1
|
Wei YJJ, Winterstein AG, Schmidt S, Fillingim RB, Schmidt S, Daniels MJ, DeKosky ST. Short- and long-term safety of discontinuing chronic opioid therapy among older adults with Alzheimer's disease and related dementia. Age Ageing 2024; 53:afae047. [PMID: 38497237 PMCID: PMC10945292 DOI: 10.1093/ageing/afae047] [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: 06/21/2023] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND Limited evidence exists on the short- and long-term safety of discontinuing versus continuing chronic opioid therapy (COT) among patients with Alzheimer's disease and related dementias (ADRD). METHODS This cohort study was conducted among 162,677 older residents with ADRD and receipt of COT using a 100% Medicare nursing home sample. Discontinuation of COT was defined as no opioid refills for ≥90 days. Primary outcomes were rates of pain-related hospitalisation, pain-related emergency department visit, injury, opioid use disorder (OUD) and opioid overdose (OD) measured by diagnosis codes at quarterly intervals during 1- and 2-year follow-ups. Poisson regression models were fit using generalised estimating equations with inverse probability of treatment weights to model quarterly outcome rates between residents who discontinued versus continued COT. RESULTS The study sample consisted of 218,040 resident episodes with COT; of these episodes, 180,916 residents (83%) continued COT, whereas 37,124 residents (17%) subsequently discontinued COT. Discontinuing (vs. continuing) COT was associated with higher rates of all outcomes in the first quarter, but these associations attenuated over time. The adjusted rates of injury, OUD and OD were 0, 69 and 60% lower at the 1-year follow-up and 11, 81 and 79% lower at the 2-year follow-up, respectively, for residents who discontinued versus continued COT, with no difference in the adjusted rates of pain-related hospitalisations or emergency department visits. CONCLUSIONS The rates of adverse outcomes were higher in the first quarter but lower or non-differential at 1-year and 2-year follow-ups between COT discontinuers versus continuers among older residents with ADRD.
Collapse
Affiliation(s)
- Yu-Jung Jenny Wei
- Division of Outcomes and Translational Sciences, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL 32610, USA
- Department of Epidemiology, Colleges of Medicine and Public Health and Health Professions, University of Florida, Gainesville, FL 32610, USA
| | - Siegfried Schmidt
- Department of Community Health and Family Medicine, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Roger B Fillingim
- Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, FL, USA
| | - Stephan Schmidt
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Michael J Daniels
- Department of Statistics, College of Liberal Arts and Sciences, University of Florida, Gainesville FL, 32610, USA
| | - Steven T DeKosky
- Department of Neurology, McKnight Brain Institute, University of Florida, Gainesville, FL 32610, USA
| |
Collapse
|
2
|
Martorella G, Miao H, Wang D, Park L, Mathis K, Park J, Sheffler J, Granville L, Teixeira AL, Schulz PE, Ahn H. Feasibility, Acceptability, and Efficacy of Home-Based Transcranial Direct Current Stimulation on Pain in Older Adults with Alzheimer's Disease and Related Dementias: A Randomized Sham-Controlled Pilot Clinical Trial. J Clin Med 2023; 12:401. [PMID: 36675330 PMCID: PMC9860690 DOI: 10.3390/jcm12020401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/20/2022] [Accepted: 12/23/2022] [Indexed: 01/05/2023] Open
Abstract
Although transcranial direct current stimulation (tDCS) is emerging as a convenient pain relief modality for several chronic pain conditions, its feasibility, acceptability, and preliminary efficacy on pain in patients with Alzheimer's disease and related dementias (ADRD) have not been investigated. The purpose of this pilot study was to assess the feasibility, acceptability, and preliminary efficacy of 5, 20-min home-based tDCS sessions on chronic pain in older adults with ADRD. We randomly assigned 40 participants to active (n = 20) or sham (n = 20) tDCS. Clinical pain intensity was assessed using a numeric rating scale (NRS) with patients and a proxy measure (MOBID-2) with caregivers. We observed significant reductions of pain intensity for patients in the active tDCS group as reflected by both pain measures (NRS: Cohen's d = 0.69, p-value = 0.02); MOBID-2: Cohen's d = 1.12, p-value = 0.001). Moreover, we found home-based tDCS was feasible and acceptable intervention approach for pain in ADRD. These findings suggest the need for large-scale randomized controlled studies with larger samples and extended versions of tDCS to relieve chronic pain on the long-term for individuals with ADRD.
Collapse
Affiliation(s)
| | - Hongyu Miao
- College of Nursing, Florida State University, Tallahassee, FL 32306, USA
- Department of Statistics, Florida State University, Tallahassee, FL 32306, USA
| | - Duo Wang
- Department of Statistics, Florida State University, Tallahassee, FL 32306, USA
| | - Lindsey Park
- College of Nursing, Florida State University, Tallahassee, FL 32306, USA
| | - Kenneth Mathis
- The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX 77030, USA
| | - JuYoung Park
- Phyllis & Harvey Sandler School of Social Work, Florida Atlantic University College of Social Work and Criminal Justice, Boca Raton, FL 33431, USA
| | - Julia Sheffler
- College of Medicine, Florida State University, Tallahassee, FL 32306, USA
| | - Lisa Granville
- College of Medicine, Florida State University, Tallahassee, FL 32306, USA
| | - Antonio L. Teixeira
- The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX 77030, USA
| | - Paul E. Schulz
- The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX 77030, USA
| | - Hyochol Ahn
- College of Nursing, Florida State University, Tallahassee, FL 32306, USA
| |
Collapse
|
3
|
Wang D, Li S, Ma X, Chen X, Tian X, Li X, Chen L, Kang Q, Wang X, Jin P, Lu X, Fu Y, Li J, Sheng J. Immunomodulatory effects of fentanyl and morphine on DSS- and TNBS-induced colitis. Immunopharmacol Immunotoxicol 2022; 44:1044-1057. [PMID: 35848944 DOI: 10.1080/08923973.2022.2102993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Opioid prescription for inflammatory bowel disease (IBD)-related pain is on the rise. However, the use of strong opioids can result in severe complications, and even death, in IBD patients. This study aimed to define the role of fentanyl and morphine, two representative strong opioids, in the pathogenesis of dextran sodium sulfate (DSS)- and 2,4,6-trinitrobenzenesulfonic acid solution (TNBS)-induced colitis. METHOD DSS and TNBS models were induced in C57BL/6J and Balb/c mice, respectively. Disease activity index (DAI), histopathology, enzyme-linked immunosorbent assay (ELISA), multiplex ELISA, and flow cytometry were performed to evaluate the effects of fentanyl and morphine. RESULT Fentanyl exacerbated DSS- and TNBS-induced colitis, while morphine exhibited no significant immunomodulatory effect. Fentanyl and morphine had no obvious effects on the serum levels of adrenocorticotropic hormone (ACTH), glucocorticoid (GC), and prostaglandin E2 (PGE-2) in DSS and TNBS models. Fentanyl elevated the proportions of Th1 cells, μ-opioid receptor (MOR) + Th1 cells, and MOR + macrophages in the colonic mucosa of DSS-treated mice, and enhanced the proportions of Th1 cells, macrophages, MOR + Th1 cells, and MOR + macrophages in the colonic mucosa of TNBS-treated mice. We found that fentanyl upregulated the levels of inflammatory cytokines/chemokines in MOR + macrophages of the colonic lamina propria mononuclear cells (LPMCs) from DSS-treated mice, whereas it had no effect on the expression of most inflammatory cytokines/chemokines in MOR + macrophages in the colonic LPMCs from TNBS-treated mice. CONCLUSION Our findings suggest that fentanyl exacerbates murine colitis via Th1 cell- and macrophage-mediated mechanisms, while morphine exhibits no significant immunomodulatory effect.
Collapse
Affiliation(s)
- Dezhi Wang
- Department of Gastroenterology, The Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Shanshan Li
- Department of Laboratory, The Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Xianzong Ma
- Department of Gastroenterology, The Seventh Medical Center of PLA General Hospital, Beijing, China.,Chinese PLA General Hospital, Beijing, China
| | - Xi Chen
- Department of Gastroenterology, The Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Xiaoran Tian
- Department of Gastroenterology, The Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Xuhang Li
- Department of Medicine/GI Division, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Linxiao Chen
- Department of Gastroenterology, The Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Qian Kang
- Department of Gastroenterology, The Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Xin Wang
- Department of Gastroenterology, The Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Peng Jin
- Department of Gastroenterology, The Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Xiaojuan Lu
- Department of Gastroenterology, The Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Yanxia Fu
- Department of Biochemistry and Molecular Biology, Capital Medical University, Beijing, China
| | - Jianghua Li
- State Key Laboratory of Membrane Biology, School of Medicine, Tsinghua University, Beijing, China
| | - Jianqiu Sheng
- Department of Gastroenterology, The Seventh Medical Center of PLA General Hospital, Beijing, China.,Chinese PLA General Hospital, Beijing, China
| |
Collapse
|
4
|
Wood S, Foy R, Willis TA, Carder P, Johnson S, Alderson S. General practice responses to opioid prescribing feedback: a qualitative process evaluation. Br J Gen Pract 2021; 71:e788-e796. [PMID: 33979300 PMCID: PMC8407857 DOI: 10.3399/bjgp.2020.1117] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 04/27/2021] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND The rise in opioid prescribing in primary care represents a significant public health challenge, associated with increased psychosocial problems, hospitalisations, and mortality. An evidence-based bimonthly feedback intervention to reduce opioid prescribing was developed and implemented, targeting 316 general practices in West Yorkshire over 1 year. AIM To understand how general practice staff received and responded to the feedback intervention. DESIGN AND SETTING Qualitative process evaluation involving semi-structured interviews, guided by Normalisation Process Theory (NPT), of primary care healthcare professionals targeted by feedback. METHOD Participants were purposively recruited according to baseline opioid prescribing levels and degree of change following feedback. Interview data were coded to NPT constructs, and thematically analysed. RESULTS Interviews were conducted with 21 staff from 20 practices. Reducing opioid prescribing was recognised as a priority. While high achievers had clear structures for quality improvement, feedback encouraged some less structured practices to embed changes. The non-prescriptive nature of the feedback reports allowed practices to develop strategies consistent with their own ways of working and existing resources. Practice concerns were allayed by the credibility of the reports and positive experiences of reducing opioid prescribing. The scale, frequency, and duration of feedback may have ensured a good overall level of practice population reach. CONCLUSION The intervention engaged general practice staff in change by targeting an issue of emerging concern, and allowing adaption to different ways of working. Practice efforts to reduce opioid prescribing were reinforced by regular feedback, credible comparative data showing progress, and shared experiences of patient benefit.
Collapse
Affiliation(s)
- Su Wood
- Leeds Institute of Health Sciences, University of Leeds, Leeds
| | - Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds
| | - Thomas A Willis
- Leeds Institute of Health Sciences, University of Leeds, Leeds
| | - Paul Carder
- West Yorkshire Research & Development, NHS Bradford District and Craven CCG, Bradford
| | - Stella Johnson
- West Yorkshire Research & Development, NHS Bradford District and Craven CCG, Bradford
| | - Sarah Alderson
- Leeds Institute of Health Sciences, University of Leeds, Leeds
| |
Collapse
|
5
|
Alderson SL, Farragher TM, Willis TA, Carder P, Johnson S, Foy R. The effects of an evidence- and theory-informed feedback intervention on opioid prescribing for non-cancer pain in primary care: A controlled interrupted time series analysis. PLoS Med 2021; 18:e1003796. [PMID: 34606504 PMCID: PMC8489725 DOI: 10.1371/journal.pmed.1003796] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 09/03/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The rise in opioid prescribing in primary care represents a significant international public health challenge, associated with increased psychosocial problems, hospitalisations, and mortality. We evaluated the effects of a comparative feedback intervention with persuasive messaging and action planning on opioid prescribing in primary care. METHODS AND FINDINGS A quasi-experimental controlled interrupted time series analysis used anonymised, aggregated practice data from electronic health records and prescribing data from publicly available sources. The study included 316 intervention and 130 control primary care practices in the Yorkshire and Humber region, UK, serving 2.2 million and 1 million residents, respectively. We observed the number of adult patients prescribed opioid medication by practice between July 2013 and December 2017. We excluded adults with coded cancer or drug dependency. The intervention, the Campaign to Reduce Opioid Prescribing (CROP), entailed bimonthly, comparative, and practice-individualised feedback reports to practices, with persuasive messaging and suggested actions over 1 year. Outcomes comprised the number of adults per 1,000 adults per month prescribed any opioid (main outcome), prescribed strong opioids, prescribed opioids in high-risk groups, prescribed other analgesics, and referred to musculoskeletal services. The number of adults prescribed any opioid rose pre-intervention in both intervention and control practices, by 0.18 (95% CI 0.11, 0.25) and 0.36 (95% CI 0.27, 0.46) per 1,000 adults per month, respectively. During the intervention period, prescribing per 1,000 adults fell in intervention practices (change -0.11; 95% CI -0.30, -0.08) and continued rising in control practices (change 0.54; 95% CI 0.29, 0.78), with a difference of -0.65 per 1,000 patients (95% CI -0.96, -0.34), corresponding to 15,000 fewer patients prescribed opioids. These trends continued post-intervention, although at slower rates. Prescribing of strong opioids, total opioid prescriptions, and prescribing in high-risk patient groups also generally fell. Prescribing of other analgesics fell whilst musculoskeletal referrals did not rise. Effects were attenuated after feedback ceased. Study limitations include being limited to 1 region in the UK, possible coding errors in routine data, being unable to fully account for concurrent interventions, and uncertainties over how general practices actually used the feedback reports and whether reductions in prescribing were always clinically appropriate. CONCLUSIONS Repeated comparative feedback offers a promising and relatively efficient population-level approach to reduce opioid prescribing in primary care, including prescribing of strong opioids and prescribing in high-risk patient groups. Such feedback may also prompt clinicians to reconsider prescribing other medicines associated with chronic pain, without causing a rise in referrals to musculoskeletal clinics. Feedback may need to be sustained for maximum effect.
Collapse
Affiliation(s)
- Sarah L. Alderson
- Leeds Institute of Health Science, University of Leeds, Leeds, United Kingdom
- * E-mail:
| | - Tracey M. Farragher
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, United Kingdom
| | - Thomas A. Willis
- Leeds Institute of Health Science, University of Leeds, Leeds, United Kingdom
| | - Paul Carder
- West Yorkshire Research and Development, National Health Service Bradford Districts Clinical Commissioning Group, Bradford, United Kingdom
| | - Stella Johnson
- West Yorkshire Research and Development, National Health Service Bradford Districts Clinical Commissioning Group, Bradford, United Kingdom
| | - Robbie Foy
- Leeds Institute of Health Science, University of Leeds, Leeds, United Kingdom
| |
Collapse
|
6
|
Tevik K, Benth JŠ, Aarøen M, Lornstad MT, Bergh S, Helvik A. Prevalence and persistent use of analgesic drugs in older adults receiving domiciliary care at baseline-A longitudinal study. Health Sci Rep 2021; 4:e316. [PMID: 34250268 PMCID: PMC8247935 DOI: 10.1002/hsr2.316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 05/21/2021] [Accepted: 06/08/2021] [Indexed: 11/24/2022] Open
Abstract
AIMS To describe the prevalence and persistence of analgesic drug use (opioids and antipyretics [ie, paracetamol and acetylsalicylic acid]) in participants (≥70 years) with and without dementia receiving domiciliary care in the eastern part of Norway. In addition, to explore factors associated with persistent drug use and examine whether drug use has changed after admission to a nursing home. METHODS A longitudinal study with 1001 participants (mean [SD] age 83.4 [5.7] years) receiving domiciliary care. Medical information including analgesic drug use was collected at baseline (A1) between August 2008 and December 2010, follow-up assessments after 18 (A2) and 36 months (A3). Analgesic drugs prescribed for regular use were recorded from the participants' medical records. The participants' cognitive and physical health was evaluated at all assessments. Level of care (domiciliary care or nursing home care) was recorded at A2 and A3. Generalized linear mixed models were used to examine the prevalence and persistence of analgesic drug use. RESULTS The prevalence of prescribed use of antipyretics and opioids was 13.6% and 9.2%, respectively. Participants with dementia had more frequent use of antipyretics in all assessments and opioids in the last assessment than participants without dementia. Persistent use of both antipyretics and opioids was high between two consecutive assessments, both for participants with and without dementia. Persistent use of analgesics was associated with poorer physical functioning, but not by level of care. Overall, there was no difference between those admitted to a nursing home and those receiving domiciliary care at follow-up, with respect to change in analgesic drug use over time. CONCLUSION The prevalence and persistent use of analgesics were high in older adults receiving domiciliary care at baseline and especially in participants with dementia. A holistic approach and interdisciplinary collaboration are essential to effectively assess and treat pain in older adults.
Collapse
Affiliation(s)
- Kjerstin Tevik
- Department of Public Health and Nursing, Faculty of Medicine and Health SciencesNorwegian University of Science and Technology (NTNU)TrondheimNorway
- Norwegian National Advisory Unit on Ageing and HealthVestfold Hospital TrustTønsbergNorway
| | - Jūratė Šaltytė Benth
- Research Centre for Age‐related Functional Decline and DiseaseInnlandet Hospital TrustOttestadNorway
- Institute of Clinical Medicine, Ahus CampusUniversity of OsloOsloNorway
- Health Services Research UnitAkershus University HospitalLørenskogNorway
| | - Marte Aarøen
- Department of Public Health and Nursing, Faculty of Medicine and Health SciencesNorwegian University of Science and Technology (NTNU)TrondheimNorway
| | - Marie Turmo Lornstad
- Department of Public Health and Nursing, Faculty of Medicine and Health SciencesNorwegian University of Science and Technology (NTNU)TrondheimNorway
| | - Sverre Bergh
- Norwegian National Advisory Unit on Ageing and HealthVestfold Hospital TrustTønsbergNorway
- Research Centre for Age‐related Functional Decline and DiseaseInnlandet Hospital TrustOttestadNorway
| | - Anne‐S. Helvik
- Department of Public Health and Nursing, Faculty of Medicine and Health SciencesNorwegian University of Science and Technology (NTNU)TrondheimNorway
- Norwegian National Advisory Unit on Ageing and HealthVestfold Hospital TrustTønsbergNorway
| |
Collapse
|
7
|
Lehti TE, Rinkinen MO, Aalto U, Roitto HM, Knuutila M, Öhman H, Kautiainen H, Karppinen H, Tilvis R, Strandberg T, Pitkälä KH. Prevalence of Musculoskeletal Pain and Analgesic Treatment Among Community-Dwelling Older Adults: Changes from 1999 to 2019. Drugs Aging 2021; 38:931-937. [PMID: 34386937 PMCID: PMC8484214 DOI: 10.1007/s40266-021-00888-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2021] [Indexed: 11/28/2022]
Abstract
Background Pain is undertreated in older populations. At the same time, increased use of opioids is of concern in the Western world. Aims We sought to analyze temporal trends in musculoskeletal pain and prescribed analgesic treatment among community-dwelling people aged 75–95 years using cross-sectional cohort data spanning 20 years. Methods The Helsinki Aging Study recruited random samples of people aged 75, 80, 85, 90, and 95 years in 1999, 2009, and 2019. In total, 5707 community-dwelling persons participated in the study. The participants reported their medical diagnoses, regular prescription medications, and the presence of back pain or joint pain within the last 2 weeks (never, sometimes, or daily). We compared analgesic use among participants reporting and not reporting musculoskeletal pain in 1999, 2009, and 2019. Results Of the participants, 57–61% reported intermittent or daily musculoskeletal pain. The percentage receiving a prescribed daily analgesic increased from 9% in 1999 to 16% in 2019. The use of non-steroidal anti-inflammatory drugs (NSAIDs) decreased from 1999 to 2019, while the use of paracetamol increased from 2 to 11%. Opioids were taken by 2% in 1999 and 3% in 2019. Of those reporting daily musculoskeletal pain, 20%, 35%, and 32% received regular pain medication in 1999, 2009, and 2019, respectively. Conclusions Pain remains undertreated in the community-dwelling older population, although the use of regular prescribed analgesics increased between 1999 and 2019. The use of NSAIDs has decreased, while the use of paracetamol has increased. Daily opioid use has remained modest.
Collapse
Affiliation(s)
- Tuuli Elina Lehti
- Primary Health Care Unit, Helsinki University Hospital, Ilkantie 10 B 22, 00400, Helsinki, Finland. .,Social Services and Health Care Division, City of Helsinki, Helsinki, Finland. .,Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland.
| | - M-O Rinkinen
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland
| | - U Aalto
- Social Services and Health Care Division, City of Helsinki, Helsinki, Finland.,Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland
| | - H M Roitto
- Social Services and Health Care Division, City of Helsinki, Helsinki, Finland.,Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland
| | - M Knuutila
- Social Services and Health Care Division, City of Helsinki, Helsinki, Finland.,Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland
| | - H Öhman
- Geriatric Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - H Kautiainen
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland
| | - H Karppinen
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland
| | - R Tilvis
- Geriatric Unit, Department of Internal Medicine, University of Helsinki, Helsinki, Finland
| | - T Strandberg
- Geriatric Unit, Department of Internal Medicine, University of Helsinki, Helsinki, Finland.,Center for Life Course Health Research, University of Oulu, Oulu, Finland
| | - K H Pitkälä
- Primary Health Care Unit, Helsinki University Hospital, Ilkantie 10 B 22, 00400, Helsinki, Finland.,Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland
| |
Collapse
|
8
|
Motor cortex transcranial direct current stimulation effects on knee osteoarthritis pain in elderly subjects with dysfunctional descending pain inhibitory system: A randomized controlled trial. Brain Stimul 2021; 14:477-487. [PMID: 33684598 DOI: 10.1016/j.brs.2021.02.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 02/19/2021] [Accepted: 02/24/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Although evidence has indicated a positive effect of transcranial direct current stimulation (tDCS) on reducing pain, few studies have focused on the elderly population with knee osteoarthritis (KOA). OBJECTIVE To evaluate whether tDCS reduces KOA pain in elderly individuals with a dysfunctional descending pain inhibitory system (DPIS). METHODS In a double-blind trial, individuals ≥ 60 years with KOA pain and a dysfunctional DPIS, we randomly assigned patients to receive 15 daily sessions of 2 mA tDCS over the primary motor cortex (anode) and contralateral supraorbital area (cathode) (M1-SO) for 20 min or sham tDCS. Change in pain perception indexed by the Brief Pain Inventory (BPI) at the end of intervention was the primary outcome. Secondary outcomes included: disability, quantitative sensory testing, pain pressure threshold and conditioned pain modulation (CPM). Subjects were followed-up for 2 months. RESULTS Of the 104 enrolled subjects, with mean (SD) age of 73.9 (8.01) years and 88 (84.6%) female, 102 finished the trial. In the intention-to-treat analysis, the active tDCS group had a significantly greater reduction in BPI compared to the sham group (difference, 1.59; 95% CI, 0.95 to 2.23; P < 0.001; Cohen's d, 0.58); and, also a significantly greater improvement in CPM-pressure in the knee (P = 0.01) and CPM-pain in the hand (P = 0.01). These effects were not sustained at follow-up. The intervention was well tolerated, with no severe adverse effects. CONCLUSION M1-SO tDCS is associated with a moderate effect size in reducing pain in elderly patients with KOA after 15 daily sessions of stimulation. This intervention has also shown to modulate the DPIS.
Collapse
|
9
|
Marttinen MK, Kautiainen H, Haanpää M, Pohjankoski H, Hintikka J, Kauppi MJ. Analgesic purchases among older adults - a population-based study. BMC Public Health 2021; 21:256. [PMID: 33517898 PMCID: PMC7849135 DOI: 10.1186/s12889-021-10272-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 01/19/2021] [Indexed: 02/07/2023] Open
Abstract
Background Pain is a frequent and inevitable factor affecting the quality of life among older people. Several studies have highlighted the ineffectiveness of treating chronic pain among the aged population, and little is known about the prevalence of analgesics administration among community-dwelling older adults. The objective was to examine older adults’ prescription analgesic purchases in relation to SF-36 pain in a population-based setting. Methods One thousand four hundred twenty community-dwelling citizens aged 62–86 years self-reported SF-36 bodily pain (pain intensity and pain-related interference) scores for the previous 4 weeks. The Social Insurance Institution of Finland register data on analgesic purchases for 6 months prior to and 6 months after the questionnaire data collection were considered. Special interest was focused on factors related to opioid purchases. Results Of all participants, 84% had purchased prescription analgesics during 1 year. NSAIDs were most frequently purchased (77%), while 41% had purchased paracetamol, 32% opioids, 17% gabapentinoids, and 7% tricyclic antidepressants. Age made no marked difference in purchasing prevalence. The number of morbidities was independently associated with analgesic purchases in all subjects and metabolic syndrome also with opioid purchases in subjects who had not reported any pain. Discussion Substantial NSAID and opioid purchases emerged. The importance of proper pain assessment and individual deliberation in terms of analgesic contraindications and pain quality, as well as non-pharmacological pain management, need to be highlighted in order to optimize older adults’ pain management.
Collapse
Affiliation(s)
- Maiju K Marttinen
- Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön katu 34, 33520, Tampere, Finland. .,Department of Anesthesiology, Intensive Care and Pain Medication, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 8, 00290, Helsinki, Finland.
| | - Hannu Kautiainen
- Folkhälsan Research Center, Topeliuksenkatu 20, 00250, Helsinki, Finland.,Primary Health Care Unit, Kuopio University Hospital, Puijonlaaksontie 2, 70200, Kuopio, Finland
| | - Maija Haanpää
- Ilmarinen Mutual Pension Insurance Company, Porkkalankatu 1, 00180, Helsinki, Finland.,Department of Neurosurgery, Helsinki University Hospital, Topeliuksenkatu 5, 00270, Helsinki, Finland
| | - Heini Pohjankoski
- Department of Paediatrics, Päijät-Häme Central Hospital, Keskussairaalankatu 7, 15850, Lahti, Finland
| | - Jukka Hintikka
- Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön katu 34, 33520, Tampere, Finland.,Department of Psychiatry, Päijät-Häme Central Hospital, Keskussairaalankatu 7, 15850, Lahti, Finland
| | - Markku J Kauppi
- Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön katu 34, 33520, Tampere, Finland.,Department of Rheumatology, Päijät-Häme Central Hospital, Keskussairaalankatu 7, 15850, Lahti, Finland
| |
Collapse
|
10
|
Pollonini L, Hernandez SAM, Park L, Miao H, Mathis K, Ahn H. Functional Near-Infrared Spectroscopy to Assess Central Pain Responses in a Nonpharmacologic Treatment Trial of Osteoarthritis. J Neuroimaging 2020; 30:808-814. [PMID: 32896933 PMCID: PMC7719610 DOI: 10.1111/jon.12782] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/31/2020] [Accepted: 08/21/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND AND PURPOSE Knee osteoarthritis (OA) is a common source of pain in older adults. Although OA-induced pain can be relieved with analgesics and anti-inflammatory drugs, the current opioid epidemic is fostering the exploration of nonpharmacologic strategies for pain mitigation. Amongs these, transcranial direct current stimulation (tDCS) and mindfulness-based meditation (MBM) hold potential for pain-relief efficacy due to their neuromodulatory effects of the central nervous system, which is known to play a fundamental role in pain perception and processing. METHODS In this double-blind study, we used functional near-infrared spectroscopy (fNIRS) to investigate the effects of tDCS combined with MBM on underlying pain processing mechanisms at the central nervous level in older adults with knee OA. Nineteen subjects were randomly assigned to two groups undergoing a 10-day active tDCS and MBM regimen and a sham tDCS and MBM regimen, respectively. RESULTS Our results showed that the neuromodulatory intervention significantly relieved pain only in the group receiving active treatment. We also found that only the active treatment group showed a significant increase in oxyhemoglobin activation of the superior motor and somatosensory cortices colocated to the placement of the tDCS anodal electrode. To our knowledge, this is the first study in which the combined effect of tDCS and MBM is investigated using fNIRS. CONCLUSION In conclusion, fNIRS can be effectively used to investigate neural mechanisms of pain at the cortical level in association with nonpharmacological, self-administered treatments.
Collapse
Affiliation(s)
- Luca Pollonini
- Department of Engineering Technology, University of Houston, Houston, TX, USA
- Department of Electrical and Computer Engineering, University of Houston, Houston, TX, USA
| | | | - Lindsey Park
- Cizik School of Nursing, University of Texas Health Science Center, Houston, TX, USA
| | - Hongyu Miao
- School of Public Health, University of Texas Health Science Center, Houston, TX, USA
| | - Kenneth Mathis
- Department of Orthopedic Surgery, School of Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Hyochol Ahn
- Cizik School of Nursing, University of Texas Health Science Center, Houston, TX, USA
| |
Collapse
|
11
|
Ritchie CS, Garrett SB, Thompson N, Miaskowski C. Unintended Consequences of Opioid Regulations in Older Adults with Multiple Chronic Conditions. THE GERONTOLOGIST 2020; 60:1343-1352. [PMID: 32222760 PMCID: PMC7491430 DOI: 10.1093/geront/gnaa016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The opioid epidemic has led to substantive regulatory and policy changes. Little is known about how these changes have impacted older adults, especially those with chronic pain and multiple chronic conditions (MCC). We sought to understand the experiences of older adults with chronic pain and MCC in the context of the opioid epidemic and policy responses to it. RESEARCH DESIGN AND METHODS Purposive sampling of older adults in a West Coast metropolitan area. Semistructured in-depth interviews lasting 45-120 min were digitally recorded and transcribed. Responses were analyzed using the constant comparative method. Participants were 25 adults aged 65 years and greater with three or more self-reported medical conditions and pain lasting for more than 6 months. RESULTS Respondents' accounts revealed numerous unintended consequences of the opioid epidemic and its policy responses. We identified four main themes: changes to the patient-clinician relationship; lack of patient agency and access in pain management; patient ambivalence and anxiety about existing opioid treatment/use; and patient concerns about future use. DISCUSSION AND IMPLICATIONS Older adults have high rates of chronic pain and MCC that may reduce their pain management options. The opioid epidemic and policies addressing it have the potential to negatively affect patient-clinician relationships and patients' pain self-management. Clinicians may be able to mitigate these unintended consequences by actively conveying respect to the patient, empowering patients in their pain self-management activities, and proactively addressing worries and fears patients may own related to their current and future pain management regimens.
Collapse
Affiliation(s)
- Christine S Ritchie
- The Mongan Institute and the Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston
| | - Sarah B Garrett
- Division of Geriatrics, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Nicole Thompson
- Osher Center for Integrative Medicine, University of California, San Francisco
| | | |
Collapse
|
12
|
Ahn H, Galle K, Mathis KB, Miao H, Montero-Hernandez S, Jackson N, Ju HH, McCrackin H, Goodwin C, Hargraves A, Jain B, Dinh H, Abdul-Mooti S, Park L, Pollonini L. Feasibility and efficacy of remotely supervised cranial electrical stimulation for pain in older adults with knee osteoarthritis: A randomized controlled pilot study. J Clin Neurosci 2020; 77:128-133. [PMID: 32402609 PMCID: PMC7308202 DOI: 10.1016/j.jocn.2020.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 05/02/2020] [Indexed: 10/24/2022]
Abstract
Cranial electrical stimulation (CES) is a noninvasive brain stimulation technique that has been shown to improve pain. However, few studies have investigated the potential benefits associated with remotely supervised CES in older adults with knee osteoarthritis (OA). The aim of this study was to examine the feasibility and preliminary efficacy of remotely supervised CES via secure videoconferencing software on clinical pain severity, experimental pain sensitivity, and pain-related cortical response in older adults with knee OA. Thirty participants with symptomatic knee OA pain were randomly assigned to receive 10 daily sessions (60 min each) of remotely supervised CES (n = 15) or sham CES (n = 15) over two weeks. We measured clinical pain severity via a Numeric Rating Scale, experimental pain sensitivity (e.g., heat pain sensitivity, pressure pain sensitivity, and conditioned pain modulation) using quantitative sensory testing, and pain-related cortical response via functional near-infrared spectroscopy imaging. We also measured participant satisfaction with treatment using the Client Satisfaction Questionnaire. Active CES significantly reduced scores on the Numeric Rating Scale and increased heat pain threshold, pressure pain thresholds, and conditioned pain modulation. We also found significant changes in pain-related cortical hemodynamic activity after CES. Participants tolerated CES well without serious adverse effects and were satisfied with the treatment. Our findings demonstrate promising clinical efficacy of remotely supervised CES for older adults with knee OA.
Collapse
Affiliation(s)
- Hyochol Ahn
- Department of Research, Cizik School of Nursing, The University of Texas Health Science Center at Houston, Houston, TX, USA.
| | - Kelli Galle
- Department of Research, Cizik School of Nursing, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Kenneth B Mathis
- Department of Orthopedic Surgery, School of Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Hongyu Miao
- Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | | | - Natalie Jackson
- Department of Research, Cizik School of Nursing, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Hsiao-Hui Ju
- Department of Research, Cizik School of Nursing, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Heather McCrackin
- Department of Research, Cizik School of Nursing, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Catherine Goodwin
- Department of Research, Cizik School of Nursing, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Allison Hargraves
- Department of Research, Cizik School of Nursing, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Bhawna Jain
- Department of Research, Cizik School of Nursing, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Helen Dinh
- Department of Research, Cizik School of Nursing, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Sarah Abdul-Mooti
- Department of Research, Cizik School of Nursing, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Lindsey Park
- Department of Research, Cizik School of Nursing, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Luca Pollonini
- Department of Engineering Technology, University of Houston, Houston, TX, USA
| |
Collapse
|
13
|
Abdelhamid K, ElHawary H, Turner JP. The Use of the Erector Spinae Plane Block to Decrease Pain and Opioid Consumption in the Emergency Department: A Literature Review. J Emerg Med 2020; 58:603-609. [DOI: 10.1016/j.jemermed.2020.02.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 12/31/2019] [Accepted: 02/16/2020] [Indexed: 12/15/2022]
|
14
|
Pollonini L, Miao H, Ahn H. Longitudinal effect of transcranial direct current stimulation on knee osteoarthritis patients measured by functional infrared spectroscopy: a pilot study. NEUROPHOTONICS 2020; 7:025004. [PMID: 32411812 PMCID: PMC7203445 DOI: 10.1117/1.nph.7.2.025004] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 04/21/2020] [Indexed: 05/15/2023]
Abstract
Significance: Knee osteoarthritis (OA) is a common joint disease causing chronic pain and functional alterations (stiffness and swelling) in the elderly population. OA is currently treated pharmacologically with analgesics, although neuromodulation via transcranial direct current stimulation (tDCS) has recently generated a growing interest as a safe side-effect free treatment alternative or a complement to medications for chronic pain conditions. Although a number of studies have shown that tDCS has a beneficial effect on behavioral measures of pain, the mechanistic action of neuromodulation on pain sensitivity and coping at the central nervous system is not well understood. Aim: We aimed at observing longitudinal changes of cortical hemodynamics in older adults with knee OA associated with a two-week-long tDCS self-treatment protocol. Approach: Hemodynamics was measured bilaterally in the motor and somatosensory cortices with functional near-infrared spectroscopy (fNIRS) in response to thermal pain induced ipsilaterally to the knee primarily affected by OA. Results: We found that both oxyhemoglobin- and deoxyhemoglobin-related functional activations significantly increased during the course of the tDCS treatment, supporting the notion that tDCS yields an increased cortical excitability. Concurrently, clinical measures of pain decreased with tDCS treatment, hinting at a potential spatial dissociation between cortically mediated pain perception and suppression and the prevalence of neuromodulatory effects over cortical pain processing. Conclusions: fNIRS is a valid method for objectively tracking pain in an ambulatory setting and it could potentially be used to inform strategies for optimized tDCS treatment and to develop innovative tDCS protocols.
Collapse
Affiliation(s)
- Luca Pollonini
- University of Houston, Department of Engineering Technology, Houston, Texas, United States
- University of Houston, Department of Electrical and Computer Engineering, Houston, Texas, United States
| | - Hongyu Miao
- University of Texas Health Science Center at Houston, School of Public Health, Houston, Texas, United States
| | - Hyochol Ahn
- University of Texas Health Science Center at Houston, Cizik School of Nursing, Houston, Texas, United States
| |
Collapse
|
15
|
Abstract
Objective: To characterize the literature describing the therapeutic use of opioids in the elderly. Data Sources: Two electronic databases, EMBASE and MEDLINE, were searched from years 1990 to September 5, 2018. Relevant reference lists were reviewed. Searches were restricted to English language. Study Selection and Data Extraction: Two reviewers independently screened 827 citations to identify observational studies, population-based cohort studies, retrospective analyses, and control trials looking at the management of persistent pain in patients aged ≥65 years and/or frail patients. Data Synthesis: Thirty-nine articles were included in the systematic review. More specifically, 17 observational studies, 7 population-based cohort studies, 10 retrospective analyses, and 4 controlled trials. The most common etiology of persistent pain was musculoskeletal (50%), and the most often adverse effects reported were central nervous system related (41%) and falls/fractures (39%). Relevance to Patient Care and Clinical Practice: As there is a lack of strong evidence-based recommendations for opioid use in the elderly, this review aims to evaluate opioid use in the elderly and compare their efficacy and safety among this population. Conclusions: Overall, central nervous system adverse effects were most commonly seen in the elderly. However, higher quality evidence is required to further appreciate the dose-related effects on efficacy and safety of opioids in the elderly.
Collapse
Affiliation(s)
- Melissa Jassal
- Royal Columbian Hospital, New Westminster, British Columbia, Canada
| | - Greg Egan
- Vernon Jubilee Hospital, Vernon, British Columbia, Canada
| | - Karen Dahri
- Vancouver General Hospital, Vancouver Coastal Health, Vancouver, British Columbia, Canada.,University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
16
|
Hachem GE, Rocha FO, Pepersack T, Jounblat Y, Drowart A, Lago LD. Advances in pain management for older patients with cancer. Ecancermedicalscience 2019; 13:980. [PMID: 32010204 PMCID: PMC6974363 DOI: 10.3332/ecancer.2019.980] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Indexed: 12/19/2022] Open
Abstract
The population of older patients is growing with a rising prevalence of cancer diagnoses and cancer-related pain syndromes. Older patients are also vulnerable to misleading pain evaluations and under treatment with opioids. Barriers to the effective and safe management of analgesics include pain assessments and the complex management of the best analgesic choice and dose-titration while achieving the fewest side effects. In this review, we will provide an overview of the challenges present in assessment and treatment choices, along with practical tips for routine clinical practice.
Collapse
Affiliation(s)
- Georges El Hachem
- Department of Hematology and Medical Oncology, Saint George Hospital University Medical Center, University of Balamand, PO Box 166378, Ashrafieh, Beirut 1100 2807, Lebanon
- Georges El Hachem and Francisco Oliveira Rocha contributed equally to writing this article
| | - Francisco Oliveira Rocha
- Medical Oncology Department, Institut Jules Bordet, L’Université Libre de Bruxelles (U.L.B), Brussels, Belgium
- Georges El Hachem and Francisco Oliveira Rocha contributed equally to writing this article
| | - Thierry Pepersack
- Medical Oncology Department, Institut Jules Bordet, L’Université Libre de Bruxelles (U.L.B), Brussels, Belgium
| | - Youssef Jounblat
- Department of Hematology and Medical Oncology, Lebanese University, PO Box 6573/14, Badaro, Museum, Beirut, Lebanon
| | - Annie Drowart
- Medical Oncology Department, Institut Jules Bordet, L’Université Libre de Bruxelles (U.L.B), Brussels, Belgium
| | - Lissandra Dal Lago
- Medical Oncology Department, Institut Jules Bordet, L’Université Libre de Bruxelles (U.L.B), Brussels, Belgium
| |
Collapse
|
17
|
Ahn H, Zhong C, Miao H, Chaoul A, Park L, Yen IH, Vila MA, Sorkpor S, Abdi S. Efficacy of combining home-based transcranial direct current stimulation with mindfulness-based meditation for pain in older adults with knee osteoarthritis: A randomized controlled pilot study. J Clin Neurosci 2019; 70:140-145. [DOI: 10.1016/j.jocn.2019.08.047] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 08/06/2019] [Indexed: 12/14/2022]
|
18
|
Ahn H, Sorkpor S, Miao H, Zhong C, Jorge R, Park L, Abdi S, Cho RY. Home-based self-administered transcranial direct current stimulation in older adults with knee osteoarthritis pain: An open-label study. J Clin Neurosci 2019; 66:61-65. [PMID: 31153751 DOI: 10.1016/j.jocn.2019.05.023] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 05/22/2019] [Indexed: 12/23/2022]
Abstract
Clinic-based transcranial direct current stimulation (tDCS) is a noninvasive brain stimulation technique that has been shown to improve pain. However, no published studies have reported using home-based self-administered tDCS in older adults with knee osteoarthritis (OA). The present study aimed to evaluate the preliminary efficacy and feasibility of home-based self-administered tDCS with real-time remote supervision on clinical pain, anxiety, depression, and sleep disturbances in older adults with knee OA. Twenty 50- to 85-year-old community-dwelling participants with knee OA received 10 daily home-based sessions of 2 mA tDCS for 20 min with real-time remote supervision. We measured clinical pain severity via the Visual Analog Scale, Western Ontario and McMaster Universities Osteoarthritis Index, and Short-Form McGill Pain Questionnaire. We assessed anxiety, depression, and sleep disturbances using the Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety-short form, depression-short form, and sleep disturbance-short form, respectively. All 20 participants completed all 10 home-based tDCS sessions without serious adverse effects. Both clinical pain severity and sleep disturbances were improved after completion of the 10 tDCS sessions. Anxiety and depression scores were not significantly improved. We demonstrated that home-based self-administered tDCS with real-time remote supervision was feasible and beneficial in alleviating clinical pain in older adults with knee OA. These findings support future studies with larger samples and longer-term follow-up evaluations.
Collapse
Affiliation(s)
- Hyochol Ahn
- Department of Research, Cizik School of Nursing, The University of Texas Health Science Center at Houston, Houston, TX, USA.
| | - Setor Sorkpor
- Department of Research, Cizik School of Nursing, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Hongyu Miao
- Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Chengxue Zhong
- Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Ricardo Jorge
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Lindsey Park
- Department of Research, Cizik School of Nursing, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Salahadin Abdi
- Department of Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Raymond Y Cho
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
19
|
Veiga DR, Mendonça L, Sampaio R, Castro-Lopes JM, Azevedo LF. A Two-Year Prospective Multicenter Study of Opioid Therapy for Chronic Noncancer Pain: Prescription Trends and Predictors. PAIN MEDICINE 2018; 20:2166-2178. [DOI: 10.1093/pm/pny275] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Objectives
Opioid use in chronic pain has increased worldwide in recent years. The aims of this study were to describe the trends and patterns of opioid therapy over two years of follow-up in a cohort of chronic noncancer pain (CNCP) patients and to assess predictors of long-term opioid use and clinical outcomes.
Methods
A prospective cohort study with two years of follow-up was undertaken in four multidisciplinary chronic pain clinics. Demographic data, pain characteristics, and opioid prescriptions were recorded at baseline, three, six, 12, and 24 months.
Results
Six hundred seventy-four CNCP patients were recruited. The prevalence of opioid prescriptions at baseline was 59.6% (N = 402), and 13% (N = 86) were strong opioid prescriptions. At 24 months, opioid prescription prevalence was as high as 74.3% (N = 501), and strong opioid prescription was 31% (N = 207). Most opioid users (71%, N = 479) maintained their prescription during the two years of follow-up. Our opioid discontinuation was very low (1%, N = 5). Opioid users reported higher severity and interference pain scores, both at baseline and after two years of follow-up. Opioid use was independently associated with continuous pain, pain location in the lower limbs, and higher pain interference scores.
Conclusions
This study describes a pattern of increasing opioid prescription in chronic pain patients. Despite the limited improvement of clinical outcomes, most patients keep their long-term opioid prescriptions. Our results underscore the need for changes in clinical practice and further research into the effectiveness and safety of chronic opioid therapy for CNPC.
Collapse
Affiliation(s)
- Dalila R Veiga
- Anesthesiology Department-Chronic Pain Center, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Liliane Mendonça
- Centro Nacional de Observação em Dor – OBSERVDOR, Porto, Portugal
| | - Rute Sampaio
- Departamento de Biomedicina - Unidade de Biologia Experimental, Faculdade de Medicina da Universidade do Porto, Portugal
- i3S—Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- IBMC—Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal
- Porto, Portugal
| | - José M Castro-Lopes
- Centro Nacional de Observação em Dor – OBSERVDOR, Porto, Portugal
- Departamento de Biomedicina - Unidade de Biologia Experimental, Faculdade de Medicina da Universidade do Porto, Portugal
- i3S—Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- IBMC—Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal
| | - Luís F Azevedo
- Centro Nacional de Observação em Dor – OBSERVDOR, Porto, Portugal
- CINTESIS - Center for Health Technology and Services Research, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- MEDCIDS - Departamento de Medicina da Comunidade Informação e Decisão em Saúde, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| |
Collapse
|
20
|
Treillet E, Laurent S, Hadjiat Y. Practical management of opioid rotation and equianalgesia. J Pain Res 2018; 11:2587-2601. [PMID: 30464578 PMCID: PMC6211309 DOI: 10.2147/jpr.s170269] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Purpose To review the recent literature on opioid rotation (ie, switching from one opioid drug to another or changing an opioid’s administration route) in cancer patients experiencing severe pain and to develop a novel equianalgesia table for use in routine clinical practice. Methods The MEDLINE database was searched with terms “cancer pain,” “opioid rotation,” “opioid switching,” “opioid ratio,” “opioid conversion ratio,” and “opioid equianalgesia” for the major opioids (morphine, oxycodone, fentanyl, and hydromorphone) and the intravenous, subcutaneous, oral, and transdermal administration routes. Selected articles were assessed for the calculated or cited opioid dose ratio, bidirectionality, and use of the oral morphine equivalent daily dose or a direct drug-to-drug ratio. Results Twenty publications met our selection criteria and were analyzed in detail. We did not find any large-scale, prospective, double-blind randomized controlled trial with robust design, and most of the studies assessed relatively small numbers of patients. Bidirectionality was investigated in seven studies only. Conclusion The updated equianalgesic table presented here incorporates the latest data and provides information on bidirectionality. Despite the daily use of equianalgesic tables, they are not based on high-level scientific evidence. More clinical research is needed on this topic.
Collapse
Affiliation(s)
- Erwan Treillet
- AP-HP, Médecine de la Douleur et Médecine Palliative, Hôpital Lariboisière, Paris, France,
| | - Sophie Laurent
- Institut de Cancérologie, Institut Gustave Roussy, Villejuif, France
| | | |
Collapse
|
21
|
Tavares DRB, Okazaki JEF, Rocha AP, Santana MVDA, Pinto ACPN, Civile VT, Santos FC, Fregni F, Trevisani VFM. Effects of Transcranial Direct Current Stimulation on Knee Osteoarthritis Pain in Elderly Subjects With Defective Endogenous Pain-Inhibitory Systems: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2018; 7:e11660. [PMID: 30373731 PMCID: PMC6234349 DOI: 10.2196/11660] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 10/02/2018] [Accepted: 10/03/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Knee osteoarthritis (OA) has been the main cause behind chronic pain and disabilities in the elderly population. The traditional treatment for knee OA pain currently concerns a number of combinations of pharmacological and nonpharmacological therapies. However, such combinations have displayed little effects on a significant group of subjects. In addition to this, pharmacological treatments often cause adverse effects, which limits their use on this population. Previous studies showed that chronic knee OA pain may be associated with maladaptive compensatory plasticity in pain-related neural central circuits indexed by a defective descending pain-inhibitory system. Transcranial direct current stimulation (tDCS) can revert some of these maladaptive changes, thus decreasing chronic pain sensation. Numerous studies have demonstrated that the use of anodal tDCS stimulation over the primary motor cortex (M1) has positive effects on chronic neuropathic pain. Yet, data on OA pain in elderly patients, including its effects on the endogenous pain-inhibitory system, remain limited. OBJECTIVE The objective of this study is to evaluate the efficacy of tDCS in reducing pain intensity caused by knee OA in elderly subjects with defective endogenous pain-inhibitory systems. METHODS We designed a randomized, sham-controlled, single-center, double-blinded clinical trial. Patients with knee OA who have maintained a chronic pain level during the previous 6 months and report a pain score of 4 or more on a 0-10 numeric rating scale (NRS) for pain in that period will undergo a conditioned pain modulation (CPM) task. Participants who present a reduced CPM response, defined as a decrease in NRS during the CPM task of less than 10%, and meet all of the inclusion criteria will be randomly assigned to receive 15 sessions of 2 mA active or sham tDCS for 20 minutes. A sample size of 94 subjects was calculated. The Brief Pain Inventory pain items will be used to assess pain intensity as our primary outcome. Secondary outcomes will include pain impact on functioning, mobility performance, quality of life, CPM, pressure pain threshold, touch-test sensory evaluation, and safety. Follow-up visits will be performed 2, 4, and 8 weeks following intervention. The data will be analyzed using the principle of intention-to-treat. RESULTS This study was approved by the institutional review board with the protocol number 1685/2016. The enrollment started in April 2018; at the time of publication of this protocol, 25 subjects have been enrolled. We estimate we will complete the enrollment process within 2 years. CONCLUSIONS This clinical trial will provide relevant data to evaluate if anodal tDCS stimulation over M1 can decrease chronic knee OA pain in elderly subjects with defective CPM. In addition, this trial will advance the investigation of the role of central sensitization in knee OA and evaluate how tDCS stimulation may affect it. TRIAL REGISTRATION ClinicalTrials.gov NCT03117231; https://clinicaltrials.gov/ct2/show/NCT03117231 (Archived by WebCite at http://webcitation.org/73WM1LCdJ). INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR1-10.2196/11660.
Collapse
Affiliation(s)
- Daniela Regina Brandao Tavares
- Department of Evidence-Based Medicine, Brazilian Cochrane Centre, Federal University of São Paulo, Sao Paulo, Brazil.,Department of Geriatrics and Gerontology, Federal University of São Paulo, Sao Paulo, Brazil
| | - Jane Erika Frazao Okazaki
- Department of Evidence-Based Medicine, Brazilian Cochrane Centre, Federal University of São Paulo, Sao Paulo, Brazil.,Department of Geriatrics and Gerontology, Federal University of São Paulo, Sao Paulo, Brazil
| | - Aline Pereira Rocha
- Department of Evidence-Based Medicine, Brazilian Cochrane Centre, Federal University of São Paulo, Sao Paulo, Brazil
| | - Marcia Valeria De Andrade Santana
- Department of Evidence-Based Medicine, Brazilian Cochrane Centre, Federal University of São Paulo, Sao Paulo, Brazil.,Department of Geriatrics and Gerontology, Federal University of São Paulo, Sao Paulo, Brazil
| | - Ana Carolina Pereira Nunes Pinto
- Department of Evidence-Based Medicine, Brazilian Cochrane Centre, Federal University of São Paulo, Sao Paulo, Brazil.,Department of Biological and Health Sciences, Federal University of Amapá, Amapá, Brazil
| | - Vinicius Tassoni Civile
- Department of Evidence-Based Medicine, Brazilian Cochrane Centre, Federal University of São Paulo, Sao Paulo, Brazil.,Institute of Health Sciences, Paulista University, Sao Paulo, Brazil
| | - Fania Cristina Santos
- Department of Geriatrics and Gerontology, Federal University of São Paulo, Sao Paulo, Brazil
| | - Felipe Fregni
- Laboratory of Neuromodulation & Center for Clinical Research Learning, Physics and Rehabilitation Department, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, United States
| | - Virginia Fernandes Moça Trevisani
- Department of Evidence-Based Medicine, Brazilian Cochrane Centre, Federal University of São Paulo, Sao Paulo, Brazil.,Department of Rheumatology, Santo Amaro University, Sao Paulo, Brazil
| |
Collapse
|
22
|
Ali A, Arif AW, Bhan C, Kumar D, Malik MB, Sayyed Z, Akhtar KH, Ahmad MQ. Managing Chronic Pain in the Elderly: An Overview of the Recent Therapeutic Advancements. Cureus 2018; 10:e3293. [PMID: 30443463 PMCID: PMC6235641 DOI: 10.7759/cureus.3293] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
A majority of the elderly suffer from chronic pain that significantly alters their daily activities and imposes an enormous burden on health care. Multiple comorbidities and the risk of polypharmacy in the elderly make it a challenge to determine the appropriate drug, dosage, and maintenance of therapy. Opioids are the most commonly used agents for this purpose in the elderly. The aim of this article is to discuss both the current well-established therapies used for managing chronic pain in the elderly and also the emerging newer therapies.
Collapse
Affiliation(s)
- Asad Ali
- Medicine, CMH Lahore Medical College and Institute of Dentistry, Lahore, PAK
| | | | - Chandur Bhan
- Internal Medicine, Chandka Medical College Hospital, Larkana, PAK
| | - Deepak Kumar
- Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | | | - Zohaib Sayyed
- Pediatrics, Shaikh Khalifa Bin Zayed Al-Nahyan Medical and Dental College, Bahawalpur, PAK
| | | | | |
Collapse
|
23
|
Pruskowski J, Wright R, Sprissler N, Bhatnagar M. Safety Considerations When Using Opioids for Older Adults #357. J Palliat Med 2018; 21:1187-1188. [DOI: 10.1089/jpm.2018.0266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
24
|
Lin YT, Lan KM, Wang LK, Chen JY. Treatment of Postherpetic Neuralgia With Intravenous Administration of Zinc Sulfate: A Case Report. A A Pract 2018; 11:8-10. [PMID: 29634548 DOI: 10.1213/xaa.0000000000000712] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Gabapentinoids (gabapentin and pregabalin) are first-line drugs for postherpetic neuralgia (PHN), but some PHN patients have inadequate therapeutic response. Zinc deficiency has been identified as a risk factor for PHN. Zinc can alleviate pain through binding to Ca(v)3.2 T-channels and N-methyl-D-aspartate receptors. Mechanisms of gabapentinoids on neuropathic pain include inhibiting N-methyl-D-aspartate receptors and calcium channels. The aforementioned findings provide a molecular pain-relieving basis for zinc supplements as an add-on therapy to pregabalin. We report 2 zinc-deficient PHN patients who received zinc sulfate intravenously as an add-on therapy to pregabalin and responded well.
Collapse
Affiliation(s)
- Yao-Tsung Lin
- From the Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan.,Department of Food Science and Applied Biotechnology, National Chung Hsing University, Taichung, Taiwan
| | - Kuo-Mao Lan
- From the Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan.,Department of Food Science and Applied Biotechnology, National Chung Hsing University, Taichung, Taiwan
| | - Li-Kai Wang
- From the Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
| | - Jen-Yin Chen
- From the Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan.,Department of the Senior Citizen Service Management, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| |
Collapse
|
25
|
Impact of Preadmission Opioid Treatment on 1-Year Mortality Following Nonsurgical Intensive Care*. Crit Care Med 2018. [DOI: 10.1097/ccm.0000000000003080] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
26
|
Withey SL, Paronis CA, Bergman J. Concurrent Assessment of the Antinociceptive and Behaviorally Disruptive Effects of Opioids in Squirrel Monkeys. THE JOURNAL OF PAIN 2018; 19:728-740. [PMID: 29477761 DOI: 10.1016/j.jpain.2018.02.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 01/10/2018] [Accepted: 02/13/2018] [Indexed: 10/17/2022]
Abstract
Although the clinical application of opioids for pain management is often hindered by undesired behavioral impairment, preclinical assays of antinociception typically do not provide information regarding the behaviorally disruptive effects of opioids that may accompany their antinociceptive effects. To address this, we modified a warm water tail withdrawal procedure to determine concurrently the effects of opioids on tail withdrawal latency (antinociception) and indices of food-maintained operant behavior (rates of responding and reinforcement density) in squirrel monkeys. Six opioid agonists were tested, and all produced dose-dependent antinociception and impairment of operant behavior. The ratio of median effective dose (ED50) values for both measures (behavioral impairment:antinociception) was used as a quantitative measure of therapeutic index. Nalbuphine had the highest ED50 ratio (4.88), reflecting antinociception with minimal behavioral disruption. Oxycodone, heroin, buprenorphine, and methadone all produced similar ED50 ratios (.82-1.14), whereas butorphanol yielded a significantly lower ED50 ratio (.17) reflecting behavioral disruption at doses producing only minimal antinociception. The antinociceptive and behaviorally disruptive effects of oxycodone and buprenorphine were further characterized using Schild analysis to calculate apparent pA2 values for antagonism of the 2 drugs by naltrexone. These analyses suggest that µ-receptor mechanisms likely mediate the antinociceptive as well as behaviorally disruptive effects of oxycodone (pA2 values: 8.13 and 8.57) and buprenorphine (pA2 values: 8.6 and 7.9). PERSPECTIVE This article presents an assay that allows for the concurrent assessment of the antinociceptive and behaviorally disruptive effects of opioids. Our results show that the tail withdrawal assay in squirrel monkeys can provide a useful index of the behavioral selectivity with which opioids produce antinociception.
Collapse
Affiliation(s)
- Sarah L Withey
- Preclinical Pharmacology Laboratory, McLean Hospital/Harvard Medical School, Belmont, Massachusetts.
| | - Carol A Paronis
- Preclinical Pharmacology Laboratory, McLean Hospital/Harvard Medical School, Belmont, Massachusetts
| | - Jack Bergman
- Preclinical Pharmacology Laboratory, McLean Hospital/Harvard Medical School, Belmont, Massachusetts
| |
Collapse
|
27
|
Ahn H, Woods AJ, Kunik ME, Bhattacharjee A, Chen Z, Choi E, Fillingim RB. Efficacy of transcranial direct current stimulation over primary motor cortex (anode) and contralateral supraorbital area (cathode) on clinical pain severity and mobility performance in persons with knee osteoarthritis: An experimenter- and participant-blinded, randomized, sham-controlled pilot clinical study. Brain Stimul 2017; 10:902-909. [PMID: 28566193 PMCID: PMC5568498 DOI: 10.1016/j.brs.2017.05.007] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 05/15/2017] [Accepted: 05/17/2017] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Previous studies indicate that transcranial direct current stimulation (tDCS) with anode over motor cortex (M1) and cathode over contralateral supraorbital region (SO) may be effective in reducing pain, but these studies are limited in number and have not focused on older adults with osteoarthritis (OA). OBJECTIVE To evaluate the preliminary efficacy and safety of M1-SO applied tDCS on clinical pain severity and mobility performance in adults with knee OA pain. METHODS Forty 50- to 70-year-old community-dwelling participants with knee OA were randomly assigned to receive five daily sessions of 2 mA tDCS for 20 min (n = 20) or sham tDCS (n = 20). We measured clinical pain severity via Numeric Rating Scale, Western Ontario and McMaster Universities Osteoarthritis Index, and Short-Form McGill Pain Questionnaire. In addition, we measured mobility performance using the 6-Minute Walk Test and the Short Physical Performance Battery. Moreover, we obtained a sensation/safety questionnaire and measured cognition changes using the PROMIS-Applied Cognition-Abilities-Short Form 8a. RESULTS Active tDCS over M1-SO significantly reduced Numeric Rating Scale of pain compared to sham tDCS after completion of the five daily sessions, and remained up to three weeks. No other measures were significantly different from sham. Participants tolerated tDCS over M1-SO well without serious adverse effects or cognition changes. CONCLUSION Although not consistent in all pain measurements, our findings demonstrate promising clinical efficacy for reduction in pain perception for older adults with knee OA. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT02512393.
Collapse
Affiliation(s)
- Hyochol Ahn
- The University of Texas Health Science Center, School of Nursing at Houston, Houston, TX, United States.
| | - Adam J Woods
- University of Florida Center for Cognitive Aging and Memory, Department of Clinical and Health Psychology, Gainesville, FL, United States
| | - Mark E Kunik
- Baylor College of Medicine, Houston, TX, United States; South Central Mental Illness Research, Education and Clinical Center, VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, United States
| | | | - Zhiguo Chen
- University of Florida Department of Statistics, Gainesville, FL, United States
| | | | - Roger B Fillingim
- University of Florida Pain Research and Intervention Center of Excellence, Gainesville, FL, United States
| |
Collapse
|
28
|
Choi NG, Snow AL, Kunik ME. Pain severity, interference, and prescription analgesic use among depressed, low-income homebound older adults. Aging Ment Health 2016; 20:804-13. [PMID: 25923452 DOI: 10.1080/13607863.2015.1037244] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Disabled, homebound individuals tend to suffer both chronic pain and depression; however, low-income, homebound older adults have been underexposed in pain and depression research. We examined the extent of pain frequency, intensity, and interference; the relationship between pain and depressive symptoms; and prescription analgesic use and its association with use of antidepressant and anxiolytic medications among these older adults. METHOD The data came from the baseline assessment of 215 homebound individuals aged 50+ who were referred to a clinical trial of depression treatment. Bivariate and multivariate analyses were used to examine the research questions. RESULTS Almost 87% (n = 186) of the participants reported having had chronic pain in the preceding three months. Of the pain reporters, the mean frequency, intensity, and interference of pain were 8.65 ± 2.05, 7.71 ± 2.10, and 7.80 ± 2.82, respectively, on a 1-10 scale, and 61% were taking a prescription analgesic. Analgesic users and nonusers did not differ in depressive symptoms and in pain frequency and intensity, but analgesic users reported higher pain interference than nonusers (8.22 ± 2.46 vs. 7.14 ± 3.22; t = 2.44, df = 184, p = .016). Pain frequency and interference were significantly associated with depressive symptoms, and pain interference was significantly associated with analgesic use in multivariate analysis. Anxiolytic medication use was also correlated with analgesic use. CONCLUSION The findings underscore the significant pain-related problems in these vulnerable individuals and the need for recognizing and treating both pain and depression more effectively using both pharmacologic and nonpharmacologic interventions.
Collapse
Affiliation(s)
- Namkee G Choi
- a The University of Texas at Austin School of Social Work , Austin , TX , USA
| | - A Lynn Snow
- b Department of Psychology , University of Alabama Center for Mental Health and Aging , Tuscaloosa , AL , USA
| | - Mark E Kunik
- c The Center for Innovations in Quality, Effectiveness and Safety (#CIN 13-413) , Michael E. DeBakey VA Medical Center , Houston , TX , USA.,d Houston VA Health Services Research and Development Center of Excellence , Houston , TX , USA.,e Department of Psychiatry , Baylor College of Medicine , Houston , TX , USA
| |
Collapse
|
29
|
Carmona-Bayonas A, Jiménez-Fonseca P, Castañón E, Ramchandani-Vaswani A, Sánchez-Bayona R, Custodio A, Calvo-Temprano D, Virizuela JA. Chronic opioid therapy in long-term cancer survivors. Clin Transl Oncol 2016; 19:236-250. [PMID: 27443415 DOI: 10.1007/s12094-016-1529-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 06/27/2016] [Indexed: 12/24/2022]
Abstract
PURPOSE Long-term cancer survivors develop special health issues and specific needs. Chronic pain, whether the consequence of their cancer or as a side effect of treatment, is one of their most prevalent concerns. METHODS We conducted a review of the English-language literature on long-term cancer survivorship and chronic opioid therapy, with the objective of determining the efficacy, safety and tolerability in this group of patients. Practical management recommendations are made on the basis of this review. RESULTS Pain syndromes encountered in the long-term cancer survivors are diverse. Opioid receptor pathways possess complex and pleiotropic functions and continuous over-activation may lead to de novo endocrinopathies, immunosuppression, neurocognitive impairment, or cell cycle disturbances with potential clinical connotations. However, there are insufficient data to support evidence-based decision making with respect to patient selection, doses, administration, monitoring and follow-up. Data about long-term treatment effectiveness and safety are limited and often aggravated by the overlapping of several diseases prevalent among long-term cancer survivors, as well as chronic opiate-induced toxicity. CONCLUSIONS Chronic opioid therapy is frequent in long-term cancer survivors, and may negatively affect the immune system, and produce health problems such as endocrinopathies, osteoporosis, neurological or cardiopulmonary effects, alterations of cell cycle kinetics, abuse and addiction. This review highlights the need for specialized teams to treat chronic pain in long-term cancer survivors from an integrative perspective.
Collapse
Affiliation(s)
- A Carmona-Bayonas
- Hematology and Medical Oncology Department, Hospital Universitario Morales Meseguer, Instituto Murciano de Investigación Biosanitaria (IMIB), Avenue Marqués de los Vélez, s/n, 30008, Murcia, Spain.
| | - P Jiménez-Fonseca
- Medical Oncology Department, Hospital Universitario Central de Asturias, Avenida de Roma, s/n, 33011, Oviedo, Principado de Asturias, Spain
| | - E Castañón
- Medical Oncology Department, Clínica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), Avenida Pío XII, 36, Pamplona, Spain
| | - A Ramchandani-Vaswani
- Medical Oncology Department, Hospital Universitario Insular de Gran Canaria, Avenida Marítima del Sur, s/n, 35016, Las Palmas de Gran Canaria, Spain
| | - R Sánchez-Bayona
- Medical Oncology Department, Clínica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), Avenida Pío XII, 36, Pamplona, Spain
| | - A Custodio
- Medical Oncology Department, Hospital Universitario La Paz, Paseo de la Castellana 261, Madrid, Spain
| | - D Calvo-Temprano
- Radiology Department, Hospital Universitario Central de Asturias, Avenida de Roma, s/n, 33011, Oviedo, Principado de Asturias, Spain
| | - J A Virizuela
- Medical Oncology Department, Hospital Virgen de la Macarena, Avd. Doctor Fedriani, 3, 41071, Seville, Spain
| |
Collapse
|
30
|
Foy R, Leaman B, McCrorie C, Petty D, House A, Bennett M, Carder P, Faulkner S, Glidewell L, West R. Prescribed opioids in primary care: cross-sectional and longitudinal analyses of influence of patient and practice characteristics. BMJ Open 2016; 6:e010276. [PMID: 27178970 PMCID: PMC4874107 DOI: 10.1136/bmjopen-2015-010276] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To examine trends in opioid prescribing in primary care, identify patient and general practice characteristics associated with long-term and stronger opioid prescribing, and identify associations with changes in opioid prescribing. DESIGN Trend, cross-sectional and longitudinal analyses of routinely recorded patient data. SETTING 111 primary care practices in Leeds and Bradford, UK. PARTICIPANTS We observed 471 828 patient-years in which all patients represented had at least 1 opioid prescription between April 2005 and March 2012. A cross-sectional analysis included 99 847 patients prescribed opioids between April 2011 and March 2012. A longitudinal analysis included 49 065 patient-years between April 2008 and March 2012. We excluded patients with cancer or treated for substance misuse. MAIN OUTCOME MEASURES Long-term opioid prescribing (4 or more prescriptions within 12 months), stronger opioid prescribing and stepping up to or down from stronger opioids. RESULTS Opioid prescribing in the adult population almost doubled for weaker opioids over 2005-2012 and rose over sixfold for stronger opioids. There was marked variation among general practices in the odds of patients stepping up to stronger opioids compared with those not stepping up (range 0.31-3.36), unexplained by practice-level variables. Stepping up to stronger opioids was most strongly associated with being underweight (adjusted OR 3.26, 1.49 to 7.17), increasing polypharmacy (4.15, 3.26 to 5.29 for 10 or more repeat prescriptions), increasing numbers of primary care appointments (3.04, 2.48 to 3.73 for over 12 appointments in the year) and referrals to specialist pain services (5.17, 4.37 to 6.12). Compared with women under 50 years, men under 50 were less likely to step down once prescribed stronger opioids (0.53, 0.37 to 0.75). CONCLUSIONS While clinicians should be alert to patients at risk of escalated opioid prescribing, much prescribing variation may be attributable to clinical behaviour. Effective strategies targeting clinicians and patients are needed to curb rising prescribing, especially of stronger opioids.
Collapse
Affiliation(s)
- Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Ben Leaman
- Calderdale Metropolitan Borough Council, Halifax, UK
| | - Carolyn McCrorie
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Duncan Petty
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Allan House
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Michael Bennett
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Paul Carder
- Yorkshire & Humber Commissioning Support Unit, Bradford, UK
| | | | - Liz Glidewell
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Robert West
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| |
Collapse
|
31
|
Bhattarai P, Hickman L, Phillips JL. Pain among hospitalized older people with heart failure and their preparation to manage this symptom on discharge: a descriptive-observational study. Contemp Nurse 2016; 52:204-15. [PMID: 27052106 DOI: 10.1080/10376178.2016.1175311] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Globally, heart failure (HF) is one of the major health issues faced by many older people. It causes significant symptom burden that requires ongoing management. This paper reports on a descriptive-observational study undertaken to: (1) describe the prevalence of pain and analgesic prescription usage in hospitalized older HF patients; (2) determine the degree to which these patients are provided with a pain self-management strategy prior to discharge; and (3) determine if the patients' pain self-management strategy has been detailed in the discharge summary. A total of 122 older HF patients were included in this study. Results indicated that moderate to severe pain (Numeric Rating Scale score ≥4) is experienced by a substantial number of older people hospitalized with HF. There is little documented evidence that older people are provided with adequate analgesic prescriptions and the instructions required to effectively manage their pain on discharge to the community.
Collapse
Affiliation(s)
| | - Louise Hickman
- b Faculty of Health , University of Technology Sydney , Sydney , Australia
| | - Jane L Phillips
- c Centre for Cardiovascular and Chronic Care , University of Technology Sydney , Sydney , Australia
| |
Collapse
|
32
|
Lentine KL, Lam NN, Schnitzler MA, Garg AX, Xiao H, Leander SE, Brennan DC, Taler SJ, Axelrod D, Segev DL. Gender differences in use of prescription narcotic medications among living kidney donors. Clin Transplant 2015; 29:927-37. [PMID: 26227016 DOI: 10.1111/ctr.12599] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2015] [Indexed: 11/27/2022]
Abstract
Prescription narcotic use among living kidney donors is not well described. Using a unique database that integrates national registry identifiers for living kidney donors (1987-2007) in the United States with billing claims from a private health insurer (2000-2007), we identified pharmacy fills for prescription narcotic medications in periods 1-4 and >4 yr post-donation and estimated relative likelihoods of post-donation narcotic use by Cox regression. We also compared narcotic fill rates and medication possession ratios (MPRs, defined as (days of medication supplied)/(days observed)), between donors and age- and sex-matched non-donors. Overall, rates of narcotic medication fills were 32.3 and 32.4 per 100 person-years in periods 1-4 and >4 yr post-donation. After age and race adjustment, women were approximately twice as likely as men to fill a narcotic prescription in years 1-4 (adjusted hazard ratio, aHR, 2.28; 95% confidence interval, CI, 1.86-2.79) and >4 yr (aHR 1.70; 95% CI 1.50-1.93). MPRs in donors were low (<2.5% days exposed), and lower than among age- and sex-matched non-donors. Prescription narcotic medication use is more common among women than men in the intermediate term after live kidney donation. Overall, total narcotic exposure is low, and lower than among non-donors from the general population.
Collapse
Affiliation(s)
- Krista L Lentine
- Center for Outcomes Research, Saint Louis University School of Medicine, St. Louis, MO, USA.,Division of Abdominal Transplantation, Department of Surgery, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Ngan N Lam
- Division of Nephrology, University of Alberta, Edmonton, AB, Canada
| | - Mark A Schnitzler
- Center for Outcomes Research, Saint Louis University School of Medicine, St. Louis, MO, USA.,Division of Abdominal Transplantation, Department of Surgery, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Amit X Garg
- Division of Nephrology, Western University, London, ON, Canada
| | - Huiling Xiao
- Center for Outcomes Research, Saint Louis University School of Medicine, St. Louis, MO, USA
| | | | - Daniel C Brennan
- Transplant Nephrology, Washington University School of Medicine, St. Louis, MO, USA
| | - Sandra J Taler
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - David Axelrod
- Division of Abdominal Transplantation, Department of Surgery, Dartmouth Hitchcock Medical Center, Hanover, NH, USA
| | - Dorry L Segev
- Division of Abdominal Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| |
Collapse
|
33
|
McCrorie C, Closs SJ, House A, Petty D, Ziegler L, Glidewell L, West R, Foy R. Understanding long-term opioid prescribing for non-cancer pain in primary care: a qualitative study. BMC FAMILY PRACTICE 2015; 16:121. [PMID: 26362559 PMCID: PMC4567803 DOI: 10.1186/s12875-015-0335-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 08/31/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND The place of opioids in the management of chronic, non-cancer pain is limited. Even so their use is escalating, leading to concerns that patients are prescribed strong opioids inappropriately and alternatives to medication are under-used. We aimed to understand the processes which bring about and perpetuate long-term prescribing of opioids for chronic, non-cancer pain. METHODS We held semi-structured interviews with patients and focus groups with general practitioners (GPs). Participants included 23 patients currently prescribed long-term opioids and 15 GPs from Leeds and Bradford, United Kingdom (UK). We used a grounded approach to the analysis of transcripts. RESULTS Patients are driven by the needs for pain relief, explanation, and improvement or maintenance of quality of life. GPs' responses are shaped by how UK general practice is organised, available therapeutic choices and their expertise in managing chronic pain, especially when facing diagnostic uncertainty or when their own approach is at odds with the patient's wishes. Four features of the resulting transaction between patients and doctors influence prescribing: lack of clarity of strategy, including the risk of any plans being subverted by urgent demands; lack of certainty about locus of control in decision-making, especially in relation to prescribing; continuity in the doctor-patient relationship; and mutuality and trust. CONCLUSIONS Problematic prescribing occurs when patients experience repeated consultations that do not meet their needs and GPs feel unable to negotiate alternative approaches to treatment. Therapeutic short-termism is perpetuated by inconsistent clinical encounters and the absence of mutually-agreed formulations of underlying problems and plans of action. Apart from commissioning improved access to appropriate specialist services, general practices should also consider how they manage problematic opioid prescribing and be prepared to set boundaries with patients.
Collapse
Affiliation(s)
- Carolyn McCrorie
- Leeds Institute of Health Sciences, Charles Thackrah Building, University of Leeds, 101 Clarendon Road, Leeds, LS2 9LJ, UK.
| | - S José Closs
- School of Healthcare, Baines Wing, University of Leeds, Leeds, LS2 9JT, UK
| | - Allan House
- Leeds Institute of Health Sciences, Charles Thackrah Building, University of Leeds, 101 Clarendon Road, Leeds, LS2 9LJ, UK
| | - Duncan Petty
- Bradford School of Pharmacy, University of Bradford, Richmond Rd, Bradford, Yorkshire, BD7 1DP, UK
| | - Lucy Ziegler
- Leeds Institute of Health Sciences, Charles Thackrah Building, University of Leeds, 101 Clarendon Road, Leeds, LS2 9LJ, UK
| | - Liz Glidewell
- Leeds Institute of Health Sciences, Charles Thackrah Building, University of Leeds, 101 Clarendon Road, Leeds, LS2 9LJ, UK
| | - Robert West
- Leeds Institute of Health Sciences, Charles Thackrah Building, University of Leeds, 101 Clarendon Road, Leeds, LS2 9LJ, UK
| | - Robbie Foy
- Leeds Institute of Health Sciences, Charles Thackrah Building, University of Leeds, 101 Clarendon Road, Leeds, LS2 9LJ, UK
| |
Collapse
|
34
|
|
35
|
Campbell G, Nielsen S, Larance B, Bruno R, Mattick R, Hall W, Lintzeris N, Cohen M, Smith K, Degenhardt L. Pharmaceutical Opioid Use and Dependence among People Living with Chronic Pain: Associations Observed within the Pain and Opioids in Treatment (POINT) Cohort. PAIN MEDICINE 2015; 16:1745-58. [PMID: 26011277 DOI: 10.1111/pme.12773] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE There is increasing concern about the appropriateness of prescribing pharmaceutical opioids for chronic non-cancer pain (CNCP), given the risks of problematic use and dependence. This article examines pharmaceutical opioid dose and dependence and examines the correlates of each. DESIGN Baseline data were obtained from a national sample of 1,424 people across Australia (median 58 years, 55% female and experiencing pain for a median of 10 years), who had been prescribed opioids for CNCP. Current opioid consumption was estimated in oral morphine equivalent (OME; mg per day), and ICD-10 pharmaceutical opioid dependence was assessed using the Composite International Diagnostic Interview. RESULTS Current opioid consumption varied widely: 8.8% were taking <20 mg OME per day, 52.1% were taking 21-90 mg OME, 24.3% were taking 91-199 mg OME, and 14.8% were taking >= 200 mg OME. Greater daily OME consumption was associated with higher odds of multiple physical and mental health issues, aberrant opioid use, problems associated with opioid medication and opioid dependence. A significant minority, 8.5%, met criteria for lifetime ICD-10 pharmaceutical opioid dependence and 4.7% met criteria for past year ICD-10 pharmaceutical opioid dependence. Multivariate analysis found past-year dependence was independently associated with being younger, exhibiting more aberrant behaviors and having a history of benzodiazepine dependence. CONCLUSIONS In this population of people taking opioids for CNCP, consumption of higher doses was associated with increased risk of problematic behaviors, and was more likely among people with a complex profile of physical and mental health problems.
Collapse
Affiliation(s)
- Gabrielle Campbell
- National Drug and Alcohol Research Centre, UNSW, Sydney, New South Wales, Australia
| | - Suzanne Nielsen
- National Drug and Alcohol Research Centre, UNSW, Sydney, New South Wales, Australia
| | - Briony Larance
- National Drug and Alcohol Research Centre, UNSW, Sydney, New South Wales, Australia
| | - Raimondo Bruno
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Richard Mattick
- National Drug and Alcohol Research Centre, UNSW, Sydney, New South Wales, Australia
| | - Wayne Hall
- Centre for Youth Substance Abuse Research, University of Queensland, Herston, Queensland, Australia.,National Addiction Centre, Kings College, London, England
| | - Nicholas Lintzeris
- Sydney Medical School, Sydney University, Herston, Queensland, Australia.,The Langton Centre, South East Sydney Local Health District (SESLHD) Drug and Alcohol Services, Sydney, New South Wales, Australia
| | - Milton Cohen
- St Vincent's Clinical School, UNSW Medicine, UNSW, Sydney, New South Wales, Australia
| | - Kimberley Smith
- National Drug and Alcohol Research Centre, UNSW, Sydney, New South Wales, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW, Sydney, New South Wales, Australia.,School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Australia.,Department of Global Health, School of Public Health, University of Washington, Washington, USA
| |
Collapse
|
36
|
Lentine KL, Lam NN, Xiao H, Tuttle-Newhall JE, Axelrod D, Brennan DC, Dharnidharka VR, Yuan H, Nazzal M, Zheng J, Schnitzler MA. Associations of pre-transplant prescription narcotic use with clinical complications after kidney transplantation. Am J Nephrol 2015; 41:165-76. [PMID: 25832723 DOI: 10.1159/000377685] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 01/29/2015] [Indexed: 01/05/2023]
Abstract
BACKGROUND The impact of narcotic use before kidney transplantation on post-transplant clinical outcomes is not well described. METHODS We examined integrated national transplant registry, pharmacy records, and Medicare billing claims to follow 16,322 kidney transplant recipients, of whom 28.3% filled a narcotic prescription in the year before transplantation. Opioid analgesic fills were normalized to morphine equivalents (ME) and expressed as mg/kg exposures (approximate quartiles: 0.1-1.7, 1.8-5.4, 5.5-23.7, and ≥ 23.8 mg/kg, respectively). Post-transplant cardiovascular, respiratory, neurological, accidents, substance abuse, and noncompliance events were identified using diagnosis codes on Medicare billing claims. Adjusted associations of ME level with post-transplant complications were quantified by multivariate Cox regression. RESULTS The incidence of complications at 3 years post-transplant among those with the highest pre-transplant ME exposure compared to no use included: ventricular arrhythmias, 1.1 vs. 0.2% (p < 0.001); cardiac arrest, 4.7 vs. 2.7% (p < 0.05); hypotension, 14 vs. 8% (p < 0.0001); hypercapnia, 1.6 vs. 0.9% (p < 0.05); mental status changes, 5.3 vs. 2.7% (p < 0.001); drug abuse/dependence, 7.0 vs. 1.7% (p < 0.0001); alcohol abuse, 1.8 vs. 0.6% (p = 0.0001); accidents, 0.9 vs. 0.3% (p < 0.05); and noncompliance, 3.5 vs. 2.3% (p < 0.05). In multivariate analyses, transplant recipients with the highest level of pre-transplant narcotic use had approximately 2 to 4 times the risks of post-transplant ventricular arrhythmias, mental status changes, drug abuse, alcohol abuse, and accidents compared with non-users, and 35-45% higher risks of cardiac arrest and hypotension. CONCLUSION Although associations may reflect underlying conditions or behaviors, high-level prescription narcotic use before kidney transplantation predicts increased risk of clinical complications after transplantation.
Collapse
Affiliation(s)
- Krista L Lentine
- Center for Outcomes Research, Saint Louis University School of Medicine, St. Louis, Mo., USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Affiliation(s)
- M Carrington Reid
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College, New York, NY 10065, USA
| | | | - Karl Pillemer
- Department of Human Development, Cornell University, Ithaca, NY, USA
| |
Collapse
|
38
|
Degenhardt L, Blanch B, Gisev N, Larance B, Pearson S. The POPPY Research Programme protocol: investigating opioid utilisation, costs and patterns of extramedical use in Australia. BMJ Open 2015; 5:e007030. [PMID: 25631315 PMCID: PMC4316424 DOI: 10.1136/bmjopen-2014-007030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Opioid prescribing is increasing in many countries. In Australia, there is limited research on patterns of prescribing and access, or the outcomes associated with this use. The aim of this research programme is to use national dispensing data to estimate opioid use and costs, including problematic or extramedical use in the Australian population. METHODS AND ANALYSIS In a cohort of persons dispensed at least one opioid in 2013, we will estimate monthly utilisation and costs of prescribed opioids, overall and according to individual opioid formulations and strengths. In a cohort of new opioid users, commencing therapy between 1 July 2009 and 31 December 2013, we will examine patterns of opioid use including initiation of therapy, duration of treatment and concomitant use of opioids and other prescribed medicines. We will also examine patterns of extramedical opioid use based on indicators including excess dosing, use of more than one opioid concomitantly, doctor/pharmacy shopping and accelerated time to prescription refill. ETHICS AND DISSEMINATION This protocol was approved by the NSW Population and Health Services Ethics Committee (March 2014) and data access approved by the Department of Human Services External Review Evaluation Committee (June 2014). This will be one of the first comprehensive Australian studies with the capability to investigate individual patterns of use and track extramedical use. In the first instance our analysis will be based on 5 years of dispensing data but will be expanded with ongoing annual data updates. This research has the capability to contribute significantly to pharmaceutical policy within Australia and globally. In particular, the trajectory of extramedical prescription-opioid use has been the subject of limited research to date. The results of this research will be published widely in general medical, pharmacoepidemiology, addiction and psychiatry journals.
Collapse
Affiliation(s)
- Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Medicine, UNSW Australia, Sydney, New South Wales, Australia
| | - Bianca Blanch
- Faculty of Pharmacy, Pharmacoepidemiology and Pharmaceutical Policy Research Group, University of Sydney, Sydney, New South Wales, Australia
| | - Natasa Gisev
- National Drug and Alcohol Research Centre, UNSW Medicine, UNSW Australia, Sydney, New South Wales, Australia
| | - Briony Larance
- National Drug and Alcohol Research Centre, UNSW Medicine, UNSW Australia, Sydney, New South Wales, Australia
| | - Sallie Pearson
- Faculty of Pharmacy, Pharmacoepidemiology and Pharmaceutical Policy Research Group, University of Sydney, Sydney, New South Wales, Australia
- School of Public Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
39
|
Abstract
IMPORTANCE Persistent pain is highly prevalent, costly, and frequently disabling in later life. OBJECTIVE To describe barriers to the management of persistent pain among older adults, summarize current management approaches, including pharmacologic and nonpharmacologic modalities; present rehabilitative approaches; and highlight aspects of the patient-physician relationship that can help to improve treatment outcomes. This review is relevant for physicians who seek an age-appropriate approach to delivering pain care for the older adult. EVIDENCE ACQUISITION Search of MEDLINE and the Cochrane database from January 1990 through May 2014, using the search terms older adults, senior, ages 65 and above, elderly, and aged along with non-cancer pain, chronic pain, persistent pain, pain management, intractable pain, and refractory pain to identify English-language peer-reviewed systematic reviews, meta-analyses, Cochrane reviews, consensus statements, and guidelines relevant to the management of persistent pain in older adults. FINDINGS Of the 92 identified studies, 35 evaluated pharmacologic interventions, whereas 57 examined nonpharmacologic modalities; the majority (n = 50) focused on older adults with osteoarthritis. This evidence base supports a stepwise approach with acetaminophen as first-line therapy. If treatment goals are not met, a trial of a topical nonsteroidal anti-inflammatory drug, tramadol, or both is recommended. Oral nonsteroidal anti-inflammatory drugs are not recommended for long-term use. Careful surveillance to monitor for toxicity and efficacy is critical, given that advancing age increases risk for adverse effects. A multimodal approach is strongly recommended-emphasizing a combination of both pharmacologic and nonpharmacologic treatments to include physical and occupational rehabilitation, as well as cognitive-behavioral and movement-based interventions. An integrated pain management approach is ideally achieved by cultivating a strong therapeutic alliance between the older patient and the physician. CONCLUSIONS AND RELEVANCE Treatment planning for persistent pain in later life requires a clear understanding of the patient's treatment goals and expectations, comorbidities, and cognitive and functional status, as well as coordinating community resources and family support when available. A combination of pharmacologic, nonpharmacologic, and rehabilitative approaches in addition to a strong therapeutic alliance between the patient and physician is essential in setting, adjusting, and achieving realistic goals of therapy.
Collapse
Affiliation(s)
- Una E Makris
- Department of Internal Medicine, Division of Rheumatic Diseases, UT Southwestern Medical Center, Dallas, Texas2Department of Medicine, Division of Rheumatology, Veterans Administration Medical Center, Dallas, Texas
| | - Robert C Abrams
- Department of Psychiatry, Weill Cornell Medical College, New York, New York4Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College, New York, New York
| | - Barry Gurland
- Stroud Center, Columbia University, New York, New York
| | - M Carrington Reid
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College, New York, New York
| |
Collapse
|
40
|
Campbell G, Mattick R, Bruno R, Larance B, Nielsen S, Cohen M, Lintzeris N, Shand F, Hall WD, Hoban B, Kehler C, Farrell M, Degenhardt L. Cohort protocol paper: the Pain and Opioids In Treatment (POINT) study. BMC Pharmacol Toxicol 2014; 15:17. [PMID: 24646721 PMCID: PMC4000138 DOI: 10.1186/2050-6511-15-17] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 03/07/2014] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Internationally, there is concern about the increased prescribing of pharmaceutical opioids for chronic non-cancer pain (CNCP). In part, this is related to limited knowledge about the long-term benefits and outcomes of opioid use for CNCP. There has also been increased injection of some pharmaceutical opioids by people who inject drugs, and for some patients, the development of problematic and/or dependent use. To date, much of the research on the use of pharmaceutical opioids among people with CNCP, have been clinical trials that have excluded patients with complex needs, and have been of limited duration (i.e. fewer than 12 weeks). The Pain and Opioids In Treatment (POINT) study is unique study that aims to: 1) examine patterns of opioid use in a cohort of patients prescribed opioids for CNCP; 2) examine demographic and clinical predictors of adverse events, including opioid abuse or dependence, medication diversion, other drug use, and overdose; and 3) identify factors predicting poor pain relief and other outcomes. METHODS/DESIGN The POINT cohort comprises around 1,500 people across Australia prescribed pharmaceutical opioids for CNCP. Participants will be followed-up at four time points over a two year period. POINT will collect information on demographics, physical and medication use history, pain, mental health, drug and alcohol use, non-adherence, medication diversion, sleep, and quality of life. Data linkage will provide information on medications and services from Medicare (Australia's national health care scheme). Data on those who receive opioid substitution therapy, and on mortality, will be linked. DISCUSSION This study will rigorously examine prescription opioid use among CNCP patients, and examine its relationship to important health outcomes. The extent to which opioids for chronic pain is associated with pain reduction, quality of life, mental and physical health, aberrant medication behavior and substance use disorders will be extensively examined. Improved understanding of the longer-term outcomes of chronic opioid therapy will direct community-based interventions and health policy in Australia and internationally. The results of this study will assist clinicians to better identify those patients who are at risk of adverse outcomes and who therefore require alternative treatment strategies.
Collapse
Affiliation(s)
- Gabrielle Campbell
- National Drug and Alcohol Research Centre, UNSW, Sydney, NSW 2052, Australia
| | - Richard Mattick
- National Drug and Alcohol Research Centre, UNSW, Sydney, NSW 2052, Australia
| | - Raimondo Bruno
- National Drug and Alcohol Research Centre, UNSW, Sydney, NSW 2052, Australia
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Briony Larance
- National Drug and Alcohol Research Centre, UNSW, Sydney, NSW 2052, Australia
| | - Suzanne Nielsen
- National Drug and Alcohol Research Centre, UNSW, Sydney, NSW 2052, Australia
- Discipline of Addiction Medicine, The University of Sydney, Sydney, Australia
- The Langton Centre, South East Sydney Local Health District (SESLHD) Drug and Alcohol Services, Surry Hills, Australia
| | - Milton Cohen
- St Vincent’s Clinical School, UNSW Medicine, UNSW, Darlinghurst, Australia
| | - Nicholas Lintzeris
- Discipline of Addiction Medicine, The University of Sydney, Sydney, Australia
- The Langton Centre, South East Sydney Local Health District (SESLHD) Drug and Alcohol Services, Surry Hills, Australia
| | - Fiona Shand
- Black Dog Institute, UNSW, Randwick, Australia
| | - Wayne D Hall
- Centre for Youth Substance Abuse Research, University of Queensland, Queensland, Australia
- National Addiction Centre, Kings College, London, England
| | - Bianca Hoban
- National Drug and Alcohol Research Centre, UNSW, Sydney, NSW 2052, Australia
| | - Chyanne Kehler
- National Drug and Alcohol Research Centre, UNSW, Sydney, NSW 2052, Australia
| | - Michael Farrell
- National Drug and Alcohol Research Centre, UNSW, Sydney, NSW 2052, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW, Sydney, NSW 2052, Australia
- School of Population and Global Health, University of Melbourne, Melbourne, Australia
- Centre for Adolescent Health, Murdoch Children’s Research Institute, Melbourne, Australia
- Department of Global Health, School of Public Health, University of Washington, Seattle, USA
| |
Collapse
|
41
|
Sullivan MD, Howe CQ. Opioid therapy for chronic pain in the United States: promises and perils. Pain 2013; 154 Suppl 1:S94-S100. [PMID: 24036286 DOI: 10.1016/j.pain.2013.09.009] [Citation(s) in RCA: 162] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Revised: 07/31/2013] [Accepted: 09/04/2013] [Indexed: 12/20/2022]
Abstract
Opioid therapy offers the promise of reducing the burden of chronic pain in not just individual patients, but among the broad population of patients with chronic pain. Randomized trials have demonstrated that opioid therapy for up to 12-16weeks is superior to placebo, but have not addressed longer-term use. In the United States, opioid sales have quadrupled during 2000-2010, with parallel increases in opioid accidental overdose deaths and substance abuse admissions. Clinical use of long-term opioid therapy is characterized by a pattern of adverse selection, where high-risk patients are prescribed high-risk opioid regimens. This adverse selection may link these trends in use, abuse, and overdose. Long-term opioid therapy appears to be associated with iatrogenic harm to the patients who receive the prescriptions and to the general population. The United States has, in effect, conducted an experiment of population-wide treatment of chronic pain with long-term opioid therapy. The population-wide benefits have been hard to demonstrate, but the harms are now well demonstrated.
Collapse
Affiliation(s)
- Mark D Sullivan
- Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | | |
Collapse
|
42
|
Parker SJ, Jessel S, Richardson JE, Reid MC. Older adults are mobile too!Identifying the barriers and facilitators to older adults' use of mHealth for pain management. BMC Geriatr 2013; 13:43. [PMID: 23647949 PMCID: PMC3673892 DOI: 10.1186/1471-2318-13-43] [Citation(s) in RCA: 152] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 04/26/2013] [Indexed: 11/10/2022] Open
Abstract
Background Mobile health (mHealth) is a rapidly emerging field with the potential to assist older adults in the management of chronic pain (CP) through enhanced communication with providers, monitoring treatment-related side effects and pain levels, and increased access to pain care resources. Little is currently known, however, about older adults’ attitudes and perceptions of mHealth or perceived barriers and facilitators to using mHealth tools to improve pain management. Methods We conducted six focus groups comprised of 41 diverse older adults (≥60 years of age) with CP. Participants were recruited from one primary care practice and two multiservice senior community day-visit centers located in New York City that serve older adults in their surrounding neighborhoods. Focus group discussions were recorded and transcribed, and transcriptions were analyzed using direct content analysis to identify and quantify themes. Results Focus group discussions generated 38 individual themes pertaining to the use of mHealth to help manage pain and pain medications. Participants had low prior use of mHealth (5% of participants), but the vast majority (85%) were highly willing to try the devices. Participants reported that mHealth devices might help them reach their healthcare provider more expeditiously (27%), as well as help to monitor for falls and other adverse events in the home (15%). Barriers to device use included concerns about the cost (42%) and a lack of familiarity with the technology (32%). Facilitators to device use included training prior to device use (61%) and tailoring devices to the functional needs of older adults (34%). Conclusions This study suggests that older adults with CP are interested and willing to use mHealth to assist in the management of pain. Participants in our study reported important barriers that medical professionals, researchers, and mHealth developers should address to help facilitate the development and evaluation of age-appropriate, and function-appropriate, mHealth devices for older persons with CP.
Collapse
Affiliation(s)
- Samantha J Parker
- Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA
| | | | | | | |
Collapse
|
43
|
Rogers E, Mehta S, Shengelia R, Reid MC. Four Strategies for Managing Opioid-Induced Side Effects in Older Adults. CLINICAL GERIATRICS 2013; 21:http://www.consultant360.com/articles/four-strategies-managing-opioid-induced-side-effects-older-adults. [PMID: 25949094 PMCID: PMC4418642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
| | - Sonal Mehta
- Department of Medicine, Division of Geriatrics and Gerontology, Weill Cornell Medical College, New York, NY
| | - Rose Shengelia
- Department of Medicine, Division of Geriatrics and Gerontology, Weill Cornell Medical College, New York, NY
| | - Manney Carrington Reid
- Department of Medicine, Division of Geriatrics and Gerontology, Weill Cornell Medical College, New York, NY
| |
Collapse
|
44
|
Thielke S, Sale J, Reid MC. Aging: are these 4 pain myths complicating care? THE JOURNAL OF FAMILY PRACTICE 2012; 61:666-670. [PMID: 23256096 PMCID: PMC4356472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Is pain a natural part of aging? Does "toughing it out" make pain more tolerable? Read on to see what the evidence really says regarding 4 common misconceptions about pain and aging.
Collapse
|
45
|
McDonald DD, Molloy B. Factors predicting older adults' use of exercise and acetaminophen for osteoarthritis pain. JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS 2012; 24:669-74. [PMID: 23088698 DOI: 10.1111/j.1745-7599.2012.00747.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE To identify predictors of older adults' use of exercise and/or acetaminophen, and avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs) to treat their osteoarthritis pain. DATA SOURCES Data were analyzed from 457 adults aged 60 and older with moderate or greater osteoarthritis pain intensity who responded to the Brief Pain Inventory between 2006 and 2007. The following predictors were entered into a logistic regression to predict use of exercise and/or acetaminophen and nonuse of NSAIDs: age, gender, ethnicity, race, education, arthritis treatment by a practitioner, pain treatment by a practitioner, pain intensity, functional interference from the pain, and percent of pain relief from current treatments. CONCLUSIONS A total of 213 (46.6%) reported using exercise and/or acetaminophen and did not report using NSAIDs. Older adults reporting arthritis treatment by a practitioner were 2.2 (confidence interval 1.08-4.59) more likely to use recommended arthritis pain treatment, p < .03. Only 3-4% of the variance for use of recommended pain management treatment was explained by the predictors. IMPLICATIONS FOR PRACTICE Results underscore the importance of guidance by practitioners who are knowledgeable about safe osteoarthritis pain management for older adults.
Collapse
|
46
|
Abstract
In the past 20 years, primary care physicians have greatly increased prescribing of long-term opioid therapy. However, the rise in opioid prescribing has outpaced the evidence regarding this practice. Increased opioid availability has been accompanied by an epidemic of opioid abuse and overdose. The rate of opioid addiction among patients receiving long-term opioid therapy remains unclear, but research suggests that opioid misuse is not rare. Recent studies report increased risks for serious adverse events, including fractures, cardiovascular events, and bowel obstruction, although further research on medical risks is needed. New data indicate that opioid-related risks may increase with dose. From a societal perspective, higher-dose regimens account for the majority of opioids dispensed, so cautious dosing may reduce both diversion potential and patient risks for adverse effects. Limiting long-term opioid therapy to patients for whom it provides decisive benefits could also reduce risks. Given the warning signs and knowledge gaps, greater caution and selectivity are needed in prescribing long-term opioid therapy. Until stronger evidence becomes available, clinicians should err on the side of caution when considering this treatment.
Collapse
|
47
|
Abstract
In the past 20 years, primary care physicians have greatly increased prescribing of long-term opioid therapy. However, the rise in opioid prescribing has outpaced the evidence regarding this practice. Increased opioid availability has been accompanied by an epidemic of opioid abuse and overdose. The rate of opioid addiction among patients receiving long-term opioid therapy remains unclear, but research suggests that opioid misuse is not rare. Recent studies report increased risks for serious adverse events, including fractures, cardiovascular events, and bowel obstruction, although further research on medical risks is needed. New data indicate that opioid-related risks may increase with dose. From a societal perspective, higher-dose regimens account for the majority of opioids dispensed, so cautious dosing may reduce both diversion potential and patient risks for adverse effects. Limiting long-term opioid therapy to patients for whom it provides decisive benefits could also reduce risks. Given the warning signs and knowledge gaps, greater caution and selectivity are needed in prescribing long-term opioid therapy. Until stronger evidence becomes available, clinicians should err on the side of caution when considering this treatment.
Collapse
|
48
|
Adherence and long-term effect of oxycodone/paracetamol in chronic noncancer pain: a retrospective study. Adv Ther 2011; 28:418-26. [PMID: 21491171 DOI: 10.1007/s12325-011-0020-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Long-term administration of opiates in patients with chronic noncancer pain (CNCP) is subject to debate due to insufficient clinical evidence to support efficacy and tolerability. METHODS This retrospective analysis used hospital records to investigate the effects of low doses of the combination of oxycodone/paracetamol on CNCP in an outpatient clinic setting to verify adherence to therapy and long-term efficacy. All patients receiving therapy for CNCP were examined between May and September 2010 and information was collected on medication, duration of therapy, and static and dynamic pain measured using numeric rating scales (NRS) from relevant charts. RESULTS Two hundred and thirty-one patients (157 men, 68%) with a mean (± SD) age of 66.4±15.5 years were analyzed. Pain indexes at baseline revealed a mean (± SD) static NRS (sNRS) of 3.5±1.77 and a mean dynamic NRS (dNRS) of 7.24±1.33. At last follow-up, mean (± SD) pain reductions versus baseline were 1.58±1.42 for sNRS and 3.04±1.43 for dNRS (P<0.0001 for both). Regarding the duration of therapy, 54 patients (23.4%) were treated for <4 months, and 177 patients (76.6%) for 4 months up to 23 months. Pain reduction was significant in all groups (P<0.0001) but was greatest in patients who had been receiving therapy for ≥4 months. Improvements in pain relief were not associated with an increase in daily dose, which remained stable or decreased slightly over time. DISCUSSION The results of this study support the hypothesis that an opiate-based combination at low doses improves tolerability and adherence and results in patients obtaining long-term efficacy. Larger studies of the use of opiates in this setting and clinical monitoring on the regional and national level may convince clinicians to view opiates as efficacious analgesics and not as dangerous substances of abuse.
Collapse
|
49
|
Current world literature. Curr Opin Support Palliat Care 2011; 5:174-83. [PMID: 21521986 DOI: 10.1097/spc.0b013e3283473351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
50
|
|