Buprenorphine for Chronic Pain Management: a Narrative Review

PURPOSE OF REVIEW

The aim of this review is to educate healthcare professionals regarding buprenorphine for the use of opioid use disorder (OUD) as well as for chronic pain management. This review provides physicians and practitioners with updated information regarding the distinct characteristics and intricacies of prescribing buprenorphine.

RECENT FINDINGS

Buprenorphine is approved by the US Food and Drug Administration (FDA) for acute pain, chronic pain, opioid use disorder (OUD), and opioid dependence. When compared to most other opioids, buprenorphine offers superior patient tolerability, an excellent half-life, and minimal respiratory depression. Buprenorphine does have notable side effects as well as pharmacokinetic properties that require special attention, especially if patients require future surgical interventions. Many physicians are not trained to initiate or manage patients on buprenorphine. However, buprenorphine offers a potentially safer alternative for medication management for patients who require chronic opioid therapy for pain or have OUD. This review provides updated information on buprenorphine for both chronic pain and OUD.

Aiding the prescriber: developing a machine learning approach to personalized risk modeling for chronic opioid therapy amongst US Army soldiers

The opioid epidemic is a major policy concern. The widespread availability of opioids, which is fueled by physician prescribing patterns, medication diversion, and the interaction with potential illicit opioid use, has been implicated as proximal cause for subsequent opioid dependence and mortality. Risk indicators related to chronic opioid therapy (COT) at the point of care may influence physicians' prescribing decisions, potentially reducing rates of dependency and abuse. In this paper, we investigate the performance of machine learning algorithms for predicting the risk of COT. Using data on over 12 million observations of active duty US Army soldiers, we apply machine learning models to predict the risk of COT in the initial months of prescription. We use the area under the curve (AUC) as an overall measure of model performance, and we focus on the positive predictive value (PPV), which reflects the models' ability to accurately target military members for intervention. Of the many models tested, AUC ranges between 0.83 and 0.87. When we focus on the top 1% of members at highest risk, we observe a PPV value of 8.4% and 20.3% for months 1 and 3, respectively. We further investigate the performance of sparse models that can be implemented in sparse data environments. We find that when the goal is to identify patients at the highest risk of chronic use, these sparse linear models achieve a performance similar to models trained on hundreds of variables. Our predictive models exhibit high accuracy and can alert prescribers to the risk of COT for the highest risk patients. Optimized sparse models identify a parsimonious set of factors to predict COT: initial supply of opioids, the supply of opioids in the month being studied, and the number of prescriptions for psychotropic medications. Future research should investigate the possible effects of these tools on prescriber behavior (e.g., the benefit of clinician nudging at the point of care in outpatient settings).

A collaborative care intervention to improve opioid prescribing among providers caring for persons with HIV: Impact on satisfaction, confidence, and trust

BACKGROUND

HIV clinicians report low confidence and satisfaction prescribing chronic opioid therapy (COT). We hypothesized that the Targeting Effective Analgesia in Clinics for HIV (TEACH) intervention [a system-level improvement to increase guideline concordant care for COT] would improve satisfaction, confidence, and trust among PWH and their clinicians.

METHODS

We conducted a two-arm, unblinded cluster randomized controlled trial (RCT) to assess the TEACH intervention. Clinicians were randomized in a 1:1 ratio to receive either the TEACH intervention (an IT-enabled nurse care manager, opioid education, academic detailing, and access to addiction specialists) or usual care. Outcomes were the following: clinician satisfaction (primary); confidence prescribing COT; patient satisfaction with COT; and trust in clinician. Intention-to-treat analyses were conducted using linear and logistic regression models.

RESULTS

Clinicians (n = 41) were randomized and their 114 patients assessed. At 12 months, the adjusted mean difference in satisfaction with COT was 1.11 points for intervention vs control clinicians (Scale 1-10; 95% confidence interval [CI]: -0.04 to 2.26, p = 0.06). The adjusted mean confidence with prescribing COT was 1.01 points higher among intervention clinicians (Scale 1-10; 95% CI: 0.05-1.96, p = 0.04). There were no significant differences in patient satisfaction with COT (adjusted odds ratio (AOR) 1.17, 95% CI: 0.50-2.76, p = 0.72) or trust in provider (AOR 1.63, 95% CI: 0.65-4.09, p = 0.30).

CONCLUSIONS

TEACH did not significantly affect prescriber satisfaction, patient satisfaction with pain management or patient trust; however, it did improve prescriber confidence. TEACH is a promising strategy to improve provider prescribing of COT for PWH without adverse patient satisfaction or trust in provider.

Chronic Opioid Therapy in Cancer Survivors at a Specialty Oncology Pain Clinic: Opioid Dosing, Efficacy, and Safety During Five Years of Pain Management

There are limited data regarding long-term safety and efficacy in cancer survivors receiving chronic opioid therapy. With conflicting recommendations on opioid-prescribing practices and lack of available outcome data, this study aimed to provide a longitudinal perspective on opioid prescribing in cancer survivors. A retrospective chart review at a comprehensive cancer care center pain clinic used data from pain clinic provider notes from 2013 to 2018. Inclusion criteria were patients in clinical remission not receiving active chemotherapy or immunotherapy and receiving opioids during the study period. Opioid dosing changes and outcomes between zero and five years were evaluated by standard statistical analysis. Thirty-two patients met inclusion criteria. Solid malignancies were more common than hematologic malignancies (72% vs. 28%). Common pain complaints were related to postsurgical changes (43%), postradiation (32%), and chemotherapy-induced pain syndromes (25%). There were no serious adverse events. One patient exhibited possible aberrant behavior. At the initial visit, the median morphine milligram equivalent per day (MME/day) was 130. Median MME/day at Year 0 (study start) and Year 5 was 135 and 159, respectively (P = 0.475). Functional status was satisfactory in 58% at Year 0 and increased to 91% of patients meeting their functional goals at Year 5. In a carefully monitored group of cancer survivors with persistent pain, chronic opioid therapy was safely managed during extended periods without significant opioid escalation or evidence of serious adverse events including aberrant behaviors. This population benefited when opioid therapy was managed with a focus on function rather than reduction of pain intensity scores.

Current status of opioid epidemic in the United Kingdom and strategies for treatment optimisation in chronic pain

The increase in opioid prescriptions in the United States has been accompanied by an increase in misuse as well as overdose and toxicity related morbidity and mortality. However, the extent of the increased opioid use, including misuse in the United Kingdom, currently remains less debated. Recent studies in the United Kingdom have shown a rise in opioid use and attributed deaths, particularly in areas with higher deprivation. There are also large variations amongst the devolved nations; Scotland has the highest drug-related deaths and year-on-year increase within Europe. Better clinical guidelines that can enable person-centred management of chronic pain, medicines optimisation, and early diagnosis and treatment of opioid use disorder are crucial to addressing opioid-related morbidity and mortality in the United Kingdom.

Chronic Opioid Therapy: A Scoping Literature Review on Evolving Clinical and Scientific Definitions

The management of chronic noncancer pain (CNCP) with chronic opioid therapy (COT) is controversial. There is a lack of consensus on how COT is defined resulting in unclear clinical guidance. This scoping review identifies and evaluates evolving COT definitions throughout the published clinical and scientific literature. Databases searched included PubMed, Embase, and Web of Science. A total of 227 studies were identified from 8,866 studies published between January 2000 and July 2019. COT definitions were classified by pain population of application and specific dosage/duration definition parameters, with results reported according to PRISMA-ScR. Approximately half of studies defined COT as "days' supply duration >90 days" and 9.3% defined as ">120 days' supply," with other days' supply cut-off points (>30, >60, or >70) each appearing in <5% of total studies. COT was defined by number of prescriptions in 63 studies, with 16.3% and 11.0% using number of initiations or refills, respectively. Few studies explicitly distinguished acute treatment and COT. Episode duration/dosage criteria was used in 90 studies, with 7.5% by Morphine Milligram Equivalents + days' supply and 32.2% by other "episode" combination definitions. COT definitions were applied in musculoskeletal CNCP (60.8%) most often, and typically in adults aged 18 to 64 (69.6%). The usage of ">90 days' supply" COT definitions increased from 3.2 publications/year before 2016 to 20.7 publications/year after 2016. An increasing proportion of studies define COT as ">90 days' supply." The most recent literature trends toward shorter duration criteria, suggesting that contemporary COT definitions are increasingly conservative. PERSPECTIVE: This study summarized the most common, current definition criteria for chronic opioid therapy (COT) and recommends adoption of consistent definition criteria to be utilized in practice and research. The most recent literature trends toward shorter duration criteria overall, suggesting that COT definition criteria are increasingly stringent.

Medicaid trends in prescription opioid and non-opioid use by HIV status

BACKGROUND

Pain is more common among people living with HIV (PLWH) than their counterparts; however, it is unclear whether analgesic use differs by HIV status.

METHODS

We analyzed Medicaid pharmacy claims from adults in 14 US states from 2001 to 2009 to identify opioid and non-opioid analgesic prescriptions and compared prescribing trends by HIV status. We accounted for clinical and demographic differences by using inverse probability weights and by restricting the sample to a subgroup with a common comorbidity, diabetes, chosen for its high prevalence and association with lifestyle and chronic pain. We estimated the incidence of chronic opioid therapy (COT) (≥90 consecutive days with an opioid prescription) among opioid-naïve individuals.

RESULTS

Rates of opioid and non-opioid use increased approximately two-fold from 2001 to 2009. PLWH received approximately twice as many prescriptions as those without HIV. In an unadjusted Cox regression, PLWH were three times more likely to receive COT compared to those without HIV (hazard ratio (HR) = 3.06, 95% CI 2.76-3.39). When restricting to patients with diabetes and adjusting for age, sex, state, comorbidity score, depression, bipolar disorder, and schizophrenia, the HR decreased to 1.26 (95% CI 0.97-1.63).

CONCLUSIONS

Higher opioid use among PLWH was largely a function of patients' demographic characteristics and health status. The high incidence of COT among PLWH underscores the importance of practice guidelines that minimize adverse events associated with opioid use.

Comparing Pain and Depressive Symptoms of Chronic Opioid Therapy Patients Receiving Dose Reduction and Risk Mitigation Initiatives With Usual Care

Dose reduction and risk mitigation initiatives have been recommended to reduce opioid-related risks among patients receiving chronic opioid therapy (COT), but questions remain over whether these initiatives worsen pain control and quality of life. In 2014 to 2015, we interviewed 1,588 adult COT patients within a health care system in Washington State and compared those who received dose reduction and risk mitigation initiatives in primary care clinics (intervention) with patients in comparable health care settings without initiatives (control). The primary outcomes were pain assessed using the pain, enjoyment, and general activity (PEG) scale, a 3-item scale to assess global pain intensity and interference, with secondary measures including depression (Patient Health Questionnaire-8 scale). Generalized estimating equations for linear regression models were used to estimate differences in mean scores between intervention and control sites. Estimated differences, adjusted for patient characteristics and weighted for nonresponse, between patients at intervention and control clinics were not clinically significant for the PEG (-.03, 95% confidence interval = -.25 to .19) or Patient Health Questionnaire-8 (-.64, 95% confidence interval = -1.19 to -.08). We found no evidence that COT patients in clinics with dose reduction and risk mitigation initiatives had clinically meaningful differences in pain intensity, interference with activities and enjoyment of life, or depressive symptoms compared with control health care settings.

PERSPECTIVE

This article evaluates the effect of dose reduction and risk mitigation initiatives, such as those recently recommended by the Centers for Disease Control and Prevention, to reduce risks associated with COT on global pain and interference, depressive symptoms, and perceived pain relief and bothersomeness of side effects.

Suicidal ideation and suicidal self-directed violence following clinician-initiated prescription opioid discontinuation among long-term opioid users

OBJECTIVE

Little is known about patient outcomes following discontinuation of opioid therapy, which may include suicidal ideation (SI) and suicidal self-directed violence (SSV). The purpose of this study was to examine correlates of SI and non-fatal SSV in a sample of patients discontinued from long-term opioid therapy (LTOT).

METHOD

Five hundred-nine Veterans Health Administration (VHA) patients whose clinicians discontinued them from LTOT were selected from a national cohort of VHA patients who discontinued opioids in 2012. The sample comprised patients with a substance use disorder and matched controls. Patient electronic health records were manually reviewed to identify discontinuation reasons and the presence of SI or SSV in the 12months following discontinuation.

RESULTS

Forty-seven patients (9.2%) had SI only, while 12 patients (2.4%) had SSV. In covariate-adjusted logistic regression models, mental health diagnoses associated with having SI/SSV included post-traumatic stress disorder (aOR=2.56, 95% CI=1.23-5.32) and psychotic disorders (aOR=3.19, 95% CI=1.14-8.89). Other medical comorbidities, substance use disorder and pain diagnoses, opioid dose, and benzodiazepine prescriptions were unrelated to SI/SSV.

CONCLUSIONS

Among patients with a substance use disorder and matched controls, there are high rates of SI/SSV following opioid discontinuation, suggesting that these "high risk" patients may require close monitoring and risk prevention.

Medication Overuse in Chronic Pain

PURPOSE OF REVIEW

Chronic pain is usually managed by various pharmacotherapies after exhausting the conservative modalities such as over-the-counter choices. The goal of this review is to investigate current state of opioids and non-opioid medication overuse that includes NSAIDs, skeletal muscle relaxants, antidepressants, membrane stabilization agents, and benzodiazepine. How to minimize medication overuse and achieve better outcome in chronic pain management?

RECENT FINDINGS

Although antidepressants and membrane stabilization agents contribute to the crucial components for neuromodulation, opioids were frequently designated as a rescue remedy in chronic pain since adjunct analgesics usually do not provide instantaneous relief. The updated CDC guideline for prescribing opioids has gained widespread attention via media exposure. Both patients and prescribers are alerted to respond to the opioid epidemic and numerous complications. However, there has been overuse of non-opioid adjunct analgesics that caused significant adverse effects in addition to concurrent opioid consumption. It is a common practice to extrapolate the WHO three-step analgesic ladder for cancer pain to apply in non-cancer pain that emphasizes solely on pharmacologic therapy which may result in overuse and escalation of opioids in non-cancer pain. There has been promising progress in non-pharmacologic therapies such as biofeedback, complementary, and alternative medicine to facilitate pain control instead of dependency on pharmacologic therapies. This review article presents the current state of medication overuse in chronic pain and proposes precaution to balance the risk and benefit ratio. It may serve as a premier for future study on clinical pathway for comprehensive chronic pain management and reduce medication overuse.

Prescription Opioid Taper Support for Outpatients With Chronic Pain: A Randomized Controlled Trial

Patients receiving long-term opioid therapy for chronic pain and interested in tapering their opioid dose were randomly assigned to a 22-week taper support intervention (psychiatric consultation, opioid dose tapering, and 18 weekly meetings with a physician assistant to explore motivation for tapering and learn pain self-management skills) or usual care (N = 35). Assessments were conducted at baseline and 22 and 34 weeks after randomization. Using an intention to treat approach, we constructed linear regression models to compare groups at each follow-up. At 22 weeks, adjusted mean daily morphine-equivalent opioid dose in the past week (primary outcome) was lower in the taper support group, but this difference was not statistically significant (adjusted mean difference = -42.9 mg; 95% confidence interval, -92.42 to 6.62; P = .09). Pain severity ratings (0-10 numeric rating scale) decreased in both groups at 22 weeks, with no significant difference between groups (adjusted mean difference = -.68; 95% confidence interval, -2.01 to .64; P = .30). The taper support group improved significantly more than the usual care group in self-reported pain interference, pain self-efficacy, and prescription opioid problems at 22 weeks (all P-values < .05). This taper support intervention is feasible and shows promise in reducing opioid dose while not increasing pain severity or interference.

PERSPECTIVE

In a pilot randomized trial comparing a prescription opioid taper support intervention to usual care, lower opioid doses and pain severity ratings were observed at 22 weeks in both groups. The groups did not differ significantly at 22 weeks in opioid dose or pain severity, but the taper support group improved significantly more in pain interference, pain self-efficacy, and perceived opioid problems. These results support the feasibility and promise of this opioid taper support intervention.

Chronic opioid therapy in long-term cancer survivors

PURPOSE

Long-term cancer survivors develop special health issues and specific needs. Chronic pain, whether the consequence of their cancer or as a side effect of treatment, is one of their most prevalent concerns.

METHODS

We conducted a review of the English-language literature on long-term cancer survivorship and chronic opioid therapy, with the objective of determining the efficacy, safety and tolerability in this group of patients. Practical management recommendations are made on the basis of this review.

RESULTS

Pain syndromes encountered in the long-term cancer survivors are diverse. Opioid receptor pathways possess complex and pleiotropic functions and continuous over-activation may lead to de novo endocrinopathies, immunosuppression, neurocognitive impairment, or cell cycle disturbances with potential clinical connotations. However, there are insufficient data to support evidence-based decision making with respect to patient selection, doses, administration, monitoring and follow-up. Data about long-term treatment effectiveness and safety are limited and often aggravated by the overlapping of several diseases prevalent among long-term cancer survivors, as well as chronic opiate-induced toxicity.

CONCLUSIONS

Chronic opioid therapy is frequent in long-term cancer survivors, and may negatively affect the immune system, and produce health problems such as endocrinopathies, osteoporosis, neurological or cardiopulmonary effects, alterations of cell cycle kinetics, abuse and addiction. This review highlights the need for specialized teams to treat chronic pain in long-term cancer survivors from an integrative perspective.

Exploring the Use of Chronic Opioid Therapy for Chronic Pain: When, How, and for Whom?

This article provides a broad overview regarding intent to initiate and consider ongoing chronic opioid therapy (COT) for treatment of chronic noncancer pain (CNCP). COT should be an individualized decision based on a comprehensive evaluation, assessment, and monitoring. It is imperative that providers discuss various risks and benefits of COT initially and at follow-up visits, and continue appropriate monitoring and follow-up at regular intervals. The decision to initiate or continue opioid therapy is based on clinical judgment; however, it is understood that opioid and other medication therapy represent one piece of the complete treatment plan for patients with CNCP.

Automated prediction of risk for problem opioid use in a primary care setting

Identification of patients at increased risk for problem opioid use is recommended by chronic opioid therapy (COT) guidelines, but clinical assessment of risks often does not occur on a timely basis. This research assessed whether structured electronic health record (EHR) data could accurately predict subsequent problem opioid use. This research was conducted among 2,752 chronic noncancer pain patients initiating COT (≥70 days' supply of an opioid in a calendar quarter) during 2008 to 2010. Patients were followed through the end of 2012 or until disenrollment from the health plan, whichever was earlier. Baseline risk indicators were derived from structured EHR data for a 2-year period prior to COT initiation. Problem opioid use after COT initiation was assessed by reviewing clinician-documented problem opioid use in EHR clinical notes identified using natural language processing techniques followed by computer-assisted manual review of natural language processing-positive clinical notes. Multivariate analyses in learning and validation samples assessed prediction of subsequent problem opioid use. The area under the receiver operating characteristic curve (c-statistic) for problem opioid use was .739 (95% confidence interval = .688, .790) in the validation sample. A measure of problem opioid use derived from a simple weighted count of risk indicators was found to be comparably predictive of the natural language processing measure of problem opioid use, with 60% sensitivity and 72% specificity for a weighted count of ≥4 risk indicators.

PERSPECTIVE

An automated surveillance method utilizing baseline risk indicators from structured EHR data was moderately accurate in identifying COT patients who had subsequent problem opioid use.

Doctors and patients in pain: Conflict and collaboration in opioid prescription in primary care

Use of chronic opioid therapy (COT) for chronic noncancer pain has dramatically increased in the United States. Patients seek compassionate care and relief while physicians struggle to manage patients' pain effectively without doing harm. This study explores the narratives of chronic noncancer pain patients receiving chronic opioid therapy and those of their physicians to better understand the effects of COT on the doctor-patient relationship. A mixed method study was conducted that included in-depth interviews and qualitative analysis of 21 paired patients with chronic pain and their physicians in the following groups: patients, physicians, and patient-physician pairs. Findings revealed that patients' narratives focus on suffering from chronic pain, with emphasis on the role of opioid therapy for pain relief, and physicians' narratives describe the challenges of treating patients with chronic pain on COT. Results elucidate the perceptions of ideal vs difficult patients and show that divergent patterns surrounding the consequences, utility, and goals of COT can negatively affect the doctor-patient relationship. The use of paired interviews through a narrative lens in this exploratory study offers a novel and informative approach for clinical practice and research. The findings have significant implications for improving doctor-patient communication and health outcomes by encouraging shared decision making and goal-directed health care encounters for physicians and patients with chronic pain on COT.

PERSPECTIVE

This study found patterns of understanding pain, opioid pain medications, and the doctor-patient relationship for patients with chronic pain and their physicians using a narrative lens. Thematic findings in this exploratory study, which include a portrayal of collaborative vs conflictual relationships, suggest areas of future intervention and investigation.