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Siaton BC, Hogans BB, Frey-Law LA, Brown LM, Herndon CM, Buenaver LF. Pain, comorbidities, and clinical decision-making: conceptualization, development, and pilot testing of the Pain in Aging, Educational Assessment of Need instrument. FRONTIERS IN PAIN RESEARCH 2024; 5:1254792. [PMID: 38455875 PMCID: PMC10918012 DOI: 10.3389/fpain.2024.1254792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 01/26/2024] [Indexed: 03/09/2024] Open
Abstract
Introduction Pain is highly prevalent in older adults and often contextualized by multiple clinical conditions (pain comorbidities). Pain comorbidities increase with age and this makes clinical decisions more complex. To address gaps in clinical training and geriatric pain management, we established the Pain in Aging-Educational Assessment of Need (PAEAN) project to appraise the impacts of medical and mental health conditions on clinical decision-making regarding older adults with pain. We here report development and pilot testing of the PAEAN survey instrument to assess clinician perspectives. Methods Mixed-methods approaches were used. Scoping review methodology was applied to appraise both research literature and selected Medicare-based data. A geographically and professionally diverse interprofessional advisory panel of experts in pain research, medical education, and geriatrics was formed to advise development of the list of pain comorbidities potentially impacting healthcare professional clinical decision-making. A survey instrument was developed, and pilot tested by diverse licensed healthcare practitioners from 2 institutions. Respondents were asked to rate agreement regarding clinical decision-making impact using a 5-point Likert scale. Items were scored for percent agreement. Results Scoping reviews indicated that pain conditions and comorbidities are prevalent in older adults but not universally recognized. We found no research literature directly guiding pain educators in designing pain education modules that mirror older adult clinical complexity. The interprofessional advisory panel identified 26 common clinical conditions for inclusion in the pilot PAEAN instrument. Conditions fell into three main categories: "major medical", i.e., cardio-vascular-pulmonary; metabolic; and neuropsychiatric/age-related. The instrument was pilot tested by surveying clinically active healthcare providers, e.g., physicians, nurse practitioners, who all responded completely. Median survey completion time was less than 3 min. Conclusion This study, developing and pilot testing our "Pain in Aging-Educational Assessment of Need" (PAEAN) instrument, suggests that 1) many clinical conditions impact pain clinical decision-making, and 2) surveying healthcare practitioners about the impact of pain comorbidities on clinical decision-making for older adults is highly feasible. Given the challenges intrinsic to safe and effective clinical care of older adults with pain, and attendant risks, together with the paucity of existing relevant work, much more education and research are needed.
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Affiliation(s)
- Bernadette C. Siaton
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
- Geriatric Research Education and Clinical Center, VA Maryland Health Care System, Baltimore, MD, United States
| | - Beth B. Hogans
- Geriatric Research Education and Clinical Center, VA Maryland Health Care System, Baltimore, MD, United States
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Laura A. Frey-Law
- Department of Physical Therapy and Rehabilitative Science, University of Iowa Carver College of Medicine, Iowa City, IA, United States
| | - Lana M. Brown
- Geriatric Research Education and Clinical Center, Central Arkansas Veterans Healthcare System, Little Rock, AR, United States
| | - Christopher M. Herndon
- Department of Pharmacy Practice, Southern Illinois University Edwardsville School of Pharmacy, Edwardsville, IL, United States
- Department of Family and Community Medicine, St. Louis University School of Medicine, St. Louis, MO, United States
| | - Luis F. Buenaver
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, United States
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Fortuna RJ, Venci J, Johnson W, Clark JS, Schlagman S, Vandermark K, Stetzer A, Nasra GS, Martin-Stancil-El SG, Judge S. Comprehensive Approach to Opioid Management in a Primary Care Network. Popul Health Manag 2024; 27:1-7. [PMID: 38237106 DOI: 10.1089/pop.2023.0234] [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] [Indexed: 02/09/2024] Open
Abstract
In response to the opioid epidemic, the Centers for Disease Control and Prevention released best practice recommendations for prescribing, yet adoption of these guidelines has been fragmented and frequently met with uncertainty by both patients and providers. This study aims to describe the development and implementation of a comprehensive approach to improving opioid stewardship in a large network of primary care providers. The authors developed a 3-tier approach to opioid management: (1) establishment and implementation of best practices for prescribing opioids, (2) development of a weaning process to decrease opioid doses when the risk outweighs benefits, and (3) support for patients when opioid use disorders were identified. Across 44 primary care practices caring for >223,000 patients, the total number of patients prescribed a chronic opioid decreased from 4848 patients in 2018 to 3106 patients in 2021, a decrease of 36% (P < 0.001). The percent of patients with a controlled substance agreement increased from 13% to 83% (P < 0.001) and the percent of patients completing an annual urine drug screen increased from 17% to 53% (P < 0.001). The number of patients coprescribed benzodiazepines decreased from 1261 patients at baseline to 834 at completion. A total of 6.5% of patients were referred for additional support from a certified alcohol and substance abuse counselor embedded within the program. Overall, the comprehensive opioid management program provided the necessary structure to support opioid prescribing and resulted in improved adherence to best practices, facilitated weaning of opioids when medically appropriate, and enhanced support for patients with opioid use disorders.
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Affiliation(s)
- Robert J Fortuna
- Department of Internal Medicine, University of Rochester, Rochester, New York, USA
- Primary Care Network, University of Rochester, Rochester, New York, USA
| | - Jineane Venci
- Department of Internal Medicine, University of Rochester, Rochester, New York, USA
| | - Wallace Johnson
- Department of Internal Medicine, University of Rochester, Rochester, New York, USA
- Primary Care Network, University of Rochester, Rochester, New York, USA
| | - John S Clark
- Primary Care Network, University of Rochester, Rochester, New York, USA
| | - Shalom Schlagman
- Department of Internal Medicine, University of Rochester, Rochester, New York, USA
| | - Kelly Vandermark
- Primary Care Network, University of Rochester, Rochester, New York, USA
- Department of Psychiatry, University of Rochester, Rochester, New York, USA
| | - Alisa Stetzer
- Primary Care Network, University of Rochester, Rochester, New York, USA
| | - George S Nasra
- Department of Psychiatry, University of Rochester, Rochester, New York, USA
| | - Sheniece Griffin Martin-Stancil-El
- Primary Care Network, University of Rochester, Rochester, New York, USA
- School of Nursing, University of Rochester, Rochester, New York, USA
| | - Stephen Judge
- Department of Internal Medicine, University of Rochester, Rochester, New York, USA
- Primary Care Network, University of Rochester, Rochester, New York, USA
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Sharif L, Gunaseelan V, Lagisetty P, Bicket M, Waljee J, Englesbe M, Brummett CM. High-risk Prescribing Following Surgery Among Payer Types for Patients on Chronic Opioids. Ann Surg 2023; 278:1060-1067. [PMID: 37335197 DOI: 10.1097/sla.0000000000005938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
OBJECTIVE Among those on chronic opioids, to determine whether patients with Medicaid coverage have higher rates of high-risk opioid prescribing following surgery compared with patients on private insurance. BACKGROUND Following surgery, patients on chronic opioids experience gaps in transitions of care back to their usual opioid prescriber, but differences by payer type are not well understood. This study aimed to analyze how new high-risk opioid prescribing following surgery compares between Medicaid and private insurance. METHODS In this retrospective cohort study through the Michigan Surgical Quality Collaborative, perioperative data from 70 hospitals across Michigan were linked to prescription drug monitoring program data. Patients with either Medicaid or private insurance were compared. The outcome of interest was new high-risk prescribing, defined as a new occurrence of: overlapping opioids or benzodiazepines, multiple prescribers, high daily doses, or long-acting opioids. Data were analyzed using multivariable regressions and a Cox regression model for return to usual prescriber. RESULTS Among 1435 patients, 23.6% (95% CI: 20.3%-26.8%) with Medicaid and 22.7% (95% CI: 19.8%-25.6%) with private insurance experienced new, postoperative high-risk prescribing. New multiple prescribers was the greatest contributing factor for both payer types. Medicaid insurance was not associated with higher odds of high-risk prescribing (odds ratio: 1.067, 95% CI: 0.813-1.402). CONCLUSIONS Among patients on chronic opioids, new high-risk prescribing following surgery was high across payer types. This highlights the need for future policies to curb high-risk prescribing patterns, particularly in vulnerable populations that are at risk of greater morbidity and mortality.
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Affiliation(s)
- Limi Sharif
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
| | - Vidhya Gunaseelan
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
| | - Pooja Lagisetty
- Department of Medicine, Michigan Medicine, Ann Arbor, MI
- Center for Clinical Management and Research, Ann Arbor, MI
- Institute for Healthcare Innovation and Policy, Ann Arbor, MI
| | - Mark Bicket
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
- Institute for Healthcare Innovation and Policy, Ann Arbor, MI
- School of Public Health, University of Michigan, Ann Arbor, MI
| | - Jennifer Waljee
- Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | - Michael Englesbe
- Department of Medicine, Michigan Medicine, Ann Arbor, MI
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | - Chad M Brummett
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
- Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
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Gorbaty J, Wally MK, Odum S, Yu Z, Hamid N, Hsu JR, Beuhler M, Bosse M, Gibbs M, Griggs C, Jarrett S, Karunakar M, Kempton L, Leas D, Phelps K, Roomian T, Runyon M, Saha A, Sims S, Watling B, Wyatt S, Seymour R. Patients with glenohumeral arthritis are more likely to be prescribed opioids in the emergency department or urgent care setting. J Opioid Manag 2023; 19:495-505. [PMID: 38189191 DOI: 10.5055/jom.0834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
OBJECTIVE The objective is to quantify the rate of opioid and benzodiazepine prescribing for the diagnosis of shoulder osteoarthritis across a large healthcare system and to describe the impact of a clinical decision support intervention on prescribing patterns. DESIGN A prospective observational study. SETTING One large healthcare system. PATIENTS AND PARTICIPANTS Adult patients presenting with shoulder osteoarthritis. INTERVENTIONS A clinical decision support intervention that presents an alert to prescribers when patients meet criteria for increased risk of opioid use disorder. MAIN OUTCOME MEASURE The percentage of patients receiving an opioid or benzodiazepine, the percentage who had at least one risk factor for misuse, and the percent of encounters in which the prescribing decision was influenced by the alert were the main outcome measures. RESULTS A total of 5,380 outpatient encounters with a diagnosis of shoulder osteoarthritis were included. Twenty-nine percent (n = 1,548) of these encounters resulted in an opioid or benzodiazepine prescription. One-third of those who received a prescription had at least one risk factor for prescription misuse. Patients were more likely to receive opioids from the emergency department or urgent care facilities (40 percent of encounters) compared to outpatient facilities (28 percent) (p < .0001). Forty-four percent of the opioid prescriptions were for "potent opioids" (morphine milliequivalent conversion factor > 1). Of the 612 encounters triggering an alert, the prescribing decision was influenced (modified or not prescribed) in 53 encounters (8.7 percent). All but four (0.65 percent) of these encounters resulted in an opioid prescription. CONCLUSION Despite evidence against routine opioid use for osteoarthritis, one-third of patients with a primary diagnosis of glenohumeral osteoarthritis received an opioid prescription. Of those who received a prescription, over one-third had a risk factor for opioid misuse. An electronic clinic decision support tool influenced the prescription in less than 10 percent of encounters.
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Affiliation(s)
- Jacob Gorbaty
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Meghan K Wally
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Susan Odum
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute; OrthoCarolina Research Institute, Charlotte, North Carolina
| | - Ziqing Yu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Nady Hamid
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute; OrthoCarolina, Shoulder and Elbow Center, Charlotte, North Carolina
| | - Joseph R Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Michael Beuhler
- North Carolina Poison Control, Atrium Health, Charlotte, North Carolina
| | - Michael Bosse
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Michael Gibbs
- Department of Emergency Medicine, Atrium Health, Charlotte, North Carolina
| | - Christopher Griggs
- Department of Emergency Medicine, Atrium Health, Charlotte, North Carolina
| | | | - Madhav Karunakar
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Laurence Kempton
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Daniel Leas
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Kevin Phelps
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Tamar Roomian
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Michael Runyon
- Department of Emergency Medicine, Atrium Health, Charlotte, North Carolina
| | - Animita Saha
- Department of Internal Medicine, Atrium Health, Charlotte, North Carolina
| | - Stephen Sims
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | | | | | - Rachel Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
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Mazurenko O, McCord E, McDonnell C, Apathy NC, Sanner L, Adams MCB, Mamlin BW, Vest JR, Hurley RW, Harle CA. Examining primary care provider experiences with using a clinical decision support tool for pain management. JAMIA Open 2023; 6:ooad063. [PMID: 37575955 PMCID: PMC10412405 DOI: 10.1093/jamiaopen/ooad063] [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] [Received: 12/28/2022] [Revised: 06/22/2023] [Accepted: 07/25/2023] [Indexed: 08/15/2023] Open
Abstract
Objective To evaluate primary care provider (PCP) experiences using a clinical decision support (CDS) tool over 16 months following a user-centered design process and implementation. Materials and Methods We conducted a qualitative evaluation of the Chronic Pain OneSheet (OneSheet), a chronic pain CDS tool. OneSheet provides pain- and opioid-related risks, benefits, and treatment information for patients with chronic pain to PCPs. Using the 5 Rights of CDS framework, we conducted and analyzed semi-structured interviews with 19 PCPs across 2 academic health systems. Results PCPs stated that OneSheet mostly contained the right information required to treat patients with chronic pain and was correctly located in the electronic health record. PCPs used OneSheet for distinct subgroups of patients with chronic pain, including patients prescribed opioids, with poorly controlled pain, or new to a provider or clinic. PCPs reported variable workflow integration and selective use of certain OneSheet features driven by their preferences and patient population. PCPs recommended broadening OneSheet access to clinical staff and patients for data entry to address clinician time constraints. Discussion Differences in patient subpopulations and workflow preferences had an outsized effect on CDS tool use even when the CDS contained the right information identified in a user-centered design process. Conclusions To increase adoption and use, CDS design and implementation processes may benefit from increased tailoring that accommodates variation and dynamics among patients, visits, and providers.
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Affiliation(s)
- Olena Mazurenko
- Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana, USA
- Clem McDonald Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Indiana, USA
| | - Emma McCord
- Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana, USA
| | - Cara McDonnell
- Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Nate C Apathy
- Clem McDonald Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Indiana, USA
- MedStar Health Research Institute
| | - Lindsey Sanner
- Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana, USA
| | - Meredith C B Adams
- Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Burke W Mamlin
- Clem McDonald Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Indiana, USA
- School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Joshua R Vest
- Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana, USA
- Clem McDonald Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Indiana, USA
| | - Robert W Hurley
- Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Christopher A Harle
- Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana, USA
- Clem McDonald Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Indiana, USA
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Wally MK, Thompson ME, Odum S, Kazemi DM, Hsu JR, Seymour RB. Opioid Prescribing for Chronic Musculoskeletal Conditions: Trends over Time and Implementation of Safe Opioid-Prescribing Practices. Appl Clin Inform 2023; 14:961-972. [PMID: 38057261 PMCID: PMC10700149 DOI: 10.1055/s-0043-1776879] [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: 05/10/2023] [Accepted: 10/09/2023] [Indexed: 12/08/2023] Open
Abstract
OBJECTIVES This study aimed (1) to determine the impact of a clinical decision support (CDS) tool on rate of opioid prescribing and opioid dose for patients with chronic musculoskeletal conditions and (2) to identify prescriber and facility characteristics associated with adherence to the Centers for Disease Control and Prevention guideline for prescribing opioids for chronic pain in this population.We conducted an interrupted time series analysis to assess trends in percentage of patients from 2016 to 2020, receiving an opioid and the average opioid dose, as well as the change associated with implementation of the CDS toolkit. We conducted a retrospective cohort study to assess the association between prescriber and facility characteristics and safe opioid-prescribing practices. METHODS We assessed the impact of the CDS intervention on percent of patients receiving an opioid and average opioid dose (morphine milligram equivalents). We operationalized safe opioid prescribing as a composite score of several behaviors (i.e., prescribing naloxone, initiating a pain agreement, prescribing <90 MME, avoiding extended-release prescriptions for opioid-naïve patients, and avoiding coprescribing opioids and benzodiazepines) and used a hierarchical linear regression model to assess associations between prescriber and facility characteristics and safe opioid prescribing. RESULTS This CDS intervention had a modest but statistically significant 1.6% reduction on the percent of patients (n = 1,290,746) receiving an opioid (mean: 15% preintervention; 10% postintervention). The average dose of opioid prescriptions did not significantly change. Advanced practice providers and prescribers with higher percentages of patients aged 18 to 64 exhibited safer opioid prescribing, while prescribers with higher percentages of white patients and larger numbers of patients on opioids exhibited less safe opioid prescribing. CONCLUSION A CDS intervention was associated with a small improvement in percent of patients receiving an opioid, but not on average dose. Clinicians are not prescribing opioids for chronic musculoskeletal conditions frequently, when they do, they are generally adhering to guidelines.
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Affiliation(s)
- Meghan K. Wally
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, United States
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina, United States
| | - Michael E. Thompson
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina, United States
| | - Susan Odum
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, United States
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina, United States
| | - Donna M. Kazemi
- School of Nursing, College of Health and Human Services, University of North Carolina at Charlotte, Charlotte, North Carolina, United States
| | - Joseph R. Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, United States
| | - Rachel B. Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, United States
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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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Corriere MA, Dickson AL, Daniel LL, Nepal P, Hall K, Plummer WD, Dupont WD, Murray KT, Stein CM, Ray WA, Chung CP. Duloxetine, Gabapentin, and the Risk for Acute Myocardial Infarction, Stroke, and Out-of-Hospital Death in Medicare Beneficiaries With Non-Cancer Pain. Clin J Pain 2023; 39:203-208. [PMID: 37094085 PMCID: PMC10127144 DOI: 10.1097/ajp.0000000000001105] [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: 08/15/2022] [Accepted: 02/11/2023] [Indexed: 04/26/2023]
Abstract
OBJECTIVE Duloxetine is a serotonin-norepinephrine reuptake inhibitor prescribed for musculoskeletal and other forms of chronic pain. Its dual pharmacologic properties have the potential to either raise or lower cardiovascular risk: adrenergic activity may increase the risk for acute myocardial infarction (AMI) and stroke, but antiplatelet activity may decrease risk. Gabapentin is another nonopioid medication used to treat pain, which is not thought to have adrenergic/antiplatelet effects. With the current emphasis on the use of nonopioid medications to treat patients with chronic pain, assessing cardiovascular risks associated with these medications among high-risk patients is important. MATERIALS AND METHODS We conducted a retrospective cohort study among a 20% sample of Medicare enrollees, aged 65 to 89, with chronic pain who were new users between 2015 and 2018 of either duloxetine (n = 34,009) or gabapentin (n = 233,060). We excluded individuals with cancer or other life-threatening conditions at study drug initiation. The primary outcome was a composite of AMI, stroke, and out-of-hospital mortality. We adjusted for comorbidity differences with time-dependent inverse probability of treatment weighting. RESULTS During 115,668 person-years of follow-up, 2361 patients had the composite primary outcome; the rate among new users of duloxetine was 16.7/1000 person-years compared with new users of gabapentin (21.1/1000 person-years), adjusted hazard ratio = 0.98 (95% CI: 0.83, 1.16). Results were similar for the individual components of the composite outcome as well as in analyses stratified by demographic and clinical characteristics. DISCUSSION In summary, cohort Medicare patients with non-cancer pain beginning treatment with duloxetine had rates of AMI, stroke, and out-of-hospital mortality comparable to those who initiated gabapentin.
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Affiliation(s)
| | | | - Laura L Daniel
- Departments of Medicine
- Department of Medicine, University of Miami, Miami, FL
| | - Puran Nepal
- Departments of Medicine
- Department of Medicine, University of Miami, Miami, FL
| | | | | | | | | | | | - Wayne A Ray
- Health Policy, Vanderbilt University Medical Center, Nashville, TN
| | - Cecilia P Chung
- Departments of Medicine
- Department of Medicine, University of Miami, Miami, FL
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Overstreet DS, Pester BD, Wilson JM, Flowers KM, Kline NK, Meints SM. The Experience of BIPOC Living with Chronic Pain in the USA: Biopsychosocial Factors that Underlie Racial Disparities in Pain Outcomes, Comorbidities, Inequities, and Barriers to Treatment. Curr Pain Headache Rep 2023; 27:1-10. [PMID: 36527589 PMCID: PMC10683048 DOI: 10.1007/s11916-022-01098-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW This review synthesizes recent findings related to the biopsychosocial processes that underlie racial disparities in chronic pain, while highlighting opportunities for interventions to reduce disparities in pain treatment among BIPOC. RECENT FINDINGS Chronic pain is a prevalent and costly public health concern that disproportionately burdens Black, Indigenous, and people of color (BIPOC). This unequal burden arises from an interplay among biological, psychological, and social factors. Social determinants of health (e.g., income, education level, and lack of access or inability to utilize healthcare services) are known to affect overall health, including chronic pain, and disproportionately affect BIPOC communities. This burden is exacerbated by exposure to psychosocial stressors (i.e., perceived injustice, discrimination, and race-based traumatic stress) and can affect biological systems that modulate pain (i.e., inflammation and pain epigenetics). Further, there are racial/ethnic disparities in pain treatment, perpetuating the cycle of undermanaged chronic pain among BIPOC.
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Affiliation(s)
- Demario S Overstreet
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Woman's Hospital, 75 Francis Street, Boston, MA, 02411, USA
- Harvard Medical School, Boston, MA, USA
| | - Bethany D Pester
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Woman's Hospital, 75 Francis Street, Boston, MA, 02411, USA
- Harvard Medical School, Boston, MA, USA
| | - Jenna M Wilson
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Woman's Hospital, 75 Francis Street, Boston, MA, 02411, USA
- Harvard Medical School, Boston, MA, USA
| | - K Mikayla Flowers
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Woman's Hospital, 75 Francis Street, Boston, MA, 02411, USA
- Harvard Medical School, Boston, MA, USA
| | - Nora K Kline
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Woman's Hospital, 75 Francis Street, Boston, MA, 02411, USA
- Department of Psychology, Clark University, Worcester, MA, USA
| | - Samantha M Meints
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Woman's Hospital, 75 Francis Street, Boston, MA, 02411, USA.
- Harvard Medical School, Boston, MA, USA.
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Atkins N, Mukhida K. The relationship between patients’ income and education and their access to pharmacological chronic pain management: A scoping review. Can J Pain 2022; 6:142-170. [PMID: 36092247 PMCID: PMC9450907 DOI: 10.1080/24740527.2022.2104699] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Nicole Atkins
- Department of Anesthesiology, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Karim Mukhida
- Department of Anesthesiology, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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11
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Prescription quantity and duration predict progression from acute to chronic opioid use in opioid-naïve Medicaid patients. PLOS DIGITAL HEALTH 2022; 1:e0000075. [PMID: 36203857 PMCID: PMC9534483 DOI: 10.1371/journal.pdig.0000075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Opiates used for acute pain are an established risk factor for chronic opioid use (COU). Patient characteristics contribute to progression from acute opioid use to COU, but most are not clinically modifiable. To develop and validate machine-learning algorithms that use claims data to predict progression from acute to COU in the Medicaid population, Adult opioid naïve Medicaid patients from 6 anonymized states who received an opioid prescription between 2015 and 2019 were included. Five machine learning (ML) Models were developed, and model performance assessed by area under the receiver operating characteristic curve (auROC), precision and recall. In the study, 29.9% (53820/180000) of patients transitioned from acute opioid use to COU. Initial opioid prescriptions in COU patients had increased morphine milligram equivalents (MME) (33.2 vs. 23.2), tablets per prescription (45.6 vs. 36.54), longer prescriptions (26.63 vs 24.69 days), and higher proportions of tramadol (16.06% vs. 13.44%) and long acting oxycodone (0.24% vs 0.04%) compared to non- COU patients. The top performing model was XGBoost that achieved average precision of 0.87 and auROC of 0.63 in testing and 0.55 and 0.69 in validation, respectively. Top-ranking prescription-related features in the model included quantity of tablets per prescription, prescription length, and emergency department claims. In this study, the Medicaid population, opioid prescriptions with increased tablet quantity and days supply predict increased risk of progression from acute to COU in opioid-naïve patients. Future research should evaluate the effects of modifying these risk factors on COU incidence.
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12
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Pierce RP, Eskridge B, Ross B, Wright M, Selva T. Impact of a Vendor-Developed Opioid Clinical Decision Support Intervention on Adherence to Prescribing Guidelines, Opioid Prescribing, and Rates of Opioid-Related Encounters. Appl Clin Inform 2022; 13:419-430. [PMID: 35445387 PMCID: PMC9021002 DOI: 10.1055/s-0042-1745830] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Provider prescribing practices contribute to an excess of opioid-related deaths in the United States. Clinical guidelines exist to assist providers with improving prescribing practices and promoting patient safety. Clinical decision support systems (CDSS) may promote adherence to these guidelines and improve prescribing practices. The aim of this project was to improve opioid guideline adherence, prescribing practices, and rates of opioid-related encounters through the implementation of an opioid CDSS. METHODS A vendor-developed, provider-targeted CDSS package was implemented in a multi-location academic health center. An interrupted time-series analysis was performed, evaluating 30 weeks pre- and post-implementation time periods. Outcomes were derived from vendor-supplied key performance indicators and directly from the electronic health record (EHR) database. Opioid-prescribing outcomes included count of opioid prescriptions, morphine milligram equivalents per prescription, counts of opioids with concurrent benzodiazepines, and counts of short-acting opioids in opioid-naïve patients. Encounter outcomes included rates of encounters for opioid abuse and dependence and rates of encounters for opioid poisoning and overdose. Guideline adherence outcomes included rates of provision of naloxone and documentation of opioid treatment agreements. RESULTS The opioid CDSS generated an average of 1,637 alerts per week. Rates of provision of naloxone and opioid treatment agreements improved after CDSS implementation. Vendor-supplied prescribing outcomes were consistent with prescribing outcomes derived directly from the EHR, but all prescribing and encounter outcomes were unchanged. CONCLUSION A vendor-developed, provider-targeted opioid CDSS did not improve opioid-prescribing practices or rates of opioid-related encounters. The CDSS improved some measures of provider adherence to opioid-prescribing guidelines. Further work is needed to determine the optimal configuration of opioid CDSS so that opioid-prescribing patterns are appropriately modified and encounter outcomes are improved.
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Affiliation(s)
- Robert P Pierce
- Department of Family and Community Medicine, University of Missouri School of Medicine, Columbia, Missouri, United States
| | - Bernie Eskridge
- Department of Child Health, University of Missouri School of Medicine, Columbia, Missouri, United States
| | - Brandi Ross
- Tiger Institute, Cerner Corporation, Columbia, Missouri, United States
| | - Matthew Wright
- University of Missouri Health Care, Columbia, Missouri, United States
| | - Thomas Selva
- Department of Child Health, University of Missouri School of Medicine, Columbia, Missouri, United States
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13
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Situational Awareness of Opioid Consumption: The Missing Link to Reducing Dependence After Surgery? Anesth Analg 2022; 135:653-658. [PMID: 35110517 DOI: 10.1213/ane.0000000000005923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
A tool for collecting and analyzing morphine milligram equivalents (MMEs) can be used to overcome barriers to situational awareness around opioid utilization in the setting of multimodal pain management. Our software application (App) has facilitated data collection, analysis, and benchmarking in a manner that is not logistically feasible using manual methods. Real-time postoperative tracking of MME over the course of an episode of care can be prohibitively labor-intensive, and teams must have practical strategies to overcome this obstacle. In view of the link between the magnitude of opioid prescriptions at discharge and persistent opioid use after cardiac surgery, we believe that improving situational awareness among the patient care team is a vital first step in reducing opioid dependence after cardiac surgery.
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14
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Haq N, McMahan VM, Torres A, Santos GM, Knight K, Kushel M, Coffin PO. Race, pain, and opioids among patients with chronic pain in a safety-net health system. Drug Alcohol Depend 2021; 222:108671. [PMID: 33810908 PMCID: PMC8687128 DOI: 10.1016/j.drugalcdep.2021.108671] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/29/2020] [Accepted: 01/03/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Recent changes in opioid prescribing practices in the US may exacerbate disparities in opioid access among Black compared to White patients. METHODS To evaluate racial disparities in opioid prescribing and stewardship, we used baseline data collected from 2017 to 2019 for a longitudinal cohort of patients with chronic non-cancer pain and a history of illicit substance use. Sociodemographic characteristics, pain, psychological distress, substance use, and opioid prescription practices were compared between Black and White participants. We conducted multivariable logistic regression with race as the outcome. We also compared yellow flag events (opioid-related emergency department visits, illicit substances on urine drug screens, provider-documentation of concerning behaviors) by race. RESULTS Over half of participants analyzed were Black (57%) and the remainder White (43%). Participants with worse average pain in the past three months (adjusted odds ratio [AOR]:1.29, 95%CI:1.08-1.55, p = 0.006) had higher odds of being Black. Past-year injection drug use (AOR:0.39, 95%CI:0.16-0.94, p = 0.04) and a higher past-year maximum opioid dose (AOR per 10 morphine milligram equivalents (MME):0.99, 95%CI:0.98-1.00, p = 0.006) were associated with lower odds of being Black. We found no differences by race in the use of opioid stewardship measures or discontinuation of opioids based on yellow flag events. CONCLUSION Lower past-year maximum MME dose, despite higher average pain and less injection drug use, may represent bias away from prescribing opioids for chronic pain among Black patients. This could be due to unmeasured implicit provider bias or patient-level factors (e.g., utilizing non-opioid pain coping strategies or being less likely to request additional opioids).
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Affiliation(s)
- Nimah Haq
- San Francisco Department of Public Health, 25 Van Ness Avenue, San Francisco, CA, USA.
| | - Vanessa M McMahan
- San Francisco Department of Public Health, 25 Van Ness Avenue, San Francisco, CA, USA
| | - Andrea Torres
- San Francisco Department of Public Health, 25 Van Ness Avenue, San Francisco, CA, USA
| | - Glenn-Milo Santos
- San Francisco Department of Public Health, 25 Van Ness Avenue, San Francisco, CA, USA; University of California, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Kelly Knight
- University of California, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Margot Kushel
- University of California, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Phillip O Coffin
- San Francisco Department of Public Health, 25 Van Ness Avenue, San Francisco, CA, USA; University of California, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
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15
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Goudman L, De Smedt A, Forget P, Eldabe S, Moens M. High-Dose Spinal Cord Stimulation Reduces Long-Term Pain Medication Use in Patients With Failed Back Surgery Syndrome Who Obtained at Least 50% Pain Intensity and Medication Reduction During a Trial Period: A Registry-Based Cohort Study. Neuromodulation 2021; 24:520-531. [PMID: 33474789 DOI: 10.1111/ner.13363] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 12/17/2020] [Accepted: 12/21/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES High-dose spinal cord stimulation (HD-SCS) revealed positive results for obtaining pain relief in patients with failed back surgery syndrome (FBSS). However, it is less clear whether HD-SCS also is able to reduce pain medication use. The aim of this registry-based cohort study is to explore the impact of HD-SCS on pain medication use in FBSS patients. MATERIALS AND METHODS Data from the Discover registry was used in which the effectiveness of HD-SCS was explored in neurostimulation-naïve FBSS patients as well as in rescue patients. All neurostimulation-naïve FBSS patients positively responded to a four-week SCS trial period in which at least 50% pain relief and 50% medication reduction were obtained. Medication use was measured with the Medication Quantification Scale III (MQS) in 259 patients at baseline and at 1, 3, and 12 months of HD-SCS. Additionally, defined daily doses (DDD) and morphine milligram equivalents (MME) were calculated as well. RESULTS One hundred thirty patients reached the visit at 12 months. In neurostimulation-naïve patients, a statistically significant decrease in MQS (χ2 = 62.92, p < 0.001), DDD (χ2 = 11.47, p = 0.009), and MME (χ2 = 21.55, p < 0.001) was found. In rescue patients, no statistically significant improvements were found. In both patient groups, statistically significant reductions in the proportion of patients on high-risk MME doses ≥90 were found over time. At the intraindividual level, positive correlations were found between MSQ scores and pain intensity for back (r = 0.56, r = 0.31, p < 0.001) and leg pain (r = 0.61, r = 0.22, p < 0.001) in neurostimulation-naïve and rescue patients, respectively. CONCLUSIONS Registry data on HD-SCS in FBSS patients revealed a statistically significant and sustained decrease in pain medication use, not only on opioids, but also on anti-neuropathic agents in neurostimulation-naïve patients, who positively responded to an SCS trial period with at least 50% pain relief and 50% pain medication decrease, but not in rescue patients.
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Affiliation(s)
- Lisa Goudman
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Jette, Belgium.,Center for Neurosciences (C4N), Vrije Universiteit Brussel, Jette, Belgium.,STIMULUS consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Universitair Ziekenhuis Brussel, Brussels, Belgium.,Pain in Motion International Research Group, Jette, Belgium
| | - Ann De Smedt
- Center for Neurosciences (C4N), Vrije Universiteit Brussel, Jette, Belgium.,STIMULUS consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Universitair Ziekenhuis Brussel, Brussels, Belgium.,Department of Physical Medicine and Rehabilitation, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Patrice Forget
- Institute of Applied Health Sciences, NHS Grampian, University of Aberdeen, Aberdeen, UK
| | - Sam Eldabe
- Pain Clinic, The James Cook University Hospital, Middlesbrough, UK
| | - Maarten Moens
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Jette, Belgium.,Center for Neurosciences (C4N), Vrije Universiteit Brussel, Jette, Belgium.,STIMULUS consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Universitair Ziekenhuis Brussel, Brussels, Belgium.,Department of Radiology, Universitair Ziekenhuis Brussel, Jette, Belgium
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16
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Price-Haywood EG, Burton J, Harden-Barrios J, Bazzano A, Lefante J, Shi L, Jamison RN. Depression, anxiety, pain and chronic opioid management in primary care: Type II effectiveness-implementation hybrid stepped wedge cluster randomized trial. Contemp Clin Trials 2020; 101:106250. [PMID: 33326877 DOI: 10.1016/j.cct.2020.106250] [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: 09/13/2020] [Revised: 11/14/2020] [Accepted: 12/08/2020] [Indexed: 11/17/2022]
Abstract
Even though current prescribing trends reveal that high-dose opioid prescribing and opioid prescribing in general has decreased, sustained efforts are needed to help providers adopt and maintain safe prescribing behaviors. The purpose of this four-year type 2 effectiveness-implementation hybrid stepped wedge cluster randomized trial is to: (1) compare the clinical and cost effectiveness of electronic medical record-based clinical decision support [EMR-CDS] versus additional integrated, collaborative behavioral health [EMR-CDS + BHI-CCM] for opioid management of patients with co-morbid chronic non-cancer pain with depression or anxiety; and (2) examine facilitators and barriers to implementing these interventions within 35 primary care clinics in a integrated delivery health system. The EMR-CDS alerts providers to employ opioid risk mitigation and safe prescribing practices at the point of care. The BHI-CCM consists of primary care embedded community health workers for case management; licensed clinical social workers for cognitive behavioral therapy, and a clinical pharmacist for medication management who provide care management via telemedicine (virtual video or audio only visits) under the guidance of a consulting psychiatrist. The primary outcome is reduction in the percentage of patients with average daily opioid dose ≥50 mg morphine equivalent. Secondary outcomes include changes in service utilization, patient reported outcomes and processes of care. The investigators anticipate that study results will elucidate the role of technology versus care team optimization in changing opioid prescribing behaviors. The investigators further anticipate that integrated mental/behavioral health care will increase value-based care and the efficiency with which guideline concordant care is delivered.
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Affiliation(s)
- Eboni G Price-Haywood
- Ochsner Center for Outcomes and Health Services Research, 1514 Jefferson Highway, New Orleans, LA 70121, USA; Ochsner Clinical School, University of Queensland, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
| | - Jeffrey Burton
- Ochsner Center for Outcomes and Health Services Research, 1514 Jefferson Highway, New Orleans, LA 70121, USA
| | - Jewel Harden-Barrios
- Ochsner Center for Outcomes and Health Services Research, 1514 Jefferson Highway, New Orleans, LA 70121, USA
| | - Alessandra Bazzano
- Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, New Orleans, LA 70112, USA
| | - John Lefante
- Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, New Orleans, LA 70112, USA
| | - Lizheng Shi
- Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, New Orleans, LA 70112, USA
| | - Robert N Jamison
- Brigham and Women's Hospital, Pain Management Center, 850 Boylston Street, Chestnut Hill, MA 02467, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
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