESIGN

Observational study of inpatient and outpatient administrative data.

PARTICIPANTS

All veterans with acute medical admissions to 129 Veterans Administration hospitals during fiscal years 2009 to 2011, residing in the community, and with outpatient pharmacy use.

MEASUREMENTS

We defined COT as 90 or more days of opioids prescribed in the 6 months prior to hospitalization. Patient characteristics included demographic variables and major comorbidities. Outcomes included 30-day readmission and death during hospitalization or within 30 days, with associations ascertained using multivariable logistic regression.

RESULTS

Of 122,794 hospitalized veterans, 31,802 (25.9%) received COT. These patients differed from comparators in age, sex, race, residence, and presence of chronic noncancer pain, chronic obstructive pulmonary disease, complicated diabetes, cancer, and mental health diagnoses including post-traumatic stress disorder. After adjustment for demographic factors, comorbidities, and admission diagnosis, COT was associated with hospital readmission (odds ratio [OR]: 1.15, 95% confidence interval [CI]: 1.10-1.20) and death (OR: 1.19, 95% CI: 1.10-1.29).

CONCLUSIONS

COT is common among medical inpatients. Patients on COT differ from patients without COT beyond dissimilarities in pain and cancer diagnoses. Occasional and chronic opioid use are associated with increased risk of hospital readmission, and COT is associated with increased risk of death. Additional research relating COT to hospitalization outcomes is warranted.

Influence of religiosity on the quality of life and on pain intensity in chronic pancreatitis patients after neurolytic celiac plexus block: case-controlled study

The quality of life in patients with chronic pancreatitis (CP) is reduced due to their suffering of high levels of pain. It has been presented that quality of life can also be linked to religiosity and/or spirituality. The aim of this study is to assess the influence of religious practices on the quality of life and on the subjective level of pain in CP patients. Ninety-two patients (37 women and 55 men) with chronic pancreatitis were treated invasively for pain with neurolytic celiac plexus block (NCPB). The religiosity of the patients was recorded and served as a dichotomizer. Group 1 was for patients who claimed to have no contact with the church or to have very sporadic contact (N = 35 patients). Group 2 was for patients who claimed to have deep faith and were regular participants at church activities (N = 57 patients). Visual analogue scale was used to assess pain, while the quality of life was measured by using QLQ C-30 questionnaire adapted for chronic pancreatitis patients in Polish population. The patients were assessed prior to the pain-relieving intervention and subsequently 2 and 8 weeks after it. The intensity of pain was reduced in both groups significantly after performing the NCPB. Patients who declared a deep faith reported higher level of pain on the VAS scale prior to intervention than non-religious patients. Quality of life in both groups of patients significantly improved after NCPB. Following NCPB, global quality of life in patients who declared higher religiosity/church attendance was significantly higher (79.88) than for those patients who have no contact or sporadic contact with the church (44.21, P < 0.05). NCPB resulted in significant reduction of pain and increase in quality of life in both groups of patients with CP. Nevertheless, in the group declaring higher religiosity/church attendance, reported pain was higher, but, despite that, quality of life better. It may be concluded that religious practices might serve as an additional factor improving quality of life and coping in patients suffering from chronic pancreatitis.

Professional experience guides opioid prescribing for chronic joint pain in primary care

BACKGROUND

Chronic joint pain is common and is a leading cause of disability. Most chronic joint pain is managed in primary care. Opioid pain medication is one option for pain management, but research suggests that its use by general practitioners (GPs) may be suboptimal. There is a widespread perception that doctors' concerns about misuse and addiction limit use of opioids.

OBJECTIVES

To explore GPs' opinions about opioids and decision-making processes when prescribing 'strong' opioids for chronic joint pain.

METHODS

Qualitative semi-structured interviews were conducted with 27 GPs. Using thematic analysis methods, the data were coded and grouped into themes.

RESULTS

GPs described a variety of prescribing habits for chronic joint pain. Opioids engendered strong opinions. GPs said that decisions about prescribing were based on careful assessment of patients' needs and their personal views about the management of adverse effects. Although addiction and misuse were discussed, there was limited concern about these issues. The overarching influence on prescribing decisions was GPs' previous experience, including previous outcomes and exposure to palliative care settings.

CONCLUSIONS

GPs' prescribing decisions are primarily influenced by previous professional experience of opioids. Much existing literature stresses that opioids are not prescribed due to concerns about addiction or misuse, but our study indicates otherwise. Augmenting GPs' exposure to and experience of opioids may be key to providing better pain management for patients.

Morphinofobia: the situation among the general population and health care professionals in North-Eastern Portugal

Background

Morphinofobia among the general population (GP) and among health care professionals (HP) is not without danger for the patients: it may lead to the inappropriate management of debilitating pain. The aim of our study was to explore among GP and HP the representation and attitudes concerning the use of morphine in health care.

Methods

A cross-sectional study was done among 412 HP (physicians and nurses) of the 4 hospitals and 10 community health centers of Beira Interior (Portugal)and among 193 persons of the GP randomly selected in public places. Opinions were collected through a translated self-administered questionnaire.

Results

A significant difference of opinion exists among GP and HP about the use of morphine. The word morphine first suggests drug to GP (36,2%) and analgesia to HP (32,9%.). The reasons for not using morphine most frequently cited are: for GP morphine use means advanced disease (56%), risk of addiction (50%), legal requirements (49,7%); for HP it means legal risks (56,3%) and adverse side effects of morphine such as somnolence - sedation (30,5%) The socio-demographic situation was correlated with the opinions about the use of morphine.

Conclusions

False beliefs about the use of morphine exist among the studied groups. There seems to be a need for developing information campaigns on pain management and the use of morphine targeting. Better training and more information of HP might also be needed.

Veterans affairs primary care clinicians' attitudes toward chronic pain and correlates of opioid prescribing rates

OBJECTIVES

The primary objective of this study was to identify veterans affairs (VA) primary care clinicians' attitudes regarding chronic pain treatment. A secondary objective was to explore relationships between clinician and practice characteristics and an objective measure of opioid prescribing rates.

DESIGN

Cross-sectional study of clinician survey and pharmacy data.

PARTICIPANTS

Forty-five VA clinicians from five primary care clinics of one VA medical center.

MEASURES

Survey of pain-related attitudes and behaviors, satisfaction with treatment resources, and job satisfaction; percentage of patients in clinicians' panels prescribed opioids (PCPO).

RESULTS

Seventy-one percent of clinicians felt moderately or strongly confident in their ability to treat chronic pain, and 77% moderately or strongly agreed that skilled pain management is a high priority. However, 73% moderately or strongly agreed that patients with chronic pain are a major source of frustration and 38% reported moderate or greater dissatisfaction with their ability to provide optimal pain treatment. Fifty-two percent moderately or strongly agreed that their management is influenced by previous experiences with patients addicted to drugs. The mean PCPO was 16.5% (SD = 6.7). In bivariate comparisons, clinician panel size, job and resource satisfaction, and professional training were associated with opioid prescribing rates.

CONCLUSION

High clinician confidence and interest in treating chronic pain concurrent with low satisfaction with ability to provide optimal treatment suggests a need for more system support. VA primary care clinicians are frequently influenced by fears of contributing to dependence or addiction. The relationships among panel size, job satisfaction, and opioid prescribing rates merit additional investigation.

A longitudinal study of the efficacy of a comprehensive pain rehabilitation program with opioid withdrawal: comparison of treatment outcomes based on opioid use status at admission

Use of opioids for chronic non-cancer pain is controversial and the efficacy of comprehensive pain rehabilitation programs (CPRPs) that incorporate opioid withdrawal requires further investigation. We test the hypothesis that patients with chronic pain and longstanding opioid use who undergo opioid withdrawal in the course of rehabilitative treatment will experience significant and sustained improvement in pain and functioning similar to patients who were not taking opioids. A longitudinal design study compared 373 consecutive patients admitted to the Mayo Clinic Pain Rehabilitation Center at admission, discharge and six-month posttreatment by opioid status at admission. Measures of pain severity, depression, psychosocial functioning, health status, and pain catastrophizing were used to assess between- and within-group differences. Treatment involved a 3-week interdisciplinary pain rehabilitation program focused on functional restoration. Over one-half of patients (57.1%) were taking opioids daily at admission. The majority of patients (91%) completed rehabilitation and 70% of patients who completed the program returned questionnaires six months posttreatment. On admission, patients taking low- and high-dose opioids reported significantly greater pain severity (P=.001) and depression (P=.001) than the non-opioid group. Significant improvement was found on all outcome variables following treatment (P<.001) and six-month posttreatment (P<.001) regardless of opioid status at admission. There were no differences between the opioid and non-opioid groups upon discharge from the program or at six months following treatment.

CONCLUSION

Patients with longstanding CPRP on chronic opioid therapy, who choose to participate in interdisciplinary rehabilitation that incorporates opioid withdrawal, can experience significant and sustained improvement in pain severity and functioning.

Individual differences in opioid efficacy for chronic noncancer pain

OBJECTIVE

Over a decade ago, Jamison noted the lack of studies that identify patient profiles or specific groups that might be best suited for opioid treatment of chronic noncancer pain.

METHODS

This paper reviews the studies that provide evidence for individual differences in opioid analgesia for chronic noncancer pain.

RESULTS

What we have found is that few investigations have addressed these important aspects of pain treatment. The most consistent finding is that depression and anxiety are associated with increased risk for drug abuse and decreased opioid efficacy.

DISCUSSION

The question remains whether the psychologic disorders antedated the pain condition or whether the experience of chronic pain exerts psychologic pressures that cause changes in behavior and psychologic processes. Additionally, the overall pattern suggests that younger age is predictive of opioid abuse and greater opioid efficacy. We also present a brief review of biologic mechanisms that support individual differences on opioid analgesia.