Chronic overlapping pain conditions and long-term opioid treatment

OBJECTIVES

One in 5 people in the United States lives with chronic pain. Many patients with chronic pain experience a subset of specific co-occurring pain conditions that may share a common pain mechanism and that have been designated as chronic overlapping pain conditions (COPCs). Little is known about chronic opioid prescribing patterns among patients with COPCs in primary care settings, especially among socioeconomically vulnerable patients. This study aims to evaluate opioid prescribing among patients with COPCs in US community health centers and to identify individual COPCs and their combinations that are associated with long-term opioid treatment (LOT).

STUDY DESIGN

Retrospective cohort study.

METHODS

We conducted analyses of more than 1 million patients 18 years and older based on electronic health record data from 449 US community health centers across 17 states between January 1, 2009, and December 31, 2018. Logistic regression models were used to assess the relationship between COPCs and LOT.

RESULTS

Individuals with COPCs were prescribed LOT 4 times more often than individuals without a COPC (16.9% vs 4.0%). The presence of chronic low back pain, migraine headache, fibromyalgia, or irritable bowel syndrome combined with any of the other COPCs increased the odds of LOT prescribing compared with the presence of a single COPC.

CONCLUSIONS

Although LOT prescribing has declined over time, it remains relatively high among patients with certain COPCs and for those with multiple COPCs. These study findings suggest target populations for future interventions to manage chronic pain among socioeconomically vulnerable patients.

Sedative-hypnotic Co-prescribing with Opioids in a Large Network of Community Health Centers

OBJECTIVE

When prescribed with opioids, sedative-hypnotics substantially increase the risk of overdose. The objective of this paper was to describe characteristics and trends in opioid sedative-hypnotic co-prescribing in a network of safety-net clinics serving low-income, publicly insured, and uninsured individuals.

METHODS

This retrospective longitudinal analysis of prescription orders examined opioid sedative-hypnotic co-prescribing rates between 2009 and 2018 in the OCHIN network of safety-net community health centers. Sedative-hypnotics included benzodiazepine and non-benzodiazepine sedatives (eg, zolpidem). Co-prescribing patterns were assessed overall and across patient demographic and co-morbidity characteristics.

RESULTS

From 2009 to 2018, 240 587 patients had ≥1 opioid prescriptions. Most were White (65%), female (59%), and had Medicaid insurance (43%). One in 4 were chronic opioid users (25%). During this period, 55 332 (23%) were co-prescribed a sedative-hypnotic. The prevalence of co-prescribing was highest for females (26% vs 19% for males), non-Hispanic Whites (28% vs 13% for Hispanic to 20% for unknown), those over 44 years of age (25% vs 20% for <44 years), Medicare insurance (30% vs 21% for uninsured to 22% for other/unknown), and among those on chronic opioid therapy (40%). Co-prescribing peaked in 2010 (32%) and declined steadily through 2018 (20%). Trends were similar across demographic subgroups. Co-prescribed sedative-hypnotics remained elevated for those with chronic opioid use (27%), non-Hispanic Whites (24%), females (23%), and those with Medicare (23%) or commercial insurance (22%).

CONCLUSIONS

Co-prescribed sedative-hypnotic use has declined steadily since 2010 across all demographic subgroups in the OCHIN population. Concurrent use remains elevated in several population subgroups.

Impact of the Affordable Care Act Medicaid Expansion on Weight Loss among Community Health Center Patients with Obesity

Context: Obesity affects over 40% of the US population and is linked to multiple preventable health conditions which can cause premature morbidity and mortality. Weight loss of at least 5% in patients with obesity reduces their risk of comorbid conditions and leads to improvement in some conditions, such as diabetes. Patients with obesity from underserved populations are less likely to access primary and preventive care services. The Affordable Care Act (ACA) improved access to care, which may in turn improve access to obesity prevention and treatment and assist with weight loss. Objective: Assess whether the proportion of patients with a weight loss ≥5% was higher in states that expanded Medicaid relative to non-expansion states among patients with obesity receiving care in community health centers (CHCs) which provide health care to underserved patients. Study Design: Retrospective observational cohort study. Setting: Electronic health record data from the ADVANCE (Advancing Data Value Across a National Community Health Center) clinical research network, during years 2012-2017. Population Studied: Patients from 346 CHCs age 19-64 with a body mass index of ≥ 30 kg/m2 during the pre-ACA period (n=34,027). Outcome measures: Proportion of patients with weight loss >5% (WL5+) from pre- to post-ACA. Medicaid expansion status (expansion vs. non-expansion states) stratified by pattern of insurance (uninsured, continuously insured, newly insured, discontinuously insured) and race and ethnicity. Results: The proportion of patients with WL5+ for newly insured patients was greater in expansion (26%) than non-expansion states (20%) (χ2=9.75, p=0.002). Among newly insured patients, Hispanic (22%) and Black (29%) patients residing in expansion states, had larger proportion of patients with WL5+ than those in non-expansion states (20% and 18%, respectively). No differences were observed among non-Hispanic White patients (expansion 28% vs non-expansion 27%). Conclusions: The findings suggest greater improvement in weight management among patients residing in expansion states than those in non-expansion states, especially among racial and ethnic minorities receiving care in CHCs.

Characterizing acute and chronic complications among patients with diabetes mellitus in community health centers

Context: Diabetes mellitus affects about 10% of the world's population and can lead to serious complications, which reduce life quality and expectancy. People with low income have higher risk of diabetes complications than those with high income, but data on the trends of diabetes complications in underserved populations are scarce. Community health centers (CHCs) serve millions of patients in the United States regardless of their health insurance status and are an ideal setting for assessing the rate of diabetes complications in underserved populations. Objectives: To describe diabetes-related acute and chronic complications among patients served by CHCs. Study Design: Retrospective cohort study of electronic health record data from the ADVANCE clinical research network. Population studied: Patients with diabetes between ages 19 and 64 (excluding pregnant women) and ≥1 primary care ambulatory CHC visit in 2017 (N=85,442). Outcome Measures: Rates and type of diabetes-related acute and chronic complications recorded in 2017. Results: The incidence of acute complications among patients with diabetes in 2017 was 14%. Patients experiencing acute diabetes-related complications had on average 1.8 complications (range 1-33). The most common acute complications were infections (58.3%), abnormal blood glucose or related metabolic abnormalities (20.5%), and strokes or transient neurological deficits (6.8%). Patients with acute complications were proportionally more likely to be female, non-Hispanic white, have Medicaid insurance, out-of-control diabetes, a prescription for insulin, a diagnosis of substance use disorder, and co-occurring physical or mental conditions. For chronic complications, the prevalence in 2017 was 77% among patients with diabetes. Patients experiencing chronic diabetes-related complications had on average 2.3 complications (range 1-19). The most common chronic complications were cardiovascular disease (33.9%), endocrine/metabolic symptoms (22.8%), and neurological symptoms (13.0%). Patients with chronic complications were proportionally more likely to be male, non-Hispanic black, have health insurance, obesity, substance use disorder, longer period with diabetes diagnosis, and co-occurring conditions. Conclusions: The vast majority of patients with diabetes receiving care in CHCs had chronic complications. These findings are concerning, as diabetes-related complications are associated with greater healthcare utilization and patient morbidity.

Characterizations of Opioid Prescribing in Community Health Centers in 2018

Objective:

To identify the patient- and clinic-level correlates of any prescription opioid use, chronic use, and high-dose opioid use in a multi-state network of Community Health Centers (CHCs).

Methods:

We used electronic health record data from 337 primary care clinics serving 610 983 patients across 15 states in 2018. The primary outcomes were prescription of any opioid, chronic opioid, and high-dose opioid.

Results:

Overall, 6.5% of patients were prescribed an opioid; of these, 31% were chronic users and 5% were high-dose users. Males had 5% lower odds (Odds Ratio [OR] = 0.95; 95% Confidence Interval = 0.93-0.97) of being prescribed an opioid but 16% higher odds (OR = 1.16; 95% CI = 1.10-1.21) of being chronic users and 48% (OR = 1.48; 95% CI = 1.36-1.64) higher odds of being high-dose users than females. Rural clinics had higher rates of chronic opioid (rate ratio = 1.86; 95% CI = 1.20, 2.88) and high-dose users (rate ratio = 2.95; 95% CI = 1.81-4.81).

Conclusions:

Our study highlights variations in opioid prescribing with regard to patient-level and clinic-level factors. Targeted efforts and resources may be required to support rural CHCs who seek to reduce high-risk opioid prescribing.

Assessment of Opioid Prescribing Patterns in a Large Network of US Community Health Centers, 2009 to 2018

IMPORTANCE

Understanding opioid prescribing patterns in community health centers (CHCs) that disproportionately serve low-income patients may help to guide strategies to reduce opioid-related harms.

OBJECTIVE

To assess opioid prescribing patterns between January 1, 2009, and December 31, 2018, in a network of safety-net clinics serving high-risk patients.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of 3 227 459 opioid prescriptions abstracted from the electronic health records of 2 129 097 unique primary care patients treated from 2009 through 2018 at a network of CHCs that included 449 clinic sites in 17 states. All age groups were included in the analysis.

MAIN OUTCOMES AND MEASURES

The following measures were described at the population level for each study year: (1) percentage of patients with at least 1 prescription for an opioid by age and sex, (2) number of opioid prescriptions per 100 patients, (3) number of long-acting opioid prescriptions per 100 patients, (4) mean annual morphine milligram equivalents (MMEs) per patient, (5) mean MME per prescription, (6) number of chronic opioid users, and (7) mean of high-dose opioid users.

RESULTS

The study population included 2 129 097 patients (1 158 413 women [54.4%]) with a mean (SD) age of 32.2 (21.1) years and a total of 3 227 459 opioid prescriptions. The percentage of patients receiving at least 1 opioid prescription in a calendar year declined 67.4% from 15.9% in 2009 to 5.2% in 2018. Over the 10-year study period, a greater percentage of women received a prescription (13.1%) compared with men (10.9%), and a greater percentage of non-Hispanic White patients (18.1%) received an opioid prescription compared with non-Hispanic Black patients (9.5%), non-Hispanic patients who self-identified as other races (8.0%), and Hispanic patients (6.9%). The number of opioid prescriptions for every 100 patients decreased 73.7% from 110.8 in 2009 to 29.1 in 2018. The number of long-acting opioids for every 100 patients decreased 85.5% during the same period, from 22.0 to 3.2. The MMEs per patient decreased from 1682.7 in 2009 to 243.1 in 2018, a decline of 85.6%.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, the opioid prescribing rate in 2009 in the CHC network was higher than national population estimates but began to decline earlier and more precipitously. This finding likely reflects harm mitigation policies and efforts at federal, state, and clinic levels and strong clinical quality improvement strategies within the CHCs.

Hypnosis Intervention Effects on Sleep Outcomes: A Systematic Review

STUDY OBJECTIVES

Sleep improvement is a promising target for preventing and modifying many health problems. Hypnosis is considered a cost-effective and safe intervention with reported benefits for multiple health conditions. There is a growing body of research assessing the efficacy of hypnosis for various health conditions in which sleep was targeted as a primary or secondary outcome. This review aimed to investigate the effects of hypnosis interventions on sleep, to describe the hypnotic procedures, and to evaluate potential adverse effects of hypnosis.

METHODS

We reviewed studies (prior to January 2017) using hypnosis in adults for sleep problems and other conditions comorbid with sleep problems, with at least one sleep outcome measure. Randomized controlled trials and other prospective studies were included.

RESULTS

One hundred thirty-nine nonduplicate abstracts were screened, and 24 of the reviewed papers were included for qualitative analysis. Overall, 58.3% of the included studies reported hypnosis benefit on sleep outcomes, with 12.5% reporting mixed results, and 29.2% reporting no hypnosis benefit; when only studies with lower risk of bias were reviewed the patterns were similar. Hypnosis intervention procedures were summarized and incidence of adverse experiences assessed.

CONCLUSIONS

Hypnosis for sleep problems is a promising treatment that merits further investigation. Available evidence suggests low incidence of adverse events. The current evidence is limited because of few studies assessing populations with sleep complaints, small samples, and low methodological quality of the included studies. Our review points out some beneficial hypnosis effects on sleep but more high-quality studies on this topic are warranted.

Aroma Effects on Physiologic and Cognitive Function Following Acute Stress: A Mechanism Investigation

OBJECTIVE

Aromas may improve physiologic and cognitive function after stress, but associated mechanisms remain unknown. This study evaluated the effects of lavender aroma, which is commonly used for stress reduction, on physiologic and cognitive functions. The contribution of pharmacologic, hedonic, and expectancy-related mechanisms of the aromatherapy effects was evaluated.

METHODS

Ninety-two healthy adults (mean age, 58.0 years; 79.3% women) were randomly assigned to three aroma groups (lavender, perceptible placebo [coconut], and nonperceptible placebo [water] and to two prime subgroups (primed, with a suggestion of inhaling a powerful stress-reducing aroma, or no prime). Participants' performance on a battery of cognitive tests, physiologic responses, and subjective stress were evaluated at baseline and after exposure to a stress battery during which aromatherapy was present. Participants also rated the intensity and pleasantness of their assigned aroma.

RESULTS

Pharmacologic effects of lavender but not placebo aromas significantly benefited post-stress performance on the working memory task (F(2, 86) = 5.41; p = 0.006). Increased expectancy due to positive prime, regardless of aroma type, facilitated post-stress performance on the processing speed task (F(1, 87) = 8.31; p = 0.005). Aroma hedonics (pleasantness and intensity) played a role in the beneficial lavender effect on working memory and physiologic function.

CONCLUSIONS

The observable aroma effects were produced by a combination of mechanisms involving aroma-specific pharmacologic properties, aroma hedonic properties, and participant expectations. In the future, each of these mechanisms could be manipulated to produce optimal functioning.

A systems approach to stress, stressors and resilience in humans

The paper focuses on the biology of stress and resilience and their biomarkers in humans from the system science perspective. A stressor pushes the physiological system away from its baseline state toward a lower utility state. The physiological system may return toward the original state in one attractor basin but may be shifted to a state in another, lower utility attractor basin. While some physiological changes induced by stressors may benefit health, there is often a chronic wear and tear cost due to implementing changes to enable the return of the system to its baseline state and maintain itself in the high utility baseline attractor basin following repeated perturbations. This cost, also called allostatic load, is the utility reduction associated with both a change in state and with alterations in the attractor basin that affect system responses following future perturbations. This added cost can increase the time course of the return to baseline or the likelihood of moving into a different attractor basin following a perturbation. Opposite to this is the system's resilience which influences its ability to return to the high utility attractor basin following a perturbation by increasing the likelihood and/or speed of returning to the baseline state following a stressor. This review paper is a qualitative systematic review; it covers areas most relevant for moving the stress and resilience field forward from a more quantitative and neuroscientific perspective.