Management Of Chronic Non-cancer Pain Research Articles

Healthcare provider knowledge, attitudes, beliefs, and practices surrounding the prescription of opioids for chronic non-cancer pain in North America: protocol for a mixed-method systematic review

BackgroundEvidence from diverse areas of medicine (e.g., cardiovascular disease, diabetes) indicates that healthcare providers (HCPs) often do not adhere to clinical practice guidelines (CPGs) despite a clear indication to implement recommendations—a phenomenon commonly termed clinical inertia. There are a variety of reasons for clinical inertia, but HCP-related factors (e.g., knowledge, motivation, agreement with guidelines) are the most salient and amenable to intervention aimed to improve adherence. CPGs have been developed to support the safe and effective prescription of opioid medication for the management of chronic non-cancer pain. The extent of physician uptake and adherence to such guidelines is not yet well understood. The purpose of this review is to synthesize the published evidence about knowledge, attitudes, beliefs, and practices that HCPs hold regarding the prescription of opioids for chronic non-cancer pain.MethodsAn experienced information specialist will perform searches of CINAHL, Embase, MEDLINE, and PsycINFO bibliographic databases. The Cochrane library, PROSPERO, and the Joanna Briggs Institute will be searched for systematic reviews. Searches will be performed from inception to the present. Quantitative and qualitative study designs that report on HCP knowledge, attitudes, beliefs, or practices in North America will be eligible for inclusion. Studies reporting on interventions to improve HCP adherence to opioid prescribing CPGs will also be eligible for inclusion. Two trained graduate-level research assistants will independently screen articles for inclusion, perform data extraction, and perform risk of bias and quality assessment using recommended tools. Confidence in qualitative evidence will be evaluated using the Grades of Recommendation, Assessment, Development, and Evaluation-Confidence in the Evidence from Qualitative Reviews (GRADE-CERQual) approach. Confidence in quantitative evidence will be assessed using the GRADE approach.DiscussionThe ultimate goal of this work is to support interventions aiming to optimize opioid prescribing practices in order to prevent opioid-related morbidity and mortality without restricting a HCP’s ability to select the most appropriate treatment for an individual patient.Systematic review registrationPROSPERO CRD42018091640.

Patient Reported Outcomes in Women With IBS Using Opioids for Chronic Non-Cancer Pain: ACG/Radhika Srinivasan Gender-Based Research Award: Presidential Poster Award

Introduction: Opioids can reduce gut motility, causing a number of adverse GI effects including vomiting, nausea, and constipation. These side effects are further exacerbated in individuals with functional bowel disorders such as IBS. Consequently, opioids are not recommended to treat pain in IBS. Yet, opioids continue to be prescribed at alarming rates particularly for chronic noncancer pain, and there is limited research on the extent to which an IBS diagnosis would discourage a clinician from prescribing narcotics to a patient. We sought to better understand opioid use and health outcomes in women with chronic noncancer pain and comorbid IBS. Methods: Cross-sectional data on comorbidities, current medication use, and patient-reported outcomes relating to physical health, mental health, and pain interference was collected as part of a larger study assessing patient preferences for chronic noncancer pain management. We conducted a subgroup analysis on respondents who selected IBS as a comorbidity (N = 209), restricting the sample to females (N = 194) due to insufficient male response (N = 15). Linear regressions were used to examine differences in PROMIS t-scores for mental health, physical health, and pain interference among opioid users and non-users, after adjusting for age and ethnicity. Results: 42.8% of female respondents with chronic pain and comorbid IBS reported currently using opioids compared to 36.3% of women without IBS (p = 0.107). Respondents had mean t-scores of 38, 32, and 64 for mental health, physical health, and pain interference, respectively. Adjusting for age and ethnicity, women using opioids reported lower PROMIS mental health scores (B = -4.37; p = 0.018) and physical health scores (B = -3.15; p < 0.001) than those not using opioids. Pain interference did not differ between women using opioids and those not using opioids, independent of age and ethnicity (p = 0.652).Conclusion: Opioid use in women with chronic pain and comorbid IBS was associated with reduced mental and physical health. Pain interference was higher than the general population for women with comorbid IBS, with no improvement in pain interference observed as a result of opioid use. Despite this, women with IBS using opioids to treat a primary pain condition reported similar rates of opioid use as respondents without IBS, indicating that an IBS diagnosis may not discourage opioid prescribing. Further research should investigate the risks and benefits of opioid use in women with chronic pain and IBS.460_A Figure 1. Mean mental health t-score as measured by PROMIS Global Health for women with comorbid IBS currently using opioids and those not using opioids.460_B Figure 2. Mean physical health t-score as measured by PROMIS Global Health for women with comorbid IBS currently using opioids and those not using opioids.460_C Figure 3. Mean pain interference t-score as measured by PROMIS Pain Interference for women with comorbid IBS currently using opioids and those not using opioids.

Integrating Patient-Controlled Analgesia Using Implanted Intrathecal Pumps for Postoperative Pain Management: A Case Report.

Intrathecal patient-controlled analgesia (IT-PCA) through implanted intrathecal infusion pumps has been increasingly utilized for severe cancer and chronic noncancer pain management. However, its application for acute postoperative pain management has not been reported to date. We present a case of a patient with an implanted intrathecal pump for chronic nonmalignant back pain who underwent an extensive spinal fusion surgery. The IT-PCA functionality of her intrathecal pump was successfully integrated into her postoperative multimodal pain regimen. Hence, IT-PCA can be safely incorporated into acute postoperative pain management with vigilant monitoring and close multidisciplinary collaboration.

Chronic pain management and the development of opioid use disorder

Chronic pain is a common condition that impacts quality of life and often precipitates the need for medical attention. Despite evidence that long-term opioid use provides limited relief, prescription opioid therapy remains a cornerstone in the medical management of chronic non-cancer pain. Presently, 13% of Canadians are prescribed opioids for pain management, and physicians play a crucial role in preventing the development of opioid use disorders. However, Canadian physicians lack knowledge of and comfort with evidence-based principles of opioid stewardship. In this article, we aim to highlight ongoing Canadian efforts to address physician discomfort and improve clinical practice. We focus on 2017 Canadian guidelines that provide clinicians with evidence-based recommendations for opioid use in chronic non-cancer pain management. In addition, we call attention to provincial efforts to implement physician accountability measures. In reviewing the existing literature, we uncovered inadequacies in pain management curricula within the Canadian undergraduate and continuing medical education (CME) systems. We consulted the educational practices of the European Pain Federation and the Centers for Disease Control and Prevention to make recommendations for improvement to current Canadian pain curricula. Based on our findings, we recommend that (1) Canadian medical institutions expand upon current core pain curricula, (2) pain management education be made compulsory, (3) academic detailing be emphasized as a means of CME, and (4) multidisciplinary non-medical management of chronic pain be featured more extensively.

Updates on chronic non-cancer pain management in face of the opioid crisis

Chronic pain not associated with malignancy is experienced by a significant proportion of the Canadian population. As the quality of life and physical functioning are markedly impaired in patients with chronic non-cancer pain, clinicians have commonly turned to opioid therapy for pain management. Since the 1990s, the steady increase in dispensing of prescription opioids has paralleled trends in opioid-related hospitalizations, overdoses, and fatalities. In fact, over-prescription and longterm opioid therapy are among the many root causes fueling Canada’s rise in opioid addiction and opioid-related deaths. Physicians and medical regulators have responded to this public health crisis by developing the 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain. The new evidence-based guideline aims to encourage safe prescribing practices, reduce and eliminate the use of opioid analgesics and promote non-opioid pharmacotherapy. While clear clinical guidelines will optimize physician prescribing patterns, it is imperative to recognize the need for non-pharmacological modalities for pain management, treatment, and care to holistically address the complex roots of opioid abuse.

A Pharmacological Rationale to Reduce the Incidence of Opioid Induced Tolerance and Hyperalgesia: A Review.

Chronic pain is an important health and social problem. Misuse and abuse of opioids in chronic non-cancer pain management seem to be a huge problem, in some countries. This could probably affect the normal use of such analgesics in patients in need of them. Basic and clinical researches should find the solution to mitigate the potential damage. Dysregulation of mast cell and microglia activation plays an important role in the pathogenesis and management of chronic pain. Persistent mast cell activation sensitizes nociceptors and initiates central nervous system inflammatory processes, involving microglial cell activation and sensitization of spinal somatosensory neurons. Exposure of mast cells and microglia to opioids is well known to provoke activation of these non-neuronal immune cell populations, thereby contributing to an exacerbation of pro-inflammatory and pro-nociceptive processes and promoting, over the long-term, opioid-induced hyperalgesia and tolerance. This review is intended to provide the reader with an overview of the role for these non-neuronal cells in opioid-induced chronic pain and tolerance as a consequence of prolonged exposure to these drugs. In addition, we will examine a potential strategy with the aim to modulate opioid-induced over-activation of glia and mast cells, based on endogenous defense mechanisms and fatty acid amide signaling molecules.

Do pain specialists meet the needs of the referring physician? A survey of primary care providers

To study the factors that influence the use of opioids in the management of chronic noncancer pain (CNCP) by primary care providers (PCPs) for patients returning from a pain specialist. A survey of PCPs. Two physician groups in the Minneapolis-St. Paul metropolitan area. Two seventy-six PCPs surveyed and 80 surveys returned. Participants rated the importance of specific concerns regarding the role of pain specialists and the use of opioids in the management of CNCP. Past experience with pain specialists, comfort using opioids, and opinions regarding a trilateral opioid agreement were also examined. The top concerns for PCPs were as follows: the use of opioids in patients with chemical dependency or psychological issues, the escalation of opioid dosing, and the use of opioids in pain states without objective findings. They also ranked highly the importance of coordinating the return of patients from a pain specialist with explicit opioid instructions and the availability of consultation by phone or a timely follow-up visit. PCPs were supportive of the concept of a trilateral opioid agreement. PCPs have significant concerns regarding the prescribing of opioids in CNCP. They desire closer collaboration with pain specialists, including more explicit plans of care when patients are transferred back to them. The trilateral agreement may provide one framework for better collaboration.

Overview of the Management of Chronic Non-Cancer Pain in Patients with Spinal Disease

Overview of the Management of Chronic Non-Cancer Pain in Patients with Spinal Disease

Overview of the Management of Chronic Non-Cancer Pain in Patients with Spinal Disease

Overview of the Management of Chronic Non-Cancer Pain in Patients with Spinal Disease

Interventions for the reduction of prescribed opioid use in chronic non-cancer pain.

This is the first update of the original Cochrane Review published in 2013. The conclusions of this review have not changed from the 2013 publication. People with chronic non-cancer pain who are prescribed and are taking opioids can have a history of long-term, high-dose opioid use without effective pain relief. In those without good pain relief, reduction of prescribed opioid dose may be the desired and shared goal of both patient and clinician. Simple, unsupervised reduction of opioid use is clinically challenging, and very difficult to achieve and maintain. To investigate the effectiveness of different methods designed to achieve reduction or cessation of prescribed opioid use for the management of chronic non-cancer pain in adults compared to controls. For this update we searched CENTRAL, MEDLINE, and Embase in January 2017, as well as bibliographies and citation searches of included studies. We also searched one trial registry for ongoing trials. Included studies had to be randomised controlled trials comparing opioid users receiving an intervention with a control group receiving treatment as usual, active control, or placebo. The aim of the study had to include a treatment goal of dose reduction or cessation of opioid medication. Two review authors independently extracted data and assessed risk of bias. We sought data relating to prescribed opioid use, adverse events of opioid reduction, pain, and psychological and physical function. We planned to assess the certainty of the evidence using the GRADE approach, however, due to the heterogeneity of studies, we were unable to combine outcomes in a meta-analysis and therefore we did not assess the evidence with GRADE. Three studies are new to this update, resulting in five included studies in total (278 participants). Participants were primarily women (mean age 49.63 years, SD = 11.74) with different chronic pain conditions. We judged the studies too heterogeneous to pool data in a meta-analysis, so we have summarised the results from each study qualitatively. The studies included acupuncture, mindfulness, and cognitive behavioral therapy interventions aimed at reducing opioid consumption, misuse of opioids, or maintenance of chronic pain management treatments. We found mixed results from the studies. Three of the five studies reported opioid consumption at post-treatment and follow-up. Two studies that delivered 'Mindfulness-Oriented Recovery Enhancement' or 'Therapeutic Interactive Voice Response' found a significant difference between groups at post-treatment and follow-up in opioid consumption. The remaining study found reduction in opioid consumption in both treatment and control groups, and between-group differences were not significant. Three studies reported adverse events related to the study and two studies did not have study-related adverse events. We also found mixed findings for pain intensity and physical functioning. The interventions did not show between-group differences for psychological functioning across all studies. Overall, the risk of bias was mixed across studies. All studies included sample sizes of fewer than 100 and so we judged all studies as high risk of bias for that category. There is no evidence for the efficacy or safety of methods for reducing prescribed opioid use in chronic pain. There is a small number of randomised controlled trials investigating opioid reduction, which means our conclusions are limited regarding the benefit of psychological, pharmacological, or other types of interventions for people with chronic pain trying to reduce their opioid consumption. The findings to date are mixed: there were reductions in opioid consumption after intervention, and often in control groups too.

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

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 where opioids are routinely used for pain management. There are concerns that the use of high doses of opioids for chronic non-cancer pain 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 (here defined as 200 mg morphine equivalent or more per day) for chronic non-cancer pain. We identified Cochrane Reviews and Overviews through a search of the Cochrane Database of Systematic Reviews (The Cochrane Library). The date of the last search was 18 April 2017. Two review authors independently assessed the search results. We planned to analyse data on any opioid agent used at high dose for two weeks or more for the treatment of chronic non-cancer pain in adults. We did not identify any reviews or overviews meeting the inclusion criteria. The excluded reviews largely reflected low doses or titrated doses where all doses were analysed as a single group; no data for high dose only could be extracted. There is a critical lack of high-quality evidence regarding how well high-dose opioids work for the management of chronic non-cancer pain 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. Trials typically used doses below our cut-off; we need to know the efficacy and harm of higher doses, which are often used in clinical practice.

New Department of Veterans Affairs and Department of Defense Guidelines on Pain Management With Opioids: Comment and Concern.

The Department of Veterans Affairs/Department of Defense recently revised guidelines on prescribing opioids for the management of chronic noncancer pain. This commentary discusses the guidelines an...

Chronic Non-Cancer Pain Management Capacity in Karachi

Chronic non-cancer pain (CNCP) affects people everywhere in the world, but people in developing countries have far less access to therapies that provide relief. There are often missed opportunities to implement these therapies. Karachi shares many characteristics with megacities of the global south and represents Pakistan in the global city league. This review informs readers about the availability of health management and pain services for CNCP in Karachi, and their comparability to those found in other global cities. The literature about CNCP and its management in Karachi and Pakistan is scarce. Nevertheless, some conclusions can be made. In order to inform readers based in other global cities, a brief review of the current health system and pain services in Karachi and Pakistan are discussed together with barriers that impede pain service outputs. The present review employs vignettes to illustrate typical experiences of CNCP patients seeking pain management services in three sectors: public, charitable, and private institutions.

Opioid pharmacovigilance: A clinical-social history of the changes in opioid prescribing for patients with co-occurring chronic non-cancer pain and substance use

There is growing concern among US-based clinicians, patients, policy makers, and in the media about the personal and community health risks associated with opioids. Perceptions about the efficacy and appropriateness of opioids for the management of chronic non-cancer pain (CNCP) have dramatically transformed in recent decades. Yet, there is very little social scientific research identifying the factors that have informed this transformation from the perspectives of prescribing clinicians. As part of an on-going ethnographic study of CNCP management among clinicians and their patients with co-occurring substance use, we interviewed 23 primary care clinicians who practice in safety-net clinical settings. In this paper, we describe the clinical and social influences informing three historic periods: (1) the escalation of opioid prescriptions for CNCP; (2) an interim period in which the efficacy of and risks associated with opioids were re-assessed; and (3) the current period of “opioid pharmacovigilance,” characterized by the increased surveillance of opioid prescriptions. Clinicians reported that interpretations of the evidence-base in favor of and opposing opioid prescribing for CNCP evolved within a larger clinical-social context. Historically, pharmaceutical marketing efforts and clinicians' concerns about racialized healthcare disparities in pain treatment influenced opioid prescription decision-making. Clinicians emphasized how patients' medical complexity (e.g. multiple chronic health conditions) and structural vulnerability (e.g. poverty, community violence) impacted access to opioids within resource-limited healthcare settings. This clinical-social history of opioid prescribing practices helps to elucidate the ongoing challenges of CNCP treatment in the US healthcare safety net and lends needed specificity to the broader, nationwide conversation about opioids.

Responsible, Safe, and Effective Prescription of Opioids for Chronic Non-Cancer Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines

Responsible, Safe, and Effective Prescription of Opioids for Chronic Non-Cancer Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines

Use and Misuse of Opioids in Chronic Pain.

The prescribing of opioid analgesics for pain management-particularly for management of chronic noncancer pain (CNCP)-has increased more than fourfold in the United States since the mid-1990s. Yet there is mounting evidence that opioids have only limited effectiveness in the management of CNCP, and the increased availability of prescribed opioids has contributed to upsurges in opioid-related addiction cases and overdose deaths. These concerns have led to critical revisiting and modification of prior pain management practices (e.g., guidelines from the Centers for Disease Control and Prevention), but the much-needed changes in clinical practice will be facilitated by a better understanding of the pharmacology and behavioral effects of opioids that underlie both their therapeutic effects (analgesia) and their adverse effects (addiction and overdose). With these goals in mind, this review first presents an overview of the contemporary problems associated with opioid management of CNCP and the related public health issues of opioid diversion, overdose, and addiction. It then discusses the pharmacology underlying the therapeutic and main adverse effects of opioids and its implications for clinical management of CNCP within the framework of recent clinical guidelines for prescribing opioids in the management of CNCP.

An observational study of the impact of genetic testing for pain perception in the clinical management of chronic non-cancer pain

ObjectivePain levels are a key metric in clinical care. However, the assessment of pain is limited to basic questionnaires and physician interpretation, which yield subjective data. Genetic markers of pain sensitivity, such as single nucleotide polymorphisms in the catechol-O-methyltransferase gene, have been shown to be associated with pain perception and have been used to provide objective information about a patient's pain. The goal of this study was to determine if physician treatment adjustments based on genetic tests of pain perception resulted in improved outcomes for patients. Material and methodsA prospective, longitudinal study was conducted with 134 chronic non-cancer pain patients genotyped for pain perception-related catechol-O-methyltransferase haplotypes. Physicians were provided with patients’ results and asked to document 1) their assessment of benefit of the genetic test; 2) treatment changes made based on the genetic test; and 3) patient clinical responses to changes implemented. ResultsBased on genetic testing results, physicians adjusted treatment plans for 40% of patients. When medication changes were made based on genetic testing results, 72% of patients showed improvement in clinical status. When non-pharmacological actions were performed, 69% of physicians felt their patients’ clinical status improved. Moreover, physicians believed the genetic test results were consistent with patient pain levels in 85% of cases. ConclusionsThese results demonstrate that providing personalized medicine with genetic information related to pain perception affected physician clinical decision-making for a substantial proportion of patients in this study, and that the availability and utilization of this information was a contributing factor in clinical improvement.

Opioid Prescribing Practices and Training Needs of Québec Family Physicians for Chronic Noncancer Pain

Aim To examine medical practices and training needs of Québec family physicians with respect to pain management and opioid prescription for chronic noncancer pain (CNCP). Methodology An online survey was carried out in 2016. Results Of 636 respondents (43.0% men; 54.3% ≥ 50 years old), 15.2% and 70.9% felt very or somewhat confident that they could properly prescribe opioids for CNCP. Concerns related to abuse (72.5% strongly/somewhat agree), dependence (73.2%), and lack of support (75.4%) were the main barriers reported. Only 19.7% always/often screened their patients for risks of abuse and dependence using a screening tool. About two-thirds of participants (65.7%) had recently (last five years) taken part in continuing education programs on opioid use for CNCP and 73.4% on CNCP management. Patient evaluation and differential diagnoses of chronic pain syndromes were rated as a top priority for further training. Conclusions This study provides insights into Québec family physicians' concerns, practices, and needs with respect to the management of CNCP. Physicians' difficulties around the application of strategies to mitigate the problem of opioid abuse and addiction are worrying. The need to better train physicians in the field of pain and addiction cannot be emphasized enough.

Patient expectations for management of chronic non-cancer pain: A systematic review.

BackgroundChronic pain is a major economic and social health problem. Up to 79% of chronic pain patients are unsatisfied with their pain management. Meeting patients’ expectations is likely to produce greater satisfaction with care. The challenge is to explore patients’ genuine expectations and needs. However, the term expectation encompasses several concepts and may concern different aspects of health‐care provision.ObjectiveThis review aimed to systematically collect information on types and subject of patients’ expectations for chronic pain management.Search strategyWe searched for quantitative and qualitative studies. Because of the multidimensional character of the term “expectations,” the search included subject headings and free text words related to the concept of expectations.Data extraction and synthesisA framework for understanding patients’ expectations was used to map types of expectations within structure, process or outcome of health care.Main resultsTwenty‐three research papers met the inclusion criteria: 18 quantitative and five qualitative. This review found that assessment of patients’ expectations for treatment is mostly limited to outcome expectations (all 18 quantitative papers and four qualitative papers). Patients generally have high expectations regarding pain reduction after treatment, but expectations were higher when expressed as an ideal expectation (81‐93% relief) than as a predicted expectation (44‐64%).Discussion and conclusionsFor health‐care providers, for pain management and for pain research purposes, the awareness that patients express different types of expectations is important. For shared decision making in clinical practice, it is important that predicted expectations of the patient are known to the treating physician and discussed.Structure and process expectations are under‐represented in our findings. However, exploring and meeting patients’ expectations regarding structure, process and outcome aspects of pain management may increase patient satisfaction.

Opioid therapy for chronic non-cancer pain: guidelines for Hong Kong.

Opioids are increasingly used to control chronic non-cancer pain globally. International opioid guidelines have been issued in many different countries but a similar document is not generally available in Hong Kong. Chronic opioid therapy has a role in multidisciplinary management of chronic non-cancer pain despite insufficient evidence for its effectiveness and safety for long-term use. This document reviews the current literature to inform Hong Kong practitioners about the rational use of chronic opioid therapy in chronic non-cancer pain. It also aims to provide useful recommendations for the appropriate, effective, and safe use of such therapy in the management of chronic non-cancer pain in adults. Physicians should conduct a comprehensive biopsychosocial evaluation of patients prior to the commencement of opioid therapy. When opioid use is deemed appropriate, the patient should provide informed consent within an agreement that specifies treatment goals and expectations. A trial of opioid can be commenced and, provided there is progress towards treatment goals, then chronic therapy can be considered at a dose that minimises harm. Monitoring of effectiveness, safety, and drug misuse should be continued. Treatment should be stopped when opioids become ineffective, intolerable, or misused. The driving principles for opioid prescription in chronic pain management should be: start with a low dose, titrate slowly, and maintain within the shortest possible time.