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Baltes A, Horton DM, Malicki J, Trevino C, Agarwal, S, Zarzaur BL, Brown RT. Pain management in trauma: the need for trauma-informed opioid prescribing guidelines. Trauma Surg Acute Care Open 2024; 9:e001294. [PMID: 38352958 PMCID: PMC10862252 DOI: 10.1136/tsaco-2023-001294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 01/27/2024] [Indexed: 02/16/2024] Open
Abstract
Background/objectives Surgical populations and particularly injury survivors often present with complex trauma that elevates their risk for prolonged opioid use and misuse. Changes in opioid prescribing guidelines during the past several years have yielded mixed results for pain management after trauma, with a limiting factor being the heterogeneity of clinical populations and treatment needs in individuals receiving opioids. The present analysis illuminates this gap between clinical guidelines and clinical practice through qualitative feedback from hospital trauma providers and unit staff members regarding current opioid prescribing guidelines and practices in the setting of traumatic injury. Methods The parent study aimed to implement a pilot screening tool for opioid misuse in four level I and II trauma hospitals throughout Wisconsin. As part of the parent study, focus groups were conducted at each study site to explore the facilitators and barriers of implementing a novel screening tool, as well as to examine the current opioid prescribing guidelines, trainings, and resources available for trauma and acute care providers. Focus group transcripts were independently coded and analyzed using a modified grounded theory approach to identify themes related to the facilitators and barriers of opioid prescribing guidelines in trauma and acute care. Results Three major themes were identified as impactful to opioid-related prescribing and care provided in the setting of traumatic injury; these include (1) acute treatment strategies; (2) patient interactions surrounding pain management; and (3) the multifactorial nature of trauma on pain management approaches. Conclusion Providers and staff at four Wisconsin trauma centers called for trauma-specific opioid prescribing guidelines in the setting of trauma and acute care. The ubiquitous prescription of opioids and challenges in long-term pain management in these settings necessitate additional community-integrated research to inform development of federal guidelines. Level of evidence Therapeutic/care management, level V.
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Affiliation(s)
- Amelia Baltes
- Department of Family Medicine and Community Health, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - David M Horton
- Department of Family Medicine and Community Health, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Julia Malicki
- Department of Family Medicine and Community Health, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Colleen Trevino
- Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Ben L Zarzaur
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Randall T Brown
- Department of Family Medicine and Community Health, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
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Baltes A, Horton D, Trevino C, Quanbeck A, Deyo B, Nicholas C, Brown R. Feasibility of implementing a screening tool for risk of opioid misuse in a trauma surgical population. IMPLEMENTATION RESEARCH AND PRACTICE 2024; 5:26334895231226193. [PMID: 38322804 PMCID: PMC10838038 DOI: 10.1177/26334895231226193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024] Open
Abstract
Background As the opioid crisis continues to affect communities across the United States, new interventions for screening and prevention are needed to mitigate its impact. Mental health diagnoses have been identified as a risk factor for opioid misuse, and surgical populations and injury survivors are at high risk for prolonged opioid use and misuse. This study investigated the implementation of a novel opioid risk screening tool that incorporated putative risk factors from a recent study in four trauma units across Wisconsin. Method The screening tool was implemented across a 6-month period at four sites. Data was collected via monthly meeting notes and "Plan, Do, Study, Act" (PDSA) forms. Following implementation, focus groups reflected on the facilitators and barriers to implementation. Meeting notes, PDSA forms, and focus group data were analyzed using the consolidated framework for implementation research, followed by thematic analyses, to generate themes surrounding the facilitators and barriers to implementing an opioid misuse screener. Results Implementation facilitators included ensuring patient understanding of the screener, minimizing staff burden from screening, and educating staff to encourage engagement. Barriers included infrastructure limitations that prevented seamless administration of the screener within current workflows, overlap of the screener with existing measures, and lack of guidance surrounding treatment options corresponding to risk. Recommended solutions to address barriers include careful timing of screener administration, accommodating workflows, integration of the screening tool within the electronic health record, and evidence-based interventions guided by screener results. Conclusion Four trauma centers across Wisconsin successfully implemented a pilot opioid misuse screening tool. Trauma providers and unit staff members believe that this tool would be a beneficial addition to their repertoire if their recommendations were adopted. Future research should refine opioid misuse risk factors and ensure screening items are well-validated with psychometric research supporting treatment responses to screener-indicated risk categories.
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Affiliation(s)
- Amelia Baltes
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - David Horton
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Colleen Trevino
- Department of Surgery, Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Andrew Quanbeck
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Brienna Deyo
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Christopher Nicholas
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Randall Brown
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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3
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Tilhou AS, Glass JE, Hetzel SJ, Shana OE, Borza T, Baltes A, Deyo BMF, Agarwal S, O'Rourke A, Brown RT. Association between spine injury and opioid misuse in a prospective cohort of Level I trauma patients. OTA Int 2022; 5:e205.1-6. [PMID: 36275837 PMCID: PMC9575565 DOI: 10.1097/oi9.0000000000000205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 03/20/2022] [Indexed: 11/25/2022]
Abstract
Objective To explore patient and treatment factors explaining the association between spine injury and opioid misuse. Design Prospective cohort study. Setting Level I trauma center in a Midwestern city. Participants English speaking patients aged 18 to 75 on Trauma and Orthopedic Surgical Services receiving opioids during hospitalization and prescribed at discharge. Exposure Spine injury on the Abbreviated Injury Scale. Main outcome measures Opioid misuse was defined by using opioids: in a larger dose, more often, or longer than prescribed; via a non-prescribed route; from someone other than a prescriber; and/or use of heroin or opium. Exploratory factor groups included demographic, psychiatric, pain, and treatment factors. Multivariable logistic regression estimated the association between spine injury and opioid misuse when adjusting for each factor group. Results Two hundred eighty-five eligible participants consented of which 258 had baseline injury location data and 224 had follow up opioid misuse data. Most participants were male (67.8%), white (85.3%) and on average 43.1 years old. One-quarter had a spine injury (25.2%). Of those completing follow-up measures, 14 (6.3%) developed misuse. Treatment factors (injury severity, intubation, and hospital length of stay) were significantly associated with spine injury. Spine injury significantly predicted opioid misuse [odds ratio [OR] 3.20, 95% confidence interval [CI] (1.05, 9.78)]. In multivariable models, adjusting for treatment factors attenuated the association between spine injury and opioid misuse, primarily explained by length of stay. Conclusion Spine injury exhibits a complex association with opioid misuse that predominantly operates through treatment factors. Spine injury patients may represent a subpopulation requiring early intervention to prevent opioid misuse.
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Affiliation(s)
- Alyssa Shell Tilhou
- Department of Family Medicine, Boston University/Boston Medical Center, Boston, MA
| | - Joseph E Glass
- Kaiser Permanente Washington Health Research Group, Seattle, WA
| | - Scott J Hetzel
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health
| | | | - Tudor Borza
- Departments of Urology and Surgery, University of Wisconsin School of Medicine and Public Health
| | - Amelia Baltes
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Bri M F Deyo
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Ann O'Rourke
- Department of Surgery, University of Wisconsin School of Medicine and Public Health
| | - Randall T Brown
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Sex differences in the association of adverse childhood experiences on past 30-day opioid misuse among Florida justice-involved children. J Subst Abuse Treat 2022; 140:108787. [DOI: 10.1016/j.jsat.2022.108787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 03/06/2022] [Accepted: 04/13/2022] [Indexed: 11/17/2022]
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Brown RT, Deyo B, Nicholas C, Baltes A, Hetzel S, Tilhou A, Quanbeck A, Glass J, O'Rourke A, Agarwal S. Screening in Trauma for Opioid Misuse Prevention (STOMP): Results from a prospective cohort of victims of traumatic injury. Drug Alcohol Depend 2022; 232:109286. [PMID: 35101814 DOI: 10.1016/j.drugalcdep.2022.109286] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 12/23/2021] [Accepted: 12/26/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Traumatic injury frequently requires opioid analgesia to manage pain and avoid catastrophic complications. Risk screening for opioid misuse and the development of use disorder remains uninvestigated. METHODS Participants were Trauma/Orthopedic Surgical Services patients at a Level I Trauma Center who were English speaking, aged 18-75, received an opioids prescription at discharge, and were under control of their own medications at discharge. Baseline measures included validated self-report instruments for psychosocial factors, such as anxiety, depression, pain coping, and social support. Health record data included diagnosis codes, procedures, Injury Severity Score, and pain severity (0-10 scale). Opioid use disorder (by Clinical International Diagnostic Interview-Substance Abuse Module) or opioid misuse (Current Opioid Misuse Measure (COMM) and survey items) were assessed at 24 weeks post-discharge. RESULTS 295 patients enrolled with 237 completing the 24 week assessments. Stepwise regression modeling demonstrated pre-injury PTSD symptoms, Opioid Risk score, medication use behaviors, social support, and length of stay predicted opioid misuse. Pre-injury PTSD symptoms, pain coping, and length of stay predicted use disorder. The final regression models for opioid misuse by COMM, opioid misuse via survey items, and for opioid use disorder had highly favorable areas under the receiver operating curve (0.880, 0.790, and 0.943 respectively). CONCLUSIONS Pre-injury presence of PTSD-related symptoms, impaired pain coping, social support, and hospitalization > 6 days predicted opioid misuse and opioid addiction at 6 months after hospital discharge. Behavioral screening and management strategies appear warranted in the population of traumatic injury victims to reduce opioid-related risks.
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Affiliation(s)
- Randall T Brown
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, USA.
| | - Brienna Deyo
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, USA.
| | - Christopher Nicholas
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, USA.
| | - Amelia Baltes
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, USA.
| | - Scott Hetzel
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, USA.
| | - Alyssa Tilhou
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, USA.
| | - Andrew Quanbeck
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, USA.
| | - Joseph Glass
- Kaiser Permanente Washington Health Research Group, USA.
| | - Ann O'Rourke
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, USA.
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Optimization of postoperative opioid prescriptions in gynecologic oncology: Striking a balance between opioid reduction and pain control. Gynecol Oncol 2021; 162:756-762. [PMID: 34226021 DOI: 10.1016/j.ygyno.2021.06.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/17/2021] [Accepted: 06/23/2021] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To implement a quality-improvement initiative to assess the impact various patient and procedural factors have on postoperative opioid use. To develop a tailored opioid prescribing algorithm for gynecologic oncology patients. METHODS A retrospective cohort study was performed of patients who underwent a laparoscopy or laparotomy procedure for a suspected or known gynecologic malignancy between 3/2019-9/2020. Patients were assessed preoperatively for the presence of suspected risk factors for opioid misuse (depression, anxiety, chronic pain, current opioid use, or substance abuse). Patients completed a 30-day postoperative questionnaire assessing for total opioid pill use and refills requests. Multivariate models were developed to estimate the independent effect of sociodemographic characteristics, risk factors for opioid misuse and procedural factors on patient reported postoperative opioid use. RESULTS A total of 390 patients were analyzed. Thirty-nine percent (N = 151/390) of patients reported not using opioids after discharge and 5% (N = 20/390) received an opioid refill. For both minimally invasive procedures and laparotomy procedures, body mass index, comorbidities, intraoperative or postoperative complications and final diagnosis of malignancy were not associated with the amount of opioid consumption. However, younger age and history of risk factors for opioid misuse significantly impacted postoperative opioid use. In multivariate analysis, age (p = 0.038) and risk factors (p < 0.001) remained significant after controlling for other factors. CONCLUSIONS Two out of every five patients did not use opioids after surgery. Younger patients and those with risk factors for opioid misuse need a tailored approach to prescribing opioids to balance the need for adequate pain control with the risk of misuse.
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Shah RF, Gwilym SE, Lamb S, Williams M, Ring D, Jayakumar P. Factors associated with persistent opioid use after an upper extremity fracture. Bone Jt Open 2021; 2:119-124. [PMID: 33595348 PMCID: PMC7925210 DOI: 10.1302/2633-1462.22.bjo-2020-0167.r1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Aims The increase in prescription opioid misuse and dependence is now a public health crisis in the UK. It is recognized as a whole-person problem that involves both the medical and the psychosocial needs of patients. Analyzing aspects of pathophysiology, emotional health, and social wellbeing associated with persistent opioid use after injury may inform safe and effective alleviation of pain while minimizing risk of misuse or dependence. Our objectives were to investigate patient factors associated with opioid use two to four weeks and six to nine months after an upper limb fracture. Methods A total of 734 patients recovering from an isolated upper limb fracture were recruited in this study. Opioid prescription was documented retrospectively for the period preceding the injury, and prospectively at the two- to four-week post-injury visit and six- to nine-month post-injury visit. Bivariate and multivariate analysis sought factors associated with opioid prescription from demographics, injury-specific data, Patient Reported Outcome Measurement Instrumentation System (PROMIS), Depression computer adaptive test (CAT), PROMIS Anxiety CAT, PROMIS Instrumental Support CAT, the Pain Catastrophizing Scale (PCS), the Pain Self-efficacy Questionnaire (PSEQ-2), Tampa Scale for Kinesiophobia (TSK-11), and measures that investigate levels of social support. Results A new prescription of opioids two to four weeks after injury was independently associated with less social support (odds ratio (OR) 0.26, p < 0.001), less instrumental support (OR 0.91, p < 0.001), and greater symptoms of anxiety (OR 1.1, p < 0.001). A new prescription of opioids six to nine months after injury was independently associated with less instrumental support (OR 0.9, p < 0.001) and greater symptoms of anxiety (OR 1.1, p < 0.001). Conclusion This study demonstrates that potentially modifiable psychosocial factors are associated with increased acute and chronic opioid prescriptions following upper limb fracture. Surgeons prescribing opioids for upper limb fractures should be made aware of the screening and management of emotional and social health. Cite this article: Bone Jt Open 2021;2(2):119–124.
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Affiliation(s)
- Romil Fenil Shah
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Texas, USA
| | - Stephen E Gwilym
- Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, Oxford University Hospitals, Oxford, UK
| | - Sarah Lamb
- Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, Oxford University Hospitals, Oxford, UK
| | - Mark Williams
- Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, Oxford University Hospitals, Oxford, UK
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Texas, USA
| | - Prakash Jayakumar
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Texas, USA.,Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, Oxford University Hospitals, Oxford, UK
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Clarke HA, Manoo V, Pearsall EA, Goel A, Feinberg A, Weinrib A, Chiu JC, Shah B, Ladak SSJ, Ward S, Srikandarajah S, Brar SS, McLeod RS. Consensus Statement for the Prescription of Pain Medication at Discharge after Elective Adult Surgery. Can J Pain 2020; 4:67-85. [PMID: 33987487 PMCID: PMC7951150 DOI: 10.1080/24740527.2020.1724775] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 01/30/2020] [Accepted: 01/30/2020] [Indexed: 12/12/2022]
Abstract
This Consensus Statement provides recommendations on the prescription of pain medication at discharge from hospital for opioid-naïve adult patients who undergo elective surgery. It encourages health care providers (surgeons, anesthesiologists, nurses/nurse practitioners, pain teams, pharmacists, allied health professionals, and trainees) to (1) use nonopioid therapies and reduce the prescription of opioids so that fewer opioid pills are available for diversion and (2) educate patients and their families/caregivers about pain management options after surgery to optimize quality of care for postoperative pain. These recommendations apply to opioid-naïve adult patients who undergo elective surgery. This consensus statement is intended for use by health care providers involved in the management and care of surgical patients. A modified Delphi process was used to reach consensus on the recommendations. First, the authors conducted a scoping review of the literature to determine current best practices and existing guidelines. From the available literature and expertise of the authors, a draft list of recommendations was created. Second, the authors asked key stakeholders to review and provide feedback on several drafts of the document and attend an in-person consensus meeting. The modified Delphi stakeholder group included surgeons, anesthesiologists, residents, fellows, nurses, pharmacists, and patients. After multiple iterations, the document was deemed complete. The recommendations are not graded because they are mostly based on consensus rather than evidence.
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Affiliation(s)
- Hance A. Clarke
- Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Transitional Pain Service, Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Anaesthesia, University of Toronto, Toronto, Ontario, Canada
- University of Toronto Centre for the Study of Pain, University of Toronto, Toronto, Ontario, Canada
| | - Varuna Manoo
- Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Transitional Pain Service, Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Emily A. Pearsall
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Akash Goel
- Transitional Pain Service, Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Anaesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Adina Feinberg
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Aliza Weinrib
- Transitional Pain Service, Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Jenny C. Chiu
- Department of Pharmacy, North York General Hospital, Toronto, Ontario, Canada
| | - Bansi Shah
- Transitional Pain Service, Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Salima S. J. Ladak
- Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Transitional Pain Service, Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Sarah Ward
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, St. Michaels Hospital, Toronto, Ontario, Canada
| | - Sanjho Srikandarajah
- Department of Anaesthesia, North York General Hospital, Toronto, Ontario, Canada
| | - Savtaj S. Brar
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Robin S. McLeod
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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9
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Blum K, Bowirrat A, Baron D, Lott L, Ponce JV, Brewer R, Siwicki D, Boyett B, Gondre-Lewis MC, Smith DE, Panayotis K T, Badgaiyan S, Hauser M, Fried L, A R, Downs BW, Badgaiyan RD. Biotechnical development of genetic addiction risk score (GARS) and selective evidence for inclusion of polymorphic allelic risk in substance use disorder (SUD). ACTA ACUST UNITED AC 2019; 6. [PMID: 33614164 PMCID: PMC7891477 DOI: 10.15761/jsin.1000221] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Research into the neurogenetic basis of addiction identified and characterized by Reward Deficiency Syndrome (RDS) includes all drug and non-drug addictive, obsessive and compulsive behaviors. We are proposing herein that a new model for the prevention and treatment of Substance Use Disorder (SUD) a subset of RDS behaviors, based on objective biologic evidence, should be given serious consideration in the face of a drug epidemic. The development of the Genetic Addiction Risk Score (GARS) followed seminal research in 1990, whereby, Blum’s group identified the first genetic association with severe alcoholism published in JAMA. While it is true that no one to date has provided adequate RDS free controls there have been many studies using case –controls whereby SUD has been eliminated. We argue that this deficiency needs to be addressed in the field and if adopted appropriately many spurious results would be eliminated reducing confusion regarding the role of genetics in addiction. However, an estimation, based on these previous literature results provided herein, while not representative of all association studies known to date, this sampling of case- control studies displays significant associations between alcohol and drug risk. In fact, we present a total of 110,241 cases and 122,525 controls derived from the current literature. We strongly suggest that while we may take argument concerning many of these so-called controls (e.g. blood donors) it is quite remarkable that there are a plethora of case –control studies indicating selective association of these risk alleles ( measured in GARS) for the most part indicating a hypodopaminergia. The paper presents the detailed methodology of the GARS. Data collection procedures, instrumentation, and the analytical approach used to obtain GARS and subsequent research objectives are described. Can we combat SUD through early genetic risk screening in the addiction field enabling early intervention by the induction of dopamine homeostasis? It is envisaged that GARS type of screening will provide a novel opportunity to help identify causal pathways and associated mechanisms of genetic factors, psychological characteristics, and addictions awaiting additional scientific evidence including a future meta- analysis of all available data –a work in progress.
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Affiliation(s)
- K Blum
- Western University Health Sciences Graduate School of Biomedical Sciences, Pomona, CA, USA.,Department of Precision Behavioral Management, Geneus Health, San Antonio, TX, USA.,Division Addiction Services, Dominion Diagnostics, LLC, North Kingston, RI, USA.,Division of Nutrigenomics, Victory Nutrition International. Inc. Lederach, PA, USA.,Divion of Neuroscience & Addiction Research, Pathway HealthCare, LLC, Birmingham, AL.,Institute of Psychology, ELTE Eötvös Loránd University, Budapest, Hungary.,Department of Psychiatry, University of Vermont, Burlington, VM. USA.,Centre for Genomics and Applied Gene Technology, Institute of Integrative Omics and Applied Biotechnology, Nonakuri, Purba Medinipur, West Bengal, India.,Department of Psychiatry, Wright State University Boonshoft School of Medicine and Dayton VA Medical Centre, Dayton, OH, USA
| | - A Bowirrat
- Departments of Clinical Neuroscience and Population Genetics, Interdisciplinary Center (IDC) Herzliya, Department of Neuroscience, Israel
| | - D Baron
- Western University Health Sciences Graduate School of Biomedical Sciences, Pomona, CA, USA
| | - L Lott
- Department of Precision Behavioral Management, Geneus Health, San Antonio, TX, USA
| | - J V Ponce
- Department of Precision Behavioral Management, Geneus Health, San Antonio, TX, USA
| | - R Brewer
- Department of Precision Behavioral Management, Geneus Health, San Antonio, TX, USA
| | - D Siwicki
- Department of Precision Behavioral Management, Geneus Health, San Antonio, TX, USA
| | - B Boyett
- Divion of Neuroscience & Addiction Research, Pathway HealthCare, LLC, Birmingham, AL
| | - M C Gondre-Lewis
- National Human Genome Center, Howard University, Washington DC, USA.,Departments of Anatomy, and Psychiatry & Behavioral Sciences, Howard University College of Medicine, Washington DC, USA
| | - D E Smith
- Department of Pharmacology, University of California San Francisco School of Medicine, San Francisco, USA
| | - Thanos Panayotis K
- Behavioral Neuropharmacology and Neuroimaging Laboratory on Addictions, Research Institute on Addictions, University at Buffalo, Buffalo, NY, USA
| | - S Badgaiyan
- Department of Precision Behavioral Management, Geneus Health, San Antonio, TX, USA
| | - M Hauser
- Division Addiction Services, Dominion Diagnostics, LLC, North Kingston, RI, USA
| | - L Fried
- Transformations Treatment Center, Del-Ray Beach, FL, USA
| | - Roy A
- Department of Psychiatry, Tulane University School of Medicine, New Orleans, LA, USA
| | - B W Downs
- Division of Nutrigenomics, Victory Nutrition International. Inc. Lederach, PA, USA
| | - R D Badgaiyan
- Department of Psychiatry, Ichan School of Medicine at Mount Sinai, New York, NY., USA.,Department of Psychiatry, South Texas Veteran Health Care System, Audie L. Murphy Memorial VA Hospital, San Antonio, TX, USA.,Long School of Medicine, University of Texas Medical Center, San Antonio, USAInstituto Nacional de Neurología y Neurocirugía
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10
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Colloca L, Lee SE, Luhowy MN, Haycock N, Okusogu C, Yim S, Raghuraman N, Goodfellow R, Murray RS, Casper P, Lee M, Scalea T, Fouche Y, Murthi S. Relieving acute pain (RAP) study: a proof-of-concept protocol for a randomised, double-blind, placebo-controlled trial. BMJ Open 2019; 9:e030623. [PMID: 31719077 PMCID: PMC6858101 DOI: 10.1136/bmjopen-2019-030623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/26/2019] [Accepted: 10/17/2019] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Physicians and other prescribing clinicians use opioids as the primary method of pain management after traumatic injury, despite growing recognition of the major risks associated with usage for chronic pain. Placebos given after repeated administration of active treatments can acquire medication-like effects based on learning mechanisms. This study hypothesises that dose-extending placebos can be an effective treatment in relieving clinical acute pain in trauma patients who take opioids. METHODS AND ANALYSIS The relieving acute pain is a proof-of-concept randomised, placebo-controlled, double-blinded, single-site study enrolling 159 participants aged from 18 to 65 years with one or more traumatic injuries treated with opioids. Participants will be randomly assigned to three different arms. Arm 1 will receive the full dose of opioids with non-steroidal anti-inflammatory drugs (NSAIDs). Arm 2 will receive the 50% overall reduction in opioid dosage, dose-extending placebos and NSAIDs. Arm 3 (control) will receive NSAIDs and placebos. The trial length will be 3 days of hospitalisation (phase I) and 2-week, 1-month, 3-month and 6-month follow-ups (exploratory phase II). Primary and secondary outcomes include feasibility and acceptability of the study. Pain intensity, functional pain, emotional distress, rates of rescue therapy requests and patient-initiated medication denials will be collected. ETHICS AND DISSEMINATION All activities associated with this protocol are conducted in full compliance with the Institutional Review Board policies and federal regulations. Publishing this study protocol will enable researchers and funding bodies to stay up to date in their fields by providing exposure to research activity that may not otherwise be widely publicised. DATE AND PROTOCOL VERSION IDENTIFIER 3/6/2019 (HP-00078742). TRIAL REGISTRATION NUMBER NCT03426137.
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Affiliation(s)
- Luana Colloca
- Department of Pain and Translational Symptom Science, University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Se Eun Lee
- Department of Pain and Translational Symptom Science, University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Meghan Nichole Luhowy
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Nathaniel Haycock
- Department of Pain and Translational Symptom Science, University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Chika Okusogu
- Department of Pain and Translational Symptom Science, University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Soojin Yim
- Department of Pain and Translational Symptom Science, University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Nandini Raghuraman
- Department of Pain and Translational Symptom Science, University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Robert Goodfellow
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Robert Scott Murray
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Patricia Casper
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Myounghee Lee
- Investigational Drug Services, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Thomas Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Yvette Fouche
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sarah Murthi
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland, USA
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11
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Hruschak V, Hildenbrand AK, Cochran G. Psychiatric comorbidity and co-occurring opioid misuse: Depression mediates the relationship between post-traumatic stress disorder and opioid misuse in community pharmacy settings. Subst Abus 2019; 41:77-84. [PMID: 31638877 DOI: 10.1080/08897077.2019.1621238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
AbstractsBackground: Individuals who misuse opioids frequently have comorbid psychiatric issues, including post-traumatic stress disorder (PTSD) and depression. However, little is known about the mechanisms by which these disorders are associated with opioid misuse and specifically in community pharmacy settings. The current study examined whether depression mediated the relationship between PTSD and opioid misuse in patients filling opioid prescriptions. Methods: We administered a health survey in four community pharmacies among patients filling opioid medications in southwestern Pennsylvania. Univariate statistics were used to assess relationships among demographic and clinical characteristics of PTSD, depression, and opioid misuse behaviors. We then examined whether depression mediated the relationship between PTSD and opioid misuse using ordinary least squares path analysis with bootstrapping. Results: A total of 333 participants completed the health survey. Opioid misuse was reported among 15.9% of all participants, 33.3% among those with a positive PTSD screen, and 29.3% of those who screened positive for depression. Depression significantly mediated the relationship between PTSD and opioid misuse. Specifically, there was a statistically significant indirect effect (ab) of PTSD on opioid misuse through a pathway mediated by depression (ab = .06, SEab = .02, 95% CI = .02-.10). The direct effect (c') of PTSD on opioid misuse was also significant (c' = .12, SEc' = .05, P = .01, 95% CI = .03-.22), suggesting partial mediation. Conclusions: Results suggest an indirect pathway by which clinical intervention may help ameliorate outcomes in patients with PTSD. Further, there is an increased need for screening, assessment, and intervention protocols for this patient population in which community pharmacy is a novel setting to expand future efforts within the patient population.
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Affiliation(s)
- Valerie Hruschak
- University of Pittsburgh, School of Social Work, Pittsburgh, Pennsylvania, USA
| | - Aimee K Hildenbrand
- Center for Healthcare Delivery Science, Nemours Children's Health System, Division of Behavioral Health, Nemours/Alfred I. duPont Hospital for Children, The Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Gerald Cochran
- Department of Internal Medicine, University of Utah, Pittsburgh, Pennsylvania, USA
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13
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Harmon L, Sukri L, Kufera JA, Nguyen A, Grunnagle M, Ramirez CL, Botwinick I, Cucher D, Feather CB, Scalea TM, Stein DM. Is Opioid Prescribing Driving Trauma Recidivism or is Trauma Driving Opioid Use? Am Surg 2019. [DOI: 10.1177/000313481908500618] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In the past 30 years, opioid prescription rates have quadrupled and hospital admissions for overdose are rising. Previous studies have focused on alcohol use and trauma recidivism, however rarely evaluating recidivism and opioid use. We hypothesized there is an association between opioid use and trauma recidivism. This is a retrospective review of patients with multiple admissions for traumatic injury. Demographics, opioid toxicology screen (TS) results, and injury characteristics were collected. Statistical analysis was performed with chi-squared and Poisson regression models. One thousand six hundred forty-nine patients (age ≥18 years) had multiple trauma admissions. Seven hundred nine patients had TS data for both admissions. Thirty-one per cent (218) were TS positive on the 1st admission compared with 34 per cent (244) on their 2nd admission. Fifty-five per cent of patients who were TS positive on the 1st admission were positive on their 2nd admission, whereas 25 per cent who were TS negative on the 1st admission were subsequently positive on their 2nd admission ( P < 0.0001). Patients who were TS positive on the subsequent admission were less severely injured than TS negative patients (Injury Severity Score > 15, 26.3% vs 22.3%, P = 0.04). The only significant risk factor for being TS positive on the 2nd admission was being TS positive on the 1st admission (relative risk = 2.18, P < 0.001). A previous history of opioid use is the strongest predictor of recurrent use in recidivists.
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Affiliation(s)
- Laura Harmon
- University of Maryland R Adams Cowley Shock Trauma Center, Baltimore, Maryland
- University of Colorado Denver, Anschutz, Denver, Colorado
| | - Leah Sukri
- University of Maryland R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Joseph A. Kufera
- University of Maryland R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Andrew Nguyen
- University of Maryland R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Meilin Grunnagle
- University of Maryland R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | | | - Isadora Botwinick
- Northwell Health, Long Island Jewish Hospital, Long Island, New York; and
| | | | - Cristina B. Feather
- University of Maryland R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Thomas M. Scalea
- University of Maryland R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Deborah M. Stein
- University of Maryland R Adams Cowley Shock Trauma Center, Baltimore, Maryland
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Adverse childhood experiences predict autonomic indices of emotion dysregulation and negative emotional cue-elicited craving among female opioid-treated chronic pain patients. Dev Psychopathol 2019; 31:1101-1110. [DOI: 10.1017/s0954579419000622] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AbstractThrough autonomic and affective mechanisms, adverse childhood experiences (ACEs) may disrupt the capacity to regulate negative emotions, increasing craving and exacerbating risk for opioid use disorder (OUD) among individuals with chronic pain who are receiving long-term opioid analgesic pharmacotherapy. This study examined associations between ACEs, heart rate variability (HRV) during emotion regulation, and negative emotional cue-elicited craving among a sample of female opioid-treated chronic pain patients at risk for OUD. A sample of women (N= 36, mean age = 51.2 ± 9.5) with chronic pain receiving long-term opioid analgesic pharmacotherapy (mean morphine equivalent daily dose = 87.1 ± 106.9 mg) were recruited from primary care and pain clinics to complete a randomized task in which they viewed and reappraised negative affective stimuli while HRV and craving were assessed. Both ACEs and duration of opioid use significantly predicted blunted HRV during negative emotion regulation and increased negative emotional cue-elicited craving. Analysis of study findings from a multiple-levels-of-analysis approach suggest that exposure to childhood abuse occasions later emotion dysregulation and appetitive responding toward opioids in negative affective contexts among adult women with chronic pain, and thus this vulnerable clinical population should be assessed for OUD risk when initiating a course of extended, high-dose opioids for pain management.
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