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Zugaj MR, Züger A, Keßler J. [Factors influencing analgesic use patterns in patients with chronic tumor-associated pain. : A qualitative pilot study considering different groups of medications]. Schmerz 2023:10.1007/s00482-023-00765-y. [PMID: 37955709 DOI: 10.1007/s00482-023-00765-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Patients are surviving tumor diseases longer and longer due to the improvement of tumor-specific therapy and pain is a common symptom. The gold standard for tumor-associated chronic pain is multimodal therapy. Non-adherence causes high costs and may put patients at risk. The aim of this study was to investigate the adherence behavior and subjective treatment compliance of patients with tumor-associated chronic pain. The focus was on the patients' perspective. Different groups of medications, such as NOPA, opioids, co-analgesics and cannabinoids, as well as non-drug treatments were included. METHODS Semistructured guided interviews with 10 patients with chronic tumor pain were conducted within a qualitative research approach. The interviews were recorded and transcribed. The evaluation was using a focused content structuring interview analysis according to Kuckartz and Rädiker. RESULTS Five main categories were defined. The central category based on the research question was "Adherence behavior from the patient's perspective." The category "Medication therapy" formed the framework of the study. Other main categories were "History of illness", "Relationship with treatment providers" and "Attitudes and beliefs". A total of 77 additional subcategories were formed and interpreted. Adherence behavior from the patients' perspective differed between the different medication groups. A palliative setting influenced treatment decisions and adherence. The medication regimens used were complex and dynamic, especially when there were multiple practitioners involved. Furthermore, there was ambiguity in the use of cannabinoids. Non-drug therapies were marginalized by patients. From the point of view of the patients interviewed, it was not so much the treatment providers who influenced their adherence behavior, but rather their own experiences, attitudes, and convictions. DISCUSSION The study included all medication groups and non-drug therapies equally, complementing previous literature in a qualitative setting. Adherence factors known from previous research were reflected in the subjective perception of the group of patients with chronic pain after tumor diseases. Marginalization of non-medication methods could be explained by the fact that multimodal therapy approaches were too rarely constantly used and controlled in the phase of chronification. Therefore, drug and non-drug therapies should be applied even more consistently to patients with tumor-associated pain.
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Affiliation(s)
- Marco Richard Zugaj
- Universität Heidelberg, Medizinische Fakultät Heidelberg, Klinik für Anästhesiologie, Sektion Schmerzmedizin, Im Neuenheimer Feld 131, 69120, Heidelberg, Deutschland.
| | - Andrea Züger
- Nationales Centrum für Tumorerkrankungen (NCT), NCT Heidelberg, eine Partnerschaft zwischen DKFZ und dem Universitätsklinikum Heidelberg, Deutschland, Universität Heidelberg, Medizinische Fakultät Heidelberg, Abteilung für Medizinische Onkologie, Sektion für translationale Medizinethik, Im Neuenheimer Feld 460, 69120, Heidelberg, Deutschland
| | - Jens Keßler
- Universität Heidelberg, Medizinische Fakultät Heidelberg, Klinik für Anästhesiologie, Sektion Schmerzmedizin, Im Neuenheimer Feld 131, 69120, Heidelberg, Deutschland
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Alcohol, Tobacco, and Substance Use and Association with Opioid Use Disorder in Patients with Non-malignant and Cancer Pain: a Review. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00415-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Affiliation(s)
- Kimberly J Templeton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
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Chapman KB, Pas MM, Abrar D, Day W, Vissers KC, van Helmond N. Development and Performance of a Web-Based Tool to Adjust Urine Toxicology Testing Frequency: Retrospective Study. JMIR Med Inform 2020; 8:e16069. [PMID: 32319958 PMCID: PMC7203611 DOI: 10.2196/16069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 01/23/2020] [Accepted: 03/25/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Several pain management guidelines recommend regular urine drug testing (UDT) in patients who are being treated with chronic opioid analgesic therapy (COAT) to monitor compliance and improve safety. Guidelines also recommend more frequent testing in patients who are at high risk of adverse events related to COAT; however, there is no consensus on how to identify high-risk patients or on the testing frequency that should be used. Using previously described clinical risk factors for UDT results that are inconsistent with the prescribed COAT, we developed a web-based tool to adjust drug testing frequency in patients treated with COAT. OBJECTIVE The objective of this study was to evaluate a risk stratification tool, the UDT Randomizer, to adjust UDT frequency in patients treated with COAT. METHODS Patients were stratified using an algorithm based on readily available clinical risk factors into categories of presumed low, moderate, high, and high+ risk of presenting with UDT results inconsistent with the prescribed COAT. The algorithm was integrated in a website to facilitate adoption across practice sites. To test the performance of this algorithm, we performed a retrospective analysis of patients treated with COAT between June 2016 and June 2017. The primary outcome was compliance with the prescribed COAT as defined by UDT results consistent with the prescribed COAT. RESULTS 979 drug tests (867 UDT, 88.6%; 112 oral fluid testing, 11.4%) were performed in 320 patients. An inconsistent drug test result was registered in 76/979 tests (7.8%). The incidences of inconsistent test results across the risk tool categories were 7/160 (4.4%) in the low risk category, 32/349 (9.2%) in the moderate risk category, 28/338 (8.3%) in the high risk category, and 9/132 (6.8%) in the high+ risk category. Generalized estimating equation analysis demonstrated that the moderate risk (odds ratio (OR) 2.1, 95% CI 0.9-5.0; P=.10), high risk (OR 2.0, 95% CI 0.8-5.0; P=.14), and high risk+ (OR 2.0, 95% CI 0.7-5.6; P=.20) categories were associated with a nonsignificantly increased risk of inconsistency vs the low risk category. CONCLUSIONS The developed tool stratified patients during individual visits into risk categories of presenting with drug testing results inconsistent with the prescribed COAT; the higher risk categories showed nonsignificantly higher risk compared to the low risk category. Further development of the tool with additional risk factors in a larger cohort may further clarify and enhance its performance.
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Affiliation(s)
- Kenneth B Chapman
- Department of Anesthesiology, New York University Langone Medical Center, New York, NY, United States
- The Spine & Pain Institute of New York, New York, NY, United States
| | - Martijn M Pas
- The Spine & Pain Institute of New York, New York, NY, United States
- Radboud University Medical College, Nijmegen, Netherlands
| | - Diana Abrar
- The Spine & Pain Institute of New York, New York, NY, United States
- Radboud University Medical College, Nijmegen, Netherlands
| | - Wesley Day
- The Spine & Pain Institute of New York, New York, NY, United States
| | - Kris C Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Noud van Helmond
- The Spine & Pain Institute of New York, New York, NY, United States
- Department of Anesthesiology, Cooper Medical School of Rowan University, Cooper University Health Care, Camden, NJ, United States
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López-Martínez AE, Reyes-Pérez Á, Serrano-Ibáñez ER, Esteve R, Ramírez-Maestre C. Chronic pain, posttraumatic stress disorder, and opioid intake: A systematic review. World J Clin Cases 2019; 7:4254-4269. [PMID: 31911906 PMCID: PMC6940350 DOI: 10.12998/wjcc.v7.i24.4254] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 10/17/2019] [Accepted: 11/26/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The literature suggests that there is a high degree of co-occurrence between chronic pain and posttraumatic stress disorder (PTSD). An association has been found between PTSD and substance abuse. PTSD is a severe disorder that should be taken into account when opioids are prescribed. It has been found that the prevalence of opioid use disorder (OUD) in chronic pain patients is higher among those with PTSD than those without this disorder.
AIM To perform a systematic review on the association between PTSD, chronic non-cancer pain (CNCP), and opioid intake (i.e., prescription, misuse, and abuse).
METHODS We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The Patient, Intervention, Comparator, and Outcomes (PICOS) criteria were formulated a priori in the protocol of the systematic review. A search was conducted of the PROSPERO database. In March 2019, searches were also conducted of 5 other databases: PubMed, MEDLINE, PsycINFO, Web of Science, and PILOTS. The Scottish Intercollegiate Guidelines Network checklist for cohort studies was used to assess the selected studies for their methodological quality and risk of bias. Each study was evaluated according to its internal validity, participant sampling, confounding variables, and the statistical analysis.
RESULTS A total of 151 potentially eligible studies were identified of which 17 were retained for analysis. Only 10 met the selection criteria. All the studies were published between 2008 and 2018 and were conducted in the United States. The eligible studies included a total of 1622785 unique participants. Of these, 196516 had comorbid CNCP and PTSD and were consuming opiates. The participants had a cross-study mean age of 35.2 years. The majority of participants were men (81.6%). The most common chronic pain condition was musculoskeletal pain: back pain (47.14% across studies; range: 16%-60.6%), arthritis and joint pain (31.1%; range: 18%-67.5%), and neck pain (28.7%; range: 3.6%-63%). In total, 42.4% of the participants across studies had a diagnosis of PTSD (range: 4.7%-95%). In relation to opioid intake, we identified 2 different outcomes: opioid prescription and OUD. All the studies reported evidence of a greater prevalence of PTSD in CNCP patients who were receiving prescribed opioids and that PTSD was associated with OUD in CNCP patients.
CONCLUSION Opioid analgesic prescription as the treatment of choice for CNCP patients should include screening for baseline PTSD to ensure that these drugs are safely consumed.
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Affiliation(s)
- Alicia E López-Martínez
- Facultad de Psicología, Instituto de Investigaciones Biomédicas (IBIMA), Universidad de Málaga, Málaga 29071, Spain
| | - Ángela Reyes-Pérez
- Facultad de Psicología, Instituto de Investigaciones Biomédicas (IBIMA), Universidad de Málaga, Málaga 29071, Spain
| | - Elena Rocío Serrano-Ibáñez
- Facultad de Psicología, Instituto de Investigaciones Biomédicas (IBIMA), Universidad de Málaga, Málaga 29071, Spain
| | - Rosa Esteve
- Facultad de Psicología, Instituto de Investigaciones Biomédicas (IBIMA), Universidad de Málaga, Málaga 29071, Spain
| | - Carmen Ramírez-Maestre
- Facultad de Psicología, Instituto de Investigaciones Biomédicas (IBIMA), Universidad de Málaga, Málaga 29071, Spain
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Guarino H, Fong C, Marsch LA, Acosta MC, Syckes C, Moore SK, Cruciani RA, Portenoy RK, Turk DC, Rosenblum A. Web-Based Cognitive Behavior Therapy for Chronic Pain Patients with Aberrant Drug-Related Behavior: Outcomes from a Randomized Controlled Trial. PAIN MEDICINE (MALDEN, MASS.) 2018; 19:2423-2437. [PMID: 29346579 PMCID: PMC6294413 DOI: 10.1093/pm/pnx334] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective There is high unmet need for effective behavioral treatments for chronic pain patients at risk for or with demonstrated histories of opioid misuse. Despite growing evidence supporting technology-based delivery of self-management interventions for chronic pain, very few such programs target co-occurring chronic pain and aberrant drug-related behavior. This randomized controlled trial evaluated the effectiveness of a novel, web-based self-management intervention, grounded in cognitive behavior therapy, for chronic pain patients with aberrant drug-related behavior. Methods Opioid-treated chronic pain patients at a specialty pain practice who screened positive for aberrant drug-related behavior (N = 110) were randomized to receive treatment as usual plus the web-based program or treatment as usual alone. The primary outcomes of pain severity, pain interference, and aberrant drug-related behavior, and the secondary outcomes of pain catastrophizing and pain-related emergency department visits, were assessed during the 12-week intervention and at one and three months postintervention. Results Patients assigned to use the web-based program reported significantly greater reductions in aberrant drug-related behavior, pain catastrophizing, and pain-related emergency department visits-but not pain severity or pain interference-relative to those assigned to treatment as usual. The positive outcomes were observed during the 12-week intervention and for three months postintervention. Conclusions A web-based self-management program, when delivered in conjunction with standard specialty pain treatment, was effective in reducing chronic pain patients' aberrant drug-related behavior, pain catastrophizing, and emergency department visits for pain. Technology-based self-management tools may be a promising therapeutic approach for the vulnerable group of chronic pain patients who have problems managing their opioid medication.
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Affiliation(s)
- Honoria Guarino
- National Development and Research Institutes (NDRI), Inc., New York, New York
| | - Chunki Fong
- National Development and Research Institutes (NDRI), Inc., New York, New York
| | - Lisa A Marsch
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire
| | - Michelle C Acosta
- National Development and Research Institutes (NDRI), Inc., New York, New York
| | - Cassandra Syckes
- National Development and Research Institutes (NDRI), Inc., New York, New York
- U.S. Sentencing Commission, Washington, DC
| | | | - Ricardo A Cruciani
- Department of Neurology, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | | | - Dennis C Turk
- Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Andrew Rosenblum
- National Development and Research Institutes (NDRI), Inc., New York, New York
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8
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Kwong TC, Magnani B, Moore C. Urine and oral fluid drug testing in support of pain management. Crit Rev Clin Lab Sci 2017; 54:433-445. [PMID: 28990451 DOI: 10.1080/10408363.2017.1385053] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
In recent years, the abuse of opioid drugs has resulted in greater prevalence of addiction, overdose, and deaths attributable to opioid abuse. The epidemic of opioid abuse has prompted professional and government agencies to issue practice guidelines for prescribing opioids to manage chronic pain. An important tool available to providers is the drug test for use in the initial assessment of patients for possible opioid therapy, subsequent monitoring of compliance, and documentation of suspected aberrant drug behaviors. This review discusses the issues that most affect the clinical utility of drug testing in chronic pain management with opioid therapy. It focuses on the two most commonly used specimen matrices in drug testing: urine and oral fluid. The advantages and disadvantages of urine and oral fluid in the entire testing process, from specimen collection and analytical methodologies to result interpretation are reviewed. The analytical sensitivity and specificity limitations of immunoassays used for testing are examined in detail to draw attention to how these shortcomings can affect result interpretation and influence clinical decision-making in pain management. The need for specific identification and quantitative measurement of the drugs and metabolites present to investigate suspected aberrant drug behavior or unexpected positive results is analyzed. Also presented are recent developments in optimization of test menus and testing strategies, such as the modification of the standard screen and reflexed-confirmation testing model by eliminating some of the initial immunoassay-based tests and proceeding directly to definitive testing by mass spectrometry assays.
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Affiliation(s)
- Tai C Kwong
- a Department of Pathology and Laboratory Medicine , University of Rochester Medical Center , Rochester , NY , USA
| | - Barbarajean Magnani
- b Department of Pathology and Laboratory Medicine , Tufts Medical Center , Boston , MA , USA
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Hassan AN, Le Foll B, Imtiaz S, Rehm J. The effect of post-traumatic stress disorder on the risk of developing prescription opioid use disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions III. Drug Alcohol Depend 2017; 179:260-266. [PMID: 28818717 DOI: 10.1016/j.drugalcdep.2017.07.012] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 06/24/2017] [Accepted: 07/11/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate the effect of baseline post-traumatic stress disorder (PTSD) and each symptoms cluster on the risk of developing opioid use disorder (OUD) in those exposed to opioid painkillers and to assess the effect of comorbid PTSD and OUD on functioning, OUD severity, and treatment seeking compared with individuals with OUD only. METHODS We obtained data from 4025 individuals exposed to opioid painkillers from the National Epidemiologic Survey on Alcohol and Related Conditions III. We matched individuals with baseline PTSD with individuals without PTSD on demographics, developmental background, family history, personalities, and exposure to stressful life events with propensity score methodology. We controlled for clinical diagnoses and other risk factors that may have occurred after PTSD onset. Quality of life was assessed with the SF-12; the number of diagnostic criteria met indicated OUD severity. RESULTS Baseline PTSD predicted OUD after controlling for matching variables and other risk factors, including baseline mood/anxiety disorders and other substance use disorders (odds ratio[OR]: 1.58; 95% confidence interval[CI]: 1.14-2.17; p=0.02). Among individuals with PTSD, arousal/reactivity cluster predicted OUD. Individuals with comorbid PTSD and OUD had lower mean scores on the SF-12 scale and greater severity of OUD than individuals with OUD. There were no differences in help-seeking. CONCLUSION Baseline PTSD increases the risk of developing OUD after exposure to opioid painkillers. Clinicians should screen for PTSD diagnosis and arousal/reactivity symptoms prior to prescribing painkillers. Integrated treatments are strongly recommended for patients with this dual diagnosis.
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Affiliation(s)
- Ahmed N Hassan
- Addictions Division, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada.
| | - Bernard Le Foll
- Addictions Division, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Departments of Family and Community Medicine, Pharmacology and Toxicology, and Psychiatry, Institute of Medical Sciences, University of Toronto, Toronto, Canada; Campbell Family Mental Health Research Institute, CAMH, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Sameer Imtiaz
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Jürgen Rehm
- Department of Psychiatry, University of Toronto, Toronto, Canada; Campbell Family Mental Health Research Institute, CAMH, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto,155 College Street, Toronto, Ontario, Canada
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Urine drug screen findings among ambulatory oncology patients in a supportive care clinic. Support Care Cancer 2017; 25:1859-1864. [PMID: 28120116 DOI: 10.1007/s00520-017-3575-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 01/09/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE Professional organizations provide no guidelines regarding assessment and management of opioid abuse risk in cancer. Universal precautions (UP) developed for non-cancer pain, include assessments for aberrant behavior, screening questionnaires, and urine drug screens (UDS). The role of UDS for identifying opioid abuse risk in cancer is uncertain. Our aim is to characterize inappropriate UDS, and identify a potential role for UDS in therapeutic decision-making. METHODS An observational retrospective chart review of 232 consecutive supportive care clinic patients were seen during the study. Twenty-eight of the two hundred thirty-two did not meet inclusion criteria. One hundred fifty of the two hundred four had active cancer, while 54 had no evidence of active disease. Clinicians ordered UDS based on their clinical judgment of patients' substance misuse risk. Edmonton symptom assessment scores, history of substance abuse, alcohol use, tobacco use, aberrant behavior, and morphine equivalent daily dose (MEDD) were obtained. RESULTS Pain scores and MEDD were higher (p = 0.021; p < 0.001) in the UDS group vs non-UDS. Forty percent of the patients (n = 82/204) had at least one UDS and 70% (60/82) had an inappropriate result. Thirty-nine percent (32) were inappropriately negative, showing no prescribed opioids. Forty-nine of the eighty-two were positive for non-prescribed opioids, benzodiazepine, or illicit substance. Eleven of the forty-nine had only cannabis metabolites in their urine. There were no significant differences between appropriate and inappropriate UDS groups regarding pain scores, MEDD or referral to psychology, psychiatry, or substance abuse specialists. CONCLUSIONS UDS on the 82 oncology patients at high risk for substance misuse were frequently positive (46%) for non-prescribed opioids, benzodiazepines or potent illicit drugs such as heroin or cocaine, and 39% had inappropriately negative UDS, raising concerns for diversion.
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Abstract
STUDY DESIGN A population-based cross-sectional survey. OBJECTIVE The aim of this study was to compare the prevalence of illicit drug use among US adults with and without chronic low back pain (cLBP). SUMMARY OF BACKGROUND DATA Although addictive medications, such as opioids and benzodiazepines, are frequently prescribed to patients with cLBP, little is known about illicit drug use among Americans with cLBP. METHODS We used data from the back pain survey, administered to a representative sample of US adults aged 20 to 69 years (N = 5103) during the 2009 to 2010 cycle of the National Health and Nutrition Examination Survey (NHANES). Participants with pain in the area between the lower posterior margin of the ribcage and the horizontal gluteal fold for at least 3 months were classified as having cLBP (N = 700). The drug use questionnaire was self-administered in a private setting, and included data on lifetime and current use of marijuana or hashish, cocaine, heroin, and methamphetamine. Chi-square tests, one-way analysis of variance, and logistic regression, adjusted for age, gender, race, and level of education, were used for comparisons. RESULTS About 46.5% of US adults with cLBP used marijuana versus 42% of those without cLBP [Adjusted odds ratio (aOR) 1.36, 95% confidence interval (95% CI) 1.06-1.74]. About 22% versus 14% used cocaine (aOR 1.80, 95% CI 1.45-2.24), 9% versus 5% used methamphetamine (aOR 2.03, 95% CI 1.30-3.16), and 5% versus 2% used heroin (aOR 2.43, 95% CI 1.44-4.11). Subjects with cLBP who reported lifetime illicit drug use were more likely to have an active prescription for opioid analgesics than those without illicit drug use history: 22.5% versus 15.3%, P = 0.018. CONCLUSION cLBP in community-based US adults was associated with higher odds of using marijuana, cocaine, heroin, and methamphetamine. Prescription opioid analgesic use was more common in cLBP sufferers with a history of illicit drug use. LEVEL OF EVIDENCE 2.
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Arthur JA, Edwards T, Lu Z, Reddy S, Hui D, Wu J, Liu D, Williams JL, Bruera E. Frequency, predictors, and outcomes of urine drug testing among patients with advanced cancer on chronic opioid therapy at an outpatient supportive care clinic. Cancer 2016; 122:3732-3739. [PMID: 27509305 DOI: 10.1002/cncr.30240] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 06/01/2016] [Accepted: 07/01/2016] [Indexed: 11/09/2022]
Abstract
BACKGROUND Data are limited on the use and outcomes of urine drug tests (UDTs) among patients with advanced cancer. The main objective of this study was to determine the factors associated with UDT ordering and results in outpatients with advanced cancer. METHODS A retrospective chart review was conducted of 1058 patients who attended an outpatient supportive care clinic from March 2014 to November 2015. Sixty-one patients who were receiving chronic opioid therapy and underwent UDTs were identified. A control group of 120 patients who did not undergo UDTs was selected for comparison. RESULTS Sixty-one of 1058 patients (6%) underwent UDTs, and 33 of 61 patients (54%) had abnormal results. Multivariate analysis indicated that the odds ratio for UDT ordering was 3.9 in patients who had positive Cut Down, Annoyed, Guilty, and Eye Opener (CAGE) questionnaire results (P = .002), 4.41 in patients aged < 45 years (P < .001), 5.58 in patients who had moderate-to-severe pain (Edmonton Symptom Assessment Scale pain scores ≥4; P < .001), 0.27 in patients with advanced-stage cancer, (P = .008), and 0.25 in patients who had moderate-to-severe fatigue (P = .001). Among 52 abnormal UDT results in 33 patients, the most common opioid findings were prescribed opioids absent in urine (14 of 52 tests; 27%) and unprescribed opioids in urine (13 of 52 tests; 25%). CONCLUSIONS UDTs were used infrequently among outpatients with advanced cancer who were receiving chronic opioid therapy. Younger age, positive CAGE questionnaire results, early stage cancer or no evidence of disease status, higher pain intensity, and lower fatigue scores were significant predictors of UDT ordering. More than 50% of UDT results were abnormal. More research is necessary to better characterize aberrant opioid use in patients with advanced cancer. Cancer 2016;122:3732-9. © 2016 American Cancer Society.
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Affiliation(s)
- Joseph A Arthur
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, Texas
| | - Tonya Edwards
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, Texas
| | - Zhanni Lu
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, Texas
| | - Suresh Reddy
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, Texas
| | - David Hui
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, Texas
| | - Jimin Wu
- Department of Quantitative Sciences, The University of Texas MD Anderson Cancer, Houston, Texas
| | - Diane Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer, Houston, Texas
| | - Janet L Williams
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, Texas
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, Texas
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Nikulina V, Guarino H, Acosta MC, Marsch LA, Syckes C, Moore SK, Portenoy RK, Cruciani RA, Turk DC, Rosenblum A. Patient vs provider reports of aberrant medication-taking behavior among opioid-treated patients with chronic pain who report misusing opioid medication. Pain 2016; 157:1791-1798. [PMID: 27082008 PMCID: PMC4949142 DOI: 10.1097/j.pain.0000000000000583] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
During long-term opioid therapy for chronic noncancer pain, monitoring medication adherence of patients with a history of aberrant opioid medication-taking behaviors (AMTB) is an essential practice. There is limited research, however, into the concordance among existing monitoring tools of self-report, physician report, and biofluid screening. This study examined associations among patient and provider assessments of AMTB and urine drug screening using data from a randomized trial of a cognitive-behavioral intervention designed to improve medication adherence and pain-related outcomes among 110 opioid-treated patients with chronic pain who screened positive for AMTB and were enrolled in a pain program. Providers completed the Aberrant Behavior Checklist (ABC) and patients completed the Current Opioid Misuse Measure (COMM) and the Chemical Coping Inventory (CCI). In multivariate analyses, ABC scores were compared with COMM and CCI scores, while controlling for demographics and established risk factors for AMTB, such as pain severity. Based on clinical cutoffs, 84% of patients reported clinically significant levels of AMTB and providers rated 36% of patients at elevated levels. Provider reports of AMTB were not correlated with COMM or CCI scores. However, the ABC ratings of experienced providers (nurse practitioners/attending physicians) were higher than those of less experienced providers (fellows) and were correlated with CCI scores and risk factors for AMTB. Associations between patient- and provider-reported AMTB and urine drug screening results were low and largely nonsignificant. In conclusion, concordance between patient and provider reports of AMTB among patients with chronic pain prescribed opioid medication varied by provider level of training.
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Affiliation(s)
- Valentina Nikulina
- Queens College, CUNY; Department of Psychology, 6530 Kissena Boulevard, Flushing, NY 11367, T: (718) 997-3215; F: (718) 997-3257; http://www.qc.cuny.edu/Academics/Degrees/DMNS/Psychology/Pages/default.aspx
| | - Honoria Guarino
- National Development and Research Institutes, Inc., New York, NY
| | | | - Lisa A. Marsch
- Dartmouth Center for Technology and Behavioral Health, Lebanon, NH
| | - Cassandra Syckes
- National Development and Research Institutes, Inc., New York, NY
| | - Sarah K. Moore
- Dartmouth Center for Technology and Behavioral Health, Lebanon, NH
| | | | | | | | - Andrew Rosenblum
- National Development and Research Institutes, Inc., New York, NY
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Lee CT, Vo TT, Cohen AS, Ahmed S, Zhang Y, Mao J, Chen L. Profiles of Urine Drug Test in Clinical Pain Patients vs Pain Research Study Subjects. PAIN MEDICINE 2016; 17:636-43. [PMID: 26398237 DOI: 10.1111/pme.12900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 07/27/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To examine similarities and differences in urine drug test (UDT) results in clinical pain patients and pain subjects participating in pain research studies. DESIGN An observational study with retrospective chart review and data analysis. METHODS We analyzed 1,874 UDT results obtained from 1) clinical pain patients (Clinical Group; n = 1,529) and 2) pain subjects consented to participate in pain research studies (Research Group; n = 345). Since several medications such as opioids used in pain management are drugs of abuse (DOA) and can result in a positive UDT, we specifically identified those cases of positive UDT due to nonprescribed DOA and designated these cases as positive UDT with DOA (PUD). RESULTS We found that 1) there was a higher rate of PUD in clinical pain patients (41.3%) than in pain research study subjects (14.8%); 2) although subjects in the Research Group were informed ahead of time that UDT will be conducted as a screening test, a substantial number (14.8%) of pain research study subjects still showed PUD; 3) there were different types of DOA between clinical pain patients (cannabinoids as the top DOA) and research study subjects (cocaine as the top DOA); and 4) a common factor associated with PUD was opioid therapy in both Clinical Group and Research Group. CONCLUSION These results support previous findings that PUD is a common finding in clinical pain patients, particularly in those prescribed opioid therapy, and we suggest that UDT be used as routine screening testing in pain research studies.
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Affiliation(s)
- Cheng-ting Lee
- *University of Texas Southwestern Medical Center in Dallas, Texas, USA
| | - Trang T Vo
- MGH Center for Translational Pain Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Abigail S Cohen
- MGH Center for Translational Pain Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Shihab Ahmed
- MGH Center for Translational Pain Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yi Zhang
- MGH Center for Translational Pain Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jianren Mao
- MGH Center for Translational Pain Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lucy Chen
- MGH Center for Translational Pain Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Hadi MA, Alldred DP, Briggs M, Marczewski K, Closs SJ. Effectiveness of a community based nurse-pharmacist managed pain clinic: A mixed-methods study. Int J Nurs Stud 2016; 53:219-27. [DOI: 10.1016/j.ijnurstu.2015.09.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 09/01/2015] [Accepted: 09/01/2015] [Indexed: 11/15/2022]
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Abstract
Opioid use in chronic pain treatment is complex, as patients may derive both benefit and harm. Identification of individuals currently using opioids in a problematic way is important given the substantial recent increases in prescription rates and consequent increases in morbidity and mortality. The present review provides updated and expanded information regarding rates of problematic opioid use in chronic pain. Because previous reviews have indicated substantial variability in this literature, several steps were taken to enhance precision and utility. First, problematic use was coded using explicitly defined terms, referring to different patterns of use (ie, misuse, abuse, and addiction). Second, average prevalence rates were calculated and weighted by sample size and study quality. Third, the influence of differences in study methodology was examined. In total, data from 38 studies were included. Rates of problematic use were quite broad, ranging from <1% to 81% across studies. Across most calculations, rates of misuse averaged between 21% and 29% (range, 95% confidence interval [CI]: 13%-38%). Rates of addiction averaged between 8% and 12% (range, 95% CI: 3%-17%). Abuse was reported in only a single study. Only 1 difference emerged when study methods were examined, where rates of addiction were lower in studies that identified prevalence assessment as a primary, rather than secondary, objective. Although significant variability remains in this literature, this review provides guidance regarding possible average rates of opioid misuse and addiction and also highlights areas in need of further clarification.
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Dixon RB, Mbeunkui F, Wiegel JV. Stability study of opioids and benzodiazepines in urine samples by liquid chromatography tandem mass spectrometry. J Anal Sci Technol 2015. [DOI: 10.1186/s40543-015-0057-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Hadi MA, Alldred DP. Promoting the role of pharmacists in chronic pain management: how can we make an impact on policy and practice? INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2015; 23:165-6. [PMID: 25868486 DOI: 10.1111/ijpp.12181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hughes HK, Korthuis PT, Saha S, Eggly S, Sharp V, Cohn J, Moore R, Beach MC. A mixed methods study of patient-provider communication about opioid analgesics. PATIENT EDUCATION AND COUNSELING 2015; 98:453-461. [PMID: 25601279 PMCID: PMC4417607 DOI: 10.1016/j.pec.2014.12.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Revised: 12/21/2014] [Accepted: 12/22/2014] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To describe patient-provider communication about opioid pain medicine and explore how these discussions affect provider attitudes toward patients. METHODS We audio-recorded 45 HIV providers and 423 patients in routine outpatient encounters at four sites across the country. Providers completed post-visit questionnaires assessing their attitudes toward patients. We identified discussions about opioid pain management and analyzed them qualitatively. We used logistic regression to assess the association between opioid discussion and providers' attitudes toward patients. RESULTS 48 encounters (11% of the total sample) contained substantive discussion of opioid-related pain management. Most conversations were initiated by patients (n=28, 58%) and ended by the providers (n=36, 75%). Twelve encounters (25%) contained dialog suggesting a difference of opinion or conflict. Providers more often agreed than disagreed to give the prescription (50% vs. 23%), sometimes reluctantly; in 27% (n=13) of encounters, no decision was made. Fewer than half of providers (n=20, 42%) acknowledged the patient's experience of pain. Providers had a lower odds of positive regard for the patient (adjusted OR=0.51, 95% CI: 0.27-0.95) when opioids were discussed. CONCLUSIONS Pain management discussions are common in routine outpatient HIV encounters and providers may regard patients less favorably if opioids are discussed during visits. The sometimes-adversarial nature of these discussions may negatively affect provider attitudes toward patients. PRACTICE IMPLICATIONS Empathy and pain acknowledgment are tools that clinicians can use to facilitate productive discussions of pain management.
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Affiliation(s)
| | | | - Somnath Saha
- Oregon Health Sciences University, Portland, USA; Portland VA Medical Center, Portland, USA
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20
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Describing Prescription Opioid Adherence among Individuals with Chronic Pain using Urine Drug Testing. Pain Manag Nurs 2015; 16:51-9. [DOI: 10.1016/j.pmn.2014.04.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Revised: 04/05/2014] [Accepted: 04/07/2014] [Indexed: 11/23/2022]
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21
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Schmidt T, Zimam A, Nielsen A, Wakeland W. Data Sources Regarding the Nonmedical Use of Pharmaceutical Opioids in the United States. REVIEWS IN HEALTH CARE 2014; 5:33-50. [PMID: 25525498 DOI: 10.7175/rhc.v5i1.883] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Recent increases in the nonmedical use of pharmaceutical opioids and the adverse outcomes associated with them have stimulated a large amount of research and data collection on this public health problem. Systematic organization of the available data sources is needed to facilitate ongoing research, analysis, and evaluation. This work offers a systematic categorization of data sources regarding the nonmedical use of pharmaceutical opioids in the United States. METHODS A list of keywords regarding the nonmedical use of pharmaceutical opioids was used to conduct systematic searches in PubMed®. Filtration of search results generated 92 peer-reviewed academic articles, published between January 1995 and April 2012, as well as a number of primary data sources. Lists of topics were developed independently by two researchers which were later compared and consolidated. All sources were then categorized according to their relevance to each of these topics and according to their capacity for geographical and longitudinal trend analysis. RESULTS Tables cataloging data sources can be used to identify data relevant to specific topics in diversion, nonmedical use, and adverse outcomes associated with pharmaceutical opioids, and they illustrate global trends in data coverage, identifying several topics that have minimal data. A network diagram illustrates global trends in data coverage, showing variation among sources in the number of topics they cover, as well as variation among topics in the number of sources that cover them. CONCLUSIONS The categorization of data sources is hoped to facilitate ongoing research, analysis, and evaluation of this public health problem by serving as a guide for researchers, policy makers, and others who seek data regarding the nonmedical use of pharmaceutical opioids in the United States.
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Affiliation(s)
- Teresa Schmidt
- Systems Science Graduate Program Portland State University
| | - Amanuel Zimam
- Systems Science Graduate Program Portland State University
| | | | - Wayne Wakeland
- Systems Science Graduate Program Portland State University
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Turner JA, Saunders K, Shortreed SM, LeResche L, Riddell K, Rapp SE, Von Korff M. Chronic opioid therapy urine drug testing in primary care: prevalence and predictors of aberrant results. J Gen Intern Med 2014; 29:1663-71. [PMID: 25217208 PMCID: PMC4242878 DOI: 10.1007/s11606-014-3010-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 07/25/2014] [Accepted: 08/11/2014] [Indexed: 03/17/2023]
Abstract
BACKGROUND Urine drug tests (UDTs) are recommended for patients on chronic opioid therapy (COT). Knowledge of the risk factors for aberrant UDT results could help optimize their use. OBJECTIVE To identify primary care COT patient and opioid regimen characteristics associated with aberrant UDT results. DESIGN Population-based observational. SAMPLE 5,420 UDTs for Group Health integrated group practice COT patients. MEASURES Group Health database measures of patient demographics, medical history, COT characteristics, and UDT results. RESULTS Thirty percent of UDTs had aberrant results, including prescribed opioid non-detection (12.3%), tetrahydrocannabinol (THC; 11.2%), non-prescribed opioid (5.3%), illicit drug (excluding THC; 0.6%), non-prescribed benzodiazepine (1.7%), and dilute (4.8%). Adjusted odds ratios (95% CI) of any aberrant result were higher for males than females (1.24 [1.07, 1.43]), patients with versus without prior substance use disorder diagnoses (1.42 [1.17, 1.72]), and current smokers versus non-smokers (1.50 [1.30, 1.73]). Odds ratios were lower for patients aged 45-64 (0.77 [0.65, 0.92]) and 65+ (0.40 [0.32, 0.50]) versus patients aged 20-44 and for patients on long-acting opioids only (0.72 [0.55, 0.95]) or long-acting plus short-acting (0.67 [0.54, 0.83]) versus short-acting only. Adjusted odds of prescribed opioid non-detection were lower for patients aged 45-64 (0.79 [0.63, 0.998]) and 65+ (0.44 [0.32, 0.59]) versus patients aged 20-44, for those on 40-<120 mg daily morphine-equivalent dose (0.52 [0.39, 0.70]) or 120+ mg (0.22 [0.11, 0.43]) versus <40 mg, and for patients on long-acting (0.35 [0.21, 0.57]) or long-acting plus short-acting (0.35 [0.24, 0.50]) opioids (versus short-acting only); and odds ratios were higher for patients with versus without prior diagnoses of substance use disorder (1.70 [1.31, 2.20]). CONCLUSIONS In this primary care setting, results were aberrant for 30% of UDTs of COT patients, largely because of prescribed opioid non-detection and THC. Aberrant results of almost all types were more likely among patients under the age of 45. Other risk factors varied across aberrancies, but commonly included current smoking and prior substance use disorder diagnosis.
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Affiliation(s)
- Judith A Turner
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA,
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23
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Future applications of high-resolution MS to meet the demands for pain management drug testing. Bioanalysis 2014; 6:2839-53. [DOI: 10.4155/bio.14.163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Urine specimens submitted for pain management drug testing often contain multiple psychotherapeutic drugs, in addition to opioids. Immunoassay-based screen-and-confirm approaches typically used for clinical drug testing have limited sensitivity to detect therapeutic concentrations of many drugs prescribed in pain management and do not differentiate between drugs in the same class. In addition, screening for all the various illicit and prescription drugs that may be present in the pain management population requires as many as 10–20 individual immunoassays. High-resolution MS approaches have the potential to transform the way clinical drug testing is performed for pain management.
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Pergolizzi JV, Ben-Joseph R, Chang CL, Hess G. Predicting medication persistence to buprenorphine transdermal system. Pain Pract 2014; 15:140-9. [PMID: 24444055 DOI: 10.1111/papr.12155] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 11/07/2013] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Persistence, the duration a patient remains on therapy, in chronic, symptomatic conditions plays an important role in therapy effectiveness. Understanding the duration and patient factors associated with prescribed medication persistence is, therefore, an important step toward better treatment and health outcomes for patients. In the following study, an analysis of such factors associated with buprenorphine transdermal system (BTDS) persistence was conducted utilizing a large US private practitioner and pharmacy claims database and is herein reported. METHODS Patients aged ≥ 18 years initiating BTDS during January 1, 2011-November 30, 2011 were identified in the IMS Private Practitioner Medical Claims and Pharmacy Claims databases. An index date was defined as the first prescription of BTDS during the studied interval. During the preindex period, Charlson Comorbidity Index (CCI), chronic pain-related conditions, and prior medication use were assessed. Concomitant medications and various treatment patterns (eg, last dose strength and dose adjustments) were assessed in the postindex 6-month period. Persistence was measured as the duration of BTDS from initiation to the 1st >28-day refill gap in the postindex 6-month period. Descriptive statistical and survival analysis was used to assess the predictors of BTDS persistence. RESULTS During the study period, 10,457 patients newly treated with BTDS were identified. Patients' mean (± SD) age was 54.5 (± 15.2) years; 69.9% were women, and the mean (± SD) CCI was 1 (± 1.4). Utilizing a hierarchical approach, patients were separated into different cohorts based on the initial analgesic prescription identified during postindex period with 91.7%, 34.7%, and 59.0% of the patients using opioids, NSAIDs and adjuvant analgesics, respectively. Multivariate regression analyses showed that patients with prior opioid and adjuvant analgesic use were 21% and 5% less likely to discontinue BTDS (P < 0.05), respectively, as compared to patients not using these agents. Patients with concomitant use of adjuvant analgesics were 15% less likely to discontinue therapy (P < 0.05) as compared to patients without concomitant use of these agents. Long-term BTDS persistence was also observed in patients who had a dose change or a last dose strength >5 mcg/hour. Sensitivity analyses for those with 30-day prior opioid use and patients with ≥ 2 claims of BTDS confirmed these findings. CONCLUSIONS Prior and concomitant use of adjuvant analgesics, prior use of opioids, and dose adjustments were associated with significantly longer persistence among patients initiating BTDS. The results suggest that patients are less likely to discontinue BTDS early if practitioners account for prior treatment history and dose titration.
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Affiliation(s)
- Joseph V Pergolizzi
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A.; Temple University School of Medicine, Philadelphia, Pennsylvania, U.S.A.; Naples Anesthesia and Pain Associates, Naples, Florida, U.S.A
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25
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Manchikanti L, Benyamin R, Datta S, Vallejo R, Smith H. Opioids in chronic noncancer pain. Expert Rev Neurother 2014; 10:775-89. [DOI: 10.1586/ern.10.37] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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26
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McMillin GA, Slawson MH, Marin SJ, Johnson-Davis KL. Demystifying Analytical Approaches for Urine Drug Testing to Evaluate Medication Adherence in Chronic Pain Management. J Pain Palliat Care Pharmacother 2013; 27:322-39. [DOI: 10.3109/15360288.2013.847889] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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27
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Brennan MJ. Update on prescription extended-release opioids and appropriate patient selection. J Multidiscip Healthc 2013; 6:265-80. [PMID: 23900563 PMCID: PMC3726523 DOI: 10.2147/jmdh.s38562] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Chronic pain is largely underdiagnosed, often undertreated, and expected to increase as the American population ages. Many patients with chronic pain require long-term treatment with analgesic medications, and pain management may involve use of prescription opioids for patients whose pain is inadequately controlled through other therapies. Yet because of the potential for abuse and addiction, many clinicians hesitate to treat their patients with pain with potentially beneficial agents. Finding the right opioid for the right patient is the first - often complicated - step. Ensuring that patients continue to properly use the medication while achieving therapeutic analgesic effects is the long-term goal. Combined with careful patient selection and ongoing monitoring, new formulations using extended-release technologies incorporating tamper-resistant features may help combat the growing risk of abuse or misuse, which will hopefully reduce individual suffering and the societal burden of chronic pain. The objective of this manuscript is to provide an update on extended-release opioids and to provide clinicians with a greater understanding of which patients might benefit from these new opioid formulations and how to integrate the recommended monitoring for abuse potential into clinical practice.
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Kissin I. Long-term opioid treatment of chronic nonmalignant pain: unproven efficacy and neglected safety? J Pain Res 2013; 6:513-29. [PMID: 23874119 PMCID: PMC3712997 DOI: 10.2147/jpr.s47182] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND For the past 30 years, opioids have been used to treat chronic nonmalignant pain. This study tests the following hypotheses: (1) there is no strong evidence-based foundation for the conclusion that long-term opioid treatment of chronic nonmalignant pain is effective; and (2) the main problem associated with the safety of such treatment - assessment of the risk of addiction - has been neglected. METHODS Scientometric analysis of the articles representing clinical research in this area was performed to assess (1) the quality of presented evidence (type of study); and (2) the duration of the treatment phase. The sufficiency of representation of addiction was assessed by counting the number of articles that represent (1) editorials; (2) articles in the top specialty journals; and (3) articles with titles clearly indicating that the addiction-related safety is involved (topic-in-title articles). RESULTS Not a single randomized controlled trial with opioid treatment lasting >3 months was found. All studies with a duration of opioid treatment ≥6 months (n = 16) were conducted without a proper control group. Such studies cannot provide the consistent good-quality evidence necessary for a strong clinical recommendation. There were profound differences in the number of addiction articles related specifically to chronic nonmalignant pain patients and to opioid addiction in general. An inadequate number of chronic pain-related publications were observed with all three types of counted articles: editorials, articles in the top specialty journals, and topic-in-title articles. CONCLUSION There is no strong evidence-based foundation for the conclusion that long-term opioid treatment of chronic nonmalignant pain is effective. The above identified signs indicating neglect of addiction associated with the opioid treatment of chronic nonmalignant pain were present.
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Affiliation(s)
- Igor Kissin
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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29
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Xie L, Joshi AV, Schaaf D, Mardekian J, Harnett J, Shah ND, Baser O. Differences in Healthcare Utilization and Associated Costs Between Patients Prescribed vs. Nonprescribed Opioids During an Inpatient or Emergency Department Visit. Pain Pract 2013; 14:446-56. [DOI: 10.1111/papr.12098] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Accepted: 05/06/2013] [Indexed: 12/22/2022]
Affiliation(s)
- Lin Xie
- STATinMED Research; Ann Arbor Michigan U.S.A
| | | | | | | | | | | | - Onur Baser
- STATinMED Research; Ann Arbor Michigan U.S.A
- The University of Michigan; Ann Arbor Michigan U.S.A
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Abstract
An epidemic of prescription drug abuse in the United States has increased the burden on clinical toxicology testing laboratories. Urine drug testing provides objective evidence for compliance and aberrant drug behavior in patients on chronic (non-cancer) pain management. This article describes the testing menu, drug testing assays including tandem mass spectrometry and their limitations, interpretation of opiate results and clinical considerations.
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Affiliation(s)
- Barbarajean Magnani
- Department of Pathology and Laboratory Medicine, Tufts Medical Center, 800 Washington Street, Box 115, Boston MA 02115, USA.
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31
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Ballantyne JC. "Safe and effective when used as directed": the case of chronic use of opioid analgesics. J Med Toxicol 2012; 8:417-23. [PMID: 22983893 PMCID: PMC3550253 DOI: 10.1007/s13181-012-0257-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Opioid analgesics have been used increasingly over the past 20 years for the management of chronic non-cancer pain in the USA under the assumption that they were safe and effective when used as directed. The accuracy of that assumption has not been tested against accumulated evidence. The safety of opioids used on a long-term basis has not been tested in clinical trials. Epidemiologic evidence from examinations of such use in the general population indicates that the risk of overdose increases in a dose-response manner. Such evidence also suggests increased risk of fractures and acute myocardial infarctions among elderly users of opioids for chronic pain. Experimental evidence supports short-term use of opioids, but trials of long-term use for chronic pain have not been conducted. Epidemiologic evidence suggests that long-term use does not result in improvement in function or quality of life while being associated with significant dropout rates and a high prevalence of adverse drug effects. Substantial fractions of patients are not using opioid analgesics as directed, while millions of US residents are using them without a prescription for nonmedical reasons. A prudent treatment approach consistent with the available evidence would be to reserve chronic opioid therapy for serious pain-related problems for which the effectiveness of opioids has been demonstrated and for patients whose use as directed is assured through close monitoring and for whom an explicit, informed calculation has been made that the benefits of opioids outweigh the risks.
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Affiliation(s)
- Jane C Ballantyne
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA 98195, USA.
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Mao J. Current challenges in translational pain research. Trends Pharmacol Sci 2012; 33:568-73. [PMID: 22959652 PMCID: PMC3482290 DOI: 10.1016/j.tips.2012.08.001] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2012] [Revised: 08/08/2012] [Accepted: 08/13/2012] [Indexed: 12/31/2022]
Abstract
The current gap between basic science research and the development of new analgesics presents a serious challenge for the future of pain medicine. This challenge is particularly difficult in the search for better treatment for comorbid chronic pain conditions because: (i) animal 'pain' models do not simulate multidimensional clinical pain conditions; (ii) animal behavioral testing does not assess subjective pain experience; (iii) preclinical data provide little assurance regarding the direction of new analgesic development; and (iv) clinical trials routinely use over-sanitized study populations and fail to capture the multidisciplinary consequences of comorbid chronic pain. Therefore, a paradigm shift in translational pain research is necessary to transform the current strategy from focusing on molecular switches of nociception to studying pain as a system-based integral response that includes psychosocial comorbidities. Several key issues of translational pain research are discussed in this review.
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Affiliation(s)
- Jianren Mao
- MGH Center for Translational Pain Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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Abstract
Chronic pain is commonly treated by prescribing an opioid medication. For those suffering from both chronic pain and substance dependence, barriers to adequate pain management increase. This often causes both disorders to exacerbate one another. Effective treatment may also be hampered by opioid-induced hyperalgesia, tolerance, physical dependence, "chemical coping," and diminished physical and emotional functioning. This article reviews current research trends, potential problems stemming from prescription opioid use, and suggestions for clinical practice.
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Affiliation(s)
- Mel Pohl
- Las Vegas Recovery Center, Las Vegas, NV 89129, USA.
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Spiropulos NG, Heemstra JM. Templating effect in DNA proximity ligation enables use of non-bioorthogonal chemistry in biological fluids. ARTIFICIAL DNA, PNA & XNA 2012; 3:123-8. [PMID: 23370267 DOI: 10.4161/adna.23842] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Here we describe the first example of selective reductive amination in biological fluids using split aptamer proximity ligation (StAPL). Utilizing the cocaine split aptamer, we demonstrate small-molecule-dependent ligation that is dose-dependent over a wide range of target concentrations in buffer, human blood serum and artificial urine medium. We explore the substrate binding preferences of the split aptamer and find that the cinchona alkaloids quinine and quinidine bind to the aptamer with higher affinity than cocaine. This increased affinity leads to improved detection limits for these small-molecule targets. We also demonstrate that linker length and hydrophobicity impact the efficiency of split aptamer ligation. The ability to carry out selective chemical transformations using non-bioorthogonal chemistry in media where competing reactive groups are present highlights the power of the increased effective molarity provided by DNA assembly. Obviating the need for bioorthogonal chemistry would dramatically expand the repertoire of chemical transformations available for use in templated reactions such as proximity ligation assays, in turn enabling the development of novel methods for biomolecule detection.
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Affiliation(s)
- Nicholas G Spiropulos
- Department of Chemistry, Center for Cell and Genome Science, University of Utah, Salt Lake City, UT USA
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35
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Pesce A, West C, Egan City K, Strickland J. Interpretation of Urine Drug Testing in Pain Patients. PAIN MEDICINE 2012; 13:868-85. [DOI: 10.1111/j.1526-4637.2012.01350.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Rosser BA, McCracken LM, Velleman SC, Boichat C, Eccleston C. Concerns about medication and medication adherence in patients with chronic pain recruited from general practice. Pain 2011; 152:1201-1205. [PMID: 21376463 DOI: 10.1016/j.pain.2011.01.053] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2010] [Revised: 01/26/2011] [Accepted: 01/27/2011] [Indexed: 11/17/2022]
Abstract
This study examines the concerns and beliefs about medication reported by patients with nonmalignant chronic pain encountered within general practice. Two hundred thirty-nine patients with chronic pain took part in this research. Patients completed the Pain Medication Attitudes Questionnaire, a measure of patient concerns and beliefs relating to addiction, withdrawal, side effects, mistrust in doctors, perceived need of medication, scrutiny from others, and tolerance. The data revealed that patient concerns and beliefs predicted general medication nonadherence. In addition, concerns were related to the direction of nonadherence: overuse of medication was related to increased perceived need for medication and greater concern over side effects; underuse was related to decreased concerns over withdrawal and increased mistrust in the prescribing doctor. Analyses also indicated that patient attitudes and concerns about medication were more predictive of nonadherence than both level of pain and the reported frequency of experienced side effects. This research contributes to the increasing evidence that patient attitudes and beliefs about pain medication are associated with adherence behavior. Training general practitioners to identify and address these concerns may reduce concerns, improve adherence, and facilitate the doctor-patient relationship.
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Affiliation(s)
- Benjamin A Rosser
- Bath Centre for Pain Research, University of Bath, Bath, UK Bath Centre for Pain Services, Royal National Hospital for Rheumatic Diseases, Bath, UK
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Schatman ME. The Role of the Health Insurance Industry in Perpetuating Suboptimal Pain Management. PAIN MEDICINE 2011; 12:415-26. [DOI: 10.1111/j.1526-4637.2011.01061.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Pergolizzi J, Pappagallo M, Stauffer J, Gharibo C, Fortner N, De Jesus MN, Brennan MJ, Richmond C, Hussey D. The Role of Urine Drug Testing for Patients on Opioid Therapy. Pain Pract 2010; 10:497-507. [DOI: 10.1111/j.1533-2500.2010.00375.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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