Assessing reasons for decreased primary care access for individuals on prescribed opioids: an audit study

Difficult Encounters in Chronic Pain Patients: A Cohort Study

OBJECTIVE

To determine variables associated with difficult clinical encounters.

PATIENTS AND METHODS

This was a cross-sectional study of 428 new patients evaluated from 2022 to 2023. Demographic, clinical, social (eg, missed appointments, prior felony conviction, prior pain physicians, medical assistance) and visit-related (eg, visit took longer than expected, difficulty communicating) information was recorded, supplemented by in-person history gathered by the trainee and attending whose demographic data were also recorded. Physicians independently rated the "difficulty" of the encounter on a 6-point Likert scale from 1 = very easy/pleasant, 2 = easy/pleasant, 3 = neutral/average, 4 = difficult, 5 = very difficult, to 6 = extremely difficult. A difficult encounter was a combined trainee and attending rating of one IQR above the median of 2.0±1.75.

RESULTS

Among 428 participants, mean ± SD age was 54.2±15.8 years and 261 (61.0%) were female. Attending gender, gender concordance, race and racial concordance, and years of physician experience were not associated with difficulty. In multivariable analysis, requesting opioids (P=.001), lengthier than expected visit (P<.001), hostile/demanding behavior (P=.003), refusal to try recommended treatment (P=.002), unrealistic expectations (P<0.001), and difficulty communicating (P=.02) were associated with difficult encounters.

CONCLUSION

Most variables associated with physician impressions of difficult encounters were visit-related, suggesting some patient-related factors (eg, prior substance abuse, translator requirement) may be less relevant in pain patients. Future research should evaluate interventions designed to decrease the difficulty of encounters and determine their effect on patients and physicians.

"Saving us to Death": Ideology and Communicative (Dis)enfranchisement in Misapplications of the 2016 CDC Opioid Prescribing Guidelines

Guided by the theory of communicative (dis)enfranchisement (TCD), this study interrogates how interactions in which chronic pain patients are force tapered from their prescribed opioids are constrained and afforded by the hegemonic ideologies. To interrogate the harms caused for chronic pain patients by ideological policies enacted by the Centers for Disease Control and Prevention and assess what communicative mechanisms reify and resist such ideologies, this research analyzes 238 posts authored by chronic pain patient Reddit users. Reflexive thematic analysis illuminated a hegemonic ideology of opiophobia, (im)material ramifications of (a) discrimination by doctors, and (b) political and legal interference; mechanisms of reification: (a) positioning suicide as a rational option, (b) advocating for the use of illicit substances, and (c) stopping opioids voluntarily; and mechanisms of resistance: (a) counter-organizing and (b) counter-generating knowledge. We offer theoretical implications for the TCD and practical implications for patients, providers, patient advocacy organizations, and policymakers.

Access to care for patients with chronic pain receiving prescription opioids, cannabis, or other treatments

Changes in chronic noncancer pain treatment have led to decreases in prescribing of opioids and increases in the availability of medical cannabis, despite its federal prohibition. Patients may face barriers to establishing new care with a physician based on use of these treatments. We compared physician willingness to accept patients based on prescription opioid, cannabis, or other pain treatment use. This study of 36 states and Washington, DC, with active medical cannabis programs surveyed physicians who treat patients with chronic noncancer pain between July 13 and August 4, 2023. Of 1000 physician respondents (34.5% female, 63.2% White, 78.1% primary care), 852 reported accepting new patients with chronic pain. Among those accepting new patients with chronic pain, more physicians reported that they would not accept new patients taking prescription opioids (20.0%) or cannabis (12.7%) than those taking nonopioid prescription analgesics (0.1%). In contrast, 68.1% reported willingness to accept new patients using prescribed opioids on a daily basis. For cannabis, physicians were more likely to accept new patients accessing cannabis through medical programs (81.6%) than from other sources (60.2%). Access to care for persons with chronic noncancer pain appears to be the most restricted among those taking prescription opioids, although patients taking cannabis may also encounter reduced access.

Paths Forward for Clinicians Amidst the Rise of Unregulated Clinical Decision Support Software: Our Perspective on NarxCare

Amidst the US overdose epidemic, policymakers, law enforcement agencies, and healthcare institutions have contributed to a decrease in opioid prescribing, assuming reduced mortality would result-an assumption we now understand was oversimplified. At this intersection between public health and public safety domains as they relate to opioid prescribing, unregulated and proprietary clinical decision support tools have emerged without rigorous external validation or public data sharing. In the following piece, we discuss challenges facing clinicians practicing medicine amidst unregulated clinical decision support tools, using the case of Bamboo Health's NarxCare-a prescription drug monitoring program-based analytics platform marketed as a clinical decision support tool-that is already positioned to impact over 1 billion patient encounters annually. We argue that sufficient evidence does not yet exist to support NarxCare's wide implementation, and that clinical decision support tools like NarxCare have flourished in recent years due to a lack of federal regulatory oversight and shielding by their proprietary formulas, which have facilitated their unchecked and outsized influence on patient care. Finally, we suggest specific actions by federal regulatory agencies, healthcare institutions, individual clinicians, and researchers, as well as academic journals, to mitigate potential harms associated with unregulated clinical decision support tools.

Improving Access to Care for Patients Taking Opioids for Chronic Pain: Recommendations from a Modified Delphi Panel in Michigan

Purpose

About 5-8 million US patients take long-term opioid therapy for chronic pain. In the context of policies and guidelines instituted to reduce inappropriate opioid prescribing, abrupt discontinuations in opioid prescriptions have increased and many primary care clinics will not prescribe opioids for new patients, reducing access to care. This may result in uncontrolled pain and other negative outcomes, such as transition to illicit opioids. The objective of this study was to generate policy, intervention, and research recommendations to improve access to care for these patients.

Participants and Methods

We conducted a RAND/UCLA Modified Delphi, consisting of workshops, background videos and reading materials, and moderated web-based panel discussions held September 2020-January 2021. The panel consisted of 24 individuals from across Michigan, identified via expert nomination and snowball recruitment, including clinical providers, health science researchers, state-level policymakers and regulators, care coordination experts, patient advocates, payor representatives, and community and public health experts. The panel proposed intervention, policy, and research recommendations, scored the feasibility, impact, and importance of each on a 9-point scale, and ranked all recommendations by implementation priority.

Results

The panel produced 11 final recommendations across three themes: reimbursement reform, provider education, and reducing racial inequities in care. The 3 reimbursement-focused recommendations were highest ranked (theme average = 4.2/11), including the two top-ranked recommendations: increasing reimbursement for time needed to treat complex chronic pain (ranked #1/11) and bundling payment for multimodal pain care (#2/11). Four provider education recommendations ranked slightly lower (theme average = 6.2/11) and included clarifying the spectrum of opioid dependence and training providers on multimodal treatments. Four recommendations addressed racial inequities (theme average = 7.2/11), such as standardizing pain management protocols to reduce treatment disparities.

Conclusion

Panelists indicated reimbursement should incentivize traditionally lower-paying evidence-based pain care, but multiple strategies may be needed to meaningfully expand access.

Drug use patterns and factors related to the use and discontinuation of medications for opioid use disorder in the age of fentanyl: findings from a mixed-methods study of people who use drugs

BACKGROUND

Medications for opioid use disorder (MOUD; methadone, buprenorphine, naltrexone) are the most effective treatments for OUD, and MOUD is protective against fatal overdoses. However, continued illegal drug use can increase the risk of treatment discontinuation. Given the widespread presence of fentanyl in the drug supply, research is needed to understand who is at greatest risk for concurrent MOUD and drug use and the contexts shaping use and treatment discontinuation.

METHODS

From 2017 to 2020, Massachusetts residents with past-30-day illegal drug use completed surveys (N = 284) and interviews (N = 99) about MOUD and drug use. An age-adjusted multinomial logistic regression model tested associations between past-30-day drug use and MOUD use (current/past/never). Among those on methadone or buprenorphine (N = 108), multivariable logistic regression models examined the association between socio-demographics, MOUD type; and past-30-day use of heroin/fentanyl; crack; benzodiazepines; and pain medications. Qualitative interviews explored drivers of concurrent drug and MOUD use.

RESULTS

Most (79.9%) participants had used MOUD (38.7% currently; 41.2% past), and past 30-day drug use was high: 74.4% heroin/fentanyl; 51.4% crack cocaine; 31.3% benzodiazepines, and 18% pain medications. In exploring drug use by MOUD history, multinomial regression analyses found that crack use was positively associated with past and current MOUD use (outcome referent: never used MOUD); whereas benzodiazepine use was not associated with past MOUD use but was positively associated with current use. Conversely, pain medication use was associated with reduced odds of past and current MOUD use. Among those on methadone or buprenorphine, separate multivariable logistic regression models found that benzodiazepine and methadone use were positively associated with heroin/fentanyl use; living in a medium-sized city and sex work were positively associated with crack use; heroin/fentanyl use was positively associated with benzodiazepine use; and witnessing an overdose was inversely associated with pain medication use. Many participants qualitatively reported reducing illegal opioid use while on MOUD, yet inadequate dosage, trauma, psychological cravings, and environmental triggers drove their continued drug use, which increased their risk of treatment discontinuation and overdose.

CONCLUSIONS

Findings highlight variations in continued drug use by MOUD use history, reasons for concurrent use, and implications for MOUD treatment delivery and continuity.

Facilitating Overdose Risk Mitigation Among Patients Following a Clinician Office Closure: A Connecticut Case Study of the Opioid Rapid Response Program

The Opioid Rapid Response Program (ORRP) is a federal program designed to support states in mitigating risks to patients who lose access to a prescriber of opioids or other controlled substances. Displaced patients might face risks of withdrawal, overdose, or other harms. Rapid response efforts to mitigate risks require coordination across multiple parts of the health care system. This case study describes an ORRP-coordinated event, including notification from law enforcement, information sharing with state health officials, state-coordinated response efforts, key observations, and lessons learned. Timely risk mitigation and care continuity required coordination between law enforcement and public health in advance of the disruption and throughout the state-led response. Patients' acute and prolonged health care needs were complex and highlight the importance of investing time and resources in coordinated, multisector state and local preparedness for these types of disruptions.

Stigma by Association: To what Extent is the Attitude Toward Naloxone Affected by the Stigma of Opioid Use Disorder?

The United States opioid epidemic is fueled by illicit opioid abuse and prescription opioid misuse and abuse. Consequently, cases of opioid use disorder (OUD, opioid addiction), opioid overdose, and related deaths have increased since the year 2000. Naloxone is an opioid antagonist that rapidly reverses opioid intoxication to prevent death from overdose. It is one of the major risk mitigation strategies recommended in the 2016 Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain. However, despite the exponential increase in dispensing and distribution of naloxone, opioid overdose and related deaths have continued to increase; suggesting that the increased naloxone supply still lags the need. This discordance is attributed at least in part to the negative attitude toward naloxone, which is based on the belief that naloxone is only meant for "addicts" and "abusers" (OUD patients). This negative attitude or so-called naloxone stigma is therefore considered a major barrier for naloxone distribution and consequently, overdose-death prevention efforts. This article presents evidence that challenges common assertions about OUD stigma being the sole and direct driving force behind naloxone stigma, and the purported magnitude of the barrier that naloxone stigma constitutes for naloxone distribution programs among the stakeholders (patients, pharmacists, and prescribers). The case was then made to operationalize and quantify the construct among the stakeholders to determine the extent to which OUD stigma drives naloxone stigma, and the relative impact of naloxone stigma as a barrier for naloxone distribution efforts.

Engagement in Prescription Opioid Tapering Research: the EMPOWER Study and a Coproduction Model of Success

Patients with chronic pain experience stigma within the healthcare system. This stigma is compounded for those taking long-term prescription opioids. Often, public messaging and organizational policies have telegraphed that opioid treatment is a problem to be solved by focusing only on medication reduction efforts. Lack of data has contributed to misperceptions and poor opioid policies. In part, data collection remains poor because patients feel fractured from systems of care and are often not interested in engaging with opioid reduction mandates and research. Similarly, clinicians may fail to engage with opioid stewardship and research due to complexities that exceed their training or capacities. The EMPOWER study applies a coproduction model that engages researchers, patients, clinicians, managers, and other health system users. Key stakeholders shaped the design of the study to best ensure acceptability and engagement of the "end users"-patients who enroll in the study and the clinicians who implement the opioid tapers. Targeting the needs of any stakeholder group in isolation is suboptimal. Accordingly, we detail the EMPOWER patient-centered opioid tapering clinical research framework and specific strategies to address stakeholder concerns. We also discuss how this framework may be applied to enhance engagement in healthcare research broadly.

Influence of provider type on chronic pain prescribing patterns A systematic review

BACKGROUND

Chronic pain affects 100 million Americans and is most often treated in primary care, where the health care provider shortage remains a challenge. Nurse practitioners (NPs) represent a growing solution, yet their patterns of chronic pain management are understudied. Additionally, prescriptive authority limitations in many states limit NPs from prescribing opioids and often exist due to concerns of NP-driven opioid overprescribing. Little evidence on NP pain management prescribing patterns exists to address these issues.

OBJECTIVE

Systematic review, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, to examine opioid and nonopioid prescribing patterns of physicians, NPs, and physician assistants (PAs) in primary care. Eligible studies scored ≥60% on the Joanna Briggs Institute Critical Appraisal checklist.

DATA SOURCES

Searches within PubMed, Embase, CINAHL, and Web of Science.

CONCLUSIONS

Three themes were elucidated: 1) opioid prescribing in primary care, 2) similarities and differences in opioid prescribing by provider type, and 3) nonopioid pain management strategies. All provider groups had similar opioid prescribing patterns, although NPs and PAs may be slightly less likely to prescribe opioids than physicians. Although some studies suggested that NPs/PAs had higher opioid prescribing rates compared with physicians, methodological flaws may undermine these conclusions. Evidence is also lacking on nonopioid prescribing patterns across disciplines.

IMPLICATIONS FOR PRACTICE

Nurse practitioner/PA prescriptive authority limitations may not be as effective of a solution for addressing opioid overprescribing as transdisciplinary interventions targeting the highest subset of opioid prescribers. Future research should examine prescribing patterns of nonopioid, including nonpharmacologic, therapies.

Development of an unannounced standardized patient protocol to evaluate opioid use disorder treatment in pregnancy for American Indian and rural communities

BACKGROUND

Opioid use disorder (OUD) disproportionately impacts rural and American Indian communities and has quadrupled among pregnant individuals nationwide in the past two decades. Yet, limited data are available about access and quality of care available to pregnant individuals in rural areas, particularly among American Indians (AIs). Unannounced standardized patients (USPs), or "secret shoppers" with standardized characteristics, have been used to assess healthcare access and quality when outcomes cannot be measured by conventional methods or when differences may exist between actual versus reported care. While the USP approach has shown benefit in evaluating primary care and select specialties, its use to date for OUD and pregnancy is very limited.

METHODS

We used literature review, current practice guidelines for perinatal OUD management, and stakeholder engagement to design a novel USP protocol to assess healthcare access and quality for OUD in pregnancy. We developed two USP profiles-one white and one AI-to reflect our target study area consisting of three rural, predominantly white and AI US counties. We partnered with a local community health center network providing care to a large AI population to define six priority outcomes for evaluation: (1) OUD treatment knowledge among clinical staff answering telephones; (2) primary care clinic facilitation and provision of prenatal care and buprenorphine treatment; (3) appropriate completion of evidence-based screening, symptom assessment, and initial steps in management; (4) appropriate completion of risk factor screening/probing about individual circumstances that may affect care; (5) patient-directed tone, stigma, and professionalism by clinic staff; and (6) disparities in care between whites and American Indians.

DISCUSSION

The development of this USP protocol tailored to a specific environment and high-risk patient population establishes an innovative approach to evaluate healthcare access and quality for pregnant individuals with OUD. It is intended to serve as a roadmap for our own study and for future related work within the context of substance use disorders and pregnancy.

Non-canonical Molecular Targets for Novel Analgesics: Intracellular Calcium and HCN Channels

Pain is a prevalent biopsychosocial condition that poses a significant challenge to healthcare providers, contributes substantially to a disability, and is a major economic burden worldwide. An overreliance on opioid analgesics, which primarily target the μ-opioid receptor, has caused devastating morbidity and mortality in the form of misuse and overdose-related death. Thus, novel analgesic medications are needed that can effectively treat pain and provide an alternative to opioids. A variety of cellular ion channels contribute to nociception, the response of the sensory nervous system to a noxious stimulus that commonly leads to pain. Ion channels involved in nociception may provide a suitable target for pharmacologic modulation to achieve pain relief. This narrative review summarizes the evidence for two ion channels that merit consideration as targets for non-opioid pain medications: ryanodine receptors (RyRs), which are intracellular calcium channels, and hyperpolarization-activated cyclic nucleotide-gated (HCN) channels, which belong to the superfamily of voltage-gated K+ channels. The role of these channels in nociception and neuropathic pain is discussed and suitability as targets for novel analgesics and antihyperalgesics is considered.