The Impact of the “Business” of Pain Medicine on Patient Care

Opioid prescribing rates from the emergency department: Down but not out

INTRODUCTION

To examine opioid prescribing rates following emergency department (ED) discharge stratified by patient's clinical and demographic characteristics over an 11-year period.

MATERIAL AND METHODS

We used 3.9 million ED visits from commercially insured enrollees and 15.2 million ED visits from Medicaid enrollees aged 12 to 64 over 2005-2016 from the IBM® MarketScan® Research Databases. We calculated rates of opioid prescribing at discharge from the ED and the average number of pills per opioid prescription filled.

RESULTS

Approximately 15-20% of ED visits resulted in opioid prescriptions filled. Rates increased from 2005 into late 2009 and 2010 and then declined steadily through 2016. Prescribing rates were similar for commercially insured and Medicaid enrollees. Being aged 25-54 years was associated with the highest rates of opioid prescriptions being filled. Hydrocodone was the most commonly prescribed opioid, but rates for hydrocodone prescription filling also fell the most. Rates for oxycodone were stable, and rates for tramadol increased. The average number of pills dispensed from prescriptions filled remained steady over the study period at 18-20.

DISCUSSION

Opioid prescribing rates from the ED have declined steadily since 2010 in reversal of earlier trends; however, about 15% of ED patients still received opioid prescriptions in 2016 amidst a national opioid crisis.

CONCLUSIONS

Efforts to reduce opioid prescribing could consider focusing on the pain types, age groups, and regions with high prescription rates identified in this study.

Chronic pain assessment from bench to bedside: lessons along the translation continuum

The first step to providing effective healthcare is accurate assessment and diagnosis. The importance of accurate assessment is particularly important for chronic pain, given its subjective and multidimensional nature. The purpose of the current review is to discuss the dilemma of chronic pain assessment within a translational framework. First, assessment issues specific to chronic pain will be introduced along the entire continuum of translational activities. Important barriers along the continuum include inconsistent measurement of pain, possibly inaccurate preclinical models, and other practical limitations such as time, cost, and training. Second, the review will highlight promising areas worth further consideration in research and practice to bridge some of the gaps that currently impede effective chronic pain assessment and care. Specifically, consideration will be given to observational, biological, and technology-driven measures of chronic pain.

Management of Chronic Pain in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline

PURPOSE

To provide evidence-based guidance on the optimum management of chronic pain in adult cancer survivors.

METHODS

An ASCO-convened expert panel conducted a systematic literature search of studies investigating chronic pain management in cancer survivors. Outcomes of interest included symptom relief, pain intensity, quality of life, functional outcomes, adverse events, misuse or diversion, and risk assessment or mitigation.

RESULTS

A total of 63 studies met eligibility criteria and compose the evidentiary basis for the recommendations. Studies tended to be heterogeneous in terms of quality, size, and populations. Primary outcomes also varied across the studies, and in most cases, were not directly comparable because of different outcomes, measurements, and instruments used at different time points. Because of a paucity of high-quality evidence, many recommendations are based on expert consensus.

RECOMMENDATIONS

Clinicians should screen for pain at each encounter. Recurrent disease, second malignancy, or late-onset treatment effects in any patient who reports new-onset pain should be evaluated, treated, and monitored. Clinicians should determine the need for other health professionals to provide comprehensive pain management care in patients with complex needs. Systemic nonopioid analgesics and adjuvant analgesics may be prescribed to relieve chronic pain and/or to improve function. Clinicians may prescribe a trial of opioids in carefully selected patients with cancer who do not respond to more conservative management and who continue to experience distress or functional impairment. Risks of adverse effects of opioids should be assessed. Clinicians should clearly understand terminology such as tolerance, dependence, abuse, and addiction as it relates to the use of opioids and should incorporate universal precautions to minimize abuse, addiction, and adverse consequences. Additional information is available at www.asco.org/chronic-pain-guideline and www.asco.org/guidelineswiki.

Pain in patients attending outpatient rehabilitation: results of a pilot study

The aim of the study was to investigate pain occurrence, characteristics and correlations in an outpatient rehabilitation setting. This was an observational pilot study. The setting was an outpatient rehabilitation facility. The subjects included all patients attending physiotherapy in the week 25th to 29th September 2010 and the interventions were made using self-administered questionnaire. Ongoing pain was assessed by a yes-no question, pain intensity by a numeric rating scale (NRS) ranging 0-10. Pain-related medication was investigated, along with pain characteristics, patient treatment expectations, life satisfaction, and catastrophism. Of the 201 patients, 12 were excluded and 189 enrolled (age 63.6 ± 15.6; 70.4% women). Pain (mean NRS = 5.6 ± 2.4) was reported by 60.9% patients (66% orthopedic and 40% neurological). In 87.8% cases, pain was chronic (>6 months). According to patients reporting pain, the main objectives of treatment were both pain relief and functional recovery for 51%; pain relief for 24.9%; functional recovery for 22.8%. Low treatment expectations were reported by 15.3% patients; catastrophism by 40.7%; 28.6% patients were on pain medication: use of drugs was related to age (p = 0.005), pain intensity (p = 0.009) and catastrophism (p = 0.0003). In a multivariate analysis, pain was independently correlated with an orthopedic versus neurological diagnosis (p = 0.000), and with reduced treatment expectations (p = 0.020), while independent of age (p = 0.74) gender (p = 0.22), and catastrophism (0.17). A high prevalence of pain was observed in outpatients undergoing rehabilitation. Pain was chronic in most cases. Pain relief was the most desired treatment outcome by patients reporting pain. Pain complaint was independently correlated to orthopedic vs neurological diagnosis and to reduced treatment expectations.

Translational PK-PD modeling in pain

The current gap between animal research and clinical development of analgesic drugs presents a challenge for the application of translational PK-PD modeling and simulation. First, animal pain models lack predictive and construct validity to accurately reflect human pain etiologies and, secondly, clinical pain is a multidimensional sensory experience that can't always be captured by objective and robust measures. These challenges complicate the use of translational PK-PD modeling to project PK-PD data generated in preclinical species to a plausible range of clinical doses. To date only a few drug targets identified in animal studies have shown to be successful in the clinic. PK-PD modeling of biomarkers collected during the early phase of clinical development can bridge animal and clinical pain research. For drugs with novel mechanism of actions understanding of the target pharmacology is essential in order to increase the success of clinical development. There is a specific interest in the application of human pain models that can mimic different aspects of acute/chronic pain symptoms and serves as link between animal and clinical pain research. In early clinical development the main objective of PK-PD modeling is to characterize the relationship between target site binding and downstream biomarkers that have a potential link to the clinical endpoint (e.g. readouts from the human pain models) so as to facilitate the selection of doses for proof of concept studies. In patient studies, the role of PK-PD modeling and simulation is to characterize and confirm patient populations in terms of responder profiles with the aim to find the right dose for the right patient.

Lifestyle-oriented non-pharmacological treatments for fibromyalgia: a clinical overview and applications with home-based technologies

Fibromyalgia (FM) is a persistent and disabling widespread pain condition often accompanied by chronic fatigue, cognitive problems, sleep disturbance, depression, anxiety, and headache. To date, the most thoroughly studied non-pharmacological approaches to managing FM are those with a focus on changing patient activities and beliefs that affect the illness. These interventions are intended to facilitate enduring improvement in pain and functional status. Lifestyle-oriented treatments include patient education, aerobic or other physical exercise, and cognitive-behavioral therapy (CBT). These interventions in FM can be delivered in medical or behavioral health care settings by trained professionals, through patient-oriented treatment manuals, or via remote-access technologies. Non-pharmacological treatments, in particular exercise and CBT, have yielded effect sizes and cost–benefit ratios comparable to medications. This paper describes lifestyle-oriented non-pharmacological treatments for FM and highlights selected literature reviews of these interventions. In addition, behavioral and practical issues are addressed that may affect these non-pharmacological treatments, including patient expectations, participant burden, and treatment availability. Recommendations are made to facilitate these interventions and potentially improve outcomes. In particular, the increasing availability of convenient home-based mobile technologies to deliver these non-pharmacological treatments is described.

Interventional pain medicine: retreat from the biopsychosocial model of pain

The field of pain medicine has shifted from multidisciplinary rehabilitation to procedure-focused interventional pain medicine (IPM). Considerable controversy exists regarding the efficacy of IPM and its more narrow focus on nociception as an exclusive target of pain treatment. This topical review aims to examine pain research and treatment outcome studies that support a biopsychosocial model of pain, and to critique the clinical practice of IPM given its departure from the premises of a biopsychosocial model. A modern definition of pain and findings from clinical and basic science studies indicate that pain-related psychological factors are integral to pain perception. The clinical viability of IPM is challenged based upon its biomedical view of peripheral nociception as a primary source of pain and the potential of this viewpoint to foster maladaptive pain attributions and discourage the use of pain coping strategies among chronic pain patients. IPM should adopt a biopsychosocial perspective on pain and operate within a framework of multidisciplinary pain rehabilitation to improve its effectiveness.