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Schmidt-Hansen M, Bennett MI, Arnold S, Bromham N, Hilgart JS, Page AJ, Chi Y. Oxycodone for cancer-related pain. Cochrane Database Syst Rev 2022; 6:CD003870. [PMID: 35679121 PMCID: PMC9180760 DOI: 10.1002/14651858.cd003870.pub7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Many people with cancer experience moderate to severe pain that requires treatment with strong opioids, such as oxycodone and morphine. Strong opioids are, however, not effective for pain in all people, neither are they well tolerated by all people. The aim of this review was to assess whether oxycodone is associated with better pain relief and tolerability than other analgesic options for adults with cancer pain. This is an updated Cochrane review previously published in 2017. OBJECTIVES To assess the effectiveness and tolerability of oxycodone by any route of administration for pain in adults with cancer. SEARCH METHODS For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE and MEDLINE In-Process (Ovid), Embase (Ovid), Science Citation Index, Conference Proceedings Citation Index - Science (ISI Web of Science), BIOSIS (ISI), and PsycINFO (Ovid) to November 2021. We also searched four trial registries, checked the bibliographic references of relevant studies, and contacted the authors of the included studies. We applied no language, date, or publication status restrictions. SELECTION CRITERIA We included randomised controlled trials (parallel-group or cross-over) comparing oxycodone (any formulation or route of administration) with placebo or an active drug (including oxycodone) for cancer background pain in adults by examining pain intensity/relief, adverse events, quality of life, and participant preference. DATA COLLECTION AND ANALYSIS Two review authors independently sifted the search, extracted data and assessed the included studies using standard Cochrane methodology. We meta-analysed pain intensity data using the generic inverse variance method, and pain relief and adverse events using the Mantel-Haenszel method, or summarised these data narratively along with the quality of life and participant preference data. We assessed the overall certainty of the evidence using GRADE. MAIN RESULTS For this update, we identified 19 new studies (1836 participants) for inclusion. In total, we included 42 studies which enrolled/randomised 4485 participants, with 3945 of these analysed for efficacy and 4176 for safety. The studies examined a number of different drug comparisons. Controlled-release (CR; typically taken every 12 hours) oxycodone versus immediate-release (IR; taken every 4-6 hours) oxycodone Pooled analysis of three of the four studies comparing CR oxycodone to IR oxycodone suggest that there is little to no difference between CR and IR oxycodone in pain intensity (standardised mean difference (SMD) 0.12, 95% confidence interval (CI) -0.1 to 0.34; n = 319; very low-certainty evidence). The evidence is very uncertain about the effect on adverse events, including constipation (RR 0.71, 95% CI 0.45 to 1.13), drowsiness/somnolence (RR 1.03, 95% CI 0.69 to 1.54), nausea (RR 0.85, 95% CI 0.56 to 1.28), and vomiting (RR 0.66, 95% CI 0.38 to 1.15) (very low-certainty evidence). There were no data available for quality of life or participant preference, however, three studies suggested that treatment acceptability may be similar between groups (low-certainty evidence). CR oxycodone versus CR morphine The majority of the 24 studies comparing CR oxycodone to CR morphine reported either pain intensity (continuous variable), pain relief (dichotomous variable), or both. Pooled analysis indicated that pain intensity may be lower (better) after treatment with CR morphine than CR oxycodone (SMD 0.14, 95% CI 0.01 to 0.27; n = 882 in 7 studies; low-certainty evidence). This SMD is equivalent to a difference of 0.27 points on the Brief Pain Inventory scale (0-10 numerical rating scale), which is not clinically significant. Pooled analyses also suggested that there may be little to no difference in the proportion of participants achieving complete or significant pain relief (RR 1.02, 95% CI 0.95 to 1.10; n = 1249 in 13 studies; low-certainty evidence). The RR for constipation (RR 0.75, 95% CI 0.66 to 0.86) may be lower after treatment with CR oxycodone than after CR morphine. Pooled analyses showed that, for most of the adverse events, the CIs were wide, including no effect as well as potential benefit and harm: drowsiness/somnolence (RR 0.88, 95% CI 0.74 to 1.05), nausea (RR 0.93, 95% CI 0.77 to 1.12), and vomiting (RR 0.81, 95% CI 0.63 to 1.04) (low or very low-certainty evidence). No data were available for quality of life. The evidence is very uncertain about the treatment effects on treatment acceptability and participant preference. Other comparisons The remaining studies either compared oxycodone in various formulations or compared oxycodone to different alternative opioids. None found any clear superiority or inferiority of oxycodone for cancer pain, neither as an analgesic agent nor in terms of adverse event rates and treatment acceptability. The certainty of this evidence base was limited by the high or unclear risk of bias of the studies and by imprecision due to low or very low event rates or participant numbers for many outcomes. AUTHORS' CONCLUSIONS The conclusions have not changed since the previous version of this review (in 2017). We found low-certainty evidence that there may be little to no difference in pain intensity, pain relief and adverse events between oxycodone and other strong opioids including morphine, commonly considered the gold standard strong opioid. Although we identified a benefit for pain relief in favour of CR morphine over CR oxycodone, this was not clinically significant and did not persist following sensitivity analysis and so we do not consider this important. However, we found that constipation and hallucinations occurred less often with CR oxycodone than with CR morphine; but the certainty of this evidence was either very low or the finding did not persist following sensitivity analysis, so these findings should be treated with utmost caution. Our conclusions are consistent with other reviews and suggest that, while the reliability of the evidence base is low, given the absence of important differences within this analysis, it seems unlikely that larger head-to-head studies of oxycodone versus morphine are justified, although well-designed trials comparing oxycodone to other strong analgesics may well be useful. For clinical purposes, oxycodone or morphine can be used as first-line oral opioids for relief of cancer pain in adults.
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Affiliation(s)
- Mia Schmidt-Hansen
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, London, UK
| | | | | | - Nathan Bromham
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Jennifer S Hilgart
- Scientific Resource Center, VA Portland Research Foundation, Portland, Oregon, USA
| | - Andrew J Page
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Yuan Chi
- Yealth Network, Beijing Yealth Technology Co., Ltd, Beijing, China
- Cochrane Campbell Global Ageing Partnership, UK
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Chen C, Lo-Ciganic WH, Winterstein AG, Tighe P, Wei YJJ. Concurrent Use of Prescription Opioids and Gabapentinoids in Older Adults. Am J Prev Med 2022; 62:519-528. [PMID: 34802816 PMCID: PMC9426287 DOI: 10.1016/j.amepre.2021.08.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Concurrent use of prescription opioids with gabapentinoids may pose risks of serious drug interactions. Yet, little is known about the trends in and patient characteristics associated with concurrent opioid-gabapentinoid use among older Medicare opioid users with chronic noncancer pain. METHODS A cross-sectional study was conducted among Medicare older beneficiaries (aged ≥65 years) with chronic noncancer pain who filled ≥1 opioid prescription within 3 months after a randomly selected chronic noncancer pain diagnosis (index date) in a calendar year between 2011 and 2018. Patient characteristics were measured in the 6-month baseline before the index date, and concurrent opioid-gabapentinoid use for ≥1 day was measured in the 3-month follow-up after the index date. Multivariable modified Poisson regression hwas used to assess the trends and characteristics of concurrent opioid-gabapentinoid use. Analyses were conducted from January to June 2021. RESULTS Among 464,721 eligible older beneficiaries with chronic noncancer pain and prescription opioids, the prevalence of concurrent opioid-gabapentinoid use increased from 17.0% in 2011 to 23.5% in 2018 (adjusted prevalence ratio=1.48, 95% CI=1.45, 1.53). Concurrent users versus opioid-only users tended to be non-Black, low-income subsidy recipients, and Southern residents. The clinical factors associated with concurrent opioid-gabapentinoid use included having a diagnosis of neuropathic pain, polypharmacy, and risk factors for opioid-related adverse events. CONCLUSIONS Concurrent opioid-gabapentinoid use among older Medicare beneficiaries with chronic noncancer pain and prescription opioids has increased significantly between 2011 and 2018. Future studies are warranted to investigate the impact of concurrent use on outcomes in older patients. Interventions that reduce inappropriate concurrent use may target older patients with identified characteristics.
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Affiliation(s)
- Cheng Chen
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida; Department of Epidemiology, College of Public Health and Health Professions & College of Medicine, University of Florida, Gainesville, Florida
| | - Patrick Tighe
- Department of Anesthesiology, College of Medicine, University of Florida, Gainesville, Florida
| | - Yu-Jung J Wei
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida.
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Diagnostic and Predictive Capacity of the Spanish Versions of the Opioid Risk Tool and the Screener and Opioid Assessment for Patients with Pain-Revised: A Preliminary Investigation in a Sample of People with Noncancer Chronic Pain. Pain Ther 2022; 11:493-510. [PMID: 35128624 PMCID: PMC9098780 DOI: 10.1007/s40122-022-00356-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/17/2022] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Accurate assessment of the risk of opioid abuse and misuse in people with noncancer chronic pain is crucial for their prevention. This study aimed to provide preliminary evidence of the diagnostic and predictive capacity of the Spanish versions of the Opioid Risk Tool (ORT) and the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R). METHODS We used the Current Opioid Misuse Measure (COMM) as criterion measure to assess the capacity of each tool to identify patients misusing opioids at the time of the assessment. Eighteen months later, we used the COMM and the Drug Abuse Screening Test-10 (DAST-10) to assess their predictive capacity. In total, 147 people with noncancer chronic pain participated in the diagnostic study, and 42 in the predictive study. RESULTS Receiver operating curve analysis showed that the SOAPP-R had an excellent capacity to identify participants who were misusing opioids at the time of assessment (area under the curve [AUC] = 0.827). The diagnostic capacity of the ORT was close to acceptable (AUC = 0.649-0.669), whereas its predictive capacity was poor (AUC = 0.522-0.554). The predictive capacity of the SOAPP-R was close to acceptable regarding misuse (AUC = 0.672) and poor regarding abuse (AUC = 0.423). CONCLUSION In the setting of Spanish-speaking communities, clinicians should be cautious when using these instruments to make decisions on opioid administration. Further research is needed on the diagnostic and predictive capacity of the Spanish versions of both instruments.
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Jantarada C, Silva C, Guimarães-Pereira L. Prevalence of Problematic Use of Opioids in Patients with Chronic Noncancer Pain: A Systematic Review with Meta-analysis. Pain Pract 2021; 21:715-729. [PMID: 33528858 DOI: 10.1111/papr.13001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 01/05/2021] [Accepted: 01/28/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVE Opioid prescription for chronic noncancer pain is associated with problematic use. We aimed to review and summarize the evidence on the prevalence of problematic use of opioids in adults with chronic noncancer pain and investigate whether the prevalence rates were changing over time. DATABASES AND DATA TREATMENT A systematic review of the literature was undertaken following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. We systematically searched the literature in the electronic databases MEDLINE, SCOPUS, and Web of Science and studies with adult participants with chronic noncancer pain using opioids with indication of one or more of the following terms about problematic opioid use: abuse, misuse, addiction, dependence, problematic use, and aberrant behavior/use were eligible for data extraction. Meta-analysis was performed to estimate the pooled prevalence rates using a random-effects model, and subanalysis was conducted. RESULTS Our search identified a total of 784 potentially relevant studies. After a thorough evaluation, 19 papers, mostly from the United States, were included in our qualitative and quantitative synthesis. The majority of the data came from speciality pain clinics. The estimated prevalence of problematic use of opioids in adults with chronic noncancer pain was 36.3% (95% confidence interval: 27.4 to 45.2%; I2 = 99.64%). Problematic opioid use was mostly identified using the questionnaire method. Thirteen studies (68%) presented a low risk of bias. CONCLUSIONS Our study presents an alarming estimate regarding the prevalence of problematic use of opioids among patients with noncancer pain. These results deserve special attention from health care professionals and health authorities.
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Affiliation(s)
- Cláudia Jantarada
- Department of Anesthesiology, Centro Hospitalar de São João, Porto, Portugal
| | - Catarina Silva
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Luís Guimarães-Pereira
- Department of Anesthesiology, Centro Hospitalar de São João, Porto, Portugal.,Faculty of Medicine, University of Porto, Porto, Portugal
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Finkelman MD, Jamison RN, Kulich RJ, Butler SF, Smits N, Weiner SG. A Comparison of Short Forms of the Screener and Opioid Assessment for Patients With Pain – Revised (SOAPP-R). EUROPEAN JOURNAL OF PSYCHOLOGICAL ASSESSMENT 2020. [DOI: 10.1027/1015-5759/a000519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Abstract. The Screener and Opioid Assessment for Patients with Pain – Revised (SOAPP-R) is a 24-item self-report questionnaire that assesses risk of aberrant medication-related behavior among chronic pain patients. Recently, an 8-item version of the SOAPP-R that weights items differentially was proposed. However, no previous study had compared the 8-item form with other short versions of the SOAPP-R, including a static 12-item short form and computer-based versions customizing the test length to the individual respondent. Moreover, no prior research had investigated combining the 8-item short form with customized computer-based stopping rules to further enhance efficiency. The objectives of this study were to compare the 8-item version with previously recommended short forms of the SOAPP-R, and to develop and evaluate a new version of the SOAPP-R combining the 8-item version with computer-based stopping rules. Versions were compared via sensitivity, specificity, and mean test length using real-data simulation of three datasets. Although results varied across datasets, the 8-item SOAPP-R compared favorably to previously recommended forms. Combining the 8-item form with computer-based stopping rules reduced the mean test length without affecting sensitivity or specificity; thus, the combined approach is recommended. The methodology used to shorten questionnaires via computer-based testing can also be applied to other instruments.
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Affiliation(s)
- Matthew D. Finkelman
- Department of Public Health and Community Service, Tufts University School of Dental Medicine, Boston, MA, USA
| | - Robert N. Jamison
- Departments of Anesthesiology and Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Ronald J. Kulich
- Craniofacial Pain and Headache Center, Tufts University School of Dental Medicine, Boston, MA, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Niels Smits
- Department of Methods and Statistics, Research Institute of Child Development and Education, University of Amsterdam, The Netherlands
| | - Scott G. Weiner
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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6
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Chibi B, Torres NF, Mashamba-Thompson TP. Prescription drug diversion, misuse, and abuse among people living with HIV: a scoping review protocol. Syst Rev 2020; 9:29. [PMID: 32051029 PMCID: PMC7014649 DOI: 10.1186/s13643-020-1273-4] [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] [Received: 09/29/2017] [Accepted: 01/06/2020] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Prescription drugs are controlled medicines due to their potential risks of being diverted, misused, and abused. Since the introduction of antiretroviral (ARVs) drugs, HIV is currently regarded as a chronic condition. However, prescription drug diversion, misuse, and abuse might serve as one of the critical barriers for achieving optimal medication adherence among people living with HIV, thereby negatively impacting the HIV care mandate. The primary aim of this scoping review is to gather evidence on the prevalence, practices, risk factors, and motives associated with prescription drug diversion, misuse, and abuse, as well as the evidence on the association between prescription drug diversion, misuse, and abuse with antiretroviral treatment (ART) adherence. METHODS This review will be guided by Arksey and O'Malley's framework as well as recommendations by Levac et al. (Implement Sci 5:69, 2010). We will search the following databases for relevant literature meeting our eligibility criteria: PubMed, Google Scholar, EBSCOhost (Academic Search Complete, MEDLINE, and Newspaper Source), World Health Organization, Science Direct, and Open Access Theses and Dissertations. Studies published within the period of January 1996 to June 2019 are eligible. The included studies should report evidence on the prevalence, practices, risk factors, motives, or association between ART adherence and prescription drug diversion, misuse, and abuse. Thematic analysis will be applied to summarize the review findings. DISCUSSION We anticipate finding a considerable number of research studies on prescription drug diversion, misuse, and abuse among people living with HIV. Our synthesis of this evidence base is intended to serve as guidance for future research studies. The study findings will be disseminated through the traditional academic platforms, such as peer-reviewed publications and presentations at relevant local and international conferences, symposiums, and seminars. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017074076.
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Affiliation(s)
- Buyisile Chibi
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, 4001, South Africa.,HIV/AIDS, STIs and TB Research Programme, Human Sciences Research Council, Durban, South Africa.,Centre for the AIDS Programme of Research in South Africa, Doris Duke Medical Research Institute, 2nd Floor, 719 Umbilo Road, Durban, 4041, South Africa
| | - Neusa Fernanda Torres
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, 4001, South Africa. .,ISCISA-Higher Institute for Health Sciences, Maputo, Mozambique.
| | - Tivani P Mashamba-Thompson
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, 4001, South Africa.,Department of Public Health, Faculty of Health Sciences, University of Limpopo, Mankweng, South Africa
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Abstract
The US FDA has encouraged the development of abuse-deterrent formulations (ADFs) of opioid analgesics as one component in a comprehensive effort to combat prescription opioid abuse. Guidance issued by the FDA outlines three types of premarket studies for evaluating abuse deterrence: laboratory-based in vitro manipulation and extraction studies, pharmacokinetic studies and human abuse potential studies. After approval, postmarket studies are needed to evaluate the impact of an ADF product on abuse in real-world settings. This review summarizes the regulatory issues involved in the development of ADF opioids and clarifies abuse-deterrence claims in product labels, in order to assist clinicians in critically evaluating the available evidence pertaining to the abuse-deterrent features of opioid analgesics.
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Affiliation(s)
- Adam J Carinci
- Department of Anesthesiology & Perioperative Medicine, University of Rochester, Rochester, NY 14620, USA
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8
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Carpenter RW, Lane SP, Bruehl S, Trull TJ. Concurrent and lagged associations of prescription opioid use with pain and negative affect in the daily lives of chronic pain patients. J Consult Clin Psychol 2019; 87:872-886. [PMID: 31556664 DOI: 10.1037/ccp0000402] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Prescribed opioids for chronic pain management contribute significantly to the opioid crisis. There is a need to understand the real-world benefits that, despite risks, lead chronic pain patients to persist in opioid use. Negative reinforcement models of addiction posit that individuals use substances to reduce aversive states but have seldom been applied to prescribed opioids. Using ecological momentary assessment, we examined reciprocal associations between opioid use and physical pain, for which opioids are prescribed, and negative affect (NA), for which they are not. METHOD Chronic low back pain patients on long-term opioid therapy (n = 34) without significant past-year opioid misuse reported multiple times daily via smartphone over 2 weeks (nobservations = 2,285). We hypothesized that pain and NA would be positively associated with subsequent opioid use, and that use would be negatively associated with subsequent pain and NA. RESULTS Time-lagged multilevel models indicated that participants were more likely to use opioids and in larger doses following elevated pain and NA. There was also an interaction of concurrent pain and NA on opioid dose. In turn, participants reported reduced pain and NA following larger doses. Additionally, individuals at high risk for opioid misuse, compared with low risk, took larger doses following pain, but also experienced smaller subsequent pain and NA reductions. CONCLUSIONS Opioid use was bidirectionally associated with pain and NA. Findings fit negative reinforcement models associated with risk of developing opioid use disorder. Educating patients and providers about negative reinforcement may help reduce opioid use and opioid-associated risks. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Affiliation(s)
| | - Sean P Lane
- Department of Psychological Sciences, Purdue University
| | - Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center
| | - Timothy J Trull
- Department of Psychological Sciences, University of Missouri
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Lee CS, Kim D, Park SY, Lee SC, Kim YC, Moon JY. Usefulness of the Korean Version of the CAGE-Adapted to Include Drugs Combined With Clinical Predictors to Screen for Opioid-Related Aberrant Behavior. Anesth Analg 2019; 129:864-873. [PMID: 31425231 DOI: 10.1213/ane.0000000000003580] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND As national opioid consumption in South Korea has soared, well-validated screening tools for opioid use disorder (OUD) have become indispensable. The aims of our study were to evaluate OUD using the Korean version of the CAGE-Adapted to Include Drugs (CAGE-AID) and the CAGE-Opioid (an alternative version of the CAGE-AID), and to investigate clinical predictors that might be useful to screen for OUD in conjunction with the CAGE-AID/Opioid questionnaires. METHODS A single-center, prospective, observational study was performed. After linguistic validation of the Korean version of the CAGE-AID/Opioid questionnaires, we assessed OUD in patients with chronic opioid treatment. Multivariable logistic models of the CAGE-AID/Opioid questionnaires combined with relevant clinical predictors were established. Then, the receiver operating characteristic curve analysis of the multivariable CAGE-AID/Opioid models was conducted to assess diagnostic accuracy to screen for OUD. Next, we calculated predicted probability with >85% sensitivity and >50% specificity in each CAGE-AID and CAGE-Opioid model. Using the optimal value of the predicted probability, a cutoff score of the CAGE-AID/Opioid questionnaires combined with the relevant clinical factors was suggested to screen for OUD. RESULTS Among 201 participants, 51 patients showed ≥1 OUDs. In the multivariable regression model, male sex, comorbid neuropsychiatric disorder, and current heavy drinking significantly remained as clinical variables to predict OUD combined with the scores of the Korean CAGE-AID/Opioid questionnaire. The area under the curve was 0.77 (95% confidence interval, 0.71-0.83) for the CAGE-AID model and 0.78 (95% confidence interval, 0.71-0.83) for the CAGE-Opioid model. The optimal predicted probability values to screen for OUD in the CAGE-AID/Opioid models were >0.135 (sensitivity, 0.86; specificity, 0.52) and >0.142 (sensitivity, 0.86; specificity, 0.53), respectively. When we used these predictive probabilities, the cutoff score of the CAGE-AID/Opioid questionnaires ranged from 0 to 3, which was dependent on the presence of the relevant clinical variables in each model. CONCLUSIONS In this study, one fourth of the total participants with chronic opioid treatment showed OUD in the Korean population. The multivariable models of the CAGE-AID/Opioid with sex, comorbid neuropsychiatric disorder, and current heavy drinking are valid parameters to screen for OUD, with the cutoff scores of the CAGE-AID/Opioid questionnaires ranging from 0 to 3 depending on the presence of the clinical variables.
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Affiliation(s)
- Chang-Soon Lee
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital College of Medicine, Seoul, Republic of Korea
| | - Daehyun Kim
- Department of Anesthesiology and Pain Medicine, National Cancer Center, Gwangju, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Sang-Yoen Park
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital College of Medicine, Seoul, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Sang Chul Lee
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital College of Medicine, Seoul, Republic of Korea
| | - Young-Chul Kim
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital College of Medicine, Seoul, Republic of Korea
| | - Jee Youn Moon
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital College of Medicine, Seoul, Republic of Korea
- Department of Integrated Cancer Care Center, Seoul National University Cancer Hospital, Seoul, Republic of Korea
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Bruehl S, Stone AL, Palmer C, Edwards DA, Buvanendran A, Gupta R, Chont M, Kennedy M, Burns JW. Self-reported cumulative medical opioid exposure and subjective responses on first use of opioids predict analgesic and subjective responses to placebo-controlled opioid administration. Reg Anesth Pain Med 2019; 44:92-99. [PMID: 30640659 PMCID: PMC10853921 DOI: 10.1136/rapm-2018-000008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 05/11/2018] [Accepted: 05/16/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVES To expand the evidence base needed to enable personalized pain medicine, we evaluated whether self-reported cumulative exposure to medical opioids and subjective responses on first opioid use predicted responses to placebo-controlled opioid administration. METHODS In study 1, a survey assessing cumulative medical opioid exposure and subjective responses on first opioid use was created (History of Opioid Medical Exposure (HOME)) and psychometric features documented in a general sample of 307 working adults. In study 2, 49 patients with chronic low back pain completed the HOME and subsequently rated back pain intensity and subjective opioid effects four times after receiving saline placebo or intravenous morphine (four incremental doses) in two separate double-blinded laboratory sessions. Placebo-controlled morphine effects were derived for all outcomes. RESULTS Two HOME subscales were supported: cumulative opioid exposure and euphoric response, both demonstrating high test-retest reliability (Intraclass Correlation Coefficients > 0.93) and adequate internal consistency (Revelle's Omega Total = 0.73-0.77). In study 2, higher cumulative opioid exposure scores were associated with significantly greater morphine-related reductions in back pain intensity (p=0.02), but not with subjective drug effects. Higher euphoric response subscale scores were associated with significantly lower overall perceived morphine effect (p=0.003), less sedation (p=0.04), greater euphoria (p=0.03) and greater desire to take morphine again (p=0.02). DISCUSSION Self-reports of past exposure and responses to medical opioid analgesics may have utility for predicting subsequent analgesic responses and subjective effects. Further research is needed to establish the potential clinical and research utility of the HOME. TRIAL REGISTRATION NUMBER NCT02469077.
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Affiliation(s)
- Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amanda L Stone
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Pediatrics, Oregon Health & Science University, Portland, Oregon, USA
| | - Cassandra Palmer
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David A Edwards
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Rajnish Gupta
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Melissa Chont
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mary Kennedy
- Department of Behavioral Science, Rush University, Chicago, Illinois, USA
| | - John W Burns
- Department of Behavioral Science, Rush University, Chicago, Illinois, USA
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Gómez-del Valle MC, Zertuche-Maldonado T, Bruera E. Compensación química y adicción a opioides: evidencia, valoración de riesgo y manejo en pacientes con cuidados paliativos. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/j.medipa.2016.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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12
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Go SI, Song HN, Lee SJ, Bruera E, Kang JH. Craving Behavior from Opioid Addiction Controlled with Olanzapine in an Advanced Cancer Patient: A Case Report. J Palliat Med 2018; 21:1367-1370. [PMID: 30070936 DOI: 10.1089/jpm.2017.0636] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Opioid addiction, although uncommon in cancer patients, can be a significant challenge for optimal pain management in certain patients. We present a case of a 59-year-old man with advanced colon cancer whose compulsive craving for the buccal tablet of fentanyl citrate (BTFC) was improved with the use of olanzapine. He was hospitalized for abdominal pain caused by disease progression. He had visited several times at outpatient follow-up to obtain a prescription for BTFC because he took all medications before the appointed times. After admission, intravenous infusion of oxycodone and opioid rotation were applied to the patient to control his pain. However, he complained that the pain was not relieved at all and persistently asked for only BTFC 7 to 15 times per day. With the diagnosis of opioid addiction, the transdermal buprenorphine patch was applied, but was ineffective for controlling the addictive behaviors. Finally, olanzapine (10 mg/day per os), a dopamine receptor antagonist, was given to control the craving behavior because psychological dependence is mediated by the dopaminergic system. Three days later, opioid craving was reduced from five to one on a 5-point Likert scale. The pain was well controlled to numeric rating scale 1 or 2 without cravings for BTFC. Craving behavior as a result of opioid addiction may be controlled with olanzapine. Further prospective studies on this issue are warranted.
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Affiliation(s)
- Se-Il Go
- 1 Division of Hematology-Oncology, Department of Internal Medicine, Gyeongsang National University Changwon Hospital, College of Medicine, Gyeongsang National University , Changwon, South Korea
| | - Haa-Na Song
- 2 Department of Internal Medicine, College of Medicine, Gyeongsang National University , Jinju, South Korea
| | - So-Jin Lee
- 3 Department of Psychiatry, College of Medicine, Gyeongsang National University , Jinju, South Korea
| | - Eduardo Bruera
- 4 Department of Palliative Care and Rehabilitation Medicine, MD Anderson Cancer Center , Houston, Texas
| | - Jung Hun Kang
- 2 Department of Internal Medicine, College of Medicine, Gyeongsang National University , Jinju, South Korea
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Núñez Olarte JM, Francisco López MDC, Conti Jiménez M, Sánchez Isac M, Pérez Aznar C, Solano Garzón ML, Guevara Méndez S. Manejo de conductas aberrantes inducidas por opioides en una consulta externa de «cuidados paliativos precoces». ACTA ACUST UNITED AC 2018. [DOI: 10.1016/j.medipa.2017.02.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
BACKGROUND Many people with cancer experience moderate to severe pain that requires treatment with strong opioids, such as oxycodone and morphine. Strong opioids are, however, not effective for pain in all people, neither are they well-tolerated by all people. The aim of this review was to assess whether oxycodone is associated with better pain relief and tolerability than other analgesic options for adults with cancer pain. This is an updated version of the original Cochrane review published in 2015, Issue 2 on oxycodone for cancer-related pain. OBJECTIVES To assess the effectiveness and tolerability of oxycodone by any route of administration for pain in adults with cancer. SEARCH METHODS For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE and MEDLINE In-Process (Ovid), Embase (Ovid), Science Citation Index, Conference Proceedings Citation Index - Science (ISI Web of Science), BIOSIS (ISI), and PsycINFO (Ovid) to November 2016. We also searched four trial registries, checked the bibliographic references of relevant studies, and contacted the authors of the included studies. We applied no language, date, or publication status restrictions. SELECTION CRITERIA We included randomised controlled trials (parallel group or cross-over) comparing oxycodone (any formulation or route of administration) with placebo or an active drug (including oxycodone) for cancer background pain in adults by examining pain intensity/relief, adverse events, quality of life, and participant preference. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the included studies using standard Cochrane methodology. We meta-analysed pain intensity data using the generic inverse variance method, and adverse events using the Mantel-Haenszel method, or summarised these data narratively along with the quality of life and participant preference data. We assessed the overall quality of the evidence using GRADE. MAIN RESULTS For this update, we identified six new studies (1258 participants) for inclusion. In total, we included 23 studies which enrolled/randomised 2648 participants, with 2144 of these analysed for efficacy and 2363 for safety. The studies examined a number of different drug comparisons.Pooled analysis of three of the four studies comparing controlled-release (CR) oxycodone to immediate-release (IR) oxycodone showed that the ability of CR and IR oxycodone to provide pain relief were similar (standardised mean difference (SMD) 0.1, 95% confidence interval (CI) -0.06 to 0.26; low quality evidence). Pooled analyses of adverse events showed no significant differences between CR and IR oxycodone for asthenia (risk ratio (RR) 0.58, 95% CI 0.2 to 1.68), confusion (RR 0.78, 95% CI 0.2 to 3.02), constipation (RR 0.71, 95% CI 0.45 to 1.13), dizziness/lightheadedness (RR 0.74, 95% CI 0.4 to 1.37), drowsiness/somnolence (RR 1.03, 95% CI 0.69 to 1.54), dry mouth (RR 1.14, 95% CI 0.48 to 2.75), insomnia (RR 1.04, 95% CI 0.31 to 3.53), nausea (RR 0.85, 95% CI 0.56 to 1.28), nervousness (RR 0.57, 95% CI 0.2 to 1.64), pruritus (RR 1.46, 95% CI 0.65 to 3.25), vomiting (RR 0.66, 95% CI 0.38 to 1.15), and discontinuation due to adverse events (RR 0.6, 95% CI 0.29 to 1.22). The quality of the evidence was very low for all these adverse events. Three of the four studies found similar results for treatment acceptability.Pooled analysis of seven of the nine studies comparing CR oxycodone to CR morphine indicated that pain relief was significantly better after treatment with CR morphine than CR oxycodone (SMD 0.14, 95% CI 0.01 to 0.27; low quality evidence). However, sensitivity analysis did not corroborate this result (SMD 0.12, 95% CI -0.02 to 0.26).Pooled analyses of adverse events showed no significant differences between CR oxycodone and CR morphine for confusion (RR 1.01 95% CI 0.78 to 1.31), constipation (RR 0.98, 95% CI 0.82 to 1.16), dizziness/lightheadedness (RR 0.76, 95% CI 0.33 to 1.76), drowsiness/somnolence (RR 0.9, 95% CI 0.75 to 1.08), dry mouth (RR 1.01, 95% CI 0.8 to 1.26), dysuria (RR 0.71, 95% CI 0.4 to 1.26), nausea (RR 1.02, 95% CI 0.82 to 1.26), pruritus (RR 0.81, 95% CI 0.51 to 1.29), vomiting (RR 0.94, 95% CI 0.68 to 1.29), and discontinuation due to adverse events (RR 1.06, 95% CI 0.43 to 2.6). However, the RR for hallucinations was significantly lower after treatment with CR oxycodone compared to CR morphine (RR 0.52, 95% CI 0.28 to 0.97). The quality of the evidence was very low for all these adverse events. There were no marked differences in treatment acceptability or quality of life ratings.The remaining studies either compared oxycodone in various formulations or compared oxycodone to different alternative opioids. None found any clear superiority or inferiority of oxycodone for cancer pain, neither as an analgesic agent nor in terms of adverse event rates and treatment acceptability.The quality of this evidence base was limited by the high or unclear risk of bias of the studies and by imprecision due to low or very low event rates or participant numbers for many outcomes. AUTHORS' CONCLUSIONS The conclusions have not changed since the previous version of this review. The data suggest that oxycodone offers similar levels of pain relief and overall adverse events to other strong opioids including morphine. Although we identified a clinically insignificant benefit on pain relief in favour of CR morphine over CR oxycodone, this did not persist following sensitivity analysis and so we do not consider this important. However, in this updated analysis, we found that hallucinations occurred less often with CR oxycodone than with CR morphine, but the quality of this evidence was very low so this finding should be treated with utmost caution. Our conclusions are consistent with other reviews and suggest that while the reliability of the evidence base is low, given the absence of important differences within this analysis it seems unlikely that larger head to head studies of oxycodone versus morphine are justified, although well-designed trials comparing oxycodone to other strong analgesics may well be useful. For clinical purposes, oxycodone or morphine can be used as first-line oral opioids for relief of cancer pain in adults.
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Affiliation(s)
- Mia Schmidt‐Hansen
- Royal College of Obstetricians and GynaecologistsNational Guideline Alliance27 Sussex PlRegent's ParkLondonUKNW1 4RG
| | - Michael I Bennett
- University of LeedsLeeds Institute of Health SciencesCharles Thackrah Building101 Clarendon RoadLeedsUKLS2 9LJ
| | - Stephanie Arnold
- Royal College of Obstetricians and Gynaecologists27 Sussex PlaceRegent's parkLondonUKNW1 4RG
| | - Nathan Bromham
- Royal College of Obstetricians and GynaecologistsNational Guideline Alliance27 Sussex PlRegent's ParkLondonUKNW1 4RG
| | - Jennifer S Hilgart
- National Collaborating Centre for Cancer2nd Floor, Park House, Greyfriars RoadCardiffWalesUKCF10 3AF
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Temporal preference in individuals reporting chronic pain: discounting of delayed pain-related and monetary outcomes. Pain 2017; 157:1724-1732. [PMID: 27075431 DOI: 10.1097/j.pain.0000000000000576] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Opioid therapy for pain is associated with an increased risk for substance use disorders. This study's purpose was to determine the association between opioid misuse propensity (Screener and Opioid Assessment for Patients in Pain-Revised) and delay discounting (DD), a behavioral process linked to substance use disorders, which quantifies the extent to which outcomes are devalued because of their delay. Participants reporting chronic pain (N = 249) answered pain and opioid use questions and then completed 4 DD tasks. Each of these tasks assessed either money or pain consequences, framed as either rewards or punishments. Each task involved hypothetical choices between immediate smaller vs delayed larger consequences. The extant Monetary Choice Questionnaire assessed DD of money rewards, and a modified version assessed discounting of money losses (immediate smaller loss vs larger delayed loss). Based on the Monetary Choice Questionnaire, the novel Pain Relief Choice Questionnaire assessed choices between an immediate short duration of pain relief vs a longer duration of pain relief. Similarly, the novel Additional Pain Choice Questionnaire assessed choices between an immediate short duration of additional pain vs a longer duration of additional pain. Discounting of both additional pain and money losses were significantly associated with high Screener and Opioid Assessment for Patients in Pain-Revised scores-indicating participants at greatest risk for opioid misuse discount future punishments rather than future rewards compared with those at low risk. Measures of DD may have promise in more accurately identifying individuals at highest risk for opioid misuse during chronic opioid therapy.
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Olarte JMN. Breakthrough cancer pain and rational drug use. Support Care Cancer 2017; 25:11-17. [PMID: 28213817 PMCID: PMC5357276 DOI: 10.1007/s00520-017-3636-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 12/27/2016] [Indexed: 12/21/2022]
Abstract
Recent data indicate that there are large disparities in the use of opioid analgesics to control breakthrough cancer pain (BTcP) in Europe and worldwide. While it is clear that affordability is a key factor, it is certainly not the only one, and other factors, such as cultural differences and overall awareness, are undoubtedly responsible. More work remains to be done to overcome barriers in the use of these medications when warranted. When prescribing a medication for BTcP, it must be considered that its time profile is different from chronic persistent pain. The best control of background pain can best be achieved with a low dose of an extended opioid, and managing BTcP with a rapid-onset opioid, providing a good combination of overall pain control and lower opioid exposure. Notwithstanding their efficacy, greater attention needs to be paid to inappropriate use of opioids. It is important to evaluate patients for potential opioid misuse, including assessment of risk factors, and aberrant drug-taking behaviours must be investigated. In our institution, several measures have been adopted in this patient population in order to prevent aberrant opioid-induced behaviours. The adoption of some or all of these principles, depending on the individual patient and treatment setting, can undoubtedly help to reduce the risk of developing an aberrant behaviour related to opioid use as rescue medication for BTcP.
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Affiliation(s)
- Juan Manuel Núñez Olarte
- Palliative Care Unit, Hospital General Universitario Gregorio Marañón, c/Dr Esquerdo 46, 28007, Madrid, Spain.
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17
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Nikulina V, Guarino H, Acosta MC, Marsch LA, Syckes C, Moore SK, Portenoy RK, Cruciani RA, Turk DC, Rosenblum A. Patient vs provider reports of aberrant medication-taking behavior among opioid-treated patients with chronic pain who report misusing opioid medication. Pain 2016; 157:1791-1798. [PMID: 27082008 PMCID: PMC4949142 DOI: 10.1097/j.pain.0000000000000583] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
During long-term opioid therapy for chronic noncancer pain, monitoring medication adherence of patients with a history of aberrant opioid medication-taking behaviors (AMTB) is an essential practice. There is limited research, however, into the concordance among existing monitoring tools of self-report, physician report, and biofluid screening. This study examined associations among patient and provider assessments of AMTB and urine drug screening using data from a randomized trial of a cognitive-behavioral intervention designed to improve medication adherence and pain-related outcomes among 110 opioid-treated patients with chronic pain who screened positive for AMTB and were enrolled in a pain program. Providers completed the Aberrant Behavior Checklist (ABC) and patients completed the Current Opioid Misuse Measure (COMM) and the Chemical Coping Inventory (CCI). In multivariate analyses, ABC scores were compared with COMM and CCI scores, while controlling for demographics and established risk factors for AMTB, such as pain severity. Based on clinical cutoffs, 84% of patients reported clinically significant levels of AMTB and providers rated 36% of patients at elevated levels. Provider reports of AMTB were not correlated with COMM or CCI scores. However, the ABC ratings of experienced providers (nurse practitioners/attending physicians) were higher than those of less experienced providers (fellows) and were correlated with CCI scores and risk factors for AMTB. Associations between patient- and provider-reported AMTB and urine drug screening results were low and largely nonsignificant. In conclusion, concordance between patient and provider reports of AMTB among patients with chronic pain prescribed opioid medication varied by provider level of training.
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Affiliation(s)
- Valentina Nikulina
- Queens College, CUNY; Department of Psychology, 6530 Kissena Boulevard, Flushing, NY 11367, T: (718) 997-3215; F: (718) 997-3257; http://www.qc.cuny.edu/Academics/Degrees/DMNS/Psychology/Pages/default.aspx
| | - Honoria Guarino
- National Development and Research Institutes, Inc., New York, NY
| | | | - Lisa A. Marsch
- Dartmouth Center for Technology and Behavioral Health, Lebanon, NH
| | - Cassandra Syckes
- National Development and Research Institutes, Inc., New York, NY
| | - Sarah K. Moore
- Dartmouth Center for Technology and Behavioral Health, Lebanon, NH
| | | | | | | | - Andrew Rosenblum
- National Development and Research Institutes, Inc., New York, NY
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Factors Associated with Opioid Use in a Cohort of Patients Presenting for Surgery. PAIN RESEARCH AND TREATMENT 2015; 2015:829696. [PMID: 26881072 PMCID: PMC4736213 DOI: 10.1155/2015/829696] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 12/15/2015] [Indexed: 01/09/2023]
Abstract
Objectives. Patients taking opioids prior to surgery experience prolonged postoperative opioid use, worse clinical outcomes, increased pain, and more postoperative complications. We aimed to compare preoperative opioid users to their opioid naïve counterparts to identify differences in baseline characteristics. Methods. 107 patients presenting for thoracotomy, total knee replacement, total hip replacement, radical mastectomy, and lumpectomy were investigated in a cross-sectional study to characterize the associations between measures of pain, substance use, abuse, addiction, sleep, and psychological measures (depressive symptoms, Posttraumatic Stress Disorder symptoms, somatic fear and anxiety, and fear of pain) with opioid use. Results. Every 9-point increase in the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) score was associated with 2.37 (95% CI 1.29–4.32) increased odds of preoperative opioid use (p = 0.0005). The SOAPP-R score was also associated with 3.02 (95% CI 1.36–6.70) increased odds of illicit preoperative opioid use (p = 0.007). Also, every 4-point increase in baseline pain at the future surgical site was associated with 2.85 (95% CI 1.12–7.27) increased odds of legitimate preoperative opioid use (p = 0.03). Discussion. Patients presenting with preoperative opioid use have higher SOAPP-R scores potentially indicating an increased risk for opioid misuse after surgery. In addition, legitimate preoperative opioid use is associated with preexisting pain.
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Porta-Sales J, Pérez C, Escobar Y, Martínez V. Diagnosis and management of breakthrough cancer pain: Have all the questions been resolved? A Delphi-based consensus assessment (DOIRON). Clin Transl Oncol 2015; 18:945-54. [PMID: 26693731 DOI: 10.1007/s12094-015-1468-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 12/07/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To ascertain the level of agreement and achieve a consensus among cancer pain specialists in Spain with regard to the optimal definition, diagnosis, and management of breakthrough cancer pain (BTcP). DESIGN Two-round Delphi methodology survey (February-May 2013) using seven-point Likert scales (ranging from 1 "strongly disagree" to 7 "strongly agree") was carried out. Mean scores >5 or <3 indicated, respectively, agreement or disagreement. Scores from 3 to 5 indicated no consensus. RESULTS A total of 126 experienced specialists were surveyed. Response rates were 68 % in round 1 and 90 % in round 2. Agreement (mean Likert score) was strongest for the proposed BTcP definition (6.6), the use of oral (6.1), and intranasal (6.0) transmucosal fentanyl, the need for early assessment after BTcP treatment initiation, and the need to improve staff knowledge of BTcP. Broad agreement was also reached regarding the need to systematically screen all cancer patients for BTcP (5.9). Most respondents (82 %) considered strong opioids to be appropriate treatment. In contrast, no consensus was reached regarding strong opioid treatment for baseline pain as a prerequisite for BTcP diagnosis. CONCLUSIONS Consensus was strong for most treatment, and diagnostic aspects were evaluated in the study. However, several important issues remain unresolved, particularly whether the diagnostic criteria must include strong opioids for background pain. Nurses' awareness and understanding of BTcP was considered insufficient, and more training is needed in this area. Overall, agreement among specialists was good, but more work is needed to better define the optimal diagnostic features and treatments for this condition.
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Affiliation(s)
- J Porta-Sales
- Palliative Care Service, Institut Català d'Oncologia (ICO), Bellvitge Biomedical Research Institute (IDIBELL), WeCare Chair: End of Life Care, Institut Català d'Oncologia, Barcelona, Spain
| | - C Pérez
- Pain Clinic, Hospital Universitario de la Princesa, C/Diego de León 62, 28002, Madrid, Spain
| | - Y Escobar
- Department of Medical Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Bruehl S, Burns JW, Passik SD, Gupta R, Buvanendran A, Chont M, Schuster E, Orlowska D, France CR. The Contribution of Differential Opioid Responsiveness to Identification of Opioid Risk in Chronic Pain Patients. THE JOURNAL OF PAIN 2015; 16:666-75. [PMID: 25892658 PMCID: PMC4486517 DOI: 10.1016/j.jpain.2015.04.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 03/16/2015] [Accepted: 04/10/2015] [Indexed: 11/29/2022]
Abstract
UNLABELLED The Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) predicts increased risk of opioid misuse in chronic pain patients. We evaluated whether higher SOAPP-R scores are associated with greater opioid reinforcing properties, potentially contributing to their predictive utility. Across 2 counterbalanced laboratory sessions, 55 chronic low back pain sufferers completed the SOAPP-R at baseline and measures of back pain intensity, evoked pain responsiveness (thermal, ischemic), and subjective opioid effects after receiving intravenous morphine (.08 mg/kg) or saline placebo. Morphine effect measures were derived for all outcomes, reflecting the difference between morphine and placebo condition values. Higher SOAPP-R scores were significantly associated with greater desire to take morphine again, less feeling down and feeling bad, and greater reductions in sensory low back pain intensity following morphine administration. This latter effect was due primarily to SOAPP-R content assessing medication-specific attitudes and behavior. Individuals exceeding the clinical cutoff (18 or higher) on the SOAPP-R exhibited significantly greater morphine liking, desire to take morphine again, and feeling sedated; less feeling bad; and greater reductions in sensory low back pain following morphine. The SOAPP-R may predict elevated opioid risk in part by tapping into individual differences in opioid reinforcing effects. PERSPECTIVE Based on placebo-controlled morphine responses, associations were observed between higher scores on a common opioid risk screener (SOAPP-R) and greater desire to take morphine again, fewer negative subjective morphine effects, and greater analgesia. Opioids may provide the best analgesia in those patients at greatest risk of opioid misuse.
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Affiliation(s)
- Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee.
| | - John W Burns
- Department of Behavioral Science, Rush University, Chicago, Illinois
| | | | - Rajnish Gupta
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | - Melissa Chont
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Erik Schuster
- Department of Behavioral Science, Rush University, Chicago, Illinois
| | - Daria Orlowska
- Department of Behavioral Science, Rush University, Chicago, Illinois
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Nielsen S, Roxburgh A, Bruno R, Lintzeris N, Jefferson A, Degenhardt L. Changes in non-opioid substitution treatment episodes for pharmaceutical opioids and heroin from 2002 to 2011. Drug Alcohol Depend 2015; 149:212-9. [PMID: 25707708 DOI: 10.1016/j.drugalcdep.2015.02.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 01/27/2015] [Accepted: 02/03/2015] [Indexed: 01/28/2023]
Abstract
BACKGROUND There has been a well-documented increase in the non-medical use of pharmaceutical opioids (PO) worldwide. However, there has been little detailed examination of treatment demand, or the characteristics of those presenting for treatment, particularly for treatments other than opioid substitution. METHODS Data from closed drug and alcohol treatment episodes from the Alcohol and Other Drug Treatment Services National Minimum Data Set (AODTS-NMDS, representing non-opioid substitution treatment) in Australia for 2002-2003 to 2010-2011 were examined. In the four jurisdictions where detailed data were available, episodes where heroin was the principal drug of concern were compared to episodes for the four most frequently reported pharmaceutical opioids (morphine, codeine, fentanyl and oxycodone). RESULTS In 2002-2003, most (93%) opioid treatment was related to heroin with seven percent of all opioid treatment episodes reporting a PO as the principal drug of concern. In 2010-2011, 20% of all opioid treatment episodes were attributed to POs. Distinct changes over time were observed for different opioids. There was an increase in the average age at the start of treatment for heroin and oxycodone episodes, and a reduction in the proportion of females for codeine episodes, with 67% in 2002-2003 compared with 44% in 2010-2011. Codeine and oxycodone episodes had the lowest current or past injection rates. CONCLUSIONS Clear differences were observed over time and between different opioids. Monitoring these emerging patterns will be important to inform treatment needs, particularly in light of different patterns of poly drug use, different routes of administration and changing demographic characteristics.
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Affiliation(s)
- S Nielsen
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales 2052, Australia; Drug and Alcohol Services, South Eastern Sydney Local Health District, 591 South Dowling St, Surry Hills 2010, Australia.
| | - A Roxburgh
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales 2052, Australia
| | - R Bruno
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales 2052, Australia; School of Medicine, University of Tasmania, Level 1, Medical Science 1, 17 Liverpool Street, Hobart 7000, Australia
| | - N Lintzeris
- Drug and Alcohol Services, South Eastern Sydney Local Health District, 591 South Dowling St, Surry Hills 2010, Australia; University of Sydney, Department of Addiction Medicine, Missenden Road, Camperdown 2006, Australia
| | - A Jefferson
- Tobacco, Alcohol and Other Drugs Unit, Australian Institute of Health and Welfare, 1 Thynne Street, Fern Hill Park, Bruce 2617, Australia
| | - L Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales 2052, Australia
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Ehrentraut JH, Kern KD, Long SA, An AQ, Faughnan LG, Anghelescu DL. Opioid misuse behaviors in adolescents and young adults in a hematology/oncology setting. J Pediatr Psychol 2014; 39:1149-60. [PMID: 25225182 DOI: 10.1093/jpepsy/jsu072] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To describe the occurrence and psychosocial correlates of aberrant opioid-associated behavior (AOB) in adolescent and young adult (AYA) hematology and oncology patients prescribed opioid therapy. METHODS Structured retrospective chart reviews were conducted for AYA patients (N = 398) accepted for active treatment at a large pediatric hematology/oncology institution over a 17-month period. Opioid therapy was documented in the records of 94 out of the 398 patients. The records of those 94 patients were further reviewed to identify documented AOB and documented correlates of AOB. RESULTS Of the 94 patients prescribed opioid therapy, 11.7% exhibited AOB. At least one psychosocial risk factor was identified in 90.9% of patients with AOB. Concurrent use of multiple opioids was significantly associated with AOB (p = .003). CONCLUSIONS Hematology/oncology AYA patients may exhibit AOB despite a legitimate clinical indication for opioid therapy. Clinicians should consider young patients' psychosocial risk factors when using opioid therapy.
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Affiliation(s)
- Jennifer Harman Ehrentraut
- Department of Psychology, Division of Anesthesia, Department of Pediatric Medicine, and Department of Biostatistics, St. Jude Children's Research Hospital
| | - Kathleen Danielle Kern
- Department of Psychology, Division of Anesthesia, Department of Pediatric Medicine, and Department of Biostatistics, St. Jude Children's Research Hospital
| | - Sarah A Long
- Department of Psychology, Division of Anesthesia, Department of Pediatric Medicine, and Department of Biostatistics, St. Jude Children's Research Hospital
| | - Angel Qi An
- Department of Psychology, Division of Anesthesia, Department of Pediatric Medicine, and Department of Biostatistics, St. Jude Children's Research Hospital
| | - Lane G Faughnan
- Department of Psychology, Division of Anesthesia, Department of Pediatric Medicine, and Department of Biostatistics, St. Jude Children's Research Hospital
| | - Doralina L Anghelescu
- Department of Psychology, Division of Anesthesia, Department of Pediatric Medicine, and Department of Biostatistics, St. Jude Children's Research Hospital
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Webster LR, Slevin KA, Narayana A, Earl CQ, Yang R. Fentanyl Buccal Tablet Compared with Immediate-Release Oxycodone for the Management of Breakthrough Pain in Opioid-Tolerant Patients with Chronic Cancer and Noncancer Pain: A Randomized, Double-Blind, Crossover Study Followed by a 12-Week Open-Label Phase to Evaluate Patient Outcomes. PAIN MEDICINE 2013; 14:1332-45. [DOI: 10.1111/pme.12184] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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