1
|
Sullivan MD, Katers L, Wang J, Arbabi S, Tauben D, Baldwin LM. A randomized trial of collaborative support for opioid taper after trauma hospitalization. Subst Abuse Treat Prev Policy 2024; 19:33. [PMID: 38915106 PMCID: PMC11197264 DOI: 10.1186/s13011-024-00613-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 06/06/2024] [Indexed: 06/26/2024] Open
Abstract
The COTAT (Collaborative Opioid Taper After Trauma) Study was a randomized trial of an opioid taper support program using a physician assistant (PA) to provide pain and opioid treatment guidance to primary care providers assuming care for adult patients with moderate to severe trauma discharged from a Level I trauma center on opioid therapy. Patients were recruited, assessed, and randomized individually by a surgery research recruitment team one to two days prior to discharge to home. Participants randomized to the opioid taper support program were contacted by phone within a few days of discharge by the PA interventionist to confirm enrollment and their primary care provider (PCP). The intervention consisted of PA support as needed to the PCP concerning pain and opioid care at weeks 1, 2, 4, 8, 12, 16, and 20 after discharge or until the PCP office indicated they no longer needed support or the patient had tapered off opioids. The PA was supervised by a pain physician-psychiatrist, a family physician, and a trauma surgeon. Patients randomized to usual care received standard hospital discharge instructions and written information on managing opioid medications after discharge. Trial results were analyzed using repeated measures analysis. 37 participants were randomized to the intervention and 36 were randomized to usual care. The primary outcomes of the trial were pain, enjoyment, general activity (PEG score) and mean daily opioid dose at 3 and 6 months after hospital discharge. Treatment was unblinded but assessment was blinded. No significant differences in PEG or opioid outcomes were noted at either time point. Physical function at 3 and 6 months and pain interference at 6 months were significantly better in the usual care group. No significant harms of the intervention were noted. COVID-19 (corona virus 2019) limited recruitment of high-risk opioid tolerant subjects, and limited contact between the PA interventionist and the participants and the PCPs. Our opioid taper support program failed to improve opioid and pain outcomes, since both control and intervention groups tapered opioids and improved PEG scores after discharge. Future trials of post-trauma opioid taper support with populations at higher risk of persistent opioid use are needed. This trial is registered at clinicaltrials.gov under NCT04275258 19/02/2020. This trial was funded by a grant from the Centers for Disease Control and Prevention to the University of Washington Harborview Injury Prevention & Research Center (R49 CE003087, PI: Monica S. Vavilala, MD). The funder had no role in the analysis or interpretation of the data.
Collapse
Affiliation(s)
- Mark D Sullivan
- Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, 98195, USA.
| | - Laura Katers
- Internal Medicine, Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Jin Wang
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA, USA
| | - Sam Arbabi
- Harborview Trauma Surgery, University of Washington, Seattle, WA, USA
| | - David Tauben
- Internal Medicine, Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | | |
Collapse
|
2
|
Boyd A, Malige A, Limpisvasti O. Physician Trainees' Perception of Cannabidiol Use in Medicine: A Survey Study. Cureus 2023; 15:e47228. [PMID: 38022327 PMCID: PMC10653979 DOI: 10.7759/cureus.47228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
PURPOSE Given the ongoing national opiate crisis, physicians have been challenged with mitigating the risk of opiate dependence in their patients. With current physician efforts to mitigate the risks of treating pain with opioid prescriptions, this study evaluates medical students' and residents' understanding and perceptions regarding cannabidiol (CBD) in current medical care and their future medical practice. METHODS Orthopedic residents from all American programs and medical students from 50 medical schools, regardless of training year or future specialty plans, were eligible to participate in this survey-based study administered from December 2022 to March 2023. The surveys ask questions about demographic information, what education they receive on CBD utilization in medicine, thoughts on CBD effectiveness in pain control, and future plans on utilizing CBD. RESULTS A total of 55 residents (1.4%) and 53 medical students (5.1%) responded. Trainees in CBD-legal states were more likely to work with physicians who use CBD in their practice. Most trainees, regardless of location, believe CBD use has a stigma attached to it. Many responders were concerned about the role of CBD in pain control. Finally, most trainees believed that CBD is easy to access if desired and is affordable to purchase. CONCLUSION The trajectory of CBD use in the United States indicates that the therapeutic benefits of CBD will be targeted, and future physicians are not always provided adequate educational opportunities to learn about its potential medical uses. Continued training as well as interactions with patients may help decrease the stigma surrounding medical CBD use and help solidify its therapeutic use in pain control.
Collapse
Affiliation(s)
- Alexandra Boyd
- Orthopaedic Surgery, Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, USA
| | - Ajith Malige
- Orthopaedic Surgery, Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, USA
| | - Orr Limpisvasti
- Orthopaedic Surgery, Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, USA
| |
Collapse
|
3
|
Buttorff C, Wang GS, Wilks A, Tung G, Kress A, Schwam D, Pacula RL. Impact of Recreational Cannabis Legalization on Opioid Prescribing and Opioid-Related Hospital Visits in Colorado: an Observational Study. J Gen Intern Med 2023; 38:2726-2733. [PMID: 37340250 PMCID: PMC10506996 DOI: 10.1007/s11606-023-08195-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 03/30/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND Cannabis may be a substitute for opioids but previous studies have found conflicting results when using data from more recent years. Most studies have examined the relationship using state-level data, missing important sub-state variation in cannabis access. OBJECTIVE To examine cannabis legalization on opioid use at the county level, using Colorado as a case study. Colorado allowed recreational cannabis stores in January 2014. Local communities could decide whether to allow dispensaries, creating variation in the level of exposure to cannabis outlets. DESIGN Observational, quasi-experimental design exploiting county-level variation in allowance of recreational dispensaries. SUBJECTS Colorado residents MEASURES: We use licensing information from the Colorado Department of Revenue to measure county-level exposure to cannabis outlets. We use the state's Prescription Drug Monitoring Program (2013-2018) to construct opioid-prescribing measures of number of 30-day fills and total morphine equivalents, both per county resident per quarter. We construct outcomes of opioid-related inpatient visits (2011-2018) and emergency department visits (2013-2018) with Colorado Hospital Association data. We use linear models in a differences-in-differences framework that accounts for the varying exposure to medical and recreational cannabis over time. There are 2048 county-quarter observations used in the analysis. RESULTS We find mixed evidence of cannabis exposure on opioid-related outcomes at the county level. We find increasing exposure to recreational cannabis is associated with a statistically significant decrease in number of 30-day fills (coefficient: -117.6, p-value<0.01) and inpatient visits (coefficient: -0.8, p-value: 0.03), but not total MME nor ED visits. Counties with no medical exposure prior to recreational legalization experience greater reductions in the number of 30-day fills and MME than counties with prior medical exposure (p=0.02 for both). CONCLUSIONS Our mixed findings suggest that further increases in cannabis beyond medical access may not always reduce opioid prescribing or opioid-related hospital visits at a population level.
Collapse
Affiliation(s)
| | - George Sam Wang
- Department of Pediatrics, Children’s Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Asa Wilks
- RAND Corporation, Santa Monica, CA USA
| | - Gregory Tung
- Department of Health Systems, Management & Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Amii Kress
- ECHO Data Analysis Center, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | | | - Rosalie Liccardo Pacula
- Sol Price School of Public Policy, Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, CA USA
| |
Collapse
|
4
|
Strategies aimed at preventing long-term opioid use in trauma and orthopaedic surgery: a scoping review. BMC Musculoskelet Disord 2022; 23:238. [PMID: 35277150 PMCID: PMC8917706 DOI: 10.1186/s12891-022-05044-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 01/18/2022] [Indexed: 12/12/2022] Open
Abstract
Abstract
Background
Long-term opioid use, which may have significant individual and societal impacts, has been documented in up to 20% of patients after trauma or orthopaedic surgery. The objectives of this scoping review were to systematically map the research on strategies aiming to prevent chronic opioid use in these populations and to identify knowledge gaps in this area.
Methods
This scoping review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. We searched seven databases and websites of relevant organizations. Selected studies and guidelines were published between January 2008 and September 2021. Preventive strategies were categorized as: system-based, pharmacological, educational, multimodal, and others. We summarized findings using measures of central tendency and frequency along with p-values. We also reported the level of evidence and the strength of recommendations presented in clinical guidelines.
Results
A total of 391 studies met the inclusion criteria after initial screening from which 66 studies and 20 guidelines were selected. Studies mainly focused on orthopaedic surgery (62,1%), trauma (30.3%) and spine surgery (7.6%). Among system-based strategies, hospital-based individualized opioid tapering protocols, and regulation initiatives limiting the prescription of opioids were associated with statistically significant decreases in morphine equivalent doses (MEDs) at 1 to 3 months following trauma and orthopaedic surgery. Among pharmacological strategies, only the use of non-steroidal anti-inflammatory drugs and beta blockers led to a significant reduction in MEDs up to 12 months after orthopaedic surgery. Most studies on educational strategies, multimodal strategies and psychological strategies were associated with significant reductions in MEDs beyond 1 month. The majority of recommendations from clinical practice guidelines were of low level of evidence.
Conclusions
This scoping review advances knowledge on existing strategies to prevent long-term opioid use in trauma and orthopaedic surgery patients. We observed that system-based, educational, multimodal and psychological strategies are the most promising. Future research should focus on determining which strategies should be implemented particularly in trauma patients at high risk for long-term use, testing those that can promote a judicious prescription of opioids while preventing an illicit use, and evaluating their effects on relevant patient-reported and social outcomes.
Collapse
|
5
|
Aebischer JH, Dieckmann NF, Jones KD, St John AW. Chronic Pain Clinical and Prescriptive Practices in the Cannabis Era. Pain Manag Nurs 2021; 23:109-121. [PMID: 34973920 DOI: 10.1016/j.pmn.2021.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 11/20/2021] [Accepted: 11/27/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND To explore how health care providers in the United States are adapting clinical recommendations and prescriptive practices in response to patient use of medical cannabis (MC) for chronic pain symptoms. DESIGN Literature searches queried MeSH/Subject terms "chronic pain," "clinician," "cannabis," and Boolean text words "practice" and "analgesics" in EBSCOHost, EMBASE, PubMed, and Scopus, published 2010-2021 in the United States. Twenty-one primary, peer-reviewed studies met criteria. METHODS Studies are synthesized under major headings: recommending MC for chronic pain; MC and prescription opioids; and harm reduction of MC. RESULTS MC is increasingly utilized by patients for chronic pain symptoms. Clinical recommendations for or against MC are influenced by scopes of practice, state or federal laws, institutional policies, education, potential patient harm (or indirect harm of others), and perceived confidence. Epidemiologic and cohort studies show downward trajectories of opioid prescribing and consumption in states with legal cannabis. However, clinicians' recommendations and prescription practices are nonuniform. Impacts of cannabis laws are clear between nongovernmental and governmental institutions. Strategies addressing MC and opioid use include frequent visits, and, to reduce harm, suggesting alternative therapies and treating substance use disorders. CONCLUSIONS MC use for chronic pain is increasing with cannabis legalization. Provider practices are heterogenous, demonstrating a balance of treating chronic pain using available evidence, while being aware of potential harms associated with MC and opioids.
Collapse
Affiliation(s)
| | - Nathan F Dieckmann
- Oregon Health & Science University, School of Nursing, Portland, OR; Oregon Health & Science University & Portland State University, School of Public Health, Core Faculty, Portland, OR; Oregon Health & Science University, School of Medicine, Division of Psychology & Psychiatry, Portland, OR
| | - Kim D Jones
- Linfield University, School of Nursing, Portland, OR
| | - Amanda W St John
- Oregon Health & Science University, School of Medicine, Division of Anesthesiology & Perioperative Medicine, Portland, OR
| |
Collapse
|
6
|
Lee JB, Ghanem G, Saadat S, Yanuck J, Yeung B, Chakravarthy B, Nelson A, Shah S. Positive Toxicology Results Are Not Associated with Emergency Physicians' Opioid Prescribing Behavior. West J Emerg Med 2021; 22:1067-1075. [PMID: 34546882 PMCID: PMC8463062 DOI: 10.5811/westjem.2021.5.52378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/21/2021] [Indexed: 11/12/2022] Open
Abstract
Introduction Given the general lack of literature on opioid and naloxone prescribing guidelines for patients with substance use disorder, we aimed to explore how a physician’s behavior and prescribing habits are altered by knowledge of the patient’s concomitant use of psychotropic compounds as evident on urine and serum toxicology screens. Methods We conducted a retrospective chart review study at a tertiary, academic, Level I trauma center between November 2017–October 2018 that included 358 patients who were discharged from the emergency department (ED) with a diagnosis of fracture, dislocation, or amputation and received an opioid prescription upon discharge. We extracted urine and serum toxicology results, number and amount of prescription opioids upon discharge, and the presence of a naloxone script. Results The study population was divided into five subgroups that included the following: negative urine and serum toxicology screen; depressants; stimulants; mixed; and no toxicology screens. When comparing the 103 patients in which toxicology screens were obtained to the 255 patients without toxicology screens, we found no statistically significant differences in the total prescribed morphine milligram equivalent (75.0 and 75.0, respectively) or in the number of pills prescribed (15.0 and 13.5, respectively). Notably, none of the 103 patients who had toxicology screens were prescribed naloxone upon discharge. Conclusion Our study found no association between positive urine toxicology results for psychotropically active substances and the rates of opioid prescribing within a single-center, academic ED. Notably, none of the 103 patients who had toxicology screens were prescribed naloxone upon discharge. More research on the associations between illicit drug use, opioids, and naloxone prescriptions is necessary to help establish guidelines for high-risk patients.
Collapse
Affiliation(s)
- Jonathan B Lee
- University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Ghadi Ghanem
- University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Soheil Saadat
- University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Justin Yanuck
- University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Brent Yeung
- University of California, Irvine, Department of Anesthesiology & Perioperative Care, Orange, California
| | - Bharath Chakravarthy
- University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Ariana Nelson
- University of California, Irvine, Department of Anesthesiology & Perioperative Care, Orange, California
| | - Shalini Shah
- University of California, Irvine, Department of Anesthesiology & Perioperative Care, Orange, California
| |
Collapse
|
7
|
Jugl S, Okpeku A, Costales B, Morris EJ, Alipour-Haris G, Hincapie-Castillo JM, Stetten NE, Sajdeya R, Keshwani S, Joseph V, Zhang Y, Shen Y, Adkins L, Winterstein AG, Goodin A. A Mapping Literature Review of Medical Cannabis Clinical Outcomes and Quality of Evidence in Approved Conditions in the USA from 2016 to 2019. Med Cannabis Cannabinoids 2021; 4:21-42. [PMID: 34676348 PMCID: PMC8525213 DOI: 10.1159/000515069] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 02/03/2021] [Indexed: 12/15/2022] Open
Abstract
In 2017, a National Academies of Sciences, Engineering, and Medicine (NASEM) report comprehensively evaluated the body of evidence regarding cannabis health effects through the year 2016. The objectives of this study are to identify and map the most recently (2016-2019) published literature across approved conditions for medical cannabis and to evaluate the quality of identified recent systematic reviews, published following the NASEM report. Following the literature search from 5 databases and consultation with experts, 11 conditions were identified for evidence compilation and evaluation: amyotrophic lateral sclerosis, autism, cancer, chronic noncancer pain, Crohn's disease, epilepsy, glaucoma, human immunodeficiency virus/AIDS, multiple sclerosis (MS), Parkinson's disease, and posttraumatic stress disorder. A total of 198 studies were included after screening for condition-specific relevance and after imposing the following exclusion criteria: preclinical focus, non-English language, abstracts only, editorials/commentary, case studies/series, and non-U.S. study setting. Data extracted from studies included: study design type, outcome definition, intervention definition, sample size, study setting, and reported effect size. Few completed randomized controlled trials (RCTs) were identified. Studies classified as systematic reviews were graded using the Assessing the Methodological Quality of Systematic Reviews-2 tool to evaluate the quality of evidence. Few high-quality systematic reviews were available for most conditions, with the exceptions of MS (9 of 9 graded moderate/high quality; evidence for 2/9 indicating cannabis improved outcomes; evidence for 7/9 indicating cannabis inconclusive), epilepsy (3 of 4 graded moderate/high quality; 3 indicating cannabis improved outcomes; 1 indicating cannabis inconclusive), and chronic noncancer pain (12 of 13 graded moderate/high quality; evidence for 7/13 indicating cannabis improved outcomes; evidence from 6/7 indicating cannabis inconclusive). Among RCTs, we identified few studies of substantial rigor and quality to contribute to the evidence base. However, there are some conditions for which significant evidence suggests that select dosage forms and routes of administration likely have favorable risk-benefit ratios (i.e., epilepsy and chronic noncancer pain). The body of evidence for medical cannabis requires more rigorous evaluation before consideration as a treatment option for many conditions, and evidence necessary to inform policy and treatment guidelines is currently insufficient for many conditions.
Collapse
Affiliation(s)
- Sebastian Jugl
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | - Aimalohi Okpeku
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | - Brianna Costales
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | - Earl J. Morris
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | - Golnoosh Alipour-Haris
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | - Juan M. Hincapie-Castillo
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | | | - Ruba Sajdeya
- Epidemiology, University of Florida, Gainesville, Florida, USA
| | - Shailina Keshwani
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | - Verlin Joseph
- Epidemiology, University of Florida, Gainesville, Florida, USA
| | - Yahan Zhang
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | - Yun Shen
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | - Lauren Adkins
- Health Sciences Center Libraries, University of Florida, Gainesville, Florida, USA
| | - Almut G. Winterstein
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | - Amie Goodin
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| |
Collapse
|
8
|
Wolf J, Urits I, Orhurhu V, Peck J, Orhurhu MS, Giacomazzi S, Smoots D, Piermarini C, Manchikanti L, Kaye AD, Kaye RJ, Viswanath O. The Role of the Cannabinoid System in Pain Control: Basic and Clinical Implications. Curr Pain Headache Rep 2020; 24:35. [PMID: 32506272 DOI: 10.1007/s11916-020-00873-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to provide a comprehensive update of the different known components of the endogenous cannabinoid system and the mechanisms of action, as it applies to analgesia. RECENT FINDINGS Following the discovery of the endogenous cannabinoid system in the early 1990s and the subsequent characterization of the cannabinoid receptor, there has been a renewed interest in cannabinoid research. Recent work has demonstrated its efficacy as a pharmacologic agent. There is limited evidence in the literature about the understanding of the endocannabinoid system and its role in the treatment and management of acute and chronic pain. Further work may elucidate additional roles for the endocannabinoid system within our nervous system and, moreover, additional subtypes of cannabinoid receptors have yet to be discovered. Cannabinoid compounds mediate their biological effects via binding and subsequent activation of cannabinoid receptors. These receptors are located throughout the body and make up the endocannabinoid system. These receptors are best understood and have been cloned, type 1 (CB1) and type 2 (CB2) [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)]. The CB2 receptor is located primarily in the immune system. CB1 receptors are primarily located in the nervous system with the highest concentrations in the brain and lower concentrations in the spine and peripheral nervous tissues. Cannabinoids may be promising treatments for neuropathic pain with limited evidence, whereas, the evidence for other uses is insufficient.
Collapse
Affiliation(s)
- John Wolf
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA
| | - Ivan Urits
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA.
| | - Vwaire Orhurhu
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jacquelin Peck
- Department of Anesthesiology, Mount Sinai Medical Center of Florida, Miami Beach, FL, USA
| | - Mariam Salisu Orhurhu
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA
| | - Stephen Giacomazzi
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA
| | - Daniel Smoots
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA
| | | | | | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Rachel J Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Omar Viswanath
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, LA, USA.,Valley Anesthesiology and Pain Consultants, Envision Physician Services, Phoenix, AZ, USA.,Department of Anesthesiology, University of Arizona College of Medicine, Phoenix, Phoenix, AZ, USA.,Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
| |
Collapse
|
9
|
Use of Tetrahydrocannabinol and Cannabidiol Products in the Perioperative Period Around Primary Unilateral Total Hip and Knee Arthroplasty. J Arthroplasty 2020; 35:S138-S143. [PMID: 32173619 DOI: 10.1016/j.arth.2020.01.077] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 01/07/2020] [Accepted: 01/28/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Given the opioid crisis in America, patients are trying alternative medications including tetrahydrocannabinol (THC) and other cannabidiol (CBD) containing products in the perioperative period, especially in states where these products are legal. This study sought to analyze usage rates of CBD/THC products in the perioperative period for primary unilateral total hip and knee arthroplasty (THA/TKA) patients and identify a possible association with post-operative opioid use. METHODS A prospective cohort of primary unilateral THA/TKA patients were enrolled at a single institution. Patients who completed detailed pain journals were retrospectively surveyed for CBD/THC product usage. Pain medications were converted to morphine milligram equivalents (MME). RESULTS Data from 195 of the 210 patients (92.9% response rate) following primary arthroplasty were analyzed. Overall, 16.4% of arthroplasty-22.6% (n = 19) of TKA and 11.7% (n = 13) of THA-patients used CBD/THC products in the perioperative period. There was a wide variety of usage patterns among those using CBD/THC products. In comparing CBD/THC users and non-users, there was no significant difference in the length of narcotic use, total morphine milligram equivalents taken, narcotic pills taken, average post-op pain scores, the percentage of patients requiring a refill of narcotics, or length of stay. CONCLUSION Understanding that CBD/THC usage was not consistent for patients who used these products, 22.6% of TKA and 11.7% of THA patients tried CBD/THC products in the perioperative period. In this small sample, CBD/THC use was not associated with a major effect on narcotic requirements. Further studies on the effects of CBD/THC are needed as these therapies become more widely available.
Collapse
|
10
|
Dhadwal S, Kulich RJ, Monga P, Schatman ME. Dentistry's Role in Assessing and Managing Controlled Substance Risk: Historical Overview, Current Barriers, and Working Toward Best Practices. Dent Clin North Am 2020; 64:491-501. [PMID: 32448453 DOI: 10.1016/j.cden.2020.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Dentistry is in a unique position among the health care professions to assess and manage the patient with controlled substance risk. The concern over opioid risk is not new, and historically dentists have had to balance the critical need for adequate pain care with the importance of recognizing the consequences of using controlled substances for their patients. Barriers for providing adequate patient assessment and management may be greater in dentistry than other health care fields, although these barriers can be recognized and overcome. Collaboration with cotreating providers will improve patient outcomes and reduce patient risk.
Collapse
Affiliation(s)
- Shuchi Dhadwal
- Department of Diagnostic Sciences, Tufts University School of Dental Medicine, 1 Kneeland Street, Boston, MA 02111, USA.
| | - Ronald J Kulich
- Department of Diagnostic Sciences, Tufts University School of Dental Medicine, 1 Kneeland Street, Boston, MA 02111, USA; Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Priyanka Monga
- Department of Diagnostic Sciences, Tufts University School of Dental Medicine, 1 Kneeland Street, Boston, MA 02111, USA
| | - Michael E Schatman
- Department of Diagnostic Sciences, Tufts University School of Dental Medicine, 1 Kneeland Street, Boston, MA 02111, USA; Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
| |
Collapse
|
11
|
Kulich RJ, Keith DA, Vasciannie AA, Thomas HF. Interprofessional Collaboration in the Assessment and Management of Substance Use Risk. Dent Clin North Am 2020; 64:571-583. [PMID: 32448460 DOI: 10.1016/j.cden.2020.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Substance use disorder assessment strategies are increasingly being employed by dentistry, while adequate evaluation requires reaching out to other cotreating providers and collaborating on patient care. The field of dentistry has a range of barriers often not experienced in other professions, including limitations on e-record communication and clinical practice setting often isolated from the patient's general medical care. Barriers can be overcome if the dentist facilitates communication.
Collapse
Affiliation(s)
- Ronald J Kulich
- Tufts University School of Dental Medicine, Department of Diagnostic Sciences, Craniofacial Pain & Headache Center, 1 Kneeland Street, Boston, MA 02111, USA; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.
| | - David A Keith
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Oral and Maxillofacial Surgery, Harvard School of Dental Medicine, Boston, MA, USA
| | - Alexis A Vasciannie
- Department of Diagnostic Sciences, Tufts University School of Dental Medicine, 1 Kneeland Street, Boston, MA 02111, USA
| | - Huw F Thomas
- Tufts University School of Dental Medicine, One Kneeland Street, Room 1163, Boston, MA 02111, USA
| |
Collapse
|
12
|
Viswanath A, Barreveld AM, Fortino M. Assessment and Management of the High-Risk Dental Patient with Active Substance Use Disorder. Dent Clin North Am 2020; 64:547-558. [PMID: 32448458 DOI: 10.1016/j.cden.2020.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Every dentist cares for patients with a history of substance use disorder (SUD), regardless of a patient's socioeconomic status, education, or ethnicity. SUD is a global epidemic, with approximately 8% of the general US population meeting diagnostic criteria for a SUD and more than 20% of the global population experiencing a SUD. The importance of understanding how to identify substance use, manage patients with a SUD, and offer appropriate referral is essential for all dental professionals. In 2005, the American Dental Association published, "Statement on Provision of Dental Treatment for Patients with Substance Use Disorders."
Collapse
Affiliation(s)
- Archana Viswanath
- Department of Oral and Maxillofacial Surgery, Tufts University School of Dental Medicine, 1 Kneeland Street, Boston, MA 02111, USA; Department of Diagnostic Sciences, Tufts University School of Dental Medicine, 1 Kneeland Street, Boston, MA 02111, USA
| | - Antje M Barreveld
- Department of Anesthesiology, Tufts University School of Medicine, 1 Kneeland Street, Boston, MA 02111, USA; Pain Management Services, Substance Use Services, Newton-Wellesley Hospital, Newton, MA, USA
| | - Matthew Fortino
- Department of Diagnostic Sciences, Center for Pain Medicine, Tufts University School of Dental Medicine, 1 Kneeland Street, Boston, MA 02111, USA; Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA.
| |
Collapse
|
13
|
Goggin MM, Shahriar BJ, Stead A, Janis GC. Reduced urinary opioid levels from pain management patients associated with marijuana use. Pain Manag 2019; 9:441-447. [PMID: 31496363 DOI: 10.2217/pmt-2019-0017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Marijuana use has been postulated to modulate opioid use, dependence and withdrawal. Broad target drug testing results provide a unique perspective to identify any potential interaction between marijuana use and opioid use. Materials & methods: Using a dataset of approximately 800,000 urine drug test results collected from pain management patients of a time from of multiple years, creatinine corrected opioid levels were evaluated to determine if the presence of the primary marijuana marker 11-nor-carboxy-tetrahydrocannabinol (THC-COOH) was associated with statistical differences in excreted opioid concentrations. Results & conclusion: For each of the opioids investigated (codeine, morphine, hydrocodone, hydromorphone, oxycodone, oxymorphone, fentanyl and buprenorphine), marijuana use was associated with statistically significant lower urinary opiate levels than in samples without indicators of marijuana use.
Collapse
Affiliation(s)
- Melissa M Goggin
- MedTox Laboratories, Laboratory Corporation of America Holdings, St Paul, MN 55112, USA
| | - Breane J Shahriar
- MedTox Laboratories, Laboratory Corporation of America Holdings, St Paul, MN 55112, USA
| | | | - Gregory C Janis
- MedTox Laboratories, Laboratory Corporation of America Holdings, St Paul, MN 55112, USA
| |
Collapse
|
14
|
Raji MA, Abara NO, Salameh H, Westra JR, Kuo YF. Association between cannabis laws and opioid prescriptions among privately insured adults in the US. Prev Med 2019; 125:62-68. [PMID: 31125629 PMCID: PMC6582995 DOI: 10.1016/j.ypmed.2019.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 04/23/2019] [Accepted: 05/20/2019] [Indexed: 11/27/2022]
Abstract
We examine the association between opioid prescription patterns in privately insured adults and changes in state cannabis laws among five age groups (18-25, 26-35 36-45, 46-55 and 56-64 years). Using the 2016 Clinformatics Data Mart, a nationwide commercial health insurance database, we performed a cross-sectional analysis of two types of opioid prescribing (>30-day and >90-day prescriptions) among all adults aged 18-64 based on the stringency of cannabis laws. We found a significant interaction between age and cannabis law on opioid prescriptions. Age-stratified multilevel multivariable analyses showed lower opioid prescription rates in the four younger age groups only in states with medical cannabis laws, when considering both >30 day and >90 day opioid use [>30 day adjusted odds ratio (aOR) = 0.56, in 18-25, aOR = 0.67 in 26-35, aOR = 0.67 in 36-45, and aOR = 0.76 in 46-54 years; >90 day aOR = 0.56, in 18-25, aOR = 0.68 in 26-35, aOR = 0.69 in 36-45, and aOR = 0.77 in 46-54 years, P < 0.0001 for all]. This association was not significant in the oldest age group of 55-64 years. There was no significant association between opioid prescriptions and other categories of cannabis laws (recreational use and decriminalization) in any of the age groups studied.
Collapse
Affiliation(s)
- Mukaila A Raji
- Department of Internal Medicine, Division of Geriatrics, University of Texas Medical Branch, Galveston, TX 77555-0177, United States of America; Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX 77555-0177, United States of America.
| | - N Ogechi Abara
- Department of Internal Medicine, Division of Geriatrics, University of Texas Medical Branch, Galveston, TX 77555-0177, United States of America
| | - Habeeb Salameh
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Texas Medical Branch, Galveston, TX, United States of America
| | - Jordan R Westra
- Office of Biostatistics, Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX 77555-1148, United States of America
| | - Yong-Fang Kuo
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX 77555-0177, United States of America; Office of Biostatistics, Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX 77555-1148, United States of America
| |
Collapse
|
15
|
DiBenedetto DJ, Wawrzyniak KM, Schatman ME, Shapiro H, Kulich RJ. Increased frequency of urine drug testing in chronic opioid therapy: rationale for strategies for enhancing patient adherence and safety. J Pain Res 2019; 12:2239-2246. [PMID: 31413622 PMCID: PMC6661994 DOI: 10.2147/jpr.s213536] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 06/23/2019] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To determine the average amount of time required to detect opioid aberrancy based upon varying frequencies of urine drug testing (UDT) in a community-based, tertiary care pain management center. SUBJECTS This study was a retrospective analysis of 513 consecutive patients enrolled in a medication management program, receiving chronic opioid therapy between January 1, 2018 and December 31, 2018. METHODS Data were extracted from medical records including age at start of the study period, sex, ethnicity, marital status, and smoking status. UDT was performed at each prescribing visit via semi-quantitative immunoassay, and at the discretion of the clinician, a sample was sent for external confirmation using gas chromatography or mass spectrometry testing to clarify questions of inconsistency with patients' reports or prescribed medications. For purposes of the study, "opioid aberrancy" was defined through inconsistent UDT. RESULTS One hundred and fifteen patients (22.4%) had at least one inconsistent UDT during the study period, and 160 (2.8%) of all UDTs were inconsistent. At this rate of inconsistency, it was determined that with monthly screening, it would require up to 36 months to detect a single aberrancy, and semi-annual testing would require as long as 216 months to detect an aberrancy. CONCLUSIONS More frequent UDT can be helpful in terms of earlier detection of opioid aberrancy. This has significant implications for helping avoid misuse, overdose, and potential diversion. Furthermore, early detection will ideally result in earlier implementation of treatment of the emotional and behavioral factors causing aberrancy. Such early intervention is more likely to be successful in terms of reducing substance misuse in a chronic pain population, providing a higher degree of patient adherence and safety, as well as producing superior overall patient outcomes. Finally, economic benefits may include substantial savings through avoidance of the necessity for drug rehabilitation and the empirically established higher costs of treating opioid misuse comorbidities.
Collapse
Affiliation(s)
- David J DiBenedetto
- Research and Network Development, Boston PainCare, Waltham, MA, USA
- Department of Diagnostic Sciences, Tufts School of Dental Medicine, Boston, MA, USA
| | - Kelly M Wawrzyniak
- Research and Network Development, Boston PainCare, Waltham, MA, USA
- Department of Diagnostic Sciences, Tufts School of Dental Medicine, Boston, MA, USA
| | - Michael E Schatman
- Research and Network Development, Boston PainCare, Waltham, MA, USA
- Deparment of Public Health and Community Medicine, Tufts School of Medicine, Boston, MA, USA
| | - Hannah Shapiro
- Research and Network Development, Boston PainCare, Waltham, MA, USA
- Department of Biopsychology, Tufts University, Medford, MA, USA
| | - Ronald J Kulich
- Department of Diagnostic Sciences, Tufts School of Dental Medicine, Boston, MA, USA
- Department of Anesthesia Critical Care and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
16
|
Langley PC. Outcomes, Registries and Medical Marijuana: Towards Establishing Dispensary Monitoring and Reporting Standards. Innov Pharm 2018; 9. [PMID: 34007733 PMCID: PMC7640779 DOI: 10.24926/iip.v9i4.1527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The acceptance by a large number of state governments of medical marijuana dispensaries and the regulatory framework to support their licensing has put to one side the issue of monitoring and reporting outcomes. This is a major oversight. It is an untenable situation given the limited evidence base for the clinical benefits and risks associated with dispensed botanical marijuana. The purpose of this commentary is to propose that, as a condition of licensing, marijuana dispensaries should be required to establish a registry to support ongoing monitoring of patient response associated with botanical cannabis formulations. Patients should be monitored over the course of their treatment to assess, in the case of severe non-cancer pain as an example, pain intensity and functional status by pain location. The dispensary, in meeting required audit standards, should be in a position to report on patient response over baseline to the provider who has recommended botanical cannabis. As well, registries should be in a position to report to state licensing agencies response to therapy by target patient groups. Establishing site-specific registries should go some way to meeting the present evidence deficit for botanical marijuana, reducing barriers to its acceptance by providers, patients and health agencies.
Collapse
Affiliation(s)
- Paul C Langley
- Adjunct Professor, College of Pharmacy, University of Minnesota
| |
Collapse
|