Using opioids with persisting noncancer pain: a biopsychosocial perspective

The Association Between Local Economic Conditions and Opioid Prescriptions Among Disabled Medicare Beneficiaries

BACKGROUND

This paper concerns public health crises today-the problem of opioid prescription access and related abuse. Inspired by Case and Deaton's seminal work on increasing mortality among white Americans with lower education, this paper explores the relationship between opioid prescribing and local economic factors.

OBJECTIVE

We examined the association between county-level socioeconomic factors (median household income, unemployment rate, Gini index) and opioid prescribing.

SUBJECTS

We used the complete 2014 Medicare enrollment and part D drug prescription data from the Center for Medicare and Medicaid Services to study opioid prescriptions of disabled Medicare beneficiaries without record of cancer treatment, palliative care, or end-of-life care.

MEASURES AND RESEARCH DESIGN

We summarized the demographic and geographic variation, and investigated how the local economic environment, measured by county median household income, unemployment rate, Gini index, and urban-rural classification correlated with various measures of individual opioid prescriptions. Measures included number of filled opioid prescriptions, total days' supply, average morphine milligram equivalent (MME)/day, and annual total MME dosage. To assess the robustness of the results, we controlled for individual and other county characteristics, used multiple estimation methods including linear least squares, logistic regression, and Tobit regression.

RESULTS AND CONCLUSIONS

Lower county median household income, higher unemployment rates, and less income inequality were consistently associated with more and higher MME opioid prescriptions among disabled Medicare beneficiaries. Geographically, we found that the urban-rural divide was not gradual and that beneficiaries in large central metro counties were less likely to have an opioid prescription than those living in other areas.

Are self-management strategies effective in chronic pain treatment?

It has long been recognized that in the management of chronic illnesses generally, medical care alone is unlikely to be sufficient without the active contribution of the patient. This perspective has also been enunciated in numerous guidelines for the management of chronic pain. However, in the case of chronic pain at least, the nature and role of self-management have been poorly defined and, as a result, poorly understood and researched. This review considers the nature of self-management strategies for chronic pain, evidence of their effectiveness and ways in which self-management can be facilitated for those in chronic pain. A research and training agenda is proposed for where this work could go next.

Chronic Pain in the Outpatient Palliative Care Clinic

Chronic pain is common. Many patients with cancer and other life-limiting illnesses have chronic pain that is related to their disease, and some have comorbid chronic nonmalignant chronic pain. As palliative care continues to move upstream and outpatient palliative care programs develop, palliative care clinicians will be called upon to treat chronic pain. Chronic pain differs from acute pain in the setting of advanced disease and a short prognosis in terms of its etiology, comorbidities—especially psychiatric illness and substance abuse—and management. To successfully care for these patients, palliative care providers will need to learn new clinical competencies. This article will review chronic pain management core competencies for palliative care providers.

Economic impact of potential drug-drug interactions in opioid analgesics

OBJECTIVE

Patients managing chronic non-cancer pain with cytochrome P450 (CYP450)-metabolized opioid analgesics who concurrently take another CYP450-metabolized medication experience a drug-drug exposure (DDE), which puts them at risk for a pharmacokinetic drug-drug interaction (PK DDI). This study examined the economic impact of incident DDEs with the potential to cause PK DDIs compared to similar patients without such exposure.

STUDY DESIGN

This retrospective analysis used paid claims from a large, commercially insured population during January 1, 2004 through December 31, 2008.

METHODS

Propensity matching was used to control for baseline differences in comparisons between 85,043 exposed and 85,043 non-exposed patients.

RESULTS

Comparisons yielded mean total costs 6 months after the DDEs that were significantly higher in subjects with DDE versus matched subjects without DDE [$8165 (SD $11,357) vs. $7498 (SD $11,668), respectively, p<0.01] resulting in a difference of $667. This was driven by medical costs [$5520 (SD $10,505) vs. $5222 (SD $10,689), respectively, p<0.01] a $298 difference, and total prescription costs [$2646 (SD $3262) vs. $2276 (SD $3907), respectively, p<0.01] a $369 difference.

LIMITATIONS

The study design demonstrates associations only and cannot establish causal relationships. Further, relevant DDEs were not included if concurrent consumption occurred outside the index period and when CYP450 substances were consumed that are not reflected in pharmacy claims (herbals, over-the-counter medications).

CONCLUSION

Since concurrent exposure to DDEs with the potential to cause PK DDIs may be relatively common, policy decisions-makers should consider the use of long-acting opioids that are not metabolized through the CYP450 pathway.

Understanding primary care physicians' treatment of chronic low back pain: the role of physician and practice factors

BACKGROUND

An increasing number of Operation Iraqi Freedom/Operation Enduring Freedom veterans experience chronic pain. Despite treatment guidelines, there is wide variation in physicians' approaches to pain treatment, and many physicians are unsure of the best treatment approach. Research has examined factors associated with opioid prescribing, but there is little information on physician characteristics that predict patterns of clinical responses to pain.

OBJECTIVES

To identify patterns in primary care physicians' treatment decisions for nonmalignant chronic pain, and identify physician and practice characteristics that predict treatment decision patterns.

METHODS

A national sample of 381 primary care physicians who responded to a mailed vignette involving a veteran with chronic low back pain (LBP) were categorized into latent classes by clinical actions taken to treat the pain. The associations between newly derived treatment patterns and physician and practice characteristics were examined with multivariate models.

RESULTS

Latent class analysis identified three treatment approaches: 1) Multimodal/Aggressive (14%); 2) Low Action (38%); and 3) Psychosocial/Non-Opioid (48%). In a multivariate model, treatment pattern was associated with demographic and personality factors; opioid-related attitudes, beliefs, and concerns; perceptions of the patient; availability of resources; and practice characteristics.

CONCLUSIONS

There may be distinct patterns in primary care physicians' responses to patients with chronic pain. Relatively few physicians use the multimodal approach endorsed by proponents of the biopsychosocial model of pain treatment. Several physician and practice characteristics predict patterns of clinical action.

Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society

STUDY DESIGN

Clinical practice guideline.

OBJECTIVE

To develop evidence-based recommendations on use of interventional diagnostic tests and therapies, surgeries, and interdisciplinary rehabilitation for low back pain of any duration, with or without leg pain.

SUMMARY OF BACKGROUND DATA

Management of patients with persistent and disabling low back pain remains a clinical challenge. A number of interventional diagnostic tests and therapies and surgery are available and their use is increasing, but in some cases their utility remains uncertain or controversial. Interdisciplinary rehabilitation has also been proposed as a potentially effective noninvasive intervention for persistent and disabling low back pain.

METHODS

A multidisciplinary panel was convened by the American Pain Society. Its recommendations were based on a systematic review that focused on evidence from randomized controlled trials. Recommendations were graded using methods adapted from the US Preventive Services Task Force and the Grading of Recommendations, Assessment, Development, and Evaluation Working Group.

RESULTS

Investigators reviewed 3348 abstracts. A total of 161 randomized trials were deemed relevant to the recommendations in this guideline. The panel developed a total of 8 recommendations.

CONCLUSION

Recommendations on use of interventional diagnostic tests and therapies, surgery, and interdisciplinary rehabilitation are presented. Due to important trade-offs between potential benefits, harms, costs, and burdens of alternative therapies, shared decision-making is an important component of a number of the recommendations.

Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain

Use of chronic opioid therapy for chronic noncancer pain has increased substantially. The American Pain Society and the American Academy of Pain Medicine commissioned a systematic review of the evidence on chronic opioid therapy for chronic noncancer pain and convened a multidisciplinary expert panel to review the evidence and formulate recommendations. Although evidence is limited, the expert panel concluded that chronic opioid therapy can be an effective therapy for carefully selected and monitored patients with chronic noncancer pain. However, opioids are also associated with potentially serious harms, including opioid-related adverse effects and outcomes related to the abuse potential of opioids. The recommendations presented in this document provide guidance on patient selection and risk stratification; informed consent and opioid management plans; initiation and titration of chronic opioid therapy; use of methadone; monitoring of patients on chronic opioid therapy; dose escalations, high-dose opioid therapy, opioid rotation, and indications for discontinuation of therapy; prevention and management of opioid-related adverse effects; driving and work safety; identifying a medical home and when to obtain consultation; management of breakthrough pain; chronic opioid therapy in pregnancy; and opioid-related policies.

PERSPECTIVE

Safe and effective chronic opioid therapy for chronic noncancer pain requires clinical skills and knowledge in both the principles of opioid prescribing and on the assessment and management of risks associated with opioid abuse, addiction, and diversion. Although evidence is limited in many areas related to use of opioids for chronic noncancer pain, this guideline provides recommendations developed by a multidisciplinary expert panel after a systematic review of the evidence.

Individual differences in opioid efficacy for chronic noncancer pain

OBJECTIVE

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

METHODS

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

RESULTS

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

DISCUSSION

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

What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review

DESIGN

This is a structured evidence-based review of all available studies on the development of abuse/addiction and aberrant drug-related behaviors (ADRBs) in chronic pain patients (CPPs) with nonmalignant pain on exposure to chronic opioid analgesic therapy (COAT).

OBJECTIVES

To determine what percentage of CPPs develop abuse/addiction and/or ADRBs on COAT exposure.

METHOD

Computer and manual literature searches yielded 79 references that addressed this area of study. Twelve of the studies were excluded from detailed review based on exclusion criteria important to this area. Sixty-seven studies were reviewed in detail and sorted according to whether they reported percentages of CPPs developing abuse/addiction or developing ADRBs, or percentages diagnosed with alcohol/illicit drug use as determined by urine toxicology. Study characteristics were abstracted into tabular form, and each report was characterized according to the type of study it represented based on the Agency for Health Care Policy and Research Guidelines. Each study was independently evaluated by two raters according to 12 quality criteria and a quality score calculated. Studies were not utilized in the calculations unless their quality score (utilizing both raters) was greater than 65%. Within each of the above study groupings, the total number of CPPs exposed to opioids on COAT treatment was calculated. Similarly, the total number of CPPs in each grouping demonstrating abuse/addiction, ADRBs, or alcohol/illicit drug use was also calculated. Finally, a percentage for each of these behaviors was calculated in each grouping, utilizing the total number of CPPs exposed to opioids in each grouping.

RESULTS

All 67 reports had quality scores greater than 65%. For the abuse/addiction grouping there were 24 studies with 2,507 CPPs exposed for a calculated abuse/addiction rate of 3.27%. Within this grouping for those studies that had preselected CPPs for COAT exposure for no previous or current history of abuse/addiction, the percentage of abuse/addiction was calculated at 0.19%. For the ADRB grouping, there were 17 studies with 2,466 CPPs exposed and a calculated ADRB rate of 11.5%. Within this grouping for preselected CPPs (as above), the percentage of ADRBs was calculated at 0.59%. In the urine toxicology grouping, there were five studies (15,442 CPPs exposed). Here, 20.4% of the CPPs had no prescribed opioid in urine and/or a nonprescribed opioid in urine. For five studies (1,965 CPPs exposed), illicit drugs were found in 14.5%.

CONCLUSION

The results of this evidence-based structured review indicate that COAT exposure will lead to abuse/addiction in a small percentage of CPPs, but a larger percentage will demonstrate ADRBs and illicit drug use. These percentages appear to be much less if CPPs are preselected for the absence of a current or past history of alcohol/illicit drug use or abuse/addiction.

Interstitial cystitis pathogenesis and treatment

PURPOSE OF REVIEW

Interstitial cystitis remains an idiopathic illness characterized by urinary frequency, urgency and pelvic pain with substantial morbidity in those affected. There is significant variability in the presentation, severity of symptoms and response to therapy. This review focuses on recent findings on the possible pathogenesis and potential treatments for this disease.

RECENT FINDINGS

Interstitial cystitis is manifested by sensory hypersensitivity. A small volume of urine will be associated with an exaggerated sensation of pain or pressure and urinary urgency. There is continued research regarding how this process is initiated and maintained and to what extent systemic dysfunction of the immune or autonomic nervous system may play a role. The urothelial lining has been demonstrated to be capable of secreting a large number of potential signaling molecules that may be significant factors in the disease.

SUMMARY

The pathogenesis of interstitial cystitis remains uncertain and the illness has significant diversity. Additional research is needed to establish subtypes that share common processes that can be targeted for treatment as a single effective therapy for the condition remains elusive.

Does a Combination of Intensive Cognitive-Behavioral Pain Management and a Spinal Implantable Device Confer any Advantage? A Preliminary Examination

Research suggests that a combination of a somatic and a psychosocial intervention for chronic noncancer pain should be associated with a better outcome than either alone. This study presents data on a series of 31 patients who underwent sequential treatment with an implantable device targeting pain relief and a cognitive-behavioral pain management program that targeted improved function. A combination of treatments was used as there was a suboptimal response to the initial treatment. There were improvements in a range of outcomes at a long-term follow-up. Significant improvements were found in disability, affective distress, self-efficacy, and catastrophizing, but not in average pain severity. Further analyses failed to demonstrate an order effect. These results support the view that combined somatic and psychosocial interventions can achieve better outcomes than either alone in selected chronic pain patients. This approach requires that psychological assessment is essential before the use of an implantable device. This may not only improve patient selection, but also identify psychosocial factors that may be modified to enhance the effectiveness of invasive interventions. In addition, consideration for an implantable device following a suboptimal response to treatment in a cognitive-behavioral pain management program should include a re-evaluation of the patients' beliefs and use of self-management (coping) strategies before deciding on further treatment options.