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Hansen JL, Heilig M, Kalso E, Stubhaug A, Knutsson D, Sandin P, Dorling P, Beck C, Grip ET, Blakeman KH, Arendt-Nielsen L. Problematic opioid use among osteoarthritis patients with chronic post-operative pain after joint replacement: analyses from the BISCUITS study. Scand J Pain 2023; 23:353-363. [PMID: 36799711 DOI: 10.1515/sjpain-2022-0137] [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: 09/19/2022] [Accepted: 01/31/2023] [Indexed: 02/18/2023]
Abstract
OBJECTIVES Opioids are commonly used to manage pain, despite an increased risk of adverse events and complications when used against recommendations. This register study uses data of osteoarthritis (OA) patients with joint replacement surgery to identify and characterize problematic opioid use (POU) prescription patterns. METHODS The study population included adult patients diagnosed with OA in specialty care undergoing joint replacement surgery in Denmark, Finland, Norway, and Sweden during 1 January 2011 to 31 December 2014. Those with cancer or OA within three years before the first eligible OA diagnosis were excluded. Patients were allocated into six POU cohorts based on dose escalation, frequency, and dosing of prescription opioids post-surgery (definitions were based on guidelines, previous literature, and clinical experience), and matched on age and sex to patients with opioid use, but not in any of the six cohorts. Data on demographics, non-OA pain diagnoses, cardiovascular diseases, psychiatric disorders, and clinical characteristics were used to study patient characteristics and predictors of POU. RESULTS 13.7% of patients with OA and a hip/knee joint replacement were classified as problematic users and they had more comorbidities and higher pre-surgery doses of opioids than matches. Patients dispensing high doses of opioids pre-surgery dispensed increased doses post-surgery, a pattern not seen among patients prescribed lower doses pre-surgery. Being dispensed 1-4,500 oral morphine equivalents in the year pre-surgery or having a non-OA pain diagnosis was associated with post-surgery POU (OR: 1.44-1.50, and 1.11-1.20, respectively). CONCLUSIONS Based on the discovered POU predictors, the study suggests that prescribers should carefully assess pain management strategies for patients with a history of comorbidities and pre-operative, long-term opioid use. Healthcare units should adopt risk assessment tools and ensure that these patients are followed up closely. The data also demonstrate potential areas for further exploration in improving patient outcomes and trajectories.
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Affiliation(s)
- Johan Liseth Hansen
- Quantify Research, Stockholm, Sweden
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Markus Heilig
- Center for Social and Affective Neuroscience (CSAN), Department of Biomedical and Clinical Sciences (BKV), Linköping University, Linköping, Sweden
| | - Eija Kalso
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Audun Stubhaug
- Department of Pain Management and Research, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | | | | | | | | | - Emilie Toresson Grip
- Quantify Research, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | | | - Lars Arendt-Nielsen
- Center for Neuroplasticity and Pain (CNAP), SMI, Department of Health Science and Technology, School of Medicine, Aalborg University, Aalborg, Denmark
- Department of Medical Gastroenterology (Mech-Sense), Aalborg University Hospital, Aalborg, Denmark
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2
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Wei YJJ, Chen C, Lewis MO, Schmidt SO, Winterstein AG. Trajectories of prescription opioid dose and risk of opioid-related adverse events among older Medicare beneficiaries in the United States: A nested case-control study. PLoS Med 2022; 19:e1003947. [PMID: 35290389 PMCID: PMC8923459 DOI: 10.1371/journal.pmed.1003947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 02/14/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Despite the rising number of older adults with medical encounters for opioid misuse, dependence, and poisoning, little is known about patterns of prescription opioid dose and their association with risk for opioid-related adverse events (ORAEs) in older patients. The study aims to compare trajectories of prescribed opioid doses in 6 months preceding an incident ORAE for cases and a matched control group of older patients with chronic noncancer pain (CNCP). METHODS AND FINDINGS We conducted a nested case-control study within a cohort of older (≥65 years) patients diagnosed with CNCP who were new users of prescription opioids, assembled using a 5% national random sample of Medicare beneficiaries from 2011 to 2018. From the cohort with a mean follow-up of 2.3 years, we identified 3,103 incident ORAE cases with ≥1 opioid prescription in 6 months preceding the event, and 3,103 controls matched on sex, age, and time since opioid initiation. Key exposure was trajectories of prescribed opioid morphine milligram equivalent (MME) daily dosage over 6 months before the incident ORAE or matched controls. Among the cases and controls, 2,192 (70.6%) were women, and the mean (SD) age was 77.1 (7.1) years. Four prescribed opioid trajectories before the incident ORAE diagnosis or matched date emerged: gradual dose discontinuation (from ≤3 to 0 daily MME, 1,456 [23.5%]), gradual dose increase (from 0 to >3 daily MME, 1,878 [30.3%]), consistent low dose (between 3 and 5 daily MME, 1,510 [24.3%]), and consistent moderate dose (>20 daily MME, 1,362 [22.0%]). Few older patients (<5%) were prescribed a mean daily dose of ≥90 daily MME during 6 months before diagnosis or matched date. Patients with gradual dose discontinuation versus those with a consistent low dose, moderate dose, and increase dose were more likely to be younger (65 to 74 years), Midwest US residents, and receiving no low-income subsidy. Compared to patients with gradual dose discontinuation, those with gradual dose increase (adjusted odds ratio [aOR] = 3.4; 95% confidence interval (CI) 2.8 to 4.0; P < 0.001), consistent low dose (aOR = 3.8; 95% CI 3.2 to 4.6; P < 0.001), and consistent moderate dose (aOR = 8.5; 95% CI 6.8 to 10.7; P < 0.001) had a higher risk of ORAE, after adjustment for covariates. Our main findings remained robust in the sensitivity analysis using a cohort study with inverse probability of treatment weighting analyses. Major limitations include the limited generalizability of the study findings and lack of information on illicit opioid use, which prevents understanding the clinical dose threshold level that increases the risk of ORAE in older adults. CONCLUSIONS In this sample of older patients who are Medicare beneficiaries, 4 prescription opioid dose trajectories were identified, with most prescribed doses below 90 daily MME within 6 months before ORAE or matched date. An increased risk for ORAE was observed among older patients with a gradual increase in dose or among those with a consistent low-to-moderate dose of prescribed opioids when compared to patients with opioid dose discontinuation. Whether older patients are susceptible to low opioid doses warrants further investigations.
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Affiliation(s)
- Yu-Jung Jenny Wei
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida, United States of America
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida, United States of America
- * E-mail:
| | - Cheng Chen
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida, United States of America
| | - Motomori O. Lewis
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida, United States of America
| | - Siegfried O. Schmidt
- Department of Community Health and Family Medicine, University of Florida College of Medicine, Gainesville, Florida, United States of America
| | - Almut G. Winterstein
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida, United States of America
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida, United States of America
- Department of Epidemiology, University of Florida Colleges of Medicine and Public Health and Health Professions, Gainesville, Florida, United States of America
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3
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Vanoli J, Nava CR, Airoldi C, Ucciero A, Salvi V, Barone-Adesi F. Use of State Sequence Analysis in Pharmacoepidemiology: A Tutorial. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182413398. [PMID: 34949007 PMCID: PMC8705850 DOI: 10.3390/ijerph182413398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 12/14/2021] [Accepted: 12/16/2021] [Indexed: 11/22/2022]
Abstract
While state sequence analysis (SSA) has been long used in social sciences, its use in pharmacoepidemiology is still in its infancy. Indeed, this technique is relatively easy to use, and its intrinsic visual nature may help investigators to untangle the latent information within prescription data, facilitating the individuation of specific patterns and possible inappropriate use of medications. In this paper, we provide an educational primer of the most important learning concepts and methods of SSA, including measurement of dissimilarities between sequences, the application of clustering methods to identify sequence patterns, the use of complexity measures for sequence patterns, the graphical visualization of sequences, and the use of SSA in predictive models. As a worked example, we present an application of SSA to opioid prescription patterns in patients with non-cancer pain, using real-world data from Italy. We show how SSA allows the identification of patterns in prescriptions in these data that might not be evident using standard statistical approaches and how these patterns are associated with future discontinuation of opioid therapy.
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Affiliation(s)
- Jacopo Vanoli
- London School of Hygiene and Tropical Medicine (LSHTM), London WC1E 7HT, UK;
- School of Tropical Medicine and Global Health (TMGH), Nagasaki University, Nagasaki 852-8521, Japan
| | - Consuelo Rubina Nava
- Department of Economics and Statistics “Cognetti de Martiis”, University of Turin, 10124 Turin, Italy
- Correspondence:
| | - Chiara Airoldi
- Department of Translational Medicine, University of Eastern Piedmont, 28100 Novara, Italy; (C.A.); (A.U.)
| | - Andrealuna Ucciero
- Department of Translational Medicine, University of Eastern Piedmont, 28100 Novara, Italy; (C.A.); (A.U.)
| | - Virginio Salvi
- Department of Neuroscience, ASST Fatebenefratelli Sacco, 20157 Milan, Italy; (V.S.); (F.B.-A.)
| | - Francesco Barone-Adesi
- Department of Neuroscience, ASST Fatebenefratelli Sacco, 20157 Milan, Italy; (V.S.); (F.B.-A.)
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Fredheim OM, Skurtveit S, Sjøgren P, Aljabri B, Hjellvik V. Prescriptions of analgesics during chronic cancer disease trajectories: A complete national cohort study. Pharmacoepidemiol Drug Saf 2021; 30:1504-1513. [PMID: 34251721 DOI: 10.1002/pds.5329] [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: 01/11/2021] [Revised: 05/29/2021] [Accepted: 07/09/2021] [Indexed: 11/12/2022]
Abstract
PURPOSE Pain management principles vary considerably between chronic noncancer, acute and cancer pain. Cancer patients responding to oncological treatment may live with low tumor burden for years. Opioid treatment should reflect that the ratio between benefits and risks in these patients is different from patients with a rapidly progressive disease. Our study investigated the prescription patterns of analgesics in patients who died 6 to 9 years after cancer diagnosis. PATIENTS AND METHODS A pharmaco-epidemiological study based on the Norwegian Prescription Database and Cancer Registry of Norway. The 1-year periodic prevalence of receiving different analgesics and of persistent opioid use were analyzed. Persistent opioid use was defined as >365 Defined Daily Doses or >9000 mg Oral Morphine Equivalents during 365 days with prescriptions in all quarters of the 365 days period. Data were reported for the first 7 years for patients who lived 8-9 years after cancer diagnosis (N = 1502), while for patients who lived 6-7 years (N = 3817) data was reported for the first 5 years after diagnosis. RESULTS Compared to age- and gender adjusted general population, the 1-year periodic prevalence of opioid prescription was doubled the first year after diagnosis and remained raised with approximately 50%. The prevalence of persistent opioid use was threefold of the general population. Approximately 55% of patients with persistent opioid use 4 years after a cancer diagnosis were co-medicated with high doses of benzodiazepines and/or benzodiazepine-related hypnotics. CONCLUSION The findings of increased opioid use raise concerns regarding whether the benefits outweigh risks and side effects in this population.
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Affiliation(s)
- Olav Magnus Fredheim
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.,Norwegian Advisory Unit on Complex Symptom Disorders, St. Olav University Hospital, Trondheim, Norway.,Department of Palliative Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Svetlana Skurtveit
- Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway.,Department of Mental Disorders, Norwegian Institute of Public Health, Oslo, Norway
| | - Per Sjøgren
- Section of Palliative Medicine, Department of Oncology, Rigshospitalet-Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Belal Aljabri
- Department of Palliative Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Vidar Hjellvik
- Department of Chronic Diseases and Ageing, Norwegian Institute of Public Health, Oslo, Norway
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5
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Shen Y, Bhagwandass H, Branchcomb T, Galvez SA, Grande I, Lessing J, Mollanazar M, Ourhaan N, Oueini R, Sasser M, Valdes IL, Jadubans A, Hollmann J, Maguire M, Usmani S, Vouri SM, Hincapie-Castillo JM, Adkins LE, Goodin AJ. Chronic Opioid Therapy: A Scoping Literature Review on Evolving Clinical and Scientific Definitions. THE JOURNAL OF PAIN 2020; 22:246-262. [PMID: 33031943 DOI: 10.1016/j.jpain.2020.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/21/2020] [Accepted: 09/22/2020] [Indexed: 01/24/2023]
Abstract
The management of chronic noncancer pain (CNCP) with chronic opioid therapy (COT) is controversial. There is a lack of consensus on how COT is defined resulting in unclear clinical guidance. This scoping review identifies and evaluates evolving COT definitions throughout the published clinical and scientific literature. Databases searched included PubMed, Embase, and Web of Science. A total of 227 studies were identified from 8,866 studies published between January 2000 and July 2019. COT definitions were classified by pain population of application and specific dosage/duration definition parameters, with results reported according to PRISMA-ScR. Approximately half of studies defined COT as "days' supply duration >90 days" and 9.3% defined as ">120 days' supply," with other days' supply cut-off points (>30, >60, or >70) each appearing in <5% of total studies. COT was defined by number of prescriptions in 63 studies, with 16.3% and 11.0% using number of initiations or refills, respectively. Few studies explicitly distinguished acute treatment and COT. Episode duration/dosage criteria was used in 90 studies, with 7.5% by Morphine Milligram Equivalents + days' supply and 32.2% by other "episode" combination definitions. COT definitions were applied in musculoskeletal CNCP (60.8%) most often, and typically in adults aged 18 to 64 (69.6%). The usage of ">90 days' supply" COT definitions increased from 3.2 publications/year before 2016 to 20.7 publications/year after 2016. An increasing proportion of studies define COT as ">90 days' supply." The most recent literature trends toward shorter duration criteria, suggesting that contemporary COT definitions are increasingly conservative. PERSPECTIVE: This study summarized the most common, current definition criteria for chronic opioid therapy (COT) and recommends adoption of consistent definition criteria to be utilized in practice and research. The most recent literature trends toward shorter duration criteria overall, suggesting that COT definition criteria are increasingly stringent.
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Affiliation(s)
- Yun Shen
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida
| | - Hemita Bhagwandass
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Tychell Branchcomb
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Sophia A Galvez
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Ivanna Grande
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Julia Lessing
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Mikela Mollanazar
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Natalie Ourhaan
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Razanne Oueini
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Michael Sasser
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Ivelisse L Valdes
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Ashmita Jadubans
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Josef Hollmann
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Michael Maguire
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Silken Usmani
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Scott M Vouri
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida
| | - Juan M Hincapie-Castillo
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida; Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, Florida
| | - Lauren E Adkins
- University of Florida Health Science Center Libraries, Gainesville, Florida
| | - Amie J Goodin
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida.
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Garland EL, Hudak J, Hanley AW, Nakamura Y. Mindfulness-oriented recovery enhancement reduces opioid dose in primary care by strengthening autonomic regulation during meditation. AMERICAN PSYCHOLOGIST 2020; 75:840-852. [PMID: 32915027 PMCID: PMC7490853 DOI: 10.1037/amp0000638] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The current opioid crisis was fueled by escalation of opioid dosing among patients with chronic pain. Yet, there are few evidence-based psychological interventions for opioid dose reduction among chronic pain patients treated with long-term opioid analgesics. Mindfulness-Oriented Recovery Enhancement (MORE), which was designed to target mechanisms underpinning chronic pain and opioid misuse, has shown promising results in 2 randomized clinical trials (RCTs) and could facilitate opioid sparing and tapering by bolstering self-regulation. Here we tested this hypothesis with secondary analyses of data from a Stage 2 RCT. Chronic pain patients (N = 95) on long-term opioid therapy were randomized to 8 weeks of MORE or a support group (SG) control delivered in primary care. Opioid dose was assessed with the Timeline Followback through 3-month follow-up. Heart rate variability (HRV) during mindfulness meditation was quantified as an indicator of self-regulatory capacity. Participants in MORE evidenced a greater decrease in opioid dosing (a 32% decrease) by follow-up than did the SG, F(2, 129.77) = 5.35, p = .006, d = 1.07. MORE was associated with a significantly greater increase in HRV during meditation than was the SG. Meditation-induced change in HRV partially mediated the effect of MORE on opioid dose reduction (p = .034). MORE may boost self-regulatory strength via mindfulness and thereby facilitate self-control over opioid use, leading to opioid dose reduction in people with chronic pain. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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Affiliation(s)
- Eric L. Garland
- Center on Mindfulness and Integrative Health Intervention Development, University of Utah
- College of Social Work, University of Utah
| | - Justin Hudak
- Center on Mindfulness and Integrative Health Intervention Development, University of Utah
- College of Social Work, University of Utah
| | - Adam W. Hanley
- Center on Mindfulness and Integrative Health Intervention Development, University of Utah
- College of Social Work, University of Utah
| | - Yoshio Nakamura
- Center on Mindfulness and Integrative Health Intervention Development, University of Utah
- Pain Research Center, Division of Pain Medicine, Dept. of Anesthesiology, University of Utah School of Medicine
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7
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Sujan AC, Quinn PD, Rickert ME, Wiggs KK, Lichtenstein P, Larsson H, Almqvist C, Öberg AS, D’Onofrio BM. Maternal prescribed opioid analgesic use during pregnancy and associations with adverse birth outcomes: A population-based study. PLoS Med 2019; 16:e1002980. [PMID: 31790390 PMCID: PMC6886755 DOI: 10.1371/journal.pmed.1002980] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 11/04/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Published research on prescribed opioid analgesic (POA) use during pregnancy and birth outcomes is limited in scope and has not adequately adjusted for potential confounding factors. To help address these gaps, we estimated associations between maternal POAs during pregnancy and two adverse birth outcomes using a large population-based dataset, multiple definitions of POA exposure, and several methods to evaluate the influence of both measured and unmeasured confounding factors. METHODS AND FINDINGS We obtained data by linking information from several Swedish registers and conducted a retrospective cohort study on a population-based sample of 620,458 Swedish births occurring between 2007 and 2013 (48.6% female; 44.4% firstborn). We evaluated associations between prenatal POA exposure and risk for preterm birth (PTB; <37 gestational weeks) and small for gestational age (SGA; birth weight 2 standard deviations below the expected weight for gestational age or lower). We evaluated the influence of confounding by adjusting for a wide range of measured covariates while comparing exposed and unexposed infants. Additionally, we adjusted for unmeasured confounding factors by using several advanced epidemiological designs. Infants exposed to POAs anytime during pregnancy were at increased risk for PTB compared with unexposed infants (6.4% exposed versus 4.4% unexposed; adjusted odds ratio [OR] = 1.38, 95% confidence interval [CI] 1.31-1.45, p < 0.001). This association was attenuated when we compared POA-exposed infants with acetaminophen-exposed infants (OR = 1.18, 95% CI 1.07-1.30, p < 0.001), infants born to women who used POAs before pregnancy only (OR = 1.05, 95% CI 0.96-1.14, p = 0.27), and unexposed siblings (OR = 0.99, 95% CI 0.85-1.14, p = 0.92). We also evaluated associations with short-term versus persistent POA use during pregnancy and observed a similar pattern of results, although the magnitudes of associations with persistent exposure were larger than associations with any use or short-term use. Although short-term use was not associated with SGA (adjusted ORsingle-trimester = 0.95, 95% CI 0.87-1.04, p = 0.29), persistent use was associated with increased risk for SGA (adjusted ORmultiple-trimester = 1.40, 95% CI 1.17-1.67, p < 0.001) compared with unexposed infants. The association with persistent exposure was attenuated when we used alternative comparison groups (e.g., sibling comparison OR = 1.22, 95% CI 0.60-2.48, p = 0.58). Of note, our study had limitations, including potential bias from exposure misclassification, an inability to adjust for all sources of confounding, and uncertainty regarding generalizability to countries outside of Sweden. CONCLUSIONS Our results suggested that observed associations between POA use during pregnancy and risk of PTB and SGA were largely due to unmeasured confounding factors, although we could not rule out small independent associations, particularly for persistent POA use during pregnancy.
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Affiliation(s)
- Ayesha C. Sujan
- Department of Psychological & Brain Sciences, Indiana University Bloomington, Bloomington, Indiana, United States of America
- * E-mail:
| | - Patrick D. Quinn
- Department of Applied Health Science, School of Public Health, Indiana University Bloomington, Bloomington, Indiana, United States of America
| | - Martin E. Rickert
- Department of Psychological & Brain Sciences, Indiana University Bloomington, Bloomington, Indiana, United States of America
| | - Kelsey K. Wiggs
- Department of Psychological & Brain Sciences, Indiana University Bloomington, Bloomington, Indiana, United States of America
| | - Paul Lichtenstein
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Larsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Catarina Almqvist
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - A. Sara Öberg
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Epidemiology, T.H. Chan School of Public Health, Harvard, Boston, United States of America
| | - Brian M. D’Onofrio
- Department of Psychological & Brain Sciences, Indiana University Bloomington, Bloomington, Indiana, United States of America
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Risk Factors for Misuse of Prescribed Opioids: A Systematic Review and Meta-Analysis. Ann Emerg Med 2019; 74:634-646. [DOI: 10.1016/j.annemergmed.2019.04.019] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 04/02/2019] [Accepted: 04/17/2019] [Indexed: 01/24/2023]
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9
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Tramadol use in Norway: A register-based population study. Pharmacoepidemiol Drug Saf 2018; 28:54-61. [DOI: 10.1002/pds.4626] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 06/06/2018] [Accepted: 07/05/2018] [Indexed: 12/29/2022]
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Abstract
Recent studies suggest that longer durations of opioid use, independent of maximum morphine equivalent dose (MED) achieved, is associated with increased risk of new-onset depression (NOD). Conversely, other studies, not accounting for duration, found that higher MED increased probability of depressive symptoms. To determine whether rate of MED increase is associated with NOD, a retrospective cohort analysis of Veterans Health Administration data (2000-2012) was conducted. Eligible patients were new, chronic (>90 days) opioid users, aged 18 to 80, and without depression diagnoses for 2 years before start of follow-up (n = 7051). Mixed regression models of MED across follow-up defined 4 rate of dose change categories: stable, decrease, slow increase, and rapid increase. Cox proportional hazard models assessed the relationship of rate of dose change and NOD, controlling for pain, duration of use, maximum MED, and other confounders using inverse probability of treatment-weighted propensity scores. Incidence rate for NOD was 14.1/1000PY (person-years) in stable rate, 13.0/1000PY in decreasing, 19.3/1000PY in slow increasing, and 27.5/1000PY in rapid increasing dose. Compared with stable rate, risk of NOD increased incrementally for slow (hazard ratio = 1.22; 95% confidence interval: 1.05-1.42) and rapid (hazard ratio = 1.58; 95% confidence interval: 1.30-1.93) rate of dose increase. Faster rates of MED escalation contribute to NOD, independent of maximum dose, pain, and total opioid duration. Dose escalation may be a proxy for loss of control or undetected abuse known to be associated with depression. Clinicians should avoid rapid dose increase when possible and discuss risk of depression with patients if dose increase is warranted for pain.
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Quinn PD, Hur K, Chang Z, Krebs EE, Bair MJ, Scott EL, Rickert ME, Gibbons RD, Kroenke K, D'Onofrio BM. Incident and long-term opioid therapy among patients with psychiatric conditions and medications: a national study of commercial health care claims. Pain 2017; 158:140-148. [PMID: 27984526 DOI: 10.1097/j.pain.0000000000000730] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
There is growing evidence that opioid prescribing in the United States follows a pattern in which patients who are at the highest risk of adverse outcomes from opioids are more likely to receive long-term opioid therapy. These patients include, in particular, those with substance use disorders (SUDs) and other psychiatric conditions. This study examined health insurance claims among 10,311,961 patients who filled prescriptions for opioids. Specifically, we evaluated how opioid receipt differed among patients with and without a wide range of preexisting psychiatric and behavioral conditions (ie, opioid and nonopioid SUDs, suicide attempts or other self-injury, motor vehicle crashes, and depressive, anxiety, and sleep disorders) and psychoactive medications (ie, antidepressants, benzodiazepines, hypnotics, mood stabilizers, antipsychotics, and medications used for SUD, tobacco cessation, and attention-deficit/hyperactivity disorder). Relative to those without, patients with all assessed psychiatric conditions and medications had modestly greater odds of subsequently filling prescriptions for opioids and, in particular, substantially greater risk of long-term opioid receipt. Increases in risk for long-term opioid receipt in adjusted Cox regressions ranged from approximately 1.5-fold for prior attention-deficit/hyperactivity disorder medication prescriptions (hazard ratio [HR] = 1.53; 95% confidence interval [CI], 1.48-1.58) to approximately 3-fold for prior nonopioid SUD diagnoses (HR = 3.15; 95% CI, 3.06-3.24) and nearly 9-fold for prior opioid use disorder diagnoses (HR = 8.70; 95% CI, 8.20-9.24). In sum, we found evidence of greater opioid receipt among commercially insured patients with a breadth of psychiatric conditions. Future studies assessing behavioral outcomes associated with opioid prescribing should consider preexisting psychiatric conditions.
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Affiliation(s)
- Patrick D Quinn
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, MN, USA.,Center for Health Statistics, University of Chicago, Chicago, IL, USA
| | - Kwan Hur
- Center for Health Statistics, University of Chicago, Chicago, IL, USA
| | - Zheng Chang
- Center for Health Statistics, University of Chicago, Chicago, IL, USA.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Erin E Krebs
- VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA.,University of Minnesota Medical School, Minneapolis, MN, USA
| | - Matthew J Bair
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, USA.,Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.,Regenstrief Institute, Indianapolis, IN, USA
| | - Eric L Scott
- Department of Pediatrics and Communicable Diseases and Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Martin E Rickert
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, MN, USA
| | - Robert D Gibbons
- Center for Health Statistics, University of Chicago, Chicago, IL, USA
| | - Kurt Kroenke
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, IN, USA.,Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.,Regenstrief Institute, Indianapolis, IN, USA
| | - Brian M D'Onofrio
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, MN, USA
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12
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Problematic use of prescribed opioids for chronic noncancer pain—no scarcity of data outside the United States. Pain 2017; 158:2277. [DOI: 10.1097/j.pain.0000000000001048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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13
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Birke H, Ekholm O, Sjøgren P, Kurita GP, Højsted J. Long-term opioid therapy in Denmark: A disappointing journey. Eur J Pain 2017; 21:1516-1527. [PMID: 28481052 DOI: 10.1002/ejp.1053] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Longitudinal population-based studies of long-term opioid therapy (L-TOT) in chronic non-cancer pain (CNCP) patients are sparse. Our study investigated incidence and predictors for initiating L-TOT and changes in self-rated health, pain interference and physical activities in long-term opioid users. METHODS Data were obtained from the national representative Danish Health and Morbidity Surveys and The Danish National Prescription Registry. Respondents with no dispensed opioids the year before the survey were followed from 2000 and from 2005 until the end of 2012 (n = 12,145). A nationally representative subsample of individuals (n = 2015) completed the self-administered questionnaire in both 2000 and 2013. Collected information included chronic pain (≥6 months), health behaviour, self-rated health, pain interference with work activities and physical activities. Long-term users were defined as those who were dispensed at least one opioid prescription in six separate months within a year. RESULTS The incidence of L-TOT was substantially higher in CNCP patients at baseline than in others (9/1000 vs. 2/1000 person-years). Smoking behaviour and dispensed benzodiazepines were significantly associated with initiation of L-TOT in individuals with CNCP at baseline. During follow-up, L-TOT in CNCP patients increased the likelihood of negative changes in pain interference with work (OR 9.2; 95% CI 1.9-43.6) and in moderate activities (OR 3.7; 95% CI 1.1-12.6). The analysis of all individuals indicated a dose-response relationship between longer treatment duration and the risk of experiencing negative changes. CONCLUSIONS Individuals on L-TOT seemed not to achieve the key goals of opioid therapy: pain relief, improved quality of life and functional capacity. SIGNIFICANCE Long-term opioid therapy does not seem to provide pain relief, improvement in HRQOL and physical capacity in CNCP patients in a general population.
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Affiliation(s)
- H Birke
- Department of Oncology, Rigshospitalet Copenhagen University Hospital, Denmark
| | - O Ekholm
- National Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - P Sjøgren
- Department of Oncology, Rigshospitalet Copenhagen University Hospital, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences University of Copenhagen, Denmark
| | - G P Kurita
- Department of Oncology, Rigshospitalet Copenhagen University Hospital, Denmark.,Multidisciplinary Pain Centre, Rigshospitalet Copenhagen University Hospital, Denmark
| | - J Højsted
- Multidisciplinary Pain Centre, Rigshospitalet Copenhagen University Hospital, Denmark
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14
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Wolter DK. Abhängigkeitspotenzial und andere Risiken von Opioidanalgetika im Alter. SUCHT-ZEITSCHRIFT FUR WISSENSCHAFT UND PRAXIS 2017. [DOI: 10.1024/0939-5911/a000475] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Zusammenfassung. Zielsetzung: Übersicht über Suchtpotenzial und andere Risiken von Opioidanalgetika im höheren Lebensalter. Methodik: Narrativ review. Literaturrecherche in PubMed (Suchbegriffe: opioid analgesics UND abuse; opioid analgesics UND dependence; opioid analgesics UND addiction; opioid analgesics UND adverse effects; jeweils UND elderly) sowie aktuellen einschlägigen Standardwerken; Auswahl nach altersmedizinischer Relevanz und Aktualität. Ergebnisse: Die Verordnung von Opioidanalgetika (OA) hat in den letzten 25 Jahren massiv zugenommen, die weitaus meisten Verordnungen entfallen auf alte Menschen und Menschen mit chronischen Nicht-Tumorschmerzen (CNTS). Die diagnostischen Kriterien für die Opiatabhängigkeit in ICD-10 und DSM-5 sind für die OA-Behandlung von CNTS ungeeignet. Bei langfristiger OA-Behandlung bei CNTS kann eine spezifische Form von Abhängigkeit entstehen, die nicht mit der illegalen Opiat-(Heroin-)Sucht gleichzusetzen ist. Vorbestehende Suchterkrankungen und andere psychische Störungen sind die wesentlichsten Risikofaktoren. Weitere Nebenwirkungen sind zu beachten. Schmerztherapie bei Suchtkranken stellt eine besondere Herausforderung dar. Schlussfolgerungen: Die Anwendung von OA bei CNTS verlangt eine sorgfältige Indikationsstellung. Die besondere Form der Abhängigkeit von OA ist nicht ausreichend erforscht und wird zu wenig beachtet.
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Affiliation(s)
- Dirk K. Wolter
- Psykiatrien i Region Syddanmark, Gerontopsykiatrisk Afdeling, Aabenraa, Denmark
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15
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Birke H, Kurita GP, Sjøgren P, Højsted J, Simonsen MK, Juel K, Ekholm O. Chronic non-cancer pain and the epidemic prescription of opioids in the Danish population: trends from 2000 to 2013. Acta Anaesthesiol Scand 2016; 60:623-33. [PMID: 26861026 DOI: 10.1111/aas.12700] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Revised: 11/20/2015] [Accepted: 12/18/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND Chronic pain has serious consequences for individuals and society. In addition, opioid prescription for chronic non-cancer pain (CNCP) has become more frequent. This study aims to examine the trends regarding the prevalence of CNCP, dispensed opioids, and concurrent use of benzodiazepine (BZD)/BZD-related drugs in the Danish population. METHODS Data from the cross-sectional national representative Danish Health and Morbidity Surveys (2000, 2005, 2010, and 2013) were combined with The Danish National Prescription Registry at an individual level. The study populations varied between 5000 and 13,000 individuals ≥16 years (response rates: 51-63%). Respondents completed a self-administered questionnaire, which included the analyzed items on identification of chronic pain (≥6 months). RESULTS From 2000 to 2013, the prevalence of CNCP increased and subsequently the annual prevalence of opioid use from 4.1% to 5.7% among CNCP individuals. Higher CNCP prevalence was related to female gender, no cohabitation partner, short education, non-Western origin, and overweight/obesity. In addition, women with CNCP, especially >65 years, became more frequent users of opioids and used higher doses than men. Concurrent use of BZD/BZD-related drugs decreased (13%) from 2010 to 2013, still one-third of long-term opioid user were co-medicated with these drugs. CONCLUSIONS The use of opioids has increased in Denmark, especially among elderly women. The concurrent use of BZD/BZD-related drugs has decreased from 2010 to 2013, but still one-third of long-term opioid users were co-medicated.
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Affiliation(s)
- H. Birke
- Department of Oncology; Rigshospitalet; Copenhagen Denmark
| | - G. P. Kurita
- Department of Oncology; Rigshospitalet Copenhagen University Hospital; Copenhagen Denmark
| | - P. Sjøgren
- Department of Oncology; Rigshospitalet Copenhagen University Hospital; Copenhagen Denmark
| | - J. Højsted
- Multidisciplinary Pain Centre; Rigshospitalet Copenhagen University Hospital; Copenhagen Denmark
| | - M. K. Simonsen
- Finsencenter; Rigshospitalet Copenhagen University Hospital; Copenhagen Denmark
| | - K. Juel
- National Institute of Public Health; University of Southern Denmark; Copenhagen Denmark
| | - O. Ekholm
- National Institute of Public Health; University of Southern Denmark; Copenhagen Denmark
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16
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Donaldson R, Sun Y, Liang DY, Zheng M, Sahbaie P, Dill DL, Peltz G, Buck KJ, Clark JD. The multiple PDZ domain protein Mpdz/MUPP1 regulates opioid tolerance and opioid-induced hyperalgesia. BMC Genomics 2016; 17:313. [PMID: 27129385 PMCID: PMC4850636 DOI: 10.1186/s12864-016-2634-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 04/22/2016] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Opioids are a mainstay for the treatment of chronic pain. Unfortunately, therapy-limiting maladaptations such as loss of treatment effect (tolerance), and paradoxical opioid-induced hyperalgesia (OIH) can occur. The objective of this study was to identify genes responsible for opioid tolerance and OIH. RESULTS These studies used a well-established model of ascending morphine administration to induce tolerance, OIH and other opioid maladaptations in 23 strains of inbred mice. Genome-wide computational genetic mapping was then applied to the data in combination with a false discovery rate filter. Transgenic mice, gene expression experiments and immunoprecipitation assays were used to confirm the functional roles of the most strongly linked gene. The behavioral data processed using computational genetic mapping and false discovery rate filtering provided several strongly linked biologically plausible gene associations. The strongest of these was the highly polymorphic Mpdz gene coding for the post-synaptic scaffolding protein Mpdz/MUPP1. Heterozygous Mpdz +/- mice displayed reduced opioid tolerance and OIH. Mpdz gene expression and Mpdz/MUPP1 protein levels were lower in the spinal cords of low-adapting 129S1/Svlm mice than in high-adapting C57BL/6 mice. Morphine did not alter Mpdz expression levels. In addition, association of Mpdz/MUPP1 with its known binding partner CaMKII did not differ between these high- and low-adapting strains. CONCLUSIONS The degrees of maladaptive changes in response to repeated administration of morphine vary greatly across inbred strains of mice. Variants of the multiple PDZ domain gene Mpdz may contribute to the observed inter-strain variability in tolerance and OIH by virtue of changes in the level of their expression.
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Affiliation(s)
- Robin Donaldson
- Department of Computer Science, Stanford University, Stanford, CA, USA
| | - Yuan Sun
- Anesthesiology Service, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave., Anesthesiology, 112A, Palo Alto, CA, 94304, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - De-Yong Liang
- Anesthesiology Service, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave., Anesthesiology, 112A, Palo Alto, CA, 94304, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Ming Zheng
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Peyman Sahbaie
- Anesthesiology Service, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave., Anesthesiology, 112A, Palo Alto, CA, 94304, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - David L Dill
- Department of Computer Science, Stanford University, Stanford, CA, USA
| | - Gary Peltz
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Kari J Buck
- Department of Behavioral Neuroscience, Oregon Health and Science University, Portland, OR, USA
| | - J David Clark
- Anesthesiology Service, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave., Anesthesiology, 112A, Palo Alto, CA, 94304, USA. .,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.
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18
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Moisset X, Trouvin AP, Tran VT, Authier N, Vergne-Salle P, Piano V, Martinez V. Utilisation des opioïdes forts dans la douleur chronique non cancéreuse chez l’adulte. Recommandations françaises de bonne pratique clinique par consensus formalisé (SFETD). Presse Med 2016; 45:447-62. [DOI: 10.1016/j.lpm.2016.02.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 01/19/2016] [Accepted: 02/23/2016] [Indexed: 02/02/2023] Open
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19
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Tjagvad C, Skurtveit S, Bramness JG, Gjersing L, Gossop M, Clausen T. Misuse of prescription drugs and overdose deaths. JOURNAL OF SUBSTANCE USE 2016. [DOI: 10.3109/14659891.2015.1077280] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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20
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Häuser W, Petzke F, Radbruch L, Tölle TR. The opioid epidemic and the long-term opioid therapy for chronic noncancer pain revisited: a transatlantic perspective. Pain Manag 2016; 6:249-63. [PMID: 26988312 DOI: 10.2217/pmt.16.5] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The rise of opioid prescriptions and associated deaths ('opioid epidemic') in North America has evoked worldwide discussions on the long-term efficacy and safety of long-term opioid therapy (LtOT) for chronic noncancer pain (CNCP). We discuss if the opioid epidemic is a real worldwide or a more North American phenomenon. We consider reasons of the opioid epidemic. We highlight differences in the appraisal of the evidence of recent systematic reviews on LtOT for CNCP of US and European authors. We discuss similarities and differences of recent North American and European guidelines on LtOT for chronic CNCP. We point out potential indications and contraindications of LtOT in CNCP syndromes.
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Affiliation(s)
- Winfried Häuser
- Internal Medicine 1, Klinikum Saarbrücken, Winterberg 1, D-66119 Saarbrücken, Germany.,Department of Psychosomatic Medicine & Psychotherapy, Technische Universität München, Ismaningerstraβe 22, D-81675 München, Germany
| | - Frank Petzke
- Day Clinic & Out Patient Department Pain Therapy, Universitätsmedizin Göttingen, D-37075 Göttingen, Germany
| | - Lukas Radbruch
- Department of Palliative Medicine, University Hospital Bonn, Center of Palliative Care, Malteser Hospital Seliger Gerhard Bonn/Rhein-Sieg, D-53127 Bonn, Germany
| | - Thomas R Tölle
- Department of Neurology, Technische Universität München, Ismaningerstraβe 22, D-81675 München, Germany
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21
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Mellbye A, Karlstad Ø, Skurtveit S, Borchgrevink PC, Fredheim OMS. The duration and course of opioid therapy in patients with chronic non-malignant pain. Acta Anaesthesiol Scand 2016; 60:128-37. [PMID: 26242816 DOI: 10.1111/aas.12594] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 05/31/2015] [Accepted: 07/02/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND Prescription databases provide the opportunity for investigating opioid treatment and co-medication within large populations. So far, few studies have investigated the duration of opioid therapy, and large differences in discontinuation rates have been reported. METHODS Data from the Norwegian Prescription Database were used to follow the study population of all adult persistent opioid users with non-malignant pain in Norway in 2005 (n = 44,867) for 6 years. Persistent opioid use was defined as being dispensed ≥ 180 defined daily doses (DDD) or 4500 mg oral morphine equivalents (OMEQ) during a 365-day period. The study population was stratified according to previous opioid use into new persistent opioid users, without previous persistent opioid use, and previous low-dose or previous high-dose persistent opioid users, having earlier persistent opioid use and received less or more than 120 mg OMEQ/day in 2005, respectively. RESULTS Twenty-seven percent of new, 59% of previous low-dose, and 55% of previous high-dose users met the criteria of persistent use of opioids each year. Exactly, 22%, 11%, and 3% increased their cumulative yearly opioid dose by 200% or more during the study period. With 80% still being regular users of either drugs, 6 years later, long-term persistent opioid users were more likely to continue concomitant use of benzodiazepines or z-hypnotics than other users, CONCLUSION The findings confirm high discontinuation rates in patients receiving opioids for chronic non-malignant pain. However, a clinically significant number of patients increase their doses over 6 years and many patients combine long-term opioid treatment with benzodiazepines and z-hypnotics.
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Affiliation(s)
- A. Mellbye
- Department of Circulation and Medical Imaging; Pain and Palliation Research Group; Faculty of Medicine; Norwegian University of Science and Technology; Trondheim Norway
- National Competence Centre for Complex Symptom Disorders; St. Olav's University Hospital; Trondheim Norway
| | - Ø. Karlstad
- Department of Pharmacoepidemiology; Division of Epidemiology; Norwegian Institute of Public Health; Oslo Norway
| | - S. Skurtveit
- Norwegian Centre for Addiction Research; University of Oslo; Oslo Norway
- Department of Pharmacoepidemiology; Division of Epidemiology; Norwegian Institute of Public Health; Oslo Norway
| | - P. C. Borchgrevink
- Department of Circulation and Medical Imaging; Pain and Palliation Research Group; Faculty of Medicine; Norwegian University of Science and Technology; Trondheim Norway
- National Competence Centre for Complex Symptom Disorders; St. Olav's University Hospital; Trondheim Norway
| | - O. M. S. Fredheim
- Department of Circulation and Medical Imaging; Pain and Palliation Research Group; Faculty of Medicine; Norwegian University of Science and Technology; Trondheim Norway
- National Competence Centre for Complex Symptom Disorders; St. Olav's University Hospital; Trondheim Norway
- Centre of Palliative Medicine; Akershus University Hospital; Oslo Norway
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Is Early Prescribing of Opioid and Psychotropic Medications Associated With Delayed Return to Work and Increased Final Workers’ Compensation Cost? J Occup Environ Med 2015; 57:1315-8. [DOI: 10.1097/jom.0000000000000557] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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23
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Song J, Foell J. An exploration of opioid medication management for non-malignant pain in primary care. Br J Pain 2015; 9:181-9. [PMID: 26516575 DOI: 10.1177/2049463715574111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The present study aimed to explore how prescription of opioid medication for chronic non-malignant pain (CNMP) is managed in primary care. We used audit as a research tool, and one general practitioner (GP) practice in West London acted as an exemplar. Of the practice population with CNMP, 1% had repeat prescription of at least 12 months duration for opioid analgesics at the time of data collection. These 1% are on highly controlled opioids. Our study showed the following: (1) long-term opioid prescription appears to follow a fluctuating course as opposed to staying the same; (2) we found that medication reviews were done in most cases (85.7%), but the quality of the process is difficult to assess and ascertain; and (3) we identified two incidences where opioid contract was implemented. In both cases, contracts were used as a last chance warning for patients who were already problematic, suggesting that opioid contracts served as a disciplinary tool rather than a preventative measure. Our findings highlight a need for a more structured and specific review of analgesic medication, and a need for a simple and effective way to identify patients at high risk of developing problematic use, to ensure better monitoring and early presentations.
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Affiliation(s)
- Jia Song
- Centre for Primary Care and Public Health, The Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK ; Richford Gate Medical Practice, London, UK
| | - Jens Foell
- Centre for Primary Care and Public Health, The Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK ; Richford Gate Medical Practice, London, UK
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24
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Marschall U, L'hoest H, Radbruch L, Häuser W. Long-term opioid therapy for chronic non-cancer pain in Germany. Eur J Pain 2015; 20:767-76. [DOI: 10.1002/ejp.802] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2015] [Indexed: 11/05/2022]
Affiliation(s)
- U. Marschall
- Department of Business Strategy; BARMER GEK Head Office; Wuppertal Germany
| | - H. L'hoest
- Department of Business Strategy; BARMER GEK Head Office; Wuppertal Germany
| | - L. Radbruch
- Palliative care; Universitätsklinikum Bonn; Germany
| | - W. Häuser
- Internal Medicine I; Klinikum Saarbrücken GmbH; Germany
- Department of Psychosomatic Medicine and Psychotherapy; Technische Universität München; Germany
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25
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McCrorie C, Closs SJ, House A, Petty D, Ziegler L, Glidewell L, West R, Foy R. Understanding long-term opioid prescribing for non-cancer pain in primary care: a qualitative study. BMC FAMILY PRACTICE 2015; 16:121. [PMID: 26362559 PMCID: PMC4567803 DOI: 10.1186/s12875-015-0335-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 08/31/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND The place of opioids in the management of chronic, non-cancer pain is limited. Even so their use is escalating, leading to concerns that patients are prescribed strong opioids inappropriately and alternatives to medication are under-used. We aimed to understand the processes which bring about and perpetuate long-term prescribing of opioids for chronic, non-cancer pain. METHODS We held semi-structured interviews with patients and focus groups with general practitioners (GPs). Participants included 23 patients currently prescribed long-term opioids and 15 GPs from Leeds and Bradford, United Kingdom (UK). We used a grounded approach to the analysis of transcripts. RESULTS Patients are driven by the needs for pain relief, explanation, and improvement or maintenance of quality of life. GPs' responses are shaped by how UK general practice is organised, available therapeutic choices and their expertise in managing chronic pain, especially when facing diagnostic uncertainty or when their own approach is at odds with the patient's wishes. Four features of the resulting transaction between patients and doctors influence prescribing: lack of clarity of strategy, including the risk of any plans being subverted by urgent demands; lack of certainty about locus of control in decision-making, especially in relation to prescribing; continuity in the doctor-patient relationship; and mutuality and trust. CONCLUSIONS Problematic prescribing occurs when patients experience repeated consultations that do not meet their needs and GPs feel unable to negotiate alternative approaches to treatment. Therapeutic short-termism is perpetuated by inconsistent clinical encounters and the absence of mutually-agreed formulations of underlying problems and plans of action. Apart from commissioning improved access to appropriate specialist services, general practices should also consider how they manage problematic opioid prescribing and be prepared to set boundaries with patients.
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Affiliation(s)
- Carolyn McCrorie
- Leeds Institute of Health Sciences, Charles Thackrah Building, University of Leeds, 101 Clarendon Road, Leeds, LS2 9LJ, UK.
| | - S José Closs
- School of Healthcare, Baines Wing, University of Leeds, Leeds, LS2 9JT, UK
| | - Allan House
- Leeds Institute of Health Sciences, Charles Thackrah Building, University of Leeds, 101 Clarendon Road, Leeds, LS2 9LJ, UK
| | - Duncan Petty
- Bradford School of Pharmacy, University of Bradford, Richmond Rd, Bradford, Yorkshire, BD7 1DP, UK
| | - Lucy Ziegler
- Leeds Institute of Health Sciences, Charles Thackrah Building, University of Leeds, 101 Clarendon Road, Leeds, LS2 9LJ, UK
| | - Liz Glidewell
- Leeds Institute of Health Sciences, Charles Thackrah Building, University of Leeds, 101 Clarendon Road, Leeds, LS2 9LJ, UK
| | - Robert West
- Leeds Institute of Health Sciences, Charles Thackrah Building, University of Leeds, 101 Clarendon Road, Leeds, LS2 9LJ, UK
| | - Robbie Foy
- Leeds Institute of Health Sciences, Charles Thackrah Building, University of Leeds, 101 Clarendon Road, Leeds, LS2 9LJ, UK
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27
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Liang Y, Turner BJ. Assessing risk for drug overdose in a national cohort: role for both daily and total opioid dose? THE JOURNAL OF PAIN 2014; 16:318-25. [PMID: 25486625 DOI: 10.1016/j.jpain.2014.11.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 11/04/2014] [Accepted: 11/11/2014] [Indexed: 01/22/2023]
Abstract
UNLABELLED Current research on the risk of opioid analgesics with drug overdose does not account for the total morphine equivalent dose (MED) of opioids filled by a patient. In this study, time from first opioid prescription until drug overdose was examined for 206,869 privately insured patients aged 18 to 64 with noncancer pain and ≥2 filled prescriptions for Schedule II or III opioids from January 2009 to July 2012. Opioid therapy was examined in 6-month intervals including 6 months before an overdose and categorized as mean daily MED (0, 1-19, 20-49, 50-99, ≥100 mg) and total MED divided at top quartile (0, 1-1,830, >1,830 mg). Survival analysis was used, adjusting for demographics, clinical conditions, and psychoactive drugs. Relative to no opioid therapy, persons at highest risk for overdose (adjusted hazard ratios of 2-3) received a daily MED of ≥100 mg regardless of total dose or a daily MED of 50 to 99 mg with a high total MED (>1,830 mg). The hazard ratio was significantly lower (1.43, 95% confidence interval = 1.15-1.79) for 50 to 99 mg daily MED with a lower total MED (≤1,830 mg), whereas hazard ratios for lower daily MEDs did not differ by total dose. This analysis suggests that clinicians should consider total MED to assess risk of overdose for persons prescribed 50 to 99 mg daily MED. PERSPECTIVE When addressing risks for drug overdose, this analysis supports the need for clinicians, administrators, and policy makers to monitor not only daily opioid dose but also total dose for patients receiving 50 to 99 mg daily MED.
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Affiliation(s)
- Yuanyuan Liang
- Department of Epidemiology and Biostatistics, University of Texas Health Science Center at San Antonio, San Antonio, Texas; Center for Research to Advance Community Health (ReACH), University of Texas Health Science Center at San Antonio, San Antonio, Texas; School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas
| | - Barbara J Turner
- Center for Research to Advance Community Health (ReACH), University of Texas Health Science Center at San Antonio, San Antonio, Texas; School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas; Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas.
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Impact of the Combined Use of Benzodiazepines and Opioids on Workers' Compensation Claim Cost. J Occup Environ Med 2014; 56:973-8. [DOI: 10.1097/jom.0000000000000203] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Fredheim OMS, Mahic M, Skurtveit S, Dale O, Romundstad P, Borchgrevink PC. Chronic pain and use of opioids: a population-based pharmacoepidemiological study from the Norwegian prescription database and the Nord-Trøndelag health study. Pain 2014; 155:1213-1221. [PMID: 24637039 DOI: 10.1016/j.pain.2014.03.009] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 03/08/2014] [Accepted: 03/11/2014] [Indexed: 10/25/2022]
Abstract
In previous studies on prescription patterns of opioids, accurate data on pain are missing, and previous epidemiological studies of pain lack accurate data on opioid use. The present linkage study, which investigates the relationship between pain and opioid use, is based on accurate individual data from the complete national Norwegian prescription database and the Nord-Trøndelag health study 3, which includes about 46,000 people. Baseline data were collected in 2006 to 2008, and the cohort was followed up for 3 years. Of 14,477 people who reported chronic nonmalignant pain, 85% did not use opioids at all, 3% used opioids persistently, and 12% used opioids occasionally. Even in the group reporting severe or very severe chronic pain, the number not using opioids (2680) was far higher than the number who used opioids persistently (304). However, three quarters of people using opioids persistently reported strong or very strong pain in spite of the medication. Risk factors for the people with chronic pain who were not persistent opioid users at baseline to use opioids persistently 3 years later were occasional use of opioids, prescription of >100 defined daily doses per year of benzodiazepines, physical inactivity, reports of strong pain intensity, and prescription of drugs from 8 or more Anatomical Therapeutic Chemical groups. The study showed that most people having chronic nonmalignant pain are not using opioids, even if the pain is strong or very strong. However, the vast majority of patients with persistent opioid use report strong or very strong pain in spite of opioid treatment.
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Affiliation(s)
- Olav Magnus S Fredheim
- Pain and Palliation Research Group, Department of Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway National Competence Centre for Complex Symptom Disorders, Department of Pain and Complex Disorders, St. Olav University Hospital, Trondheim, Norway Centre of Palliative Medicine, Surgical Division, Akershus University Hospital, Lørenskog, Norway Department of Pharmacoepidemiology, Division of Epidemiology, The Norwegian Institute of Public Health, Oslo, Norway Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway Department of Emergency Medicine, St. Olav University Hospital, Trondheim, Norway Department of Public Health and General Practice, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
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