1
|
Wesolowicz DM, Spelman JF, Edmond SN, Schwartz AR, Kravetz JD, Edens EL, Becker WC. Increasing buprenorphine access for patients with chronic pain: a quality improvement initiative. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:226-230. [PMID: 37847654 DOI: 10.1093/pm/pnad140] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 10/06/2023] [Accepted: 10/12/2023] [Indexed: 10/19/2023]
Abstract
OBJECTIVE Buprenorphine is effective for chronic pain and safer than full-agonist opioids; however, limited education about and support for buprenorphine can result in under-prescribing in primary care and reduced access in specialty pain clinics. The purpose of this quality improvement initiative was to optimize and evaluate procedures for transferring patients stable on buprenorphine for chronic pain from a specialty pain clinic back to primary care. SETTING Eight primary care clinics within a Veterans Health Administration health care system. METHODS A standard operating procedure for facilitated transfer of prescribing was developed after a needs assessment and was introduced during an educational session with primary care providers, and providers completed a survey assessing attitudes about buprenorphine prescribing. Success of the initiative was measured through the number of patients transferred back to primary care over the course of 18 months. RESULTS Survey results indicated that primary care providers with previous experience prescribing buprenorphine were more likely to view buprenorphine prescribing for pain as within the scope of their practice and to endorse feeling comfortable managing a buprenorphine regimen. Providers identified systemic and educational barriers to prescribing, and they identified ongoing support from specialty pain care and primary care as a facilitator of prescribing. Metrics suggested that the standard operating procedure was generally successful in transferring and retaining eligible patients in primary care. CONCLUSION This quality improvement initiative suggests that a facilitated transfer procedure can be useful in increasing buprenorphine prescribing for pain in primary care. Future efforts to increase primary care provider comfort and address systemic barriers to buprenorphine prescribing are needed.
Collapse
Affiliation(s)
- Danielle M Wesolowicz
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT 06516, United States
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06504, United States
| | - Juliette F Spelman
- VA Connecticut Healthcare System, West Haven, CT 06516, United States
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT 06504, United States
| | - Sara N Edmond
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT 06516, United States
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06504, United States
| | - Amy R Schwartz
- VA Connecticut Healthcare System, West Haven, CT 06516, United States
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT 06504, United States
| | - Jeffrey D Kravetz
- VA Connecticut Healthcare System, West Haven, CT 06516, United States
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT 06504, United States
| | - Ellen L Edens
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06504, United States
- VA Connecticut Healthcare System, West Haven, CT 06516, United States
| | - William C Becker
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT 06516, United States
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT 06504, United States
| |
Collapse
|
2
|
Jones KF, Khodyakov D, Han BH, Arnold RM, Dao E, Morrison J, Kapo J, Meier DE, Paice JA, Liebschutz JM, Ritchie CS, Merlin JS, Bulls HW. Expert consensus-based guidance on approaches to opioid management in individuals with advanced cancer-related pain and nonmedical stimulant use. Cancer 2023; 129:3978-3986. [PMID: 37691479 PMCID: PMC10910244 DOI: 10.1002/cncr.34921] [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: 02/13/2023] [Revised: 03/19/2023] [Accepted: 04/17/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND Clinicians treating cancer-related pain with opioids regularly encounter nonmedical stimulant use (i.e., methamphetamine, cocaine), yet there is little evidence-based management guidance. The aim of the study is to identify expert consensus on opioid management strategies for an individual with advanced cancer and cancer-related pain with nonmedical stimulant use according to prognosis. METHODS The authors conducted two modified Delphi panels with palliative care and addiction experts. In Panel A, the patient's prognosis was weeks to months and in Panel B the prognosis was months to years. Experts reviewed, rated, and commented on the case using a 9-point Likert scale from 1 (very inappropriate) to 9 (very appropriate) and explained their responses. The authors applied the three-step analytical approach outlined in the RAND/UCLA to determine consensus and level of clinical appropriateness of management strategies. To better conceptualize the quantitative results, they thematically analyzed and coded participant comments. RESULTS Consensus was achieved for all management strategies. The 120 Experts were mostly women (47 [62%]), White (94 [78%]), and physicians (115 [96%]). For a patient with cancer-related and nonmedical stimulant use, regardless of prognosis, it was deemed appropriate to continue opioids, increase monitoring, and avoid opioid tapering. Buprenorphine/naloxone transition was inappropriate for a patient with a short prognosis and of uncertain appropriateness for a patient with a longer prognosis. CONCLUSION Study findings provide urgently needed consensus-based guidance for clinicians managing cancer-related pain in the context of stimulant use and highlight a critical need to develop management strategies to address stimulant use disorder in people with cancer. PLAIN LANGUAGE SUMMARY Among palliative care and addiction experts, regardless of prognosis, it was deemed appropriate to continue opioids, increase monitoring, and avoid opioid tapering in the context of cancer-related pain and nonmedical stimulant use. Buprenorphine/naloxone transition as a harm reduction measure was inappropriate for a patient with a short prognosis and of uncertain appropriateness for a patient with a longer prognosis.
Collapse
Affiliation(s)
- Katie Fitzgerald Jones
- New England Geriatric Research, Education and Clinical Center and Division of Palliative Care, VA Boston Healthcare System, Boston, Massachusetts, USA
| | | | - Benjamin H. Han
- Division of Geriatrics, Gerontology, and Palliative Care, University of California, San Diego, California, USA
| | - Robert M. Arnold
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Emily Dao
- RAND Corporation, Santa Monica, California, USA
| | - Jeni Morrison
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jennifer Kapo
- Palliative Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Diane E. Meier
- Department of Geriatrics and Palliative Medicine, Center to Advance Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Judith A. Paice
- Division Hematology-Oncology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jane M. Liebschutz
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christine S. Ritchie
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jessica S. Merlin
- Challenges in Managing and Preventing Pain Clinical Research Center, Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hailey W. Bulls
- Challenges in Managing and Preventing Pain Clinical Research Center, Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
3
|
Rogers DG, Frank JW, Wesolowicz DM, Nolan C, Schroeder A, Falker C, Abelleira A, Moore BA, Becker WC, Edmond SN. Video-telecare collaborative pain management during COVID-19: a single-arm feasibility study. BMC PRIMARY CARE 2023; 24:134. [PMID: 37386370 PMCID: PMC10308713 DOI: 10.1186/s12875-023-02052-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 04/02/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Chronic pain is among the most common conditions presenting to primary care and guideline-based care faces several challenges. A novel pain management program, Video-Telecare Collaborative Pain Management (VCPM), was established to support primary care providers and meet new challenges to care presented by the COVID-19 pandemic. METHODS The present single-arm feasibility study aimed to evaluate the feasibility and acceptability of VCPM and its components among U.S. veterans on long-term opioid therapy for chronic pain at ≥ 50 mg morphine equivalent daily dose (MEDD). VCPM consists of evidence-based interventions, including opioid reassessment and tapering, rotation to buprenorphine and monitoring, and encouraging behavioral pain and opioid-use disorder self-management. RESULTS Of the 133 patients outreached for VPCM, 44 completed an initial intake (33%) and 19 attended multiple VCPM appointments (14%). Patients were generally satisfied with VCPM, virtual modalities, and provider interactions. Nearly all patients who attended multiple appointments maintained a buprenorphine switch or tapered opioids (16/19; 84%), and buprenorphine switches were generally reported as acceptable by patients. Patients completing an initial intake with VCPM had reduced morphine equivalent daily dose after three months (means = 109 mg MEDD vs 78 mg), with greater reductions among those who attended multiple appointments compared to intake only (ΔMEDD = -58.1 vs. -8.40). Finally, 29 referrals were placed for evidence-based non-pharmacologic interventions. CONCLUSION Pre-defined feasibility and acceptability targets for VCPM and its components were broadly met, and preliminary data are encouraging. Novel strategies to improve enrollment and engagement and future directions are discussed.
Collapse
Affiliation(s)
- Daniel G. Rogers
- VA Connecticut Healthcare System, West Haven, CT USA
- Department of Psychiatry, Yale School of Medicine, West Haven, USA
| | - Joseph W. Frank
- VA Eastern Colorado Health Care System, Aurora, USA
- University of Colorado School of Medicine, Aurora, USA
| | - Danielle M. Wesolowicz
- VA Connecticut Healthcare System, West Haven, CT USA
- Department of Psychiatry, Yale School of Medicine, West Haven, USA
| | | | | | - Caroline Falker
- VA Connecticut Healthcare System, West Haven, CT USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, USA
| | - Audrey Abelleira
- VA Connecticut Healthcare System, West Haven, CT USA
- Department of Psychiatry, Yale School of Medicine, West Haven, USA
| | - Brent A. Moore
- VA Connecticut Healthcare System, West Haven, CT USA
- Department of Psychiatry, Yale School of Medicine, West Haven, USA
| | - William C. Becker
- VA Connecticut Healthcare System, West Haven, CT USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, USA
| | - Sara N. Edmond
- VA Connecticut Healthcare System, West Haven, CT USA
- Department of Psychiatry, Yale School of Medicine, West Haven, USA
| |
Collapse
|
4
|
Powell VD, Macleod C, Sussman J, Lin LA, Bohnert ASB, Lagisetty P. Variation in Clinical Characteristics and Longitudinal Outcomes in Individuals with Opioid Use Disorder Diagnosis Codes. J Gen Intern Med 2023; 38:699-706. [PMID: 35819683 PMCID: PMC9971398 DOI: 10.1007/s11606-022-07732-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 06/28/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Patterns of opioid use vary, including prescribed use without aberrancy, limited aberrant use, and potential opioid use disorder (OUD). In clinical practice, similar opioid-related International Classification of Disease (ICD) codes are applied across this spectrum, limiting understanding of how groups vary by sociodemographic factors, comorbidities, and long-term risks. OBJECTIVE (1) Examine how Veterans assigned opioid abuse/dependence ICD codes vary at diagnosis and with respect to long-term risks. (2) Determine whether those with limited aberrant use share more similarities to likely OUD vs those using opioids as prescribed. DESIGN Longitudinal observational cohort study. PARTICIPANTS National sample of Veterans categorized as having (1) likely OUD, (2) limited aberrant opioid use, or (3) prescribed, non-aberrant use based upon enhanced medical chart review. MAIN MEASURES Comparison of sociodemographic and clinical factors at diagnosis and rates of age-adjusted mortality, non-fatal opioid overdose, and hospitalization after diagnosis. An exploratory machine learning analysis investigated how closely those with limited aberrant use resembled those with likely OUD. KEY RESULTS Veterans (n = 483) were categorized as likely OUD (62.1%), limited aberrant use (17.8%), and prescribed, non-aberrant use (20.1%). Age, proportion experiencing homelessness, chronic pain, anxiety disorders, and non-opioid substance use disorders differed by group. All-cause mortality was high (44.2 per 1000 person-years (95% CI 33.9, 56.7)). Hospitalization rates per 1000 person-years were highest in the likely OUD group (831.5 (95% CI 771.0, 895.5)), compared to limited aberrant use (739.8 (95% CI 637.1, 854.4)) and prescribed, non-aberrant use (411.9 (95% CI 342.6, 490.4). The exploratory analysis reclassified 29.1% of those with limited aberrant use as having likely OUD with high confidence. CONCLUSIONS Veterans assigned opioid abuse/dependence ICD codes are heterogeneous and face variable long-term risks. Limited aberrant use confers increased risk compared to no aberrant use, and some may already have OUD. Findings warrant future investigation of this understudied population.
Collapse
Affiliation(s)
- Victoria D Powell
- Palliative Care Program, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, MI, USA.
- Geriatrics Research, Education, and Clinical Center, LTC Charles S. Kettles VA Medical Center, Ann Arbor, MI, USA.
| | - Colin Macleod
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jeremy Sussman
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Lewei A Lin
- VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Amy S B Bohnert
- VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Pooja Lagisetty
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| |
Collapse
|
5
|
Bruneau A, Poirier C, Bérubé M, Boulanger A, Gélinas C, Guénette L, Lacasse A, Lussier D, Tousignant-Laflamme Y, Pagé MG, Martel MO. French-Canadian Translation and Cultural Adaptation of the Clinical Opiate Withdrawal Scale: The COWS-FC. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2022; 67:701-711. [PMID: 35290134 PMCID: PMC9449138 DOI: 10.1177/07067437221087066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The main objective of the present study was to develop a French-Canadian translation and adaptation of the COWS (i.e., the COWS-FC) for the assessment of opioid withdrawal symptoms in clinical and research settings. METHODS The French-Canadian translation and cultural adaptation of the COWS was performed following guidelines for the translation and cross-cultural adaptation of self-report measures. The steps consisted of (1) initial translation from English to French, (2) synthesis of the translation, (3) back-translation from French to English, (4) expert committee meeting, (5) test of the prefinal version among healthcare professionals and (6) review of final version by the expert committee. The expert committee considered four major areas where the French-Canadian version should achieve equivalence with the original English-version of the COWS. These areas were (1) semantic equivalence; (2) idiomatic equivalence; (3) experiential equivalence and (4) conceptual equivalence. RESULTS Rigorous steps based on the guidelines for the translation and cultural adaptation of assessment tools were followed, which led to a semantically equivalent version of the COWS. After a pretest among healthcare professionals, members from the expert committee agreed upon slight modifications to the French-Canadian version of the COWS to yield a final COWS-FC version. CONCLUSIONS A French-Canadian translation and adaptation of the COWS (i.e., the COWS-FC) was developed. The COWS-FC could be used for the assessment of opioid withdrawal symptoms in clinical and research settings.
Collapse
Affiliation(s)
- Alice Bruneau
- Faculty of Medicine, 5620McGill University, Montreal, Quebec, Canada
| | - Clarice Poirier
- Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Mélanie Bérubé
- Faculty of Nursing, Université Laval, Québec City, Quebec, Canada.,177460Centre de recherche du Centre hospitalier universitaire de Québec, Population Health and Optimal Health Practices Research Unit, Québec City, Quebec, Canada
| | - Aline Boulanger
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada.,Pain Clinic, Centre hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Céline Gélinas
- Ingram School of Nursing, 5620McGill University, Montreal, Quebec, Canada
| | - Line Guénette
- 177460Centre de recherche du Centre hospitalier universitaire de Québec, Population Health and Optimal Health Practices Research Unit, Québec City, Quebec, Canada.,Faculty of Pharmacy, 4440Laval University, Quebec City, Quebec, Canada
| | - Anaïs Lacasse
- Department of Health Sciences, 7001Université du Québec en Abitibi-Témiscamingue, Rouyn-Noranda, Quebec, Canada
| | - David Lussier
- Centre de recherche, l'Institut universitaire de gériatrie de Montréal du CIUSSS du Centre-Sud-de-l'Ile-de Montréal, Montreal, Quebec, Canada.,Département de médecine, Faculté de médecine, Université de Montréal, Montreal, Quebec, Canada
| | - Yannick Tousignant-Laflamme
- School of Rehabilitation, Faculty of Medicine and Health Sciences, 7321Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - M Gabrielle Pagé
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada.,Centre de recherche, Centre hospitalier de l'5622Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| | - Marc O Martel
- Faculty of Dentistry & Department of Anesthesiology, 5620McGill University, Montreal, Quebec, Canada
| | | |
Collapse
|
6
|
Fitzgerald Jones K, Ho J, Sager Z, Broglio K, Wilson Childers J. Sublingual Buprenorphine Initiation: The Traditional Method #441. J Palliat Med 2022; 25:1151-1153. [PMID: 35775890 DOI: 10.1089/jpm.2022.0135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
|
7
|
Fitzgerald Jones K, Khodyakov D, Arnold R, Bulls H, Dao E, Kapo J, Meier D, Paice J, Liebschutz J, Ritchie C, Merlin J. Consensus-Based Guidance on Opioid Management in Individuals With Advanced Cancer-Related Pain and Opioid Misuse or Use Disorder. JAMA Oncol 2022; 8:1107-1114. [PMID: 35771550 DOI: 10.1001/jamaoncol.2022.2191] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Opioid misuse and opioid use disorder (OUD) are important comorbidities in people with advanced cancer and cancer-related pain, but there is a lack of consensus on treatment. Objective To develop consensus among palliative care and addiction specialists on the appropriateness of various opioid management strategies in individuals with advanced cancer-related pain and opioid misuse or OUD. Design, Setting, and Participants For this qualitative study, using ExpertLens, an online platform and methodology for conducting modified Delphi panels, between August and October 2020, we conducted 2 modified Delphi panels to understand the perspectives of palliative and addiction clinicians on 3 common clinical scenarios varying by prognosis (weeks to months vs months to years). Of the 129 invited palliative or addiction medicine specialists, 120 participated in at least 1 round. A total of 84 participated in all 3 rounds. Main Outcomes and Measures Consensus was investigated for 3 clinical scenarios: (1) a patient with a history of an untreated opioid use disorder, (2) a patient taking more opioid than prescribed, and (3) a patient using nonprescribed benzodiazepines. Results Participants were mostly women (47 [62%]), White (94 (78 [65%]), and held MD/DO degrees (115 [96%]). For a patient with untreated OUD, regardless of prognosis, it was deemed appropriate to begin treatment with buprenorphine/naloxone and inappropriate to refer to a methadone clinic. Beginning split-dose methadone was deemed appropriate for patients with shorter prognoses and of uncertain appropriateness for those with longer prognoses. Beginning a full opioid agonist was deemed of uncertain appropriateness for those with a short prognosis and inappropriate for those with a longer prognosis. Regardless of prognosis, for a patient with no medical history of OUD taking more opioids than prescribed, it was deemed appropriate to increase monitoring, inappropriate to taper opioids, and of uncertain appropriateness to increase the patient's opioids or transition to buprenorphine/naloxone. For a patient with a urine drug test positive for non-prescribed benzodiazepines, regardless of prognosis, it was deemed appropriate to increase monitoring, inappropriate to taper opioids and prescribe buprenorphine/naloxone. Conclusions and Relevance The findings of this qualitative study provide urgently needed consensus-based guidance for clinicians and highlight critical research and policy gaps.
Collapse
Affiliation(s)
- Katie Fitzgerald Jones
- William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts.,VA Boston Healthcare System, Boston, Massachusetts
| | | | - Robert Arnold
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Hailey Bulls
- CHAllenges in Managing and Preventing Pain (CHAMPP) Clinical Research Center, Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Emily Dao
- RAND Corporation, Santa Monica, California
| | - Jennifer Kapo
- MSCE Palliative Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Diane Meier
- Department of Geriatrics and Palliative Medicine, Center to Advance Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Judith Paice
- RN Feinberg School of Medicine, Division of Hematology-Oncology, Northwestern University, Chicago, Illinois
| | - Jane Liebschutz
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christine Ritchie
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston
| | - Jessica Merlin
- CHAllenges in Managing and Preventing Pain (CHAMPP) Clinical Research Center, Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
8
|
Sowicz TJ, Hausmann LRM. Veterans' Experiences of an Opioid Specialty Clinic. PAIN MEDICINE 2021; 22:2242-2251. [PMID: 33693898 DOI: 10.1093/pm/pnab096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Opioid specialty clinics have emerged as an approach for mitigating the risks associated with opioid therapies. Many opioid specialty clinics within the Department of Veterans Affairs (VA) have been described in the extant literature, yet veterans' experiences of these remain absent. This research study was undertaken to describe veterans' responses (e.g., knowledge, attitudes, and beliefs) toward being evaluated in an opioid specialty clinic. DESIGN Qualitative descriptive research study. SETTING A VA medical center in the northeast United States. SUBJECTS Twenty veterans were interviewed between December 2017 and May 2018. METHODS Veterans' characteristics were extracted from the VA's electronic health record and analyzed with descriptive statistics. Qualitative data about veterans' experiences with the opioid specialty clinic were collected via semistructured interviews (in person or via telephone) and were analyzed with qualitative content analysis. RESULTS Most participants were older, non-Hispanic or non-Latino white men. Generally, veterans had positive experiences in the opioid specialty clinic. However, there was wide variation in their understanding of the purpose of the clinic, who staffed the clinic, and why they had been referred to the clinic. CONCLUSIONS For veterans prescribed opioid therapies, this clinic served as an adjunct service for ensuring appropriate and safe prescribing. Data from this study can be used to inform interventions to promote veterans' understanding across the total opioid safety clinic experience-referral, actual visit, and follow-up.
Collapse
Affiliation(s)
- Timothy Joseph Sowicz
- UNC Greensboro, Department of Family and Community Nursing, Greensboro, North Carolina, USA
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Department of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
9
|
Day-to-day hedonic and calming effects of opioids, opioid craving, and opioid misuse among patients with chronic pain prescribed long-term opioid therapy. Pain 2021; 162:2214-2224. [PMID: 33729213 DOI: 10.1097/j.pain.0000000000002220] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 12/16/2020] [Indexed: 12/28/2022]
Abstract
ABSTRACT Concerns have been raised regarding the misuse of opioids among patients with chronic pain. Although a number of factors may contribute to opioid misuse, research has yet to examine if the hedonic and calming effects that can potentially accompany the use of opioids contribute to opioid misuse. The first objective of this study was to examine the degree to which the hedonic and calming effects of opioids contribute to opioid misuse in patients with chronic pain. We also examined whether the hedonic and calming effects of opioids contribute to patients' daily levels of opioid craving, and whether these associations were moderated by patients' daily levels of pain intensity, catastrophizing, negative affect, or positive affect. In this longitudinal diary study, patients (n = 103) prescribed opioid therapy completed daily diaries for 14 consecutive days. Diaries assessed a host of pain, psychological, and opioid-related variables. The hedonic and calming effects of opioids were not significantly associated with any type of opioid misuse behavior. However, greater hedonic and calming effects were associated with heightened reports of opioid craving (both P's < 0.005). Analyses revealed that these associations were moderated by patients' daily levels of pain intensity, catastrophizing, and negative affect (all P's < 0.001). Results from this study provide valuable new insights into our understanding of factors that may contribute to opioid craving among patients with chronic pain who are prescribed long-term opioid therapy. The implications of our findings for the management of patients with chronic pain are discussed.
Collapse
|
10
|
Martel MO, Bruneau A, Edwards RR. Mind-body approaches targeting the psychological aspects of opioid use problems in patients with chronic pain: evidence and opportunities. Transl Res 2021; 234:114-128. [PMID: 33676035 DOI: 10.1016/j.trsl.2021.02.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 02/26/2021] [Accepted: 02/26/2021] [Indexed: 12/27/2022]
Abstract
Opioids are commonly prescribed for the management of patients with chronic noncancer pain. Despite the potential analgesic benefits of opioids, long-term opioid therapy (LTOT) may be accompanied by problems such as opioid misuse and opioid use disorder (OUD). In this review, we begin with a description of opioid misuse and OUD and the patient-specific factors associated with these problems among patients with chronic pain. We will focus primarily on highlighting the predominant role played by psychological factors in the occurrence of opioid misuse and OUD in these patients. Several psychological factors have been found to be associated with opioid use problems in patients with chronic pain, and evidence indicates that patients presenting with psychological disturbances are particularly at risk of transitioning to long-term opioid use, engaging in opioid misuse behaviors, and developing OUD. The biological factors that might underlie the association between psychological disturbances and opioid use problems in patients with chronic pain have yet to be fully elucidated, but a growing number of studies suggest that dysfunctions in reward, appetitive, autonomic, and neurocognitive systems might be involved. We end with an overview of specific types of psychological interventions that have been put forward to prevent or reduce the occurrence of opioid misuse and OUD in patients with chronic pain who are prescribed LTOT.
Collapse
Affiliation(s)
- Marc O Martel
- Faculty of Dentistry & Department of Anesthesiology, McGill University, Montreal, Canada; Division of Experimental Medicine, McGill University, Montreal, Canada
| | - Alice Bruneau
- Division of Experimental Medicine, McGill University, Montreal, Canada
| | - Robert R Edwards
- Department of Anesthesiology & Pain Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| |
Collapse
|
11
|
Smith RG. Mitigating the opioid crisis for the lower extremity provider opioid stewardship programs. Foot (Edinb) 2020; 45:101708. [PMID: 33049426 DOI: 10.1016/j.foot.2020.101708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 06/04/2019] [Accepted: 06/18/2020] [Indexed: 02/04/2023]
Abstract
Opioids are an effective form of analgesia for pain treatment. Over prescribing of opioids agents have becom;1;e detrimental to the United States' public health. One of the most difficult challenges for any prescriber is to balance the potential benefits versus the potential risks of opioid prescribing. Addressing the opioid crisis requires an interprofessional team approach. The utilization of an opioid stewardship program provides the necessary frame work to identify gaps in the in quality and development in the implementation of a change of long standing opioid culture and practice. These programs address opioid prescribing, treatment for opioid use disorder, educational initiatives, and the use of information technology. A few acronyms have been created to assist providers to guide them when prescribing opioids. The purpose of this article is to explore the central theme of responsible opioid pain management. It will introduce, define, and defend with clinical base evidence a proposed acronym "MORPHINE" to assist and help shape prescription opioid strategies used for lower extremity pain. Implications for practicing lower extremity providers need to acknowledge the potential harm that prescribing opioids may cause to their patients. Opioid stewardship principles should become a priority in podiatric medicine and podiatric surgery.
Collapse
Affiliation(s)
- Robert G Smith
- Shoe String Podiatry, 723 Lucerne Circle, Ormond Beach, Florida 32174, USA
| |
Collapse
|
12
|
Viswanath A, Barreveld AM, Fortino M. Assessment and Management of the High-Risk Dental Patient with Active Substance Use Disorder. Dent Clin North Am 2020; 64:547-558. [PMID: 32448458 DOI: 10.1016/j.cden.2020.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Every dentist cares for patients with a history of substance use disorder (SUD), regardless of a patient's socioeconomic status, education, or ethnicity. SUD is a global epidemic, with approximately 8% of the general US population meeting diagnostic criteria for a SUD and more than 20% of the global population experiencing a SUD. The importance of understanding how to identify substance use, manage patients with a SUD, and offer appropriate referral is essential for all dental professionals. In 2005, the American Dental Association published, "Statement on Provision of Dental Treatment for Patients with Substance Use Disorders."
Collapse
Affiliation(s)
- Archana Viswanath
- Department of Oral and Maxillofacial Surgery, Tufts University School of Dental Medicine, 1 Kneeland Street, Boston, MA 02111, USA; Department of Diagnostic Sciences, Tufts University School of Dental Medicine, 1 Kneeland Street, Boston, MA 02111, USA
| | - Antje M Barreveld
- Department of Anesthesiology, Tufts University School of Medicine, 1 Kneeland Street, Boston, MA 02111, USA; Pain Management Services, Substance Use Services, Newton-Wellesley Hospital, Newton, MA, USA
| | - Matthew Fortino
- Department of Diagnostic Sciences, Center for Pain Medicine, Tufts University School of Dental Medicine, 1 Kneeland Street, Boston, MA 02111, USA; Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA.
| |
Collapse
|
13
|
Abstract
This paper is the fortieth consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2017 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).
Collapse
Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, CUNY, 65-30 Kissena Blvd., Flushing, NY, 11367, United States.
| |
Collapse
|
14
|
Merlin JS, Samet JH, Cheng DM, Lira MC, Tsui JI, Forman LS, Colasanti J, Walley AY, Del Rio C, Liebschutz JM. Marijuana Use and Its Associations With Pain, Opioid Dose, and HIV Viral Suppression Among Persons Living With HIV on Chronic Opioid Therapy. J Acquir Immune Defic Syndr 2019; 82:195-201. [PMID: 31513554 PMCID: PMC6746234 DOI: 10.1097/qai.0000000000002119] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Medical marijuana is legal in 29 US states and the District of Columbia: both HIV and chronic pain are "approved conditions" for receipt. Chronic pain is common among people living with HIV (PLWH). We anticipate PLWH will question their providers about medical marijuana for chronic pain. We examined marijuana use and its associations with pain, opioid dose, and HIV viral suppression among PLWH receiving chronic opioid therapy. METHODS PLWH prescribed chronic opioid therapy were recruited into the Targeting Effective Analgesia in Clinics for HIV cohort. The main exposure variable was any past 12-month marijuana use. The primary outcomes were (1) opioid misuse (≥9 on the Current Opioid Misuse Measure) and (2) opioid dose (morphine equivalent daily dose). HIV viral load (VL) suppression (<200 copies/μL) and pain severity and interference using the Brief Pain Inventory were exploratory outcomes. RESULTS Participants (n = 166) were men (65%), Black (72%), and had an undetectable VL (89%). We found no significant association between current marijuana use and opioid misuse, opioid dose, or pain. Current marijuana use was associated with 3.03 times the odds of having a detectable VL (95% odds ratio: 1.11-8.31, P = 0.03) while controlling for depressive symptoms and other substance use. DISCUSSION We did not detect an association between marijuana use and opioid misuse behaviors, opioid dose, or pain. In an exploratory analysis, current marijuana use was associated with 3× greater odds of having a detectable VL. This study provides insights into potential consequences of marijuana use among PLWH with chronic pain.
Collapse
Affiliation(s)
- Jessica S Merlin
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jeffrey H Samet
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA
- Department of Medicine, Boston University School of Medicine, Boston, MA
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA
| | - Debbie M Cheng
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Marlene C Lira
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA
| | - Judith I Tsui
- Section of General Internal Medicine, Department of Medicine, University of Washington and Harborview Medical Center, Seattle, WA
| | - Leah S Forman
- Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, MA
| | - Jonathan Colasanti
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Alexander Y Walley
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA
- Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Carlos Del Rio
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Jane M Liebschutz
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| |
Collapse
|
15
|
Nack B, Haas SE, Portnof J. Opioid Use Disorder in Dental Patients: The Latest on How to Identify, Treat, Refer and Apply Laws and Regulations in Your Practice. Anesth Prog 2018; 64:178-187. [PMID: 28858546 PMCID: PMC5579823 DOI: 10.2344/anpr-64-03-09] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 06/11/2017] [Indexed: 12/21/2022] Open
Abstract
Opioid use disorder is a persistent problem in the United States and has become an important issue to medical and dental professionals. Americans are the largest users of opioids by a large margin. The importance of knowing how to identify, handle, refer, and treat patients with opioid use disorder cannot be understated. This article attempts to educate dental professionals on the current epidemiology of opioid use, explain the physiology of addiction, teach practitioners how to identify chronic opioid users, gives options for treating dental pain, establishes criteria for referring to an addiction specialist, and describes the laws, regulations, and resources available to practitioners. With this article, practitioners should have a greater understanding of the current problem of opioid use disorder and be able to develop a protocol for treating these patients.
Collapse
Affiliation(s)
- Bryan Nack
- Resident, Oral and Maxillofacial Surgery Department, Nova Southeastern University College of Dental Medicine, Ft Lauderdale, Florida
| | - Steven E. Haas
- Associate Dean of Clinical Services, Nova Southeastern University College of Dental Medicine, Ft Lauderdale, Florida
| | - Jason Portnof
- Director, Pediatric Craniomaxillofacial Surgery, Department of Oral and Maxillofacial Surgery, Nova Southeastern University College of Dental Medicine; Associate Professor of Oral and Maxillofacial Surgery, Oral and Maxillofacial Surgery Department, Nova Southeastern University College of Dental Medicine, Ft Lauderdale, Florida
| |
Collapse
|
16
|
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.
Collapse
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
| |
Collapse
|