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Seymour RB, Wally MK, Hsu JR. Impact of clinical decision support on controlled substance prescribing. BMC Med Inform Decis Mak 2023; 23:234. [PMID: 37864226 PMCID: PMC10588193 DOI: 10.1186/s12911-023-02314-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 09/29/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND Prescription drug overdose and misuse has reached alarming numbers. A persistent problem in clinical care is lack of easy, immediate access to all relevant information at the actionable time. Prescribers must digest an overwhelming amount of information from each patient's record as well as remain up-to-date with current evidence to provide optimal care. This study aimed to describe prescriber response to a prospective clinical decision support intervention designed to identify patients at risk of adverse events associated with misuse of prescription opioids/benzodiazepines and promote adherence to clinical practice guidelines. METHODS This study was conducted at a large multi-center healthcare system, using data from the electronic health record. A prospective observational study was performed as clinical decision support (CDS) interventions were sequentially launched (January 2016-July 2019). All data were captured from the medical record prospectively via the CDS tools implemented. A consecutive series of all patient encounters including an opioid/benzodiazepine prescription were included in this study (n = 61,124,172 encounters; n = 674,785 patients). Physician response to the CDS interventions was the primary outcome, and it was assessed over time using control charts. RESULTS An alert was triggered in 23.5% of encounters with a prescription (n = 555,626). The prescriber decision was influenced in 18.1% of these encounters (n = 100,301). As the number of risk factors increased, the rate of decision being influenced also increased (p = 0.0001). The effect of the alert differed by drug, risk factor, specialty, and facility. CONCLUSION The delivery of evidence-based, patient-specific information had an influence on the final prescription in nearly 1 in 5 encounters. Our intervention was sustained with minimal prescriber fatigue over many years in a large and diverse health system.
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Affiliation(s)
- Rachel B Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, 1000 Blythe Boulevard, Charlotte, NC, 28203, USA.
- Atrium Health Musculoskeletal Institute, 2001 Vail Avenue, 6th floor, Charlotte, NC, 28207, USA.
| | - Meghan K Wally
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, 1000 Blythe Boulevard, Charlotte, NC, 28203, USA
| | - Joseph R Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, 1000 Blythe Boulevard, Charlotte, NC, 28203, USA
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2
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Brondeel KC, Malone KT, Ditmars FR, Vories BA, Ahmadzadeh S, Tirumala S, Fox CJ, Shekoohi S, Cornett EM, Kaye AD. Algorithms to Identify Nonmedical Opioid Use. Curr Pain Headache Rep 2023; 27:81-88. [PMID: 37022564 DOI: 10.1007/s11916-023-01104-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2023] [Indexed: 04/07/2023]
Abstract
The rise in nonmedical opioid overdoses over the last two decades necessitates improved detection technologies. Manual opioid screening exams can exhibit excellent sensitivity for identifying the risk of opioid misuse but can be time-consuming. Algorithms can help doctors identify at-risk people. In the past, electronic health record (EHR)-based neural networks outperformed Drug Abuse Manual Screenings in sparse studies; however, recent data shows that it may perform as well or less than manual screenings. Herein, a discussion of several different manual screenings and recommendations is contained, along with suggestions for practice. A multi-algorithm approach using EHR yielded strong predictive values of opioid use disorder (OUD) over a large sample size. A POR (Proove Opiate Risk) algorithm provided a high sensitivity for categorizing the risk of opioid abuse within a small sample size. All established screening methods and algorithms reflected high sensitivity and positive predictive values. Neural networks based on EHR also showed significant effectiveness when corroborated with Drug Abuse Manual Screenings. This review highlights the potential of algorithms for reducing provider costs and improving the quality of care by identifying nonmedical opioid use (NMOU) and OUD. These tools can be combined with traditional clinical interviewing, and neural networks can be further refined while expanding EHR.
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Affiliation(s)
- Kimberley C Brondeel
- University of Texas Medical Branch, University of Texas, 301 University Blvd, 77555, Galveston, TX, USA
| | - Kevin T Malone
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, LA, 71103, Shreveport, USA
| | - Frederick R Ditmars
- University of Texas Medical Branch, University of Texas, 301 University Blvd, 77555, Galveston, TX, USA
| | - Bridget A Vories
- University of Texas Medical Branch, University of Texas, 301 University Blvd, 77555, Galveston, TX, USA
| | - Shahab Ahmadzadeh
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA
| | - Sridhar Tirumala
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA
| | - Charles J Fox
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA
| | - Sahar Shekoohi
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA.
| | - Elyse M Cornett
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA
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3
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Strigo IA, Murphy E, Mitchell JM, Spadoni AD. Learning from addiction: Craving of prescription opioids in chronic pain sufferers. Neurosci Biobehav Rev 2022; 142:104904. [PMID: 36202255 PMCID: PMC10917419 DOI: 10.1016/j.neubiorev.2022.104904] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/30/2022] [Accepted: 10/01/2022] [Indexed: 01/19/2023]
Abstract
Prescription opioids are a primary driver of opioid-related deaths. Although craving is a substantial component of OUD, the degree to which craving leads to misuse among chronic pain patients on long-term prescription opioids is unknown. A clear understanding of the factors that lead to misuse in this vulnerable population is needed for the development of safe and effective practices for opioid taper. This narrative review summarizes the relevant literature on the role of craving in addiction and chronic pain through epidemiological and behavioral studies. The first part of this review examines the role of craving in predicting opioid use/misuse in individuals with chronic pain with and without OUD. The second part covers methods on how craving is evaluated experimentally using both subjective and objective measures and provides related findings. The overall goal of this review is to facilitate the development of a population-specific description of craving in those who use opioids to control chronic pain and to describe how it may be mechanistically linked to patterns of opioid (mis)use.
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Affiliation(s)
- Irina A Strigo
- Emotion and Pain Laboratory, San Francisco Veterans Affairs Healthcare Center, 4150 Clement Street, San Francisco, CA 94121, USA; Department of Psychiatry, University of California San Francisco, 401 Parnassus Ave, San Francisco, CA 94143, USA.
| | - Emily Murphy
- Emotion and Pain Laboratory, San Francisco Veterans Affairs Healthcare Center, 4150 Clement Street, San Francisco, CA 94121, USA
| | - Jennifer M Mitchell
- Department of Psychiatry, University of California San Francisco, 401 Parnassus Ave, San Francisco, CA 94143, USA; Department of Neurology, University of California San Francisco, 401 Parnassus Ave, San Francisco, CA 94143, USA
| | - Andrea D Spadoni
- San Diego Veterans Affairs Healthcare Center, 3350 La Jolla Village Drive, San Diego, CA 92121, USA; Department of Psychiatry, University of California San Diego, San Diego, CA 92300, USA
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4
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AlFaraj A, AlFaraidy M, AlZaher Z, Al Wosaibai A, AlShabeb A, AlHashim H, AlKhulaif Z. Continuous local anesthetic wound infusion: Impact on pain score and opioid use in patients undergoing elective mastectomy. Saudi J Anaesth 2022; 16:374-378. [DOI: 10.4103/sja.sja_874_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/11/2022] [Accepted: 03/04/2022] [Indexed: 11/04/2022] Open
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Turner HN, Oliver J, Compton P, Matteliano D, Sowicz TJ, Strobbe S, St Marie B, Wilson M. Pain Management and Risks Associated With Substance Use: Practice Recommendations. Pain Manag Nurs 2021; 23:91-108. [PMID: 34965906 DOI: 10.1016/j.pmn.2021.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 11/13/2021] [Indexed: 01/08/2023]
Abstract
Assessing and managing pain while evaluating risks associated with substance use and substance use disorders continues to be a challenge faced by health care clinicians. The American Society for Pain Management Nursing and the International Nurses Society on Addictions uphold the principle that all persons with co-occurring pain and substance use or substance use disorders have the right to be treated with dignity and respect, and receive evidence-based, high quality assessment, and management for both conditions. The American Society for Pain Management Nursing and International Nurses Society on Addictions have updated their 2012 position statement on this topic supporting an integrated, holistic, multidimensional approach, which includes nonopioid and nonpharmacological modalities. Opioid use disorder is used as an exemplar for substance use disorders and clinical recommendations are included with expanded attention to risk assessment and mitigation with interventions targeted to minimize the risk for relapse or escalation of substance use. Opioids should not be excluded for anyone when indicated for pain management. A team-based approach is critical, promotes the active involvement of the person with pain and their support systems, and includes pain and addiction specialists whenever possible. Health care systems should establish policies and procedures that facilitate and support the principles and recommendations put forth in this article.
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Affiliation(s)
| | - June Oliver
- Swedish Hospital, Northshore University Healthsystem, Chicago, IL.
| | | | | | | | | | - Barbara St Marie
- University of Iowa College of Nursing, Washington State University, College of Nursing
| | - Marian Wilson
- Oregon Health & Science University School of Nursing; Washington State University, College of Nursing
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6
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You DS, Mardian AS, Darnall BD, Chen CYA, De Bruyne K, Flood PD, Kao MC, Karnik AD, McNeely J, Porter JG, Schwartz RP, Stieg RL, Mackey SC. A Brief Screening Tool for Opioid Use Disorder: EMPOWER Study Expert Consensus Protocol. Front Med (Lausanne) 2021; 8:591201. [PMID: 33869240 PMCID: PMC8044786 DOI: 10.3389/fmed.2021.591201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 02/23/2021] [Indexed: 11/13/2022] Open
Abstract
Growing concerns about the safety of long-term opioid therapy and its uncertain efficacy for non-cancer pain have led to relatively rapid opioid deprescribing in chronic pain patients who have been taking opioid for years. To date, empirically supported processes for safe and effective opioid tapering are lacking. Opioid tapering programs have shown high rates of dropouts and increases in patient distress and suicidal ideation. Therefore, safe strategies for opioid deprescribing that are more likely to succeed are urgently needed. In response to this demand, the EMPOWER study has been launched to examine the effectiveness of behavioral medicine strategies within the context of patient-centered opioid tapering in outpatient settings (https://empower.stanford.edu/). The EMPOWER protocol requires an efficient process for ensuring that collaborative opioid tapering would be offered to the most appropriate patients while identifying patients who should be offered alternate treatment pathways. As a first step, clinicians need a screening tool to identify patients with Opioid Use Disorder (OUD) and to assess for OUD severity. Because such a tool is not available, the study team composed of eight chronic pain and/or addiction experts has extended a validated screening instrument to develop a brief and novel consensus screening tool to identify OUD and assess for OUD severity for treatment stratification. Our screening tool has the potential to assist busy outpatient clinicians to assess OUD among patients receiving long-term opioid therapy for chronic pain.
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Affiliation(s)
- Dokyoung S You
- Department Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Aram S Mardian
- Department of Family, Community and Preventive Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States.,Phoenix VA Health Care System, Phoenix, AZ, United States
| | - Beth D Darnall
- Department Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Chwen-Yuen A Chen
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Korina De Bruyne
- Division of Primary, Preventive, and Community Care, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Pamela D Flood
- Department Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Ming-Chih Kao
- Department Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Anita D Karnik
- Phoenix VA Health Care System, Department of Psychiatry, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States
| | - Jennifer McNeely
- Department of Population Health, Section on Tobacco, Alcohol, and Drug Use, New York University School of Medicine, New York, NY, United States
| | - Joel G Porter
- Intermountain Healthcare, Family Medicine, Layton, UT, United States
| | | | | | - Sean C Mackey
- Department Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
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7
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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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8
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Acuña JP. RIESGO DE ADICCIÓN A ANALGÉSICOS OPIOIDES EN EL TRATAMIENTO DE DOLOR CRÓNICO NO ONCOLÓGICO. REVISTA MÉDICA CLÍNICA LAS CONDES 2019. [DOI: 10.1016/j.rmclc.2019.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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9
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Galindo SR, da Nóbrega Marinho MH, Gatchel RJ, de Paula Santana da Silva T, Viana EHS, Vasconcelos SC, da Costa Lima MD. Cross-cultural adaptation of the Pain Medication Questionnaire for use in Brazil. BMC Med Res Methodol 2019; 19:188. [PMID: 31547804 PMCID: PMC6757373 DOI: 10.1186/s12874-019-0821-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 08/15/2019] [Indexed: 01/14/2023] Open
Abstract
Background The Pain Medication Questionnaire (PMQ) assesses the risk of opioid abuse in people with non-oncological chronic pain. Methods This is a methodological study conducted at a hemotherapy centre in Recife, Pernambuco state, Brazil. A Cross-cultural adaptation was carried out by a committee of nine specialists, and we applied the PMQ to a pre-final sample of 40 individuals with sickle cell anemia, in addition to a sociodemographic and clinical questionnaire. Results The mean agreement indexes for PMQ equivalences were the following: semantic (0.996), idiomatic (0.970), experiential (0.991), conceptual (0.953), language clarity (0.991), practical relevance (0.906), and theoretical relevance (0.945). Assessment of the PMQ showed that 50% of participants obtained a score equivalent to medium risk of opioid abuse. Cronbach’s alpha coefficient for the adapted PMQ instrument was 0.705, ranging from 0.641 to 0.736 among its items. Conclusion The cross-cultural adaptation of the Pain Medication Questionnaire was satisfactory and easy to apply in the Brazilian population. It is clinically relevant, contributing professional practice and enlightening patients with sickle cell anemia on their behavioral dynamics with respect to opioid consumption. It will also contribute to teaching and research, because it is a useful tool for investigating the risk of abusive behavior in people with chronic pain. Electronic supplementary material The online version of this article (10.1186/s12874-019-0821-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sheila Raposo Galindo
- Neuropsychiatry and Behavioral Sciences, Federal University of Pernambuco (UFPE), Av. João Cardoso Ayres, 480, Boa Viagem, Recife, Pernambuco, Brazil.
| | | | | | | | | | - Selene Cordeiro Vasconcelos
- Neuroscience, Neuropsychiatry and Behavioral Sciences, Federal University of Paraíba (UFPB), João Pessoa, Paraíba, Brazil
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10
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Esposito DB, Cepeda MS, Lyons JG, Yin R, Lanes S. Medical record-based ascertainment of behaviors suggestive of opioid misuse, diversion, abuse, and/or addiction among individuals showing evidence of doctor/pharmacy shopping. J Pain Res 2019; 12:2291-2303. [PMID: 31413626 PMCID: PMC6661981 DOI: 10.2147/jpr.s203350] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 05/24/2019] [Indexed: 12/04/2022] Open
Abstract
Objectives Doctor/pharmacy shopping, the practice of seeking prescriptions from multiple healthcare sources without their coordination, may be a measure of prescription medicine abuse. This cross-sectional study examined the relationship between a claims-based doctor/pharmacy shopping definition and medical record documented behaviors suggestive of misuse, diversion, abuse and/or addiction. Methods Patients with ≥2 opioid dispensings starting in 2012 in a US administrative claims database were grouped into doctor/pharmacy shopping categories by number of providers and pharmacies used over 18 months: no shopping, minimal shopping, moderate shopping and severe shopping. Medical charts of opioid prescribers were reviewed to identify behaviors suggestive of misuse, diversion, abuse and/or addiction. Results Among 581,940 opioid users, 78% were classified as no shopping, 11% minimal shopping, 8% moderate shopping and 3% severe shopping. Almost 40% of severe shopping patients had no medical record documented behaviors (positive predictive value: 24.3%). Compared with no shopping, the odds ratio [OR] of ≥3 behaviors was 1.70 (95% confidence interval [CI] 0.50–5.78) for minimal shopping, 1.81 (95% CI 0.54–6.03) for moderate shopping, and 8.93 (95% CI 3.12–25.54) for severe shopping. Conclusions Claims-identified severe doctor/pharmacy shopping was strongly associated with behaviors suggestive of misuse, diversion, abuse and/or addiction, but the proportion of medical records documenting these was low.
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Affiliation(s)
- Daina B Esposito
- Department of Safety and Epidemiology, HealthCore, Inc, Wilmington, DE, USA
| | - M Soledad Cepeda
- Department of Research and Development, Janssen, Titusville, NJ, USA
| | - Jennifer G Lyons
- Department of Safety and Epidemiology, HealthCore, Inc, Wilmington, DE, USA
| | - Ruihua Yin
- Department of Safety and Epidemiology, HealthCore, Inc, Wilmington, DE, USA
| | - Stephan Lanes
- Department of Safety and Epidemiology, HealthCore, Inc, Wilmington, DE, USA
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11
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Oberleitner LMS, Lumley MA, Grekin ER, M Z Smith K, Loree AM, Carty JN, Valentino D. Problematic Prescription Opioid Use in a Chronic Pain Treatment Facility: The Role of Emotional Processes. Subst Use Misuse 2019; 54:495-505. [PMID: 30380985 DOI: 10.1080/10826084.2018.1521426] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Factors associated with prescription opioid misuse in a chronic pain treatment population are limited, and increasing our understanding of associated factors could lead to improved targeting of prevention and intervention efforts. OBJECTIVE The aim of this study was to evaluate factors associated with problematic prescription opioid use in patients with chronic pain, and whether assessing emotional processes - alexithymia, ambivalence over emotional expression (AEQ), and emotional approach coping - improves understanding of problematic prescription opioid use beyond traditional risk factors. METHODS Participants were 100 patients with chronic pain (mean age = 47.57 years, SD = 11.57; 53% female; 81% African American) who were receiving a self-administered opioid medication through a local pain clinic. We assessed traditional risk factors (substance use history, pain, psychiatric distress, and pain catastrophizing), the three emotional processes, and problematic prescription opioid-related outcomes. RESULTS Zero-order correlations revealed that alexithymia was significantly, positively related to problematic prescription opioid use behaviors (PDUQ), and AEQ was significantly positively related to both prescription opioid misuse behaviors and opioid use disorder symptoms. Multiple regressions that included traditional risk factors and the three emotional processes indicated that AEQ was a unique correlate of problematic opioid use behaviors (β=.27, p=.04) and prescription opioid-related symptoms of abuse and dependence (β=.37, p=.01); history of substance use disorders was also associated. CONCLUSIONS In addition to personal history of substance use problems, AEQ is a modifiable risk factor - and thus potential treatment target - for prescription opioid misuse and opioid use disorders.
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Affiliation(s)
- Lindsay M S Oberleitner
- a Department of Psychology , Wayne State University , New Haven, Michigan , USA.,b Department of Psychiatry , Yale University School of Medicine , New Haven , Connecticut , USA
| | - Mark A Lumley
- a Department of Psychology , Wayne State University , New Haven, Michigan , USA
| | - Emily R Grekin
- a Department of Psychology , Wayne State University , New Haven, Michigan , USA
| | - Kathryn M Z Smith
- a Department of Psychology , Wayne State University , New Haven, Michigan , USA.,c Department of Psychiatry, Division on Substance Abuse , Columbia University Medical Center/New York State Psychiatric Institute , New York , New York , USA
| | - Amy M Loree
- a Department of Psychology , Wayne State University , New Haven, Michigan , USA.,d Henry Ford Health System , Center for Health Services Research , Detroit , Michigan , USA
| | - Jennifer N Carty
- a Department of Psychology , Wayne State University , New Haven, Michigan , USA.,e Department of Family Medicine & Community Health , University of Massachusetts Medical School , Worcester , Massachusetts , USA
| | - Deborah Valentino
- a Department of Psychology , Wayne State University , New Haven, Michigan , USA
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12
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Black RA, McCaffrey SA, Villapiano AJ, Jamison RN, Butler SF. Development and Validation of an Eight-Item Brief Form of the SOAPP-R (SOAPP-8). PAIN MEDICINE 2018; 19:1982-1987. [PMID: 29024987 DOI: 10.1093/pm/pnx194] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective Although the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) has become a widely used screener for aberrant opioid-related behavior in adults, the length of the instrument may limit its utility. The purpose of the current study was to develop a short form of the SOAPP-R by retaining as few items as possible while maximizing predictive accuracy. Methods Participants (N = 555), recruited from pain clinics, completed the 24-item SOAPP-R and participated in a five-month follow-up visit to evaluate aberrant drug-related behaviors. Opioid aberrant-related behavior was determined through self-report, physician report, and urine toxicology screen. The optimal subset of SOAPP-R items to predict aberrant opioid-related behavior was identified empirically by employing the LASSO selection method and the leave-one-out cross-validation (LOOCV) method offered in the GLMSELECT procedure in SAS 9.4 in conjunction with content expertise. Results Eight items were identified before the selection method stopped. The receiver operating characteristic curve generated from the predicted probabilities from the model produced an area under the curve (AUC) value greater than the AUC value produced by the 24-item SOAPP-R total score and yielded a sensitivity of 0.74 and a specificity of 0.66. Conclusions These results provide strong preliminary support for the SOAPP-8 as a brief screening tool of aberrant opioid-related behavior in chronic pain patients.
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Affiliation(s)
| | | | | | - Robert N Jamison
- Anesthesia and Psychiatry, Brigham and Women's Hospital, Boston, MA
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13
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Wilson‐Poe AR, Morón JA. The dynamic interaction between pain and opioid misuse. Br J Pharmacol 2018; 175:2770-2777. [PMID: 28602044 PMCID: PMC6016619 DOI: 10.1111/bph.13873] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 04/21/2017] [Accepted: 05/09/2017] [Indexed: 12/22/2022] Open
Abstract
In 2014, drug overdose surpassed automobile accidents as the number one cause of accidental death for the first time in the history of the United States. The overdose epidemic is largely driven by opioids, and genuine prescription opioid analgesics play the biggest role in this phenomenon. Despite advancements in abuse deterrent formulations, prescription drug monitoring programmes and clinical assessments for the detection of abuse potential, drug overdoses continue to escalate. The Center for Disease Control has recently issued new guidelines for opioid prescription, yet even these recommendations have their shortcomings. Furthermore, undertreated pain in patients with comorbid substance use disorder poses a major clinical challenge, particularly for patients on opioid replacement therapy. Despite the seemingly obvious interaction between the presence of pain and the abuse of pain-relieving opioids, there is surprisingly little mechanistic data to further our understanding of this vitally important topic. The need for novel pain interventions that minimize abuse liability is critical. Without a fundamental characterization of pain neurobiology and the interaction between chronic pain and the brain's reward system, we are unlikely to make progress in the alleviation of the opioid epidemic. LINKED ARTICLES This article is part of a themed section on Emerging Areas of Opioid Pharmacology. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v175.14/issuetoc.
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Affiliation(s)
- Adrianne R Wilson‐Poe
- Pain Center, Department of AnesthesiologyWashington University School of MedicineSt. LouisMOUSA
| | - Jose A Morón
- Pain Center, Department of AnesthesiologyWashington University School of MedicineSt. LouisMOUSA
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14
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Higgins C, Smith B, Matthews K. Incidence of iatrogenic opioid dependence or abuse in patients with pain who were exposed to opioid analgesic therapy: a systematic review and meta-analysis. Br J Anaesth 2018; 120:1335-1344. [DOI: 10.1016/j.bja.2018.03.009] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 02/16/2018] [Accepted: 03/16/2018] [Indexed: 11/24/2022] Open
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Severino AL, Shadfar A, Hakimian JK, Crane O, Singh G, Heinzerling K, Walwyn WM. Pain Therapy Guided by Purpose and Perspective in Light of the Opioid Epidemic. Front Psychiatry 2018; 9:119. [PMID: 29740351 PMCID: PMC5925443 DOI: 10.3389/fpsyt.2018.00119] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 03/21/2018] [Indexed: 12/12/2022] Open
Abstract
Prescription opioid misuse is an ongoing and escalating epidemic. Although these pharmacological agents are highly effective analgesics prescribed for different types of pain, opioids also induce euphoria, leading to increasing diversion and misuse. Opioid use and related mortalities have developed in spite of initial claims that OxyContin, one of the first opioids prescribed in the USA, was not addictive in the presence of pain. These claims allayed the fears of clinicians and contributed to an increase in the number of prescriptions, quantity of drugs manufactured, and the unforeseen diversion of these drugs for non-medical uses. Understanding the history of opioid drug development, the widespread marketing campaign for opioids, the immense financial incentive behind the treatment of pain, and vulnerable socioeconomic and physical demographics for opioid misuse give perspective on the current epidemic as an American-born problem that has expanded to global significance. In light of the current worldwide opioid epidemic, it is imperative that novel opioids are developed to treat pain without inducing the euphoria that fosters physical dependence and addiction. We describe insights from preclinical findings on the properties of opioid drugs that offer insights into improving abuse-deterrent formulations. One finding is that the ability of some agonists to activate one pathway over another, or agonist bias, can predict whether several novel opioid compounds bear promise in treating pain without causing reward among other off-target effects. In addition, we outline how the pharmacokinetic profile of each opioid contributes to their potential for misuse and discuss the emergence of mixed agonists as a promising pipeline of opioid-based analgesics. These insights from preclinical findings can be used to more effectively identify opioids that treat pain without causing physical dependence and subsequent opioid abuse.
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Affiliation(s)
- Amie L. Severino
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, United States
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, United States
- Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, United States
- UCLA Brain Research Institute, Los Angeles, Los Angeles, CA, United States
| | - Arash Shadfar
- Department of Psychiatry, Western University of Health Sciences, Pomona, CA, United States
| | - Joshua K. Hakimian
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, United States
- UCLA Brain Research Institute, Los Angeles, Los Angeles, CA, United States
| | - Oliver Crane
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, United States
- UCLA Brain Research Institute, Los Angeles, Los Angeles, CA, United States
| | - Ganeev Singh
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, United States
- UCLA Brain Research Institute, Los Angeles, Los Angeles, CA, United States
| | - Keith Heinzerling
- Department of Family Medicine, David Geffen School of Medicine at the University of California, Los Angeles, CA, United States
| | - Wendy M. Walwyn
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, United States
- UCLA Brain Research Institute, Los Angeles, Los Angeles, CA, United States
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Cheatle MD, Gallagher RM, O’Brien CP. Low Risk of Producing an Opioid Use Disorder in Primary Care by Prescribing Opioids to Prescreened Patients with Chronic Noncancer Pain. PAIN MEDICINE (MALDEN, MASS.) 2018; 19:764-773. [PMID: 28379504 PMCID: PMC6659007 DOI: 10.1093/pm/pnx032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Objective To examine the risk of developing aberrant behaviors that might lead to a substance use disorder (addiction) when prescribing opioids for the relief of chronic noncancer pain in primary care settings. Design Longitudinal, prospective, descriptive design with repeated measures. Setting Private community-based internal medicine and family medicine clinics. Subjects Patients with chronic musculoskeletal pain. Methods Standardized measures of patient status (pain, functional impairment, psychiatric disorders, family history) and treatments provided, urine drug monitoring, and medical chart audits (presence of aberrant drug-related behaviors) were obtained in a cohort of 180 patients at the time of initiating opioids for chronic noncancer pain and at three, six, and 12 months thereafter. Results Over the 12-month follow-up period, subjects demonstrated stable, mild to moderate levels of depression (PHQ-9 scores ranging from 9.43 to 10.92), mild anxiety (BAI scores ranging from 11.80 to 14.67), minimal aberrant drug-related behaviors as assessed by chart reviews, and a low percentage of illicit drug use as revealed by results of urine drug monitoring. Less than 5% of our study population revealed any evidence of substance use disorder. Conclusions This prospective study suggests that patients without a recent or prior history of substance use disorder who were prescribed primarily short-acting opioids in low doses for chronic noncancer pain have a low risk for developing a substance use disorder. This finding supports the importance of prescreening patients being considered for opioid therapy and that prescription of opioids for noncancer pain may carry a lower risk of abuse in selected populations such as in private, community-based practices.
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Affiliation(s)
- Martin D Cheatle
- Center for Studies of Addiction, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rollin M Gallagher
- Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Departments of Psychiatry and Anesthesiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Charles P O’Brien
- Center for Studies of Addiction, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Abstract
Pharmacoepidemiologic analysis found that OEF/OIF/OND veterans have high rates of opioid use, characterized by moderate dose intensity and long treatment duration. There is a great deal of concern about opioid use in veterans, particularly those who served in Afghanistan (OEF) and Iraq (OIF and OND). The current study provides a detailed pharmacoepidemiologic analysis of opioid use among OEF/OIF/OND veterans from FY09 to FY12. Data from 3 data repositories from the Veterans Health Administration (VHA) were used to describe demographic, clinical, and medication characteristics associated with opioid use among OEF/OIF/OND veterans and among those with TBI. Logistic regression models were used to identify risks associated with chronic opioid use in FY12. Approximately 23% of all OEF/OIF/OND veterans and 35% of those with TBI received any opioid medications. Most received moderate doses ranging from 26 to 30 mg morphine equivalent dose daily. Median days of opioid use for all OEF/OIF/OND veterans were 30 to 40 days. Factors associated with chronic use in both groups included young age, male sex, white race, being married, and living in rural areas. A diagnosis of PTSD (odds ratio [OR] = 1.22, P < 0.0001), major depressive disorder (OR = 1.14, P < 0.0001), and tobacco use disorder (OR = 1.18, P < 0.0001) were strongly associated with chronic opioid use. Back pain was also strongly associated with chronic use (OR = 2.50, P < 0.0001). As pain severity increased the odds of chronic opioid use also increased: mild pain (OR = 3.76, P < 0.0001), moderate pain (OR = 6.80, P < 0.0001), and severe pain (OR = 8.49, P < 0.0001). Opioid use among OEF/OIF/OND veterans is characterized by moderate doses that are used over relatively long periods of time by a minority of veterans.
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Ware MA, Martel MO, Jovey R, Lynch ME, Singer J. A prospective observational study of problematic oral cannabinoid use. Psychopharmacology (Berl) 2018; 235:409-417. [PMID: 29250737 DOI: 10.1007/s00213-017-4811-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 12/05/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Despite evidence supporting the benefits of cannabinoids for symptom control across a wide range of medical conditions, concerns have been raised regarding the potential misuse and/or problematic use of cannabinoids (CBs). OBJECTIVE The first objective of this study was to examine the incidence of problematic prescription cannabinoid use (PPCBU) over a 12-month period among patients initiating cannabinoid therapy. The second objective was to examine the factors associated with PPCBU. A total of 265 patients who were prescribed oral cannabinoid therapy as part of usual medical practice were enrolled into this prospective observational study. Patients first completed a series of baseline questionnaires assessing demographic, clinical, and substance use variables. Three measures designed to assess PPCBU were then administered at 3, 6, and 12 months after initiation of cannabinoid therapy. RESULTS At each of the follow-up assessment time points, a significantly greater number of patients scored below (vs above) cutoff scores on the three main PPCBU outcomes (all p's < .001). At any follow-up time point, a maximum of roughly 25% of patients demonstrated PPCBU. Heightened odds of PPCBU were observed among patients with a history of psychiatric problems, tobacco smokers, and recreational cannabis users (all p's < .05). Results indicated that past-year substance abuse, assessed using the DAST-20, was the strongest predictor of PPCBU (p < .005). CONCLUSION Findings from the present study could have implications for clinicians considering the use of cannabinoids for the management of patients with medical conditions. Although results indicated that the majority of patients included in this study did not reach cutoff scores on the three main PPCBU outcomes, our findings suggest that PPCBU should be routinely assessed and monitored over the course of cannabinoid therapy, particularly among patients with a history of psychiatric or substance use problems.
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Affiliation(s)
- Mark A Ware
- Department of Anesthesia, Faculty of Medicine, McGill University, Montreal, Canada. .,Department of Family Medicine, McGill University, Montreal, Canada. .,Alan Edwards Pain Management Unit, McGill University Health Centre, Montreal, Canada. .,Montreal General Hospital, A5.140, 1650 Cedar Avenue, Montreal, Quebec, H3G 1A4, Canada.
| | - Marc O Martel
- Department of Anesthesia, Faculty of Medicine, McGill University, Montreal, Canada.,Alan Edwards Pain Management Unit, McGill University Health Centre, Montreal, Canada.,Faculty of Dentistry, McGill University, Montreal, Canada
| | - Roman Jovey
- CPM Centres for Pain Management, Mississauga, Ontario, Canada
| | - Mary E Lynch
- Department of Anesthesia, Pain Medicine, and Perioperative Care, Dalhousie University, Halifax, Canada
| | - Joel Singer
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
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Seymour RB, Ring D, Higgins T, Hsu JR. Leading the Way to Solutions to the Opioid Epidemic: AOA Critical Issues. J Bone Joint Surg Am 2017; 99:e113. [PMID: 29088045 DOI: 10.2106/jbjs.17.00066] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND In the past 2 decades, overdoses and deaths from prescription opioids have reached epidemic proportions in the United States. The widespread use of opioids complicates management of the orthopaedic surgery patient in the acute and chronic settings. Orthopaedic surgeons are some of the top prescribers of opioids in the complex setting of chronic use, abuse, and diversion. METHODS The literature regarding the basic science of pharmacologic options for pain management (e.g., opioids and nonsteroidal anti-inflammatory drugs), the impact of strategies on bone and soft-tissue healing, and pain relief are summarized as they relate to the management of orthopaedic injuries and conditions. Additionally, a section on designing solutions to address the current opioid crisis is presented. RESULTS The mechanism of action of different classes of analgesic medications is discussed, as well as the basic scientific evidence regarding the impact of narcotic and nonnarcotic analgesic medications on bone-healing and on other organ systems. Differences between pain and nociception, various treatment strategies, and clinical comparisons of the effectiveness of various analgesics compared with opioids are summarized. Finally, options for addressing the opioid crisis, including the description of a large system-wide intervention to impact prescriber behavior at the point of care using health-information solutions, are presented. CONCLUSIONS Orthopaedic leaders, armed with information and strategies, can help lead the way to solutions to the opioid epidemic in their respective communities, institutions, and subspecialty societies. Through leadership and education, orthopaedic surgeons can help shape the solution for this critical public health issue.
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Affiliation(s)
- Rachel B Seymour
- 1Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, North Carolina 2Department of Orthopaedic Surgery, University of Texas at Austin, Austin, Texas 3Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
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20
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Pouget ER, Bennett AS, Elliott L, Wolfson-Stofko B, Almeñana R, Britton PC, Rosenblum A. Development of an opioid-related Overdose Risk Behavior Scale (ORBS). Subst Abus 2017; 38:239-244. [PMID: 28113004 PMCID: PMC5522769 DOI: 10.1080/08897077.2017.1282914] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Drug overdose has emerged as the leading cause of injury-related death in the United States, driven by prescription opioid (PO) misuse, polysubstance use, and use of heroin. To better understand opioid-related overdose risks that may change over time and across populations, there is a need for a more comprehensive assessment of related risk behaviors. Drawing on existing research, formative interviews, and discussions with community and scientific advisors an opioid-related Overdose Risk Behavior Scale (ORBS) was developed. METHODS Military veterans reporting any use of heroin or POs in the past month were enrolled using venue-based and chain referral recruitment. The final scale consisted of 25 items grouped into 5 subscales eliciting the number of days in the past 30 during which the participant engaged in each behavior. Internal reliability, test-retest reliability and criterion validity were assessed using Cronbach's alpha, intraclass correlations (ICC) and Pearson's correlations with indicators of having overdosed during the past 30 days, respectivelyInternal reliability, test-retest reliability and criterion validity were assessed using Cronbach's alpha, intraclass correlations (ICC) and Pearson's correlations with indicators of having overdosed during the past 30 days, respectively. RESULTS Data for 220 veterans were analyzed. The 5 subscales-(A) Adherence to Opioid Dosage and Therapeutic Purposes; (B) Alternative Methods of Opioid Administration; (C) Solitary Opioid Use; (D) Use of Nonprescribed Overdose-associated Drugs; and (E) Concurrent Use of POs, Other Psychoactive Drugs and Alcohol-generally showed good internal reliability (alpha range = 0.61 to 0.88), test-retest reliability (ICC range = 0.81 to 0.90), and criterion validity (r range = 0.22 to 0.66). The subscales were internally consistent with each other (alpha = 0.84). The scale mean had an ICC value of 0.99, and correlations with validators ranged from 0.44 to 0.56. CONCLUSIONS These results constitute preliminary evidence for the reliability and validity of the new scale. If further validated, it could help improve overdose prevention and response research and could help improve the precision of overdose education and prevention efforts.
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Affiliation(s)
- Enrique R. Pouget
- National Development and Research Institutes, Inc., New York, New York, USA
| | - Alex S. Bennett
- National Development and Research Institutes, Inc., New York, New York, USA
| | - Luther Elliott
- National Development and Research Institutes, Inc., New York, New York, USA
| | | | - Ramona Almeñana
- National Development and Research Institutes, Inc., New York, New York, USA
| | - Peter C. Britton
- Canandaigua VA Medical Center, Center of Excellence for Suicide Prevention, Canandaigua, New York, USA
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
| | - Andrew Rosenblum
- National Development and Research Institutes, Inc., New York, New York, USA
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Misuse of prescription opioids among chronic pain patients suffering from anxiety: A cross-sectional analysis. Gen Hosp Psychiatry 2017; 47:36-42. [PMID: 28807136 DOI: 10.1016/j.genhosppsych.2017.04.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 04/17/2017] [Accepted: 04/21/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVE In the past two decades, chronic pain has been increasingly treated with prescription opioids, particularly in developed countries. This has drawn public concern of possible risks associated with the potential misuse of prescriptions opioids. Previous research has indicated that this may be particularly true among individuals suffering from co-occurring psychiatric disorders. The present study sought to explore rates of misuse among chronic pain patients prescribed opioids, comparing individuals with and without anxiety. METHODS Chronic pain patients receiving prescription opioids (N=554) were screened for anxiety using the Generalized Anxiety Disorder (GAD-7) scale and for opioid misuse using the Current Opioid Misuse Measure (COMM). RESULTS Among patients who screened positive for anxiety (GAD-7≥10), 50% also screened positive for opioid misuse, compared to 10% among those without anxiety. After controlling for possible confounding sociodemographic and clinical variables, patients with anxiety were significantly more prone to screen positive for opioid misuse (Adjusted Odds Ratio (AOR)=2.18; 95% Confidence Interval (CI)=1.37-4.17) compared to those without anxiety. This was maintained when conducting separate comparisons for severe, but not mild or moderate, level of anxiety. CONCLUSIONS These findings highlight the importance of detecting and addressing co-occurring anxiety when treating patients with chronic pain who receive prescription opioids.
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Abstract
OBJECTIVES To determine opioid-prescribing practices to the orthopaedic trauma (OT) population at one Level I trauma center. DESIGN A retrospective study of discharge prescriptions for adult patients with OT. Prescription details, injury burden, and patient demographics were abstracted for patients from initial injury through a 2-month follow-up. SETTING Level I trauma center. PATIENTS/PARTICIPANTS Adult patients with OT admitted over a 30-day period (n = 110). INTERVENTION All discharge and follow-up opioid prescriptions were recorded. MAIN OUTCOME MEASUREMENTS Morphine milligram equivalents (MMEs) per day, number of opioid prescriptions, type/dose of medication prescribed. RESULTS One hundred thirty-five discharge prescriptions were written for 110 patients with orthopaedic injuries during the review period. All patients received opioids at the time of discharge. The MMEs prescribed at the time of discharge was 114 mg (54-300 mg) for a mean of 7.21 days (2-36.7 days). Although patients with preinjury risk factors were prescribed discharge opioids for a similar duration (7.00 days vs. 7.30 days, P = 0.81) than those without risk factors, they were prescribed significantly more MMEs than those without (130 vs. 108, P < 0.05) and were more likely to receive extended-release and long-acting opioids than those without (42.11% vs. 21.98%). CONCLUSIONS Pain management after OT continues to be opioid-centric despite involving a population at risk. Further focus on prescriber and patient education, risk evaluation with mitigation, guideline development, and comprehensive pain management strategies are warranted in the OT population. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Measures That Identify Prescription Medication Misuse, Abuse, and Related Events in Clinical Trials: ACTTION Critique and Recommended Considerations. THE JOURNAL OF PAIN 2017; 18:1287-1294. [PMID: 28479207 DOI: 10.1016/j.jpain.2017.03.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 03/20/2017] [Accepted: 03/30/2017] [Indexed: 11/20/2022]
Abstract
Accurate assessment of inappropriate medication use events (ie, misuse, abuse, and related events) occurring in clinical trials is an important component in evaluating a medication's abuse potential. A meeting was convened to review all instruments measuring such events in clinical trials according to previously published standardized terminology and definitions. Only 2 approaches have been reported that are specifically designed to identify and classify misuse, abuse, and related events occurring in clinical trials, rather than to measure an individual's risk of using a medication inappropriately: the Self-Reported Misuse, Abuse, and Diversion (SR-MAD) instrument and the Misuse, Abuse, and Diversion Drug Event Reporting System (MADDERS). The conceptual basis, strengths, and limitations of these methods are discussed. To our knowledge, MADDERS is the only system available to comprehensively evaluate inappropriate medication use events prospectively to determine the underlying intent. MADDERS can also be applied retrospectively to completed trial data. SR-MAD can be used prospectively; additional development may be required to standardize its implementation and fully appraise the intent of inappropriate use events. Additional research is needed to further demonstrate the validity and utility of MADDERS as well as SR-MAD. PERSPECTIVE Identifying a medication's abuse potential requires assessing inappropriate medication use events in clinical trials on the basis of a standardized event classification system. The strengths and limitations of the 2 published methods designed to evaluate inappropriate medication use events are reviewed, with recommended considerations for further development and current implementation.
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Abstract
OBJECTIVE In light of the recent uptrend in the prescription of opioids, this study seeks to identify patterns of opioid misuse among orthopaedic postoperative patients and principal external sources in obtaining these medications. DESIGN Ten-month survey-based study. SETTING Two Level I trauma centers (urban and suburban). PATIENTS/PARTICIPANTS Two hundred seven patients between the ages of 18 and 89 years who underwent surgical fixation of fractures involving the pelvis, long bones, or periarticular regions of the knee, ankle, elbow, and wrist. MAIN OUTCOME MEASUREMENTS Patients who believed they were undermedicated, used prescribed opioids at higher than recommended doses, and took extra opioids in addition to their prescribed analgesics were analyzed by age, employment, income, education, controlled substance use, pain interference with activities of daily living, and anatomic surgical site. RESULTS One hundred eighty-two patients completed the survey; 19.2% of patients (n = 35) felt undermedicated [unemployed (P < 0.05), low income (P < 0.05), and self-reported controlled substance users (P < 0.05)]; 12.6% of patients (n = 23) admitted to using pain medications at a higher dose than prescribed [unemployed (P < 0.05), lower income (P < 0.05), nonhigh school graduates (P < 0.05), and previous controlled substance users (P < 0.05)]; 9.3% (n = 17) admitted to using external opioids [unemployed patients (P < 0.05) and self-reported controlled substance users (P < 0.05)]. Major sources of extraneous opioids include family/friends (n = 5) and other doctors (n = 4). CONCLUSION Unemployed and lower-income patients were significantly more likely to believe that their surgeon was not prescribing them enough pain medications as well as use their prescribed opioid medications at a higher than recommended dose compared with their employed counterparts with higher incomes. Unemployed patients were also significantly more likely to use additional opioid analgesics in addition to those prescribed to them by their primary surgeon. Surgeon awareness of a patient's socioeconomic background and associated risk of opioid misuse is crucial to prescribe the safest most effective pain regimen. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Arteta J, Cobos B, Hu Y, Jordan K, Howard K. Evaluation of How Depression and Anxiety Mediate the Relationship Between Pain Catastrophizing and Prescription Opioid Misuse in a Chronic Pain Population. PAIN MEDICINE 2017; 17:295-303. [PMID: 26235471 DOI: 10.1111/pme.12886] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE We investigated the extent to which anxiety and depression mediate the relationship between pain catastrophizing and the risk of prescription opioid misuse in chronic pain patients. METHODS 215 patients with chronic occupational musculoskeletal disorders completed self-report measures upon admission to a functional restorational program. A bootstrap multivariate regression analysis was conducted to assess how depression and anxiety mediated the relationship between pain catastrophizing and prescription opioid misuse. RESULTS Catastrophizing, anxiety, and depression predicted higher risk for prescription opioid misuse. Furthermore, anxiety and depression acted as mediators while controlling for the effects of gender and age. Finally, it was found that the effects of catastrophizing on risk for prescription opioid misuse were completely eliminated by those of depression. CONCLUSION Due to the partially independent relationship of anxiety and catastrophizing, it is recommended that treatments for chronic pain patients employ techniques addressing both behaviors. The relationship between depression and catastrophizing requires more research since it was observed that their effects were confounded.
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Kutlu MG, Gould TJ. Effects of drugs of abuse on hippocampal plasticity and hippocampus-dependent learning and memory: contributions to development and maintenance of addiction. Learn Mem 2016; 23:515-33. [PMID: 27634143 PMCID: PMC5026208 DOI: 10.1101/lm.042192.116] [Citation(s) in RCA: 183] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 07/19/2016] [Indexed: 11/25/2022]
Abstract
It has long been hypothesized that conditioning mechanisms play major roles in addiction. Specifically, the associations between rewarding properties of drugs of abuse and the drug context can contribute to future use and facilitate the transition from initial drug use into drug dependency. On the other hand, the self-medication hypothesis of drug abuse suggests that negative consequences of drug withdrawal result in relapse to drug use as an attempt to alleviate the negative symptoms. In this review, we explored these hypotheses and the involvement of the hippocampus in the development and maintenance of addiction to widely abused drugs such as cocaine, amphetamine, nicotine, alcohol, opiates, and cannabis. Studies suggest that initial exposure to stimulants (i.e., cocaine, nicotine, and amphetamine) and alcohol may enhance hippocampal function and, therefore, the formation of augmented drug-context associations that contribute to the development of addiction. In line with the self-medication hypothesis, withdrawal from stimulants, ethanol, and cannabis results in hippocampus-dependent learning and memory deficits, which suggest that an attempt to alleviate these deficits may contribute to relapse to drug use and maintenance of addiction. Interestingly, opiate withdrawal leads to enhancement of hippocampus-dependent learning and memory. Given that a conditioned aversion to drug context develops during opiate withdrawal, the cognitive enhancement in this case may result in the formation of an augmented association between withdrawal-induced aversion and withdrawal context. Therefore, individuals with opiate addiction may return to opiate use to avoid aversive symptoms triggered by the withdrawal context. Overall, the systematic examination of the role of the hippocampus in drug addiction may help to formulate a better understanding of addiction and underlying neural substrates.
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Affiliation(s)
- Munir Gunes Kutlu
- Department of Biobehavioral Health, Penn State University, University Park, Pennsylvania 16802, USA
| | - Thomas J Gould
- Department of Biobehavioral Health, Penn State University, University Park, Pennsylvania 16802, USA
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Weinberg DS, Napora JK, West WH, Grimberg DC, Vallier HA. Factors Associated With Narcotic Use After Clavicle Fractures. Orthopedics 2016; 39:e917-23. [PMID: 27359278 DOI: 10.3928/01477447-20160623-06] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 04/20/2016] [Indexed: 02/03/2023]
Abstract
Clavicle fractures are common in adults. Recent studies have shown that operative treatment of clavicle fractures has benefits in many situations. However, there is controversy about the indications. Data on social outcomes are limited. A total of 434 patients with 436 clavicle fractures treated both operatively and nonoperatively at a level 1 trauma center were identified. Narcotic use was recorded 2, 4, 6, 8, 10, 12, 14, and 16 weeks after injury for both treatment groups. Other descriptive data included age, sex, laterality, hand dominance, rib fractures, smoking, alcohol use, employment, long bone or spine fracture, open clavicle fracture, and mechanism of injury. Logistic regression analysis was performed to determine the independent predictors of narcotic use after clavicle fracture. Open reduction and internal fixation was performed in 105 fractures (24%), and 329 fractures were managed nonoperatively. A total of 154 patients (35%) reported some narcotic use 2 weeks after injury, and 15% were still using narcotics 16 weeks after injury. Narcotic use decreased over time in patients treated with open reduction and internal fixation (10% vs 15% after nonoperative management). Patients treated with open reduction and internal fixation reported reduced narcotic use at 16 weeks (odds ratio [OR], 0.454; P=.070). Concurrent rib fracture (OR, 5.668; P<.001), smoking (OR, 3.095; P=.013), unemployment (OR, 5.429; P<.0005), and long bone or spine fracture (OR, 6.761; P<.001) were predictors of narcotic use. Further studies of the social, economic, and financial outcomes of clavicle fracture and osteosynthesis are warranted. [Orthopedics. 2016; 39(5):e917-e923.].
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Argoff CE, Viscusi ER. The use of opioid analgesics for chronic pain: minimizing the risk for harm. ACTA ACUST UNITED AC 2016; 2:3-8. [PMID: 25207607 DOI: 10.1038/ajgsup.2014.3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Chronic noncancer pain is common and consequential, affecting ∼100 million people in the United States alone and costing, when direct and indirect costs are combined, in excess of $635 billion. For certain individuals, opioids may be an effective option for the management of chronic pain; however, a series of critical decisions must be made before prescribing opioids to ensure that their potential benefits and possible risks are appropriately and realistically addressed. A thorough history, physical examination, and appropriate testing, including an assessment of risk for substance abuse, misuse, or addiction, should be conducted in patients who are being considered for opioid therapy. Proactively developing a treatment plan that matches the needs and expectations of the patient, while minimizing the potential for substance abuse, is central to the success of pain management. Current standard of care suggests that for most patients, a trial of nonopioid therapies should generally be tried first. There is no single opioid of choice that universally provides the best outcomes for all patients; thus, it is critical for the health-care practitioner to become familiar with the available subclasses, formulations, and modes of administration, and base the treatment plan on clinical experience with the drug, prior patient experience, the availability of the formulation, and cost and coverage. Pain is a dynamic phenomenon in that its characteristics and response to treatment evolve over time, as does the patient's general health state. Both positive and negative changes over time may necessitate a change in medication. Opioids can be prescribed safely and effectively, and when used with appropriate attention to individual patient characteristics may have a positive impact on pain and function. When contemplating initiation of opioid analgesics, clinicians would do well to make it clear to their patient that they will be prescribed on a trial basis with a clear exit strategy for discontinuing such treatment if there is no clear benefit including lack of analgesia, insurmountable adverse effects, and/or frank misuse or abuse of the prescribed drug.
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Affiliation(s)
- Charles E Argoff
- Department of Neurology, Albany Medical College, Albany, New York, USA
| | - Eugene R Viscusi
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Who Benefits from Chronic Opioid Therapy? Rethinking the Question of Opioid Misuse Risk. Healthcare (Basel) 2016; 4:healthcare4020029. [PMID: 27417617 PMCID: PMC4934582 DOI: 10.3390/healthcare4020029] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 05/17/2016] [Accepted: 05/17/2016] [Indexed: 01/14/2023] Open
Abstract
Beginning in the late 1990s, a movement began within the pain management field focused upon the underutilization of opioids, thought to be a potentially safe and effective class of pain medication. Concern for addiction and misuse were present at the start of this shift within pain medicine, and an emphasis was placed on developing reliable and valid methods and measures of identifying those at risk for opioid misuse. Since that time, the evidence for the safety and effectiveness of chronic opioid therapy (COT) has not been established. Rather, the harmful, dose-dependent deleterious effects have become clearer, including addiction, increased risk of injuries, respiratory depression, opioid induced hyperalgesia, and death. Still, many individuals on low doses of opioids for long periods of time appear to have good pain control and retain social and occupational functioning. Therefore, we propose that the question, “Who is at risk of opioid misuse?” should evolve to, “Who may benefit from COT?” in light of the current evidence.
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Al Dabbagh Z, Jansson KÅ, Stiller CO, Montgomery S, Weiss RJ. Long-term pattern of opioid prescriptions after femoral shaft fractures. Acta Anaesthesiol Scand 2016; 60:634-41. [PMID: 26707940 DOI: 10.1111/aas.12666] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Revised: 10/25/2015] [Accepted: 10/28/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND The use of opioids in non-cancer-related pain following skeletal trauma is controversial due to the presumed risk of dose escalation and dependence. We therefore examined the pattern of opioid prescriptions, that is, those actually dispensed, in patients with femoral shaft fractures. METHODS We analysed data from the Swedish National Hospital Discharge Register and the Swedish Prescribed Drug Register between 2005 and 2008. RESULTS We identified 1471 patients with isolated femoral shaft fractures. The median age was 75 (16-102) years and 56% were female. In this cohort, 891 patients (61%) received dispensed opioid prescriptions during a median follow-up of 20 months (interquartile range 11-32). In the age- and sex-matched comparison cohort (7339 individuals) without fracture, 25% had opioid prescriptions dispensed during the same period. The proportions of patients receiving opioid analgesics at 6 and 12 months after the fracture were 45% (95% CI 42-49) and 36% (32-39), respectively. The median daily morphine equivalent dose (MED) was between 15 and 17 mg 1-12 months post-fracture. After 3 months, less than 5% used prescription doses higher than 20 mg MED per day. Older age (≥ 70 compared with < 70 years) was a significant predictor of earlier discontinuation of opioid use (Hazard ratio [HR] 1.9). CONCLUSION A notable proportion of patients continued to receive dispensed prescriptions for opioids for over 6 months (45%) and more than a third of them (36%) continued treatment for at least 12 months. However, the risk of dose escalation seems to be small in opioid-naïve patients.
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Affiliation(s)
- Z. Al Dabbagh
- Department of Molecular Medicine and Surgery; Section of Orthopaedics and Sports Medicine; Karolinska University Hospital; Karolinska Institutet; Stockholm Sweden
| | - K. Å. Jansson
- Department of Molecular Medicine and Surgery; Section of Orthopaedics and Sports Medicine; Karolinska University Hospital; Karolinska Institutet; Stockholm Sweden
| | - C. O. Stiller
- Department of Medicine; Clinical Pharmacology Unit; Karolinska University Hospital; Karolinska Institutet; Stockholm Sweden
| | - S. Montgomery
- Clinical Epidemiology and Biostatistics; Faculty of Medicine and Health; School of Health and Medical Sciences; Örebro University; Örebro Sweden
- Clinical Epidemiology Unit; Karolinska University Hospital; Karolinska Institutet; Stockholm Sweden
- Department of Epidemiology and Public Health; University College London; London UK
| | - R. J. Weiss
- Department of Molecular Medicine and Surgery; Section of Orthopaedics and Sports Medicine; Karolinska University Hospital; Karolinska Institutet; Stockholm Sweden
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Park TW, Saitz R, Nelson KP, Xuan Z, Liebschutz JM, Lasser KE. The association between benzodiazepine prescription and aberrant drug-related behaviors in primary care patients receiving opioids for chronic pain. Subst Abus 2016; 37:516-520. [PMID: 27092738 DOI: 10.1080/08897077.2016.1179242] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Benzodiazepine use has been associated with addiction-related risks, but little is known about its association with aberrant drug-related behaviors in patients receiving opioids for chronic pain. The authors examined the association between receipt of a benzodiazepine prescription and 2 aberrant drug-related behaviors, early opioid refills and illicit drug (cocaine) use in patients receiving opioids for noncancer chronic pain. METHODS This was a retrospective cohort study of 847 patients with ≥1 visit to either a hospital-based primary care clinic or one of two community health centers between September 1, 2011, and August 31, 2012. All patients received ≥3 opioid prescriptions written at least 21 days apart within 6 months, and ≥1 urine drug screen during the study period. A Cox proportional hazards model estimated the hazard of a second early opioid refill, defined as an opioid prescription written 7-25 days after the previous prescription for the same drug, as a function of time-varying benzodiazepine prescription. A logistic regression model examined the relationship between benzodiazepine prescription and a positive urine test for cocaine. Models were adjusted for demographics and mental/substance use disorder diagnoses. RESULTS Twenty-three percent (n = 196) of patients received ≥1 benzodiazepine prescription during the study period. Twenty-two percent (n = 183) of patients had ≥2 early opioid refills, and 11% (n = 93) had ≥1 positive urine drug tests for cocaine. Receipt of benzodiazepine prescription was associated with an increased hazard of having a second early opioid refill, adjusted hazard ratio = 1.54 (95% confidence interval [CI]: 1.09-2.18), but not associated with a positive cocaine test, adjusted odds ratio = 1.07 (95% CI: 0.55-2.23). CONCLUSIONS Among primary care patients receiving chronic opioid therapy, benzodiazepine prescription was associated with early opioid refills but not with cocaine use. Further research should better elucidate the risks and benefits of prescribing benzodiazepines to patients receiving opioids for chronic pain.
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Affiliation(s)
- Tae Woo Park
- a Division of General Internal Medicine, Department of Medicine, Alpert Medical School and Rhode Island Hospital , Providence , Rhode Island , USA.,b Department of Psychiatry and Human Behavior , Alpert Medical School and Rhode Island Hospital , Providence , Rhode Island , USA
| | - Richard Saitz
- c Department of Community Health Sciences , Boston University School of Public Health , Boston , Massachusetts , USA.,d Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center , Boston , Massachusetts , USA
| | - Kerrie P Nelson
- e Department of Biostatistics , Boston University School of Public Health , Boston , Massachusetts , USA
| | - Ziming Xuan
- c Department of Community Health Sciences , Boston University School of Public Health , Boston , Massachusetts , USA
| | - Jane M Liebschutz
- d Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center , Boston , Massachusetts , USA
| | - Karen E Lasser
- c Department of Community Health Sciences , Boston University School of Public Health , Boston , Massachusetts , USA.,d Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center , Boston , Massachusetts , USA
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Efficacy of the Opioid Compliance Checklist to Monitor Chronic Pain Patients Receiving Opioid Therapy in Primary Care. THE JOURNAL OF PAIN 2016; 17:414-23. [DOI: 10.1016/j.jpain.2015.12.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 12/03/2015] [Accepted: 12/08/2015] [Indexed: 12/31/2022]
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Larance B, Bruno R, Lintzeris N, Degenhardt L, Black E, Brown A, Nielsen S, Dunlop A, Holland R, Cohen M, Mattick RP. Development of a brief tool for monitoring aberrant behaviours among patients receiving long-term opioid therapy: The Opioid-Related Behaviours In Treatment (ORBIT) scale. Drug Alcohol Depend 2016; 159:42-52. [PMID: 26710979 DOI: 10.1016/j.drugalcdep.2015.11.026] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 11/04/2015] [Accepted: 11/05/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Early identification of problems is essential in minimising the unintended consequences of opioid therapy. This study aimed to develop a brief scale that identifies and quantifies recent aberrant behaviour among diverse patient populations receiving long-term opioid treatment. METHOD 40 scale items were generated via literature review and expert panel (N=19) and tested in surveys of: (i) N=41 key experts, and (ii) N=426 patients prescribed opioids >3 months (222 pain patients and 204 opioid substitution therapy (OST) patients). We employed item and scale psychometrics (exploratory factor analyses, confirmatory factor analyses and item-response theory statistics) to refine items to a brief scale. RESULTS Following removal of problematic items (poor retest-reliability or wording, semantic redundancy, differential item functioning, collinearity or rarity) iterative factor analytic procedures identified a 10-item unifactorial scale with good model fit in the total sample (N=426; CFI=0.981, TLI=0.975, RMSEA=0.057), and among pain (CFI=0.969, TLI=0.960, RMSEA=0.062) and OST subgroups (CFI=0.989, TFI=0.986, RMSEA=0.051). The 10 items provided good discrimination between groups, demonstrated acceptable test-retest reliability (ICC 0.80, 95% CI 0.60-0.89; Cronbach's alpha=0.89), were moderately correlated with related constructs, including opioid dependence (SDS), depression and stress (DASS subscales) and Social Relationships and Environment domains of the WHO-QoL, and had strong face validity among advising clinicians. CONCLUSIONS The Opioid-Related Behaviours In Treatment (ORBIT) scale is brief, reliable and validated for use in diverse patient groups receiving opioids. The ORBIT has potential applications as a checklist to prompt clinical discussions and as a tool to quantify aberrant behaviour and assess change over time.
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Affiliation(s)
- Briony Larance
- National Drug and Alcohol Research Centre, UNSW Australia, Sydney, NSW 2052, Australia.
| | - Raimondo Bruno
- School of Medicine, University of Tasmania, Sandy Bay Campus, Hobart, Tasmania 7001, Australia
| | - Nicholas Lintzeris
- The Langton Centre, South East Sydney Local Health District (SESLHD) Drug and Alcohol Services, 591 South Dowling Street, Surry Hills, NSW 2010, Australia; University of Sydney, Camperdown, NSW 2050, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Australia, Sydney, NSW 2052, Australia; School of Population and Global Health, The University of Melbourne, Parkville, VIC 3010, Australia; Murdoch Children's Research Institute, The Royal Children's Hospital, Flemington Road, Parkville, VIC 3052, Australia; Department of Global Health, School of Public Health, University of Washington, 325 9th Avenue, Seattle, WA 98104, USA
| | - Emma Black
- National Drug and Alcohol Research Centre, UNSW Australia, Sydney, NSW 2052, Australia
| | - Amanda Brown
- Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, Australia
| | - Suzanne Nielsen
- National Drug and Alcohol Research Centre, UNSW Australia, Sydney, NSW 2052, Australia; University of Sydney, Camperdown, NSW 2050, Australia
| | - Adrian Dunlop
- Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, Australia; School of Medicine and Public Health, The University of Newcastle, University Drive, Callaghan, NSW 2308, Australia
| | - Rohan Holland
- Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, Australia
| | - Milton Cohen
- St Vincent's Clinical School, UNSW Australia, Darlinghurst, NSW 2010, Australia
| | - Richard P Mattick
- National Drug and Alcohol Research Centre, UNSW Australia, Sydney, NSW 2052, Australia
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Hollingshead NA, Meints S, Middleton SK, Free CA, Hirsh AT. Examining influential factors in providers' chronic pain treatment decisions: a comparison of physicians and medical students. BMC MEDICAL EDUCATION 2015; 15:164. [PMID: 26427937 PMCID: PMC4591590 DOI: 10.1186/s12909-015-0441-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 09/12/2015] [Indexed: 05/23/2023]
Abstract
BACKGROUND Chronic pain treatment guidelines are unclear and conflicting, which contributes to inconsistent pain care. In order to improve pain care, it is important to understand the various factors that providers rely on to make treatment decisions. The purpose of this study was to examine factors that reportedly influence providers' chronic pain treatment decisions. A secondary aim was to examine differences across participant training level. METHODS Eighty-five participants (35 medical students, 50 physicians) made treatment decisions for 16 computer-simulated patients with chronic pain. Participants then selected from provided lists the information they used and the information they would have used (had it been available) to make their chronic pain treatment decisions for the patient vignettes. RESULTS Frequency analyses indicated that most participants reported using patients' pain histories (97.6 %) and pain description (95.3 %) when making treatment decisions, and they would have used information about patients' previous treatments (97.6 %) and average and current pain ratings (96.5 %) had this information been available. Compared to physicians, medical students endorsed more frequently that they would have used patients' employment and/or disability status (p < 0.05). A greater proportion of medical students wanted information on patients' use of illicit drugs and alcohol to make treatment decisions; while a greater proportion of physicians reported using personal experience to inform their decisions. DISCUSSION This study found providers use patients' information and their own experiences and intuition to make chronic pain treatment decisions. Also, participants of different training levels report using different patient and personal factors to guide their treatment decisions. CONCLUSIONS These results highlight the complexity of chronic pain care and suggest a need for more chronic pain education aimed at medical students and practicing providers.
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Affiliation(s)
- Nicole A Hollingshead
- Department of Psychology, Indiana University - Purdue University Indianapolis, 402 N Blackford, Indianapolis, IN, 46202, USA.
| | - Samantha Meints
- Department of Psychology, Indiana University - Purdue University Indianapolis, 402 N Blackford, Indianapolis, IN, 46202, USA.
| | - Stephanie K Middleton
- Department of Psychology, Indiana University - Purdue University Indianapolis, 402 N Blackford, Indianapolis, IN, 46202, USA.
| | - Charnelle A Free
- Department of Psychology, Indiana University - Purdue University Indianapolis, 402 N Blackford, Indianapolis, IN, 46202, USA.
| | - Adam T Hirsh
- Department of Psychology, Indiana University - Purdue University Indianapolis, 402 N Blackford, Indianapolis, IN, 46202, USA.
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Greene MS, Chambers RA. Pseudoaddiction: Fact or Fiction? An Investigation of the Medical Literature. CURRENT ADDICTION REPORTS 2015; 2:310-317. [PMID: 26550549 PMCID: PMC4628053 DOI: 10.1007/s40429-015-0074-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Tremendous growth in opioid prescribing over two decades in the USA has correlated with proportional increases in diversion, addiction, and overdose deaths. Pseudoaddiction, a concept coined in 1989, has frequently been cited to indicate that under-treatment of pain, rather than addiction, is the more pressing and authentic clinical problem in opioid-seeking patients. This investigative review searched Medline articles containing the term "pseudoaddiction" to determine its footprint in the literature with a focus on how it has been characterized and empirically validated. By 2014, pseudoaddiction was discussed in 224 articles. Only 18 of these articles contributed to or questioned pseudoaddiction from an anecdotal or theoretical standpoint, and none empirically tested or confirmed its existence. Twelve of these articles, including all four that acknowledged pharmaceutical funding, were proponents of pseudoaddiction. These papers described pseudoaddiction as an iatrogenic disease resulting from withholding opioids for pain that can be diagnosed, prevented, and treated with more aggressive opioid treatment. In contrast, six articles, none with pharmaceutical support, questioned pseudoaddiction as a clinical construct. Empirical evidence supporting pseudoaddiction as a diagnosis distinct from addiction has not emerged. Nevertheless, the term has been accepted and proliferated in the literature as a justification for opioid therapy for non-terminal pain in patients who may appear to be addicted but should not, from the perspective of pseudoaddiction, be diagnosed with addiction. Future studies should examine whether acceptance of pseudoaddiction has complicated accurate pain assessment and treatment, and whether it has contributed to or reflected medical-cultural shifts that produced the iatrogenic opioid addiction epidemic.
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Affiliation(s)
- Marion S. Greene
- />Center for Health Policy, Richard M. Fairbanks School of Public Health, Indiana University-Purdue University Indianapolis (IUPUI), 714 N Senate Ave, Indianapolis, IN 46202 USA
| | - R. Andrew Chambers
- />Laboratory for Translational Neuroscience of Dual Diagnosis & Development, Department of Psychiatry, IU Neuroscience Center, Indiana University School of Medicine, 320 W. 15th Street, Indianapolis, IN 46202 USA
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The Canary in the Coal Mine Tweets: Social Media Reveals Public Perceptions of Non-Medical Use of Opioids. PLoS One 2015; 10:e0135072. [PMID: 26252774 PMCID: PMC4529203 DOI: 10.1371/journal.pone.0135072] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 07/17/2015] [Indexed: 11/19/2022] Open
Abstract
Objective Non-medical prescription opioid use is a growing public health concern. Social media is an emerging tool to understand health attitudes, beliefs, and behaviors. Methods We retrieved a sample of publicly available Twitter messages in early 2014, using common opioid medication names and slang search terms. We used content analysis to code messages by user, context of message (personal vs general experiences), and key content themes. Results We reviewed 540 messages, of which 375 (69%) messages were related to opioid behaviors. Of these, 316 (84%) originated from individual user accounts; 125 messages expressed personal experience with opioids. The majority of personal messages referenced using opioids to obtain a “high”, use for sleep, or other non-intended use (87,70%). General attitudes regarding opioid use included positive sentiment (52, 27%), comments on others peoples opioid use (57, 30%), and messages containing public health information or links (48, 25%). Conclusions In a sample of social media messages mentioning opioid medications, the most common theme amongst English users related to various forms of opioid misuse. Social media can provide insights into the types of misuse of opioids that might aid public health efforts to reduce non-medical opioid use.
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Layton D, Osborne V, Al-Shukri M, Shakir SAW. Indicators of drug-seeking aberrant behaviours: the feasibility of use in observational post-marketing cohort studies for risk management. Drug Saf 2015; 37:639-50. [PMID: 24969120 PMCID: PMC4134477 DOI: 10.1007/s40264-014-0193-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Problematic prescription drug use is reflected by or associated with drug-seeking aberrant behaviours. Research gaps include lack of post-marketing evidence and instruments. As part of the pharmacovigilance requirements, a risk management plan was developed for fentanyl buccal tablets (FEBT) by the manufacturer, with an additional pharmacovigilance activity requested by the regulatory authority, to investigate the risks of misuse, abuse, criminal use, off-label use and accidental exposure to FEBT after the product became commercially available. A Modified Prescription-Event Monitoring (M-PEM), observational, post-authorisation safety surveillance (PASS) study was conducted, with an overall aim to examine the use of FEBT in relation to their safety as prescribed in primary care in England. One of the exploratory objectives included estimating the prevalence of aberrant behaviours during FEBT treatment. Objective To determine the feasibility of estimating the prevalence of risk factors associated with dependence on starting treatment and aberrant behaviours in patients during treatment with a prototypical abuse liable substance (fentanyl), as based on the application of an existing index (the Chabal criteria). Methods Data were collected as part of the M-PEM PASS study; exposure and outcome data (including risk factors for dependence and aberrant behaviours based on behavioural not clinical manifestations) were derived from questionnaires sent to primary care physicians in England during April 2008 to June 2011. For the exploratory objective of interest, descriptive statistics and simple (non-weighted) risk scores were constructed on aggregate counts (score ≥3 considered ‘high-risk’). Supplementary analyses explored the relationship between the two indices and the characteristics of patients with aberrant behaviours and those without (crude odds ratios plus 95 % confidence interval (CI) were calculated). Results In a cohort of 551 patients, the prevalence of at least one pre-existing risk factor for dependence was 26 % (n = 145), whilst the frequency of aberrant behaviours observed during treatment was 8 % (n = 46). Patients with aberrant behaviours had several different characteristics to patients without. The two indices were associated (χ2 df (20) = 58.72, p < 0.001), but a high-dependence risk-factor score provided a poor indication of high aberrant behaviour risk; the area under the receiver operating characteristic curve was 0.58 (95 % CI 0.41, 0.74). Limitations Study limitations included subjectivity in relation to physicians identifying aberrant behaviours, and under-reporting thereof in PASS observational study designs. The presence of these criteria does not confirm misuse, but should be considered as a signal of problematic opioid misuse, which requires investigation. Further research is needed to develop a more robust analytical construct. Conclusion In this PASS study, the prevalence of at least one pre-existing risk factor for dependence was 26 %, whilst the frequency of aberrant behaviours observed during treatment was 8 %. Patients with aberrant behaviours had several different characteristics to patients without. This study demonstrates the feasibility of the systematic collection of physician reports of risk factors for dependence and aberrant behaviours to facilitate the development of risk scores, using these reports to support the post-marketing risk management of products with misuse potential.
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Affiliation(s)
- Deborah Layton
- Drug Safety Research Unit, Bursledon Hall, Blundell Lane, Southampton, SO31 1AA, UK,
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Muniraj T, Aslanian HR, Farrell J, Jamidar PA. Chronic pancreatitis, a comprehensive review and update. Part II: Diagnosis, complications, and management. Dis Mon 2015; 61:5-37. [PMID: 25681098 DOI: 10.1016/j.disamonth.2014.12.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Smith SM, Paillard F, McKeown A, Burke LB, Edwards RR, Katz NP, Papadopoulos EJ, Rappaport BA, Slagle A, Strain EC, Wasan AD, Turk DC, Dworkin RH. Instruments to Identify Prescription Medication Misuse, Abuse, and Related Events in Clinical Trials: An ACTTION Systematic Review. THE JOURNAL OF PAIN 2015; 16:389-411. [PMID: 25660826 DOI: 10.1016/j.jpain.2015.01.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 01/07/2015] [Accepted: 01/08/2015] [Indexed: 11/27/2022]
Abstract
UNLABELLED Measurement of inappropriate medication use events (eg, abuse or misuse) in clinical trials is important in characterizing a medication's abuse potential. However, no gold standard assessment of inappropriate use events in clinical trials has been identified. In this systematic review, we examine the measurement properties (ie, content validity, cross-sectional reliability and construct validity, longitudinal construct validity, ability to detect change, and responder definitions) of instruments assessing inappropriate use of opioid and nonopioid prescription medications to identify any that meet U.S. and European regulatory agencies' rigorous standards for outcome measures in clinical trials. Sixteen published instruments were identified, most of which were not designed for the selected concept of interest and context of use. For this reason, many instruments were found to lack adequate content validity (or documentation of content validity) to evaluate current inappropriate medication use events; for example, evaluating inappropriate use across the life span rather than current use, including items that did not directly assess inappropriate use (eg, questions about anger), or failing to capture information pertinent to inappropriate use events (eg, intention and route of administration). In addition, the psychometric data across all instruments were generally limited in scope. A further limitation is the heterogeneous, nonstandardized use of inappropriate medication use terminology. These observations suggest that available instruments are not well suited for assessing current inappropriate medication use within the specific context of clinical trials. Further effort is needed to develop reliable and valid instruments to measure current inappropriate medication use events in clinical trials. PERSPECTIVE This systematic review evaluates the measurement properties of inappropriate medication use (eg, abuse or misuse) instruments to determine whether any meet regulatory standards for clinical trial outcome measures to assess abuse potential.
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Affiliation(s)
- Shannon M Smith
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York.
| | | | - Andrew McKeown
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | | | - Robert R Edwards
- Department of Anesthesiology, Brigham & Women's Hospital, Boston, Massachusetts
| | - Nathaniel P Katz
- Department of Anesthesia, Tufts University, Boston, Massachusetts; Analgesic Solutions, Natick, Massachusetts
| | | | - Bob A Rappaport
- United States Food and Drug Administration, Silver Spring, Maryland
| | - Ashley Slagle
- United States Food and Drug Administration, Silver Spring, Maryland
| | - Eric C Strain
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ajay D Wasan
- Departments of Anesthesiology and Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Dennis C Turk
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Robert H Dworkin
- Departments of Anesthesiology and Neurology, and Center for Human Experimental Therapeutics, University of Rochester School of Medicine and Dentistry, Rochester, New York
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Jamison RN, Martel MO, Edwards RR, Qian J, Sheehan KA, Ross EL. Validation of a brief Opioid Compliance Checklist for patients with chronic pain. THE JOURNAL OF PAIN 2014; 15:1092-1101. [PMID: 25092233 PMCID: PMC4253010 DOI: 10.1016/j.jpain.2014.07.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 07/05/2014] [Accepted: 07/21/2014] [Indexed: 01/22/2023]
Abstract
UNLABELLED There has been a need for a brief assessment tool to determine compliance with use of prescribed opioids for pain. The purpose of this study was to develop and begin the validation of a brief and simple compliance checklist (Opioid Compliance Checklist [OCC]) for chronic pain patients prescribed long-term opioid therapy. A review of the literature of opioid therapy agreements led to a 12-item OCC that was repeatedly administered to 157 patients who were taking opioids for chronic pain and followed for 6 months. Validation of the OCC was conducted by identifying those patients exhibiting aberrant drug-related behavior as determined by any of the following: positive urine toxicology screen, a positive score on the Prescription Drug Use Questionnaire interview or Current Opioid Misuse Measure, and/or ratings by staff on the Addiction Behavior Checklist. Of the original 12 items, 5 OCC items appeared to best predict subsequent aberrant behaviors based on multivariate logistic regression analyses (cross-validated area under the receiver operating characteristic curve = .67). Although further testing is needed, these results suggest that the OCC is an easy-to-use, promising measure in monitoring opioid adherence among persons with chronic pain. PERSPECTIVE This study presents validation of a brief 5-item compliance checklist for use with chronic pain patients prescribed long-term opioid therapy. This measure asks patients about aberrant drug-related behavior over the past month, and any positive response indicates problems with adherence with opioids. Further cross-validation testing is needed.
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Affiliation(s)
- Robert N Jamison
- Pain Management Center, Departments of Anesthesia and Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Marc O Martel
- Pain Management Center, Departments of Anesthesia and Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert R Edwards
- Pain Management Center, Departments of Anesthesia and Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jing Qian
- Division of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts, Amherst, Massachusetts
| | - Kerry Anne Sheehan
- Pain Management Center, Departments of Anesthesia and Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Edgar L Ross
- Pain Management Center, Departments of Anesthesia and Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Grenald SA, Largent-Milnes TM, Vanderah TW. Animal models for opioid addiction drug discovery. Expert Opin Drug Discov 2014; 9:1345-54. [PMID: 25307021 DOI: 10.1517/17460441.2014.966076] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Since ancient times, the opium poppy has been used in a variety of settings, including pain management. Natural and synthetic derivatives of opium are commonly used in medicine today and include drugs, such as morphine, codeine, hydromorphone and oxycodone. Although excellent at inhibiting pain, these narcotics often produce a state of euphoria leading to misuse and abuse by the general population, particularly in young adults. The misuse of prescription opiates has continually increased over the past 10 years despite associated negative outcomes, resulting in opiate psychological dependence, withdrawal and relapse. AREAS COVERED This paper briefly refers to the history of opiate use and the modern challenges associated with chronic exposure. The authors present the prevalence of addiction and misuse of prescription opiates and discuss some of the opiate-associated effects. This includes activation of reward circuitry and compensatory receptor mechanisms. Finally, the authors provide a review on neuroadaptive changes that manifest during opiate dependence, withdrawal and relapse in animal models. EXPERT OPINION In spite of the various methods available to treat opiate addiction, there is still a huge unmet need for its management, including the creative design of novel, non-addictive pain medications. The authors believe that multifunctional compounds or combinations of compounds that inhibit pain pathways, whereas not activating the reward pathways, will begin to subdue the opiate addiction endemic.
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Affiliation(s)
- Shaness A Grenald
- University of Arizona, Department of Pharmacology , Tucson, AZ 85724-5050 , USA +1 520 626 7801 ; +1 520 626 2204 ;
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Juan Pablo Acuña B. Tratamiento del dolor agudo en el paciente dependiente de sustancias. REVISTA MÉDICA CLÍNICA LAS CONDES 2014. [DOI: 10.1016/s0716-8640(14)70088-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Childers JW, King LA, Arnold RM. Chronic Pain and Risk Factors for Opioid Misuse in a Palliative Care Clinic. Am J Hosp Palliat Care 2014; 32:654-9. [DOI: 10.1177/1049909114531445] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objectives: To describe the prevalence of chronic pain and the risk of opioid misuse in a palliative care clinic. Methods: We reviewed patient records for 6 months for source of pain, treatment status, opioid misuse risk (Cut down, Annoyed, Guilty, and Eye-opener [CAGE] and Screener and Opioid Assessment for Patients with Pain version 1.0—Short Form [SOAPP-SF] scores), and urine drug screens. Results: Of 323 patients, 91% had cancer, 56% undergoing cancer treatment, while 28% had no evidence of disease. Eighty-six (27%) patients had noncancer pain. In all, 46% of new patients had positive scores on the SOAPP-SF and 15% had a positive CAGE. Of the less than 5% of visits that included a urine drug screen, 56% had aberrant results. Conclusion: Chronic pain and indicators of opioid misuse risk were prevalent. Outpatient palliative care practices should develop policies to address these issues.
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Affiliation(s)
- Julie W. Childers
- Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Linda A. King
- Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert M. Arnold
- Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA, USA
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Matteliano D, St Marie BJ, Oliver J, Coggins C. Adherence monitoring with chronic opioid therapy for persistent pain: a biopsychosocial-spiritual approach to mitigate risk. Pain Manag Nurs 2014; 15:391-405. [PMID: 24602442 PMCID: PMC3950820 DOI: 10.1016/j.pmn.2012.08.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Revised: 08/17/2012] [Accepted: 08/17/2012] [Indexed: 10/27/2022]
Abstract
Opioids represent a mainstay in the pharmacologic management of persistent pain. Although these drugs are intended to support improved comfort and function, the inherent risk of abuse or addiction must be considered in the delivery of care. The experience of living with persistent pain often includes depression, fear, loss, and anxiety, leading to feelings of hopelessness, helplessness, and spiritual crisis. Collectively, these factors represent an increased risk for all patients, particularly those with a history of substance abuse or addiction. This companion article to the American Society for Pain Management Nursing "Position Statement on Pain Management in Patients with Substance Use Disorders" (2012) focuses on the intersection of persistent pain, substance use disorder (SUD), and chronic opioid therapy and the clinical implications of monitoring adherence with safe use of opioids for those with persistent pain. This paper presents an approach to the comprehensive assessment of persons with persistent pain when receiving opioid therapy by presenting an expansion of the biopsychosocial model to include spiritual factors associated with pain and SUD, thus formulating a biopsychosocial-spiritual approach to mitigate risk. Key principles are provided for adherence monitoring using the biopsychosocial-spiritual assessment model developed by the authors as a means of promoting sensitive and respectful care.
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Affiliation(s)
- Deborah Matteliano
- School of Nursing, State University of New York, Buffalo, New York; Pain Management and Rehabilitation Center, Buffalo, New York.
| | - Barbara J St Marie
- College of Nursing, University of Iowa, Iowa City, Iowa; Fairview Ridges Hospital, Burnsville, MN
| | - June Oliver
- Swedish Covenant Hospital, Chicago, Illinois
| | - Candace Coggins
- Hospice Care of the Low Country, Coastal Pain and Spine Center, Bluffton, South Carolina
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Martel MO, Dolman AJ, Edwards RR, Jamison RN, Wasan AD. The association between negative affect and prescription opioid misuse in patients with chronic pain: the mediating role of opioid craving. THE JOURNAL OF PAIN 2014; 15:90-100. [PMID: 24295876 PMCID: PMC3877217 DOI: 10.1016/j.jpain.2013.09.014] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 07/30/2013] [Accepted: 09/26/2013] [Indexed: 01/08/2023]
Abstract
UNLABELLED Over the past decade, considerable research has accumulated showing that chronic pain patients experiencing high levels of negative affect (NA) are at increased risk for prescription opioid misuse. The primary objective of the present study was to examine the factors that underlie the association between NA and prescription opioid misuse among patients with chronic pain. In this study, 82 patients with chronic musculoskeletal pain being prescribed opioid medication completed the Current Opioid Misuse Measure, a well-validated self-report questionnaire designed to assess prescription opioid misuse. Patients were also asked to complete self-report measures of pain intensity, NA, and opioid craving. A bootstrapped multiple mediation analysis was used to examine the mediating role of patients' pain intensity and opioid craving in the association between NA and prescription opioid misuse. Consistent with previous research, we found a significant association between NA and prescription opioid misuse. Interestingly, results revealed that opioid craving, but not pain intensity, mediated the association between NA and opioid misuse. The Discussion addresses the potential psychological and neurobiological factors that might contribute to the interrelationships among NA, opioid craving, and prescription opioid misuse in patients with pain. The clinical implications of our findings are also discussed. PERSPECTIVE Our study provides new insights into the factors that underlie the association between negative affect and prescription opioid misuse in patients with chronic pain. Our findings could have important clinical implications, particularly for patients being prescribed opioid medication, and for reducing rates of opioid misuse in patients with pain.
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Affiliation(s)
- Marc O Martel
- Department of Anesthesiology, Harvard Medical School, Brigham & Women's Hospital, Boston, Massachusetts.
| | - Andrew J Dolman
- Department of Anesthesiology, Harvard Medical School, Brigham & Women's Hospital, Boston, Massachusetts
| | - Robert R Edwards
- Department of Anesthesiology, Harvard Medical School, Brigham & Women's Hospital, Boston, Massachusetts
| | - Robert N Jamison
- Department of Anesthesiology, Harvard Medical School, Brigham & Women's Hospital, Boston, Massachusetts; Department of Psychiatry, Harvard Medical School, Brigham & Women's Hospital, Boston, Massachusetts
| | - Ajay D Wasan
- Department of Anesthesiology, Harvard Medical School, Brigham & Women's Hospital, Boston, Massachusetts; Department of Psychiatry, Harvard Medical School, Brigham & Women's Hospital, Boston, Massachusetts
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George JM, Menon M, Gupta P, Tan M. Use of strong opioids for chronic non-cancer pain: a retrospective analysis at a pain centre in Singapore. Singapore Med J 2013; 54:506-10. [DOI: 10.11622/smedj.2013173] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Martel MO, Wasan AD, Jamison RN, Edwards RR. Catastrophic thinking and increased risk for prescription opioid misuse in patients with chronic pain. Drug Alcohol Depend 2013; 132:335-41. [PMID: 23618767 PMCID: PMC3745790 DOI: 10.1016/j.drugalcdep.2013.02.034] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 02/25/2013] [Accepted: 02/27/2013] [Indexed: 01/04/2023]
Abstract
BACKGROUND As a consequence of the substantial rise in the prescription of opioids for the treatment of chronic noncancer pain, greater attention has been paid to the factors that may be associated with an increased risk for prescription opioid misuse. Recently, a growing number of studies have shown that patients with high levels of catastrophizing are at increased risk for prescription opioid misuse. OBJECTIVE The primary objective of this study was to examine the variables that might underlie the association between catastrophizing and risk for prescription opioid misuse in patients with chronic pain. METHODS Patients with chronic musculoskeletal pain (n=115) were asked to complete the SOAPP-R, a validated self-report questionnaire designed to identify patients at risk for prescription opioid misuse. Patients were also asked to complete self-report measures of pain intensity, catastrophizing, anxiety, and depression. RESULTS Consistent with previous research, we found that catastrophizing was associated with an increased risk for prescription opioid misuse. Results also revealed that the association between catastrophizing and risk for opioid misuse was partially mediated by patients' levels of anxiety. Follow-up analyses, however, indicated that catastrophizing remained a significant 'unique' predictor of risk for opioid misuse even when controlling for patients' levels of pain severity, anxiety and depressive symptoms. DISCUSSION Discussion addresses the factors that might place patients with high levels of catastrophizing at increased risk for prescription opioid misuse. The implications of our findings for the management of patients considered for opioid therapy are also discussed.
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Affiliation(s)
- MO Martel
- Department of Anesthesiology, Harvard Medical School, BWH Pain Management Center, 850 Boylston St. Chestnut Hill, MA 02467, USA
| | - AD Wasan
- Department of Anesthesiology, Harvard Medical School, BWH Pain Management Center, 850 Boylston St. Chestnut Hill, MA 02467, USA,Department of Psychiatry, Harvard Medical School, 401 Park Drive, Boston, MA 02215, USA
| | - RN Jamison
- Department of Anesthesiology, Harvard Medical School, BWH Pain Management Center, 850 Boylston St. Chestnut Hill, MA 02467, USA,Department of Psychiatry, Harvard Medical School, 401 Park Drive, Boston, MA 02215, USA
| | - RR Edwards
- Department of Anesthesiology, Harvard Medical School, BWH Pain Management Center, 850 Boylston St. Chestnut Hill, MA 02467, USA
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Barrantes F, Luan FL, Kommareddi M, Alazem K, Yaqub T, Roth RS, Sung RS, Cibrik DM, Song P, Samaniego M. A history of chronic opioid usage prior to kidney transplantation may be associated with increased mortality risk. Kidney Int 2013; 84:390-6. [DOI: 10.1038/ki.2013.136] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Revised: 01/30/2013] [Accepted: 02/07/2013] [Indexed: 12/20/2022]
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Brennan MJ. Update on prescription extended-release opioids and appropriate patient selection. J Multidiscip Healthc 2013; 6:265-80. [PMID: 23900563 PMCID: PMC3726523 DOI: 10.2147/jmdh.s38562] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Chronic pain is largely underdiagnosed, often undertreated, and expected to increase as the American population ages. Many patients with chronic pain require long-term treatment with analgesic medications, and pain management may involve use of prescription opioids for patients whose pain is inadequately controlled through other therapies. Yet because of the potential for abuse and addiction, many clinicians hesitate to treat their patients with pain with potentially beneficial agents. Finding the right opioid for the right patient is the first - often complicated - step. Ensuring that patients continue to properly use the medication while achieving therapeutic analgesic effects is the long-term goal. Combined with careful patient selection and ongoing monitoring, new formulations using extended-release technologies incorporating tamper-resistant features may help combat the growing risk of abuse or misuse, which will hopefully reduce individual suffering and the societal burden of chronic pain. The objective of this manuscript is to provide an update on extended-release opioids and to provide clinicians with a greater understanding of which patients might benefit from these new opioid formulations and how to integrate the recommended monitoring for abuse potential into clinical practice.
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