Select practice behaviors of clinicians on the use of opioids for adolescents with subacute and chronic nonmalignant pain

Interviewing and Urine Drug Toxicology Screening in a Pediatric Pain Management Center: An Analysis of Analgesic Nonadherence and Aberrant Behaviors in Adolescents and Young Adults

OBJECTIVES

Many adolescents and young adults report having chronic pain. Urine drug toxicology (UDT) is not routinely used in the pediatric pain management population, despite more routine use in adults with pain, particularly those prescribed opioids. As a first step toward establishing monitoring practices in pediatric and adolescent pain management, the present study evaluated the role of UDT in conjunction with a standard clinical interview in identifying the rate of adherence to an established analgesic regimen. The study also aimed to assess the use of UDT in identifying possible aberrant behaviors in this population.

METHODS

Data were acquired from a convenience sample of 50 pediatric and adolescent pain management initial consultations, during which a clinical interview and UDT were conducted. Data were analyzed to determine adherence to an established analgesic prescription regimen, and for identification of aberrant behaviors including concurrent use of illicit substances and prescription medication misuse. Other pertinent demographic and clinical factors were examined as factors in adherence.

RESULTS

Opioid medications were prescribed for 42% of the sample receiving pain medications, and 22% of the sample was nonadherent to their prescription analgesic regimen. Factors associated with a higher likelihood of nonadherence were an older age and having an opioid prescription. The majority (90%) of those nonadherent to their analgesic regimen displayed some form of aberrant behavior. Among the nonadherent patients, 50% were identified by UDT alone, and 50% were identified by self-report during the clinical encounter.

CONCLUSIONS

These results highlight the challenges of identifying nonadherence to a prescription regimen among adolescents with chronic pain. In addition, this preliminary work suggests that UDT could be used in conjunction with careful clinical interviewing to substantiate patient report and increase the likelihood of detecting analgesic nonadherence and aberrant behaviors.

Bidirectional associations between pain and physical activity in adolescents

OBJECTIVES

The objectives were to: (1) examine temporal relationships between pain and activity in youth, specifically, whether physical activity affects pain intensity and whether intensity of pain affects subsequent physical activity levels on a daily basis, and (2) examine clinical predictors of this relationship.

METHODS

Participants were 119 adolescents (59 with chronic pain and 60 healthy) aged 12 to 18 years, 71% female. Adolescents completed 10 days of actigraphic monitoring of physical activity and daily electronic diary recordings of pain intensity, medication use, sleep quality, and mood. Linear mixed models assessed daily associations among physical activity and pain. Daily mean (average count/min) and peak (highest daily level) activity were used for analyses. Medication use, sleep quality, and mood ratings were included as covariates, and age, sex, and body mass index percentile were adjusted for.

RESULTS

Higher pain intensity was associated with lower peak physical activity levels on the next day (t641=-2.25, P=0.03) and greater medication use predicted lower mean physical activity levels the same day (t641=-2.10, P=0.04). Higher mean physical activity levels predicted lower pain intensity ratings at the end of the day (t705=-2.92, P=0.004), but only in adolescents with chronic pain.

DISCUSSION

Youth experiencing high pain intensity limit their physical activity level on a day-to-day basis. Activity was related to subsequent pain intensity, and may represent an important focus in chronic pain treatment. Further study of the effect of medications on subsequent activity is needed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Mental health disorders and long-term opioid use among adolescents and young adults with chronic pain

PURPOSE

The purpose of this study was to examine the association between mental health disorders and subsequent risk for long-term opioid use among adolescents and young adults presenting with common chronic pain complaints (back pain, neck pain, headache, and arthritis/joint pain).

METHODS

Using claims data from January 1, 2001 to June 30, 2008, we conducted a longitudinal analysis of opioid use patterns among 13-24-year-old subjects presenting with a new episode of chronic pain. Long-term opioid use was defined as receiving >90 days of opioids within a 6-month period with no gap of >30 days in use of opioids in the 18 months after the first qualifying pain diagnosis. Mental health disorders were identified from claims in the 6 months before the first qualifying pain diagnosis.

RESULTS

Fifty-nine thousand seventy-seven youth met criteria for a new episode of chronic pain. Among these youth, 321 (.5%) met criteria for long-term opioid use, and 16,172 (27.4%) had some opioid use. After controlling for demographic and clinical factors, youth with preexisting mental health diagnoses had a 2.4-fold increased risk of subsequently receiving long-term opioids versus no opioids (odds ratio = 2.36, 95% confidence interval = 1.73-3.23) and a 1.8-fold increased likelihood of receiving long-term opioids versus some opioids (odds ratio = 1.83, 95% confidence interval = 1.34-2.50).

CONCLUSIONS

Mental health disorders are associated with increased risk for long-term opioid use among adolescents and emerging young adults. Further study is warranted to examine risks and benefits of long-term opioid use in this population.