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Chen M, Li T. Impacts of social determinants of health on chronic opioid therapy for chronic non-cancer pain. Pain Manag 2024:1-7. [PMID: 38904289 DOI: 10.1080/17581869.2024.2366145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 06/05/2024] [Indexed: 06/22/2024] Open
Abstract
Aim: We aimed to investigate the association between social determinants of health and chronic opioid therapy. Materials & methods: We conducted a retrospective analysis of electronic health records from five family medicine and internal medicine clinics in Oregon in 2020 and 2021. Our outcome variable was whether a patient was receiving chronic opioid therapy for chronic non-cancer pain. Our variables of interest included financial difficulty, insurance types, transportation barriers, currently married or living with a partner and organizations participation. Results: Our results showed that patients with financial difficulty were more likely to have chronic opioid therapy (OR: 2.69; 95% CI: 1.14, 6.33). Conclusion: Addressing patients' social determinants of health disadvantages is important for optimizing pain management.
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Affiliation(s)
- Minghui Chen
- Department of Internal Medicine, Good Samaritan Regional Medical Center, Corvallis, OR 97330, USA
- (Present affiliation) Department of Anesthesiology, Boston Medical Center, Boston, MA 02118, USA
| | - Tao Li
- Health Management & Policy, College of Health, Oregon State University, Corvallis, OR 97331, USA
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2
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Incze MA. Redesigning Opioid Pain Agreements to Promote Patient-Centered Care. JAMA Intern Med 2023; 183:179-180. [PMID: 36745430 DOI: 10.1001/jamainternmed.2022.6520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This Viewpoint discusses opioid pain agreements to promote patient-centered care.
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Affiliation(s)
- Michael A Incze
- Division of General Internal Medicine, University of Utah, Salt Lake City.,Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
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3
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Coffin PO, Martinez RS, Wylie B, Ryder B. Primary care management of Long-Term opioid therapy. Ann Med 2022; 54:2451-2469. [PMID: 36111417 PMCID: PMC9487960 DOI: 10.1080/07853890.2022.2121417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
The United States underwent massive expansion in opioid prescribing from 1990-2010, followed by opioid stewardship initiatives and reduced prescribing. Opioids are no longer considered first-line therapy for most chronic pain conditions and clinicians should first seek alternatives in most circumstances. Patients who have been treated with opioids long-term should be managed differently, sometimes even continued on opioids due to physiologic changes wrought by long-term opioid therapy and documented risks of discontinuation. When providing long-term opioid therapy, clinicians should document opioid stewardship measures, including assessments, consents, medication reconciliation, and offering naloxone, along with the rationale to continue opioid therapy. Clinicians should screen regularly for opioid use disorder and arrange for or directly provide treatment. In particular, buprenorphine can be highly useful for co-morbid pain and opioid use disorder. Addressing other substance use disorders, as well as preventive health related to substance use, should be a priority in patients with opioid use disorder. Patient-centered practices, such as shared decision-making and attending to related facets of a patient's life that influence health outcomes, should be implemented at all points of care.Key messagesAlthough opioids are no longer considered first-line therapy for most chronic pain, management of patients already taking long-term opioid therapy must be individualised.Documentation of opioid stewardship measures can help to organise opioid prescribing and protect clinicians from regulatory scrutiny.Management of resultant opioid use disorder should include provision of medications, most often buprenorphine, and several additional screening and preventive measures.
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Affiliation(s)
- Phillip O Coffin
- San Francisco Department of Public Health, Center on Substance Use and Health, San Francisco, CA, USA
| | - Rebecca S Martinez
- San Francisco Department of Public Health, Center on Substance Use and Health, San Francisco, CA, USA
| | - Brian Wylie
- San Francisco Department of Public Health, Center on Substance Use and Health, San Francisco, CA, USA
| | - Bunny Ryder
- San Francisco Department of Public Health, Center on Substance Use and Health, San Francisco, CA, USA
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Rowe CL, Eagen K, Ahern J, Faul M, Hubbard A, Coffin P. Evaluating the Effects of Opioid Prescribing Policies on Patient Outcomes in a Safety-net Primary Care Clinic. J Gen Intern Med 2022; 37:117-124. [PMID: 34173204 PMCID: PMC8738839 DOI: 10.1007/s11606-021-06920-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 05/06/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND After decades of liberal opioid prescribing, multiple efforts have been made to reduce reliance upon opioids in clinical care. Little is known about the effects of opioid prescribing policies on outcomes beyond opioid prescribing. OBJECTIVE To evaluate the combined effects of multiple opioid prescribing policies implemented in a safety-net primary care clinic in San Francisco, CA, in 2013-2014. DESIGN Retrospective cohort study and conditional difference-in-differences analysis of nonrandomized clinic-level policies. PATIENTS 273 patients prescribed opioids for chronic non-cancer pain in 2013 at either the treated (n=151) or control clinic (n=122) recruited and interviewed in 2017-2018. INTERVENTIONS Policies establishing standard protocols for dispensing opioid refills and conducting urine toxicology testing, and a new committee facilitating opioid treatment decisions for complex patient cases. MAIN MEASURES Opioid prescription (active prescription, mean dose in morphine milligram equivalents [MME]) from electronic medical charts, and heroin and opioid analgesics not prescribed to the patient (any use, use frequency) from a retrospective interview. KEY RESULTS The interventions were associated with a reduction in mean prescribed opioid dose in the first three post-policy years (year 1 conditional difference-in-differences estimate: -52.0 MME [95% confidence interval: -109.9, -10.6]; year 2: -106.2 MME [-195.0, -34.6]; year 3: -98.6 MME [-198.7, -23.9]; year 4: -72.6 MME [-160.4, 3.6]). Estimates suggest a possible positive association between the interventions and non-prescribed opioid analgesic use (year 3: 5.2 absolute percentage points [-0.1, 11.2]) and use frequency (year 3: 0.21 ordinal frequency scale points [0.00, 0.47]) in the third post-policy year. CONCLUSIONS Clinic-level opioid prescribing policies were associated with reduced dose, although the control clinic achieved similar reductions by the fourth post-policy year, and the policies may have been associated with increased non-prescribed opioid analgesic use. Clinicians should balance the urgency to reduce opioid prescribing with potential harms from rapid change.
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Affiliation(s)
- Christopher L Rowe
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, CA, USA.
- Center on Substance Use and Health, San Francisco Department of Public Health, San Francisco, USA.
| | - Kellene Eagen
- Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, USA
| | - Jennifer Ahern
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Mark Faul
- Health Systems and Trauma Systems Branch, Centers for Disease Control and Prevention, Atlanta, USA
| | - Alan Hubbard
- Division of Biostatistics, School of Public Health, University of California, Berkeley, Berkeley, USA
| | - Phillip Coffin
- Center on Substance Use and Health, San Francisco Department of Public Health, San Francisco, USA
- Division of HIV, Infectious Disease & Global Medicine, University of California San Francisco, San Francisco, USA
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5
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Factors Associated with Pain Treatment Satisfaction Among Patients with Chronic Non-Cancer Pain and Substance Use. J Am Board Fam Med 2021; 34:1082-1095. [PMID: 34772764 PMCID: PMC8813175 DOI: 10.3122/jabfm.2021.06.210214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/09/2021] [Accepted: 07/26/2021] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION A better understanding of pain treatment satisfaction in patients with chronic noncancer pain (CNCP) and substance use is needed, especially as opioid prescribing policies are changing. We sought to identify factors associated with pain treatment satisfaction in individuals with CNCP on recent opioid therapy and prior or active substance use. METHODS An exploratory cross-sectional analysis using baseline data from a cohort study of 300 adults with CNCP receiving >20 morphine milligram equivalents of opioids for ≥3 of the preceding 12 months and prior or active substance use. Participants completed interviews, clinical assessments, urine drug screening, and medical chart review. RESULTS Participants were predominantly middle-aged (mean age 57.5 years), Black (44%), and cisgender men (60%). One-third (33%) had high, 28% moderate, and 39% low pain treatment satisfaction. Post-traumatic stress disorder (PTSD), tobacco use, past-year opioid discontinuation, and higher average pain scores were associated with lower satisfaction. HIV and prescription cannabis use were associated with higher satisfaction. CONCLUSIONS The relationship between PTSD and tobacco use with lower satisfaction should be explored to augment pain outcomes. Higher satisfaction among individuals with HIV and prescription cannabis use presents potential research areas to guide CNCP management and reduce reliance on opioid therapies.
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Abstract
Opioid treatment agreements are written agreements between physicians and patients enumerating the risks associated with opioid medications along with the requirements that patients must meet to receive these medications on an ongoing basis. The choice to use such agreements goes beyond the standard informed consent process and has a distinctive symbolic significance. Specifically, it suggests that physicians regard it as important to hold their patients accountable for adhering to various protocols regarding the use of their opioid medications. After laying out a taxonomy of accountability relations between physicians and patients, I argue that opioid treatment agreements are justifiable for physicians to use in their provision of care only if they improve patient or public health outcomes, which has yet to be demonstrated.
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A National Survey on Patient Provider Agreements When Prescribing Opioids for Chronic Pain. J Gen Intern Med 2021; 36:600-605. [PMID: 33420560 PMCID: PMC7947101 DOI: 10.1007/s11606-020-06364-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 11/25/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Many national guidelines recommend the use of patient provider agreements (PPAs) when prescribing opioids for chronic pain. There are no standards for PPA content, readability, or administration processes. OBJECTIVE Conduct a national survey of providers who use PPAs to describe the process of administering them, assess views on their utility, and obtain PPAs to evaluate thematic content and readability. DESIGN Cross-sectional electronic survey and request for PPAs. PARTICIPANTS Registrants for the Safer/Competent Opioid Prescribing Education (SCOPE of Pain) Program between March 2013 and June 2017. MAIN MEASURES Respondents' reports on how PPAs are administered and views on their usefulness. A sample of PPAs assessed for themes and readability. KEY RESULTS Using a convenience sample of 62,530 SCOPE of Pain registrants, we obtained a cohort of 430 individuals from 43 states who use PPAs. The majority of respondents worked in primary care (64%) and pain (18%) specialties. Reviewing PPAs with patients was primarily done by prescribers (80%), and the average perceived time to administer PPAs was 13 min. Although 66% of respondents thought PPAs were "often" or "always" worth the effort, only 28% considered them "often" or "always" effective in reducing opioid misuse. The PPA reading burden surpassed recommended patient education standards, with only 2.5% at or below fifth-grade reading level. PPAs focused more on rules and consequences of patients' non-compliance than on a shared treatment plan. CONCLUSIONS Most respondents perceive patient provider agreements (PPAs) as time-consuming and minimally effective in reducing opioid misuse yet still view them as valuable. PPAs are written far above recommended reading levels and serve primarily to convey consequences of non-compliance. Because PPAs are recommended by national safer opioid prescribing guidelines as a risk mitigation strategy, it would be beneficial to develop a standard PPA and study its effectiveness.
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Thakarar K, Kulkarni A, Lodi S, Walley AY, Lira MC, Forman LS, Colasanti JA, del Rio C, Samet JH. Emergency Department Utilization Among People Living With HIV on Chronic Opioid Therapy. J Int Assoc Provid AIDS Care 2021; 20:23259582211010952. [PMID: 33888001 PMCID: PMC8072919 DOI: 10.1177/23259582211010952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 03/17/2021] [Accepted: 03/23/2021] [Indexed: 11/17/2022] Open
Abstract
Chronic pain among people with HIV (PWH) is a driving factor of emergency department (ED) utilization, and it is often treated with chronic opioid therapy (COT). We conducted a cross-sectional analysis of a prospective observational cohort of PWH on COT at 2 hospital-based clinics to determine whether COT-specific factors are associated with ED utilization among PWH. The primary outcome was an ED visit within 12 months after study enrollment. We used stepwise logistic regression including age, gender, opioid duration, hepatitis C, depression, prior ED visits, and Charlson comorbidity index. Of 153 study participants, n = 69 (45%) had an ED visit; 25% of ED visits were pain-related. High dose opioids, benzodiazepine co-prescribing, and lack of opioid treatment agreements were not associated with ED utilization, but prior ED visits (p = 0.002), depression (p = 0.001) and higher Charlson comorbidity score (p = 0.003) were associated with ED utilization. COT-specific factors were not associated with increased ED utilization among PWH.
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Affiliation(s)
- Kinna Thakarar
- Maine Medical Center Research Institute, Boston, MA, USA
- Tufts University School of Medicine, Boston, MA, USA
| | - Amoli Kulkarni
- Boston Medical Center / Boston University School of Medicine, Boston, MA, USA
| | - Sara Lodi
- Boston University School of Public Health, Boston, MA, USA
| | - Alexander Y. Walley
- Boston Medical Center / Boston University School of Medicine, Boston, MA, USA
| | - Marlene C. Lira
- Boston Medical Center / Boston University School of Medicine, Boston, MA, USA
| | - Leah S. Forman
- Boston University School of Public Health, Boston, MA, USA
| | | | - Carlos del Rio
- Emory University, Atlanta, GA, USA
- Grady Health System, Atlanta, GA, USA
| | - Jeffrey H. Samet
- Boston Medical Center / Boston University School of Medicine, Boston, MA, USA
- Boston University School of Public Health, Boston, MA, USA
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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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Curseen KA, Taj J, Grant Q. Pain Management in Patients with Serious Illness. Med Clin North Am 2020; 104:415-438. [PMID: 32312407 DOI: 10.1016/j.mcna.2020.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Managing pain in patients with serious illness can be complex. However, pain is often a prominent symptom in patients with malignant and nonmalignant serious illness and providers have to be adept at balancing effective pain management and safety. Clinicians should start with a standard pain assessment that lays important groundwork for developing a tailored multimodal approach to pain management. It is important to identify physical causes of pain and also existential causes. Opioids are not always appropriate but are still an important tool for managing pain. Basic opioid management and safe practices are essential when managing this population.
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Affiliation(s)
- Kimberly Angelia Curseen
- Internal Medicine, Division of Palliative Medicine, Family and Preventive Medicine Emory School of Medicine, Emory Palliative Care Center, 1821 Clifton Road, Northeast, Suite 1017, Atlanta, GA 30329, USA.
| | - Jabeen Taj
- Hospice and Palliative Medicine, Cardiac Palliative Care, Medicine, Division of Palliative Medicine, Family and Preventive Medicine Emory School of Medicine, Emory University Hospital, 1821 Clifton Road, Northeast, Suite 1017, Atlanta, GA 30329, USA
| | - Quintesia Grant
- Palliative and Supportive Care, Grady Memorial Hospital, Harbor Grace Hospice, Atlanta, GA, USA; Medicine, Division of Palliative Medicine, Family and Preventive Medicine Emory School of Medicine, 1821 Clifton Road, Northeast, Suite 1017, Atlanta, GA 30329, USA
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McAuliffe Staehler TM, Palombi LC. Beneficial opioid management strategies: A review of the evidence for the use of opioid treatment agreements. Subst Abus 2020; 41:208-215. [PMID: 31900073 DOI: 10.1080/08897077.2019.1692122] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background: The Centers for Disease Control and Prevention (CDC) and American Society of Interventional Pain Physicians (ASIPP) guidelines recommend opioid treatment agreements to reduce the misuse and abuse of opioids, but evidence of their effectiveness has not been well-established. This controversy has led to their varied use in primary care settings. The purpose of this review is to collect studies that assess the value of opioid treatment agreements and associated opioid misuse outcomes in patients with chronic non-cancer pain. Methods: This study used a modified preferred reporting items for systematic reviews and meta-analyses (PRISMA) approach which is organized by five distinct elements or steps: beginning with a clearly formulated question, using the question to develop clear inclusion criteria to identify relevant studies, using an approach to appraise the studies or a subset of the studies, summarizing the evidence using an explicit methodology, and interpreting the findings of the review. Results: Of 283 articles identified, six eligible studies were evaluated and assessed for quality. The study design, setting, and participants varied across the studies evaluated, and the methods of measuring primary and secondary outcomes were also diverse across all studies. One study was a randomized clinical trial (RCT), four studies were retrospective cohort studies (RCS), and one study was a prospective cohort study (PCS). The design, methods, and indication for misuse of these studies contributed to quality scores of very low for one study, low for four studies, and moderate for one study. Conclusion: This systematic review shows weak evidence to support the effectiveness of patient prescriber agreements in the reduction and mitigation of opioid misuse and abuse. Further research is needed to determine if these agreements are beneficial as an opioid management strategy.
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Affiliation(s)
- Tuesday M McAuliffe Staehler
- Department of Pharmacy Practice and Pharmaceutical Science, University of Minnesota, College of Pharmacy, Duluth, Minnesota, USA
| | - Laura C Palombi
- Department of Pharmacy Practice and Pharmaceutical Science, University of Minnesota, College of Pharmacy, Duluth, Minnesota, USA
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12
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Guidelines for Monitoring Patients Using Opioid Therapy. Clin Obstet Gynecol 2019; 62:59-66. [PMID: 30601143 DOI: 10.1097/grf.0000000000000424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Opioid-related morbidity and mortality have increased to epidemic proportions over the past 20 years. Gynecologists play an integral role in addressing this epidemic through management of patients with pain, specifically through prescribing and monitoring practices. Practical recommendations are provided for clinicians caring for noncancer patients on chronic opioid therapy. Recommendations are largely based on national consensus guidelines with a focus on frequency and content of follow-up, identification of high risk behaviors, and reassessment of goals of treatment.
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Philpot LM, Ramar P, Elrashidi MY, Sinclair TA, Ebbert JO. A Before and After Analysis of Health Care Utilization by Patients Enrolled in Opioid Controlled Substance Agreements for Chronic Noncancer Pain. Mayo Clin Proc 2018; 93:1431-1439. [PMID: 30244811 DOI: 10.1016/j.mayocp.2018.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 05/10/2018] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To evaluate the impact of opioid controlled substance agreements (CSAs) enrollment on health care utilization. PATIENTS AND METHODS We retrospectively evaluated health care utilization changes among 772 patients receiving long-term opioid therapy for chronic noncancer pain enrolled in a CSA between July 1, 2015, and December 31, 2015. We ascertained patient characteristics and utilization 12 months before and after CSA enrollment. Decreased utilization was defined as a decrease of 1 or more hospitalizations or emergency department visits and 3 or more outpatient primary and specialty care visits. Multivariate modeling assessed demographic characteristics associated with utilization changes. RESULTS The 772 patients enrolled in an opioid CSA during the study period had a mean ± SD age of 63.5±14.9 years and were predominantly female, white, and married. The CSA enrollment was associated with decreased outpatient primary care visits (odds ratio [OR], 0.16; 95% CI, 0.14-0.19) and increased diagnostic radiology services (OR, 1.22; 95% CI, 1.02-1.47). After CSA enrollment, patients with greater comorbidity (Charlson Comorbidity Index score >3) were more likely to have reduced hospitalizations (adjusted OR, 2.8; 95% CI, 1.3-6.0; P=.008), reduced outpatient primary care visits (adjusted OR, 2.0; 95% CI, 1.2-3.2; P=.005), and reduced specialty care visits (adjusted OR, 2.0; 95% CI, 1.2-3.3; P=.006). CONCLUSION For patients receiving long-term opioid therapy for chronic noncancer pain, CSA enrollment is associated with reductions in primary care visits and increased radiologic service utilization. Patients with greater comorbidity were more likely to have reductions in hospitalizations, outpatient primary care visits, and outpatient specialty clinic visits after CSA enrollment. The observational nature of the study does not allow the conclusion that CSA implementation is the primary reason for these observed changes.
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Affiliation(s)
- Lindsey M Philpot
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Priya Ramar
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Muhamad Y Elrashidi
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic College of Medicine and Science, Rochester, MN; Division of Primary Care Internal Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Tiffany A Sinclair
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Jon O Ebbert
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic College of Medicine and Science, Rochester, MN; Division of Primary Care Internal Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN.
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Philpot LM, Ramar P, Elrashidi MY, Mwangi R, North F, Ebbert JO. Controlled Substance Agreements for Opioids in a Primary Care Practice. J Pharm Policy Pract 2017; 10:29. [PMID: 28919978 PMCID: PMC5596855 DOI: 10.1186/s40545-017-0119-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/06/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Opioids are widely prescribed for chronic non cancer pain (CNCP). Controlled substance agreements (CSAs) are intended to increase adherence and mitigate risk with opioid prescribing. We evaluated the demographic characteristics of and opioid dosing for patients with CNCP enrolled in CSAs in a primary care practice. METHODS We conducted a retrospective cohort study of 1066 patients enrolled in CSAs between May 9, 2013 and August 15, 2016 for CNCP in a Midwest primary care practice. RESULTS Patients were prescribed an average of 40.8 (SD ± 57.0) morphine milligram equivalents per day (MME/day), and 21.5% of patients were receiving ≥50 MME/day and 9.7% were receiving ≥90 MME/day. Patients who were younger in age (≥ 65 vs. < 65 years, P < 0.0001), male gender (P = 0.0001), and used tobacco (P = 0.0002) received significantly higher MME/day. Patients with more co-morbidities (Charlson Comorbidity Index, CCI) received higher MME/day (CCI > 3 vs. CCI ≤ 3, P = 0.03), and reported higher average pain (CCI > 3 mean 5.8 [SD ± 2.1] vs. CCI ≤ 3 mean 5.3 [SD ± 2.0], P = 0.0011). Patients on an identified tapering plan (6.9%) had higher MME/day than patients not on a tapering plan (P = 0.0002). CONCLUSIONS CSAs present an opportunity to engage patients taking higher doses of opioids in discussions about opioid safety, appropriate dosing and tapering. CSAs could be leveraged to develop a population health management approach to the care of patients with CNCP.
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Affiliation(s)
- Lindsey M Philpot
- Robert D. and Patricia E. Kern Mayo Clinic Center for the Science of Health Care Delivery, Mayo Clinic College of Medicine, 200 1st Street SW, Rochester, MN 55905 USA
| | - Priya Ramar
- Robert D. and Patricia E. Kern Mayo Clinic Center for the Science of Health Care Delivery, Mayo Clinic College of Medicine, 200 1st Street SW, Rochester, MN 55905 USA
| | - Muhamad Y Elrashidi
- Robert D. and Patricia E. Kern Mayo Clinic Center for the Science of Health Care Delivery, Mayo Clinic College of Medicine, 200 1st Street SW, Rochester, MN 55905 USA.,Primary Care Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN USA
| | - Raphael Mwangi
- Robert D. and Patricia E. Kern Mayo Clinic Center for the Science of Health Care Delivery, Mayo Clinic College of Medicine, 200 1st Street SW, Rochester, MN 55905 USA
| | - Frederick North
- Primary Care Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN USA
| | - Jon O Ebbert
- Robert D. and Patricia E. Kern Mayo Clinic Center for the Science of Health Care Delivery, Mayo Clinic College of Medicine, 200 1st Street SW, Rochester, MN 55905 USA.,Primary Care Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN USA
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Efficacy of the Opioid Compliance Checklist to Monitor Chronic Pain Patients Receiving Opioid Therapy in Primary Care. THE JOURNAL OF PAIN 2016; 17:414-23. [DOI: 10.1016/j.jpain.2015.12.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 12/03/2015] [Accepted: 12/08/2015] [Indexed: 12/31/2022]
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Using health information technology to improve adherence to opioid prescribing guidelines in primary care. Clin J Pain 2016; 31:573-9. [PMID: 25411860 PMCID: PMC4422375 DOI: 10.1097/ajp.0000000000000177] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objective: To evaluate the impact of a clinical dashboard for opioid analgesic management on opioid prescribing and adherence to opioid practice guidelines in primary care. Methods: A pre/postimplementation evaluation using electronic health record (EHR) data from patients receiving chronic opioid therapy (COT) between April 1, 2011 and March 31, 2013. Measures include annual proportions of COT patients who received urine drug testing, signed an opioid treatment agreement, had a documented assessment of pain-related functional status, and had at least 1 visit with a behavioral health provider. Results: Adherence to several opioid prescribing guidelines improved in the postimplementation year compared with the preimplementation year: (1) the proportions of COT patients with a signed opioid treatment agreement and urine drug testing increased from 49% to 63% and 66% to 86%, respectively. The proportion of COT patients with a documented assessment of functional status increased from 33% to 46% and those with a behavioral health visit increased from 24% to 28%. However, there was a small decline in the proportion of patients prescribed COT from 3.4% to 3.1%. Discussion: Implementation of an opioid dashboard led to increased adherence to certain opioid practice guidelines and a decline in COT. This may be attributable to more efficient team-based pain management facilitated by the dashboard and increased transparency of opioid prescription practices. Health Information Technology solutions such as clinical dashboards can increase adherence to practice guidelines.
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Wilsey B, Atkinson JH, Marcotte TD, Grant I. The Medicinal Cannabis Treatment Agreement: Providing Information to Chronic Pain Patients Through a Written Document. Clin J Pain 2015; 31:1087-96. [PMID: 25370134 PMCID: PMC4417655 DOI: 10.1097/ajp.0000000000000145] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
AIM Pain practitioners would seem to have an obligation to understand and inform their patients on key issues of the evidence base on cannabinoid therapeutics. One way to fulfill this obligation might be to borrow from concepts developed in the prescription of opioids: the use of a written agreement to describe and minimize risks. Regrettably, the widespread adoption of opioids was undertaken while harmful effects were minimized; obviously, no one wants to repeat this misstep. OBJECTIVE This article describes a method of educating patients in a manner analogous to other treatment agreements. BACKGROUND Surveys have demonstrated that pain is the most common indication for medical use of cannabis. As more individuals gain access to this botanical product through state ballot initiatives and legislative mandate, the pain specialist is likely to be confronted by patients either seeking such treatment where permitted, or otherwise inquiring about its potential benefits and harms, and alternative pharmaceuticals containing cannabinoids. METHODS PubMed searches were conducted using the following keywords: cannabis guidelines, harmful effects of cannabis, medical marijuana, medicinal cannabis, opioid cannabis interaction, cannabis dependence and cannabis abuse RESULTS : The authors selected individual tenets a medicinal cannabis patient would be asked to review and acknowledge via signature. CONCLUSIONS Undoubtedly, the knowledge base concerning risks will be an iterative process as we learn more about the long-term use of medicinal cannabis. But we should start the process now so that patients may be instructed about our current conception of what the use of medicinal cannabis entails.
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Affiliation(s)
- Barth Wilsey
- VA Northern California Health Care System
- Department of Physical Medicine and Rehabilitation, University of California, Davis, Sacramento, CA
| | - J. Hampton Atkinson
- VA San Diego Health Care System
- Department of Psychiatry, University of California, San Diego, La Jolla
| | | | - Igor Grant
- Department of Psychiatry, University of California, San Diego, La Jolla
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Jurcik DC, Sundaram AH, Jamison RN. Chronic pain, negative affect, and prescription opioid abuse. Curr Opin Psychol 2015. [DOI: 10.1016/j.copsyc.2015.03.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Jamison RN, Scanlan E, Matthews ML, Jurcik DC, Ross EL. Attitudes of Primary Care Practitioners in Managing Chronic Pain Patients Prescribed Opioids for Pain: A Prospective Longitudinal Controlled Trial. PAIN MEDICINE 2015; 17:99-113. [DOI: 10.1111/pme.12871] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Robert N. Jamison
- Psychiatry
- Departments of Anesthesiology, Perioperative and Pain Medicine; Pain Management Center, Brigham and Women's Hospital; Chestnut Hill Massachusett
| | - Elizabeth Scanlan
- Departments of Anesthesiology, Perioperative and Pain Medicine; Pain Management Center, Brigham and Women's Hospital; Chestnut Hill Massachusett
| | - Michele L. Matthews
- Departments of Anesthesiology, Perioperative and Pain Medicine; Pain Management Center, Brigham and Women's Hospital; Chestnut Hill Massachusett
| | - Dylan C. Jurcik
- Departments of Anesthesiology, Perioperative and Pain Medicine; Pain Management Center, Brigham and Women's Hospital; Chestnut Hill Massachusett
| | - Edgar L. Ross
- Departments of Anesthesiology, Perioperative and Pain Medicine; Pain Management Center, Brigham and Women's Hospital; Chestnut Hill Massachusett
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Challenges in managing acute on chronic pain in a pregnant woman at high risk for opioid use disorder in the general hospital setting. Harv Rev Psychiatry 2015; 23:157-66. [PMID: 25747928 DOI: 10.1097/hrp.0000000000000080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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McGee S, Silverman RD. Treatment Agreements, Informed Consent, and the Role of State Medical Boards in Opioid Prescribing. PAIN MEDICINE 2015; 16:25-9. [DOI: 10.1111/pme.12580] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Jamison RN, Martel MO, Edwards RR, Qian J, Sheehan KA, Ross EL. Validation of a brief Opioid Compliance Checklist for patients with chronic pain. THE JOURNAL OF PAIN 2014; 15:1092-1101. [PMID: 25092233 PMCID: PMC4253010 DOI: 10.1016/j.jpain.2014.07.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 07/05/2014] [Accepted: 07/21/2014] [Indexed: 01/22/2023]
Abstract
UNLABELLED There has been a need for a brief assessment tool to determine compliance with use of prescribed opioids for pain. The purpose of this study was to develop and begin the validation of a brief and simple compliance checklist (Opioid Compliance Checklist [OCC]) for chronic pain patients prescribed long-term opioid therapy. A review of the literature of opioid therapy agreements led to a 12-item OCC that was repeatedly administered to 157 patients who were taking opioids for chronic pain and followed for 6 months. Validation of the OCC was conducted by identifying those patients exhibiting aberrant drug-related behavior as determined by any of the following: positive urine toxicology screen, a positive score on the Prescription Drug Use Questionnaire interview or Current Opioid Misuse Measure, and/or ratings by staff on the Addiction Behavior Checklist. Of the original 12 items, 5 OCC items appeared to best predict subsequent aberrant behaviors based on multivariate logistic regression analyses (cross-validated area under the receiver operating characteristic curve = .67). Although further testing is needed, these results suggest that the OCC is an easy-to-use, promising measure in monitoring opioid adherence among persons with chronic pain. PERSPECTIVE This study presents validation of a brief 5-item compliance checklist for use with chronic pain patients prescribed long-term opioid therapy. This measure asks patients about aberrant drug-related behavior over the past month, and any positive response indicates problems with adherence with opioids. Further cross-validation testing is needed.
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Affiliation(s)
- Robert N Jamison
- Pain Management Center, Departments of Anesthesia and Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Marc O Martel
- Pain Management Center, Departments of Anesthesia and Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert R Edwards
- Pain Management Center, Departments of Anesthesia and Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jing Qian
- Division of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts, Amherst, Massachusetts
| | - Kerry Anne Sheehan
- Pain Management Center, Departments of Anesthesia and Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Edgar L Ross
- Pain Management Center, Departments of Anesthesia and Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Starrels JL, Wu B, Peyser D, Fox AD, Batchelder A, Barg FK, Arnsten JH, Cunningham CO. It made my life a little easier: primary care providers' beliefs and attitudes about using opioid treatment agreements. J Opioid Manag 2014; 10:95-102. [PMID: 24715664 PMCID: PMC3983567 DOI: 10.5055/jom.2014.0198] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Revised: 10/28/2013] [Accepted: 01/06/2014] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To understand primary care providers (PCPs)' experiences, beliefs, and attitudes about using opioid treatment agreements (OTAs) for patients with chronic pain. DESIGN Qualitative research study. PARTICIPANTS Twenty-eight internists and family medicine physicians at two health centers. APPROACH Semistructured telephone interviews, informed by the Integrative Model of Behavioral Prediction. Themes were analyzed using a Grounded Theory approach, and similarities and differences in themes were examined among OTA adopters, nonadopters, and selective adopters. RESULTS Participants were 64 percent female and 68 percent white, and practiced for a mean of 9.5 years. Adoption of OTAs varied: seven were adopters, five were nonadopters, and 16 were selective adopters. OTA adoption reflected PCPs' beliefs and attitudes in the following three thematic categories: 1) perceived effect of OTA use on the therapeutic alliance, 2) beliefs about the utility of OTAs for patients or providers, and 3) perception of patients' risk for opioid misuse. PCPs commonly believed that OTAs were useful for physician self-protection, but few believed that they prevent opioid misuse. Selective adopters expressed ambivalent beliefs and made decisions about OTA use for individual patients based on both observed data and a subjective sense of each patient's risk for misuse. CONCLUSIONS Substantial variability in PCP use of OTAs reflects differences in PCP beliefs and attitudes. Research to understand the impact of OTA use on providers, patients, and the therapeutic alliance is urgently needed to guide best practices.
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Affiliation(s)
- Joanna L. Starrels
- Assistant Professor of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Bryan Wu
- Candidate, MD/MPH Program at Oregon Health & Sciences University, Portland, OR, USA
| | - Deena Peyser
- Candidate, Clinical Psychology PhD program, Rutgers University, New Brunswick, NJ
| | - Aaron D. Fox
- Assistant Professor of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Abigail Batchelder
- Predoctoral Fellow in the Clinical Psychology Training Program at University of California, San Francisco, USA
| | - Frances K. Barg
- Associate Professor of Family Medicine and Community Health at the Hospital of the University of Pennsylvania, and Associate Professor of Anthropology, University of Pennsylvania, Philadelphia, PA, USA
| | - Julia H. Arnsten
- Professor of Medicine and Chief, Division of General Internal Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
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Sekhon R, Aminjavahery N, Davis CN, Roswarski MJ, Robinette C. Compliance with Opioid Treatment Guidelines for Chronic Non-Cancer Pain (CNCP) in Primary Care at a Veterans Affairs Medical Center (VAMC). PAIN MEDICINE 2013; 14:1548-56. [DOI: 10.1111/pme.12164] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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