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Tseng TY, Mitchell MM, Chander G, Latkin C, Kennedy C, Knowlton AR. Patient-centered Engagement as a Mediator in the Associations of Healthcare Discrimination, Pain Care Denial, and Later Substance Use Among a Sample of Predominately African Americans Living with HIV. AIDS Behav 2024; 28:429-438. [PMID: 38060111 DOI: 10.1007/s10461-023-04235-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 12/08/2023]
Abstract
Chronic pain is prevalent and often under-addressed among people with HIV and people who use drugs, likely compounding the stress of discrimination in healthcare, and self-medicating along with its associated overdose risk or other problematic coping. Due to challenges in treating pain and HIV in the context of substance use, collaborative, patient-centered patient-provider engagement (PCE) may be particularly important for mitigating the impact of pain on illicit drug use and promoting sustained recovery. We examined whether PCE with primary care provider (PCE-PCP) mediated the effects of pain, discrimination, and denial of prescription pain medication on later substance use for pain among a sample of 331 predominately African Americans with HIV and a drug use history in Baltimore, Maryland, USA. Baseline pain level was directly associated with a higher chance of substance use for pain at 12 months (Standardized Coefficient = 0.26, p < .01). Indirect paths were observed from baseline healthcare discrimination (Standardized Coefficient = 0.05, 95% CI=[0.01, 0.13]) and pain medication denial (Standardized Coefficient = 0.06, 95% CI=[0.01, 0.14]) to a higher chance of substance use for pain at 12 months. Effects of prior discrimination and pain medication denial on later self-medication were mediated through worse PCE-PCP at 6 months. Results underscore the importance of PCE interpersonal skills and integrative care models in addressing mistreatment in healthcare and substance use in this population. An integrated approach for treating pain and substance use disorders concurrently with HIV and other comorbidities is much needed. Interventions should target individuals at multiple risks of discriminations and healthcare professionals to promote PCE.
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Affiliation(s)
- Tuo-Yen Tseng
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | | | | | - Carl Latkin
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Caitlin Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Amy R Knowlton
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Abstract
IMPORTANCE Negative attitudes toward patients can adversely impact health care quality and contribute to health disparities. Stigmatizing language written in a patient's medical record can perpetuate negative attitudes and influence decision-making of clinicians subsequently caring for that patient. OBJECTIVE To identify and describe physician language in patient health records that may reflect, or engender in others, negative and positive attitudes toward the patient. DESIGN, SETTING, AND PARTICIPANTS This qualitative study analyzed randomly selected encounter notes from electronic medical records in the ambulatory internal medicine setting at an urban academic medical center. The 600 encounter notes were written by 138 physicians in 2017. Data were analyzed in 2019. MAIN OUTCOMES AND MEASURES Common linguistic characteristics reflecting an overall positive or negative attitude toward the patient. RESULTS A total of 138 clinicians wrote encounter notes about 507 patients. Of these patients, 350 (69%) were identified as female, 406 (80%) were identified as Black/African American, and 76 (15%) were identified as White. Of 600 encounter notes included in this study, there were 5 major themes representing negative language and 6 themes representing positive language. The majority of negative language was not explicit and generally fell into one or more of the following categories: (1) questioning patient credibility, (2) expressing disapproval of patient reasoning or self-care, (3) stereotyping by race or social class, (4) portraying the patient as difficult, and (5) emphasizing physician authority over the patient. Positive language was more often more explicit and included (1) direct compliments, (2) expressions of approval, (3) self-disclosure of the physician's own positive feelings toward the patient, (4) minimization of blame, (5) personalization, and (6) highlighting patient authority for their own decisions. CONCLUSIONS AND RELEVANCE This qualitative study found that physicians express negative and positive attitudes toward patients when documenting in the medical record. Although often not explicit, this language could potentially transmit bias and affect the quality of care that patients subsequently receive. These findings suggest that increased physician awareness when writing and reading medical records is needed to prevent the perpetuation of negative bias in medical care.
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Affiliation(s)
- Jenny Park
- Oregon Health and Science University, Portland
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Somnath Saha
- Oregon Health and Science University, Portland
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
| | - Brant Chee
- Applied Physics Laboratory, Johns Hopkins University, Baltimore, Maryland
| | - Janiece Taylor
- Johns Hopkins School of Nursing, Johns Hopkins University, Baltimore, Maryland
| | - Mary Catherine Beach
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland
- Center for Health Equity, Johns Hopkins University, Baltimore, Maryland
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Young SR, Azari S, Becker WC, Edelman EJ, Liebschutz JM, Roy P, Starrels JL, Merlin JS. Common and Challenging Behaviors Among Individuals on Long-term Opioid Therapy. J Addict Med 2021; 14:305-310. [PMID: 31855919 PMCID: PMC7297656 DOI: 10.1097/adm.0000000000000587] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Long-term opioid therapy (LTOT) is commonly prescribed for chronic pain, despite risks such as opioid use disorder (OUD) and overdose. Caring for patients on LTOT can be difficult, given lack of evidence about assessment of challenging behaviors among patients on LTOT. To develop this evidence, a critical first step is to systematically identify the common and challenging behaviors that primary care providers encounter among patients on LTOT, and also to highlight to diverse range of behaviors encountered. METHOD We conducted a Delphi study in 42 chronic pain experts to determine consensus on how to address the top common and challenging behaviors. This paper reports on the first round of the study, which elicited a range of behaviors. We conducted thematic analysis of the behaviors and also used the Diagnostic and Statistical Manual (DSM)-5 criteria for OUD as a priori codes. RESULTS In all, 124 unique behaviors were identified by participants and coded into 4 thematic categories: concerning behaviors that map onto DSM-5 criteria for OUD, and those that do not which were: behaviors that suggest deception, signs of diversion, and nonadherence to treatment plan. Those behaviors that fell outside of OUD criteria we identified as "gray zone" behaviors. CONCLUSIONS While some of these challenging behaviors fall under the criteria for an OUD, many fall outside of this framework, making diagnosis and treatment difficult, and consensus on how to deal with these "gray zone" behaviors is vital. Future research should explore how these "gray zone" behaviors can best be assessed and managed in a primary care setting.
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Affiliation(s)
- Sarah R. Young
- Department of Social Work, College of Community and Public Affairs, Binghamton University, Binghamton, NY. 13902, USA
| | - Soraya Azari
- University of California, San Francisco, 1001 Potrero Ave, 1311F, San Francisco, CA
| | - William C. Becker
- VA Connecticut Healthcare System, 950 Campbell Avenue, Mail Stop 151B, West Haven, CT 06516, USA
- Yale School of Medicine, 367 Cedar Street, New Haven, CT 06510, USA
| | | | - Jane M. Liebschutz
- University of Pittsburgh Department of Medicine, McKee Building, 230 McKee Place, Suite 600, Pittsburgh, PA 15213
| | - Payel Roy
- Boston Medical Center, Boston University School of Medicine, 801 Massachusetts Avenue, Boston, MA 02118
| | - Joanna L. Starrels
- Albert Einstein College of Medicine and Montefiore Medical Center, 111 E. 210 Street Bronx NY 10467
| | - Jessica S. Merlin
- University of Pittsburgh Department of Medicine, McKee Building, 230 McKee Place, Suite 600, Pittsburgh, PA 15213
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Buonora M, Perez HR, Stumph J, Allen R, Nahvi S, Cunningham CO, Merlin JS, Starrels JL. Medical Record Documentation About Opioid Tapering: Examining Benefit-to-Harm Framework and Patient Engagement. PAIN MEDICINE 2021; 21:2574-2582. [PMID: 32142143 DOI: 10.1093/pm/pnz361] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Guidelines recommend that clinicians make decisions about opioid tapering for patients with chronic pain using a benefit-to-harm framework and engaging patients. Studies have not examined clinician documentation about opioid tapering using this framework. DESIGN AND SETTING Thematic and content analysis of clinician documentation about opioid tapering in patients' medical records in a large academic health system. METHODS Medical records were reviewed for patients aged 18 or older, without cancer, who were prescribed stable doses of long-term opioid therapy between 10/2015 and 10/2016 then experienced an opioid taper (dose reduction ≥30%) between 10/2016 and 10/2017. Inductive thematic analysis of clinician documentation within six months of taper initiation was conducted to understand rationale for taper, and deductive content analysis was conducted to determine the frequencies of a priori elements of a benefit-to-harm framework. RESULTS Thematic analysis of 39 patients' records revealed 1) documented rationale for tapering prominently cited potential harms of continuing opioids, rather than observed harms or lack of benefits; 2) patient engagement was variable and disagreement with tapering was prominent. Content analysis found no patients' records with explicit mention of benefit-to-harm assessments. Benefits of continuing opioids were mentioned in 56% of patients' records, observed harms were mentioned in 28%, and potential harms were mentioned in 90%. CONCLUSIONS In this study, documentation of opioid tapering focused on potential harms of continuing opioids, indicated variable patient engagement, and lacked a complete benefit-to-harm framework. Future initiatives should develop standardized ways of incorporating a benefit-to-harm framework and patient engagement into clinician decisions and documentation about opioid tapering.
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Affiliation(s)
- Michele Buonora
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York
| | - Hector R Perez
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York
| | - Jordan Stumph
- Department of Physical Medicine and Rehabilitation, New York-Presbyterian Columbia/Cornell, New York, New York
| | - Robert Allen
- Department of Emergency Medicine, SUNY Downstate Medical Center, Brooklyn, New York
| | - Shadi Nahvi
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York
| | - Chinazo O Cunningham
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York
| | - Jessica S Merlin
- Center for Research on Healthcare, Divisions of General Internal Medicine and Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Joanna L Starrels
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York
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Beyond the numbers: Utilising existing textual data for qualitative research in pharmacy and health services research. Res Social Adm Pharm 2021; 18:2193-2199. [PMID: 33903065 DOI: 10.1016/j.sapharm.2021.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 03/02/2021] [Accepted: 04/09/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Qualitative research is a well-established branch of scientific enquiry that draws insights from experiences.1, 2Within social and administrative pharmacy research, interview and focus group methods are a mainstay of collecting data. However, other disciplines such as sociology, psychology and anthropology, use existing data that is routinely to provide a substance for qualitative inquiry. Drawing on our experiences of using interdisciplinary research methods, this paper presents three case studies where textual data was qualitatively analysed and critically examines the strengths and weaknesses of these method in relation to pharmacy practice. METHODS Three case studies were selected that access different types of existing, routinely collected data from pharmacy practice. This included 1) a study utilising boardroom meeting minutes, 2) a study using incident reports and 3) a study using WhatsApp messages as data. Each case study is described and critically examined. The strengths and weaknesses of this approach are based on our own reflections of completing the studies. RESULTS Relationships between people, products and organisations can be examined in documents, records and text that is routinely collected. Existing data can also provide insights into culture, working patterns, education and errors. Practical advantages of using existing data include faster data collection and access to first-hand, accounts of experiences of human relationship with pharmaceutical products and practice. Drawbacks of using existing data are that some data may be missing, participants may no longer be accessible for participant checking and the context of language may have changed. CONCLUSION This paper critically examined the use of methods rarely used in pharmacy practice research which draw on existing, routinely collected data. Adopting a wider range of data collection methods may will provide new understanding and insights into social and clinical pharmacy practice.
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Edelman EJ, Li Y, Barry D, Braden JB, Crystal S, Kerns RD, Gaither JR, Gordon KS, Manhapra A, Merlin JS, Moore BA, Oldfield BJ, Park LS, Rentsch CT, Skanderson M, Williams EC, Justice AC, Tate JP, Becker WC, Marshall BD. Trajectories of Self-Reported Opioid Use Among Patients With HIV Engaged in Care: Results From a National Cohort Study. J Acquir Immune Defic Syndr 2020; 84:26-36. [PMID: 32267658 PMCID: PMC7147724 DOI: 10.1097/qai.0000000000002310] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND No prior studies have characterized long-term patterns of opioid use regardless of source or reason for use among patients with HIV (PWH). We sought to identify trajectories of self-reported opioid use and their correlates among a national sample of PWH engaged in care. SETTING Veterans Aging Cohort Study, a prospective cohort including PWH receiving care at 8 US Veterans Health Administration (VA) sites. METHODS Between 2002 and 2018, we assessed past year opioid use frequency based on self-reported "prescription painkillers" and/or heroin use at baseline and follow-up. We used group-based trajectory models to identify opioid use trajectories and multinomial logistic regression to determine baseline factors independently associated with escalating opioid use compared to stable, infrequent use. RESULTS Among 3702 PWH, we identified 4 opioid use trajectories: (1) no lifetime use (25%); (2) stable, infrequent use (58%); (3) escalating use (7%); and (4) de-escalating use (11%). In bivariate analysis, anxiety; pain interference; prescribed opioids, benzodiazepines and gabapentinoids; and marijuana use were associated with escalating opioid group membership compared to stable, infrequent use. In multivariable analysis, illness severity, pain interference, receipt of prescribed benzodiazepine medications, and marijuana use were associated with escalating opioid group membership compared to stable, infrequent use. CONCLUSION Among PWH engaged in VA care, 1 in 15 reported escalating opioid use. Future research is needed to understand the impact of psychoactive medications and marijuana use on opioid use and whether enhanced uptake of evidence-based treatment of pain and psychiatric symptoms can prevent escalating use among PWH.
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Affiliation(s)
- E. Jennifer Edelman
- Yale School of Medicine, New Haven, CT
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT
| | - Yu Li
- Brown University School of Public Health, Providence, RI
| | | | - Jennifer Brennan Braden
- University of Washington School of Medicine, Seattle, WA
- Valley Medical Center Psychiatry and Counseling, Behavioral Health Integration Program
| | - Stephen Crystal
- Center for Health Services Research, Institute for Health, Rutgers University, Rutgers, NJ
| | - Robert D. Kerns
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | | | - Kirsha S. Gordon
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Ajay Manhapra
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | | | - Brent A. Moore
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | | | | | - Christopher T. Rentsch
- VA Connecticut Healthcare System, West Haven, CT
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Emily C. Williams
- VA Puget Sound Health Services Research and Development and Department of Health Services, University of Washington, Seattle, WA
| | - Amy C. Justice
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Janet P. Tate
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - William C. Becker
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
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Lingeman JM, Wang P, Becker W, Yu H. Detecting Opioid-Related Aberrant Behavior using Natural Language Processing. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2018; 2017:1179-1185. [PMID: 29854186 PMCID: PMC5977697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The United States is in the midst of a prescription opioid epidemic, with the number of yearly opioid-related overdose deaths increasing almost fourfold since 20001. To more effectively prevent unintentional opioid overdoses, the medical profession requires robust surveillance tools that can effectively identify at-risk patients. Drug-related aberrant behaviors observed in the clinical context may be important indicators of patients at risk for or actively abusing opioids. In this paper, we describe a natural language processing (NLP) method for automatic surveillance of aberrant behavior in medical notes relying only on the text of the notes. This allows for a robust and generalizable system that can be used for high volume analysis of electronic medical records for potential predictors of opioid abuse.
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Affiliation(s)
| | | | - William Becker
- Yale Medical School, New Haven, CT
- West Haven VAMC, West Haven, CT
| | - Hong Yu
- University of Massachusetts Medical School, Worcester, MA
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Merlin JS, Young SR, Starrels JL, Azari S, Edelman EJ, Pomeranz J, Roy P, Saini S, Becker WC, Liebschutz JM. Managing Concerning Behaviors in Patients Prescribed Opioids for Chronic Pain: A Delphi Study. J Gen Intern Med 2018; 33:166-176. [PMID: 29204977 PMCID: PMC5789105 DOI: 10.1007/s11606-017-4211-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 09/12/2017] [Accepted: 10/25/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Current guideline-recommended monitoring of patients prescribed long-term opioid therapy (LTOT) for chronic pain will likely result in increased identification of behaviors of concern for misuse and addiction, but there is a dearth of empiric evidence about how these behaviors should be managed. OBJECTIVE To establish expert consensus about treatment approaches for common and challenging concerning behaviors that arise among patients on LTOT. DESIGN We used a Delphi approach, which allows for generation of consensus. PARTICIPANTS Participants were clinical experts in chronic pain and opioid prescribing recruited from professional societies and other expert groups. MAIN MEASURES The Delphi process was conducted online, and consisted of an initial brainstorming round to identify common and challenging behaviors, a second round to identify management strategies for each behavior, and two rounds to establish consensus and explore disagreement/uncertainty. KEY RESULTS Forty-two participants completed round 1, 22 completed round 2, 30 completed round 3, and 28 completed round 4. Half of round 1 participants were female (52%), and the majority were white (83%). Most (71%) were physicians, and most participants practiced in academic primary (40%) or specialty care (19%).The most frequently cited common and challenging behaviors were missing appointments, taking opioids for symptoms other than pain, using more opioid medication than prescribed, asking for an increase in opioid dose, aggressive behavior, and alcohol and other substance use. Across behaviors, participants agreed that patient education and information gathering were important approaches. Participants also agreed that stopping opioids is not important initially, but if initial approaches do not work, tapering opioids and stopping opioids immediately may become important approaches. CONCLUSIONS This study presents clinical expert consensus on how to manage concerning behaviors among patients on LTOT. Future research is needed to investigate how implementing these management strategies would impact patient outcomes, practice and policy.
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Affiliation(s)
- Jessica S Merlin
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA. .,Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Sarah R Young
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA.,Department of Social Work, College of Community and Public Affairs, Binghamton University, Binghamton, NY, USA
| | - Joanna L Starrels
- Division of General Internal Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Soraya Azari
- Division of General Internal Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA
| | - E Jennifer Edelman
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jamie Pomeranz
- Department of Occupational Therapy, University of Florida, Gainesville, FL, USA
| | - Payel Roy
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Shalini Saini
- Department of Medicine, Information Technology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - William C Becker
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.,VA Connecticut Healthcare System, West Haven, CT, USA
| | - Jane M Liebschutz
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
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Copenhaver DJ, Karvelas NB, Fishman SM. Risk Management for Opioid Prescribing in the Treatment of Patients With Pain From Cancer or Terminal Illness. Anesth Analg 2017; 125:1610-1615. [DOI: 10.1213/ane.0000000000002463] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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10
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Campbell CI, Kline-Simon AH, Von Korff M, Saunders KW, Weisner C. Alcohol and Drug Use and Aberrant Drug-Related Behavior Among Patients on Chronic Opioid Therapy. Subst Use Misuse 2017; 52:1283-1291. [PMID: 28346056 PMCID: PMC5834235 DOI: 10.1080/10826084.2016.1276189] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To better identify individuals on chronic opioid therapy (COT) at high risk for aberrant-drug related behavior (ADRB). We examine whether patients with low level alcohol and drug use have similar characteristics to those with alcohol and drug disorders. We then examined the relationship of alcohol and drug use to ADRBs among COT patients. METHODS The sample was 972 randomly selected COT patients (age 21-80 years old) from a large health system in Northern California, USA, and interviewed in 2009. Logistic regression models were used to model the dependent variables of: alcohol use, illicit drug use, alcohol disorders, illicit drug disorders, and ADRBs. RESULTS The odds of daily/weekly alcohol use were lower for those with a high daily opioid dose (120+ mg/day vs. <20 mg/day) (OR = 0.32, p < 0.010). Illicit drug disorders were associated with depression (OR = 2.31, p < .001) and being on a high daily opioid dose (OR = 5.51, p < .01). Participants with illicit drug use had higher odds of giving (OR = 2.57, p < 0.01) and receiving opioids from friends or family (OR = 3.25, p < 0.001), but disorder diagnoses were not associated with ADRBs. CONCLUSIONS Findings reinforce that illicit drug use should be of high concern to clinicians prescribing opioids, and suggest it should be considered separately from alcohol use and alcohol disorders in the evaluation of ADRBs. Frequent alcohol use is low, but not uncommon, and suggests a need to discuss specific issues regarding safe use of opioids among persons who use alcohol that may differ from their risk of drug use.
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Affiliation(s)
- Cynthia I Campbell
- a Kaiser Permanente Northern California , Oakland , California , USA.,b Department of Psychiatry , University of California San Francisco , San Francisco , California , USA
| | | | - Michael Von Korff
- c Kaiser Permanente Washington Health Research Institute , Seattle , Washington , USA
| | - Kathleen W Saunders
- c Kaiser Permanente Washington Health Research Institute , Seattle , Washington , USA
| | - Constance Weisner
- a Kaiser Permanente Northern California , Oakland , California , USA.,b Department of Psychiatry , University of California San Francisco , San Francisco , California , USA
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Dragovich A, Beltran T, Baylor GM, Swanson M, Plunkett A. Determinants of Patient Satisfaction in a Private Practice Pain Management Clinic. Pain Pract 2017; 17:1015-1022. [DOI: 10.1111/papr.12554] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 09/24/2016] [Accepted: 11/14/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Anthony Dragovich
- Blue Ridge Pain Management; Salem Virginia
- Department of Surgery; Virginia College of Osteopathic Medicine; Blacksburg Virginia
| | | | - George M. Baylor
- Blue Ridge Pain Management; Salem Virginia
- Department of Surgery; Virginia College of Osteopathic Medicine; Blacksburg Virginia
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Merlin JS, Young SR, Azari S, Becker WC, Liebschutz JM, Pomeranz J, Roy P, Saini S, Starrels JL, Edelman EJ. Management of problematic behaviours among individuals on long-term opioid therapy: protocol for a Delphi study. BMJ Open 2016; 6:e011619. [PMID: 27154486 PMCID: PMC4861114 DOI: 10.1136/bmjopen-2016-011619] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Given the sharp rise in opioid prescribing and heightened recognition of opioid addiction and overdose, opioid safety has become a priority. Clinical guidelines on long-term opioid therapy (LTOT) for chronic pain consistently recommend routine monitoring and screening for problematic behaviours. Yet, there is no consensus definition regarding what constitutes a problematic behaviour, and recommendations for appropriate management to inform front-line providers, researchers and policymakers are lacking. This creates a barrier to effective guideline implementation. Thus, our objective is to present the protocol for a Delphi study designed to: (1) elicit expert opinion to identify the most important problematic behaviours seen in clinical practice and (2) develop consensus on how these behaviours should be managed in the context of routine clinical care. METHODS/ANALYSIS We will include clinical experts, defined as individuals who provide direct patient care to adults with chronic pain who are on LTOT in an ambulatory setting, and for whom opioid prescribing for chronic non-malignant pain is an area of expertise. The Delphi study will be conducted online in 4 consecutive rounds. Participants will be asked to list problematic behaviours and identify which behaviours are most common and challenging. They will then describe how they would manage the most frequently occurring common and challenging behaviours, rating the importance of each management strategy. Qualitative analysis will be used to categorise behaviours and management strategies, and consensus will be based on a definition established a priori. ETHICS/DISSEMINATION This study has been approved by the Institutional Review Board (IRB) of the University of Alabama at Birmingham (UAB). This study will generate Delphi-based expert consensus on the management of problematic behaviours that arise in individuals on LTOT, which we will publish and disseminate to appropriate professional societies. Ultimately, our findings will provide guidance to front-line providers, researchers and policymakers.
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Affiliation(s)
- Jessica S Merlin
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sarah R Young
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Soraya Azari
- Division of General Internal Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, USA
| | - William C Becker
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Jane M Liebschutz
- Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Clinical Addiction, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jamie Pomeranz
- Department of Occupational Therapy, University of Florida, Gainesville, Florida, USA
| | - Payel Roy
- Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Clinical Addiction, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Shalini Saini
- Department of Medicine, Information Technology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Joanna L Starrels
- Division of General Internal Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - E Jennifer Edelman
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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Becker WC, Gordon K, Edelman EJ, Kerns RD, Crystal S, Dziura JD, Fiellin LE, Gordon AJ, Goulet JL, Justice AC, Fiellin DA. Trends in Any and High-Dose Opioid Analgesic Receipt Among Aging Patients With and Without HIV. AIDS Behav 2016; 20:679-86. [PMID: 26384973 PMCID: PMC5006945 DOI: 10.1007/s10461-015-1197-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Harms of opioid analgesics, especially high-dose therapy among individuals with comorbidities and older age, are increasingly recognized. However, trends in opioid receipt among HIV-infected patients are not well characterized. We examined trends, from 1999 to 2010, in any and high-dose (≥120 mg/day) opioid receipt among patients with and without HIV, by age strata, controlling for demographic and clinical correlates. Of 127,216 patients, 64 % received at least one opioid prescription. Opioid receipt increased substantially among HIV-infected and uninfected patients over the study; high-dose therapy was more prevalent among HIV-infected patients. Trends in high-dose receipt stratified by three age groups revealed an increasing trend in each age strata, higher among HIV-infected patients. Correlates of any opioid receipt included HIV, PTSD and major depression. Correlates of high-dose receipt included HIV, PTSD, major depression and drug use disorders. These findings suggest a need for appropriate balance of risks and benefits, especially as these populations age.
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Affiliation(s)
- William C Becker
- Internal Medicine, West Haven VA Medical Center, VA Connecticut Healthcare System, Mail Stop 151B, 950 Campbell Avenue, West Haven, CT, 06516, USA.
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.
| | - Kirsha Gordon
- Internal Medicine, West Haven VA Medical Center, VA Connecticut Healthcare System, Mail Stop 151B, 950 Campbell Avenue, West Haven, CT, 06516, USA
| | - E Jennifer Edelman
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Robert D Kerns
- Psychology, VA Connecticut Healthcare System, West Haven, CT, USA
- Psychology, Yale University School of Medicine, New Haven, CT, USA
| | - Stephen Crystal
- Center for Health Services Research, Rutgers University, New Brunswick, NJ, USA
| | - James D Dziura
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Lynn E Fiellin
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Adam J Gordon
- University of Pittsburgh and Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Joseph L Goulet
- Psychology, VA Connecticut Healthcare System, West Haven, CT, USA
- Psychology, Yale University School of Medicine, New Haven, CT, USA
| | - Amy C Justice
- Internal Medicine, West Haven VA Medical Center, VA Connecticut Healthcare System, Mail Stop 151B, 950 Campbell Avenue, West Haven, CT, 06516, USA
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - David A Fiellin
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
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