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Arthur J, Edwards T, Lu Z, Amoateng MD, Koom-Dadzie K, Zhu H, Long J, Do KA, Bruera E. Healthcare provider perceptions and reported practices regarding opioid prescription for patients with chronic cancer pain. Support Care Cancer 2024; 32:121. [PMID: 38252311 DOI: 10.1007/s00520-024-08323-7] [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] [Received: 09/18/2023] [Accepted: 01/11/2024] [Indexed: 01/23/2024]
Abstract
PURPOSE Data indicates that clinicians might be under-prescribing opioids for patients with chronic cancer pain, and this could impact adequate pain management. Few studies have sought to understand healthcare provider (HCP) perceptions and practices regarding the prescription of opioids for chronic cancer pain. We assessed HCP perceptions and practices regarding opioid prescription for patients with chronic cancer pain since the onset of the COVID-19 pandemic. METHODS An anonymous cross-sectional survey was conducted among 186 HCPs who attended an opioid educational event in April 2021 and 2022. RESULTS Sixty-one out of 143 (44%) opioid prescribers reported reluctance to prescribe opioids for chronic cancer pain. In a multivariate logistic model, younger participants (log OR - 0.04, 95% CI - 0.085, - 0.004; p = 0.033) and pain medicine clinicians (log OR - 1.89, CI - 3.931, - 0.286; p = 0.034) were less reluctant, whereas providers who worry about non-medical opioid use were more reluctant to prescribe opioids (log OR 1.58 95% CI 0.77-2.43; p < 0.001). Fifty-three out of 143 (37%) prescribers had experienced increased challenges regarding opioid dispensing at pharmacies, and 84/179 (47%) of all respondents reported similar experience by their patients. Fifty-four out of 178(30%) were aware of opioid-related harmful incidents to patients or their families, including incidents attributed to opioid misuse by a household or family member. CONCLUSION A considerable number of opioid prescribers were reluctant to prescribe opioids for patients with chronic cancer pain. Many reported challenges regarding dispensing of opioids at the pharmacies. These may be unintended consequences of policies to address the opioid crisis. Future measures should focus on addressing regulatory barriers without undermining the gains already made to combat the opioid crisis.
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Affiliation(s)
- Joseph Arthur
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, 1515 Holcombe Boulevard, Houston, TX, 77030, USA.
| | - Tonya Edwards
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Zhanni Lu
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Magdelene Doris Amoateng
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Kwame Koom-Dadzie
- Department of Hospital Medicine, The University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Hongxu Zhu
- Department of Biostatistics, The University of Texas MD Anderson Cancer, Houston, TX, USA
| | - James Long
- Department of Biostatistics, The University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Kim-Anh Do
- Department of Biostatistics, The University of Texas MD Anderson Cancer, Houston, TX, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
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Arthur J, Edwards T, Lu Z, Amoateng DM, Koom-Dadzie K, Zhu H, Long J, Do KA, Bruera E. Healthcare provider perceptions and reported practices regarding opioid prescription for patients with chronic pain. RESEARCH SQUARE 2023:rs.3.rs-3367358. [PMID: 37841840 PMCID: PMC10571602 DOI: 10.21203/rs.3.rs-3367358/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
PURPOSE Data indicates that clinicians might be under-prescribing opioids for patients with chronic cancer pain, and this could impact adequate chronic pain management. Few studies have sought to understand healthcare provider (HCP) perceptions and practices regarding the prescription of opioids for chronic pain. We assessed HCP perceptions and practices regarding opioid prescription for patients with chronic pain since the onset of the COVID-19 pandemic. METHODS An anonymous cross-sectional survey was conducted among 186 HCPs who attended an opioid educational event in April 2021 and 2022. RESULTS 61/143(44%) opioid prescribers reported reluctance to prescribe opioids for chronic pain. In a multivariate logistic model, younger participants (log OR -0.04, 95% CI: -0.085, -0.004; p = 0.033) and pain medicine clinicians (log OR -1.89, CI: -3.931, -0.286; p = 0.034) were less reluctant, whereas providers who worry about non-medical opioid use (NMOU) were more reluctant to prescribe opioids (log OR 1.58 95% CI: 0.77-2.43; p < 0.001). 53/143(37%) respondents had experienced increased challenges regarding opioid dispensing at pharmacies, and 84/179(47%) reported similar experience by their patients. 54/178(30%) HCPs were aware of opioid-related harmful incidents to patients or their families, including incidents attributed to opioid misuse by a household or family member. CONCLUSION A significant number of opioid prescribers were reluctant to prescribe opioids for patients with chronic pain. Many reported challenges regarding dispensing of opioids at the pharmacies. These may be unintended consequences of policies to address the opioid crisis. Future measures should focus on addressing regulatory barriers without undermining the gains already made to combat the opioid crisis.
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Affiliation(s)
| | | | - Zhanni Lu
- The University of Texas MD Anderson Cancer
| | | | | | - Hongxu Zhu
- The University of Texas MD Anderson Cancer
| | - James Long
- The University of Texas MD Anderson Cancer
| | - Kim-Anh Do
- The University of Texas MD Anderson Cancer
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Hébert HL, Morales DR, Torrance N, Smith BH, Colvin LA. Assessing the impact of a national clinical guideline for the management of chronic pain on opioid prescribing rates: a controlled interrupted time series analysis. Implement Sci 2022; 17:77. [PMID: 36419195 PMCID: PMC9682704 DOI: 10.1186/s13012-022-01251-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 11/09/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Opioids can be effective analgesics, but long-term use may be associated with harms. In 2013, the first national, comprehensive, evidence-based pain management guideline was published, from the Scottish Intercollegiate Guideline Network (SIGN 136: Management of Chronic Pain) with key recommendations on analgesic prescribing. This study aimed to examine the potential impact on national opioid prescribing rates in Scotland. METHODS Trends in national and regional community opioid prescribing data for Scotland were analysed from quarter one (Q1) 2005 to Q2 2020. Interrupted time series regression examined the association of SIGN 136 publication with prescribing rates for opioid-containing drugs. Gabapentinoid prescribing was used as a comparison drug. RESULTS After a positive prescribing trend pre-publication, the timing of SIGN 136 publication was associated with a negative change in the trend of opioid prescribing rates (-2.82 items per 1000 population per quarter [PTPPQ]; P < 0.01). By Q2 2020, the relative reduction in the opioid prescribing rate was -20.67% (95% CI: -23.61, -17.76). This persisted after correcting for gabapentinoid prescribing and was mainly driven by the reduction in weak opioids, whereas strong opioid prescribing rates continued to rise. Gabapentinoid prescribing showed a significant rise in level (8.00 items per 1000 population; P = 0.01) and trend (0.27 items PTPPQ; P = 0.01) following SIGN 136 publication. CONCLUSIONS The publication of SIGN 136 was associated with a reduction in opioid prescribing rates. This suggests that changes in clinical policy through evidence-based national clinical guidelines may affect community opioid prescribing, though this may be partially replaced by gabapentinoids, and other factors may also contribute.
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Affiliation(s)
- Harry L Hébert
- Division of Population Health and Genomics, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF, UK.
| | - Daniel R Morales
- Division of Population Health and Genomics, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF, UK
| | - Nicola Torrance
- School of Nursing, Midwifery & Paramedic Practice, Robert Gordon University, Aberdeen, UK
| | - Blair H Smith
- Division of Population Health and Genomics, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF, UK
| | - Lesley A Colvin
- Division of Population Health and Genomics, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF, UK
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Spithoff S, Mogic L, Hum S, Moineddin R, Meaney C, Kiran T. Examining Access to Primary Care for People With Opioid Use Disorder in Ontario, Canada: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2233659. [PMID: 36178686 PMCID: PMC9526081 DOI: 10.1001/jamanetworkopen.2022.33659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE People with opioid use disorder are less likely than others to have a primary care physician. OBJECTIVE To determine if family physicians are less likely to accept people with opioid use disorder as new patients than people with diabetes. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial used an audit design to survey new patient intake at randomly selected family physicians in Ontario, Canada. Eligible physicians were independent practitioners allowed to prescribe opioids who were located in an office within 50 km of a population center greater than 20 000 people. A patient actor made unannounced telephone calls to family physicians asking for a new patient appointment. The data were analyzed in September 2021. INTERVENTION In the first randomly assigned scenario, the patient actor played a role of patient with diabetes in treatment with an endocrinologist. In the second scenario, the patient actor played a role of a patient with opioid use disorder undergoing methadone treatment with an addiction physician. MAIN OUTCOMES AND MEASURES Total offers of a new patient appointment; a secondary analysis compared the proportions of patients offered an appointment stratified by gender, population, model of care, and years in practice. RESULTS Of a total 383 family physicians included in analysis, a greater proportion offered a new patient appointment to a patient with diabetes (21 of 185 physicians [11.4%]) than with opioid use disorder (8 of 198 physicians [4.0%]) (absolute difference, 7.4%; 95% CI, 2.0 to 12.6; P = .007). Physicians with more than 20 years in practice were almost 13 times less likely to offer an appointment to a patient with opioid use disorder compared with diabetes (1 of 108 physicians [0.9%] vs 10 of 84 physicians [11.9%]; absolute difference, 11.0; 95% CI, 3.8 to 18.1; P = .001). Women were almost 5 times less likely (3 of 111 physicians [2.7%] vs 14 of 114 physicians [12.3%]; absolute difference, 9.6%; 95% CI, 2.4 to 16.3; P = .007) to offer an appointment to a patient with opioid use disorder than with diabetes. CONCLUSIONS AND RELEVANCE In this randomized clinical trial, family physicians were less likely to offer a new patient appointment to a patient with opioid use disorder compared with a patient with diabetes. Potential health system solutions to this disparity include strengthening policies for accepting new patients, improved compensation, and clinician anti-oppression training. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05484609.
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Affiliation(s)
- Sheryl Spithoff
- Department of Family and Community Medicine, Women’s College Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Women’s College Hospital Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
| | - Lana Mogic
- Department of Family and Community Medicine, Women’s College Hospital, Toronto, Ontario, Canada
| | - Susan Hum
- Department of Family and Community Medicine, Women’s College Hospital, Toronto, Ontario, Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Meaney
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tara Kiran
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Toronto, Ontario, Canada
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Jenkin DE, Naylor JM, Descallar J, Harris IA. Effectiveness of Oxycodone Hydrochloride (Strong Opioid) vs Combination Acetaminophen and Codeine (Mild Opioid) for Subacute Pain After Fractures Managed Surgically: A Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2134988. [PMID: 34787656 PMCID: PMC8600392 DOI: 10.1001/jamanetworkopen.2021.34988] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Patients with a surgically managed fracture are commonly discharged from the hospital with a strong opioid prescription, but limited evidence exists to support this practice. OBJECTIVE To test the hypothesis that strong opioids provide greater analgesia than mild opioids over the first week postdischarge from hospital after fracture surgical treatment. DESIGN, SETTING, AND PARTICIPANTS This double-blind, superiority, randomized clinical trial was conducted at a single-center, major trauma hospital in Sydney, Australia. Participants were inpatients who had sustained an acute nonpathological facture of a long bone or the pelvis, patella, calcaneus, or talus who were treated with surgical fixation and enrolled from July 27, 2016, to August 22, 2017. Data were analyzed from June through October 2018. INTERVENTIONS Initiation at discharge of oxycodone hydrochloride 5 mg of 10 mg (ie, 1 or 2 tablets) or combination acetaminophen and codeine 500 mg and 8 mg or 1000 mg and 16 mg (ie, 1 or 2 tablets) 4 times daily for a maximum duration of 3 weeks. MAIN OUTCOMES AND MEASURES The primary outcome was the mean of daily pain scores collected during week 1 of treatment measured using the Numerical Pain Rating Scale (NRS). Participants were asked to rate their mean pain over the previous 24 hours daily using an NRS score from 0 to 10, with 0 representing no pain and 10 representing the worst pain imaginable. The key secondary outcomes were EuroQol 5-Dimension 5-Level Questionnaire (EQ-5D-5L) responses, worst pain, medication adverse events, global perceived effect, and return to work. RESULTS A total of 120 patients with 1 or more acute orthopedic fractures requiring surgical fixation were randomized, including 59 patients in the strong-opioid group (43 [72.9%] men; mean [SD] age, 36.0 [14.1] years; mean oral morphine equivalent for days 1-7 of 32.9 mg) and 61 patients in the mild opioid group (47 [77.1%] men; mean [SD] age, 38.2 [13.5] years; mean oral morphine equivalent for days 1-7 of 5.5 mg). From days 1 to 7 postdischarge, the mean daily NRS mean pain score was 4.04 (95% Cl, 3.67 to 4.41) in the strong opioid group and 4.54 (95% Cl, 4.17 to 4.90) in the mild opioid group. The between-group difference of the primary outcome was not statistically significant (-0.50 [95% Cl, -1.11 to 0.12]; P = .11) despite a 6-fold increased dose of opioids being delivered in the strong opioid group. CONCLUSIONS AND RELEVANCE This study found that treatment with strong opioid medication subacutely was not superior to treatment with milder medication for treatment of pain among patients with surgically managed orthopedic fractures. These findings suggest that ongoing first-line strong opioid use after discharge from the hospital should not be supported. TRIAL REGISTRATION Australia New Zealand Clinical Trial Registry No.: ACTRN12616000941460.
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Affiliation(s)
- Deanne E. Jenkin
- University of New South Wales, South Western Sydney Clinical School, Sydney, Australia
- Whitlam Orthopaedic Research Centre, Liverpool, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
- Presently with Daffodil Centre, University of Sydney, a joint venture with Cancer Council New South Wales, Kings Cross, New South Wales, Australia
| | - Justine M. Naylor
- University of New South Wales, South Western Sydney Clinical School, Sydney, Australia
- Whitlam Orthopaedic Research Centre, Liverpool, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
- Liverpool Hospital, South Western Sydney Local Health District, Sydney, New South Wales, Australia
| | - Joseph Descallar
- University of New South Wales, South Western Sydney Clinical School, Sydney, Australia
- Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
| | - Ian A. Harris
- University of New South Wales, South Western Sydney Clinical School, Sydney, Australia
- Whitlam Orthopaedic Research Centre, Liverpool, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
- Liverpool Hospital, South Western Sydney Local Health District, Sydney, New South Wales, Australia
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Consensus and Controversies Between Pain and Addiction Experts on the Prevention, Diagnosis, and Management of Prescription Opioid Use Disorder. J Addict Med 2021; 14:1-11. [PMID: 31743124 DOI: 10.1097/adm.0000000000000577] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Prescription opioid use disorder (POUD) is an established public health crisis in many countries, and current evidence indicates it is a growing problem in Europe. Many specialists play a role, including pain and addiction medicine specialists, in the diagnosis and management of POUD, but neither group can fully address these patients' needs alone. The purpose of this consensus process was to bring together experts from pain and addiction medicine to examine the positions of both specialties. METHODS In all, 13 international pain medicine, addiction medicine, and addiction psychiatry experts convened a meeting to formulate a set of consensus statements on the diagnosis and management of POUD. The statements were further refined by a wider group of 22 European expert clinicians. At a second meeting of all 35 participants, a set of controversy statements was also developed to recognize some of the key areas of divergent opinion. RESULTS/CONCLUSIONS There was a high level of agreement between pain and addiction specialists. Key themes that emerged were the need to strengthen interdisciplinary communication, a desire for greater education and training for clinicians in both specialties, and mutual acknowledgment of the importance of multidisciplinary management of POUD. The blurred line between poorly managed pain and POUD was also a subject of much discussion, reflecting the difficulties in defining and diagnosing this complex condition.
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Willman AS. Chronic non-cancer pain training and practice-based small group learning in defence primary healthcare. BMJ Mil Health 2021; 168:243. [PMID: 33664090 DOI: 10.1136/bmjmilitary-2021-001805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 02/15/2021] [Accepted: 02/17/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Antony Sean Willman
- Academic Department of General Practice, Royal Defence Medical College, Birmingham, UK
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Strong opioids and non-cancer chronic pain in Catalonia. An analysis of the family physicians prescription patterns. ACTA ACUST UNITED AC 2019; 67:68-75. [PMID: 31740046 DOI: 10.1016/j.redar.2019.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 07/27/2019] [Accepted: 08/22/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To identify family doctor prescription patterns for strong opioids for chronic, non-cancer-related pain. MATERIALS AND METHODS Design A descriptive study based on a self-administered email questionnaire. LOCATION All primary health care centres in Catalonia. PARTICIPANTS 3,602 family doctors, all members of the Catalan Society of Family and Community Medicine. INTERVENTIONS Email survey of Catalan family doctors. MAIN MEASUREMENTS Demographic data, number of patients treated with potent opioids for chronic non-cancer pain, type of opioid used and indications, prescribing patterns and relationship with the Pain Management Unit. RESULTS A total of 551 answers were obtained from 3,602 questionnaires sent (response rate of 15.3%), in which 480 physicians (87%) prescribed strong opioids for musculoskeletal pain, 268 (48.6%) prescribed ultra-rapid fentanyl and 434 (78.7%) reduced benzodiazepines dosage when prescribing potent opioids. The most common adverse effects were constipation and nausea. The main problems related with opioid prescription were improper use (341, 71%) and patient and/or practitioner reluctance (87, 18.1%). The assessment of the relationship with Pain Management Units was 2±1 (on a 1 to 5 scale), with communication (271, 52.2%) and accessibility (141, 27.1%) being the areas most in need of improvement. CONCLUSIONS Opioid prescribing patterns generally follow clinical guidelines (e.g. reduction of benzodiazepine use or dose titration). However, there are some areas of improvement, such as sparse use of laxatives or use of ultra-rapid opioids for unapproved indications and in patients with no background opioid therapy. Family doctors perceive patient reluctance to adhere to the prescribed treatment, and call for specific training and better relationships with Pain Management Units.
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Marshall EG, Burge F, Gibson RJ, Lawson B, O'Connell C. Accepting new patients who require opioids into family practice: results from the MAAP-NS census survey study. BMC FAMILY PRACTICE 2019; 20:141. [PMID: 31640570 PMCID: PMC6806488 DOI: 10.1186/s12875-019-1027-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 09/20/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND Acceptance to a family practice is key to access and continuity of care. While Canadian patients increasingly report not being able to acquire acceptance to a family practice, little is known about the association between requiring opioids and acceptance. We aim to determine the proportion of family physicians who would accept new patients who require opioids and describe physician and practice characteristics associated with willingness to accept these patients. METHODS Census telephone survey of family physicians' practices in Nova Scotia, Canada. MEASURES physician (i.e., age, sex, years in practice) and practice (i.e., number/type of provider in the practice, care hours/week) characteristics and practice-reported willingness to accept new patients who require opioids. RESULTS The survey was completed for 587 family physicians (83.7% response rate). 354 (60.3%) were taking new patients unconditionally or with conditions; 326 provided a response to whether they would accept new patients who require opioids; 91 (27.9%) reported they would not accept a new patient who requires opioids. Compared to family physicians who would not accept patients who require opioids, in bivariate analysis, those who would, tended to work in larger practices; had fewer years in practice; are female; and provided more patient care. The relationship to number of providers in the practice, having a nurse, and experience persisted in multivariate analysis. CONCLUSIONS The strongest predictors of willingness to accept patients who require opioids are fewer years in practice (OR = 0.96 [95% CI 0.93, 0.99]) and variables indicating a family physician has support of a larger (OR = 1.19 [95% CI 1.00, 1.42]), interdisciplinary team (e.g., nurses, mental health professionals) (OR = 1.15 [95% CI 1.11, 5.05]). Almost three-quarters (72.1%) of surveyed family physicians would accept patients requiring opioids.
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Affiliation(s)
- Emily Gard Marshall
- Department of Family Medicine, Dalhousie University, Suite 402, 1465 Brenton Street, Halifax, Nova Scotia, B3J 3T4, Canada.
| | - Frederick Burge
- Department of Family Medicine, Dalhousie University, Suite 402, 1465 Brenton Street, Halifax, Nova Scotia, B3J 3T4, Canada
| | - Richard J Gibson
- Nova Scotia Health Authority, Department of Family Practice, Mumford Professional Centre, 6960 Mumford Road, Suite 265, Halifax, Nova Scotia, B3L 4P1, Canada
| | - Beverley Lawson
- Department of Family Medicine, Dalhousie University, Suite 402, 1465 Brenton Street, Halifax, Nova Scotia, B3J 3T4, Canada
| | - Colleen O'Connell
- Department of Family Medicine, Dalhousie University, Suite 402, 1465 Brenton Street, Halifax, Nova Scotia, B3J 3T4, Canada
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Abstract
INTRODUCTION Opioids are widely used after orthopaedic procedures. Nonmedical opioid use is a growing public health issue. METHODS An anonymous online survey was distributed by e-mail to the orthopaedic societies of all 50 states and several large private practices to assess practicing orthopaedic surgeons' opioid prescribing practices. RESULTS A total of 555 orthopaedic surgeons practicing in 37 states responded. The most commonly prescribed opioid for both teenagers and adults was hydrocodone/acetaminophen. Of note, 42.3% reported that a patient they have prescribed opioids for developed an opioid dependency, whereas 35.3% do not believe that opioid use is a problem in their practice. Of note, 30.3% reported prescribing refills, and factors significantly associated with increased prescribing of refills included a greater number of years in practice (P < 0.001) and practicing in a suburban rather than an urban or rural environment (P = 0.03). CONCLUSION Orthopaedic surgeons rarely prescribe any refills, tend to prescribe less opioids to teenagers than adults, and prescribe fairly uniformly for patients who are treated nonsurgically or undergo minor or arthroscopic surgery. They exhibit considerable variation in prescribing for fractures and major procedures.
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Veiga DR, Mendonça L, Sampaio R, Castro-Lopes JM, Azevedo LF. A Two-Year Prospective Multicenter Study of Opioid Therapy for Chronic Noncancer Pain: Prescription Trends and Predictors. PAIN MEDICINE 2018; 20:2166-2178. [DOI: 10.1093/pm/pny275] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Objectives
Opioid use in chronic pain has increased worldwide in recent years. The aims of this study were to describe the trends and patterns of opioid therapy over two years of follow-up in a cohort of chronic noncancer pain (CNCP) patients and to assess predictors of long-term opioid use and clinical outcomes.
Methods
A prospective cohort study with two years of follow-up was undertaken in four multidisciplinary chronic pain clinics. Demographic data, pain characteristics, and opioid prescriptions were recorded at baseline, three, six, 12, and 24 months.
Results
Six hundred seventy-four CNCP patients were recruited. The prevalence of opioid prescriptions at baseline was 59.6% (N = 402), and 13% (N = 86) were strong opioid prescriptions. At 24 months, opioid prescription prevalence was as high as 74.3% (N = 501), and strong opioid prescription was 31% (N = 207). Most opioid users (71%, N = 479) maintained their prescription during the two years of follow-up. Our opioid discontinuation was very low (1%, N = 5). Opioid users reported higher severity and interference pain scores, both at baseline and after two years of follow-up. Opioid use was independently associated with continuous pain, pain location in the lower limbs, and higher pain interference scores.
Conclusions
This study describes a pattern of increasing opioid prescription in chronic pain patients. Despite the limited improvement of clinical outcomes, most patients keep their long-term opioid prescriptions. Our results underscore the need for changes in clinical practice and further research into the effectiveness and safety of chronic opioid therapy for CNPC.
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Affiliation(s)
- Dalila R Veiga
- Anesthesiology Department-Chronic Pain Center, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Liliane Mendonça
- Centro Nacional de Observação em Dor – OBSERVDOR, Porto, Portugal
| | - Rute Sampaio
- Departamento de Biomedicina - Unidade de Biologia Experimental, Faculdade de Medicina da Universidade do Porto, Portugal
- i3S—Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- IBMC—Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal
- Porto, Portugal
| | - José M Castro-Lopes
- Centro Nacional de Observação em Dor – OBSERVDOR, Porto, Portugal
- Departamento de Biomedicina - Unidade de Biologia Experimental, Faculdade de Medicina da Universidade do Porto, Portugal
- i3S—Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- IBMC—Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal
| | - Luís F Azevedo
- Centro Nacional de Observação em Dor – OBSERVDOR, Porto, Portugal
- CINTESIS - Center for Health Technology and Services Research, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- MEDCIDS - Departamento de Medicina da Comunidade Informação e Decisão em Saúde, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
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Incidence and Health Related Quality of Life of Opioid-Induced Constipation in Chronic Noncancer Pain Patients: A Prospective Multicentre Cohort Study. PAIN RESEARCH AND TREATMENT 2018; 2018:5704627. [PMID: 30112202 PMCID: PMC6077510 DOI: 10.1155/2018/5704627] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 06/10/2018] [Indexed: 12/13/2022]
Abstract
Background High rates of opioid use for chronic noncancer pain (CNCP) have been reported worldwide, despite its association with adverse events, inappropriate use, and limited analgesic effect. Opioid-induced constipation (OIC) is the most prevalent and disabling adverse effect associated with opioid therapy. Our aim was to assess the incidence, health related quality of life (HRQOL), and disability in OIC patients. Methods A prospective cohort study was performed, with 6 months of follow-up, of adult CNCP patients consecutively admitted in 4 multidisciplinary pain clinics (MPC). Demographic and clinical data have been collected. Brief Pain Inventory (BPI) and Short version of Treatment Outcomes in Pain Survey (S-TOPS) were used to measure functional outcomes and HRQOL. OIC was assessed using Bowel Function Index (BFI). Results 694 patients were recruited. OIC prevalence at baseline was 25.8%. At 6 months, OIC incidence was 24.8%. Female gender (OR = 1.65, p = 0.039), opioid therapy (OR 1.65, p = 0.026), and interference pain score on BPI (OR 1.10, p = 0.009) were identified as OIC independent predictors. OIC patients presented higher disability and pain interference and severity scores. OIC patients reported less satisfaction with outcome (p = 0.038). Discussion Constipation is a common adverse event among opioid users with major functional and quality of life impairment. These findings emphasise the need of OIC adequate assessment and management.
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Guan Q, Khuu W, Martins D, Tadrous M, Chiu M, Do MT, Gomes T. Evaluating the early impacts of delisting high-strength opioids on patterns of prescribing in Ontario. Health Promot Chronic Dis Prev Can 2018; 38:256-262. [PMID: 29911823 PMCID: PMC6034971 DOI: 10.24095/hpcdp.38.6.07] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Ontario delisted high-strength fentanyl, hydromorphone and morphine from the public drug formulary for non-palliative care prescribers on 31 January, 2017. Our aim is to assess the early impact of this policy on prescribing patterns and to examine whether this impact varied by prescriber type, opioid type and opioid strength. METHODS We conducted a population-based, cross-sectional study on palliative and non-palliative care patients dispensed fentanyl, hydromorphone or morphine through the Ontario public drug program between 1 January, 2014, and 31 July, 2017. For each month during the study period, we reported the total number of high-strength opioid recipients stratified by prescriber type, and the total volume of each drug dispensed, stratified by strength. We used interventional autoregressive integrated moving average (ARIMA) models to assess the policy's impact on prescribing patterns. RESULTS We observed a 98% decrease in the total number of publicly funded recipients of high-strength opioids between December 2016 and July 2017 (5930 to 133 recipients) for all prescribers. The policy led to a significant decline in the total volume of all three opioids dispensed: hydromorphone from 20 374 621 to 16 952 097 mg (p < .01); morphine from 40 644 190 to 33 555 480 mg (p < .03); and fentanyl from 9 604 913 to 5 842 405 mcg/h (p < .01). For both fentanyl and hydromorphone, this reduction generally corresponded to an increase in the number of low-strength opioids dispensed. CONCLUSION Delisting high-strength opioids substantially reduced the number of highstrength opioid recipients and reduced the overall volume of long-acting opioids dispensed in Ontario through the public drug program. Future studies should examine its impact on patient outcomes.
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Affiliation(s)
- Qi Guan
- The Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Wayne Khuu
- The Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Diana Martins
- The Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Mina Tadrous
- The Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Maria Chiu
- The Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- The Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Minh T Do
- Public Health Agency of Canada, Ottawa, Ontario, Canada
- Department of Health Sciences, Carleton University, Ottawa, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Tara Gomes
- The Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- The Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
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Webster LR, Nalamachu S, Morlion B, Reddy J, Baba Y, Yamada T, Arjona Ferreira JC. Long-term use of naldemedine in the treatment of opioid-induced constipation in patients with chronic noncancer pain: a randomized, double-blind, placebo-controlled phase 3 study. Pain 2018; 159:987-994. [PMID: 29419653 PMCID: PMC5916485 DOI: 10.1097/j.pain.0000000000001174] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 01/09/2018] [Accepted: 01/29/2018] [Indexed: 12/15/2022]
Abstract
The long-term safety of naldemedine, a peripherally acting µ-opioid receptor antagonist, was evaluated in patients with opioid-induced constipation and chronic noncancer pain in a 52-week, randomized, double-blind, phase 3 study. Eligible adults who could be on a routine laxative regimen were randomized 1:1 to receive once-daily oral naldemedine 0.2 mg (n = 623) or placebo (n = 623). The primary endpoint was summary measures of treatment-emergent adverse events (AEs). Additional endpoints included opioid withdrawal on the Clinical Opiate Withdrawal Scale and the Subjective Opiate Withdrawal Scale, pain intensity on Numeric Rating Scale, frequency of bowel movements, and constipation-related symptoms and quality of life on the Patient Assessment of Constipation Symptoms and Patient Assessment of Constipation Quality of Life scales, respectively. Treatment-emergent AEs (naldemedine, 68.4% vs placebo, 72.1%; difference: -3.6% [95% confidence interval: -8.7 to 1.5]) and treatment-emergent AEs leading to study discontinuation (6.3% vs 5.8%; difference: 0.5% [-2.2 to 3.1)] were reported for similar proportions of patients. Diarrhea was reported more frequently with naldemedine (11.0%) vs placebo (5.3%; difference: 5.6% [2.6-8.6]). There were no meaningful differences between groups in opioid withdrawal or pain intensity. Sustained significant improvements in bowel movement frequency and overall constipation-related symptoms and quality of life were observed with naldemedine (P ≤ 0.0001 vs placebo at all time points). Naldemedine was generally well tolerated for 52 weeks and did not interfere with opioid-mediated analgesia or precipitate opioid withdrawal. Naldemedine significantly increased bowel movement frequency, improved symptomatic burden of opioid-induced constipation, and increased patients' quality of life vs placebo.
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Affiliation(s)
- Lynn R. Webster
- Scientific Affairs -- Neuroschences PRA Health Sciences, PRA Health Sciences, Salt Lake City, UT, USA
| | | | - Bart Morlion
- Department of Cardiovascular Sciences, Unit Anesthesiology and Algology, University of Leuven, Leuven Center for Algology and Pain Management, University Hospital Leuven, Catholic University of Leuven, Leuven, Belgium
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Ponton R, Sawyer R. Opioid prescribing in general practice: use of a two-stage review tool to identify and assess high-dose prescribing. Br J Pain 2017; 12:171-182. [PMID: 30057762 DOI: 10.1177/2049463717742420] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Long-term opioid analgesic prescribing in chronic non-cancer pain (CNCP) is a growing worldwide concern. This has implications for optimal healthcare management in general and chronic pain management specifically. This work documents the development of a review tool and its use in the South West of England in a locality that showed opioid prescribing levels higher than surrounding localities. Methods An electronic tool which enabled calculation of total prescribed morphine-equivalent doses was developed to allow general practitioners (GPs) to undertake reviews of CNCP patients. This tool was used to assess strong opioid prescribing over a 3-month period at every GP practice (n = 41) in the locality. Every prescription for morphine, oxycodone, pethidine and fentanyl during this period was included.Aspects assessed included drug(s) prescribed, dose prescribed, whether tramadol was prescribed concurrently, whether the drugs were potentially being overused and/or whether the patient was in palliative care. Patients prescribed over 120 mg morphine equivalent per day were reviewed in greater depth, as this is an indication for specialist input. Results In total, 1881 patients received a prescription in the assessment period. Morphine was the most commonly prescribed drug (n = 847). In all, 363 CNCP patients were prescribed a dose equal to or above 120 mg morphine a day, with a maximum morphine-equivalent dose of 890 mg being prescribed. Over 11% (n = 211) of patients were concurrently prescribed tramadol. The most frequently cited reason for prescription of high-dose opioids was found to be a musculoskeletal pain of the back, neck, joints or limbs. The care of 85 specific CNCP patients was reviewed and optimised. Discussion No published work to date has documented such an in-depth analysis of primary-care opioid analgesic prescribing utilising prescriber data. Assessing total-dose morphine-equivalent prescribing using this method provides valuable insights into the potential need for urgent medication review. The tool developed may be of value to other GP practices following validation.
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Affiliation(s)
- Rhys Ponton
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Richard Sawyer
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Opioid Prescribing Practices and Training Needs of Québec Family Physicians for Chronic Noncancer Pain. Pain Res Manag 2017; 2017:1365910. [PMID: 28831278 PMCID: PMC5555017 DOI: 10.1155/2017/1365910] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 05/02/2017] [Accepted: 05/24/2017] [Indexed: 11/18/2022]
Abstract
Aim To examine medical practices and training needs of Québec family physicians with respect to pain management and opioid prescription for chronic noncancer pain (CNCP). Methodology An online survey was carried out in 2016. Results Of 636 respondents (43.0% men; 54.3% ≥ 50 years old), 15.2% and 70.9% felt very or somewhat confident that they could properly prescribe opioids for CNCP. Concerns related to abuse (72.5% strongly/somewhat agree), dependence (73.2%), and lack of support (75.4%) were the main barriers reported. Only 19.7% always/often screened their patients for risks of abuse and dependence using a screening tool. About two-thirds of participants (65.7%) had recently (last five years) taken part in continuing education programs on opioid use for CNCP and 73.4% on CNCP management. Patient evaluation and differential diagnoses of chronic pain syndromes were rated as a top priority for further training. Conclusions This study provides insights into Québec family physicians' concerns, practices, and needs with respect to the management of CNCP. Physicians' difficulties around the application of strategies to mitigate the problem of opioid abuse and addiction are worrying. The need to better train physicians in the field of pain and addiction cannot be emphasized enough.
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Dureja GP, Jain PN, Joshi M, Saxena A, Das G, Ahdal J, Narang P. Addressing the barriers related with opioid therapy for management of chronic pain in India. Pain Manag 2017; 7:311-330. [PMID: 28699380 DOI: 10.2217/pmt-2016-0064] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
India has a high prevalence of chronic disorders which may be associated with persistent pain. Despite the availability of multiple treatment options, chronic pain is largely untreated and contributes to disability and mortality. Medical consumption of opioids remains low due to various barriers that prevent access to opioids for patients and healthcare practitioners. Stringent regulatory provisions outlined in the Narcotic Drugs and Psychotropic Substances Act (1985) have been major deterrents to adequate opioid use. Although multiple amendments to the act have ensured ease of opioid access for medicinal purposes, concerns such as lack of awareness and prescribing practices and attitudes of physicians/patients still need to be addressed. This review aims to identify these barriers and suggest recommendations to overcome them.
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Affiliation(s)
| | | | | | - Ashok Saxena
- Department of Anesthesiology, Pain Clinic, University College of Medical Sciences, University of Delhi, New Delhi, India
| | - Gautam Das
- Daradia Pain Clinic, Kolkata, West Bengal, India
| | - Jaishid Ahdal
- Medical Affairs, Johnson & Johnson Pvt. Ltd., Mumbai, Maharashtra, India
| | - Prashant Narang
- Medical Affairs, Johnson & Johnson Pvt. Ltd., Mumbai, Maharashtra, India
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Currow DC, Phillips J, Clark K. Using opioids in general practice for chronic non-cancer pain: an overview of current evidence. Med J Aust 2017; 204:305-9. [PMID: 27125804 DOI: 10.5694/mja16.00066] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 03/10/2016] [Indexed: 01/03/2023]
Abstract
Chronic non-cancer pain (lasting more than 3 months) is highly prevalent in Australia (17% of males and 20% of females) and its optimal management is crucial to the health and wellbeing of the community. For 5% of the population, such pain interferes markedly with daily function. Part of the treatment for acute non-cancer pain for many people will include opioid analgesics at least for days to weeks. However, as pain becomes chronic, evidence to support ongoing prescription of opioids is lacking. There is increasing pressure to ensure that prescribing opioid analgesics is minimised to reduce not only the risk of dependence and illicit diversion but also the potential harms associated with tolerance, side effects and complications. Frameworks for considering opioid prescribing include assessing suitability of the patient for opioids; initiating a trial of therapy; and monitoring long term use. There is limited evidence of the long term efficacy of opioids for chronic non-cancer pain, and documented clinical consequences beyond addiction include acceleration of loss of bone mineral density, hypogonadism and an association with increased risk of acute myocardial infarction. Careful clinical selection of patients can help optimise the evidence-based use of opioids for chronic non-cancer pain: only treat pain that has been as well defined as possible when non-opioid therapies have not been effective; consider referral to specialist services for assessment if doses are above 100 mg oral morphine equivalent per 24 hours or the duration of therapy is longer than 4 weeks; limit prescribing to only one practitioner; seek an agreement with the patient for the initiation and potential withdrawal of opioids if the therapeutic trial is not effective.
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Crowley RS, Riley AP, Sherwood AM, Groer CE, Shivaperumal N, Biscaia M, Paton K, Schneider S, Provasi D, Kivell BM, Filizola M, Prisinzano TE. Synthetic Studies of Neoclerodane Diterpenes from Salvia divinorum: Identification of a Potent and Centrally Acting μ Opioid Analgesic with Reduced Abuse Liability. J Med Chem 2016; 59:11027-11038. [PMID: 27958743 DOI: 10.1021/acs.jmedchem.6b01235] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Opioids are widely used to treat millions suffering from pain, but their analgesic utility is limited due to associated side effects. Herein we report the development and evaluation of a chemical probe exhibiting analgesia and reduced opioid-induced side effects. This compound, kurkinorin (5), is a potent and selective μ-opioid receptor (MOR) agonist (EC50 = 1.2 nM, >8000 μ/κ selectivity). 5 is a biased activator of MOR-induced G-protein signaling over β-arrestin-2 recruitment. Metadynamics simulations of 5's binding to a MOR crystal structure suggest energetically preferred binding modes that differ from crystallographic ligands. In vivo studies with 5 demonstrate centrally mediated antinociception, significantly reduced rewarding effects, tolerance, and sedation. We propose that this novel MOR agonist may represent a valuable tool in distinguishing the pathways involved in MOR-induced analgesia from its side effects.
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Affiliation(s)
- Rachel Saylor Crowley
- Department of Medicinal Chemistry, School of Pharmacy, The University of Kansas , 1251 Wescoe Hall Drive, 4070 Malott, Lawrence, Kansas 66045, United States
| | - Andrew P Riley
- Department of Chemistry, The University of Kansas , Lawrence, Kansas 66045, United States
| | - Alexander M Sherwood
- Department of Medicinal Chemistry, School of Pharmacy, The University of Kansas , 1251 Wescoe Hall Drive, 4070 Malott, Lawrence, Kansas 66045, United States
| | - Chad E Groer
- Department of Medicinal Chemistry, School of Pharmacy, The University of Kansas , 1251 Wescoe Hall Drive, 4070 Malott, Lawrence, Kansas 66045, United States
| | - Nirajmohan Shivaperumal
- Centre for Biodiscovery, School of Biological Sciences, Victoria University of Wellington , Wellington 6140, New Zealand
| | - Miguel Biscaia
- Centre for Biodiscovery, School of Biological Sciences, Victoria University of Wellington , Wellington 6140, New Zealand
| | - Kelly Paton
- Centre for Biodiscovery, School of Biological Sciences, Victoria University of Wellington , Wellington 6140, New Zealand
| | - Sebastian Schneider
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai , New York, New York 10029, United States
| | - Davide Provasi
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai , New York, New York 10029, United States
| | - Bronwyn M Kivell
- Centre for Biodiscovery, School of Biological Sciences, Victoria University of Wellington , Wellington 6140, New Zealand
| | - Marta Filizola
- Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai , New York, New York 10029, United States
| | - Thomas E Prisinzano
- Department of Medicinal Chemistry, School of Pharmacy, The University of Kansas , 1251 Wescoe Hall Drive, 4070 Malott, Lawrence, Kansas 66045, United States
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