Perception of opioids among medical students: unveiling the complexities and implications

CONTEXT

From 2000 to 2019, drug overdoses, combined intentional and unintentional, were the number one cause of death for Americans under 50 years old,with the number of overdoses increasing every year. Between 2012 and 2018, approximately 85 % of all opioid users obtained their opioids through prescriptions from healthcare providers, predominantly physicians. Increased education about the severity of this issue may increase the likelihood of physicians integrating alternative forms of care such as cognitive behavioral approaches, nonopioid therapies, and nonpharmacologic therapies into treatment plans for chronic pain.

OBJECTIVES

This study investigates medical students' beliefs, experiences, and perceived impact of opioids at Ohio University Heritage College of Osteopathic Medicine (OU-HCOM) and University of Toledo College of Medicine and Life Sciences (UT).

METHODS

A total of 377 students from OU-HCOM (years 1-4, n=312) and UT (years 1-2, n=65) were surveyed on their beliefs, experiences, and perceived impact of opioids. Multiple t tests were conducted to compare the difference in perceived severity and stigma between participants who were impacted by the epidemic and those who were not. A Kendall rank test was performed to analyze the relationship between the county drug overdose rate and perceived severity for medical students. p <0.05 defined statistical significance for all statistical tests performed in this study.

RESULTS

In comparing medical students' personal experiences with the opioid crisis, it was found that many more participants had experiences with an affected classmate or patient (4.1; 95 % CI, 4.0-4.2), as opposed to direct experiences within their family or group of friends (1.9; 95 % CI, 1.8-2.0). However, this group of participants who directly experienced the opioid crisis were found to be more likely to view the crisis as more severe in Ohio's adult population than those without that direct experience (p=0.03, α=0.05). The difference in experience and severity outlook did not make one group of medical students more likely to hold a stigma toward those struggling with opioid addiction (p=0.3, α=0.05). The study did not find a significant relationship between the county drug overdose rate and the perceived severity among medical students (R=0.05, p=0.6, α=0.05).

CONCLUSIONS

This study gave an insight into the beliefs, experiences, and perceived impact of opioids within a group of 377 medical students. It was shown that differences in background can lead to differences in perception of the crisis. Knowing these differences can lead to beneficial changes in education and curriculum design in medical education.

Reconceptualizing Somatic Dysfunction in the Light of a Neuroaesthetic Enactive Paradigm

Background: Palpatory findings are considered a central element of osteopathic practice, especially when associated with a patient's altered regulative functions than with named somatic dysfunctions. Although osteopathic theories for somatic dysfunction could be plausible, the clinical applicability of the concept is debated, especially because it is largely related to simple cause-effect models of osteopathic care. In contrast to a linear kind of diagnosis of a "tissue as a producer of symptoms", this perspective article aims to provide a conceptual and operational framework in which the somatic dysfunction evaluation process is seen as a neuroaesthetic (en)active encounter between osteopath and patient. Subsections relevant to the subject: To summarize all concepts of the hypothesis, the enactive neuroaesthetics principles are proposed as a critical foundation for the osteopathic assessment and treatment of the person, specifically addressing a new paradigm for somatic dysfunction. Conclusions, and future directions: The present perspective article represents a proposition to blend technical rationality informed by neurocognitive and social sciences, and professional artistry clinical experience informed by traditional tenets, to overcome the controversy around somatic dysfunction, rather than dismissing the concept.

Successful buprenorphine transition while overlapping with a full opioid agonist to treat chronic pain: a case report

Buprenorphine is a partial mu opioid agonist that has been increasingly utilized to treat patients with chronic pain and opioid use disorder (OUD). The drug has proven to provide significant chronic pain relief at low doses ranging from 75 to 1800 mcg. The conventional buprenorphine transitional process delays its introduction until patients begin withdrawal. However, this process can pose a barrier to both patients and providers due to some patients' inability to tolerate traditional prerequisite withdrawal. To our knowledge, this is a rare reported case to describe a transitional process utilizing buccal buprenorphine in which a patient with chronic pain simultaneously tapered completely off an extended-release (ER) full opioid agonist and uptitrated buprenorphine. The patient was weaned from oxycodone ER 30 mg every 12 h and oxycodone/acetaminophen 10/325 mg 3x/day for breakthrough pain utilizing an unconventional approach. Tapering down to oxycodone ER 20 mg 2x/day for the first 2 weeks was successful. However, reducing to oxycodone ER 10 mg 2x/day for the following 2 weeks presented adherence difficulty and increased breakthrough pain. At this time, buccal buprenorphine was added at 300 mcg daily for 3 days. From days 4 to 6, buprenorphine was increased to 300 mcg 2x/day and oxycodone ER decreased to 10 mg daily. Six days later, oxycodone ER was discontinued and oxycodone/acetaminophen continued as needed. The patient exhibited no signs of withdrawal and adequate relief of symptoms through this tapering process. At the 1-month follow-up, the patient was doing well and was being treated solely with buprenorphine and oxycodone/acetaminophen to control her breakthrough pain. After 5 months, buprenorphine was increased to 600 mcg 2x/day and her oxycodone/acetaminophen decreased to 5/325 mg 3x/day as needed. From the start of the patient's taper to her current transition, the patient reduced her morphine milligram equivalent (MME) dosage from 135 MME to 22.5 MME. The Clinical Opioid Withdrawal Scale (COWS), which measures the severity of a patient's opioid withdrawal symptoms, was consistently less than 5. This buprenorphine schedule demonstrated a successful tapering approach for this patient because she had reported improved quality of life and function. A patient-centered osteopathic treatment approach was utilized when the patient presented with mid-taper adherence difficulty. Transitioning patients from full to partial opioid agonists could become an important practice standard for patient safety not only for formal pain management practices but also in primary care, family practice, and even geriatric offices.

Overcoming reward deficiency syndrome by the induction of “dopamine homeostasis” instead of opioids for addiction: illusion or reality?

Many individuals in the United States are plagued by addiction, and the rate at which it is affecting people in the United States only seems to be increasing. Research shows that addiction is a preventable disorder rather than a flaw in one’s moral fiber. It is driven by the imbalance of dopamine and the brain’s reward system. Although medication-assisted treatment (MAT), the most common treatment for addiction, are effective in reducing harm, they provide minimal aid in addressing the root cause of this preventable disorder. The authors aim to convey that the proper treatment should help restore dopamine balance so the quality of life can be improved in the recovering community. Osteopathic principles emphasize the importance of homeostasis and allostasis in allowing the body to heal itself. Viewing reward deficiency syndrome (RDS) through this osteopathic lens can bring about treatments that aim to restore the dopamine homeostasis. The article discusses various potential therapeutic modalities that can provide dopamine homeostasis via activation of dopaminergic pathways.

Review of medication-assisted treatment for opioid use disorder

CONTEXT

The American opioid epidemic has necessitated the search for safe and effective means of treatment for opioid use disorder (OUD). Medication-assisted treatment (MAT) encompasses select medications that are proven effective treatments for OUD. Understanding the mechanisms of action, indications, and implementation of MAT is paramount to increasing its availability to all individuals struggling with opioid addiction.

OBJECTIVES

This review is based on an educational series that aims to educate healthcare providers and ancillary healthcare members on the use of MAT for the treatment of OUD.

METHODS

The database PubMed was utilized to retrieve articles discussing the implementation of MAT. Boolean operators and Medical Subject Headings (MeSHs) were applied including: MAT and primary care, MAT and telehealth, methadone, buprenorphine, naltrexone, MAT and osteopathic, MAT and group therapy, and MAT and COVID-19.

RESULTS

Three medications have been approved for the treatment of OUD: methadone, naltrexone, and buprenorphine. Identifying ways to better treat and manage OUD and to combat stigmatization are paramount to dismantling barriers that have made treatment less accessible. Studies suggest that primary care providers are well positioned to provide MAT to their patients, particularly in rural settings. However, no study has compared outcomes of different MAT models of care, and more research is required to guide future efforts in expanding the role of MAT in primary care settings.

CONCLUSIONS

The coronavirus disease 2019 (COVID-19) pandemic has led to changes in the way MAT care is managed. Patients require a novel point-of-care approach to obtain care. This review will define the components of MAT, consider the impact of MAT in the primary care setting, and identify barriers to effective MAT. Increasing the availability of MAT treatment will allow for greater access to comprehensive treatment and will set the standard for accessibility of novel OUD treatment in the future.

Complications of Neurofibromatosis 1 (NF1) in an Adult With Multiple Comorbidities

Neurofibromatosis (NF) is an autosomal genetic disorder with three types, including NF1, NF2, and schwannomatosis. It is characterized by bulging and deforming masses arising from multiple nerves involving skin folds and connective tissues. Prompt diagnosis and provision of care for NF1 patients by clinicians aware of the diverse clinical features of this disorder are needed for optimum patient care and management. A 65-year-old African American female with a past medical history significant for multiple neurofibromas covering more than 95% of her total body surface area (TBSA), presented to a primary care clinic with an enlarged ulcerated neurofibroma of the right elbow. She reported associated pulsating, sharp pain, which was radiating to her entire right upper extremity. For most of her adult life, the lesion has been present and began as the rest of the neurofibromas on her body but gradually enlarged with eventual ulceration three months before the visit. The patient reported a failed surgical resection for the same neurofibroma several years ago. She also reported diffuse tenderness of the lesion, which severely impaired her daily living activities and limited her sleep ability. She acknowledged using multiple over-the-counter analgesics, prescription hydrocodone/acetaminophen 5/325 mg as needed, and gabapentin 300 mg orally twice daily but denied significant symptom alleviation. The patient was started on oral clindamycin hydrochloride 300 mg every six hours for 10 days and a topical mupirocin ointment 2% three times daily for five days. Subsequent visits showed no improvement of the ulcer, which necessitated a referral to wound care. After multiple wound care visits without progress, the patient was referred to a plastic surgeon for evaluation for repeat ulcer resection. NF1 patients develop multiple tumors (neurofibromas); approximately 8%-15% percent of them present with malignant peripheral nerve sheath tumors (MPNST) within the patient's lifetime. Tumor ulceration is a rare but possible complication of NF1. Due to the acute ulcerated fibromas' complications, previous unsuccessful cosmetic management, and ambiguity about NF1 disorder, the patient's quality of life was impaired. The physical and emotional pain the patient experienced impacted her activities of daily living and likely contributed to or exacerbated her diagnoses of substance use disorder and major depressive disorder. NF1 is incurable and can be associated with complications that deteriorate the quality of life, depending on symptom severity. The condition impacts patients' bodies, minds, and spirits, as seen in this patient who had diagnoses of substance use disorder and major depressive disorder, as well as a history of suicidal ideation and suicide attempts. The treatment of conditions related to NF1 is best managed in centers equipped with doctors experienced in treating patients with NF1. A multidisciplinary management approach is ideal. Preferably, for the management of chronic pain and beyond, the osteopathic holistic approach, targeting the body, mind, and spirit, in combination with other innovative non-pharmacotherapies and pharmacotherapy methods, would be beneficial.

Perceptions of nonopioid treatment for pain in a homeless population

CONTEXT

Opioid abuse has developed into a public health emergency within the last decade because opioid medications, while addictive, are effective and commonly used for pain management. In 2016, over 42,000 deaths were attributed to opioids. Chronic pain affects about 50% of people experiencing homelessness in the US, and they have a higher overall rate of chronic pain than the general population; opioids are among the methods they might use to manage that pain. Complementary and alternative therapies for pain management have largely gone unexplored in the homeless population.

OBJECTIVES

To determine, among people experiencing homelessness, the willingness to use and current use of complementary and alternative treatments (physical and massage therapy, chiropractic treatments). A secondary objective was to investigate awareness and perception of osteopathic manipulative treatment (OMT) as a complementary treatment for chronic pain among the homeless population.

METHODS

A 32 question survey was administered verbally to guests of True Worth Place Homeless Shelter in Fort Worth, Texas in three 4 hour sessions from February 2019 to April 2019. If participants gave verbal consent, a researcher read the questionnaire, one question at a time, and recorded the participant's responses. The survey included queries for opioid and nonopioid treatment modalities (physical and massage therapy, chiropractic, and OMT) to assess the perception of and current use of each among the population. Appropriate nonparametric statistical analysis was conducted to assess significance and correlations among the treatment groups.

RESULTS

Of the 200 survey participants, 126 (91.3%) reported a history of opiate use for pain, but 136 (68.0%) believed that a nondrug pain intervention could better treat their pain. Additionally, 150 participants (75.0%) believed that regular manipulation, including OMT, would decrease their need for pain medications. Participants with a history of opioid use for pain were more likely to believe that the availability of regular manipulation, including OMT, at True Worth Place could decrease their need for pain medication (odds ratio=3.7143; 95% confidence interval=1.6122-8.5572; p=0.0009). Moreover, some participants (141; 70.5%) were already pursuing nondrug pain management modalities such as PT, massage therapy, and chiropractic care. The greatest barriers to receiving OMT were transportation and cost.

CONCLUSIONS

This survey study was conducted to determine whether a homeless population would be willing to use nonopioid treatment, particularly OMT, for chronic pain management. Results revealed both a willingness to use and a previous use of nonopioid treatments for pain, along with a high prevalence of opiate use. Despite limited exposure to OMT, this population reported being potentially willing to pursue manipulation, including OMT, as a complementary treatment for pain relief alongside opioids if readily available.

Role of Opioid-Involved Drug Interactions in Chronic Pain Management

The use of opioids for chronic pain management is extraordinarily common despite substantial evidence of only modest benefits, when compared with nonopioid analgesics. Opioid use is also associated with serious risks, including overdose and death. A growing body of evidence suggests that opioids are involved in significant drug interactions that often go unrecognized in clinical practice. Understanding opioid-involved drug interactions is of great practical importance for all health care professionals caring for patients with chronic pain. In this article, we describe the mechanisms of opioid-involved drug interactions and their potential consequences, which have major public health implications. Additionally, this article provides practical strategies to aid health care professionals in avoiding and mitigating opioid-involved drug interactions in order to obtain a favorable balance in the risk-benefit ratio associated with opioid use. These strategies include using osteopathic principles for chronic pain management, separating the times of administration of the opioid(s) from the nonopioid(s) involved in the interaction, changing the opioid(s) adversely affected by the interaction, changing the nonopioid(s) causing the interaction, and partnering with pharmacists in clinical practice.

Influence of Future Prescribers' Personal and Clinical Experiences With Opioids on Plans to Treat Patients With Opioid Use Disorder

CONTEXT

Recreational use of opioids is a growing problem in the United States, particularly in the Midwest. Educators have called for inclusion of pain- and opioid-specific courses in health professional school curricula, yet more research is needed to address future prescribers' beliefs, experiences, and postgraduate plans related to opioids.

OBJECTIVE

To examine health professional students' perceived severity of the opioid crisis and opioid-related beliefs, experiences, and postgraduate plans.

METHODS

Using a descriptive, cross-sectional design, researchers evaluated health professional students from 3 academic programs (nurse practitioner [NP], physician assistant [PA], and doctor of osteopathic medicine [DO]) using a 25-item survey that assessed perceived opioid crisis severity and opioid-related beliefs, experiences, and postgraduate plans. Demographics of respondents were assessed using descriptive statistics and frequencies. Responses were compared between academic programs with 1-way analysis of variance or Kruskal-Wallis tests, and relationships between students' experiences and postgraduate plans were assessed.

RESULTS

A total of 491 students (mean [SD] age, 27.2 [5.4] years; 62.7% female; 68.2% DO students) participated in the survey (response rate, 40.4%). The opioid crisis was perceived to be severely impacting the health care system (mean [SD] score, 79.7 [16.8] out of 100), and most respondents (415 [84.5%]) reported that opioid use affected their communities. Clinical experience varied by program, with NP students (75 [81.5%]) reporting the most experience treating acute overdose. Most respondents (317 [64.6%]) agreed that their postgraduate practice would involve caring for patients addicted to opioids; however, only 232 students (47.3%) felt confident in their ability to treat patients with addiction. Experiences managing acute overdose and handling drug-seeking behavior were positively associated with a belief that postgraduate work would involve working with patients with addiction (U=38,275.5, Z=5.92, P<.001; U=25,346.0, Z=4.94, P<.001) and confidence in treating patients with opioid addictions (U=36,806.5, Z=4.96, P<.001; U=23,765.5, Z=3.66, P<.001).

CONCLUSION

Although health professional students had similar beliefs and perceptions regarding the opioid crisis, there were notable differences between academic programs. Students with clinical opioid experiences were more likely to plan on working with patients addicted to opioids and be confident in treating these patients. Thus, the inclusion of experiential learning in the medical curricula may be beneficial for both students and their future patients.

Review of Opioid Prescribing in the Osteopathic and Ambulatory Setting

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.

Does Osteopathic Manipulative Treatment Make a Neuropsychological Difference in Adults With Pain? A Rationale for a New Approach

Cognitive impairment is common in patients with pain. While symptoms of pain are effectively treated with osteopathic manipulative treatment (OMT), the cognitive complaint is vastly ignored. Pain-induced cognitive dysfunction can be severe and is particularly apparent in working memory and attention. There is good reason to expect cognitive responsiveness to OMT. Previous research has reported the effects of OMT on related psychiatric outcomes, including relief from depression and anxiety, suggesting that OMT may produce more cortical benefits than is currently thought. The rationale to link OMT to cognition comes from the tenets of osteopathic medicine: body unity, homeostasis, and the structure-function relationship. The present article provides background evidence to support the hypothetical link between OMT and cognitive benefits and proposes a physiological mechanism of how OMT could exert its effect on cognition. Research strategies are discussed to test the hypotheses that are generated from the proposed theoretical framework.