Analgesic Prescription Research Articles

Leveraging a Learning Collaborative Model to Develop and Pilot Quality Measures to Improve Opioid Prescribing in the Emergency Department

The American College of Emergency Physicians (ACEP) Emergency Medicine Quality Network (E-QUAL) Opioid Initiative was launched in 2018 to advance the dissemination of evidence-based resources to promote the care of emergency department (ED) patients with opioid use disorder. This virtual platform-based national learning collaborative includes a low-burden, structured quality improvement project, data benchmarking, tailored educational content, and resources designed to support a nationwide network of EDs with limited administrative and research infrastructure. As a part of this collaboration, we convened a group of experts to identify and design a set of measures to improve opioid prescribing practices to provide safe analgesia while reducing opioid-related harms. We present those measures here, alongside initial performance data on those measures from a sample of 370 nationwide community EDs participating in the 2019 E-QUAL collaborative. Measures include proportion of opioid administration in the ED, proportion of alternatives to opioids as first-line treatment, proportion of opioid prescription, opioid pill count per prescription, and patient medication safety education among ED visits for atraumatic back pain, dental pain, or headache. The proportion of benzodiazepine and opioid coprescribing for ED visits for atraumatic back pain was also evaluated. This project developed and effectively implemented a collection of 6 potential measures to evaluate opioid analgesic prescribing across a national sample of community EDs, representing the first feasibility assessment of opioid prescribing-related measures from rural and community EDs.

Modern concepts of treatment of phantom limb pain

Phantom limb pain is a specific entity of neuropathic pain that develops in 30%85% of patients with amputated limbs and leads to considerable worsening of the quality of life. The number of such cases increases during military conflicts. It can be caused by a traumatic amputation due to mine blast injury, peculiarities of provided medical assistance, and the special psychological state of casualties being in extremely stressful situations at the moment of wounding. Phantom limb pain development is accompanied by multiple functional and structural changes at different levels of the peripheral and central nervous systems. As a result, different theories of pathogenesis are proposed. However, at present, no final opinion concerns mechanisms of phantom limb pain development. Although different versions of drug and non-drug therapy have been suggested, none of them turned out to be universal and fully effective. Many medications were found to be linked to phantom limb pain pathogenesis; however, even first-line therapy drugs (non-steroidal anti-inflammatory drugs, tricyclic antidepressants, narcotic analgesics, and anticonvulsants) often fail to provide adequate analgesia. Long-term prescription of narcotic analgesics is at risk of the development of addictive disorders. Surgical interventions have not demonstrated their effectiveness as well. Thus, their use is justified only in the case of ineffective conservative treatment. Poor efficacy of conventional concepts of phantom limb pain treatment led to the use of new means such as botulinum toxin therapy, non-drug methods (psychotherapy, mirror therapy, biological feedback, virtual reality, acupuncture, massage, hypnosis, etc.). Thus, the search for original methods based on the development and introduction of new drug therapy schemes is imperative. A possible solution to this problem is not only creating absolutely new non-opioid analgesics but also using adjuvant therapeutic means in the multimodality schemes of analgesia. The latter promotes neurotransmission in the antinociceptive system and potentiates the effect of traditional analgesics.

Adherence to Opioid Prescribing Guidelines in a Statewide Surgical Quality Improvement Collaborative

IntroductionThe opioid crisis is an ongoing crisis in the United States. Postoperative patients who receive opioid prescriptions have a 3%-7% risk of developing a chronic opioid abuse problem. This study aims to describe on-target opioid prescribing and use of multimodal pain management strategies 2 y after the implementation of a multicomponent quality improvement initiative across our statewide collaborative. MethodsFrom July 2020 to September 2021, we prospectively collected data on opioid-prescribing and multimodal strategies for 10 targeted procedures in general, gynecologic, and orthopedic surgery at three hospitals. Prescribing was on-target if a patient was prescribed ≤50 daily morphine milligram equivalents. Multimodal strategies were defined as two or more nonopioid adjuncts used within 48 h of surgery. ResultsOne thousand and eleven targeted procedures were performed with prescription data available for 993 cases. The on-target prescribing rate was 79.6% (n = 790), with general surgery 92.5% (n = 285), gynecology 84.9% (n = 331), and orthopedic surgery 59.0% (n = 174). Patients who received multimodal pain approaches were associated with interventions such as patient education, transversus abdominus plane block, and prescriptions for nonopioid analgesics at discharge. There was no evidence to support a difference in the use of multimodal pain control approaches between patients whose opioid prescribing was on-target or not (73.8% versus 77.3%, P = 0.30). At the first postoperative visit, data on continued opioid use were missing in 57.3% of patients, number of pills used was missing in 93.8%, and adequate pain control was missing in 52.8%. ConclusionsOn-target prescribing and multimodal strategies are common but vary by specialty. Additionally, postoperative pain control and opioid use are often not documented. To better match prescribing to patient needs, understanding patient-level and specialty-level opioid use is important.

Evaluation of audit and feedback to family physicians on prescribing of opioid analgesics to opioid-naïve patients: A pragmatic randomized delay trial

BackgroundExposure to opioid analgesics have historically raised concern for a risk of developing opioid use disorder. Prescriber audit-and-feedback interventions may reduce opioid prescribing, but some studies have shown detrimental effects for current users. We examined the effectiveness of an audit and feedback intervention, named Portrait, to reduce initiation of opioid analgesics among opioid-naïve patients experiencing pain. MethodsREDONNA was a single-blinded, two-arm (Early vs Delayed mailing) randomized trial of a portrait for eligible family physicians (FPs) in British Columbia (BC), Canada. The primary outcome was the change in the number of initiations of opioid analgesic prescriptions written by FPs for acute/chronic pain management. We compared outcomes for a 6-month window before vs. after each mailed intervention, using differences in percent differences (DPD) with 95% confidence intervals (CI) and odds ratios (OR) from logistic regressions adjusted for clustering of patients by FP. ResultsIn the Early (n = 2260) and Delayed (n = 2156) groups, opioid initiations per month were the same in the Before (2.10 Early; 2.06 Delayed) and After (1.94 Early; 1.95 Delayed) windows. The DPD was −2.1% (CI: −4.4% to 0.3%), and ORs were: 0.98 (CI: 0.96 to 1.01) for any opioid, 0.97 (CI: 0.94 to 1.01) for codeine (62% of initiations), and 1.0 (CI: 0.97 to 1.07) for tramadol (25% of initiations). There were no differences in mean quantity of tablets, mean milligrams of morphine equivalents (MME), or mean number of days. ConclusionPortrait had no impact on FPs' rates of prescribing opioid analgesics to opioid-naïve patients experiencing pain. Trial registrationThe study was registered prospectively on 30 March 2020 at the ISRCTN Register (https://www.isrctn.com/ISRCTN34246811).

THU647 Patient With Successful Conception During Treatment For Cushing Disease: Case Report

Abstract Disclosure: C. Iweha: None. E.K. Babler: None. M. Castillo: None. Introduction Cushing Disease (CD) is an endocrine disorder that predominantly affects women of childbearing age and is characterized by excess secretion of adrenocorticotropic hormone (ACTH) with hypercortisolism. We report a case of a woman with ACTH-dependent hypercortisolism treated with pasireotide who had a successful pregnancy while on treatment. Clinical Case A 27-year-old woman presented to the initial consult on 9/01/2011 with a 4-year history of ongoing symptoms of hirsutism, diaphoresis, oligomenorrhea, myalgia, and acne. A physical exam revealed an overweight female with mild facial acne and hirsutism. Family history included autoimmune disease in mother (lupus and multiple sclerosis). She was frustrated by the lack of a definitive diagnosis over 4 years; she was anxious and using multiple medications, including anxiolytics and analgesics, without relief of symptoms. Patient did not use alcohol and never smoked. Labs revealed initial morning (AM) cortisol = 26.9 µg/dL (normal range: 5-23 µg/dL) and ACTH = 14 pg/mL (normal: 6-58 pg/mL); 24-hour urinary cortisol was 110.6 µg/24 h (normal:<100 µg/dL) and serum ACTH =8 pg/mL. Low-dose (1 mg) dexamethasone suppression test reduced AM cortisol to 1.7 µg/dL and ACTH of 8 pg/mL. No evidence of adrenal adenoma on abdominal CT or pituitary adenoma on brain MRI, and IPSS confirmed diagnosis. Based on hypercortisolism and normal ACTH level, diagnosis was ACTH-dependent CD. We advised the patient to join a clinical trial for pasireotide, and she began treatment on 1/3/2013. She presented for follow-up on 6/17/2014 and reported improvement of some symptoms on 0.6 mg pasireotide twice daily, the highest dose she could tolerate. She reported experiencing chronic pain; medications included prescription analgesics, muscle relaxants, and anxiolytics. On 6/23/2015, our patient returned for a follow-up when she was 5.5 months pregnant. While on pasireotide, she became pregnant and subsequently left the study and discontinued treatment. She reported recurrence of hirsutism, acne, fatigue, and hyperemesis with discontinuation of pasireotide. Patient returned twice more during pregnancy and had a successful delivery and healthy infant. Clinical Conclusions Successful conception and pregnancy are unusual with CD due to fertility-inhibiting hormonal effects of excess cortisol. Some medications for CD impede pregnancy through their mechanism (eg, mifepristone). Our patient conceiving while on treatment is promising for women with CD. Although her CD symptoms returned when pasireotide was discontinued, she delivered a healthy infant; limited pasireotide data in pregnant women are insufficient to inform a drug-associated risk for major birth defects and miscarriage. Our case underscores the potential for successful conception for women with CD when cortisol levels are normalized with treatment that avoids suppressing menstruation. Presentation: Thursday, June 15, 2023

Trends in Repeat Opioid Analgesic Prescription Utilization for Acute Pain in Children: 2013–2018

Our study examined the change in repeat opioid analgesic prescription trends in children and adolescents experiencing acute pain between 2013 and 2018. Eligible individuals were children and adolescents between 1 and 17 years of age enrolled in a Medicaid Managed Care plan and filled an incident opioid analgesic prescription from 2013 to 2018. A repeat opioid prescription was defined as receiving a subsequent opioid prescription within 30 days from the end of the incident opioid prescription. A generalized linear regression analysis was conducted to examine changes in repeat opioid analgesic dispensing over time at quarterly intervals from January 1, 2013, to December 31, 2018. The cohort comprised 17,086 children and adolescents receiving an incident opioid analgesic. Of these, 1780 (10.4%) filled a repeat opioid analgesic prescription. There was a significant decline in the repeat opioid analgesic trend from 11.5% in Q1 2013 to 9.6% in Q4 2018. Stratified analyses by age, sex, and race and ethnicity in a sub-cohort of patients undergoing surgical procedures showed that a significant decline in repeat opioid utilization over time has been observed in all racial/ethnic groups stratified by age and sex, with the most significant decline found in non-Hispanic White children and Hispanic adolescents. At the end of the 6-year follow-up, the racial and ethnic variations in repeat opioid utilization associated with surgical procedures had significantly reduced in children yet persisted among adolescents. Approximately 10% of incident pediatric opioid analgesic recipients received a repeat opioid prescription. There has been a moderate but steady decline (∼7% per quarter) in repeat opioid analgesic utilization between 2013 and 2018.

Do we really know if they are in pain? A cross-sectional study in hospitalised adult patients in Spain.

To describe the prevalence and characteristics of pain in adult hospitalised patients, as well as to analyse the concordance between patient-reported and recorded pain and its impact on analgesic management. A cross sectional study. The study was performed on a sample of 611 patients, from October to December 2017. Data were obtained from patient interviews, review of medical and nursing records and review of electronic prescribing. The prevalence of pain at the time of the interview was 36.7%. The median VAS score was 4. 90% of the patients had their pain assessed within the last 24 h; however, concordance between patient-reported pain and recorded pain in the nursing record was slight. Pain is still often documented inadequately. Despite the wide use of analgesics, half of the patients with moderate to severe pain do not have adequate pain management. A systematic assessment and recording of pain promotes appropriate analgesic prescription. The findings of our study provide insight into the main gaps in the correct management of pain in hospitalised patients. A systematic assessment and recording of the pain suffered by the patient facilitates its control and allows a better management of the analgesic prescription by the physician. This information could help hospital managers to develop training programmes on pain assessment and on the importance of doctor-nurse collaboration to improve pain management, increasing the quality of care and reducing hospital costs. The study has adhered to the relevant EQUATOR guidelines, according to The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.

Older Adult-Onset of Inflammatory Bowel Diseases Is Associated With Higher Utilization of Analgesics: A Nationwide Cohort Study.

Patients with inflammatory bowel diseases (IBD) commonly require analgesic medications to treat pain, which may be associated with complications. We examined trends of analgesic use according to age at IBD onset. This nationwide cohort study included adults diagnosed with IBD between 1996 and 2021 in Denmark. Patients were stratified according to their age at IBD onset: 18-39 years (young adult), 40-59 years (adult), and older than 60 years (older adult). We examined the proportion of patients who received prescriptions for analgesic medications within 1 year after IBD diagnosis: strong opioids, tramadol, codeine, nonsteroidal anti-inflammatory drugs, and paracetamol. Multivariable logistic regression analysis was performed to examine the association between age at IBD onset and strong opioid prescriptions and the composite of strong opioid/tramadol/codeine prescriptions. We identified 54,216 adults with IBD. Among them, 25,184 (46.5%) were young adults, 16,106 (29.7%) were adults, and 12,926 (23.8%) were older adults at IBD onset. Older adults most commonly received analgesic prescriptions of every class. Between 1996 and 2021, strong opioid, tramadol, and codeine prescriptions were stable, while paracetamol prescriptions increased and nonsteroidal anti-inflammatory drug prescriptions decreased. After multivariable logistic regression analysis, older adults had higher adjusted odds of receiving strong opioid prescriptions (adjusted odds ratio 1.95, 95% confidence interval 1.77-2.15) and the composite of strong opioid/tramadol/codeine prescriptions (adjusted odds ratio 1.93, 95% confidence interval 1.81-2.06) within 1 year after IBD diagnosis compared with adults. In this nationwide cohort, older adults most commonly received analgesic prescriptions within 1 year after IBD diagnosis. Additional research is needed to examine the etiology and sequelae of increased analgesic prescribing to this demographic.

Use of prescribed analgesics before and after exercise therapy and patient education in patients with knee or hip osteoarthritis

The aim of this study was to investigate utilisation patterns of prescribed analgesics before, during, and after an exercise therapy and patient education program among patients with knee or hip osteoarthritis. This cohort study is based on data from the nationwide Good Life with osteoarthritis in Denmark (GLA:D®) patient-register linked with national health registries including data on prescribed analgesics. GLA:D® consists of 8–12 weeks of exercise and patient education. We included 35,549 knee/hip osteoarthritis patients starting the intervention between January 2013 and November 2018. Utilisation patterns the year before, 3 months during, and the year after the intervention were investigated using total dispensed defined daily doses (DDDs) per month per 1000 population as outcome. During the year before the intervention, use of prescribed paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), and opioids increased with 85%, 79% and 22%, respectively. During the intervention, use of paracetamol decreased with 16% with a stable use the following year. Use of NSAIDs and opioids decreased with 38% and 8%, respectively, throughout the intervention and the year after. Sensitivity analyses indicated that the prescription of most analgesics changed over time. For paracetamol, NSAIDs, and opioids, 10% of analgesic users accounted for 45%, 50%, and 70%, respectively, of the total DDDs dispensed during the study period. In general, analgesic use increased the year before the intervention followed by a decrease during the intervention and the year after. A small proportion of analgesic users accounted for half or more of all paracetamol, NSAIDs, and opioids dispensed during the study period.

From Two Dimensions to Multidimensions: A Mechanistic Model to Support Deliberate CPD Development, Coordination, and Evaluation.

The effectiveness of continuing professional development as an intervention to improve health professional behavior and patient health is variable and contentious. To clarify the causal relationships underlying program outcomes and facilitate a necessary shift from outcomes-only-based approaches to outcome-based and theory-based approaches in program development and evaluation, we developed a model of mechanisms mapped to relevant outcomes. Mechanisms identified in a prior realist synthesis of opioid agonist therapy continuing professional development programs were iteratively tested and refined using purposive and opportunistic sampling and realist approaches against two systematic reviews of programs in analgesic prescribing and palliative care. Further testing involved practical application within programs in sustainable health care and pain management. Ninety reports on 75 programs and practical application to multiple additional programs informed the final model consisting of five distinct mechanisms: motivation transformation, expert influence, confidence development, self-efficacy facilitation, and community of practice expansion. The mechanisms and related analysis emphasize that continuing professional development is heterogeneous, complex, and context dependent. Shifting toward outcome-based and theory-based approaches facilitates further conceptual shifts at intraprogram and interprogram and interintervention levels toward more deliberate program development and evaluation, increased program complementarity and subsequent collaboration. It clarifies opportunities for intercalation of continuing professional development with other intervention sciences. The model presents a resource for practitioners, researchers, and policymakers to advance continuing professional development planning, coordination, and evaluation.

Pain and quality of life in nursing home residents with dementia after admission – a longitudinal study

BackgroundPain in nursing home (NH) residents with dementia is commonly reported and may affect Quality of Life (QoL) negatively. Few longitudinal studies have explored how pain and QoL develop in NH residents with dementia starting from their admission to the NH.AimThe aim was to explore pain, QoL, and the association between pain and QoL over time in persons with dementia admitted to a NH.MethodsA convenience sample, drawn from 68 non-profit NHs, included a total of 996 Norwegian NH residents with dementia (mean age 84.5 years, SD 7.6, 36.1% men) at NH admission (A1), with annual follow-ups for two years (A2 and A3). Pain and QoL were assessed using the Mobilization-Observation-Behavior-Intensity-Dementia-2 (MOBID-2) Pain Scale and the Quality of Life in Late-Stage Dementia (QUALID) scale, respectively, at all assessments. Severity of dementia, personal level of activities of daily living, general medical health, neuropsychiatric symptoms, and the prescription of psychotropic drugs and analgesics (opioids and/or paracetamol) were also assessed at all assessments.ResultsMean (SD) MOBID-2 pain intensity scores were 2.1 (2.1), 2.2 (2.2), and 2.4 (2.1) at A1, A2, and A3, respectively. Participants who were prescribed analgesics had higher pain intensity scores at all assessments than participants not prescribed analgesics. The mean (SD) QUALID scores at each assessment were 19.8 (7.1), 20.8 (7.2), and 22.1 (7.5) at A1, A2, and A3, respectively. In the adjusted linear mixed model, higher pain intensity score, prescription of opioids, and prescription of paracetamol were associated with poorer QoL (higher QUALID total score and higher scores in the QoL dimensions of sadness and tension) when assessed simultaneously. No time trend in QoL was found in these adjusted analyses.ConclusionNH residents with dementia who have higher pain intensity scores or are prescribed analgesics are more likely to have poorer QoL. Clinicians, NH administrators, and national healthcare authorities need to look into strategies and actions for pharmacological and non-pharmacological pain treatment to reduce pain intensity while simultaneously avoiding negative side effects of pain treatment that hamper QoL.

Dental Pain Medication Prescriptions in Minas Gerais, Brazil (2011-2021): A Time-Series Analysis.

To describe trends of dentist-prescribed non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics, from January 2011 to December 2021, as well as to examine the relationship between these trends and characteristics of public oral health services in Minas Gerais, Brazil. In this time-series analysis, all drugs were classified according to the Anatomical Therapeutic Chemical classification system. Drugs categorized as NSAIDs (M01A), and other analgesics and antipyretics (N02B) were included for analysis. The outcome was the number of Defined Daily Doses (DDDs)/1000 inhabitants/year for NSAIDs and analgesics in each town. Covariates referred to characteristics of public oral health services, such as coverage, estimates of dental procedures, and frequency of toothache. Linear time-series regression models were used to determine the influence of covariates on the outcome. Overall, there were 58,482 prescriptions of NSAIDs recorded in thirty-eight towns, while 47,499 prescriptions of analgesics in forty-three towns. For each year, there was a 0.38 (p < 0.001), and 0.28 (p < 0.001) increase in the average log of DDD/1000 inhabitants/year for NSAIDs and analgesics, respectively. A positive association was detected between toothache (p < 0.001) and the prescription of NSAIDs. Over the eleven years, there was a general rising trend in the prescriptions. Toothache was the only characteristic of public oral health services associated with the prescription rates of NSAIDs, implying that as the frequency of toothaches increase, so do the prescriptions of NSAIDs in the studied towns.

Allele frequency and genotype distribution of the opioid receptor μ-1 (OPRM1) A118G polymorphism in the Western Saudi population.

The single nucleotide polymorphism (SNP) A118G (rs1799971) in the Mu Opioid Receptor 1 (OPRM1) gene is associated with significant variations in analgesic doses and adverse effects of opioids. The A118G OPRM1 allele distributions vary significantly between different populations worldwide. The study aimed to assess the allele frequency and genotype distribution of OPRM1 A118G SNP in Saudis. This cross-sectional study included 124 healthy Saudis (62 males and 62 females) visiting the King Abdulaziz University Hospital in Jeddah, Saudi Arabia. The Oragene®-DISCOVER (OGR-600) kits were used to collect saliva samples from the participants. Polymerase chain reaction-restriction fragment length polymorphism was utilized to assess the SNP. Among the tested population, 79.03% (95% C.I. 70.81-85.82) were homozygous wild-type A118A, 16.13% (95% C.I. 10.14-23.80) were heterozygous A118G, and 4.84% (95% C.I. 1.80-10.23) were homozygous mutant G118G. OPRM1 A118G polymorphism allele frequencies were 87% (95% C.I. 79.89-92.44) and 13% (95% C.I. 7.56-20.11) for the 118A and 118G alleles, respectively. A higher frequency of the OPRM1 118G allele was present in females, 21% (95% C.I. 11.66-33.17) compared to males, 5% (95% C.I. 1.01-13.50). Relative to other Asian countries, the Saudi population showed a low prevalence of the OPRM1 A118G polymorphism, with a higher frequency of the 118G allele in females. Our research will contribute to the existing knowledge on the prevalence of OPRM1 A118G polymorphism, which could be considered for the personalized prescribing of opioid analgesics.

350 Evaluation of analgesia prescribing in hospitalised adults ≥ 65

Abstract Background Pain is common in hospitalised patients aged ≥65. It is recommended to follow the World Health Organisation pain ladder but special consideration should be given to the adverse effects of opiates and Non-Steroidal Anti-Inflammatory Drugs (NSAIDs). Methods A retrospective review of geriatric medicine inpatients aged ≥65 years was conducted. Data was collected from August 2023 over a 24-hour period using electronic patient records. Results One hundred and nineteen patient records were reviewed. The average age was 84 years (SD = 3.53 years); 56% female. One hundred and eleven patients (93%) were prescribed analgesia. Seventy patients (56%) had pain documented as a clinical issue with musculoskeletal (MSK) pain, the most common type at 64%(n = 45)), 10% (n = 7) undocumented pain source, 8.5%(n = 6) visceral pain, 8.5% (n = 6) vascular pain, 3% (n = 2) neuropathic pain, 3% (n = 2) cancer related pain, and 3% (n = 2) dental pain. Fifty-five patients (49.5%) were prescribed regular paracetamol, and fifty-one (46%) as required (PRN) paracetamol. Twenty-two (20%) were on a regular opiate and forty-two (38%) on a PRN opiate. Oramorph was the most common opiate prescribed (n = 26). Nineteen patients (17%) were on a regular NSAID; with twenty-one (19%) on a PRN NSAID. Topical diclofenac was the most common agent (28 patients). Sixteen (14%) patients were on a neuropathic agent, of which pregabalin was the most common (9 patients). 53% (N = 63) of patients were newly prescribed paracetamol, 26% (N = 31) opiates, 18% (N = 21) NSAIDs and 8% (N = 9) neuropathic agents. Twelve patients without an active pain issue were charted regular paracetamol. Thirty-four patients prescribed opiates had renal impairment. Conclusion There was a high rate of analgesia prescribing among older hospitalised patients (93%). Paracetamol was followed by opiates, NSAIDS and neuropathic agents in frequency. Issues identified include paracetamol over prescribing, NSAID underuse and use of opiates in renal impairment. These findings suggest that clinicians would benefit from a local guideline for the management of pain in the older population.

Trends in Racial Inequalities in the Administration of Opioid and Non-opioid Pain Medication in US Emergency Departments Across 1999-2020.

Despite initiatives to eradicate racial inequalities in pain treatment, there is no clear picture on whether this has translated to changes in clinical practice. To determine whether racial disparities in the receipt of pain medication in the emergency department have diminished over a 22-year period from 1999 to 2020. We used data from the National Hospital Ambulatory Medical Care Survey, an annual, cross-sectional probability sample of visits to emergency departments of non-federal general and short-stay hospitals in the USA. Pain-related visits to the ED by Black or White patients. Prescriptions for opioid and non-opioid analgesics. A total of 203,854 of all sampled 625,433 ED visits (35%) by Black or White patients were pain-related, translating to a population-weighted estimate of over 42 million actual visits to US emergency departments for pain annually across 1999-2020. Relative risk regression found visits by White patients were 1.26 (95% CI, 1.22-1.30; p<0.001) times more likely to result in an opioid prescription for pain compared to Black patients (40% vs. 32%). Visits by Black patients were also 1.25 (95% CI, 1.21-1.30; p<0.001) times more likely to result in non-opioid analgesics only being prescribed. Results were not substantively altered after adjusting for insurance status, type and severity of pain, geographical region, and other potential confounders. Spline regression found no evidence of meaningful change in the magnitude of racial disparities in prescribed pain medication over 22 years. Initiatives to create equitable healthcare do not appear to have resulted in meaningful alleviation of racial disparities in pain treatment in the emergency department.

Prevalence and perceptions of pain in people with haemophilia: A UK study.

Joint bleeds in haemophilia cause destruction of articular structures, impaired function and pain. Up to 70% of people with haemophilia (PWH) report chronic pain. Little is known about the pain experiences in PWH in the UK. To identify prevalence and perceptions of pain among PWH living in the UK. A cross-sectional, non-interventional survey study conducted among PWH (all severities). The survey incorporated elements from validated tools (EQ-5D; EQ-VAS) and was distributed via participating treatment centres. Five hundred and ninety-nine PWH responded, 91% aged>18. 81% used factor prophylactically or on demand. More pain was reported by those treated on demand versus prophylaxis particularly in those who reported daily pain. 65% reported 'problem joints' based on individual impact rather than medically defined 'target joints', 2/3 reported multiple joint issues. The ankle was most commonly affected. 59% reported frequent pain, with 56% aware of pain constantly or most of the time and were more likely to report less favourable EQ-5D or EQ-VAS scores (p<.001). Pain frequency/awareness was consistent across all severities. Most discussed pain with care teams, 31% only when asked; 25% did not discuss it. Pain discussions resulted in physiotherapy referral (63%) analgesia prescription (48%), and a minority specialist pain referral (9%). Most felt well supported with regard to their pain, but 70% reported learning to live with it. Pain affects PWH of all ages and severities even in a well-resourced country significantly impacting quality of life. Clinicians must be more aware of chronic pain in PWH. Biopsychosocial approaches to pain assessment and management are recommended.

Features of opioid analgesia s in patients with phantom limb pain after amputation due to gunshot wounds

Background. Since the beginning of the large-scale war on the territory of Ukraine, the incidence of limb injuries has reached 40 %: 15 % of them are upper limb injuries, 25 % are lower limb injuries, and the proportion of patients who have lost limbs due to trauma has increased significantly. In these patients, phantom pain occurs in more than 60 % of cases. Such pain is extremely difficult to treat with standard approaches. Usually, the prescription of opioid analgesics is required, but there is no data on their effectiveness in the comprehensive therapy of phantom pain, which appears as a result of limb amputation and is one of the most difficult clinical problems today. Materials and methods. Our study involved 57 patients. The diagnosis of phantom pain was made based on the clinical picture and patient description. The severity of pain was studied using the visual analog scale. To determine the neuropathic component of pain, Douleur Neuropathique 4 questions were used. The distribution of quantitative indicators for normality was checked with the Shapiro-Wilk test and Student’s test. Results. According to the visual analog scale data, no significant statistical difference was found between group 1 and 2 (p &gt; 0.05). The data of Douleur Neuropathique 4 questions indicate that group 1 has statistically better results than group 2 (p &lt; 0.05). Conclusions. The results of pain relief in patients with phantom limb pain after amputation due to gunshot wounds in comprehensive therapy shows a better result than tramadol.

Identifying populations with chronic pain in primary care: developing an algorithm and logic rules applied to coded primary care diagnostic and medication data

BackgroundEstimates of chronic pain prevalence using coded primary care data are likely to be substantially lower than estimates derived from community surveys. Most primary care studies have estimated chronic pain prevalence using data searches confined to analgesic medication prescriptions. Increasingly, following recent NICE guideline recommendations, patients and doctors opt for non-drug treatment of chronic pain thus excluding these patients from prevalence estimates based on medication codes. We aimed to develop and test an algorithm combining medication codes with selected diagnostic codes to estimate chronic pain prevalence using coded primary care data.MethodsFollowing a scoping review 4 criteria were developed to identify cohorts of people with chronic pain. These were (1) people with one of 12 (‘tier 1’) conditions that almost always results in the individual having chronic pain (2) people with one of 20 (‘tier 2’) conditions included when there are also 3 or more prescription-only analgesics issued in the last 12 months (3) chronic neuropathic pain, or (4) 4 or more prescription-only analgesics issued in the last 12 months. These were translated into 8 logic rules which included 1,932 SNOMED CT codes.ResultsThe algorithm was run on primary care data from 41 GP Practices in Lambeth. The total population consisted of 386,238 GP registered adults ≥ 18 years as of the 31st March 2021. 64,135 (16.6%) were identified as people with chronic pain. This definition demonstrated notably high rates in Black ethnicity females, and higher rates in the most deprived, and older population.ConclusionsEstimates of chronic pain prevalence using structured healthcare data have previously shown lower prevalence estimates for chronic pain than reported in community surveys. This has limited the ability of researchers and clinicians to fully understand and address the complex multifactorial nature of chronic pain. Our study demonstrates that it may be possible to establish more representative prevalence estimates using structured data than previously possible. Use of logic rules offers the potential to move systematic identification and population-based management of chronic pain into mainstream clinical practice at scale and support improved management of symptom burden for people experiencing chronic pain.

Analgesic prescribing in patients with inflammatory arthritis in England: observational studies in the Clinical Practice Research Datalink.

Despite little evidence that analgesics are effective in inflammatory arthritis (IA), studies report substantial opioid prescribing. The extent this applies to other analgesics is uncertain. We undertook a comprehensive evaluation of analgesic prescribing in patients with IA in the Clinical Practice Research Datalink Aurum to evaluate this. From 2004 to 2020, cross-sectional analyses evaluated analgesic prescription annual prevalence in RA, PsA and axial spondyloarthritis (axSpA), stratified by age, sex, ethnicity, deprivation and geography. Joinpoint regression evaluated temporal prescribing trends. Cohort studies determined prognostic factors at diagnosis for chronic analgesic prescriptions using Cox proportional hazards models. Analgesic prescribing declined over time but remained common: 2004 and 2020 IA prescription prevalence was 84.2/100 person-years (PY) (95% CI 83.9, 84.5) and 64.5/100 PY (64.2, 64.8), respectively. In 2004, NSAIDs were most prescribed (56.1/100 PY; 55.8, 56.5), falling over time. Opioids were most prescribed in 2020 (39.0/100 PY; 38.7, 39.2). Gabapentinoid prescribing increased: 2004 prevalence 1.1/100 PY (1.0, 1.2); 2020 prevalence 9.9/100 PY (9.7, 10.0). Most opioid prescriptions were chronic (2020 prevalence 23.4/100 PY [23.2, 23.6]). Non-NSAID analgesic prescribing was commoner in RA, older people, females and deprived areas/northern England. Conversely, NSAID prescribing was commoner in axSpA/males, varying little by deprivation/geography. Peri-diagnosis was high-risk for starting chronic opioid/NSAID prescriptions. Prognostic factors for chronic opioid/gabapentinoid and NSAID prescriptions differed, with NSAIDs having no consistently significant association with deprivation (unlike opioids/gabapentinoids). IA analgesic prescribing of all classes is widespread. This is neither evidence-based nor in line with guidelines. Peri-diagnosis is an opportune moment to reduce chronic analgesic prescribing.

Patellofemoral pain in general practice: the incidence and management.

Patellofemoral pain (PFP) is a nontraumatic knee problem primarily observed in physically active adolescents. The objective of this study was to determine the incidence and management of PFP in children and adolescents in general practice. A retrospective cohort study was conducted using a regional primary care database containing full electronic health records of over 300,000 patients. Patients with a new PFP diagnosis between the years 2013 and 2019 were extracted using a search algorithm based on International Classification of Primary Health Care coding and search terms in free text. Data on the management of PFP were manually checked and analysed. In addition, a sub-analysis for chronic and nonchronic PFP patients was performed. The mean incidence of PFP over the study period was 3.4 (95% CI 3.2-3.6) per 1,000 person years in the age group of 7-24 years. Girls had a higher incidence rate (4.6 [95% CI 4.3-5.0]) compared to boys (2.3 [95% CI 2.1-2.5]). Peak incidence was at age 13 years for both sexes. The most commonly applied management strategy was advice (55.1%), followed by referral to physiotherapy (28.2%), analgesics prescription (10.4%), and referral to the orthopaedic surgeon (8.9%). No differences were found in age, sex, and treatment between chronic and nonchronic PFP patients. The average Dutch general practitioner sees approximately 1.4 new child or adolescent with PFP per year. Overall management strategies were in concordance with current Dutch general practice guideline on nontraumatic knee problems. More insight should be gained in the population with chronic complaints.