Management Of Chronic Non-cancer Pain Research Articles

Clinical prediction of opioid use disorder in chronic pain patients: a cohort-retrospective study with a pharmacogenetic approach.

Opioids are widely used in chronic non-cancer pain (CNCP) management. However, they remain controversial due to serious risk of causing opioid use disorder (OUD). Our main aim was to develop a predictive model for future clinical translation that include pharmacogenetic markers. An observational study was conducted in 806 pre-screened Spanish CNCP patients, under long-term use of opioids, to compare cases (with OUD, N.=137) with controls (without OUD, N.=669). Mu-opioid receptor 1 (OPRM1, A118G, rs1799971) and catechol-O-methyltransferase (COMT, G472A, rs4680) genetic variants plus cytochrome P450 2D6 (CYP2D6) liver enzyme phenotypes were analyzed. Socio-demographic, clinical and pharmacological outcomes were also registered. A logistic regression model was performed. The model performance and diagnostic accuracy were calculated. OPRM1-AA genotype and CYP2D6 poor and ultrarapid metabolizers together with three other potential predictors: 1) age; 2) work disability; 3) oral morphine equivalent daily dose (MEDD), were selected with a satisfactory diagnostic accuracy (sensitivity: 0.82 and specificity: 0.85), goodness of fit (P=0.87) and discrimination (0.89). Cases were ten-year younger with lower incomes, more sleep disturbances, benzodiazepines use, and history of substance use disorder in front of controls. Functional polymorphisms related to OPRM1 variant and CYP2D6 phenotypes may predict a higher OUD risk. Established risk factors such as young age, elevated MEDD and lower incomes were identified. A predictive model is expected to be implemented in clinical setting among CNCP patients under long-term opioids use.

Patient perspectives on primary care providers role in long-term opioid therapy.

Over the past decade, long-term use of prescription opioids for chronic non-cancer pain (CNCP) has risen globally despite the associated risks. The majority of opioid users receive their first prescription in primary care. To investigate the perspective of long-term opioid users in primary care regarding the role of healthcare providers (HCP) in their prolonged opioid use. Semi-structured interviews in Dutch primary care Methods: We recruited long-term opioid users for CNCP from seven community pharmacies in the Netherlands. In-depth, semi-structured interviews focussed on experiences with long term opioid use, access to opioids, and the guidance of their HCPs. A directed content analysis was conducted on the transcribed interviews using NVivo. Participants (n=25) mentioned ways HCPs impacted their long-term use of opioids. These encompassed: 1) the initiation of treatment, 2) chronic use of opioids, 3) discontinuation of treatment. Participants stressed the need for risk counselling during initial prescriptions, ongoing medication evaluations including tapering conversations, and more support from their HCP during a tapering attempt. Patients' perspective illustrates the important role of HCPs across the spectrum of opioid usage - from initiation to tapering. It underscores the importance of clear risk counselling starting at the initial prescription, continuous medication assessments throughout treatment, addressing tapering at regular intervals and strong support during tapering. These insights carry significant implications for clinical practice, emphasising the importance of informed and patient-centred care when it comes to opioid use for chronic non-cancer pain management.

Opioid and the usage in chronic non cancer pain

The use of opioid in various guidelines for chronic non-cancer pain is controversial because evidence of their long-term benefits is weak. The potential for serious adverse effects and local regulations warrant caution in both prescribers and users. However, opioids have a role in the management of chronic non-cancer pain in carefully selected patients with regular monitoring and as a part of multimodal therapy. Common adverse effects should be treated promptly to improve patient compliance. We believe that opioid therapy at low doses is beneficial in some patients. It should not be denied but carefully considered on a case-by-case basis.

Shifting quality chronic pain treatment measures from processes to outcomes.

Misapplication of the 2016 Centers for Disease Control (CDC) opioid prescribing guidelines has led to overem-phasis of morphineequivalent daily dose (MEDD) as a "metric of success" in chronic noncancer pain (CNCP), resulting in unintentional harms to patients. This article reviews CNCP-related guidelines and patient preferences in order to identify pragmatic, patient-centered metrics to assess treatment response and safety in opioid-treated CNCP. We reviewed the clinical (CDC), research (Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials), and implementability-related guidelines (GuideLine Implementability Appraisal), along with relevant patient-identified treatment goals. From these, we summarize a guideline-concordant, patient-centered, implementable set of measures to aid the clinical management of opioid-treated CNCP. We identify metrics across three domains of care: (1) treatment response metrics, which align with the CNCP care goals (pain intensity, pain interference including function and quality of life, and global impression of change); (2) risk assessment ("safety") metrics, eg, MEDD, benzodiazepine-opioid or naloxone-opioid coprescribing, and severity of mental health disorders, which evaluate the risk-benefit profile of opioid therapy; and (3) adherence ("process") metrics, which assess clinician/patient adherence to the guideline-recommended opioid therapy monitoring practices, eg, the presence of completed treatment agreement or urine toxicology testing. All metrics should be informed by implementability principles, eg, be decidable, executable, and measurable. This article summarizes guideline-concordant, patient-centered, implementable metrics for assessing treatment response, safety, and adherence in opioid-treated CNCP. Regardless of which specific treatment guidelines are applied, this approach could help conceptualize and standardize the collection and reporting of CNCP-relevant metrics, compare them across health systems, and optimize care and treatment outcomes in opioid-treated CNCP.

Addiction stigma and opioid use in chronic non-cancer pain management in Nigeria.

This study uses 26 in-depth interviews conducted with people who use drugs (PWUD) who had sought care for chronic non-cancer pain in public health facilities in Nigeria, to explore how drug consumption stigma constitutes patient legitimacy based on neoliberal ideals. It found drug consumption stigma to be salient and pervasive in PWUD health-care encounters, operating through interpersonal interactions and institutionalised policies and practices to shape access to care. Crucially, stigma emerged through disciplinary opioid prescribing and dispensing practices that defined, categorised and marginalised PWUD based on how their drug consumption disrupted normative values of rationality and responsibility. Accounts additionally revealed disengagement from biomedical care and reliance on alternative pain management approaches (e.g. herbal remedies and illegal drugs), which show how structural positions shape the exercise of choice and agency in socially marginalised populations. In conclusion, the study considers the need to improve the health-care experiences of PWUD as a strategy for enhancing health-care engagement and improving health outcomes. It called for interventions to address the structural factors and interactional dynamics that influence stigma in health-care settings as well as for a review of current guidelines and practices to improve access to opioids for chronic non-cancer pain management.

Evaluation of a pharmacist-led interprofessional chronic pain clinic in Canada.

Chronic noncancer pain (CNCP) is a common condition that affects individuals at a biopsychosocial level and can significantly impair function and quality of life. Referral to an interprofessional CNCP program is recommended for most patients; however, these clinics are limited in number and capacity. Expanding access by testing new service delivery models would be of value. The purpose of this study was to measure the impact of a new pharmacist-led, interprofessional model of care developed at the University of Saskatchewan Chronic Pain Clinic. A retrospective chart audit was conducted using data that included adult patients referred for CNCP management between May 2020 and December 2021. Medication use, overall health status (using the Clinical Global Impression of Change-Improvement [CGI-I] scale) and patient readiness to change (using the Transtheoretical Model) were measured 6 months after the initial appointment. The study included 138 patients. Of the 80 patients taking an opioid, 22.5% were switched to buprenorphine/naloxone and the remainder had their mean morphine-equivalent dose reduced by a mean of 41.7 mg/d. Overall patient health status was minimally improved and many patients moved into the Action stage of change. Changes in opioid use demonstrate a clinically important shift toward safer medication regimens that are less likely to lead to toxicity and unintended overdose. CGI-I data suggest that these patients, whose health status is typically very difficult to change, did not deteriorate but slightly improved after attending the clinic. The unique pharmacist-led, interprofessional model of care used by the University of Saskatchewan Chronic Pain Clinic may offer a viable alternative to traditional physician-led models.

Cancer Pain Management: A Narrative Review of Current Concepts, Strategies, and Techniques.

Pain is frequently reported during cancer disease, and it still remains poorly controlled in 40% of patients. Recent developments in oncology have helped to better control pain. Targeted treatments may cure cancer disease and significantly increase survival. Therefore, a novel population of patients (cancer survivors) has emerged, also enduring chronic pain (27.6% moderate to severe pain). The present review discusses the different options currently available to manage pain in (former) cancer patients in light of progress made in the last decade. Major progress in the field includes the recent development of a chronic cancer pain taxonomy now included in the International Classification of Diseases (ICD-11) and the update of the WHO analgesic ladder. Until recently, cancer pain management has mostly relied on pharmacotherapy, with opioids being considered as the mainstay. The opioids crisis has prompted the reassessment of opioids use in cancer patients and survivors. This review focuses on the current utilization of opioids, the neuropathic pain component often neglected, and the techniques and non-pharmacological strategies available which help to personalize patient treatment. Cancer pain management is now closer to the management of chronic non-cancer pain, i.e., "an integrative and supportive pain care" aiming to improve patient's quality of life.

Attrition of methylnaltrexone treatment-emergent adverse events in patients with chronic noncancer pain and opioid-induced constipation: a post hoc pooled analysis of two clinical trials.

Background: Opioids prescribed for the management of chronic noncancer pain are associated with nausea, vomiting, and constipation. Methylnaltrexone, a peripherally acting µ-opioid receptor antagonist, has demonstrated robust efficacy and was well-tolerated in treating opioid-induced constipation without affecting central analgesia. Our objective was to assess changes in the frequency of treatment-emergent adverse events (TEAEs) after the first or second dose of methylnaltrexone or placebo. Methods: This post hoc analysis pooled data from two randomized, placebo-controlled clinical trials assessing methylnaltrexone for opioid-induced constipation in the outpatient setting. Patients received subcutaneous methylnaltrexone (12 mg once daily or 12 mg once every other day), oral methylnaltrexone (150, 300, or 450 mg daily), or placebo. TEAEs, opioid withdrawal symptoms, pain intensity, and rescue-free bowel movements (RFBMs) within 4 hours of the first dose (i.e., RFBM responders) were assessed. Associations between TEAE frequencies and RFBM response were also evaluated. Results: The analysis included 1263 adult patients with chronic noncancer pain. TEAE rates declined from treatment day 1 to 2 (methylnaltrexone: 16.2%-5.3%; placebo: 6.6%-5.4%). Among methylnaltrexone-treated patients, significantly greater proportions of RFBM responders versus nonresponders reported gastrointestinal TEAEs on day 1. No associations between RFBM response and the frequency of TEAEs were observed in the placebo group. No meaningful changes in opioid withdrawal symptoms or pain intensity were observed. Conclusions: Early-onset TEAEs following methylnaltrexone treatment, particularly gastrointestinal TEAEs, are at least partially due to laxation. Methylnaltrexone treatment effectively relieves opioid-induced constipation without affecting the central analgesic effects of opioids.

The intersection of drug use discrimination and racial discrimination in the management of chronic non-cancer pain in United States primary care safety-net clinics: Implications for healthcare system and clinic-level changes

BackgroundClinicians’ bias related to patients’ race and substance use history play a role in pain management. However, patients’ or clinicians’ understandings about discriminatory practices and the structural factors that contribute to and exacerbate these practices are underexamined. We report on perceptions of discrimination from the perspectives of patients with chronic non-cancer pain (CNCP) and a history of substance use and their clinicians within the structural landscape of reductions in opioid prescribing in the United States. MethodsWe interviewed 46 clinicians and 94 patients, using semi-structured interview guides, from eight safety-net primary care clinics across the San Francisco Bay Area from 2013 to 2020. We used a modified grounded theory approach to code and analyze transcripts. ResultsClinicians discussed using opioid prescribing guidelines with the goals of increased opioid safety and reduced bias in patient monitoring. While patients acknowledged the validity of clinicians’ concerns about opioid safety, they indicated that clinicians made assumptions about opioid misuse towards Black patients and patients suspected of substance use. Clinicians discussed evidence of discrimination in opioid prescribing at the clinic-wide level; racialized stereotypes about patients likely to misuse opioids; and their own struggles to overcome discriminatory practices regarding CNCP management. ConclusionWhile clinicians and patients acknowledged opioid safety concerns, the practical application of opioid prescribing guidelines impacted how patients perceived and engaged with CNCP care particularly for patients who are Black and/or report a history of substance use. We recommend healthcare system and clinic-level interventions that may remediate discriminatory practices and associated disparities.

Telehealth for management of chronic non-cancer pain and opioid use disorder in safety net primary care

BackgroundThe SARS-CoV-2 (COVID-19) pandemic increased use of telehealth for the management of opioid use disorder and chronic non-cancer pain in primary care safety net clinical systems. Significant barriers to telehealth exist, little is known about how these barriers impact urban safety net, primary care providers and their patients. The objective of this study was to qualitatively assess the benefits and challenges of telehealth for management of chronic non-cancer pain, opioid use disorder, and multi-morbidity in primary care, safety net clinical systems.MethodsWe interviewed patients with chronic non-cancer pain and history of substance use (n = 22) and their primary care clinicians (n = 7) in the San Francisco Bay Area, March-July 2020. We recorded, transcribed, coded, and content analyzed interviews.ResultsCOVID-19 shelter-in-place orders contributed to increases in substance use and uncontrolled pain, and posed challenges for monitoring opioid safety and misuse through telehealth. None of the clinics used video visits due to low digital literacy/access. Benefits of telehealth included decreased patient burden and missed appointments and increased convenience and control of some chronic conditions (e.g., diabetes, hypertension). Telehealth challenges included loss of contact, greater miscommunication, and less comprehensive care interactions.ConclusionsThis study is one of the first to examine telehealth use in urban safety net primary care patients with co-occurring chronic non-cancer pain and substance use. Decisions to continue or expand telehealth should consider patient burden, communication and technology challenges, pain control, opioid misuse, and medical complexity.

Knowledge, attitudes and practices of neurologists regarding the management of chronic non-cancer pain in the Republic of Moldova

Background: Chronic pain is a public health problem due to its high prevalence, disability, and associated comorbidities. In the Republic of Moldova, there are no health policies or strategies regarding chronic pain, and the burden on the population is not known because it is not registered nor monitored by the state. The aim was to analyze the knowledge, attitudes, and practices of neurologists regarding the management of chronic pain in the Republic of Moldova. Material and methods: Mixed observational study (qualitative and quantitative) was designed and carried out using a Knowledge, Attitudes, Practices research questionnaire. The study includes 50 neurologists, average age of 47.4±9.52 years, women (82%), and urban area (80%), interacting with chronic pain patients on a daily basis (86%). Results: 42% of neurologists know about pain measurement tools, 40% of them use these pain measurement tools, 40% of neurologist know clinical guidelines, 92% of them practice pharmacological and non-pharmacological treatments. The neurologists (62%) presented negative attitudes about chronic pain patients. Just 18% of them have sufficient knowledge and skills to deal with such a patient, 64% of neurologists received training on chronic pain issues. Conclusions: Neurologists have little knowledge of pain measurement tools and guidelines and don’t use them, which makes chronic pain poorly addressed, evaluated, and treated at the national level. They recognize the right of the patient to live without suffering and to benefit from quality services focused on their needs, but consider patients difficult to approach, communicate and work with.

High-dose opioids for chronic non-cancer pain: an overview of Cochrane Reviews.

This overview was originally published in 2017, and is being updated in 2022. Chronic pain is typically described as pain on most days for at least three months. Chronic non-cancer pain (CNCP) is any chronic pain that is not due to a malignancy. Chronic non-cancer pain in adults is a common and complex clinical issue, for which opioids are prescribed by some physicians for pain management. There are concerns that the use of high doses of opioids for CNCP lacks evidence of effectiveness, and may increase the risk of adverse events. To describe the evidence from Cochrane Reviews and overviews regarding the efficacy and safety of high-dose opioids (defined as 200 mg morphine equivalent or more per day) for CNCP. We identified Cochrane Reviews and overviews by searching the Cochrane Database of Systematic Reviews in The Cochrane Library. The date of the last search was 21 July 2022. Two overview authors independently assessed the search results. We planned to analyse data on any opioid agent used at a high dose for two weeks or more for the treatment of CNCP in adults. We did not identify any reviews or overviews that met the inclusion criteria. The excluded reviews largely reflected low doses or titrated doses, where all doses were analysed as a single group; we were unable to extract any data for high-dose use only. There is a critical lack of high-quality evidence, in the form of Cochrane Reviews, about how well high-dose opioids work for the management of CNCP in adults, and regarding the presence and severity of adverse events. No evidence-based argument can be made on the use of high-dose opioids, i.e. 200 mg morphine equivalent or more daily, in clinical practice. Considering that high-dose opioids have been, and are still being used in clinical practice to treat CNCP, knowing about the efficacy and safety of these higher doses is imperative.

Chronic noncancer pain management: Integration of a nurse-led program in primary care.

Chronic noncancer pain is often excessively managed with medications (most notably opioids) instead of nonpharmacologic options or multidisciplinary care-the gold standards. To offer an effective alternative to pharmacologic management of chronic noncancer pain in primary care. Patients 18 years of age or older with chronic noncancer pain were referred by family physicians or nurse practitioners in a family health team (outpatient, multidisciplinary clinic) in Ottawa, Ont. A registered nurse used the Pain Explanation and Treatment Diagram with patients, taught self-management skills (related to habits [smoking, consumption of alcohol, diet], exercise, sleep, ergonomics, and psychosocial factors), and referred patients to relevant resources. A nurse-led chronic pain program, initiated without extra funding, was successfully integrated into a primary care setting. Among the participating patients in the pilot project, outcomes related to pain intensity, pain interference with daily living, and opioid use were encouraging. This program could serve as a model for improving chronic noncancer pain management in primary care.

Annals for Hospitalists - March 2023

Annals for Hospitalists - March 2023

Prioritizing patient values for chronic pain care: a path out of the pain reduction regime?

Recently, the Centers for Disease Control and Prevention (CDC) updated their Clinical Practice Guideline for Prescribing Opioids for Pain.1 Although the guidelines focus on prescribing opioids for pain, the initial recommendations strongly encourage providers to prescribe nonpharmacologic and nonopioid medications in lieu of opioids. Recommendation 1 begins: “Nonopioid therapies are at least as effective as opioids for many types of acute pain.” Recommendation 2 begins: “Nonopioid therapies are preferred for subacute and chronic pain.” These recommendations echo other guidelines. The first recommendation of the 2022 Veterans Administration (VA) Opioid Guidelines begins: “We recommend against the initiation of opioid therapy for the management of chronic non-cancer pain.”2 The American College of Physicians (ACP) guideline on low back pain recommends nonopioid and nonpharmacological treatments3 and the United Kingdom’s National Institute for Health and Care Excellence (NICE) instructs providers to not initiate opioids as part of chronic pain treatment and to wean when there is a lack of evidence of benefit.4 Nevertheless, opioid treatment of chronic pain remains common. In 2020, 43.3 prescriptions were written per 100 US residents, a total of more than 142 million opioid prescriptions.5 While the United States has the highest level of opioid prescription rates in the world, and consequently the highest level of opioid-related problems, there is evidence of continued elevated opioid prescription and related problems in many developed countries.6

Chronic non-cancer pain management - insights from Australian general practitioners: a qualitative descriptive study.

The study explored the experiences and perceptions of GPs regarding the management of chronic non-cancer pain (CNCP). Specifically, participants were asked to identify perceived enablers and barriers to CNCP care and how the care of patients with CNCP may be improved. The study utilised a qualitative descriptive methodology. General practice in Western Australia. The sample was purposive with 12 Australian GPs from predominantly metropolitan locations and with experience in managing CNCP. Semi structured interviews were conducted. Each interview was of 45-60min duration. All interviews were audio recorded and transcribed using a secure transcription service. Thematic analysis developed themes inductively and deductively. Themes emerged regarding: the importance of a holistic and personalised approach; the important role of a coordinating GP; the need for an evidence-based approach to opioid management; concerns relating to access to multidisciplinary services; the importance of clinician and patient education regarding CNCP; and an acknowledgement of the challenges for doctors and patients in managing CNCP. Currently, the management of CNCP in Australia is challenging. Notable challenges include: difficulties with continuity of patient care; challenges with patient expectations of treatment, in particular opioid medications; difficulty with access to the health services required to enable holistic care; and the need for improved pain education in the community. The breadth of these challenges suggests there is a need for supportive organisational and structural considerations in the healthcare system to enable optimal care of CNCP in the community.

The Two Opioid Crises Problems, Causes, and Potential Solutions: An Analytic Review

Introduction: The United States currently faces two opioid crises, an evolved crisis currently manifesting as widespread abuse of illicit opioids, and a crisis in pain management largely manufactured by the Centers for Disease Control and Prevention 2016 Guideline. Our goal in this paper is to identify root causes, trace the trajectory of forces unleashed over time, and define potential solutions to these crises. Methods: Analytic review of the scientific, socioeconomic, and historical literature. Results: The evolved crisis reflects a socioeconomic rift in American society that began in the 1970s and has resulted in disintegration of lives and rising levels of desperation, particularly among the under-educated, rendering them susceptible to the lure of illicit opioids. Present manifestations of that crisis reflect a complex series of events starting with a consensus in the late1990s that opioids were fully acceptable in the management of chronic noncancer pain. This was followed by vast opportunism by pill mills, drug distributors, and the manufacturers that supplied them; aggressive actions by state governments to rein in the pill mills; and ultimately, the development of an enormous black market in heroin and fentanyl. The manufactured crisis reflects intrusion into the medical care of patients in chronic pain by the Centers for Disease Control that had been politicized decades earlier and that, in 2016, issued a Guideline that reflected serious mis-construal of the causes of the opioid crisis. We trace this history and review the literature on treatment of addiction, including medically assisted therapy, treatment of depression, psychosocial interventions, 12-step programs, programs that seek to address the causes of desperation, supervised injection facilities, decriminalization, legalization, and the impact of the comprehensive approach taken by Portugal. We also analyze the problems affecting the Centers for Disease Control that led to the publication of its ill-advised 2016 Guideline. Discussion: We conclude that many approaches currently being taken to treat addiction are well supported by scientific evidence but that the overall efficacy of treatment programs is not optimal and only a small fraction of all patients actually enter such programs. We also conclude that the Centers for Disease Control should have no future role in the regulation of patient care.

Management of chronic non-cancer pain in primary care.

Management of chronic non-cancer pain in primary care.

Reward Drive Moderates the Effect of Depression-Related Cognitive Mechanisms on Risk of Prescription Opioid Misuse Among Patients With Chronic Non-Cancer Pain

Depression, a prognostic factor for prescription opioid misuse commonly occurs in people with chronic non-cancer pain (CNCP). However, the mechanisms linking depression and prescription opioid misuse remain unclear. This study examined the potential mediating role of pain catastrophizing in the association between depressive symptoms and prescription opioid misuse risk, and impulsivity traits as possible moderators of these relationships. Individuals (N = 198; 77% women) with CNCP using prescription opioids participated in a cross-sectional online survey with validated measures of depression, pain catastrophizing, rash impulsiveness, reward drive, anxiety, pain severity and prescription opioid misuse. Meditation analyses with percentile-based bootstrapping examined pathways to prescription opioid use, controlling for age, sex, pain severity, and anxiety symptoms. Partial moderated mediation of the indirect effect of depressive symptoms on prescription opioid misuse risk through pain catastrophizing by rash impulsiveness and reward drive were estimated. Pain catastrophizing mediated depressive symptoms and prescription opioid misuse risk. Indirect effects were stronger when moderate to high levels of reward drive were included in the model. Findings suggest the risk of prescription opioid misuse in those experiencing depressive symptoms and pain catastrophizing is particularly higher for those higher in reward drive. Treatments targeting these mechanisms may reduce opioid misuse risk. PerspectiveThis article identifies reward drive as a potentially important factor increasing the effects of depression-related cognitive mechanisms on risk of prescription opioid misuse in those with CNCP. These findings could assist in personalizing clinical CNCP management to reduce the risks associated with opioid misuse.

Neurosurgical Treatment of Pain.

The aim of this review is to draw attention to neurosurgical approaches for treating chronic and opioid-resistant pain. In a first chapter, an up-to-date overview of the main pathophysiological mechanisms of pain has been carried out, with special emphasis on the details in which the surgical treatment is based. In a second part, the principal indications and results of different surgical approaches are reviewed. Cordotomy, Myelotomy, DREZ lesions, Trigeminal Nucleotomy, Mesencephalotomy, and Cingulotomy are revisited. Ablative procedures have a limited role in the management of chronic non-cancer pain, but they continues to help patients with refractory cancer-related pain. Another ablation lesion has been named and excluded, due to lack of current relevance. Peripheral Nerve, Spine Cord, and the principal possibilities of Deep Brain and Motor Cortex Stimulation are also revisited. Regarding electrical neuromodulation, patient selection remains a challenge.