Opioids For Chronic Pain Research Articles

To what extent are we confident that tapentadol induces less constipation and other side effects than the other opioids in chronic pain patients? a confidence evaluation in network meta-analysis.

A confidence evaluation helps to make informed decisions about the results of meta-analyses. The goal of this work is to perform a confidence evaluation of results of a network meta-analysis (NMA) on the digestive side effects of tapentadol in patients with chronic pain. An updated search in PubMed/Medline and Web of Science search until March 2020 was done to perform pairwise meta-analyses with NMA using random-effect models and confidence in network meta-analysis (CiNeMA) for the confidence analysis. Twenty-five studies were included in the final analyses. Pairwise and indirect comparisons showed a reduced risk of constipation with tapentadol compared to oxycodone. The confidence evaluation did not raise any concerns in terms of confidence for the oxycodone versus tapentadol comparisons. The oxycodone-naloxone versus tapentadol comparisons showed some concerns, particularly in terms of imprecision and incoherence. Regarding the overall risk of any side effects, the confidence evaluation showed a major concern regarding imprecision, but not for the comparison between tapentadol and oxycodone. However, this comparison showed a major heterogeneity. A confidence evaluation in meta-analysis on the effect of tapentadol compared to other opioids in chronic pain showed possible imprecision, heterogeneity and/or incoherence. However, with a high level of confidence, tapentadol was associated with a lower incidence of constipation than oxycodone. Confidence analyses can help to get more information from meta-analyses.

New Challenges in Addiction Medicine: COVID-19 Infection in Patients With Alcohol and Substance Use Disorders-The Perfect Storm.

New Challenges in Addiction Medicine: COVID-19 Infection in Patients With Alcohol and Substance Use Disorders-The Perfect Storm.

Use of cannabis and opioids for chronic pain by older adults: Distinguishing clinical and contextual influences

Chronic pain is one of the most common health-related conditions experienced by Americans over the age of 65. In this study, we examine the intersection between pain, opioids and cannabis use among older adults in Colorado and Illinois and examine how medical needs and other variables associated with a persons' background and attitudes influence choices concerning the use of opioids and cannabis to treat pain. Data were collected via a survey about cannabis and opioids use, and questions related to individual need factors (e.g. pain, quality of life) and contextual factors (e.g. sex, finances, personal attitudes, interaction with physicians) were included in this study. We built a logistic regression model to evaluate factors associated with drug use and a multinomial regression model to understand factors that influence drug choices between cannabis and opioids. A total of 436 individuals completed the survey; 62 used opioids only, 71 cannabis only and 72 used both. When comparing drug users to non-drug users, pain was significantly associated with using cannabis and/or opioids when controlling for other covariates. However, when we compared cannabis users to opioid users, pain was no longer a determining factor. Instead, other contextual factors such as sex, personal beliefs and physician attitudes influenced an individual's choice between cannabis or opioids. This study showed that contextual factors appear to have more influence on an individual's decision to use cannabis as an alternative to opioids than individual need or characteristics.

Revisiting pharmacy-based naloxone with pharmacists and naloxone consumers in 2 states: 2017 perspectives and evolving approaches

ObjectivesPharmacies provide accessible sources of naloxone to caregivers, patients taking opioids, and individuals using drugs. While laws permit expanded pharmacy naloxone access, prior work identified barriers like concerns about stigma of addiction and time constraints that inhibit scale-up. We sought to examine similarities and differences in experiences obtaining naloxone at the pharmacy over a 1-year period in 2 states, and to explore reactions from people with opioid use disorder, patients taking opioids for chronic pain, caregivers of opioid users, and pharmacists to communication tools and patient outreach materials designed to improve naloxone uptake. DesignEight focus groups (FGs) held December 2016 to April 2017 in Massachusetts and Rhode Island. Setting and participantsParticipants were recruited from pharmacies, health clinics, and community organizations; pharmacists were recruited from professional organizations and pharmacy colleges. Outcome measuresThe FGs were led by trained qualitative researchers using a topic guide and prototypes designed for input. Five analysts applied a coding scheme to transcripts. Thematic analysis involved synthesis of coded data and connections between themes, with comparisons across groups and to first-year findings. ResultsA total of 56 individuals participated: patients taking opioids for chronic pain (n = 13), people with opioid use disorders (n = 15), caregivers (n = 13), and pharmacists (n = 16). Fear of future consequences and stigma in the pharmacy was a prominent theme from the previous year. Four new themes emerged: experience providing pharmacy naloxone, clinician-pharmacist–partnered approaches, naloxone coprescription, and fentanyl as motivator for pharmacy naloxone. Prototypes for prompting consumers about naloxone availability, materials facilitating naloxone conversations, and posters designed to address stigma were well received. ConclusionsExperiences dispensing naloxone are quickly evolving, and a greater diversity of patients are obtaining pharmacy naloxone. Persistent stigma-related concerns underscore the need for tools to help pharmacists offer naloxone, facilitate patient requests, and provide reassurance when getting naloxone.

Amitifadine, a triple reuptake inhibitor, reduces self-administration of the opiate remifentanil in rats.

A variety of neural systems are involved in drug addiction, and some of these systems are shared across different addictive drugs. We have found several different types of drug treatments that successfully reduce nicotine self-administration. The current set of studies is the first in a series to determine if drug treatments that have been found to significantly reduce nicotine self-administration would reduce opiate self-administration. Amitifadine, a triple reuptake inhibitor of dopamine, norepinephrine, and serotonin, was assessed in female Sprague-Dawley rats to determine whether it significantly reduces remifentanil self-administration with either acute or chronic treatment. Acutely, amitifadine doses of 5, 10, and 20mg/kg each significantly reduced remifentanil self-administration. In a chronic study, repeated treatment with 10mg/kg of amitifadine continued to reduce remifentanil self-administration, even after the cessation of treatment. However, amitifadine was not found to attenuate the rise in remifentanil self-administration with continued access. This study and our earlier one showed that the 10mg/kg amitifadine dose did not significantly affect food motivated responding. Amitifadine did not attenuate remifentanil-induced antinociception as measured on the hot plate test but extended and maintained antinociceptive effects. These studies show the promise of amitifadine as a treatment for countering opiate self-administration for adjunctive use with opioids for analgesia. Further studies are needed to determine the possible efficacy of amitifadine for combating opiate addiction or preventing it in humans during adjunctive use with opioids for chronic pain.

Study protocol for evaluating Six Building Blocks for opioid management implementation in primary care practices

BackgroundThe Six Building Blocks for improving opioid management (6BBs) is a program for improving the management of patients in primary care practices who are on long-term opioid therapy for chronic pain. The 6BBs include building leadership and consensus; aligning policies, patient agreements, and workflows; tracking and monitoring patient care; conducting planned, patient-centered visits; tailoring care for complex patients; and measuring success. The Agency for Healthcare Research and Quality funded the development of a 6BBs implementation guide: a step-by-step approach for independently implementing the 6BBs in a practice. This mixed-method study seeks to assess practices’ use of the implementation guide to implement the 6BBs and the effectiveness of 6BBs implementation on opioid management processes of care among practices using the implementation guide.MethodsData collection is guided by the Consolidated Framework for Implementation Research, Proctor’s taxonomy of implementation outcomes, and the Centers for Disease Control and Prevention’s Guideline for Prescribing Opioids for Chronic Pain. A diverse group of health care organizations with primary care clinics across the USA will participate in the study over 15 months. Qualitative data collection will include semi-structured interviews with stakeholders at each organization at two time points, notes from routine check-in calls, and document review. These data will be used to understand practices’ motivation for participation, history with opioid management efforts, barriers and facilitators to implementation, and implementation progress. Quantitative data collection will consist of a provider and staff survey, an implementation milestones assessment, and quarterly opioid prescribing quality measures. These data will supplement our understanding of implementation progress and will allow us to assess changes over time in providers’ opioid prescribing practices, prescribing self-efficacy, challenges to providing guideline-driven care, and practices’ opioid prescribing quality measures. Qualitative data will be coded and analyzed for emergent themes. Quantitative data will be analyzed using descriptive statistics and clustered multivariate regression.DiscussionThis study contributes to the knowledge of the implementation and effectiveness of a team-based approach to opioid management in primary care practices. Information gleaned from this study can be used to inform efforts to curtail opioid prescribing and assist primary care practices considering implementing the 6BBs.

Predictive factors for sleep apnoea in patients on opioids for chronic pain

BackgroundThe risk of death is elevated in patients taking opioids for chronic non-cancer pain. Respiratory depression is the main cause of death due to opioids and sleep apnoea is an...

Improving Residency Education on Chronic Pain and Opioid Use Disorder: Evaluation of CDC Guideline-Based Education

Background: National surveys show that primary care physicians feel responsible for addressing the opioid epidemic. They feel their training in managing chronic pain and addiction was insufficient, and commonly endorse the need for more residency training in these areas. However, residency training in these areas remains low, with a lack of faculty expertise and time as the most commonly cited barriers for improvement. Objective: To evaluate the feasibility of an educational program for chronic pain management and addiction that does not rely on faculty expertise or additional time, and assess resident opioid-prescribing practices and confidence in managing chronic pain after its implementation. Methods: A 16-week educational curriculum was incorporated into existing residency didactics. Internal medicine residents attended six educational sessions in 2016 over a 16-week period and implemented a protocol based on CDC Guidelines for Prescribing Opioids for Chronic Pain. Surveys were completed pre- and post-intervention. Results: Implementation of this educational intervention was feasible. Surveys showed improvement in resident confidence in detecting and managing addiction and improved prescribing practices and adherence to CDC recommendations. Conclusion: This pilot study demonstrates that increasing residency education in managing chronic pain and opioid use disorder is feasible, and no longer needs to be postponed due to lack of time or faculty expertise.

"It Sometimes Doesn't Even Work": Patient Opioid Assessments as Clues to Therapeutic Flexibility in Primary Care.

Physicians' fear of difficult patient interactions is an important barrier to discontinuing long-term opioid therapy. To identify patient statements about opioids that indicate potential openness to tapering opioids or trying non-opioid pain treatments DESIGN: This is an observational study of regularly scheduled primary care visits involving discussion of chronic pain management. A coding system to characterize patient assessments about opioids, physician responses to assessments, and patient-endorsed opioid side effects was developed and applied to transcripts of video-recorded visits. All visits were independently coded by 2 authors. Eighty-six established adult patients taking opioids for chronic pain; 49 physicians in 2 academic primary care clinics MAIN MEASURES: Frequency and topic of patients' opioid assessments; proportion of opioid assessments classified as clues (assessments indicating potential willingness to consider non-opioid pain treatments or lower opioid doses); physician responses to patient clues; frequency and type of patient-endorsed side effects KEY RESULTS: Patients made a mean of 3.2 opioid assessments (median 2) per visit. The most common assessment topics were pain relief (51%), effect on function (21%), and opioid safety (14%). Forty-seven percent of opioid assessments (mean 1.5 per visit) were classified as clues. Fifty-three percent of visits included ≥ 1 clue; 21% of visits contained ≥ 3 clues. Physicians responded to patient clues with no/minimal response 43% of the time, sympathetic/empathetic statements 14% of the time, and further explored clues 43% of the time. Fifty-eight percent of patients endorsed ≥ 1 opioid-related side effect; 10% endorsed ≥ 3 side effects. The most commonly endorsed side effects were constipation (15% of patients), sedation (15%), withdrawal symptoms (13%), and nausea (12%). Patient statements suggesting openness to non-opioid pain treatments or lower opioid doses are common during routine primary care visits. Listening for and exploring these clues may be a patient-centered strategy for broaching difficult topics with patients on long-term opioid therapy.

Opioid Exposure Negatively Affects Antidepressant Response to Venlafaxine in Older Adults with Chronic Low Back Pain and Depression.

Serotonin norepinephrine reuptake inhibitors (SNRIs) are commonly co-prescribed with opioids for chronic pain. The purpose of this study was to describe pain and mood response to venlafaxine among older adults with chronic low back pain (CLBP) and depression relative to opioid exposure. Secondary analyses were collected from a randomized clinical trial testing a stepped-care approach to comorbid pain and depression in older patients: the Addressing Depression and Pain Together study (ADAPT: 2010-2016). University-based late-life mental health research clinic. Two hundred twenty-seven adults aged 65+ years with CLBP and depression. Participants received six weeks of lower-dose venlafaxine (≤150 mg/d). Pain and depression were measured each week. Response for both pain and depression at the end of six weeks was defined by a ≥30% improvement on a 0-20 numeric rating scale for low back pain and a Patient Health Questionnaire-9 score ≤5. Opioid exposure was analyzed as prescribed (yes or no) and by morphine equivalent dosing (MED). Patients co-prescribed an opioid were less likely to report a pain response to venlafaxine. MED was negatively correlated with pain response. Depression response was not impacted. Opioids are negatively associated with older adults' early analgesic response to lower-dose venlafaxine. These findings suggest that clinicians may wish to consider either nonopioid or alternative antidepressant approaches to pain management in these complex patients. It is reassuring that opioids do not prevent depression response. Future research should examine both longer duration of treatment and a wider range of doses.

Postoperative Opioid Prescribing and Consumption Patterns after Tonsillectomy.

Despite increased concern with the opioid epidemic, literature remains scant regarding narcotic prescription and use following tonsillectomy. Retrospective cohort study with telephone interview. A chart review from January to August 2018 evaluated the difference between prescribed amounts of narcotic and patient-reported usage following tonsillectomy (Current Procedural Terminology codes 42821 and 42826). Patients were excluded if they used opioids for chronic pain, had a history of chronic opioid use or substance abuse, or underwent tonsillectomy to exclude malignancy. A telephone interview assessed opioid and nonopioid usage and pain control postoperatively, including amount and form of narcotics remaining. Sixty-four patients were enrolled at a mean 4.47 months after tonsillectomy. The mean ± SD prescribed morphine milligram equivalent (MME) was 456.1 ± 281.7, with only 302.8 ± 206.2 consumed. The mean MME prescribed per day was 74.1 ± 44.8, and average days of narcotic usage postoperatively was 9.6 ± 4.6, correlating with a mean MME per day of 49.2 ± 34.3 if the maximum prescribed dose per day was consumed. Fifty-four (84.4%) patients reported pain as well controlled. Forty-three (67.2%) patients reported residual narcotic medication, with 228.1 ± 208.5 MMEs remaining per patient. Narcotic solutions were more completely consumed than tablet forms, with 23.1% and 44.0% remaining, respectively. Patients cited uncertainty about safe disposal and safeguarding for future use as reasons for keeping residual narcotic. Patient-reported narcotic use is significantly lower than the amount prescribed after tonsillectomy for benign disease. Providers can use these data to adjust narcotic-prescribing patterns while maintaining appropriate pain management for patients undergoing tonsillectomy.

Managing Chronic Pain in an Opioid Crisis: What Is the Role of Shared Decision-Making?

ABSTRACT Shared decision-making (SDM) is a widely-advocated practice that has been linked to improved patient adherence, satisfaction, and clinical outcomes. SDM is a process in which patients and providers share information, express opinions, and build consensus toward a treatment decision. Chronic pain and its treatment present unique challenges for SDM, especially in the current environment in which opioids are viewed as harmful and a national opioid crisis has been declared. The purpose of this qualitative study is to understand treatment decision-making with patients taking opioids for chronic pain. Ninety-five clinic visits and 31 interviews with patients and primary care providers (PCPs) were analyzed using the constant comparison method. Results revealed that 1) PCPs desire patient participation in treatment decisions, but with caveats where opioids are concerned; 2) Disagreements about opioids, including perceptions of lack of listening, presented challenges to SDM; and 3) PCPs described engaging in persuasion or negotiation to convince patients to try alternatives to opioids, or appeasing patients requesting opioids with very small amounts in an effort to maintain the patient-provider relationship. Results are discussed through the lens of Charles, Gafni, and Whelan’s SDM model, and implications of the role of the patient-provider relationship in SDM and chronic pain treatment are discussed.

SAT-383 Prevalence of Opioid Induced Adrenal Insufficiency in Patients Taking Chronic Opioids

BACKGROUND: Chronic opioid use may lead to adrenal insufficiency due to central suppression of the hypothalamic-pituitary-adrenal axis. Opioid induced adrenal insufficiency (OIAI) is likely under-recognized and its prevalence is unclear. OBJECTIVE: To determine the prevalence of OIAI in patients taking opioids for chronic pain and to identify predictors of OIAI. METHODS: A prospective study of patients admitted to the Pain Rehabilitation Center (PRC) at an academic medical center completed between 2016 and 2018. Inclusion criteria were: 1) age ≥18 years, 2) intermittent or continuous opioid use of at least 90 days, 3) am cortisol measurement on admission. Exclusion criteria were: 1) known pituitary or adrenal dysfunction, 2) exogenous glucocorticoid use within 3 months. Each patient’s opioid daily dose was converted into a morphine mg equivalent (MME). All patients had a functional 5-minute walk test and measurements of quality of life on admission to the PRC. Diagnosis of OIAI was based on the endocrine evaluation. RESULTS: One hundred sixty-two patients (median age of 53.5 years (range 21-84), 67% women, 95 % Caucasian) met inclusion criteria. Patients used opioids daily (141, 87%) or as needed (21, 13.0%) at a median MME of 30 mg (3-840), median duration of 60 months (3-360). In addition to morning cortisol (CORT), 112 (69.1%) patients had measurements of corticotropin (ACTH) and 106 (65.4%) - dehydroepiandrosterone sulfate (DHEAS). CORT was directly correlated with both DHEAS (p=0.04) and ACTH (p<0.0001). Overall, low concentrations of CORT (<7mcg/dl), ACTH (<10pg/mL) and DHEAS (<25mcg/dL) were observed in 17%, 14% and 21% of patients, respectively. Patients with either low CORT or ACTH had a lower performance on the 5-minute walk test (1080 feet (range 175-1899) vs 1261 feet (361-2008), p=0.04). No significant differences were found on measures of quality of life. OIAI was confirmed through endocrine evaluation in 8 (5%) patients (7 women, median age 53 years (48-76)). At the time of admission, patients with OIAI had median CORT of 5 mcg/dl (1-9.9), ACTH of 11.5pg/mL (5-15), and DHEAS of 17mcg/dL (15-22). MME of patients with OIAI was higher than patients without OIAI (median 110 (20-392) vs. 30 (1-840), p=0.01). No patient taking opioid at <MME of 20 mg/day developed OIAI (sensitivity of 100% for MME>20 mg), however specificity of MME cutoff >20 mg to predict OIAI development was only 34%. After opioid discontinuation, 3/8 patients recovered adrenal function when reassessed at 14 months (5-14). CONCLUSION: The prevalence of OIAI based on the endocrine evaluation was 5%, with MME being the only predictor for OIAI development. Patients on MMED of 20 mg and above should be monitored for OIAI. Abnormalities in the hypothalamic-pituitary-adrenal axis were frequent, affecting 14-21% of patients taking opioids, possibly contributing to patients’ symptoms, physical performance and well-being.

Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine

Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine

(370) Opioid Management in Primary Care: A Response to the Opioid Epidemic

In March 2016, in response to a national opioid epidemic, the CDC released guidelines for prescribing opioids for chronic pain. Pain Specialists at a comprehensive, interdisciplinary Pain Clinic within an integrated health system in suburban Minneapolis, Minnesota - a Clinic designed in large part to respond to the opioid epidemic - evaluated patients for participation in a pain treatment program with emphasis on SELF- versus MEDICATION-management of their chronic pain. While recognizing success in the Pain Clinic (95% of the patients had maintained decreased opioid use, and 38% of the patients showed a 100% reduction in opioid use), review of the primary care clinics in the catchment area of the pain clinic showed very little adherence to CDC Guidelines and limited success in tapering and discontinuing opioids for chronic pain management. To improve guideline adherence, pain specialists and a pain psychologist conducted education at two primary care clinics for a three-month period, and then were placed in situ at one of two clinics studied. On site presence, after three months, showed a decrease in prescribed mean MME (26.7) vs. the clinic without on-site presence (34.3) after a 3 month trial. The on-site pain team clinic helped more patients to cease opioid usage (19% vs. 15%) and helped reduce prescribed MMEs for more patients (63% vs. 42%). Preliminary findings support embedding pain specialists within primary care clinics as an additional opportunity to address the needs of patients who resist referral to a comprehensive pain management clinic, and to help primary care providers reduce patient dependence on opioid medications for management of chronic pain.

(134) Spinal Cord Stimulator (SCS) Therapy among Active Duty Military Members Decreased Opioid Therapy and Improves Overall Pain

Active duty military members (ADMM) are at greater risk of developing chronic pain compared to civilians. The use of opioids for chronic pain can impact ADMM ability to remain in the military. Spinal cord stimulators (SCS) are a treatment option for some ADMM to manage pain and increase functioning. The objective of this quality improvement project was to determine if SCS implantation improves outcomes for ADMM. This project compared a sub-sample of the Walter Reed National Military Medical Center (WRNMMC) SCS Cohort: patients who were ADMM at the time of implantation and for those whom we had data at 3-months and 6-months following implantation (N=89). The majority of our patient population was male, in the U.S. Army, and had experienced non-combat related injuries. RANOVA results suggest that ADMM who underwent SCS implantation, and were prescribed opioids pre-implantation, had a significant reduction in morphine equivalent (MEQ) from baseline (mean=29.086) to 3-months (mean=8.054) and baseline to 6-months (mean=3.009) post-implantation. RANOVA results also suggest a significant reduction in pain intensity from baseline (mean pain score=6.322) to 3-months (mean pains score=3.844) and baseline to 6-months (mean=4.256) post-implantation. The findings suggest that SCS implantation in ADMM who are undergoing opioid medication management may have a significant reduction in MEQ at both 3 and 6-months post-implantation. These findings may suggest that SCS implantation may reduce the pain intensity and increase the functionality of ADMM who may have otherwise be disqualified from certain jobs and/or remaining in the military.

(288) Reducing High Dose Narcotic Therapy for Chronic Non-Cancer Related Pain

Following the release of the 2016 CDC Guidelines for Prescribing Opioids for Chronic Pain, there have been intense efforts to reduce the utilization of high dose narcotic therapy for the management of non-cancer related chronic pain. Most prior research on prescription narcotic over-utilization has focused on geographical and community-based statistics, including investigating prescribers with inconsistent prescribing practices and guidelines. To date, there have been few published reports of these efforts in a large health system. In our presentation, we fill this gap by sharing the results of an intervention designed to reduce high dose narcotic therapy for non-cancer related chronic pain in a high-volume hospital-based pain center (census 5,000 patients) embedded within a large health system (11,000 employees). Our multi-modality pain intervention included the development of well-defined prescribing guidelines that enforced a maximum 100 Morphine Equivalent Dose (MED) daily threshold for narcotic therapy in patients with non-cancer related chronic pain. Our team openly communicated the goals of this intervention and related monitoring procedures to pain center patients and staff, as well as care providers across the health system. Outcome measures were collected for 30 months, from January 2016 through June 2018. During this study period, high dose narcotic prescriptions decreased from 20.5% to 0.5%, in established patients with non-cancer related chronic pain undergoing therapy in our pain center. The results suggest our approach – well-defined prescribing guidelines, 100 MED max daily narcotic dosing, and strategic system-wide and patient level communication – should be considered by other health systems as a method to improve adherence with CDC guidelines for opioid prescription.

Meeting Physician Compliance Recommendations in the Management of Opioids in Chronic Pain: The Chronic Pain Management Registry (CPMR).

In a recent commentary in INNOVATIONS in Pharmacy, details were given on a recently released Chronic Pain Management Registry (CPMR). The CPMR was designed to provide a tracking and audit framework for evaluating claims made for therapy interventions in chronic pain management. At the same time, the CPMR was seen as a key element in monitoring physician and practice compliance with requirements for the prescribing of opioids and other scheduled substances. The purpose of the present commentary is to expand upon the role of the CPMR in the management of opioids in detailing the concordance of the CPMR data collection requirements with the latest recommendations of the American Society of Interventional Pain Physicians (ASIPP) for responsible, safe and effective opioid prescribing in chronic non-cancer pain. Given ongoing concerns with opioid misuse and abuse, the opioid epidemic, physician practices are at risk for what may be judged as poor therapy decisions in evaluating medical necessity and a failure to monitor effectively response to therapy. Adoption of a platform such as the CPMR may, through providing a comprehensive evidence base and tracking capability, support more effective prescribing decisions and adherence to therapy. At the same time, the ability to justify decisions through a CPMR documentation audit may not only alleviate physician concerns if their decisions are challenged but also lead to improved outcomes in the treatment of chronic pain.

“Like being put on an ice floe and shoved away”: A qualitative study of the impacts of opioid-related policy changes on people who take opioids

AimsTo characterize the impacts of policies intended to improve opioid prescribing and prevent opioid-related overdose and death on individuals who take opioids. MethodsWe conducted a qualitative study using focus groups with 48 adults aged 18 years and over who had experience taking opioids. Participants were recruited from across Ontario, Canada, and separate focus groups were held for individuals taking opioids for chronic pain and individuals taking opioids for other reasons. We drew upon stigma theory to interpret participants’ accounts. ResultsFollowing analysis and interpretation, we generated three themes describing the impacts of recently implemented opioid-related policies and harm reduction interventions on people who take opioids: ‘propagating stigma: addict as dominant status’, ‘loss of autonomy’ and ‘producing/reproducing structural vulnerabilities’. Specifically, participants characterize an environment in which ‘addict’ has become the dominant social identity ascribed to people who take opioids, and where relationships with providers have become strained as participants perceive themselves to be powerless when decisions regarding opioid use and pain management are made. These shifts in identity and relationships had negative repercussions when help-seeking and exposed larger vulnerabilities related to poverty and criminalization. ConclusionsThe introduction of opioid-related policies had unintended consequences for people who take opioids. Potential measures for mitigating these consequences include ensuring that people who take opioids are involved in all facets of policy development and implementation, integrating peer workers into the care of these individuals, and respecting patient agency when decisions about pain management and opioid use are made.

Opioids for chronic pain: scarcely any added value

Opioids for chronic pain: scarcely any added value