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Coloma-Carmona A, Carballo JL. Assessing Opioid Abuse in Chronic Pain Patients: Further Validation of the Prescription Opioid Misuse Index (POMI) Using Item Response Theory. Int J Ment Health Addict 2023. [DOI: 10.1007/s11469-023-01029-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
Abstract
AbstractDue the limitations of the previous validations, the purpose of this study was to further validate the Prescription Opioid Misuse Index (POMI) in a larger sample of chronic non-cancer pain (CNCP) patients and to examine differential item functioning (DIF) across sex. Participants (n=225 CNCP patients under long-term opioid therapy) completed patient characteristics, self-reported POMI and DSM-5 prescription opioid use disorder measurements. Reliability and factor structure were assessed using both item response theory and classical test theory. ROC curve analysis was used to establish the optimum cut-off score for detecting the presence of DSM-5 prescription opioid-use disorder. Concurrent validity was also tested. The POMI showed a unidimensional factor structure and acceptable internal consistency (ωcat =0.62). DIF analysis showed that males and females respond similarly to each item of the POMI, supporting unbiased measurement of the latent trait across both groups. A cut-off point of 2 is suggested in order to maximize the accuracy of the instrument as a first-screening tool for opioid misuse (AUC=0.78; p<0.001; CI 95%: 0.72–0.85). Concurrent validity of the POMI was high with DSM-5 moderate to severe opioid-use disorder criteria (OR=7.824, p<0.001). These results indicate that the POMI is a valid and clinically feasible screening instrument for detecting CNCP patients who misuse opioid medications. The short length of the scale could meet the needs of clinical practice as it allows clinicians to precisely identify and monitor prescription opioid misuse in both male and female patients.
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Mishra M, Pickett M, Weiskopf NG. The Role of Informatics in Implementing Guidelines for Chronic Opioid Therapy Risk Assessment in Primary Care: A Narrative Review Informed by the Socio-Technical Model. Stud Health Technol Inform 2022; 290:447-451. [PMID: 35673054 PMCID: PMC10128894 DOI: 10.3233/shti220115] [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] [Indexed: 04/12/2023]
Abstract
Approximately 2 million Americans live with opioid use disorder (OUD), most of whom also have chronic pain. The economic burden of chronic pain and prescription opioid misuse runs into billions of dollars. Patients on prescription opioids for chronic non-cancer pain (CNCP) are at increased risk for OUD and overdose. By adhering to the Center for Disease Control and Prevention (CDC) opioid prescribing guidelines, primary care providers (PCPs) have the potential to improve patient outcomes. But numerous provider, patient, and practice-specific factors challenge adherence to guidelines in primary care. Many of the barriers may be mediated by informatics interventions, but gaps in knowledge and unmet needs exist. This narrative review examines the risk assessment and harm reduction process in a socio-technical context to highlight the gaps in knowledge and unmet needs that can be mediated through informatics intervention.
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Affiliation(s)
- Meenakshi Mishra
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, OR, USA
| | - Mary Pickett
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, OR, USA
| | - Nicole G. Weiskopf
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, OR, USA
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3
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Young SR, Azari S, Becker WC, Edelman EJ, Liebschutz JM, Roy P, Starrels JL, Merlin JS. Common and Challenging Behaviors Among Individuals on Long-term Opioid Therapy. J Addict Med 2021; 14:305-310. [PMID: 31855919 PMCID: PMC7297656 DOI: 10.1097/adm.0000000000000587] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Long-term opioid therapy (LTOT) is commonly prescribed for chronic pain, despite risks such as opioid use disorder (OUD) and overdose. Caring for patients on LTOT can be difficult, given lack of evidence about assessment of challenging behaviors among patients on LTOT. To develop this evidence, a critical first step is to systematically identify the common and challenging behaviors that primary care providers encounter among patients on LTOT, and also to highlight to diverse range of behaviors encountered. METHOD We conducted a Delphi study in 42 chronic pain experts to determine consensus on how to address the top common and challenging behaviors. This paper reports on the first round of the study, which elicited a range of behaviors. We conducted thematic analysis of the behaviors and also used the Diagnostic and Statistical Manual (DSM)-5 criteria for OUD as a priori codes. RESULTS In all, 124 unique behaviors were identified by participants and coded into 4 thematic categories: concerning behaviors that map onto DSM-5 criteria for OUD, and those that do not which were: behaviors that suggest deception, signs of diversion, and nonadherence to treatment plan. Those behaviors that fell outside of OUD criteria we identified as "gray zone" behaviors. CONCLUSIONS While some of these challenging behaviors fall under the criteria for an OUD, many fall outside of this framework, making diagnosis and treatment difficult, and consensus on how to deal with these "gray zone" behaviors is vital. Future research should explore how these "gray zone" behaviors can best be assessed and managed in a primary care setting.
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Affiliation(s)
- Sarah R. Young
- Department of Social Work, College of Community and Public Affairs, Binghamton University, Binghamton, NY. 13902, USA
| | - Soraya Azari
- University of California, San Francisco, 1001 Potrero Ave, 1311F, San Francisco, CA
| | - William C. Becker
- VA Connecticut Healthcare System, 950 Campbell Avenue, Mail Stop 151B, West Haven, CT 06516, USA
- Yale School of Medicine, 367 Cedar Street, New Haven, CT 06510, USA
| | | | - Jane M. Liebschutz
- University of Pittsburgh Department of Medicine, McKee Building, 230 McKee Place, Suite 600, Pittsburgh, PA 15213
| | - Payel Roy
- Boston Medical Center, Boston University School of Medicine, 801 Massachusetts Avenue, Boston, MA 02118
| | - Joanna L. Starrels
- Albert Einstein College of Medicine and Montefiore Medical Center, 111 E. 210 Street Bronx NY 10467
| | - Jessica S. Merlin
- University of Pittsburgh Department of Medicine, McKee Building, 230 McKee Place, Suite 600, Pittsburgh, PA 15213
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Buonora M, Perez HR, Stumph J, Allen R, Nahvi S, Cunningham CO, Merlin JS, Starrels JL. Medical Record Documentation About Opioid Tapering: Examining Benefit-to-Harm Framework and Patient Engagement. PAIN MEDICINE 2021; 21:2574-2582. [PMID: 32142143 DOI: 10.1093/pm/pnz361] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Guidelines recommend that clinicians make decisions about opioid tapering for patients with chronic pain using a benefit-to-harm framework and engaging patients. Studies have not examined clinician documentation about opioid tapering using this framework. DESIGN AND SETTING Thematic and content analysis of clinician documentation about opioid tapering in patients' medical records in a large academic health system. METHODS Medical records were reviewed for patients aged 18 or older, without cancer, who were prescribed stable doses of long-term opioid therapy between 10/2015 and 10/2016 then experienced an opioid taper (dose reduction ≥30%) between 10/2016 and 10/2017. Inductive thematic analysis of clinician documentation within six months of taper initiation was conducted to understand rationale for taper, and deductive content analysis was conducted to determine the frequencies of a priori elements of a benefit-to-harm framework. RESULTS Thematic analysis of 39 patients' records revealed 1) documented rationale for tapering prominently cited potential harms of continuing opioids, rather than observed harms or lack of benefits; 2) patient engagement was variable and disagreement with tapering was prominent. Content analysis found no patients' records with explicit mention of benefit-to-harm assessments. Benefits of continuing opioids were mentioned in 56% of patients' records, observed harms were mentioned in 28%, and potential harms were mentioned in 90%. CONCLUSIONS In this study, documentation of opioid tapering focused on potential harms of continuing opioids, indicated variable patient engagement, and lacked a complete benefit-to-harm framework. Future initiatives should develop standardized ways of incorporating a benefit-to-harm framework and patient engagement into clinician decisions and documentation about opioid tapering.
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Affiliation(s)
- Michele Buonora
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York
| | - Hector R Perez
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York
| | - Jordan Stumph
- Department of Physical Medicine and Rehabilitation, New York-Presbyterian Columbia/Cornell, New York, New York
| | - Robert Allen
- Department of Emergency Medicine, SUNY Downstate Medical Center, Brooklyn, New York
| | - Shadi Nahvi
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York
| | - Chinazo O Cunningham
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York
| | - Jessica S Merlin
- Center for Research on Healthcare, Divisions of General Internal Medicine and Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Joanna L Starrels
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York
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Argoff CE, Alford DP, Fudin J, Adler JA, Bair MJ, Dart RC, Gandolfi R, McCarberg BH, Stanos SP, Gudin JA, Polomano RC, Webster LR. Rational Urine Drug Monitoring in Patients Receiving Opioids for Chronic Pain: Consensus Recommendations. PAIN MEDICINE 2019; 19:97-117. [PMID: 29206984 PMCID: PMC6516588 DOI: 10.1093/pm/pnx285] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objective To develop consensus recommendations on urine drug monitoring (UDM) in patients with chronic pain who are prescribed opioids. Methods An interdisciplinary group of clinicians with expertise in pain, substance use disorders, and primary care conducted virtual meetings to review relevant literature and existing guidelines and share their clinical experience in UDM before reaching consensus recommendations. Results Definitive (e.g., chromatography-based) testing is recommended as most clinically appropriate for UDM because of its accuracy; however, institutional or payer policies may require initial use of presumptive testing (i.e., immunoassay). The rational choice of substances to analyze for UDM involves considerations that are specific to each patient and related to illicit drug availability. Appropriate opioid risk stratification is based on patient history (especially psychiatric conditions or history of opioid or substance use disorder), prescription drug monitoring program data, results from validated risk assessment tools, and previous UDM. Urine drug monitoring is suggested to be performed at baseline for most patients prescribed opioids for chronic pain and at least annually for those at low risk, two or more times per year for those at moderate risk, and three or more times per year for those at high risk. Additional UDM should be performed as needed on the basis of clinical judgment. Conclusions Although evidence on the efficacy of UDM in preventing opioid use disorder, overdose, and diversion is limited, UDM is recommended by the panel as part of ongoing comprehensive risk monitoring in patients prescribed opioids for chronic pain.
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Affiliation(s)
- Charles E Argoff
- Department of Neurology, Albany Medical Center, Albany, New York
| | - Daniel P Alford
- Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Jeffrey Fudin
- Scientific and Clinical Affairs, Remitigate, LLC, Delmar, New York
| | - Jeremy A Adler
- Pacific Pain Medicine Consultants, Encinitas, California
| | - Matthew J Bair
- HSR&D Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indiana University School of Medicine, and Regenstrief Institute, Indianapolis, Indiana
| | | | | | - Bill H McCarberg
- Department of Family Medicine, University of California at San Diego School of Medicine, San Diego, California
| | - Steven P Stanos
- Swedish Pain Services, Swedish Health System, Seattle, Washington
| | - Jeffrey A Gudin
- Department of Pain Management and Palliative Care, Englewood Hospital and Medical Center, Englewood, New Jersey
| | - Rosemary C Polomano
- Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Lynn R Webster
- Scientific Affairs, PRA International, Salt Lake City, Utah, USA
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Transnational trends in prescription drug misuse among women: A systematic review. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 63:56-73. [DOI: 10.1016/j.drugpo.2018.10.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 09/14/2018] [Accepted: 10/09/2018] [Indexed: 12/21/2022]
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7
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Whiteside LK, Goldstick J, Dora-Laskey A, Thomas L, Walton M, Cunningham R, Bohnert AS. Patient Preference for Pain Medication in the Emergency Department Is Associated with Non-fatal Overdose History. West J Emerg Med 2018; 19:722-730. [PMID: 30013710 PMCID: PMC6040914 DOI: 10.5811/westjem.2018.4.37019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 03/06/2018] [Accepted: 04/09/2018] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Opioid overdose is a major public health problem. Emergency physicians need information to better assess a patient's risk for overdose or opioid-related harms. The purpose of this study was to determine if patient-reported preference for specific pain medications was associated with a history of lifetime overdose among patients seeking care in the emergency department (ED). METHODS ED patients (18-60 years) completed a screening survey that included questions on overdose history, ED utilization, opioid misuse behaviors as measured by the Current Opioid Misuse Measure (COMM), and analgesic medication preferences for previous ED visits for pain with specific responses for preference for hydromorphone (Dilaudid®), morphine, ketorolac (Toradol®), "no preference" or "never visited the ED for pain." We compared individuals who reported a lifetime history of overdose descriptively to those without a lifetime history of overdose. Logistic regression was used to determine factors associated with a history of overdose. RESULTS We included 2,233 adults in the analysis (71.5% response rate of patients approached) with 532 reporting at least one lifetime overdose. In the univariate analysis, medication preference was significantly associated with overdose history (p < .001); more patients in the overdose group reported preferring morphine and hydromorphone and those without a history of overdose were more likely to have no preference or say they had never visited the ED for pain. In the logistic regression analysis, patients with higher odds of overdose included those of Caucasian race, participants with a higher COMM score, preference for ketorolac, morphine or hydromorphone. Those who were younger, female and reported never having visited the ED for pain had lower odds of reporting a lifetime overdose. Having "any preference" corresponded to 48% higher odds of lifetime overdose. CONCLUSION Patients with a pain medication preference have higher odds of having a lifetime overdose compared to patients without a specific pain medication preference, even after accounting for level of opioid misuse. This patient-reported preference could cue emergency physicians to identifying high-risk patients for overdose and other substance-related harms.
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Affiliation(s)
- Lauren K. Whiteside
- University of Washington, Department of Emergency Medicine, Seattle, Washington
| | - Jason Goldstick
- University of Michigan Medical School, University of Michigan Injury Center, Ann Arbor, Michigan
| | - Aaron Dora-Laskey
- University of Michigan Medical School, University of Michigan Injury Center, Ann Arbor, Michigan
- University of Michigan Medical School, Department of Emergency Medicine, Ann Arbor, Michigan
| | - Laura Thomas
- University of Michigan Medical School, Addiction Center and Department of Psychiatry, Ann Arbor, Michigan
- VA Center for Clinical Management Research, Department of Veterans Affairs Healthcare System, Ann Arbor, Michigan
| | - Maureen Walton
- University of Michigan Medical School, University of Michigan Injury Center, Ann Arbor, Michigan
- University of Michigan Medical School, Addiction Center and Department of Psychiatry, Ann Arbor, Michigan
| | - Rebecca Cunningham
- University of Michigan Medical School, University of Michigan Injury Center, Ann Arbor, Michigan
- University of Michigan Medical School, Department of Emergency Medicine, Ann Arbor, Michigan
| | - Amy S.B. Bohnert
- University of Michigan Medical School, University of Michigan Injury Center, Ann Arbor, Michigan
- University of Michigan Medical School, Addiction Center and Department of Psychiatry, Ann Arbor, Michigan
- VA Center for Clinical Management Research, Department of Veterans Affairs Healthcare System, Ann Arbor, Michigan
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8
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Nagpal AS, Eckmann M, Weinstein SM. Maintaining Opioid Prescription for Chronic Back Pain: Pro Versus Con. PM R 2018; 10:83-89. [PMID: 29413121 DOI: 10.1016/j.pmrj.2017.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 12/11/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Ameet S Nagpal
- Departments of Anesthesiology and PM&R, UT Health San Antonio, 7703 Floyd Curl Dr, MC 7838, San Antonio, TX 78209.,Departments of Anesthesiology and PM&R, UT Health San Antonio, San Antonio, TX.,Department of Rehabilitation Medicine, Orthopaedic Surgery and Sports Medicine, and Neurological Surgery, University of Washington, Seattle, WA
| | - Maxim Eckmann
- Departments of Anesthesiology and PM&R, UT Health San Antonio, 7703 Floyd Curl Dr, MC 7838, San Antonio, TX 78209.,Departments of Anesthesiology and PM&R, UT Health San Antonio, San Antonio, TX.,Department of Rehabilitation Medicine, Orthopaedic Surgery and Sports Medicine, and Neurological Surgery, University of Washington, Seattle, WA
| | - Stuart M Weinstein
- Departments of Anesthesiology and PM&R, UT Health San Antonio, 7703 Floyd Curl Dr, MC 7838, San Antonio, TX 78209.,Departments of Anesthesiology and PM&R, UT Health San Antonio, San Antonio, TX.,Department of Rehabilitation Medicine, Orthopaedic Surgery and Sports Medicine, and Neurological Surgery, University of Washington, Seattle, WA
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9
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Merlin JS, Young SR, Starrels JL, Azari S, Edelman EJ, Pomeranz J, Roy P, Saini S, Becker WC, Liebschutz JM. Managing Concerning Behaviors in Patients Prescribed Opioids for Chronic Pain: A Delphi Study. J Gen Intern Med 2018; 33:166-176. [PMID: 29204977 PMCID: PMC5789105 DOI: 10.1007/s11606-017-4211-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 09/12/2017] [Accepted: 10/25/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Current guideline-recommended monitoring of patients prescribed long-term opioid therapy (LTOT) for chronic pain will likely result in increased identification of behaviors of concern for misuse and addiction, but there is a dearth of empiric evidence about how these behaviors should be managed. OBJECTIVE To establish expert consensus about treatment approaches for common and challenging concerning behaviors that arise among patients on LTOT. DESIGN We used a Delphi approach, which allows for generation of consensus. PARTICIPANTS Participants were clinical experts in chronic pain and opioid prescribing recruited from professional societies and other expert groups. MAIN MEASURES The Delphi process was conducted online, and consisted of an initial brainstorming round to identify common and challenging behaviors, a second round to identify management strategies for each behavior, and two rounds to establish consensus and explore disagreement/uncertainty. KEY RESULTS Forty-two participants completed round 1, 22 completed round 2, 30 completed round 3, and 28 completed round 4. Half of round 1 participants were female (52%), and the majority were white (83%). Most (71%) were physicians, and most participants practiced in academic primary (40%) or specialty care (19%).The most frequently cited common and challenging behaviors were missing appointments, taking opioids for symptoms other than pain, using more opioid medication than prescribed, asking for an increase in opioid dose, aggressive behavior, and alcohol and other substance use. Across behaviors, participants agreed that patient education and information gathering were important approaches. Participants also agreed that stopping opioids is not important initially, but if initial approaches do not work, tapering opioids and stopping opioids immediately may become important approaches. CONCLUSIONS This study presents clinical expert consensus on how to manage concerning behaviors among patients on LTOT. Future research is needed to investigate how implementing these management strategies would impact patient outcomes, practice and policy.
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Affiliation(s)
- Jessica S Merlin
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA. .,Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Sarah R Young
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA.,Department of Social Work, College of Community and Public Affairs, Binghamton University, Binghamton, NY, USA
| | - Joanna L Starrels
- Division of General Internal Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Soraya Azari
- Division of General Internal Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA
| | - E Jennifer Edelman
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jamie Pomeranz
- Department of Occupational Therapy, University of Florida, Gainesville, FL, USA
| | - Payel Roy
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Shalini Saini
- Department of Medicine, Information Technology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - William C Becker
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.,VA Connecticut Healthcare System, West Haven, CT, USA
| | - Jane M Liebschutz
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
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Merlin JS, Young SR, Azari S, Becker WC, Liebschutz JM, Pomeranz J, Roy P, Saini S, Starrels JL, Edelman EJ. Management of problematic behaviours among individuals on long-term opioid therapy: protocol for a Delphi study. BMJ Open 2016; 6:e011619. [PMID: 27154486 PMCID: PMC4861114 DOI: 10.1136/bmjopen-2016-011619] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Given the sharp rise in opioid prescribing and heightened recognition of opioid addiction and overdose, opioid safety has become a priority. Clinical guidelines on long-term opioid therapy (LTOT) for chronic pain consistently recommend routine monitoring and screening for problematic behaviours. Yet, there is no consensus definition regarding what constitutes a problematic behaviour, and recommendations for appropriate management to inform front-line providers, researchers and policymakers are lacking. This creates a barrier to effective guideline implementation. Thus, our objective is to present the protocol for a Delphi study designed to: (1) elicit expert opinion to identify the most important problematic behaviours seen in clinical practice and (2) develop consensus on how these behaviours should be managed in the context of routine clinical care. METHODS/ANALYSIS We will include clinical experts, defined as individuals who provide direct patient care to adults with chronic pain who are on LTOT in an ambulatory setting, and for whom opioid prescribing for chronic non-malignant pain is an area of expertise. The Delphi study will be conducted online in 4 consecutive rounds. Participants will be asked to list problematic behaviours and identify which behaviours are most common and challenging. They will then describe how they would manage the most frequently occurring common and challenging behaviours, rating the importance of each management strategy. Qualitative analysis will be used to categorise behaviours and management strategies, and consensus will be based on a definition established a priori. ETHICS/DISSEMINATION This study has been approved by the Institutional Review Board (IRB) of the University of Alabama at Birmingham (UAB). This study will generate Delphi-based expert consensus on the management of problematic behaviours that arise in individuals on LTOT, which we will publish and disseminate to appropriate professional societies. Ultimately, our findings will provide guidance to front-line providers, researchers and policymakers.
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Affiliation(s)
- Jessica S Merlin
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sarah R Young
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Soraya Azari
- Division of General Internal Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, USA
| | - William C Becker
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Jane M Liebschutz
- Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Clinical Addiction, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jamie Pomeranz
- Department of Occupational Therapy, University of Florida, Gainesville, Florida, USA
| | - Payel Roy
- Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Clinical Addiction, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Shalini Saini
- Department of Medicine, Information Technology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Joanna L Starrels
- Division of General Internal Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - E Jennifer Edelman
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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Buchman DZ, Ho A, Illes J. You Present like a Drug Addict: Patient and Clinician Perspectives on Trust and Trustworthiness in Chronic Pain Management. PAIN MEDICINE 2016; 17:1394-406. [PMID: 26759389 DOI: 10.1093/pm/pnv083] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 11/07/2015] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Past research has demonstrated that trust is central to an effective therapeutic relationship, but the role of trust in chronic pain management is not well understood. The objective of this study was to provide an in-depth examination of how adults living with chronic pain negotiate trust and demonstrate trustworthiness with clinicians in therapeutic encounters. METHODS This qualitative study focused on adults living in an urban setting in British Columbia, Canada. Semi-structured interviews (N = 27) were conducted with participants with chronic low back pain. The results were triangulated by two feedback groups comprising re-contacted interview participants (n = 4) and physicians with expertise in pain and addiction management (n = 6). RESULTS Grounded theory analysis of the adult patient interviews and feedback groups yielded four major themes: 1) threats to trustworthiness and iatrogenic suffering; 2) communicating the invisible and subjective condition of chronic pain; 3) motive, honesty, and testimony; and 4) stigmatized identities. The following two themes emerged from the analysis of the physician feedback group: 1) challenges of the practice context, and 2) complicated clinical relationships. CONCLUSIONS We found that perceived trustworthiness is important in therapeutic encounters as it helps to negotiate tensions with respect to subjective pain symptoms, addiction, and prescription opioid use. An attitude of epistemic humility may help both clinicians and patients cultivate a trustworthy clinical environment, manage the challenges associated with uncertain testimony, place trust wisely, and promote optimal pain care.
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Affiliation(s)
- Daniel Z Buchman
- *National Core for Neuroethics, Division of Neurology, Department of Medicine, and
| | - Anita Ho
- W. Maurice Young Centre for Applied Ethics, the University of British Columbia, Vancouver, British Columbia, Canada Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Judy Illes
- *National Core for Neuroethics, Division of Neurology, Department of Medicine, and
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Abstract
Opioid use in chronic pain treatment is complex, as patients may derive both benefit and harm. Identification of individuals currently using opioids in a problematic way is important given the substantial recent increases in prescription rates and consequent increases in morbidity and mortality. The present review provides updated and expanded information regarding rates of problematic opioid use in chronic pain. Because previous reviews have indicated substantial variability in this literature, several steps were taken to enhance precision and utility. First, problematic use was coded using explicitly defined terms, referring to different patterns of use (ie, misuse, abuse, and addiction). Second, average prevalence rates were calculated and weighted by sample size and study quality. Third, the influence of differences in study methodology was examined. In total, data from 38 studies were included. Rates of problematic use were quite broad, ranging from <1% to 81% across studies. Across most calculations, rates of misuse averaged between 21% and 29% (range, 95% confidence interval [CI]: 13%-38%). Rates of addiction averaged between 8% and 12% (range, 95% CI: 3%-17%). Abuse was reported in only a single study. Only 1 difference emerged when study methods were examined, where rates of addiction were lower in studies that identified prevalence assessment as a primary, rather than secondary, objective. Although significant variability remains in this literature, this review provides guidance regarding possible average rates of opioid misuse and addiction and also highlights areas in need of further clarification.
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13
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Variability in opioid prescription monitoring and evidence of aberrant medication taking behaviors in urban safety-net clinics. Pain 2015; 156:335-340. [PMID: 25599455 DOI: 10.1097/01.j.pain.0000460314.73358.ff] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Little is known about variability in primary care providers' (PCPs) adherence to opioid-monitoring guidelines for patients. We examined variability of adherence to monitoring guidelines among PCPs and ascertained the relationship between PCP adherence and opioid misuse by their patients. We included primary care patients receiving long-term opioids (≥3 prescriptions within 6 months) for chronic noncancer pain and PCPs with ≥4 eligible patients. We examined guideline adherence using: (1) electronic health record documentation of opioid treatment agreement, (2) past-year urine drug screen (UDS), and (3) evidence of misuse through early refills (≥2 opioid prescriptions written 7-25 days after the previous prescription). Covariates included morphine equivalent daily opioid medication dose (MED, >50 mg/d vs ≤50mg/d). Multilevel regression models assessed variability among PCPs, and odds ratios examined associations among patient-level binary outcomes. Sixty-seven PCPs prescribed opioids to 1546 patients. Significant variability was found between PCPs in use of agreement (variance = 1.27, P < 0.001), UDS (variance = 1.75, P < 0.001), and early refills (variance = 0.29, P = 0.002). Primary care providers had a mean of 48% of patients with agreement (range, 9%-84%), 56% with ≥1 UDS (range, 7%-91%) and 36% with early refills (range, 19%-60%). High MED among patients was associated with increased odds of agreement (1.93, confidence interval [CI], 1.53-2.44), UDS (2.65, CI: 2.06-3.41), and early refill (2.92, CI: 2.30-3.70). Primary care providers varied significantly in adherence to opioid prescription guidelines. Increased patient risk was associated with increased monitoring and with greater misuse. Future work should study system-level interventions to enable clinical monitoring and support opioid guideline adherence.
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Merlin JS, Turan J, Herbey I, Westfall AO, Starrels JL, Kertesz SG, Saag M, Ritchie CS. Aberrant drug-related behaviors: a qualitative analysis of medical record documentation in patients referred to an HIV/chronic pain clinic. PAIN MEDICINE (MALDEN, MASS.) 2014; 15:1724-33. [PMID: 25138608 PMCID: PMC4208944 DOI: 10.1111/pme.12533] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Due to rising rates of opioid addiction and overdose among individuals on chronic opioid therapy, aberrant drug-related behaviors (ADRBs) are an important and challenging issue. Our objective was to qualitatively investigate the documentation of ADRBs in the medical record. METHODS Manually abstracted provider notes from an HIV primary care clinic were analyzed using content analysis methods. RESULTS Categories of ADRBs identified included patients requesting opioids, obtaining nonprescribed opioids, and becoming emotional about opioids. We also identified several types of provider language used when documenting ADRBs, including purely descriptive language and emotional language such as labeling, frustration, and concern, and responses such as setting conditions for opioid prescription and action-oriented language. CONCLUSIONS The impact of including emotional language in the medical record is unknown. Development of instruments that can be used to facilitate ADRB documentation, as well as evidence-based approaches to addressing ADRBs, is needed.
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Affiliation(s)
- Jessica S. Merlin
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Janet Turan
- School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Ivan Herbey
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Andrew O. Westfall
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Joanna L. Starrels
- Division of General Internal Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| | - Stefan G. Kertesz
- Birmingham VA Medical Center
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Michael Saag
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Christine S. Ritchie
- San Francisco VA Medical Center, San Francisco, CA
- Jewish Home of San Francisco Center for Research on Aging, San Francisco, CA
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Meltzer EC, Suppes A, Burns S, Shuman A, Orfanos A, Sturiano CV, Charney P, Fins JJ. Stigmatization of Substance Use Disorders Among Internal Medicine Residents. Subst Abus 2013; 34:356-62. [DOI: 10.1080/08897077.2013.815143] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Hamill-Ruth RJ, Larriviere K, McMasters MG. Addition of objective data to identify risk for medication misuse and abuse: the inconsistency score. PAIN MEDICINE 2013; 14:1900-7. [PMID: 23947737 DOI: 10.1111/pme.12221] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To identify and quantify the rate of aberrant drug-taking behaviors using objective data. DESIGN Institutional Review Board-approved anonymous, voluntary, quality improvement project. SETTING University-based, multidisciplinary pain management center. SUBJECTS Consecutive initial visit patients. METHODS Patients were interviewed, asked to provide a urine sample, and filled out a brief questionnaire about recent prescription, over-the-counter, and illicit drug use. Discrepancies between patient report (PQ), the Virginia State prescription monitoring program (PMP), referring physician records (MRs), and the point-of-care urine drug screen (POC UDS) results were scored from 0 (none) to a maximum of 2 points (2+ discrepancies) for each potential comparator between data sets. Maximum potential inconsistency score (IS) was 16 points. RESULTS Two hundred nine patients were interviewed to yield 118 specimens. Mean age of participants was 48.2 years (22-83 year); 65.3% were female. IS scores ranged from 1 to 11, and 52.5% of the patients had an IS ≥ 3. Higher IS scores correlated with higher numbers of pharmacies, prescribing physicians, prescriptions on the PMP, and presence of illicit substances in the urine. Addition of either POC UDS or PMP to PQ and MR increased identification of inconsistencies by >400%, and PMP plus UDS by >900%. CONCLUSIONS Patient report and the medical record are inadequate to screen for aberrant drug-related behaviors. Addition of PMP and POC UDS contribute significantly to identification of inconsistencies through higher IS scores and differentiate patients at higher risk of medication misuse, abuse, or diversion. Comparison of multiple sources of objective information provides better insight into inconsistencies of report and behavior, and may assist in more appropriate and safer prescribing decisions.
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Affiliation(s)
- Robin J Hamill-Ruth
- Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Division of Pain Medicine, University of Virginia Health System, Charlottesville, Virginia, USA
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Meltzer EC, Hall WD, Fins JJ. Error and Bias in the Evaluation of Prescription Opioid Misuse: Should the FDA Regulate Clinical Assessment Tools? PAIN MEDICINE 2013; 14:982-7. [DOI: 10.1111/pme.12099] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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