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Khazen M, Kamin-Friedman S. Overlooking the obvious: the importance of communicating safety and risks of opioids-the Israeli context. Front Pharmacol 2024; 15:1356968. [PMID: 38855742 PMCID: PMC11157061 DOI: 10.3389/fphar.2024.1356968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 04/29/2024] [Indexed: 06/11/2024] Open
Affiliation(s)
- Maram Khazen
- Max Stern Academic College of Emek Yezreel, Emek Yezreel, Israel
| | - Shelly Kamin-Friedman
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Department of Bioethics, The School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
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Jung M, Xia T, Ilomäki J, Pearce C, Nielsen S. Trajectories of prescription opioid tapering in patients with chronic non-cancer pain: a retrospective cohort study, 2015-2020. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:263-274. [PMID: 38191211 PMCID: PMC10988287 DOI: 10.1093/pm/pnae002] [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: 05/18/2023] [Revised: 11/30/2023] [Accepted: 12/16/2023] [Indexed: 01/10/2024]
Abstract
OBJECTIVE To identify common opioid tapering trajectories among patients commencing opioid taper from long-term opioid therapy for chronic non-cancer pain and to examine patient-level characteristics associated with these different trajectories. DESIGN A retrospective cohort study. SETTING Australian primary care. SUBJECTS Patients prescribed opioid analgesics between 2015 and 2020. METHODS Group-based trajectory modeling and multinomial logistic regression analysis were conducted to determine tapering trajectories and to examine demographic and clinical factors associated with the different trajectories. RESULTS A total of 3369 patients commenced a taper from long-term opioid therapy. Six distinct opioid tapering trajectories were identified: low dose / completed taper (12.9%), medium dose / faster taper (12.2%), medium dose / gradual taper (6.5%), low dose / noncompleted taper (21.3%), medium dose / noncompleted taper (30.4%), and high dose / noncompleted taper (16.7%). A completed tapering trajectory from a high opioid dose was not identified. Among patients prescribed medium opioid doses, those who completed their taper were more likely to have higher geographically derived socioeconomic status (relative risk ratio [RRR], 1.067; 95% confidence interval [CI], 1.001-1.137) and less likely to have sleep disorders (RRR, 0.661; 95% CI, 0.463-0.945) than were those who didn't complete their taper. Patients who didn't complete their taper were more likely to be prescribed strong opioids (eg, morphine, oxycodone), regardless of whether they were tapered from low (RRR, 1.444; 95% CI, 1.138-1.831) or high (RRR, 1.344; 95% CI, 1.027-1.760) doses. CONCLUSIONS Those prescribed strong opioids and high doses appear to be less likely to complete tapering. Further studies are needed to evaluate the clinical outcomes associated with the identified trajectories.
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Affiliation(s)
- Monica Jung
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, VIC 3199, Australia
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC 3052, Australia
| | - Ting Xia
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, VIC 3199, Australia
| | - Jenni Ilomäki
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC 3052, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Christopher Pearce
- Melbourne East General Practice Network (trading as Outcome Health), Surrey Hills, VIC 3127, Australia
- Department of General Practice, School of Primary and Allied Health Care, Monash University, Melbourne, VIC 3168, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, VIC 3199, Australia
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3
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Flores MW, Sharp A, Lu F, Cook BL. Examining Racial/Ethnic Differences in Patterns of Opioid Prescribing: Results from an Urban Safety-Net Healthcare System. J Racial Ethn Health Disparities 2024; 11:719-729. [PMID: 36892815 PMCID: PMC9997438 DOI: 10.1007/s40615-023-01555-z] [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: 11/08/2022] [Revised: 02/17/2023] [Accepted: 02/23/2023] [Indexed: 03/10/2023]
Abstract
Prescription opioids still account for a large proportion of overdose deaths and contribute to opioid use dependence (OUD). Studies earlier in the epidemic suggest clinicians were less likely to prescribe opioids to racial/ethnic minorities. As OUD-related deaths have increased disproportionately amongst minority populations, it is essential to understand racial/ethnic differences in opioid prescribing patterns to inform culturally sensitive mitigation efforts. The purpose of this study is to estimate racial/ethnic differences in opioid medication use among patients prescribed opioids. Using electronic health records and a retrospective cohort study design, we estimated multivariable hazard models and generalized linear models, assessing racial/ethnic differences in OUD diagnosis, number of opioid prescriptions, receiving only one opioid prescription, and receiving ≥18 opioid prescriptions. Study population (N=22,201) consisted of adult patients (≥18years), with ≥3 primary care visits (ensuring healthcare system linkage), ≥1 opioid prescription, who did not have an OUD diagnoses prior to the first opioid prescription during the 32-month study period. Relative to racial/ethnic minority patients, White patients, in both unadjusted and adjusted analyses, had a greater number of opioid prescriptions filled, a higher proportion received ≥18 opioid prescriptions, and a greater hazard of having an OUD diagnosis subsequent to receiving an opioid prescription (all groups p<0.001). Although opioid prescribing rates have declined nationally, our findings suggest White patients still experience a high volume of opioid prescriptions and greater risk of OUD diagnosis. Racial/ethnic minorities are less likely to receive follow-up pain medications, which may signal low care quality. Identifying provider bias in pain management of racial/ethnic minorities could inform interventions seeking balance between adequate pain treatment and risk of opioid misuse/abuse.
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Affiliation(s)
- Michael William Flores
- Health Equity Research Lab, Cambridge Health Alliance, 1035 Cambridge Street, Suite 26, Cambridge, MA, 02141, USA.
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
| | - Amanda Sharp
- Health Equity Research Lab, Cambridge Health Alliance, 1035 Cambridge Street, Suite 26, Cambridge, MA, 02141, USA
- Center for Mindfulness and Compassion, Cambridge Health Alliance, Cambridge, MA, USA
| | - Frederick Lu
- Boston University School of Medicine, Boston, MA, USA
| | - Benjamin Lê Cook
- Health Equity Research Lab, Cambridge Health Alliance, 1035 Cambridge Street, Suite 26, Cambridge, MA, 02141, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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4
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Appa A, McMahan VM, Long K, Shade SB, Coffin PO. Stimulant use and opioid-related harm in patients on long-term opioids for chronic pain. Drug Alcohol Depend 2024; 256:111065. [PMID: 38245963 PMCID: PMC10999379 DOI: 10.1016/j.drugalcdep.2023.111065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 12/08/2023] [Accepted: 12/15/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND There is lack of clarity regarding the impact of and optimal clinical response to stimulant use among people prescribed long-term opioid therapy (LTOT) for pain. OBJECTIVE To determine if a positive urine drug test (UDT) for stimulants was associated with subsequent opioid-related harm or discontinuation of LTOT. DESIGN Retrospective cohort study. PATIENTS People living with and without HIV living in a major metropolitan area with public insurance, prescribed LTOT for chronic, non-cancer pain (n=600). MAIN MEASURES UDT results from January 2012 to June 2019 were evaluated against 1) opioid-related emergency department (ED) visits (oversedation, constipation, infections associated with injecting opioids, and opioid seeking) or death in each 90-day period following a UDT, using logistic regression, and 2) LTOT discontinuation. RESULTS There were no opioid overdose deaths within 90 days following a stimulant-positive UDT. A stimulant-positive UDT was not statistically significantly associated with opioid-related ED visits within 90 days (adjusted odds ratio [aOR] 1.39; 95% CI=0.88-2.21). Stimulant-positive UDT was independently associated with subsequent discontinuation of LTOT within 90 days (aOR 2.96; 95% CI=2.13 - 4.12). Living with HIV was independently associated with decreased odds of LTOT discontinuation (aOR 0.65; 95% CI 0.43 - 0.99). CONCLUSIONS Despite no association between a stimulant-positive UDT and subsequent opioid-related harm, there was an association with subsequent LTOT discontinuation, with heterogeneity across clinical groups. Detection of stimulant use should result in a discussion of substance use and risk, rather than reflex LTOT discontinuation.
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Affiliation(s)
- Ayesha Appa
- University of California, San Francisco (UCSF), Division of HIV, Infectious Diseases & Global Medicine, Department of Medicine, 995 Potrero Ave, Box 0874, San Francisco, CA 94110, USA.
| | - Vanessa M McMahan
- San Francisco Department of Public Health, 25 Van Ness Avenue, San Francisco, CA 94102, USA
| | - Kyna Long
- San Francisco Department of Public Health, 25 Van Ness Avenue, San Francisco, CA 94102, USA
| | - Starley B Shade
- University of California San Francisco, Institute for Global Health Science, Division of Infectious Disease and Global Epidemiology, Department of Epidemiology and Biostatistics, 550 16th St, Box 0886, San Francisco, CA 94158, USA
| | - Phillip O Coffin
- San Francisco Department of Public Health, 25 Van Ness Avenue, San Francisco, CA 94102, USA
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5
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Crouch TB, Donovan E, Smith WR, Barth K, Becker WC, Svikis D. Patient Motivation to Reduce or Discontinue Opioids for Chronic Pain: Self-efficacy, Barriers, and Readiness to Change. Clin J Pain 2024; 40:18-25. [PMID: 37855333 PMCID: PMC10841444 DOI: 10.1097/ajp.0000000000001167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/17/2023] [Indexed: 10/20/2023]
Abstract
OBJECTIVES This study aimed to assess levels and predictors of self-efficacy and motivation to change opioid use among a community sample of patients using opioids for chronic pain, as well as patient-reported barriers to pursuing opioid discontinuation. METHODS Participants with a variety of chronic pain conditions, recruited from ResearchMatch.org , completed a battery of electronic, self-report questionnaires assessing demographic and medical characteristics, pain treatment history, and levels of readiness, self-efficacy, and other attitudes toward reducing or discontinuing opioid use. Multiple regression analyses and analyses of variance were conducted to examine predictors of readiness and self-efficacy to change opioid use. A modified version of rapid qualitative analysis was utilized to analyze themes in participant responses to an open-ended item about "what it would take" to consider opioid discontinuation. RESULTS The final sample included N=119 participants, the majority of whom were female (78.2%), Caucasian (77.3%), and well-educated. Readiness and self-efficacy to decrease or stop opioid use were fairly low on a 0 to 10 Visual Analog Scale (2.6 to 3.8) and significantly higher to decrease than stop ( P <0.01). Higher readiness to change was predicted by lower pain severity and higher concern about opioids, whereas higher self-efficacy was predicted by shorter pain duration. Results from the qualitative analyses revealed that the availability of an alternative treatment option was the most commonly cited requirement to consider opioid discontinuation. DISCUSSION Patients with lower pain severity, shorter duration of pain, and higher concerns about opioids may be a prime target from a motivation standpoint for interventions addressing opioid tapering and discontinuation.
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Affiliation(s)
| | - Emily Donovan
- Department of Psychology, Virginia Commonwealth University, Richmond, VA
| | - Wally R Smith
- Department of Internal Medicine, Division of General Internal Medicine, Virginia Commonwealth University School of Medicine
| | - Kelly Barth
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC
| | - William C Becker
- Department of Internal Medicine, Yale School of Medicine
- VA Connecticut Healthcare System, New Haven, CT
| | - Dace Svikis
- Obstetrics and Gynecology
- Institute for Women's Health
- Department of Psychology, Virginia Commonwealth University, Richmond, VA
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6
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Manoharan D, Xie A, Hsu YJ, Flynn HK, Beiene Z, Giagtzis A, Shechter R, McDonald E, Marsteller J, Hanna M, Speed TJ. Patient Experiences and Clinical Outcomes in a Multidisciplinary Perioperative Transitional Pain Service. J Pers Med 2023; 14:31. [PMID: 38248732 PMCID: PMC10821325 DOI: 10.3390/jpm14010031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 01/23/2024] Open
Abstract
Siloed pain management across the perioperative period increases the risk of chronic opioid use and impedes postoperative recovery. Transitional perioperative pain services (TPSs) are innovative care models that coordinate multidisciplinary perioperative pain management to mitigate risks of chronic postoperative pain and opioid use. The objective of this study was to examine patients' experiences with and quality of recovery after participation in a TPS. Qualitative interviews were conducted with 26 patients from The Johns Hopkins Personalized Pain Program (PPP) an average of 33 months after their first PPP visit. A qualitative content analysis of the interview data showed that participants (1) valued pain expectation setting, individualized care, a trusting patient-physician relationship, and shared decision-making; (2) perceived psychiatric treatment of co-occurring depression, anxiety, and maladaptive behaviors as critical to recovery; and (3) successfully sustained opioid tapers and experienced improved functioning after PPP discharge. Areas for improved patient-centered care included increased patient education, specifically about the program, continuity of care with pain specialists while tapering opioids, and addressing the health determinants that impede access to pain care. The positive patient experiences and sustained clinical benefits for high-risk complex surgical patient support further efforts to implement and adapt similar models of perioperative pain care.
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Affiliation(s)
- Divya Manoharan
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (D.M.)
| | - Anping Xie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.X.); (Z.B.); (R.S.); (M.H.)
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD 21202, USA;
| | - Yea-Jen Hsu
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | - Hannah K. Flynn
- Loyola College of Arts & Sciences, Loyola University Maryland, Baltimore, MD 21210, USA
| | - Zodina Beiene
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.X.); (Z.B.); (R.S.); (M.H.)
| | - Alexandros Giagtzis
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (D.M.)
| | - Ronen Shechter
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.X.); (Z.B.); (R.S.); (M.H.)
| | - Eileen McDonald
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | - Jill Marsteller
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD 21202, USA;
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | - Marie Hanna
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.X.); (Z.B.); (R.S.); (M.H.)
| | - Traci J. Speed
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (D.M.)
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7
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Compton P. The United States opioid crisis: Big pharma alone is not to blame.". Prev Med 2023; 177:107777. [PMID: 37967618 DOI: 10.1016/j.ypmed.2023.107777] [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: 09/28/2023] [Revised: 10/27/2023] [Accepted: 11/09/2023] [Indexed: 11/17/2023]
Abstract
OBJECTIVE The opioid crisis in the United States continues essentially unabated, fueled by fentanyl contamination of the heroin supply and resulting in 79,770 reported opioid-involved overdose deaths in the calendar year 2022. To prevent another such crisis emerging, it is necessary to fully identify its root causes. METHODS Despite the well-recognized role the pharmaceutical industry played in facilitating the crisis via the aggressive marketing of prescription opioids, several other less appreciated but perhaps more influential factors were also contributors, and the overall goal of this review is to ensure that these are not be lost to history in a concerted effort to blame opioid manufacturers and distributors. Presented is a historical review of research and regulatory documents beginning with the loosening of opioid prescription for chronic pain through current thought and practice today. Beginning with a necessary decoupling of the current opioid crisis from the increased use of opioids to treat chronic pain, this review will examine these contributing factors. RESULTS Clinical concerns about under- or untreated pain, practice guidelines from standard-setting organizations and government entities, and a health system-wide move away from specialty interdisciplinary pain programs together set the stage for an over-reliance on opioids in chronic pain care. CONCLUSIONS This review reminds the health care community that despite the deep pockets of the pharmaceutical industry and highly the organized efforts of the drug cartels, additional self-reflection is warranted to fully understand the true root causes of the current epidemic and ways to prevent similar epidemics in the future.
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Affiliation(s)
- Peggy Compton
- Claire M. Fagin Hall, 418 Curie Boulevard, Room 402, School of Nursing, University of Pennsylvania, Philadelphia, PA 19104-4217, USA.
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8
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Manhapra A, MacLean RR, Rosenheck R, Becker WC. Are opioids effective analgesics and is physiological opioid dependence benign? Revising current assumptions to effectively manage long-term opioid therapy and its deprescribing. Br J Clin Pharmacol 2023. [PMID: 37990580 DOI: 10.1111/bcp.15972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 11/10/2023] [Accepted: 11/14/2023] [Indexed: 11/23/2023] Open
Abstract
A re-examination of clinical principles of long-term opioid therapy (LTOT) for chronic pain is long overdue amid the ongoing opioid crisis. Most patients on LTOT report ineffectiveness (poor pain control, function and health) but still find deprescribing challenging. Although prescribed as analgesics, opioids more likely provide pain relief primarily through reward system actions (enhanced relief and motivation) and placebo effect and less through antinociceptive effects. The unavoidable physiologic LTOT dependence can automatically lead to a paradoxical worsening of pain, disability and medical instability (maladaptive opioid dependence) without addiction due to allostatic opponent neuroadaptations involving reward/antireward and nociceptive/antinociceptive systems. This opioid-induced chronic pain syndrome (OICP) can persist/progress whether LTOT dose is maintained at the same level, increased, decreased or discontinued. Current conceptualization of LTOT as a straightforward long-term analgesic therapy appears incongruous in view of the complex mechanisms of opioid action, LTOT dependence and OICP. LTOT can be more appropriately conceptualized as therapeutic induction and maintenance of an adaptive LTOT dependence for functional improvement irrespective of analgesic benefits. Adaptive LTOT dependence should be ideally used for a limited time to achieve maximum functional recovery and deprescribed while maintaining functional gains. Patients on LTOT should be regularly re-evaluated to identify if maladaptive LTOT dependence with OICP has diminished any functional gains or leads to ineffectiveness. Ineffective LTOT (with maladaptive LTOT dependence) should be modified to make it safer and more effective. An adequately functional life without opioids is the ideal healthy long-term goal for both LTOT initiation and LTOT modification.
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Affiliation(s)
- Ajay Manhapra
- Section of Pain Medicine, Department of Physical Medicine & Rehabilitation Sciences, Hampton VA Medical Center, Hampton, Virginia, USA
- New England Mental Illness Research Education and Clinical Center, West Haven, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
- Departments of Physical Medicine and Rehabilitation and Psychiatry, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - R Ross MacLean
- New England Mental Illness Research Education and Clinical Center, West Haven, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Robert Rosenheck
- New England Mental Illness Research Education and Clinical Center, West Haven, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - William C Becker
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Pain Research, Informatics, Multimorbidities & Education Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut, USA
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9
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Xia T, Picco L, Lalic S, Buchbinder R, Bell JS, Andrew NE, Lubman DI, Pearce C, Nielsen S. Determining the Impact of Opioid Policy on Substance Use and Mental Health-Related Harms: Protocol for a Data Linkage Study. JMIR Res Protoc 2023; 12:e51825. [PMID: 37847553 PMCID: PMC10618880 DOI: 10.2196/51825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 08/21/2023] [Accepted: 08/21/2023] [Indexed: 10/18/2023] Open
Abstract
BACKGROUND Increasing harms related to prescription opioids over the past decade have led to the introduction of a range of key national and state policy initiatives across Australia. These include introducing a mandatory real-time prescription drug-monitoring program in the state of Victoria from April 2020 and a series of changes to subsidies for opioids on the Pharmaceutical Benefit Scheme from June 2020. Together, these changes aim to influence opioid supply and reduce harms related to prescription opioids, yet few studies have specifically explored how these policies have influenced opioid prescribing and related harms in Australia. OBJECTIVE The aim of this study is to examine the impact of a range of opioid-related policies on hospital admissions and emergency department (ED) presentations in Victoria, Australia. In particular, the study aims to understand the effect of various opioid policies and opioid-prescribing changes on (1) the number and rates of ED presentations and hospital admissions attributed to substance use (ie, opioid and nonopioid related) or mental ill-health (eg, suicide, self-harm, anxiety, and depression), (2) the association between differing opioid dose trajectories and the likelihood of ED presentations and hospital admissions related to substance use and mental ill-health, and (3) whether changes in an individual's opioid prescribing change the risk related to ED presentations and hospital admissions related to substance use and mental ill-health. METHODS We will conduct a population-level linked data study. General practice health records obtained from the Population Level Analysis and Reporting platform are linked with person-level data from 3 large hospital networks in Victoria, Australia. Interrupted time series analysis will be used to examine the impact of opioid policies on a range of harms, including the rates of presentations related to substance use (opioid and nonopioid) and mental ill-health among the primary care cohort. Group-based trajectory modeling and a case-crossover design will be used to further explore the impact of changes in opioid dosage and other covariates on opioid and nonopioid poisonings and mental ill-health-related presentations at the patient level. RESULTS Given that this paper serves as a protocol, there are currently no results available. The deidentified primary health data were sourced from electronic medical records of approximately 4,717,000 patients from 542 consenting general practices over a 6-year period (2017-2022). The submission of results for publication is planned for early 2024. CONCLUSIONS This study will add to the limited evidence base to help understand the impact of opioid policies in Australia, including whether intended or unintended outcomes are occurring as a result. TRIAL REGISTRATION EU PAS Register EUPAS104005; https://www.encepp.eu/encepp/viewResource.htm?id=104006. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/51825.
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Affiliation(s)
- Ting Xia
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Australia
| | - Louisa Picco
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Australia
| | - Samanta Lalic
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
- Pharmacy Department, Monash Health, Clayton, Australia
| | - Rachelle Buchbinder
- Musculoskeletal Health and Wiser Health Care Units, School of Public Health and Preventive Medicine, Monash University, St Kilda, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Nadine E Andrew
- Peninsula Clinical School, Central Clinical School, Peninsula Health, Monash University, Frankston, Australia
| | - Dan I Lubman
- Turning Point, Eastern Health, Richmond, Australia
| | | | - Suzanne Nielsen
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Australia
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10
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Picco L, Jung M, Cangadis-Douglass H, Lam T, Nielsen S. Identifying Prescription-Opioid-Related Risks Using Prescription Drug Monitoring Programs' Algorithms and Clinical Screening Tools. PHARMACY 2023; 11:164. [PMID: 37888509 PMCID: PMC10609676 DOI: 10.3390/pharmacy11050164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/02/2023] [Accepted: 10/09/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND Pharmacists adopt various approaches to identifying prescription-opioid-related risks and harms, including prescription drug monitoring programs (PDMPs) and clinical screening tools. This study aims to compare 'at-risk' patients according to the published Australian PDMP algorithms with the validated Routine Opioid Outcome Monitoring (ROOM) clinical screening tool. METHODS Data were used from an implementation study amongst people who had been prescribed regular opioids. We examined the results from ROOM and the patients' dispensing history over the previous 90 days. A chi-squared test was used to examine the association between risk according to (i) a PDMP alert and a clinical risk per ROOM; (ii) a PDMP alert and positive screening for opioid use disorder; and (iii) a PDMP 'high-dose' alert (average of >100 mg OME/day in the past 90 days) and any ROOM-validated risk. RESULTS No significant associations were found between being 'at-risk' according to any of the PDMP alerts and clinical risk as identified via the ROOM tool (x2 = 0.094, p = 0.759). There was only minimal overlap between those identified as 'at-risk' via PDMP alerts and those meeting the clinical risk indicators; most patients who were 'at-risk' of clinical opioid-related risk factors were not identified as 'at-risk' based on PDMP alerts. CONCLUSIONS PDMP alerts were not predictive of clinical risk (as per the ROOM tool), as many people with well-established clinical risks would not receive a PDMP alert. Pharmacists should be aware that PDMPs are limited to identifying medication-related risks which are derived using algorithms; therefore, augmenting PDMP information with clinical screening tools can help create a more detailed narrative of patients' opioid-related risks.
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Affiliation(s)
- Louisa Picco
- Monash Addiction Research Centre, Peninsula Campus, Monash University, 47-49 Moorooduc Hwy Frankston, Victoria 3199, Australia; (M.J.); (H.C.-D.); (T.L.)
| | - Monica Jung
- Monash Addiction Research Centre, Peninsula Campus, Monash University, 47-49 Moorooduc Hwy Frankston, Victoria 3199, Australia; (M.J.); (H.C.-D.); (T.L.)
- Centre for Medicine Use and Safety (CMUS), Parkville Campus, Monash University, 381 Royal Parade Parkville, Victoria 3052, Australia
| | - Helena Cangadis-Douglass
- Monash Addiction Research Centre, Peninsula Campus, Monash University, 47-49 Moorooduc Hwy Frankston, Victoria 3199, Australia; (M.J.); (H.C.-D.); (T.L.)
- Centre for Medicine Use and Safety (CMUS), Parkville Campus, Monash University, 381 Royal Parade Parkville, Victoria 3052, Australia
| | - Tina Lam
- Monash Addiction Research Centre, Peninsula Campus, Monash University, 47-49 Moorooduc Hwy Frankston, Victoria 3199, Australia; (M.J.); (H.C.-D.); (T.L.)
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Peninsula Campus, Monash University, 47-49 Moorooduc Hwy Frankston, Victoria 3199, Australia; (M.J.); (H.C.-D.); (T.L.)
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11
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Latimore AD, Salisbury-Afshar E, Duff N, Freiling E, Kellett B, Sullenger RD, Salman A. Primary, Secondary, and Tertiary Prevention of Substance Use Disorders through Socioecological Strategies. NAM Perspect 2023; 2023:202309b. [PMID: 38784638 PMCID: PMC11114594 DOI: 10.31478/202309b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Affiliation(s)
| | | | | | | | | | | | - Aisha Salman
- National Academy of Medicine; and the Prevention, Treatment, and Recovery Services Working Group of the National Academy of Medicine's Action Collaborative on Countering the U.S. Opioid Epidemic
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12
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Lyden JR, Xu S, Narwaney KJ, Glanz JM, Binswanger IA. Opioid Overdose Risk Following Hospital Discharge Among Individuals Prescribed Long-Term Opioid Therapy: a Risk Interval Analysis. J Gen Intern Med 2023; 38:2560-2567. [PMID: 36697930 PMCID: PMC9876414 DOI: 10.1007/s11606-022-08014-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/23/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Individuals prescribed long-term opioid therapy (LTOT) have increased risk of readmission and death after hospital discharge. The risk of opioid overdose during the immediate post-discharge time period is unknown. OBJECTIVE To examine the association between time since hospital discharge and opioid overdose among individuals prescribed LTOT. DESIGN Self-controlled risk interval analysis. PARTICIPANTS Adults prescribed LTOT with at least one hospital discharge at a safety-net health system and a non-profit healthcare organization in Colorado. MAIN MEASURES We identified individuals prescribed LTOT who were discharged from January 2006 through June 2019. The outcome was a composite of fatal and non-fatal opioid overdoses during a 90-day post-discharge observation period, identified using electronic health record (EHR) and vital statistics data. Risk intervals included days 0-6 after index and subsequent hospital discharges. Control intervals ranged from days 7 to 89 after index discharge and included all other time during the observation period that did not fall within a risk interval or time readmitted during a subsequent hospitalization, which was excluded. Poisson regression was used to estimate incidence rate ratios (IRR) and 95% confidence intervals (CI) for overdose events during risk in comparison to control intervals. KEY RESULTS We identified 7695 adults (63.3% over 55 years, 59.4% female, 20.3% Hispanic) who experienced 9499 total discharges during the study period. Twenty-one overdoses occurred during their observation periods (1174 per 100,000 person-years [9 in risk, 12 in control]). Overdose risk was significantly higher during the risk interval in comparison to the control interval (IRR 6.92; 95% CI 2.92-16.43). CONCLUSION During the first 7 days after hospital discharge, individuals prescribed LTOT appear to be at elevated risk for opioid overdose. Clarifying mechanisms of overdose risk may help inform in-hospital and post-discharge prevention strategies.
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Affiliation(s)
- Jennifer R Lyden
- Division of Hospital Medicine, Department of Medicine, Denver Health, 777 Bannock Street, Denver, CO, 80204, USA.
- Division of Hospital Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Stanley Xu
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Komal J Narwaney
- Institute of Health Research, Kaiser Permanente Colorado, Denver, CO, USA
| | - Jason M Glanz
- Institute of Health Research, Kaiser Permanente Colorado, Denver, CO, USA
- Department of Epidemiology, University of Colorado School of Public Health, Aurora, CO, USA
| | - Ingrid A Binswanger
- Institute of Health Research, Kaiser Permanente Colorado, Denver, CO, USA
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Colorado Permanente Medical Group, Denver, CO, USA
- Bernard J. Tyson Kaiser Permanente School of Medicine, Pasadena, CA, USA
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13
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Butler C, Stechlinski P. Modeling Opioid Abuse: A Case Study of the Opioid Crisis in New England. Bull Math Biol 2023; 85:45. [PMID: 37088864 PMCID: PMC10122875 DOI: 10.1007/s11538-023-01148-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 03/22/2023] [Indexed: 04/25/2023]
Abstract
For the past two decades, the USA has been embroiled in a growing prescription drug epidemic. The ripples of this epidemic have been especially apparent in the state of Maine, which has fought hard to mitigate the damage caused by addiction to pharmaceutical and illicit opioids. In this study, we construct a mathematical model of the opioid epidemic incorporating novel features important to better understanding opioid abuse dynamics. These features include demographic differences in population susceptibility, general transmission expressions, and combined consideration of pharmaceutical opioid and heroin abuse. We demonstrate the usefulness of this model by calibrating it with data for the state of Maine. Model calibration is accompanied by sensitivity and uncertainty analysis to quantify potential error in parameter estimates and forecasts. The model is analyzed to determine the mechanisms most influential to the number of opioid abusers and to find effective ways of controlling opioid abuse prevalence. We found that the mechanisms most influential to the overall number of abusers in Maine are those involved in illicit pharmaceutical opioid abuse transmission. Consequently, preventative strategies that controlled for illicit transmission were more effective over alternative approaches, such as treatment. These results are presented with the hope of helping to inform public policy as to the most effective means of intervention.
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Affiliation(s)
- Cole Butler
- Department of Mathematics and Statistics, University of Maine, 5752 Neville Hall, Orono, ME, 04469, USA
| | - Peter Stechlinski
- Department of Mathematics and Statistics, University of Maine, 5752 Neville Hall, Orono, ME, 04469, USA.
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14
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Shrestha S, Khatiwada AP, Sapkota B, Sapkota S, Poudel P, KC B, Teoh SL, Blebil AQ, Paudyal V. What is "Opioid Stewardship"? An Overview of Current Definitions and Proposal for a Universally Acceptable Definition. J Pain Res 2023; 16:383-394. [PMID: 36798077 PMCID: PMC9926985 DOI: 10.2147/jpr.s389358] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 01/19/2023] [Indexed: 02/11/2023] Open
Abstract
Introduction Opioid stewardship has been widely used to promote rational use, monitoring and discontinuation of opioid therapy; however, its definition and scope of practice remain unclear. Objective To synthesize definitions of opioid stewardship proposed by clinical practice guidelines and professional societies, and to offer a proposal for a universally acceptable definition. Methods Systematic literature searches were performed (earliest records to May 2022) in six databases (MEDLINE, EMBASE, APA PsycINFO, Scopus, and CENTRAL) and grey sources guidelines development bodies and professional societies through Google. The conventional but widely applied content analysis and word frequencies were used to analyze the definitions and scope of practice. Results After removing duplicates, 449 articles were retrieved (439 databases and registers and 11 from other sources), 19 of which included a definition of "opioids stewardship". A total of 12 themes was identified in the definitions, including 1) improvement or appropriateness of prescribing opioids use, 2) mitigation of risk from opioids, 3) monitoring opioid use, 4) evaluation of opioid use, 5) judicious opioid use, 6) appropriateness of opioid disposal, 7) identification and treatment of opioid use disorder, 8) reduction in mortality associated with opioid overdoses, 9) appropriate procurement practices, 10) appropriate storage, 11) promoting better communications between patients and prescribers including education provision and 12) patient-centered decision-making. Conclusion Opioid stewardship is inconsistently defined across professional and research literature. While there is a greater focus on appropriateness and need for improvement of prescribing and monitoring of opioid use, the importance of communications between patients and prescribers, and patient involvement in both prescribing and deprescribing decision-making remains sparse. A comprehensive definition has been proposed as part of the work. There is a need to develop and validate the proposed definition and scope of practice to promote rationale for opioid prescribing, use and attainment of favourable outcomes through international consensus involving practitioners, researchers, and patients.
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Affiliation(s)
- Sunil Shrestha
- School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, Bandar Sunway, Selangor, 47500, Malaysia,Correspondence: Sunil Shrestha; Vibhu Paudyal, Tel +60 102874113, Email ; ;
| | | | - Binaya Sapkota
- Department of Pharmaceutical Sciences, Nobel College, Kathmandu, Nepal
| | - Simit Sapkota
- Department of Clinical Oncology, Civil Service Hospital, Minbhawan, Kathmandu, Bagmati Province, Nepal,Department of Clinical Oncology, Kathmandu Cancer Center, Tathali, Bagmati Province, Nepal
| | - Prabhat Poudel
- Nepal Medical College Hospital, Kathmandu, Province Bagmati, Nepal
| | - Bhuvan KC
- College of Public Health, Medical & Veterinary Sciences, James Cook University, Townsville, QLD, Australia,Faculty of Pharmacy and Pharmaceutical Sciences Monash University Parkville Campus Parkville, Melbourne, VIC 3052, Australia
| | - Siew Li Teoh
- School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, Bandar Sunway, Selangor, 47500, Malaysia
| | - Ali Qais Blebil
- School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, Bandar Sunway, Selangor, 47500, Malaysia
| | - Vibhu Paudyal
- School of Pharmacy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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15
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Bérubé M, Côté C, Moore L, Turgeon AF, Belzile ÉL, Richard-Denis A, Dale CM, Berry G, Choinière M, Pagé GM, Guénette L, Dupuis S, Tremblay L, Turcotte V, Martel MO, Chatillon CÉ, Perreault K, Lauzier F. Strategies to prevent long-term opioid use following trauma: a Canadian practice survey. Can J Anaesth 2023; 70:87-99. [PMID: 36163458 PMCID: PMC9513000 DOI: 10.1007/s12630-022-02328-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 06/10/2022] [Accepted: 07/07/2022] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To evaluate how Canadian clinicians involved in trauma patient care and prescribing opioids perceive the use and effectiveness of strategies to prevent long-term opioid therapy following trauma. Barriers and facilitators to the implementation of these strategies were also assessed. METHODS We conducted a web-based cross-sectional survey. Potential participants were identified by trauma program managers and directors of the targeted departments in three Canadian provinces. We designed our questionnaire using standard health survey research methods. The questionnaire was administered between April 2021 and November 2021. RESULTS Our response rate was 47% (350/744), and 52% (181/350) of participants completed the entire survey. Most respondents (71%, 129/181) worked in teaching hospitals. Multimodal analgesia (93%, 240/257), nonsteroidal anti-inflammatory agents (77%, 198/257), and physical stimulation (75%, 193/257) were the strategies perceived to be the most frequently used. Several preventive strategies were perceived to be very effective by over 80% of respondents. Of these, some that were reported as not being frequently used were perceived to be among the most effective ones, including guidelines or protocols, assessing risk factors for opioid misuse, physical health follow-up by a professional, training for clinicians, patient education, and prescription monitoring systems. Staff shortages, time constraints, and organizational practices were identified as the main barriers to the implementation of the highest ranked preventive strategies. CONCLUSIONS Several strategies to prevent long-term opioid therapy following trauma are perceived as being effective by those prescribing opioids in this population. Some of these strategies appear to be commonly used in everyday practice and others less so. Future research should focus on which preventive strategies should be given higher priority for implementation before assessing their effectiveness.
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Affiliation(s)
- Mélanie Bérubé
- Population Health and Optimal Practices Research Unit Research Unit (Trauma - Emergency-Critical Care Medicine), CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Quebec City, QC, G1V 1Z4, Canada. .,Faculty of Nursing, Université Laval, Quebec City, QC, Canada. .,Quebec Pain Research Network, Sherbrooke, QC, Canada.
| | - Caroline Côté
- Population Health and Optimal Practices Research Unit Research Unit (Trauma – Emergency–Critical Care Medicine), CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Quebec City, QC G1V 1Z4 Canada ,Faculty of Nursing, Université Laval, Quebec City, QC Canada
| | - Lynne Moore
- Population Health and Optimal Practices Research Unit Research Unit (Trauma – Emergency–Critical Care Medicine), CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Quebec City, QC G1V 1Z4 Canada ,Department of Social Preventive Medicine, Université Laval, Quebec City, QC Canada
| | - Alexis F. Turgeon
- Population Health and Optimal Practices Research Unit Research Unit (Trauma – Emergency–Critical Care Medicine), CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Quebec City, QC G1V 1Z4 Canada ,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, QC Canada
| | - Étienne L. Belzile
- Division of Orthopedic Surgery, Department of Surgery, CHU de Québec-Université Laval, Quebec City, QC Canada
| | - Andréane Richard-Denis
- Department of Medicine, Université de Montréal, Montreal, Quebec Canada ,Research Centre of the CIUSSS du Nord-de-l’île-de-Montréal, Montreal, QC Canada
| | - Craig M. Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON Canada ,University of Toronto Centre for the Study of Pain (UTCSP), Toronto, ON Canada
| | - Gregory Berry
- Department of Orthopaedic Surgery, McGill University Health Centre, Montreal, QC Canada
| | - Manon Choinière
- Quebec Pain Research Network, Sherbrooke, QC Canada ,Research Center of the Centre hospitalier de l’Université de Montréal, Montreal, QC Canada ,Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC Canada
| | - Gabrielle M. Pagé
- Quebec Pain Research Network, Sherbrooke, QC Canada ,Research Center of the Centre hospitalier de l’Université de Montréal, Montreal, QC Canada ,Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC Canada
| | - Line Guénette
- Population Health and Optimal Practices Research Unit Research Unit (Trauma – Emergency–Critical Care Medicine), CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Quebec City, QC G1V 1Z4 Canada ,Quebec Pain Research Network, Sherbrooke, QC Canada ,Faculty of Pharmacy, Université Laval, Quebec City, QC Canada
| | - Sébastien Dupuis
- Department of Pharmacy, CIUSSS du Nord-de-l’île-de-Montréal, Montreal, QC Canada
| | - Lorraine Tremblay
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON Canada
| | - Valérie Turcotte
- Department of Nursing, CIUSSS du Nord-de-l’île-de-Montréal, Montreal, QC Canada
| | - Marc-Olivier Martel
- Quebec Pain Research Network, Sherbrooke, QC Canada ,Faculty of Medicine & Dentistry, McGill University, Montreal, QC Canada
| | - Claude-Édouard Chatillon
- Division of Neurosurgery, CIUSSS de la Mauricie-et-du-Centre-du-Québec, Trois-Rivières, QC Canada
| | - Kadija Perreault
- Quebec Pain Research Network, Sherbrooke, QC Canada ,Centre interdisciplinaire de recherche en réadaptation et intégration sociale (Cirris), CIUSSS de la Capitale-Nationale, Quebec City, QC Canada
| | - François Lauzier
- Population Health and Optimal Practices Research Unit Research Unit (Trauma – Emergency–Critical Care Medicine), CHU de Québec-Université Laval Research Centre, 1401, 18e rue, Quebec City, QC G1V 1Z4 Canada ,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, QC Canada ,Department of Medicine, Université Laval, Quebec City, QC Canada
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16
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Maierhofer CN, Ranapurwala SI, DiPrete BL, Fulcher N, Ringwalt CL, Chelminski PR, Ives TJ, Dasgupta N, Go VF, Pence BW. Intended and unintended consequences: Changes in opioid prescribing practices for postsurgical, acute, and chronic pain indications following two policies in North Carolina, 2012-2018 - Controlled and single-series interrupted time series analyses. Drug Alcohol Depend 2023; 242:109727. [PMID: 36516549 PMCID: PMC9801483 DOI: 10.1016/j.drugalcdep.2022.109727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 12/01/2022] [Accepted: 12/02/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND The potential misapplication of current opioid prescribing policies remains understudied and may have substantial adverse implications for patient safety. METHODS We used autoregressive integrated moving average models to assess level and trend changes in monthly 1) prescribing rates, 2) days' supply, and 3) daily morphine milligram equivalents (MME) of incident opioid prescriptions relative to 1) a state medical board initiative to reduce high-dose and -volume opioid prescribing and 2) legislation to limit initial opioid prescriptions for acute and postsurgical pain. We examined outcomes by pain indication overall and by cancer history, using prescribing patterns for benzodiazepines to control for temporal trends. We used large private health insurance claims data to include North Carolina residents, aged 18-64, insured at any point between January 2012 and August 2018. RESULTS After the medical board initiative, prescribing patterns for chronic pain patients did not change; conversely, acute and postsurgical pain patients experienced immediate declines in daily MME. Post-legislation prescription rates did not decline for those with acute, postsurgical, and non-cancer pain, but instead declined among cancer patients with chronic pain. Chronic pain patients experienced the largest days' supply declines post-legislation, instead of acute and postsurgical pain patients. CONCLUSIONS We found mixed evidence on the potential impact of two opioid prescribing policies, with some observed declines in a group not intended to be impacted by the policy. This study provides evidence of the need for clearer opioid prescribing policies to ensure impacts on intended populations and avoid unintended consequences.
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Affiliation(s)
- Courtney N Maierhofer
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, 135 Dauer Drive, Chapel Hill, NC 27599, USA.
| | - Shabbar I Ranapurwala
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, 135 Dauer Drive, Chapel Hill, NC 27599, USA; Injury Prevention Research Center, University of North Carolina, 521S Greensboro St, Carrboro, NC 27510, USA.
| | - Bethany L DiPrete
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, 135 Dauer Drive, Chapel Hill, NC 27599, USA; Injury Prevention Research Center, University of North Carolina, 521S Greensboro St, Carrboro, NC 27510, USA.
| | - Naoko Fulcher
- Injury Prevention Research Center, University of North Carolina, 521S Greensboro St, Carrboro, NC 27510, USA.
| | - Christopher L Ringwalt
- Injury Prevention Research Center, University of North Carolina, 521S Greensboro St, Carrboro, NC 27510, USA; Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, 135 Dauer Drive, Chapel Hill, NC 27599, USA.
| | - Paul R Chelminski
- Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, 321S. Columbia Street, Chapel Hill, NC 27599, USA.
| | - Timothy J Ives
- Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, 321S. Columbia Street, Chapel Hill, NC 27599, USA; Division of Practice Advancement and Clinical Education, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 301 Pharmacy Ln, Chapel Hill, NC 27599, USA.
| | - Nabarun Dasgupta
- Injury Prevention Research Center, University of North Carolina, 521S Greensboro St, Carrboro, NC 27510, USA.
| | - Vivian F Go
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, 135 Dauer Drive, Chapel Hill, NC 27599, USA.
| | - Brian W Pence
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, 135 Dauer Drive, Chapel Hill, NC 27599, USA.
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17
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Coffin PO, Martinez RS, Wylie B, Ryder B. Primary care management of Long-Term opioid therapy. Ann Med 2022; 54:2451-2469. [PMID: 36111417 PMCID: PMC9487960 DOI: 10.1080/07853890.2022.2121417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
The United States underwent massive expansion in opioid prescribing from 1990-2010, followed by opioid stewardship initiatives and reduced prescribing. Opioids are no longer considered first-line therapy for most chronic pain conditions and clinicians should first seek alternatives in most circumstances. Patients who have been treated with opioids long-term should be managed differently, sometimes even continued on opioids due to physiologic changes wrought by long-term opioid therapy and documented risks of discontinuation. When providing long-term opioid therapy, clinicians should document opioid stewardship measures, including assessments, consents, medication reconciliation, and offering naloxone, along with the rationale to continue opioid therapy. Clinicians should screen regularly for opioid use disorder and arrange for or directly provide treatment. In particular, buprenorphine can be highly useful for co-morbid pain and opioid use disorder. Addressing other substance use disorders, as well as preventive health related to substance use, should be a priority in patients with opioid use disorder. Patient-centered practices, such as shared decision-making and attending to related facets of a patient's life that influence health outcomes, should be implemented at all points of care.Key messagesAlthough opioids are no longer considered first-line therapy for most chronic pain, management of patients already taking long-term opioid therapy must be individualised.Documentation of opioid stewardship measures can help to organise opioid prescribing and protect clinicians from regulatory scrutiny.Management of resultant opioid use disorder should include provision of medications, most often buprenorphine, and several additional screening and preventive measures.
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Affiliation(s)
- Phillip O Coffin
- San Francisco Department of Public Health, Center on Substance Use and Health, San Francisco, CA, USA
| | - Rebecca S Martinez
- San Francisco Department of Public Health, Center on Substance Use and Health, San Francisco, CA, USA
| | - Brian Wylie
- San Francisco Department of Public Health, Center on Substance Use and Health, San Francisco, CA, USA
| | - Bunny Ryder
- San Francisco Department of Public Health, Center on Substance Use and Health, San Francisco, CA, USA
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18
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Kennedy MC, Crabtree A, Nolan S, Mok WY, Cui Z, Chong M, Slaunwhite A, Ti L. Discontinuation and tapering of prescribed opioids and risk of overdose among people on long-term opioid therapy for pain with and without opioid use disorder in British Columbia, Canada: A retrospective cohort study. PLoS Med 2022; 19:e1004123. [PMID: 36454732 PMCID: PMC9714711 DOI: 10.1371/journal.pmed.1004123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 10/14/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The overdose crisis in North America has prompted system-level efforts to restrict opioid prescribing for chronic pain. However, little is known about how discontinuing or tapering prescribed opioids for chronic pain shapes overdose risk, including possible differential effects among people with and without concurrent opioid use disorder (OUD). We examined associations between discontinuation and tapering of prescribed opioids and risk of overdose among people on long-term opioid therapy for pain, stratified by diagnosed OUD and prescribed opioid agonist therapy (OAT) status. METHODS AND FINDINGS For this retrospective cohort study, we used a 20% random sample of residents in the provincial health insurance client roster in British Columbia (BC), Canada, contained in the BC Provincial Overdose Cohort. The study sample included persons aged 14 to 74 years on long-term opioid therapy for pain (≥90 days with ≥90% of days on therapy) between October 2014 and June 2018 (n = 14,037). At baseline, 7,256 (51.7%) persons were female, the median age was 55 years (quartile 1-3: 47-63), 227 (1.6%) persons had been diagnosed with OUD (in the past 3 years) and recently (i.e., in the past 90 days) been prescribed OAT, and 483 (3.4%) had been diagnosed with OUD but not recently prescribed OAT. The median follow-up duration per person was 3.7 years (quartile 1-3: 2.6-4.0). Marginal structural Cox regression with inverse probability of treatment weighting (IPTW) was used to estimate the effect of prescribed opioid treatment for pain status (discontinuation versus tapered therapy versus continued therapy [reference]) on risk of overdose (fatal or nonfatal), stratified by the following groups: people without diagnosed OUD, people with diagnosed OUD receiving OAT, and people with diagnosed OUD not receiving OAT. In marginal structural models with IPTW adjusted for a range of demographic, prescription, comorbidity, and social-structural exposures, discontinuing opioids (i.e., ≥7-day gap[s] in therapy) was associated with increased overdose risk among people without OUD (adjusted hazard ratio [AHR] = 1.44; 95% confidence interval [CI] 1.12, 1.83; p = 0.004), people with OUD not receiving OAT (AHR = 3.18; 95% CI 1.87, 5.40; p < 0.001), and people with OUD receiving OAT (AHR = 2.52; 95% CI 1.68, 3.78; p < 0.001). Opioid tapering (i.e., ≥2 sequential decreases of ≥5% in average daily morphine milligram equivalents) was associated with decreased overdose risk among people with OUD not receiving OAT (AHR = 0.31; 95% CI 0.14, 0.67; p = 0.003). The main study limitations are that the outcome measure did not capture overdose events that did not result in a healthcare encounter or death, medication dispensation may not reflect medication adherence, residual confounding may have influenced findings, and findings may not be generalizable to persons on opioid therapy in other settings. CONCLUSIONS Discontinuing prescribed opioids was associated with increased overdose risk, particularly among people with OUD. Prescribed opioid tapering was associated with reduced overdose risk among people with OUD not receiving OAT. These findings highlight the need to avoid abrupt discontinuation of opioids for pain. Enhanced guidance is needed to support prescribers in implementing opioid therapy tapering strategies with consideration of OUD and OAT status.
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Affiliation(s)
- Mary Clare Kennedy
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
- School of Social Work, University of British Columbia–Okanagan, Kelowna, British Columbia, Canada
- * E-mail:
| | - Alexis Crabtree
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Seonaid Nolan
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
- Department of Medicine, University of British Columbia, St. Paul’s Hospital, Vancouver, British Columbia, Canada
| | - Wing Yin Mok
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Zishan Cui
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mei Chong
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Amanda Slaunwhite
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Lianping Ti
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
- Department of Medicine, University of British Columbia, St. Paul’s Hospital, Vancouver, British Columbia, Canada
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19
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Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022. MMWR Recomm Rep 2022; 71:1-95. [PMID: 36327391 PMCID: PMC9639433 DOI: 10.15585/mmwr.rr7103a1] [Citation(s) in RCA: 407] [Impact Index Per Article: 203.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
This guideline provides recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients aged ≥18 years. It updates the CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016 (MMWR Recomm Rep 2016;65[No. RR-1]:1-49) and includes recommendations for managing acute (duration of <1 month), subacute (duration of 1-3 months), and chronic (duration of >3 months) pain. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care. The guideline addresses the following four areas: 1) determining whether or not to initiate opioids for pain, 2) selecting opioids and determining opioid dosages, 3) deciding duration of initial opioid prescription and conducting follow-up, and 4) assessing risk and addressing potential harms of opioid use. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Recommendations are based on systematic reviews of the scientific evidence and reflect considerations of benefits and harms, patient and clinician values and preferences, and resource allocation. CDC obtained input from the Board of Scientific Counselors of the National Center for Injury Prevention and Control (a federally chartered advisory committee), the public, and peer reviewers. CDC recommends that persons with pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient's circumstances. Recommendations should not be applied as inflexible standards of care across patient populations. This clinical practice guideline is intended to improve communication between clinicians and patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death.
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Silvis J, Rowe CL, Dobbins S, Haq N, Vittinghoff E, McMahan VM, Appa A, Coffin PO. Engagement in HIV care and viral suppression following changes in long-term opioid therapy for treatment for chronic pain. AIDS Behav 2022; 26:3220-3230. [PMID: 35380287 DOI: 10.1007/s10461-022-03671-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 11/28/2022]
Abstract
Chronic pain is common among persons living with HIV and changes in opioid prescribing practices may complicate HIV care management. Using medical record data from a retrospective cohort study conducted January 1, 2012 to June 30, 2019 for 300 publicly insured HIV-positive primary care patients prescribed opioids for chronic non-cancer pain in San Francisco, we examined associations between opioid dose changes and both time to disengagement from HIV care and experiencing virologic failure using logistic regression. Discontinuation of prescribed opioids was associated with increased odds of disengagement in care at 3, 6, and 9 months after discontinuation. There were no associations with virologic failure. Providers and policy makers must weigh impacts on HIV care when implementing necessary changes in opioid prescribing.
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Affiliation(s)
- Janelle Silvis
- University of California San Francisco, 500 Parnassus Ave, 94143, San Francisco, CA, United States
| | - Christopher L Rowe
- San Francisco Department of Public Health, 25 Van Ness Avenue, Ste. 500, 94102, San Francisco, CA, United States
| | - Sarah Dobbins
- University of California San Francisco, 500 Parnassus Ave, 94143, San Francisco, CA, United States
| | - Nimah Haq
- San Francisco Department of Public Health, 25 Van Ness Avenue, Ste. 500, 94102, San Francisco, CA, United States
| | - Eric Vittinghoff
- University of California San Francisco, 500 Parnassus Ave, 94143, San Francisco, CA, United States
| | - Vanessa M McMahan
- San Francisco Department of Public Health, 25 Van Ness Avenue, Ste. 500, 94102, San Francisco, CA, United States
| | - Ayesha Appa
- University of California San Francisco, 500 Parnassus Ave, 94143, San Francisco, CA, United States
| | - Phillip O Coffin
- University of California San Francisco, 500 Parnassus Ave, 94143, San Francisco, CA, United States.
- San Francisco Department of Public Health, 25 Van Ness Avenue, Ste. 500, 94102, San Francisco, CA, United States.
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21
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Affiliation(s)
- Stefan G Kertesz
- Birmingham VA Health Care System, Birmingham, Alabama
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham
| | - Allyson L Varley
- Birmingham VA Health Care System, Birmingham, Alabama
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham
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22
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Abstract
This paper is the forty-third consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2020 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).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY, 11367, United States.
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23
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Avery N, McNeilage AG, Stanaway F, Ashton-James CE, Blyth FM, Martin R, Gholamrezaei A, Glare P. Efficacy of interventions to reduce long term opioid treatment for chronic non-cancer pain: systematic review and meta-analysis. BMJ 2022; 377:e066375. [PMID: 35379650 PMCID: PMC8977989 DOI: 10.1136/bmj-2021-066375] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To review interventions to reduce long term opioid treatment in people with chronic non-cancer pain, considering efficacy on dose reduction and discontinuation, pain, function, quality of life, withdrawal symptoms, substance use, and adverse events. DESIGN Systematic review and meta-analysis of randomised controlled trials and non-randomised studies of interventions. DATA SOURCES Medline, Embase, PsycINFO, CINAHL, and the Cochrane Library searched from inception to July 2021. Reference lists and previous reviews were also searched and experts were contacted. ELIGIBILITY CRITERIA FOR STUDY SELECTION Original research in English. Case reports and cross sectional studies were excluded. DATA EXTRACTION AND SYNTHESIS Two authors independently selected studies, extracted data, and used the Cochrane risk-of-bias tools for randomised and non-randomised studies (RoB 2 and ROBINS-I). Authors grouped interventions into five categories (pain self-management, complementary and alternative medicine, pharmacological and biomedical devices and interventions, opioid replacement treatment, and deprescription methods), estimated pooled effects using random effects meta-analytical models, and appraised the certainty of evidence using GRADE (grading of recommendations, assessment, development, and evaluation). RESULTS Of 166 studies meeting inclusion criteria, 130 (78%) were considered at critical risk of bias and were excluded from the evidence synthesis. Of the 36 included studies, few had comparable treatment arms and sample sizes were generally small. Consequently, the certainty of the evidence was low or very low for more than 90% (41/44) of GRADE outcomes, including for all non-opioid patient outcomes. Despite these limitations, evidence of moderate certainty indicated that interventions to support prescribers' adherence to guidelines increased the likelihood of patients discontinuing opioid treatment (adjusted odds ratio 1.5, 95% confidence interval 1.0 to 2.1), and that these prescriber interventions as well as pain self-management programmes reduced opioid dose more than controls (intervention v control, mean difference -6.8 mg (standard error 1.6) daily oral morphine equivalent, P<0.001; pain programme v control, -14.31 mg daily oral morphine equivalent, 95% confidence interval -21.57 to -7.05). CONCLUSIONS Evidence on the reduction of long term opioid treatment for chronic pain continues to be constrained by poor study methodology. Of particular concern is the lack of evidence relating to possible harms. Agreed standards for designing and reporting studies on the reduction of opioid treatment are urgently needed. REVIEW REGISTRATION PROSPERO CRD42020140943.
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Affiliation(s)
- Nicholas Avery
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - Amy G McNeilage
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - Fiona Stanaway
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Claire E Ashton-James
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - Fiona M Blyth
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Rebecca Martin
- Michael J Cousins Pain Management and Research Centre, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Ali Gholamrezaei
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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Quinn PD, Chang Z, Bair MJ, Rickert ME, Gibbons RD, Kroenke K, D’Onofrio BM. Associations of opioid prescription dose and discontinuation with risk of substance-related morbidity in long-term opioid therapy. Pain 2022; 163:e588-e595. [PMID: 34326295 PMCID: PMC8795234 DOI: 10.1097/j.pain.0000000000002415] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/28/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Efforts to reduce opioid-related harms have decreased opioid prescription but have provoked concerns about unintended consequences, particularly for long-term opioid therapy (LtOT) recipients. Research is needed to address the knowledge gap regarding how risk of substance-related morbidity changes across LtOT and its discontinuation. This study used nationwide commercial insurance claims data and a within-individual design to examine associations of LtOT dose and discontinuation with substance-related morbidity. We identified 194,839 adolescents and adults who initiated opioid prescription in 2010 to 2018 and subsequently received LtOT. The cohort was followed for a median of 965 days (interquartile range, 525-1550), of which a median of 176 days (119-332) were covered by opioid prescription. During follow-up, there were 17,582 acute substance-related morbidity events, defined as claims for emergency visits, inpatient hospitalizations, and ambulance transportation with substance use disorder or overdose diagnoses. Relative to initial treatment, risk was greater within individual during subsequent periods of >60 to 120 (adjusted odds ratio [OR], 1.29; 95% CI, 1.12 to 1.49) and >120 (OR, 1.48; 95% CI, 1.24-1.76) daily morphine milligram equivalents. Risk was also greater during days 1 to 30 after discontinuations than during initial treatment (OR, 1.19; 95% CI, 1.05-1.35). However, it was no greater than during the 30 days before discontinuations, indicating that the risk may not be wholly attributable to discontinuation itself. Results were supported by a negative control pharmacotherapy analysis and additional sensitivity analyses. They suggest that LtOT recipients may experience increased substance-related morbidity risk during treatment subsequent to initial opioid prescription, particularly in periods involving higher doses.
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Affiliation(s)
- Patrick D. Quinn
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington, Indiana
| | - Zheng Chang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Matthew J. Bair
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
- Regenstrief Institute, Indianapolis, Indiana
| | - Martin E. Rickert
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, Indiana
| | - Robert D. Gibbons
- Center for Health Statistics, University of Chicago, Chicago, Illinois
- Department of Medicine, University of Chicago, Chicago, Illinois
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
| | - Kurt Kroenke
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
- Regenstrief Institute, Indianapolis, Indiana
| | - Brian M. D’Onofrio
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, Indiana
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25
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Strategies aimed at preventing long-term opioid use in trauma and orthopaedic surgery: a scoping review. BMC Musculoskelet Disord 2022; 23:238. [PMID: 35277150 PMCID: PMC8917706 DOI: 10.1186/s12891-022-05044-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 01/18/2022] [Indexed: 12/12/2022] Open
Abstract
Abstract
Background
Long-term opioid use, which may have significant individual and societal impacts, has been documented in up to 20% of patients after trauma or orthopaedic surgery. The objectives of this scoping review were to systematically map the research on strategies aiming to prevent chronic opioid use in these populations and to identify knowledge gaps in this area.
Methods
This scoping review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. We searched seven databases and websites of relevant organizations. Selected studies and guidelines were published between January 2008 and September 2021. Preventive strategies were categorized as: system-based, pharmacological, educational, multimodal, and others. We summarized findings using measures of central tendency and frequency along with p-values. We also reported the level of evidence and the strength of recommendations presented in clinical guidelines.
Results
A total of 391 studies met the inclusion criteria after initial screening from which 66 studies and 20 guidelines were selected. Studies mainly focused on orthopaedic surgery (62,1%), trauma (30.3%) and spine surgery (7.6%). Among system-based strategies, hospital-based individualized opioid tapering protocols, and regulation initiatives limiting the prescription of opioids were associated with statistically significant decreases in morphine equivalent doses (MEDs) at 1 to 3 months following trauma and orthopaedic surgery. Among pharmacological strategies, only the use of non-steroidal anti-inflammatory drugs and beta blockers led to a significant reduction in MEDs up to 12 months after orthopaedic surgery. Most studies on educational strategies, multimodal strategies and psychological strategies were associated with significant reductions in MEDs beyond 1 month. The majority of recommendations from clinical practice guidelines were of low level of evidence.
Conclusions
This scoping review advances knowledge on existing strategies to prevent long-term opioid use in trauma and orthopaedic surgery patients. We observed that system-based, educational, multimodal and psychological strategies are the most promising. Future research should focus on determining which strategies should be implemented particularly in trauma patients at high risk for long-term use, testing those that can promote a judicious prescription of opioids while preventing an illicit use, and evaluating their effects on relevant patient-reported and social outcomes.
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Seitz AE, Janiszewski KA, Guy GP, Tapscott RT, Einstein EB, Meyer TE, Tierney J, Staffa J, Jones CM, Compton WM. Evaluating Opioid Analgesic Prescribing Limits: A Narrative Review. Pharmacoepidemiol Drug Saf 2022; 31:605-613. [PMID: 35247021 DOI: 10.1002/pds.5425] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 12/01/2021] [Accepted: 03/01/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Amy E Seitz
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, United States
| | - Karen A Janiszewski
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, United States
| | - Gery P Guy
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ryan T Tapscott
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Emily B Einstein
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland, United States
| | - Tamra E Meyer
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, United States
| | - Jessica Tierney
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, United States
| | - Judy Staffa
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, United States
| | - Christopher M Jones
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Wilson M Compton
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland, United States
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27
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Coffin PO, Barreveld AM. Inherited Patients Taking Opioids for Chronic Pain - Considerations for Primary Care. N Engl J Med 2022; 386:611-613. [PMID: 35148038 PMCID: PMC9555806 DOI: 10.1056/nejmp2115244] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Phillip O Coffin
- From the San Francisco Department of Public Health and the University of California, San Francisco - both in San Francisco (P.O.C.); and Tufts University School of Medicine, Boston, and the Department of Anesthesiology, Newton-Wellesley Hospital, Newton - both in Massachusetts (A.M.B.)
| | - Antje M Barreveld
- From the San Francisco Department of Public Health and the University of California, San Francisco - both in San Francisco (P.O.C.); and Tufts University School of Medicine, Boston, and the Department of Anesthesiology, Newton-Wellesley Hospital, Newton - both in Massachusetts (A.M.B.)
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28
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Rowe CL, Eagen K, Ahern J, Faul M, Hubbard A, Coffin P. Evaluating the Effects of Opioid Prescribing Policies on Patient Outcomes in a Safety-net Primary Care Clinic. J Gen Intern Med 2022; 37:117-124. [PMID: 34173204 PMCID: PMC8738839 DOI: 10.1007/s11606-021-06920-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 05/06/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND After decades of liberal opioid prescribing, multiple efforts have been made to reduce reliance upon opioids in clinical care. Little is known about the effects of opioid prescribing policies on outcomes beyond opioid prescribing. OBJECTIVE To evaluate the combined effects of multiple opioid prescribing policies implemented in a safety-net primary care clinic in San Francisco, CA, in 2013-2014. DESIGN Retrospective cohort study and conditional difference-in-differences analysis of nonrandomized clinic-level policies. PATIENTS 273 patients prescribed opioids for chronic non-cancer pain in 2013 at either the treated (n=151) or control clinic (n=122) recruited and interviewed in 2017-2018. INTERVENTIONS Policies establishing standard protocols for dispensing opioid refills and conducting urine toxicology testing, and a new committee facilitating opioid treatment decisions for complex patient cases. MAIN MEASURES Opioid prescription (active prescription, mean dose in morphine milligram equivalents [MME]) from electronic medical charts, and heroin and opioid analgesics not prescribed to the patient (any use, use frequency) from a retrospective interview. KEY RESULTS The interventions were associated with a reduction in mean prescribed opioid dose in the first three post-policy years (year 1 conditional difference-in-differences estimate: -52.0 MME [95% confidence interval: -109.9, -10.6]; year 2: -106.2 MME [-195.0, -34.6]; year 3: -98.6 MME [-198.7, -23.9]; year 4: -72.6 MME [-160.4, 3.6]). Estimates suggest a possible positive association between the interventions and non-prescribed opioid analgesic use (year 3: 5.2 absolute percentage points [-0.1, 11.2]) and use frequency (year 3: 0.21 ordinal frequency scale points [0.00, 0.47]) in the third post-policy year. CONCLUSIONS Clinic-level opioid prescribing policies were associated with reduced dose, although the control clinic achieved similar reductions by the fourth post-policy year, and the policies may have been associated with increased non-prescribed opioid analgesic use. Clinicians should balance the urgency to reduce opioid prescribing with potential harms from rapid change.
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Affiliation(s)
- Christopher L Rowe
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, CA, USA.
- Center on Substance Use and Health, San Francisco Department of Public Health, San Francisco, USA.
| | - Kellene Eagen
- Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, USA
| | - Jennifer Ahern
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Mark Faul
- Health Systems and Trauma Systems Branch, Centers for Disease Control and Prevention, Atlanta, USA
| | - Alan Hubbard
- Division of Biostatistics, School of Public Health, University of California, Berkeley, Berkeley, USA
| | - Phillip Coffin
- Center on Substance Use and Health, San Francisco Department of Public Health, San Francisco, USA
- Division of HIV, Infectious Disease & Global Medicine, University of California San Francisco, San Francisco, USA
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29
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Beliveau CM, McMahan VM, Arenander J, Angst MS, Kushel M, Torres A, Santos GM, Coffin PO. Stimulant use for self-management of pain among safety-net patients with chronic non-cancer pain. Subst Abus 2022; 43:179-186. [PMID: 33798030 PMCID: PMC8791072 DOI: 10.1080/08897077.2021.1903654] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Chronic pain affects one-fifth of US adults. Reductions in opioid prescribing have been associated with increased non-prescription opioid use and, chronologically, increased stimulant (methamphetamine and cocaine) use. While non-prescription opioid use is commonly attributed to pain self-management, the role of stimulants in managing pain is unclear. METHODS We analyzed baseline data from a longitudinal study of patients with chronic non-cancer pain in an urban safety-net healthcare system who had been prescribed an opioid for ≥3 of the last 12 months, and had a history of non-prescription opioid, cocaine, or amphetamine use (N = 300). We estimated the prevalence and identified correlates of stimulant use to treat pain among a subgroup of patients who reported past-year stimulant use (N = 105). Data sources included computer-assisted questionnaire (demographics, substance use, pain), clinical exam and procedures (pain, pain tolerance), and chart abstraction (opioid prescriptions). We conducted bivariate analyses to assess associations between demographics, pain characteristics, non-opioid therapies, substance use, opioid prescriptions, and self-reported symptoms, with reporting using stimulants to treat pain. Demographic variables and those with significant bivariate associations were included in a multivariable logistic regression model. RESULTS Fifty-two percent of participants with past-year stimulant use reported using stimulants in the past year to treat pain. Participants who used stimulants for pain reported slightly higher average pain in the past 3 months (median of 8 (IQR: 6-8) vs 7 (7-9) out of 10, p = 0.049). In the multivariable analysis, female gender (AOR= 3.20, 95% CI: 1.06-9.63, p = 0.039) and higher score on the Douleur Neuropathique 4 neuropathic pain questionnaire (AOR = 1.34, 95% CI: 1.05-1.70, p = 0.017) were associated with past-year stimulant use to treat pain. CONCLUSION Stimulants may be used for pain self-management, particularly for neuropathic pain and among women. Our findings suggest an underexplored motivation for stimulant use in an era of reduced access to prescribed opioids.
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Affiliation(s)
- Cathleen M. Beliveau
- Center on Substance Use and Health, San Francisco Department of Public Health, San Francisco, CA, USA
| | - Vanessa M. McMahan
- Center on Substance Use and Health, San Francisco Department of Public Health, San Francisco, CA, USA
| | - Justine Arenander
- Center on Substance Use and Health, San Francisco Department of Public Health, San Francisco, CA, USA
| | - Martin S. Angst
- Department of Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Margot Kushel
- University of California San Francisco, San Francisco, CA, USA
| | - Andrea Torres
- Center on Substance Use and Health, San Francisco Department of Public Health, San Francisco, CA, USA
| | - Glenn-Milo Santos
- Center on Substance Use and Health, San Francisco Department of Public Health, San Francisco, CA, USA.,University of California San Francisco, San Francisco, CA, USA
| | - Phillip O. Coffin
- Center on Substance Use and Health, San Francisco Department of Public Health, San Francisco, CA, USA.,University of California San Francisco, San Francisco, CA, USA
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30
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Gonzalez M, Sanders-Jackson A. Traditional Cigarette and Poly-Tobacco Use Are Associated with Medical Opioid Use in Rural Areas of the US. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182211864. [PMID: 34831619 PMCID: PMC8619274 DOI: 10.3390/ijerph182211864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/04/2021] [Accepted: 11/06/2021] [Indexed: 11/16/2022]
Abstract
Introduction: Medical prescriptions for opioids are higher in rural areas of the US as compared to urban areas. Tobacco use may also play a role in this process. This analysis examines the association between differing types of tobacco use and medical opioid use. Methods: We analyze the relationship between tobacco product use and medical opioid use among the US general population living in rural (non-metropolitan) areas using the publicly available sample adult file 2019 National Health Interview Survey (NHIS) (n = 5028). Tobacco use was classified into the following categories: only using cigarettes, only using e-cigarettes/vapes, only using cigars, only using smokeless tobacco, or using two or more of the following products. We used a binary logistic regression, controlling for individual differences. Results: Individuals who reported using only traditional cigarettes (and no other tobacco product, OR = 1.62, 95% CI: 1.31, 2.01), or who reported being a poly-tobacco users (OR = 2.13, 95% CI: 1.40, 3.22) had higher odds of medical opioid use in the last twelve months. Conclusion: Results suggest a link between tobacco use, particularly cigarette use and poly-tobacco use, and medical opioid use in rural communities. Clinical and structural level interventions need to be implemented in rural communities to reduce comorbid tobacco and opioid use.
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Affiliation(s)
- Mariaelena Gonzalez
- Department of Public Health, School of Social Sciences Humanities and the Arts, University of California Merced, Merced, CA 95343, USA
- Nicotine and Cannabis Policy Center, University of California Merced, Merced, CA 95343, USA
- Correspondence:
| | - Ashley Sanders-Jackson
- Department of Advertising and Public Relations, College of Communications Arts and Sciences, Michigan State University, East Lansing, MI 48824, USA;
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Factors Associated with Pain Treatment Satisfaction Among Patients with Chronic Non-Cancer Pain and Substance Use. J Am Board Fam Med 2021; 34:1082-1095. [PMID: 34772764 PMCID: PMC8813175 DOI: 10.3122/jabfm.2021.06.210214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/09/2021] [Accepted: 07/26/2021] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION A better understanding of pain treatment satisfaction in patients with chronic noncancer pain (CNCP) and substance use is needed, especially as opioid prescribing policies are changing. We sought to identify factors associated with pain treatment satisfaction in individuals with CNCP on recent opioid therapy and prior or active substance use. METHODS An exploratory cross-sectional analysis using baseline data from a cohort study of 300 adults with CNCP receiving >20 morphine milligram equivalents of opioids for ≥3 of the preceding 12 months and prior or active substance use. Participants completed interviews, clinical assessments, urine drug screening, and medical chart review. RESULTS Participants were predominantly middle-aged (mean age 57.5 years), Black (44%), and cisgender men (60%). One-third (33%) had high, 28% moderate, and 39% low pain treatment satisfaction. Post-traumatic stress disorder (PTSD), tobacco use, past-year opioid discontinuation, and higher average pain scores were associated with lower satisfaction. HIV and prescription cannabis use were associated with higher satisfaction. CONCLUSIONS The relationship between PTSD and tobacco use with lower satisfaction should be explored to augment pain outcomes. Higher satisfaction among individuals with HIV and prescription cannabis use presents potential research areas to guide CNCP management and reduce reliance on opioid therapies.
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A qualitative trajectory analysis of patients' experiences tapering opioids for chronic pain. Pain 2021; 163:e246-e260. [PMID: 33990111 DOI: 10.1097/j.pain.0000000000002336] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 04/28/2021] [Indexed: 11/25/2022]
Abstract
ABSTRACT Tapering opioids for chronic pain can be challenging for both patients and prescribers, both of whom may be unsure of what to expect in terms of pain, distress, activity interference, and withdrawal symptoms over the first few weeks and months of the taper. To better prepare clinicians to provide patient-centred tapering support, the current research used prospective longitudinal qualitative methods to capture individual-level variation in patients' experience over the first few months of a voluntary physician-guided taper. The research aimed to identify patterns in individuals' experience of tapering and explore whether patient characteristics, readiness to taper, opioid tapering self-efficacy, or psychosocial context were related to tapering trajectory. Twenty-one patients with chronic noncancer pain commencing tapering of long-term opioid therapy were recruited from a metropolitan tertiary pain clinic (n = 13) and a regional primary care practice (n = 8). Semistructured phone interviews were conducted a mean of 8 times per participant over a mean duration of 12 weeks (N = 173). Four opioid-tapering trajectories were identified, which we characterised as thriving, resilient, surviving, and distressed. High and low readiness to taper was a defining characteristic of thriving and distressed trajectories, respectively. Life adversity was a prominent theme of resilient and distressed trajectories, with supportive relationships buffering the effects of adversity for those who followed a resilient trajectory. Discussion focuses on the implications of these findings for the preparation and support of patients with chronic pain who are commencing opioid tapering.
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Haq N, McMahan VM, Torres A, Santos GM, Knight K, Kushel M, Coffin PO. Race, pain, and opioids among patients with chronic pain in a safety-net health system. Drug Alcohol Depend 2021; 222:108671. [PMID: 33810908 PMCID: PMC8687128 DOI: 10.1016/j.drugalcdep.2021.108671] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/29/2020] [Accepted: 01/03/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Recent changes in opioid prescribing practices in the US may exacerbate disparities in opioid access among Black compared to White patients. METHODS To evaluate racial disparities in opioid prescribing and stewardship, we used baseline data collected from 2017 to 2019 for a longitudinal cohort of patients with chronic non-cancer pain and a history of illicit substance use. Sociodemographic characteristics, pain, psychological distress, substance use, and opioid prescription practices were compared between Black and White participants. We conducted multivariable logistic regression with race as the outcome. We also compared yellow flag events (opioid-related emergency department visits, illicit substances on urine drug screens, provider-documentation of concerning behaviors) by race. RESULTS Over half of participants analyzed were Black (57%) and the remainder White (43%). Participants with worse average pain in the past three months (adjusted odds ratio [AOR]:1.29, 95%CI:1.08-1.55, p = 0.006) had higher odds of being Black. Past-year injection drug use (AOR:0.39, 95%CI:0.16-0.94, p = 0.04) and a higher past-year maximum opioid dose (AOR per 10 morphine milligram equivalents (MME):0.99, 95%CI:0.98-1.00, p = 0.006) were associated with lower odds of being Black. We found no differences by race in the use of opioid stewardship measures or discontinuation of opioids based on yellow flag events. CONCLUSION Lower past-year maximum MME dose, despite higher average pain and less injection drug use, may represent bias away from prescribing opioids for chronic pain among Black patients. This could be due to unmeasured implicit provider bias or patient-level factors (e.g., utilizing non-opioid pain coping strategies or being less likely to request additional opioids).
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Affiliation(s)
- Nimah Haq
- San Francisco Department of Public Health, 25 Van Ness Avenue, San Francisco, CA, USA.
| | - Vanessa M McMahan
- San Francisco Department of Public Health, 25 Van Ness Avenue, San Francisco, CA, USA
| | - Andrea Torres
- San Francisco Department of Public Health, 25 Van Ness Avenue, San Francisco, CA, USA
| | - Glenn-Milo Santos
- San Francisco Department of Public Health, 25 Van Ness Avenue, San Francisco, CA, USA; University of California, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Kelly Knight
- University of California, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Margot Kushel
- University of California, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Phillip O Coffin
- San Francisco Department of Public Health, 25 Van Ness Avenue, San Francisco, CA, USA; University of California, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
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El-Bassel N, Shoptaw S, Goodman-Meza D, Ono H. Addressing long overdue social and structural determinants of the opioid epidemic. Drug Alcohol Depend 2021; 222:108679. [PMID: 33810910 DOI: 10.1016/j.drugalcdep.2021.108679] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
| | - Steven Shoptaw
- Department of Family Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - David Goodman-Meza
- Department of Medicine and Department of Family Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Hiromi Ono
- Independent Scholar, Washington D.C., USA
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Slat S, Yaganti A, Thomas J, Helminski D, Heisler M, Bohnert A, Lagisetty P. Opioid Policy and Chronic Pain Treatment Access Experiences: A Multi-Stakeholder Qualitative Analysis and Conceptual Model. J Pain Res 2021; 14:1161-1169. [PMID: 33948090 PMCID: PMC8088411 DOI: 10.2147/jpr.s282228] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 03/11/2021] [Indexed: 01/17/2023] Open
Abstract
Purpose Patients on long-term opioid therapy (LTOT) for pain have difficulty accessing primary care clinicians who are willing to prescribe opioids or provide multimodal pain treatment. Recent treatment guidelines and statewide policies aimed at reducing inappropriate prescribing may exacerbate these access issues, but further research is needed on this issue. This study aimed to understand barriers to primary care access and multimodal treatment for chronic pain from the perspective of multiple stakeholders. Methods Qualitative, semi-structured phone interviews were conducted with adult patients with chronic pain, primary care clinicians, and clinic office staff in Michigan. Interview questions covered stakeholder experiences with prescription opioids, opioid-related policies, and access to care for chronic pain. Interviews were coded using inductive and deductive methods for thematic analysis. Results A total of 25 interviews were conducted (15 patients, 7 primary care clinicians, and 3 office staff). Barriers to treatment access were attributed to six themes: (1) reduced clinic willingness to manage prescribed opioids for new patients; (2) lack of time and reimbursement for quality opioid-related care; (3) paucity of multimodal care and coordination between providers; (4) fear of liability and use of new guidelines to justify not prescribing opioids; (5) delayed prescription receipt due to prior authorization and pharmacy issues; and (6) poor availability of effective non-opioid treatments. Conclusion Issues of policy, logistics, and clinic-level resources converge to disrupt treatment access for patients with chronic pain, as many clinics both do not offer multimodal pain care and are unwilling to prescribe LTOT. The resulting conceptual model can inform the development of policy interventions to help mitigate these access barriers.
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Affiliation(s)
- Stephanie Slat
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Avani Yaganti
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jennifer Thomas
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Danielle Helminski
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Michele Heisler
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,Center for Clinical Management and Research, Ann Arbor VA Hospital, Ann Arbor, MI, USA.,Department of Health Behavior & Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Amy Bohnert
- Center for Clinical Management and Research, Ann Arbor VA Hospital, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Departments of Anesthesiology and Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Pooja Lagisetty
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,Center for Clinical Management and Research, Ann Arbor VA Hospital, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
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Damiescu R, Banerjee M, Lee DYW, Paul NW, Efferth T. Health(care) in the Crisis: Reflections in Science and Society on Opioid Addiction. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:E341. [PMID: 33466370 PMCID: PMC7795923 DOI: 10.3390/ijerph18010341] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 12/28/2020] [Accepted: 12/30/2020] [Indexed: 12/21/2022]
Abstract
Opioid abuse and misuse have led to an epidemic which is currently spreading worldwide. Since the number of opioid overdoses is still increasing, it is becoming obvious that current rather unsystematic approaches to tackle this health problem are not effective. This review suggests that fighting the opioid epidemic requires a structured public health approach. Therefore, it is important to consider not only scientific and biomedical perspectives, but societal implications and the lived experience of groups at risk as well. Hence, this review evaluates the risk factors associated with opioid overdoses and investigates the rates of chronic opioid misuse, particularly in the context of chronic pain as well as post-surgery treatments, as the entrance of opioids in people's lives. Linking pharmaceutical biology to narrative analysis is essential to understand the modulations of the usual themes of addiction and abuse present in the opioid crisis. This paper shows that patient narratives can be an important resource in understanding the complexity of opioid abuse and addiction. In particular, the relationship between chronic pain and social inequality must be considered. The main goal of this review is to demonstrate how a deeper transdisciplinary-enriched understanding can lead to more precise strategies of prevention or treatment of opioid abuse.
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Affiliation(s)
- Roxana Damiescu
- Department of Pharmaceutical Biology, Institute of Pharmaceutical and Biomedical Sciences, Johannes Gutenberg University, 55128 Mainz, Germany;
| | - Mita Banerjee
- Department of English and Linguistics, Obama Institute for Transnational American Studies, Johannes Gutenberg University, 55128 Mainz, Germany;
| | - David Y. W. Lee
- McLean Hospital, Harvard Medical School, Boston, MA 02478, USA;
| | - Norbert W. Paul
- Institute for History, Philosophy and Ethics of Medicine, Johannes Gutenberg University Medical Center, 55128 Mainz, Germany;
| | - Thomas Efferth
- Department of Pharmaceutical Biology, Institute of Pharmaceutical and Biomedical Sciences, Johannes Gutenberg University, 55128 Mainz, Germany;
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Binswanger IA, Glanz JM, Faul M, Shoup JA, Quintana LM, Lyden J, Xu S, Narwaney KJ. The Association between Opioid Discontinuation and Heroin Use: A Nested Case-Control Study. Drug Alcohol Depend 2020; 217:108248. [PMID: 32927194 PMCID: PMC10959283 DOI: 10.1016/j.drugalcdep.2020.108248] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/12/2020] [Accepted: 08/15/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Opioid prescribing guidelines recommend reducing or discontinuing opioids for chronic pain if harms of opioid treatment outweigh benefits. As opioid discontinuation becomes more prevalent, it is important to understand whether opioid discontinuation is associated with heroin use. In this study, we sought to assess the association between opioid discontinuation and heroin use documented in the medical record. METHODS A matched nested case-control study was conducted in an integrated health plan and delivery system in Colorado. Patients receiving opioid therapy in the study period (January 2006-June 2018) were included. Opioid discontinuation was defined as ≥45 days with no opioids dispensed after initiating opioid therapy. The heroin use onset date represented the index date. Case patients were matched to up to 20 randomly selected patients without heroin use (control patients) by age, sex, calendar time, and time between initiating opioid therapy and the index date. Conditional logistic regression models estimated matched odds ratios (mOR) for the association between an opioid discontinuation prior to the index date and heroin use. RESULTS Among 22,962 patients prescribed opioid therapy, 125 patients (0.54%) used heroin after initiating opioid therapy, of which 74 met criteria for inclusion in the analysis. The odds of opioid discontinuation were approximately two times higher in case patients (n = 74) than control patients (n = 1045; mOR = 2.19; 95% CI 1.27-3.78). CONCLUSIONS Among patients prescribed chronic opioid therapy, the observed increased risk for heroin use associated with opioid discontinuation should be balanced with potential benefits.
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Affiliation(s)
- Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO; Colorado Permanente Medical Group, Aurora, CO; Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO.
| | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO; Colorado School of Public Health, Aurora, CO
| | - Mark Faul
- Centers for Disease Control and Prevention, Atlanta, GA
| | - Jo Ann Shoup
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - LeeAnn M Quintana
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Jennifer Lyden
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO; Denver Health, Department of Medicine, Denver, CO
| | - Stan Xu
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO; Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Komal J Narwaney
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
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