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Holkenborg J, Frenken BA, Bon BVDKV, Vroegop MP, Van Meggelen MGM, Kramers C, Schellekens AFA, Kraaijvanger N. The prevalence of prescription opioid use and misuse among emergency department patients in The Netherlands. J Eval Clin Pract 2024; 30:473-480. [PMID: 38251860 DOI: 10.1111/jep.13965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 12/06/2023] [Accepted: 12/31/2023] [Indexed: 01/23/2024]
Abstract
RATIONALE Prescription opioid use and misuse have increased rapidly in many Western countries in the past decade. Patients (mis)using opioids are at risk of presenting to the emergency department (ED) with opioid-related problems. European data concerning prescription opioid (mis)use among the ED population is lacking. AIMS AND OBJECTIVES This study aims to determine prevalence of prescription opioid use, misuse, and opioid use disorder (OUD) among Dutch ED patients. Secondary objectives were to explore factors associated with prescription opioid misuse and the number of patients discharged with a new opioid prescription. METHODS In a cross-sectional multicenter study at three hospitals in the Netherlands, adult ED patients were screened for current prescription opioid use. Opioid users filled out questionnaires regarding opioid (mis)use, and underwent a structured interview to assess OUD criteria. The primary outcomes were prevalence rates of (1) current prescription opioid use, (2) prescription opioid misuse (based on a Current Opioid Misuse Measure [COMM] score > 8), (3) OUD, based on DSM-5 criteria. Independent T-tests, Pearson χ2 and Fisher's Exact tests were used to analyse differences in characteristics between groups. RESULTS A total of 997 patients were screened, of which 15% (n = 150) used prescription opioids. Out of 93 patients assessed, 22.6% (n = 21) showed signs of prescription opioid misuse, and 9.8% (n = 9, 95% CI: 4.5-17.8) fulfilled criteria for OUD. A medical history of psychiatric disorder was significantly more common in patients with prescription opioid misuse and OUD. CONCLUSION This study shows that prescription opioid use is relatively common in ED patients in the Netherlands, compared to the overall population. Over one fifth of these patients shows signs of opioid misuse or OUD. Awareness among ED personnel about the high prevalence of prescription opioid (mis)use in their population is critical for signalling opioid-related problems.
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Affiliation(s)
- Joris Holkenborg
- Emergency Department, Rijnstate Hospital, Arnhem, The Netherlands
| | | | | | - Maurice P Vroegop
- Emergency Department, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Cees Kramers
- Department of Pharmacology-Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Arnt F A Schellekens
- Nijmegen Institute for Science Practitioners in Addiction (NISPA), Nijmegen, The Netherlands
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands
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2
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Wague A, O'Donnell JM, Stroud S, Filley A, Rangwalla K, Baldwin A, El Naga AN, Gendelberg D, Berven S. Association between opioid utilization and patient reported outcome measures following lumbar spine surgery. Spine J 2024:S1529-9430(24)00075-5. [PMID: 38365008 DOI: 10.1016/j.spinee.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 01/10/2024] [Accepted: 02/06/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND CONTEXT The patient-reported outcomes measurement information system (PROMIS), created by the National institute of Health, is a reliable and valid survey for patients with lumbar spine pathology. Preoperative opioid use has been shown to be an important predictor variable of self-reported health status in legacy patient reported outcome measures. PURPOSE To investigate the impact of chronic preoperative opiate use on PROMIS survey scores. STUDY DESIGN Retrospective database analysis. PATIENT SAMPLE Between March 2019 and November 2021, 227 patients underwent lumbar decompression ± ≤ 2 level fusion. Fifty-seven patients (25.11%) had chronic preoperative opioid use. OUTCOME MEASURES Oswestry disability index (ODI) and PROMIS survey scores. METHODS A retrospective analysis of a prospectively maintained single center patient-reported outcome database was performed with a minimum of 2 year follow-up. PROMIS Anxiety, Depression, Fatigue, Pain Interference (PI), Physical Function (PF), Sleep disturbance (SD), and Social Roles (SR) surveys were recorded at preoperative intake with subsequent follow-up at 6, 12, and 24 months postoperatively. Patients were grouped into chronic opioid users as defined by >6-month duration of use. Differences in mean survey scores were evaluated using Welch t-tests. RESULTS Two hundred and twenty-seven patients met our inclusion criteria of completed PROMIS surveys at the designated timepoints. A total of 57 (25.11%) were chronic opioid users (COU) prior to surgery. Analysis of patient-reported health outcomes shows that long term opioid use correlated with worse ODI and PROMIS scores at baseline compared to nonchronic users (NOU). At 1 and 2 year follow-up, the COU cohort continued to have significantly worse ODI, PROMIS Fatigue, PF, PI, SD, and SR scores. There is a statistical difference in the magnitude of change in health status between the 2 cohorts at 1 year follow-up in PROMIS Depression (-5.04±7.88 vs. -2.49±8.73, p=.042), PF (6.25±7.11 vs. 9.03±9.04, p=.019), and PI (-7.40±7.37 vs. -10.58±9.87, p=.011) and 2 year follow-up in PROMIS PF (5.58±6.84 vs. 7.99±9.64, p=.041) and PI (-6.71±8.32 vs. -9.62±10.06, p=.032). Mean improvement in PROMIS scores for the COU cohort at 2 year follow-up exceeded minimal clinically important difference (MCID) in all domains except PROMIS Depression, SR and SD. CONCLUSION Patients with chronic opioid use status have worse baseline PROMIS scores compared with patients who had nonchronic use. However, patients in the COU cohort displayed clinically significant postoperative improvement in multiple PROMIS domains. These results show that patients with chronic opioid use can benefit greatly from surgical intervention and will allow physicians to better set expectations with their patients.
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Affiliation(s)
- Aboubacar Wague
- University of California San Francisco School of Medicine, San Francisco, CA 94143, USA.
| | - Jennifer M O'Donnell
- University of California San Francisco, Department of Orthopaedic Surgery, San Francisco, CA 94143, USA
| | - Sarah Stroud
- University of California San Francisco, Department of Orthopaedic Surgery, San Francisco, CA 94143, USA
| | - Anna Filley
- University of California San Francisco, Department of Orthopaedic Surgery, San Francisco, CA 94143, USA
| | - Khuzaima Rangwalla
- University of California San Francisco School of Medicine, San Francisco, CA 94143, USA
| | - Avionna Baldwin
- University of California San Francisco, Department of Orthopaedic Surgery, San Francisco, CA 94143, USA
| | - Ashraf N El Naga
- University of California San Francisco, Department of Orthopaedic Surgery, San Francisco, CA 94143, USA; Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - David Gendelberg
- University of California San Francisco, Department of Orthopaedic Surgery, San Francisco, CA 94143, USA; Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Sigurd Berven
- University of California San Francisco, Department of Orthopaedic Surgery, San Francisco, CA 94143, USA
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Davies LEM, Koster ES, Damen KF, Beurmanjer H, van Dam VW, Bouvy ML, Schellekens AF. Patients' perspectives on tapering programmes for prescription opioid use disorder: a qualitative study. BMJ Open 2023; 13:e075246. [PMID: 38070938 PMCID: PMC10729188 DOI: 10.1136/bmjopen-2023-075246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 11/13/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVES Approximately 10% of chronic pain patients who receive opioids develop an opioid use disorder (OUD). Tapering programmes for these patients show high drop-out rates. Insight into chronic pain patients' experiences with tapering programmes for prescription OUD could help improve such programmes. Therefore, we investigated the perspectives of chronic pain patients with prescription OUD to identify facilitators and barriers to initiate and complete a specialised OUD tapering programme. DESIGN A qualitative study using semi-structured interviews on experiences with initiation and completion of opioid tapering was audio recorded, transcribed and subject to directed content analysis. SETTING This study was conducted in two facilities with specialised opioid tapering programmes in the Netherlands. PARTICIPANTS Twenty-five adults with chronic pain undergoing treatment for prescription OUD participated. RESULTS Participants indicated that tapering is a personal process, where willingness and motivation to taper, perceived (medical) support and pain coping strategies have an impact on the tapering outcome. The opportunity to join a medical-assisted tapering programme, shared decision-making regarding tapering pace, tapering location, and receiving medical and psychological support facilitated completion of an opioid tapering programme. CONCLUSIONS According to patients, a successful treatment of prescription OUD requires a patient-centred approach that combines personal treatment goals with shared decision-making on opioid tapering. Referral to a specialised tapering programme that incorporates opioid rotation, non-judgmental attitudes, and psychological support can create a safe and supportive environment, fostering successful tapering and recovery.
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Affiliation(s)
- Lisa Eveline Maria Davies
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
| | - Ellen S Koster
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
- Netherlands Association of Internal Medicine, Utrecht, The Netherlands
| | | | - Harmen Beurmanjer
- Novadic-Kentron, Vught, The Netherlands
- Radboud University Behavioural Science Institute, Nijmegen, The Netherlands
| | - Vivienne Wt van Dam
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
| | - Marcel L Bouvy
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
| | - Arnt Fa Schellekens
- Department of Psychiatry, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands
- Nijmegen Institute for Scientist Practitioners in Addiction, Nijmegen, The Netherlands
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4
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López-Arteaga T, Moreno-Rubio C, Mohedano-Moriano A. Risk factors for opioid addiction in chronic non-cancer pain. Heliyon 2023; 9:e19707. [PMID: 37809400 PMCID: PMC10558926 DOI: 10.1016/j.heliyon.2023.e19707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 07/17/2023] [Accepted: 08/30/2023] [Indexed: 10/10/2023] Open
Abstract
Opioids are very effective pain medications, but they are not without complications. Its use in chronic cancer pain is clearly established, but not in chronic non-cancer pain. Opioid use has increased in recent years, but at the same time, it has been accompanied by an increase in side effects and related complications, including abuse, abuse and opioid addiction. If we look in the literature on the subject there is a global concern to make an adequate therapy with risk reduction, but the samples studied make it difficult to extrapolate results to the general population and even more so if we take into account factors such as psychiatric comorbidity. This leads us to consider the need to study our own population, its characteristics and see how it is being treated, to refine as much as possible on an appropriate prescription. The authors have carried out a cross-sectional study on patients with non-cancer chronic pain referred to psychiatry and the presence of opioid use disorder. We found risk factors related to the biopsychosocial characteristics of the patients and the characteristics of pain and its treatment. Knowing the risk factors, we can avoid yatrogeny, implement primary and secondary prevention and, ultimately, improve the quality of patient care.
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Affiliation(s)
- Teresa López-Arteaga
- Médico Psiquiatra. Directora Médica Área Integrada de Talavera. Hospital General Universitario Ntra. Sra. Del Prado. Talavera de la Reina, Spain
| | - Carlos Moreno-Rubio
- Jefe de Servicio de Psiquiatría. Hospital General Universitario Ntra. Sra. Del Prado. Talavera de la Reina, Spain
| | - Alicia Mohedano-Moriano
- Titular de la Facultad de Ciencias de la Salud Talavera de la Reina. Universidad de Castilla-La Mancha, Spain
- Académica del Vicerrectorado de Ciencias de la Salud de la Universidad de Castilla-La Mancha, Spain
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5
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Robert C, Wilson CS. Thirty-year survey of bibliometrics used in the research literature of pain: Analysis, evolution, and pitfalls. FRONTIERS IN PAIN RESEARCH 2023; 4:1071453. [PMID: 36937565 PMCID: PMC10017016 DOI: 10.3389/fpain.2023.1071453] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 02/08/2023] [Indexed: 03/05/2023] Open
Abstract
During the last decades, the emergence of Bibliometrics and the progress in Pain research have led to a proliferation of bibliometric studies on the medical and scientific literature of pain (B/P). This study charts the evolution of the B/P literature published during the last 30 years. Using various searching techniques, 189 B/P studies published from 1993 to August 2022 were collected for analysis-half were published since 2018. Most of the selected B/P publications use classic bibliometric analysis of Pain in toto, while some focus on specific types of Pain with Headache/Migraine, Low Back Pain, Chronic Pain, and Cancer Pain dominating. Each study is characterized by the origin (geographical, economical, institutional, …) and the medical/scientific context over a specified time span to provide a detailed landscape of the Pain research literature. Some B/P studies have been developed to pinpoint difficulties in appropriately identifying the Pain literature or to highlight some general publishing pitfalls. Having observed that most of the recent B/P studies have integrated newly emergent software visualization tools (SVTs), we found an increase of anomalies and suggest that readers exercise caution when interpreting results in the B/P literature details.
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Affiliation(s)
| | - Concepción Shimizu Wilson
- School of Information Systems, Technology and Management, University of New South Wales, UNSW Sydney, Sydney, NSW, Australia
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6
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DE Oliveira MF, Johnson DS, Demchak T, Tomazoni SS, Leal-Junior EC. Low-intensity LASER and LED (photobiomodulation therapy) for pain control of the most common musculoskeletal conditions. Eur J Phys Rehabil Med 2022; 58:282-289. [PMID: 34913330 PMCID: PMC9980499 DOI: 10.23736/s1973-9087.21.07236-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pain is the most common reason for physician consultations and the number one reason for missed work or school days is musculoskeletal pain. Pain management is utilized for easing the suffering and improving the Quality of Life of those living with chronic pain. Over the past several decades, physicians have become increasingly willing to prescribe opioids to manage pain. However, the opioid use can cause side effects as poor coordination, sedation, mood swings, depression, and anxiety combined with a dependence on the drugs. In the rehabilitation setting, patients benefit most when their health providers utilize a multimodal approach combining different types of therapies and when patients take on a significant role in optimal management of their own pain. The use of light as a therapeutic alternative form of medicine to manage pain and inflammation has been proposed to fill this void. Photobiomodulation therapy applied in the form of low-intensity Light Amplification by Stimulated Emission of Radiation (LASER) and light-emitting diode (LED) has been shown to reduce inflammation and swelling, promote healing, and reduce pain for an array of musculoskeletal conditions. There is evidence that photobiomodulation therapy reduces pain intensity in non-specific knee pain, osteoarthritis, pain post-total hip arthroplasty, fibromyalgia, temporomandibular diseases, neck pain, and low back pain. Therefore, the purpose of this paper was to present the up-to-dated evidence about the effects of low-intensity LASER and LED (photobiomodulation therapy) on pain control of the most common musculoskeletal conditions. We observed that the photobiomodulation therapy offers a non-invasive, safe, drug-free, and side-effect-free method for pain relief of both acute and chronic musculoskeletal conditions as well as fibromyalgia.
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Affiliation(s)
- Marcelo F DE Oliveira
- Laboratory of Phototherapy and Innovative Technologies in Health (LaPIT), Postgraduate Program in Rehabilitation Sciences, Nove de Julho University, São Paulo, Brazil
| | | | | | - Shaiane S Tomazoni
- Department of Global Public Health and Primary Care, Physiotherapy Research Group, University of Bergen, Bergen, Norway
| | - Ernesto C Leal-Junior
- Laboratory of Phototherapy and Innovative Technologies in Health (LaPIT), Postgraduate Program in Rehabilitation Sciences, Nove de Julho University, São Paulo, Brazil - .,Department of Global Public Health and Primary Care, Physiotherapy Research Group, University of Bergen, Bergen, Norway.,ELJ Consultancy, Scientific Consultants, São Paulo, Brazil
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7
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Dworsky-Fried Z, Chadwick CI, Kerr BJ, Taylor AMW. Multiple Sclerosis and the Endogenous Opioid System. Front Neurosci 2021; 15:741503. [PMID: 34602975 PMCID: PMC8484329 DOI: 10.3389/fnins.2021.741503] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 08/26/2021] [Indexed: 01/10/2023] Open
Abstract
Multiple sclerosis (MS) is an autoimmune disease characterized by chronic inflammation, neuronal degeneration and demyelinating lesions within the central nervous system. The mechanisms that underlie the pathogenesis and progression of MS are not fully known and current therapies have limited efficacy. Preclinical investigations using the murine experimental autoimmune encephalomyelitis (EAE) model of MS, as well as clinical observations in patients with MS, provide converging lines of evidence implicating the endogenous opioid system in the pathogenesis of this disease. In recent years, it has become increasingly clear that endogenous opioid peptides, binding μ- (MOR), κ- (KOR) and δ-opioid receptors (DOR), function as immunomodulatory molecules within both the immune and nervous systems. The endogenous opioid system is also well known to play a role in the development of chronic pain and negative affect, both of which are common comorbidities in MS. As such, dysregulation of the opioid system may be a mechanism that contributes to the pathogenesis of MS and associated symptoms. Here, we review the evidence for a connection between the endogenous opioid system and MS. We further explore the mechanisms by which opioidergic signaling might contribute to the pathophysiology and symptomatology of MS.
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Affiliation(s)
- Zoë Dworsky-Fried
- Department of Pharmacology, University of Alberta, Edmonton, AB, Canada
| | - Caylin I. Chadwick
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
| | - Bradley J. Kerr
- Department of Pharmacology, University of Alberta, Edmonton, AB, Canada
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, AB, Canada
| | - Anna M. W. Taylor
- Department of Pharmacology, University of Alberta, Edmonton, AB, Canada
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, AB, Canada
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8
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Zajacova A, Grol-Prokopczyk H, Zimmer Z. Pain Trends Among American Adults, 2002-2018: Patterns, Disparities, and Correlates. Demography 2021; 58:711-738. [PMID: 33834222 PMCID: PMC8035485 DOI: 10.1215/00703370-8977691] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Determining long-term trends in chronic pain prevalence is critical for evaluating and shaping U.S. health policies, but little research has examined such trends. This study (1) provides estimates of pain trends among U.S. adults across major population groups; (2) tests whether sociodemographic disparities in pain have widened or narrowed over time; and (3) examines socioeconomic, behavioral, psychological, and medical correlates of pain trends. Regression and decomposition analyses of joint, low back, neck, facial/jaw pain, and headache/migraine using the 2002-2018 National Health Interview Survey for adults aged 25-84 (N = 441,707) assess the trends and their correlates. We find extensive escalation of pain prevalence in all population subgroups: overall, reports of pain in at least one site increased by 10%, representing an additional 10.5 million adults experiencing pain. Socioeconomic disparities in pain are widening over time, and psychological distress and health behaviors are among the salient correlates of the trends. This study thus comprehensively documents rising pain prevalence among Americans across the adult life span and highlights socioeconomic, behavioral, and psychological factors as important correlates of the trends. Chronic pain is an important dimension of population health, and demographic research should include it when studying health and health disparities.
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Affiliation(s)
- Anna Zajacova
- Department of Sociology, The University of Western Ontario, London, Ontario, Canada
| | - Hanna Grol-Prokopczyk
- Department of Sociology, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Zachary Zimmer
- Department of Family Studies and Gerontology and Global Aging and Community Initiative, Mount Saint Vincent University, Halifax, Nova Scotia, Canada
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9
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Smit T, Rogers AH, Garey L, Allan NP, Viana AG, Zvolensky MJ. Anxiety sensitivity and pain intensity independently predict opioid misuse and dependence in chronic pain patients. Psychiatry Res 2020; 294:113523. [PMID: 33189986 DOI: 10.1016/j.psychres.2020.113523] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 10/17/2020] [Indexed: 01/20/2023]
Abstract
The United States (US) population consumes an estimated 68% of the world's prescribed opioids each year, and over 2 million adults in the US suffer from an opioid use disorder. Although chronic pain populations are among the highest risk segments of the general population for opioid misuse and dependence, there is little understanding of individual risk characteristics that may contribute to greater risk for these outcomes among this group. The present investigation explored the concurrent role of anxiety sensitivity and pain intensity and their interaction in relation to opioid misuse and dependence among 429 adults with chronic pain (73.9% female, Mage = 38.32 years, SD = 11.07). Results revealed that both anxiety sensitivity and pain intensity were associated with opioid misuse and dependence. There was no evidence of an interaction for either outcome. Post-hoc analyses indicated that of the lower-order anxiety sensitivity facets, physical and mental incapacitation concerns contributed to variance in opioid misuse and only mental incapacitation concerns contributed to variance in opioid dependence. Overall, the current findings suggest the importance of assessing anxiety sensitivity in screening for opioid-related problems among persons with chronic pain, as it may represent a distinct pathway to poorer opioid-related outcomes among this group.
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Affiliation(s)
- Tanya Smit
- Department of Psychology, University of Houston, Houston, TX, USA
| | - Andrew H Rogers
- Department of Psychology, University of Houston, Houston, TX, USA
| | - Lorra Garey
- Department of Psychology, University of Houston, Houston, TX, USA
| | | | - Andres G Viana
- Department of Psychology, University of Houston, Houston, TX, USA
| | - Michael J Zvolensky
- Department of Psychology, University of Houston, Houston, TX, USA; Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; HEALTH Institute, University of Houston, Houston, TX, USA.
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10
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Wunsch H, Hill AD, Fu L, Fowler RA, Wang HT, Gomes T, Fan E, Juurlink DN, Pinto R, Wijeysundera DN, Scales DC. New Opioid Use after Invasive Mechanical Ventilation and Hospital Discharge. Am J Respir Crit Care Med 2020; 202:568-575. [PMID: 32348694 DOI: 10.1164/rccm.201912-2503oc] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Rationale: Patients who receive invasive mechanical ventilation (IMV) are usually exposed to opioids as part of their sedation regimen. The rates of posthospital prescribing of opioids are unknown.Objectives: To determine the frequency of persistent posthospital opioid use among patients who received IMV.Methods: We assessed opioid-naive adults who were admitted to an ICU, received IMV, and survived at least 7 days after hospital discharge in Ontario, Canada over a 26-month period (February, 2013 through March, 2015). The primary outcome was new, persistent opioid use during the year after discharge. We assessed factors associated with persistent use by multivariable logistic regression. Patients receiving IMV were also compared with matched hospitalized patients who did not receive intensive care (non-ICU).Measurements and Main Results: Among 25,085 opioid-naive patients on IMV, 5,007 (20.0%; 95% confidence interval [CI], 19.5-20.5) filled a prescription for opioids in the 7 days after hospital discharge. During the next year, 648 (2.6%; 95% CI, 2.4-2.8) of the IMV cohort met criteria for new, persistent opioid use. The patient characteristic most strongly associated with persistent use in the IMV cohort was being a surgical (vs. medical) patient (adjusted odds ratio, 3.29; 95% CI, 2.72-3.97). The rate of persistent use was slightly higher than for matched non-ICU patients (2.6% vs. 1.5%; adjusted odds ratio, 1.37 [95% CI, 1.19-1.58]).Conclusions: A total of 20% of IMV patients received a prescription for opioids after hospital discharge, and 2.6% met criteria for persistent use, an average of 300 new persistent users per year in a population of 14 million. Receipt of surgery was the factor most strongly associated with persistent use.
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Affiliation(s)
- Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine.,Department of Anesthesia
| | - Andrea D Hill
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada
| | | | - Rob A Fowler
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine.,Department of Medicine, and
| | - Han Ting Wang
- Critical Care Division, Department of Medicine, Maisonneuve-Rosemont Hospital affiliated with the University of Montreal, Montreal, Quebec, Canada; and
| | - Tara Gomes
- ICES, Toronto, Ontario, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute and
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine.,Department of Medicine, and
| | - David N Juurlink
- Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Department of Medicine, and
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Duminda N Wijeysundera
- ICES, Toronto, Ontario, Canada.,Department of Anesthesia.,Li Ka Shing Knowledge Institute and.,Department of Anesthesia, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Damon C Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine.,Department of Medicine, and
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11
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Cuménal M, Selvy M, Kerckhove N, Bertin C, Morez M, Courteix C, Busserolles J, Balayssac D. The Safety of Medications used to Treat Peripheral Neuropathic Pain, Part 2 (Opioids, Cannabinoids and Other Drugs): review of Double-Blind, Placebo-Controlled, Randomized Clinical Trials. Expert Opin Drug Saf 2020; 20:51-68. [PMID: 33103931 DOI: 10.1080/14740338.2021.1842871] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Peripheral neuropathic pain is a disabling condition for patients and a challenge for physicians. Although many drugs have been assessed in scientific studies, few have demonstrated clear clinical efficacy against neuropathic pain. Moreover, the paucity of data regarding their safety raises the question of the benefit-risk ratio when used in patients experiencing peripheral neuropathies. AREAS COVERED We conducted a review of double-blind, placebo-controlled, randomized clinical trials to assess the safety of medications used to treat peripheral neuropathic pain. This second review was focused on opioids, cannabinoids, and other medications. The aim was to provide an overview of the treatment-emergent adverse events (TEAEs) (≥10%) and the serious adverse effects described in clinical trials. EXPERT OPINION Opioids and cannabinoids had significantly more TEAEs than placebos. Locally administered analgesics, such as capsaicin, lidocaine, botulinum toxin A seemed to have the most acceptable safety with only local adverse effects. The results for NMDA antagonists were inconclusive since no safety report was available. Less than half of the studies included presented a good description of TEAEs that included a statistical comparison versus a placebo group. Major methodological improvements must be made to ameliorate the assessment of medication safety in future clinical trials.
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Affiliation(s)
- Mélissa Cuménal
- Université Clermont Auvergne, INSERM U1107, NEURO-DOL , Clermont-Ferrand, France
| | - Marie Selvy
- Université Clermont Auvergne,CHU Clermont-Ferrand, INSERM U1107, NEURO-DOL , Clermont-Ferrand, France
| | - Nicolas Kerckhove
- Université Clermont Auvergne, CHU Clermont-Ferrand, INSERM U1107 NEURO-DOL, Institut Analgesia , Clermont-Ferrand, France
| | - Célian Bertin
- Université Clermont Auvergne, CHU Clermont-Ferrand, INSERM U1107 NEURO-DOL, Institut Analgesia , Clermont-Ferrand, France
| | - Margaux Morez
- Université Clermont Auvergne, INSERM U1107, NEURO-DOL , Clermont-Ferrand, France
| | - Christine Courteix
- Université Clermont Auvergne, INSERM U1107, NEURO-DOL , Clermont-Ferrand, France
| | - Jérôme Busserolles
- Université Clermont Auvergne, INSERM U1107, NEURO-DOL , Clermont-Ferrand, France
| | - David Balayssac
- Université Clermont Auvergne,CHU Clermont-Ferrand, INSERM U1107, NEURO-DOL , Clermont-Ferrand, France
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Marszalek D, Martinson A, Smith A, Marchand W, Sweeney C, Carney J, Lowery T, Clinton-Lont J. Examining the Effect of a Whole Health Primary Care Pain Education and Opioid Monitoring Program on Implementation of VA/DoD-Recommended Guidelines for Long-term Opioid Therapy in a Primary Care Chronic Pain Population. PAIN MEDICINE 2020; 21:2146-2153. [PMID: 32529228 DOI: 10.1093/pm/pnaa155] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To describe the core elements of a Whole Health Primary Care Pain Education and Opioid Monitoring Program (PC-POP) and examine its effectiveness at increasing adherence to six of the Veteran Affairs/Department of Defense (VA/DoD) recommended guidelines for long-term opioid therapy (LOT) among chronic noncancer patients seen in primary care (i.e., urine drug screens [UDS], prescription drug monitoring program [PDMP] queries, informed consent, naloxone education/prescriptions, morphine equivalent daily dose [MEDD], and referrals to nonpharmacological pain interventions). DESIGN/METHODS A within-subjects comparison of outcomes was conducted between pre- and post-PC-POP enrollees (N = 25), as was a a between-subjects comparison to a comparison group (N = 25) utilizing a six-month range post-index date of 10/1/2018 (i.e., between-subjects comparison at Time 2). SUBJECTS A convenience sample of adult veterans with chronic noncancer pain receiving opioid therapy consecutively for the past three months in primary care. RESULTS Results showed increased concordance with VA/DoD guidelines among those enrolled in the PC-POP, characterized by increased documentation of urine drug screens, prescription drug monitoring program queries, informed consent, naloxone education/prescriptions, and a decrease in MEDD among patients enrolled in the PC-POP. CONCLUSIONS The PC-POP shows promise for increasing guideline-concordant care for providers working in primary care.
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Affiliation(s)
| | - Amber Martinson
- VA Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Psychiatry, University of Utah, Salt Lake City, Utah, USA
| | - Andrew Smith
- VA Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Psychiatry, University of Utah, Salt Lake City, Utah, USA
| | - William Marchand
- VA Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Psychiatry, University of Utah, Salt Lake City, Utah, USA
| | | | - Julie Carney
- VA Salt Lake City Health Care System, Salt Lake City, Utah
| | - Tiffany Lowery
- VA Salt Lake City Health Care System, Salt Lake City, Utah
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13
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Weesie YM, Hek K, Schermer TRJ, Schellevis FG, Leufkens HGM, Rook EJ, van Dijk L. Use of Opioids Increases With Age in Older Adults: An Observational Study (2005-2017). Front Pharmacol 2020; 11:648. [PMID: 32477127 PMCID: PMC7241279 DOI: 10.3389/fphar.2020.00648] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 04/22/2020] [Indexed: 11/13/2022] Open
Abstract
Aim Pain is increasingly treated with opioids. Potential harms of opioid therapy disproportionally affect older patients. This study aims to provide information on trends, nature and duration of opioid prescribing to older adults, in primary care and to explore differences between older patients from different ages. Methods Primary care data (2005-2017) were derived from routine electronic medical records of patients in Nivel Primary Care Database. All opioid prescriptions with Anatomical Therapeutic Chemical Classification (ATC) code N02A were selected (except for codeine). Diagnoses were recorded using the International Classification of Primary Care (ICPC). Patients were categorized in three age groups (65-74, 75-84, and ≥85 years). Descriptive analyses were used to describe the trend of opioid prescriptions for specific opioids, the duration of use and underlying diagnoses. Results 283,600 patients were included of which 32,287 had at least one opioid prescription in 2017. An increase in the number of older adults who received at least one opioid was seen between 2005 and 2017. The oldest patients were more likely to be prescribed an opioid, especially when it comes to strong opioids, the increase in the volume of prescribing was highest in this group. Moreover, over 40% of the oldest patients used strong opioids chronically. Strong opioids were mostly prescribed for musculoskeletal diagnoses. Cancer was the second most common diagnosis for strong opioids in the younger subgroups, whereas less specified diagnoses were as second in the oldest subgroup. Conclusion Opioid prescription changes with increasing age in frequency, nature, and duration, despite higher harm risks among older patients. Because of the high prevalence of chronic use, it is important to monitor the patient throughout the treatment and to critically evaluate the initiation and continuation of opioid prescriptions.
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Affiliation(s)
- Yvette M Weesie
- Pharmaceutical Care, Netherlands Institute for Health Services Research (Nivel), Utrecht, Netherlands
| | - Karin Hek
- Pharmaceutical Care, Netherlands Institute for Health Services Research (Nivel), Utrecht, Netherlands
| | - Tjard R J Schermer
- Pharmaceutical Care, Netherlands Institute for Health Services Research (Nivel), Utrecht, Netherlands.,Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, Netherlands
| | - Francois G Schellevis
- Pharmaceutical Care, Netherlands Institute for Health Services Research (Nivel), Utrecht, Netherlands.,Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers location VUmc, Amsterdam, Netherlands
| | - Hubertus G M Leufkens
- Utrecht Institute for Pharmaceutical Sciences, Utrecht University (UU), Utrecht, Netherlands
| | | | - Liset van Dijk
- Pharmaceutical Care, Netherlands Institute for Health Services Research (Nivel), Utrecht, Netherlands.,Department of PharmacoTherapy,-Epidemiology & -Economics (PTEE), Faculty of Mathematics and Natural Sciences, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, Netherlands
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14
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Donatello NN, Emer AA, Salm DC, Ludtke DD, Bordignon SASR, Ferreira JK, Salgado ASI, Venzke D, Bretanha LC, Micke GA, Martins DF. Lavandula angustifolia essential oil inhalation reduces mechanical hyperalgesia in a model of inflammatory and neuropathic pain: The involvement of opioid and cannabinoid receptors. J Neuroimmunol 2020; 340:577145. [DOI: 10.1016/j.jneuroim.2020.577145] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 12/30/2019] [Accepted: 01/08/2020] [Indexed: 01/19/2023]
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15
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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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16
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Brennan MJ, Gudin JA. The prescription opioid conundrum: 21st century solutions to a millennia-long problem. Postgrad Med 2019; 132:17-27. [PMID: 31591925 DOI: 10.1080/00325481.2019.1677383] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Health-care professionals are faced with a daunting task: balancing appropriate care for chronic pain with their responsibility to keep patients and others safe from treatment-related harm. Whereas opioids have historically been considered an effective tool in the analgesic armamentarium, the rise of opioid abuse has caused the pendulum to swing away from prescribing opioids to an emphasis on safety. This paradigm shift risks neglecting the very real consequences of untreated/undertreated pain. Using data from the medical literature, this review examines influences on the real and perceived benefit-to-risk ratio for opioids and provides clinicians with a practical approach to prescribing opioids that minimizes the risk for abuse/misuse. There is appreciable clinical trial and observational evidence of efficacy/effectiveness with opioids used for pain management over the short or long term when considered in the context of pharmacologic alternatives. Enhancing the relative safety and minimizing the risk for abuse/misuse may be achieved through proactive prescription practices that include careful patient selection, risk assessment, individualized and multimodal treatment plans with established goals, initiating opioid treatment cautiously with an exit plan in place, ongoing assessments of response to therapy, and routine patient monitoring. Additionally, prescribing opioids with a lower potential for abuse or misuse (e.g. abuse-deterrent formulations) may provide a benefit. Using a pragmatic approach to prescribing practices, we postulate that the balance between benefit and risk can be favorable for opioid therapy in select patients, even for long-term treatment of chronic pain.
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Affiliation(s)
| | - Jeffrey A Gudin
- Pain Management and Palliative Care, Englewood Hospital and Medical Center, Englewood, NJ, USA
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17
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Irons JY, Kuipers P, Wan A, Stewart DE. Group Singing Has Multiple Benefits in the Context of Chronic Pain: An Exploratory Pilot Study. Pain Manag Nurs 2019; 21:259-264. [PMID: 31495739 DOI: 10.1016/j.pmn.2019.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 06/28/2019] [Accepted: 07/23/2019] [Indexed: 10/26/2022]
Abstract
AIMS This paper reports findings of a pilot singing intervention to assist people living with chronic pain. METHODS Pain Management Clinic outpatients participated in 10 weekly group singing sessions. Benefits of the intervention and its impact on participants' (N = 4) experiences of pain were explored qualitatively. RESULTS Three main themes comprising over 20 separate codes indicated physical, psychological, and social dimensions associated with the intervention. People with chronic pain identify multiple benefits from participating in a group singing program. CONCLUSIONS Results indicate that group singing in chronic pain settings has multiple benefits and may positively complement clinical outcomes, serving as an effective adjunct to conventional pain management care and nursing.
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Affiliation(s)
- J Yoon Irons
- Health and Social Care Research Centre, University of Derby, Derby, UK.
| | - Pim Kuipers
- Hopkins Centre, Menzies Health Institute of Queensland, Griffith University, Brisbane, Queensland, Australia
| | - Aston Wan
- Persistent Pain Management Service, Princess Alexandra Hospital, Metro South, Queensland Health, Brisbane, Australia
| | - Donald E Stewart
- School of Medicine, Griffith University, Brisbane, Queensland, Australia
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18
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Correll DJ, Kissin I. Problems with Developments of Breakthrough Analgesics: Recent History via Scientometric Analysis. J Anesth Hist 2019; 5:49-57. [PMID: 31400836 DOI: 10.1016/j.janh.2019.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 03/18/2019] [Accepted: 03/19/2019] [Indexed: 11/27/2022]
Abstract
This study evaluated 13 specific topics representing molecular targets for pain during the period 1982-2016. The evaluation was performed by measuring research efforts via a scientometric approach on one hand and by assessing successful outcomes of these efforts, as indicated by the development of FDA-approved analgesics, on the other. A number of new analgesics were developed during this period, some of them with a completely novel mechanism of action. However, the main problems with approved drugs, as well as drug candidates, are relatively low levels of clinical superiority in effectiveness and narrow spectrum of action in different types of pain, compared to opioids or NSAIDs. The most interesting feature of the scientometric analysis of the 13 analgesic discovery topics is the long-lasting growth in the number of articles. The total number of all PubMed articles persistently increased over each of many 5-year periods in every topic even without any success in the development of new analgesics. Scientometric indices of NIH-supported studies are not better at predicting successes in the discovery of new analgesics than indices applied to all publications without regard to the category of support. Thus, even the highly valued NIH-based funding system did not demonstrate a clear advantage for discovery efforts centered on pain-related molecular targets. The evaluated research efforts did not result in breakthrough analgesics that could demonstrably affect the current use of opioids or NSAIDs. Orthodox thinking-both in research and research funding-might be the main reason for the absence of breakthrough analgesics.
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Affiliation(s)
- Darin J Correll
- The Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Igor Kissin
- The Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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19
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Adams RS, Thomas CP, Ritter GA, Lee S, Saadoun M, Williams TV, Larson MJ. Predictors of Postdeployment Prescription Opioid Receipt and Long-term Prescription Opioid Utilization Among Army Active Duty Soldiers. Mil Med 2019; 184:e101-e109. [PMID: 30007291 DOI: 10.1093/milmed/usy162] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 06/10/2018] [Indexed: 12/12/2022] Open
Abstract
Introduction Little is known about long-term prescription opioid utilization in the Military Health System. The objectives of this study were to examine predictors of any prescription opioid receipt, and predictors of long-term opioid utilization among active duty soldiers in the year following deployment. Materials and Methods The analytic sample consisted of Army active duty soldiers returning from deployment to Operation Enduring Freedom, Operation Iraqi Freedom, or Operation New Dawn in fiscal years 2008-2014 (N = 540,738). The Heckman probit procedure was used to jointly examine predictors of any opioid prescription receipt and long-term opioid utilization (i.e., an episode of 90 days or longer where days-supply covered at least two-thirds of days) in the postdeployment year. Predictors were based on diagnoses and characteristics of opioid prescriptions. Results More than one-third of soldiers (34.8%, n = 188,211) had opioid receipt, and among those soldiers, 3.3% had long-term opioid utilization (or 1.1% of the cohort, n = 6,188). The largest magnitude predictors of long-term opioid utilization were receiving a long-acting opioid within the first 30 days of the episode, diagnoses of chronic pain (no specified source), back/neck pain, or peripheral/central nervous system pain, and severe pain score in vital records. Conclusions Soldiers returning from deployment were more likely to receive an opioid prescription than the overall active duty population, and 1.1% initiated a long-term opioid episode. We report a declining rate of opioid receipt and long-term opioid utilization among Army members from fiscal years 2008-2014. This study demonstrates that the most important predictors of opioid receipt were not demographic factors, but generally clinical indicators of acute pain or physical trauma.
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Affiliation(s)
- Rachel Sayko Adams
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA
| | - Cindy Parks Thomas
- Schneider Institute for Health Policy, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA
| | - Grant A Ritter
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA
| | - Sue Lee
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA
| | - Mayada Saadoun
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA
| | | | - Mary Jo Larson
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA
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20
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Choi YK. Lumbar foraminal neuropathy: an update on non-surgical management. Korean J Pain 2019; 32:147-159. [PMID: 31257823 PMCID: PMC6615450 DOI: 10.3344/kjp.2019.32.3.147] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 06/11/2019] [Accepted: 06/11/2019] [Indexed: 01/16/2023] Open
Abstract
Lumbar foraminal pathology causing entrapment of neurovascular contents and radicular symptoms are commonly associated with foraminal stenosis. Foraminal neuropathy can also be derived from inflammation of the neighboring lateral recess or extraforaminal spaces. Conservative and interventional therapies have been used for the treatment of foraminal inflammation, fibrotic adhesion, and pain. This update reviews the anatomy, pathophysiology, clinical presentation, diagnosis, and current treatment options of foraminal neuropathy.
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Affiliation(s)
- Young Kook Choi
- New Jersey Pain Medicine for the Difficult and Failed Pain, Robert Wood Johnson University Hospital Rahway, Rahway, NJ, USA
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21
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Abstract
PURPOSE We aimed to produce comprehensive guidelines and recommendations that can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury. METHODS A panel of 15 members with expertise in orthopaedic trauma, pain management, or both was convened to review the literature and develop recommendations on acute musculoskeletal pain management. The methods described by the Grading of Recommendations Assessment, Development, and Evaluation Working Group were applied to each recommendation. The guideline was submitted to the Orthopaedic Trauma Association (OTA) for review and was approved on October 16, 2018. RESULTS We present evidence-based best practice recommendations and pain medication recommendations with the hope that they can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury. Recommendations are presented regarding pain management, cognitive strategies, physical strategies, strategies for patients on long term opioids at presentation, and system implementation strategies. We recommend the use of multimodal analgesia, prescribing the lowest effective immediate-release opioid for the shortest period possible, and considering regional anesthesia. We also recommend connecting patients to psychosocial interventions as indicated and considering anxiety reduction strategies such as aromatherapy. Finally, we also recommend physical strategies including ice, elevation, and transcutaneous electrical stimulation. Prescribing for patients on long term opioids at presentation should be limited to one prescriber. Both pain and sedation should be assessed regularly for inpatients with short, validated tools. Finally, the group supports querying the relevant regional and state prescription drug monitoring program, development of clinical decision support, opioid education efforts for prescribers and patients, and implementing a department or organization pain medication prescribing strategy or policy. CONCLUSIONS Balancing comfort and patient safety following acute musculoskeletal injury is possible when utilizing a true multimodal approach including cognitive, physical, and pharmaceutical strategies. In this guideline, we attempt to provide practical, evidence-based guidance for clinicians in both the operative and non-operative settings to address acute pain from musculoskeletal injury. We also organized and graded the evidence to both support recommendations and identify gap areas for future research.
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22
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Vargas-Schaffer G, Cogan J. Attitudes Toward Opioids and Risk of Misuse/Abuse in Patients with Chronic Noncancer Pain Receiving Long-term Opioid Therapy. PAIN MEDICINE 2019; 19:319-327. [PMID: 28340165 DOI: 10.1093/pm/pnw338] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Objectives To determine the attitudes of patients toward long-term opioid therapy (LtOT) and the potential risk of misuse/abuse in patients with chronic noncancer pain (CNCP). Design Prospective, descriptive epidemiological study. Setting Multidisciplinary tertiary care pain center within the Montreal University Health Center. Subjects Patients who had had at least one visit at least one year prior to the invitation. Methods We used four questionnaires: demographic questionnaire, the Drug Attitude Inventory Modified (DAI-M), the Opioid Risk Tool (ORT), and the Screening Tool for Addiction Risk (STAR). All questionnaires were administered in their validated French version. Results Three hundred seventy patients completed questionnaires. The response rate was 79.26%. Of those who responded, 61.62% women and 38.38% men, the mean age was 57 years. The patients had been treated with LtOT for an average of 6.31 years, and the median dose per day in morphine equivalents was 48.21 mg. The DAI-M showed that 32.16% had a positive attitude toward opioids, 39.73% had a negative attitude, and 22.16% had a neutral attitude. The ORT questionnaire demonstrated that 86.2% of the patients were at low risk of abuse/misuse, 13.2% were at moderate risk, and only 0.54% were at high risk. The STAR questionnaire showed that 4.2% had a low risk of abuse/misuse. Conclusions Despite public opinion, patients treated with LtOT for CNCP and followed in a tertiary care pain center are at low risk for opioid misuse/abuse. We need to refine the way of prescribing opioids, should be selective with our patients, and should relive their pain adequately.
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Affiliation(s)
- Grisell Vargas-Schaffer
- Anesthesiology and Pain Management, CHUM Pain Center, Montreal, QC, Canada
- Departments of Pharmacology
- Anesthesiology, University of Montreal, Montreal, QC, Canada
- Montreal University Hospital Center, CRCHUM, Montreal, QC, Canada
| | - Jennifer Cogan
- Anesthesiology, University of Montreal, Montreal, QC, Canada
- Anesthesiology and Pain Management, Montreal Heart Institute, Montreal, QC, Canada
- Montreal Heart Institute Research Center, Montreal, QC, Canada
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Borsook D, Youssef AM, Simons L, Elman I, Eccleston C. When pain gets stuck: the evolution of pain chronification and treatment resistance. Pain 2018; 159:2421-2436. [PMID: 30234696 PMCID: PMC6240430 DOI: 10.1097/j.pain.0000000000001401] [Citation(s) in RCA: 99] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
It is well-recognized that, despite similar pain characteristics, some people with chronic pain recover, whereas others do not. In this review, we discuss possible contributions and interactions of biological, social, and psychological perturbations that underlie the evolution of treatment-resistant chronic pain. Behavior and brain are intimately implicated in the production and maintenance of perception. Our understandings of potential mechanisms that produce or exacerbate persistent pain remain relatively unclear. We provide an overview of these interactions and how differences in relative contribution of dimensions such as stress, age, genetics, environment, and immune responsivity may produce different risk profiles for disease development, pain severity, and chronicity. We propose the concept of "stickiness" as a soubriquet for capturing the multiple influences on the persistence of pain and pain behavior, and their stubborn resistance to therapeutic intervention. We then focus on the neurobiology of reward and aversion to address how alterations in synaptic complexity, neural networks, and systems (eg, opioidergic and dopaminergic) may contribute to pain stickiness. Finally, we propose an integration of the neurobiological with what is known about environmental and social demands on pain behavior and explore treatment approaches based on the nature of the individual's vulnerability to or protection from allostatic load.
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Affiliation(s)
- David Borsook
- Center for Pain and the Brain, Boston Children’s (BCH), McLean and Massachusetts Hospitals (MGH), Boston MA
- Departments of Anesthesia (BCH), Psychiatry (MGH, McLean) and Radiology (MGH)
| | - Andrew M Youssef
- Center for Pain and the Brain, Boston Children’s (BCH), McLean and Massachusetts Hospitals (MGH), Boston MA
| | - Laura Simons
- Department of Anesthesia, Stanford University, Palo Alto, CA
| | | | - Christopher Eccleston
- Centre for Pain Research, University of Bath, UK
- Department of Clinical and Health Psychology, Ghent University, Belgium
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Association of Patient-Reported Narcotic Use With Short- and Long-Term Outcomes After Adult Spinal Deformity Surgery: Multicenter Study of 425 Patients With 2-year Follow-up. Spine (Phila Pa 1976) 2018. [PMID: 29538242 DOI: 10.1097/brs.0000000000002631] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective analysis of a prospective registry OBJECTIVE.: To investigate associations of preoperative narcotic use with outcomes after adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA We hypothesized that preoperative narcotic use would predict longer hospital stays, greater postoperative narcotic use, and greater disability 2 years after ASD surgery. METHODS A multicenter database of surgical ASD patients was analyzed retrospectively for patients with self-reported data on preoperative narcotic use. Patients were categorized as using narcotics daily or non-daily (including those who used no narcotics), according to self-report. Outcomes were prolonged length of hospital stay (LOS) (>7 days); length of intensive care unit (ICU) stay; and daily narcotic use and Oswestry Disability Index (ODI) scores 2 years postoperatively. Groups were compared by demographic characteristics, pain, disability, radiographic deformity, and surgical invasiveness. Multivariate logistic and linear regression were used to determine associations between preoperative narcotic use and outcomes. RESULTS Of 575 patients who met the inclusion criteria, 425 (74%) had complete 2-year follow-up data. Forty-four percent reported daily preoperative narcotic use. Compared with non-daily users, daily narcotic users were older, had more comorbidities, more severe back pain, higher ODI scores, longer operative times, and worse preoperative malalignment and were more likely to undergo 3-column osteotomy (all, P < 0.05). Daily narcotic use independently predicted prolonged LOS (odds ratio [OR] = 1.7, 95% confidence interval [CI] = 1.1-2.9), longer ICU stay (difference = 16 hours, 95% CI = 1.9-30 hours), and daily narcotic use 2 years postoperatively (OR = 6.9, 95% CI = 3.7-13), as well as worse 2-year ODI score (difference = 4.5, 95% CI: 0.7-8.3, P = 0.021). CONCLUSION Daily narcotic use before ASD surgery was associated with prolonged LOS, longer ICU stays, and increased risk of daily narcotic use and greater disability 2 years postoperatively. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Cathy Stannard
- Consultant in Complex Pain and Pain Transformation Programme Clinical Lead, NHS Gloucestershire CCG, Sanger House, 5220 Valiant Court, Gloucester Business Park, Brockworth, GL3 4FE
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Chenaf C, Kaboré JL, Delorme J, Pereira B, Mulliez A, Zenut M, Delage N, Ardid D, Eschalier A, Authier N. Prescription opioid analgesic use in France: Trends and impact on morbidity-mortality. Eur J Pain 2018; 23:124-134. [PMID: 30051548 DOI: 10.1002/ejp.1291] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND While data from USA and Canada demonstrate an opioid overdose epidemic, very little nation-wide European studies have been published on this topical subject. METHODS Using a nationally representative sample of the French Claims database (>700,000 patients), the exhaustive nationwide hospital discharge database, and national mortality registry, all patients dispensed at least one prescription opioid (PO) in 2004-2017 were identified, to describe trends in PO analgesic use, shopping behaviour, opioid-related hospitalizations and deaths. Annual prevalence of PO use and shopping behaviour (≥1 day of overlapping prescriptions from ≥2 prescribers, dispensed by ≥3 pharmacies) was estimated. RESULTS In 2004-2017, the annual prevalence of weak opioid use codeine, tramadol and opium rose by 150%, 123%, and 244%, respectively (p < 0.05). Strong opioid use increased from 0.54% to 1.1% (+104%, p < 0.05), significantly for oxycodone (+1950%). Strong opioid use in chronic noncancer pain rose by 88% (p < 0.05) and 1180% for oxycodone. Opioid shopping increased from 0.50% to 0.67% (+34%, p < 0.05), associated with higher mortality risk HR = 2.8 [95% confidence interval (CI): 1.2-6.4]. Opioid-related hospitalizations increased from 15 to 40 per 1,000,000 population (+167%, 2000-2017), and opioid-related deaths from 1.3 to 3.2 per 1,000,000 population (+146%, 2000-2015). CONCLUSIONS This study provided a first European approach to a nationwide estimation with complete access to several national registries. In 2004-2017 in France, PO use excluding dextropropoxyphene more than doubled. The increase in oxycodone and fentanyl use, and nontrivial increasing trend in opioid-related morbidity-mortality should prompt authorities to closely monitor PO consumption in order to prevent alarming increases in opioid-related morbidity-mortality. SIGNIFICANCE In 2004-2017, prescription opioid use in France at least doubled and oxycodone use increased particularly, associated with a nontrivial increase in opioid-related morbidity-mortality. Although giving no indication for an 'opioid epidemic,' these findings call for proper monitoring of opioid use.
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Affiliation(s)
- C Chenaf
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, Délégation à la Recherche Clinique et à l'Innovation, F-63001, Clermont-Ferrand, France.,Observatoire Français des Médicaments Antalgiques (OFMA)/French Monitoring Centre for Analgesic Drugs, CHU Clermont-Ferrand, Université Clermont Auvergne, F-63001, Clermont-Ferrand, France.,Institut Analgesia, Faculté de Médecine, BP38, F-63001, Clermont-Ferrand, France
| | - J-L Kaboré
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, Délégation à la Recherche Clinique et à l'Innovation, F-63001, Clermont-Ferrand, France.,Institut Analgesia, Faculté de Médecine, BP38, F-63001, Clermont-Ferrand, France
| | - J Delorme
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, Délégation à la Recherche Clinique et à l'Innovation, F-63001, Clermont-Ferrand, France.,Observatoire Français des Médicaments Antalgiques (OFMA)/French Monitoring Centre for Analgesic Drugs, CHU Clermont-Ferrand, Université Clermont Auvergne, F-63001, Clermont-Ferrand, France.,Institut Analgesia, Faculté de Médecine, BP38, F-63001, Clermont-Ferrand, France
| | - B Pereira
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, Délégation à la Recherche Clinique et à l'Innovation, F-63001, Clermont-Ferrand, France
| | - A Mulliez
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, Délégation à la Recherche Clinique et à l'Innovation, F-63001, Clermont-Ferrand, France
| | - M Zenut
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, Délégation à la Recherche Clinique et à l'Innovation, F-63001, Clermont-Ferrand, France.,Observatoire Français des Médicaments Antalgiques (OFMA)/French Monitoring Centre for Analgesic Drugs, CHU Clermont-Ferrand, Université Clermont Auvergne, F-63001, Clermont-Ferrand, France.,Institut Analgesia, Faculté de Médecine, BP38, F-63001, Clermont-Ferrand, France
| | - N Delage
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, Délégation à la Recherche Clinique et à l'Innovation, F-63001, Clermont-Ferrand, France.,Observatoire Français des Médicaments Antalgiques (OFMA)/French Monitoring Centre for Analgesic Drugs, CHU Clermont-Ferrand, Université Clermont Auvergne, F-63001, Clermont-Ferrand, France.,Institut Analgesia, Faculté de Médecine, BP38, F-63001, Clermont-Ferrand, France
| | - D Ardid
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, Délégation à la Recherche Clinique et à l'Innovation, F-63001, Clermont-Ferrand, France.,Institut Analgesia, Faculté de Médecine, BP38, F-63001, Clermont-Ferrand, France
| | - A Eschalier
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, Délégation à la Recherche Clinique et à l'Innovation, F-63001, Clermont-Ferrand, France.,Observatoire Français des Médicaments Antalgiques (OFMA)/French Monitoring Centre for Analgesic Drugs, CHU Clermont-Ferrand, Université Clermont Auvergne, F-63001, Clermont-Ferrand, France.,Institut Analgesia, Faculté de Médecine, BP38, F-63001, Clermont-Ferrand, France
| | - N Authier
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, Délégation à la Recherche Clinique et à l'Innovation, F-63001, Clermont-Ferrand, France.,Observatoire Français des Médicaments Antalgiques (OFMA)/French Monitoring Centre for Analgesic Drugs, CHU Clermont-Ferrand, Université Clermont Auvergne, F-63001, Clermont-Ferrand, France.,Institut Analgesia, Faculté de Médecine, BP38, F-63001, Clermont-Ferrand, France
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Larson MJ, Adams RS, Ritter GA, Linton A, Williams TV, Saadoun M, Bauer MR. Associations of Early Treatments for Low-Back Pain with Military Readiness Outcomes. J Altern Complement Med 2018; 24:666-676. [PMID: 29589956 PMCID: PMC6065526 DOI: 10.1089/acm.2017.0290] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Chronic low-back pain (LBP) is a frequent cause of work absence and disability, and is frequently associated with long-term use of opioids. OBJECTIVE To describe military readiness-related outcomes at follow-up in soldiers with LBP grouped by the type of early treatment received for their LBP. Treatment groups were based on receipt of opioid or tramadol prescription and receipt of nonpharmacologic treatment modalities (NPT). Design, Subjects, Measures: A retrospective longitudinal analysis of U.S. soldiers with new LBP episodes persisting more than 90 days between October 2012 and September 2014. Early treatment groups were constructed based on utilization of services within 30 days of the first LBP claim. Outcomes were measured 91-365 days after the first LBP claim. Outcomes were constructed to measure five indicators of limitations of military readiness: military duty limitations, pain-related hospitalization, emergency room visit for LBP, pain score of moderate/severe, and prescription for opioid/tramadol. RESULTS Among soldiers with no opioid receipt in the prior 90 days, there were 30,612 new episodes of LBP, which persisted more than 90 days. Multivariable logistic regression models found that compared to the reference group (no NPT, no opioids/tramadol receipt), soldiers who received early NPT-only had lower likelihoods for military duty limitations, pain-related hospitalization, and opioid/tramadol prescription at follow-up, while soldiers' that started with opioid receipt (at alone or follow-up in conjunction with NPT) exhibited higher likelihoods on many of these negative outcomes. CONCLUSION This observational study of soldiers with a new episode of LBP and no opioid receipt in the prior 90 days suggests that early receipt of NPT may be associated with small, significant gains in ability to function as a soldier and reduced reliance on opioid/tramadol medication. While further research is warranted, increased access to NPT at the beginning of LBP episodes should be considered.
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Affiliation(s)
- Mary Jo Larson
- The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Rachel Sayko Adams
- The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Grant A. Ritter
- The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Andrea Linton
- AXIOM Resource Management, Inc., Falls Church, Virginia
| | | | - Mayada Saadoun
- The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Mark R. Bauer
- The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
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28
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Malon J, Shah P, Koh WY, Cattabriga G, Li E, Cao L. Characterizing the demographics of chronic pain patients in the state of Maine using the Maine all payer claims database. BMC Public Health 2018; 18:810. [PMID: 29954350 PMCID: PMC6022454 DOI: 10.1186/s12889-018-5673-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 06/05/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic pain is currently a significant health problem in the United States. A comprehensive strategy is needed to increase prevention of chronic pain and to improve care for chronic pain patients. However, development of a successful strategy relies, in part, on a better understanding of the demographics and socioeconomics of patients living with chronic pain conditions. The current study was designed to understand the burden of chronic pain in the state of Maine by identifying the prevalence of chronic pain and its relationship with selected demographic and socioeconomic factors in Maine. METHODS The Maine All Payer Claims Database (MEAPCD) (2006-2011) was used in the secondary data analysis to assess the demographic characteristics (such as age, sex, insurance type, and county of residence) of chronic pain patients in Maine. Chronic pain patients were identified based on the presence of pre-identified chronic pain-associated ICD-9 code(s) and opioid prescription information. Potential associations between the prevalence of chronic pain and a number of socioeconomic factors were determined by comparisons to Maine Census data. RESULTS More women in the state were identified as having chronic pain across all counties and all age groups (> 10 years old). Surprisingly, the majority of chronic pain patients were identified based on the diagnostic code criteria and not the opioid prescription criteria. A greater utilization of public health insurance was seen within the chronic pain patients. At the county level, although neither education level nor income were associated with the prevalence of chronic pain, these factors significantly correlated with the usage of public health insurance. CONCLUSIONS Further detailed characterization of the chronic pain patient population in the state of Maine, using multiple data sources, can help design population-targeted strategies to prevent and manage chronic pain.
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Affiliation(s)
- Jennifer Malon
- Center for Excellence in the Neurosciences, University of New England, 11 Hills Beach Rd., Biddeford, ME 04005 USA
| | - Parth Shah
- College of Osteopathic Medicine, University of New England, Biddeford, ME USA
| | - Woon Yuen Koh
- Department of Mathematical Sciences, University of New England, Biddeford, ME USA
| | | | - Edward Li
- College of Pharmacy, University of New England, Portland, ME USA
| | - Ling Cao
- Center for Excellence in the Neurosciences, University of New England, 11 Hills Beach Rd., Biddeford, ME 04005 USA
- College of Osteopathic Medicine, University of New England, Biddeford, ME USA
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29
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Richardson E, Bedson J, Chen Y, Lacey R, Dunn K. Increased risk of reproductive dysfunction in women prescribed long-term opioids for musculoskeletal pain: A matched cohort study in the Clinical Practice Research Datalink. Eur J Pain 2018; 22:1701-1708. [DOI: 10.1002/ejp.1256] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2018] [Indexed: 11/05/2022]
Affiliation(s)
- E. Richardson
- Research Institute for Primary Care & Health Sciences; Keele University; UK
| | - J. Bedson
- Research Institute for Primary Care & Health Sciences; Keele University; UK
| | - Y. Chen
- Research Institute for Primary Care & Health Sciences; Keele University; UK
| | - R. Lacey
- Research Institute for Primary Care & Health Sciences; Keele University; UK
| | - K.M. Dunn
- Research Institute for Primary Care & Health Sciences; Keele University; UK
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30
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Snow R, Wynn ST. Managing Opioid Use Disorder and Co-Occurring Posttraumatic Stress Disorder Among Veterans. J Psychosoc Nurs Ment Health Serv 2018; 56:36-42. [DOI: 10.3928/02793695-20180212-03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Accepted: 12/19/2017] [Indexed: 11/20/2022]
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31
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Adewumi AD, Hollingworth SA, Maravilla JC, Connor JP, Alati R. Prescribed Dose of Opioids and Overdose: A Systematic Review and Meta-Analysis of Unintentional Prescription Opioid Overdose. CNS Drugs 2018; 32:101-116. [PMID: 29498021 DOI: 10.1007/s40263-018-0499-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND The rate of an unintentional drug overdose involving prescription opioids continues to rise. An understanding of the threshold dose and dose(s) associated with unintentional prescription opioid overdose will help to mitigate this epidemic. OBJECTIVE The objective of this systematic review is to systematically synthesise and meta-analyse studies on doses of prescription opioids and ascertain the doses of opioids that are associated with increased risk of severe opioid poisoning or mortality. DATA SOURCES A search of PubMed, EMBASE, CINAHL and Web of Science from inception to 16 January 2017 was conducted using search strategies and the MeSH (Medical Subject Headings) terms for studies of adult patients using prescription opioids who experienced an accidental overdose. STUDY SELECTION Of the 1332 studies identified, 117 were selected for full article review. Ten met the inclusion criteria for qualitative analysis, but only seven studies were meta-analysed. The included studies were in English, and participants met predetermined International Classification of Diseases (ICD) codes. Studies were excluded if they included only paediatric participants or the participants met the ICD code for intentional self-harm. DATA EXTRACTION AND SYNTHESIS Two researchers elaborated and validated a data extraction form. Data were then independently extracted by both reviewers as per this form. We assessed study quality using the Newcastle-Ottawa Scale (NOS) for non-randomised studies in meta-analyses. We performed a meta-regression using a random-effect model and summarised the results using relative risk (RR) and 95% confidence intervals (CIs). The threshold dose for an unintentional overdose is 20 morphine milligram equivalents (MME)/day. There were higher risks with larger doses: (1) ≤ 20 versus ≥ 21 MME/day: RR 2.81, 95% CI 1.09-7.22, p < 0.001; (2) ≤ 50 versus > 50 MME/day: RR 3.87, 95% CI 2.36-6.33, p < 0.001; (3) ≤ 100 versus > 100 MME/day: RR 4.28, 95% CI 2.61-7.1, p < 0.001; and (4) ≤ 50 versus > 50-100 MME/day: RR 3.09, 95% CI 1.84-5.18, p < 0.001). Heterogeneity was explained by the type of overdose event, inpatient or outpatient status, and length of observation. Type of pain (cancer or non-cancer pain) had no impact on heterogeneity. LIMITATIONS The definition of exposure in studies included in the meta-analysis was heterogeneous. Some studies defined exposure as the filling of a prescription while others defined exposure as the prescription of an opioid to the patient, and all studies assumed that patients took the prescribed opioid. Medications that may contribute to overdose, such as benzodiazepines and other drugs, were not considered. CONCLUSIONS A significantly increased risk of inadvertent prescription opioid overdose was found with 20-50 MME/day, with fatality more likely with opioid doses above 50 MME/day, although extensive heterogeneity was found with the dose comparisons. Clinicians should inform patients of this risk and monitor them closely. PROTOCOL REGISTRATION This protocol was registered with PROSPERO 2017: CRD42017058426.
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Affiliation(s)
- Adeleke D Adewumi
- Institute for Social Science Research, The University of Queensland, Indooroopilly, 4068, QLD, Australia. .,Maryborough Hospital Pharmacy, Wide Bay Hospital and Health Service, 185 Walker Street, Maryborough, QLD, 4650, Australia. .,School of Clinical Medicine, Rural Clinical School, The University of Queensland, Hervey Bay, 4655, QLD, Australia.
| | - Samantha A Hollingworth
- School of Pharmacy, The University of Queensland, 20 Cornwall St, Woolloongabba, QLD, 4102, Australia
| | - Joemer C Maravilla
- Institute for Social Science Research, The University of Queensland, Indooroopilly, 4068, QLD, Australia
| | - Jason P Connor
- Centre for Youth Substance Abuse Research, The University of Queensland, St Lucia, 4067, QLD, Australia.,Discipline of Psychiatry, The University of Queensland, Herston, QLD, 4029, Australia
| | - Rosa Alati
- Institute for Social Science Research, The University of Queensland, Indooroopilly, 4068, QLD, Australia
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32
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Davis CS, Carr DH. The Law and Policy of Opioids for Pain Management, Addiction Treatment, and Overdose Reversal. ACTA ACUST UNITED AC 2017. [DOI: 10.18060/3911.0027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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33
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Elsesser K, Cegla T. Long-term treatment in chronic noncancer pain: Results of an observational study comparing opioid and nonopioid therapy. Scand J Pain 2017; 17:87-98. [DOI: 10.1016/j.sjpain.2017.07.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 06/29/2017] [Accepted: 07/05/2017] [Indexed: 12/17/2022]
Abstract
Abstract
Background and aims
Recent studies reveal high prevalence rates of patients receiving long-term opioids. However, well designed studies assessing effectiveness with longer than 3 months follow-up are sparse. The present study investigated the outcomes of long-term opioid therapy compared to nonopioid treatment in CNCP patients with respect to measures of pain, functional disability, psychological wellbeing, and quality of life (QoL).
Methods
Three hundred and thirty three consecutive patients at our pain clinic were included and divided into patients with continuous opioid treatment for at least 3 months (51%) and patients receiving nonopioid analgesics (49%). Further, outcome of different doses of opioid (<120 mg vs. >120 mg morphine equivalents) and differences between high and low potency opioids were examined.
Results
The opioid and nonopioid groups did not differ with regard to pain intensity or satisfaction with analgesic. Patients with continuous opioids treatment reported higher neuropathic like pain, longer duration of pain disorder, lower functional level, wellbeing, and physical QoL in comparison to patients receiving nonopioid analgesics. Higher opioid doses were associated with male gender, intake of high potency opioids and depression but there were no differences with regard to pain relief or improvement of functional level between high and low doses. Similarly, patients on high potency opioids reported more psychological impairment than patients on low potency opioids but no advantage with regard to pain relief. Overall, remaining level of pain, functional disability and poor QoL were quite high irrespective of the analgesic used or opioid dosing.
Conclusions
In the long-term no clear advantage of opioid vs. non-opioid analgesics could be revealed. In terms of remaining pain intensity, functional disability and quality of life, treatment with pain medication proved insufficient. Additionally, with higher doses of opioids the benefit to risk relationship becomes worse and patients on high potency opioids reported more psychological impairment than patients on low potency opioids but no advantage with regard to pain relief.
Implications
Our results raise questions about the long-term effectiveness of analgesic treatment regimens irrespective of analgesics type employed and call for more multidisciplinary treatment strategies.
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Affiliation(s)
- Karin Elsesser
- Sankt Josef Krankenhaus , Clinic of Pain Medicine, Bergstr , 6-12, 42105 Wuppertal , Germany
| | - Thomas Cegla
- Sankt Josef Krankenhaus , Clinic of Pain Medicine, Bergstr , 6-12, 42105 Wuppertal , Germany
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34
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Cooper S, Campbell G, Larance B, Murnion B, Nielsen S. Perceived stigma and social support in treatment for pharmaceutical opioid dependence. Drug Alcohol Rev 2017; 37:262-272. [DOI: 10.1111/dar.12601] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 07/29/2017] [Accepted: 07/31/2017] [Indexed: 01/19/2023]
Affiliation(s)
- Sasha Cooper
- National Drug and Alcohol Research Centre; University of New South Wales; Sydney Australia
| | - Gabrielle Campbell
- National Drug and Alcohol Research Centre; University of New South Wales; Sydney Australia
| | - Briony Larance
- National Drug and Alcohol Research Centre; University of New South Wales; Sydney Australia
| | - Bridin Murnion
- Drug Health Services, Royal Prince Alfred Hospital; Sydney Local Health District; Sydney Australia
- Faculty of Medicine; University of Sydney; Sydney Australia
| | - Suzanne Nielsen
- National Drug and Alcohol Research Centre; University of New South Wales; Sydney Australia
- Drug and Alcohol Services; South Eastern Sydney Local Health District; Sydney Australia
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35
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“Unsettling circularity”: Clinical trial enrichment and the evidentiary politics of chronic pain. BIOSOCIETIES 2017. [DOI: 10.1057/biosoc.2016.7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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36
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Saulle R, Vecchi S, Gowing L. Supervised dosing with a long-acting opioid medication in the management of opioid dependence. Cochrane Database Syst Rev 2017; 4:CD011983. [PMID: 28447766 PMCID: PMC6478186 DOI: 10.1002/14651858.cd011983.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Opioid dependence (OD) is an increasing clinical and public health problem worldwide. International guidelines recommend opioid substitution treatment (OST), such as methadone and buprenorphine, as first-line medication treatment for OD. A negative aspect of OST is that the medication used can be diverted both through sale on the black market, and the unsanctioned use of medications. Daily supervised administration of medications used in OST has the advantage of reducing the risk of diversion, and may promote therapeutic engagement, potentially enhancing the psychosocial aspect of OST, but costs more and is more restrictive on the client than dispensing for off-site consumption. OBJECTIVES The objective of this systematic review is to compare the effectiveness of OST with supervised dosing relative to dispensing of medication for off-site consumption. SEARCH METHODS We searched in Cochrane Drugs and Alcohol Group Specialised Register and Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, Web of Science from inception up to April 2016. Ongoing and unpublished studies were searched via ClinicalTrials.gov (www.clinicaltrials.gov) and World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (http://www.who.int/ictrp/en/).All searches included non-English language literature. We handsearched references on topic-related systematic reviews. SELECTION CRITERIA Randomised controlled trials (RCTs), controlled clinical trials (CCTs), and prospective controlled cohort studies, involving people who are receiving OST (methadone, buprenorphine) and comparing supervised dosing with dispensing of medication to be consumed away from the dispensing point, usually without supervision. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. MAIN RESULTS Six studies (four RCTs and two prospective observational cohort studies), involving 7999 participants comparing supervised OST treatment with unsupervised treatment, met the inclusion criteria. The risk of bias was generally moderate across trials, but the results reported on outcomes that we planned to consider were limited. Overall, we judged the quality of the evidence from very low to low for all the outcomes.We found no difference in retention at any duration with supervised compared to unsupervised dosing (RR 0.99, 95% CI 0.88 to 1.12, 716 participants, four trials, low-quality evidence) or in retention in the shortest follow-up period, three months (RR 0.94; 95% CI 0.84 to 1.05; 472 participants, three trials, low-quality evidence). Additional data at 12 months from one observational study found no difference in retention between groups (RR 0.94, 95% CI 0.77 to 1.14; n = 300).There was no difference in abstinence at the end of treatment (self-reported drug use) (67% versus 60%, P = 0.33, 293 participants, one trial, very low-quality evidence); and in diversion of medication (5% versus 2%, 293 participants, one trial, very low-quality evidence).Regarding our secondary outcomes, we did not found a difference in the incidence of adverse effects in the supervised compared to unsupervised control group (RR 0.63; 96% CI 0.10 to 3.86; 363 participants, two trials, very low-quality evidence). Data on severity of dependence were very limited (244 participants, one trial) and showed no difference between the two approaches. Data on deaths were reported in two studies. One trial reported two deaths in the supervised group (low-quality evidence), while in the cohort study all-cause mortality was found lower in regular supervision group (crude mortality rate 0.60 versus 0.81 per 100 person-years), although after adjustment insufficient evidence existed to suggest that regular supervision was protective (mortality rate ratio = 1.23, 95% CI = 0.67 to 2.27).No studies reported pain symptoms, drug craving, aberrant opioid-related behaviours, days of unsanctioned opioid use and overdose. AUTHORS' CONCLUSIONS Take-home medication strategies are attractive to treatment services due to lower costs, and place less restrictions on clients, but it is unknown whether they may be associated with increased risk of diversion and unsanctioned use of medication. There is uncertainty about the effects of supervised dosing compared with unsupervised medication due to the low and very low quality of the evidence for the primary outcomes of interest for this review. Data on defined secondary outcomes were similarly limited. More research comparing supervised and take-home medication strategies is needed to support decisions on the relative effectiveness of these strategies. The trials should be designed and conducted with high quality and over a longer follow-up period to support comparison of strategies at different stages of treatment. In particular, there is a need for studies assessing in more detail the risk of diversion and safety outcomes of using supervised OST to manage opioid dependence.
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Affiliation(s)
- Rosella Saulle
- Lazio Regional Health ServiceDepartment of EpidemiologyVia di S. CostanzaRomeItaly00198
| | - Simona Vecchi
- Lazio Regional Health ServiceDepartment of EpidemiologyVia di S. CostanzaRomeItaly00198
| | - Linda Gowing
- University of AdelaideDiscipline of PharmacologyFrome RoadAdelaideSouth AustraliaAustralia5005
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Morrone LA, Scuteri D, Rombolà L, Mizoguchi H, Bagetta G. Opioids Resistance in Chronic Pain Management. Curr Neuropharmacol 2017; 15:444-456. [PMID: 28503117 PMCID: PMC5405610 DOI: 10.2174/1570159x14666161101092822] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 08/11/2016] [Accepted: 10/24/2016] [Indexed: 01/07/2023] Open
Abstract
Chronic pain management represents a serious healthcare problem worldwide. Chronic pain affects approximately 20% of the adult European population and is more frequent in women and older people. Unfortunately, its management in the community remains generally unsatisfactory and rarely under the control of currently available analgesics. Opioids have been used as analgesics for a long history and are among the most used drugs; however, while there is no debate over their short term use for pain management, limited evidence supports their efficacy of long-term treatment for chronic non-cancer pain. Therapy with opioids is hampered by inter-individual variability and serious side effects and some opioids often result ineffective in the treatment of chronic pain and their use is controversial. Accordingly, for a better control of chronic pain a deeper knowledge of the molecular mechanisms underlying resistance to opiates is mandatory.
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Affiliation(s)
- Luigi A. Morrone
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy
- University Consortium for Adaptive Disorders and Head Pain (UCADH), Section of Neuropharmacology of Normal and Pathological Neuronal Plasticity, University of Calabria, Rende, Italy
| | - Damiana Scuteri
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy
| | - Laura Rombolà
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy
| | - Hirokazu Mizoguchi
- Department of Physiology and Anatomy, Tohoku Pharmaceutical University, 4-4-1 Komatsushima, Aoba-ku, Sendai 981-8558, Japan
| | - Giacinto Bagetta
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy
- University Consortium for Adaptive Disorders and Head Pain (UCADH), Section of Neuropharmacology of Normal and Pathological Neuronal Plasticity, University of Calabria, Rende, Italy
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Rasu RS, Knell ME. Determinants of Opioid Prescribing for Nonmalignant Chronic Pain in US Outpatient Settings. PAIN MEDICINE 2017; 19:524-532. [DOI: 10.1093/pm/pnx025] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Rafia S Rasu
- Division of Pharmacy Practice, *University of Kansas School of Pharmacy, Lawrence, Kansas
| | - Maureen E Knell
- Division of Pharmacy Practice and Administration, Kansas City School of Pharmacy, University of Missouri, Kansas City, Missouri, USA
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Sanga P, Katz N, Polverejan E, Wang S, Kelly KM, Haeussler J, Thipphawong J. Long-Term Safety and Efficacy of Fulranumab in Patients With Moderate-to-Severe Osteoarthritis Pain: A Phase II Randomized, Double-Blind, Placebo-Controlled Extension Study. Arthritis Rheumatol 2017; 69:763-773. [PMID: 27748055 DOI: 10.1002/art.39943] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 09/20/2016] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To evaluate the long-term safety and efficacy of fulranumab in patients with knee or hip pain caused by moderate-to-severe chronic osteoarthritis (OA). METHODS In this phase II double-blind, placebo-controlled extension study, patients who were randomized in equal proportions to receive subcutaneous doses of either placebo or fulranumab (1 mg every 4 weeks, 3 mg every 8 weeks, 3 mg every 4 weeks, 6 mg every 8 weeks, or 10 mg every 8 weeks) in the 12-week double-blind efficacy phase and who completed this double-blind efficacy phase were eligible to continue the dosage throughout a 92-week double-blind extension phase, followed by a 24-week posttreatment follow-up period. Safety assessments included evaluation of treatment-emergent adverse events (TEAEs), pre-identified AEs of interest, and joint replacements. Efficacy assessments included changes from baseline to the end of the double-blind extension phase in scores on the patient's global assessment and the pain and physical function subscales of the Western Ontario and McMaster Universities Osteoarthritis Index. RESULTS Overall, 401 of the 423 patients who completed the 12-week double-blind efficacy phase entered the extension study. Long-term sustained improvements were observed in all efficacy parameters following fulranumab treatment (1 mg every 4 weeks, 3 mg every 4 weeks, and 10 mg every 8 weeks) as compared with placebo. Similar percentages of patients in both groups experienced TEAEs (88% taking placebo and 91% taking fulranumab; all phases). Across all fulranumab groups, arthralgia (21%) and OA (18%) (e.g., exacerbation of OA pain) were the most common TEAEs. The most common serious TEAEs were the requirement for knee (10%) and hip (7%) arthroplasty, with 80% occurring during the posttreatment follow-up period. Neurologic-related TEAEs (28%; all phases) were generally mild-to-moderate. Overall, 81 joint replacements were performed in 71 patients (8 [11%] receiving placebo and 63 [89%] receiving fulranumab); 15 patients (21%) had rapid progression of OA (RPOA). All cases of RPOA occurred in fulranumab-treated patients who were concurrently receiving nonsteroidal antiinflammatory drugs and occurred in joints with preexisting OA. CONCLUSION Long-term treatment with fulranumab was generally well-tolerated and efficacious. RPOA was observed as a safety signal. Future studies are warranted to demonstrate whether the risk of RPOA can be reduced in patients taking fulranumab.
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Affiliation(s)
- Panna Sanga
- Janssen Research & Development, Titusville, New Jersey
| | - Nathaniel Katz
- Analgesic Solutions, Natick, Massachusetts, and Tufts University School of Medicine, Boston, Massachusetts
| | | | - Steven Wang
- Janssen Research & Development, Titusville, New Jersey
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Bauer SR, Hitchner L, Harrison H, Gerstenberger J, Steiger S. Predictors of higher-risk chronic opioid prescriptions in an academic primary care setting. Subst Abus 2017; 37:110-7. [PMID: 26848633 DOI: 10.1080/08897077.2015.1129020] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Patients with chronic noncancer pain treated with higher doses of opioids or concurrent substance use are at increased risk of adverse events. Although several national guidelines recommend maximum dosing thresholds and urine drug testing, adherence to these guidelines is inconsistent. METHODS To identify predictors of higher-risk opioid prescriptions in 2 academic primary care clinics, the authors developed a retrospective cohort of 842 patients who were prescribed ≥5 opioid prescriptions for noncancer pain between March 2012 and March 2013. The authors evaluated odds of higher-dose opioid prescriptions and urine drug testing using multivariate logistic models. RESULTS Among study subjects, 47% received prescriptions for the equivalent of ≥50 mg morphine per day. After adjustment for confounders, patients with a resident primary care provider were less likely to receive higher-dose prescriptions compared with faculty providers (odds ratio = 0.66, 95% confidence interval [CI]: 0.46-0.94), whereas patients with a nonlocal home address were more likely to be prescribed higher doses (odds ratio = 2.1, 95% CI: 1.5-2.9). Hispanic, Asian, and older patients were also less likely to be prescribed higher doses. Urine drug testing was not regularly completed (35% over 2 years), but odds of testing were higher for patients who self-identified as black, had resident primary care providers, lived locally, or were prescribed higher opioid doses. CONCLUSIONS In this academic clinical setting, patients with a resident primary care provider are less likely to receive higher-risk opioid prescriptions, as are Hispanic, Asian, and older patients. Black patients complete urine drug tests more frequently independent of other patient and provider characteristics. Additional studies are needed to assess why patients who travel larger distances to their primary care clinic are prescribed higher doses of opioids for chronic noncancer pain.
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Affiliation(s)
- Scott R Bauer
- a Division of General Internal Medicine , University of California San Francisco , San Francisco , California , USA
| | - Lily Hitchner
- b School of Medicine , University of California, San Francisco , San Francisco , California , USA
| | - Hannah Harrison
- b School of Medicine , University of California, San Francisco , San Francisco , California , USA
| | - John Gerstenberger
- b School of Medicine , University of California, San Francisco , San Francisco , California , USA
| | - Scott Steiger
- a Division of General Internal Medicine , University of California San Francisco , San Francisco , California , USA
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Häuser W, Bernardy K, Maier C. [Long-term opioid therapy in chronic noncancer pain. A systematic review and meta-analysis of efficacy, tolerability and safety in open-label extension trials with study duration of at least 26 weeks]. Schmerz 2016; 29:96-108. [PMID: 25503691 DOI: 10.1007/s00482-014-1452-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The efficacy and safety of long-term (≥ 6 months) opioid therapy (LtOT) in chronic noncancer pain (CNCP) is under debate. A systematic review with meta-analysis of the efficacy and harms of opioids in open-label extension studies of randomized controlled trials (RCTs) has not been conducted until now. METHODS We screened MEDLINE and clinicaltrials.gov (through to December 2013), as well as reference sections of systematic reviews of long-term RCTs of opioids in CNCP. We included open-label extension trials with a study duration ≥ 26 weeks of RCTs of ≥ 2 weeks duration. Using a random effects model, pooled estimates of event rates for categorical data and standardized mean differences (SMD) for continuous variables were calculated. RESULTS We included 11 open-label extension studies with 2445 participants with nociceptive (low back, osteoarthritis) and neuropathic (radicular, polyneuropathy) pain. Median study duration was 26 (range 26-108) weeks. Four studies tested oxycodone, two studies tramadol and buprenorphine; hydromorphone, morphine, oxymorphone and tapentadol were each tested in one study. Of the patients randomized at baseline, 28.5 % (95 % confidence interval, CI, 17.9-39.2 %) finished the open-label period; 53.5 % (95 % CI 38.1-68.2 %) of patients entering the open-label period finished the open-label period. In sum, the total loss was 71.5 % (95 % CI 60.9-83.1 %) of all patients primarily included into the RCT. A total of 4.9 % (95 % CI 2.9-8.2 %) of patients dropped out due lack of efficacy; 16.8 % (95 % CI 11.0-24.8 %) dropped out to due adverse events (AE) in the open-label period and 0.08 % (95 % CI 0.001-0.05 %) of patients died during the open-label period. Only one study systematically assessed aberrant drug behavior of the patients: 5.7 % (95 % CI 3.4-9.6 %) showed aberrant drug behavior in the opinion of the investigators and 2.6 % (95 % CI 1.2-5.8 %) were judged to show aberrant drug behavior by independent expert assessment. There was no significant change (p = 0.50) in pain intensity between the end of the randomized period and the end of open-label phase (SMD 0.19 [- 0.03, 0.41]; six studies with 1360 participants). CONCLUSION Only a minority of patients selected for opioid therapy at randomization finished the long-term open-label study. However, sustained effects of pain reduction could be demonstrated in these patients. LtOT can be considered in carefully selected and monitored CNCP patients who experience clinically meaningful pain reduction with at least tolerable AE in short-term opioid therapy. The English full-text version of this article is freely available at SpringerLink (under "Supplementary Material").
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Affiliation(s)
- W Häuser
- Innere Medizin I, Klinikum Saarbrücken gGmbH, Winterberg 1, 66119, Saarbrücken, Deutschland,
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Petzke F, Welsch P, Klose P, Schaefert R, Sommer C, Häuser W. [Opioids in chronic low back pain. A systematic review and meta-analysis of efficacy, tolerability and safety in randomized placebo-controlled studies of at least 4 weeks duration]. Schmerz 2016; 29:60-72. [PMID: 25503883 DOI: 10.1007/s00482-014-1449-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The efficacy and safety of opioid therapy in chronic low back pain (CLBP) is under debate. We updated a recent systematic review on the efficacy and safety of opioids in CLBP. METHODS We screened MEDLINE, Scopus and the Cochrane Central Register of Controlled Trials (CENTRAL) up until October 2013, as well as reference sections of original studies and systematic reviews of randomized controlled trials (RCTs) of opioids in CLBP. We included double-blind randomized placebo-controlled studies of at least 4 weeks duration. Using a random effects model, absolute risk differences (RD) were calculated for categorical data and standardized mean differences (SMD) for continuous variables. RESULTS We included 12 RCTs with 17 treatment arms and 4375 participants. Median study duration was 12 (4-16) weeks. Of the 17 treatment arms, seven (41.2 %) used oxycodone; four (23.6 %) tramadol; buprenorphine and oxymorphone were each used in two (11.8 %) and hydromorphone and tapentadol each in one (5.8 %). The results for studies with parallel/cross-over design were as follows (with 95 % confidence interval, CI): opioids were superior to placebo in reducing pain intensity (SMD - 0.29 [- 0.37, - 0.21], p < 0.0001; six studies with 2896 participants). Opioids were superior to placebo in 50 % pain reduction (RD 0.05 [0.01, 0.10], p = 0.01; two studies with 1492 participants; number needed to benefit (NNTB) 19 [95 % CI 10-107]). Opioids were not superior to placebo in reports of much or very much improved pain (RD 0.16 [- 0.01, 0.34], p = 0.07; two studies with 1153 participants). Opioids were superior to placebo in improving physical functioning (SMD - 0.22 [- 0.31, - 0.12], p < 0.0001; four studies with 1895 participants). Patients dropped out less frequently with opioids than with placebo due to lack of efficacy (RD - 0.10 [- 0.16, - 0.04], p = 0.001; five studies with 3168 participants; NNTB 10 [8-13]). Patients dropped out more frequently with opioids than with placebo due to adverse events (RD 0.12 [0.05, 0.19], p = 0.0007; six studies with 2910 participants; number needed to harm (NNTH) 7 [95 % CI 6-8]). There was no significant difference between opioids and placebo in terms of the frequency of serious adverse events or deaths. CONCLUSION Opioids were superior to placebo in terms of efficacy and inferior in terms of tolerability. Opioids and placebo did not differ in terms of safety during the study period. The conclusion on the safety of opioids compared to placebo is limited by the low number of serious adverse events and deaths. Short-term and intermediate-term opioid therapy may be considered in selected CLBP patients. The English full-text version of this article is freely available at SpringerLink (under "Supplemental").
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Affiliation(s)
- F Petzke
- Schmerz-Tagesklinik und -Ambulanz, Universitätsmedizin Göttingen, Göttingen, Deutschland
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[Opioids in chronic noncancer pain-are opioids different? A systematic review and meta-analysis of efficacy, tolerability and safety in randomized head-to-head comparisons of opioids of at least four week's duration]. Schmerz 2016; 29:73-84. [PMID: 25376545 DOI: 10.1007/s00482-014-1432-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND We updated a systematic review on the comparative efficacy, tolerability and safety of opioids and of their routes of application in chronic noncancer pain (CNCP). METHODS We screened MEDLINE, Scopus and the Cochrane Central Register of Controlled Trials (CENTRAL) up until October 2013, as well as the reference sections of original studies and systematic reviews of randomized controlled trials (RCTs) of opioids in CNCP. We included randomized head-to-head comparisons of opioids (opioid of the sponsor of the study versus standard opioid) of at least 4 week's duration. Using a random effects model, absolute risk differences (RD) were calculated for categorical data and standardized mean differences (SMD) for continuous variables. The quality of evidence was rated by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. RESULTS We included 13 RCTs with 6748 participants. Median study duration was 15 weeks (range 4-56 weeks). Hydromorphone, morphine, oxymorphone and tapentadol were compared to oxycodone; fentanyl to morphine and buprenorphine to tramadol. In pooled analysis, there were no significant differences between the two groups of opioids in terms of mean pain reduction (low-quality evidence), the patient global impression to be much or very much improved outcome (low-quality evidence), physical function (very low-quality evidence), serious adverse events (moderate-quality evidence) or mortality (moderate-quality evidence). There was no significant difference between transdermal and oral application of opioids in terms of mean pain reduction, physical function, serious adverse events, mortality (all low-quality evidence) or dropout due to adverse events (very low-quality). CONCLUSION Pooled head-to-head comparisons of opioids (opioid of the sponsor of the study versus standard opioid) provide no rational for preferring one opioid and/or administration route over another in the therapy of patients with CNCP. The English full-text version of this article is freely available at SpringerLink (under "Supplemental").
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Häuser W, Bock F, Engeser P, Hege-Scheuing G, Hüppe M, Lindena G, Maier C, Norda H, Radbruch L, Sabatowski R, Schäfer M, Schiltenwolf M, Schuler M, Sorgatz H, Tölle T, Willweber-Strumpf A, Petzke F. [Recommendations of the updated LONTS guidelines. Long-term opioid therapy for chronic noncancer pain]. Schmerz 2016; 29:109-30. [PMID: 25616996 DOI: 10.1007/s00482-014-1463-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The regular update of the German S3 guidelines on long-term opioid therapy for chronic noncancer pain (CNCP), the"LONTS" (AWMF registration number 145/003), began in November 2013. METHODS The guidelines were developed by 26 scientific societies and two patient self-help organisations under the coordination of the Deutsche Schmerzgesellschaft (German Pain Society). A systematic literature search in the Cochrane Central Register of Controlled Trials (CENTRAL), Medline and Scopus databases (up until October 2013) was performed. Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine. The strength of the recommendations was established by multistep formal procedures, in order to reach a consensus according to German Association of the Medical Scientific Societies ("Arbeitsgemeinschaft der Wissenschaftlich Medizinischen Fachgesellschaften", AWMF) regulations. The guidelines were reviewed by the Drug Commission of the German Medical Association, the Austrian Pain Society and the Swiss Association for the Study of Pain. RESULTS Opioids are one drug-based treatment option for short- (4-12 weeks), intermediate- (13-25 weeks) and long-term (≥ 26 weeks) therapy of chronic osteoarthritis, diabetic polyneuropathy, postherpetic neuralgia and low back pain. Contraindications are primary headaches, as well as functional somatic syndromes and mental disorders with the (cardinal) symptom pain. For all other clinical presentations, a short- and long-term therapy with opioid-containing analgesics should be evaluated on an individual basis. Long-term therapy with opioid-containing analgesics is associated with relevant risks (sexual disorders, increased mortality). CONCLUSION Responsible application of opioid-containing analgesics requires consideration of possible indications and contraindications, as well as regular assessment of efficacy and adverse effects. Neither an uncritical increase in opioid application, nor the global rejection of opioid-containing analgesics is justified in patients with CNCP.
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Affiliation(s)
- W Häuser
- Medizinisches Versorgungszentrum (Schmerztherapie, Palliativmedizin, Psychiatrie, Psychotherapie) Saarbrücken - St. Johann, Saarbrücken, Deutschland,
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Lee J, Yoon JS, Lee JH, Chung SH, Lee KY, Kim YY, Kim JM, Kong MH, Kang UG, Park YS. Clinical Usefulness of Long-term Application of Fentanyl Matrix in Chronic Non-Cancer Pain: Improvement of Pain and Physical and Emotional Functions. Clin Orthop Surg 2016; 8:465-474. [PMID: 27904731 PMCID: PMC5114261 DOI: 10.4055/cios.2016.8.4.465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 06/13/2016] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Opioids are recently recommended for those who do not gain adequate pain relief from the use of acetaminophen or nonsteroidal anti-inflammatory drugs. Medical opioids are administered in various routes, and transdermal opioid products that can make up for the weaknesses of the oral or intravenous products have been developed. This study is to evaluate the clinical usefulness of fentanyl matrix in terms of the long-term improvement in pain and physical and mental functions. METHODS This was a multicenter, open, prospective, observational study that was conducted in 54 institutions in Korea. Patients with non-cancerous chronic pain completed questionnaires, and investigators also completed questionnaires. A total of 1,355 subjects participated in this study, and 639 subjects completed the study. Subjects received transdermal fentanyl matrix (12 µg/hr, 25 µg/hr, or 50 µg/hr depending on the patient's response and demand). Subjects visited at 29 ± 7 days, 85 ± 14 days, and 169 ± 14 days after administration, respectively, to receive drug titration and fill out the questionnaires. The results were analyzed using the intention-to-treat (ITT) analysis, full analysis set (FAS), and per-protocol (PP) analysis. The FAS analysis included only 451 participants; the PP analysis, 160 participants; and the ITT analysis, 1,355 participants. RESULTS The intensity of pain measured by the Numeric Rating Scale decreased from 7.07 ± 1.78 to 4.93 ± 2.42. The physical assessment score and mental assessment score of the Short-Form Health Survey 12 improved from 28.94 ± 7.23 to 35.90 ± 10.25 and from 35.80 ± 11.76 to 42.52 ± 10.58, respectively. These differences were significant, and all the other indicators also showed improvement. Adverse events with an incidence of ≥ 1% were nausea, dizziness, vomiting, and pruritus. CONCLUSIONS The long-term administration of fentanyl matrix in patients with non-cancerous pain can reduce the intensity of pain and significantly improves activities of daily living and physical and mental capabilities.
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Affiliation(s)
- Jaewon Lee
- Department of Orthopedic Surgery, Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Joon Shik Yoon
- Department of Physical Medicine and Rehabilitation, Korea University College of Medicine, Seoul, Korea
| | - Jae Hyup Lee
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - So-Hak Chung
- Department of Orthopedic Surgery, Kosin University Gospel Hospital, Kosin University School of Medicine, Busan, Korea
| | - Kyu-Yeol Lee
- Department of Orthopedic Surgery, Dong-A University College of Medicine, Busan, Korea
| | - Young Yul Kim
- Department of Orthopedic Surgery, Daejeon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Daejeon, Korea
| | - Jong Moon Kim
- Department of Rehabilitation, Konkuk University College of Medicine, Chungju, Korea
| | - Min Ho Kong
- Department of Neurosurgery, Seoul Medical Center, Seoul, Korea
| | - Ung Gu Kang
- Department of Psychiatry and Behavioral Science, Seoul National University College of Medicine, Seoul, Korea
| | - Ye-Soo Park
- Department of Orthopedic Surgery, Guri Hospital, Hanyang University College of Medicine, Guri, Korea
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Codeine Shopping Behavior in a Retrospective Cohort of Chronic Noncancer Pain Patients: Incidence and Risk Factors. THE JOURNAL OF PAIN 2016; 17:1291-1301. [DOI: 10.1016/j.jpain.2016.08.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 08/23/2016] [Accepted: 08/24/2016] [Indexed: 02/02/2023]
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Cooper S, Nielsen S. Stigma and Social Support in Pharmaceutical Opioid Treatment Populations: a Scoping Review. Int J Ment Health Addict 2016. [DOI: 10.1007/s11469-016-9719-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Shah D, Anupindi VR, Vaidya V. Pharmacoeconomic Analysis of Pain Medications Used to Treat Adult Patients with Chronic Back Pain in the United States. J Pain Palliat Care Pharmacother 2016; 30:300-307. [DOI: 10.1080/15360288.2016.1231735] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Bockhold CR, Hughes AK. The ethics of opioids for chronic noncancer pain. Nursing 2016; 46:63-67. [PMID: 27654445 DOI: 10.1097/01.nurse.0000484981.83948.9c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Colleen R Bockhold
- Colleen R. Bockhold works in quality management and Ashley Kate Hughes is a nurse practitioner in the Central Texas Veteran's Healthcare System in Temple, Tex. Yvonne D'Arcy, MS, RN, CRNP, CNS, FAANP is the coordinator of Controlling Pain and a Nursing2016 editorial board member
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Kissin I. Opioid prescriptions for pain and epidemic of overdose death: can the dramatic reduction in anesthesia mortality serve as an example? J Pain Res 2016; 9:453-6. [PMID: 27418852 PMCID: PMC4935029 DOI: 10.2147/jpr.s108067] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The annual number of US deaths from prescription-opioid overdose quadrupled between 1999 and 2010 and in 2010 alone reached 16,651. Deaths from opioid overdose have now surpassed the historic death toll from another drug-related epidemic - anesthesia mortality. In 1954, Beecher and Todd published reliable data on anesthesia-related mortality in the US, estimating the annual number of deaths to be nearly 5,000. Presently anesthesia/anesthetics are reported as the underlying cause in approximately 34 deaths in the US annually. This spectacular decline in anesthesia-related mortality could serve as an example for attempts to curb the epidemic of opioid overdose death. The main reason that led to the dramatic decline in anesthesia-related mortality is the context in which anesthetics are used. It includes training of the anesthesia providers, the introduction of specific standards of patient safety, and anesthesia monitoring. I suggest that the introduction of a similar multifactorial proper context for the use of opioids in the treatment of chronic nonmalignant pain might be the same "game changer" it was for safety in anesthesia.
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Affiliation(s)
- Igor Kissin
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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