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Meshberg-Cohen S, Gilstad-Hayden K, Martino S, Lazar CM, Sellinger J, Rosen MI. Do veterans with risky substance use (RSU) use distinct pain treatment modalities? Am J Addict 2024; 33:675-684. [PMID: 38849976 DOI: 10.1111/ajad.13620] [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: 12/06/2023] [Revised: 05/20/2024] [Accepted: 05/23/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Risky substance use (RSU) is common among people with chronic pain and is associated with worse pain treatment outcomes. Nonopioid treatment is recommended, but it is unknown whether people with RSU use different or fewer pain treatment modalities. This study describes use of different pain treatments by veterans with and without RSU and those receiving versus not receiving opioid medication. METHODS Veterans (N = 924) who filed service-connected disability claims related to musculoskeletal conditions and rated their pain four or higher on the Numeric Rating Scale, reported on 25 different pain services in the preceding 90 days. Recent RSU was identified via Alcohol, Smoking, and Substance Involvement Test (ASSIST) cutoffs and/or nail sample toxicology. RESULTS Overall, RSU was not associated with number of provider-delivered or self-delivered pain modalities. Over-the-counter medications (71%), self-structured exercise (69%), and nonopioid prescription medications (38%) were the most used modalities. Veterans receiving prescribed opioids (8.4%) were more likely to see primary care, receive injections, and attend exercise and/or meditation classes, compared to those without opioid prescriptions. DISCUSSION AND CONCLUSIONS Opioid and nonopioid pain treatment utilization did not differ based on RSU, and those prescribed opioids were more likely to engage in other nonopioid pain treatments. Regardless of RSU, veterans appear willing to try provider-delivered (58%) and self-delivered (79%) pain treatment. SCIENTIFIC SIGNIFICANCE In this first-ever evaluation of 25 different pain treatment modalities among veterans with and without RSU, people with RSU did not use less treatment modalities.
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Affiliation(s)
- Sarah Meshberg-Cohen
- Psychology Service/Department of Psychiatry, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Kathryn Gilstad-Hayden
- Psychology Service/Department of Psychiatry, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Steve Martino
- Psychology Service/Department of Psychiatry, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Christine M Lazar
- Psychology Service/Department of Psychiatry, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
| | - John Sellinger
- Psychology Service/Department of Psychiatry, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Marc I Rosen
- Psychology Service/Department of Psychiatry, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
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Ma P, Cheng Y, Goulet JL, Sandbrink F, Brandt C, Spevak C, Kean JT, Becker W, Libin A, Shara N, Sheriff HM, Houston JS, Butler J, Workman ET, Agrawal RM, Kupersmith J, Zeng-Treitler Q. Guideline concordant opioid therapy in Veterans receiving VA and community care. BMC Health Serv Res 2024; 24:1284. [PMID: 39456008 DOI: 10.1186/s12913-024-11742-1] [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: 05/17/2024] [Accepted: 10/10/2024] [Indexed: 10/28/2024] Open
Abstract
Guideline concordant opioid therapy is a key part of the concerted effort to address the opioid crisis in the United States. The study aimed to compare the rates of guideline concordant care between veterans who solely used VA services (mono users) and veterans who used both VA services and community care (dual-system users). We used electronic health record data from the Washington DC and Baltimore VA Medical Centers from 2015 to 2019. We provided descriptive statistics as well as generalized estimating equations models to find associations between mono vs. dual-system users and each guideline outcome, controlling for demographic factors and comorbid conditions. The study found that overall rates of guideline concordant care were high in both mono and dual-system users with over 90% adherence rates for the majority of recommendations. However, there were variations in adherence to specific guidelines, with urine drug screening at initiation being the least commonly followed recommendation (8.9% of mono-user opioid initiators and 11.2% of dual-user initiators). This study also found that there was no consistent pattern of higher guideline adherence in mono vs. dual-system users but did show that through the course of this study (2015-2019) overall rates of guideline concordance increased. Future research will explore additional guideline recommendations and potential coordination issues among dual-system users.
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Affiliation(s)
- Phillip Ma
- Washington DC VA Medical Center, Washington, DC, USA
- George Washington University, Washington, DC, USA
| | - Yan Cheng
- Washington DC VA Medical Center, Washington, DC, USA
- George Washington University, Washington, DC, USA
| | - Joseph L Goulet
- Washington DC VA Medical Center, Washington, DC, USA
- Yale University, New Haven, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | | | - Cynthia Brandt
- Yale University, New Haven, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Chris Spevak
- Georgetown University School of Medicine, Washington, DC, USA
- Georgetown Howard Universities Center for Clinical and Translational Science, Washington, DC, USA
| | - Jacob T Kean
- Washington DC VA Medical Center, Washington, DC, USA
| | - William Becker
- Yale University, New Haven, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Alexander Libin
- Georgetown University School of Medicine, Washington, DC, USA
- MedStar Health, Columbia, MD, USA
- Georgetown Howard Universities Center for Clinical and Translational Science, Washington, DC, USA
| | - Nawar Shara
- Georgetown University School of Medicine, Washington, DC, USA
- MedStar Health, Columbia, MD, USA
- Georgetown Howard Universities Center for Clinical and Translational Science, Washington, DC, USA
| | - Helen M Sheriff
- Washington DC VA Medical Center, Washington, DC, USA
- George Washington University, Washington, DC, USA
| | | | | | - Elizabeth T Workman
- Washington DC VA Medical Center, Washington, DC, USA
- George Washington University, Washington, DC, USA
| | | | - Joel Kupersmith
- Washington DC VA Medical Center, Washington, DC, USA
- Georgetown University School of Medicine, Washington, DC, USA
| | - Qing Zeng-Treitler
- Washington DC VA Medical Center, Washington, DC, USA.
- George Washington University, Washington, DC, USA.
- University Biomedical Informatics Center, 2600 Virginia Ave NW, Suite 300, 20037, Washington, DC, USA.
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Kintzle S, Alday E, Sutherland A, Castro CA. Drivers of Veterans' Healthcare Choices and Experiences with Veterans Affairs and Civilian Healthcare. Healthcare (Basel) 2024; 12:1852. [PMID: 39337193 PMCID: PMC11430980 DOI: 10.3390/healthcare12181852] [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: 07/23/2024] [Revised: 09/10/2024] [Accepted: 09/13/2024] [Indexed: 09/30/2024] Open
Abstract
BACKGROUND Access to quality healthcare is essential to the well-being of U.S. veterans. Little is known about what drives veterans' healthcare decisions. The purpose of this study was to explore factors that drive healthcare choices in veterans, and their experiences in the Veterans Health Administration (VA) and non-VA healthcare settings. METHODS Fifty-nine veterans participated in eight focus groups. Participants were asked to discuss factors that led to their choice of provider and their healthcare experiences. Thematic analysis was conducted to reveal themes around healthcare choices and use. RESULTS VA and non-VA users described positive experiences with care. VA users reported cost, quality, and ease of care as reasons for use. Non-VA healthcare setting users reported eligibility issues, negative perceptions of the VA, administrative bureaucracy, and lack of continuity of care as reasons they chose not to use VA care. VA users reported difficulty with red tape, continuity of care, limitations to gender specific care, and having to advocate for themselves. CONCLUSIONS Veterans were satisfied with care regardless of where they received it. Experiences with civilian providers indicate that more could be done to provide veterans with choices in the care they receive. Despite positive experiences with the VA, the veterans highlighted needed improvements in key areas.
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Affiliation(s)
- Sara Kintzle
- USC Suzanne Dworak-Peck School of Social Work, University of Southern California, 669 West 34th Street, Los Angeles, CA 90089, USA
| | - Eva Alday
- USC Suzanne Dworak-Peck School of Social Work, University of Southern California, 669 West 34th Street, Los Angeles, CA 90089, USA
| | - Aubrey Sutherland
- USC Suzanne Dworak-Peck School of Social Work, University of Southern California, 669 West 34th Street, Los Angeles, CA 90089, USA
| | - Carl A Castro
- USC Suzanne Dworak-Peck School of Social Work, University of Southern California, 669 West 34th Street, Los Angeles, CA 90089, USA
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Moyo P, Merlin JS, Gairola R, Girard A, Shireman TI, Trivedi AN, Marshall BDL. Association of Opioid Use Disorder Diagnosis with Management of Acute Low Back Pain: A Medicare Retrospective Cohort Analysis. J Gen Intern Med 2024; 39:2097-2105. [PMID: 38829451 PMCID: PMC11306843 DOI: 10.1007/s11606-024-08799-3] [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: 11/22/2023] [Accepted: 05/06/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Practice guidelines recommend nonpharmacologic and nonopioid therapies as first-line pain treatment for acute pain. However, little is known about their utilization generally and among individuals with opioid use disorder (OUD) for whom opioid and other pharmacologic therapies carry greater risk of harm. OBJECTIVE To determine the association between a pre-existing OUD diagnosis and treatment of acute low back pain (aLBP). DESIGN Retrospective cohort study using 2016-2019 Medicare data. PARTICIPANTS Fee-for-service Medicare beneficiaries with a new episode of aLBP. MAIN MEASURES The main independent variable was OUD diagnosis measured prior to the first LBP claim (i.e., index date). Using multivariable logistic regressions, we assessed the following outcomes measured within 30 days of the index date: (1) nonpharmacologic therapies (physical therapy and/or chiropractic care), and (2) prescription opioids. Among opioid recipients, we further assessed opioid dose and co-prescription of gabapentin. Analyses were conducted overall and stratified by receipt of physical therapy, chiropractic care, opioid fills, or gabapentin fills during the 6 months before the index date. KEY RESULTS We identified 1,263,188 beneficiaries with aLBP, of whom 3.0% had OUD. Two-thirds (65.8%) did not receive pain treatments of interest at baseline. Overall, nonpharmacologic therapy receipt was less prevalent and opioid and nonopioid pharmacologic therapies were more common among beneficiaries with OUD than those without OUD. Beneficiaries with OUD had lower odds of receiving nonpharmacologic therapies (aOR = 0.62, 99%CI = 0.58-0.65) and higher odds of prescription opioid receipt (aOR = 2.24, 99%CI = 2.17-2.32). OUD also was significantly associated with increased odds of opioid doses ≥ 90 morphine milligram equivalents/day (aOR = 2.43, 99%CI = 2.30-2.56) and co-prescription of gabapentin (aOR = 1.15, 99%CI = 1.09-1.22). Similar associations were observed in stratified groups though magnitudes differed. CONCLUSIONS Medicare beneficiaries with aLBP and OUD underutilized nonpharmacologic pain therapies and commonly received opioids at high doses and with gabapentin. Complementing the promulgation of practice guidelines with implementation science could improve the uptake of evidence-based nonpharmacologic therapies for aLBP.
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Affiliation(s)
- Patience Moyo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Jessica S Merlin
- Division of General Internal Medicine, Challenges in Managing and Preventing Pain Clinical Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Richa Gairola
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Anthony Girard
- Department of Biostatistics, Brown University School of Public Health, Providence, RI, USA
| | - Theresa I Shireman
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Amal N Trivedi
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
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Nakamoto CH, Huskamp HA, Donohue JM, Barnett ML, Gordon AJ, Mehrotra A. Medicare Payment for Opioid Treatment Programs. JAMA HEALTH FORUM 2024; 5:e241907. [PMID: 39028654 PMCID: PMC11259898 DOI: 10.1001/jamahealthforum.2024.1907] [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: 02/02/2024] [Accepted: 05/19/2024] [Indexed: 07/21/2024] Open
Abstract
Importance Medicare began paying for medications for opioid use disorder (MOUD) at opioid treatment programs (OTPs) that dispense methadone and other MOUD in January 2020. There has been little research describing the response to this payment change and whether it resulted in more patients receiving MOUD or just a shift in who pays for this care. Objective To describe how many and which Medicare beneficiaries receive care from OTPs and how this compares to those receiving MOUD in other settings. Design, Setting, and Participants This cross-sectional study included all patients receiving MOUD care identified in 2019-2022 100% US Medicare Parts B and D claims. Patients receiving care in an OTP who were dually insured with Medicare and Medicaid in the 2019-2020 Transformed Medicaid Statistical Information System were also included. Exposure Receiving MOUD care in an OTP. Main Outcomes and Measures Comparisons of 2022 beneficiaries treated in OTPs vs other non-OTP settings in 2022. Results The share of Medicare beneficiaries treated by OTPs rose steadily from 4 per 10 000 (14 160 beneficiaries) in January 2020 to 7 per 10 000 (25 596 beneficiaries) in August 2020, then plateaued through December 2022; of 38 870 patients (23% ≥66 years; 35% female) treated at an OTP in 2022, 96% received methadone. Patients in OTPs, compared to those receiving MOUD in other settings, were more likely be 65 years and younger (65% vs 62%; P < .001), less likely to be White (72% vs 82%; P < .001), and more likely to be an urban resident (86% vs 74%; P < .001). When Medicare OTP coverage began, there was no associated drop in the number of dually insured patients with Medicaid with an OTP claim. Of the 1854 OTPs, 1115 (60%) billed Medicare in 2022, with the share billing Medicare ranging from 13% to 100% across states. Conclusions and Relevance This study showed that since the initiation of Medicare OTP coverage in 2020, there has been a rapid increase in the number of Medicare beneficiaries with claims for OTP services for MOUD, and most OTPs have begun billing Medicare. Patients in OTPs were more likely to be urban residents and members of racial or ethnic minority groups than the patients receiving other forms of MOUD.
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Affiliation(s)
- Carter H. Nakamoto
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Haiden A. Huskamp
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Julie M. Donohue
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - Michael L. Barnett
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Adam J. Gordon
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
- VA Salt Lake City Health Care System, Salt Lake City, Utah
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Shanahan ML, Rand KL, Galloway A, Matthias MS. Treatment Goals and Preferences of Black Veterans with Chronic Musculoskeletal Pain. THE JOURNAL OF PAIN 2024; 25:104487. [PMID: 38336030 DOI: 10.1016/j.jpain.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 01/25/2024] [Accepted: 02/01/2024] [Indexed: 02/12/2024]
Abstract
Understanding patient goals and preferences is critical in the context of complex conditions such as chronic pain. This need may be especially pronounced for Black patients, who experience significant health and healthcare disparities. The primary aim of this study was to describe the treatment goals and preferences of Black veterans with chronic musculoskeletal pain who were enrolled in the intervention arm of a randomized controlled trial testing a coaching intervention. In the coaching sessions, participants (n = 106) identified their most important pain-related treatment goals and preferences. Participants' top treatment goals were to improve physical functioning (61%), increase engagement in valued activities (45%), and reduce pain intensity (37%). Most participants (73%) preferred non-pharmacological treatments (eg, physical therapy, exercise, acupuncture, yoga). The 17% of participants who identified medications as a preferred treatment demonstrated higher levels of depression and anxiety compared to those who did not. Approximately 42% and 21% of participants stated a preference to avoid pharmacological and surgical pain treatments, respectively. Black patients with chronic pain prioritize improving physical functioning and pain intensity in service of increasing their engagement in exercise, work, relationships, and leisure activities. Also, in the current study, patients expressed a clear preference for non-pharmacological pain treatments. Future research should investigate ways to improve communication of goals and preferences with providers and facilitate access to non-pharmacological treatments for Black patients with chronic pain. PERSPECTIVE: This article describes the treatment goals and preferences of Black veterans with chronic pain. Most patients prioritized goals to improve physical functioning, pain severity, and participation in valued activities. Patients primarily preferred non-pharmacological treatments. This emphasizes the need for clear communication with Black patients regarding pain-related goals and non-pharmacological treatment options.
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Affiliation(s)
- Mackenzie L Shanahan
- Center for Innovations in Quality Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Kevin L Rand
- Department of Psychology, Indiana University, Indianapolis, Indiana
| | - Amanda Galloway
- Department of Psychology, Indiana University, Indianapolis, Indiana
| | - Marianne S Matthias
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana; Regenstrief Institute, Indianapolis, Indiana; Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
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Courtney RE, Halsey E, Patil T, Mastronardi KV, Browne HS, Darnall BD. Prescription opioid tapering practices and outcomes at a rural VA health care system. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:480-482. [PMID: 38450417 PMCID: PMC11224602 DOI: 10.1093/pm/pnae013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 01/15/2024] [Accepted: 02/15/2024] [Indexed: 03/08/2024]
Affiliation(s)
- Rena Elizabeth Courtney
- PREVAIL Center for Chronic Pain, Salem VA Health Care System; Virginia Tech Carilion School of Medicine, United States
| | - Emily Halsey
- Pharmacy Department, Salem VA Health Care System, United States
| | - Tanvi Patil
- Pharmacy Department, Salem VA Health Care System, United States
| | | | | | - Beth D Darnall
- Stanford University; Stanford University School of Medicine, United States
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8
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Howard IM, Sedarsky K, Gallagher M, Miller M, Puffer RC. Combat-related peripheral nerve injuries. Muscle Nerve 2024. [PMID: 38837797 DOI: 10.1002/mus.28168] [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: 11/21/2023] [Revised: 04/09/2024] [Accepted: 04/24/2024] [Indexed: 06/07/2024]
Abstract
Active-duty service members (ADSM) and military Veterans represent a population with increased occupational risk for nerve injuries sustained both during training operations and wartime. Mechanisms of war-related nerve injuries have evolved over time, from the musket ball-related traumas described by S.W. Mitchell to complex blast injuries and toxic exposures sustained during Middle East conflicts in the 21st century. Commonly encountered nerve injury etiologies in this population currently include compression, direct trauma, nutritional deficits, traumatic limb amputation, toxic chemical exposures, or blast-related injuries. Expeditious identification and comprehensive, interdisciplinary treatment of combat-associated neuropathies, as well as prevention of these injuries whenever possible is critical to reduce chronic morbidity and disability for service members and to maintain a well-prepared military. However, diagnosis of a combat-associated nerve injury may be particularly challenging due to comorbid battlefield injuries or delayed presentation of neuropathy from military toxic exposures. Advances in imaging for nerve injury, including MRI and ultrasound, provide useful tools to compliment EMG in establishing a diagnosis of combat-associated nerve injury, particularly in the setting of anatomic disruption or edema. Surgical techniques can improve pain control or restoration of function. In all cases, comprehensive interdisciplinary rehabilitation provides the best framework for optimization of recovery. Further work is needed to prevent combat-associated nerve injuries and promote nerve recovery following injury.
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Affiliation(s)
- Ileana M Howard
- Rehabilitation Care Services, VA Puget Sound Healthcare System, Seattle, Washington, USA
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Kaye Sedarsky
- Department of Neurology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Michael Gallagher
- Rehabilitation Care Services, VA Puget Sound Healthcare System, Seattle, Washington, USA
| | - Matthew Miller
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Ross C Puffer
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
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Jung M, Xia T, Ilomäki J, Pearce C, Nielsen S. Opioid characteristics and nonopioid interventions associated with successful opioid taper in patients with chronic noncancer pain. Pain 2024; 165:1327-1335. [PMID: 38112755 PMCID: PMC11090027 DOI: 10.1097/j.pain.0000000000003133] [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: 05/27/2023] [Revised: 10/27/2023] [Accepted: 11/04/2023] [Indexed: 12/21/2023]
Abstract
ABSTRACT Current research indicates that tapering opioids may improve pain and function in patients with chronic noncancer pain. However, gaps in the literature remain regarding the choice of opioid and nonopioid interventions to support a successful taper. This study used an Australian primary care data set to identify a cohort of patients on long-term opioid therapy commencing opioid taper between January 2016 and September 2019. Using logistic regression analysis, we compared key clinical factors associated with differing taper outcomes. Of a total of 3371 patients who commenced taper, 1068 (31.7%) completed taper within 12 months. In the 3 months after commencement of taper, compared with those who did not complete taper, patients who successfully completed opioid taper were less likely to be prescribed buprenorphine (odds ratio [OR] 0.691; 95% CI: 0.530-0.901), fentanyl (OR, 0.429; 95% CI: 0.295-0.622), and long-acting (LA) opioids, including methadone (OR, 0.349; 95% CI: 0.157-0.774), oxycodone-naloxone (OR, 0.521; 95% CI: 0.407-0.669), and LA tapentadol (OR, 0.645; 95% CI: 0.461-0.902), but more likely to be prescribed codeine (OR, 1.308; 95% CI: 1.036-1.652). Compared with those who did not complete taper, patients who successfully tapered were less likely to be prescribed any formulations of oxycodone (short-acting [SA]: OR, 0.533; 95% CI: 0.422-0.672, LA: OR, 0.356; 95% CI: 0.240-0.530) and tramadol (SA: OR, 0.370; 95% CI: 0.218-0.628, LA: OR, 0.317; 95% CI: 0.234-0.428). The type of opioid prescribed in the months after commencement of taper seems to influence the taper outcomes. These findings may inform prospective studies on opioid taper.
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Affiliation(s)
- Monica Jung
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Australia
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Ting Xia
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Jenni Ilomäki
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Christopher Pearce
- Melbourne East General Practice Network (trading as Outcome Health), Surrey Hills, Australia
- Department of General Practice, School of Primary and Allied Health Care, Monash University, Notting Hill, Melbourne, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Australia
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Hickey TR, Manepalli AK, Hitt JM. Buprenorphine Facilitates Rapid Weaning From Very-High-Dose Intrathecal Hydromorphone. Cureus 2024; 16:e59134. [PMID: 38803786 PMCID: PMC11129534 DOI: 10.7759/cureus.59134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2024] [Indexed: 05/29/2024] Open
Abstract
Pain management in patients on chronic opioid therapy is a common clinical challenge. The phenomena of opioid-induced hyperalgesia and tolerance are important contributors to that challenge. There are multiple strategies described to wean opioid doses and/or transition patients off opioids altogether. However, there is very little data to guide transitions off chronic intrathecal opioids. Here, we report on two patients with intractable post-laminectomy pain syndrome, resulting in severe functional limitation in the setting of opioid escalation culminating in the intrathecal delivery of hydromorphone to daily doses as high as 20 mg/day. We describe their rapid successful weaning off opioids using low-dose buprenorphine, which resulted in a dramatic improvement in pain and function.
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Affiliation(s)
- Thomas R Hickey
- Anesthesiology, Yale University School of Medicine, VA Connecticut Healthcare System, West Haven, USA
| | - Ashok K Manepalli
- Anesthesiology, Northeast Anesthesia and Pain Specialists, Concord, USA
| | - James M Hitt
- Anesthesiology, VA Western New York Healthcare System, Buffalo, USA
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11
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Liu MC, Guo QF, Zhang WW, Luo HL, Zhang WJ, Hu HJ. Olfactory ensheathing cells as candidate cells for chronic pain treatment. J Chem Neuroanat 2024; 137:102413. [PMID: 38492895 DOI: 10.1016/j.jchemneu.2024.102413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 02/28/2024] [Accepted: 03/12/2024] [Indexed: 03/18/2024]
Abstract
Chronic pain is often accompanied by tissue damage and pain hypersensitivity. It easily relapses and is challenging to cure, which seriously affects the patients' quality of life and is an urgent problem to be solved. Current treatment methods primarily rely on morphine drugs, which do not address the underlying nerve injury and may cause adverse reactions. Therefore, in recent years, scientists have shifted their focus from chronic pain treatment to cell transplantation. This review describes the classification and mechanism of chronic pain through the introduction of the characteristics of olfactory ensheathing cells (OECs), an in-depth discussion of special glial cells through the phagocytosis of nerve debris, receptor-ligand interactions, providing nutrition, and other inhibition of neuroinflammation, and ultimately supporting axon regeneration and mitigation of chronic pain. This review summarizes the potential and limitations of OECs for treating chronic pain by objectively analyzing relevant clinical trials and methods to enhance efficacy and future development prospects.
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Affiliation(s)
- Mei-Chen Liu
- The Second Clinical Medical College, Nanchang University, China
| | - Qing-Fa Guo
- The Second Clinical Medical College, Nanchang University, China
| | - Wei-Wei Zhang
- The Second Clinical Medical College, Nanchang University, China
| | - Hong-Liang Luo
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital, Nanchang University, Nanchang, Jiangxi, China
| | - Wen-Jun Zhang
- Department of Rehabilitation Medicine, The Second Affiliated Hospital, Nanchang University, Nanchang, Jiangxi, China
| | - Hai-Jun Hu
- Anesthesiology Department, The Second Affiliated Hospital, Nanchang University, Nanchang, Jiangxi, China.
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Barenie RE, Bateman BT, Connery HS, Tsacogianis T, Kesselheim AS. Rates and costs of drug testing practices for private payors in the outpatient setting in the United States, 2015-2019. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 159:209243. [PMID: 38052268 DOI: 10.1016/j.josat.2023.209243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 06/08/2023] [Accepted: 11/30/2023] [Indexed: 12/07/2023]
Abstract
INTRODUCTION Clinical practice guidelines recommend drug testing patients who are receiving opioids chronically for pain or medication for a substance use disorder (SUD)-particularly opioid use disorder (OUD)-but practices vary due to a lack of consensus on testing frequency during follow-up. This study aimed to evaluate rates and costs of outpatient drug testing practices for patients receiving opioids for chronic pain or medication for an SUD. METHODS Using claims data from a large de-identified claims data warehouse, we conducted a retrospective cohort study of chronic opioid, buprenorphine, and naltrexone users between January 2015 and December 2019. We identified two cohorts-chronic opioid medication cohort (CO) and SUD-indicated medication cohort (SUD). We assessed drug testing rates during follow-up using procedure codes and costs using copayment, deductible, co-insurance, and out-of-pocket data. RESULTS Among 6,657,515 eligible claimants, 367,118 (5.5 %) received opioids chronically and 73,303 (1.1 %) received an SUD-indicated medication. The cumulative proportion of drug testing during follow-up was similar between cohorts (CO: 36 %; SUD: 35 %), but rate of testing was consistently twice as frequent for the SUD cohort. All cost variables for the first drug test were higher on average in the SUD cohort than the CO cohort except copay: deductible (SUD: $18.54; CO: $7.33); co-insurance (SUD: $10.36; CO: $2.53); out-of-pocket (SUD: $29.39; CO: $10.57); copay (CO: $0.71; SUD: $0.49) (all p < 0.001). CONCLUSIONS Overall proportion of drug testing was similar between cohorts, but testing frequency was at least double during follow-up in the SUD cohort. Most cost variables were higher in the SUD cohort. Whether the high cost of drug testing is a barrier to medication use or is associated with treatment discontinuation should be evaluated.
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Affiliation(s)
- Rachel E Barenie
- University of Tennessee Health Science Center College of Pharmacy, 881 Madison Ave, Memphis, TN 38163, United States of America.
| | - Brian T Bateman
- Perioperative and Pain Medicine and Chair of the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine; 300 Pasteur Dr Rm H3589, Stanford, CA 94305, United States of America.
| | - Hilary S Connery
- Clinical Director of Division of Alcohol, Drugs, and Addiction, 115 Mill Street, Belmont, MA 02478, United States of America.
| | - Theodore Tsacogianis
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont St., Suite 3030, Boston, MA 02120, United States of America.
| | - Aaron S Kesselheim
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont St., Suite 3030, Boston, MA 02120, United States of America.
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Adler J, Mallick-Searle T, Garofoli M, Zimmerman A. Frontline Perspectives on Buprenorphine for the Management of Chronic Pain. J Multidiscip Healthc 2024; 17:1375-1383. [PMID: 38563040 PMCID: PMC10982663 DOI: 10.2147/jmdh.s449748] [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: 12/08/2023] [Accepted: 03/08/2024] [Indexed: 04/04/2024] Open
Abstract
Due to the prevalence of chronic pain and high-impact chronic pain in the US, a significant percentage of the population is prescribed opioids for pain management. However, opioid use disorder is associated with reduced quality of life, along with fatal opioid overdoses, and is a significant burden on the US economy. Considering the clinical needs of patients with intractable chronic pain and the potential harms associated with prescribed and illicit opioids in our communities, having a deep understanding of current treatment options, supporting evidence, and clinical practice guidelines is essential for optimizing treatment selections. Buprenorphine is a Schedule III opioid with a unique mechanism of action, allowing effective and long-lasting analgesia at microgram doses with fewer negative side effects and adverse events, including respiratory depression, when compared with other immediate-release, long-acting, and extended-release prescription opioids. Due to its relatively lower risk for overdose and misuse, buprenorphine was recently added to the Clinical Practice Guideline for the Use of Opioids in the Management of Chronic Pain as a first-line treatment for chronic pain managed by opioids by the US Departments of Defense and Veterans Affairs, and the Department of Health and Human Services recommends that buprenorphine be made available for the treatment of chronic pain. In this narrative review, we discuss the different buprenorphine formulations, clinical efficacy, advantages for older adults and other special populations, clinical practice guideline recommendations, and payer considerations of buprenorphine and suggest that buprenorphine products approved for chronic pain should be considered as a first-line treatment for this indication.
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Affiliation(s)
- Jeremy Adler
- Pacific Pain Medicine Consultants, Encinitas, CA, USA
| | | | - Mark Garofoli
- West Virginia University School of Pharmacy, Morgantown, WV, USA
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Moyo P, Merlin JS, George M, Shireman TI, Marshall BD. Association of Opioid Use Disorder Diagnosis With Use of Physical Therapy and Chiropractic Care Among Chronic Low Back Pain Patients: A Group-Based Trajectory Analysis. THE JOURNAL OF PAIN 2024; 25:742-754. [PMID: 37820847 PMCID: PMC10922407 DOI: 10.1016/j.jpain.2023.10.003] [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: 06/07/2023] [Revised: 10/05/2023] [Accepted: 10/06/2023] [Indexed: 10/13/2023]
Abstract
Nonpharmacologic approaches are recommended as first-line treatment for chronic pain, and their importance is heightened among individuals with co-occurring opioid use disorder (OUD), in whom opioid therapies may be particularly detrimental. Our objectives were to assess the receipt and trajectories of nonpharmacologic pain treatment and determine the association of OUD diagnosis with these trajectories. This retrospective cohort study used Medicare claims data from 2016 to 2018 and applied group-based trajectory models to identify distinct patterns of physical therapy (PT) or chiropractic care treatment over the 12 months following a new episode of chronic low back pain. We used logistic regression models to estimate the association of co-occurring OUD with group membership in PT and chiropractic trajectories. Our sample comprised 607,729 beneficiaries at least 18 years of age, of whom 11.4% had a diagnosis of OUD. The 12-month prevalence of PT and chiropractic treatment receipt was 24.7% and 27.1%, respectively, and lower among Medicare beneficiaries with co-occurring OUD (PT: 14.6%; chiropractic: 6.8%). The final models identified 3 distinct trajectories each for PT (no/little use [76.6% of sample], delayed and increasing use [8.2%], and early and declining use [15.2%]); and chiropractic (no/little use [75.0% of sample], early and declining use [17.3%], and early and sustained use [7.7%]). People with OUD were more likely to belong in trajectories with little/no PT or chiropractic care as compared to other trajectories. The findings indicate that people with co-occurring chronic pain and OUD often do not receive early or any nonpharmacologic pain therapies as recommended by practice guidelines. PERSPECTIVE: PT and chiropractic care use were low overall and even lower among Medicare beneficiaries with co-occurring OUD compared with those without OUD. As updated guidelines on pain management are promulgated, targeted interventions (eg, insurance policy, provider, and patient education) are needed to ensure equitable access to guideline-recommended pain therapies.
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Affiliation(s)
- Patience Moyo
- Brown University School of Public Health, Department of Health Services, Policy, and Practice, Providence, RI, USA
| | - Jessica S. Merlin
- Challenges in Managing and Preventing Pain Clinical Research Center, Division of General Internal Medicine, University of Pittsburgh, PA, USA
| | - Miriam George
- Brown University School of Public Health, Department of Health Services, Policy, and Practice, Providence, RI, USA
| | - Theresa I. Shireman
- Brown University School of Public Health, Department of Health Services, Policy, and Practice, Providence, RI, USA
| | - Brandon D.L. Marshall
- Brown University School of Public Health, Department of Epidemiology, Providence, RI, USA
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15
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Mudumbai SC, He H, Chen JQ, Kapoor A, Regala S, Mariano ER, Stafford RS, Abnet CC, Pfeiffer RM, Freedman ND, Etemadi A. Opioid use in cancer patients compared with noncancer pain patients in a veteran population. JNCI Cancer Spectr 2024; 8:pkae012. [PMID: 38457606 PMCID: PMC11009465 DOI: 10.1093/jncics/pkae012] [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: 10/04/2023] [Revised: 02/05/2024] [Accepted: 02/13/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND Opioid safety initiatives may secondarily impact opioid prescribing and pain outcomes for cancer care. METHODS We reviewed electronic health record data at a tertiary Veterans Affairs system (VA Palo Alto) for all patients from 2015 to 2021. We collected outpatient Schedule II opioid prescriptions data and calculated morphine milligram equivalents (MMEs) using Centers for Disease Control and Prevention conversion formulas. To determine the clinical impact of changes in opioid prescription, we used the highest level of pain reported by each patient on the 0-to-10 Numeric Rating Scale in each year, categorized into mild (0-3), moderate (4-6), and severe (7 and above). RESULTS Among 89 569 patients, 9073 had a cancer diagnosis. Cancer patients were almost twice as likely to have an opioid prescription compared with noncancer patients (69.0% vs 36.7%, respectively). The proportion of patients who received an opioid prescription decreased from 27.1% to 18.1% (trend P < .01) in cancer patients and from 17.0% to 10.2% in noncancer patients (trend P < .01). Cancer and noncancer patients had similar declines of MMEs per year between 2015 and 2019, but the decline was more rapid for cancer patients (1462.5 to 946.4, 35.3%) compared with noncancer patients (1315.6 to 927.7, 29.5%) from 2019 to 2021. During the study period, the proportion of noncancer patients who experienced severe pain was almost unchanged, whereas it increased among cancer patients, reaching a significantly higher rate than among noncancer patients in 2021 (31.9% vs 27.4%, P < .01). CONCLUSIONS Our findings suggest potential unintended consequences for cancer care because of efforts to manage opioid-related risks.
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Affiliation(s)
- Seshadri C Mudumbai
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Han He
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Ji-Qing Chen
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Aditi Kapoor
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Samantha Regala
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Edward R Mariano
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Randall S Stafford
- Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Christian C Abnet
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Ruth M Pfeiffer
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Neal D Freedman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Arash Etemadi
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
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16
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Edmond SN, Wesolowicz DM, Snow JL, Currie S, Jankelovits A, Chhabra MS, Becker WC. Qualitative Analysis of Patient Perspectives of Buprenorphine After Transitioning From Long-Term, Full-Agonist Opioid Therapy Among Veterans With Chronic Pain. THE JOURNAL OF PAIN 2024; 25:132-141. [PMID: 37549775 DOI: 10.1016/j.jpain.2023.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 07/21/2023] [Accepted: 07/27/2023] [Indexed: 08/09/2023]
Abstract
Guidelines recommend consideration of modification, tapering, or discontinuation of long-term, full-agonist opioid therapy when harms outweigh benefits; one alternative to tapering or discontinuing full-agonist opioids for the management of chronic pain is switching to the partial agonist buprenorphine. As the use of buprenorphine for pain expands, understanding the patient experience during and after the transition to buprenorphine is critical. We conducted 45- to 60-minute semistructured qualitative interviews with 19 patients to understand the experiences of patients with chronic pain actively maintained on buprenorphine after previously receiving full-agonist, long-term opioid therapy. Patients were recruited from 2 medical centers via provider referral. Through thematic analysis, 5 overall themes were identified, including satisfaction with buprenorphine, the importance of preconceptions about buprenorphine, experiences with transitions, patient-provider communication, and potential contributions to racial disparities in pain care. While we heard a range of experiences, most patients were satisfied with buprenorphine, reporting either equivalent pain control to their previous regimens or reporting less analgesia but improved functioning due to a reduction in side effects (eg, mental clarity). Patients also emphasized the importance of a nonjudgmental, patient-centered approach, including education about the risks and benefits of buprenorphine. The few Black patients interviewed all reported limited access to pain care, which is consistent with the well-documented existence of racial disparities in access to pain treatment. As buprenorphine is used more frequently for pain management, provider education focused on pain treatment disparities, patient-centered approaches informed by motivational interviewing, and increasing acceptance of buprenorphine as an option for pain are needed. PERSPECTIVE: Qualitative analyses of patient experiences transitioning from full-agonist opioids to buprenorphine for chronic pain revealed general satisfaction. Patients reflected on functioning, tradeoffs between analgesia and side effects, patient-centered care, and access to treatment, highlighting how future research should focus on outcomes valued by patients.
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Affiliation(s)
- Sara N Edmond
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut; Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Danielle M Wesolowicz
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut; Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Jennifer L Snow
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | | | | | - Manik S Chhabra
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - William C Becker
- Pain Research Informatics Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut; Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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17
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Becker WC, Frank JW, Edmond SN, Starrels JL. When harms outweigh benefits of long-term opioid therapy for pain: Need for a new diagnostic entity, research and improved treatments. Addiction 2024; 119:4-5. [PMID: 37766414 DOI: 10.1111/add.16348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 08/31/2023] [Indexed: 09/29/2023]
Affiliation(s)
- William C Becker
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale School of Medicine, New Haven, Connecticut, USA
| | - Joseph W Frank
- VA Eastern Colorado Health Care System, Aurora, Colorado, USA
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Sara N Edmond
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale School of Medicine, New Haven, Connecticut, USA
| | - Joanna L Starrels
- Montefiore Health System and Albert Einstein College of Medicine, Bronx, New York, USA
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18
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Perry A, Wheeler-Martin K, Hasin DS, Terlizzi K, Mannes ZL, Jent V, Townsend TN, Pamplin JR, Crystal S, Martins SS, Cerdá M, Krawczyk N. Utilization and disparities in medication treatment for opioid use disorder among patients with comorbid opioid use disorder and chronic pain during the COVID-19 pandemic. Drug Alcohol Depend 2023; 253:111023. [PMID: 37984034 PMCID: PMC10841620 DOI: 10.1016/j.drugalcdep.2023.111023] [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: 04/06/2023] [Revised: 10/10/2023] [Accepted: 10/31/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND The COVID-19 pandemic's impact on utilization of medications for opioid use disorder (MOUD) among patients with opioid use disorder (OUD) and chronic pain is unclear. METHODS We analyzed New York State (NYS) Medicaid claims from pre-pandemic (August 2019-February 2020) and pandemic (March 2020-December 2020) periods for beneficiaries with and without chronic pain. We calculated monthly proportions of patients with OUD diagnoses in 6-month-lookback windows utilizing MOUD and proportions of treatment-naïve patients initiating MOUD. We used interrupted time series to assess changes in MOUD utilization and initiation rates by medication type and by race/ethnicity. RESULTS Among 20,785 patients with OUD and chronic pain, 49.3% utilized MOUD (versus 60.3% without chronic pain). The pandemic did not affect utilization in either group but briefly disrupted initiation among patients with chronic pain (β=-0.009; 95% CI [-0.015, -0.002]). Overall MOUD utilization was not affected by the pandemic for any race/ethnicity but opioid treatment program (OTP) utilization was briefly disrupted for non-Hispanic Black individuals (β=-0.007 [-0.013, -0.001]). The pandemic disrupted overall MOUD initiation in non-Hispanic Black (β=-0.007 [-0.012, -0.002]) and Hispanic individuals (β=-0.010 [-0.019, -0.001]). CONCLUSIONS Adults with chronic pain who were enrolled in NYS Medicaid before the COVID-19 pandemic had lower MOUD utilization than those without chronic pain. MOUD initiation was briefly disrupted, with disparities especially in racial/ethnic minority groups. Flexible MOUD policy initiatives may have maintained overall treatment utilization, but disparities in initiation and care continuity remain for patients with chronic pain, and particularly for racial/ethnic minoritized subgroups.
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Affiliation(s)
- Allison Perry
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States.
| | - Katherine Wheeler-Martin
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States
| | - Deborah S Hasin
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, United States
| | - Kelly Terlizzi
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States
| | - Zachary L Mannes
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, United States
| | - Victoria Jent
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States
| | - Tarlise N Townsend
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States
| | - John R Pamplin
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States; Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, United States
| | - Stephen Crystal
- Rutgers Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ, United States
| | - Silvia S Martins
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, United States
| | - Magdalena Cerdá
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States
| | - Noa Krawczyk
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States
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Michalowski A, Cavanaugh KL, Hamm M, Wilkie C, Olejniczak DM, Eneanya ND, Colditz J, Jhamb M, Bulls HW, Liebschutz JM. Stakeholder-Driven Intervention Development for Dialysis Trials Using a Design Sprint Methodology. Kidney Med 2023; 5:100729. [PMID: 38028030 PMCID: PMC10630159 DOI: 10.1016/j.xkme.2023.100729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
Rationale & Objective Stigma contributes to ineffective treatment for pain among individuals with kidney failure on dialysis, particularly with buprenorphine pain treatment. To address stigma, we adapted a Design Sprint, an industry-developed structured exercise where an interdisciplinary group works over 5 days to clarify the problem, identify and choose a solution, and build and test a prototype. Study Design Adapted Design Sprint which clarified the problem to be solved, proposed solutions, and created a blueprint for the selected solution. Settings & Participants Five individuals with pain and kidney disease receiving dialysis, 5 physicians (nephrology, palliative care, and addiction medicine) and 4 large dialysis organization leaders recruited for specific expertise or experience. Conducted through online platform (Zoom) and virtual white board (Miro board). Analytical Approach Descriptions of the Design Sprint adaptations and processes. Results To facilitate patient comfort, a patient-only phase included four 90-minute sessions over 2-weeks, during which patient participants used a mapping process to define the critical problem and sketch out solutions. In a physician-only phase, consisting of two 120-minute sessions, participants accomplished the same tasks. During a combined phase of two 120-minute sessions, patients, physicians, and large dialysis organization representatives vetted and developed solutions from earlier phases, leading to an intervention blueprint. Videoconferencing technology allowed for geographically diverse representation and facilitated participation from patients experiencing medical illness. The electronic whiteboard permitted interactive written contributions and voting on priorities instead of only verbal discussion, which may privilege physician participants. A skilled qualitative researcher facilitated the sessions. Limitations Challenges included the time commitment of the sessions, absences owing to illness or emergencies, and technical difficulties. Conclusions An adapted Design Sprint is a novel method of efficiently and rapidly incorporating multiple stakeholders to develop solutions for clinical challenges in kidney disease. Plain Language Summary Stigma contributes to ineffective treatment for pain among individuals with kidney failure on dialysis, particularly when using buprenorphine, an opioid pain medicine with a lower risk of sedation used to treat addiction. To develop a stigma intervention, we adapted a Design Sprint, an industry-developed structured exercise where an interdisciplinary group works over 5 days to clarify the problem, identify and choose a solution, and build and test a prototype. We conducted 3 sprints with (1) patients alone, (2) physicians alone, and (3) combined patients, physicians, and dialysis organization representatives. This paper describes the adaptations and products of sprints as a method for gathering diverse stakeholder voices to create an intervention blueprint efficiently and rapidly.
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Affiliation(s)
- Allison Michalowski
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA
| | - Kerri L. Cavanaugh
- Division of Nephrology & Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Megan Hamm
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA
| | | | - Donna M. Olejniczak
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA
| | - Nwamaka D. Eneanya
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA
| | - Jason Colditz
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA
| | - Manisha Jhamb
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA
| | - Hailey W. Bulls
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, UPMC, Pittsburgh, PA
| | - Jane M. Liebschutz
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA
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20
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Chwistek M, Sherry D, Kinczewski L, Silveira MJ, Davis M. Should Buprenorphine Be Considered a First-Line Opioid for the Treatment of Moderate to Severe Cancer Pain? J Pain Symptom Manage 2023; 66:e638-e643. [PMID: 37343903 DOI: 10.1016/j.jpainsymman.2023.06.022] [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: 05/12/2023] [Revised: 06/02/2023] [Accepted: 06/09/2023] [Indexed: 06/23/2023]
Abstract
Cancer pain remains a significant problem worldwide, affecting more than half of patients receiving anti-cancer treatment and most patients with advanced disease. Opioids remain the cornerstone of therapy, and morphine, given its availability, multiple formulations, price, and evidence base, is typically considered the first-line treatment for moderate to severe cancer pain. Buprenorphine has emerged in recent decades as an alternative opioid for treating chronic pain and substance use disorder (SUD). However, it remains controversial whether buprenorphine should be considered a first-line opioid for moderate to severe cancer pain. In this "Controversies in Palliative Care" article, three expert clinicians independently answer this question. Specifically, each group provides a synopsis of the key studies that inform their thought process, share practical advice on their clinical approach, and highlight the opportunities for future research. All three groups agree that there is a place for the use of buprenorphine as a first-line opioid in cancer pain. Specifically, they mention populations of elderly patients, patients with renal failure, and those with (SUD). They also underscore many unique and favorable characteristics of buprenorphine, such as the low risk for respiratory depression, lack of adverse effects on testosterone levels in men, no risk of serotonin syndrome when combined with antidepressants, and ease of use given its transdermal, transmucosal, and sublingual formulations. However, further studies are needed to guide the use of buprenorphine for cancer pain-primarily randomized clinical trials (RCTs) comparing buprenorphine with other opioids in various pain syndromes.
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Affiliation(s)
- Marcin Chwistek
- Department of Hematology and Oncology (M.C., D.S., L.K.), Fox Chase Cancer Center/Temple University Health System, Philadelphia, PA, USA.
| | - Dylan Sherry
- Department of Hematology and Oncology (M.C., D.S., L.K.), Fox Chase Cancer Center/Temple University Health System, Philadelphia, PA, USA
| | - Leigh Kinczewski
- Department of Hematology and Oncology (M.C., D.S., L.K.), Fox Chase Cancer Center/Temple University Health System, Philadelphia, PA, USA
| | - Maria J Silveira
- Division of Geriatric and Palliative Medicine (M.J.S.), University of Michigan & Geriatric Research Education and Clinical Center, Ann Arbor Veteran Administration Medical Center, Ann Arbor, MI, USA
| | - Mellar Davis
- Department of Palliative Care, Geisinger Medical Center, Geisinger Health Geisinger Commonwealth School of Medicine (M.D.), Danville, PA, USA
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Hasin DS, Wall MM, Alschuler DM, Mannes ZL, Malte C, Olfson M, Keyes KM, Gradus JL, Cerdá M, Maynard CC, Keyhani S, Martins SS, Fink DS, Livne O, McDowell Y, Sherman S, Saxon AJ. Chronic pain, cannabis legalisation, and cannabis use disorder among patients in the US Veterans Health Administration system, 2005 to 2019: a repeated, cross-sectional study. Lancet Psychiatry 2023; 10:877-886. [PMID: 37837985 PMCID: PMC10627060 DOI: 10.1016/s2215-0366(23)00268-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/24/2023] [Accepted: 07/28/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND Cannabis use disorder is associated with considerable comorbidity and impairment in functioning, and prevalence is increasing among adults with chronic pain. We aimed to assess the effect of introduction of medical cannabis laws (MCL) and recreational cannabis laws (RCL) on the increase in cannabis use disorder among patients in the US Veterans Health Administration (VHA). METHODS Data from patients with one or more primary care, emergency, or mental health visit to the VHA in 2005-19 were analysed using 15 repeated cross-sectional VHA electronic health record datasets (ie, one dataset per year). Patients in hospice or palliative care were excluded. Patients were stratified as having chronic pain or not using an American Pain Society taxonomy of painful medical conditions. We used staggered-adoption difference-in-difference analyses to estimate the role of MCL and RCL enactment in the increases in prevalence of diagnosed cannabis use disorder and associations with presence of chronic pain, accounting for the year that state laws were enacted. We did this by fitting a linear binomial regression model stratified by pain, with time-varying cannabis law status, fixed effects for state, categorical year, time-varying state-level sociodemographic covariates, and patient covariates (age group [18-34 years, 35-64 years, and 65-75 years], sex, and race and ethnicity). FINDINGS Between 2005 and 2019, 3 234 382-4 579 994 patients were included per year. Among patients without pain in 2005, 5·1% were female, mean age was 58·3 (SD 12·6) years, and 75·7%, 15·6%, and 3·6% were White, Black, and Hispanic or Latino, respectively. In 2019, 9·3% were female, mean age was 56·7 (SD 15·2) years, and 68·1%, 18·2%, and 6·5% were White, Black, and Hispanic or Latino, respectively. Among patients with pain in 2005, 7·1% were female, mean age was 57·2 (SD 11·4) years, and 74·0%, 17·8%, and 3·9% were White, Black, and Hispanic or Latino, respectively. In 2019, 12·4% were female, mean age was 57·2 (SD 13·8) years, and 65·3%, 21·9%, and 7·0% were White, Black, and Hispanic or Latino, respectively. Among patients with chronic pain, enacting MCL led to a 0·135% (95% CI 0·118-0·153) absolute increase in cannabis use disorder prevalence, with 8·4% of the total increase in MCL-enacting states attributable to MCL. Enacting RCL led to a 0·188% (0·160-0·217) absolute increase in cannabis use disorder prevalence, with 11·5% of the total increase in RCL-enacting states attributable to RCL. In patients without chronic pain, enacting MCL and RCL led to smaller absolute increases in cannabis use disorder prevalence (MCL: 0·037% [0·027-0·048], 5·7% attributable to MCL; RCL: 0·042% [0·023-0·060], 6·0% attributable to RCL). Overall, associations of MCL and RCL with cannabis use disorder were greater in patients with chronic pain than in patients without chronic pain. INTERPRETATION Increasing cannabis use disorder prevalence among patients with chronic pain following state legalisation is a public health concern, especially among older age groups. Given cannabis commercialisation and widespread public beliefs about its efficacy, clinical monitoring of cannabis use and discussion of the risk of cannabis use disorder among patients with chronic pain is warranted. FUNDING NIDA grant R01DA048860, New York State Psychiatric Institute, and the VA Centers of Excellence in Substance Addiction Treatment and Education.
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Affiliation(s)
- Deborah S Hasin
- Columbia University Irving Medical Center, New York, NY, USA; Columbia University Mailman School of Public Health, New York, NY, USA; New York State Psychiatric Institute, New York, NY, USA.
| | - Melanie M Wall
- Columbia University Irving Medical Center, New York, NY, USA; New York State Psychiatric Institute, New York, NY, USA
| | | | | | - Carol Malte
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA; Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Mark Olfson
- Columbia University Irving Medical Center, New York, NY, USA
| | - Katherine M Keyes
- Columbia University Mailman School of Public Health, New York, NY, USA
| | | | | | - Charles C Maynard
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA; University of Washington, Seattle, WA, USA
| | - Salomeh Keyhani
- San Francisco VA Health System, San Francisco, CA, USA; University of California at San Francisco, San Francisco, CA, USA
| | - Silvia S Martins
- Columbia University Mailman School of Public Health, New York, NY, USA
| | - David S Fink
- New York State Psychiatric Institute, New York, NY, USA
| | - Ofir Livne
- New York State Psychiatric Institute, New York, NY, USA
| | - Yoanna McDowell
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Scott Sherman
- New York University, New York, NY, USA; VA Manhattan Harbor Healthcare, New York, NY, USA
| | - Andrew J Saxon
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA; Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, Seattle, WA, USA; University of Washington School of Medicine, Seattle, WA, USA
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22
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Cohen SP, Dawson TC, Pasquina PF. The Use of Opioids in the Management of Chronic Pain. Ann Intern Med 2023; 176:eL230224. [PMID: 37722121 DOI: 10.7326/l23-0224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/20/2023] Open
Affiliation(s)
- Steven P Cohen
- Johns Hopkins School of Medicine, Baltimore, Maryland, and Walter Reed National Military Medical Center, Bethesda, Maryland
| | | | - Paul F Pasquina
- Walter Reed National Military Medical Center and Uniformed Services University of the Health Sciences, Bethesda, Maryland
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23
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Sullivan MD, Linder JA, Doctor JN. Centers for Disease Control and Prevention Guideline for Prescribing Opioids, 2022-Need for Integrating Dosing Benchmarks With Shared Decision-Making. JAMA Intern Med 2023; 183:899-900. [PMID: 37459113 DOI: 10.1001/jamainternmed.2023.2847] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
This viewpoint evaluates the CDC’s 2022 clinical practice guideline for prescribing opioids and suggests a model for supplemented shared decision-making between patients and clinicians about long-term opioid therapy.
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Affiliation(s)
- Mark D Sullivan
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
| | - Jeffrey A Linder
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jason N Doctor
- Department of Health Policy and Management, Price School of Public Policy, University of Southern California, Los Angeles
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24
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Darnall BD, Edwards KA, Courtney RE, Ziadni MS, Simons LE, Harrison LE. Innovative treatment formats, technologies, and clinician trainings that improve access to behavioral pain treatment for youth and adults. FRONTIERS IN PAIN RESEARCH 2023; 4:1223172. [PMID: 37547824 PMCID: PMC10397413 DOI: 10.3389/fpain.2023.1223172] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 07/04/2023] [Indexed: 08/08/2023] Open
Abstract
Chronic pain is prevalent across the life span and associated with significant individual and societal costs. Behavioral interventions are recommended as the gold-standard, evidence-based interventions for chronic pain, but barriers, such as lack of pain-trained clinicians, poor insurance coverage, and high treatment burden, limit patients' ability to access evidenced-based pain education and treatment resources. Recent advances in technology offer new opportunities to leverage innovative digital formats to overcome these barriers and dramatically increase access to high-quality, evidenced-based pain treatments for youth and adults. This scoping review highlights new advances. First, we describe system-level barriers to the broad dissemination of behavioral pain treatment. Next, we review several promising new pediatric and adult pain education and treatment technology innovations to improve access and scalability of evidence-based behavioral pain treatments. Current challenges and future research and clinical recommendations are offered.
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Affiliation(s)
- Beth D. Darnall
- Stanford Pain Relief Innovations Lab, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Karlyn A. Edwards
- Stanford Pain Relief Innovations Lab, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Rena E. Courtney
- Salem VA Health Care System, PREVAIL Center for Chronic Pain, Salem, VA, United States
- Virginia Tech Carilion School of Medicine, Department of Psychiatry and Behavioral Medicine, Roanoke, VA, United States
| | - Maisa S. Ziadni
- Systems Neuroscience and Pain Lab, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Laura E. Simons
- Biobehavioral Pediatric Pain Lab, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Lauren E. Harrison
- Biobehavioral Pediatric Pain Lab, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
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25
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Mestdagh F, Steyaert A, Lavand'homme P. Cancer Pain Management: A Narrative Review of Current Concepts, Strategies, and Techniques. Curr Oncol 2023; 30:6838-6858. [PMID: 37504360 PMCID: PMC10378332 DOI: 10.3390/curroncol30070500] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/15/2023] [Accepted: 07/17/2023] [Indexed: 07/29/2023] Open
Abstract
Pain is frequently reported during cancer disease, and it still remains poorly controlled in 40% of patients. Recent developments in oncology have helped to better control pain. Targeted treatments may cure cancer disease and significantly increase survival. Therefore, a novel population of patients (cancer survivors) has emerged, also enduring chronic pain (27.6% moderate to severe pain). The present review discusses the different options currently available to manage pain in (former) cancer patients in light of progress made in the last decade. Major progress in the field includes the recent development of a chronic cancer pain taxonomy now included in the International Classification of Diseases (ICD-11) and the update of the WHO analgesic ladder. Until recently, cancer pain management has mostly relied on pharmacotherapy, with opioids being considered as the mainstay. The opioids crisis has prompted the reassessment of opioids use in cancer patients and survivors. This review focuses on the current utilization of opioids, the neuropathic pain component often neglected, and the techniques and non-pharmacological strategies available which help to personalize patient treatment. Cancer pain management is now closer to the management of chronic non-cancer pain, i.e., "an integrative and supportive pain care" aiming to improve patient's quality of life.
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Affiliation(s)
- François Mestdagh
- Department of Anesthesiology and Pain Clinic, Cliniques Universitaires Saint Luc, University Catholic of Louvain, Av Hippocrate 10, B-1200 Brussels, Belgium
| | - Arnaud Steyaert
- Department of Anesthesiology and Pain Clinic, Cliniques Universitaires Saint Luc, University Catholic of Louvain, Av Hippocrate 10, B-1200 Brussels, Belgium
| | - Patricia Lavand'homme
- Department of Anesthesiology and Acute Postoperative & Transitional Pain Service, Cliniques Universitaires Saint Luc, University Catholic of Louvain, Av Hippocrate 10, B-1200 Brussels, Belgium
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26
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Hasin DS, Wall MM, Alschuler D, Mannes ZL, Malte C, Olfson M, Keyes KM, Gradus JL, Cerdá M, Maynard CC, Keyhani S, Martins SS, Fink DS, Livne O, McDowell Y, Sherman S, Saxon AJ. Chronic Pain, Cannabis Legalization and Cannabis Use Disorder in Veterans Health Administration Patients, 2005 to 2019. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.07.10.23292453. [PMID: 37503049 PMCID: PMC10370240 DOI: 10.1101/2023.07.10.23292453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Background The risk for cannabis use disorder (CUD) is elevated among U.S. adults with chronic pain, and CUD rates are disproportionately increasing in this group. Little is known about the role of medical cannabis laws (MCL) and recreational cannabis laws (RCL) in these increases. Among U.S. Veterans Health Administration (VHA) patients, we examined whether MCL and RCL effects on CUD prevalence differed between patients with and without chronic pain. Methods Patients with ≥1 primary care, emergency, or mental health visit to the VHA and no hospice/palliative care within a given calendar year, 2005-2019 (yearly n=3,234,382 to 4,579,994) were analyzed using VHA electronic health record (EHR) data. To estimate the role of MCL and RCL enactment in the increases in prevalence of diagnosed CUD and whether this differed between patients with and without chronic pain, staggered-adoption difference-in-difference analyses were used, fitting a linear binomial regression model with fixed effects for state, categorical year, time-varying cannabis law status, state-level sociodemographic covariates, a chronic pain indicator, and patient covariates (age group [18-34, 35-64; 65-75], sex, and race and ethnicity). Pain was categorized using an American Pain Society taxonomy of painful medical conditions. Outcomes In patients with chronic pain, enacting MCL led to a 0·14% (95% CI=0·12%-0·15%) absolute increase in CUD prevalence, with 8·4% of the total increase in CUD prevalence in MCL-enacting states attributable to MCL. Enacting RCL led to a 0·19% (95%CI: 0·16%, 0·22%) absolute increase in CUD prevalence, with 11·5% of the total increase in CUD prevalence in RCL-enacting states attributable to RCL. In patients without chronic pain, enacting MCL and RCL led to smaller absolute increases in CUD prevalence (MCL: 0·037% [95%CI: 0·03, 0·05]; RCL: 0·042% [95%CI: 0·02, 0·06]), with 5·7% and 6·0% of the increases in CUD prevalence attributable to MCL and RCL. Overall, MCL and RCL effects were significantly greater in patients with than without chronic pain. By age, MCL and RCL effects were negligible in patients age 18-34 with and without pain. In patients age 35-64 with and without pain, MCL and RCL effects were significant (p<0.001) but small. In patients age 65-75 with pain, absolute increases were 0·10% in MCL-only states and 0·22% in MCL/RCL states, with 9·3% of the increase in CUD prevalence in MCL-only states attributable to MCL, and 19.4% of the increase in RCL states attributable to RCL. In patients age 35-64 and 65-75, MCL and RCL effects were significantly greater in patients with pain. Interpretation In patients age 35-75, the role of MCL and RCL in the increasing prevalence of CUD was greater in patients with chronic pain than in those without chronic pain, with particularly pronounced effects in patients with chronic pain age 65-75. Although the VHA offers extensive behavioral and non-opioid pharmaceutical treatments for pain, cannabis may seem a more appealing option given media enthusiasm about cannabis, cannabis commercialization activities, and widespread public beliefs about cannabis efficacy. Cannabis does not have the risk/mortality profile of opioids, but CUD is a clinical condition with considerable impairment and comorbidity. Because cannabis legalization in the U.S. is likely to further increase, increasing CUD prevalence among patients with chronic pain following state legalization is a public health concern. The risk of chronic pain increases as individuals age, and the average age of VHA patients and the U.S. general population is increasing. Therefore, clinical monitoring of cannabis use and discussion of the risk of CUD among patients with chronic pain is warranted, especially among older patients. Research in Context Evidence before this study: Only three studies have examined the role of state medical cannabis laws (MCL) and/or recreational cannabis laws (RCL) in the increasing prevalence of cannabis use disorder (CUD) in U.S. adults, finding significant MCL and RCL effects but with modest effect sizes. Effects of MCL and RCL may vary across important subgroups of the population, including individuals with chronic pain. PubMed was searched by DH for publications on U.S. time trends in cannabis legalization, cannabis use disorders (CUD) and pain from database inception until March 15, 2023, without language restrictions. The following search terms were used: (medical cannabis laws) AND (pain) AND (cannabis use disorder); (recreational cannabis laws) AND (pain) AND (cannabis use disorder); (cannabis laws) AND (pain) AND (cannabis use disorder). Only one study was found that had CUD as an outcome, and this study used cross-sectional data from a single year, which cannot be used to determine trends over time. Therefore, evidence has been lacking on whether the role of state medical and recreational cannabis legalization in the increasing US adult prevalence of CUD differed by chronic pain status.Added value of this study: To our knowledge, this is the first study to examine whether the effects of state MCL and RCL on the nationally increasing U.S. rates of adult cannabis use disorder differ by whether individuals experience chronic pain or not. Using electronic medical record data from patients in the Veterans Health Administration (VHA) that included extensive information on medical conditions associated with chronic pain, the study showed that the effects of MCL and RCL on the prevalence of CUD were stronger among individuals with chronic pain age 35-64 and 65-75, an effect that was particularly pronounced in older patients ages 65-75.Implications of all the available evidence: MCL and RCL are likely to influence the prevalence of CUD through commercialization that increases availability and portrays cannabis use as 'normal' and safe, thereby decreasing perception of cannabis risk. In patients with pain, the overall U.S. decline in prescribed opioids may also have contributed to MCL and RCL effects, leading to substitution of cannabis use that expanded the pool of individuals vulnerable to CUD. The VHA offers extensive non-opioid pain programs. However, positive media reports on cannabis, positive online "information" that can sometimes be misleading, and increasing popular beliefs that cannabis is a useful prevention and treatment agent may make cannabis seem preferable to the evidence-based treatments that the VHA offers, and also as an easily accessible option among those not connected to a healthcare system, who may face more barriers than VHA patients in accessing non-opioid pain management. When developing cannabis legislation, unintended consequences should be considered, including increased risk of CUD in large vulnerable subgroups of the population.
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Affiliation(s)
- Deborah S Hasin
- Columbia University Irving Medical Center, 630 West 168th Street, New York, NY 10032, USA
- Columbia University Mailman School of Public Health, 722 W 168th St, New York, NY 10032, USA
- New York State Psychiatric Institute, 1051 Riverside Dr, New York, NY 10032, USA
| | - Melanie M Wall
- Columbia University Irving Medical Center, 630 West 168th Street, New York, NY 10032, USA
- New York State Psychiatric Institute, 1051 Riverside Dr, New York, NY 10032, USA
| | - Dan Alschuler
- New York State Psychiatric Institute, 1051 Riverside Dr, New York, NY 10032, USA
| | - Zachary L Mannes
- New York State Psychiatric Institute, 1051 Riverside Dr, New York, NY 10032, USA
| | - Carol Malte
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108, USA
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108, USA
| | - Mark Olfson
- Columbia University Irving Medical Center, 630 West 168th Street, New York, NY 10032, USA
| | - Katherine M Keyes
- Columbia University Mailman School of Public Health, 722 W 168th St, New York, NY 10032, USA
| | - Jaimie L Gradus
- Boston University School of Public Health, 715 Albany St, Boston, MA 02118, USA
| | - Magdalena Cerdá
- New York University, 50 West 4th Street, New York, NY 10012, USA
| | - Charles C Maynard
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108, USA
- University of Washington, 1400 Ne Campus Parkway, Seattle, WA 98195, USA
| | - Salomeh Keyhani
- San Francisco VA Health System, 4150 Clement St, San Francisco, CA 94121, USA
- University of California at San Francisco, 505 Parnassus Ave, San Francisco, CA 94143, USA
| | - Silvia S Martins
- Columbia University Mailman School of Public Health, 722 W 168th St, New York, NY 10032, USA
| | - David S Fink
- New York State Psychiatric Institute, 1051 Riverside Dr, New York, NY 10032, USA
| | - Ofir Livne
- New York State Psychiatric Institute, 1051 Riverside Dr, New York, NY 10032, USA
| | - Yoanna McDowell
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108, USA
| | - Scott Sherman
- New York University, 50 West 4th Street, New York, NY 10012, USA
- VA Manhattan Harbor Healthcare, 423 E 23rd St, New York, NY 10010, USA
| | - Andrew J Saxon
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108, USA
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108, USA
- University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195, USA
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27
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Cunningham CO, Starrels JL. Guideline Promoting Buprenorphine for Treatment of Chronic Pain: Transformative Yet Underdeveloped. Ann Intern Med 2023; 176:419-420. [PMID: 36780656 DOI: 10.7326/m23-0229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2023] Open
Affiliation(s)
- Chinazo O Cunningham
- New York State Office of Addiction Services and Supports, New York, and Albert Einstein College of Medicine, Bronx, New York
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