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Wilson H, Roxas BH, Lintzeris N, Harris MF. Diagnosing and managing prescription opioid use disorder in patients prescribed opioids for chronic pain in Australian general practice settings: a qualitative study using the theory of Planned Behaviour. BMC PRIMARY CARE 2024; 25:236. [PMID: 38961328 PMCID: PMC11223276 DOI: 10.1186/s12875-024-02474-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 06/11/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND Chronic pain is a debilitating and common health issue. General Practitioners (GPs) often prescribe opioids to treat chronic pain, despite limited evidence of benefit and increasing evidence of harms, including prescription Opioid Use Disorder (pOUD). Australian GPs are worried about the harms of long-term opioids, but few are involved in the treatment of pOUD. There is little research on GPs' experiences diagnosing and managing pOUD in their chronic pain patients. METHODS This qualitative research used semi-structured interviews and a case study to investigate GPs' experiences through the lens of the Theory of Planned Behaviour (TPB). TPB describes three factors, an individual's perceived beliefs/attitudes, perceived social norms and perceived behavioural controls. Participants were interviewed via an online video conferencing platform. Interviews were transcribed verbatim and thematically analysed. RESULTS Twenty-four GPs took part. Participants were aware of the complex presentations for chronic pain patients and concerned about long-term opioid use. Their approach was holistic, but they had limited understanding of pOUD diagnosis and suggested that pOUD had only one treatment: Opioid Agonist Treatment (OAT). Participants felt uncomfortable prescribing opioids and were fearful of difficult, conflictual conversations with patients about the possibility of pOUD. This led to avoidance and negative attitudes towards diagnosing pOUD. There were few positive social norms, few colleagues diagnosed or managed pOUD. Participants reported that their colleagues only offered positive support as this would allow them to avoid managing pOUD themselves, while patients and other staff were often unsupportive. Negative behavioural controls were common with low levels of knowledge, skill, professional supports, inadequate time and remuneration described by many participants. They felt OAT was not core general practice and required specialist management. This dichotomous approach was reflected in their views that the health system only supported treatment for chronic pain or pOUD, not both conditions. CONCLUSIONS Negative beliefs, negative social norms and negative behavioural controls decreased individual behavioural intention for this group of GPs. Diagnosing and managing pOUD in chronic pain patients prescribed opioids was perceived as difficult and unsupported. Interventions to change behaviour must address negative perceptions in order to lead to more positive intentions to engage in the management of pOUD.
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Affiliation(s)
- Hhk Wilson
- Drug and Alcohol Services, South East Sydney Local Health District, Sydney, NSW, Australia.
- School of Population Health, University of New South Wales, Sydney, NSW, Australia.
- Centre for Primary Health Care and Equity (CPHCE), University of New South Wales, Sydney, NSW, Australia.
| | - B Harris Roxas
- School of Population Health, University of New South Wales, Sydney, NSW, Australia
| | - N Lintzeris
- Drug and Alcohol Services, South East Sydney Local Health District, Sydney, NSW, Australia
- Department Addiction Medicine, University of Sydney, Sydney, NSW, Australia
- NSW Drug and Alcohol Clinical Research and Improvement Network (DACRIN), NSW Health, Sydney, NSW, Australia
- Centre for Primary Health Care and Equity (CPHCE), University of New South Wales, Sydney, NSW, Australia
| | - M F Harris
- Centre for Primary Health Care and Equity (CPHCE), University of New South Wales, Sydney, NSW, Australia
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Hopkins RE, Campbell G, Degenhardt L, Lintzeris N, Larance B, Nielsen S, Gisev N. Self-reported challenges obtaining ongoing prescription opioids among Australians with chronic non-cancer pain. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 105:103708. [DOI: 10.1016/j.drugpo.2022.103708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 03/06/2022] [Accepted: 04/19/2022] [Indexed: 11/24/2022]
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Potential for Harm Associated with Discharge Opioids After Hospital Stay: A Systematic Review. Drugs 2020; 80:573-585. [DOI: 10.1007/s40265-020-01294-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Lau ET, Tan SH, Antwertinger YJ, Hall T, Nissen LM. Counseling interactions between patients living with persistent pain and pharmacists in Australia: are we on the same page? J Pain Res 2019; 12:2441-2455. [PMID: 31496787 PMCID: PMC6689145 DOI: 10.2147/jpr.s199017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 04/23/2019] [Indexed: 12/14/2022] Open
Abstract
Background People living with persistent pain in Australia often cannot access adequate care to manage their pain. Therefore, as the most accessible healthcare professionals, community pharmacists have an important role to play in helping to improve patient outcomes. Hence, it is important to investigate patient needs and expectations in terms of counseling interactions with pharmacists, along with pharmacists’ approach to counseling interactions with these patients. Method The nature of patient–pharmacist counseling interactions was explored with seven patients (one focus group), and 10 practicing pharmacists (two focus groups, three semi-structured interviews). The themes identified informed the development of an online survey that was advertised online to patients and pharmacists across Australia. Results A total of 95 patients and 208 pharmacists completed the survey. Overall, more than half of patients (77/95) were satisfied with the care provided by their pharmacist, but only a third (71/205) of pharmacists were satisfied with the care they provided to patients. The majority of patients (67/94) reported that pharmacists provided good information about medications. This aligned with pharmacists’ responses, as most reported focusing on medication side effects (118/188) and instructions for taking pain medication (93/183) during patient interactions. However, when asked about empathy and rapport from pharmacists, only half to two-thirds (48–61/95) of patients expressed positive views. Overall, half of the patients (39/75) wanted a caring, empathetic, respectful, and private conversation with the pharmacist, and nearly half (40/89) perceived the pharmacist's role as providing (new) information on alternative pharmacological and non-pharmacological therapies, including general advice on pain management. Conclusion There was a disparity in the nature of the interaction and information that patients wanted from pharmacists, compared to what was provided by pharmacists. Training and education may help pharmacists to better engage in patient-centered care when interacting with people living with persistent pain, thereby improving health outcomes for these patients.
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Affiliation(s)
- Esther Tl Lau
- School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia.,School of Pharmacy, University of Queensland, Brisbane, QLD, Australia
| | - Shirin H Tan
- School of Pharmacy, University of Queensland, Brisbane, QLD, Australia.,Clinical Research Center, Sarawak General Hospital, Kuching, Sarawak, Malaysia
| | - Yasmin J Antwertinger
- School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
| | - Tony Hall
- School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
| | - Lisa M Nissen
- School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia.,School of Pharmacy, University of Queensland, Brisbane, QLD, Australia
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Quast T, Bright MA, Delcher C. The relationship between foster care entries and high-dose opioid prescribing in California. Addict Behav 2019; 93:52-58. [PMID: 30685568 DOI: 10.1016/j.addbeh.2019.01.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 11/15/2018] [Accepted: 01/14/2019] [Indexed: 12/25/2022]
Abstract
An important effect of the current opioid epidemic is on children whose parents are unable to provide appropriate care. We employ quarterly, county-level data for California for 2009-2016 to study the relationship between foster care entries and opioid misuse by their parents. Our linear regression analysis includes both county and time fixed effects and controls related to child removal risk. We improve on the limited existing research in the area by analyzing higher frequency data, examining a proximal measure of opioid abuse, and allowing for differential associations by urbanicity. We found a positive association between the rate of child removals and the rate of residents who were cumulatively prescribed a high dose of opioids (>90 morphine milligram equivalents (MMEs) per day) during the quarter. A one standard deviation in this rate is associated with a roughly 9% increase in the overall removal rate. We further found that the association between removals and high MMEs is especially pronounced in rural areas and largely not existent in urban areas. Our results provide a more precise estimate of the relationship between the potential for opioid misuse and child welfare.
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Hulme S, Bright D, Nielsen S. The source and diversion of pharmaceutical drugs for non-medical use: A systematic review and meta-analysis. Drug Alcohol Depend 2018; 186:242-256. [PMID: 29626777 DOI: 10.1016/j.drugalcdep.2018.02.010] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 02/18/2018] [Accepted: 02/20/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND The non-medical use (NMU) of pharmaceutical drugs is an increasing public health concern. This systematic review consolidates current knowledge about how pharmaceutical drugs are obtained for NMU and the processes and people involved in diversion. METHODS Peer-reviewed and grey literature databases were searched for empirical studies published between 1996 and 2017 that examined the source or diversion of pharmaceutical opioids, sedatives or stimulants for NMU in countries with reported misuse problems. Pooled prevalence meta-analyses using random effects models were used to estimate the prevalence of medical and non-medical sourcing reported by end-users, and gifting, selling and trading by various populations. RESULTS This review synthesizes the findings of 54 cross-sectional studies via meta-analyses, with a remaining 95 studies examined through narrative review. Pharmaceutical drugs are primarily sourced for NMU from friends and family (57%, 95% CI 53%-62%, I2 = 98.5, n = 30) and despite perceptions of healthcare professionals to the contrary, illegitimate practices such as doctor shopping are uncommon (7%, 95% CI 6%-10%, I2 = 97.4, n = 29). Those at risk of diversion include patients displaying aberrant medication behaviors, people with substance use issues and students in fraternity/sorority environments. Sourcing via dealers is also common (32%, 95% CI 23%-41%, I2 = 99.8, n = 25) and particularly so among people who use illicit drugs (47%, 95% CI 35%-60%, I2 = 99.1, n = 15). There is little to no organized criminal involvement in the pharmaceutical black market. CONCLUSION Pharmaceutical drugs for NMU are primarily sourced by end-users through social networks. Future research should examine how dealers source pharmaceutical drugs.
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Affiliation(s)
- Shann Hulme
- National Drug and Alcohol Research Centre, 22-32 King St, Randwick, NSW, 2031, Australia.
| | - David Bright
- School of Social Sciences, UNSW Australia, High Street, Kensington, NSW, 2052, Australia
| | - Suzanne Nielsen
- National Drug and Alcohol Research Centre, 22-32 King St, Randwick, NSW, 2031, Australia
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Hurstak EE, Kushel M, Chang J, Ceasar R, Zamora K, Miaskowski C, Knight K. The risks of opioid treatment: Perspectives of primary care practitioners and patients from safety-net clinics. Subst Abus 2017; 38:213-221. [PMID: 28394752 PMCID: PMC5568522 DOI: 10.1080/08897077.2017.1296524] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Patients with a history of substance use are more likely than those without substance use to experience chronic noncancer pain (CNCP), to be prescribed opioids, and to experience opioid misuse or overdose. Primary care practitioners (PCPs) in safety-net settings care for low-income patients with CNCP and substance use, usually without specialist consultation. To inform communication related to opioid risk, we explored PCPs' and patients' perceptions of the risks of chronic opioid therapy. METHODS We conducted semistructured interviews with 23 PCPs and 46 of their patients, who had a history of CNCP and substance use. We recruited from 6 safety-net health care settings in the San Francisco Bay Area. We transcribed interviews verbatim and analyzed transcripts using grounded theory methodology. RESULTS (1) PCPs feared harming patients and the community by opioid prescribing. PCPs emphasized fear of opioid overdose. (2) Patients did not highlight concerns about the adverse health consequences of opioids, except for addiction. (3) Both patients and PCPs were concerned about PCPs' medicolegal risks related to opioid prescribing. (4) Patients reported feeling stigmatized by policies aimed at reducing opioid misuse. CONCLUSION We identified differences in how clinicians and patients perceive opioid risk. To improve the informed consent process for opioid therapy, patients and PCPs need to have a shared understanding of the risks of opioids and engage in discussions that promote patient autonomy and safety. As clinics implement opioid prescribing policies, clinicians must develop effective communication strategies in order to educate patients about opioid risks and decrease patients' experiences of stigma and discrimination.
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Affiliation(s)
- Emily E. Hurstak
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
- Division of General Internal Medicine, University of California San Francisco/Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Margot Kushel
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
- Division of General Internal Medicine, University of California San Francisco/Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Jamie Chang
- Department of Psychiatry, University of California San Francisco, San Francisco, California, USA
| | - Rachel Ceasar
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kara Zamora
- United States Department of Veterans Affairs, San Francisco, California, USA
| | - Christine Miaskowski
- School of Nursing, University of California San Francisco, San Francisco, California, USA
| | - Kelly Knight
- Department of Anthropology, History, and Social Medicine, and Global Health Sciences, University of California San Francisco, San Francisco, California, USA
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Martins SS, Segura LE, Santaella-Tenorio J, Perlmutter A, Fenton MC, Cerdá M, Keyes KM, Ghandour LA, Storr CL, Hasin DS. Prescription opioid use disorder and heroin use among 12-34 year-olds in the United States from 2002 to 2014. Addict Behav 2017; 65:236-241. [PMID: 27614657 DOI: 10.1016/j.addbeh.2016.08.033] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 08/23/2016] [Accepted: 08/28/2016] [Indexed: 10/21/2022]
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Lin CWC, McLachlan AJ, Latimer J, Day RO, Billot L, Koes BW, Maher CG. OPAL: a randomised, placebo-controlled trial of opioid analgesia for the reduction of pain severity in people with acute spinal pain. Trial protocol. BMJ Open 2016; 6:e011278. [PMID: 27558901 PMCID: PMC5013345 DOI: 10.1136/bmjopen-2016-011278] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Low back pain and neck pain are extremely prevalent and are responsible for an enormous burden of disease globally. Strong analgesics, such as opioid analgesics, are recommended by clinical guidelines for people with acute low back pain or neck pain who are slow to recover and require more pain relief. Opioid analgesics are widely and increasingly used, but there are no strong efficacy data supporting the use of opioid analgesics for acute low back pain or neck pain. Concerns regarding opioid use are further heightened by the risks of adverse events, some of which can be serious (eg, dependency, misuse and overdose). METHODS AND ANALYSIS OPAL is a randomised, placebo-controlled, triple-blinded trial that will investigate the judicious use of an opioid analgesic in 346 participants with acute low back pain and/or neck pain who are slow to recover. Participants will be recruited from general practice and randomised to receive the opioid analgesic (controlled release oxycodone plus naloxone up to 20 mg per day) or placebo in addition to guideline-based care (eg, reassurance and advice of staying active) for up to 6 weeks. Participants will be followed-up for 3 months for effectiveness outcomes. The primary outcome will be pain severity. Secondary outcomes will include physical functioning and time to recovery. Medication-related adverse events will be assessed and a cost-effectiveness analysis will be conducted. We will additionally assess long-term use and risk of misuse of opioid analgesics for up to 12 months. ETHICS AND DISSEMINATION Ethical approval has been obtained. Trial results will be disseminated by publications and conference presentations, and via the media. TRIAL REGISTRATION NUMBER ACTRN12615000775516: Pre-results.
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Affiliation(s)
- Chung-Wei Christine Lin
- The George Institute for Global Health and Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Andrew J McLachlan
- Faculty of Pharmacy and The Centre for Education and Research on Ageing (CERA), The University of Sydney and Concord Hospital, Sydney, New South Wales, Australia
| | - Jane Latimer
- The George Institute for Global Health and Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Ric O Day
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital Sydney and Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Laurent Billot
- The George Institute for Global Health and Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Bart W Koes
- Department of General Practice, Erasmus MC, Rotterdam, The Netherlands
| | - Chris G Maher
- The George Institute for Global Health and Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
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Busardò FP, Jones AW. GHB pharmacology and toxicology: acute intoxication, concentrations in blood and urine in forensic cases and treatment of the withdrawal syndrome. Curr Neuropharmacol 2016; 13:47-70. [PMID: 26074743 PMCID: PMC4462042 DOI: 10.2174/1570159x13666141210215423] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 10/01/2014] [Accepted: 10/25/2014] [Indexed: 11/29/2022] Open
Abstract
The illicit recreational drug of abuse, γ-hydroxybutyrate (GHB) is a potent central nervous
system depressant and is often encountered during forensic investigations of living and deceased
persons. The sodium salt of GHB is registered as a therapeutic agent (Xyrem®), approved in some
countries for the treatment of narcolepsy-associated cataplexy and (Alcover®) is an adjuvant
medication for detoxification and withdrawal in alcoholics. Trace amounts of GHB are produced
endogenously (0.5-1.0 mg/L) in various tissues, including the brain, where it functions as both a
precursor and a metabolite of the major inhibitory neurotransmitter γ-aminobutyric acid (GABA). Available information
indicates that GHB serves as a neurotransmitter or neuromodulator in the GABAergic system, especially via binding to
the GABA-B receptor subtype. Although GHB is listed as a controlled substance in many countries abuse still continues,
owing to the availability of precursor drugs, γ-butyrolactone (GBL) and 1,4-butanediol (BD), which are not regulated.
After ingestion both GBL and BD are rapidly converted into GHB (t½ ~1 min). The Cmax occurs after 20-40 min and
GHB is then eliminated from plasma with a half-life of 30-50 min. Only about 1-5% of the dose of GHB is recoverable in
urine and the window of detection is relatively short (3-10 h). This calls for expeditious sampling when evidence of drug
use and/or abuse is required in forensic casework. The recreational dose of GHB is not easy to estimate and a
concentration in plasma of ~100 mg/L produces euphoria and disinhibition, whereas 500 mg/L might cause death from
cardiorespiratory depression. Effective antidotes to reverse the sedative and intoxicating effects of GHB do not exist. The
poisoned patients require supportive care, vital signs should be monitored and the airways kept clear in case of emesis.
After prolonged regular use of GHB tolerance and dependence develop and abrupt cessation of drug use leads to
unpleasant withdrawal symptoms. There is no evidence-based protocol available to deal with GHB withdrawal, apart from
administering benzodiazepines.
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Affiliation(s)
- Francesco P Busardò
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Alan W Jones
- Department of Clinical Pharmacology, University of Linköping, Linköping, Sweden
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Larance B, Lintzeris N, Bruno R, Peacock A, Cama E, Ali R, Kihas I, Hordern A, White N, Degenhardt L. The characteristics of a cohort who tamper with prescribed and diverted opioid medications. J Subst Abuse Treat 2015; 58:51-61. [DOI: 10.1016/j.jsat.2015.06.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 05/29/2015] [Accepted: 06/01/2015] [Indexed: 11/28/2022]
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The Pain and Opioids IN Treatment study: characteristics of a cohort using opioids to manage chronic non-cancer pain. Pain 2015; 156:231-242. [PMID: 25599444 DOI: 10.1097/01.j.pain.0000460303.63948.8e] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
There has been a recent increase in public and professional concern about the prescription of strong prescription opioids for pain. Despite this concern, research to date has been limited because of a number of factors such as small sample sizes, exclusion of people with complex comorbidities, and studies of short duration. The Pain and Opioids IN Treatment is a 2-year prospective cohort study of 1500 people prescribed with pharmaceutical opioids for their chronic pain. This article provides an overview of the demographic and clinical characteristics of the cohort using the baseline data of 1514 community-based people across Australia. Participants had been in pain for a period of 10 years and had been on prescription opioids for approximately 4 years. One in 10 was on a daily morphine equivalent dose of ≥200 mg. Employment and income levels were low, and two-thirds of the sample reported that their pain had impacted on their employment status. Approximately 50% screened positive for current moderate-to-severe depression, and 1 in 5 had made a lifetime suicide attempt. There were a number of age-related differences. The younger groups experienced higher levels of pain and pain interference, more mental health and substance use issues, and barriers to treatment, compared with the older group. This study found that the people who have been prescribed strong opioids for chronic pain have very complex demographic and clinical profiles. Major age-related differences in the experiences of pain, coping, mental health, and substance use suggest the necessity of differential approaches to treatment.
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