Increasing the benefits and reducing the harms of prescription opioid analgesics

"And this is the life jacket, the lifeline they've been wanting": Participant perspectives on navigating challenges and successes of prescribed safer supply

BACKGROUND

In 2021, 43% of drug toxicity deaths in Ontario were reported by public health units serving medium-sized urban and rural communities. Safer supply programs (SSPs) have been primarily established in large urban centres. Given this, the current study is based on an evaluation of a SSP based in a medium-sized urban centre with a large catchment area that includes rural and Indigenous communities. The aim of this research paper is to understand the challenges and successes of the nurse practitioner-led SSP from the perspective of program participants.

METHODS

Interpretive description was used to understand the experiences of 14 participants accessing a SSP. Each participant was interviewed using a semi-structured approach, and 13 of the interviewees also completed surveys accessed through Qualtrics. An iterative process using NVivo software was used to code interviews, and a constant comparative data analysis approach was used to refine and categorize codes to themes.

FINDINGS

Three overarching themes were the result of this analysis: feeling better, renewed hope, and safety. These three themes capture the experiences of participants in the SSP, including both the challenges and successes they faced.

CONCLUSION

The findings and subsequent discussion focus on both the key best practices of the program, and areas for future development and improvement. Despite barriers to services, prescribed SSPs are improving the lives of people who use drugs, and the current outcomes align with reports and evaluations from other SSPs across Canada.

Management Strategies for Spinal Cord Injury Pain Updated for the Twenty-First Century

Traumatic spinal cord injury (SCI) often results in several life-altering impairments, including paralysis, sensory loss, and neurogenic bowel/bladder dysfunction. Some of these SCI-related conditions can be accommodated with compensatory strategies. Perhaps no SCI-associated condition is more troublesome and recalcitrant to the treating physiatrist than chronic neuropathic pain. In addition to the expected challenges in treating any chronic pain condition, treatment of SCI-related pain has the added difficulty of disruption of normal neural pathways that subserve pain transmission and attenuation. This article reviews selected treatment strategies for SCI-associated neuropathic pain.

Pain Management in Patients with Serious Illness

Managing pain in patients with serious illness can be complex. However, pain is often a prominent symptom in patients with malignant and nonmalignant serious illness and providers have to be adept at balancing effective pain management and safety. Clinicians should start with a standard pain assessment that lays important groundwork for developing a tailored multimodal approach to pain management. It is important to identify physical causes of pain and also existential causes. Opioids are not always appropriate but are still an important tool for managing pain. Basic opioid management and safe practices are essential when managing this population.

Engagement in online pain self-management improves pain in adults on medication-assisted behavioral treatment for opioid use disorders

INTRODUCTION

Persistent pain has been recognized as an important motivator that can lead individuals to misuse opioids. New approaches are needed to test pain treatments that can improve outcomes for people with persistent pain in medication-assisted behavioral treatment for opioid use disorder. This study piloted an online pain self-management program to explore acceptability and treatment effects.

METHODS

A sample of 60 adults diagnosed with chronic non-cancer pain and receiving medication-assisted behavioral treatment at one of two clinics were randomized into either treatment group with access to an online pain management program or waitlist attention control. Participants received online surveys via email at baseline and post-treatment at week 8.

RESULTS

The majority of participants (n = 44; 73%) reported that their first use of opioids was in response to a painful event. Those who engaged in the online program had significantly lower pain interference, pain severity, opioid misuse measures, and depressive symptoms after eight weeks while pain self-efficacy was increased.

CONCLUSION

Our results suggest the online pain self-management program content may be helpful for managing physical and emotional symptoms experienced by individuals with co-occurring pain and opioid use disorders. To improve online engagement, more support is necessary to assist with technology access and completion of online activities.

Buprenorphine-based opioid substitution therapy in India: A few observations, thoughts, and opinions

The most evidence-based treatment for opioid dependence is opioid agonist maintenance treatment also known as opioid substitution therapy (OST). However, there are some critical, yet unaddressed issues of buprenorphine-based substitution therapy, especially in the Indian context. These comprise of generalizability of the evidence for OST, especially for natural and pharmaceutical opioids and for all age groups, optimum dose and duration of OST, and mode of treatment delivery including the frequency of dispensing. Notwithstanding the use of buprenorphine-naloxone combination, abuse and diversion are serious but often underreported problems. There is an urgent need for health services research in India on OST, focusing on these aspects. Rather than directly copying from Western models, it is important to try to understand the useful and safe program and policy options likely to be applicable in the Indian setting, with our own assets as well as vulnerabilities.

Participant Perspectives on Benefits and Challenges of Engaging in an Online Pain Self-Management Program

The purpose of this study was to evaluate participants' perspectives after engaging in an 8-week online pain self-management program. Unexplored qualitative data for this analysis were collected via secure online surveys distributed during a previously published randomized controlled trial. Participants for the present study were 47 adults prescribed opioid medicines for chronic pain. A qualitative descriptive approach using content analysis methods was used to identify common themes regarding online participation. Three themes described the benefits of the program and included: positive reframing, improved accountability, and feeling supported. Two themes described how participants would like to improve the program experience and included: ease of use and desire for personalizing. Participants' insights can assist health care providers and program developers in understanding how online programs may improve chronic disease self-management for a multitude of health problems.

Seeking prescription opioids from physicians for nonmedical use among people who inject drugs in a Canadian setting

BACKGROUND AND OBJECTIVES

Despite the high prevalence of prescription opioid (PO) misuse, little is known about the phenomenon of seeking POs for nonmedical use among high-risk populations, such as people who inject drugs (PWID). We therefore sought to examine the prevalence and correlates of seeking POs from a physician for nonmedical use among PWID in Vancouver, Canada.

METHODS

Cross-sectional data from two open prospective cohort studies of PWID in Vancouver were collected between June 2013 and May 2014 (n = 1252). Multivariable logistic regression was used to identify factors associated with seeking POs from physicians for nonmedical use.

RESULTS

Of 1252 participants, 458 individuals (36.6%) reported ever trying to get a PO prescription from a physician for nonmedical use and, of these, 343 (74.9%, comprising 27.4% of the total sample) reported ever being successful. Variables independently and positively associated with PO-seeking behavior included older age (adjusted odds ratio [AOR] = 1.02), Caucasian ethnicity (AOR = 1.38), having ever overdosed (AOR = 1.32), having ever participated in methadone maintenance therapy (AOR = 1.90), having ever dealt drugs (AOR = 1.65), and having ever been refused a prescription for pain medication (AOR = 2.02) (all p < .05).

DISCUSSION AND CONCLUSIONS

We observed that PO-seeking behavior was common among this sample of PWID and associated with several markers of higher intensity drug use.

SCIENTIFIC SIGNIFICANCE

Our findings highlight the need to identify evidence-based public health and clinical strategies to mitigate PO misuse among PWID without compromising care for PWID with legitimate medical concerns. (Am J Addict 2016;25:275-282).

Denial of prescription analgesia among people who inject drugs in a Canadian setting

INTRODUCTION AND AIMS

Despite the high prevalence of pain among people who inject drugs (PWIDs), clinicians may be reluctant to prescribe opioid-based analgesia to those with a history of drug use or addiction. We sought to examine the prevalence and correlates of PWIDs reporting being denied of prescription analgesia (PA). We also explored reported reasons for and actions taken after being denied PA.

DESIGN AND METHODS

Using data from two prospective cohort studies of PWIDs, multivariate logistic regression was used to identify the prevalence and correlates of reporting being denied PA. Descriptive statistics were used to characterise reasons for denials and subsequent actions.

RESULTS

Approximately two-thirds (66.5%) of our sample of 462 active PWIDs reported having ever been denied PA. We found that reporting being denied PA was significantly and positively associated with having ever been enrolled in methadone maintenance treatment (adjusted odds ratio 1.76, 95% confidence interval 1.11-2.80) and daily cocaine injection (adjusted odds ratio 2.38, 95% confidence interval 1.00-5.66). The most commonly reported reason for being denied PA was being accused of drug seeking (44.0%). Commonly reported actions taken after being denied PA included buying the requested medication off the street (40.1%) or obtaining heroin to treat pain (32.9%).

DISCUSSION AND CONCLUSIONS

These findings highlight the challenges of addressing perceived pain and the need for strategies to prevent high-risk methods of self-managing pain, such as obtaining diverted medications or illicit substances for pain. Such strategies may include integrated pain management guidelines within methadone maintenance treatment and other substance use treatment programs.

Les troubles liés à l’utilisation des opioïdes prescrits médicalement

Épidémiologie Au cours des 10 à 15 dernières années, le Canada est devenu le deuxième plus grand consommateur d’opioïdes de prescription (OP), principalement pour le traitement de la douleur. Cette augmentation a été plus marquée chez les 55 ans et plus. Même si personne ne conteste le droit des patients à recevoir des traitements adéquats pour la douleur, il n’en demeure pas moins que cette disponibilité accrue a entraîné son lot de problèmes : augmentation des visites à l’urgence et des décès liés aux opioïdes ainsi que du trouble lié à l’utilisation (TLU) des opioïdes, trouble qui est d’ailleurs associé à une prévalence accrue, de l’ordre de 40 %, de divers problèmes psychiatriques, dont les troubles dépressifs majeurs.

Neuroscience De nouvelles connaissances issues des neurosciences nous permettent de mieux comprendre la réaction du cerveau lors de l’exposition à ces substances et le caractère chronique du TLU des opioïdes. Quoique historiquement perçu comme une faiblesse de caractère ou un vice, le TLU des opioïdes est maintenant reconnu comme une condition chronique résultant d’une interaction complexe entre une substance, des facteurs d’environnement et un génotype individuel. Malheureusement, ces évidences scientifiques ne sont pas encore largement appliquées à la clinique et la majorité des médecins n’ont pas les habiletés nécessaires pour diagnostiquer et traiter le TLU des opioïdes.

Guides de pratique clinique Des recommandations et guides de pratique peuvent nous aider à identifier les personnes plus vulnérables à un mésusage, et à mieux encadrer la prescription et la gestion de la médication. Il ne s’agit pas de se désintéresser de ces patients et de les abandonner à leur sort mais plutôt de leur offrir des soins inspirés des meilleures pratiques et appuyés sur des évidences scientifiques de qualité.

Can monitoring consumer requests for opioid-replacement therapy improve access to treatment?

OBJECTIVE

This study examined data recorded by one urban publicly funded opioid-replacement therapy clinic (from 2009 to 2011) to identify whether these data could be used to inform the rostering of clinicians more effectively to improve access to treatment.

METHODS

Data analysis incorporated descriptive and inferential methods.

RESULTS

There were trends in the times of the year consumers seek opioid-replacement therapy, similarity and differences between gender requests for treatment and variation in consumer wait time on triage.

CONCLUSIONS

National reporting of opioid-replacement therapy triages would help gain a better understanding of the number of people in need of treatment. If opioid-replacement therapy providers monitored consumer triages, they could roster more effectively, have gender-specific clinicians available, acknowledge and inform consumers of wait time on triage and allow re-orientation of services to lower wait time.

Accessibility versus quality of care plus retention: the formula for service delivery in Australian opioid replacement therapy?

The aim of this paper is to investigate how Australian Opioid Replacement Therapy (ORT) policy influences access to ORT treatment, including the resources required for implementation. In doing so, we also compare the accessibility of ORT treatment in Australia (AU) with ORT in the United Kingdom (UK) and United States (US). A review of government data and policy that influence service delivery was undertaken. When comparing across AU, the UK, and the US, we found several differences. To improve access to treatment in Australia more general practitioners need to provide ORT. Additionally, criteria for quality care, a centralised intake system, a national ORT treatment outcome measure, and a shift towards a recovery focus are recommended.

Triage in opioid replacement therapy: what's the wait?

In Australia, a wait for Opioid Replacement Therapy (ORT) has been reported although the magnitude is unknown. This study examined data recorded by one urban publicly funded ORT clinic (from 2009 to 2011) to identify if people (n = 803) were waiting for ORT assessment appointments and to explore how triage influences access to ORT. Data analysis incorporated descriptive methods and the use of Kaplan-Meier estimator of the cumulative incidence function. The implications and limitations of this study are included with further research suggestions.