Treatment Of Chronic Noncancer Pain Research Articles

Is general practitioner involvement in the initiation of opioids for chronic non-cancer pain associated with opioid dose and concurrent drug use?

Objective Is the involvement of the regular general practitioner (GP) in the decision to initiate opioid treatment for chronic non-cancer pain (CNCP) associated with two main risk factors for serious adverse events: increased opioid dose and the concomitant use of prescribed benzodiazepines or benzodiazepine-related medications? Design and setting An anonymous web-based survey was conducted in the county of Rogaland, Norway, during the spring of 2021. Subjects GPs who self-reported applying at least once for reimbursement of opioids prescribed to treat CNCP. They were asked to answer the survey based on the last patient for whom they recalled submitting a reimbursement application. Main outcome measures 1) Total opioid dose in daily oral morphine equivalents (OMEQ). 2) Concurrent use of benzodiazepines and/or benzodiazepine-related drugs. Results The daily opioid dose was lower when the surveyed GPs initiated the opioid treatment (36 OMEQ, n = 25), than when others had initiated the treatment (108 OMEQ, n = 31, p = 0.001). For concurrent use of benzodiazepine or benzodiazepine-related drugs, no significant difference was found (33%, n = 9 with GP involvement vs. 47%, n = 16, p = 0.279 with no GP involvement). Conclusions GP involvement in the initiation of opioid medication for CNCP was associated with a lower opioid dose being prescribed. Implications GP involvement in the initiation of opioid prescriptions may facilitate safer prescribing.

Choosing Wisely in Physical Medicine and Rehabilitation: Developing Canadian Recommendations for Resource Stewardship

ABSTRACT Choosing Wisely Canada (CWC) aims to reduce potentially harmful or unnecessary diagnostic investigations and practices in health care delivery. A committee of the Canadian Association of Physical Medicine & Rehabilitation (PM&R) surveyed the general membership seeking suggestions on new or revised PM&R CWC recommendations. Draft recommendations were revised and refined with an emphasis on resource stewardship and alignment with the CWC mission. The updated 2023 CWC recommendations for PM&R are to avoid: (1) investigating and treating asymptomatic bacteriuria in patients with neurogenic bladder; (2) recommending more than a brief period of physical and cognitive rest after mild traumatic brain injury; (3) starting opioid treatment for chronic noncancer pain without exhausting other approaches; (4) ordering diagnostic imaging for low back pain in the absence of red flags; (5) repeating injections without evaluating patients’ responses to them; and, (6) recommending carpal tunnel release without first confirming nerve entrapment with electrodiagnostic studies or ultrasonography. We present unique implementation tools to equip practitioners with quality improvement strategies to adopt these recommendations into their practices. Future work will include developing recommendations that consider planetary health co-benefits, creating knowledge translation tools, and assessing the impact of recommendation adoption into clinical practice.

Access to care for patients with chronic pain receiving prescription opioids, cannabis, or other treatments

Abstract Changes in chronic noncancer pain treatment have led to decreases in prescribing of opioids and increases in the availability of medical cannabis, despite its federal prohibition. Patients may face barriers to establishing new care with a physician based on use of these treatments. We compared physician willingness to accept patients based on prescription opioid, cannabis, or other pain treatment use. This study of 36 states and Washington, DC, with active medical cannabis programs surveyed physicians who treat patients with chronic noncancer pain between July 13 and August 4, 2023. Of 1000 physician respondents (34.5% female, 63.2% White, 78.1% primary care), 852 reported accepting new patients with chronic pain. Among those accepting new patients with chronic pain, more physicians reported that they would not accept new patients taking prescription opioids (20.0%) or cannabis (12.7%) than those taking nonopioid prescription analgesics (0.1%). In contrast, 68.1% reported willingness to accept new patients using prescribed opioids on a daily basis. For cannabis, physicians were more likely to accept new patients accessing cannabis through medical programs (81.6%) than from other sources (60.2%). Access to care for persons with chronic noncancer pain appears to be the most restricted among those taking prescription opioids, although patients taking cannabis may also encounter reduced access.

Nabilone for Chronic Non-Cancer Pain

What Is the Issue? Chronic pain is pain that lasts beyond 3 months. Chronic non-cancer pain conditions include osteoarthritis, low back pain, musculoskeletal pain, fibromyalgia, and neuropathic pain. Approximately 1 in 5 people in Canada live with chronic pain. Nabilone (a cannabinoid) is indicated for the management of severe nausea and vomiting associated with cancer chemotherapy. Nabilone is also used in the management of chronic non-cancer pain. It is important to understand the potential benefits and harms of nabilone in people living with chronic non-cancer pain to support decision-making. What Did We Do? We sought to identify, summarize, and critically appraise literature comparing the clinical effectiveness of nabilone and placebo or alternative pharmacological options. We also searched for evidence-based guidelines that provide recommendations about the use of nabilone for the treatment of chronic non-cancer pain. We searched key resources, including journal citation databases, and conducted a focused internet search for relevant evidence published since 2015. One reviewer screened articles for inclusion based on predefined criteria, critically appraised the included studies, and narratively summarized the findings. What Did We Find? We found 1 overview of reviews and 2 systematic reviews that assessed the clinical efficacy and safety of nabilone for the treatment of chronic non-cancer pain. The evidence on the clinical efficacy of nabilone was mixed with some studies reporting an improvement in pain in those treated with nabilone versus placebo or active comparators and other studies reporting no difference between groups. Adverse events were more common in people living with chronic non-cancer pain who received nabilone than those who received placebo, ibuprofen, or amitriptyline. Adverse events were more common in those who received dihydrocodeine or gabapentin than nabilone. It is uncertain if nabilone is an effective treatment for people living with chronic non-cancer pain due to the varied results and methodological limitations of the included studies. We found 1 guideline that included a recommendation specific to nabilone and 2 guidelines that included recommendations on the use of cannabinoids in general. One guideline recommends against the use of nabilone for chronic pain, 1 guideline recommends offering a trial of non-inhaled cannabinoids (such as nabilone) for people living with chronic pain, and 1 guideline suggests cannabinoids be avoided in people with osteoarthritis and low back pain and discussed with people with neuropathic pain. What Does This Mean? Due to the uncertainty of the clinical evidence, decision-makers may wish to consider other factors such as costs, equity, and patient values and preferences when making decisions on the use of nabilone for people living with chronic non-cancer pain. Future high-quality, longer-term (e.g., RCT with follow-up studies) studies are needed to understand the efficacy and safety of nabilone for the treatment of people living with chronic non-cancer pain.

Factors Associated With Interest in Engaging in Psychological Interventions for Pain Management.

Engagement in evidence-based psychological interventions for pain management is low. Identifying characteristics associated with interest in interventions can inform approaches to increase uptake and engagement. The purpose of this study was to examine factors associated with interest in psychological interventions among persons with chronic noncancer pain receiving prescription opioids. Participants with chronic noncancer pain and a new 30 to 90 day opioid prescription were recruited from 2 health systems. Participants (N=845) completed measures regarding pain, opioid use, psychiatric symptoms, emotional support, and interest in psychological interventions for pain management. There were 245 (29.0%) participants who reported a high interest in psychological interventions for pain management. In bivariate analyses, variables associated with interest included younger age, female sex, greater pain severity, greater pain interference, greater number of pain sites, lower emotional support, depression, anxiety, and post-traumatic stress disorder ( P <0.05). In a multivariate model, greater pain severity (odds ratio [OR]=1.17; CI: 1.04-1.32), depression (OR=2.10; CI: 1.39-3.16), post-traumatic stress disorder (OR=1.85; CI: 1.19-2.95), and lower emotional support (OR=0.69; CI: 0.5-0.97) remained statistically significant. The rate of interest in psychological interventions for pain management was low, which may indicate that patients initiating opioid treatment of chronic noncancer pain have low interest in psychological interventions. Greater pain severity and psychiatric distress were related to interest, and patients with these characteristics may especially benefit from psychological interventions. Providers may want to refer to psychological interventions before or when opioids are initiated. Additional work is needed to determine whether this would reduce long-term opioid use.

Exploring the facilitators and barriers in opioid deprescribing for non-cancer pain treatment experienced by general practitioners: A qualitative study.

Guidelines recommend opioid deprescribing in patients on long-term opioid treatment for chronic non-cancer pain. This study aims to explore facilitators and barriers in opioid deprescribing among general practitioners in the Netherlands. In addition, this study aims to identify possibilities for improvement regarding opioid deprescribing in primary care. Focus group discussions with Dutch General practitioners were held by two skilled moderators. The focus group discussions were transcribed verbatim and analysed using MAXQDA software. Three independent reviewers searched for overarching themes using thematic analysis with an inductive approach. Discussions were organized until data saturation was reached. Twenty-two general practitioners participated in four focus group discussions. Five main themes emerged from the data: (1) patient-centred care; (2) ensuring proper pain management (3) dilemmas and hardships in dealing with opioid use disorder; (4) the competency gap; (5) needs and possibilities to improve opioid deprescribing in primary care. The first theme addresses the main facilitators in opioid tapering. The following three themes emerged as main barriers in opioid deprescribing. The fifth theme identified possibilities for change. This study indicates the importance of intrinsic motivation and a tailored approach to deprescribe opioids in patients with chronic pain on long-term opioid treatment. Identified barriers include struggles in pain management, challenges caused by opioid use disorder, insufficient capacities such as time constraints and lack of skills. Recommendations for improvement involve enhanced collaboration with healthcare professionals in primary and secondary care, provision of practical tools and assurance of sufficient time. This focus group study among 22 Dutch general practitioners elucidates the complexities of opioid deprescribing and reveals pivotal themes such as patient-centred care, pain management challenges, and competency gaps. The findings underscore the crucial role of intrinsic motivation and that of a tailored approach in opioid deprescribing, while demonstrating how a lack in effective pain treatments, practical capacities and challenges caused by opioid dependence, impede opioid deprescribing. By uncovering these complexities, this study aims to inform future deprescribing strategies.

Mental disorders and symptoms with persistent opioid use for chronic non-cancer pain – a registry study

Knowledge of mental disorders among patients with persistent opioid use for the treatment of chronic non-cancer pain is essential, as mental disorders and symptoms can exacerbate or perpetuate pain and impact on the ability of patients to manage their illness. We have studied the prevalence of mental disorders and symptoms, including substance use disorders, in patients with persistent opioid use in 2019. Persons ≥18 years with persistent opioid use and persons ≥18 years with at least one registered mental disorder in the specialist healthcare service in 2019 were included. Data were retrieved from national health registries in Norway. Patients who received opioids reimbursed for the treatment of chronic pain were compared with those who received opioids without reimbursement. The prevalence of mental disorders and symptoms was 34% among 14403 persons who received reimbursed opioids, and 42% among 38001 persons who received opioids without reimbursement. This is equivalent to a two to threefold increase in prevalence compared to the general population. There was a particularly higher prevalence of anxiety disorders and substance use disorders. The prevalence of mental disorders and symptoms was highest in the age group 18-44 years (49-55%). Among patients with persistent opioid use, a large proportion had mental disorders and symptoms, which are known risk factors for developing problematic opioid use and opioid use disorder.

Ketamine for Chronic Non-Cancer Pain: A 2023 Update

What Is the Issue?&#x0D; &#x0D; Doctors use ketamine to induce loss of consciousness as general anesthesia during surgery. At low doses that do not produce dissociation, practitioners use ketamine to relieve acute or chronic pain.&#x0D; The previous CADTH report published in 2020 found that IV ketamine, compared to placebo, could only provide short-term pain relief in patients with chronic non-cancer pain, with increased risks of nausea, vomiting, and psychomimetic effects. The included guidelines did not provide definitive recommendations due to insufficient evidence.&#x0D; Decision-makers want to know if there is any new evidence to support the use of ketamine for treating of chronic non-cancer pain in adults.&#x0D; &#x0D; What Did We Do?&#x0D; &#x0D; To inform decisions about the use of ketamine for treating of chronic non-cancer pain, CADTH sought to update the previous report by identifying and summarizing literature comparing the clinical effectiveness and cost-effectiveness of ketamine with placebo or other pharmacological therapies for chronic non-cancer pain. We also attempted to identify evidence-based recommendations from most recent guidelines for the use of ketamine for chronic non-cancer pain.&#x0D; A research information specialist conducted a literature search of the peer-reviewed and grey literature with a search strategy focused on ketamine, chronic non-cancer pain, and adults. The search was limited to English-language documents published since 2020 up to November 06, 2023. One reviewer screened articles for inclusion based on predefined criteria, critically appraised the included studies, and narratively summarized the findings.&#x0D; &#x0D; What Did We Find?&#x0D; &#x0D; We found 3 SRs and 1 randomized controlled trial on the use of ketamine for the treatment of patients with neuropathic pain, complex regional pain syndrome, fibromyalgia, and other chronic pain conditions. Collective evidence from the included studies suggests that ketamine treatment was associated with short-term pain reduction in patients with chronic non-cancer pain. However, the long-term efficacy of ketamine in pain relief remains unclear.&#x0D; Adverse events (AEs) associated with ketamine treatment were with psychedelic effects, discomfort, dizziness, fatigue, headache, and nausea; all of those events appeared to be short-lasting.&#x0D; There were mixed results regarding the effect of ketamine on quality of life and functional improvement.&#x0D; We did not find any studies on the cost-effectiveness of ketamine or new evidence-based guidelines on the use of ketamine for treating chronic non-cancer pain.&#x0D; &#x0D; What Does It Mean?&#x0D; &#x0D; The findings in this review are consistent with the previous CADTH report published in 2020.&#x0D; Well-controlled studies with larger populations and longer follow-ups are needed to determine the optimal treatment protocol of ketamine for each specific type of chronic pain.&#x0D; Given that ketamine is a dissociative drug that could be associated with the development of a substance use disorder, decision-makers may wish to consider the use of ketamine for long-term treatment of chronic non-cancer pain. The long-term effects and dangers of ketamine remain to be determined.&#x0D;

Physicians' perception about predictors of opioid abuse in patients with chronic non-cancer pain: a Delphi study.

Opioids are being prescribed widely, and increasingly, for the treatment of chronic non-cancer pain (CNCP). However, several side effects are associated with mid- and long-term opioid use and, for certain patients, with the risk of problematic opioid use. The aim of this study is to know the perception of the physicians about which variables could be associated with increased risk of patients with CNCP developing a problem of abuse or misuse of the prescribed opioid medication. Twenty-nine physicians with experience in CNCP pain management and opioids prescription participated in a two-round Delphi study focused on the risk factors for opioid misuse and abuse. The variables that reached consensus regarding their relationship with the increased risk of suffering a problem of opioid abuse or misuse were: (1) Experiencing pain on a daily basis, (2) previous use of high-dose opioids, (3) generalized anxiety, (4) hopelessness, (5) benzodiazepine intake, (6) use of opioids for reasons other than pain, (7) family problems, family instability or family breakdown, and (8) having access to several opioid prescribers. The only variable that reached consensus regarding it not being associated to a possible risk of abuse or misuse was having mild pain intensity (0-4 on a NRS-11). This study provides useful information that could help make decisions about the use of opioids for CNCP treatment and prevent future difficulties. Prospective studies testing the relationship of the variables that reached consensus with the risk of opioid misuse and abuse are warranted. This study shows the variables of CNCP that the professional must take into account in order to avoid possible problems when prescribing opioids.

Study: Medical cannabis did not reduce opioid pain prescriptions

State laws that allow medical cannabis to be prescribed and dispensed did not result in the reduced treatment of chronic noncancer pain, researchers have found. In the study, “Effects of U.S. State Medical Cannabis Laws on Treatment of Chronic Noncancer Pain,” lead author Emma E. McGinty, Ph.D., and colleagues found that the availability of medical cannabis did not reduce opioid prescriptions or non‐opioid procedures for pain. Proponents of cannabis legalization have long used the opioid epidemic as an argument for making the cannabis more available, but this study, published in the July issue of the Annals of Internal Medicine, said cannabis did not have any effect. The study looked at 583,820 commercially insured adults with chronic noncancer pain and reported that the availability of medical cannabis did not change their practices. The researchers used data from 12 states that implemented medical cannabis laws and compared that data to 17 other states. The study found that medical cannabis laws led to an average difference of 0.05 percentage points in the proportion of patients who received any opioid prescription. The study looked at the first three years of the law implementation. The researchers were able to predict what would have happened had the law not been implemented. Their study limitations included assumptions involving parallel trends, a finite number of states, and the possible lack of generalizability to non‐commercially insured populations, each of which could not be validated by testing.

Opioid use for chronic pain: Part 2

Opioid use for chronic pain: Part 2 Norm Buckley and Jason Busse from the Michael G. DeGroote Institute for Pain Research &amp; Care in Canada probe the effectiveness of opioid use in Canada as a treatment for chronic noncancer pain. Current best estimates suggest that 12% of individuals with chronic noncancer pain will achieve meaningful pain relief with opioids; however, there is a disconnect between the evidence for effectiveness and the ubiquity of opioid prescribing in North America.

Accounting for the interplay of interpersonal and structural trauma in the treatment of chronic non-cancer pain, opioid use disorder, and mental health in urban safety-net primary care clinics

While the epidemiological literature recognizes associations between chronic non-cancer pain (CNCP), opioid use disorder (OUD), and interpersonal trauma stemming from physical, emotional, sexual abuse or neglect, the complex etiologies and interplay between interpersonal and structural traumas in CNCP populations are under-examined. Research has documented the relationship between experiencing multiple adverse childhood experiences (ACEs) and the likelihood of developing an OUD as an adult. However, the ACEs framework is criticized for failing to name the social and structural contexts that shape ACE vulnerabilities in families. Social scientific theory and ethnographic methods offer useful approaches to explore how interpersonally- and structurally-produced traumas inform the experiences of co-occurring CNCP, substance use, and mental health. We report findings from a qualitative and ethnographic longitudinal cohort study of patients with CNCP (n = 48) who received care in safety-net settings and their primary care providers (n = 23). We conducted semi-structured interviews and clinical and home-based participant observation from 2018 to 2020. Here we focus our analyses on how patients and providers explained and situated the role of patient trauma in the larger clinical context of reductions in opioid prescribing to highlight the political landscape of the United States opioid overdose crisis and its impact on clinical interactions. Findings reveal the disproportionate burden structurally-produced, racialized trauma places on CNCP, substance use and mental health symptoms that shapes patients’ embodied experiences of pain and substance use, as well as their emotional experiences with their providers. Experiences of trauma impacted clinical care trajectories, yet providers and patients expressed limited options for redress. We argue for an adaptation of trauma-informed care approaches that contextualize the structural determinants of trauma and their interplay with interpersonal experiences to improve clinical care outcomes.

Effects of U.S. State Medical Cannabis Laws on Treatment of Chronic Noncancer Pain.

State medical cannabis laws may lead patients with chronic noncancer pain to substitute cannabis in place of prescription opioid or clinical guideline-concordant nonopioid prescription pain medications or procedures. To assess effects of state medical cannabis laws on receipt of prescription opioids, nonopioid prescription pain medications, and procedures for chronic noncancer pain. Using data from 12 states that implemented medical cannabis laws and 17 comparison states, augmented synthetic control analyses estimated laws' effects on receipt of chronic noncancer pain treatment, relative to predicted treatment receipt in the absence of the law. United States, 2010 to 2022. 583 820 commercially insured adults with chronic noncancer pain. Proportion of patients receiving any opioid prescription, nonopioid prescription pain medication, or procedure for chronic noncancer pain; volume of each treatment type; and mean days' supply and mean morphine milligram equivalents per day of prescribed opioids, per patient in a given month. In a given month during the first 3 years of law implementation, medical cannabis laws led to an average difference of 0.05 percentage points (95% CI, -0.12 to 0.21 percentage points), 0.05 percentage points (CI, -0.13 to 0.23 percentage points), and -0.17 percentage points (CI, -0.42 to 0.08 percentage points) in the proportion of patients receiving any opioid prescription, any nonopioid prescription pain medication, or any chronic pain procedure, respectively, relative to what we predict would have happened in that month had the law not been implemented. This study used a strong nonexperimental design but relies on untestable assumptions involving parallel counterfactual trends. Statistical power is limited by the finite number of states. Results may not generalize to noncommercially insured populations. This study did not identify important effects of medical cannabis laws on receipt of opioid or nonopioid pain treatment among patients with chronic noncancer pain. National Institute on Drug Abuse.

Cannabinoid-based medicines in clinical care of chronic non-cancer pain: an analysis of pain mechanism and cannabinoid profile

Aim: Among treatments for chronic non-cancer pain (CNCP), cannabinoid-based medicines (CBMs) have become extremely popular. Evidence remains modest and limited primarily to delta-9-tetrahydrocannabinol (THC) for neuropathic pain; nevertheless, the use of various CBMs, including cannabidiol (CBD) to treat neuropathic, nociceptive, and mixed pain has increased globally. This observational case-series assessed the impact of CBMs as a complementary treatment by pain mechanism and cannabinoid profile over three months. Methods: An analysis of patients with CNCP and treated with CBMs who consented to an ongoing registry was performed. Outcomes were patient-reported such as the Edmonton symptom assessment system-revised, brief pain inventory-short form, and 36-item short form health survey. Data from patients with complete outcomes for baseline and 3-month follow-up was extracted. Characteristics of adverse drug reactions (ADRs), including a description of the suspected product were also assessed. Results: A total of 495 patients were part of this analysis (mean age = 56 years old; 67% women). At 3-month, the proportional use of THC:CBD balanced and THC-dominant products increased. Patients with neuropathic pain had higher pain-severity scores vs. nociceptive pain. In addition to patients with neuropathic pain, patients with nociceptive and mixed pain also reported improvements in pain severity and secondary symptoms such as anxiety, depression, drowsiness, fatigue, sleep disturbances, and overall, health-related quality of life. THC-dominant treatment is more likely to be recommended when pain is severe, whereas CBD-dominant is favored for less severe cases. ADRs were more frequent among cannabis-naive patients and included dizziness, headache, and somnolence among others. Conclusions: Findings suggest that CBMs can be effective for neuropathic as well as nociceptive and mixed pain. THC is more frequently recommended for neuropathic and severe pain. Future research on CBMs in pain management must include details of CBM composition, and pain mechanism and must consider potential ADRs.

Can academic detailing reduce opioid prescriptions in chronic non-cancer pain?

BackgroundOne measure to support optimal opioid prescription is academic detailing (AD) with one-to-one visits by trained professionals (academic detailers) to general practitioners (GPs).Objective: To investigate the usefulness of AD visits on GPs’ opioid prescribing patterns in Norway, and academic detailers’ experiences with AD visits to GPs on opioid prescription.MethodsDesign: A quantitative registry study on opioid prescriptions and a qualitative focus group interview study with academic detailers.Participants: For the registry study, municipalities where more than 75% of the GPs had received an AD visit were considered intervention municipalities, whereas in the non-intervention municipalities no GPs had received AD-visits. In the focus groups, academic detailers who had conducted three or more AD-visits were invited to participate.Intervention: A campaign on opioid prescription with AD visits using a brochure with key messages based on the national guideline for treatment of chronic non-cancer pain and updated evidence on the potential benefits and risks of prescribing opioids. The AD visits in the campaign were planned for 20–25 min in a one-to-one setting in the GP’s office.Main Measures: The Norwegian Prescription Database (NorPD) was utilized for registry data. Data on amount of drugs dispensed are recoded as Defined Daily Doses (DDDs).ResultsCompared to non-intervention, the intervention resulted in a decrease in the number of prevalent and incident users of opioids and incident users of reimbursed opioids for chronic non-cancer pain in municipalities in Central Norway. The results from the focus group interviews were categorized into the themes: “To get in position”, “Adjusting messages”, “What did the GPs struggle with, in relation to opioid prescription?” and “Did we reach the right recipients with the visits?”.ConclusionsIn Central Norway, the intervention resulted in a desired effect on number of opioid users. According to the academic detailers, the GPs’ length of working experience and familiarity with the topic gave different presumptions for making use of the information presented in the AD-visits.

Barriers and Facilitators Influencing Nurses' Confidence in Managing Family Nursing Conversations in the Treatment of Chronic Noncancer Pain: A Longitudinal Qualitative Study.

This mixed-methods research examined the translation of a family nursing conversation intervention to the multidisciplinary treatment of patients experiencing chronic noncancer pain. The intervention required educating nurses who offered family nursing interventions to these families. The research uncovered barriers and facilitators influencing the nurses' perceived self-efficacy related to the process of incorporating family nursing conversations in their nursing care. A qualitative, descriptive, longitudinal design with three focus group interviews was implemented. A template analysis, using a priori themes based on Bandura's self-efficacy theory, illuminated a process initially predominated by barriers. Learning how to offer family nursing conversations was initially overwhelming for nurses because they were concerned about harming the family. Over time, the nurses came to understand the usefulness of the therapeutic conversation with families. Significant facilitators were the project manager's role, a strong nursing community, and the positive influence of the family intervention on the nurses' professional identity.

Is Cannabis a Viable Treatment of Chronic Non-Cancer Pain? - A Mini Review

The practice of pain medicine today is faced with the ever-rising burden of the nation's opioid epidemic. There has been a strong push to redefine chronic pain treatments and to find analgesic alternatives that avoid the harmful risks of opioid use that lead to diversion, overdose and addiction. Cannabis has been suggested to be an efficacious and safer alternative or replacement for opioids, but a large gap remains between the reported opioid-sparing benefits of cannabis and scientific evidence from high-quality research.

Equity Reporting in Systematic Reviews of Opioid Treatment of Chronic Non-Cancer Pain with Patient-Reported Outcomes

Chronic non-cancer pain can affect a patient’s social life, ability to work, and overall quality of life (QoL). Opioid therapy is often prescribed as therapeutic treatment in chronic pain. Systematic reviews (SRs)—the pinnacle of research quality—are often used in guideline development; however, pain may differ across cultures and communities. Thus, examination of equity reporting in such SR is necessary. This study examines reporting using the PROGRESS (Place of resident, Race, Occupation, Gender, Religion, Education, Socioeconomic status, Social capital)-Plus framework to examine equity within SRs with patient reported outcomes of chronic, non-cancer pain. A systematic search for SRs was conducted, which were evaluated for PROGRESS-Plus items and study characteristics were extracted. Among the 46 included SRs, seven did not include any PROGRESS-Plus items. The most commonly reported items were age, included within 34 SRs, followed by gender (30/46), and duration of pain (14/46). All other items were reported in five or less studies. Our investigation revealed a deficiency in SR’s reporting of equity measures for opioid treatment of chronic non-cancer pain. Given the need to address healthcare disparities among minorities, implementing the PROGRESS-Plus framework may influence QoL and patient-centered care.

Effects of Opioid Prescribing Cap Laws on Opioid and Other Pain Treatments Among Persons with Chronic Pain.

Many states have adopted laws that limit the amount or duration of opioid prescriptions. These limits often focus on prescriptions for acute pain, but there may be unintended consequences for those diagnosed with chronic pain, including reduced opioid prescribing without substitution of appropriate non-opioid treatments. To evaluate the effects of state opioid prescribing cap laws on opioid and non-opioid treatment among those diagnosed with chronic pain. We used a difference-in-differences approach that accounts for staggered policy adoption. Treated states included 32 states that implemented a prescribing cap law between 2017 and 2019. A total of 480,856 adults in the USA who were continuously enrolled in medical and pharmacy coverage from 2013 to 2019 and diagnosed with a chronic pain condition between 2013 and 2016. Among individuals with chronic pain in each state: proportion with at least one opioid prescription and with prescriptions of a specific duration or dose, average number of opioid prescriptions, average opioid prescription duration and dose, proportion with at least one non-opioid chronic pain prescription, average number of such prescriptions, proportion with at least one chronic pain procedure, and average number of such procedures. State laws limiting opioid prescriptions were not associated with changes in opioid prescribing, non-opioid medication prescribing, or non-opioid chronic pain procedures among patients with chronic pain diagnoses. These findings do not support an association between state opioid prescribing cap laws and changes in the treatment of chronic non-cancer pain.

Trends in opioid and non-opioid treatment for chronic non-cancer pain and cancer pain among privately insured adults in the United States, 2012-2019.

Recent clinical guidelines have emphasized non-opioid treatments in lieu of prescription opioids for chronic non-cancer pain, exempting cancer patients from these recommendations. In this study, we determine trends in opioid and non-opioid treatment among privately insured adults with chronic non-cancer pain (CNCP) or cancer. Using administrative claims data from IBM MarketScan Research Databases, we identified privately-insured adults who were continuously enrolled in insurance for at least one calendar year from 2012 to 2019. We identified individuals with CNCP diagnosis, defined as a diagnosis of arthritis, headache, low back pain, and/or neuropathic pain, and a individuals with cancer diagnosis in a calendar year. Outcomes included receipt of any opioid, non-opioid medication, or non-pharmacologic CNCP therapy and opioid prescribing volume, MME-per-day, and days’ supply. Estimates were regression-adjusted for age, sex, and region. Between 2012 and 2019, the proportion of patients who received any opioid decreased across both groups (CNCP: 49.7 to 30.5%, p<0.01; cancer: 86.0 to 78.7%, p<0.01). Non-opioid pain medication receipt remained steady for individuals with CNCP (66.7 to 66.4%, p<0.01) and increased for individuals with cancer (74.4 to 78.8%, p<0.01), while non-pharmacologic therapy use rose among individuals with CNCP (62.4 to 66.1%, p<0.01). Among those prescribed opioids, there was a decrease in the receipt of at least one prescription with >90 MME/day (CNCP: 13.9% in 2012 to 4.9% in 2019, p<0.01; Cancer: 26.2% to 7.6%, p<0.01); >7 days of supply (CNCP: 56.3% to 30.7%, p <0.01; Cancer: 47.5% to 22.7%, p<0.01), the mean number of opioid prescriptions (CNCP: 5.2 to 3.9, p<0.01; Cancer: 4.0 to 2.7, p<0.01) and mean MME/day (CNCP: 49.9 to 38.0, p<0.01; Cancer: 62.4 to 44.7, p<0.01). Overall, from 2012–2019, opioid prescribing declined for CNCP and cancer, with larger reductions for patients with CNCP. For both groups, reductions in prescribed opioids outpaced increases in non-opioid alternatives.