Opioids and the treatment of chronic pain in a primary care sample

A Practical Guide to Sigma-1 Receptor Positron Emission Tomography/Magnetic Resonance Imaging: A New Clinical Molecular Imaging Method to Identify Peripheral Pain Generators in Patients with Chronic Pain

Accurately identifying the peripheral pain generator in patients with chronic pain remains a major challenge for modern medicine. Millions of patients around the world suffer endlessly from difficult-to-manage debilitating pain because of very limited diagnostic tests and a paucity of pain therapies. To help these patients, we have developed a novel clinical molecular imaging approach, and, in its early stages, it has been shown to accurately identify the exact site of pain generation using an imaging biomarker for the sigma-1 receptor and positron emission tomography/magnetic resonance imaging. We hope the description of the work in this article can help others begin their own pain imaging programs at their respective institutions.

Predictors of Opioid Prescribing for Non-Malignant Low Back Pain in an Italian Primary Care Setting

This study explores which patient characteristics could affect the likelihood of starting low back pain (LBP) treatment with opioid analgesics vs. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) in an Italian primary care setting. Through the computerized medical records of 65 General Practitioners, non-malignant LBP subjects who received the first pain intensity measurement and an NSAID or opioid prescription, during 2015–2016, were identified. Patients with an opioid prescription 1-year before the first pain intensity measurement were excluded. A multivariable logistic regression model was used to determine predictive factors of opioid prescribing. Results were reported as Odds Ratios (ORs) with a 95% confidence interval (CI), with p < 0.05 indicating statistical significance. A total of 505 individuals with LBP were included: of those, 72.7% received an NSAID prescription and 27.3% an opioid one (64% of subjects started with strong opioid). Compared to patients receiving an NSAID, those with opioid prescriptions were younger, reported the highest pain intensity (moderate pain OR = 2.42; 95% CI 1.48–3.96 and severe pain OR = 2.01; 95% CI 1.04–3.88) and were more likely to have asthma (OR 3.95; 95% CI 1.99–7.84). Despite clinical guidelines, a large proportion of LBP patients started with strong opioid therapy. Asthma, younger age and pain intensity were predictors of opioid prescribing when compared to NSAIDs for LBP treatment.

Exploring Patient Perceptions of Opioid Treatment Agreements in a Community Health Center Environment

OBJECTIVE

Describe patient attitudes toward opioid treatment agreements (OTAs) and characterize perceptions of their impact on patient care, behavior, communication with prescribers, and engagement with the health care system.

DESIGN

Qualitative descriptive study.

SETTING

Federally qualified health center with six clinic locations serving a rural population.

SUBJECTS

Patients were prescribed long-term opioid therapy and were required to sign an OTA through an in-person office visit with a clinical pharmacist.

METHODS

Patients who signed an OTA were recruited to participate in semistructured, in-person, one-on-one interviews. Data were analyzed using immersion-crystallization methods.

RESULTS

Among the 20 patients recruited, 50% were men; 70% were insured by the state's Medicaid program; and 85% were using opioids for hip, back, and/or neck pain. Four major themes arose from the interviews. First, individuals who use long-term opioids experience a wide variety of opioid-related fears and stigmas. Second, individuals articulated real or potential benefits from implementing OTAs. Third, opinions differed on whether OTAs affected behavior and reduced opioid misuse and diversion. Finally, individuals provided feedback on the health care system's OTA implementation process.

CONCLUSIONS

Patients experienced a wide variety of opioid-related fears and stigmas, including how OTA requirements can perpetuate these issues. Despite these feelings, participants articulated real or potential positive outcomes from the use of OTAs, although they were mixed on whether these agreements translated to any behavior changes. If OTAs are to become standard practice, future research is needed to describe the diversity of patient perspectives and experiences with OTAs and to evaluate their effect on patient outcomes.

Trends in Urine Drug Testing Among Long-term Opioid Users, 2012-2018

INTRODUCTION

Long-term opioid therapy increases the risk of opioid overdose death. Government agencies and medical societies, including the Center for Disease Control and Prevention and the American Society for Clinical Oncology, emphasized risk mitigation strategies, including urine drug testing, in published guidelines. Urine drug testing rates, time trends, and covariates among long-term opioid therapy users were examined to gauge guideline adherence.

METHODS

Using Optum's De-identified Clinformatics DataMart, an incidence cohort (n=28,790) and prevalence cohort (n=621,449) were created to measure baseline and annual urine drug testing, respectively, from 2012 to 2018. Urine drug testing time trends were evaluated by demographics, pain conditions, and Elixhauser comorbidity index. A multivariable generalized estimating model was developed in 2020 to examine the factors associated with urine drug testing.

RESULTS

Annual urine drug testing rates doubled from 25.6% in 2012 to 52.2% in 2018, whereas baseline urine drug testing also increased from 3.75% to 11.1%. Annual urine drug testing increased within each age group over time; however, older patients (OR=0.21, 95% CI=0.21, 0.22, aged >79 years) and patients with cancer (OR=0.82, 95% CI=0.80, 0.84) were less likely to receive urine drug testing. Patients residing in the South (OR=1.99, 95% CI=1.96, 2.01) and those with back pain (OR=2.04, 95% CI=2.02, 2.06) or with other chronic pain (OR=1.64, 95% CI=1.62, 1.66) were significantly more likely to be tested. Independent predictors of baseline urine drug testing were similar to predictors of annual urine drug testing.

CONCLUSIONS

Despite increasing urine drug testing trends from 2012 to 2018, annual and baseline urine drug testing remained low in 2018, relative to numerous guideline recommendations. Findings suggest a need for research on better guideline implementation strategies and the effectiveness of urine drug testing on patient outcomes.

Attitudes and Knowledge Regarding Pain Management and Addiction in Massachusetts: A Mixed Methods Study on Podiatric Residents

BACKGROUND

The opioid epidemic has hit disastrous levels across the United States. Many attempts have been made to counteract this, including policy changes and modification of provider and patient behavior. The purpose of this study was to understand the current state of podiatric residents' knowledge regarding pain management and addiction.

METHODS

This study used mixed quantitative-qualitative methods. Two focus groups were conducted with two podiatric residency programs to understand current issues and inform the creation of a survey. A 30-question survey was created and peer reviewed to assess general pain management knowledge, levels of confidence in pain management and addiction, and areas for improvement.

RESULTS

Pain management education in podiatry is mainly focused on opioids. These concepts are often taught in a nonstandardized method, which does not often include nonopioid alternatives. Knowledge of risk factors for addiction was lacking, whereas knowledge of behaviors concerning for addiction was more bountiful. Thirty-three surveys were completed of a possible 39. A knowledge score was created from eight survey questions for a total of 10 points, with an average score of 4.61. There was no statistical difference between those with and without a pain management rotation. Nearly all residents felt comfortable managing surgical pain. The residents are "never" or "only occasionally" inquiring about risk factors for addiction. Questions asked also suggest that the residents are not thinking about their role within the opioid epidemic.

CONCLUSIONS

As the opioid epidemic grows, it is imperative to examine the causes and solutions to the problem. Focusing efforts on educating resident physicians is one method to address the issue. The results of this study show that pain management basics need to be reinforced and more time must be spent emphasizing the importance of thorough patient histories and educating patients when prescribing pain medication.

Development and Performance of a Web-Based Tool to Adjust Urine Toxicology Testing Frequency: Retrospective Study

BACKGROUND

Several pain management guidelines recommend regular urine drug testing (UDT) in patients who are being treated with chronic opioid analgesic therapy (COAT) to monitor compliance and improve safety. Guidelines also recommend more frequent testing in patients who are at high risk of adverse events related to COAT; however, there is no consensus on how to identify high-risk patients or on the testing frequency that should be used. Using previously described clinical risk factors for UDT results that are inconsistent with the prescribed COAT, we developed a web-based tool to adjust drug testing frequency in patients treated with COAT.

OBJECTIVE

The objective of this study was to evaluate a risk stratification tool, the UDT Randomizer, to adjust UDT frequency in patients treated with COAT.

METHODS

Patients were stratified using an algorithm based on readily available clinical risk factors into categories of presumed low, moderate, high, and high+ risk of presenting with UDT results inconsistent with the prescribed COAT. The algorithm was integrated in a website to facilitate adoption across practice sites. To test the performance of this algorithm, we performed a retrospective analysis of patients treated with COAT between June 2016 and June 2017. The primary outcome was compliance with the prescribed COAT as defined by UDT results consistent with the prescribed COAT.

RESULTS

979 drug tests (867 UDT, 88.6%; 112 oral fluid testing, 11.4%) were performed in 320 patients. An inconsistent drug test result was registered in 76/979 tests (7.8%). The incidences of inconsistent test results across the risk tool categories were 7/160 (4.4%) in the low risk category, 32/349 (9.2%) in the moderate risk category, 28/338 (8.3%) in the high risk category, and 9/132 (6.8%) in the high+ risk category. Generalized estimating equation analysis demonstrated that the moderate risk (odds ratio (OR) 2.1, 95% CI 0.9-5.0; P=.10), high risk (OR 2.0, 95% CI 0.8-5.0; P=.14), and high risk+ (OR 2.0, 95% CI 0.7-5.6; P=.20) categories were associated with a nonsignificantly increased risk of inconsistency vs the low risk category.

CONCLUSIONS

The developed tool stratified patients during individual visits into risk categories of presenting with drug testing results inconsistent with the prescribed COAT; the higher risk categories showed nonsignificantly higher risk compared to the low risk category. Further development of the tool with additional risk factors in a larger cohort may further clarify and enhance its performance.

Health Disparities in Access to Nonpharmacologic Therapies in an Urban Community

OBJECTIVE

The overuse of prescription opioids for chronic pain is recognized as a public health crisis. Yet, poor access to nonpharmacologic treatments is the norm in low-income, racially and ethnically diverse patients with chronic pain. The main objective of this study was to understand how chronic pain impacts low-income individuals with chronic pain and their communities from multiple perspectives.

DESIGN

This was a qualitative study using a Science Café methodology.

SETTING

The Science Café event was held at an urban community center in Boston, MA.

SUBJECTS

Inclusion criteria included the following: having the ability to attend the event, being at least 18 years of age or older, and participating in English.

METHODS

Data were collected through self-reported questionnaires and audio or video recordings of two focus groups. Quantitative and qualitative data were analyzed with SAS 9.3 and NVivo 10.

RESULTS

Thirty participants attended the Science Café event. The average age was 45 years, 77% reported as female, 42% identified as black, and 19% as Hispanic. Participants identified themselves as either patients (46%) or providers (54%) to the chronic pain community. Our forum revealed three major themes: (1) nonpharmacologic options for chronic pain management are warranted, (2) larger sociodemographic and contextual factors influence management of chronic pain, and (3) both patients and providers value the patient-provider relationship and acknowledge the need for better communication for patients with chronic pain.

CONCLUSIONS

Future research should consider identifying and addressing disparities in access to nonpharmacologic treatments for chronic pain in relation to underlying social determinants of health, particularly for racially and ethnically diverse patients.

Clinical Utility of Definitive Drug⁻Drug Interaction Testing in Primary Care

Drug–drug interactions (DDIs) are a leading cause of morbidity and mortality. New tools are needed to improve identification and treatment of DDIs. We conducted a randomized controlled trial to assess the clinical utility of a new test to identify DDIs and improve their management. Primary care physicians (PCPs) cared for simulated patients presenting with DDI symptoms from commonly prescribed medications and other ingestants. All physicians, in either control or one of two intervention groups, cared for six patients over two rounds of assessment. Intervention physicians were educated on the DDI test and given access to these test reports when caring for their patients in the second round. At baseline, we saw no significant differences in making the DDI diagnosis (p = 0.071) or DDI-related treatment (p = 0.640) between control and intervention arms. By round two, providers who accessed the DDI test performed significantly better in making the DDI diagnosis (+41.6%) and performing DDI-specific treatment (+12.2%) than in the previous round, and were 9.8 and 20.4 times more likely to diagnose and identify the DDI (p < 0.001 for all). The introduction of a definitive DDI test significantly increased identification, appropriate management, and counseling of DDIs among PCPs, which has the potential to improve clinical care.

Drug-Drug Interaction Assessment and Identification in the Primary Care Setting

Background

Drug-drug interactions (DDIs) are ubiquitous, harmful and a leading cause of morbidity and mortality. With an aging population, growth in polypharmacy, widespread use of supplements, and the rising opioid abuse epidemic, primary care physicians (PCPs) are increasingly challenged with identifying and preventing DDIs. We set out to evaluate current clinical practices related to identifying and treating DDIs and to determine if opportunities to increase prevention of DDIs and their adverse events could be identified.

Methods

In a nationally representative sample of 330 board-certified family and internal medicine practitioners, we evaluated whether PCPs assessed DDIs in the care they provided for three simulated patients. The patients were taking common prescription medications (e.g. opioids and psychiatric medications) along with other common ingestants (e.g. supplements and food) and presented with symptoms of DDIs. Physicians were scored on their ability to inquire about the patient's medications, investigate possible DDIs, evaluate the patient, and provide treatment recommendations. We scored the physicians' care recommendations against evidence-based criteria, including overall care quality and treatment for DDIs.

Results

Average overall quality of care score was 50.5% ± 12.0%. Despite >99% self-reported use of medication reconciliation practices and tools, physicians identified DDIs in only 15.3% of patients, with 15.5% ± 20.3% of DDI-specific treatment by the physicians.

Conclusions

PCPs in this study did not recognize or adequately treat DDIs. Better methods are needed to screen for DDIs in the primary care setting.

Depression and Anxiety Among Patients on Chronic Opioid Therapy

Background:

Chronic noncancer pain (CNCP) and chronic opioid therapy (COT) commonly coexist with comorbid depression and anxiety. We investigated the prevalence of depression and anxiety and their correlates at the time of controlled substance agreement (CSA) enrollment among patients with CNCP and a history of depression or anxiety on COT.

Methods:

Retrospective analysis of 1066 patients in a Midwest primary care practice enrolled in CSAs for COT between May 9, 2013, and August 15, 2016. Patients with self-reported symptoms or a clinical history of depression or anxiety were screened at CSA enrollment using the Patient Health Questionnaire–9 item scale and the Generalized Anxiety Disorder–7 item scale.

Results:

The percentage of patients screening positive for depression and anxiety at CSA enrollment was 15.4% and 14.4%, respectively. Patients screening positive for depression or anxiety were more likely to be younger, unmarried, unemployed, and live alone compared to patients not screening positive. Patients screening positive for depression or anxiety were more likely to smoke cigarettes and report concern from friends or relatives regarding alcohol consumption. Compared to patients screening negative, patients screening positive for depression had higher odds of receiving opioid doses of ≥50 morphine milligram equivalents per day (adjusted odds ratio: 1.62; 95% confidence interval: 1.01-2.58).

Conclusion:

Anxiety and depression are prevalent at enrollment in CSAs among patients receiving COT. Future research is needed to determine whether recognition of anxiety and depression leads to improved management and outcomes for this population.

Role of Urine Drug Testing in the Current Opioid Epidemic

While the evidence for urine drug testing for patients on chronic opioid therapy is weak, the guidelines created by numerous medical societies and state and federal regulatory agencies recommend that it be included as one of the tools used to monitor patients for compliance with chronic opioid therapy. To get the most comprehensive results, clinicians should order both an immunoassay screen and confirmatory urine drug test. The immunoassay screen, which can be performed as an in-office point-of-care test or as a laboratory-based test, is a cheap and convenient study to order. Limitations of an immunoassay screen, however, include having a high threshold of detectability and only providing qualitative information about a select number of drug classes. Because of these restrictions, clinicians should understand that immunoassay screens have high false-positive and false-negative rates. Despite these limitations, though, the results can assist the clinician with making preliminary treatment decisions. In comparison, a confirmatory urine drug test, which can only be performed as a laboratory-based test, has a lower threshold of detectability and provides both qualitative and quantitative information. A urine drug test's greater degree of specificity allows for a relatively low false-negative and false-positive rate in contrast to an immunoassay screen. Like any other diagnostic test, an immunoassay screen and a confirmatory urine drug test both possess limitations. Clinicians must keep this in mind when interpreting an unexpected test result and consult with their laboratory when in doubt about the meaning of the test result to avoid making erroneous decisions that negatively impact both the patient and clinician.

Controlled Substance Agreements for Opioids in a Primary Care Practice

BACKGROUND

Opioids are widely prescribed for chronic non cancer pain (CNCP). Controlled substance agreements (CSAs) are intended to increase adherence and mitigate risk with opioid prescribing. We evaluated the demographic characteristics of and opioid dosing for patients with CNCP enrolled in CSAs in a primary care practice.

METHODS

We conducted a retrospective cohort study of 1066 patients enrolled in CSAs between May 9, 2013 and August 15, 2016 for CNCP in a Midwest primary care practice.

RESULTS

Patients were prescribed an average of 40.8 (SD ± 57.0) morphine milligram equivalents per day (MME/day), and 21.5% of patients were receiving ≥50 MME/day and 9.7% were receiving ≥90 MME/day. Patients who were younger in age (≥ 65 vs. < 65 years, P < 0.0001), male gender (P = 0.0001), and used tobacco (P = 0.0002) received significantly higher MME/day. Patients with more co-morbidities (Charlson Comorbidity Index, CCI) received higher MME/day (CCI > 3 vs. CCI ≤ 3, P = 0.03), and reported higher average pain (CCI > 3 mean 5.8 [SD ± 2.1] vs. CCI ≤ 3 mean 5.3 [SD ± 2.0], P = 0.0011). Patients on an identified tapering plan (6.9%) had higher MME/day than patients not on a tapering plan (P = 0.0002).

CONCLUSIONS

CSAs present an opportunity to engage patients taking higher doses of opioids in discussions about opioid safety, appropriate dosing and tapering. CSAs could be leveraged to develop a population health management approach to the care of patients with CNCP.

Influence of opioid-related side effects on disability, mood, and opioid misuse risk among patients with chronic pain in primary care

Patients who reported significant medication-related side effects reported greater activity interference, negative affect, catastrophizing, and opioid misuse risk compared with those with fewer side effects.

Background:

There is increasing concern among primary care practitioners about the use of opioids for chronic pain, including their adverse effects, but little attention has been given to how reports of side effects from prescription medication can contribute to outcomes among patients with chronic pain. The aim of this study was to investigate the impact of frequently reported side effects on mood, disability, and opioid misuse in patients with chronic pain prescribed opioids within primary care.

Methods:

Two hundred (N = 200) patients with chronic pain taking opioids for pain were recruited into the study. All patients completed baseline measures and a monthly side effects checklist once a month for 6 months. Patients were divided evenly based on a median split of the number of endorsed side effects over 6 months. The subjects repeated the baseline measures at the end of the study period.

Results:

Over time, reports of medication side effects tended to decrease, but differences in frequency of reported side effects from baseline to follow-up (6-month time) were not significant, and the order of the frequency of the reported side effects remained similar. Patients who reported significant medication-related adverse effects reported significantly greater activity interference, negative affect, and catastrophizing compared with those with fewer side effects (P < 0.01). In addition, those patients with pain who reported more side effects showed significantly higher scores on opioid misuse risk (P < 0.001).

Discussion:

This study demonstrates the important role of monitoring medication-related side effects among patients with chronic pain who are prescribed opioid medication for pain within primary care.

Development of functionalized hollow microporous organic capsules encapsulating morphine – an in vitro and in vivo study

Carboxylic group functionalized hollow microporous organic capsules (HMOCs) are synthesized that show extraordinary high encapsulation efficiency of morphine·HCl and its promising prolonged release.

Predictors of urine drug testing for patients with chronic pain: Results from a national cohort of U.S. veterans

BACKGROUND

Urine drug testing (UDT) is recommended for all patients who initiate chronic opioid therapy (COT) for the treatment of chronic pain; however, it is infrequently utilized. Some prior research has identified factors that may predict UDT, but studies have been limited. The purpose of this study is to examine the rate and predictors of UDT among a national sample of patients with chronic pain who had new initiations of COT.

METHODS

Administrative data were examined for all veterans receiving medical care at Department of Veterans Affairs medical facilities who had new initiations of chronic opioid therapy (COT) during fiscal year 2011.

RESULTS

Nineteen percent of patients who had new initiations of COT for chronic noncancer pain received UDT within 90 days of starting opioids. In adjusted analyses, patient-level factors that predicted increased likelihood of UDT included male gender (risk ratio [RR] = 1.23, 95% confidence interval [CI] = 1.02-1.49), Black race (RR = 1.20, 95% CI = 1.06-1.37), divorced/separated marital status (RR = 1.13, 95% CI = 1.02-1.25), higher pain intensity (RR = 1.03, 95% CI = 1.01-1.05), comorbid substance use disorder (RR = 1.42, 95% CI = 1.27-1.60), posttraumatic stress disorder (PTSD) (RR = 1.14, 95% CI = 1.01-1.29), bipolar disorder or schizophrenia (RR = 1.29, 95% CI = 1.08-1.53), having received UDT prior to initiating opioid therapy (RR = 1.43, 95% CI = 1.26-1.62), and a higher baseline opioid dose (RR = 1.38-1.81, 95% CIs = 1.20-1.58, 1.57-2.09). Age was also associated with UDT, in a nonlinear manner. Several factors were associated with lower likelihood of UDT, including living in a highly rural setting (RR = 0.62, 95% CI = 0.29-0.99), having a VA service-connected disability (RR = 0.85-0.89, 95% CIs = 0.75-0.97, 0.79-0.99), and having a nurse practitioner or physician assistant as one's primary care clinician (RR = 0.72, 95% CI = 0.61-0.85).

CONCLUSIONS

Urine drug testing was conducted with 19% of patients who had new initiations of COT. Factors that predicted UDT were multifaceted and included patient and clinician variables. Multidimensional system-level interventions may be needed to facilitate widespread implementation of UDT.

Decision support for chronic pain care: how do primary care physicians decide when to prescribe opioids? a qualitative study

BACKGROUND

Primary care physicians struggle to treat chronic noncancer pain while limiting opioid misuse, abuse, and diversion. The objective of this study was to understand how primary care physicians perceive their decisions to prescribe opioids in the context of chronic noncancer pain management. This question is important because interventions, such as decision support tools, must be designed based on a detailed understanding of how clinicians use information to make care decisions.

METHODS

We conducted in-depth qualitative interviews with family medicine and general internal medicine physicians until reaching saturation in emergent themes. We used a funneling approach to ask a series of questions about physicians' general decision making challenges and use of information when considering chronic opioids. We then used an iterative, open-coding approach to identify and characterize themes in the data.

RESULTS

We interviewed fifteen physicians with diverse clinical experiences, demographics, and practice affiliations. Physicians said that general decision making challenges in providing pain management included weighing risks and benefits of opioid therapies and time and resource constraints. Also, some physicians described their active avoidance of chronic pain treatment due to concerns about opioid risks. In their decision making, physicians described the importance of objective and consistent information, the importance of identifying "red flags" related to risks of opioids, the importance of information about physical function as an outcome, and the importance of information that engenders trust in patients.

CONCLUSIONS

This study identified and described primary care physicians' struggles to deliver high quality care as they seek and make decisions based on an array of incomplete, conflicting, and often untrusted patient information. Decision support systems, education, and other interventions that address these challenges may alleviate primary care physicians' struggles and improve outcomes for patients with chronic pain and other challenging conditions.

Hearing new voices: registered nurses and health technicians experience caring for chronic pain patients in primary care clinics

Recent national estimates from the U.S. reveal that as many as one-third of all Americans experience chronic pain resulting in high prevalence rates of visits to primary care clinics (PCC). Indeed, chronic pain appears to be an emerging global health problem. Research has largely ignored the perspective of PCC staff other than physicians in providing care for patients with chronic pain. We wanted to gain insights from the experiences of Registered Nurses (RNs) and Health Technicians (HTs) who care for this patient population. Krippendorff’s method for content analysis was used to analyze comments written in an open-ended survey from fifty-seven primary care clinic staff (RNs-N=27 and HTs-N=30) respondents. This represented an overall response rate of 75%. Five themes emerged related to the experience of RNs and HTs caring for patients with chronic pain: 1) Primacy of Medications and Accompanying Clinical Quandaries; 2) System Barriers; 3) Dealing with Failure; 4) Primacy of Patient Centered Care; and 5) Importance of Team Based Care. This study demonstrates that nursing staff provide patient-centered care, recognize the importance of their role within an interdisciplinary team and can offer valuable insight about the care of patients with chronic pain. This study provides insight into strategies that can mitigate barriers to chronic pain management while sustaining those aspects that RNs and HTs view as essential for improving patient care for this vulnerable population in PCCs.

It made my life a little easier: primary care providers' beliefs and attitudes about using opioid treatment agreements

OBJECTIVE

To understand primary care providers (PCPs)' experiences, beliefs, and attitudes about using opioid treatment agreements (OTAs) for patients with chronic pain.

DESIGN

Qualitative research study.

PARTICIPANTS

Twenty-eight internists and family medicine physicians at two health centers.

APPROACH

Semistructured telephone interviews, informed by the Integrative Model of Behavioral Prediction. Themes were analyzed using a Grounded Theory approach, and similarities and differences in themes were examined among OTA adopters, nonadopters, and selective adopters.

RESULTS

Participants were 64 percent female and 68 percent white, and practiced for a mean of 9.5 years. Adoption of OTAs varied: seven were adopters, five were nonadopters, and 16 were selective adopters. OTA adoption reflected PCPs' beliefs and attitudes in the following three thematic categories: 1) perceived effect of OTA use on the therapeutic alliance, 2) beliefs about the utility of OTAs for patients or providers, and 3) perception of patients' risk for opioid misuse. PCPs commonly believed that OTAs were useful for physician self-protection, but few believed that they prevent opioid misuse. Selective adopters expressed ambivalent beliefs and made decisions about OTA use for individual patients based on both observed data and a subjective sense of each patient's risk for misuse.

CONCLUSIONS

Substantial variability in PCP use of OTAs reflects differences in PCP beliefs and attitudes. Research to understand the impact of OTA use on providers, patients, and the therapeutic alliance is urgently needed to guide best practices.

Long-term opioid treatment of chronic nonmalignant pain: unproven efficacy and neglected safety?

BACKGROUND

For the past 30 years, opioids have been used to treat chronic nonmalignant pain. This study tests the following hypotheses: (1) there is no strong evidence-based foundation for the conclusion that long-term opioid treatment of chronic nonmalignant pain is effective; and (2) the main problem associated with the safety of such treatment - assessment of the risk of addiction - has been neglected.

METHODS

Scientometric analysis of the articles representing clinical research in this area was performed to assess (1) the quality of presented evidence (type of study); and (2) the duration of the treatment phase. The sufficiency of representation of addiction was assessed by counting the number of articles that represent (1) editorials; (2) articles in the top specialty journals; and (3) articles with titles clearly indicating that the addiction-related safety is involved (topic-in-title articles).

RESULTS

Not a single randomized controlled trial with opioid treatment lasting >3 months was found. All studies with a duration of opioid treatment ≥6 months (n = 16) were conducted without a proper control group. Such studies cannot provide the consistent good-quality evidence necessary for a strong clinical recommendation. There were profound differences in the number of addiction articles related specifically to chronic nonmalignant pain patients and to opioid addiction in general. An inadequate number of chronic pain-related publications were observed with all three types of counted articles: editorials, articles in the top specialty journals, and topic-in-title articles.

CONCLUSION

There is no strong evidence-based foundation for the conclusion that long-term opioid treatment of chronic nonmalignant pain is effective. The above identified signs indicating neglect of addiction associated with the opioid treatment of chronic nonmalignant pain were present.

Dependence and addiction during chronic opioid therapy

The use of opioids for chronic noncancer pain has increased dramatically over the past 25 years in North America and has been accompanied by a major increase in opioid addiction and overdose deaths. The increase in opioid prescribing is multifactorial and partly reflects concerns about the effectiveness and safety of alternative medications, particularly the nonsteroidal anti-inflammatory drugs. However, much of the rise in opioid prescribing reflects the assertion, widely communicated to physicians in the 1990s, that the risks of dependence and addiction during chronic opioid therapy were low, predictable, and could be minimized by the use of controlled-release opioid formulations. In this narrative review, we offer a critical appraisal of the publications most frequently cited as evidence that the risk of addiction during chronic opioid therapy is low. We conclude that very few well-designed studies support the notion that opioid addiction is rare during chronic opioid therapy and that none can be readily generalized to present-day practice. Despite serious methodological limitations, these studies have been repeatedly mischaracterized as showing that the risk of addiction during chronic opioid therapy is rare. These studies are countered by a larger, more rigorous and contemporary body of evidence demonstrating that dependence and addiction are relatively common consequences of chronic opioid therapy, occurring in up to one-third of patients in some series.

Which skills are associated with residents' sense of preparedness to manage chronic pain?

OBJECTIVE

To identify gaps in residents' confidence and knowledge in managing chronic nonmalignant pain (CNMP) and to explore whether specific skills or pain knowledge was associated with global preparedness to manage CNMP.

DESIGN

Cross-sectional web-based survey.

SETTING AND PARTICIPANTS

Internal medicine residents in Bronx, NY.

MAIN OUTCOME MEASURES

The authors assessed the following: 1) confidence in skills within the following four content areas: physical examination, diagnosis, treatment, and safer opioid prescribing; 2) pain-related knowledge on a 16-item scale; and 3) global preparedness to manage CNMP (agreement with, "I feel prepared to manage CNMP"). Gaps in confidence were skills in which fewer than 50 percent reported confidence. Gaps in knowledge were items in which fewer than 50 percent answered correctly. Using logistic regression, the authors examined whether skills or knowledge was associated with global preparedness.

RESULTS

Of 145 residents, 92 (63 percent) responded. Gaps in confidence included diagnosing fibromyalgia, performing corticosteroid injections, and using pain medication agreements. Gaps in knowledge included pharmacotherapy for neuropathic pain and interpreting urine drug test results. Twenty-four residents (26 percent) felt globally prepared to manage CNMP. Confidence using pain medication agreements (adjusted odds ratio [AOR], 5.99; 95% confidence interval [CI], 2.02-17.75), prescribing long-acting opioids (AOR, 5.85; 95% CI, 2.00-17.18), and performing corticosteroid injection of the knee (AOR, 5.76; 95% CI, 1.16-28.60]) were strongly associated with global preparedness.

CONCLUSIONS

Few internal medicine residents felt prepared to manage CNMP. Our findings suggest that educational interventions to improve residents' preparedness to manage CNMP should target complex pain syndromes (eg, fibromyalgia and neuropathic pain), safer opioid prescribing practices, and alternatives to opioid analgesics.

Opioid use among low back pain patients in primary care: Is opioid prescription associated with disability at 6-month follow-up?

Opioid prescribing for chronic noncancer pain is increasing, but there is limited knowledge about longer-term outcomes of people receiving opioids for conditions such as back pain. This study aimed to explore the relationship between prescribed opioids and disability among patients consulting in primary care with back pain. A total of 715 participants from a prospective cohort study, who gave consent for review of medical and prescribing records and completed baseline and 6 month follow-up questionnaires, were included. Opioid prescription data were obtained from electronic prescribing records, and morphine equivalent doses were calculated. The primary outcome was disability (Roland-Morris Disability Questionnaire [RMDQ]) at 6 months. Multivariable linear regression was used to examine the association between opioid prescription at baseline and RMDQ score at 6 months. Analyses were adjusted for potential confounders using propensity scores reflecting the probability of opioid prescription given baseline characteristics. In the baseline period, 234 participants (32.7%) were prescribed opioids. In the final multivariable analysis, opioid prescription at baseline was significantly associated with higher disability at 6-month follow-up (P < .022), but the magnitude of this effect was small, with a mean RMDQ score of 1.18 (95% confidence interval: 0.17 to 2.19) points higher among those prescribed opioids compared to those who were not. Our findings indicate that even after adjusting for a substantial number of potential confounders, opioids were associated with slightly worse functioning in back pain patients at 6-month follow-up. Further research may help us to understand the mechanisms underlying these findings and inform clinical decisions regarding the usefulness of opioids for back pain.

Do patients know they are on pain medication agreements? Results from a sample of high-risk patients on chronic opioid therapy

OBJECTIVE

Pain medicine agreements are frequently recommended for use with high-risk patients on chronic opioid therapy. We assessed how consistently pain medicine agreements were used and whether patients were aware that they had signed a pain medicine agreement in a sample of HIV-infected adults prescribed chronic opioid treatment.

DESIGN

We recruited patients from a longitudinal cohort of community-based HIV-infected adults and recruited the patients' primary care providers (PCPs). The patients completed in-person interviews and PCPs completed mail-based questionnaires about the patients' use of pain medicine agreements. Among patients prescribed chronic opioid therapy, we analyzed the prevalence of pain medicine agreement use, patient factors associated with their use, and agreement between patient and clinician reports of pain agreements.

RESULTS

We had 84 patient-clinician dyads, representing 38 PCPs. A total of 72.8% of patients fit the diagnostic criteria for a lifetime substance use disorder. PCPs reported using pain medicine agreements with 42.9% of patients. Patients with pain medicine agreements were more likely to be smokers (91.7% vs 58.3%; P = 0.001) and had higher mean scores on the Screener and Opioid Assessment for Patients with Pain (µ = 26.0 [standard deviation, SD] = 9.7) vs µ = 19.5 [SD = 9.3]; P = 0.003). Patients reported having a pain medicine agreement with a sensitivity of 61.1% and a specificity of 64.6%.

CONCLUSIONS

In a high-risk sample, clinicians were using agreements at a low rate, but were more likely to use them with patients at highest risk of misuse. Patients exhibited low awareness of whether they signed a pain medicine agreement.

The consequences of chronic pain

Questions from patients about analgesic pharmacotherapy and responses from authors are presented to help educate patients and make them more effective self-advocates. The topic addressed in this issue is untreated/undertreated chronic pain and the physical, emotional, and social consequences that can profoundly affect a patient's quality of life. Chronic pain is no longer considered a symptom; it is a disease entity itself. Anxiety and depression often coexist with chronic pain. Chronic pain is the enemy of happiness. Further, chronic pain can activate the sympathetic nervous system, leading to the fight-or-flight response.

Primary care providers' views on chronic pain management among high-risk patients in safety net settings

OBJECTIVE

We examined chronic pain management practices and confidence and satisfaction levels in treating chronic pain among primary care providers (PCPs) who cared for high-risk patients in safety net health settings.

DESIGN

We recruited PCPs (N = 61) through their HIV-infected patients who were enrolled in a longitudinal study on pain, use, and misuse of opioid analgesics (Pain Study). We asked PCPs to complete a questionnaire about all of their patients in their practice on the prevalence of chronic pain and illicit substance use, use of opioid analgesics, confidence and satisfaction levels in treating chronic pain, and likelihood of prescribing opioid analgesics in response to clinical vignettes.

RESULTS

All PCPs cared for at least some patients with chronic pain, and the majority prescribed opioid analgesics for its treatment. All PCPs cared for at least some patients who used illicit substances. PCPs reported low confidence and satisfaction levels in treating chronic pain. The majority (73.8%) of PCPs were highly likely to prescribe opioid analgesics to a patient without a history of substance use who had chronic pain. The majority (88.5%) were somewhat to highly likely to prescribe opioid analgesics to a patient with a prior history of substance use but not active use. Most (67.2%) were somewhat to highly likely to prescribe opioids to a patient with active substance use.

CONCLUSION

In order to improve PCPs' confidence and satisfaction in managing chronic pain, further work should explore the root causes of low confidence and satisfaction and also explore possible remedies.

Informed consent in opioid therapy: a potential obligation and opportunity

Most patients receiving opioids for the spectrum of pain disorders tolerate opioids well without major complications. However, a subset of this population encounters significant difficulties with opioid therapy (OT). These problems include protracted adverse effects, as well as misuse, abuse, and addiction, which can result in significant morbidity and mortality and make informed consent an important consideration. Opioid treatment agreements (OTAs), which may include documentation of informed consent, have been used to promote the safe use of opioids for pain. There is a debate regarding the effectiveness of OTAs in reducing the risk of opioid misuse; however, most practitioners recognize that OTAs provide an opportunity to discuss the potential risks and benefits of OT and establish mutually agreed-on treatment goals, a clear plan of treatment, and circumstances for continuation and discontinuation of opioids. Informed consent is an important component of an OTA but not often the focus of consideration in discussions of OTAs. This article examines the principles, process, and content of informed consent for OT of pain in the context of OTAs.

Opioid use and dependence among persons with migraine: results of the AMPP study

OBJECTIVE

To assess the frequency of opioid use for acute migraine treatment and characterize use groups by sociodemographics, health-care resource utilization (HRU), comorbidities and probable dependence within a large, US population-based sample of persons with migraine.

BACKGROUND

Opioids are used in the acute treatment of migraine. However, their use is controversial.

METHODS

Data from the 2009 American Migraine Prevalence and Prevention (AMPP) study were used to categorize persons with migraine into 4 groups based on reported opioid use: nonusers (between 2005 and 2009), previous users (history of use between 2005 and 2008 but no-use in 2009), and current opioid users (those reporting use of opioids in the 3 months preceding the 2009 American Migraine Prevalence and Prevention survey). Current opioid users were divided into nondependent and probable dependence users according to criteria for dependence adapted for inclusion in the survey from the Diagnostic and Statistical Manual of Mental Disorders-4th edition. All opioid-use groups were contrasted by sociodemographics, headache characteristics, medical and psychiatric comorbidities (depression [measured by the Patient Health Questionnaire-9], anxiety [measured by the Primary Care Evaluation of Mental Health Disorders, PRIME-MD], and cardiovascular events and risk factors), and headache-related HRU.

RESULTS

In a sample of 5796 migraineurs, 4076 (70.3%) were opioid nonusers, 798 (13.8%) were previous users, and 922 (15.9%) were current opioid users. Among current opioid users, 153 (16.6%) met criteria for probable dependence and 769 (83.4%) did not. Headache-related disability (Migraine Disability Assessment sum scores) increased across groups as follows: nonusers: 7.8, previous users: 13.3, current nondependent users: 19.1, and current probable dependence users: 44.4, as did monthly headache frequency: nonusers: 3.2 days/month, previous users: 4.3 days/month, current nondependent users: 5.6 days/month, and current probable dependence users: 8.6 days/month. The prevalence of depression and anxiety was highest among current users with probable dependence. Rates of headache-related HRU were higher for all opioid-use groups for emergency department/urgent care, primary care, and specialty care visits compared to nonusers.

CONCLUSIONS

Opioid use for migraine is associated with more severe headache-related disability, symptomology, comorbidities (depression, anxiety, and cardiovascular disease and events), and greater HRU for headache. Longitudinal studies are needed to further assess the directionality and causality between opioid use and the outcomes we examined.

Dynamic risk factors in the misuse of opioid analgesics

OBJECTIVE

Identify the risk factors for prescription opioid misuse among patients taking prescription opioids to deal with chronic pain.

METHODS

We examined the literature for a variety of dynamic risk factors associated with opioid misuse among the chronic pain population in order to present a narrative review. Considered were: taking single or multiple opioids, pain intensity, mental health disorders, including a history of preadolescent sexual abuse, personal and familial history of substance abuse, a history of legal problems, being a crime victim, drug-seeking behaviors, drug craving, and age.

RESULTS

A variety of risk factors have been studied in the literature. Risk factors in chronic opioid therapy patients are dynamic in that they can change with disease progression, tolerance, changes in pain quality, mental health, comorbidities, other drug therapies or drug interactions, and changes in the patient's lifestyle.

CONCLUSION

Opioid analgesic therapy must be tailored to carefully monitor all patients in order to minimize misuse and abuse, since the risk is constant and dynamic and therefore every patient is at some degree of risk for opioid misuse.

Low use of opioid risk reduction strategies in primary care even for high risk patients with chronic pain

BACKGROUND/OBJECTIVE

Experts recommend close oversight of patients receiving opioid analgesics for chronic non-cancer pain (CNCP), especially those at increased risk of misuse. We hypothesized that physicians employ opioid risk reduction strategies more frequently in higher risk patients.

DESIGN

Retrospective cohort using electronic medical records.

PARTICIPANTS

Patients on long-term opioids (≥3 monthly prescriptions in 6 months) treated for CNCP in eight primary care practices.

METHODS

We examined three risk reduction strategies: (1) any urine drug test; (2) regular office visits (at least once per 6 months and within 30 days of modifying opioid treatment); and (3) restricted early refills (one or fewer opioid refills more than a week early). Risk factors for opioid misuse included: age <45 years old, drug or alcohol use disorder, tobacco use, or mental health disorder. Associations of risk factors with each outcome were assessed in non-linear mixed effects models adjusting for patient clustering within physicians, demographics and clinical factors.

MAIN RESULTS

Of 1,612 patients, 8.0% had urine drug testing, 49.8% visited the office regularly, and 76.6% received restricted (one or fewer) early refills. Patient risk factors were: age <45 (29%), drug use disorder (7.6%), alcohol use disorder (4.5%), tobacco use (16.1%), and mental health disorder (48.4%). Adjusted odds ratios (AOR) of urine drug testing were significantly increased for patients with a drug use disorder (3.18; CI 1.94, 5.21) or a mental health disorder (1.73; CI 1.14, 2.65). However, the AOR for restricted early refills was significantly decreased for patients with a drug use disorder (0.56; CI 0.34, 0.92). After adjustment, no risk factor was significantly associated with regular office visits. An increasing number of risk factors was positively associated with urine drug testing (p < 0.001), but negatively associated with restricted early refills (p = 0.009).

CONCLUSION

Primary care physicians' adoption of opioid risk reduction strategies is limited, even among patients at increased risk of misuse.

Racial differences in primary care opioid risk reduction strategies

PURPOSE

Racial disparities in treating pain with opioids are widely reported; however, differences in use of recommended strategies to reduce the risk of opioid misuse by race/ethnicity have not been evaluated.

METHODS

In a retrospective cohort of black and white patients with chronic noncancer pain prescribed opioid analgesics for at least 3 months, we assessed physicians' use of 3 opioid risk reduction strategies: (1) urine drug testing, (2) regular office visits (at least 1 visit per 6 months on opioids and within 30 days of an opioid change), and (3) restricted early opioid refills (receipt of a refill >1 week early less than twice). Nonlinear mixed effect regression models accounted for clustering within physician and adjusted additively for demographics, substance abuse, mental health and medical comorbidities, health care factors, and practice site.

RESULTS

Of the 1,612 patients studied, 62.1% were black. Black patients were more likely than white patients to receive urine drug testing (10.4% vs 4.1%), regular office visits (56.4% vs 39.0%), and restricted early refills (79.4% vs 72.0%) (P <.001 for each). In fully adjusted models, black patients had significantly higher odds than their white counterparts of receiving regular office visits (odds ratio = 1.51; 95% confidence interval, 1.06-2.14) and restricted early refills (odds ratio = 1.55; 95% confidence interval, 1.03-2.32), but not urine drug testing (odds ratio = 1.41; 95% confidence interval, 0.78-2.54).

CONCLUSIONS

In this cohort of primary care patients receiving opioid analgesics on a long-term basis, use of risk reduction strategies was very limited overall; however, black patients were more likely than white patients to receive 2 of 3 guideline-recommended strategies. These data raise questions about lax monitoring, especially for white patients taking opioids long term.

Clinical factors associated with prescription drug use disorder in urban primary care patients with chronic pain

This study examined characteristics associated with prescription drug use disorder (PDUD) in primary-care patients with chronic pain from a cross-sectional survey conducted at an urban academically affiliated safety-net hospital. Participants were 18 to 60 years old, had pain for ≥ 3 months, took prescription or nonprescription analgesics, and spoke English. Measurements included the Composite International Diagnostic Interview (PDUD, other substance use disorders (SUD), Posttraumatic Stress Disorder [PTSD]); Graded Chronic Pain Scale, smoking status; family history of SUD; and time spent in jail. Of 597 patients (41% male, 61% black, mean age 46 years), 110 (18.4%) had PDUD of whom 99 (90%) had another SUD. In adjusted analyses, those with PDUD were more likely than those without any current or past SUD to report jail time (OR 5.1, 95% CI 2.8-9.3), family history of SUD (OR 3.4, 1.9-6), greater pain-related limitations (OR 3.8, 1.2-11.7), cigarette smoking (OR 3.6, 2-6.2), or to be white (OR 3.2, 1.7-6), male (OR 1.9, 1.1-3.5) or have PTSD (OR 1.9, 1.1-3.4). PDUD appears increased among those with easily identifiable characteristics. The challenge is to determine who, among those with risk factors, can avoid, with proper management, developing the increasingly common diagnosis of PDUD.

PERSPECTIVE

This article examines risk factors for prescription drug use disorder (PDUD) among a sample of primary-care patients with chronic pain at an urban, academic, safety-net hospital. The findings may help clinicians identify those most at risk for developing PDUD when developing appropriate treatment plans.

Characteristics of older adults receiving opioids in primary care: treatment duration and outcomes

OBJECTIVE

To describe characteristics of older adults who received opioids for chronic non-cancer pain (CP), ascertain types of opioid treatments received, and examine associations between patient characteristics and treatment outcomes.

DESIGN

Retrospective cohort study.

SETTING

Primary care practice in New York City.

PATIENTS

Eligible patients were >or=65 and newly started on an opioid for CP.

OUTCOME MEASURES

Patient characteristics and provider treatments, as well as duration of opioid therapy, proportion discontinuing therapy, and evidence of pain reduction and continued use of opioid for more than 1 year. Other outcomes included the presence and type(s) of side effects, abuse/misuse behaviors, and adverse events.

RESULTS

Participants (N = 133) had a mean age of 82 (range = 65-105), were mostly female (84%), and white (74%). Common indications for opioid treatment included back pain (37%) and osteoarthritis (35%). Mean duration of opioid use was 388 days (range = 0-1,880). Short-acting analgesics were most commonly prescribed. Physicians recorded side effects in 40% of cases. Opioids were discontinued in 48% of cases, mostly due to side effects/lack of efficacy. Pain reduction was documented in 66% of patient records, while 32% reported less pain and continued treatment for >or=1 year. Three percent displayed abuse/misuse behaviors, and 5% were hospitalized due to opioid-related adverse events.

CONCLUSIONS

Over 50% of older patients with CP tolerated treatment. Treatment was discontinued in 48% of cases, mostly due to side effects and lack of analgesic efficacy. Efforts are needed to establish the long-term safety and efficacy of opioid treatment for CP in diverse older patient populations.

Pilot study of a preliminary criterion standard for prescription opioid misuse

Multidisciplinary experts created a behaviorally defined preliminary criterion standard definition of probable prescription opioid misuse (PPOM) that could be rated from material found in administrative, pharmacy, and electronic health record databases. They then derived a scoring system to identify PPOM patients requiring referral to a specialist. Experts next rated cases of misuse and nonmisuse. Rater no. 1 correctly differentiated 37 of 40 cases (92.5%); kappa coefficient was .79 (CI: .57, 1.00). Rater no. 2 correctly identified 39 of 40 cases (97.5%); kappa was .94 (CI: .81, 1.00). Kappa for comparing raters was .73 (CI: .49, .98). This preliminary study demonstrates that multidisciplinary raters can use behaviorally based criteria to identify patients with known PPOM from health plan databases.

Self-management support and communication from nurse care managers compared with primary care physicians: a focus group study of patients with chronic musculoskeletal pain

Pain is a critical health problem, with over half of Americans suffering from chronic or recurrent pain. Many patients also experience comorbid depression. Although numerous self-management interventions have been implemented in an effort to improve pain outcomes, little attention has been devoted to the role of the provider of these services, typically a nurse care manager (NCM). Given the robust literature pointing to a link between physician-patient communication and patient outcomes, NCM-patient communication merits closer examination. This paper reports chronic pain patients' perceptions of the communication with NCMs in a pain self-management trial and patients' perceptions of the communication they experienced in primary care. Eighteen patients suffering from chronic musculoskeletal pain and depression participated in four focus groups designed to ascertain their perceptions of the intervention. A key emergent theme from these focus groups was the contrast in patients' perceptions of the communication with their primary care physicians versus with the NCMs. Patients reported feeling supported, encouraged, and listened to by their NCMs, whereas they tended to be dissatisfied with their primary care physicians, citing issues such as lack of continuity of care, poor listening skills, and under- or overprescribing of medication. The results of this study underscore the importance of the NCM, particularly for patients with chronic conditions such as pain.

Addressing the intersecting problems of opioid misuse and chronic pain treatment

Misuse of prescription opioid medications has continued as a major public health problem in the United States. Review of major epidemiologic databases shows that the prevalence of opioid misuse rose markedly through the 1990s and the early part of the current decade. In this same period of time, the number of prescriptions for chronic noncancer pain increased markedly, and the intersection of these two public health problems remains a concern. Further, despite some leveling off of the overall rate of prescription opioid misuse in the past several years, surveillance data show high and increasing mortality associated with these drugs. Analysis of the 2006 National Survey of Drug Use and Health indicates the increasing prevalence of prescription opioid misuse is associated more with an increase in the general availability of these medications than misuse of the medications by those who were directly prescribed them. National Institute on Drug Abuse initiatives to address the prescription opioid problem include programs to stimulate research in the basic and clinical sciences, and to educate physicians and other health personnel.