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Rainer M, Ommerli SM, Burden AM, Betschart L, Stämpfli D. Opioid exit plans for tapering postoperative pain control in noncancer patients: a systematic review. Patient Saf Surg 2024; 18:25. [PMID: 39080780 PMCID: PMC11290124 DOI: 10.1186/s13037-024-00408-w] [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: 05/06/2024] [Accepted: 07/08/2024] [Indexed: 08/02/2024] Open
Abstract
BACKGROUND A growing number of countries have reported sharp increases in the use and harm of opioid analgesics. High rates of new opioid initiation are observed in postoperative patients. In response, various tertiary care institutions have developed opioid exit plans (OEPs) to curb potential opioid-related harm. METHODS PubMed and Embase were systematically searched to identify, summarize, and compare the interventional elements of OEPs for postoperative patient populations published from January 1, 2000, to June 4, 2024. Two researchers independently screened the articles for eligibility following the PRISMA 2020 guidelines, extracted the data, and assessed the study quality and risk of bias. Data synthesis was performed for study characteristics, intervention details, efficacy, and development. RESULTS A total of 2,585 articles were screened, eight of which met the eligibility criteria. All studies were conducted in North America and focused on orthopedic surgery patients following total hip or knee arthroplasty (n = 5) or neurosurgery (n = 3). Most studies (n = 7) included a pre-post (n = 4) or randomized clinical design (n = 3). Three studies were of good quality, and none had a low risk of bias. The interventions varied and ranged from educational sessions (n = 1) to individualized tapering protocols (n = 4) or a combination of the two (n = 2). Key elements were instructions on how to anticipate patients' postoperative need for opioid analgesics and tapering strategies based on 24-h predischarge opioid consumption. Six studies included efficacy as an endpoint in their analysis, of which four assessed statistical significance, with all four identifying that the OEPs were successful in reducing postoperative opioid use. CONCLUSION Despite differences in design and implementation, the identified OEPs suggest that they are efficacious in reducing outpatient opioid consumption. They provide a robust estimate of postoperative analgesic requirements and a rationale for tapering duration and rate. However, more rigorous studies are needed to evaluate their real-world effectiveness.
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Affiliation(s)
- Marcel Rainer
- Institute of Pharmaceutical Sciences, ETH Zurich, Vladimir-Prelog Weg 1-5/10, 8093, Zurich, Switzerland
- Hospital Pharmacy, Department Medical Services, Kantonsspital Baden, Im Ergel, 5404, Baden, Switzerland
| | - Sarah Maleika Ommerli
- Institute of Pharmaceutical Sciences, ETH Zurich, Vladimir-Prelog Weg 1-5/10, 8093, Zurich, Switzerland
| | - Andrea Michelle Burden
- Institute of Pharmaceutical Sciences, ETH Zurich, Vladimir-Prelog Weg 1-5/10, 8093, Zurich, Switzerland
| | - Leo Betschart
- Chemistry | Biology | Pharmacy Information Center, ETH Zurich, Vladimir-Prelog Weg 10, 8093, Zurich, Switzerland
| | - Dominik Stämpfli
- Institute of Pharmaceutical Sciences, ETH Zurich, Vladimir-Prelog Weg 1-5/10, 8093, Zurich, Switzerland.
- Hospital Pharmacy, Department Medical Services, Kantonsspital Baden, Im Ergel, 5404, Baden, Switzerland.
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Jung M, Xia T, Ilomäki J, Pearce C, Nielsen S. Opioid characteristics and nonopioid interventions associated with successful opioid taper in patients with chronic noncancer pain. Pain 2024; 165:1327-1335. [PMID: 38112755 PMCID: PMC11090027 DOI: 10.1097/j.pain.0000000000003133] [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: 05/27/2023] [Revised: 10/27/2023] [Accepted: 11/04/2023] [Indexed: 12/21/2023]
Abstract
ABSTRACT Current research indicates that tapering opioids may improve pain and function in patients with chronic noncancer pain. However, gaps in the literature remain regarding the choice of opioid and nonopioid interventions to support a successful taper. This study used an Australian primary care data set to identify a cohort of patients on long-term opioid therapy commencing opioid taper between January 2016 and September 2019. Using logistic regression analysis, we compared key clinical factors associated with differing taper outcomes. Of a total of 3371 patients who commenced taper, 1068 (31.7%) completed taper within 12 months. In the 3 months after commencement of taper, compared with those who did not complete taper, patients who successfully completed opioid taper were less likely to be prescribed buprenorphine (odds ratio [OR] 0.691; 95% CI: 0.530-0.901), fentanyl (OR, 0.429; 95% CI: 0.295-0.622), and long-acting (LA) opioids, including methadone (OR, 0.349; 95% CI: 0.157-0.774), oxycodone-naloxone (OR, 0.521; 95% CI: 0.407-0.669), and LA tapentadol (OR, 0.645; 95% CI: 0.461-0.902), but more likely to be prescribed codeine (OR, 1.308; 95% CI: 1.036-1.652). Compared with those who did not complete taper, patients who successfully tapered were less likely to be prescribed any formulations of oxycodone (short-acting [SA]: OR, 0.533; 95% CI: 0.422-0.672, LA: OR, 0.356; 95% CI: 0.240-0.530) and tramadol (SA: OR, 0.370; 95% CI: 0.218-0.628, LA: OR, 0.317; 95% CI: 0.234-0.428). The type of opioid prescribed in the months after commencement of taper seems to influence the taper outcomes. These findings may inform prospective studies on opioid taper.
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Affiliation(s)
- Monica Jung
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Australia
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Ting Xia
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Jenni Ilomäki
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Christopher Pearce
- Melbourne East General Practice Network (trading as Outcome Health), Surrey Hills, Australia
- Department of General Practice, School of Primary and Allied Health Care, Monash University, Notting Hill, Melbourne, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Australia
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Jung M, Xia T, Ilomäki J, Pearce C, Nielsen S. Trajectories of prescription opioid tapering in patients with chronic non-cancer pain: a retrospective cohort study, 2015-2020. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:263-274. [PMID: 38191211 PMCID: PMC10988287 DOI: 10.1093/pm/pnae002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 11/30/2023] [Accepted: 12/16/2023] [Indexed: 01/10/2024]
Abstract
OBJECTIVE To identify common opioid tapering trajectories among patients commencing opioid taper from long-term opioid therapy for chronic non-cancer pain and to examine patient-level characteristics associated with these different trajectories. DESIGN A retrospective cohort study. SETTING Australian primary care. SUBJECTS Patients prescribed opioid analgesics between 2015 and 2020. METHODS Group-based trajectory modeling and multinomial logistic regression analysis were conducted to determine tapering trajectories and to examine demographic and clinical factors associated with the different trajectories. RESULTS A total of 3369 patients commenced a taper from long-term opioid therapy. Six distinct opioid tapering trajectories were identified: low dose / completed taper (12.9%), medium dose / faster taper (12.2%), medium dose / gradual taper (6.5%), low dose / noncompleted taper (21.3%), medium dose / noncompleted taper (30.4%), and high dose / noncompleted taper (16.7%). A completed tapering trajectory from a high opioid dose was not identified. Among patients prescribed medium opioid doses, those who completed their taper were more likely to have higher geographically derived socioeconomic status (relative risk ratio [RRR], 1.067; 95% confidence interval [CI], 1.001-1.137) and less likely to have sleep disorders (RRR, 0.661; 95% CI, 0.463-0.945) than were those who didn't complete their taper. Patients who didn't complete their taper were more likely to be prescribed strong opioids (eg, morphine, oxycodone), regardless of whether they were tapered from low (RRR, 1.444; 95% CI, 1.138-1.831) or high (RRR, 1.344; 95% CI, 1.027-1.760) doses. CONCLUSIONS Those prescribed strong opioids and high doses appear to be less likely to complete tapering. Further studies are needed to evaluate the clinical outcomes associated with the identified trajectories.
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Affiliation(s)
- Monica Jung
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, VIC 3199, Australia
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC 3052, Australia
| | - Ting Xia
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, VIC 3199, Australia
| | - Jenni Ilomäki
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC 3052, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Christopher Pearce
- Melbourne East General Practice Network (trading as Outcome Health), Surrey Hills, VIC 3127, Australia
- Department of General Practice, School of Primary and Allied Health Care, Monash University, Melbourne, VIC 3168, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, VIC 3199, Australia
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Huang X, Tao Q, Ren C. A Comprehensive Overview of the Neural Mechanisms of Light Therapy. Neurosci Bull 2024; 40:350-362. [PMID: 37555919 PMCID: PMC10912407 DOI: 10.1007/s12264-023-01089-8] [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] [Received: 03/16/2023] [Accepted: 04/22/2023] [Indexed: 08/10/2023] Open
Abstract
Light is a powerful environmental factor influencing diverse brain functions. Clinical evidence supports the beneficial effect of light therapy on several diseases, including depression, cognitive dysfunction, chronic pain, and sleep disorders. However, the precise mechanisms underlying the effects of light therapy are still not well understood. In this review, we critically evaluate current clinical evidence showing the beneficial effects of light therapy on diseases. In addition, we introduce the research progress regarding the neural circuit mechanisms underlying the modulatory effects of light on brain functions, including mood, memory, pain perception, sleep, circadian rhythm, brain development, and metabolism.
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Affiliation(s)
- Xiaodan Huang
- Guangdong-Hongkong-Macau Institute of CNS Regeneration, Ministry of Education CNS Regeneration Collaborative Joint Laboratory, Jinan University, Guangzhou, 510632, China
| | - Qian Tao
- Psychology Department, School of Medicine, Jinan University, Guangzhou, 510632, China.
| | - Chaoran Ren
- Guangdong-Hongkong-Macau Institute of CNS Regeneration, Ministry of Education CNS Regeneration Collaborative Joint Laboratory, Jinan University, Guangzhou, 510632, China.
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5
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Langford AV, Bero L, Lin CWC, Blyth FM, Doctor JN, Holliday S, Jeon YH, Moullin JC, Murnion B, Nielsen S, Penm J, Reeve E, Reid S, Wale J, Osman R, Gnjidic D, Schneider CR. Context matters: using an Evidence to Decision (EtD) framework to develop and encourage uptake of opioid deprescribing guideline recommendations at the point-of-care. J Clin Epidemiol 2024; 165:111204. [PMID: 37931823 DOI: 10.1016/j.jclinepi.2023.10.020] [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] [Received: 03/07/2023] [Revised: 10/23/2023] [Accepted: 10/30/2023] [Indexed: 11/08/2023]
Abstract
OBJECTIVES To describe the development and use of an Evidence to Decision (EtD) framework when formulating recommendations for the Evidence-Based Clinical Practice Guideline for Deprescribing Opioid Analgesics. STUDY DESIGN AND SETTING Evidence was derived from an overview of systematic reviews and qualitative studies conducted with healthcare professionals and people who take opioids for pain. A multidisciplinary guideline development group conducted extensive EtD framework review and iterative refinement to ensure that guideline recommendations captured contextual factors relevant to the guideline target setting and audience. RESULTS The guideline development group considered and accounted for the complexities of opioid deprescribing at the individual and health system level, shaping recommendations and practice points to facilitate point-of-care use. Stakeholders exhibited diverse preferences, beliefs, and values. This variability, low certainty of evidence, and system-level policies and funding models impacted the strength of the generated recommendations, resulting in the formulation of four 'conditional' recommendations. CONCLUSION The context within which evidence-based recommendations are considered, as well as the political and health system environment, can contribute to the success of recommendation implementation. Use of an EtD framework allowed for the development of implementable recommendations relevant at the point-of-care through consideration of limitations of the evidence and relevant contextual factors.
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Affiliation(s)
- Aili V Langford
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia; Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia.
| | - Lisa Bero
- School of Medicine, Colorado School of Public Health and Center for Bioethics and Humanities, University of Colorado Anschutz Medical Center, Denver, CO, USA
| | - Chung-Wei Christine Lin
- Faculty of Medicine and Health, School of Public Health, Institute for Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia; Sydney Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Fiona M Blyth
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jason N Doctor
- Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, USA
| | - Simon Holliday
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Yun-Hee Jeon
- Faculty of Medicine and Health, Sydney Nursing School, The University of Sydney, Sydney, New South Wales, Australia
| | - Joanna C Moullin
- School of Population Health, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | - Bridin Murnion
- Faculty of Medicine and Health, Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Jonathan Penm
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia; Department of Pharmacy, Prince of Wales Hospital, Randwick, Australia
| | - Emily Reeve
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia; Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Sharon Reid
- Specialty of Addiction Medicine, Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Drug Health Services, Royal Prince Alfred Hospital, Sydney Local Health District, Camperdown, New South Wales, Australia
| | - Janet Wale
- Independent Consumer Representative, Melbourne, Victoria, Australia
| | - Rawa Osman
- NPS MedicineWise, Sydney, New South Wales, Australia
| | - Danijela Gnjidic
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia
| | - Carl R Schneider
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia
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Barceló-Soler A, Morillo-Sarto H, Fernández-Martínez S, Monreal-Bartolomé A, Chambel MJ, Gardiner P, López-del-Hoyo Y, García-Campayo J, Pérez-Aranda A. A Systematic Review of the Adherence to Home-Practice Meditation Exercises in Patients with Chronic Pain. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4438. [PMID: 36901448 PMCID: PMC10001876 DOI: 10.3390/ijerph20054438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/28/2023] [Accepted: 03/01/2023] [Indexed: 06/18/2023]
Abstract
Mindfulness-, compassion-, and acceptance-based (i.e., "third wave") psychotherapies are effective for treating chronic pain conditions. Many of these programs require that patients engage in the systematic home practice of meditation experiences so they can develop meditation skills. This systematic review aimed at evaluating the frequency, duration, and effects of home practice in patients with chronic pain undergoing a "third wave" psychotherapy. A comprehensive database search for quantitative studies was conducted in PubMed, Embase, and Web of Sciences Core Collection; 31 studies fulfilled the inclusion criteria. The reviewed studies tended to indicate a pattern of moderately frequent practice (around four days/week), with very high variability in terms of time invested; most studies observed significant associations between the amount of practice and positive health outcomes. Mindfulness-Based Stress Reduction and Mindfulness-Based Cognitive Therapy were the most common interventions and presented low levels of adherence to home practice (39.6% of the recommended time). Some studies were conducted on samples of adolescents, who practiced very few minutes, and a few tested eHealth interventions with heterogeneous adherence levels. In conclusion, some adaptations may be required so that patients with chronic pain can engage more easily and, thus, effectively in home meditation practices.
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Affiliation(s)
- Alberto Barceló-Soler
- Institute of Health Research of Aragon (IIS), 50009 Zaragoza, Spain
- Navarra Medical Research Institute (IdiSNA), 31008 Pamplona, Spain
- Research Network on Chronicity, Primary Care and Health Promotion (RICAPPS), 50009 Zaragoza, Spain
| | - Héctor Morillo-Sarto
- Research Network on Chronicity, Primary Care and Health Promotion (RICAPPS), 50009 Zaragoza, Spain
- Department of Psychology and Sociology, University of Zaragoza, 50009 Zaragoza, Spain
| | - Selene Fernández-Martínez
- Institute of Health Research of Aragon (IIS), 50009 Zaragoza, Spain
- Department of Psychiatry, University of Zaragoza, 50009 Zaragoza, Spain
| | - Alicia Monreal-Bartolomé
- Institute of Health Research of Aragon (IIS), 50009 Zaragoza, Spain
- Research Network on Chronicity, Primary Care and Health Promotion (RICAPPS), 50009 Zaragoza, Spain
- Department of Psychology and Sociology, University of Zaragoza, 50009 Zaragoza, Spain
| | - Maria José Chambel
- CicPsi, Faculdade de Psicologia, Universidade de Lisboa, 1649-004 Lisbon, Portugal
| | - Paula Gardiner
- Center for Mindfulness and Compassion, Cambridge Health Alliance, Cambridge, MA 02141, USA
- Department of Family Medicine, Medical School, University of Massachusetts, Worcester, MA 01655, USA
| | - Yolanda López-del-Hoyo
- Institute of Health Research of Aragon (IIS), 50009 Zaragoza, Spain
- Research Network on Chronicity, Primary Care and Health Promotion (RICAPPS), 50009 Zaragoza, Spain
- Department of Psychology and Sociology, University of Zaragoza, 50009 Zaragoza, Spain
| | - Javier García-Campayo
- Institute of Health Research of Aragon (IIS), 50009 Zaragoza, Spain
- Research Network on Chronicity, Primary Care and Health Promotion (RICAPPS), 50009 Zaragoza, Spain
- Department of Psychiatry, University of Zaragoza, 50009 Zaragoza, Spain
| | - Adrián Pérez-Aranda
- Institute of Health Research of Aragon (IIS), 50009 Zaragoza, Spain
- Department of Basic, Developmental and Educational Psychology, 08193 Cerdanyola del Vallès, Spain
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