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Larach DB, Waljee JF, Bicket MC, Brummett CM, Bruehl S. Perioperative opioid prescribing and iatrogenic opioid use disorder and overdose: a state-of-the-art narrative review. Reg Anesth Pain Med 2024; 49:602-608. [PMID: 37931982 PMCID: PMC11070448 DOI: 10.1136/rapm-2023-104944] [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: 08/15/2023] [Accepted: 10/22/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND/IMPORTANCE Considerable attention has been paid to identifying and mitigating perioperative opioid-related harms. However, rates of postsurgical opioid use disorder (OUD) and overdose, along with associated risk factors, have not been clearly defined. OBJECTIVE Evaluate the evidence connecting perioperative opioid prescribing with postoperative OUD and overdose, compare these data with evidence from the addiction literature, discuss the clinical impact of these conditions, and make recommendations for further study. EVIDENCE REVIEW State-of-the-art narrative review. FINDINGS Nearly all evidence is from large retrospective studies of insurance claims and Veterans Health Administration (VHA) data. Incidence rates of new OUD within the first year after surgery ranged from 0.1% to 0.8%, while rates of overdose events ranged from 0.01% to 0.8%. Higher rates were seen among VHA patients, which may reflect differences in data completeness and/or risk factors. Identified risk factors included those related to substance use (preoperative opioid use; non-opioid substance use disorders; preoperative sedative, anxiolytic, antidepressant, and gabapentinoid use; and postoperative new persistent opioid use (NPOU)); demographic attributes (chiefly male sex, younger age, white race, and Medicaid or no insurance coverage); psychiatric comorbidities such as depression, bipolar disorder, and PTSD; and certain medical and surgical factors. Several challenges related to the use of administrative claims data were identified; there is a need for more granular retrospective studies and, ideally, prospective cohorts to assess postoperative OUD and overdose incidence with greater accuracy. CONCLUSIONS Retrospective data suggest an incidence of new postoperative OUD and overdose of up to 0.8% during the first year after surgery, but prospective studies are lacking.
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Affiliation(s)
- Daniel B Larach
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jennifer F Waljee
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Mark C Bicket
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Chad M Brummett
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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2
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Price-Haywood EG, Burton JH, Harden-Barrios J, Bazzano A, Shi L, Lefante J, Jamison RN. Decision Support and Behavioral Health for Reducing High-Dose Opioids in Comorbid Chronic Pain, Depression and Anxiety: Stepped-Wedge Cluster Randomized Trial. J Gen Intern Med 2024:10.1007/s11606-024-08965-7. [PMID: 39095571 DOI: 10.1007/s11606-024-08965-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 07/18/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND High prevalence of depression or anxiety with opioid use for chronic pain complicates co-management and may influence prescribing behaviors. OBJECTIVE Compare clinical effectiveness of electronic medical record clinical decision support (EMR-CDS) versus additional behavioral health (BH) care management for reducing rates of high-dose opioid prescriptions. DESIGN Type 2 effectiveness-implementation hybrid stepped-wedge cluster randomized trial in 35 primary care clinics within a health system in LA, USA. PARTICIPANTS Patients aged 18+ receiving chronic opioid therapy for non-cancer pain with depression or anxiety and matched controls. INTERVENTION EMR-CDS included opioid risk mitigation procedures. BH care included cognitive behavioral therapy; depression or anxiety medication adjustments; and case management. MAIN MEASURES Outcomes of interest included difference-in-difference (DID) estimate of changes in probability for prescribing high-dose morphine equivalent daily dose (MEDD ≥50 mg/day and MEDD ≥90), average MEDD, and rates of hospitalization, emergency department use, and opioid risk mitigation. KEY RESULTS Most participants were female with 3+ pain syndromes. Data analysis included 632 patients. Absolute risk differences for MEDD≥50 and ≥90 decreased post-index compared to pre-index (DID of absolute risk difference [95%CI]: -0.036 [-0.089, 0.016] and -0.029 [-0.060, 0.002], respectively). However, these differences were not statistically significant. The average MEDD decreased at a higher rate for the BH group compared to EMR-CDS only (DID rate ratio [95%CI]: 0.85 [0.77, 0.93]). There were no changes in hospitalization and emergency department utilization. The BH group had higher probabilities of new specialty referrals and prescriptions for naloxone and antidepressants. CONCLUSIONS Incorporation of a multidisciplinary behavioral health care team into primary care did not decrease high-dose prescribing; however, it improved adherence to clinical guideline recommendations for managing chronic opioid therapy for non-cancer pain. TRIAL REGISTRATION ClinicalTrials.gov ID NCT03889418.
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Affiliation(s)
- Eboni G Price-Haywood
- Ochsner Xavier Institute for Health Equity and Research, Academic Center - 2nd Floor, 1401A Jefferson Highway, New Orleans, LA, 70121, USA.
- Center for Outcomes Research, 1401A Jefferson Highway, New Orleans, LA, 70121, USA.
- Ochsner Clinical School, University of Queensland, 1401A Jefferson Highway, New Orleans, LA, 70121, USA.
| | - Jeffrey H Burton
- Center for Outcomes Research, 1401A Jefferson Highway, New Orleans, LA, 70121, USA
| | - Jewel Harden-Barrios
- Ochsner Xavier Institute for Health Equity and Research, Academic Center - 2nd Floor, 1401A Jefferson Highway, New Orleans, LA, 70121, USA
- Center for Outcomes Research, 1401A Jefferson Highway, New Orleans, LA, 70121, USA
| | - Alessandra Bazzano
- School of Public Health and Tropical Medicine, Tulane University, 1440 Canal Street, New Orleans, LA, 70112, USA
| | - Lizheng Shi
- School of Public Health and Tropical Medicine, Tulane University, 1440 Canal Street, New Orleans, LA, 70112, USA
| | - John Lefante
- School of Public Health and Tropical Medicine, Tulane University, 1440 Canal Street, New Orleans, LA, 70112, USA
| | - Robert N Jamison
- Brigham and Women's Hospital, Pain Management Center, 850 Boylston Street, Chestnut Hill, MA, 02467, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA
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Yao M, Fang B, Yang J, Wang S, Chen F. Simultaneous determination of 14 analgesics in postoperative analgesic solution by HPLC-DAD and LC-MS/MS. BMC Chem 2024; 18:10. [PMID: 38200560 PMCID: PMC10782708 DOI: 10.1186/s13065-024-01113-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 01/03/2024] [Indexed: 01/12/2024] Open
Abstract
A green, efficient, sensitive and accurate detection method by HPLC-DAD and LC-MS/MS was developed and validated for the quantification of morphine, hydromorphone, oxycodone, ketamine tramadol, dezocine, ropivacaine, remifentanil, butorphanol, bupivacaine, droperidol, fentanyl, lornoxicam and sufentanil. The 14 mixtures were chromatographed via HPLC-DAD method which employed 0.05 mol/L potassium dihydrogen phosphate solution-acetonitrile as the mobile phase, the analytes were gradient elution on a SinoChrom ODS-BP C18 column with a total separation time of 35 min, and 14 mixtures showed a good linear relationship in the linear range. The Limit of Quantitation (LOQ) ranged from 0.10 to 20.0 µg/mL, the inter-day and intra-day precision of each analyte is within 1.1-2.0% and 0.4-1.3%, and the average absolute recovery of all compounds was above 98%. The LC-MS/MS method was used to successfully separate the 14 mixtures within 10 min which employed 0.1% formic acid-acetonitrile as the mobile phase, the analytes were gradient elution on a ACQUITY UPLC-BEH C18 column with a total separation time of 13 min, and 14 mixtures showed a good linear relationship in the linear range. The LOQ ranged from 0.005 to 0.2 ng/mL, the inter-day and intra-day precision of each analyte is within 1.2-4.1% and 0.6-3.3%, and the average absolute recovery of all compounds was above 93%. The proposed method has been successfully applied in the clinic and provides a strong technical basis for the quantitative detection of these 14 mixtures for detecting drug abuse, and for studying the stability and compatibility of analgesic solutions. The proposed methods were validated against ICH guidelines.
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Affiliation(s)
- Manman Yao
- Sinopharm Dongfeng General Hospital, Hubei University of Medicine, Shiyan, Hubei, 442008, People's Republic of China
- School of Pharmacy, Hubei University of Medicine, Shiyan, Hubei, 442000, People's Republic of China
| | - Baoxia Fang
- Sinopharm Dongfeng General Hospital, Hubei University of Medicine, Shiyan, Hubei, 442008, People's Republic of China
| | - Jinguo Yang
- Sinopharm Dongfeng General Hospital, Hubei University of Medicine, Shiyan, Hubei, 442008, People's Republic of China
| | - Sicen Wang
- Sinopharm Dongfeng General Hospital, Hubei University of Medicine, Shiyan, Hubei, 442008, People's Republic of China.
- School of Pharmacy, Xi'an Jiaotong University, Xi'an, 710061, Shanxi, People's Republic of China.
| | - Fuchao Chen
- Sinopharm Dongfeng General Hospital, Hubei University of Medicine, Shiyan, Hubei, 442008, People's Republic of China.
- School of Pharmacy, Hubei University of Medicine, Shiyan, Hubei, 442000, People's Republic of China.
- School of Pharmacy, Xi'an Jiaotong University, Xi'an, 710061, Shanxi, People's Republic of China.
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Gebke KB, McCarberg B, Shaw E, Turk DC, Wright WL, Semel D. A practical guide to recognize, assess, treat and evaluate (RATE) primary care patients with chronic pain. Postgrad Med 2023; 135:244-253. [PMID: 35060834 DOI: 10.1080/00325481.2021.2017201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The management of patients with chronic pain is one of the most important issues In medicine and public health. Chronic pain conditions cause substantial suffering for patients, their significant others and society over years and even decades and increases healthcare utilization resources including the cost of medical care, loss of productivity and provision of disability services. Primary care providers are at the frontline in the identification and management of patients with chronic pain, as the majority of patients enter the healthcare system through primary care and are managed by primary care providers. Due to the complexity of chronic pain and the range of issues involved, the accurate diagnosis of the causes of pain and the formulation of effective treatment plans presents significant challenges in the primary care setting. In this review, we use the classification of pain types based on pathophysiology as the template to guide the assessment, treatment, and monitoring of patients with chronic pain conditions. We outline key methods that can be used to efficiently and accurately diagnose the putative pathophysiological mechanisms underlying chronic pain conditions and describe how this information should be used to tailor the treatment plan to meet the patient's needs. We discuss methods to evaluate patients and the impact of treatment plans over a series of consultations, with a particular focus on strategies to improve the patient's ability to self-manage their pain and related symptoms and perform daily functions despite persistent pain. Finally, we introduce the mnemonic RATE (Recognize, Assess, Treat, and Evaluate) as a general strategy that healthcare providers can use to aid their management of patients presenting with chronic pain.
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Affiliation(s)
- Kevin B Gebke
- Department of Family Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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Quaye A, Silvia K, Richard J, Ibrahim Y, Craig WY, Rosen C. A prospective, randomized trial of the effect of buprenorphine continuation versus dose reduction on pain control and post-operative opioid use. Medicine (Baltimore) 2022; 101:e32309. [PMID: 36595741 PMCID: PMC9794322 DOI: 10.1097/md.0000000000032309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION An increasing number of individuals are taking buprenorphine for management of opioid use disorder (OUD). Pain control can be challenging when these patients develop acute pain requiring supplemental analgesia. Buprenorphine's pharmacokinetic profile can render supplemental opioid-based analgesia ineffective. There is limited guidance on the optimal management of buprenorphine when acute pain is anticipated. Although there is growing acceptance that the risk of OUD relapse with buprenorphine discontinuation overshadows the risks of increased opioid utilization and difficult pain control with buprenorphine continuation, perioperative courses comparing buprenorphine dose reduction and full dose buprenorphine continuation have yet to be investigated. Here, we describe the protocol for our randomized controlled, prospective trial investigating the effect of buprenorphine continuation compared to buprenorphine dose reduction on pain control, post-operative opioid use, and OUD symptom management in patients on buprenorphine scheduled for elective surgery. METHODS AND ANALYSIS This is a single institution, randomized trial that aims to enroll 80 adults using 12 mg buprenorphine or greater for treatment of OUD, scheduled for elective surgery. Participants will be randomly assigned to receive 8mg of buprenorphine on the day of surgery onwards until postsurgical pain subsides or to have their buprenorphine formulation continued at full dose perioperatively. Primary outcome will be a clinically significant difference in pain scores 24 hours following surgery. Secondary outcomes will be opioid consumption at 24, 48, and 72 hours postoperatively, opioid dispensing up to 30 days following surgery, changes in mood and withdrawal symptoms, opioid cravings, relapse of opioid misuse, and continued use of buprenorphine treatment postoperatively.
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Affiliation(s)
- Aurora Quaye
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, Portland, ME
- Spectrum Healthcare Partners, South Portland, ME
- * Correspondence: Aurora Quaye, Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME 04102 (e-mail: )
| | - Kristen Silvia
- Division of Addiction Medicine, Maine Medical Center, Portland, ME
| | - Janelle Richard
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, Portland, ME
| | - Yussr Ibrahim
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, Portland, ME
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Strigo IA, Murphy E, Mitchell JM, Spadoni AD. Learning from addiction: Craving of prescription opioids in chronic pain sufferers. Neurosci Biobehav Rev 2022; 142:104904. [PMID: 36202255 PMCID: PMC10917419 DOI: 10.1016/j.neubiorev.2022.104904] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/30/2022] [Accepted: 10/01/2022] [Indexed: 01/19/2023]
Abstract
Prescription opioids are a primary driver of opioid-related deaths. Although craving is a substantial component of OUD, the degree to which craving leads to misuse among chronic pain patients on long-term prescription opioids is unknown. A clear understanding of the factors that lead to misuse in this vulnerable population is needed for the development of safe and effective practices for opioid taper. This narrative review summarizes the relevant literature on the role of craving in addiction and chronic pain through epidemiological and behavioral studies. The first part of this review examines the role of craving in predicting opioid use/misuse in individuals with chronic pain with and without OUD. The second part covers methods on how craving is evaluated experimentally using both subjective and objective measures and provides related findings. The overall goal of this review is to facilitate the development of a population-specific description of craving in those who use opioids to control chronic pain and to describe how it may be mechanistically linked to patterns of opioid (mis)use.
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Affiliation(s)
- Irina A Strigo
- Emotion and Pain Laboratory, San Francisco Veterans Affairs Healthcare Center, 4150 Clement Street, San Francisco, CA 94121, USA; Department of Psychiatry, University of California San Francisco, 401 Parnassus Ave, San Francisco, CA 94143, USA.
| | - Emily Murphy
- Emotion and Pain Laboratory, San Francisco Veterans Affairs Healthcare Center, 4150 Clement Street, San Francisco, CA 94121, USA
| | - Jennifer M Mitchell
- Department of Psychiatry, University of California San Francisco, 401 Parnassus Ave, San Francisco, CA 94143, USA; Department of Neurology, University of California San Francisco, 401 Parnassus Ave, San Francisco, CA 94143, USA
| | - Andrea D Spadoni
- San Diego Veterans Affairs Healthcare Center, 3350 La Jolla Village Drive, San Diego, CA 92121, USA; Department of Psychiatry, University of California San Diego, San Diego, CA 92300, USA
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Coca-Martinez M, Wu K. Modification of Behavioral Habits in Prehabilitation Programs. Semin Oncol Nurs 2022; 38:151331. [PMID: 36030142 DOI: 10.1016/j.soncn.2022.151331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
OBJECTIVES To review the evidence supporting the modification of behavioral habits and substance use management during cancer treatment and how to implement them as part of a multimodal optimization intervention. DATA SOURCES A literature review of the association between cancer and behavioral habits, their impact on oncological treatment outcomes, and substance use management guidelines. CONCLUSION There is an association between harmful habits, such as smoking and alcohol consumption, and cancer. The continuation of poor behavioral habits throughout oncological treatments is associated with poor oncological outcomes and increased complications. Prehabilitation could be an ideal setting to screen, assess, and modify these harmful habits. Prehabilitation programs should be equipped with professionals and resources to help patients achieve harmful habit cessation. IMPLICATIONS FOR NURSING PRACTICE This review puts into manifest the importance of a multidisciplinary approach to substance use management. It can serve as a framework to develop a harmful habit cessation intervention in the context of multimodal prehabilitation to improve surgical and oncological outcomes in the cancer population.
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Affiliation(s)
- Miquel Coca-Martinez
- Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain; Department of Anesthesia McGill University Health Centre, Montreal, Canada.
| | - Kelan Wu
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada
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Chahin M, Matosz S, Khalel I, Day S, Keruakous A. Pain Management in Oncology Patients Amidst the Opioid Epidemic: How To Minimize Non-Medical Opioid Use. Cureus 2021; 13:e19500. [PMID: 34912639 PMCID: PMC8666098 DOI: 10.7759/cureus.19500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2021] [Indexed: 11/05/2022] Open
Abstract
The opioid epidemic continues to be a significant public health concern. On the surface, it appears difficult to understate the profound consequences and unnecessary loss of life at the hands of the opioid crisis throughout the 2010s. This reality should not dissuade rigorous attention toward those who have suffered unnecessarily due to an overreaching backlash toward the opioid crisis. Oncology patients have been significantly impacted on both ends of the opioid crisis. Like other populations, cancer patients were first affected during the initial surge of opioid availability, prescription, and use at the beginning of the crisis, where opioid abuse and overdose negatively impacted cancer patient populations at similar rates as the general population. Yet, cancer patients were perhaps even more heavily affected during secondary events after the initial crisis, as opioid restrictions and the stigmatization, undoubtedly beneficial in many spaces, of opioid use became prevalent across the American society. During this second period of the opioid crisis (loosely from 2013 to the present day after the Veterans Health Administration Opioid Safety Initiative started), restrictions on opioids have significantly decreased the use and access of opioids for cancer patients. Management of pain, in general, is a complex topic, and cancer pain is no exception. Cancer patients may experience pain related to the disease itself, its treatment, or other comorbidities. This review aims to clarify the impact of reducing opioid use on cancer patients over the past eight years. We summarize the challenges facing providers as they attempt to manage cancer-related pain. Additionally, we propose tools for best practices to reduce the unnecessary suffering of cancer patients and protect against the overuse and abuse of opioids.
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Affiliation(s)
- Michael Chahin
- Department of Hematology and Oncology, Georgia Cancer Center at Augusta University, Augusta, USA
| | - Sabrina Matosz
- Department of Hematology and Oncology, Georgia Cancer Center at Augusta University, Augusta, USA
| | - Irene Khalel
- Internal Medicine, University of Alexandria, Faculty of Medicine, Alexandria, EGY
| | - Silas Day
- Hematology and Medical Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, USA
| | - Amany Keruakous
- Department of Hematology and Oncology, Georgia Cancer Center at Augusta University, Augusta, USA
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Wylie A, Zacharoff K. A Perspective from the Field: How Can We Empower the Next Generation of Physician to Heal the Opioid Epidemic? ALCOHOLISM TREATMENT QUARTERLY 2021. [DOI: 10.1080/07347324.2021.2002226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Andrew Wylie
- Departments of Pediatrics and Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kevin Zacharoff
- Renaissance School of Medicine at Stony Brook University, Stony Brook, New York, USA
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Exploring the Psychometric Properties of the Current Opioid Misuse Measure Among Adults With Chronic Pain and Opioid Use. Clin J Pain 2021; 36:578-583. [PMID: 32433073 DOI: 10.1097/ajp.0000000000000846] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The opioid epidemic is a significant public health problem that is associated with overdose and death. The increase in opioid-related problems can largely be attributed to increases in opioid prescriptions for the treatment of chronic pain. Unfortunately, there is not a consensus on a definition of opioid misuse in the context of chronic pain, making measurement a challenge. One commonly used measure to assess opioid misuse in the context of chronic pain is the Current Opioid Misuse Measure (COMM). The COMM was designed to assess opioid misuse generally, as captured by psychiatric symptoms and aberrant drug use behaviors. Although studies have examined cross-validation using correlations, little psychometric work has been conducted, and therefore it is currently unknown what domains the measure is assessing. MATERIALS AND METHODS The current study examined the factor structure of the COMM using confirmatory and exploratory factor analysis among 445 opioid-using adults with chronic pain. RESULTS The results did not support the widely accepted 1-factor opioid misuse solution; rather they supported a 2-factor, psychiatric problems and aberrant-drug-use-problems factor structure. Convergent and divergent validity were also examined at the bivariate level. DISCUSSION Given the importance and relevance for opioid misuse in the context of chronic pain, it is important for researchers to continue assessing and providing psychometric evidence for the COMM.
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American Society of Hematology 2020 guidelines for sickle cell disease: management of acute and chronic pain. Blood Adv 2021; 4:2656-2701. [PMID: 32559294 DOI: 10.1182/bloodadvances.2020001851] [Citation(s) in RCA: 176] [Impact Index Per Article: 58.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/09/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The management of acute and chronic pain for individuals living with sickle cell disease (SCD) is a clinical challenge. This reflects the paucity of clinical SCD pain research and limited understanding of the complex biological differences between acute and chronic pain. These issues collectively create barriers to effective, targeted interventions. Optimal pain management requires interdisciplinary care. OBJECTIVE These evidence-based guidelines developed by the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in pain management decisions for children and adults with SCD. METHODS ASH formed a multidisciplinary panel, including 2 patient representatives, that was thoroughly vetted to minimize bias from conflicts of interest. The Mayo Evidence-Based Practice Research Program supported the guideline development process, including updating or performing systematic reviews. Clinical questions and outcomes were prioritized according to importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used, including GRADE evidence-to-decision frameworks, to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel reached consensus on 18 recommendations specific to acute and chronic pain. The recommendations reflect a broad pain management approach, encompassing pharmacological and nonpharmacological interventions and analgesic delivery. CONCLUSIONS Because of low-certainty evidence and closely balanced benefits and harms, most recommendations are conditional. Patient preferences should drive clinical decisions. Policymaking, including that by payers, will require substantial debate and input from stakeholders. Randomized controlled trials and comparative-effectiveness studies are needed for chronic opioid therapy, nonopioid therapies, and nonpharmacological interventions.
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Krčevski Škvarč N, Morlion B, Vowles KE, Bannister K, Buchsner E, Casale R, Chenot JF, Chumbley G, Drewes AM, Dom G, Jutila L, O'Brien T, Pogatzki-Zahn E, Rakusa M, Suarez-Serrano C, Tölle T, Häuser W. European clinical practice recommendations on opioids for chronic noncancer pain - Part 2: Special situations. Eur J Pain 2021; 25:969-985. [PMID: 33655678 DOI: 10.1002/ejp.1744] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 02/05/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Opioid use for chronic non-cancer pain (CNCP) is under debate. In the absence of pan-European guidance on this issue, a position paper was commissioned by the European Pain Federation (EFIC). METHODS The clinical practice recommendations were developed by eight scientific societies and one patient self-help organization under the coordination of EFIC. A systematic literature search in MEDLINE (up until January 2020) was performed. Two categories of guidance are given: Evidence-based recommendations (supported by evidence from systematic reviews of randomized controlled trials or of observational studies) and Good Clinical Practice (GCP) statements (supported either by indirect evidence or by case-series, case-control studies and clinical experience). The GRADE system was applied to move from evidence to recommendations. The recommendations and GCP statements were developed by a multiprofessional task force (including nursing, service users, physicians, physiotherapy and psychology) and formal multistep procedures to reach a set of consensus recommendations. The clinical practice recommendations were reviewed by five external reviewers from North America and Europe and were also posted for public comment. RESULTS The European Clinical Practice Recommendations give guidance for combination with other medications, the management of frequent (e.g. nausea, constipation) and rare (e.g. hyperalgesia) side effects, for special clinical populations (e.g. children and adolescents, pregnancy) and for special situations (e.g. liver cirrhosis). CONCLUSION If a trial with opioids for chronic noncancer pain is conducted, detailed knowledge and experience are needed to adapt the opioid treatment to a special patient group and/or clinical situation and to manage side effects effectively. SIGNIFICANCE If a trial with opioids for chronic noncancer pain is conducted, detailed knowledge and experience are needed to adapt the opioid treatment to a special patient group and/or clinical situation and to manage side effects effectively. A collaboration of medical specialties and of all health care professionals is needed for some special populations and clinical situations.
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Affiliation(s)
- Nevenka Krčevski Škvarč
- Department of Anesthesiology, Intensive Care and Pain Treatment, Faculty of Medicine of University Maribor, Maribor, Slovenia
| | - Bart Morlion
- Center for Algology & Pain Management, University Hospitals Leuven, Leuven, Belgium
| | - Kevin E Vowles
- School of Psychology, Queen's University Belfast, Belfast, UK
| | - Kirsty Bannister
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Eric Buchsner
- Pain Management and Neuromodulation Centre EHC Hospital, Morges, Switzerland
| | - Roberto Casale
- Neurorehabilitation Unit, Department of Rehabilitation, HABILITA, Bergamo, Italy
| | - Jean-François Chenot
- Department of General Practice, Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Gillian Chumbley
- Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Geert Dom
- Collaborative Antwerp Psychiatric Research Institute (CAPRI), Antwerp University (UA), Antwerp, Belgium
| | | | - Tony O'Brien
- College of Medicine & Health, University College Cork, Cork, Republic of Ireland
| | - Esther Pogatzki-Zahn
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster UKM, Munster, Germany
| | - Martin Rakusa
- Department of Neurology, University Medical Centre Maribor, Maribor, Slovenia
| | | | - Thomas Tölle
- Department of Neurology, Techhnische Universität München, München, Germany
| | - Winfried Häuser
- Department Internal Medicine 1, Saarbrücken, Germany.,Department of Psychosomatic Medicine and Psychotherapy, Technische Universität München, Munich, Germany
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Price-Haywood EG, Burton J, Harden-Barrios J, Bazzano A, Lefante J, Shi L, Jamison RN. Depression, anxiety, pain and chronic opioid management in primary care: Type II effectiveness-implementation hybrid stepped wedge cluster randomized trial. Contemp Clin Trials 2020; 101:106250. [PMID: 33326877 DOI: 10.1016/j.cct.2020.106250] [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: 09/13/2020] [Revised: 11/14/2020] [Accepted: 12/08/2020] [Indexed: 11/17/2022]
Abstract
Even though current prescribing trends reveal that high-dose opioid prescribing and opioid prescribing in general has decreased, sustained efforts are needed to help providers adopt and maintain safe prescribing behaviors. The purpose of this four-year type 2 effectiveness-implementation hybrid stepped wedge cluster randomized trial is to: (1) compare the clinical and cost effectiveness of electronic medical record-based clinical decision support [EMR-CDS] versus additional integrated, collaborative behavioral health [EMR-CDS + BHI-CCM] for opioid management of patients with co-morbid chronic non-cancer pain with depression or anxiety; and (2) examine facilitators and barriers to implementing these interventions within 35 primary care clinics in a integrated delivery health system. The EMR-CDS alerts providers to employ opioid risk mitigation and safe prescribing practices at the point of care. The BHI-CCM consists of primary care embedded community health workers for case management; licensed clinical social workers for cognitive behavioral therapy, and a clinical pharmacist for medication management who provide care management via telemedicine (virtual video or audio only visits) under the guidance of a consulting psychiatrist. The primary outcome is reduction in the percentage of patients with average daily opioid dose ≥50 mg morphine equivalent. Secondary outcomes include changes in service utilization, patient reported outcomes and processes of care. The investigators anticipate that study results will elucidate the role of technology versus care team optimization in changing opioid prescribing behaviors. The investigators further anticipate that integrated mental/behavioral health care will increase value-based care and the efficiency with which guideline concordant care is delivered.
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Affiliation(s)
- Eboni G Price-Haywood
- Ochsner Center for Outcomes and Health Services Research, 1514 Jefferson Highway, New Orleans, LA 70121, USA; Ochsner Clinical School, University of Queensland, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
| | - Jeffrey Burton
- Ochsner Center for Outcomes and Health Services Research, 1514 Jefferson Highway, New Orleans, LA 70121, USA
| | - Jewel Harden-Barrios
- Ochsner Center for Outcomes and Health Services Research, 1514 Jefferson Highway, New Orleans, LA 70121, USA
| | - Alessandra Bazzano
- Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, New Orleans, LA 70112, USA
| | - John Lefante
- Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, New Orleans, LA 70112, USA
| | - Lizheng Shi
- Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, New Orleans, LA 70112, USA
| | - Robert N Jamison
- Brigham and Women's Hospital, Pain Management Center, 850 Boylston Street, Chestnut Hill, MA 02467, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
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Case AA, Walter M, Pailler M, Stevens L, Hansen E. A Practical Approach to Nonmedical Opioid Use in Palliative Care Patients With Cancer: Using the PARTNERS Framework. J Pain Symptom Manage 2020; 60:1253-1259. [PMID: 32882356 DOI: 10.1016/j.jpainsymman.2020.08.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/18/2020] [Accepted: 08/22/2020] [Indexed: 12/19/2022]
Affiliation(s)
- Amy A Case
- Department of Supportive and Palliative Care, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA; Department of Geriatrics and Palliative Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA.
| | - Michelle Walter
- Department of Supportive and Palliative Care, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA; Department of Geriatrics and Palliative Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Megan Pailler
- Department of Supportive and Palliative Care, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - LuAnn Stevens
- Department of Supportive and Palliative Care, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Eric Hansen
- Department of Supportive and Palliative Care, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA; Department of Geriatrics and Palliative Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
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Nielsen S, Picco L, Campbell G, Lintzeris N, Larance B, Farrell M, Degenhardt L, Bruno R. Development of a Brief Patient-Administered Screening Tool for Prescription Opioid Dependence for Primary Care Settings. PAIN MEDICINE (MALDEN, MASS.) 2020; 21:e79-e88. [PMID: 31591644 PMCID: PMC8204889 DOI: 10.1093/pm/pnz213] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To develop a short, patient-administered screening tool that will allow for earlier assessment of prescription opioid dependence (often referred to as addiction) in primary care settings. DESIGN AND SETTING Cross-sectional analysis (N = 1,134) from the two-year time point of the Pain and Opioids IN Treatment (POINT) cohort was used in the scale development. SUBJECTS Participants who completed two-year interviews in the POINT study, a prospective cohort study that followed people with chronic noncancer pain over a five-year period, and who were prescribed strong opioids for a minimum of six weeks at baseline. METHODS An advisory committee provided advice on wording and content for screening in primary care settings. Univariate logistic regression identified individual items that were significantly associated with meeting ICD-11 criteria for prescription opioid dependence. Exploratory and confirmatory factor analysis (EFA and CFA) were conducted, and items were reduced to identify a small item set that were discriminative and shared a simple underlying structure. RESULTS Sixty-four variables associated with ICD-11 criteria for prescription opioid dependence were initially identified. Four rounds of EFA were performed, resulting in five items remaining. CFA identified two possible four-item combinations, with the final combination chosen based on greater item endorsement and the results of goodness-of-fit indices. CONCLUSIONS Addressing prescription opioid dependence is an important part of the global public health challenge surrounding rising opioid-related harm. This study addresses an important initial requisite step to develop a brief screening tool. Further studies are required to validate the tool in clinical settings.
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Affiliation(s)
- Suzanne Nielsen
- National Drug and Alcohol Research Centre, University of New South Wales Sydney, Sydney, New South Wales, Australia
- Monash Addiction Research Centre, Monash University Peninsula Campus, Frankston, Victoria, Australia
| | - Louisa Picco
- Monash Addiction Research Centre, Monash University Peninsula Campus, Frankston, Victoria, Australia
| | - Gabrielle Campbell
- National Drug and Alcohol Research Centre, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | - Nicholas Lintzeris
- Discipline of Addiction Medicine, University of Sydney, Sydney, New South Wales, Australia
- The Langton Centre, South East Sydney Local Health District (SESLHD) Drug and Alcohol Services, Sydney, New South Wales, Australia
| | - Briony Larance
- National Drug and Alcohol Research Centre, University of New South Wales Sydney, Sydney, New South Wales, Australia
- School of Psychology, University of Wollongong, Wollongong, New South Wales, Australia
| | - Michael Farrell
- National Drug and Alcohol Research Centre, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales Sydney, Sydney, New South Wales, Australia
- School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Raimondo Bruno
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
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Lindley B, Cox N, Cochran G. Screening tools for detecting problematic opioid use and potential application to community pharmacy practice: a review. INTEGRATED PHARMACY RESEARCH AND PRACTICE 2019; 8:85-96. [PMID: 31410349 PMCID: PMC6649304 DOI: 10.2147/iprp.s185663] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 07/03/2019] [Indexed: 01/03/2023] Open
Abstract
Problematic opioid use, constituted by a myriad of conditions ranging from misuse to use disorders, has continued to receive an increasing amount of attention in recent years resulting from the high use of opioids in the United States coinciding with morbidity and mortality. Deaths from drug overdoses increased by over 11% between 2014 and 2015, which supports the need for identification of problematic opioid use in additional health care settings. One of these settings is community pharmacy. The community pharmacy is a unique health service setting to identify and potentially intervene with patients at risk of or exhibit problematic opioid use. Problematic opioid use can be identified using one of the various screening tools in conjunction with evaluating prescription drug monitoring systems. A total of 12 tools were identified that could be employed in community pharmacy settings for identifying problematic opioid use. This review highlights these tools and strategies for use that can be utilized in the community pharmacy, which should be adapted to individual pharmacy settings and local needs. Future research should assess pharmacy personnel's knowledge and perceptions of problematic opioid use and associated screening tools and interventions, which tools can be most effectively used in a community pharmacy, workflow needs to implement problematic opioid use screenings, and the impact of pharmacist engagement in problematic opioid use screening on patient clinical outcomes.
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Affiliation(s)
- Bryn Lindley
- University of Utah, College of Pharmacy, Salt Lake City, UT, USA
| | - Nicholas Cox
- University of Utah, College of Pharmacy, Department of Pharmacotherapy, Salt Lake City, UT, USA
| | - Gerald Cochran
- University of Utah, School of Medicine, Division of Epidemiology, Salt Lake City, UT, USA
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Affiliation(s)
- Kavita M Babu
- From the Division of Medical Toxicology and the Department of Emergency Medicine, University of Massachusetts Medical School, Worcester (K.M.B.); the Departments of Medicine and Emergency Medicine, University of Colorado School of Medicine, and the Department of Medicine, Colorado School of Public Health - both in Aurora (J.B.); and the Division of General Internal Medicine and the Departments of Clinical Pharmacology and Toxicology and Medicine, University of Toronto, Toronto (D.N.J.)
| | - Jeffrey Brent
- From the Division of Medical Toxicology and the Department of Emergency Medicine, University of Massachusetts Medical School, Worcester (K.M.B.); the Departments of Medicine and Emergency Medicine, University of Colorado School of Medicine, and the Department of Medicine, Colorado School of Public Health - both in Aurora (J.B.); and the Division of General Internal Medicine and the Departments of Clinical Pharmacology and Toxicology and Medicine, University of Toronto, Toronto (D.N.J.)
| | - David N Juurlink
- From the Division of Medical Toxicology and the Department of Emergency Medicine, University of Massachusetts Medical School, Worcester (K.M.B.); the Departments of Medicine and Emergency Medicine, University of Colorado School of Medicine, and the Department of Medicine, Colorado School of Public Health - both in Aurora (J.B.); and the Division of General Internal Medicine and the Departments of Clinical Pharmacology and Toxicology and Medicine, University of Toronto, Toronto (D.N.J.)
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Gabbard J, Jordan A, Mitchell J, Corbett M, White P, Childers J. Dying on Hospice in the Midst of an Opioid Crisis: What Should We Do Now? Am J Hosp Palliat Care 2018; 36:273-281. [DOI: 10.1177/1049909118806664] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
The current opioid crisis in the United States is a major problem facing health-care providers, even at the end of life. Opioids continue to be the mainstay treatment for pain at the end of life, with the prevalence of pain reported in up to 80% of patients and tends to increase as one gets closer toward the end of life. In the past year, 20.2 million Americans had a substance use disorder (SUD) and SUDs are disabling disorders that largely go untreated. In addition, the coexistence of both a mental health and SUD is very common with the use of opioids often as a means of chemical coping. Most hospice programs do not have standardized SUD policies/guidelines in place despite the increasing concerns about substance abuse within the United States. The goal of this article is to review the literature on this topic and offer strategies on how to manage pain in patients who have active SUD or who are at risk for developing SUD in those dying on hospice.
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Affiliation(s)
- Jennifer Gabbard
- Department of Internal Medicine, Internal Medicine Section of Gerontology and Geriatrics, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Allison Jordan
- Department of Palliative Medicine, Christian and Alton Memorial Hospitals, BJC Hospice, Washington University School of Medicine, St. Louis, MO, USA
| | - Julie Mitchell
- Department of Internal Medicine, Division of Hospital Medicine, Emory Palliative Care Center, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Patrick White
- Department of Internal Medicine, BJC Home Care, Washington University School of Medicine, St. Louis, MO, USA
| | - Julie Childers
- Section of Palliative Care and Medical Ethics and Section of Treatment, Research and Education in Addiction Medicine, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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