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Gold LS, Heagerty PJ, Hansen RN, Friedly JL, Johnston SK, Deyo RA, Curatolo M, Turner JA, Rundell SD, Wysham K, Jarvik JG, Suri P. Mortality with concurrent treatment with gabapentin and opioids among people with spine diagnoses in the U.S. Medicare population: a propensity-matched cohort study. medRxiv 2024:2024.04.26.24306460. [PMID: 38746254 PMCID: PMC11092734 DOI: 10.1101/2024.04.26.24306460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
IMPORTANCE Given the negative impact of opioid use on population health, prescriptions for alternative pain-relieving medications, including gabapentin, have increased. Concurrent gabapentin and opioid prescriptions are commonly reported in retrospective studies of opioid-related overdose deaths. OBJECTIVE To determine whether people who filled gabapentin and opioid prescriptions concurrently ('gabapentin + opioids') had greater mortality than those who filled an active control medication (tricyclic antidepressants [TCAs] or duloxetine) and opioids concurrently ('TCAs/duloxetine + opioids'). We hypothesized that people treated with gabapentin + opioids would have higher mortality rates compared to people treated with TCAs/duloxetine + opioids. DESIGN Propensity score-matched cohort study with an incident user, active control design. The median (maximum) follow-up was 45 (1093) days. SETTING Population-based. PARTICIPANTS Medicare beneficiaries with spine-related diagnoses 2017-2019. The primary analysis included those who concurrently (within 30 days) filled at least 1 incident gabapentin + at least 1 opioid or at least 1 incident TCA/duloxetine + at least 1 opioid. EXPOSURES People treated with gabapentin + opioids (n=67,133) were matched on demographic and clinical factors in a 1:1 ratio to people treated with TCAs/duloxetine + opioids (n=67,133). MAIN OUTCOMES AND MEASURES The primary outcome was mortality at any time. A secondary outcome was occurrence of a major medical complication at any time. RESULTS Among 134,266 participants (median age 73.4 years; 66.7% female), 2360 died before the end of follow-up. No difference in mortality was observed between groups (adjusted hazard ratio (HR) and 95% confidence interval (CI) for gabapentin + opioids was 0.98 (0.90, 1.06); p=0.63). However, people treated with gabapentin + opioids were at slightly increased risk of a major medical complication (1.02 (1.00, 1.04); p=0.03) compared to those treated with TCAs/duloxetine + opioids. Results were similar in analyses (a) restricted to less than or = 30-day follow-up and (b) that required at least 2 fills of each prescription. CONCLUSIONS AND RELEVANCE When treating pain in older adults taking opioids, the addition of gabapentin did not increase mortality risk relative to addition of TCAs or duloxetine. However, providers should be cognizant of a small increased risk of major medical complications among opioid users initiating gabapentin compared to those initiating TCAs or duloxetine.
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Deyo RA. Family reflections- One's perspective makes all the difference in the world. Pediatr Res 2023; 94:1856-1858. [PMID: 37550490 DOI: 10.1038/s41390-023-02745-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 07/07/2023] [Indexed: 08/09/2023]
Affiliation(s)
- Richard A Deyo
- Financial Consultant, Member Financial Services Institute, Planned Giving Consultant Pediatric Retina Research Foundation, Kokomo, IN, USA.
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3
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Gold LS, Cody RF, Tan WK, Marcum ZA, Meier EN, Sherman KJ, James KT, Griffith B, Avins AL, Kallmes DF, Suri P, Friedly JL, Heagerty PJ, Deyo RA, Luetmer PH, Rundell SD, Haynor DR, Jarvik JG. Osteoporosis identification among previously undiagnosed individuals with vertebral fractures. Osteoporos Int 2022; 33:1925-1935. [PMID: 35654855 PMCID: PMC10120403 DOI: 10.1007/s00198-022-06450-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 05/22/2022] [Indexed: 11/28/2022]
Abstract
UNLABELLED Because osteoporosis is under-recognized in patients with vertebral fractures, we evaluated characteristics associated with osteoporosis identification. Most patients with vertebral fractures did not receive evaluation or treatment for osteoporosis. Black, younger, and male participants were particularly unlikely to have had recognized osteoporosis, which could increase their risk of negative outcomes. INTRODUCTION Vertebral fractures may be identified on imaging but fail to prompt evaluation for osteoporosis. Our objective was to evaluate characteristics associated with clinical osteoporosis recognition in patients who had vertebral fractures detected on their thoracolumbar spine imaging reports. METHODS We prospectively identified individuals who received imaging of the lower spine at primary care clinics in 4 large healthcare systems who were eligible for osteoporosis screening and lacked indications of osteoporosis diagnoses or treatments in the prior year. We evaluated characteristics of participants with identified vertebral fractures that were associated with recognition of osteoporosis (diagnosis code in the health record; receipt of bone mineral density scans; and/or prescriptions for anti-osteoporotic medications). We used mixed models to estimate adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs). RESULTS A total of 114,005 participants (47% female; mean age 65 (interquartile range: 57-72) years) were evaluated. Of the 8579 (7%) participants with vertebral fractures identified, 3784 (44%) had recognition of osteoporosis within the subsequent year. In adjusted regressions, Black participants (OR (95% CI): 0.74 (0.57, 0.97)), younger participants (age 50-60: 0.48 (0.42, 0.54); age 61-64: 0.70 (0.60, 0.81)), and males (0.39 (0.35, 0.43)) were less likely to have recognized osteoporosis compared to white participants, adults aged 65 + years, or females. CONCLUSION Individuals with identified vertebral fractures commonly did not have recognition of osteoporosis within a year, particularly those who were younger, Black, or male. Providers and healthcare systems should consider efforts to improve evaluation of osteoporosis in patients with vertebral fractures.
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Affiliation(s)
- L S Gold
- Department of Radiology, School of Medicine, University of Washington, 4333 Brooklyn Ave NE Box 359558, Seattle, WA, 98195-9558, USA.
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, WA, USA.
| | - R F Cody
- Department of Radiology, School of Medicine, University of Washington, 4333 Brooklyn Ave NE Box 359558, Seattle, WA, 98195-9558, USA
| | - W K Tan
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, WA, USA
- Department of Biostatistics, University of Washington, Seattle, WA, USA
- Flatiron Health, Inc, New York, NY, USA
| | - Z A Marcum
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA, USA
| | - E N Meier
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - K J Sherman
- Kaiser Permanente Washington, Seattle, WA, USA
| | - K T James
- Department of Radiology, School of Medicine, University of Washington, 4333 Brooklyn Ave NE Box 359558, Seattle, WA, 98195-9558, USA
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, WA, USA
| | - B Griffith
- Department of Radiology, Henry Ford Hospital, Detroit, MI, USA
| | - A L Avins
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - D F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - P Suri
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, WA, USA
- Rehabilitation Care Services, VA Puget Sound Health Care System, Seattle, WA, USA
| | - J L Friedly
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, WA, USA
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - P J Heagerty
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, WA, USA
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - R A Deyo
- Departments of Family Medicine and Internal Medicine, Oregon Health & Science University, Portland, OR, USA
| | - P H Luetmer
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - S D Rundell
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, WA, USA
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - D R Haynor
- Department of Radiology, School of Medicine, University of Washington, 4333 Brooklyn Ave NE Box 359558, Seattle, WA, 98195-9558, USA
| | - J G Jarvik
- Department of Radiology, School of Medicine, University of Washington, 4333 Brooklyn Ave NE Box 359558, Seattle, WA, 98195-9558, USA
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, WA, USA
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Smith DH, O'Keeffe-Rosetti M, Leo MC, Mayhew M, Benes L, Bonifay A, Deyo RA, Elder CR, Keefe FJ, McMullen C, Owen-Smith A, Trinacty CM, Vollmer WM, DeBar L. Economic Evaluation: A Randomized Pragmatic Trial of a Primary Care-based Cognitive Behavioral Intervention for Adults Receiving Long-term Opioids for Chronic Pain. Med Care 2022; 60:423-431. [PMID: 35352703 PMCID: PMC9106895 DOI: 10.1097/mlr.0000000000001713] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Chronic pain is prevalent and costly; cost-effective nonpharmacological approaches that reduce pain and improve patient functioning are needed. OBJECTIVE Report the incremental cost-effectiveness ratio (ICER), compared with usual care, of cognitive behavioral therapy aimed at improving functioning and pain among patients with chronic pain on long-term opioid treatment. DESIGN Economic evaluation conducted alongside a pragmatic cluster randomized trial. SUBJECTS Adults with chronic pain on long-term opioid treatment (N=814). INTERVENTION A cognitive behavioral therapy intervention teaching pain self-management skills in 12 weekly, 90-minute groups delivered by an interdisciplinary team (behaviorists, nurses) with additional support from physical therapists, and pharmacists. OUTCOME MEASURES Cost per quality adjusted life year (QALY) gained, and cost per additional responder (≥30% improvement on standard scale assessment of Pain, Enjoyment, General Activity, and Sleep). Costs were estimated as-delivered, and replication. RESULTS Per patient intervention replication costs were $2145 ($2574 as-delivered). Those costs were completely offset by lower medical care costs; inclusive of the intervention, total medical care over follow-up was $1841 lower for intervention patients. Intervention group patients also had greater QALY and responder gains than did controls. Supplemental analyses using pain-related medical care costs revealed ICERs of $35,000, and $53,000 per QALY (for replication, and as-delivered intervention costs, respectively); the ICER when excluding patients with outlier follow-up costs was $106,000. LIMITATIONS Limited to 1-year follow-up; identification of pain-related utilization potentially incomplete. CONCLUSION The intervention was the optimal choice at commonly accepted levels of willingness-to-pay for QALY gains; this finding was robust to sensitivity analyses.
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Affiliation(s)
- David H. Smith
- Kaiser Permanente Center for Health Research, Portland
OR
| | | | - Michael C. Leo
- Kaiser Permanente Center for Health Research, Portland
OR
| | - Meghan Mayhew
- Kaiser Permanente Center for Health Research, Portland
OR
| | - Lindsay Benes
- Kaiser Permanente Center for Health Research, Portland
OR
- Montana State University College of Nursing, Missoula,
MT
| | | | - Richard A. Deyo
- Oregon Health and Science University, School of Medicine,
Portland, OR
| | | | | | | | - Ashli Owen-Smith
- Georgia State University, School of Public Health, Atlanta
GA
- Kaiser Permanente Center for Clinical and Outcomes
Research, Atlanta GA
| | | | | | - Lynn DeBar
- Kaiser Permanente Washington Health Research Institute,
Seattle WA
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5
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Curatolo M, Rundell SD, Gold LS, Suri P, Friedly JL, Nedeljkovic SS, Deyo RA, Turner JA, Bresnahan BW, Avins AL, Kessler L, Heagerty PJ, Jarvik JG. Long-term effectiveness of epidural steroid injections after new episodes of low back pain in older adults. Eur J Pain 2022; 26:1469-1480. [PMID: 35604636 PMCID: PMC9296573 DOI: 10.1002/ejp.1975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 04/21/2022] [Accepted: 05/14/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND There is limited research on the long-term effectiveness of epidural steroid injections (ESI) in older adults despite the high prevalence of back and leg pain in this age group. We tested the hypotheses that older adults undergoing ESI, compared to patients not receiving ESI: 1) have worse pain, disability and quality of life ("outcomes") pre-ESI, 2) have improved outcomes after ESI, and 3) have improved outcomes due to a specific ESI effect. METHODS We prospectively studied patients ≥65 years old presenting to primary care with new episodes of back pain in three US healthcare systems (BOLD registry). Outcomes were leg and back pain intensity, disability and quality of life, assessed at baseline and 3-, 6-, 12- and 24-month follow-ups. We categorized participants as: 1) ESI within 6 months from the index visit (n=295); 2) no ESI within 6 months (n=4,809); 3) no ESI within 6 months, propensity-score matched to group 1 (n=483). We analyzed the data using linear regression and Generalized Estimating Equations. RESULTS Pain intensity, disability and quality of life at baseline were significantly worse at baseline in ESI patients (group 1) than in group 2. The improvement from baseline to 24 months in all outcomes was statistically significant for group 1. However, no statistically significant differences were observed between outcome trajectories for the propensity-score matched groups 1 and 3. CONCLUSIONS Older adults treated with ESI have long-term improvement. However, the improvement is unlikely the result of a specific ESI effect.
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Affiliation(s)
- M Curatolo
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA.,The University of Washington Clinical Learning, , Evidence and Research (CLEAR) Center for Musculoskeletal Disorders
| | - S D Rundell
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA.,Department of Neurological Surgery, University of Washington, Seattle, WA.,The University of Washington Clinical Learning, , Evidence and Research (CLEAR) Center for Musculoskeletal Disorders
| | - L S Gold
- Department of Radiology, University of Washington, Seattle, WA.,The University of Washington Clinical Learning, , Evidence and Research (CLEAR) Center for Musculoskeletal Disorders
| | - P Suri
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA.,The University of Washington Clinical Learning, , Evidence and Research (CLEAR) Center for Musculoskeletal Disorders
| | - J L Friedly
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA.,The University of Washington Clinical Learning, , Evidence and Research (CLEAR) Center for Musculoskeletal Disorders
| | - S S Nedeljkovic
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, and Spine Unit, Harvard Vanguard Medical Associates, Boston, MA
| | - R A Deyo
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA.,The University of Washington Clinical Learning, , Evidence and Research (CLEAR) Center for Musculoskeletal Disorders
| | - J A Turner
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA.,The University of Washington Clinical Learning, , Evidence and Research (CLEAR) Center for Musculoskeletal Disorders
| | - B W Bresnahan
- Department of Radiology, University of Washington, Seattle, WA.,The University of Washington Clinical Learning, , Evidence and Research (CLEAR) Center for Musculoskeletal Disorders
| | - A L Avins
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - L Kessler
- Department of Health Systems and Population Health, University of Washington, Seattle, WA.,The University of Washington Clinical Learning, , Evidence and Research (CLEAR) Center for Musculoskeletal Disorders
| | - P J Heagerty
- Department of Family Medicine, Oregon Health and Science University, Portland, OR.,The University of Washington Clinical Learning, , Evidence and Research (CLEAR) Center for Musculoskeletal Disorders
| | - J G Jarvik
- Department of Radiology, University of Washington, Seattle, WA.,Department of Neurological Surgery, University of Washington, Seattle, WA.,The University of Washington Clinical Learning, , Evidence and Research (CLEAR) Center for Musculoskeletal Disorders
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6
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DeBar L, Mayhew M, Benes L, Bonifay A, Deyo RA, Elder CR, Keefe FJ, Leo MC, McMullen C, Owen-Smith A, Smith DH, Trinacty CM, Vollmer WM. A Primary Care-Based Cognitive Behavioral Therapy Intervention for Long-Term Opioid Users With Chronic Pain : A Randomized Pragmatic Trial. Ann Intern Med 2022; 175:46-55. [PMID: 34724405 PMCID: PMC9802183 DOI: 10.7326/m21-1436] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Chronic pain is common, disabling, and costly. Few clinical trials have examined cognitive behavioral therapy (CBT) interventions embedded in primary care settings to improve chronic pain among those receiving long-term opioid therapy. OBJECTIVE To determine the effectiveness of a group-based CBT intervention for chronic pain. DESIGN Pragmatic, cluster randomized controlled trial. (ClinicalTrials.gov: NCT02113592). SETTING Kaiser Permanente health care systems in Georgia, Hawaii, and the Northwest. PARTICIPANTS Adults (aged ≥18 years) with mixed chronic pain conditions receiving long-term opioid therapy. INTERVENTION A CBT intervention teaching pain self-management skills in 12 weekly, 90-minute groups delivered by an interdisciplinary team (behaviorist, nurse, physical therapist, and pharmacist) versus usual care. MEASUREMENTS Self-reported pain impact (primary outcome, as measured by the PEGS scale [pain intensity and interference with enjoyment of life, general activity, and sleep]) was assessed quarterly over 12 months. Pain-related disability, satisfaction with care, and opioid and benzodiazepine use based on electronic health care data were secondary outcomes. RESULTS A total of 850 patients participated, representing 106 clusters of primary care providers (mean age, 60.3 years; 67.4% women); 816 (96.0%) completed follow-up assessments. Intervention patients sustained larger reductions on all self-reported outcomes from baseline to 12-month follow-up; the change in PEGS score was -0.434 point (95% CI, -0.690 to -0.178 point) for pain impact, and the change in pain-related disability was -0.060 point (CI, -0.084 to -0.035 point). At 6 months, intervention patients reported higher satisfaction with primary care (difference, 0.230 point [CI, 0.053 to 0.406 point]) and pain services (difference, 0.336 point [CI, 0.129 to 0.543 point]). Benzodiazepine use decreased more in the intervention group (absolute risk difference, -0.055 [CI, -0.099 to -0.011]), but opioid use did not differ significantly between groups. LIMITATION The inclusion of only patients with insurance in large integrated health care systems limited generalizability, and the clinical effect of change in scores is unclear. CONCLUSION Primary care-based CBT, using frontline clinicians, produced modest but sustained reductions in measures of pain and pain-related disability compared with usual care but did not reduce use of opioid medication. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Lynn DeBar
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington (L.D.)
| | - Meghan Mayhew
- Kaiser Permanente Center for Health Research, Portland, Oregon (M.M., A.B., C.R.E., M.C.L., C.M., D.H.S., W.M.V.)
| | - Lindsay Benes
- Kaiser Permanente Center for Health Research, Portland, Oregon, and Montana State University College of Nursing, Missoula, Montana (L.B.)
| | - Allison Bonifay
- Kaiser Permanente Center for Health Research, Portland, Oregon (M.M., A.B., C.R.E., M.C.L., C.M., D.H.S., W.M.V.)
| | - Richard A Deyo
- Oregon Health & Science University School of Medicine, Portland, Oregon (R.A.D.)
| | - Charles R Elder
- Kaiser Permanente Center for Health Research, Portland, Oregon (M.M., A.B., C.R.E., M.C.L., C.M., D.H.S., W.M.V.)
| | - Francis J Keefe
- Duke University School of Medicine, Durham, North Carolina (F.J.K.)
| | - Michael C Leo
- Kaiser Permanente Center for Health Research, Portland, Oregon (M.M., A.B., C.R.E., M.C.L., C.M., D.H.S., W.M.V.)
| | - Carmit McMullen
- Kaiser Permanente Center for Health Research, Portland, Oregon (M.M., A.B., C.R.E., M.C.L., C.M., D.H.S., W.M.V.)
| | - Ashli Owen-Smith
- Georgia State University School of Public Health and Kaiser Permanente Center for Clinical and Outcomes Research, Atlanta, Georgia (A.O.)
| | - David H Smith
- Kaiser Permanente Center for Health Research, Portland, Oregon (M.M., A.B., C.R.E., M.C.L., C.M., D.H.S., W.M.V.)
| | | | - William M Vollmer
- Kaiser Permanente Center for Health Research, Portland, Oregon (M.M., A.B., C.R.E., M.C.L., C.M., D.H.S., W.M.V.)
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Suri P, Meier EN, Gold LS, Marcum ZA, Johnston SK, James KT, Bresnahan BW, O'Reilly M, Turner JA, Kallmes DF, Sherman KJ, Deyo RA, Luetmer PH, Avins AL, Griffith B, Heagerty PJ, Rundell SD, Jarvik JG, Friedly JL. Providing Epidemiological Data in Lumbar Spine Imaging Reports Did Not Affect Subsequent Utilization of Spine Procedures: Secondary Outcomes from a Stepped-Wedge Randomized Controlled Trial. Pain Med 2021; 22:1272-1280. [PMID: 33595635 DOI: 10.1093/pm/pnab065] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To evaluate the effect of inserting epidemiological information into lumbar spine imaging reports on subsequent nonsurgical and surgical procedures involving the thoracolumbosacral spine and sacroiliac joints. DESIGN Analysis of secondary outcomes from the Lumbar Imaging with Reporting of Epidemiology (LIRE) pragmatic stepped-wedge randomized trial. SETTING Primary care clinics within four integrated health care systems in the United States. SUBJECTS 238,886 patients ≥18 years of age who received lumbar diagnostic imaging between 2013 and 2016. METHODS Clinics were randomized to receive text containing age- and modality-specific epidemiological benchmarks indicating the prevalence of common spine imaging findings in people without low back pain, inserted into lumbar spine imaging reports (the "LIRE intervention"). The study outcomes were receiving 1) any nonsurgical lumbosacral or sacroiliac spine procedure (lumbosacral epidural steroid injection, facet joint injection, or facet joint radiofrequency ablation; or sacroiliac joint injection) or 2) any surgical procedure involving the lumbar, sacral, or thoracic spine (decompression surgery or spinal fusion or other spine surgery). RESULTS The LIRE intervention was not significantly associated with subsequent utilization of nonsurgical lumbosacral or sacroiliac spine procedures (odds ratio [OR] = 1.01, 95% confidence interval [CI] 0.93-1.09; P = 0.79) or any surgical procedure (OR = 0.99, 95 CI 0.91-1.07; P = 0.74) involving the lumbar, sacral, or thoracic spine. The intervention was also not significantly associated with any individual spine procedure. CONCLUSIONS Inserting epidemiological text into spine imaging reports had no effect on nonsurgical or surgical procedure utilization among patients receiving lumbar diagnostic imaging.
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Affiliation(s)
- Pradeep Suri
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA.,Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, Seattle, Washington, USA.,Rehabilitation Care Services, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Eric N Meier
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Laura S Gold
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Radiology, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Zachary A Marcum
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Sandra K Johnston
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Radiology, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Kathryn T James
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Radiology, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Brian W Bresnahan
- Department of Radiology, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Michael O'Reilly
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Radiology, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Judith A Turner
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Richard A Deyo
- Departments of Family Medicine and Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | | | - Andrew L Avins
- Division of Research (ALA), Kaiser Permanente Northern California, Oakland, California, USA
| | - Brent Griffith
- Department of Radiology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Patrick J Heagerty
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Sean D Rundell
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Jeffrey G Jarvik
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Radiology, School of Medicine, University of Washington, Seattle, Washington, USA.,Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Janna L Friedly
- Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.,Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
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8
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Von Korff M, DeBar LL, Deyo RA, Mayhew M, Kerns RD, Goulet JL, Brandt C. Identifying Multisite Chronic Pain with Electronic Health Records Data. Pain Med 2021; 21:3387-3392. [PMID: 32918481 DOI: 10.1093/pm/pnaa295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Multisite chronic pain (MSCP) is associated with increased chronic pain impact, but methods for identifying MSCP for epidemiological research have not been evaluated. OBJECTIVE We assessed the validity of identifying MSCP using electronic health care data compared with survey questionnaires. METHODS Stratified random samples of adults served by Kaiser Permanente Northwest and Washington (N = 2,059) were drawn for a survey, oversampling persons with frequent use of health care for pain. MSCP and single-site chronic pain were identified by two methods, with electronic health care data and with self-report of common chronic pain conditions by survey questionnaire. Analyses were weighted to adjust for stratified sampling. RESULTS MSCP was somewhat less common when ascertained by electronic health records (14.7% weighted prevalence) than by survey questionnaire (25.9% weighted prevalence). Agreement of the two MSCP classifications was low (kappa agreement statistic of 0.21). Ascertainment of MSCP with electronic health records was 30.9% sensitive, 91.0% specific, and had a positive predictive value of 54.5% relative to MSCP identified by self-report as the standard. After adjusting for age and gender, patients with MSCP identified by either electronic health records or self-report showed higher levels of pain-related disability, pain severity, depressive symptoms, and long-term opioid use than persons with single-site chronic pain identified by the same method. CONCLUSIONS Identification of MSCP with electronic health care data was insufficiently accurate to be used as a surrogate or screener for MSCP identified by self-report, but both methods identified persons with heightened chronic pain impact.
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Affiliation(s)
- Michael Von Korff
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Lynn L DeBar
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Richard A Deyo
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Meghan Mayhew
- Kaiser Permanente Center for Health Research, Portland, Oregon
| | - Robert D Kerns
- Department of Psychiatry, Neurology and Psychology, Yale University, New Haven, Connecticut.,VA Connecticut Healthcare System, Pain Research, Informatics, Multi-morbidities, and Education Center (PRIME), West Haven, Connecticut
| | - Joseph L Goulet
- VA Connecticut Healthcare System, Pain Research, Informatics, Multi-morbidities, and Education Center (PRIME), West Haven, Connecticut.,Yale School of Medicine, Department of Emergency Medicine, New Haven, Connecticut, USA
| | - Cynthia Brandt
- VA Connecticut Healthcare System, Pain Research, Informatics, Multi-morbidities, and Education Center (PRIME), West Haven, Connecticut.,Yale School of Medicine, Department of Emergency Medicine, New Haven, Connecticut, USA
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9
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Morasco BJ, Smith N, Dobscha SK, Deyo RA, Hyde S, Yarborough BJ. Prospective Investigation of Factors Associated with Prescription Opioid Dose Escalation among Patients in Integrated Health Systems. J Gen Intern Med 2020; 35:895-902. [PMID: 33145684 PMCID: PMC7728960 DOI: 10.1007/s11606-020-06250-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 09/17/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Prior research has identified factors associated with prescription opioid initiation, but little is known about the prevalence or predictors of dose escalation among patients already prescribed long-term opioid therapy (LTOT). OBJECTIVE This was a 2-year prospective cohort study to examine patient and clinician factors associated with opioid dose escalation. DESIGN A prospective cohort study. Participants were seen at baseline and every 6 months for a total of 2 years. PARTICIPANTS Patients prescribed a stable dose of LTOT for musculoskeletal pain were recruited from two integrated health systems (Kaiser Permanente and the Department of Veterans Affairs, respectively). MAIN MEASURES The prescription opioid dose was based on pharmacy records and self-report. Administrative data were gathered on characteristics of the opioid-prescribing clinician and healthcare utilization. Participants completed measures of pain, functioning, and quality of life. KEY RESULTS Of enrolled participants (n = 517), 19.5% had an opioid dose increase. In multivariate analyses, patient variables associated with dose escalation were lower opioid dose (hazard ratio [HR] = 0.86, 95% confidence interval [CI] = 0.79-0.94, for every 10-mg increase in baseline dose) and greater pain catastrophizing (HR = 1.03, 95% CI = 1.01-1.05). Other variables associated with dose escalation were as follows: receiving medications from a nurse practitioner primary care provider (HR = 2.10, 95% CI = 1.12-3.96) or specialty physician (HR = 3.18, 95% CI = 1.22-8.34), relative to a physician primary care provider, and having undergone surgery within the past 6 months (HR = 1.80, 95% CI = 1.10-2.94). Other variables, including pain intensity, pain disability, or depression, were not associated with dose escalation. CONCLUSIONS In this 2-year prospective cohort study, variables associated with opioid dose escalation were lower opioid dose, higher pain catastrophizing, receiving opioids from a medical specialist (rather than primary care clinician) or nurse practitioner, and having recently undergone surgery. Study findings highlight intervention points that may be helpful for reducing the likelihood of future prescription opioid dose escalation.
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Affiliation(s)
- Benjamin J Morasco
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System (R&D99), Portland, OR, USA. .,Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA.
| | - Ning Smith
- Kaiser Permanente Northwest Center for Health Research, Portland, OR, USA
| | - Steven K Dobscha
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System (R&D99), Portland, OR, USA.,Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA
| | - Richard A Deyo
- Kaiser Permanente Northwest Center for Health Research, Portland, OR, USA.,Department of Family Medicine, Oregon Health & Sciences University, Portland, OR, USA.,Department of Internal Medicine, Oregon Health & Sciences University, Portland, OR, USA.,Oregon Institute for Occupational Health Sciences, Oregon Health & Sciences University, Portland, OR, USA.,School of Public Health, Oregon Health & Sciences University, Portland, OR, USA
| | - Stephanie Hyde
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System (R&D99), Portland, OR, USA.,Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA
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10
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Jarvik JG, Meier EN, James KT, Gold LS, Tan KW, Kessler LG, Suri P, Kallmes DF, Cherkin DC, Deyo RA, Sherman KJ, Halabi SS, Comstock BA, Luetmer PH, Avins AL, Rundell SD, Griffith B, Friedly JL, Lavallee DC, Stephens KA, Turner JA, Bresnahan BW, Heagerty PJ. The Effect of Including Benchmark Prevalence Data of Common Imaging Findings in Spine Image Reports on Health Care Utilization Among Adults Undergoing Spine Imaging: A Stepped-Wedge Randomized Clinical Trial. JAMA Netw Open 2020; 3:e2015713. [PMID: 32886121 PMCID: PMC7489827 DOI: 10.1001/jamanetworkopen.2020.15713] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Lumbar spine imaging frequently reveals findings that may seem alarming but are likely unrelated to pain. Prior work has suggested that inserting data on the prevalence of imaging findings among asymptomatic individuals into spine imaging reports may reduce unnecessary subsequent interventions. OBJECTIVE To evaluate the impact of including benchmark prevalence data in routine spinal imaging reports on subsequent spine-related health care utilization and opioid prescriptions. DESIGN, SETTING, AND PARTICIPANTS This stepped-wedge, pragmatic randomized clinical trial included 250 401 adult participants receiving care from 98 primary care clinics at 4 large health systems in the United States. Participants had imaging of their backs between October 2013 and September 2016 without having had spine imaging in the prior year. Data analysis was conducted from November 2018 to October 2019. INTERVENTIONS Either standard lumbar spine imaging reports (control group) or reports containing age-appropriate prevalence data for common imaging findings in individuals without back pain (intervention group). MAIN OUTCOMES AND MEASURES Health care utilization was measured in spine-related relative value units (RVUs) within 365 days of index imaging. The number of subsequent opioid prescriptions written by a primary care clinician was a secondary outcome, and prespecified subgroup analyses examined results by imaging modality. RESULTS We enrolled 250 401 participants (of whom 238 886 [95.4%] met eligibility for this analysis, with 137 373 [57.5%] women and 105 497 [44.2%] aged >60 years) from 3278 primary care clinicians. A total of 117 455 patients (49.2%) were randomized to the control group, and 121 431 patients (50.8%) were randomized to the intervention group. There was no significant difference in cumulative spine-related RVUs comparing intervention and control conditions through 365 days. The adjusted median (interquartile range) RVU for the control group was 3.56 (2.71-5.12) compared with 3.53 (2.68-5.08) for the intervention group (difference, -0.7%; 95% CI, -2.9% to 1.5%; P = .54). Rates of subsequent RVUs did not differ between groups by specific clinical findings in the report but did differ by type of index imaging (eg, computed tomography: difference, -29.3%; 95% CI, -42.1% to -13.5%; magnetic resonance imaging: difference, -3.4%; 95% CI, -8.3% to 1.8%). We observed a small but significant decrease in the likelihood of opioid prescribing from a study clinician within 1 year of the intervention (odds ratio, 0.95; 95% CI, 0.91 to 1.00; P = .04). CONCLUSIONS AND RELEVANCE In this study, inserting benchmark prevalence information in lumbar spine imaging reports did not decrease subsequent spine-related RVUs but did reduce subsequent opioid prescriptions. The intervention text is simple, inexpensive, and easily implemented. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02015455.
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Affiliation(s)
- Jeffrey G. Jarvik
- Department of Radiology, University of Washington, Seattle
- Department of Neurological Surgery, University of Washington, Seattle
- Department of Health Services, University of Washington, Seattle
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle
| | - Eric N. Meier
- Department of Biostatistics, University of Washington, Seattle
- Center for Biomedical Statistics, University of Washington, Seattle
| | - Kathryn T. James
- Department of Radiology, University of Washington, Seattle
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle
| | - Laura S. Gold
- Department of Radiology, University of Washington, Seattle
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle
| | - Katherine W. Tan
- Department of Biostatistics, University of Washington, Seattle
- Center for Biomedical Statistics, University of Washington, Seattle
- Flatiron Health, New York, New York
| | - Larry G. Kessler
- Department of Health Services, University of Washington, Seattle
| | - Pradeep Suri
- Rehabilitation Care Services, VA Puget Sound Health Care System, Seattle, Washington
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | | | | | - Richard A. Deyo
- Departments of Family Medicine and Internal Medicine, Oregon Health and Science University, Portland
| | | | - Safwan S. Halabi
- Department of Radiology, Henry Ford Hospital, Detroit, Michigan
- Department of Radiology, Stanford University School of Medicine, Palo Alto, California
| | - Bryan A. Comstock
- Department of Biostatistics, University of Washington, Seattle
- Center for Biomedical Statistics, University of Washington, Seattle
| | | | - Andrew L. Avins
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Sean D. Rundell
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | - Brent Griffith
- Department of Radiology, Henry Ford Hospital, Detroit, Michigan
| | - Janna L. Friedly
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | | | - Kari A. Stephens
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
| | - Judith A. Turner
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle
- Department of Rehabilitation Medicine, University of Washington, Seattle
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
| | - Brian W. Bresnahan
- Department of Radiology, University of Washington, Seattle
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle
| | - Patrick J. Heagerty
- Department of Biostatistics, University of Washington, Seattle
- Center for Biomedical Statistics, University of Washington, Seattle
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11
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Rundell SD, Patel KV, Krook MA, Heagerty PJ, Suri P, Friedly JL, Turner JA, Deyo RA, Bauer Z, Nerenz DR, Avins AL, Nedeljkovic SS, Jarvik JG. Multi-site Pain Is Associated with Long-term Patient-Reported Outcomes in Older Adults with Persistent Back Pain. Pain Med 2020; 20:1898-1906. [PMID: 30615144 DOI: 10.1093/pm/pny270] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To estimate the prevalence of co-occurring pain sites among older adults with persistent back pain and associations of multisite pain with longitudinal outcomes. DESIGN Secondary analysis of a cohort study. SETTING Three integrated health systems in the United States. SUBJECTS Eight hundred ninety-nine older adults with persistent back pain. METHODS Participants reported pain in the following sites: stomach, arms/legs/joints, headaches, neck, pelvis/groin, and widespread pain. Over 18 months, we measured back-related disability (Roland Morris, scored 0-24), pain intensity (11-point numerical rating scale), health-related quality of life (EuroQol-5D [EQ-5D], utility from 0-1), and falls in the past three weeks. We used mixed-effects models to test the association of number and type of pain sites with each outcome. RESULTS Nearly all (N = 839, 93%) respondents reported at least one additional pain site. There were 216 (24%) with one additional site and 623 (69%) with multiple additional sites. The most prevalent comorbid pain site was the arms/legs/joints (N = 801, 89.1%). Adjusted mixed-effects models showed that for every additional pain site, RMDQ worsened by 0.65 points (95% confidence interval [CI] = 0.43 to 0.86), back pain intensity increased by 0.14 points (95% CI = 0.07 to 0.22), EQ-5D worsened by 0.012 points (95% CI = -0.018 to -0.006), and the odds of falling increased by 27% (odds ratio = 1.27, 95% CI = 1.12 to 1.43). Some specific pain sites (extremity pain, widespread pain, and pelvis/groin pain) were associated with greater long-term disability. CONCLUSIONS Multisite pain is common among older adults with persistent back pain. Number of pain sites was associated with all outcomes; individual pain sites were less consistently associated with outcomes.
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Affiliation(s)
- Sean D Rundell
- Department of Rehabilitation Medicine.,Comparative Effectiveness, Cost, and Outcomes Research Center.,Department of Health Services
| | | | | | - Patrick J Heagerty
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Pradeep Suri
- Department of Rehabilitation Medicine.,Comparative Effectiveness, Cost, and Outcomes Research Center.,VA Puget Sound Health Care System, Seattle, Washington
| | - Janna L Friedly
- Department of Rehabilitation Medicine.,Comparative Effectiveness, Cost, and Outcomes Research Center
| | - Judith A Turner
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington
| | - Richard A Deyo
- Department of Family Medicine.,Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Zoya Bauer
- Seattle Children's Research Institute, Seattle, Washington
| | - David R Nerenz
- Neuroscience Institute, Henry Ford Hospital, Detroit, Michigan
| | - Andrew L Avins
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Srdjan S Nedeljkovic
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, and Spine Unit, Harvard Vanguard Medical Associates, Boston, Massachusetts
| | - Jeffrey G Jarvik
- Comparative Effectiveness, Cost, and Outcomes Research Center.,Department of Health Services.,Department of Radiology.,Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
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12
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Morasco BJ, Iacocca MO, Lovejoy TI, Dobscha SK, Deyo RA, Cavese JA, Hyde S, Yarborough BJH. Utility of the Pain Medication Questionnaire to predict aberrant urine drug tests: Results from a longitudinal cohort study. Psychol Serv 2020; 18:319-327. [PMID: 32673038 DOI: 10.1037/ser0000471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Identifying patients at risk of misusing prescription opioids is a priority. Standardized risk measures exist, but prior research has been limited in an assessment of their utility by a reliance on cross-sectional or retrospective analyses. In this study, the Pain Medication Questionnaire (PMQ), a standardized self-report measure of risk for prescription opioid misuse, was used to predict aberrant urine drug test (UDT) results over the subsequent 24 months. At baseline, participants who were prescribed long-term opioid therapy completed self-report measures assessing pain, function, and quality of life; this also included the PMQ. Medical record data were abstracted for 24 months postbaseline to collect results of UDTs administered during clinical care. Among participants, 12.9% had a UDT result that was positive for a nonprescribed or illicit substance, 18.9% had an aberrant negative UDT result, 3.6% had aberrant positive and negative UDT results, and the remaining 64.6% had expected UDT results. Average PMQ score at baseline did not significantly differ based on participants' type of UDT result over 24 months of follow-up. Participant variables that were significantly associated with a subsequent aberrant positive UDT were higher prescription opioid dose and hazardous alcohol use; those associated with an aberrant negative UDT were lower prescription opioid dose and hazardous alcohol use; no variable was associated with combined positive and negative UDT results. In conclusion, total PMQ score was not predictive of aberrant positive or negative UDT results. More work is needed to identify optimal strategies of screening for risk of aberrant UDT results. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Benjamin J Morasco
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System
| | - Megan O Iacocca
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System
| | - Travis I Lovejoy
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System
| | - Steven K Dobscha
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System
| | - Richard A Deyo
- Department of Family Medicine, Oregon Health & Science University
| | | | - Stephanie Hyde
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System
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13
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Yarborough BJH, Stumbo SP, Stoneburner A, Smith N, Dobscha SK, Deyo RA, Morasco BJ. Correlates of Benzodiazepine Use and Adverse Outcomes Among Patients with Chronic Pain Prescribed Long-term Opioid Therapy. Pain Med 2020; 20:1148-1155. [PMID: 30204893 DOI: 10.1093/pm/pny179] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To examine the correlates and odds of receiving overlapping benzodiazepine and opioid prescriptions and whether co-prescription was associated with greater odds of falling or visiting the emergency department. DESIGN Cross-sectional study. SETTING A large private integrated health system and a Veterans Health Administration integrated health system. SUBJECTS Five hundred seventeen adults with musculoskeletal pain and current prescriptions for long-term opioid therapy. METHODS A multivariate logistic regression model examined correlates of having overlapping benzodiazepine and opioid prescriptions in the year before enrollment in the cross-sectional study. Negative binomial models analyzed the number of falls in the past three months and past-year emergency department visits. In addition to propensity score adjustment, models controlled for demographic characteristics, psychiatric diagnoses, medications, overall comorbidity score, and opioid morphine equivalent dose. RESULTS Twenty-five percent (N = 127) of participants had co-occurring benzodiazepine and opioid prescriptions in the prior year. Odds of receiving a benzodiazepine prescription were significantly higher among patients with the following psychiatric diagnoses: anxiety disorder (adjusted odds ratio [AOR] = 4.71, 95% confidence interval [CI] = 2.67-8.32, P < 0.001), post-traumatic stress disorder (AOR = 2.24, 95% CI = 1.14-4.38, P = 0.019), and bipolar disorder (AOR = 3.82, 95% CI = 1.49-9.81, P = 0.005). Past-year overlapping benzodiazepine and opioid prescriptions were associated with adverse outcomes, including a greater number of falls (risk ratio [RR] = 3.27, 95% CI = 1.77-6.02, P = 0.001) and emergency department visits (RR = 1.66, 95% CI = 1.08-2.53, P = 0.0194). CONCLUSIONS Among patients with chronic pain prescribed long-term opioid therapy, one-quarter of patients had co-occurring prescriptions for benzodiazepines, and dual use was associated with increased odds of falls and emergency department visits.
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Affiliation(s)
| | - Scott P Stumbo
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | - Ashley Stoneburner
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | - Ning Smith
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | - Steven K Dobscha
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon.,Department of Psychiatry, Oregon Health & Science University, Portland, Oregon
| | - Richard A Deyo
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon.,Departments of Family Medicine, Internal Medicine, and the Oregon Institute for Occupational Health Sciences, Oregon Health & Science University, Portland, Oregon, USA
| | - Benjamin J Morasco
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon.,Department of Psychiatry, Oregon Health & Science University, Portland, Oregon
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14
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Morasco BJ, Smith N, Dobscha SK, Deyo RA, Hyde S, Yarborough BJH. Outcomes of prescription opioid dose escalation for chronic pain: results from a prospective cohort study. Pain 2020; 161:1332-1340. [DOI: 10.1097/j.pain.0000000000001817] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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15
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Cherkin DC, Deyo RA, Goldberg H. Time to Align Coverage with Evidence for Treatment of Back Pain. J Gen Intern Med 2019; 34:1910-1912. [PMID: 31243710 PMCID: PMC6712111 DOI: 10.1007/s11606-019-05099-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 02/06/2019] [Accepted: 05/06/2019] [Indexed: 12/28/2022]
Abstract
Despite improved knowledge about the benefits and harms of treatments for chronic back pain in the past several decades, there is a large and consequential mismatch between treatments found safe and effective and those routinely covered by health insurance. As a result, care for back pain has, if anything, deteriorated in recent decades-expenses are higher, harms are greater, and use of ineffective treatments is more common. Deficiencies in health care delivery processes and payment models are centrally involved in the failure to improve care for back pain. A key step for accelerating progress is changing insurance coverage policies to facilitate use of the safest and most helpful approaches while discouraging riskier and less effective treatments. Relatively simple changes in reimbursement policies may minimize harm and improve quality of life for many patients with chronic back and similar pain syndromes. Such changes might also reduce health care expenditures because the costs of treatments currently covered by insurance and their associated harms may well outweigh the costs of the relatively safe and effective treatments recommended by current guidelines but poorly covered by insurance. There is no justification for continuing the status quo-patients and clinicians deserve better.
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Affiliation(s)
- Daniel C Cherkin
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA.
| | - Richard A Deyo
- Department of Family Medicine and Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Harley Goldberg
- Spine Care Program, and Complementary and Alternative Medicine Program, Northern California Kaiser Permanente, Oakland, CA, USA.,Family Medicine, Boston University School of Medicine, Boston, MA, USA
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16
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Fink PB, Deyo RA, Hallvik SE, Hildebran C. Opioid Prescribing Patterns and Patient Outcomes by Prescriber Type in the Oregon Prescription Drug Monitoring Program. Pain Med 2019; 19:2481-2486. [PMID: 29155988 DOI: 10.1093/pm/pnx283] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective Prescription drug monitoring programs (PDMPs) were created to facilitate responsible use of controlled substances. In Oregon, physicians, physician's assistants (MDs/DOs/PAs), dentists, nurse practitioners (NPs), and naturopathic physicians (NDs) may prescribe opioids, but differences in prescribing practices, patient mix, and patient outcomes among prescriber types have not been characterized. Methods De-identified Oregon PDMP data from October 2011 through October 2014 were linked with vital records and a statewide hospital discharge registry. The disciplines of registered prescribers were identified by board affiliations. Prescription profiles associated with opioid overdose risk were tabulated for patients with at least one registered prescriber. Opioid-related hospitalizations and deaths were identified using ICD-9 and ICD-10 codes. Results There were 5,935 prescribers registered during the study period. Patients of NPs or NDs received more high-risk opioid prescriptions than patients of MDs/DOs/PAs. For example, they received greater proportions of high-dose prescriptions (NP 12.9%, ND 15%, MD/DO/PA 11.1%), and had greater opioid-related hospitalization (NP 1.7%, ND 3.1%, MD/DO/PA 1.2%; P < 0.005 for all). However, patients of NPs or NDs were also more likely to have four or more prescribers (NP 45.3%, ND 58.5%, MD/DO/PA 27.1%), and most of their patients' high-risk opioid prescriptions came from prescribers in other disciplines. Conclusion Our analysis suggests significant differences in opioid prescription profiles and opioid-related hospitalization and mortality among patients receiving opioid prescriptions from nurse practitioners, naturopathic physicians, or medical clinicians in Oregon. However, these differences appear largely due to differences in patient mix between provider types rather than discipline-specific prescribing practices.
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Affiliation(s)
| | - Richard A Deyo
- Oregon Health and Science University, Portland, Oregon.,Department of Family Medicine, Department of Medicine, and Oregon Institute for Occupational Health, Portland, Oregon
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17
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Mayhew M, DeBar LL, Deyo RA, Kerns RD, Goulet JL, Brandt CA, Von Korff M. Development and Assessment of a Crosswalk Between ICD-9-CM and ICD-10-CM to Identify Patients with Common Pain Conditions. J Pain 2019; 20:1429-1445. [PMID: 31129316 DOI: 10.1016/j.jpain.2019.05.006] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 03/24/2019] [Accepted: 05/20/2019] [Indexed: 02/01/2023]
Abstract
Effective management of patients with pain requires accurate information about the prevalence, outcomes, and co-occurrence of common pain conditions. However, the transition from ICD-9-CM to ICD-10-CM diagnostic coding in 2015 left researchers without methods for comparing the prevalence of pain conditions before and after the transition. In this study, we developed and assessed a diagnostic framework to serve as a crosswalk between ICD-9-CM and ICD-10-CM diagnosis codes for common pain-related health conditions. We refined existing ICD-9-CM definitions for diagnostic clusters of common pain conditions consistent with the US National Pain Strategy and developed corresponding ICD-10-CM definitions. We then assessed the stability of prevalence estimates and associated patient socio-demographic features of each diagnostic cluster during 1-year periods before and after the transition to ICD-10-CM in 3 US health care systems using electronic health records data for in-person encounters. Prevalence estimates and socio-demographic characteristics were similar before and after the transition. The Pain Condition ICD-9-CM to ICD-10-CM Crosswalk includes a full spectrum of common pain conditions to enable prevalence estimates of multiple and chronic overlapping pain conditions. This allows the tool to serve as a foundation for a broad array of pain-related health services research utilizing electronic databases. PERSPECTIVE: This article details the development and assessment of the Pain Condition ICD-9-CM to ICD-10-CM Crosswalk, a diagnostic framework for assessing pain condition prevalence across the ICD-9-CM to ICD-10-CM transition. This framework can serve as a standardized tool for research on pain conditions, including health services and epidemiologic research.
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Affiliation(s)
- Meghan Mayhew
- Kaiser Permanente Center for Health Research, Portland, Oregon.
| | - Lynn L DeBar
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Richard A Deyo
- Oregon Health & Science University, Department of Family Medicine, Portland, Oregon
| | - Robert D Kerns
- Yale School of Medicine, Emergency Medicine Department, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut
| | - Joseph L Goulet
- Yale School of Medicine, Emergency Medicine Department, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut
| | - Cynthia A Brandt
- Yale School of Medicine, Emergency Medicine Department, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut
| | - Michael Von Korff
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
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18
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Fink PB, Deyo RA, Hallvik SE, Hildebran C. Response to "Naturopathic Physician Prescribing Patterns in Oregon". Pain Med 2019; 20:416. [PMID: 29546430 PMCID: PMC6374134 DOI: 10.1093/pm/pny047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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19
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Jarvik JG, Gold LS, Tan K, Friedly JL, Nedeljkovic SS, Comstock BA, Deyo RA, Turner JA, Bresnahan BW, Rundell SD, James KT, Nerenz DR, Avins AL, Bauer Z, Kessler L, Heagerty PJ. Long-term outcomes of a large, prospective observational cohort of older adults with back pain. Spine J 2018; 18:1540-1551. [PMID: 29391206 DOI: 10.1016/j.spinee.2018.01.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 11/25/2017] [Accepted: 01/19/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Although back pain is common among older adults, there is relatively little research on the course of back pain in this age group. PURPOSE Our primary goals were to report 2-year outcomes of older adults initiating primary care for back pain and to examine the relative importance of patient factors versus medical interventions in predicting 2-year disability and pain. STUDY DESIGN/SETTING This study used a predictive model using data from a prospective, observational cohort from a primary care setting. PATIENT SAMPLE The study included patients aged ≥65 years at the time of new primary care visits for back pain. OUTCOME MEASURES Self-reported 2-year disability (Roland-Morris Disability Questionnaire [RDQ]) and back pain (0-10 numerical rating scale [NRS]). METHODS We developed our models using a machine learning least absolute shrinkage and selection operator approach. We evaluated the predictive value of baseline characteristics and the incremental value of interventions that occurred between 0 and 90 days, and the change in patient disability and pain from 0 to 90 days. Limitations included confounding by indication and unmeasured confounding. RESULTS Of 4,665 patients (89%) with follow-up, both RDQ (from mean 9.6 [95% confidence interval {CI} 9.4-9.7] to mean 8.3 [95% CI 8.0-8.5]) and back pain NRS (from mean 5.0 [95% CI 4.9-5.1] to mean 3.5 [95% CI 3.4-3.6]) scores improved slightly. Only 16% (15%-18%) reported no back pain-related disability or back pain at 2 years after initial visits. Regression model parameters explained 40% of the variation (R2) in 2-year RDQ scores, and the addition of 0- to 3-month change in RDQ score and pain improved prediction (R2=51%). The most consistent predictors of 2-year RDQ scores and back pain NRS scores were 0- to 90-day change in each respective outcome and patient confidence in improvement. Patients experienced 50% and 43% improvement in back pain and disability, respectively, 2 years after their initial visit. However, fewer than 20% of patients had complete resolution of their back pain and disability at that time. CONCLUSIONS Baseline patient factors were more important than early interventions in explaining disability and pain after 2 years.
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Affiliation(s)
- Jeffrey G Jarvik
- Department of Radiology, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA; Department of Neurological Surgery, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA; Department of Health Services, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA; Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave, Seattle, WA, 98105, USA.
| | - Laura S Gold
- Department of Radiology, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA; Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave, Seattle, WA, 98105, USA
| | - Katherine Tan
- Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave, Seattle, WA, 98105, USA; Department of Biostatistics, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Janna L Friedly
- Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave, Seattle, WA, 98105, USA; Department of Rehabilitation Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Srdjan S Nedeljkovic
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital and Spine Unit, Harvard Vanguard Medical Associates, 75 Francis St, Boston, MA, 02115, USA
| | - Bryan A Comstock
- Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave, Seattle, WA, 98105, USA; Department of Biostatistics, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Richard A Deyo
- Department of Family Medicine, Department of Internal Medicine, Oregon Institute of Occupational Health Sciences, Oregon Health and Science University, 3303 SW Bond Ave, Portland, OR, 97239, USA
| | - Judith A Turner
- Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave, Seattle, WA, 98105, USA; Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Brian W Bresnahan
- Department of Radiology, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA; Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave, Seattle, WA, 98105, USA; Department of Pharmacy, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Sean D Rundell
- Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave, Seattle, WA, 98105, USA; Department of Rehabilitation Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Kathryn T James
- Department of Radiology, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA; Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave, Seattle, WA, 98105, USA
| | - David R Nerenz
- Neuroscience Institute, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI, 48202, USA
| | - Andrew L Avins
- Division of Research, Northern California Kaiser-Permanente, 2000 Broadway, Oakland, CA, 94612, USA
| | - Zoya Bauer
- Department of Radiology, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA; Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave, Seattle, WA, 98105, USA
| | - Larry Kessler
- Department of Health Services, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA; Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave, Seattle, WA, 98105, USA
| | - Patrick J Heagerty
- Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave, Seattle, WA, 98105, USA; Department of Biostatistics, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
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Elder C, DeBar L, Ritenbaugh C, Dickerson J, Vollmer WM, Deyo RA, Johnson ES, Haas M. Comparative Effectiveness of Usual Care With or Without Chiropractic Care in Patients with Recurrent Musculoskeletal Back and Neck Pain. J Gen Intern Med 2018; 33:1469-1477. [PMID: 29943109 PMCID: PMC6108992 DOI: 10.1007/s11606-018-4539-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 04/27/2018] [Accepted: 06/07/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Chiropractic care is a popular alternative for back and neck pain, with efficacy comparable to usual care in randomized trials. However, the effectiveness of chiropractic care as delivered through conventional care settings remains largely unexplored. OBJECTIVE To evaluate the comparative effectiveness of usual care with or without chiropractic care for patients with chronic recurrent musculoskeletal back and neck pain. STUDY DESIGN Prospective cohort study using propensity score-matched controls. PARTICIPANTS Using retrospective electronic health record data, we developed a propensity score model predicting likelihood of chiropractic referral. Eligible patients with back or neck pain were then contacted upon referral for chiropractic care and enrolled in a prospective study. For each referred patient, two propensity score-matched non-referred patients were contacted and enrolled. We followed the participants prospectively for 6 months. MAIN MEASURES Main outcomes included pain severity, interference, and symptom bothersomeness. Secondary outcomes included expenditures for pain-related health care. KEY RESULTS Both groups' (N = 70 referred, 139 non-referred) pain scores improved significantly over the first 3 months, with less change between months 3 and 6. No significant between-group difference was observed. (severity - 0.10 (95% CI - 0.30, 0.10), interference - 0.07 (- 0.31, 0.16), bothersomeness - 0.1 (- 0.39, 0.19)). After controlling for variances in baseline costs, total costs during the 6-month post-enrollment follow-up were significantly higher on average in the non-referred versus referred group ($1996 [SD = 3874] vs $1086 [SD = 1212], p = .034). Adjusting for differences in age, gender, and Charlson comorbidity index attenuated this finding, which was no longer statistically significant (p = .072). CONCLUSIONS We found no statistically significant difference between the two groups in either patient-reported or economic outcomes. As clinical outcomes were similar, and the provision of chiropractic care did not increase costs, making chiropractic services available provided an additional viable option for patients who prefer this type of care, at no additional expense.
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Affiliation(s)
- Charles Elder
- Kaiser Permanente Center for Health Research, Portland, OR, USA.
| | - Lynn DeBar
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | - John Dickerson
- Kaiser Permanente Center for Health Research, Portland, OR, USA
| | | | | | - Eric S Johnson
- Kaiser Permanente Center for Health Research, Portland, OR, USA
| | - Mitchell Haas
- Earl E. Bakken Center for Spirituality and Healing, University of Minnesota, Minneapolis, MN, USA
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Hallvik SE, Geissert P, Wakeland W, Hildebran C, Carson J, O'Kane N, Deyo RA. Opioid-Prescribing Continuity and Risky Opioid Prescriptions. Ann Fam Med 2018; 16:440-442. [PMID: 30201641 PMCID: PMC6131006 DOI: 10.1370/afm.2285] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 05/02/2018] [Accepted: 05/24/2018] [Indexed: 12/13/2022] Open
Abstract
We aimed to better understand the association between opioid-prescribing continuity, risky prescribing patterns, and overdose risk. For this retrospective cohort study, we included patients with long-term opioid use, pulling data from Oregon's Prescription Drug Monitoring Program (PDMP), vital records, and hospital discharge registry. A continuity of care index (COCI) score was calculated for each patient, and we defined metrics to describe risky prescribing and overdose. As prescribing continuity increased, likelihood of filling risky opioid prescriptions and overdose hospitalization decreased. Prescribing continuity is an important factor associated with opioid harms and can be calculated using administrative pharmacy data.
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Affiliation(s)
| | | | | | | | | | | | - Richard A Deyo
- Department of Family Medicine, Department of Medicine, and The Oregon Institute for Occupational Health Sciences, Oregon Health and Science University, Portland, Oregon
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Sun BC, Lupulescu-Mann N, Charlesworth CJ, Kim H, Hartung DM, Deyo RA, John McConnell K. Variations in prescription drug monitoring program use by prescriber specialty. J Subst Abuse Treat 2018; 94:35-40. [PMID: 30243415 DOI: 10.1016/j.jsat.2018.08.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 08/13/2018] [Accepted: 08/14/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Although prescription drug monitoring programs (PDMPs) have been widely implemented to potentially reduce abuse of prescription opioids, there is limited data on variations in PDMP use by prescriber specialty. Such knowledge may guide targeted interventions to improve PDMP use. METHODS Using data from Washington state Medicaid program, we performed a retrospective cohort study of opioid prescribers and their PDMP queries between Nov 1, 2013 and Oct 31, 2014. PDMP registration was mandatory for emergency physicians, but not for other providers. The unit of analysis was the prescriber. The primary outcome was any prescriber queries of the PDMP. We used multivariate regression models to identify variations in PDMP queries by prescriber specialty, as well as to explore explanatory pathways for observed variations. RESULTS We studied 17,390 providers who prescribed opioids, including 8718 (50%) who were not registered with PDMP, 4767 (27%) who were registered but had no recorded use of the PDMP, and 3905 (23%) PDMP users (queries/user: median 18, IQR 5-64). Compared to general medicine physicians, PDMP use was higher for emergency physicians (OR 1.4, 95%CI: 1.2-1.7), and lower for surgical specialists (OR 0.1, 95%CI: 0.08-0.1), obstetrician-gynecologists (OR 0.2, 95%CI: 0.1-0.2) and dentists (OR 0.4, 95%CI: 0.4-0.5). Higher use by emergency physicians appeared to be mediated by higher registration rates, rather than by provider level predilection to use the PDMP. CONCLUSIONS A minority of opioid prescribers to Medicaid beneficiaries used the PDMP. We identified variations in PDMP use by prescriber specialty. Interventions to increase PDMP queries should target both PDMP registration and PDMP use after registration, as well as specialties with current low use rates.
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Affiliation(s)
- Benjamin C Sun
- Center for Policy Research-Emergency Medicine, Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, United States of America.
| | - Nicoleta Lupulescu-Mann
- Center for Health Systems Effectiveness, Oregon Health and Science University, Portland, OR, United States of America
| | - Christina J Charlesworth
- Center for Health Systems Effectiveness, Oregon Health and Science University, Portland, OR, United States of America
| | - Hyunjee Kim
- Center for Health Systems Effectiveness, Oregon Health and Science University, Portland, OR, United States of America
| | - Daniel M Hartung
- College of Pharmacy, Oregon State University/Oregon Health and Science University, Portland, OR, United States of America
| | - Richard A Deyo
- Department of Family Medicine, Department of Medicine, Department of Public Health and Preventive Medicine, and Oregon Institute of Occupational Health Sciences, Oregon Health and Science University, Portland, OR, United States of America
| | - K John McConnell
- Center for Policy Research-Emergency Medicine, Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, United States of America; Center for Health Systems Effectiveness, Oregon Health and Science University, Portland, OR, United States of America
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Sun BC, Lupulescu-Mann N, Charlesworth CJ, Kim H, Hartung DM, Deyo RA, McConnell KJ. Does Prescription Opioid Shopping Increase Overdose Rates in Medicaid Beneficiaries? Ann Emerg Med 2018; 71:679-687.e3. [PMID: 29174833 PMCID: PMC5960419 DOI: 10.1016/j.annemergmed.2017.10.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 09/21/2017] [Accepted: 10/06/2017] [Indexed: 10/18/2022]
Abstract
STUDY OBJECTIVE The link between prescription opioid shopping and overdose events is poorly understood. We test the hypothesis that a history of prescription opioid shopping is associated with increased risk of overdose events. METHODS This is a secondary analysis of a linked claims and controlled substance dispense database. We studied adult Medicaid beneficiaries in 2014 with prescription opioid use in the 6 months before an ambulatory care or emergency department visit with a pain-related diagnosis. The primary outcome was a nonfatal overdose event within 6 months of the cohort entry date. The exposure of interest (opioid shopping) was defined as having opioid prescriptions by different prescribers with greater than or equal to 1-day overlap and filled at 3 or more pharmacies in the 6 months before cohort entry. We used a propensity score to match shoppers with nonshoppers in a 1:1 ratio. We calculated the absolute difference in outcome rates between shoppers and nonshoppers. RESULTS We studied 66,328 patients, including 2,571 opioid shoppers (3.9%). There were 290 patients (0.4%) in the overall cohort who experienced a nonfatal overdose. In unadjusted analyses, shoppers had higher event rates than nonshoppers (rate difference of 4.4 events per 1,000; 95% confidence interval 0.8 to 7.9). After propensity score matching, there were no outcome differences between shoppers and nonshoppers (rate difference of 0.4 events per 1,000; 95% confidence interval -4.7 to 5.5). These findings were robust to various definitions of opioid shoppers and look-back periods. CONCLUSION Prescription opioid shopping is not independently associated with increased risk of overdose events.
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Affiliation(s)
- Benjamin C Sun
- Center for Policy Research-Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR.
| | | | | | - Hyunjee Kim
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR
| | - Daniel M Hartung
- College of Pharmacy, Oregon State University, Oregon Health & Science University, Portland, OR
| | - Richard A Deyo
- Department of Family Medicine, Department of Medicine and Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, OR
| | - K John McConnell
- Center for Policy Research-Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR; Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR
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Lozier CC, Nugent SM, Smith NX, Yarborough BJ, Dobscha SK, Deyo RA, Morasco BJ. Correlates of Use and Perceived Effectiveness of Non-pharmacologic Strategies for Chronic Pain Among Patients Prescribed Long-term Opioid Therapy. J Gen Intern Med 2018; 33:46-53. [PMID: 29633138 PMCID: PMC5902344 DOI: 10.1007/s11606-018-4325-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Non-pharmacologic treatments (NPTs) are recommended for chronic pain. Information is limited on patient use or perceptions of NPTs. We examined the frequency and correlates of use and self-rated helpfulness of NPTs for chronic pain among patients who are prescribed long-term opioid therapy (LTOT). METHODS Participants (n = 517) with musculoskeletal pain who were prescribed LTOT were recruited from two integrated health systems. They rated the frequency and utility of six clinician-directed and five self-directed NPTs for chronic pain. We categorized NPT use at four levels based on number of interventions used and frequency of use (none, low, moderate, high). Analyses examined clinical and demographic factors that differed among groups for both clinician-directed and self-directed NPTs. RESULTS Seventy-one percent of participants reported use of any NPT for pain within the prior 6 months. NPTs were rated as being helpful by more than 50% of users for all treatments assessed (range 51-79%). High users of clinician-directed NPTs were younger than non-users or low-frequency users and had the most depressive symptoms. In both clinician-directed and self-directed categories, high NPT users had significantly higher pain disability compared to non-NPT users. No significant group differences were detected on other demographic or clinical variables. In multivariable analyses, clinician-directed NPT use was modestly associated with younger age (OR = 0.97, 95% CI = 0.96-0.98) and higher pain disability (OR = 1.01, 95% CI = 1.00-1.02). Variables associated with greater self-directed NPT use were some college education (OR = 1.80, 95% CI = 1.13-2.84), college graduate or more (OR = 2.02, 95% CI = 1.20-3.40), and higher pain disability (OR = 1.01, 95% CI = 1.01-1.02). CONCLUSIONS NPT use was associated with higher pain disability and younger age for both clinician-directed and self-directed NPTs and higher education for self-directed NPTs. These strategies were rated as helpful by those that used them. These results can inform intervention implementation and be used to increase engagement in NPTs for chronic pain.
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Affiliation(s)
- Crystal C Lozier
- VA Portland Health Care System, Portland, OR, USA.
- Oregon Health & Science University, Portland, OR, USA.
| | - Shannon M Nugent
- VA Portland Health Care System, Portland, OR, USA
- Oregon Health & Science University, Portland, OR, USA
| | - Ning X Smith
- Kaiser Permanente Northwest Center for Health Research, Portland, OR, USA
| | | | - Steven K Dobscha
- VA Portland Health Care System, Portland, OR, USA
- Oregon Health & Science University, Portland, OR, USA
| | - Richard A Deyo
- Oregon Health & Science University, Portland, OR, USA
- Kaiser Permanente Northwest Center for Health Research, Portland, OR, USA
| | - Benjamin J Morasco
- VA Portland Health Care System, Portland, OR, USA
- Oregon Health & Science University, Portland, OR, USA
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Adams MH, Dobscha SK, Smith NX, Yarborough BJ, Deyo RA, Morasco BJ. Prevalence and Correlates of Low Pain Interference Among Patients With High Pain Intensity Who Are Prescribed Long-Term Opioid Therapy. J Pain 2018; 19:1074-1081. [PMID: 29705347 DOI: 10.1016/j.jpain.2018.04.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 03/09/2018] [Accepted: 04/06/2018] [Indexed: 12/25/2022]
Abstract
The pain experience may vary greatly among individuals reporting equally high levels of pain. We sought to examine the demographic and clinical characteristics associated with pain interference in patients with high pain intensity. Among patients with chronic musculoskeletal pain who were prescribed long-term opioid therapy and who were recruited from 2 health care systems, we identified a subset who reported high pain intensity (n = 189). All individuals completed self-report assessments of clinical and demographic factors. Analyses examined characteristics associated with pain interference. Within this group of patients with high reported pain intensity, 16.4% (n = 31) had low pain interference, 39.2% (n = 74) had moderate pain interference, and 44.4% (n = 84) had high pain interference. In bivariate analyses, patients with lower pain interference had fewer symptoms of depression and anxiety, less pain catastrophizing, a better quality of life, and greater self-efficacy for managing pain. In multivariate analyses, variables most strongly associated with low pain interference, relative to high interference, were depression severity (odds ratio 0.90; 95% confidence interval 0.82-0.99) and pain self-efficacy (odds ratio 1.07; 95% confidence interval 1.02-1.12). Study results suggest that chronic pain treatments that address symptoms of depression and enhance pain self-efficacy may be prioritized, particularly among patients who are prescribed long-term opioid therapy. PERSPECTIVE This article describes the prevalence and correlates of pain interference categories (low, medium, and high) among patients with high pain intensity who are prescribed long-term opioid therapy. Findings reveal that 16.4% of participants with high pain intensity had low impairment. Multivariate analyses indicate that variables significantly associated with low pain interference were lower depression scores and greater pain self-efficacy.
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Affiliation(s)
- Melissa H Adams
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
| | - Steven K Dobscha
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon; Department of Psychiatry, Oregon Health & Science University, Portland, Oregon
| | - Ning X Smith
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | | | - Richard A Deyo
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon; Departments of Family Medicine, Internal Medicine, and the Oregon Institute for Occupational Health Sciences, Oregon Health & Science University, Portland, Oregon
| | - Benjamin J Morasco
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon; Department of Psychiatry, Oregon Health & Science University, Portland, Oregon.
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Keast SL, Kim H, Deyo RA, Middleton L, McConnell KJ, Zhang K, Ahmed SM, Nesser N, Hartung DM. Effects of a prior authorization policy for extended-release/long-acting opioids on utilization and outcomes in a state Medicaid program. Addiction 2018; 113:10.1111/add.14248. [PMID: 29679440 PMCID: PMC9926938 DOI: 10.1111/add.14248] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 02/09/2018] [Accepted: 04/09/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS In response to the opioid overdose epidemic, US state Medicaid programs have adopted restrictive policies for opioid analgesics, yet effects on prescribing patterns and health outcomes are uncertain. This study aimed to examine effects of a prior authorization policy for extended-release/long-acting (ER/LA) opioids on opioid use in the Oklahoma, USA state Medicaid program. DESIGN Retrospective difference-in-differences design study comparing changes in opioid use in Oklahoma Medicaid to control (Oregon Medicaid). SETTING Oklahoma and Oregon, USA. PARTICIPANTS Medicaid beneficiaries in the Oklahoma and Oregon fee-for-service Medicaid programs between July 2007 and June 2009 (33 724 in Oklahoma and 13 520 in Oregon) MEASUREMENTS: The primary outcome was incident opioid-naive ER/LA opioid use. Secondary outcomes included other opioid and non-opioid pain medication use. We also examined indicators of high-risk prescribing (e.g. high-dosage opioid use) and opioid-related hospitalizations or emergency department (ED) visits. FINDINGS The prior authorization policy was associated with a 0.7 percentage point reduction in the likelihood of incident opioid-naive ER/LA opioid use [95% confidence interval (CI) = -1.16 to -0.33 percentage points; 70% pre-policy mean reduction, a 1.4 percentage point decrease in likelihood of any new ER/LA opioid prescriptions (95% CI = -2.1 to -0.7 percentage points; 33% pre-policy mean reduction) and a decline of 0.16 in total ER/LA opioid prescriptions per enrollee (PPE) (95% CI = -0.29 to -0.04 PPE)]. There was a significant increase in the number of short-acting opioids filled after the policy (0.36; 95% CI = 0.22-0.50 PPE), increases in likelihood of having overlapping opioids and benzodiazepines, but significant reductions in likelihood of having overlapping opioids. No significant changes in opioid-related hospitalizations or ED visits were observed. CONCLUSIONS In Oklahoma, USA's July 2008 prior authorization policy for extended-release/long-acting opioids appears to have reduced the number of opioid-naive patients initiating extended-release/long-acting opioid use by more than half, but may also have increased short-acting opioid prescriptions by 7%.
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Affiliation(s)
- Shellie L. Keast
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Hyunjee Kim
- Oregon Health and Science University, Portland, OR, USA
| | | | - Luke Middleton
- Oregon State University, Oregon Health and Science University, Portland, OR, USA
| | | | - Kun Zhang
- Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Atlanta, GA, USA
| | - Sharia M. Ahmed
- Oregon State University, Oregon Health and Science University, Portland, OR, USA
| | - Nancy Nesser
- Oklahoma Health Care Authority, Oklahoma City, OK, USA
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Leichtling GJ, Irvine JM, Hildebran C, Cohen DJ, Hallvik SE, Deyo RA. Clinicians' Use of Prescription Drug Monitoring Programs in Clinical Practice and Decision-Making. Pain Med 2018; 18:1063-1069. [PMID: 27794549 DOI: 10.1093/pm/pnw251] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objectives Little is known about clinicians' use of prescription drug monitoring program (PDMP) profiles in decision-making. The objective of this qualitative study was to understand how clinicians use, interpret, and integrate PDMP profiles with other information in making clinical decisions. Design Qualitative interviews of clinician PDMP users. Setting Oregon registrants in the state's PDMP. Subjects Thirty-three clinicians practicing in primary care, emergency medicine, pain management, psychiatry, dentistry, and surgery. Methods We conducted semistructured telephone interviews with PDMP users. A multidisciplinary team used a grounded theory approach to identify patterns of PDMP use and how PDMP profiles influence clinical decisions. Results PDMP use varied from consistent monitoring to checking the PDMP only on suspicion of misuse, with inconsistent use reported particularly among short-term prescribers. Primary care clinicians reported less routine use with existing pain patients than with new patients. In response to worrisome PDMP profiles with new patients, participants reported declining to prescribe, except in the case of acute, verifiable conditions. Long-term prescribers reported sometimes continuing prescriptions for existing patients depending on perceived patient intent, honesty, and opioid misuse risk. Some long-term prescribers reported discharging patients from their practices due to worrisome PDMP profiles; others expressed strong ethical grounds for retaining patients but discontinuing controlled substances. Conclusion Greater consistency is needed in use of PDMP in monitoring existing patients and in conformity to guidelines against discharging patients from practice. Research is needed to determine optimal approaches to interpreting PDMP profiles in relation to clinical judgment, patient screeners, and other information.
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Affiliation(s)
| | | | | | | | | | - Richard A Deyo
- Departments of Family Medicine.,Medicine.,Public Health and Preventive Medicine, Oregon Health and Science University, Portland, Oregon.,Oregon Institute of Occupational Health Sciences, Oregon Health and Science University, Portland, Oregon, USA
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DeBar L, Benes L, Bonifay A, Deyo RA, Elder CR, Keefe FJ, Leo MC, McMullen C, Mayhew M, Owen-Smith A, Smith DH, Trinacty CM, Vollmer WM. Interdisciplinary team-based care for patients with chronic pain on long-term opioid treatment in primary care (PPACT) - Protocol for a pragmatic cluster randomized trial. Contemp Clin Trials 2018; 67:91-99. [PMID: 29522897 PMCID: PMC5931339 DOI: 10.1016/j.cct.2018.02.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 02/23/2018] [Accepted: 02/27/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chronic pain is one of the most common, disabling, and expensive public health problems in the United States. Interdisciplinary pain management treatments that employ behavioral approaches have been successful in helping patients with chronic pain reduce symptoms and regain functioning. However, most patients lack access to such treatments. We are conducting a pragmatic clinical trial to test the hypothesis that patients who receive an interdisciplinary biopsychosocial intervention, the Pain Program for Active Coping and Training (PPACT), at their primary care clinic will have a greater reduction in pain impact in the year following than patients receiving usual care. METHODS/DESIGN This is an effectiveness-implementation hybrid pragmatic clinical trial in which we randomize clusters of primary care providers and their patients with chronic pain who are on long-term opioid therapy to 1) receive an interdisciplinary behavioral intervention in conjunction with their current health care or 2) continue with current health care services. Our primary outcome is pain impact (a composite of pain intensity and pain-related interference) measured using the PEG, a validated three-item assessment. Secondary outcomes include pain-related disability, patient satisfaction, opioids dispensed and health care utilization. An economic evaluation assesses the resources and costs necessary to deliver the intervention and its cost-effectiveness compared with usual care. A formative evaluation employs mixed methods to understand the context for implementation in the participating health care systems. DISCUSSION This trial will inform the feasibility of implementing interdisciplinary behavioral approaches to pain management in the primary care setting, potentially providing a more effective, safer, and more satisfactory alternative to opioid-based chronic pain treatment. Clinical Trials Registration Number: NCT02113592.
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Affiliation(s)
- Lynn DeBar
- Kaiser Permanente Center for Health Research, Portland, OR, United States.
| | - Lindsay Benes
- Kaiser Permanente Center for Health Research, Portland, OR, United States; University of Portland, School of Nursing, Portland, OR, United States
| | - Allison Bonifay
- Kaiser Permanente Center for Health Research, Portland, OR, United States
| | - Richard A Deyo
- Oregon Health and Science University, School of Medicine, Portland, OR, United States
| | - Charles R Elder
- Kaiser Permanente Center for Health Research, Portland, OR, United States
| | - Francis J Keefe
- Duke University, School of Medicine, Durham, NC, United States
| | - Michael C Leo
- Kaiser Permanente Center for Health Research, Portland, OR, United States
| | - Carmit McMullen
- Kaiser Permanente Center for Health Research, Portland, OR, United States
| | - Meghan Mayhew
- Kaiser Permanente Center for Health Research, Portland, OR, United States
| | - Ashli Owen-Smith
- Georgia State University, School of Public Health, Atlanta, GA, United States; Kaiser Permanente Center for Clinical and Outcomes Research, Atlanta, GA, United States
| | - David H Smith
- Kaiser Permanente Center for Health Research, Portland, OR, United States
| | - Connie M Trinacty
- Kaiser Permanente Center for Health Research, Honolulu, HI, United States
| | - William M Vollmer
- Kaiser Permanente Center for Health Research, Portland, OR, United States
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Tapp SJ, Martin BI, Tosteson TD, Lurie JD, Weinstein MC, Deyo RA, Mirza SK, Tosteson ANA. Understanding the value of minimally invasive procedures for the treatment of lumbar spinal stenosis: the case of interspinous spacer devices. Spine J 2018; 18:584-592. [PMID: 28847740 DOI: 10.1016/j.spinee.2017.08.246] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 07/19/2017] [Accepted: 08/21/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Minimally invasive lumbar spinal stenosis procedures have uncertain long-term value. PURPOSE This study sought to characterize factors affecting the long-term cost-effectiveness of such procedures using interspinous spacer devices ("spacers") relative to decompression surgery as a case study. STUDY DESIGN Model-based cost-effectiveness analysis. PATIENT SAMPLE The Medicare Provider Analysis and Review database for the years 2005-2009 was used to model a group of 65-year-old patients with spinal stenosis who had no previous spine surgery and no contraindications to decompression surgery. OUTCOME MEASURES Costs, quality-adjusted life years (QALYs), and cost per QALY gained were the outcome measures. METHODS A Markov model tracked health utility and costs over 10 years for a 65-year-old cohort under three care strategies: conservative care, spacer surgery, and decompression surgery. Incremental cost-effectiveness ratios (ICER) reported as cost per QALY gained included direct medical costsfor surgery. Medicare claims data were used to estimate complication rates, reoperation, and related costs within 3 years. Utilities and long-term reoperation rates for decompression were derived frompublished studies. Spacer failure requiring reoperation beyond 3 years and post-spacer health utilities are uncertain and were evaluated through sensitivity analyses. In the base-case, the spacer failure rate was held constant for years 4-10 (cumulative failure: 47%). In a "worst-case" analysis, the 10-year cumulative reoperation rate was increased steeply (to 90%). Threshold analyses were performed to determine the impact of failure and post-spacer health utility on the cost-effectiveness of spacer surgery. RESULTS The spacer strategy had an ICER of $89,500/QALY gained under base-case assumptions, and remained under $100,000 as long as the 10-year cumulative probability of reoperation did not exceed 54%. Under worst-case assumptions, the spacer ICER was $482,000/QALY and fell below $100,000 only if post-spacer utility was 0.01 greater than post-decompression utility or the cost of spacer surgery was $1,600 less than the cost of decompression surgery. CONCLUSIONS Spacers may provide a reasonably cost-effective initial treatment option for patients with lumbar spinal stenosis. Their value is expected to improve if procedure costs are lower in outpatient settings where these procedures are increasingly being performed. Decision analysis is useful for characterizing the long-term cost-effectiveness potential for minimally invasive spinal stenosis treatments and highlights the importance of complication rates and prospective health utility assessment.
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Affiliation(s)
- Stephanie J Tapp
- Multidisciplinary Clinical Research Center in Musculoskeletal Diseases, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Brook I Martin
- Department of Orthopaedics, University of Utah, Salt Lake City, UT 84158, USA
| | - Tor D Tosteson
- Multidisciplinary Clinical Research Center in Musculoskeletal Diseases, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Jon D Lurie
- Multidisciplinary Clinical Research Center in Musculoskeletal Diseases, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Milton C Weinstein
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Harvard Medical School, 718 Huntington Ave, Boston, MA 02115, USA
| | - Richard A Deyo
- Departments of Family Medicine and Internal Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA
| | - Sohail K Mirza
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA
| | - Anna N A Tosteson
- Multidisciplinary Clinical Research Center in Musculoskeletal Diseases, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.
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Chiarotto A, Boers M, Deyo RA, Buchbinder R, Corbin TP, Costa LO, Foster NE, Grotle M, Koes BW, Kovacs FM, Lin CWC, Maher CG, Pearson AM, Peul WC, Schoene ML, Turk DC, van Tulder MW, Terwee CB, Ostelo RW. Core outcome measurement instruments for clinical trials in nonspecific low back pain. Pain 2018; 159:481-495. [PMID: 29194127 PMCID: PMC5828378 DOI: 10.1097/j.pain.0000000000001117] [Citation(s) in RCA: 236] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 11/09/2017] [Accepted: 11/15/2017] [Indexed: 01/09/2023]
Abstract
To standardize outcome reporting in clinical trials of patients with nonspecific low back pain, an international multidisciplinary panel recommended physical functioning, pain intensity, and health-related quality of life (HRQoL) as core outcome domains. Given the lack of a consensus on measurement instruments for these 3 domains in patients with low back pain, this study aimed to generate such consensus. The measurement properties of 17 patient-reported outcome measures for physical functioning, 3 for pain intensity, and 5 for HRQoL were appraised in 3 systematic reviews following the COSMIN methodology. Researchers, clinicians, and patients (n = 207) were invited in a 2-round Delphi survey to generate consensus (≥67% agreement among participants) on which instruments to endorse. Response rates were 44% and 41%, respectively. In round 1, consensus was achieved on the Oswestry Disability Index version 2.1a for physical functioning (78% agreement) and the Numeric Rating Scale (NRS) for pain intensity (75% agreement). No consensus was achieved on any HRQoL instrument, although the Short Form 12 (SF12) approached the consensus threshold (64% agreement). In round 2, a consensus was reached on an NRS version with a 1-week recall period (96% agreement). Various participants requested 1 free-to-use instrument per domain. Considering all issues together, recommendations on core instruments were formulated: Oswestry Disability Index version 2.1a or 24-item Roland-Morris Disability Questionnaire for physical functioning, NRS for pain intensity, and SF12 or 10-item PROMIS Global Health form for HRQoL. Further studies need to fill the evidence gaps on the measurement properties of these and other instruments.
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Affiliation(s)
- Alessandro Chiarotto
- Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, the Netherlands
- Department of Health Sciences, Faculty of Science, Amsterdam Movement Sciences Research Institute, Vrije Universiteit, Amsterdam, the Netherlands
| | - Maarten Boers
- Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, the Netherlands
- Amsterdam Rheumatology and Immunology Center, VU University Medical Center, Amsterdam, the Netherlands
| | - Richard A. Deyo
- Department of Family Medicine, Department of Internal Medicine, and Oregon Institute of Occupational Health Sciences, Oregon Health and Science University, Portland, OR, USA
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Monash Department of Clinical Epidemiology, Cabrini Institute, Malvern, Australia
| | - Terry P. Corbin
- Cochrane Collaboration, Back and Neck Review Group, Maple Grove, MN, USA
| | - Leonardo O.P. Costa
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de Sao Paulo, Sao Paulo, Brazil
| | - Nadine E. Foster
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom
| | - Margreth Grotle
- Oslo and Akershus University College, Faculty of Health Science, Oslo, Norway
- Communication and Research Unit for Musculoskeletal Disorders (FORMI), Oslo University Hospital & University of Oslo, Oslo, Norway
| | - Bart W. Koes
- Department of General Practice, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Francisco M. Kovacs
- Spanish Back Pain Research Network, Hospital Universitario HLA-Moncloa, Madrid, Spain
| | - C.-W. Christine Lin
- Sydney School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Chris G. Maher
- Sydney School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Adam M. Pearson
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, PA, USA
| | - Wilco C. Peul
- Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Mark L. Schoene
- Cochrane Collaboration, Back and Neck Review Group, Newbury, MA, USA
| | - Dennis C. Turk
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Maurits W. van Tulder
- Department of Health Sciences, Faculty of Science, Amsterdam Movement Sciences Research Institute, Vrije Universiteit, Amsterdam, the Netherlands
| | - Caroline B. Terwee
- Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, the Netherlands
| | - Raymond W. Ostelo
- Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, the Netherlands
- Department of Health Sciences, Faculty of Science, Amsterdam Movement Sciences Research Institute, Vrije Universiteit, Amsterdam, the Netherlands
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Sun BC, Charlesworth CJ, Lupulescu-Mann N, Young JI, Kim H, Hartung DM, Deyo RA, McConnell KJ. Effect of Automated Prescription Drug Monitoring Program Queries on Emergency Department Opioid Prescribing. Ann Emerg Med 2018; 71:337-347.e6. [PMID: 29248333 PMCID: PMC5820164 DOI: 10.1016/j.annemergmed.2017.10.023] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 10/12/2017] [Accepted: 10/19/2017] [Indexed: 12/17/2022]
Abstract
STUDY OBJECTIVE We assess whether an automated prescription drug monitoring program intervention in emergency department (ED) settings is associated with reductions in opioid prescribing and quantities. METHODS We performed a retrospective cohort study of ED visits by Medicaid beneficiaries. We assessed the staggered implementation (pre-post) of automated prescription drug monitoring program queries at 86 EDs in Washington State from January 1, 2013, to September 30, 2015. The outcomes included any opioid prescribed within 1 day of the index ED visit and total dispensed morphine milligram equivalents. The exposure was the automated prescription drug monitoring program query intervention. We assessed program effects stratified by previous high-risk opioid use. We performed multiple sensitivity analyses, including restriction to pain-related visits, restriction to visits with a confirmed prescription drug monitoring program query, and assessment of 6 specific opioid high-risk indicators. RESULTS The study included 1,187,237 qualifying ED visits (898,162 preintervention; 289,075 postintervention). Compared with the preintervention period, automated prescription drug monitoring program queries were not significantly associated with reductions in the proportion of visits with opioid prescribing (5.8 per 1,000 encounters; 95% confidence interval [CI] -0.11 to 11.8) or the amount of prescribed morphine milligram equivalents (difference 2.66; 95% CI -0.15 to 5.48). There was no evidence of selective reduction in patients with previous high-risk opioid use (1.2 per 1,000 encounters, 95% CI -9.5 to 12.0; morphine milligram equivalents 1.22, 95% CI -3.39 to 5.82). The lack of a selective reduction in high-risk patients was robust to all sensitivity analyses. CONCLUSION An automated prescription drug monitoring program query intervention was not associated with reductions in ED opioid prescribing or quantities, even in patients with previous high-risk opioid use.
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Affiliation(s)
- Benjamin C Sun
- Center for Policy Research-Emergency Medicine, Oregon Health & Science University, Portland, OR.
| | | | | | - Jenny I Young
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR
| | - Hyunjee Kim
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR
| | - Daniel M Hartung
- College of Pharmacy, Oregon Health & Science University, Portland, OR; College of Pharmacy, Oregon State University, Portland, OR
| | - Richard A Deyo
- Department of Family Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR; Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, OR
| | - K John McConnell
- Center for Policy Research-Emergency Medicine, Oregon Health & Science University, Portland, OR; Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR
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Hartung DM, Kim H, Ahmed SM, Middleton L, Keast S, Deyo RA, Zhang K, McConnell KJ. Effect of a high dosage opioid prior authorization policy on prescription opioid use, misuse, and overdose outcomes. Subst Abus 2018; 39:239-246. [PMID: 29016245 PMCID: PMC9926935 DOI: 10.1080/08897077.2017.1389798] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND High dosage opioid use is a risk factor for opioid-related overdose commonly cited in guidelines, recommendations, and policies. In 2012, the Oregon Medicaid program developed a prior authorization policy for opioid prescriptions above 120 mg per day morphine equivalent dose (MED). This study aimed to evaluate the effects of that policy on utilization, prescribing patterns, and health outcomes. METHODS Using administrative claims data from Oregon and a control state (Colorado) between 2011 and 2013, we used difference-in-differences analyses to examine changes in utilization, measures of high risk opioid use, and overdose after introduction of the policy. We also evaluated opioid utilization in a cohort of individuals who were high dosage opioid users before the policy. RESULTS Following implementation of Oregon's high dosage policy, the monthly probability of an opioid fill over 120 mg MED declined significantly by 1.7 percentage points (95% confidence interval [CI]; -2.0% to -1.4%), whereas it increased significantly by 1.0 percentage points (95% CI 0.4% to 1.7%) for opioid fills < 61 mg MED. Fills of medications used to treat neuropathic pain also increased by 1.2 percentage points (95% CI 0.7% to 1.8%). The monthly probability of multiple pharmacy use declined by 0.1 percentage points (-0.2% to -0.0) following the prior authorization, but there were no significant changes in ED encounters or hospitalizations for opioid overdose. Among individuals who were using a high dosage opioid before the policy, there was a 20.3 percentage point (95% CI -15.3% to -25.3%) decline in estimated probability of having a high dosage fill after the policy. CONCLUSIONS Oregon's prior authorization policy was effective at reducing high dosage opioid prescriptions. While multiple pharmacy use also declined, we found no impact on opioid overdose were observed.
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Affiliation(s)
- Daniel M. Hartung
- Oregon State University/Oregon Health & Science University, College of Pharmacy, Portland, Oregon, USA
| | - Hyunjee Kim
- Oregon Health & Science University, Center for Health Systems Effectiveness, Portland, Oregon, USA
| | - Sharia M. Ahmed
- Oregon State University/Oregon Health & Science University, College of Pharmacy, Portland, Oregon, USA
| | - Luke Middleton
- Oregon State University/Oregon Health & Science University, College of Pharmacy, Portland, Oregon, USA
| | - Shellie Keast
- University of Oklahoma College of Pharmacy, Department of Clinical and Administrative Sciences, Oklahoma City, Oklahoma, USA
| | - Richard A. Deyo
- Oregon Health & Science University, Center for Health Systems Effectiveness, Portland, Oregon, USA
| | - Kun Zhang
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - K. John McConnell
- Oregon Health & Science University, Center for Health Systems Effectiveness, Portland, Oregon, USA
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Nugent SM, Yarborough BJ, Smith NX, Dobscha SK, Deyo RA, Green CA, Morasco BJ. Patterns and correlates of medical cannabis use for pain among patients prescribed long-term opioid therapy. Gen Hosp Psychiatry 2018; 50:104-110. [PMID: 29153783 PMCID: PMC5788035 DOI: 10.1016/j.genhosppsych.2017.11.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 11/03/2017] [Accepted: 11/04/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Little is known about co-occurring long-term opioid therapy (LTOT) and medical cannabis use. We compared characteristics of patients prescribed LTOT who endorsed using medical cannabis for pain to patients who did not report cannabis use. METHOD Participants (n=371) prescribed LTOT completed self-report measures about pain, substance use, and mental health. RESULTS Eighteen percent of participants endorsed using medical cannabis for pain. No significant differences were detected on pain-related variables, depression, or anxiety between those who endorsed medical cannabis use and those who did not. Medical cannabis users had higher scores of risk for prescription opioid misuse (median=17.0 vs. 11.5, p<0.001), rates of hazardous alcohol use (25% vs. 16%, p<0.05), and rates of nicotine use (42% vs. 26%, p=0.01). Multivariable analyses indicated that medical cannabis use was significantly associated with risk of prescription opioid misuse (β=0.17, p=0.001), but not hazardous alcohol use (aOR=1.96, 95% CI=0.96-4.00, p=0.06) or nicotine use (aOR=1.61, 95% CI=0.90-2.88, p=0.11). CONCLUSION There are potential risks associated with co-occurring LTOT and medical cannabis for pain. Study findings highlight the need for further clinical evaluation in this population. Future research is needed to examine the longitudinal impact of medical cannabis use on pain-related and substance use outcomes.
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Affiliation(s)
- Shannon M. Nugent
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System,Mental Health and Clinical Neurosciences Division, VA Portland Health Care System,Department of Psychiatry, Oregon Health & Science University
| | | | - Ning X. Smith
- Kaiser Permanente Northwest Center for Health Research
| | - Steven K. Dobscha
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System,Mental Health and Clinical Neurosciences Division, VA Portland Health Care System,Department of Psychiatry, Oregon Health & Science University
| | - Richard A. Deyo
- Kaiser Permanente Northwest Center for Health Research,Departments of Family Medicine, Internal Medicine, and the Oregon Institute for Occupational Health Sciences, Oregon Health & Science University,Public Health and Preventive Medicine, Oregon Health & Science University
| | - Carla A. Green
- Kaiser Permanente Northwest Center for Health Research,Public Health and Preventive Medicine, Oregon Health & Science University
| | - Benjamin J. Morasco
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System,Mental Health and Clinical Neurosciences Division, VA Portland Health Care System,Department of Psychiatry, Oregon Health & Science University
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Marshall LM, Litwack-Harrison S, Makris UE, Kado DM, Cawthon PM, Deyo RA, Carlson NL, Nevitt MC. A Prospective Study of Back Pain and Risk of Falls Among Older Community-dwelling Men. J Gerontol A Biol Sci Med Sci 2017; 72:1264-1269. [PMID: 27852636 DOI: 10.1093/gerona/glw227] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 10/25/2016] [Indexed: 01/23/2023] Open
Abstract
Background Musculoskeletal pain is associated with increased fall risk among older men. However, the association of back pain, the most prevalent type of pain in this population, and fall risk is unknown. Methods We conducted a prospective investigation among 5,568 community-dwelling U.S. men at least 65 years of age from the Osteoporotic Fractures in Men Study (MrOS). Baseline questionnaires inquired about back pain and its location (such as low back), severity, and frequency in the past year. During 1 year of follow-up, falls were summed from self-reports obtained every 4 months. Outcomes were recurrent falls (≥2 falls) and any fall (≥1 fall). Associations of back pain and fall risk were estimated with risk ratios (RRs) and 95% confidence intervals (CIs) from multivariable log-binomial regression models adjusted for age, dizziness, arthritis, knee pain, urinary symptoms, self-rated health, central nervous system medication use, and instrumental activities of daily living. Results Most (67%) reported any back pain in the past year. During follow-up, 11% had recurrent falls and 25% fell at least once. Compared with no back pain, any back pain was associated with elevated recurrent fall risk (multivariable RR = 1.3, 95% CI: 1.1, 1.5). Multivariable RRs for 1, 2, and 3+ back pain locations were, respectively, 1.2 (95% CI: 1.0, 1.5), 1.4 (1.1, 1.8), and 1.7 (95% CI: 1.3, 2.2). RRs were also elevated for back pain severity and frequency. Back pain was also associated with risk of any fall. Conclusions Among older men, back pain is independently associated with increased fall risk.
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Affiliation(s)
- Lynn M Marshall
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland
| | | | - Una E Makris
- Department of Internal Medicine, VA North Texas Health Care System.,Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Deborah M Kado
- Department of Family Medicine and Public Health.,Department of Internal Medicine, University of California, San Diego
| | - Peggy M Cawthon
- California Pacific Medical Center Research Institute, San Francisco
| | - Richard A Deyo
- Department of Family Medicine, Oregon Health and Science University, Portland
| | - Nels L Carlson
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland
| | - Michael C Nevitt
- Department of Epidemiology and Biostatistics, University of California, San Francisco
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Hartung DM, Ahmed SM, Middleton L, Van Otterloo J, Zhang K, Keast S, Kim H, Johnston K, Deyo RA. Using prescription monitoring program data to characterize out-of-pocket payments for opioid prescriptions in a state Medicaid program. Pharmacoepidemiol Drug Saf 2017; 26:1053-1060. [PMID: 28722211 PMCID: PMC9926937 DOI: 10.1002/pds.4254] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 05/12/2017] [Accepted: 06/12/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Out-of-pocket payment for prescription opioids is believed to be an indicator of abuse or diversion, but few studies describe its epidemiology. Prescription drug monitoring programs (PDMPs) collect controlled substance prescription fill data regardless of payment source and thus can be used to study this phenomenon. OBJECTIVE To estimate the frequency and characteristics of prescription fills for opioids that are likely paid out-of-pocket by individuals in the Oregon Medicaid program. RESEARCH DESIGN Cross-sectional analysis using Oregon Medicaid administrative claims and PDMP data (2012 to 2013). SUBJECTS Continuously enrolled nondually eligible Medicaid beneficiaries who could be linked to the PDMP with two opioid fills covered by Oregon Medicaid. MEASURES Patient characteristics and fill characteristics for opioid fills that lacked a Medicaid pharmacy claim. Fill characteristics included opioid name, type, and association with indicators of high-risk opioid use. RESULTS A total of 33 592 Medicaid beneficiaries filled a total of 555 103 opioid prescriptions. Of these opioid fills, 74 953 (13.5%) could not be matched to a Medicaid claim. Hydromorphone (30%), fentanyl (18%), and methadone (15%) were the most likely to lack a matching claim. The 3 largest predictors for missing claims were opioid fills that overlapped with other opioids (adjusted odds ratio [aOR] 1.37; 95% confidence interval [CI], 1.34-1.4), long-acting opioids (aOR 1.52; 95% CI, 1.47-1.57), and fills at multiple pharmacies (aOR 1.45; 95% CI, 1.39-1.52). CONCLUSIONS Prescription opioid fills that were likely paid out-of-pocket were common and associated with several known indicators of high-risk opioid use.
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Affiliation(s)
- Daniel M. Hartung
- Oregon State University/Oregon Health & Science University, Portland, OR, USA
| | - Sharia M. Ahmed
- Oregon State University/Oregon Health & Science University, Portland, OR, USA
| | - Luke Middleton
- Oregon State University/Oregon Health & Science University, Portland, OR, USA
| | | | - Kun Zhang
- US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Shellie Keast
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Hyunjee Kim
- Oregon Health & Science University, Portland, OR, USA
| | - Kirbee Johnston
- Oregon State University/Oregon Health & Science University, Portland, OR, USA
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Friedly JL, Comstock BA, Turner JA, Heagerty PJ, Deyo RA, Bauer Z, Avins AL, Nedeljkovic SS, Nerenz DR, Shi X(R, Annaswamy T, Standaert CJ, Smuck M, Kennedy DJ, Akuthota V, Sibell D, Wasan AD, Diehn F, Suri P, Rundell SD, Kessler L, Chen AS, Jarvik JG. Long-Term Effects of Repeated Injections of Local Anesthetic With or Without Corticosteroid for Lumbar Spinal Stenosis: A Randomized Trial. Arch Phys Med Rehabil 2017; 98:1499-1507.e2. [DOI: 10.1016/j.apmr.2017.02.029] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 02/22/2017] [Accepted: 02/24/2017] [Indexed: 11/15/2022]
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Sun BC, Lupulescu-Mann N, Charlesworth CJ, Kim H, Hartung DM, Deyo RA, John McConnell K. Impact of Hospital "Best Practice" Mandates on Prescription Opioid Dispensing After an Emergency Department Visit. Acad Emerg Med 2017; 24:905-913. [PMID: 28544288 PMCID: PMC5552416 DOI: 10.1111/acem.13230] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 05/06/2017] [Accepted: 05/15/2017] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Washington State mandated seven hospital "best practices" in July 2012, several of which may affect emergency department (ED) opioid prescribing and provide a policy template for addressing the opioid prescription epidemic. We tested the hypothesis that the mandates would reduce opioid dispensing after an ED visit. We further assessed for a selective effect in patients with prior risky or chronic opioid use. METHODS We performed a retrospective, observational analysis of ED visits by Medicaid fee-for-service beneficiaries in Washington State, between July 1, 2011, and June 30, 2013. We used an interrupted time-series design to control for temporal trends and patient characteristics. The primary outcome was any opioid dispensing within 3 days after an ED visit. The secondary outcome was total morphine milligram equivalents (MMEs) dispensed within 3 days. RESULTS We analyzed 266,614 ED visits. Mandates were associated with a small reduction in opioid dispensing after an ED visit (-1.5%, 95% confidence interval [CI] = -2.8% to -0.15%). The mandates were associated with decreased opioid dispensing in 42,496 ED visits by patients with prior risky opioid use behavior (-4.7%, 95% CI = -7.1% to -2.3%) and in 20,238 visits by patients with chronic opioid use (-3.6%, 95% CI = -5.6% to -1.7%). Mandates were not associated with reductions in MMEs per dispense in the overall cohort or in either subgroup. CONCLUSIONS Washington State best practice mandates were associated with small but nonselective reductions in opioid prescribing rates. States should focus on alternative policies to further reduce opioid dispensing in subgroups of high-risk and chronic users.
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Affiliation(s)
- Benjamin C Sun
- Center for Policy Research-Emergency Medicine, Department of Emergency Medicine, Oregon Health and Science University, Portland, OR
| | | | | | - Hyunjee Kim
- Center for Health Systems Effectiveness, Oregon Health and Science University, Portland, OR
| | - Daniel M Hartung
- College of Pharmacy, Oregon State University/Oregon Health and Science University, Portland, OR
| | - Richard A Deyo
- Department of Family Medicine, Department of Medicine, Department of Public Health and Preventive Medicine, and Oregon Institute of Occupational Health Sciences, Oregon Health and Science University, Portland, OR
| | - K John McConnell
- Center for Policy Research-Emergency Medicine, Department of Emergency Medicine, Oregon Health and Science University, Portland, OR
- Center for Health Systems Effectiveness, Oregon Health and Science University, Portland, OR
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Affiliation(s)
- Richard A Deyo
- Department of Family Medicine, Oregon Health and Science University, Portland2Department of Medicine, Oregon Health and Science University, Portland3Oregon Institute for Occupational Health Sciences, Oregon Health and Science University, Portland
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Buchbinder R, Kallmes DF, Jarvik JG, Deyo RA. Conduct and reporting of a vertebroplasty trial warrants critical examination. ACTA ACUST UNITED AC 2017; 22:106-107. [DOI: 10.1136/ebmed-2016-110651] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Penney LS, Ritenbaugh C, DeBar LL, Elder C, Deyo RA. Provider and patient perspectives on opioids and alternative treatments for managing chronic pain: a qualitative study. BMC Fam Pract 2017; 17:164. [PMID: 28403822 PMCID: PMC5390355 DOI: 10.1186/s12875-016-0566-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Accepted: 11/17/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Current literature describes the limits and pitfalls of using opioid pharmacotherapy for chronic pain and the importance of identifying alternatives. The objective of this study was to identify the practical issues patients and providers face when accessing alternatives to opioids, and how multiple parties view these issues. METHODS Qualitative data were gathered to evaluate the outcomes of acupuncture and chiropractic (A/C) services for chronic musculoskeletal pain (CMP) using structured interview guides among patients with CMP (n = 90) and primary care providers (PCPs) (n = 25) purposively sampled from a managed care health care system as well as from contracted community A/C providers (n = 14). Focus groups and interviews were conducted patients with CMP with varying histories of A/C use. Plan PCPs and contracted A/C providers took part in individual interviews. All participants were asked about their experiences managing chronic pain and experience with and/or attitudes about A/C treatment. Audio recordings were transcribed and thematically coded. A summarized version of the focus group/interview guides is included in the Additional file 1. RESULTS We identified four themes around opioid use: (1) attitudes toward use of opioids to manage chronic pain; (2) the limited alternative options for chronic pain management; (3) the potential of A/C care as a tool to help manage pain; and (4) the complex system around chronic pain management. Despite widespread dissatisfaction with opioid medications for pain management, many practical barriers challenged access to other options. Most of the participants' perceived A/C care as helpful for short term pain relief. We identified that problems with timing, expectations, and plan coverage limited A/C care potential for pain relief treatment. CONCLUSIONS These results suggest that education about realistic expectations for chronic pain management and therapy options, as well as making A/C care more easily accessible, might lead to more satisfaction for patients and providers, and provide important input to policy makers. TRIAL REGISTRATION ClinicalTrials.gov NCT01345409 , date of registration 28/4/2011.
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Affiliation(s)
- Lauren S. Penney
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX 78229 USA
| | - Cheryl Ritenbaugh
- The University of Arizona, Department of Family and Community Medicine, 1450N. Cherry Ave, Tucson, AZ 85719 USA
| | - Lynn L. DeBar
- Kaiser Permanente Center for Health Research Northwest Region, 3800N. Interstate Ave, Portland, OR 97227 USA
| | - Charles Elder
- Kaiser Permanente Center for Health Research Northwest Region, 3800N. Interstate Ave, Portland, OR 97227 USA
| | - Richard A. Deyo
- Oregon Health & Science University, 3181S.W. Sam Jackson Park Rd, Portland, OR 97239 USA
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Johnson ES, Dickerson JF, Vollmer WM, Rowley AM, Ritenbaugh C, Deyo RA, DeBar L. The feasibility of matching on a propensity score for acupuncture in a prospective cohort study of patients with chronic pain. BMC Med Res Methodol 2017; 17:42. [PMID: 28302054 PMCID: PMC5356308 DOI: 10.1186/s12874-017-0318-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 03/02/2017] [Indexed: 11/13/2022] Open
Abstract
Background Propensity scores are typically applied in retrospective cohort studies. We describe the feasibility of matching on a propensity score derived from a retrospective cohort and subsequently applied in a prospective cohort study of patients with chronic musculoskeletal pain before the start of acupuncture or usual care treatment and enrollment in a comparative effectiveness study that required patient reported pain outcomes. Methods We assembled a retrospective cohort study using data from 2010 to develop a propensity score for acupuncture versus usual care based on electronic healthcare record and administrative data (e.g., pharmacy) from an integrated health plan, Kaiser Permanente Northwest. The propensity score’s probabilities allowed us to match acupuncture-referred and non-referred patients prospectively in 2013-14 after a routine outpatient visit for pain. Among the matched patients, we collected patient-reported pain before treatment and during follow-up to assess the comparative effectiveness of acupuncture. We assessed balance in patient characteristics with the post-matching c-statistic and standardized differences. Results Based on the propensity score and other characteristics (e.g., patient-reported pain), we were able to match all 173 acupuncture-referred patients to 350 non-referred (usual care) patients. We observed a residual imbalance (based on the standardized differences) for some characteristics that contributed to the score; for example, age, -0.283, and the Charlson comorbidity score, -0.264, had the largest standardized differences. The overall balance of the propensity score appeared more favorable according to the post-matching c-statistic, 0.503. Conclusion The propensity score matching was feasible statistically and logistically and allowed approximate balance on patient characteristics, some of which will require adjustment in the comparative effectiveness regression model. By transporting propensity scores to new patients, healthcare systems with electronic health records can conduct comparative effectiveness cohort studies that require prospective data collection, such as patient-reported outcomes, while approximately balancing numerous patient characteristics that might confound the benefit of an intervention. The approach offers a new study design option.
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Affiliation(s)
- Eric S Johnson
- The Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate Avenue, Portland, OR, 97227-1099, USA.
| | - John F Dickerson
- The Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate Avenue, Portland, OR, 97227-1099, USA
| | - William M Vollmer
- The Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate Avenue, Portland, OR, 97227-1099, USA
| | - Alee M Rowley
- The Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate Avenue, Portland, OR, 97227-1099, USA
| | - Cheryl Ritenbaugh
- Department of Family and Community Medicine, The University of Arizona, 1450 North Cherry Avenue, Tucson, AZ, 85719, USA
| | - Richard A Deyo
- Department of Family Medicine, Oregon Health and Science University, Mail Code FM, 3181 Sam Jackson Road, Portland, OR, 97239, USA
| | - Lynn DeBar
- The Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate Avenue, Portland, OR, 97227-1099, USA
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Deyo RA, Buckley DI, Michaels L, Kobus A, Eckstrom E, Forro V, Morris C. Performance of a Patient Reported Outcomes Measurement Information System (PROMIS) Short Form in Older Adults with Chronic Musculoskeletal Pain. Pain Med 2017; 17:314-24. [PMID: 26814279 DOI: 10.1093/pm/pnv046] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To assess reliability, validity, and responsiveness of a 29-item short-form version of the Patient Reported Outcomes Measurement Information System (PROMIS) and a novel “impact score” calculated from those measures. DESIGN Prospective cohort study. SETTING Rural primary care practices. SUBJECTS Adults aged ≥ 55 years with chronic musculoskeletal pain, not currently receiving prescription opioids. METHODS Subjects completed the PROMIS short form at baseline and after 3 months. Patient subsets were compared to assess reliability and responsiveness. Construct validity was tested by comparing baseline scores among patients who were or were not applying for Worker's Compensation; those with higher or lower catastrophizing scores; and those with or without recent falls. Responsiveness was assessed with mean score changes, effect sizes, and standardized response means. RESULTS Internal consistency was good to excellent, with Cronbach's alpha between 0.81 and 0.95 for all scales. Among patients who rated their pain as stable, test-retest scores at 3 months were around 0.70 for most scales. PROMIS scores were worse among patients seeking or receiving worker's compensation, those with high catastrophizing scores, and those with recent falls. Among patients rating pain as “much less” at 3 months, absolute effect sizes for the various scales ranged from 0.24 (Depression) to 1.93 (Pain Intensity). CONCLUSIONS Results indicate that the PROMIS short 29-item form may be useful for the study of patients with chronic musculoskeletal pain. Our findings also support use of the novel “impact score” recommended by the National Institutes of Health (NIH) Task Force on Research Standards for Chronic Low Back Pain.
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Gold LS, Bryan M, Comstock BA, Bresnahan BW, Deyo RA, Nedeljkovic SS, Nerenz DR, Heagerty P, Jarvik JG. Associations Between Relative Value Units and Patient-Reported Back Pain and Disability. Gerontol Geriatr Med 2017; 3:2333721416686019. [PMID: 28405596 PMCID: PMC5384601 DOI: 10.1177/2333721416686019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 11/23/2016] [Accepted: 11/28/2016] [Indexed: 11/27/2022] Open
Abstract
Objective: To describe associations between health care utilization measures and patient-reported outcomes (PROs). Method: Primary data were collected from patients ≥65 years with low back pain visits from 2011 to 2013. Six PROs of pain and functionality were collected 12 and 24 months after the index visits and total and spine-specific relative value units (RVUs) from electronic health records were tabulated over 1 year. We calculated correlation coefficients between RVUs and 12- and 24-month PROs and conducted linear regressions with each 12- and 24-month PRO as the outcome variables and RVUs as predictors of interest. Results: We observed very weak correlations between worse PROs at 12 and 24 months and greater 12-month utilization. In regression analyses, we observed slight associations between greater utilization and worse 12- and 24-month PROs. Discussion: We found that 12-month health care utilization is not strongly associated with PROs at 12 or 24 months.
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Affiliation(s)
| | | | | | | | | | - Srdjan S. Nedeljkovic
- Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Vanguard Medical Associates, Chestnut Hill, MA, USA
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Deyo RA, Hallvik SE, Hildebran C, Marino M, Dexter E, Irvine JM, O'Kane N, Van Otterloo J, Wright DA, Leichtling G, Millet LM. Association Between Initial Opioid Prescribing Patterns and Subsequent Long-Term Use Among Opioid-Naïve Patients: A Statewide Retrospective Cohort Study. J Gen Intern Med 2017; 32:21-27. [PMID: 27484682 PMCID: PMC5215151 DOI: 10.1007/s11606-016-3810-3] [Citation(s) in RCA: 239] [Impact Index Per Article: 34.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 06/20/2016] [Accepted: 06/29/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Long-term efficacy of opioids for non-cancer pain is unproven, but risks argue for cautious prescribing. Few data suggest how long or how much opioid can be prescribed for opioid-naïve patients without inadvertently promoting long-term use. OBJECTIVE To examine the association between initial opioid prescribing patterns and likelihood of long-term use among opioid-naïve patients. DESIGN Retrospective cohort study; data from Oregon resident prescriptions linked to death certificates and hospital discharges. PARTICIPANTS Patients filling opioid prescriptions between October 1, 2012, and September 30, 2013, with no opioid fills for the previous 365 days. Subgroup analyses examined patients under age 45 who did not die in the follow-up year, excluding most cancer or palliative care patients. MAIN MEASURES Exposure: Numbers of prescription fills and cumulative morphine milligram equivalents (MMEs) dispensed during 30 days following opioid initiation ("initiation month"). OUTCOME Proportion of patients with six or more opioid fills during the subsequent year ("long-term users"). KEY RESULTS There were 536,767 opioid-naïve patients who filled an opioid prescription. Of these, 26,785 (5.0 %) became long-term users. Numbers of fills and cumulative MMEs during the initiation month were associated with long-term use. Among patients under age 45 using short-acting opioids who did not die in the follow-up year, the adjusted odds ratio (OR) for long-term use among those receiving two fills versus one was 2.25 (95 % CI: 2.17, 2.33). Compared to those who received < 120 total MMEs, those who received between 400 and 799 had an OR of 2.96 (95 % CI: 2.81, 3.11). Patients initiating with long-acting opioids had a higher risk of long-term use than those initiating with short-acting drugs. CONCLUSIONS Early opioid prescribing patterns are associated with long-term use. While patient characteristics are important, clinicians have greater control over initial prescribing. Our findings may help minimize the risk of inadvertently initiating long-term opioid use.
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Affiliation(s)
- Richard A Deyo
- Department of Family Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code FM, Portland, OR, 97239, USA. .,Department of Public Health and Preventive Medicine, Oregon Health and Science University, Portland, OR, USA. .,Department of Medicine and The Oregon Institute for Occupational Health Sciences, Oregon Health and Science University, Portland, OR, USA.
| | | | | | - Miguel Marino
- Department of Family Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code FM, Portland, OR, 97239, USA.,Department of Public Health and Preventive Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Eve Dexter
- Department of Family Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code FM, Portland, OR, 97239, USA
| | - Jessica M Irvine
- Acumentra Health, Portland, OR, USA.,OCHIN Inc., Portland, OR, USA
| | | | - Joshua Van Otterloo
- Injury and Violence Prevention Program for the State of Oregon, Portland, OR, USA
| | - Dagan A Wright
- Injury and Violence Prevention Program for the State of Oregon, Portland, OR, USA
| | | | - Lisa M Millet
- Injury and Violence Prevention Program for the State of Oregon, Portland, OR, USA
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Elder CR, Debar LL, Ritenbaugh C, Rumptz MH, Patterson C, Bonifay A, Cowan P, Lancaster L, Deyo RA. Health Care Systems Support to Enhance Patient-Centered Care: Lessons from a Primary Care-Based Chronic Pain Management Initiative. Perm J 2017; 21:16-101. [PMID: 28406791 PMCID: PMC5391786 DOI: 10.7812/tpp/16-101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Supporting day-to-day self-care activities has emerged as a best practice when caring for patients with chronic pain, yet providing this support may introduce challenges for both patients and primary care physicians. It is essential to develop tools that help patients identify the issues and outcomes that are most important to them and to communicate this information to primary care physicians at the point of care. OBJECTIVE We describe our process to engage patients, primary care physicians, and other stakeholders in the context of a pilot randomized controlled trial of a patient-centered assessment process implemented in an everyday practice setting. We identify lessons on how to engage stakeholders and improve patient-centered care for those with chronic conditions within the primary care setting. METHODS A qualitative analysis of project minutes, interviews, and focus groups was conducted to evaluate stakeholder experiences. Stakeholders included patients, caregivers, clinicians, medical office support staff, health plan administrators, an information technology consultant, and a patient advocate. RESULTS Our stakeholders included many patients with no prior experience with research. This approach enriched the applicability of feedback but necessitated extra time for stakeholder training and meeting preparation. Types of stakeholders varied over the course of the project, and more involvement of medical assistants and Information Technology staff was required than originally anticipated. CONCLUSION Meaningful engagement of patient and physician stakeholders must be solicited in a well-coordinated manner with broad health care system supports in place to ensure full execution of patient-centered processes.
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Affiliation(s)
- Charles R Elder
- Physician Lead for Integrative Medicine at Kaiser Permanente Northwest and an Affiliate Investigator at the Center for Health Research in Portland, OR.
| | - Lynn L Debar
- Senior Investigator at the Kaiser Permanente Center for Health Research in Portland, OR.
| | - Cheryl Ritenbaugh
- Professor Emerita in the Department of Family and Community Medicine and Anthropology at the University of Arizona in Tucson.
| | - Maureen H Rumptz
- Research Program Manager in the Science Programs Department of the Center for Health Research in Portland, OR.
| | - Charlotte Patterson
- Physician in the School of Community Medicine at the University of Bristol in the United Kingdom.
| | - Allison Bonifay
- Research Associate in the Behavior Assessment and Change Department at the Center for Health Research in Portland, OR.
| | - Penney Cowan
- Director of the American Chronic Pain Associate in Rocklin, CA.
| | - Lindsay Lancaster
- Assistant Professor at the School of Nursing at the University of Portland in OR.
| | - Richard A Deyo
- Professor of Family Medicine and Internal Medicine at the Oregon Institute for Occupational Health Sciences at Oregon Health and Science University in Portland. He is also a Clinical Investigator at the Center for Health Research in Portland, OR.
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Deyo RA. Watch Your Back! How the Back Pain Industry Is Costing Us More and Giving Us Less. Fam Med 2016; 48:821-822. [PMID: 27875611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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Beachler DC, Yanik EL, Martin BI, Pfeiffer RM, Mirza SK, Deyo RA, Engels EA. Bone Morphogenetic Protein Use and Cancer Risk Among Patients Undergoing Lumbar Arthrodesis: A Case-Cohort Study Using the SEER-Medicare Database. J Bone Joint Surg Am 2016; 98:1064-72. [PMID: 27385679 PMCID: PMC4928039 DOI: 10.2106/jbjs.15.01106] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Recombinant bone morphogenetic proteins (BMPs) are growth factors utilized in lumbar arthrodeses. Limited data from randomized trials suggest that BMP may increase cancer risk. We sought to evaluate cancer risk and mortality following the use of BMP in lumbar arthrodesis. METHODS Within the linked Surveillance, Epidemiology, and End Results (SEER) Program-Medicare cohort, we conducted a case-cohort study of 7,278 individuals who were ≥65 years of age and had undergone a lumbar arthrodesis from 2004 to 2011. Of these patients, 3,627 were individuals in a 5% random subcohort of Medicare enrollees in SEER areas including 191 who developed cancer, and there were 3,651 individuals outside the subcohort who developed cancer. Weighted Cox proportional-hazards regression was used to estimate hazard ratios (HRs) and 95% confidence intervals (95% CIs) for cancer on the basis of exposure to BMP. RESULTS In the SEER-Medicare subcohort, 30.7% of individuals who underwent a lumbar arthrodesis received BMP. BMP was not associated with overall cancer risk in univariate analyses (HR, 0.92 [95% CI, 0.82 to 1.02]) or after adjustment for demographic characteristics, comorbidities, hospital size, history of cancer, and calendar year (adjusted HR, 0.94 [95% CI, 0.84 to 1.05]). Individual cancer types were also not significantly elevated (p > 0.05 for all) in BMP users compared with nonusers. In addition, BMP use was not associated with a new cancer in people who had cancer prior to undergoing lumbar arthrodesis (adjusted HR, 1.04 [95% CI, 0.71 to 1.52]) or with mortality after a cancer diagnosis (adjusted HR, 1.05 [95% CI, 0.93 to 1.19]). CONCLUSIONS In a large population of elderly U.S. adults undergoing lumbar arthrodesis, BMP use was not associated with cancer risk or mortality. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Daniel C. Beachler
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland,E-mail address for D.C. Beachler:
| | - Elizabeth L. Yanik
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Brook I. Martin
- The Dartmouth Institute for Health Policy and Clinical Practice (B.I.M. and S.K.M.) and the Department of Orthopaedic Surgery (S.K.M.), Dartmouth Geisel School of Medicine, Hanover, New Hampshire
| | - Ruth M. Pfeiffer
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Sohail K. Mirza
- The Dartmouth Institute for Health Policy and Clinical Practice (B.I.M. and S.K.M.) and the Department of Orthopaedic Surgery (S.K.M.), Dartmouth Geisel School of Medicine, Hanover, New Hampshire
| | - Richard A. Deyo
- Departments of Family Medicine, Medicine, and Public Health and Preventative Medicine and the Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, Oregon
| | - Eric A. Engels
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
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O'Kane N, Hallvik SE, Marino M, Van Otterloo J, Hildebran C, Leichtling G, Deyo RA. Preparing a prescription drug monitoring program data set for research purposes. Pharmacoepidemiol Drug Saf 2016; 25:993-7. [PMID: 27273809 DOI: 10.1002/pds.4039] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Revised: 04/21/2016] [Accepted: 04/29/2016] [Indexed: 11/07/2022]
Abstract
PURPOSE To develop a complete and consistent prescription drug monitoring program (PDMP) data set for use by drug safety researchers in evaluating patterns of high-risk use and potential abuse of scheduled drugs. METHODS Using publically available data references from the US Food and Drug Administration and the Centers for Disease Control and Prevention, we developed a strategic methodology to assign drug categories based on pharmaceutical class for the majority of prescriptions in the PDMP data set. We augmented data elements required to calculate morphine milligram equivalents and assigned duration of action (short-acting or long acting) properties for a majority of opioids in the data set. RESULTS About 10% of prescriptions in the PDMP data set did not have a vendor-assigned drug category, and 20% of opioid prescriptions were missing data needed to calculate risk metrics. Using inclusive methods, 19 133 167 (>99.9%) of prescriptions in the PDMP data set were assigned a drug category. For the opioid category, augmenting data elements resulted in 10 760 669 (99.8%) having required values to calculate morphine milligram equivalents and evaluate duration of action properties. CONCLUSIONS Drug safety researchers who require a complete and consistent PDMP data set can use the methods described here to ensure that prescriptions of interest are assigned consistent drug categories and complete opioid risk variable values. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
| | | | - Miguel Marino
- Department of Family Medicine, Oregon Health and Science University, Portland, OR, USA.,Division of Biostatistics, Department of Public Health and Preventive Medicine, Oregon Health and Science University, Portland, OR, USA
| | | | | | | | - Richard A Deyo
- Department of Family Medicine, Oregon Health and Science University, Portland, OR, USA.,Department of Medicine, Oregon Health and Science University, Portland, OR, USA.,Department of Public Health and Preventive Medicine, Oregon Health and Science University, Portland, OR, USA.,Oregon Institute of Occupational Health Sciences, Portland, OR, USA
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Affiliation(s)
- Richard A Deyo
- From the Departments of Family Medicine, Medicine, and Public Health and Preventive Medicine, and the Oregon Institute of Occupational Health Sciences, Oregon Health and Science University, Portland (R.A.D.); and the Department of Orthopaedic Surgery and the Dartmouth Institute, Dartmouth Geisel School of Medicine, Hanover, NH (S.K.M.)
| | - Sohail K Mirza
- From the Departments of Family Medicine, Medicine, and Public Health and Preventive Medicine, and the Oregon Institute of Occupational Health Sciences, Oregon Health and Science University, Portland (R.A.D.); and the Department of Orthopaedic Surgery and the Dartmouth Institute, Dartmouth Geisel School of Medicine, Hanover, NH (S.K.M.)
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Abstract
The role of the hippocampus (HFC) in trace eye-blink conditioning was evaluated using a 100-ms tone conditioned stimulus (CS), a 300- or 500-ms trace interval, and a 150-ms air puff unconditioned stimulus (UCS). Rabbits received complete hippocampectomy (dorsal & ventral), sham lesions, or neocortical lesions. Hippocampectomy produced differential effects in relation to the trace interval used. With a 300-ms trace interval, HPC-lesioned Ss showed profound resistance to extinction after acquisition. With a 500-ms trace interval, HPC-lesioned Ss did not learn the task (only 22% conditioned responses (CRs) after 25 sessions, whereas controls showed >80% after 10 sessions), and on the few trials in which a CR occurred, most were "nonadaptive" short-latency CRs (i.e., they started during or just after the CS and always terminated prior to UCS onset). The authors conclude that the HPC encodes a temporal relationship between CS and UCS, and when the trace interval is long enough (e.g., 500 ms), that the HPC is necessary for associative learning of the conditioned eye-blink response.
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Affiliation(s)
- James R Moyer
- Department of Cell, Molecular, and Structural Biology
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