Opioids For Nonmalignant Pain Research Articles

General practitioners' and community pharmacists' beliefs and practices on opioids for non-malignant pain.

In Europe, opioid use has surged, largely due to prescriptions for chronic non-malignant pain (CNMP). General practitioners (GPs) and community pharmacists (CPs) play a major role in opioid prescribing for non-malignant pain. Exploring their personal beliefs and practices might reveal underlying mechanisms to identify measures that could halt the further escalation of opioid use. Guided by the health belief model, a survey was designed and distributed nationwide to examine the practices and beliefs of GPs and CPs in the domains: threats, benefits, barriers and self-efficacy. The results of GPs and CPs were compared at the statement level using chi-square analysis. Of 214 GPs and 212 CPs who completed the survey, the majority agreed that too many opioids are used in the treatment of chronic non-malignant pain (66.8% GPs and 66.5% CPs). Furthermore, they were concerned about the addictive potential of opioids (83.1% GPs and 71.7% CPs). In general, both professions have concerns about opioid use. GPs report a slightly higher degree of self-efficacy and perceive fewer benefits from opioids in treating CNMP. GPs and CPs valued the recommended measures to reduce opioid prescribing, yet less than half actively implement these strategies in their clinics. GPs and CPs believe that opioids are being used too frequently to treat CNMP. However, both professions lack the actions to improve opioid-related care. GPs and CPs require education, collaboration and tools to implement guidelines on non-malignant pain and opioids. This study, guided by the health belief model, reveals that general practitioners and community pharmacists have serious concerns about opioid use in chronic non-malignant pain. Despite shared concerns, both professions differ in their beliefs about opioid benefits and perceived self-efficacy. Both professions have in common that they value recommended measures to reduce opioid prescribing. Also, they both struggle to implement strategies, emphasizing the urgent need for education, collaboration and tools to align practices with guidelines on non-malignant pain and opioids.

Opioid Prescriptions at Hospital Discharge Are Associated With More Postdischarge Healthcare Utilization.

BackgroundMany patients use opioids for nonmalignant pain, and opioid use in the general population has been associated with poor long‐term outcomes. The use of high‐risk medications, including opioid analgesics, may increase the risk of unplanned healthcare utilization.Methods and ResultsWe performed a nested evaluation in the VICS (Vanderbilt Inpatient Cohort Study) (N=3000) on patients with an admitting diagnosis of acute coronary syndrome and/or acute decompensated heart failure. Patient enrollment occurred from October 2011 until December 2015 and involved a single investigational site, Vanderbilt University Medical Center (Nashville, TN). Of the 2495 eligible patients, 501 (20%) were discharged with an opioid prescription and were predominantly white and men, with a median age of 59 (interquartile range, 53–67) years. Our primary outcome was unplanned healthcare utilization, which included emergency department presentation or readmission. Secondary outcomes included mortality and a composite of planned utilization behaviors: cardiac rehabilitation and provider follow‐up within 30 days. Cox proportional hazards models did not show a statistically significant association with increased unplanned utilization (adjusted hazard ratio, 1.06; 95% CI, 0.87–1.28) or mortality (adjusted hazard ratio, 1.08; 95% CI, 0.84–1.39), compared with those without opioids at discharge. Patients discharged with opioids were less likely to complete planned healthcare utilization (adjusted odds ratio, 0.69; 95% CI, 0.52–0.91).ConclusionsThere are decreased odds of planned healthcare utilization among patients with acute coronary syndrome and acute decompensated heart failure discharged with opioid medication. It is imperative to understand how opioid use can affect a patient's relationship with the healthcare system.

An observational study assessing high dose opioid prescribing and associated adrenal insufficiency

BackgroundLong-term opioid use is known to affect endocrine function, with case reports indicating an association with adrenal insufficiency.AimThis study aims to investigate long-term, high-dose opioid use (≥80mg morphine or equivalent per day) at a Suffolk (UK) General Practice and its effect on adrenal function.MethodFrom a practice list of 18,300, retrospective data was collected for patients prescribed high-dose opioids for non-cancer pain for at least three months on current repeat prescription. Patient demographics and prescribing information were collected using SystmOne. Cortisol levels in the high-dose opioid patients, and short synacthen testing if indicated, were performed.ResultsThe 35 identified patients (0.2% of practice list) were predominantly female (77%) ≥70 years old (37%), and taking opioids prescribed for osteoarthritis or back pain (77%). 6% were prescribed >280mg morphine or equivalent per day, with one patient prescribed 705 mg. Routine evaluation for development of adrenal suppression and subsequent management was poor. 31% (11 of 35) had developed symptoms potentially indicative of adrenal insufficiency. One of these patients was among the 21% (7 of 35) with suppressed serum cortisol. Adrenal insufficiency secondary to opioids was confirmed in one patient using short synacthen testing. There was no statistical difference in either opioid dose or months of use for those with or without early morning cortisol suppression.ConclusionThe investigation highlights both the considerable use of high-dose opioids for non-malignant pain and their apparent association with adrenal suppression, demonstrating the need for formal guidelines to aid recognition and diagnosis.

307 Comparative risk of respiratory depression in patients treated with opioids for non-malignant pain

307 Comparative risk of respiratory depression in patients treated with opioids for non-malignant pain

Pain Intensity and Opioid Utilization in Response to CPAP Therapy in Veterans with Obstructive Sleep Apnea on Chronic Opioid Treatment.

Sleep fragmentation has been linked to poor pain tolerance and lowered pain threshold. Little evidence exists on whether continuous positive airway pressure (CPAP) adherence in veterans with obstructive sleep apnea (OSA) who are taking opioids for non-malignant pain would ameliorate pain and reduce consumption of opioids. A retrospective case-control study was performed at a VA sleep center. Pain intensity was assessed using the Numerical Categorical Scale prior to CPAP treatment and 12-mo follow-up. Opioids intake was assessed using the morphine equivalent daily dose (MEDD). Adherence to CPAP was evaluated with the built-in meter. We reviewed 113 patients with OSA (apnea-hypopnea index [AHI] 35.9 ± 29.5) using a MEDD of 61.6 mg (range 5-980 mg) and a control group of 113 veterans with OSA (AHI 33.4 ± 27.3) on no opioids treatment. CPAP adherence was significantly lower at 12 mo in opioid-treated patients compared to controls (37% versus 55%; p = 0.01). Greater pain intensity was the only independent variable associated with CPAP non-adherence at 12-mo follow-up (p = 0.03). Compared to baseline, no significant difference was observed in pain intensity or consumption of opioids in CPAP adherent patients. CPAP treatment did not reduce pain intensity or consumption of opioids in veterans with chronic pain who have coexisting OSA. CPAP adherence was lower in opioid-treated veterans with OSA compared to opioid-free veterans with OSA. Pain intensity was the only determinant of CPAP adherence. Future studies are needed to evaluate pain management program on adherence to CPAP.

Opioids in Headache

Opioid analgesics have long been used to treat head pain of various types. This has been increasing to a significant degree over the past 25 years because of a trend for more liberal use of opioids in non-malignant pain. Opioid treatment for acute headache, as well as prophylactically for refractory chronic headache, is controversial. There are a number of adverse effects associated with acute and chronic opioid treatment. Tolerance, dependence, and addiction are prominent issues. This article attempts to analyze the benefits and disadvantages for opioids in the management of migraine and other headache disorders, relying on known properties of this class of medication as well as clinical data. It will mainly focus on 2 topics: the use of opioid medication for the acute treatment of migraine attacks and continuous prophylactic use for refractory chronic migraine.

Analgetika med refusjon ved kroniske smerter

The prevalence of chronic non-malignant pain in Norway is between 24% and 30%. The proportion of the population using opioids for non-malignant pain on a long-term basis is around 1%. The purpose of our study was to investigate how many were prescribed analgesics on reimbursable prescription under reimbursement code -71 (chronic non-malignant pain) in 2009 and 2010, which analgesics were prescribed and whether prescribing practices were in accordance with national guidelines. We retrieved pseudonymised data from the National Prescription Database on all those who received drugs with reimbursement code -71 in 2009 and 2010. The data contain information on drug, dosage, formulation, reimbursement code and date of issue. 90,731 patients received reimbursement for drugs indicated for chronic non-malignant pain in 2010. Of these, 6,875 were given opioids, 33,242 received paracetamol, 25,865 non-steroid inflammatory drugs (NSAIDs), 20,654 amitryptiline and 16,507 gabapentin. Oxycodone was the most frequently prescribed opioid, followed by buprenorphine, tramadol and codeine/paracetamol. Of those who were prescribed opioids, 4,047 (59%) received mainly slow-release opioids, 2,631 (38%) also received benzodiazepines and 2,418 (35%) received benzodiazepine-like sleep medications. The number of patients who received analgesics and opioids on reimbursable prescriptions was low compared to the proportion of the population with chronic pain and the proportion using opioids long-term. 38% of those reimbursed for opioids also used benzodiazepines, which is contrary to official Norwegian guidelines.

The Comparative Safety of Opioids for Nonmalignant Pain in Older Adults

The Comparative Safety of Opioids for Nonmalignant Pain in Older Adults

The Comparative Safety of Opioids for Nonmalignant Pain in Older Adults—Reply

The Comparative Safety of Opioids for Nonmalignant Pain in Older Adults—Reply

The Comparative Safety of Opioids for Nonmalignant Pain in Older Adults

The Comparative Safety of Opioids for Nonmalignant Pain in Older Adults

PSY3 OPIOIDS IN NON-MALIGNANT PAIN: ARE THEY EQUIVALENT IN SAFETY PROFILE? A NETWORK META-ANALYSIS

Severe non-malignant pain affects a large number of patients. Opioids are an important option for analgesia. However, there is relatively little information about the comparative safety of opioids. We sought to compare the safety and tolerability of commonly used opioids in non-malignant pain through network meta-analyses of randomized controlled trials (RCTs). Medline and Embase were searched from 2000 to 2011 for RCTs comparing commonly used opioids (tramadol, oxycodone, hydrocodone, propoxyphene, codeine) in non-malignant pain. Studies were assessed for inclusion/exclusion based on a prespecified protocol. Two reviewers undertook data extraction independently. Any disagreement was resolved by a third reviewer. A network meta-analysis was used to combine direct and indirect evidence for safety outcomes reported in the trials. Based on the incidence of adverse events (AEs) for each intervention, a probability-based ranking (probability (P) of being worst) was generated using WinBUGS. Of the 1156 studies, 5 RCTs enrolling 1399 patients were eligible for inclusion. The most commonly reported AEs were nausea, vomiting, somnolence, dizziness, headache, constipation and dry mouth. Withdrawals due to AEs were most commonly observed with codeine (P=42%) followed by hydrocodone (P=28%), tramadol (P=19%), and oxycodone (P=10%). The probability of occurrence of nausea and somnolence was the highest with codeine. Dizziness was most frequently associated with oxycodone (P= 53%). However, the incidence of dizziness and headache was the lowest with codeine. Tramadol was observed to be associated with the highest (P=40%) incidence of vomiting, while hydrocodone had the lowest incidence (P=15%). Codeine was observed to have the highest incidence of withdrawals due to AEs. It was observed that the probability of occurrence of any particular AE varied across included opioid analgesics. Codeine was observed to have been more frequently associated with nausea/somnolence while tramadol and oxycodone had the highest incidence of vomiting and dizziness respectively.

PSEUDOADDICTION REVISITED: A Commentary on Clinical and Historical Considerations

SUMMARYThe term 'pseudoaddiction' has been in the pain management lexicon for two decades. Over this time, pain management has changed significantly - in no small part as a result of a landmark publication by Weissman and Haddox in 1989. The original paper, which describes the experience of a single case study in which a young inpatient with cancer became sullen and difficult when left in uncontrolled pain, is reviewed. It is time for a critical re-examination of the concept, its use and its influence on the pain literature, and finally, how it should be applied today. A commentary is offered along with a brief literature review to determine the presence of pseudoaddiction in published literature. Arriving in the literature at a time when the application of opioid therapy to non-malignant pain was being seriously considered, based on principles borrowed from the cancer pain experience, its impact on the way in which patients' behaviors on opioids are to be interpreted has been profound. The fact that problematic drug-related behavior can be driven by uncontrolled pain and extinguished with adequate pain control became a fundamental rule of opioid therapy. This led to practices such as escalating doses in the face of noncompliance and has been extended to include behaviors unintended by the original authors (e.g., excusing the use of marijuana for pain or symptom control while on opioids for non-malignant pain).

Chronic Pain-A Primary Care Guide to Practical Management

Chronic Pain-A Primary Care Guide to Practical Management

Chronic Pain and Obstetric Management of a Patient with Tuberous Sclerosis

Chronic nonmalignant pain is very disabling and carries a heavy financial strain on the individual and society as a whole. This case describes a woman with tuberous sclerosis, in her fourth pregnancy. Approximately 18 months prior to pregnancy, intractable left loin pain, thought to be secondary to hemorrhage within a tuberous lesion in the left kidney, had led to the siteing of an intrathecal morphine pump. The risks of system failure (dislodgement, dislocation), escalating dosage, infection, use in labor, and neonatal opioid withdrawal are all explored and discussed. While data are limited, with increasing use of intrathecal opioids for nonmalignant pain, such patients may be seen more regularly in obstetric clinics. With a multidisciplinary team approach, risks can be minimized and outcome for mother and baby optimized.