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Arthur J, Childers J, Del Fabbro E. Should Urine Drug Screen be Done Universally or Selectively in Palliative Care Patients on Opioids? J Pain Symptom Manage 2023; 66:e687-e692. [PMID: 37429531 DOI: 10.1016/j.jpainsymman.2023.06.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 06/30/2023] [Indexed: 07/12/2023]
Abstract
Urine drug screen (UDS) is a useful test conducted in patients receiving opioids for chronic pain to aid in validating patient adherence to opioid treatment and to detect any nonmedical opioid use (NMOU). One controversial topic regarding its use in palliative care is whether to conduct the test universally and randomly in all patients who are receiving opioids for chronic pain irrespective of their level of risk for NMOU, or to conduct the test selectively in only those with a high risk for engaging in NMOU behaviors. In this "Controversies in Palliative Care" article, 3 expert clinicians independently answer this question. Specifically, each expert provides a synopsis of the key studies that inform their thought processes, share practical advice on their clinical approach, and highlight the opportunities for future research. They all agreed that UDS has some utility in routine palliative care practice but acknowledged the insufficient existing evidence supporting its efficacy. They also underscored the need to improve clinician proficiency in UDS interpretation to enhance its utility. Two experts endorsed random UDS in all patients receiving opioids regardless of their risk profile while the other expert recommended targeted UDS until there is more clinical evidence to support universal, random testing. Use of more methodologically robust study designs in UDS research, examination of the cost-effectiveness of UDS tests, development of innovative programs to manage NMOU behaviors, and investigation of the impact of improved clinician proficiency in UDS interpretation on clinical outcomes, were important areas of future research that the experts identified.
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Affiliation(s)
- Joseph Arthur
- Department of Palliative Care (J.A.), Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
| | - Julie Childers
- Section of Palliative Care and Medical Ethics (J.C.), Section of Treatment, Research, and Education in Addiction Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Egidio Del Fabbro
- Division of Palliative Medicine (E.D.F.), Medical College of Georgia, Augusta University, Augusta, Georgia
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2
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Singh N, Varshney U. Adaptive interventions for opioid prescription management and consumption monitoring. J Am Med Inform Assoc 2023; 30:511-528. [PMID: 36562638 PMCID: PMC9933075 DOI: 10.1093/jamia/ocac253] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 12/05/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES While opioid addiction, treatment, and recovery are receiving attention, not much has been done on adaptive interventions to prevent opioid use disorder (OUD). To address this, we identify opioid prescription and opioid consumption as promising targets for adaptive interventions and present a design framework. MATERIALS AND METHODS Using the framework, we designed Smart Prescription Management (SPM) and Smart Consumption Monitoring (SCM) interventions. The interventions are evaluated using analytical modeling and secondary data on doctor shopping, opioid overdose, prescription quality, and cost components. RESULTS SPM was most effective (30-90% improvement, for example, prescriptions reduced from 18 to 1.8 per patient) for extensive doctor shopping and reduced overdose events and mortality. Opioid adherence was improved and the likelihood of addiction declined (10-30%) as the response rate to SCM was increased. There is the potential for significant incentives ($2267-$3237) to be offered for addressing severe OUD. DISCUSSION The framework and designed interventions adapt to changing needs and conditions of the patients to become an important part of global efforts in preventing OUD. To the best of our knowledge, this is the first paper on adaptive interventions for preventing OUD by addressing both prescription and consumption. CONCLUSION SPM and SCM improved opioid prescription and consumption while reducing the risk of opioid addiction. These interventions will assist in better prescription decisions and in managing opioid consumption leading to desirable outcomes. The interventions can be extended to other substance use disorders and to study complex scenarios of prescription and nonprescription opioids in clinical studies.
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Affiliation(s)
- Neetu Singh
- Department of Management Information Systems, University of Illinois Springfield, Springfield, Illinois, USA
| | - Upkar Varshney
- Department of Computer Information Systems, Georgia State University, Atlanta, Georgia, USA
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3
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Lau J, Mazzotta P, Whelan C, Abdelaal M, Clarke H, Furlan AD, Smith A, Husain A, Fainsinger R, Hui D, Sunderji N, Zimmermann C. Opioid safety recommendations in adult palliative medicine: a North American Delphi expert consensus. BMJ Support Palliat Care 2021; 12:81-90. [PMID: 34389553 PMCID: PMC8862037 DOI: 10.1136/bmjspcare-2021-003178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 07/11/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Despite the escalating public health emergency related to opioid-related deaths in Canada and the USA, opioids are essential for palliative care (PC) symptom management.Opioid safety is the prevention, identification and management of opioid-related harms. The Delphi technique was used to develop expert consensus recommendations about how to promote opioid safety in adults receiving PC in Canada and the USA. METHODS Through a Delphi process comprised of two rounds, USA and Canadian panellists in PC, addiction and pain medicine developed expert consensus recommendations. Elected Canadian Society of Palliative Care Physicians (CSPCP) board members then rated how important it is for PC physicians to be aware of each consensus recommendation.They also identified high-priority research areas from the topics that did not achieve consensus in Round 2. RESULTS The panellists (Round 1, n=23; Round 2, n=22) developed a total of 130 recommendations from the two rounds about the following six opioid-safety related domains: (1) General principles; (2) Measures for healthcare institution and PC training and clinical programmes; (3) Patient and caregiver assessments; (4) Prescribing practices; (5) Monitoring; and (6) Patients and caregiver education. Fifty-nine topics did not achieve consensus and were deemed potential areas of research. From these results, CSPCP identified 43 high-priority recommendations and 8 high-priority research areas. CONCLUSIONS Urgent guidance about opioid safety is needed to address the opioid crisis. These consensus recommendations can promote safer opioid use, while recognising the importance of these medications for PC symptom management.
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Affiliation(s)
- Jenny Lau
- Division of Palliative care, Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada .,Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Paolo Mazzotta
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada .,Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, Ontario, Canada
| | - Ciara Whelan
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, Ontario, Canada
| | - Mohamed Abdelaal
- Division of Palliative care, Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.,Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Hance Clarke
- Department of Anesthesia, Toronto General Hospital, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Andrea D Furlan
- Department of Physiatry, Toronto Rehabilitation Institute, Toronto, Ontario, Canada.,Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Institute for Work and Health, Toronto, Ontario, Canada.,Toronto Academic Pain Medicine Institute, Toronto, Ontario, Canada
| | - Andrew Smith
- Toronto Academic Pain Medicine Institute, Toronto, Ontario, Canada.,Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Wasser Pain Management Centre, Sinai Health System, Toronto, Ontario, Canada
| | - Amna Husain
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, Ontario, Canada
| | - Robin Fainsinger
- Division of Palliative Care, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nadiya Sunderji
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.,Waypoint Centre for Mental Health Care, Penetanguishene, Ontario, Canada
| | - Camilla Zimmermann
- Division of Palliative care, Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.,Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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4
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Lau J, Mazzotta P, Fazelzad R, Ryan S, Tedesco A, Smith AJ, Sud A, Furlan AD, Zimmermann C. Assessment tools for problematic opioid use in palliative care: A scoping review. Palliat Med 2021; 35:1295-1322. [PMID: 34000897 PMCID: PMC8267087 DOI: 10.1177/02692163211015567] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Screening for problematic opioid use is increasingly recommended in patients receiving palliative care. AIM To identify tools used to assess for the presence or risk of problematic opioid use in palliative care. DESIGN Scoping review. DATA SOURCES Bibliographic databases (inception to January 31, 2020), reference lists, and grey literature were searched to find primary studies reporting on adults receiving palliative care and prescription opioids to manage symptoms from advanced cancer, neurodegenerative diseases, or end-stage organ diseases; and included tools to assess for problematic opioid use. There were no restrictions based on study design, location, or language. RESULTS We identified 42 observational studies (total 14,431 participants) published between 2009 and 2020 that used questionnaires (n = 32) and urine drug tests (n = 21) to assess for problematic opioid use in palliative care, primarily in US (n = 38) and outpatient palliative care settings (n = 36). The questionnaires were Cut down, Annoyed, Guilty, and Eye-opener (CAGE, n = 8), CAGE-Adapted to Include Drugs (CAGE-AID, n = 6), Opioid Risk Tool (n = 9), Screener and Opioid Assessment for Patients with Pain (SOAPP; n = 3), SOAPP-Revised (n = 2), and SOAPP-Short Form (n = 5). Only two studies' primary objectives were to evaluate a questionnaire's psychometric properties in patients receiving palliative care. There was wide variation in how urine drug tests were incorporated into palliative care; frequency of abnormal urine drug test results ranged from 8.6% to 70%. CONCLUSION Given the dearth of studies using tools developed or validated specifically for patients receiving palliative care, further research is needed to inform clinical practice and policy regarding problematic opioid use in palliative care.
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Affiliation(s)
- Jenny Lau
- Division of Palliative Care, University of Toronto, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Paolo Mazzotta
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, ON, Canada
| | - Rouhi Fazelzad
- UHN Library and Information Services, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Suzanne Ryan
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Division of Palliative Medicine, University of Toronto, Toronto, ON, Canada
| | - Alissa Tedesco
- Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, ON, Canada
| | - Andrew J Smith
- Addictions Division, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Abhimanyu Sud
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Medical Psychiatry Alliance, Toronto, ON, Canada
| | - Andrea D Furlan
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada.,Institute for Work and Health, Toronto, ON, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Division of Palliative Medicine, University of Toronto, Toronto, ON, Canada.,Division of Medical Oncology, University of Toronto, Toronto, ON, Canada
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5
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Terhorst Y, Messner EM, Schultchen D, Paganini S, Portenhauser A, Eder AS, Bauer M, Papenhoff M, Baumeister H, Sander LB. Systematic evaluation of content and quality of English and German pain apps in European app stores. Internet Interv 2021; 24:100376. [PMID: 33718002 PMCID: PMC7933737 DOI: 10.1016/j.invent.2021.100376] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 01/05/2021] [Accepted: 02/17/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Pain spans a broad spectrum of diseases and types that are highly prevalent and cause substantial disease burden for individuals and society. Up to 40% of people affected by pain receive no or inadequate treatment. Providing a scalable, time-, and location-independent way for pain diagnostic, management, prevention and treatment mobile health applications (MHA) might be a promising approach to improve health care for pain. However, the commercial app market is rapidly growing and unregulated, resulting in an opaque market. Studies investigating the content, privacy and security features, quality and scientific evidence of the available apps are highly needed, to guide patients and clinicians to high quality MHA.Contributing to this challenge, the present study investigates the content, quality, and privacy features of pain apps available in the European app stores. METHODS An automated search engine was used to identify pain apps in the European Google Play and Apple App store. Pain apps were screened and checked for systematic criteria (pain-relatedness, functionality, availability, independent usability, English or German). Content, quality and privacy features were assessed by two independent reviewers using the German Mobile Application Rating Scale (MARS-G). The MARS-G assesses quality on four objectives (engagement, functionality, aesthetics, information quality) and two subjective scales (perceived impact, subjective quality). RESULTS Out of 1034 identified pain apps 218 were included. Pain apps covered eight different pain types. Content included basic information, advice, assessment and tracking, and stand-alone interventions. The overall quality of the pain apps was average M = 3.13 (SD = 0.56, min = 1, max = 4.69). The effectiveness of less than 1% of the included pain apps was evaluated in a randomized controlled trial. Major problems with data privacy were present: 59% provided no imprint, 70% had no visible privacy policy. CONCLUSION A multitude of pain apps is available. Most MHA lack scientific evaluation and have serious privacy issues, posing a potential threat to users. Further research on evidence and improvements privacy and security are needed. Overall, the potential of pain apps is not exploited.
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Affiliation(s)
- Yannik Terhorst
- Department of Research Methods, Institute of Psychology and Education, Ulm University, Albert-Einstein-Allee 47, 89069 Ulm, Germany
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, Ulm University, Lise-Meitner-Str. 16, 89081 Ulm, Germany
| | - Eva-Maria Messner
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, Ulm University, Lise-Meitner-Str. 16, 89081 Ulm, Germany
| | - Dana Schultchen
- Department of Clinical and Health Psychology, Institute of Psychology and Education, Ulm University, Albert-Einstein-Allee 47, 89069 Ulm, Germany
| | - Sarah Paganini
- Department of Sport Psychology, University of Freiburg, Schwarzwaldstraße 175, 79117 Freiburg, Germany
| | - Alexandra Portenhauser
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, Ulm University, Lise-Meitner-Str. 16, 89081 Ulm, Germany
| | - Anna-Sophia Eder
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, Ulm University, Lise-Meitner-Str. 16, 89081 Ulm, Germany
| | - Melanie Bauer
- Department of Clinical and Health Psychology, Institute of Psychology and Education, Ulm University, Albert-Einstein-Allee 47, 89069 Ulm, Germany
| | - Mike Papenhoff
- Pain Medicine Clinic, BG Klinikum Duisburg, Grossenbaumer Allee 250, D-47249 Duisburg, Germany
| | - Harald Baumeister
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, Ulm University, Lise-Meitner-Str. 16, 89081 Ulm, Germany
| | - Lasse Bosse Sander
- Department of Rehabilitation Psychology and Psychotherapy, Institute of Psychology, Albert-Ludwigs-University Freiburg, Engelberger Str. 41, 79106 Freiburg im Breisgau, Germany
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6
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Arthur JA, Tang M, Lu Z, Hui D, Nguyen K, Rodriguez EM, Edwards T, Yennurajalingam S, Dalal S, Dev R, Reddy A, Tanco K, Haider A, Liu DD, Bruera E. Random urine drug testing among patients receiving opioid therapy for cancer pain. Cancer 2021; 127:968-975. [PMID: 33231885 PMCID: PMC10015495 DOI: 10.1002/cncr.33326] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/24/2020] [Accepted: 10/06/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND There is limited information regarding the true frequency of nonmedical opioid use (NMOU) among patients receiving opioid therapy for cancer pain. Data to guide patient selection for urine drug testing (UDT) as well as the timing and frequency of ordering UDT are insufficient. This study examined the frequency of abnormal UDT among patients with cancer who underwent random UDT and their characteristics. METHODS Demographic and clinical information for patients with cancer who underwent random UDT were retrospectively reviewed and compared with a historical cohort that underwent targeted UDT. Random UDT was ordered regardless of a patient's risk potential for NMOU. Targeted UDT was ordered on the basis of a physician's estimation of a patient's risk for NMOU. RESULTS In all, 552 of 573 eligible patients (96%) underwent random UDT. Among these patients, 130 (24%) had 1 or more abnormal results; 38 of the 88 patients (43%) who underwent targeted UDT had 1 or more abnormal results. When marijuana was excluded, 15% of the random group and 37% of the targeted group had abnormal UDT findings (P < .001). It took a shorter time from the initial consultation to detect 1 or more abnormalities with the random test than the targeted test (median, 130 vs 274 days; P = .02). Abnormal random UDT was independently associated with younger age (P < .0001), male sex (P = .03), Cut Down, Annoyed, Guilty, and Eye Opener-Adapted to Include Drugs positivity (P = .001), and higher Edmonton Symptom Assessment System anxiety (P = .01). CONCLUSIONS Approximately 1 in 4 patients receiving opioids for cancer pain at a supportive care clinic who underwent random UDT had 1 or more abnormalities. Random UDT detected abnormalities earlier than the targeted test. These findings suggest that random UDT is justified among patients with cancer pain.
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Affiliation(s)
- Joseph A Arthur
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael Tang
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Zhanni Lu
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David Hui
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kristy Nguyen
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eden Mae Rodriguez
- Pharmacy Services, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Tonya Edwards
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sriram Yennurajalingam
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shalini Dalal
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rony Dev
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Akhila Reddy
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kimberson Tanco
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ali Haider
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Diane D Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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7
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Chakravarthy K, Goel A, Jeha GM, Kaye AD, Christo PJ. Review of the Current State of Urine Drug Testing in Chronic Pain: Still Effective as a Clinical Tool and Curbing Abuse, or an Arcane Test? Curr Pain Headache Rep 2021; 25:12. [PMID: 33598816 DOI: 10.1007/s11916-020-00918-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2020] [Indexed: 01/04/2023]
Abstract
PURPOSE OF REVIEW Therapeutic use, misuse, abuse, and diversion of controlled substances in managing chronic non-cancer pain remain a major concern for physicians, the government, payers, and patients. The challenge remains finding effective diagnostic tools that can be clinically validated to eliminate or substantially reduce the abuse of controlled prescription drugs, while still assuring the proper treatment of those patients in pain. Urine drug testing still remains an important means of adherence monitoring, but questions arise as to its relevance and effectiveness. This review examines the role of UDT, determines its utility in current clinical practice, and investigates its relevance in current chronic pain management. RECENT FINDINGS A review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Literature was searched from year 2000 to present examining the relevance and role of UDT in monitoring chronic opioid therapy along with reliability and accuracy, appropriate use, overuse, misuse, and abuse. There are only a limited number of reviews and investigations on UDT, despite the fact that clinicians who prescribe controlled medications for chronic states commonly are expected to utilize UDT. Therefore, despite highly prevalent use, there is a limited publication base from which to draw in this present study. Regardless of experience or training background, physicians and healthcare providers can much more adequately assess opioid therapy with the aid of UDT, which often requires confirmatory testing by a laboratory for clinical and therapeutic prescribing decisions. It has become a strongly recommended aspect of pain care with controlled substances locally, regionally, and nationally. Incorporating UDT for all patients in whom chronic opioid therapy is undertaken is consistent with state and national guidelines and best practice strategies. Practice standards vary as to the frequency of UDT locally, regionally, and nationally, however.
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Affiliation(s)
- Krishnan Chakravarthy
- VA San Diego Healthcare System, UC San Diego School of Medicine, La Jolla, CA, USA. .,Department of Anesthesiology, University of California San Diego, 9500 Gilman Dr, La Jolla, CA, 92093, USA.
| | - Aneesh Goel
- Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, The Johns Hopkins University School of Medicine, 550 North Broadway, Suite 301, Baltimore, MD, 21205, USA
| | - George M Jeha
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Alan David Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA, USA.,Departments of Anesthesiology and Pharmacology, Toxicology and Neuroscience, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Paul J Christo
- Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, The Johns Hopkins University School of Medicine, 550 North Broadway, Suite 301, Baltimore, MD, 21205, USA.
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8
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Prescribing Opioids: Universal Education on Opioid Use, Storage, and Disposal. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00427-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Ghodke A, Ives TJ, Austin AE, Bennett WC, Patel NY, Eshet SA, Chelminski PR. Pain Agreements and Time-to-Event Analysis of Substance Misuse in a Primary Care Chronic Pain Program. PAIN MEDICINE 2020; 21:2154-2162. [PMID: 32186725 DOI: 10.1093/pm/pnaa033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Types and correlates of pain medication agreement (PMA) violations in the primary care setting have not been analyzed. METHODS A retrospective analysis was completed to examine patient characteristics and correlates of PMA violations, a proxy for substance misuse, over a 15-year period in an outpatient General Medicine Pain Service within the Division of General Medicine and Clinical Epidemiology, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill. Patients who signed the PMA were managed for chronic pain from 2002 through 2017 (N = 1,210). The incidence of PMA violations was measured over a 15-year span. Substance misuse was defined a priori in the study as urine toxicology screen positive for illicit or nonprescribed controlled substances, patient engagement in prescription alteration, doctor-shopping, or diversion. RESULTS Most patients received a prescription for a controlled substance (77.4%). During enrollment, 488 (40.3%) patients had one or more violations of their PMA. One-third (33.4%) of pain service patients had a violation within 365 days of signing the agreement. Active tobacco smokers had double the incidence of agreement violation within the first 30 days of enrollment. Almost one-half (49.8%) of violations were due to inconsistent use of controlled substances. Patients with any prior DWI/DUI or drug-related offense had a significantly increased rate of substance misuse (P < 0.0001). CONCLUSIONS PMA violations were common among a population of patients managed for chronic nonmalignant pain. Universal opioid prescribing precautions, including PMAs, require further investigation to assess their roles in mitigating the potential patient and societal harms associated with opioid prescribing.
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Affiliation(s)
- Ameer Ghodke
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Timothy J Ives
- Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anna E Austin
- Injury Prevention Research Center, Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - William C Bennett
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Naishal Y Patel
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Sharon A Eshet
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Paul R Chelminski
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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10
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Hosain F, Lee J, Ata A, Bhullar RK, Chang AK. Physician Renewal of Chronically Prescribed Controlled Substances Based on Urine Drug Test Results. J Prim Care Community Health 2020; 10:2150132719883632. [PMID: 31646927 PMCID: PMC6820170 DOI: 10.1177/2150132719883632] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective: The effect of specific urine drug testing (UDT) results on physician prescribing habits has not been well described. The primary objective was to report renewal rates of chronically prescribed controlled substances based on types of inconsistent UDT results. Methods: We conducted a retrospective chart review over a 5-month period comparing prescription renewals rates for patients with consistent versus inconsistent UDTs. Inconsistent UDTs were defined by prescribed drug not detected or the presence of heroin, cocaine, nonprescribed opioids, nonprescribed benzodiazepines, or marijuana. Results: Of the 474 UDTs reviewed, 214 (45.1%) were inconsistent. The most common findings among inconsistent UDTs, including overlapping results, were prescribed drug not detected (26.8%) and the presence of marijuana (20.7%), nonprescribed opioids (9.9%), and nonprescribed benzodiazepines (6.1%). In contrast, cocaine (5.5%) and heroin (0.4%) were less likely to be found on UDTs for this population. The relative risk (RR) of prescription renewal was 0.64 (95% CI 0.57-0.71) for inconsistent UDTs versus consistent UDTs. Within the inconsistent UDTs, the renewal rates when marijuana (79.6%) or nonprescribed opioids or benzodiazepines (63.6%) were present were much higher than when heroin or cocaine were present (0.0%; P < .001). Patients whose prescribed controlled substance was not detected had a 55.8% renewal rate. Conclusions: Prescription renewal rates were high when patient UDTs contained nonprescribed marijuana, opioids, and benzodiazepines, or when the prescribed drug was not detected. Prescription renewal rates were low when illicit drugs, such as heroin and cocaine, were detected.
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Affiliation(s)
| | | | - Ashar Ata
- Albany Medical Center, Albany, NY, USA
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Chapman KB, Pas MM, Abrar D, Day W, Vissers KC, van Helmond N. Development and Performance of a Web-Based Tool to Adjust Urine Toxicology Testing Frequency: Retrospective Study. JMIR Med Inform 2020; 8:e16069. [PMID: 32319958 PMCID: PMC7203611 DOI: 10.2196/16069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 01/23/2020] [Accepted: 03/25/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Several pain management guidelines recommend regular urine drug testing (UDT) in patients who are being treated with chronic opioid analgesic therapy (COAT) to monitor compliance and improve safety. Guidelines also recommend more frequent testing in patients who are at high risk of adverse events related to COAT; however, there is no consensus on how to identify high-risk patients or on the testing frequency that should be used. Using previously described clinical risk factors for UDT results that are inconsistent with the prescribed COAT, we developed a web-based tool to adjust drug testing frequency in patients treated with COAT. OBJECTIVE The objective of this study was to evaluate a risk stratification tool, the UDT Randomizer, to adjust UDT frequency in patients treated with COAT. METHODS Patients were stratified using an algorithm based on readily available clinical risk factors into categories of presumed low, moderate, high, and high+ risk of presenting with UDT results inconsistent with the prescribed COAT. The algorithm was integrated in a website to facilitate adoption across practice sites. To test the performance of this algorithm, we performed a retrospective analysis of patients treated with COAT between June 2016 and June 2017. The primary outcome was compliance with the prescribed COAT as defined by UDT results consistent with the prescribed COAT. RESULTS 979 drug tests (867 UDT, 88.6%; 112 oral fluid testing, 11.4%) were performed in 320 patients. An inconsistent drug test result was registered in 76/979 tests (7.8%). The incidences of inconsistent test results across the risk tool categories were 7/160 (4.4%) in the low risk category, 32/349 (9.2%) in the moderate risk category, 28/338 (8.3%) in the high risk category, and 9/132 (6.8%) in the high+ risk category. Generalized estimating equation analysis demonstrated that the moderate risk (odds ratio (OR) 2.1, 95% CI 0.9-5.0; P=.10), high risk (OR 2.0, 95% CI 0.8-5.0; P=.14), and high risk+ (OR 2.0, 95% CI 0.7-5.6; P=.20) categories were associated with a nonsignificantly increased risk of inconsistency vs the low risk category. CONCLUSIONS The developed tool stratified patients during individual visits into risk categories of presenting with drug testing results inconsistent with the prescribed COAT; the higher risk categories showed nonsignificantly higher risk compared to the low risk category. Further development of the tool with additional risk factors in a larger cohort may further clarify and enhance its performance.
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Affiliation(s)
- Kenneth B Chapman
- Department of Anesthesiology, New York University Langone Medical Center, New York, NY, United States
- The Spine & Pain Institute of New York, New York, NY, United States
| | - Martijn M Pas
- The Spine & Pain Institute of New York, New York, NY, United States
- Radboud University Medical College, Nijmegen, Netherlands
| | - Diana Abrar
- The Spine & Pain Institute of New York, New York, NY, United States
- Radboud University Medical College, Nijmegen, Netherlands
| | - Wesley Day
- The Spine & Pain Institute of New York, New York, NY, United States
| | - Kris C Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Noud van Helmond
- The Spine & Pain Institute of New York, New York, NY, United States
- Department of Anesthesiology, Cooper Medical School of Rowan University, Cooper University Health Care, Camden, NJ, United States
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Abstract
Urine drug test (UDT) is an effective tool used in chronic opioid therapy to ensure patient adherence to treatment and detect nonmedical opioid use. The two main types of UDT used in routine clinical practice are the screening tests or immunoassays and the confirmatory tests or laboratory-based specific drug identification tests such as gas chromatography-mass spectrometry, liquid chromatography-mass spectrometry, or tandem mass spectrometry. UDT produces objective data on some nonmedical opioid use that may otherwise go undetected, such as the use of undisclosed medications, the nonuse of prescribed medications, and the use of illegal drugs. It allows clinicians to initiate an open and effective conversation about nonmedical opioid use with their patients. However, the test has certain limitations that sometimes compromise its use. Its interpretation can be challenging to clinicians because of the complexity of the opioid metabolic pathways. Clear guidelines or recommendations regarding the use of UDT in cancer pain is limited. As a result, UDT appears to be underused among patients with cancer pain receiving opioid therapy. More studies are needed to help standardize the integration and use of UDT in routine cancer pain management. IMPLICATIONS FOR PRACTICE: Despite its potential benefits, urine drug testing (UDT) appears to be underused among patients with cancer pain receiving opioid therapy. This is partly because its interpretation can be challenging owing to the complexity of the opioid metabolic pathways. Information regarding the use of UDT in opioid therapy among patients with cancer is limited. This review article will improve clinician proficiency in UDT interpretation and assist oncologists in developing appropriate treatment plans during chronic opioid therapy.
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Affiliation(s)
- Joseph A. Arthur
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson CancerHoustonTexasUSA
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Sokol R, Albanese M, Chew A, Early J, Grossman E, Roll D, Sawin G, Wu DJ, Schuman-Olivier Z. Building a Group-Based Opioid Treatment (GBOT) blueprint: a qualitative study delineating GBOT implementation. Addict Sci Clin Pract 2019; 14:47. [PMID: 31882001 PMCID: PMC6935085 DOI: 10.1186/s13722-019-0176-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 12/11/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Group-Based Opioid Treatment (GBOT) has recently emerged as a mechanism for treating patients with opioid use disorder (OUD) in the outpatient setting. However, the more practical "how to" components of successfully delivering GBOT has received little attention in the medical literature, potentially limiting its widespread implementation and utilization. Building on a previous case series, this paper delineates the key components to implementing GBOT by asking: (a) What are the core components to GBOT implementation, and how are they defined? (b) What are the malleable components to GBOT implementation, and what conceptual framework should providers use in determining how to apply these components for effective delivery in their unique clinical environment? METHODS To create a blueprint delineating GBOT implementation, we integrated findings from a previously conducted and separately published systematic review of existing GBOT studies, conducted additional literature review, reviewed best practice recommendations and policies related to GBOT and organizational frameworks for implementing health systems change. We triangulated this data with a qualitative thematic analysis from 5 individual interviews and 2 focus groups representing leaders from 5 different GBOT programs across our institution to identify the key components to GBOT implementation, distinguish "core" and "malleable" components, and provide a conceptual framework for considering various options for implementing the malleable components. RESULTS We identified 6 core components to GBOT implementation that optimize clinical outcomes, comply with mandatory policies and regulations, ensure patient and staff safety, and promote sustainability in delivery. These included consistent group expectations, team-based approach to care, safe and confidential space, billing compliance, regular monitoring, and regular patient participation. We identified 14 malleable components and developed a novel conceptual framework that providers can apply when deciding how to employ each malleable component that considers empirical, theoretical and practical dimensions. CONCLUSION While further research on the effectiveness of GBOT and its individual implementation components is needed, the blueprint outlined here provides an initial framework to help office-based opioid treatment sites implement a successful GBOT approach and hence potentially serve as future study sites to establish efficacy of the model. This blueprint can also be used to continuously monitor how components of GBOT influence treatment outcomes, providing an empirical framework for the ongoing process of refining implementation strategies.
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Affiliation(s)
- Randi Sokol
- Malden Family Medicine Center, 195 Canal St, Malden, MA 02148 USA
| | - Mark Albanese
- Outpatient Addiction Services, 26 Central St, Somerville, MA 02143 USA
| | - Aaronson Chew
- Malden Family Medicine Center, 195 Canal St, Malden, MA 02148 USA
| | - Jessica Early
- Malden Family Medicine Center, 195 Canal St, Malden, MA 02148 USA
| | - Ellie Grossman
- Somerville Hospital Primary Care, 236 Highland Avenue, Somerville, MA 02143 USA
| | - David Roll
- Revere Care Center, 454 Broadway, Revere, MA 02151 USA
| | - Greg Sawin
- Malden Family Medicine Center, 195 Canal St, Malden, MA 02148 USA
| | - Dominic J. Wu
- Malden Family Medicine Center, 195 Canal St, Malden, MA 02148 USA
| | - Zev Schuman-Olivier
- Center for Mindfulness and Compassion, 1035 Cambridge Street, Suite 21, Cambridge, MA 02141 USA
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Moyo P, Gellad WF, Sabik LM, Cochran GT, Cole ES, Gordon AJ, Kelley DK, Donohue JM. Opioid Prescribing Safety Measures in Medicaid Enrollees With and Without Cancer. Am J Prev Med 2019; 57:540-544. [PMID: 31542131 DOI: 10.1016/j.amepre.2019.05.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 05/29/2019] [Accepted: 05/30/2019] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Opioid prescribing safety among individuals with cancer is poorly understood. This study estimates the prevalence of Pharmacy Quality Alliance opioid measures among individuals with cancer undergoing or not undergoing active treatment versus those without cancer. METHODS Pennsylvania Medicaid data (2016) were analyzed in 2018 to identify adults aged 18-64 years with and without cancer diagnoses who had 2 or more opioid prescriptions. Active cancer treatment, defined as having chemotherapy, radiotherapy, cancer surgery, or hospitalization with a primary diagnosis of cancer, was evaluated from October 2015 to December 2016 allowing a ≥3-month look-back period for cancer diagnoses observed in the first quarter of 2016. Opioid dosages (>120 morphine milligram equivalents for ≥90 consecutive days), multiple providers (4 or more prescribers and 4 or more pharmacies), and opioid and benzodiazepines overlapping ≥30 days were evaluated. RESULTS The sample with opioid prescriptions included 111,491 enrollees without cancer diagnoses and 12,819 with cancer, 58.8% of whom were not in active cancer treatment. Among enrollees undergoing cancer treatment, with cancer but not in active treatment, and without cancer, the prevalence of high morphine milligram equivalents was 7.1%, 6.0%, and 4.7% (p<0.001), respectively. The corresponding prevalence of multiple providers was 6.7%, 4.1%, and 3.4% (p<0.001). Concurrent opioid and benzodiazepine prescriptions occurred in 28.6%, 30.5%, and 26.8% (p<0.001), respectively. CONCLUSIONS Individuals with cancer, regardless of treatment status, had higher-risk opioid use based on Pharmacy Quality Alliance measures versus those without cancer. Their systematic exclusion from opioid quality surveillance could create missed opportunities to identify patients at high risk of adverse opioid-related outcomes.
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Affiliation(s)
- Patience Moyo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Walid F Gellad
- Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, Pittsburgh, Pennsylvania; Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Lindsay M Sabik
- Department of Health Policy & Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Gerald T Cochran
- Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, Pittsburgh, Pennsylvania; University of Pittsburgh, School of Social Work, Pittsburgh, Pennsylvania; Program for Addiction, Research, Clinical Care, Knowledge, and Advocacy, Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Evan S Cole
- Department of Health Policy & Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Adam J Gordon
- Program for Addiction, Research, Clinical Care, Knowledge, and Advocacy, Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah; Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) and Vulnerable Veteran Innovative PACT (VIP) Initiative, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
| | - David K Kelley
- Pennsylvania Department of Human Services, Harrisburg, Pennsylvania
| | - Julie M Donohue
- Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, Pittsburgh, Pennsylvania; Department of Health Policy & Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania.
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Paice JA. Risk Assessment and Monitoring of Patients with Cancer Receiving Opioid Therapy. Oncologist 2019; 24:1294-1298. [PMID: 31118217 PMCID: PMC6795159 DOI: 10.1634/theoncologist.2019-0301] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 05/01/2019] [Indexed: 12/20/2022] Open
Abstract
To provide safe and effective management of cancer pain, a thorough risk assessment is needed when conducting a comprehensive pain evaluation. This information provides the basis for decisions about appropriate pain relief interventions and for measures that can be taken to mitigate the potential for misuse of opioids and other substances. The primary objective of this article is to assist oncologists and advanced practice prescribers to safely and effectively minimize risk when providing opioids for cancer pain relief. The majority of people with cancer are unlikely to misuse or divert opioid medications, yet the prescriber is often unaware of those who are at risk for these behaviors. To provide skillful pain management to each patient in the oncology setting, while limiting harm to the community, all prescribers must consider the potential for risk of misuse, addiction, or diversion. To minimize this risk to the greatest degree possible, it is imperative to include a thorough risk assessment when conducting a comprehensive pain evaluation. This information is then used to triage pain relief interventions based upon the degree of risk, including whether or not to incorporate opioids into the plan of care. Risk mitigation strategies, incorporating universal precautions, are implemented to assess, monitor, and reduce the potential for opioid misuse. Universal precautions include strategies such as the use of urine toxicology, state prescription drug monitoring programs, and agreements. Ongoing monitoring is conducted with the goal being to identify aberrant behaviors early so that they can be addressed and managed appropriately. Referral to addiction specialists may be warranted when substance use disorder precludes safe use of opioids. Implications for Practice. Throughout the trajectory of cancer care, opioid use is often indicated, and, in fact, it may be unethical to limit or prohibit the use of opioids when pain is severe. Oncologists face the significant challenge of providing cancer pain control that is safe and effective, while limiting individual risk for abuse or overdose and keeping the community free of diverted substances. Most oncology providers report inadequate training in chronic pain principles and in managing addiction. Risk assessment and mitigation measures can be incorporated within oncology care to enhance effective pain management while reducing the potential for harm.
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Affiliation(s)
- Judith A Paice
- Division of Hematology-Oncology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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17
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Arthur J, Reddy A. Opioid Prescribing in an Opioid Crisis: What Basic Skills Should an Oncologist Have Regarding Opioid Therapy? Curr Treat Options Oncol 2019; 20:39. [PMID: 30937544 DOI: 10.1007/s11864-019-0636-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OPINION STATEMENT Although clinical evidence supports the use of opioids for cancer-related pain, doing so amidst the current opioid crisis remains a challenge. A proportion of opioid-related deaths in the USA are attributable to prescription opioids, which implicates health care providers as one of the major contributors. It is therefore even more important now for all clinicians to follow safe and effective opioid prescribing practices. Oncologists are often in the frontline of cancer pain management. They are encouraged to use validated tools to screen all patients receiving opioids for high risk behaviors. Those identified as high risk for potential abuse of opioids should be monitored closely. When aberrant behavior is detected, the clinician will need to openly discuss the issue and its possible implications. Oncologists may then implement measures such as limiting the dose and quantity of opioids prescribed, shortening interval between follow-ups for refills to allow for increased monitoring, setting boundaries/limitations, weaning off opioid analgesics, or/and referring to a pain or palliative medicine or drug addiction expert for co-management when necessary. These efforts may aid oncologists in safely managing cancer pain in the environment of national opioid crisis.
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Affiliation(s)
- Joseph Arthur
- Department of Palliative, Rehabilitation, & Integrative Medicine, The University of Texas MD Anderson Cancer, Unit 1414, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Akhila Reddy
- Department of Palliative, Rehabilitation, & Integrative Medicine, The University of Texas MD Anderson Cancer, Unit 1414, 1515 Holcombe Boulevard, Houston, TX, 77030, USA.
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18
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Argoff CE, Alford DP, Fudin J, Adler JA, Bair MJ, Dart RC, Gandolfi R, McCarberg BH, Stanos SP, Gudin JA, Polomano RC, Webster LR. Rational Urine Drug Monitoring in Patients Receiving Opioids for Chronic Pain: Consensus Recommendations. PAIN MEDICINE 2019; 19:97-117. [PMID: 29206984 PMCID: PMC6516588 DOI: 10.1093/pm/pnx285] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objective To develop consensus recommendations on urine drug monitoring (UDM) in patients with chronic pain who are prescribed opioids. Methods An interdisciplinary group of clinicians with expertise in pain, substance use disorders, and primary care conducted virtual meetings to review relevant literature and existing guidelines and share their clinical experience in UDM before reaching consensus recommendations. Results Definitive (e.g., chromatography-based) testing is recommended as most clinically appropriate for UDM because of its accuracy; however, institutional or payer policies may require initial use of presumptive testing (i.e., immunoassay). The rational choice of substances to analyze for UDM involves considerations that are specific to each patient and related to illicit drug availability. Appropriate opioid risk stratification is based on patient history (especially psychiatric conditions or history of opioid or substance use disorder), prescription drug monitoring program data, results from validated risk assessment tools, and previous UDM. Urine drug monitoring is suggested to be performed at baseline for most patients prescribed opioids for chronic pain and at least annually for those at low risk, two or more times per year for those at moderate risk, and three or more times per year for those at high risk. Additional UDM should be performed as needed on the basis of clinical judgment. Conclusions Although evidence on the efficacy of UDM in preventing opioid use disorder, overdose, and diversion is limited, UDM is recommended by the panel as part of ongoing comprehensive risk monitoring in patients prescribed opioids for chronic pain.
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Affiliation(s)
- Charles E Argoff
- Department of Neurology, Albany Medical Center, Albany, New York
| | - Daniel P Alford
- Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Jeffrey Fudin
- Scientific and Clinical Affairs, Remitigate, LLC, Delmar, New York
| | - Jeremy A Adler
- Pacific Pain Medicine Consultants, Encinitas, California
| | - Matthew J Bair
- HSR&D Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indiana University School of Medicine, and Regenstrief Institute, Indianapolis, Indiana
| | | | | | - Bill H McCarberg
- Department of Family Medicine, University of California at San Diego School of Medicine, San Diego, California
| | - Steven P Stanos
- Swedish Pain Services, Swedish Health System, Seattle, Washington
| | - Jeffrey A Gudin
- Department of Pain Management and Palliative Care, Englewood Hospital and Medical Center, Englewood, New Jersey
| | - Rosemary C Polomano
- Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Lynn R Webster
- Scientific Affairs, PRA International, Salt Lake City, Utah, USA
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Dalal S, Bruera E. Pain Management for Patients With Advanced Cancer in the Opioid Epidemic Era. Am Soc Clin Oncol Educ Book 2019; 39:24-35. [PMID: 31099619 DOI: 10.1200/edbk_100020] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Use of opioids for the treatment of pain is necessary for the majority of patients with advanced cancer, however its use has become challenging in the face of the opioid epidemic and the emerging evidence that patients with cancer are also at risk for nonmedical opioid use. This article proposes an assessment and treatment plan that incorporates universal screening with monitoring for all patients with cancer who are considered for opioid treatment to assess their risk for opioid misuse and harm. Timely identification with appropriate management, including referral of at-risk patients, will allow oncology professionals to optimize the risk-to-benefit and support the safe use of opioids for patients with cancer.
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Affiliation(s)
- Shalini Dalal
- 1 From the Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eduardo Bruera
- 1 From the Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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20
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Paice JA. Cancer pain management and the opioid crisis in America: How to preserve hard-earned gains in improving the quality of cancer pain management. Cancer 2018; 124:2491-2497. [PMID: 29499072 DOI: 10.1002/cncr.31303] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 01/16/2018] [Accepted: 01/24/2018] [Indexed: 11/10/2022]
Abstract
Cancer pain remains a feared consequence of the disease and its treatment. Although prevalent, cancer pain can usually be managed through the skillful application of pharmacologic and nonpharmacologic interventions. Unfortunately, access to these therapies has been hampered by interventions designed to contain another serious public health problem: the opioid misuse epidemic. This epidemic and the unintended consequences of efforts to control this outbreak are leading to significant barriers to the provision of cancer pain relief. Oncologists and other professionals treating those with cancer pain will require new knowledge and tools to provide safe and effective pain control while preventing additional cases of substance use disorders (SUDs), helping patients in recovery to maintain sobriety, and guiding those not yet in recovery to seek treatment. How do these 2 serious epidemics intersect and affect oncology practice? First, oncology professionals will need to adopt practices to prevent SUDs by assessing risk and providing safe pain care. Second, oncology practices are likely to see an increased number of patients with a current or past SUD, including opioid misuse. Few guidelines exist for the direct management of pain when opioids may be indicated in these individuals. Third, modified prescribing practices along with the education of patients and families are warranted to prevent the exposure of these medications to unintended persons. Finally, advocacy on behalf of those with cancer pain is imperative to avoid losing access to essential therapies, including opioids, for those who might benefit. Cancer 2018;124:2491-7. © 2018 American Cancer Society.
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Affiliation(s)
- Judith A Paice
- Cancer Pain Program, Division of Hematology-Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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22
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Enders JR, Smith JP, Feng S, Strickland EC, McIntire GL. Analytical Considerations When Developing an LC-MS/MS Method for More than 30 Analytes. J Appl Lab Med 2017; 2:543-554. [PMID: 33636886 DOI: 10.1373/jalm.2017.024174] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 09/13/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND While validation of analytical (LC-MS/MS) methods has been documented in any number of articles and reference texts, the optimal design and subsequent validation of a method for over 30 analytes presents special challenges. Conventional approaches to calibration curves, controls, and run time are not tenable in such methods. This report details the practical aspects of designing and implementing such a method in accordance with College of American Pathologists validation criteria. METHODS Conventional criteria were followed in the design and validation of a method for 34 analytes and 15 internal standards by LC-MS/MS. These criteria are laid out in a standard operating procedure, which is followed without exception and is consistent with College of American Pathologists criteria. RESULTS The method presented herein provides quality results and accurate medication monitoring. The method was optimized to negate interferences (both from within the method and from potential concomitant compounds), increase throughput, and provide reproducible quality quantification over relevant analyte concentrations ranges. CONCLUSIONS The method was designed primarily with quality and accurate medication monitoring in mind. The method achieves these goals by use of novel approaches to calibration curves and controls that both improve performance and minimize risk (financial and operational). As automation and LC-MS/MS equipment continue to improve, it is expected that more methods like this one will be developed.
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Affiliation(s)
- Jeffrey R Enders
- Research and Development Department, Ameritox, LLC, Greensboro, NC 27409
| | - Jeremy P Smith
- Research and Development Department, Ameritox, LLC, Greensboro, NC 27409
| | - Sheng Feng
- Research and Development Department, Ameritox, LLC, Greensboro, NC 27409
| | - Erin C Strickland
- Research and Development Department, Ameritox, LLC, Greensboro, NC 27409
| | - Gregory L McIntire
- Research and Development Department, Ameritox, LLC, Greensboro, NC 27409
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Sekhri NK, Cooney MF. Opioid Metabolism and Pharmacogenetics: Clinical Implications. J Perianesth Nurs 2017; 32:497-505. [PMID: 28938988 DOI: 10.1016/j.jopan.2017.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 07/26/2017] [Indexed: 11/30/2022]
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Moeller KE, Kissack JC, Atayee RS, Lee KC. Clinical Interpretation of Urine Drug Tests: What Clinicians Need to Know About Urine Drug Screens. Mayo Clin Proc 2017; 92:774-796. [PMID: 28325505 DOI: 10.1016/j.mayocp.2016.12.007] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 11/21/2016] [Accepted: 12/12/2016] [Indexed: 10/19/2022]
Abstract
Urine drug testing is frequently used in clinical, employment, educational, and legal settings and misinterpretation of test results can result in significant adverse consequences for the individual who is being tested. Advances in drug testing technology combined with a rise in the number of novel misused substances present challenges to clinicians to appropriately interpret urine drug test results. Authors searched PubMed and Google Scholar to identify published literature written in English between 1946 and 2016, using urine drug test, screen, false-positive, false-negative, abuse, and individual drugs of abuse as key words. Cited references were also used to identify the relevant literature. In this report, we review technical information related to detection methods of urine drug tests that are commonly used and provide an overview of false-positive/false-negative data for commonly misused substances in the following categories: cannabinoids, central nervous system (CNS) depressants, CNS stimulants, hallucinogens, designer drugs, and herbal drugs of abuse. We also present brief discussions of alcohol and tricyclic antidepressants as related to urine drug tests, for completeness. The goal of this review was to provide a useful tool for clinicians when interpreting urine drug test results and making appropriate clinical decisions on the basis of the information presented.
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Affiliation(s)
| | | | - Rabia S Atayee
- UCSD Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, CA
| | - Kelly C Lee
- UCSD Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, CA
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Vadivelu N, Lumermann L, Zhu R, Kodumudi G, Elhassan AO, Kaye AD. Pain Control in the Presence of Drug Addiction. Curr Pain Headache Rep 2016; 20:35. [PMID: 27068665 DOI: 10.1007/s11916-016-0561-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Drug addiction is present in a significant proportion of the population in the USA and worldwide. Drug addiction can occur with the abuse of many types of substances including cocaine, marijuana, stimulants, alcohol, opioids, and tranquilizers. There is a high likelihood that clinicians will encounter patients with substance abuse disorders on a regular basis with the prevalence of the use of illicit substances and the high rate of abuse of prescription drugs. The use of abuse deterrent formulations of prescription opioid agents, pill counts, and urine drug abuse screenings are all useful strategies. Optimum pain management of patients with addiction in the outpatient and inpatient setting is essential to minimize pain states. Careful selection of medications and appropriate oversight, including drug agreements, can reduce drug-induced impairments, including sleep deficits and diminished physical, social, and sexual functioning. This review, therefore, discusses the prevalence of illicit and prescription drug addiction, the challenges of achieving optimum pain control, and the therapeutic approaches to be considered in this challenging population. More research is warranted to develop improved therapies and routes of treatments for optimum pain relief and to prevent the development of central sensitization, chronic pain, and impaired physical and social functioning in patients with drug addiction.
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Affiliation(s)
- Nalini Vadivelu
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, 06520, USA.
| | | | - Richard Zhu
- Yale University School of Medicine, New Haven, CT, 06520, USA
| | - Gopal Kodumudi
- California North State University College of Medicine, 9700 W Taron, Elk Grove, CA, 95757, USA
| | - Amir O Elhassan
- Department of Anesthesiology, LSU School of Medicine, New Orleans, LA, USA
| | - Alan David Kaye
- Department of Anesthesiology, LSU School of Medicine, New Orleans, LA, USA
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Interviewing and Urine Drug Toxicology Screening in a Pediatric Pain Management Center: An Analysis of Analgesic Nonadherence and Aberrant Behaviors in Adolescents and Young Adults. Clin J Pain 2016; 32:1-6. [PMID: 25756559 DOI: 10.1097/ajp.0000000000000231] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Many adolescents and young adults report having chronic pain. Urine drug toxicology (UDT) is not routinely used in the pediatric pain management population, despite more routine use in adults with pain, particularly those prescribed opioids. As a first step toward establishing monitoring practices in pediatric and adolescent pain management, the present study evaluated the role of UDT in conjunction with a standard clinical interview in identifying the rate of adherence to an established analgesic regimen. The study also aimed to assess the use of UDT in identifying possible aberrant behaviors in this population. METHODS Data were acquired from a convenience sample of 50 pediatric and adolescent pain management initial consultations, during which a clinical interview and UDT were conducted. Data were analyzed to determine adherence to an established analgesic prescription regimen, and for identification of aberrant behaviors including concurrent use of illicit substances and prescription medication misuse. Other pertinent demographic and clinical factors were examined as factors in adherence. RESULTS Opioid medications were prescribed for 42% of the sample receiving pain medications, and 22% of the sample was nonadherent to their prescription analgesic regimen. Factors associated with a higher likelihood of nonadherence were an older age and having an opioid prescription. The majority (90%) of those nonadherent to their analgesic regimen displayed some form of aberrant behavior. Among the nonadherent patients, 50% were identified by UDT alone, and 50% were identified by self-report during the clinical encounter. CONCLUSIONS These results highlight the challenges of identifying nonadherence to a prescription regimen among adolescents with chronic pain. In addition, this preliminary work suggests that UDT could be used in conjunction with careful clinical interviewing to substantiate patient report and increase the likelihood of detecting analgesic nonadherence and aberrant behaviors.
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Webster LR, Grabois M. Current Regulations Related to Opioid Prescribing. PM R 2016; 7:S236-S247. [PMID: 26568503 DOI: 10.1016/j.pmrj.2015.08.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 08/12/2015] [Accepted: 08/18/2015] [Indexed: 10/22/2022]
Abstract
It is the responsibility of medical professionals to do all that is possible to safely alleviate pain. Opioids are frequently prescribed for pain but are associated with the potential for misuse, addiction, diversion, and overdose mortality, and thus they are strictly regulated. To adhere to legitimate practice standards, physicians and other health care providers who prescribe opioids for pain, particularly on a long-term basis, need current information on federal and state laws, treatment guidelines, and regulatory actions aimed at reducing opioid-related harm. The number of opioid-prescribing policies is increasing as federal and state governments increase scrutiny to alleviate opioid-related problems in society. Failure to adequately comply with opioid-prescribing laws and policies may put a prescriber at risk for legal or regulatory sanctions. Necessary actions include thorough documentation of prescribing decisions and assessment and follow-up of patient risk for opioid misuse or addiction. Tools to check for patient adherence to the prescribed regimen include prescription monitoring databases and urine drug screening. This article presents an overview of the legal and regulatory framework surrounding controlled substances law. It further discusses recent actions at the federal and state level to prevent opioid-related harm.
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Affiliation(s)
- Lynn R Webster
- PRA Health Sciences, 3838 South 700 East, Suite 202, Salt Lake City, UT 84106
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Kennedy AJ, Arnold RM, Childers JW. Opioids for Chronic Pain in Patients with History of Substance Use Disorders, Part 2: Management and Monitoring #312. J Palliat Med 2016; 19:890-1. [PMID: 27494225 DOI: 10.1089/jpm.2016.0077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Savage SR, Romero-Sandoval A, Schatman M, Wallace M, Fanciullo G, McCarberg B, Ware M. Cannabis in Pain Treatment: Clinical and Research Considerations. THE JOURNAL OF PAIN 2016; 17:654-68. [DOI: 10.1016/j.jpain.2016.02.007] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 01/27/2016] [Accepted: 02/09/2016] [Indexed: 12/21/2022]
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Gaither JR, Goulet JL, Becker WC, Crystal S, Edelman EJ, Gordon K, Kerns RD, Rimland D, Skanderson M, Justice AC, Fiellin DA. The Association Between Receipt of Guideline-Concordant Long-Term Opioid Therapy and All-Cause Mortality. J Gen Intern Med 2016; 31:492-501. [PMID: 26847447 PMCID: PMC4835362 DOI: 10.1007/s11606-015-3571-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE For patients receiving long-term opioid therapy (LtOT), the impact of guideline-concordant care on important clinical outcomes--notably mortality--is largely unknown, even among patients with a high comorbidity and mortality burden (e.g., HIV-infected patients). Our objective was to determine the association between receipt of guideline-concordant LtOT and 1-year all-cause mortality. METHODS Among HIV-infected and uninfected patients initiating LtOT between 2000 and 2010 through the Department of Veterans Affairs, we used Cox regression with time-updated covariates and propensity-score matched analyses to examine the association between receipt of guideline-concordant care and 1-year all-cause mortality. RESULTS Of 17,044 patients initiating LtOT between 2000 and 2010, 1048 patients (6%) died during 1 year of follow-up. Patients receiving psychotherapeutic co-interventions (hazard ratio [HR] 0.62; 95% confidence interval [CI] 0.51-0.75; P < 0.001) or physical rehabilitative therapies (HR 0.81; 95% CI 0.67-0.98; P = 0.03) had a decreased risk of all-cause mortality compared to patients not receiving these services, whereas patients prescribed benzodiazepines concurrent with opioids had a higher risk of mortality (HR 1.39; 95% CI 1.12-1.66; P < 0.001). Among patients with a current substance use disorder (SUD), those receiving SUD treatment had a lower risk of mortality than untreated patients (HR 0.47; 95% CI 0.32-0.68; P = < 0.001). No association was found between all-cause mortality and primary care visits (HR 1.12; 95% CI 0.90-1.26; P = 0.32) or urine drug testing (HR 0.96; 95% CI 0.78-1.17; P = 0.67). CONCLUSIONS Providers should use caution in initiating LtOT in conjunction with benzodiazepines and untreated SUDs. Patients receiving LtOT may benefit from multi-modal treatment that addresses chronic pain and its associated comorbidities across multiple disciplines.
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Affiliation(s)
- Julie R Gaither
- Yale School of Public Health, Yale University, New Haven, CT, USA. .,VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA. .,Yale Center for Medical Informatics, Yale School of Medicine, Yale University, New Haven, CT, USA. .,Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, CT, USA.
| | - Joseph L Goulet
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.,Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - William C Becker
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.,Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Stephen Crystal
- Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, NJ, USA
| | - E Jennifer Edelman
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, CT, USA.,Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Kirsha Gordon
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA
| | - Robert D Kerns
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.,Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - David Rimland
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA.,Atlanta VA Medical Center, Decatur, GA, USA
| | | | - Amy C Justice
- Yale School of Public Health, Yale University, New Haven, CT, USA.,VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.,Yale Center for Medical Informatics, Yale School of Medicine, Yale University, New Haven, CT, USA.,Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - David A Fiellin
- Yale School of Public Health, Yale University, New Haven, CT, USA.,Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, CT, USA.,Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
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Lee CT, Vo TT, Cohen AS, Ahmed S, Zhang Y, Mao J, Chen L. Profiles of Urine Drug Test in Clinical Pain Patients vs Pain Research Study Subjects. PAIN MEDICINE 2016; 17:636-43. [PMID: 26398237 DOI: 10.1111/pme.12900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 07/27/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To examine similarities and differences in urine drug test (UDT) results in clinical pain patients and pain subjects participating in pain research studies. DESIGN An observational study with retrospective chart review and data analysis. METHODS We analyzed 1,874 UDT results obtained from 1) clinical pain patients (Clinical Group; n = 1,529) and 2) pain subjects consented to participate in pain research studies (Research Group; n = 345). Since several medications such as opioids used in pain management are drugs of abuse (DOA) and can result in a positive UDT, we specifically identified those cases of positive UDT due to nonprescribed DOA and designated these cases as positive UDT with DOA (PUD). RESULTS We found that 1) there was a higher rate of PUD in clinical pain patients (41.3%) than in pain research study subjects (14.8%); 2) although subjects in the Research Group were informed ahead of time that UDT will be conducted as a screening test, a substantial number (14.8%) of pain research study subjects still showed PUD; 3) there were different types of DOA between clinical pain patients (cannabinoids as the top DOA) and research study subjects (cocaine as the top DOA); and 4) a common factor associated with PUD was opioid therapy in both Clinical Group and Research Group. CONCLUSION These results support previous findings that PUD is a common finding in clinical pain patients, particularly in those prescribed opioid therapy, and we suggest that UDT be used as routine screening testing in pain research studies.
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Affiliation(s)
- Cheng-ting Lee
- *University of Texas Southwestern Medical Center in Dallas, Texas, USA
| | - Trang T Vo
- MGH Center for Translational Pain Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Abigail S Cohen
- MGH Center for Translational Pain Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Shihab Ahmed
- MGH Center for Translational Pain Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yi Zhang
- MGH Center for Translational Pain Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jianren Mao
- MGH Center for Translational Pain Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lucy Chen
- MGH Center for Translational Pain Research, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Brooks A, Kominek C, Pham TC, Fudin J. Exploring the Use of Chronic Opioid Therapy for Chronic Pain: When, How, and for Whom? Med Clin North Am 2016; 100:81-102. [PMID: 26614721 DOI: 10.1016/j.mcna.2015.08.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This article provides a broad overview regarding intent to initiate and consider ongoing chronic opioid therapy (COT) for treatment of chronic noncancer pain (CNCP). COT should be an individualized decision based on a comprehensive evaluation, assessment, and monitoring. It is imperative that providers discuss various risks and benefits of COT initially and at follow-up visits, and continue appropriate monitoring and follow-up at regular intervals. The decision to initiate or continue opioid therapy is based on clinical judgment; however, it is understood that opioid and other medication therapy represent one piece of the complete treatment plan for patients with CNCP.
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Affiliation(s)
- Abigail Brooks
- Pain Management, Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Courtney Kominek
- Pain Management, Harry S. Truman Memorial Veterans' Hospital, Columbia, MO, USA
| | - Thien C Pham
- Pain & Palliative Care, Stratton VA Medical Center, Albany, NY, USA
| | - Jeffrey Fudin
- Pain Management, PGY2 Pain & Palliative Care Pharmacy Residency, Stratton VA Medical Center, Albany, NY, USA; Western New England University College of Pharmacy, Springfield, MA, USA; Albany College of Pharmacy & Health Sciences, Albany, NY, USA; University of Connecticut School of Pharmacy, Storrs, CT, USA.
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Ceasar R, Chang J, Zamora K, Hurstak E, Kushel M, Miaskowski C, Knight K. Primary care providers' experiences with urine toxicology tests to manage prescription opioid misuse and substance use among chronic noncancer pain patients in safety net health care settings. Subst Abus 2016; 37:154-60. [PMID: 26682471 PMCID: PMC4823143 DOI: 10.1080/08897077.2015.1132293] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Guideline recommendations to reduce prescription opioid misuse among patients with chronic noncancer pain include the routine use of urine toxicology tests for high-risk patients. Yet little is known about how the implementation of urine toxicology tests among patients with co-occurring chronic noncancer pain and substance use impacts primary care providers' management of misuse. Clinicians' perspectives on the benefits and challenges of implementing urine toxicology tests in the monitoring of opioid misuse and substance use in safety net health care settings are presented in this paper. METHODS Twenty-three primary care providers from 6 safety net health care settings whose patients had a diagnosis of co-occurring chronic noncancer pain and substance use were interviewed. Interviews were transcribed, coded, and analyzed using grounded theory methodology. RESULTS The benefits of implementing urine toxicology tests for primary care providers included less reliance on intuition to assess for misuse and the ability to identify unknown opioid misuse and/or substance use. The challenges of implementing urine toxicology tests included insufficient education and training about how to interpret and implement tests, and a lack of clarity on how and when to act on tests that indicated misuse and/or substance use. CONCLUSIONS These data suggest that primary care clinicians' lack of education and training to interpret and implement urine toxicology tests may impact their management of patient opioid misuse and/or substance use. Clinicians may benefit from additional education and training about the clinical implementation and use of urine toxicology tests. Additional research is needed on how primary care providers implementation and use of urine toxicology tests impacts chronic noncancer pain management in primary care and safety net health care settings among patients with co-occurring chronic non cancer pain and substance use.
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Affiliation(s)
- Rachel Ceasar
- Department of Anthropology, History, and Social Medicine, University of California San Francisco, San Francisco, California, USA
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jamie Chang
- Department of Anthropology, History, and Social Medicine, University of California San Francisco, San Francisco, California, USA
| | - Kara Zamora
- Department of Anthropology, History, and Social Medicine, University of California San Francisco, San Francisco, California, USA
| | - Emily Hurstak
- Division of General Internal Medicine, University of California San Francisco, San Francisco, California, USA
| | - Margot Kushel
- Division of General Internal Medicine, University of California San Francisco, San Francisco, California, USA
| | - Christine Miaskowski
- School of Nursing, University of California San Francisco, San Francisco, California, USA
| | - Kelly Knight
- Department of Anthropology, History, and Social Medicine, University of California San Francisco, San Francisco, California, USA
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Quantitative, Multidrug Pain Medication Testing by Liquid Chromatography: Tandem Mass Spectrometry (LC-MS/MS). Methods Mol Biol 2016; 1383:223-40. [PMID: 26660191 DOI: 10.1007/978-1-4939-3252-8_24] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Chronic pain is often treated with narcotic analgesics. The most commonly used narcotic analgesics are the opiates (natural or modified compounds of the poppy plant) or opioids (synthetic chemicals that act on opiate receptors). While opiates and opioids are excellent analgesics, they can also have significant side effects that include respiratory depression, coma, or death. Tolerance, physical dependence, and addiction (psychological dependence) are other severe side effects of opioid use. Patients who develop dependence or addiction often times abuse other, non-opioid narcotics and may trade their prescription medication for illegal street drugs (called "diversion"). In order to minimize side effects, detect possible multidrug abuse and prove diversion, simultaneous monitoring of numerous prescription and illicit drugs is required. The method described in this chapter is for the quantitative measurement of 43 different drugs in urine. The panel includes narcotic pain medications, benzodiazepines, NIDA drugs, and other, commonly abused medications. The analytes of interests are injected in the presence of deuterated internal standards to correct for possible extraction inefficiencies, ion suppression, or other interferences. The sample is prepared by adding dilution buffer with the deuterated internal standards to the sample, followed by reversed-phase, gradient HPLC separation on a Phenyl-Hexyl column using water and methanol as mobile phases. Detection of the analytes of interest is done by isotope-dilution mass spectrometry on a triple-quadrupole tandem mass spectrometer following electrospray ionization in the positive mode. Mass spectrometric (MS) data are collected in the scheduled MRM (sMRM) mode. Two MRM transitions are monitored for each analyte and one MRM transition is monitored for each IS. Quantitation of the unknown analytes is achieved by comparing the peak area ratios of the analytes to that of the internal standards and reading the unknown concentration from a seven-point calibration curve.
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Current and Future Prospects for Epigenetic Biomarkers of Substance Use Disorders. Genes (Basel) 2015; 6:991-1022. [PMID: 26473933 PMCID: PMC4690026 DOI: 10.3390/genes6040991] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 09/16/2015] [Accepted: 09/22/2015] [Indexed: 01/30/2023] Open
Abstract
Substance abuse has an enormous impact on economic and quality of life measures throughout the world. In more developed countries, overutilization of the most common forms of substances of abuse, alcohol and tobacco, is addressed primarily through prevention of substance use initiation and secondarily through the treatment of those with substance abuse or dependence. In general, these therapeutic approaches to substance abuse are deemed effective. However, there is a broad consensus that the development of additional tools to aid diagnosis, prioritize treatment selection and monitor treatment response could have substantial impact on the effectiveness of both substance use prevention and treatment. The recent demonstrations by a number of groups that substance use exposure is associated with robust changes in DNA methylation signatures of peripheral blood cells suggests the possibility that methylation assessments of blood or saliva could find broad clinical applications. In this article, we review recent progress in epigenetic approaches to substance use assessment with a particular emphasis on smoking (and alcohol) related applications. In addition, we highlight areas, such as the epigenetics of psychostimulant, opioid and cannabis abuse, which are markedly understudied and could benefit from intensified collaborative efforts to define epigenetic biomarkers of abuse and dependence.
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Johnson-Davis KL, Slawson MH. Ethyl Glucuronide Positivity Rate in a Pain Management Population. J Anal Toxicol 2015; 39:686-90. [PMID: 26324207 DOI: 10.1093/jat/bkv096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Ethanol may be consumed by some patients as a means to manage their pain or psychiatric disorder. Consequently, there is the potential to consider ethanol a co-therapeutic in pain management. The purpose of this study was to perform a retrospective analysis to evaluate the rate of ethanol use in a population of patients in pain management programs that were evaluated by our in-house pain management drug panel test. Results from this retrospective study showed that 12.6% of patients in a pain management population were positive for the direct ethanol metabolite, ethyl glucuronide (EtG), by immunoassay. Furthermore, 86% of the individuals positive for EtG were also positive for prescription pain medication and illicit drugs. Results presented here suggest that ethanol use should be routinely monitored in pain management populations in an effort to determine any potential adverse effects of ethanol-drug interactions and as a way to further evaluate the effect of ethanol on pain management outcomes. Testing this population of patients suggests that ethanol use is prevalent and the risk of drug-ethanol adverse effects should be monitored in a pain management population.
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Affiliation(s)
- Kamisha L Johnson-Davis
- University of Utah Health Sciences Center, Salt Lake City, UT 84108, USA ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT 84108, USA
| | - Matthew H Slawson
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT 84108, USA ARUP Laboratories, Salt Lake City, UT 84108, USA
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Peppin JF, Cheatle MD, Kirsh KL, McCarberg BH. The Complexity Model: A Novel Approach to Improve Chronic Pain Care. PAIN MEDICINE 2015; 16:653-66. [DOI: 10.1111/pme.12621] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Abstract
Pain remains a serious consequence of cancer and its treatment. Although significant advances have been made in providing effective cancer pain control, barriers persist. Lack of knowledge, limited time, financial restrictions, and diminished availability of necessary medications serve as significant obstacles. Safe and effective opioid use in a patient with cancer requires skill to overcome these challenges. Understanding the mechanism of action, along with the pharmacokinetics and pharmacodynamics, of opioids will lead to appropriate selection, dosing, and titration of these agents. Rotation from one opioid or route to another is an essential proficiency for oncologists. As opioid-related adverse effects often occur, the oncology team must be expert in preventing and managing constipation, nausea, sedation, and neurotoxicities. An emerging concern is overtreatment-the excessive and prolonged use of opioids in patients when these agents may produce more harm than benefit. This can occur when opioids are used inappropriately to treat comorbid psychologic issues such as anxiety and depression. Recognizing risk factors for overuse along with key components of universal precautions will promote safe use of these medications, supporting adherence and preventing diversion, thereby protecting the patient, the prescriber, and the community. Because substance use disorders are not rare in the oncology setting, attention must be given to the balance of providing analgesia while limiting harm. Caring for patients with substance misuse requires compassionate, multidisciplinary care, with input from supportive oncology/palliative care as well as addiction specialists.
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Affiliation(s)
- Eduardo Bruera
- From the The University of Texas MD Anderson Cancer Center, Houston, TX; Feinberg School of Medicine, Northwestern University, Chicago, IL; Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Judith A Paice
- From the The University of Texas MD Anderson Cancer Center, Houston, TX; Feinberg School of Medicine, Northwestern University, Chicago, IL; Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
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Turner JA, Saunders K, Shortreed SM, LeResche L, Riddell K, Rapp SE, Von Korff M. Chronic opioid therapy urine drug testing in primary care: prevalence and predictors of aberrant results. J Gen Intern Med 2014; 29:1663-71. [PMID: 25217208 PMCID: PMC4242878 DOI: 10.1007/s11606-014-3010-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 07/25/2014] [Accepted: 08/11/2014] [Indexed: 03/17/2023]
Abstract
BACKGROUND Urine drug tests (UDTs) are recommended for patients on chronic opioid therapy (COT). Knowledge of the risk factors for aberrant UDT results could help optimize their use. OBJECTIVE To identify primary care COT patient and opioid regimen characteristics associated with aberrant UDT results. DESIGN Population-based observational. SAMPLE 5,420 UDTs for Group Health integrated group practice COT patients. MEASURES Group Health database measures of patient demographics, medical history, COT characteristics, and UDT results. RESULTS Thirty percent of UDTs had aberrant results, including prescribed opioid non-detection (12.3%), tetrahydrocannabinol (THC; 11.2%), non-prescribed opioid (5.3%), illicit drug (excluding THC; 0.6%), non-prescribed benzodiazepine (1.7%), and dilute (4.8%). Adjusted odds ratios (95% CI) of any aberrant result were higher for males than females (1.24 [1.07, 1.43]), patients with versus without prior substance use disorder diagnoses (1.42 [1.17, 1.72]), and current smokers versus non-smokers (1.50 [1.30, 1.73]). Odds ratios were lower for patients aged 45-64 (0.77 [0.65, 0.92]) and 65+ (0.40 [0.32, 0.50]) versus patients aged 20-44 and for patients on long-acting opioids only (0.72 [0.55, 0.95]) or long-acting plus short-acting (0.67 [0.54, 0.83]) versus short-acting only. Adjusted odds of prescribed opioid non-detection were lower for patients aged 45-64 (0.79 [0.63, 0.998]) and 65+ (0.44 [0.32, 0.59]) versus patients aged 20-44, for those on 40-<120 mg daily morphine-equivalent dose (0.52 [0.39, 0.70]) or 120+ mg (0.22 [0.11, 0.43]) versus <40 mg, and for patients on long-acting (0.35 [0.21, 0.57]) or long-acting plus short-acting (0.35 [0.24, 0.50]) opioids (versus short-acting only); and odds ratios were higher for patients with versus without prior diagnoses of substance use disorder (1.70 [1.31, 2.20]). CONCLUSIONS In this primary care setting, results were aberrant for 30% of UDTs of COT patients, largely because of prescribed opioid non-detection and THC. Aberrant results of almost all types were more likely among patients under the age of 45. Other risk factors varied across aberrancies, but commonly included current smoking and prior substance use disorder diagnosis.
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Affiliation(s)
- Judith A Turner
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA,
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Cone EJ, DePriest AZ, Gordon A, Passik SD. Risks and responsibilities in prescribing opioids for chronic noncancer pain, part 2: best practices. Postgrad Med 2014; 126:129-38. [PMID: 25387221 DOI: 10.3810/pgm.2014.11.2841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Opioids are increasingly prescribed to provide effective therapy for chronic noncancer pain, but increased use also means an increased risk of abuse. Primary care physicians treating patients with chronic noncancer pain are concerned about adverse events and risk of abuse and dependence associated with opioids, yet many prescribers do not follow established guidelines for the use of these agents, either through unawareness or in the mistaken belief that urine toxicology testing is all that is needed to monitor compliance and thwart abuse. Although there is no foolproof way to identify an abuser and prevent abuse, the best way to minimize the risk of abuse is to follow established guidelines for the use of opioids. These guidelines entail a careful assessment of the patient, the painful condition to be treated, and the estimated level of risk of abuse based on several factors: history of abuse and current or past psychiatric disorders; design of a therapeutic regimen that includes both pharmacotherapeutic and nonpharmacologic modalities; a formal written agreement with the patient that defines treatment expectations and responsibilities; selection of an appropriate agent, including consideration of formulations designed to deter tampering and abuse; initiation of treatment at a low dosage with titration in gradual increments as needed to achieve effective analgesia; regular reassessment to watch for signs of abuse, to perform drug monitoring, and to adjust medication as needed; and established protocols for actions to be taken in case of suspected abuse. By following these guidelines, physicians can prescribe opioids to provide effective analgesia while reducing the likelihood of abuse.
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Affiliation(s)
- Edward J Cone
- Associate Professor, Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Severna Park, MD
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Cheatle MD, Barker C. Improving opioid prescription practices and reducing patient risk in the primary care setting. J Pain Res 2014; 7:301-11. [PMID: 24966692 PMCID: PMC4062552 DOI: 10.2147/jpr.s37306] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Chronic pain is complex, and the patient suffering from chronic pain frequently experiences concomitant medical and psychiatric disorders, including mood and anxiety disorders, and in some cases substance use disorders. Ideally these patients would be referred to an interdisciplinary pain program staffed by pain medicine, behavioral health, and addiction specialists. In practice, the majority of patients with chronic pain are managed in the primary care setting. The primary care clinician typically has limited time, training, or access to resources to effectively and efficiently evaluate, treat, and monitor these patients, particularly when there is the added potential liability of prescribing opioids. This paper reviews the role of opioids in managing chronic noncancer pain, including efficacy and risk for misuse, abuse, and addiction, and discusses several models employing novel technologies and health delivery systems for risk assessment, intervention, and monitoring of patients receiving opioids in a primary care setting.
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Affiliation(s)
- Martin D Cheatle
- Center for Studies of Addiction, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Cody Barker
- Center for Studies of Addiction, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Willy ME, Graham DJ, Racoosin JA, Gill R, Kropp GF, Young J, Yang J, Choi J, MaCurdy TE, Worrall C, Kelman JA. Candidate metrics for evaluating the impact of prescriber education on the safe use of extended-release/long-acting (ER/LA) opioid analgesics. PAIN MEDICINE 2014; 15:1558-68. [PMID: 24828968 DOI: 10.1111/pme.12459] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The objective of this study was to develop metrics to assess opioid prescribing behavior as part of the evaluation of the Extended-Release/Long-Acting (ER/LA) Opioid Analgesic Risk Evaluation and Mitigation Strategies (REMS). DESIGN Candidate metrics were selected using published guidelines, examined using sensitivity analyses, and applied to cross-sectional rolling cohorts of Medicare patients prescribed with extended-release oxycodone (ERO) between July 2, 2006 and July 1, 2011. Potential metrics included prescribing opioid-tolerant-only ER/LA opioid analgesics to non-opioid-tolerant patients, prescribing early fills to patients, and ordering drug screens. RESULTS Proposed definitions for opioid tolerance were seven continuous days of opioid usage of at least 30 mg oxycodone equivalents, within the 7 days (primary) or 30 days (secondary) prior to first opioid-tolerant-only ERO prescription. Forty-four percent of opioid-tolerant-only ERO episodes met the primary opioid tolerance definition; 56% met the secondary definition. Fills were deemed "early" if a prescription was filled before 70% (primary) or 50% (secondary) of the prior prescription's days' supply was to be consumed. Five percent (primary) and 2% (secondary) of episodes had more than or equal to two early fills during treatment. At least one drug screen was billed in 14% of episodes. Stratified analyses indicated that older patients were less likely to be opioid tolerant at the time of the first opioid-tolerant-only ERO prescription. CONCLUSIONS Investigators propose three metrics to monitor changes in prescribing behaviors for opioid analgesics that might be used to evaluate the ER/LA Opioid Analgesics REMS. Low frequencies of patients, particularly those >85 years, were likely to be opioid tolerant prior to receiving prescriptions for opioid-tolerant-only ERO.
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Affiliation(s)
- Mary E Willy
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
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Gudin JA, Mogali S, Jones JD, Comer SD. Risks, management, and monitoring of combination opioid, benzodiazepines, and/or alcohol use. Postgrad Med 2013; 125:115-30. [PMID: 23933900 DOI: 10.3810/pgm.2013.07.2684] [Citation(s) in RCA: 152] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The concurrent use of opioids, benzodiazepines (BZDs), and/or alcohol poses a formidable challenge for clinicians who manage chronic pain. While the escalating use of opioid analgesics for the treatment of chronic pain and the concomitant rise in opioid-related abuse and misuse are widely recognized trends, the contribution of combination use of BZDs, alcohol, and/or other sedative agents to opioid-related morbidity and mortality is underappreciated, even when these agents are used appropriately. Patients with chronic pain who use opioid analgesics along with BZDs and/or alcohol are at higher risk for fatal/nonfatal overdose and have more aberrant behaviors. Few practice guidelines for BZD treatment are readily available, especially when they are combined clinically with opioid analgesics and other central nervous system-depressant agents. However, coadministration of these agents produces a defined increase in rates of adverse events, overdose, and death, warranting close monitoring and consideration when treating patients with pain. To improve patient outcomes, ongoing screening for aberrant behavior, monitoring of treatment compliance, documentation of medical necessity, and the adjustment of treatment to clinical changes are essential. In this article, we review the prevalence and pharmacologic consequences of BZDs and/or alcohol use among patients with pain on chronic opioid therapy, as well as the importance of urine drug testing, an indispensable tool for therapeutic drug monitoring, which helps to ensure the continued safety of patients. Regardless of risk or known aberrant drug-related behaviors, patients on chronic opioid therapy should periodically undergo urine drug testing to confirm adherence to the treatment plan.
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Affiliation(s)
- Jeffrey A Gudin
- Pain Management and Wellness Center, Englewood Hospital and Medical Center, Englewood, NJ 07631, USA.
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Cheatle M, Comer D, Wunsch M, Skoufalos A, Reddy Y. Treating pain in addicted patients: recommendations from an expert panel. Popul Health Manag 2013; 17:79-89. [PMID: 24138341 DOI: 10.1089/pop.2013.0041] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Clinicians may face pragmatic, ethical, and legal issues when treating addicted patients. Equal pressures exist for clinicians to always address the health care needs of these patients in addition to their addiction. Although controversial, mainly because of the lack of evidence regarding their long-term efficacy, the use of opioids for the treatment of chronic pain management is widespread. Their use for pain management in the addicted population can present even more challenges, especially when evaluating the likelihood of drug-seeking behavior. As the misuse and abuse of opioids continues to burgeon, clinicians must be particularly vigilant when prescribing chronic opioid therapy. The purpose of this article is to summarize recommendations from a recent meeting of experts convened to recommend how primary care physicians should approach treatment of chronic pain for addicted patients when an addiction specialist is not available for a referral. As there is a significant gap in guidelines and recommendations in this specific area of care, this article serves to create a foundation for expanding chronic pain guidelines in the area of treating the addicted population. This summary is designed to be a practical how-to guide for primary care physicians, discussing risk assessment, patient stratification, and recommended therapeutic approaches.
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Affiliation(s)
- Martin Cheatle
- 1 University of Pennsylvania Center for Studies of Addiction , Philadelphia, PA
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George JM, Menon M, Gupta P, Tan M. Use of strong opioids for chronic non-cancer pain: a retrospective analysis at a pain centre in Singapore. Singapore Med J 2013; 54:506-10. [DOI: 10.11622/smedj.2013173] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Schatman ME, Darnall BD. A pendulum swings awry: seeking the middle ground on opioid prescribing for chronic non-cancer pain. PAIN MEDICINE 2013; 14:617. [PMID: 23581746 DOI: 10.1111/pme.12120] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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McCloskey LJ, Stickle DF. How well can urine hydrocodone measurements discriminate between different hydrocodone prescription dosage rates? Clin Chim Acta 2013; 419:119-21. [DOI: 10.1016/j.cca.2013.02.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 01/23/2013] [Accepted: 02/02/2013] [Indexed: 11/17/2022]
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Markotic F, Cerni Obrdalj E, Zalihic A, Pehar R, Hadziosmanovic Z, Pivic G, Durasovic S, Grgic V, Banozic A, Sapunar D, Puljak L. Adherence to pharmacological treatment of chronic nonmalignant pain in individuals aged 65 and older. PAIN MEDICINE 2013; 14:247-56. [PMID: 23368967 DOI: 10.1111/pme.12035] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Medication nonadherence is a frequent problem in the treatment of chronic conditions. OBJECTIVE To study the adherence to pharmacological treatment of chronic nonmalignant pain, as well as factors and patient attitudes related to nonadherence in patients aged ≥65 years. METHODS The cross-sectional study was conducted with a self-administered questionnaire among 100 patients aged ≥65 years by five family physicians at the Health Care Centre Mostar, Bosnia and Herzegovina. RESULTS According to their own statements, 57% of the patients were nonadherent, while 84% exhibited some form of nonadherence on the Morisky scale. The patients reported a mean pain intensity of 6.6 ± 2.2 on a visual analog scale. The most common deviation from the prescribed therapy was self-adjustment of the dose and medical regimen based on the severity of pain. Polymedication correlated positively with nonadherence. Nonsteroidal anti-inflammatory drugs were the most frequently prescribed medications. The majority of the participants (59%) believed that higher pain intensity indicates progression of the disease, and half of the participants believed that one can easily become addicted to pain medications. Nonadherence was associated with patient attitudes about addiction to analgesics and ability of analgesics to control pain. CONCLUSION.: High pain intensity and nonadherence found in this study suggest that physicians should monitor older patients with chronic nonmalignant pain more closely and pay more attention to patients' beliefs regarding analgesics to ensure better adherence to pharmacological therapy.
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Affiliation(s)
- Filipa Markotic
- Office for monitoring and quality improvement, Clinical Hospital Mostar, Mostar, Bosnia and Herzegovina
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Kulich RJ, Stone M. Risk Stratification With Opioid Therapy. Headache 2012; 52 Suppl 2:88-93. [DOI: 10.1111/j.1526-4610.2012.02236.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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