Prescribing For Chronic Pain Research Articles

Predictors of fatal and nonfatal overdose after prescription of opioids for chronic pain: a systematic review and meta-analysis of observational studies.

Higher doses of opioids, mental health comorbidities, co-prescription of sedatives, lower socioeconomic status and a history of opioid overdose have been reported as risk factors for opioid overdose; however, the magnitude of these associations and their credibility are unclear. We sought to identify predictors of fatal and nonfatal overdose from prescription opioids. We systematically searched MEDLINE, Embase, CINAHL, PsycINFO and Web of Science up to Oct. 30, 2022, for observational studies that explored predictors of opioid overdose after their prescription for chronic pain. We performed random-effects meta-analyses for all predictors reported by 2 or more studies using odds ratios (ORs) and 95% confidence intervals (CIs). Twenty-eight studies (23 963 716 patients) reported the association of 103 predictors with fatal or nonfatal opioid overdose. Moderate- to high-certainty evidence supported large relative associations with history of overdose (OR 5.85, 95% CI 3.78-9.04), higher opioid dose (OR 2.57, 95% CI 2.08-3.18 per 90-mg increment), 3 or more prescribers (OR 4.68, 95% CI 3.57-6.12), 4 or more dispensing pharmacies (OR 4.92, 95% CI 4.35-5.57), prescription of fentanyl (OR 2.80, 95% CI 2.30-3.41), current substance use disorder (OR 2.62, 95% CI 2.09-3.27), any mental health diagnosis (OR 2.12, 95% CI 1.73-2.61), depression (OR 2.22, 95% CI 1.57-3.14), bipolar disorder (OR 2.07, 95% CI 1.77-2.41) or pancreatitis (OR 2.00, 95% CI 1.52-2.64), with absolute risks among patients with the predictor ranging from 2-6 per 1000 for fatal overdose and 4-12 per 1000 for nonfatal overdose. We identified 10 predictors that were strongly associated with opioid overdose. Awareness of these predictors may facilitate shared decision-making regarding prescribing opioids for chronic pain and inform harm-reduction strategies SYSTEMATIC REVIEW REGISTRATION: Open Science Framework (https://osf.io/vznxj/).

Urine drug testing in the context of opioid analgesic prescribing for chronic pain: a content analysis of U.S. state laws in 2022.

In response to the opioid crisis, U.S. states have passed laws requiring urine drug testing (UDT) when opioid analgesics are prescribed for chronic pain. We sought to identify state law UDT requirements. We searched NexisUni legal database using terms related to UDT, chronic pain, and opioids. We included laws effective during spring 2022 that required UDT when opioids were prescribed for chronic pain. We performed deductive content analysis, coding laws for mandated UDT frequency, type of clinician and type of payer to whom the law applied, and circumstances under which UDT was mandated. We found 32 laws across 13 states that met our inclusion criteria. UDT requirements varied substantially by state, including with regard to the type of clinician to whom the law applied, the mandated frequency of UDT (eg, at initiation/assessment, at least annually, more than once per year), and the circumstances in which UDT was mandated (eg, patient had substance use disorder; dosage/day threshold). Relatively few states have UDT mandates associated with prescribing opioids as chronic pain treatment. When developing policy indicators for empirical studies, researchers evaluating how UDT policy affects health outcomes must consider the complexity and lack of uniformity of UDT requirements. In addition, even if states mandate UDT, it is unclear whether clinicians understand the best way to use the test results.

Impact of Nurse Practitioner Scope of Practice on Treatment for Chronic Pain and Opioid Use Disorder: A Scoping Review

Background Chronic pain affects nearly 50 million Americans, and its treatment is complicated by the opioid epidemic and physician shortage. Nurse practitioners (NPs) have a unique role in expanding access to care while still providing high-quality pain management; however, state restrictions prevent NPs from treating both chronic pain as well as opioid use disorder (OUD). Purpose The aim of this systematic scoping review was to examine the impact of these state-level restrictions on access to effective pain management. Methods In this systematic scoping review, the PubMed and CINAHL (Cumulative Index of Nursing and Allied Health Literature) databases were searched for articles published between 2008 and 2019. Grey literature from the same timeframe was searched via ProQuest, including policy documents, reports, doctoral student capstones and dissertations, and letters. Only peer-reviewed publications or acceptable forms of grey literature addressing either NP scope of practice or prescriptive authority laws and either pain management or opioid use disorder were included. Results Fifteen journal articles and 18 grey literature items met all inclusion criteria. We collapsed our findings into three themes pertaining to our research questions: (1) NP practice authority and chronic pain prescribing; (2) NP practice authority and OUD treatment; and (3) Changes in comprehensive education about chronic pain and OUD. Secondary findings included the trend toward autonomy in chronic pain care and policy initiatives to remove barriers to NP prescribing of medication-assisted therapy for OUD. Conclusion : A complex set of relationships exists between NP scope of practice, chronic pain care, and management of OUD. Findings suggest that scope of practice limitations have not necessarily met their intended goals of managing chronic pain while reducing opioid misuse. Policymakers should consider the impact of nursing regulatory laws on patient access to needed care for both chronic pain and OUD. Furthermore, trends toward NP leadership and autonomy in the management of both chronic pain and OUD highlight the need to further develop educational opportunities for NPs.

Opioids: long-term prescribing trends

OpenPrescribing.net1 Curtis HJ Goldacre B Open Prescribing: normalised data and software tool to research trends in English NHS primary care prescribing 1998-2016. BMJ Open. 2018; 8: e019921 Crossref PubMed Scopus (32) Google Scholar is a beautiful thing. Without so much as a login, you can produce long-term and up-to-date trends in National Health Service (NHS) primary care prescribing, visualised in exportable graphics. Go have a play. You can examine patterns for all of England, a clinical commissioning group, or just one practice. You can profile whole drug classes or a specific medicine. There is no charge. This democracy of access is remarkable. In their study published in The Lancet Psychiatry, Helen J Curtis and colleagues 2 Curtis HJ Croker R Walker AJ Richards GC Quinlan J Goldacre B Opioid prescribing trends and geographical variation in England, 1998–2018: a retrospective database study. Lancet Psychiatry. 2018; (published online Dec 20.)http://dx.doi.org/10.1016/S2215-0366(18)30471-1 PubMed Scopus (111) Google Scholar give us a case demonstration in how their tool can be used to monitor, compare, audit, and inform. In doing so, they provide new insight into the monitoring of prescription opioids. Opioid prescribing trends and geographical variation in England, 1998–2018: a retrospective database studyFailing to account for opioid strength would substantially underestimate the true increase in opioid prescribing in the National Health Service (NHS) in England. Our findings support calls for greater action to promote best practice in chronic pain prescribing and to reduce geographical variation. This study provides a model for routine monitoring of opioid prescribing to aid targeting of interventions to reduce high-dose prescribing. Full-Text PDF

Opioid prescribing trends and geographical variation in England, 1998–2018: a retrospective database study

There is a call for greater monitoring of opioid prescribing in the UK, particularly of strong opioids in chronic pain, for which there is little evidence of clinical benefit. We aimed to comprehensively assess trends and variation in opioid prescribing in primary care in England, from 1998 to 2018, and to assess factors associated with high-dose opioid prescribing behaviour in general practices. We did a retrospective database study using open data sources on prescribing for all general practices in England. For all standard opioids we calculated the number of items prescribed, costs, and oral morphine equivalency to account for variation in strength. We assessed long-term prescribing trends from 1998 to 2017, patterns of geographical variation for 2018, and investigated practice factors associated with higher opioid prescribing. We also analysed prescriptions for long-acting opioids at high doses. Between 1998 and 2016, opioid prescriptions increased by 34% in England (from 568 per 1000 patients to 761 per 1000). After correcting for total oral morphine equivalency, the increase was 127% (from 190 000 mg to 431 000 mg per 1000 population). There was a decline in prescriptions from 2016 to 2017. If every practice prescribed high-dose opioids at the lowest decile rate, 543 000 fewer high-dose prescriptions could have been issued over a period of 6 months. Larger practice list size, ruralness, and deprivation were associated with greater high-dose prescribing rates. The clinical commissioning group to which a practice belongs accounted for 11·7% of the variation in high-dose prescribing. We have developed a publicly available interactive online tool, OpenPrescribing.net, which displays all primary care opioid prescribing data in England down to the individual practice level. Failing to account for opioid strength would substantially underestimate the true increase in opioid prescribing in the National Health Service (NHS) in England. Our findings support calls for greater action to promote best practice in chronic pain prescribing and to reduce geographical variation. This study provides a model for routine monitoring of opioid prescribing to aid targeting of interventions to reduce high-dose prescribing. National Institute for Health Research (NIHR) School of Primary Care Research, NIHR Biomedical Research Centre Oxford, NHS England.

Perioperative management of opioid-tolerant patients

### Key points The assessment and treatment of opioid-tolerant patients in the perioperative and postoperative period can be challenging. Acute pain management can often be inadequate due to a number of factors. Compared with opioid-naive patients, opioid-tolerant patients will typically generate a greater workload for medical and nursing staff. Opioid tolerant patients express higher rest and dynamic pain scores, and two to three times greater opioid use via patient-controlled analgesia (PCA). They require more frequent consultations and prescription alterations.1 Medical and nursing staff may be unaccustomed to managing such patients and may be apprehensive in prescribing or administering large doses of opioids because of a fear of causing harm. Under-treatment of pain may result in opioid-seeking behaviour with the patient perceived as ‘manipulative’ and ‘non-cooperative’. This can have a negative impact on the doctor–patient relationship and overall patient care. Therefore the pain management plan for opioid tolerant patients requires careful consideration in the perioperative period in order to (i) prevent opioid withdrawal, (ii) provide effective analgesia, and (iii) to ensure continuity of care in the community after discharge from hospital. This review considers the various strategies that can be used in such settings. Opioids are prescribed to treat pain from a variety of causes, including chronic non-cancer pain, cancer pain, acute pain, and as substitution therapy in …

Benzodiazepines May Be Worse Than Opioids

Opioid prescription for noncancer pain is increasing in Europe and the United States. Research and guidance have focused on the potential for dependency and medical side effects with high doses. In contrast, benzodiazepines have received little attention in the chronic pain literature, despite evidence for dependency and cognitive impairment in long-term use. We aimed to examine the relationship between these classes of medication use, mood, and functioning. This cross-sectional study included patients (N=229) with disabling chronic pain who were about to start intensive pain rehabilitation. They completed self-report measures of mood, functioning, and responses to pain. We examined each patient's medication use and calculated a single morphine equivalent (ME) dose per person, and a similar diazepam equivalent (DE) dose. We examined the relationship between drug dose, mood, and functioning. Higher DE doses were associated with worse outcomes in most domains. Higher ME doses were more narrowly associated with worse functioning. There was no evidence for any benefit of these drugs; higher doses were not associated with less pain, fear, or disability. Higher ME doses were not more problematic, contrary to our predictions. The combination of opioids and benzodiazepines was associated with particularly poor outcomes for mood. This study is the first to examine both opioid and benzodiazepine use together in chronic pain. We found the anticipated negative effects of opioid medication, and particularly consistent associations between benzodiazepine use and poor well-being. Future guidance on chronic pain prescription should focus on restricting benzodiazepine use.

OR09-1 * COGNITIVE IMPULSIVITY AND CHRONIC OPIOID USE

Introduction. Previous studies have provided inconsistent evidence that chronic exposure to opioid drugs, including heroin and methadone, may be associated with impairments in executive neuropsychological functioning, specifically cognitive impulsivity. Methods. Participants with validated histories of illicit heroin use (n = 24), former heroin users stabilised on prescribed methadone maintenance treatment (MMT) (n = 29), licit opioid prescriptions for chronic pain without history of abuse or dependence (n = 28) and healthy controls (n = 28) were recruited and tested on measures of cognitive impulsivity, motor impulsivity and non-planning impulsivity. Results. Stable illicit heroin users showed increased motor impulsivity and impaired strategic planning. Additionally, they placed higher bets earlier and risked more. MMT participants deliberated longer and placed higher bets earlier but did not risk more. Chronic opiate exposed pain participants did not differ from healthy controls on any measures on any tasks. Conclusion. These data support the hypothesis that different aspects of neuropsychological measures of impulsivity appear to be associated with exposure to different opioids and also to the syndrome of opioid dependence. This could reflect either a neurobehavioural consequence of opioid exposure, or may represent an underlying trait vulnerability to opioid dependence.

The Methadone Epidemic

The prevalence of methadone-related overdose deaths is increasing worldwide and has been a topic of recent debate. Methadone-related deaths, to this point, have not been systematically reviewed in the state of Vermont. All of the methadone-related fatalities from 2001 to 2006 (total, 76 cases), which were examined by the Vermont Office of the Chief Medical Examiner were retrospectively reviewed. The mean age of the decedents was 36 years (range, 16-74 years), and 72% were male. The manners of death were classified as follows: 84% accident, 12% undetermined, and 4% suicide. The mean level of methadone was 457 ng/mL (range, 50-3793 ng/mL). The substances causing death were determined to be methadone alone in 26 (34%), methadone with only other prescribed medications in 29 (38%), methadone with only illicit drugs (excluding tetrahydrocannabinol) in 13 (17%), methadone with both illicit and prescribed medications in 5 (7%), and methadone with ethanol in 3 (4%). The methadone was obtained by illegal diversion (sale, gift, or theft) in 67% of cases. In the remaining cases (33%), the methadone was obtained by physician's prescription for chronic pain (60%), acute pain or injury (8%), methadone maintenance therapy for heroin dependence (8%), and unknown reasons (24%). The number of overdose deaths has increased 4-fold from 2001 (17 deaths) to 2006 (79 deaths). The proportion of methadone-related deaths has increased by 300% from 2001 (0.6% of reported deaths, 12% of overdose deaths) to 2006 (3% of reported deaths, 37% of overdose deaths). Methadone maintenance therapy for heroin dependence in our population comprises an insignificant number of the methadone-related deaths (3% of the decedents). In Vermont, the populations most at risk are those taking methadone for chronic pain and those obtaining diverted methadone for abuse. Education of clinicians regarding the increasing number of methadone-related deaths, the potential for abuse and diversion, and the pharmacokinetics of methadone may help halt this epidemic and reduce the number of fatalities from this drug.

Genetic discovery: the prescription for chronic pain

A recent publication that combined rat gene expression data and a human genetic association study has identified the first genetic risk factor for chronic pain in humans. In four of the five cohorts studied, there was a significant association of an allele within a gene (KCNS1) encoding a potassium channel (Kv9.1) with an increased risk for chronic pain. Identification of genetic risk factors for chronic pain could catalyze new advances in this difficult clinical area that has become a major public health problem. Genomic-medicine-based advances for chronic pain could include the development of a mechanism-based classification system for chronic pain, new treatment options, improved methods for treatment selection and targeted prevention strategies for high-risk individuals.