Improving opioid prescription practices and reducing patient risk in the primary care setting

Mind-body approaches targeting the psychological aspects of opioid use problems in patients with chronic pain: evidence and opportunities

Opioids are commonly prescribed for the management of patients with chronic noncancer pain. Despite the potential analgesic benefits of opioids, long-term opioid therapy (LTOT) may be accompanied by problems such as opioid misuse and opioid use disorder (OUD). In this review, we begin with a description of opioid misuse and OUD and the patient-specific factors associated with these problems among patients with chronic pain. We will focus primarily on highlighting the predominant role played by psychological factors in the occurrence of opioid misuse and OUD in these patients. Several psychological factors have been found to be associated with opioid use problems in patients with chronic pain, and evidence indicates that patients presenting with psychological disturbances are particularly at risk of transitioning to long-term opioid use, engaging in opioid misuse behaviors, and developing OUD. The biological factors that might underlie the association between psychological disturbances and opioid use problems in patients with chronic pain have yet to be fully elucidated, but a growing number of studies suggest that dysfunctions in reward, appetitive, autonomic, and neurocognitive systems might be involved. We end with an overview of specific types of psychological interventions that have been put forward to prevent or reduce the occurrence of opioid misuse and OUD in patients with chronic pain who are prescribed LTOT.

Trends in long-term opioid prescriptions for musculoskeletal conditions in Australian general practice: a national longitudinal study using MedicineInsight, 2012-2018

OBJECTIVE

Describe trends and patterns in long-term opioid prescriptions among adults with musculoskeletal conditions (MSK).

DESIGN

Interrupted time-series analysis based on an open cohort study.

SETTING

A representative sample of 402 Australian general practices contributing data to the MedicineInsight database.

PARTICIPANTS

811 174 patients aged 18+ years with an MSK diagnosis and three or more consultations in any two consecutive years between 2012 and 2018. Males represented 44.5% of the sample, 28.4% were 65+ years and 1.9% were Aboriginal or Torres Strait Islanders.

PRIMARY AND SECONDARY OUTCOME MEASURES

Annual prevalence and cumulative incidence (%) of long-term opioid prescribing (3+ prescriptions in 90 days) among patients with an MSK. Average duration of these episodes in each year between 2012 and 2018.

RESULTS

The prevalence of long-term opioid prescribing increased from 5.5% (95% CI 5.2 to 5.8) in 2012 to 9.1% (95% CI 8.8 to 9.7) in 2018 (annual change OR 1.09, 95% CI 1.08 to 1.09), but a slightly lower incidence was observed in 2018 (3.0% vs 3.6%-3.8% in other years; annual change OR 0.99, 95% CI 0.98 to 0.99). The incidence was between 37% and 52% higher among practices located in rural Australia or lower socioeconomic areas. Individual risk factors included increasing age (3.4 times higher among those aged 80+ years than the 18-34 years group in 2012, increasing to 4.8 times higher in 2018), identifying as Aboriginal or Torres Strait Islander (1.7-1.9 higher incidence than their peers), or living in disadvantaged areas (36%-57% more likely than among those living in wealthiest areas). Long-term opioid prescriptions lasted in average 287-301 days between 2012 and 2016, reducing to 229 days in 2017 and 140 days in 2018. A longer duration was observed in practices from more disadvantaged areas and females in all years, except in 2018.

CONCLUSIONS

The continued rise in the prevalence of long-term opioid prescribing is of concern, despite a recent reduction in the incidence and duration of opioid management.

Chronic Opioid Therapy: A Scoping Literature Review on Evolving Clinical and Scientific Definitions

The management of chronic noncancer pain (CNCP) with chronic opioid therapy (COT) is controversial. There is a lack of consensus on how COT is defined resulting in unclear clinical guidance. This scoping review identifies and evaluates evolving COT definitions throughout the published clinical and scientific literature. Databases searched included PubMed, Embase, and Web of Science. A total of 227 studies were identified from 8,866 studies published between January 2000 and July 2019. COT definitions were classified by pain population of application and specific dosage/duration definition parameters, with results reported according to PRISMA-ScR. Approximately half of studies defined COT as "days' supply duration >90 days" and 9.3% defined as ">120 days' supply," with other days' supply cut-off points (>30, >60, or >70) each appearing in <5% of total studies. COT was defined by number of prescriptions in 63 studies, with 16.3% and 11.0% using number of initiations or refills, respectively. Few studies explicitly distinguished acute treatment and COT. Episode duration/dosage criteria was used in 90 studies, with 7.5% by Morphine Milligram Equivalents + days' supply and 32.2% by other "episode" combination definitions. COT definitions were applied in musculoskeletal CNCP (60.8%) most often, and typically in adults aged 18 to 64 (69.6%). The usage of ">90 days' supply" COT definitions increased from 3.2 publications/year before 2016 to 20.7 publications/year after 2016. An increasing proportion of studies define COT as ">90 days' supply." The most recent literature trends toward shorter duration criteria, suggesting that contemporary COT definitions are increasingly conservative. PERSPECTIVE: This study summarized the most common, current definition criteria for chronic opioid therapy (COT) and recommends adoption of consistent definition criteria to be utilized in practice and research. The most recent literature trends toward shorter duration criteria overall, suggesting that COT definition criteria are increasingly stringent.

Qualitative insights into the opioid prescribing practices of Australian GP

BACKGROUND

Over the last three decades, Australian opioid-prescribing rates and related morbidity and mortality have dramatically increased. Opioids are frequently prescribed by general practitioners (GPs) to manage chronic non-cancer pain, despite evidence-based recommendations from the Centre for Disease Control, National Institute for Health and Care Excellence and World Health Organization widely cautioning their use. Little is known about the factors influencing the opioid prescribing decisions of Australian GPs, especially when not evidence based.

OBJECTIVE

To explore the opioid prescribing knowledge, attitudes and practices of Australian GPs.

METHODS

Semi-structured interviews with 20 GPs recruited from the Monash University practice-based research network in metropolitan, southeastern Melbourne. Thematic analysis was used to identify emergent themes. Data were managed using QSR NVivo. Ethics approval was granted by Monash University.

RESULTS

Three key themes emerged. GP attitudes towards opioid use for chronic pain varied by age of patient and goals for therapy. Use of opioids for elderly patients was positively perceived. GPs were reluctant to use opioids in younger patients due to fears of addiction and difficulty weaning. GPs felt obliged to prescribe opioids recommended by specialists, even if they believed the opioids were unsafe.

CONCLUSION

This study identified and described the patient-centred nature of GP opioid prescribing decisions. Patient age and perceived age-related opioid harm were important factors influencing prescribing decisions. Future work should inform interventions that value GP autonomy while still encouraging a collaborative inter-speciality approach to managing chronic pain patients with opioids.

The Trends in Opioid Use in Castile and Leon, Spain: A Population-Based Registry Analysis of Dispensations in 2015 to 2018

Opioids are driving-impairing medicines (DIM). To assess the evolution and trends of opioid analgesics use between 2015 and 2018 in Castile and Leon (Spain), a population-based registry study was conceived. The length of opioid use and its concomitant use with other DIMs were studied. Analyses were done considering age and gender distributions. Adjusted consumption for licensed drivers is also presented. Of the 5 million dispensations recorded between 2015 and 2018, opioid analgesics were dispensed to 11.44% of the general population and 8.72% of vehicle drivers. Increases among daily users (2.6 times higher) and chronic users (1.5% higher) were noted, supporting the overall increase in opioid use (1.5%). The use of multiple drugs including other DIMs was a common finding (mean ± SD, 2.54 ± 0.01). Acute use (5.26%) and chronic use (3.20%) were also frequent. Formulations combining opioid analgesics with nonopioid analgesics were preferred. The use of opioids increased in Spain between 2015 and 2018. Concomitant use with other DIMS especially affects women and the elderly. Frequent use of opioid analgesics with other DIMs is a serious problem for drivers and increases the risk of accidents. Promoting safe driving should be a main objective of health authorities, to be achieved by developing and implementing educational activities for healthcare professionals and patients.

Guidelines for Monitoring Patients Using Opioid Therapy

Opioid-related morbidity and mortality have increased to epidemic proportions over the past 20 years. Gynecologists play an integral role in addressing this epidemic through management of patients with pain, specifically through prescribing and monitoring practices. Practical recommendations are provided for clinicians caring for noncancer patients on chronic opioid therapy. Recommendations are largely based on national consensus guidelines with a focus on frequency and content of follow-up, identification of high risk behaviors, and reassessment of goals of treatment.

Society of Behavioral Medicine (SBM) position statement: improving access to psychosocial care for individuals with persistent pain: supporting the National Pain Strategy's call for interdisciplinary pain care

Policy makers have articulated a need for clear, evidence-based guidance to help inform pain policy. Persistent pain is common, expensive, and debilitating, and requires comprehensive assessment and treatment planning. Recently released opioid prescribing guidelines by the CDC (2016) emphasize the importance of using nonopioid therapies before considering opioid treatment for those without a malignant illness. The National Pain Strategy (2016) underscores the importance of comprehensive, interdisciplinary pain care. Unfortunately, despite persuasive evidence supporting the efficacy of psychosocial approaches, these interventions are inaccessible to the majority of Americans. Psychosocial approaches to pain management should be available for all individuals with persistent pain and in all health care settings and contexts as part of the comprehensive, interdisciplinary approach to pain care as outlined in the National Pain Strategy. To achieve this, we must prioritize reimbursement of evidence-based psychosocial approaches for pain assessment and management and improve provider training and competencies to implement these approaches.

Opioids in oral fluid of Spanish drivers

BACKGROUND

Driving under the influence of certain drugs is not allowed, and roadside drug testing is being considered an important tool for deterring driving under the influence of them. This study aimed to assess the presence and concentration of opioids, as well as their combined use with other drugs (laboratory confirmation after the on-road screening) in Spanish drivers between 2011 and 2016.

METHODS

In Spain, mandatory roadside breath alcohol and oral fluid drug testing (screening) are carried out by the Traffic Police using Dräger Alcotest^® 6810 device, and Dräger DrugTest^® 5000, DrugWipe^®, or Alere™ DDS^®2 Mobile Test System. For positive cases in the period covered, 65,244, confirmation analysis and quantification using chromatographic techniques were performed.

RESULTS

Opioids were confirmed in 8.6% of positive cases, being 7.2% positives to 6-acetylmorphine (6-AM), 6.5% to morphine, 5.4% to codeine, and 4.1% to methadone. The majority of the confirmed tests for morphine (96.5%), codeine (88.4%) and methadone (81.9) were also positive for 6-AM. The presence of other drugs, particularly cocaine and cannabis, was very common. Concentration values reached important levels. Positive results for morphine (0.1%), codeine (0.6%) or methadone (0.4%) alone were very infrequent.

CONCLUSIONS

Drivers with a confirmed positive roadside test for morphine, codeine, and methadone had also consumed heroin and/or other illicit drugs, such as cocaine and/or THC, and at relevant concentrations. Improving interventions to combat the problem of driving under the influence of driving-impairing substances is a priority.

Effect of opioid prescribing guidelines in primary care

Long-term opioid use for noncancer pain is increasingly prevalent yet controversial given the risks of addiction, diversion, and overdose. Prior literature has identified the problem and proposed management guidelines, but limited evidence exists on the actual effectiveness of implementing such guidelines in a primary care setting.A multidisciplinary working group of institutional experts assembled comprehensive guidelines for chronic opioid prescribing, including monitoring and referral recommendations. The guidelines were disseminated in September 2013 to our medical center's primary care clinics via in person and electronic education.We extracted electronic medical records for patients with noncancer pain receiving opioid prescriptions (Rxs) in seasonally matched preintervention (11/1/2012-6/1/2013) and postintervention (11/1/2013-6/1/2014) periods. For patients receiving chronic (3 or more) opioid Rxs, we assessed the rates of drug screening, specialty referrals, clinic visits, emergency room visits, and quantity of opioids prescribed.After disseminating guidelines, the percentage of noncancer clinic patients receiving any opioid Rxs dropped from 3.9% to 3.4% (P = 0.02). The percentage of noncancer patients receiving chronic opioid Rxs decreased from 2.0% to 1.6% (P = 0.03). The rate of urine drug screening increased from 9.2% to 17.3% (P = 0.005) amongst noncancer chronic opioid patients. No significant differences were detected for other metrics or demographics assessed.An educational intervention for primary care opioid prescribing is feasible and was temporally associated with a modest reduction in overall opioid Rx rates. Provider use of routine drug screening increased, but overall rates of screening and specialty referral remained low despite the intervention. Despite national pressures to introduce opioid prescribing guidelines for chronic pain, doing so alone does not necessarily yield substantial changes in clinical practice.

Risk based in vitro performance assessment of extended release abuse deterrent formulations

High strength extended release opioid products, which are indispensable tools in the management of pain, are associated with serious risks of unintentional and potentially fatal overdose, as well as of misuse and abuse that might lead to addiction. The issue of drug abuse becomes increasingly prominent when the dosage forms can be readily manipulated to release a high amount of opioid or to extract the drug in certain products or solvents. One approach to deter opioid drug abuse is by providing novel abuse deterrent formulations (ADF), with properties that may be viewed as barriers to abuse of the product. However, unlike regular extended release formulations, assessment of ADF technologies are challenging, in part due to the great variety of formulation designs available to achieve deterrence of abuse by oral, parenteral, nasal and respiratory routes. With limited prior history or literature information, and lack of compendial standards, evaluation and regulatory approval of these novel drug products become increasingly difficult. The present article describes a risk-based standardized in-vitro approach that can be utilized in general evaluation of abuse deterrent features for all ADF products.

Primary care providers' experiences with urine toxicology tests to manage prescription opioid misuse and substance use among chronic noncancer pain patients in safety net health care settings

BACKGROUND

Guideline recommendations to reduce prescription opioid misuse among patients with chronic noncancer pain include the routine use of urine toxicology tests for high-risk patients. Yet little is known about how the implementation of urine toxicology tests among patients with co-occurring chronic noncancer pain and substance use impacts primary care providers' management of misuse. Clinicians' perspectives on the benefits and challenges of implementing urine toxicology tests in the monitoring of opioid misuse and substance use in safety net health care settings are presented in this paper.

METHODS

Twenty-three primary care providers from 6 safety net health care settings whose patients had a diagnosis of co-occurring chronic noncancer pain and substance use were interviewed. Interviews were transcribed, coded, and analyzed using grounded theory methodology.

RESULTS

The benefits of implementing urine toxicology tests for primary care providers included less reliance on intuition to assess for misuse and the ability to identify unknown opioid misuse and/or substance use. The challenges of implementing urine toxicology tests included insufficient education and training about how to interpret and implement tests, and a lack of clarity on how and when to act on tests that indicated misuse and/or substance use.

CONCLUSIONS

These data suggest that primary care clinicians' lack of education and training to interpret and implement urine toxicology tests may impact their management of patient opioid misuse and/or substance use. Clinicians may benefit from additional education and training about the clinical implementation and use of urine toxicology tests. Additional research is needed on how primary care providers implementation and use of urine toxicology tests impacts chronic noncancer pain management in primary care and safety net health care settings among patients with co-occurring chronic non cancer pain and substance use.

Dental opioid prescribing practices and risk mitigation strategy implementation: Identification of potential targets for provider-level intervention

BACKGROUND

Given the regular use of immediate-release opioids for dental pain management, as well as documented opioid misuse among dental patients, the dental visit may provide a viable point of intervention to screen, identify, and educate patients regarding the risks associated with prescription opioid misuse and diversion. The aims of this statewide survey of dental practitioners were to assess (a) awareness of the scope of prescription opioid misuse and diversion; (b) current opioid prescribing practices; (c) use of and opinions regarding risk mitigation strategies; and (d) use and perceived utility of drug monitoring programs.

METHODS

This cross-sectional study surveyed dentists (N = 87) participating in statewide professional and alumni organizations. Dentists were invited via e-mail and listserv announcement to participate in a one-time, online, 59-item, self-administered survey.

RESULTS

A majority of respondents reported prescribing opioids (n = 66; 75.8%). A minority of respondents (n = 38; 44%) reported regularly screening for current prescription drug abuse. Dentists reported low rates of requesting prior medical records (n = 5; 5.8%). Only 38% (n = 33) of respondents had ever accessed a prescription drug monitoring program (PDMP), and only 4 (4.7%) consistently used a PDMP. Dentists reporting prior training in drug diversion were significantly more likely to have accessed their PDMP, P < .01. Interest in continuing education regarding assessment of prescription drug abuse/diversion and use of drug monitoring programs was high.

CONCLUSIONS

Although most dentists received training related to prescribing opioids, findings identified a gap in existing dental training in the assessment/identification of prescription opioid misuse and diversion. Findings also identified gaps in the implementation of recommended risk mitigation strategies, including screening for prescription drug abuse, consistent provision of patient education, and use of a PDMP prior to prescribing opioids.

In the Clinic. Restless Legs Syndrome

This issue provides a clinical overview of restless legs syndrome, focusing on diagnosis, treatment, and practice improvement. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of additional science writers and physician writers.

Opioid-use disorder among patients on long-term opioid therapy: impact of final DSM-5 diagnostic criteria on prevalence and correlates

Aims

Previously, we estimated the prevalence and risk factors for prescription opioid-use disorder among outpatients on opioid therapy using the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 and DSM-4 criteria. However, at the time, the DSM-5 criteria were not finalized. In the current study, we analyzed these data using the final DSM-5 criteria and compared these results.

Methods

Using electronic records from a large US health care system, we identified outpatients receiving five or more prescription orders for opioid therapy in the past 12 months for noncancer pain (mean prescription orders =10.72; standard deviation =4.96). In 2008, we completed diagnostic interviews with 705 of these patients using the DSM-4 criteria. In the current study, we reassessed these results using the final DSM-5 criteria.

Results

The lifetime prevalence of DSM-5 opioid-use disorders using the final DSM-5 criteria was 58.7% for no or few symptoms (<2), 28.1% for mild symptoms (2–3), 9.7% for moderate symptoms (4–5), and 3.5% for severe symptoms (six or more). Thus, the lifetime prevalence of “any” prescription opioid-use disorder in this cohort was 41.3% (95% confidence interval [CI] =37.6–45.0). A comparison to the DSM-4 criteria indicated that the majority of patients with lifetime DSM-4 opioid dependence were now classified as having mild opioid-use disorder, based on the DSM-5 criteria (53.6%; 95% CI =44.1–62.8). In ordinal logistic regression predicting no/few, mild, moderate, and severe opioid-use disorder, the best predictors were age <65 years, current pain impairment, trouble sleeping, suicidal thoughts, anxiety disorders, illicit drug use, and history of substance abuse treatment.

Conclusion

Given the final DSM-5 criteria, including the elimination of tolerance and withdrawal, inclusion of craving and abuse symptoms, and introduction of a new graded severity classification, the prevalence of opioid-use disorders has changed, while many of the DSM-4 risk factors for opioid dependence were similar. To our knowledge, this is one of the first studies to compare the final results for DSM-5 versus DSM-4 prescription opioid-use disorders among a high-risk patient population.