Guidelines For Use Of Opioids Research Articles

Opioid utilization after orthopaedic trauma hospitalization among Medicaid-insured adults.

Opioids are vital to pain management and sedation after trauma-related hospitalization. However, there are many confounding clinical, social, and environmental factors that exacerbate pain, post-injury care needs, and receipt of opioid prescriptions following orthopaedic trauma. This retrospective study sought to characterize differences in opioid prescribing and dosing in a national Medicaid eligible sample from 2010-2018. The study population included adults, discharged after orthopaedic trauma hospitalization, and receiving an opioid prescription within 30 days of discharge. Patients were identified using the International Classification of Diseases (ICD-9; ICD-10) codes for inpatient diagnosis and procedure. Filled opioid prescriptions were identified from National Drug Codes and converted to morphine milligram equivalents (MME). Opioid receipt and dosage (e.g., morphine milligram equivalents [MME]) were examined as the main outcomes using regressions and analyzed by year, sex, race/ethnicity, residence rurality-urbanicity, and geographic region. The study population consisted of 86,091 injured Medicaid-enrolled adults; 35.3% received an opioid prescription within 30 days of discharge. Male patients (OR = 1.12, 95% CI: 1.07-1.18) and those between 31-50 years of age (OR = 1.15, 95% CI: 1.08-1.22) were found to have increased odds ratio of receiving an opioid within 30 days of discharge, compared to female and younger patients, respectively. Patients with disabilities (OR = 0.75, 95% CI: 0.71-0.80), prolonged hospitalizations, and both Black (OR = 0.87, 95% CI: 0.83-0.92) and Hispanic patients (OR = 0.72, 95% CI: 0.66-0.77), relative to white patients, had lower odds ratio of receiving an opioid prescription following trauma. Additionally, Black and Hispanic patients received lower prescription doses compared to white patients. Individuals hospitalized in the Southeastern United States and those between the ages of 51-65 age group were found to be prescribed lower average daily MME. There were significant variations in opioid prescribing practices by race, sex, and region. National guidelines for use of opioids and other pain management interventions in adults after trauma hospitalization may help limit practice variation and reduce implicit bias and potential harms in outpatient opioid usage.

Guidelines for Opioid Use in Cancer Patients

Guidelines for Opioid Use in Cancer Patients

Migraine Headache in an Employed Population: Demographics, Health Risks, Pharmaceutical Utilization, and Productivity Loss.

Demographics, health risks, pharmaceutical utilization, and other characteristics of adults with and without migraine who were employed by a school district in the southern United States were compared. A total of 4528 employees completed a health risk appraisal. A diagnosis of migraine was reported by 11%. Employees with and without migraine were compared on several measures. Demographic and health risk differences were observed among the comparison groups. One-fifth of migraineurs had a prescription for an opioid, which was associated with very high average annual health care costs ($17,791) compared with migraineurs without opioid ($3907). Migraine is common in the workforce. Employers may want to educate employees with migraine about evidence-based treatments. Benefit plan design should be consistent with current accepted treatment guidelines for opioid use.

Management of cancer pain: challenging the evidence of the recent guidelines for opioid use in palliative care.

Opioid therapy is indisputably the mainstay of cancer pain management. However, important issues such as the worldwide variability in the availability and accessibility of opioids, myths and misconceptions about opioid use, and lack of knowledge about prescribing opioids among health care professionals have been pointed out by researchers, clinicians, and several health organizations. In an attempt to improve cancer pain management, guidelines for opioid use were elaborated to assist practitioners in prescribing opioids for the management of cancer-related pain. Recent opioid guidelines were developed based on a systematic assessment of evidence and they are considered one of the best resources to improve knowledge and clinical practice. However, most of the recommendations for cancer pain management included in these guidelines are based on low levels of evidence, which demonstrates that more studies on the use of opioids in pain management are necessary. Moreover, the increased frequency of prescribing opioids for chronic noncancer pain has raised other issues, such as iatrogenic adverse effects, which may also occur in patients with cancer pain on long-term opioid therapy (L-TOT). In this narrative review, we discussed the role of opioid guidelines and recent knowledge regarding the consequences of L-TOT, in particular opioid addiction and deficiencies of the immune and endocrine systems. Finally, we addressed new strategies to strengthen the L-TOT in the management of cancer-related pain among patients in palliative care.

Time to discontinuation of opioids in patients with cancer after curative intent radiation.

e18692 Background: Many providers expect that cancer survivors would be able to discontinue opioids soon after treatment, although this has not been well studied. The time cancer survivors that received curative intent radiation (CIR) remain on opioids and associated factors were examined. Methods: Electronic medical record data of cancer survivors between January 1, 2008 and December 31, 2018 and Kaplan Meier survival models were used to estimate time to discontinuation (TTD) of opioids. Cox proportional hazards models were employed to identify factors associated with TTD. Results: Median TTD was 16.8 months (95% CI: 13.1-19.1 months) following CIR and shorter for patients without opioid exposure prior to therapy (new persistent opioid use [NPOU]; 13.0 months, 95% CI: 10.0-17.3 months) compared to patients with opioid exposure prior to therapy (chronic opioid use [COU]; 21.4 months, 95% CI: 17.5-28.8 months) (p-value = 0.0004). NPOU (HR: 1.35, 95% CI: 1.07-1.71) compared to COU and head and neck (HR: 1.60, 95% CI: 1.01-2.53) in comparison to breast cancer were associated with shorter TTD. Surgery (HR: 0.68, 95% CI: 0.50-0.91), death (HR: 0.55, 95% CI: 0.34-0.91), alcohol use (HR: 0.63, 95% CI: 0.42-0.95) and nicotine use (HR: 0.78, 95% CI: 0.62-0.98) were associated with longer TTD. Conclusions: Cancer survivors receive opioids for almost 1.5 years after CIR. Patients receiving surgery and using alcohol or nicotine are at higher risk. Patients with NPOU or head and neck cancers have shorter TTD. Evidence-based guidelines for opioid use in cancer survivors are warranted due to opioid use following CIR.

\u201cMy life is under control with these medications\u201d: an interpretative phenomenological analysis of managing chronic pain with opioids

BackgroundThe use of opioids to relieve chronic pain has increased during the last decades, but experiences of chronic opioid therapy (COT) (> 90 days) point at risks and loss of beneficial effects. Still, some patients report benefits from opioid medication, such as being able to stay at work. Guidelines for opioid use in chronic pain do not consider the individual experience of COT, including benefits and risks, making the first person perspective an important scientific component to explore. The aim of this study was to investigate the lived experience of managing chronic pain with opioids in a sample who have severe chronic pain but are able to manage their pain sufficiently to remain at work.MethodsWe used a qualitative research design: interpretative phenomenological analysis. Ten individuals with chronic pain and opioid therapy were purposively sampled in Swedish tertiary care.ResultsThree super-ordinate themes emerged from the analyses: Without opioids, the pain becomes the boss; Opioids as a salvation and a curse, and Acknowledgement of the pain and acceptance of opioid therapy enables transition to a novel self. The participants used opioids to regain control over their pain, thus reclaiming their wanted life and self, and sense of control over one’s life-world. Using opioids to manage pain was not unproblematic and some of the participants had experienced a downward spiral of escalating pain and uncontrollable opioid use, and stigmatisation.ConclusionsAll participants emphasised the importance of control, regarding both pain and opioid use. To accomplish this, trust between participants and health care providers was essential for satisfactory treatment. Regardless of the potential sociocultural benefits of staying at work, participants had experiences of balancing positive and negative effects of opioid therapy, similar to what previous qualitative research has found.Measurable improvement of function and quality of life, may justify the long-term use of opioids in some cases. However, monitoring of adverse events should be mandatory. This requires close cooperation and a trusting relationship between the patients and their health care provider.

Opioid utilization is minimal after outpatient pediatric urologic surgery

There are no guidelines for opioid use after pediatric urologic surgery, and it is unknown to what extent prescriptions written for these patients may be contributing to the opioid epidemic in the United States. We sought to characterize opioid utilization in a prospective fashion following outpatient pediatric urologic surgery at our institution. After obtainingapproval from the Institutional Review Board, we prospectively recruited pediatric patients undergoing outpatient urologic surgery. All patients and families were counseled regarding appropriate use of over-the-counter pain medications as first-line agents, with opioids for breakthrough pain only. All patients received an opioid prescription (ORx), which we attempted to standardize to 10 doses. Parents were provided with a log for keeping track of pain medication administration. Postoperative surveys were sent at various time points after surgery to assess utilization of pain medications at home. We quantified unused opioids prescribed and evaluated factors potentially associated with opioid use. Two hundred and two patients were recruited. All patients were male, with a median age of 2.7 years (interquartile range (IQR) 5.5, range 0.5-17.9 years). One hundred and fifty-four children underwent penile surgery, 22 underwent scrotal surgery, and 27 underwent inguinal surgery. Nearly half of our study patients were black, 33.2% were white, 12.9% were Latino, and 4.0% were Asian. The median number of doses prescribed was 10 (IQR 0, range 4.0-20.8). Postoperative surveys were completed by 80.7% of study patients. The median number of opioid doses used was 0 (IQR 2), whereas the mean was 1.28 (standard deviation (SD) 1.98). None of the factors evaluated (including patient age, surgery type, perioperative pain management techniques, length of surgery, and insurance type) were associated with the amount of opioid used at home after surgery, as utilization was equally low across all groups. Ensuring adequate postoperative pain control for children is critical, yet it is also important to minimize excess ORx. We found that the majority of pediatric patients used 0-2 doses of prescription pain medication after discharge following outpatient urologic surgery, representing a small percentage of the total prescribed amount. Low utilization was seen irrespective of patient age, procedure, and perioperative factors. These data can be used to guide perioperative patient and family counseling and to guide future efforts to standardize ORx following outpatient pediatric urologic surgery.

Latin-American guidelines for opioid use in chronic nononcologic pain.

Latin-American experts in the use of opioids in patients with chronic nononcologic pain (CNOP) have updated existing recommendations to current Latin-American reality. Several key opinion leaders from Latin America participated in a face-to-face meeting in Guatemala (April 2015) to discuss the use of opioids in CNOP. Subgroups of experts worked on specific topics, reviewed the literature and shaped the final manuscript. The expert panel developed guidelines taking into consideration the utility of both opioid and nonopioid analgesics and factors pertaining to their efficacy, safety, adherence, administration and risks for abuse/addiction. Latin-American guidelines for the use of opioids in CNOP should improve pain relief and patients' quality of life by increasing access to these effective agents.

High-Dose Opioid Prescribing and Opioid-Related Hospitalization: A Population-Based Study.

AimsTo examine the impact of national clinical practice guidelines and provincial drug policy interventions on prevalence of high-dose opioid prescribing and rates of hospitalization for opioid toxicity.DesignInterventional time-series analysis.SettingOntario, Canada, from 2003 to 2014.ParticipantsOntario Drug Benefit (ODB) beneficiaries aged 15 to 64 years from 2003 to 2014.InterventionsPublication of Canadian clinical practice guidelines for use of opioids in chronic non-cancer pain (May 2010) and implementation of Ontario’s Narcotics Safety and Awareness Act (NSAA; November 2011).MeasurementsThree outcomes were explored: the rate of opioid use among ODB beneficiaries, the prevalence of opioid prescriptions exceeding 200 mg and 400 mg morphine equivalents per day, and rates of opioid-related emergency department visits and hospital admissions.FindingsOver the 12 year study period, the rate of opioid use declined 15.2%, from 2764 to 2342 users per 10,000 ODB eligible persons. The rate of opioid use was significantly impacted by the Canadian clinical practice guidelines (p-value = .03) which led to a decline in use, but no impact was observed by the enactment of the NSAA (p-value = .43). Among opioid users, the prevalence of high-dose prescribing doubled (from 4.2% to 8.7%) over the study period. By 2014, 40.9% of recipients of long-acting opioids exceeded daily doses of 200 mg morphine or equivalent, including 55.8% of long-acting oxycodone users and 76.3% of transdermal fentanyl users. Moreover, in the last period, 18.7% of long-acting opioid users exceeded daily doses of 400 mg morphine or equivalent. Rates of opioid-related emergency department visits and hospital admissions increased 55.0% over the study period from 9.0 to 14.0 per 10,000 ODB beneficiaries from 2003 to 2013. This rate was not significantly impacted by the Canadian clinical practice guidelines (p-value = .68) or enactment of the NSAA (p-value = .59).ConclusionsAlthough the Canadian clinical practice guidelines for use of opioids in chronic non-cancer pain led to a decline in opioid prescribing rates among ODB beneficiaries these guidelines and subsequent Ontario legislation did not result in a significant change in rates of opioid-related hospitalizations. Given the prevalence of high dose opioid prescribing in this population, this suggests that improved strategies and programs for the safe prescribing of long-acting opioids are needed.

Transdermal opioids for cancer pain control in patients with renal impairment

As guidelines for opioid use in renal-impaired patients with cancer are limited, the authors sought to assess the efficacy, safety, and tolerability, of transdermal buprenorphine for moderate/severe cancer pain in renal-impaired outpatients. In a prospective parallel-group active-controlled study, n = 42 consecutively recruited outpatients with or without renal impairment (serum creatinine ≥1.3 or ≤1.2 mg/dL, respectively) were treated with transdermal buprenorphine (group BUP) or fentanyl (group FEN), respectively. Patients were followed up, at home, by the nonprofit ANT-Italia-foundation physicians in Bologna, Italy. Measurements at 10 (T1), 30 (T2), and 90 (T3) days after enrollment (T0) were pain intensity (Numerical Rating Scale [NRS]), Karnofski score, opioid dose (μg/h), rescue-dose consumption, and occurrence of adverse effects. Patients recorded subjective measurements in a personal diary. Upon data analysis, investigators were blinded to the patient group. At T0, in groups BUP and FEN, median NRS score was 8.0 (CI, 7.4-8.4); its reduction over time (T3; NRS = 3.0; CI, 2.1-3.8 and 2.0-4.0, respectively) was significant and constant in both groups (t-test; T0-T1, T1-T2, and T2-T3; p < 0.0001, p < 0.001, and p < 0.05, respectively). At all times, there were no significant differences in pain scores between the groups. In all evaluations, adverse effects were reported n = 73/126 times (60.8 percent) and showed no significant association (X(2), p > 0.05) with the study groups. Transdermal buprenorphine, in outpatients with cancer and renal impairment, is as effective, safe, and tolerable as fentanyl in patients without such impairment. These results add further evidence to the notion that buprenorphine, with its peculiar pharmacokinetics, may be an appropriate choice for opioid treatment in patients with renal impairment.

Prevention of Opioid Abuse in Chronic NonCancer Pain: An Algorithmic, Evidence Based Approach

Background: The use of opioids for chronic non-cancer pain has grown exponentially in the last 15 years. Associated with that, dramatic increases in abuse and overdose deaths from opioid use have been noted. Objectives: Most opioid abuse stems from legitimate prescriptions, putting the onus on prescribers to use opioids responsibly for chronic pain. Very little evidence-based guidance exists for those who wish to prescribe opioids for legitimate chronic pain and at the same time prevent opioid abuse. Methods: A review of literature was performed for articles focused on guidelines for opioid use when prescribed for chronic pain, opioid abuse, and overdose, strategies to detect and prevent abuse of opioids, urine drug screens (UDS) in chronic pain settings, prescription monitoring programs (PMP), and the relationship between opioid dosing and abuse. Results: Based on the existing literature, an evidence-based algorithmic approach was developed to decrease opioid abuse in the chronic pain environment. The pillars of prevention are the screening of patients into high, medium, and low risk categories using screening tools; monitoring patients using UDS, PMP, and pill counts, and lastly, dose limitations. Conclusion: This algorithmic approach may enable physicians to prescribe opioids for patients with chronic pain and also to reduce opioid abuse. Key words: Opioids, chronic pain, abuse, prescription, overdose, deaths, overdose deaths, urine drug screens, prescription monitoring programs, opioid dose, screening, monitoring

NICE Opioids in Palliative Care (Clinical Guideline 140) - A Guideline Summary.

The following article summarises the recent National Institute of Clinical Evidence (NICE) clinical guidelines for opioid use in palliative care.1 With the population rapidly ageing, cancer is becoming more common. As such, there is an increasing need to address the pain associated with severe and progressive disease. The updated NICE guidance (CG 140) targets non-specialists initiating treatment with strong opioids for adults with advanced and progressive disease.1 It addresses step three of the pain ladder for malignancy according to the World Health Organization pain ladder.2 It does not address treatment in patients’ final days of life or second-line treatment. An adapted pathways is presented in Figure 1. Fig 1 Opioid pathway (adapted from NICE guideline CG 140).1 Professionals should be aware of patients’ preferences and needs and aid them in making informed decisions. Informed consent is required and practitioners should refer to the Mental Capacity Act if necessary.

A systematic review of the use of opioid medication for those with moderate to severe cancer pain and renal impairment: A European Palliative Care Research Collaborative opioid guidelines project

Background: Opioid use in patients with renal impairment can lead to increased adverse effects. Opioids differ in their effect in renal impairment in both efficacy and tolerability. This systematic literature review forms the basis of guidelines for opioid use in renal impairment and cancer pain as part of the European Palliative Care Research Collaborative’s opioid guidelines project. Objective: The objective of this study was to identify and assess the quality of evidence for the safe and effective use of opioids for the relief of cancer pain in patients with renal impairment and to produce guidelines. Search strategy: The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, MedLine, EMBASE and CINAHL were systematically searched in addition to hand searching of relevant journals. Selection criteria: Studies were included if they reported a clinical outcome relevant to the use of selected opioids in cancer-related pain and renal impairment. The selected opioids were morphine, diamorphine, codeine, dextropropoxyphene, dihydrocodeine, oxycodone, hydromorphone, buprenorphine, tramadol, alfentanil, fentanyl, sufentanil, remifentanil, pethidine and methadone. No direct comparator was required for inclusion. Studies assessing the long-term efficacy of opioids during dialysis were excluded. Data collection and analysis: This is a narrative systematic review and no meta-analysis was performed. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the quality of the studies and to formulate guidelines. Main results: Fifteen original articles were identified. Eight prospective and seven retrospective clinical studies were identified but no randomized controlled trials. No results were found for diamorphine, codeine, dihydrocodeine, buprenorphine, tramadol, dextropropoxyphene, methadone or remifentanil. Conclusions: All of the studies identified have a significant risk of bias inherent in the study methodology and there is additional significant risk of publication bias. Overall evidence is of very low quality. The direct clinical evidence in cancer-related pain and renal impairment is insufficient to allow formulation of guidelines but is suggestive of significant differences in risk between opioids. Recommendations: Recommendations regarding opioid use in renal impairment and cancer pain are made on the basis of pharmacokinetic data, extrapolation from non-cancer pain studies and from clinical experience. The risk of opioid use in renal impairment is stratified according to the activity of opioid metabolites, potential for accumulation and reports of successful or harmful use. Fentanyl, alfentanil and methadone are identified, with caveats, as the least likely to cause harm when used appropriately. Morphine may be associated with toxicity in patients with renal impairment. Unwanted side effects with morphine may be satisfactorily dealt with by either increasing the dosing interval or reducing the 24 hour dose or by switching to an alternative opioid.

Opioide bei muskuloskelettalen Schmerzen

Opioide sind die potentesten verfügbaren Analgetika und sind bei der Behandlung von starken akuten Schmerzen, in der perioperativen Phase und bei Tumorschmerzen fest etabliert. Aufgrund der guten Wirksamkeit wird auch der Einsatz bei nicht durch Tumore verursachten chronischen Schmerzen propagiert. Allerdings ist der Einsatz von Opioiden wegen potenzieller Nebenwirkungen, der möglichen Ausprägung einer Toleranz, Abhängigkeit oder Entzugssymptomatik und den administrativen Schwierigkeiten bei der Verordnung umstritten. Chronische rheumatologische Erkrankungen, vor allem chronischer Rückenschmerz und Gelenkschmerzen, zählen zu den häufigsten Ursachen von chronischen nicht-Tumor Schmerzen (CNTS). Im Folgenden soll ein kurzer Überblick über den Einsatz von Opioiden bei chronisch rheumatologischen Erkrankungen gegeben werden und auf die im letzten Jahr publizierte Leitlinie für den Einsatz von Opioiden bei CNTS (LONTS) eingegangen werden.

Treatment of Pain Due to Vaso-Occlusive Crises (VOC) in Adults with Sickle Cell Disease (SCD): Limited Awareness of Available Guidelines.

SCD is characterized by frequent VOC marked by severe pain often requiring emergency department visits and inpatient admissions for treatment with parenteral opioids. Guidelines for managing pain due to VOC, published in the US (in 1999 and 2002) and England (in 2003) suggest: 1) rapid initiation of parenteral opioids (within 15–30 min of arrival); 2) use of an adequate opioid starting dose (usually 5–10 mg or 0.1 mg/kg of morphine intravenously); 3) use of frequent repeat opioid doses (every 15–30 min) until pain is significantly improved; and 4) selection of an alternative treatment regimens based on an individual’s prior opioid-response history. However, attending physicians on the adult hematology service were generally unaware of the existence of these guidelines. Thus, all standard textbooks in internal medicine (N=7), hematology (N=3) and emergency medicine (N=3) available in hard-copy or on-line at the Yale University School of Medicine library and published after 2002 were reviewed for recommendations regarding: a) treatment of pain due to VOC; b) treatment of pain due to acute myocardial infarction; and c) treatment of bleeding due to Hemophilia A. For treatment of pain due to VOC, none of the texts indicated a target time for initiating opioid therapy and only 2 texts commented on the need to individualize therapy based on patient history. Suggested starting doses of opioids were not given in 5 of 13 references and were lower than guideline recommendations in one additional text. The frequency of opioid administration was not noted in 6 reference books; only 2 texts suggested repeat doses within a 20–30 minute interval; one text suggested an interval of 1 to 3 hours; and the other 4 texts suggested intervals of 2 to 4 hours. Overall, appropriate initial opioid doses were provided in 7 texts (54%); recommendations for dosing frequency were consistent with guidelines in 2 texts (15%); the need to individualize therapy based on patient history was noted in 2 texts (15%); and no text indicated a target time for the initiation of analgesic therapy. In 1996, guidelines for opioid use in the treatment of pain due to acute myocardial infarction suggested doses of 2–4 mg of intravenous morphine administered as often as every 5 minutes. Of the 10 relevant internal medicine and emergency medicine texts reviewed, recommendations were not given in one text but both the morphine dose and frequency of administration were consistent with these guidelines in the remaining 9 (90%). Finally, for hemophilia A, all 13 reference works provided specific and consistent directions for the calculation of Factor VIII treatment requirements while 10 texts (77%) described available Factor VIII preparations. In conclusion, standard texts do not present adequate infomation to permit effective treatment of acute pain in SCD. Since guidelines for frequent opioid use to treat pain due to acute myocardial infarction are given in most texts, this cannot be explained by constraints on recommending opioid therapy per se. Nor can it be explained by the rarity of SCD since more detailed information is provided for the treatment of hemophilia, an even less common disorder. It is of note then that only 5 of 13 texts (38%) reassure readers that narcotic addiction is infrequent in SCD patients while 9 of 10 texts (90%) offer this reassurance when discussing cancer pain treatment. Thus, greater educational efforts are needed to facilitate pain treatment in the VOC of SCD.

Assessment of efficacy of long-term opioid therapy in pain patients with substance abuse potential.

Clinical experience supports the notion that opioids can be used successfully to treat many chronic pain conditions. Unfortunately, few controlled trials have assessed which individuals benefit from long-term opioid therapy, and there is concern about the use of long-term opioid therapy in individuals with a substance-abuse history. This article contains three sections relevant to the assessment of individuals with chronic pain and a substance-abuse history who are receiving long-term opioid therapy. The first reviews the literature on opioid therapy, with a critique of biologic and environmental susceptibility factors for addiction. The second briefly reviews uncontrolled and controlled trials of opioid therapy for pain. The third reviews areas critical in assessing treatment efficacy and substance abuse in patients with chronic pain, both in terms of documentation of past behaviors and as a measure of outcome of opioid therapy. Potential guidelines for use of opioids in patients with chronic noncancer pain are outlined. Finally, questions are posed for future investigations of the efficacy of opioid therapy for patients with chronic pain and a substance-abuse history.