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Encinosa W, Bernard D, Selden TM. Opioid and non-opioid analgesic prescribing before and after the CDC's 2016 opioid guideline. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2022; 22:1-52. [PMID: 33963977 PMCID: PMC8105705 DOI: 10.1007/s10754-021-09307-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 04/26/2021] [Indexed: 05/07/2023]
Abstract
The U.S. has addressed the opioid crisis using a two-front approach: state regulations limiting opioid prescriptions for acute pain patients, and voluntary federal CDC guidelines on shifting chronic pain patients to lower opioid doses and non-opioids. No opioid policy research to date has accounted for this two-pronged approach in their research design. We develop a theory of physician prescribing behavior under this two-pronged incentive structure. Using the Medical Expenditure Panel Survey, we empirically corroborate the theory: regulations and guidelines have the intended effects of reducing opioid prescriptions for acute and chronic pain, respectively, as well as the predicted unintended effects-income effects cause regulations on acute pain treatment to increase chronic pain opioid prescriptions and the chronic pain treatment guidelines spillover to reduce opioids for acute pain. Moreover, we find that the guidelines worked as intended in terms of the reduced usage, with chronic pain patients shifting to non-opioids and also tapering opioid doses. For those who discontinued opioids under regulations and guidelines, we find no harm in terms of increased work limitations due to pain a year after discontinuing opioids. Finally, we observe an unexplained dichotomy-regulations reduce opioid use by causing fewer new starts, whereas guidelines reduce opioid use by discontinuing current users, with no impact on new starts.
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Affiliation(s)
- William Encinosa
- Division of Research and Modeling, Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, and the McCourt School of Public Policy, Georgetown University, Rockville, MD USA
| | - Didem Bernard
- Division of Research and Modeling, Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, and the McCourt School of Public Policy, Georgetown University, Rockville, MD USA
| | - Thomas M. Selden
- Division of Research and Modeling, Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, and the McCourt School of Public Policy, Georgetown University, Rockville, MD USA
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2
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Gorito V, Monjardino T, Azevedo I, Lucas R. Potentially unrecognised pain in children: Population-based birth cohort study at 7 years of age. J Paediatr Child Health 2022; 58:474-480. [PMID: 34553809 DOI: 10.1111/jpc.15749] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 07/19/2021] [Accepted: 09/05/2021] [Indexed: 11/27/2022]
Abstract
AIM To estimate agreement in the point prevalence of any pain, high-intensity pain and pain in two or more sites according to parental and child report. METHODS We conducted a prospective study of 5639 children from a Portuguese birth cohort - Generation XXI, where parents and 7-year-old children answered the same questions at the same time. We assessed the accuracy of parental report, considering children's self-report as the gold standard. RESULTS At 7 years of age, 499 children (8.8% (95% confidence interval (CI) 8.1-9.6)) reported having pain at the time of the interview. Of those, 44.1% had high-intensity pain (3.9% (95% CI 3.4-4.4) of the whole sample) and 12.4% reported pain in two or more sites (1.1% (95% CI 0.8-1.4) of the whole sample). In this community setting, pain prevalence and intensity were lower when collected from parents. Parental report had sensitivity below 20% and specificity above 95% but its positive predictive value was at most 25%. CONCLUSION Our findings support that, outside acute care, parents have a specific but not sensitive report of children's pain at the age of 7 years. Their report seemed useful to exclude major complaints but limited to screen children's pain. This limitation was higher for more severe pain, that is two or more sites or high-intensity pain. Children should be asked directly about pain to avoid under-estimating paediatric pain.
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Affiliation(s)
- Vanessa Gorito
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal.,Serviço Pediatria, Centro Materno-Pediátrico, Centro Hospitalar e Universitário de São João, Porto, Portugal.,Departamento de Ginecologia e Obstetrícia, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Teresa Monjardino
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
| | - Inês Azevedo
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal.,Serviço Pediatria, Centro Materno-Pediátrico, Centro Hospitalar e Universitário de São João, Porto, Portugal.,Departamento de Ginecologia e Obstetrícia, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Raquel Lucas
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal.,Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
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Wilkes JL, Montalban JN, Pringle BD, Monroe D, Miller A, Zapata I, Brooks AE, Ross DW. A Demographic and Regional Comparison of Opioid-Related Hospital Visits within Community Type in the United States. J Clin Med 2021; 10:3460. [PMID: 34441753 PMCID: PMC8397219 DOI: 10.3390/jcm10163460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/30/2021] [Accepted: 08/02/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The opioid epidemic is a complex national crisis in the United States with a 400% increase in related deaths over the past two decades with no signs of slowing. The purpose of this study was to assess the incidence of opioid use, based on the geographic and population characteristics. METHODS The opioid-related hospital inpatient stays and emergency department visits obtained from the 2010 to 2018 Healthcare Cost and Utilization Project and demographic confounders, including age, race, education, and income gathered from US Census data were analyzed through generalized linear mixed models and reported by community size and region. RESULTS Opioid use varies among population center sizes and the region analyzed. In general, opioid visits in the southwest region were greatest across the majority of population center sizes. Rural usage was greatest in the northeast, southeast, and southwest. Unemployment and diverse ethnicities were commonly associated with opioid use in the metro areas studied but these associations were not seen in rural areas. CONCLUSION Opioid use remains significant among diverse populations across the United States. Understanding the unique dynamics associated with opioid usage in populations within the regions studied is important in guiding future interventions to fight this crisis.
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Affiliation(s)
- Jordan L. Wilkes
- Department of Specialty Medicine, Rocky Vista University, Parker, CO 80134, USA; (J.L.W.); (J.N.M.); (B.D.P.); (D.M.); (A.M.)
| | - Jessica N. Montalban
- Department of Specialty Medicine, Rocky Vista University, Parker, CO 80134, USA; (J.L.W.); (J.N.M.); (B.D.P.); (D.M.); (A.M.)
| | - Brian D. Pringle
- Department of Specialty Medicine, Rocky Vista University, Parker, CO 80134, USA; (J.L.W.); (J.N.M.); (B.D.P.); (D.M.); (A.M.)
| | - Devin Monroe
- Department of Specialty Medicine, Rocky Vista University, Parker, CO 80134, USA; (J.L.W.); (J.N.M.); (B.D.P.); (D.M.); (A.M.)
| | - Adela Miller
- Department of Specialty Medicine, Rocky Vista University, Parker, CO 80134, USA; (J.L.W.); (J.N.M.); (B.D.P.); (D.M.); (A.M.)
| | - Isain Zapata
- Department of Biomedical Sciences, Rocky Vista University, Parker, CO 80134, USA;
| | - Amanda E. Brooks
- Office of Research and Scholarly Activity, Rocky Vista University, Ivins, UT 84738, USA;
| | - David W. Ross
- Department of Specialty Medicine, Rocky Vista University, Parker, CO 80134, USA; (J.L.W.); (J.N.M.); (B.D.P.); (D.M.); (A.M.)
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Ruffolo LI, Jackson KM, Juviler P, Kaur R, Chennell T, Glover DM, Linehan DC, Moalem J. Narcotic Free Cervical Endocrine Surgery: A Shift in Paradigm. Ann Surg 2021; 274:e143-e149. [PMID: 31356280 DOI: 10.1097/sla.0000000000003443] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND OBJECTIVE The opioid epidemic has stimulated initiatives to reduce the number of unnecessary narcotic prescriptions. We adopted an opt-in prescription system for patients undergoing ambulatory cervical endocrine surgery (CES). We hypothesized that empowering patients to decide whether or not to receive narcotics for pain control would result in fewer unnecessary opioid prescriptions. METHODS We enrolled all patients scheduled for outpatient CES between July 2017 and June 2018 in a narcotic opt-in program. Patient demographics, procedure characteristics, and postoperative pain scores were collected prospectively. Statistical analyses were performed to correlate clinical predictors with narcotic request. Results were compared against a historical control group. The study was approved by the University IRB. RESULTS A total of 216 consecutive patients underwent outpatient CES following implementation of the program. Only nine (4%) requested prescription narcotic medication at discharge, and no patient called after discharge to request analgesic medications. Compared with our prior treatment paradigm, we achieved a 96.6% reduction in the number of narcotic tablets prescribed, and a 98% reduction in unconsumed tablets. Univariate analysis suggested history of substance abuse (P < 0.001), anxiety (P = 0.01), depression (P < 0.001), baseline narcotic use (P = 0.004), highest pain postoperatively (P = 0.004), and incision length (P = 0.007) as predictive for narcotic request. Multivariate analysis retained significance with incision length and history of substance abuse. CONCLUSION By empowering patients undergoing ambulatory CES to accept or decline a prescription, we reduced the number of prescribed narcotic tablets by 96.6%. Although longer incisions and prior substance abuse predict higher likelihood of requesting pain medication on discharge, 207 of 216 patients were treated with acetaminophen alone.
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Affiliation(s)
- Luis I Ruffolo
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
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Talwar R, Joshi SS. Minimizing opioid consumption following robotic surgery. Transl Androl Urol 2021; 10:2289-2296. [PMID: 34159111 PMCID: PMC8185686 DOI: 10.21037/tau.2019.08.11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 07/30/2019] [Indexed: 12/20/2022] Open
Abstract
The American opioid epidemic has led to one of the worse public health crises in recent history, and emerging evidence has highlighted the role of healthcare professionals in exposing patients and communities to potent opioid drugs. Surgeons, in treating postoperative pain, are at the forefront of this epidemic. In Urology, investigators are beginning to establish how patients handle and consume opioids following common urologic procedures in an effort to limit excess prescribing. However, there is a paucity of data to define acceptable amounts of opioid medications to adequately treat postoperative pain after urologic surgery. Many common urologic procedures are now routinely performed with robotic technology. Robotic, minimally-invasive approaches decrease incision size and accelerate postoperative recovery, thereby presenting a unique opportunity to curb excessive opioid prescribing in the postoperative patient. Herein, we explore the roots of the current crisis, outline current literature guiding pain control after surgery, and review the current, though sparse, literature that may guide urologists in decreasing opioid use after robotic surgery.
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Affiliation(s)
- Ruchika Talwar
- Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Shreyas S. Joshi
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
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Abstract
Opioids form an important component of general anesthesia and perioperative analgesia. Discharge opioid prescriptions are identified as a contributor for persistent opioid use and diversion. In parallel, there is increased enthusiasm to advocate opioid-free strategies, which include a combination of known analgesics and adjuvants, many of which are in the form of continuous infusions. This article critically reviews perioperative opioid use, especially in view of opioid-sparing versus opioid-free strategies. The data indicate that opioid-free strategies, however noble in their cause, do not fully acknowledge the limitations and gaps within the existing evidence and clinical practice considerations. Moreover, they do not allow analgesic titration based on patient needs; are unclear about optimal components and their role in different surgical settings and perioperative phases; and do not serve to decrease the risk of persistent opioid use, thereby distracting us from optimizing pain and minimizing realistic long-term harms.
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Carius BM, April MD, Pedersen CS, Schauer SG. Historical Alternans in the Emergency Department (H.A.t.E.D.) for Pain: An Analysis of Patient Pain Descriptors to Attending and Trainee Clinicians. South Med J 2021; 114:23-27. [PMID: 33398356 DOI: 10.14423/smj.0000000000001195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The concept of "historical alternans" (HA), a teaching folklore term referring to different descriptions of patient histories to trainees versus attending clinicians, can cause disjointed care and be a source of frustration for the trainee. Increased focus on the proper evaluation and treatment of pain in the emergency department (ED) setting prompts an evaluation of the HA concept as it relates to pain. METHODS We conducted a prospective observational pilot study comparing pain descriptions given to attending and trainee clinicians in the ED using a five-question pain description survey. Trainees included emergency medicine physician residents, emergency medicine physician assistant residents, off-service residents, and students. Trainees completed the first survey and attending clinicians repeated survey questions after at least a 10-minute washout. Surveys include descriptions of pain as part of patients' primary concern, severity indicated by a verbal numerical rating score (VNRS), and pain location, quality, and duration. RESULTS During a 10-day period, surveys were completed for 97 patient encounters. Most trainee clinicians were emergency medicine physician residents (53%), followed by emergency medicine physician assistants (32%), students (13%), and off-service residents (2%). Pain complaints centered on the abdomen (18.5%), chest (12%), and knee (6%). Differences in pain description were found in the majority of cases (55%), with most having one categorical difference. The majority of categorical differences were VNRS (38%), although the difference in scores was not statistically significant (P = 0.20). Medical students had the highest variance in VNRS difference compared with attending clinicians. There was no significant difference in described duration (P = 0.99) or quality of pain (P = 0.99) between trainee and attending clinicians. CONCLUSIONS Most patient encounters had at least one difference in categorical pain descriptors between trainee and attending clinicians. Although differences in severity of pain were present, they were not significant. HA does occur in the ED setting, but the magnitude of difference may be minimal.
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Affiliation(s)
- Brandon M Carius
- From Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, 2nd Brigade, 4th Infantry Division, Fort Collins, Colorado, Uniformed Services University of the Health Sciences, Bethesda, Maryland, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, and 59th Medical Wing, JBSA Lackland, Texas
| | - Michael D April
- From Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, 2nd Brigade, 4th Infantry Division, Fort Collins, Colorado, Uniformed Services University of the Health Sciences, Bethesda, Maryland, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, and 59th Medical Wing, JBSA Lackland, Texas
| | - Craig S Pedersen
- From Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, 2nd Brigade, 4th Infantry Division, Fort Collins, Colorado, Uniformed Services University of the Health Sciences, Bethesda, Maryland, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, and 59th Medical Wing, JBSA Lackland, Texas
| | - Steve G Schauer
- From Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, 2nd Brigade, 4th Infantry Division, Fort Collins, Colorado, Uniformed Services University of the Health Sciences, Bethesda, Maryland, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, and 59th Medical Wing, JBSA Lackland, Texas
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Duensing K, Twillman R, Ziegler S, Cepeda MS, Kern D, Salas M, Wedin G. An Examination of State and Federal Opioid Analgesic and Continuing Education Policies: 2016-2018. J Pain Res 2020; 13:2431-2442. [PMID: 33061558 PMCID: PMC7534855 DOI: 10.2147/jpr.s267448] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/19/2020] [Indexed: 12/25/2022] Open
Abstract
Introduction Opioid overdose deaths in the United States have climbed sharply over the past two decades. Simultaneously, increased awareness of inadequately treated chronic pain has resulted in increased opioid analgesic prescribing. The correlation between these two phenomena has led policymakers to posit that they are causally linked, and to implement policy changes supporting safe opioid prescribing. Purpose To evaluate the impact of its Opioid Analgesic Risk Evaluation and Mitigation Strategy (REMS) program, the US Food and Drug Administration (FDA) requested the opioid manufacturers responsible for implementing that program provide information regarding opioid policy changes from 2016 to 2018. FDA also requested a survey of state requirements for pain and opioid prescribing continuing education (CE), the number of prescribers affected by those requirements, the extent to which a REMS-compliant CE program would meet each state’s requirements, and the number of relevant CE programs available. Results Results indicate that 527 federal and state opioid-related policies (statutes, rules/regulations, and guidelines) were approved during the 2016–2018 study period. While the largest number of these policies focused on prescription drug monitoring programs, 170 specifically imposed limits on opioid prescribing and an additional 35 specifically referred to, or incorporated, the Centers for Disease Control and Prevention opioid prescribing guideline. We also found that 46 states and the District of Columbia mandated some amount of pain or opioid prescribing CE for prescribers renewing their licenses. These mandates potentially affected as many as 1.7 million prescribers. In 69% of cases, a REMS-compliant CE program would fully meet the state mandates for various types of prescribers. Conclusion The severity and complexity of the problems of pain management and opioid overdose have led to large-scale intervention by policymakers. Assessing the impact of these changes is difficult, at best, but will be necessary if interventions are to be refined to increase their effectiveness.
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Affiliation(s)
| | - Robert Twillman
- RKT Consulting, LLC, Lenexa, KS, USA.,Behavioral Health Section, Saint Luke's Health System, Kansas City, MO, USA.,Department of Psychiatry and Behavioral Sciences, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Stephen Ziegler
- Center for Effective Regulatory Policy and Safe Access, Denver, CO, USA.,College of Professional Studies, Purdue University, Fort Wayne, IN, USA
| | - M Soledad Cepeda
- Department of Epidemiology, Janssen Research & Development, Titusville, NJ, USA
| | - David Kern
- Department of Epidemiology, Janssen Research & Development, Titusville, NJ, USA
| | - Maribel Salas
- Department of Epidemiology, Clinical Safety and Pharmacovigilance, Daiichi Sankyo, Basking Ridge, NJ, USA.,University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Gregory Wedin
- Upsher-Smith Laboratories, LLC, Pharmacovigilance and Risk Management, Maple Grove, MN, USA
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Whale CS, Henningsen JD, Huff S, Schneider AD, Hijji FY, Froehle AW. Effects of the Ohio Opioid Prescribing Guidelines on Total Joint Arthroplasty Postsurgical Prescribing and Refilling Behavior of Surgeons and Patients. J Arthroplasty 2020; 35:2397-2404. [PMID: 32418742 DOI: 10.1016/j.arth.2020.04.036] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 04/10/2020] [Accepted: 04/15/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The opioid epidemic has been declared a public health crisis, with thousands of Americans dying from overdoses each year. In 2017, Ohio passed the Opioid Prescribing Guidelines (OPG) limiting narcotic prescriptions for acute pain. The present study sought to evaluate the effects of OPG on the prescribing behavior of orthopedists following total knee arthroplasty (TKA) and total hip arthroplasty (THA). METHODS An institutional database was queried to compare morphine equivalent dose (MED) prescribed at discharge, acute follow-up (<90 days), and chronic follow-up (>90 days) pre-OPG and post-OPG. Cases were identified over a 2-year period starting 1 year before OPG implementation. RESULTS Nine orthopedic surgeons performed 1160 TKAs (692 pre-OPG, 468 post-OPG) and 834 THAs (530 pre-OPG, 304 post-OPG). Total MED for TKA and THA dropped post-OPG (1602.6 ± 54.3 vs 1145.8 ± 66.1, P < .01; 1302.3 ± 47.0 vs 878.3 ± 62.2, P < .01). Much of the total MED decrease was accounted for by the decrease in discharge MED, which was the largest in magnitude (904.8 ± 16.4 vs 606.2 ± 20.0, P < .01; 948.4 ± 19.6 vs 630.6 ± 25.9, P < .01). Seven of the 9 surgeons statistically reduced mean MED prescribed at discharge following OPG. The percentage of patients receiving new narcotic scripts at acute follow-up increased post-OPG for both TKA (41.5% vs 47.2%, P = .05) and THA (18.3% vs 25.7%, P = .01). CONCLUSION Orthopedists reduced total MED prescribed after TKA and THA following the onset of OPG. The majority of this decrease is explained by decreased MED at discharge. Conversely, the post-OPG period saw slightly more new narcotic scripts written during acute follow-up.
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Affiliation(s)
- Casey S Whale
- Department of Orthopaedics, Wright State University, Dayton, OH
| | | | - Scott Huff
- Department of Orthopaedics, Wright State University, Dayton, OH
| | | | - Fady Y Hijji
- Department of Orthopaedics, Wright State University, Dayton, OH
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Vangeel L, Benoit M, Miron Y, Miller PE, De Clercq K, Chaltin P, Verfaillie C, Vriens J, Voets T. Functional expression and pharmacological modulation of TRPM3 in human sensory neurons. Br J Pharmacol 2020; 177:2683-2695. [PMID: 31985045 DOI: 10.1111/bph.14994] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 12/09/2019] [Accepted: 01/12/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND AND PURPOSE The transient receptor potential (TRP) ion channel TRPM3 functions as a noxious heat sensor, plays a key role in acute pain sensation and inflammatory hyperalgesia in rodents. Despite its potential as a novel analgesic drug target, little is known about the expression, function and modulation in the humans. EXPERIMENTAL APPROACH We studied TRPM3 in freshly isolated human dorsal root ganglion (hDRG) neurons and human stem cell-derived sensory (hSCDS) neurons. Expression was analysed at the mRNA level using RT-qPCR. Channel function was assessed using Fura-2-based calcium imaging and whole-cell patch-clamp recordings. KEY RESULTS TRPM3 was detected at the mRNA level in both hDRG and hSCDS neurons. The TRPM3 agonists pregnenolone sulphate (PS) and CIM0216 evoked robust intracellular Ca2+ responses in 52% of hDRG and 58% of hSCDS neurons. Whole-cell patch-clamp recordings in hSCDS neurons revealed pregnenolone sulphate (PS)- and CIM0216-evoked currents exhibiting the characteristic current-voltage relation of TRPM3. PS-induced calcium responses in hSCDS neurons were reversed in a dose-dependent manner by the flavonoid isosakuranetin and by antiseizure drug primidone. Finally, the μ-opioid receptor agonist DAMGO and the GABAB receptor agonist baclofen inhibited PS-evoked TRPM3 responses in a subset of hSCDS neurons. CONCLUSION AND IMPLICATIONS These results provide the first direct evidence of functional expression of the pain receptor TRPM3 in human sensory neurons, largely mirroring the channel's properties observed in mouse sensory neurons. hSCDS neurons represent a valuable and readily accessible in vitro model to study TRPM3 regulation and pharmacology in a relevant human cellular context.
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Affiliation(s)
- Laura Vangeel
- Laboratory of Ion Channel Research, VIB-KU Leuven Center for Brain & Disease Research, Leuven, Belgium.,Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Melissa Benoit
- Laboratory of Ion Channel Research, VIB-KU Leuven Center for Brain & Disease Research, Leuven, Belgium.,Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | | | | | - Katrien De Clercq
- Laboratory of Ion Channel Research, VIB-KU Leuven Center for Brain & Disease Research, Leuven, Belgium.,Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium.,Laboratory of Endometrium, Endometriosis & Reproductive Medicine, Department of Development and Regeneration, G-PURE, KU Leuven, Leuven, Belgium
| | - Patrick Chaltin
- Center for Drug Design and Discovery, Bio-Incubator 2, Heverlee, Belgium
| | - Catherine Verfaillie
- Department of Development and Regeneration, Stem Cell Institute, KU Leuven, Leuven, Belgium
| | - Joris Vriens
- Laboratory of Endometrium, Endometriosis & Reproductive Medicine, Department of Development and Regeneration, G-PURE, KU Leuven, Leuven, Belgium
| | - Thomas Voets
- Laboratory of Ion Channel Research, VIB-KU Leuven Center for Brain & Disease Research, Leuven, Belgium.,Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
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Hussein AI, Bekampis CF, Jermyn RT. Review of Opioid Prescribing in the Osteopathic and Ambulatory Setting. J Osteopath Med 2019; 119:820-832. [PMID: 31790128 DOI: 10.7556/jaoa.2019.134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The opioid epidemic in the United States is one of the largest modern health crises in the nation's history. The crisis has been cultivated in academic journals, driven by the medical-pharmaceutical complex, and fueled by campaigns representing the most prestigious health care organizations and advocacy groups. Comprehensive guidelines for proper prescribing have been released in addition to state-sponsored prescription drug-monitoring programs (PDMPs) in response to overprescribing habits. When considering opioid treatment for a patient, physicians should document a thorough history of pain, give an appropriate physical examination, and complete a risk assessment using the proper diagnostic tools. Considering the osteopathic philosophy and approach to chronic pain, physicians should account for an integrative treatment approach for improved patient outcomes when considering applying the osteopathic philosophy to chronic pain management. A successful treatment plan can integrate cognitive behavioral therapy and promote self-healing by treating somatic dysfunctions with osteopathic manipulative treatment. This literature review discusses how to treat patients with chronic pain and how to properly use and prescribe opioids. The researchers analyzed the history and current status of the opioid epidemic, examined opioid management in the outpatient setting, reviewed the current domestic and international opioid prescribing guidelines, and discussed the incorporation of the osteopathic philosophy to manage chronic pain.
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13
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Variation in postoperative narcotic prescribing after pediatric appendectomy. J Pediatr Surg 2019; 54:1866-1871. [PMID: 30819545 DOI: 10.1016/j.jpedsurg.2018.11.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 11/27/2018] [Accepted: 11/29/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Overuse of prescription opioids by both pediatric and adult patients has garnered significant attention in recent years. Educational interventions have been shown to decrease prescription opioids post-operatively in the adult population; similar data have not previously been reported in pediatrics. METHODS Educational interventions included staff education, institution of opioid standardization protocol, and distribution of educational materials to families. Chart review was performed pre- and post-intervention to compare prescribing practices following appendectomy in patients less than 19 years of age. Follow-up phone calls were used to assess patient satisfaction and pain control. RESULTS Three hundred thirteen cases were identified pre-intervention [PRE] and compared to 119 cases postintervention [POST]. 84.3% of patients were given a prescription for opioids at time of discharge in the PRE cohort compared to 6.7% (p < 0.001) POST. There was a significant increase in non-opioid analgesia (p < 0.001) POST. There was no significant variability in opioid usage by type of surgery performed, attending provider, or patients' gender or age. Of the patients in the POST cohort, 60.5% were available for telephone follow-up. More than 80% of patients were given acetaminophen and/or ibuprofen POST and 94.4% reported adequate pain control; 88.9% reported that they would agree to avoid opioids again in the future. On follow-up survey, there was no increase in emergency department visits or phone calls for poorly controlled pain following the intervention. CONCLUSION Low-fidelity educational interventions and creation of a standardized pathway is an effective tool to reduce opioid prescribing and promote alternative means of analgesia without an increase in readmissions or presentation for pain. LEVEL OF EVIDENCE III.
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Wilson MP, Cucciare MA, Porter A, Chalmers CE, Mullinax S, Mancino M, Oliveto AH. The utility of a statewide prescription drug-monitoring database vs the Current Opioid Misuse Measure for identifying drug-aberrant behaviors in emergency department patients already on opioids. Am J Emerg Med 2019; 38:503-507. [PMID: 31221474 DOI: 10.1016/j.ajem.2019.05.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/07/2019] [Accepted: 05/16/2019] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The most recent guidelines on prescribing opioids from the United States Centers for Disease Control recommend that clinicians not prescribe opioids as first-line therapy for chronic non-cancer pain. If an opioid prescription is considered for a patient already on opioids, prescribers are encouraged to check the statewide prescription drug monitoring database (PDMP). Some additional guidelines recommend screening tools such as the Current Opioid Misuse Measure (COMM) which may also help identify drug-aberrant behaviors. OBJECTIVE To compare the PDMP and the Current Opioid Misuse Measure (COMM), a commonly-recommended screening tool for patients on opioids, in detecting drug-aberrant behaviors in patients already taking opioids at the time of ED presentation. METHODS Patients on opioids were enrolled prospectively in a mixed urban-suburban ED seeing approximately 65,000 patients per year. The sensitivity, specificity, likelihood ratios, and diagnostic odds ratios of the PDMP and COMM were compared against objective criteria of drug-aberrant behaviors as documented in the electronic medical record (EMR) and medical examiner databases. RESULTS Compared to the COMM, the PDMP had similar sensitivity (36% vs 45%) and similar specificity (79% vs 55%), but better positive predictive value, better negative predictive value, and better diagnostic odds ratio. The combination of the PDMP and the COMM did not improve the detection of drug-aberrant behaviors. CONCLUSIONS The PDMP alone is a more useful as a screening instrument than either the COMM or the combination of the PDMP plus COMM in patients already taking opioids at time of ED presentation. However, the PDMP misses a majority of patients with documented drug-aberrant behaviors in the EMR, and should not be used in isolation to justify whether a particular opioid prescription is appropriate.
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Affiliation(s)
- Michael P Wilson
- Division of Research and Evidence-Based Medicine, Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America; Department of Emergency Medicine Behavioral Emergencies Research (DEMBER) lab, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America; Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America.
| | - Michael A Cucciare
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America; VA South Central Mental Illness Research, Education, and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR 72205 USA; Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Affairs Healthcare System, North Little Rock, AR 72205 USA
| | - Austin Porter
- College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America; Arkansas Department of Health, Little Rock, AR, United States of America
| | - Christen E Chalmers
- School of Medicine, University of California, Irvine, United States of America
| | - Samuel Mullinax
- Department of Emergency Medicine Behavioral Emergencies Research (DEMBER) lab, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Michael Mancino
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Alison H Oliveto
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
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Wee Jun Yan I, Lim Tian Ying B, Brennan F. Public Policy: An Analgesia for Opioid Diversion. J Pain Palliat Care Pharmacother 2019; 32:178-191. [PMID: 30676178 DOI: 10.1080/15360288.2018.1546788] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Although opioids are a commonly prescribed form of analgesics among the armamentarium for their efficacy and safety when used responsibly, societal problems of drug diversion are highly prevalent. This review seeks to examine the importance of opioids and the extent of diversion and its impact, drawbacks, and controversies in law, public policies, and strategies. In particular, the law has skewed its focus toward the regulation of opioid suppliers (as compared to consumers), giving rise to a chilling effect where physicians are hesitant to prescribe opioids to patients with legitimate needs. This has downplayed the importance of medically treating pain, especially in the context of palliative care. This article recommends the intelligent use of public policy to alleviate the opioid diversion problem while acknowledging the importance of appropriate pain management. Concurrently, this article recommends providing continuous education and support for physicians, dispensers, and the like and adoption of soft law approaches by legislators and enforcement bodies to prevent relentless clamping down on opioid abusers. In conclusion, appropriate policies and guidelines are necessary to support the entire health care body in executing a coordinated approach and exercising vigilance to better manage the opioid diversion problem.
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Preissner S, Siramshetty VB, Dunkel M, Steinborn P, Luft FC, Preissner R. Pain-Prescription Differences - An Analysis of 500,000 Discharge Summaries. Curr Drug Res Rev 2019; 11:58-66. [PMID: 30207223 DOI: 10.2174/1874473711666180911091846] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 08/30/2018] [Accepted: 09/03/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Pain-relief prescriptions have led to an alarming increase in drug-related abuse. OBJECTIVE In this study, we estimate the pain reliever prescription rates at a major German academic hospital center and compare with the nationwide trends from Germany and prescription reports from the USA. METHODS We analysed >500,000 discharge summaries from Charité, encompassing the years 2006 to 2015, and extracted the medications and diagnoses from each discharge summary. Prescription reports from the USA and Germany were collected and compared with the trends at Charité to identify the frequently prescribed pain relievers and their world-wide utilization trends. The average costs of pain therapy were also calculated and compared between the three regions. RESULTS Metamizole (dipyrone), a non-opioid analgesic, was the most commonly prescribed pain reliever at Charité (59%) and in Germany (23%) while oxycodone (29%), a semi-synthetic opioid, was most commonly ordered in the USA. Surprisingly, metamizole was prescribed to nearly 20% of all patients at Charité, a drug that has been banned for safety reasons (agranulocytosis) in most developed countries including Canada, United Kingdom, and USA. A large number of prospective cases with high risk for agranulocytosis and other side effects were found. The average cost of pain therapy greatly varied between the USA (125.3 EUR) and Charité (17.2 EUR). CONCLUSION The choice of pain relievers varies regionally and is often in disagreement with approved indications and regulatory guidelines. A pronounced East-West gradient was observed with metamizole use and the opposite with prescription opioids.
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Affiliation(s)
- Saskia Preissner
- Dental, Oral and Maxillary Medicine, Department of Operative Dentistry, Charite - University Medicine Berlin, Berlin, Germany
| | - Vishal B Siramshetty
- Structural Bioinformatics Group, Experimental and Clinical Research Centre, Charite - University Medicine Berlin, Berlin, Germany
- German Cancer Consortium (DKTK), German Cancer Research Centre (DKFZ), Heidelberg, Germany
- BB3R - Berlin Brandenburg 3R Graduate School, Free University of Berlin, Berlin, Germany
| | - Mathias Dunkel
- Structural Bioinformatics Group, Institute of Physiology, Charite - University Medicine Berlin, Berlin, Germany
| | - Paul Steinborn
- Structural Bioinformatics Group, Experimental and Clinical Research Centre, Charite - University Medicine Berlin, Berlin, Germany
| | - Friedrich C Luft
- Experimental and Clinical Research Centre and Max-Delbrück Centre for Molecular Medicine, Berlin, Germany; The Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Robert Preissner
- Structural Bioinformatics Group, Experimental and Clinical Research Centre, Charite - University Medicine Berlin, Berlin, Germany
- German Cancer Consortium (DKTK), German Cancer Research Centre (DKFZ), Heidelberg, Germany
- BB3R - Berlin Brandenburg 3R Graduate School, Free University of Berlin, Berlin, Germany
- Structural Bioinformatics Group, Institute of Physiology, Charite - University Medicine Berlin, Berlin, Germany
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17
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Morlion B, Schäfer M, Betteridge N, Kalso E. Non-invasive patient-controlled analgesia in the management of acute postoperative pain in the hospital setting. Curr Med Res Opin 2018; 34:1179-1186. [PMID: 29625532 DOI: 10.1080/03007995.2018.1462785] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Acute postoperative pain is experienced by the majority of hospitalized patients undergoing surgical procedures, with many reporting inadequate pain relief and/or high levels of dissatisfaction with their pain management. Patient-controlled analgesia (PCA) ensures patient involvement in acute pain control, a key component for implementing a quality management system. This narrative article overviews the clinical evidence for conventional PCA and briefly discusses new, non-invasive PCA systems, namely the sufentanil sublingual tablet system (SSTS) and the fentanyl iontophoretic transdermal system (FITS). METHODS A Medline literature search ("patient-controlled analgesia" and "acute postoperative pain") was conducted to 1 April 2017; results from the main clinical trials are discussed. Additional literature was identified from the reference lists of cited publications. RESULTS Moderate to low quality evidence supports opioid-based intravenous PCA as an efficacious alternative to non-patient-controlled systemic analgesia for postoperative pain. However, despite the benefits of PCA, conventional intravenous PCA is limited by system-, drug- and human-related issues. The non-invasive SSTS and FITS have demonstrated good efficacy and safety in placebo- and intravenous morphine PCA-controlled trials, and are associated with high patient/healthcare practitioner satisfaction/ease of care ratings and offer early patient mobilization. CONCLUSIONS Evidence-based guidelines for acute postoperative pain management support the use of multimodal regimens in many situations. As effective and safe alternatives to conventional PCA, and with the added benefits of being non-invasive, easy to use and allowing early patient mobilization, the newer PCA systems may complement multimodal approaches, or potentially replace certain regimens, in hospitalized patients with acute postoperative pain.
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Affiliation(s)
- Bart Morlion
- a Leuven Centre for Algology & Pain Management , University Hospitals Leuven, KU Leuven , Leuven , Belgium
| | - Michael Schäfer
- b Department of Anaesthesiology and Intensive Care Medicine , Charité University Berlin, Campus Virchow Klinikum , Berlin , Germany
| | | | - Eija Kalso
- d Pain Clinic, Departments of Anaesthesiology, Intensive Care, and Pain Medicine , Helsinki University Central Hospital , Helsinki , Finland
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18
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Smith CL, Severtsen B, Vandermause R, Barbosa-Leiker C, Wilson M, Roll J. Seeking Chronic Pain Relief: A Hermeneutic Exploration. Pain Manag Nurs 2018; 19:652-662. [PMID: 29935910 DOI: 10.1016/j.pmn.2018.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 02/28/2018] [Accepted: 05/04/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND In the United States, chronic pain is experienced by over 39.4 million adults, many of whom are treated with opioid pain medications. AIM This research presents an interpretation of the experience of seeking pain relief for a group of people taking opioid pain medications whose pain is not adequately controlled. METHODS A concurrent embedded mixed-methods design was used, including a Heideggerian hermeneutic qualitative approach that focuses on the participants' perceptions as a vehicle for understanding the phenomenon of seeking pain relief with descriptive quantitative data in a supporting role. Thirteen interviews and 15 surveys were analyzed, all of which met the following criteria: (1) self-reported chronic pain (persistent pain lasting a minimum of six months), (2) current use of prescription opioid medications, (3) pain not successfully controlled. RESULTS The analysis revealed a paradox, which we describe as being lost/finding myself in the health care system. This paradox became the overarching pattern of experience that subsumed several dynamic, overlapping practices described in the patterns: (1) seeking relief as suffering; (2) being classified as an addict but not an addict; (3) living with pain as remembering; and (4) experiencing treatment modalities as fickle possibilities. CONCLUSION Explication of and interpretive commentary on these patterns shift the focus from drug seeking to pain relief seeking behaviors in chronic pain sufferers. Such a shift could change the manner in which providers work with chronic pain sufferers to find appropriate treatment modalities.
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Affiliation(s)
- Crystal Lederhos Smith
- College of Nursing, Washington State University, Spokane, Washington; Program of Excellence in Addictions Research, Washington State University, Spokane, Washington; Translational Addiction Research Center, Washington State University, Spokane, Washington.
| | - Billie Severtsen
- College of Nursing, Washington State University, Spokane, Washington
| | | | - Celestina Barbosa-Leiker
- College of Nursing, Washington State University, Spokane, Washington; Program of Excellence in Addictions Research, Washington State University, Spokane, Washington; Translational Addiction Research Center, Washington State University, Spokane, Washington
| | - Marian Wilson
- College of Nursing, Washington State University, Spokane, Washington; Program of Excellence in Addictions Research, Washington State University, Spokane, Washington
| | - John Roll
- College of Nursing, Washington State University, Spokane, Washington; Program of Excellence in Addictions Research, Washington State University, Spokane, Washington; Translational Addiction Research Center, Washington State University, Spokane, Washington; College of Medicine, Washington State University, Spokane, Washington
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19
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deShazo RD, Johnson M, Eriator I, Rodenmeyer K. Backstories on the US Opioid Epidemic. Good Intentions Gone Bad, an Industry Gone Rogue, and Watch Dogs Gone to Sleep. Am J Med 2018; 131:595-601. [PMID: 29410156 DOI: 10.1016/j.amjmed.2017.12.045] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 12/18/2017] [Accepted: 12/28/2017] [Indexed: 10/18/2022]
Abstract
Epidemics of opioid use are old news in the United States, but an epidemic that kills over 200,000 Americans is not. A multiplicity of intertwined factors have brought us to this place. From 30,000 feet, it is the story of good intentions gone bad, a drug industry gone rogue, and government watch dog agencies gone to sleep. At ground level, it is the story of physicians unfamiliar with addictive drugs and drug addiction, new long-acting opioids deceptively marketed, cheap black tar heroin, encouragement to use opioids for chronic noncancer pain by professional organizations with conflicts of interest and without science, a culture intolerant to pain and tolerant to drug use, and the greedy response of the pharmaceutical industry and drug cartels to an expanding market opportunity. These factors are among those that have joined to form a tsunami of addiction and deaths that keeps on coming. A better understanding of them could speed the end of the present cycle of opioid abuse, perhaps prevent others, and inform future decisions about pain management.
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Affiliation(s)
- Richard D deShazo
- University of Mississippi Medical Center Department of Medicine, Jackson; University of Mississippi Medical Center Department of Pediatrics, Jackson; Mississippi Public Broadcasting, Jackson.
| | - McKenzie Johnson
- University of Mississippi Medical Center Department of Medicine, Jackson
| | - Ike Eriator
- University of Mississippi Medical Center Department of Anesthesiology, Jackson
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Schottenfeld JR, Waldman SA, Gluck AR, Tobin DG. Pain and Addiction in Specialty and Primary Care: The Bookends of a Crisis. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2018; 46:220-237. [PMID: 30146986 DOI: 10.1177/1073110518782923] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Specialists and primary care physicians play an integral role in treating the twin epidemics of pain and addiction. But inadequate access to specialists causes much of the treatment burden to fall on primary physicians. This article chronicles the differences between treatment contexts for both pain and addiction - in the specialty and primary care contexts - and derives a series of reforms that would empower primary care physicians and better leverage specialists.
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Affiliation(s)
- Joseph R Schottenfeld
- Joseph Schottenfeld, is a member of the Yale Law School class of 2019. Abbe R. Gluck, J.D., is Professor of Law and Faculty Director of the Solomon Center for Health Law and Policy at Yale Law School. She earned her J.D. from Yale Law School. Seth A. Waldman, M.D., is Director, Division of Pain Management, Department of Anesthesiology, Critical Care & Pain Management, at the Hospital for Special Surgery in New York. He completed his his internships in surgery and medicine at Mount Sinai Medical School - Beth Israel Medical Center, his residency training in anesthesiology at Harvard Medical School - Beth Israel Hospital, and his fellowship training in pain management at Massachusetts General Hospital. Daniel G. Tobin, M.D., F.A.C.P., is an Associate Professor of Medicine at the Yale University School of Medicine (New Haven, CT) and the Medical Director for the Yale-New Haven Hospital SRC Adult Primary Care Center. He earned his medical degree from Cornell University Medical College (New York, NY) before completing his Internal Medicine Internship and Residency at Yale-New Haven Hospital
| | - Seth A Waldman
- Joseph Schottenfeld, is a member of the Yale Law School class of 2019. Abbe R. Gluck, J.D., is Professor of Law and Faculty Director of the Solomon Center for Health Law and Policy at Yale Law School. She earned her J.D. from Yale Law School. Seth A. Waldman, M.D., is Director, Division of Pain Management, Department of Anesthesiology, Critical Care & Pain Management, at the Hospital for Special Surgery in New York. He completed his his internships in surgery and medicine at Mount Sinai Medical School - Beth Israel Medical Center, his residency training in anesthesiology at Harvard Medical School - Beth Israel Hospital, and his fellowship training in pain management at Massachusetts General Hospital. Daniel G. Tobin, M.D., F.A.C.P., is an Associate Professor of Medicine at the Yale University School of Medicine (New Haven, CT) and the Medical Director for the Yale-New Haven Hospital SRC Adult Primary Care Center. He earned his medical degree from Cornell University Medical College (New York, NY) before completing his Internal Medicine Internship and Residency at Yale-New Haven Hospital
| | - Abbe R Gluck
- Joseph Schottenfeld, is a member of the Yale Law School class of 2019. Abbe R. Gluck, J.D., is Professor of Law and Faculty Director of the Solomon Center for Health Law and Policy at Yale Law School. She earned her J.D. from Yale Law School. Seth A. Waldman, M.D., is Director, Division of Pain Management, Department of Anesthesiology, Critical Care & Pain Management, at the Hospital for Special Surgery in New York. He completed his his internships in surgery and medicine at Mount Sinai Medical School - Beth Israel Medical Center, his residency training in anesthesiology at Harvard Medical School - Beth Israel Hospital, and his fellowship training in pain management at Massachusetts General Hospital. Daniel G. Tobin, M.D., F.A.C.P., is an Associate Professor of Medicine at the Yale University School of Medicine (New Haven, CT) and the Medical Director for the Yale-New Haven Hospital SRC Adult Primary Care Center. He earned his medical degree from Cornell University Medical College (New York, NY) before completing his Internal Medicine Internship and Residency at Yale-New Haven Hospital
| | - Daniel G Tobin
- Joseph Schottenfeld, is a member of the Yale Law School class of 2019. Abbe R. Gluck, J.D., is Professor of Law and Faculty Director of the Solomon Center for Health Law and Policy at Yale Law School. She earned her J.D. from Yale Law School. Seth A. Waldman, M.D., is Director, Division of Pain Management, Department of Anesthesiology, Critical Care & Pain Management, at the Hospital for Special Surgery in New York. He completed his his internships in surgery and medicine at Mount Sinai Medical School - Beth Israel Medical Center, his residency training in anesthesiology at Harvard Medical School - Beth Israel Hospital, and his fellowship training in pain management at Massachusetts General Hospital. Daniel G. Tobin, M.D., F.A.C.P., is an Associate Professor of Medicine at the Yale University School of Medicine (New Haven, CT) and the Medical Director for the Yale-New Haven Hospital SRC Adult Primary Care Center. He earned his medical degree from Cornell University Medical College (New York, NY) before completing his Internal Medicine Internship and Residency at Yale-New Haven Hospital
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21
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Moran MM, Szallasi A. Targeting nociceptive transient receptor potential channels to treat chronic pain: current state of the field. Br J Pharmacol 2018; 175:2185-2203. [PMID: 28924972 PMCID: PMC5980611 DOI: 10.1111/bph.14044] [Citation(s) in RCA: 137] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 08/27/2017] [Accepted: 09/03/2017] [Indexed: 12/12/2022] Open
Abstract
Control of chronic pain is frequently inadequate and/or associated with intolerable adverse effects, prompting a frantic search for new therapeutics and new therapeutic targets. Nearly two decades of preclinical and clinical research supports the involvement of transient receptor potential (TRP) channels in temperature perception, nociception and sensitization. Although there has been considerable excitement around the therapeutic potential of this channel family since the cloning and identification of TRPV1 cation channels as the capsaicin receptor more than 20 years ago, only modulators of a few channels have been tested clinically. TRPV1 channel antagonists have suffered from side effects related to the channel's role in temperature sensation; however, high dose formulations of capsaicin have reached the market and shown therapeutic utility. A number of potent, small molecule antagonists of TRPA1 channels have recently advanced into clinical trials for the treatment of inflammatory and neuropathic pain, and TRPM8 antagonists are following closely behind for cold allodynia. TRPV3, TRPV4, TRPM2 and TRPM3 channels have also been of significant interest. This review discusses the preclinical promise and status of novel analgesic agents that target TRP channels and the challenges that these compounds may face in development and clinical practice. LINKED ARTICLES This article is part of a themed section on Recent Advances in Targeting Ion Channels to Treat Chronic Pain. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v175.12/issuetoc.
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Affiliation(s)
| | - Arpad Szallasi
- Clinical LaboratoriesBaptist Medical CenterJacksonvilleFLUSA
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22
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Jukiewicz DA, Alhofaian A, Thompson Z, Gary FA. Reviewing opioid use, monitoring, and legislature: Nursing perspectives. Int J Nurs Sci 2017; 4:430-436. [PMID: 31406787 PMCID: PMC6626213 DOI: 10.1016/j.ijnss.2017.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 08/17/2017] [Accepted: 09/04/2017] [Indexed: 11/30/2022] Open
Abstract
The phenomena of prescription opioid misuse and abuse have a complicated history of contributing factors including policies, practices, and prescribing leading to contemporary phenomena. Some factors implicated in the opioid drug abuse problem include inefficient prescribing and improper use, lack of knowledge related to interpretation and assessment of pain levels, and decreased oversight and regulation from government and policy agents. Nurses, often frontline providers, need to be knowledgeable and embrace the guidelines, and necessary implications associated with both prescribing and administration of opioids. Additionally, all providers including physicians, physician assistants, nurse practitioners, and bedside nurses must have a firm understanding of the improper use and abuse of opioids. The examination and review of opioid policies at the state and federal level has revealed inconsistency with regulations, policies, and guidelines that have lead to the current situation. The use of an interdisciplinary team with nurses and various other practitioners is a good strategy to help reduce this problem.
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Affiliation(s)
- Deniece A. Jukiewicz
- Case Western Reserve University, Frances Payne Bolton School of Nursing, 10900 Euclid Ave., Cleveland, OH 44106, USA
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Barth KS, Guille C, McCauley J, Brady KT. Targeting practitioners: A review of guidelines, training, and policy in pain management. Drug Alcohol Depend 2017; 173 Suppl 1:S22-S30. [PMID: 28363316 PMCID: PMC5555357 DOI: 10.1016/j.drugalcdep.2016.08.641] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 08/31/2016] [Accepted: 08/31/2016] [Indexed: 01/03/2023]
Abstract
This paper reviews the current literature on clinical guidelines, practitioner training, and government/payer policies that have come forth in response to the national rise in prescription opioid overdoses. A review of clinical opioid prescribing guidelines highlights the need for more research on safe and effective treatment options for chronic pain, improved guidance for the best management of post-operative pain, and evaluation of the implementation and impact of guideline recommendations on patient risk and outcomes. Although there is increasing attention to training in pain management in medical schools and medical residency programs, educational opportunities remain highly variable, and the need for additional clinician training in the recognition and treatment of pain as well as opioid use disorder has been recognized. Mandated use of private, federal and state educational and clinical initiatives such as Risk Evaluation and Mitigation Strategies (REMS) and Prescription Drug Monitoring Programs (PDMPs) generally increase utilization of these initiatives, but more research is needed to determine the impact of these initiatives on provider behaviors, treatment access, and patient outcomes. Finally, there is an acute need for more research on safe and effective treatments for chronic pain as well as an increased multi-level focus on improving training and access to evidence-based treatment for opioid use disorder as well as non-pharmacologic and non-interventional chronic pain treatments, so that these guideline-recommended interventions can become mainstream, accessible, first-line interventions for chronic pain and/or opioid use disorders.
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Affiliation(s)
- Kelly S Barth
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, United States.
| | - Constance Guille
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, United States.
| | - Jenna McCauley
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, United States.
| | - Kathleen T Brady
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, United States.
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