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Hopkins RE, Campbell G, Degenhardt L, Gisev N. 'We didn't cause the opioid epidemic': The experiences of Australians prescribed opioids for chronic non-cancer pain at a time of increasing restrictions. Drug Alcohol Rev 2024; 43:1625-1635. [PMID: 38803123 DOI: 10.1111/dar.13879] [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: 08/10/2023] [Revised: 04/11/2024] [Accepted: 05/09/2024] [Indexed: 05/29/2024]
Abstract
INTRODUCTION Many countries have implemented strategies to reduce opioid-related harms, including policies and prescribing restrictions. This study aimed to explore the lived experiences of Australians prescribed opioids for chronic non-cancer pain (CNCP) in the context of increasing restrictions for accessing opioids. METHODS Semi-structured interviews were conducted with 14 Australians (aged 24-65-years; 10 female/4 male) self-reporting regular use of prescribed opioids for CNCP. Participants were asked to describe their experiences using prescribed opioids, and perceived and actual changes in pain management including access to treatments. Using thematic analysis, four dominant themes were identified. RESULTS In 'On them for a reason': Opioids as a last resort, participants described the role of opioids as an important tool for pain management following unsuccessful treatment using other strategies. In 'You're problematic': Deepening stigma, participants described how increased attention and restrictions led to increasing stigma of opioid use and CNCP. In 'We didn't cause the opioid epidemic': Perceiving and redirecting blame, participants described feeling unfairly blamed for public health problems and an 'opioid epidemic' they described as 'imported' from America, drawing distinctions between legitimate and illegitimate opioid use. Finally, in 'Where do we go from here?': Fearing the future, participants described anticipating further restrictions and associating these with increased pain and disability. DISCUSSION AND CONCLUSIONS The experience of being prescribed opioids for CNCP in Australia in the context of increasing restrictions was characterised by stigma, blame and fear. There is a need to ensure people prescribed opioids for pain are considered when designing measures to reduce opioid-related harms.
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Affiliation(s)
- Ria E Hopkins
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Gabrielle Campbell
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
- School of Psychology, University of Queensland, Brisbane, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Natasa Gisev
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
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Woodcock C, Cornwall N, Dikomitis L, Harrisson SA, White S, Helliwell T, Knaggs R, Hodgson E, Pincus T, Santer M, Mallen CD, Ashworth J, Jinks C. Designing a primary care pharmacist-led review for people treated with opioids for persistent pain: a multi-method qualitative study. BJGP Open 2024:BJGPO.2023.0221. [PMID: 38631722 DOI: 10.3399/bjgpo.2023.0221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 03/04/2024] [Accepted: 03/26/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Opioids are frequently prescribed for persistent non-cancer pain despite limited evidence of long-term effectiveness and risk of harm. Evidence-based interventions to address inappropriate opioid prescribing are lacking. AIM To explore perspectives of people living with persistent pain to understand barriers and facilitators in reducing opioids in the context of a pharmacist-led primary care review, and identify review components and features for optimal delivery. DESIGN & SETTING A multi-method qualitative study undertaken in the primary care setting in the UK. METHOD Adults with experience of persistent pain and taking opioids participated in semi-structured interviews (n = 15, 73% female) and an online discussion forum (n = 31). The Theoretical Domains Framework (TDF) provided a framework for data collection and thematic analysis, involving deductive analysis to TDF domains, inductive analysis within domains to generate sub-themes, and sub-theme comparison to form across-domain overarching themes. The behaviour change technique taxonomy (v1) and motivational behaviour change technique classification system were used to systematically map themes to behaviour change techniques to identify potential review components and delivery features. RESULTS Thirty-two facilitator and barrier sub-themes for patients reducing opioids were identified across 13 TDF domains. These combined into the following six overarching themes: learning to live with pain; opioid reduction expectations; assuming a medical model; pharmacist-delivered reviews; pharmacist-patient relationship; and patient engagement. Sub-themes mapped to 21 unique behaviour change techniques, yielding 17 components and five delivery features for the proposed PROMPPT review. CONCLUSION This study generated theoretically informed evidence for design of a practice pharmacist-led PROMPPT review. Future research will test the feasibility and acceptability of the PROMPPT review and pharmacist training.
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Affiliation(s)
- Charlotte Woodcock
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Keele, UK
| | - Nicola Cornwall
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Keele, UK
| | - Lisa Dikomitis
- Centre for Health Services Studies and Kent and Medway Medical School, University of Kent, Canterbury, UK
| | - Sarah A Harrisson
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Keele, UK
- Midlands Partnership University NHS Foundation Trust, Haywood Hospital, High Lane, Burslem, Stoke on Trent, UK
| | - Simon White
- School of Pharmacy and Bioengineering, Keele University, Keele, United Kingdom
| | - Toby Helliwell
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Keele, UK
- Midlands Partnership University NHS Foundation Trust, Haywood Hospital, High Lane, Burslem, Stoke on Trent, UK
| | - Roger Knaggs
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK
- Primary Integrated Community Services Ltd, Nottingham, UK
| | | | - Tamar Pincus
- Department of Psychology, University of Southampton, Southampton, UK
| | - Miriam Santer
- Primary Care Research Centre, University of Southampton, Southampton, UK
| | - Christian D Mallen
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Keele, UK
- Midlands Partnership University NHS Foundation Trust, Haywood Hospital, High Lane, Burslem, Stoke on Trent, UK
| | - Julie Ashworth
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Keele, UK
- Midlands Partnership University NHS Foundation Trust, Haywood Hospital, High Lane, Burslem, Stoke on Trent, UK
| | - Clare Jinks
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Keele, UK
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Montgomery C, Poole HM, Begley E, Abbasi Y. Taking the pain out of pain. Br J Pain 2023; 17:514-518. [PMID: 37969134 PMCID: PMC10642502 DOI: 10.1177/20494637231208167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023] Open
Affiliation(s)
| | - Helen M Poole
- School of Psychology, Liverpool John Moores University, Liverpool, UK
| | - Emma Begley
- School of Psychology, Aston University, Birmingham, UK
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Haines S, Savic M, Nielsen S, Carter A. Opioid-related policy changes: Experiences and perspectives from people who use opioids to manage non-cancer chronic pain. Drug Alcohol Rev 2023; 42:1482-1492. [PMID: 37254597 PMCID: PMC10946843 DOI: 10.1111/dar.13683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 04/17/2023] [Accepted: 04/17/2023] [Indexed: 06/01/2023]
Abstract
INTRODUCTION People who use prescription opioids to manage non-cancer chronic pain are particularly vulnerable to opioid-related policy change. This study aims to better understand what prescription opioids provide this population, what concerns they have in the context of new and changing opioid policies, such as the recently implemented prescription drug monitoring program in Victoria, Australia, their experiences of prescription opioid use, chronic pain and what they would like their healthcare to look like. METHODS Semi-structured interviews were conducted with 30 people who use opioids to manage chronic non-cancer pain. RESULTS Prescription opioids played an important role in supporting quality of life and mental health. However, experiences of stigma and lack of empathy from healthcare providers were common. Participants sought accurate information about their medications and expressed a desire for shared decision-making in healthcare. DISCUSSION AND CONCLUSION Prescription opioids can play an important role in pain management as well as social and psychological functioning for people living with non-cancer chronic pain. Opioid-related policy changes to medication availability need to consider the potential impacts that reducing, limiting or discontinuing opioids may have on this population. Including the voices of people who use prescription opioids to manage non-cancer chronic pain in respectful, compassionate and meaningful ways.
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Affiliation(s)
- Sarah Haines
- Turner Institute for Brain and Mental HealthMonash UniversityMelbourneAustralia
| | - Michael Savic
- Turning Point, Eastern HealthMelbourneAustralia
- Monash Addiction Research CentreMonash UniversityMelbourneAustralia
| | - Suzanne Nielsen
- Monash Addiction Research CentreMonash UniversityMelbourneAustralia
| | - Adrian Carter
- Turner Institute for Brain and Mental HealthMonash UniversityMelbourneAustralia
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Ljungvall H, Lind AL, Zetterberg H, Wagner S, Ekselius L, Karlsten R, Heilig M, Åsenlöf P. U-PAIN cohort study among patients with chronic pain in specialised pain care: a feasibility study. BMJ Open 2022; 12:e062265. [PMID: 36517106 PMCID: PMC9756188 DOI: 10.1136/bmjopen-2022-062265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES To examine acceptability of study participation and feasibility of (1) recruitment, (2) data collection and (3) outcome measures for the prospective U-PAIN cohort. DESIGN Internal feasibility study of a prospective cohort. PARTICIPANTS AND SETTING 64 patients, >18 years, with chronic pain at a multidisciplinary pain centre at a university hospital in Sweden. OUTCOME MEASURES Acceptability of study participation was measured with a study-specific 10-item Likert scale. A score <3 was considered feasible, for the two items that assessed respondent burden a higher score indicated lesser participant burden and a score >3 was feasible. Recruitment was assessed by participation rates at baseline and retention at the 1-year follow-up, with threshold values for feasibility at 75% and 80%, respectively. Data collection and outcome measures were examined by completions rates of study procedures (90% was considered feasible), sample scores, internal consistency (α>0.70 was considered feasible), and agreement between self-reported data and data retrieved from medical records on opioid use (ICC or κ>0.60 was considered feasible). RESULTS Acceptability for study procedures was feasible, but participation rates were low: 25%. The retention rate at 1-year follow-up was 81% for those included in the feasibility study, that is, filling out computerised patient-reported outcome measures, and 65% for those using paper and pencil format. The completion rates for the different data collection methods ranged from 83% to 95%. Agreement between self-reported opioid use and prescribed dose and between opioid use disorder according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), and clinical International Classification of Diseases-10 (ICD-10) diagnoses for opioid dependence were almost perfect (κ=0.91 and κ=0.90, respectively). CONCLUSIONS This feasibility study has helped to explore and improve methods for recruitment, data collection and use of outcome measures for the U-PAIN cohort. Low participation rate and high refusal rate at baseline is a challenge that needs to be further addressed.
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Affiliation(s)
- Hanna Ljungvall
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Anne-Li Lind
- Department of Neuroscience, Uppsala Universitet, Uppsala, Sweden
| | - Hedvig Zetterberg
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Sofia Wagner
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Lisa Ekselius
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Rolf Karlsten
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Markus Heilig
- Department of Biomedical and Clinical Sciences, Linkopings universitet, Linkoping, Sweden
| | - Pernilla Åsenlöf
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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Ljungvall H, Öster C, Katila L, Åsenlöf P. "Opioids are opioids" - A phenomenographic analyses of physicians' understanding of what makes the initial prescription of opioids become long-term opioid therapy. Scand J Pain 2022; 22:494-505. [PMID: 35172418 DOI: 10.1515/sjpain-2021-0171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 01/25/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To explore prescribers' understanding of what makes initial prescription of opioids become long-term opioid therapy (opioids >90 days). METHODS A qualitative research design, phenomenography, was used for this study. Fifteen attending physicians working within primary, secondary and tertiary care in Sweden in the fields of general practice, rehab medicine, orthopedic surgery, neurosurgery, or obstetrics and gynecology were purposively recruited consecutively until categorical saturation was reached. Semi-structured interviews were used for data collection. The transcripts were analyzed and categorized by two researchers. A third researcher checked for consistency between the data and the categories. An outcome space was constructed representing the logical relationship between the categories. RESULTS The analysis identified six categories: The addictive opioid, The deserving patient, The ignorant prescriber, The lost patient, The compassionate prescriber, and The exposed prescriber. The differences in conceptions among the categories were clarified through three main contributors related to opioid therapy: prescriber's characteristics, patient's characteristics, and the healthcare organization. CONCLUSIONS Opioids were understood as being addictive with long-term use promoting a downward spiral of tolerance and withdrawal driving the pain, leading to continued prescription. Long-term opioid therapy could be justified for patients who improved in function, and who were perceived as trustworthy. Inadequate follow-up of patients, poor training in pain management and addiction medicine, personal attitudes and beliefs about opioids, a perceived professional obligation to treat patients with pain, and lack of collegial support, were factors understood to promote clinically unindicated long-term opioid therapy.
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Affiliation(s)
- Hanna Ljungvall
- Department of Women's and Children's Health, Uppsala University, Sweden
- Department of Sociology, Centre for Social Work (CESAR), Uppsala University, Sweden
| | - Caisa Öster
- Department of Medical Sciences, Uppsala University, Sweden
| | - Lenka Katila
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Pernilla Åsenlöf
- Department of Women's and Children's Health, Uppsala University, Sweden
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Manhapra A. Complex Persistent Opioid Dependence-an Opioid-induced Chronic Pain Syndrome. Curr Treat Options Oncol 2022; 23:921-935. [PMID: 35435616 DOI: 10.1007/s11864-022-00985-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2022] [Indexed: 11/03/2022]
Abstract
OPINION STATEMENT Long-term opioid therapy (LTOT) for chronic cancer and non-cancer pain is commonly ineffective in providing its stated goal of improving function through good control of pain. Opioid tapering (slow dose reduction and/or discontinuation), the logical solution, also appears to be ineffective among many patients on LTOT as it often leads to even worse pain control and function, leaving the patients and providers managing LTOT in a clinical conundrum with little treatment choices. Complex persistent opioid dependence (CPOD) was recently offered as a heuristic to explain this clinical conundrum exemplified by the ineffectiveness of both LTOT and opioid tapering. This manuscript provides a detailed description of the neurobehavioral underpinnings of CPOD, explaining how long-term opioid use can lead to more pain even while experiencing relief with each opioid dose. CPOD is characterized by the allostatic opponent mechanisms of neuroadaptations related to the progression of opioid dependence and tolerance involving nociceptive/anti-nociceptive brain systems causing opioid-induced hyperalgesia and reward/anti-reward systems causing hyperkatefia or suffering that induces pain experience through the cognitive/emotional component of pain mechanisms. "Opioid Induced Chronic Pain syndrome" (OICP) is offered as an alternate clinical diagnostic term instead of CPOD that has several limitations as a diagnosis term including poor patient acceptance due to stigma towards addiction and clinical confounding with opioid use disorder, a related but separate clinical entity. OICP with LTOT is conceptualized as a recoverable iatrogenic problem that can be managed by pain providers. Broad guidance on management of OICP is also provided.
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Affiliation(s)
- Ajay Manhapra
- Pain Medicine, Hampton VA Medical Center, 100 Emancipation Drive, Hampton, VA, 23667, USA. .,New England Mental Illness Research Education and Clinical Center (MIRECC), West Haven, CT, USA. .,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA. .,Departments of Physical Medicine and Rehabilitation and Psychiatry, Eastern Virginia Medical School, Norfolk, VA, USA.
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Parkes T, Foster R, McAuley A, Steven D, Matheson C, Baldacchino A. Chronic pain, prescribed opioids and overdose risk: a qualitative exploration of the views of affected individuals and family members. DRUGS: EDUCATION, PREVENTION AND POLICY 2022. [DOI: 10.1080/09687637.2021.2022100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Tessa Parkes
- Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Rebecca Foster
- Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Andrew McAuley
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | | | - Catriona Matheson
- Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Alex Baldacchino
- Population and Behavioural Science Division, School of Medicine, University of St Andrews, St Andrews, UK
- NHS Addiction Services, NHS Fife, Kirkcaldy, UK
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9
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De Sola H, Maquibar A, Failde I, Salazar A, Goicolea I. Living with opioids: A qualitative study with patients with chronic low back pain. Health Expect 2020; 23:1118-1128. [PMID: 32558064 PMCID: PMC7696128 DOI: 10.1111/hex.13089] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 05/16/2020] [Accepted: 05/19/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Opioids are one of the most prescribed treatments for chronic pain (CP). However, their long-term use (>3 months) has been surrounded by controversy, due to loss of beneficial effects. OBJECTIVE To explore the experiences of people with chronic non-malignant low back pain in Spain undergoing long-term treatment with opioids. DESIGN Qualitative study. SETTING AND PARTICIPANTS We conducted 15 semi-structured interviews at the Pain Clinic with persons taking opioid treatment. METHODS The interviews were analysed by qualitative content analysis as described by Graneheim and Lundman, and developed categories and themes discussed in light of a biomedicalization framework. MAIN RESULTS We developed one overarching theme-Living with opioids: dependence and autonomy while seeking relief-and three categories: The long pathway to opioids due to the invisibility of pain; Opioids: from blind date to a long-term relationship; and What opioids cannot fix. DISCUSSION The long and difficult road to find effective treatments was a fundamental part of coping with pain, involving long-term relationships with the health system. This study reflects the benefits, and drawbacks of opioids, along with struggles to maintain autonomy and make decisions while undergoing long-term treatment with opioids. The paper also highlights the consequences of pain in the economy, family and social life of patients. CONCLUSIONS Patients' experiences should be considered to a greater extent by health-care professionals when giving information about opioids and setting treatment goals. Greater consideration of the social determinants of health that affect CP experiences might lead to more effective solutions to CP.
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Affiliation(s)
- Helena De Sola
- The Observatory of Pain, University of Cádiz, Cádiz, Spain.,Biomedical Research and Innovation Institute of Cádiz (INiBICA), Cádiz, Spain.,Preventive Medicine and Public Health Area, Cádiz, Spain
| | - Amaia Maquibar
- Department of Nursing I, Faculty of Medicine and Nursing, University of the Basque Country UPV/EHU, Leioa, Bizkaia, Spain
| | - Inmaculada Failde
- The Observatory of Pain, University of Cádiz, Cádiz, Spain.,Biomedical Research and Innovation Institute of Cádiz (INiBICA), Cádiz, Spain.,Preventive Medicine and Public Health Area, Cádiz, Spain
| | - Alejandro Salazar
- The Observatory of Pain, University of Cádiz, Cádiz, Spain.,Biomedical Research and Innovation Institute of Cádiz (INiBICA), Cádiz, Spain.,Department of Statistics and Operational Research, University of Cádiz, Cádiz, Spain
| | - Isabel Goicolea
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
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