Analgesics For Chronic Non-cancer Pain Research Articles

Prescription of Opioid Analgesics for Chronic Non-Cancer Pain in Germany despite Contraindications: Administrative Claims Data Analysis.

In Germany, long-term opioid treatment (L-TOT) for chronic non-tumor pain (CNTP) is discussed as not being performed according to the German guideline on L-TOT for CNTP. In the present analysis, the occurrence and predictors of inappropriate care/overuse in a cohort of German insureds with L-TOT for CNTP by the presence of a contraindication with concurrent opioid analgesic (OA) therapy were investigated. We also analyzed whether prescribing physicians themselves diagnosed a contraindication. The retrospective cohort study was based on administrative claims data from a German statutory health insurance. Eight contraindication groups were defined based on the German guideline. Logistic regressions were performed in order to identify predictors for OA prescriptions despite contraindications. The possible knowledge of the prescribing physician about the contraindication was approximated by analyzing concordant unique physician identification numbers of OA prescriptions and contraindication diagnoses. A total of 113,476 individuals (75% female) with a mean age of 72 years were included. The most common documented contraindications were primary headaches (8.7%), severe mood disorders (7.7%) and pain in somatoform disorders (4.5%). The logistic regressions identified a younger age, longer history of OA therapy, opioid related psychological problems, and outpatient psychosomatic primary care as positive predictors for all contraindication groups.

A Survey of the Incidence of Constipation in Patients with Chronic Non-cancer Pain Using Opioid Analgesics in Japan.

IntroductionAlthough opioids have potent analgesic properties, their use is associated with side effects, including opioid-induced constipation (OIC). This study investigated the incidence of OIC based on the Rome IV diagnostic criteria in patients using opioid analgesics for chronic non-cancer pain and to explore and compare the risk factors for the development of OIC in opioid analgesic users.MethodsWe surveyed patients aged 20 years or more living in Japan via the internet; who had been using opioid or non-opioid analgesics (N = 500 each) for at least 3 months for relief from chronic non-cancer musculoskeletal pain (low back pain or osteoarthritis); and who provided electronic consent to participate in and complete the survey. The groups were matched for age and sex.ResultsOf the patients using opioid analgesics, 89% were taking weak opioids. The proportion of patients perceiving constipation was comparable between the opioid and non-opioid analgesic groups (34% vs 29%, respectively); however, a significantly higher proportion of patients in the opioid group, compared to the non-opioid group, reported self-assessed constipation (40% vs 18%, respectively) after using an analgesic and fulfilled two or more symptoms of the Rome IV diagnostic criteria for constipation (28% vs 19%, respectively). A higher proportion of patients were taking prescribed medicine for constipation in the opioid group compared with the non-opioid group (33% vs 18%, respectively). Low back pain, but not opioid strength and scheduled dosing, was identified as a risk factor for OIC among various covariates assessed in the logistic regression analysis in 81 patients with OIC and Rome IV diagnosis vs 419 patients without OIC in the opioid group.ConclusionUse of opioid analgesics, including weak opioids, for treating chronic non-cancer musculoskeletal pain is associated with OIC. This finding highlights the need for appropriate treatment of constipation in patients with chronic non-cancer pain in Japan.Trial RegistrationUMIN000043985.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40122-022-00392-y.

Transcultural validation of a French-European version of the Prescription Opioid Misuse Index Scale (POMI-5F).

The Prescription Opioid Misuse Index scale (POMI) is a brief questionnaire used to assess opioid prescription misuse. In view of the increase in the prescription of opioid analgesics for chronic noncancer pain (CNCP), this tool is particularly useful during medical consultations to screen opioid misuse in patients using opioids. We sought to generate and validate a French-European translation of the POMI. We conducted an observational, longitudinal, and multicenter psychometric study with crosscultural validation. All adult CNCP patients who were treated with opioids for at least three months, were followed in pain clinics, and spoke French were eligible. From September 2015 to November 2017, we included 163 patients and analyzed 154. We performed a pretest on a sample of representative patients to evaluate acceptability and understanding of translation. Study patients completed the POMI scale at a pain clinic (test phase), and we assessed test-retest reliability after two to four weeks by a second completion of the POMI scale at home by patients (retest phase). We subsequently explored psychometric properties of the POMI (acceptability, internal consistency, reproducibility, and external validity). Due to poor internal consistency and reproducibility, items 4, 7, and 8 of the original POMI scale were removed, and we proposed a five-question French-European version (POMI-5F). The internal consistency of POMI-5F was good (Cronbach's α = 0.71), as was test-retest reliability (r = 0.65 [0.55-0.67]). The external validity of POMI-5F, compared with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, was moderate but significant (r = 0.45; P < 0.001). The optimal POMI-5F cut-off score to indicate misuse was 2/5 (sensitivity = 0.95 and specificity = 0.54). We generated and validated a French-European translation of the POMI scale, POMI-5F, for use by French researchers and physicians to identify opioid misuse in CNCP patients.

Barriers and enablers to monitoring and deprescribing opioid analgesics for chronic non-cancer pain: a systematic review with qualitative evidence synthesis using the Theoretical Domains Framework

BackgroundUnderstanding barriers and enablers to monitoring and deprescribing opioids will enable the development of tailored interventions to improve both practices.ObjectiveTo perform a qualitative evidence synthesis of the barriers and enablers...

288What proportion of patients with chronic noncancer pain are prescribed an opioid medicine?

Abstract Background Guidelines now discourage opioid analgesics for chronic non-cancer pain because the benefits frequently do not outweigh the harms. This review determined the proportion of patients with chronic non-cancer pain who are prescribed an opioid, the types prescribed, and factors associated with prescribing. Methods Database searches were conducted from inception to 29th October 2018 without restrictions. We included observational studies of adults with chronic non-cancer pain measuring opioid prescribing. Opioids were categorised as weak (e.g. codeine) or strong (e.g. oxycodone). Risk of bias assessed study quality. Results were pooled using a random-effects model. Meta-regression investigated study-level factors associated with prescribing. The overall evidence quality was assessed using GRADE criteria. Results Of the 42 studies (5,059,098 participants) included, majority (n = 28) from the United States of America. Eleven studies were at low risk of bias. The pooled estimate of the proportion of patients with chronic non-cancer pain prescribed opioids was 30.7% (95%CI 28.7% to 32.7%, 42 studies, moderate-quality evidence). Strong opioids were more frequently prescribed than weak (18.4% (95%CI 16.0% to 21.0%, n = 15 studies, low-quality evidence), versus 8.5% (95%CI 7.2% to 9.9%, n = 15 studies, low-quality evidence)). Meta-regression determined opioid prescribing was associated with year of sampling (more prescribing in recent years) (p = 0.014) and not geographic region (p = 0.056). Conclusions Opioid prescribing for patients with chronic non-cancer pain is common and has increased over time. Key message Opioid prescribing for patients with chronic non-cancer pain and has increased over time. This review is the first systematic review to synthesized such data.

Racism in Pain Medicine: We Can and Should Do More

Racism in Pain Medicine: We Can and Should Do More

All-cause mortality in patients with long-term opioid therapy compared with non-opioid analgesics for chronic non-cancer pain: a database study

BackgroundHitherto only studies with selected populations have found an increased all-cause mortality of some selected opioids compared to selected non-opioids for chronic non-cancer pain (CNCP). We have examined the all-cause mortality for CNCP associated with all established opioids compared to non-opioid analgesic therapy (anticonvulsants, antidepressants, dipyrone, non-steroidal agents).MethodsThe study used the InGef (Institute for Applied Health Research Berlin) database which is an anonymized healthcare claims database including 4,711,668 insured persons who were covered by 61 German statutory health insurances between 2013 and 2017.The health insurance companies are the owners of the database. All-cause mortality was determined from death certificates. Adjusted hazard ratios (HRs) including age, gender, comorbidity index, and propensity score as covariates and risk differences (RD) in incidence of death between patients with long-term opioid therapy (LTOT) and control-drug therapy were calculated.ResultsThe mean age of participants was 66 years; 55% were women. There were 554 deaths during 10,435 person-years for the LTOT patients, whereas there were 340 deaths during 11,342 person-years in the control group. The HR for all-cause mortality was 1.59 (95% CI, 1.38–1.82) with a risk difference of 148 excess deaths (95% CI 99–198) per 10,000 person-years. The elevated risk of death for LTOT was confined to the out-of-hospital deaths: LTOT patients had 288 out-of-hospital deaths during 10,435 person-years (276 per 10,000 person-years) whereas there were 110 deaths during 11,342 person-years (97 per 10,000 person-years) in the control group. HR was 2.29 (95% CI 1.86, 2.83). Although our propensity score matching model indicated a good classification, residual confounding cannot be fully excluded. The opioid group had a higher prevalence of heart failure and a higher use of anti-thrombotic and antiplatelet agents and of psycholeptics.ConclusionsLTOT for CNCP compared to non-opioid analgesics was associated with an increased risk for all-cause mortality. When considering treatment options for patients with CNCP, the relevant risk of increased all-cause mortality with opioids should be discussed.Trial registrationClinicalTrials.gov, NCT03778450, Registered on 7 December 2018

What proportion of patients with chronic noncancer pain are prescribed an opioid medicine? Systematic review and meta-regression of observational studies.

Guidelines now discourage opioid analgesics for chronic noncancer pain because the benefits frequently do not outweigh the harms. We aimed to determine the proportion of patients with chronic noncancer pain who are prescribed an opioid, the types prescribed and factors associated with prescribing. Database searches were conducted from inception to 29 October 2018 without language restrictions. We included observational studies of adults with chronic noncancer pain measuring opioid prescribing. Opioids were categorized as weak (e.g. codeine) or strong (e.g. oxycodone). Study quality was assessed using a risk of bias tool designed for observational studies measuring prevalence. Individual study results were pooled using a random-effects model. Meta-regression investigated study-level factors associated with prescribing (e.g. sampling year, geographic region as per World Health Organization). The overall evidence quality was assessed using Grading of Recommendations Assessment, Development and Evaluation criteria. Of the 42 studies (5,059,098 participants) identified, themajority (n=28) were from the United States of America. Eleven studies were at low risk of bias. The pooled estimate of the proportion of patients with chronic noncancer pain prescribed opioids was 30.7% (95% CI 28.7% to 32.7%, n=42 studies, moderate-quality evidence). Strong opioids were more frequently prescribed than weak (18.4% (95% CI 16.0-21.0%, n=15 studies, low-quality evidence), versus 8.5% (95% CI 7.2-9.9%, n=15 studies, low-quality evidence)). Meta-regression determined thatopioid prescribing was associated with year of sampling (more prescribing in recent years) (P=0.014) and not geographic region (P=0.056). Opioid prescribing for patients with chronic noncancer pain is common and has increased over time.

Barriers and enablers to monitoring and deprescribing opioid analgesics for chronic non-cancer pain: protocol for a qualitative evidence synthesis using the Theoretical Domains Framework

IntroductionThe over-prescription and overuse of opioid analgesics for chronic non-cancer pain (CNCP) is a growing issue. Synthesis of evidence about the barriers and enablers to reducing long-term opioid prescribing and...

Reducing substance abuse in patients receiving prescription opioids for chronic non-cancer pain: a quality improvement and patient safety study in a primary care setting

ABSTRACTBackground: Chronic non-cancer pain is a common cause of primary care physicians’ office visits.Objective: To determine the impact of adopting screening and monitoring measures in primary care settings on the illicit substance use behavior of patients receiving opioid analgesic prescriptions.Methods: This was a retrospective analysis of data on patients who were prescribed opioid analgesics for chronic non-cancer pain between 2014 and 2017 Q1 (i.e., first quarter of 2017). Study participants were patients who sought medical care at our academic primary care clinic practice that is part of an internal medicine residency program. Participants were adults (>18 years) who were considered eligible for opioid analgesics for chronic non-cancer pain.Interventions: (1) Rolling out of the chronic non-cancer pain management policy to clinic staff; (2) pain medication contracts with patients; (3) random urine drug screen (UDS) testing performed on patients during their clinic visits; 4) a didactics curriculum for internal medicine residents to highlight the key elements in utilizing and interpreting UDS results; (5) adding alerts to the electronic medical record that notifies clinic staff of discrepancy between patients’ prescribed medications and UDS findings, as well as for quick identification of patients who had violated a stipulation of the contract; (6) mandatory regular utilization of Michigan State’s online prescription monitoring records; and (7) employment of an on-site behavioral specialist for patients with mental illness or at risk of drug abuse.Main outcomes and measures: The main endpoint was the percentage of illicit drug use detected per year.Results: A total of 8096 UDS samples were collected over the study period. Mean (SD) participant age was 52 (SD 12) and 51% were male. Urine samples which had at least one illicit substance constituted 41% of the samples in 2014 prior to intervention. We found a significant decrease in the percentage of illicit substances after initiation of the intervention to 37% in 2015, 19% in 2016, and 12% in 2017Q1 (p < 0.001).Conclusion: Adopting a system-wide screening and monitoring measures in a primary care setting can significantly reduce the amount of illicit drug use among patients receiving an opioid prescription for non-cancer pain. This has important implications for patient safety and the current opioid epidemic in the USA. Further studies are needed to evaluate similar interventions in other settings such as a pain clinic.

7B Integration of Opioid Prescribing Guidelines in Primary Care to Improve Quality and Safety

Ministry and Affinity Medical Groups, representing 45 clinics within Ascension Wisconsin, are adopting the Wisconsin Medical Examining Board Opioid Prescribing Guideline as the framework for prescribing opioid analgesics for chronic non-cancer pain. Recognizing the need to address quality and safety of chronic pain management, the medical groups seek to implement strategies that address the complex biopsychosocial needs of patients in addition to safe opioid prescribing practices.

Effects of Testosterone Replacement on Pain Catastrophizing and Sleep Quality in Men with Opioid-Induced Androgen Deficiency

The objective of this investigation was to determine the effects of testosterone administration on pain catastrophizing and sleep quality in adult men with opioid-induced androgen deficiency. Sixty-two men aged 18-64 years using opioid analgesics for chronic non-cancer pain with total testosterone levels < 350 ng/dl were randomized to 14 weeks of transdermal testosterone gel or placebo gel daily. Total testosterone levels were measured by liquid chromatography mass spectrometry and free testosterone was calculated using the law of mass action equation. Outcomes were assessed by administering validated instruments such as Pain Catastrophizing Scale (PCS) and Insomnia Severity Index (ISI) at baseline and 14 weeks. Baseline characteristics were similar between the two groups. Mean (SD) total testosterone concentrations increased from 223 ± 86 to 775 ± 555 ng/dl in the testosterone group, but did not meaningfully change in placebo group. Mean changes in PCS and ISI scores during intervention did not differ significantly between groups and were not related to changes in on-treatment serum testosterone concentrations. In this 14-week trial, testosterone administration in men with opioid-induced androgen deficiency was not associated with improvements in pain catastrophizing or sleep quality.

Effects of testosterone replacement on metabolic and inflammatory markers in men with opioid-induced androgen deficiency.

Symptomatic androgen deficiency is common in patients taking opioid analgesics, and testosterone replacement in these men improves libido, quality of life and body composition. However, the effects of testosterone replacement on metabolic and inflammatory markers in this setting have not been evaluated. This is important as opiate use itself has been associated with metabolic abnormalities. The objective of this investigation was to determine the effects of testosterone administration on metabolic and inflammatory markers in adult men with opioid-induced androgen deficiency. Sixty-four nondiabetic men aged 18 to 64 years using opioid analgesics for chronic noncancer pain with total testosterone levels <12 nmol/l were randomized to 14 weeks of transdermal testosterone gel or placebo gel daily. Total testosterone levels were measured by liquid chromatography mass spectrometry, and free testosterone was calculated using the law-of-mass-action equation. Metabolic parameters, inflammatory markers and oral glucose tolerance test (OGTT) were evaluated at baseline and 14 weeks. Baseline characteristics were similar between the two groups. Testosterone concentrations increased from 7·7 ± 3·0 to 27 ± 19 nmol/l in the testosterone group, but did not meaningfully change in placebo group. Mean changes in metabolic and inflammatory markers during intervention did not differ significantly between groups and were not related to changes in on-treatment serum testosterone concentrations. Glucose and insulin response to the 75 g OGTT also did not differ between groups. In this 14-week trial, testosterone administration in men with opioid-induced androgen deficiency was not associated with worsening of metabolic and inflammatory markers.

Binge drinkers have greater vulnerability to engage in risky behaviors in traffic and drug use

Binge drinkers have greater vulnerability to engage in risky behaviors in traffic and drug use

A qualitative study of veterans on long-term opioid analgesics: barriers and facilitators to multimodality pain management.

The aim of this study was to examine barriers and facilitators to multimodality chronic pain care among veterans on high-dose opioid analgesics for chronic non-cancer pain. A Veterans Health Administration clinic in San Antonio. Twenty-five veterans taking at least 50 mg morphine equivalent daily oral opioid doses for more than 6 months. Three semi-structured focus groups, each with seven to nine veterans. Interview guide addressed: chronic pain effects on quality of life, attitudes/experiences with multimodality pain care, social support, and interest in peer support. In an iterative process using grounded theory, three reviewers reviewed de-identified transcripts for themes. The theory of planned behavior (TPB) framework was used to classify barriers and facilitators to multimodal pain management. The 25 participants had a mean age of 54 years (39-70); 32% were women and 24% non-white. The three TPB dimensions (attitudes, social norms, and perceived behavioral control) were reflected in emergent themes: 1) uncontrollable impact of pain in all aspects of life; 2) reliance on opioids and challenges in obtaining these drugs despite ambivalence about benefits; 3) poor access to and beliefs about non-pharmacologic therapies; 4) frustrations with Department of Veterans Affairs health care; and 5) poor social support and isolation reflected by limited interest in peer support. Veterans with chronic pain on long-term opioids hold pervasive attitudes that prevent them from using multimodality pain management options, lack social support and social norms for non-opioid-based pain treatment options, and have poor perceived control due to poor access to multimodality care.

Effects of testosterone replacement in men with opioid-induced androgen deficiency: a randomized controlled trial.

Symptomatic androgen deficiency is common in patients taking opioid analgesics, as these drugs potently suppress the hypothalamic-pituitary-gonadal axis. However, the efficacy of testosterone replacement in this setting remains unclear. The objective of this trial was to evaluate the efficacy of testosterone replacement on pain perception and other androgen-dependent outcomes in men with opioid-induced androgen deficiency. We conducted a randomized, double-blind, parallel placebo-controlled trial at an outpatient academic research center. Participants were men aged 18 to 64 years on opioid analgesics for chronic noncancer pain, and total testosterone levels were <350 ng/dL. Participants were randomly assigned to 14 weeks of daily transdermal gel that contained 5 g of testosterone or placebo. Primary outcomes were changes in self-reported clinical pain and objectively assessed pain sensitivity. Sexual function, quality of life, and body composition were also assessed. The mean age was 49 years. The median total and free testosterone levels at baseline were 243 ng/dL and 47 pg/mL and 251 ng/dL and 43 pg/mL in the testosterone and placebo arm, respectively. Of the 84 randomized participants, 65 had follow-up data on efficacy outcomes. Compared with men assigned to the placebo arm, those assigned to testosterone replacement experienced greater improvements in pressure and mechanical hyperalgesia, sexual desire, and role limitation due to emotional problems. Testosterone administration was also associated with an improvement in body composition. There were no between-group differences in changes in self-reported pain. In conclusion, in men with opioid-induced androgen deficiency, testosterone administration improved pain sensitivity, sexual desire, body composition, and aspects of quality of life.

Racial Differences in Prescription of Opioid Analgesics for Chronic Noncancer Pain in a National Sample of Veterans

The purpose of this study was to investigate possible racial differences in opioid prescriptions among primary care patients with chronic noncancer pain receiving care in the Veterans Affairs health care system. This was a retrospective cohort study of 99,903 veterans with diagnoses of low back, neck, or joint pain selected to participate in the Veterans Affairs Survey of the Healthcare Experiences of Patients in fiscal year 2006. The outcome was prescription of opioids in the year following the first pain diagnosis, obtained through electronic medical record data. Analyses incorporated fixed effects for race, most recent pain intensity rating, new or established primary care patient status, and an interaction between race and most recent pain intensity rating, together with random effects for health care facility and race within facility. The association between patient race and prescription of opioids was moderated by baseline level of pain intensity scores (assessed on a 0–10 scale) and patient age. Among patients under 65 years of age, blacks with moderate (4–6) or high (7–10) levels of pain were less likely to receive opioids than whites (P = .0025, P = .0011); however, there were no significant differences between black and white patients with low levels of pain intensity (1–3) and those with pain intensity ratings of 0 (no pain). Among patients 65 and older with pain intensity ratings of zero, blacks were more likely than whites to receive opioid prescriptions (P = .0087), but there were no significant racial differences in opioid prescriptions in those with low to high levels of pain. PerspectiveAmong veterans under age 65 reporting moderate to high levels of chronic noncancer pain, blacks were less likely to be prescribed opioids than whites, even after controlling for clinical and system-level factors. Results underscore the challenges of eliminating racial differences in pain treatment, despite comprehensive systemwide improvement initiatives.

Review: Opioids are more effective than placebo but not other analgesics for chronic noncancer pain

Source Citation Furlan AD, Sandoval JA, Mailis-Gagnon A, Tunks E. Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects. CMAJ. 2006;174:1589-94. 16717269

Opioid drugs: a comparative survey of therapeutic and "street" use.

The prescription of strong opioid analgesics for chronic non-cancer pain (CNCP) is described as controversial and can result in misidentification of patients as drug abusers or individuals with an addiction. This study compared the effects of opioid drugs on CNCP patients and "street" users. The groups comprised 36 CNCP patients attending a pain clinic and 39 street users, recruited on London streets. CNCP patients were interviewed in a pain clinic and street users in a street setting. A questionnaire was used to assess drug craving, dose escalation, cessation of use, compulsion to use, effects on career, relationships and activities, experience of "highs," and problems due to intoxication. To assess physiological dependence, subjects answered questions on specific effects e.g. stomach pains, nausea/vomiting, cramps/aches, etc.). Efficacy was assessed in CNCP patients by determining analgesia and physical function. CNCP patients started therapy in the low dose range for oral morphine (</=60 mg/day) and most (83%) did not move into a higher dose range once adequate levels of analgesia were attained. Street users started smoking heroin intermittently, before daily use. Most escalated their dose by increasing the amount used and by switching from smoking to injecting. Unlike CNCP patients, street users demonstrated patterns of compulsive drug use, social problems and intoxication. Only 3 / 31 (9.5%) pain patients that discontinued opioid therapy reported withdrawal symptoms on abstaining from the drug compared to 35 (89.5%) of street users. Findings suggest that CNCP patients prescribed strong opioid analgesics derive more benefit than harm.

Randomised trial of oral morphine for chronic non-cancer pain

SummaryBackground The use of opioid analgesics for chronic non-cancer pain is controversial. Some surveys report good pain relief and improvement in performance while others suggest a poor outcome with a propensity to psychological dependence or addiction.Methods We undertook a randomised double-blind crossover study to test the hypothesis that oral morphine relieves pain and improves the quality of life in patients with chronic regional pain of soft tissue or musculoskeletal origin who have not responded to codeine, antiinflammatory agents, and antidepressants. Morphine was administered as a sustained-release preparation in doses up to 60 mg twice daily and compared with benztropine (active placebo) in doses up to 1 mg twice daily over three-week titration, six-week evaluation, and two-week washout phases. Pain intensity, pain relief, and drug liking were rated weekly and psychological features, functional status, and cognition were assessed at baseline and at the end of each evaluation phase.Findings After dose titration in the 46 patients who completed the study, the mean daily doses of drugs were morphine 83·5 mg and benztropine 1·7 mg. On visual analogue scales, the morphine group showed a reduction in pain intensity relative to placebo in period I (p=0·01) and this group also fared better in a crossover analysis of the sum of pain intensity differences from baseline (p=0·02). No other significant differences were detected.Interpretation In patients with treatment-resistant chronic regional pain of soft-tissue or musculoskeletal origin, nine weeks of oral morphine in doses up to 120 mg daily may confer analgesic benefit with a low risk of addiction but is unlikely to yield psychological or functional improvement.