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Buonora M, Perez HR, Heo M, Cunningham CO, Starrels JL. Race and Gender Are Associated with Opioid Dose Reduction Among Patients on Chronic Opioid Therapy. PAIN MEDICINE 2020; 20:1519-1527. [PMID: 30032197 DOI: 10.1093/pm/pny137] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Among patients with chronic pain, risk of opioid use is elevated with high opioid dose or concurrent benzodiazepine use. This study examined whether these clinical factors, or sociodemographic factors of race and gender, are associated with opioid dose reduction. DESIGN AND SETTING A retrospective cohort study of outpatients prescribed chronic opioid therapy between 2007 and 2012 within a large, academic health care system in Bronx, New York, using electronic medical record data. Included patients were prescribed a stable dose of chronic opioid therapy over a one-year "baseline period" and did not have cancer. METHODS The primary outcome was opioid dose reduction (≥30% reduction from baseline) within two years. Multivariable logistic regression tested the associations of two clinical variables (baseline daily opioid dose and concurrent benzodiazepine prescription) and two sociodemographic variables (race/ethnicity and gender) with opioid dose reduction. RESULTS Of 1,097 patients, 463 (42.2%) had opioid dose reduction. High opioid dose (≥100 morphine-milligram equivalents [MME]) was associated with lower odds of opioid dose reduction compared with an opioid dose <100 MME (adjusted odds ratio [AOR] = 0.69, 95% confidence interval [CI] = 0.54-0.89). Concurrent benzodiazepine prescription was not associated with opioid dose reduction. Black (vs white) race and female (vs male) gender were associated with greater odds of opioid dose reduction (AOR = 1.82, 95% CI = 1.22-2.70; and AOR = 1.43, 95% CI = 1.11-1.83, respectively). CONCLUSIONS Black race and female gender were associated with greater odds of opioid dose reduction, whereas clinical factors of high opioid dose and concurrent benzodiazepine prescription were not. Efforts to reduce opioid dose should target patients based on clinical factors and address potential biases in clinical decision-making.
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Affiliation(s)
| | - Hector R Perez
- Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
| | - Moonseong Heo
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Chinazo O Cunningham
- Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
| | - Joanna L Starrels
- Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
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Ziadni MS, Chen AL, Winslow T, Mackey SC, Darnall BD. Efficacy and mechanisms of a single-session behavioral medicine class among patients with chronic pain taking prescription opioids: study protocol for a randomized controlled trial. Trials 2020; 21:521. [PMID: 32532346 PMCID: PMC7290153 DOI: 10.1186/s13063-020-04415-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 05/14/2020] [Indexed: 01/28/2023] Open
Abstract
Background Independent of pain intensity, pain-specific distress is highly predictive of pain treatment needs, including the need for prescription opioids. Given the inherently distressing nature of chronic pain, there is a need to equip individuals with pain education and self-regulatory skills that are shown to improve adaptation and improve their response to medical treatments. Brief, targeted behavioral medicine interventions may efficiently address the key individual factors, improve self-regulation in the context of pain, and reduce the need for opioid therapy. This highlights the critical need for targeted, cost-effective interventions that efficiently address the key psychological factors that can amplify the need for opioids and increased risk for misuse. In this trial, the primary goal is to test the comparative efficacy of a single-session skills-based pain management class to a health education active control group among patients with chronic pain who are taking opioids. Methods/design Our study is a randomized, double-blind clinical trial testing the superiority of our 2-h, single-session skills-based pain management class against a 2-h health education class. We will enroll 136 adult patients with mixed-etiology chronic pain who are taking opioid prescription medication and randomize 1:1 to one of the two treatment arms. We hypothesize superiority for the skills-based pain class for pain control, self-regulation of pain-specific distress, and reduced opioid use measured by daily morphine equivalent. Team researchers masked to treatment assignment will assess outcomes up to 12 months post treatment. Discussion This study aims to test the utility of a single-session, 2-h skills-based pain management class to improve self-regulation of pain and reduce opioid use. Findings from our project have the potential to shift current research and clinical paradigms by testing a brief and scalable intervention that could reduce the need for opioids and prevent misuse effectively, efficiently, and economically. Further, elucidation of the mechanisms of opioid use can facilitate refinement of more targeted future treatments. Trial registration ClinicalTrials.gov, ID: NCT03950791. Registered on 10 May 2019.
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Affiliation(s)
- Maisa S Ziadni
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford University, 1070 Arastradero Road, Suite 200, Palo Alto, CA, 94304, USA. .,Division of Pain Medicine, Stanford Systems Neuroscience and Pain Laboratory, Stanford University School of Medicine, 1070 Arastradero Road, Suite 200, MC 2C2728, Palo Alto, CA, 94304, USA.
| | - Abby L Chen
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford University, 1070 Arastradero Road, Suite 200, Palo Alto, CA, 94304, USA
| | - Tyler Winslow
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford University, 1070 Arastradero Road, Suite 200, Palo Alto, CA, 94304, USA
| | - Sean C Mackey
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford University, 1070 Arastradero Road, Suite 200, Palo Alto, CA, 94304, USA
| | - Beth D Darnall
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford University, 1070 Arastradero Road, Suite 200, Palo Alto, CA, 94304, USA
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D Sullivan M, Boudreau D, Ichikawa L, Cronkite D, Albertson-Junkans L, Salgado G, VonKorff M, Carrell DS. Primary Care Opioid Taper Plans Are Associated with Sustained Opioid Dose Reduction. J Gen Intern Med 2020; 35:687-695. [PMID: 31907789 PMCID: PMC7080895 DOI: 10.1007/s11606-019-05445-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 09/26/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Primary care providers prescribe most long-term opioid therapy and are increasingly asked to taper the opioid doses of these patients to safer levels. A recent systematic review suggests that multiple interventions may facilitate opioid taper, but many of these are not feasible within the usual primary care practice. OBJECTIVE To determine if opioid taper plans documented by primary care providers in the electronic health record are associated with significant and sustained opioid dose reductions among patients on long-term opioid therapy. DESIGN A nested case-control design was used to compare cases (patients with a sustained opioid taper defined as average daily opioid dose of ≤ 30 mg morphine equivalent (MME) or a 50% reduction in MME) to controls (patients matched to cases on year and quarter of cohort entry, sex, and age group, who had not achieved a sustained taper). Each case was matched with four controls. PARTICIPANTS Two thousand four hundred nine patients receiving a ≥ 60-day supply of opioids with an average daily dose of ≥ 50 MME during 2011-2015. MAIN MEASURES Opioid taper plans documented in prescription instructions or clinical notes within the electronic health record identified through natural language processing; opioid dosing, patient characteristics, and taper plan components also abstracted from the electronic health record. KEY RESULTS Primary care taper plans were associated with an increased likelihood of sustained opioid taper after adjusting for all patient covariates and near peak dose (OR = 3.63 [95% CI 2.96-4.46], p < 0.0001). Both taper plans in prescription instructions (OR = 4.03 [95% CI 3.19-5.09], p < 0.0001) and in clinical notes (OR = 2.82 [95% CI 2.00-3.99], p < 0.0001) were associated with sustained taper. CONCLUSIONS These results suggest that planning for opioid taper during primary care visits may facilitate significant and sustained opioid dose reduction.
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Affiliation(s)
| | - Denise Boudreau
- Kaiser Permanente Washington Research Institute, Seattle, WA, USA
| | - Laura Ichikawa
- Kaiser Permanente Washington Research Institute, Seattle, WA, USA
| | - David Cronkite
- Kaiser Permanente Washington Research Institute, Seattle, WA, USA
| | | | - Gladys Salgado
- Kaiser Permanente Washington Research Institute, Seattle, WA, USA
| | - Michael VonKorff
- Kaiser Permanente Washington Research Institute, Seattle, WA, USA
| | - David S Carrell
- Kaiser Permanente Washington Research Institute, Seattle, WA, USA
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Danielson EC, Mazurenko O, Andraka-Christou BT, DiIulio J, Downs SM, Hurley RW, Harle CA. An Analysis of Primary Care Clinician Communication About Risk, Benefits, and Goals Related to Chronic Opioid Therapy. MDM Policy Pract 2019; 4:2381468319892572. [PMID: 31853506 PMCID: PMC6906357 DOI: 10.1177/2381468319892572] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 10/19/2019] [Indexed: 11/15/2022] Open
Abstract
Background. Safe opioid prescribing and effective pain care are particularly important issues in the United States, where decades of widespread opioid prescribing have contributed to high rates of opioid use disorder. Because of the importance of clinician-patient communication in effective pain care and recent initiatives to curb rising opioid overdose deaths, this study sought to understand how clinicians and patients communicate about the risks, benefits, and goals of opioid therapy during primary care visits. Methods. We recruited clinicians and patients from six primary care clinics across three health systems in the Midwest United States. We audio-recorded 30 unique patients currently receiving opioids for chronic noncancer pain from 12 clinicians. We systematically analyzed transcribed, clinic visits to identify emergent themes. Results. Twenty of the 30 patient participants were females. Several patients had multiple pain diagnoses, with the most common diagnoses being osteoarthritis (n = 10), spondylosis (n = 6), and low back pain (n = 5). We identified five themes: 1) communication about individual-level and population-level risks, 2) communication about policies or clinical guidelines related to opioids, 3) communication about the limited effectiveness of opioids for chronic pain conditions, 4) communication about nonopioid therapies for chronic pain, and 5) communication about the goal of the opioid tapering. Conclusions. Clinicians discuss opioid-related risks in varying ways during patient visits, which may differentially affect patient experiences. Our findings may inform the development and use of more standardized approaches to discussing opioids during primary care visits.
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Affiliation(s)
- Elizabeth C Danielson
- Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana
| | - Olena Mazurenko
- Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana
| | | | | | - Sarah M Downs
- Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana
| | - Robert W Hurley
- Wake Forest University School of Medicine, Winston Salem, North Carolina
| | - Christopher A Harle
- Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana
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de Heer EW, Dekker J, Beekman ATF, van Marwijk HWJ, Holwerda TJ, Bet PM, Roth J, Timmerman L, van der Feltz-Cornelis CM. Comparative Effect of Collaborative Care, Pain Medication, and Duloxetine in the Treatment of Major Depressive Disorder and Comorbid (Sub)Chronic Pain: Results of an Exploratory Randomized, Placebo-Controlled, Multicenter Trial (CC:PAINDIP). Front Psychiatry 2018; 9:118. [PMID: 29674981 PMCID: PMC5895661 DOI: 10.3389/fpsyt.2018.00118] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 03/20/2018] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Evidence exists for the efficacy of collaborative care (CC) for major depressive disorder (MDD), for the efficacy of the consequent use of pain medication against pain, and for the efficacy of duloxetine against both MDD and neuropathic pain. Their relative effectiveness in comorbid MDD and pain has never been established so far. This study explores the effectiveness of CC with pain medication and duloxetine, and CC with pain medication and placebo, compared with duloxetine alone, on depressive and pain symptoms. This study was prematurely terminated because of massive reorganizations and reimbursement changes in mental health care in the Netherlands during the study period and is therefore of exploratory nature. METHODS Three-armed, randomized, multicenter, placebo-controlled trial at three specialized mental health outpatient clinics with patients who screened positive for MDD. Interventions lasted 12 weeks. Pain medication was administered according to an algorithm that avoids opiate prescription as much as possible, where paracetamol, COX inhibitors, and pregabalin are offered as steps before opiates are considered. Patients who did not show up for three or more sessions were registered as non-compliant. Explorative, intention-to-treat and per protocol, multilevel regression analyses were performed. The trial is listed in the trial registration (http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1089; NTR number: NTR1089). RESULTS Sixty patients completed the study. Patients in all treatment groups reported significantly less depressive and pain symptoms after 12 weeks. CC with placebo condition showed the fastest decrease in depressive symptoms compared with the duloxetine alone group (b = -0.78; p = 0.01). Non-compliant patients (n = 31) did not improve over the 12-week period, in contrast to compliant patients (n = 29). Pain outcomes did not differ between the three groups. CONCLUSION In MDD and pain, patient's compliance and placebo effects are more important in attaining effect than choice of one of the treatments. Active pain management with COX inhibitors and pregabalin as alternatives to tramadol or other opiates might provide an attractive alternative to the current WHO pain ladder as it avoids opiate prescription as much as possible. The generalizability is limited due to the small sample size. Larger studies are needed.
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Affiliation(s)
- Eric W. de Heer
- GGz Breburg, Clinical Centre of Excellence for Body, Mind and Health, Tilburg, Netherlands
- Tranzo Department, Tilburg School of Behavioral and Social Sciences, Tilburg University, Tilburg, Netherlands
| | - Jack Dekker
- Faculty of Behavioral and Movement Sciences, VU University, Amsterdam, Netherlands
- Arkin, Mental Health Institute, Amsterdam, Netherlands
| | - Aartjan T. F. Beekman
- Department of Psychiatry, VU University Medical Centre, Amsterdam, Netherlands
- GGz inGeest, Mental Health Institute, Amsterdam, Netherlands
| | - Harm W. J. van Marwijk
- EMGO Institute for Health and Care Research (EMGO+), Amsterdam, Netherlands
- Department of General Practice, VU University Medical Centre, Amsterdam, Netherlands
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, United Kingdom
| | | | - Pierre M. Bet
- Department of Clinical Pharmacology and Pharmacy, VU University Medical Centre, Amsterdam, Netherlands
| | - Joost Roth
- GGz inGeest, Mental Health Institute, Amsterdam, Netherlands
| | - Lotte Timmerman
- GGz Breburg, Clinical Centre of Excellence for Body, Mind and Health, Tilburg, Netherlands
| | - Christina M. van der Feltz-Cornelis
- GGz Breburg, Clinical Centre of Excellence for Body, Mind and Health, Tilburg, Netherlands
- Tranzo Department, Tilburg School of Behavioral and Social Sciences, Tilburg University, Tilburg, Netherlands
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