Undertreatment Of Pain In Patients Research Articles

Opoid Use Disorder and Vaso-Occlusive Crisis Outcomes: A Retrospective Assesement

Introduction Concerns by providers for addiction can lead to under-treatment of pain in patients with sickle cell disease presenting with vaso-occlusive crisis. In patients who experience frequent vaso-occlusive crises, opioid dependence may be due to the need for pain control as opposed to addiction and the clinical meaning of a diagnosis of opioid use disorder and its impact on outcomes in this population is not known. Methods We retrospectively assessed hospitalizations in the United States for vaso-occlusive crisis in adult patients afflicted with Sickle cell disease from 2016-2019 using the National Inpatient Sample database. Outcomes were compared between those with and without a diagnosis of opioid use disorder using linear and logistical regression. Results In total, there were 273,460 hospitalizations for vaso-occlusive crisis, 23,120 (8.5%) of which involved a secondary diagnosis of opioid use disorder. Black Race was associated with opioid use disorder, but age, sex and income were not. After adjusting for confounders, hospital length of stay was increased in patients with opioid use disorder by 1.23 days (95% CI: 1.02 to 1.45, p<0.001) and total hospital charges were increased by $5,566 (95% CI: 3,863 to 7,269, p<0.001) (Table 1). Mortality was decreased in vaso-occulsive crisis hospitalizations in those with opioid use disorder, but the difference was not significant (OR=0.58, 95% CI: 0.026-1.33, p=0.199). Conclusion Opioid use disorder is associated with an increased length of stay and cost in patients with vaso-occlusive crisis. Providers should consider under-treatment of pain as a potential diagnosis when addiction concerns are present and individualized pain plans should be explored.

Feasibility of a digital medicine program in optimizing opioid pain control in cancer patients (SWOG S1916).

TPS12126 Background: The undertreatment of pain in patients with advanced or metastatic cancer is well described in cancer research. Overcoming barriers that prevent successful use of opioid analgesics for cancer pain requires a clear understanding of how individuals use oral medications at home. The Proteus Discover is a digital medicine program (DMP) consisting of an FDA-approved ingestible sensor made of dietary minerals co-encapsulated with patients’ medications, a wearable sensor patch, and a mobile device app that enables patients to electronically transmit their medication adherence patterns. Use of the DMP has demonstrated improved clinical outcomes vs. usual care in patients with diabetes and hypertension, shown superiority over directly-observed therapy in tuberculosis and has been studied in the treatment of patients with hepatitis C, HIV, cancer and severe mental illness, but it has not been previously studied with opioids or in monitoring cancer-related pain. Methods: We are conducting a multicenter pilot study at SWOG NCORP sites to test the feasibility of using the DMP to monitor opioid use in the treatment of metastatic cancer pain. Eligible patients must have a diagnosis of metastatic cancer, have a baseline Brief Pain Inventory worst pain score of ≥3, be deemed by their physician to need initiation or up-titration of oxycodone-acetaminophen for pain control, and be able to read English. Primary outcomes include: (1) study accrual of 60 patients within six months of study activation at all participating sites; (2) patient retention defined as ≥50 patients completing the study, and; (3) adherence to the DMP defined as ≥66% of patients wearing the sensor patch for ≥28 days of the 42-day observation period. Secondary outcomes include change in Brief Pain Inventory pain scores, opioid medication consumption, number of safety alert triggers for high consumption, hospital or emergency room visits for pain, activity levels, and frequency of changes to the pain control regimen. The study will enroll patients at six sites; the first patient was enrolled on 1/20/2020. If successful, this study will inform design of a randomized controlled trial of the DMP vs. usual care in optimizing medication utilization and controlling cancer-related pain. Clinical trial information: NCT04194528 .

Diagnoses indicating pain and analgesic drug prescription in patients with dementia: a comparison to age- and sex-matched controls

BackgroundThe evidence of undertreatment of pain in patients with dementia is inconsistent. This may largely be due to methodological differences and shortcomings of studies. In a large cohort of patients with incident dementia and age- and sex-matched controls we examined (1) how often they receive diagnoses indicating pain, (2) how often they receive analgesics and (3) in which agents and formulations.MethodsUsing health insurance claims data we identified 1,848 patients with a first diagnosis of dementia aged ≥ 65 years and 7,385 age- and sex-matched controls. We analysed differences in diagnoses indicating pain and analgesic drugs prescribed between these two groups within the incidence year. We further fitted logistic regression models and stepwise adjusted for several covariates to study the relation between dementia and analgesics.ResultsOn average, patients were 78.7 years old (48% female). The proportions receiving at least one diagnosis indicating pain were similar between the dementia and control group (74.4% vs. 72.5%; p = 0.11). The proportion who received analgesics was higher in patients with dementia in the crude analysis (47.5% vs. 44.7%; OR: 1.12; 95% CI: 1.01-1.24), but was significantly lower when adjusted for socio-demographic variables, care dependency, comorbidities and diagnoses indicating pain (OR: 0.78; 95% CI: 0.68-0.88). Analgesics in liquid form such as metamizole and tramadol were more often used in dementia.ConclusionsOur findings show a comparable documentation of diagnoses indicating pain in persons with incident dementia compared to those without. However, there still seems to be an undertreatment of pain in patients with dementia. Irrespective of dementia, analgesics seem to be more often prescribed to sicker patients and to control pain in the context of mobility.

Multidimensional pain assessment in patients with dementia

It is well known that patients with dementia complain less about pain and receive fewer analgesics than other patients. The question arises of whether disorders associated with dementia change the processing of pain. A total of 20 patients with dementia and 40 patients with mild cognitive impairment (MCI) as well as 40 healthy control subjects were investigated for their subjective (category scale), facial (FACS) and motor (R-III reflex) pain responses to mechanical and electrical stimuli. Patients with dementia did not rate the intensity of the stimuli differently; however, they were less frequently capable of providing ratings. At equal levels of stimulus intensity, demented patients showed stronger facial responses. The R-III reflex thresholds were lowered in demented patients. MCI patients appeared only slightly changed. Our findings suggest that the processing of acute noxious stimuli is intensified in patients with dementia. Against the background of a reduced prescription of analgesics, an under-treatment of pain in patients with dementia might be the consequence.

The Measurement of Pain from Metastatic Bone Disease: Capturing the Patient's Experience

Pain is prevalent for large numbers of patients with metastatic cancer, and this pain is often due to bone metastases. Despite the availability of effective pain treatments and various pain management guidelines, multiple studies document the undertreatment of pain in patients with cancer. The most frequently identified barriers to appropriate pain management are physician underestimation of the patient's pain, inadequate pain assessment, and patient reluctance to report pain. A first step toward reducing inadequate pain control in clinical practice is adequate assessment of cancer pain using validated pain measurement instruments. Using treatment for bone pain as an example, we discuss how patient satisfaction measures and self-report measures of pain and other symptoms, symptom interference with patient function, and related adverse effects can be combined with appropriate trial design to provide the information needed to choose the best possible treatment for bone pain. Symptom assessment needs to be done via standardized questionnaires, administered at appropriate times during the trial. The Brief Pain Inventory uses 11-point numerical rating scales to measure both pain severity and the resulting functional interference caused by pain. These severity and interference ratings can be further categorized as mild, moderate, or severe, as required to implement most pain management guidelines and define outcome expectations for clinical trials. Consistent pain measurement and standardized recording of analgesic use across clinical trials would enhance comparability and increase the chances that treatment decisions for management of bone pain could be evidence based. These and other considerations in the design of clinical trials are discussed.

Pain and Its Treatment in Patients with Cancer in Korea

Substantial pain is experienced by a lot of patients with cancer, and undertreated pain significantly undermines their quality of life. Despite international and national guidelines on cancer pain management, the practical effectiveness of management is still problematic. We did a prospective cross-sectional survey on pain prevalence, pain intensity, its impact on daily activity, and adequacy of pain management in 823 patients treated by medical oncologists and radiologic oncologists. At the time of the survey, 29.7% of the patients had pain that was moderate or severe. Performance status and tumor extent were significant predictors of pain presence and its intensity. Pain severity and the proportion of the patients whose function is impaired are highly associated. Among the patients with pain, only 37% rated pain relief as satisfactory. Forty-one percent of the patients with pain received inadequate pain management. Physicians did not adjust the analgesic prescription in about 53% of the patients who reported severe pain. These results demonstrate the alarming degree of undertreatment of pain in patients with cancer in Korea, and indicate the need to improve the management of cancer-related pain. Future research should elucidate the factors that impede adequate pain management in order to overcome obstacles to adequate treatment.

Clinicians' Perceptions of Barriers to Pain Management in AIDS

A growing body of literature has demonstrated the widespread undertreatment of pain in patients with AIDS. While clinician-related barriers to cancer pain management have been studied, to date there has been no systematic attempt to survey clinician-related barriers to the management of pain in patients with AIDS. We surveyed AIDS health care providers' attitudes towards pain management, as well as their perception of the barriers to adequate pain management in patients with HIV disease. Subjects were 492 AIDS care providers attending continuing education symposia on the clinical management of pain in patients with AIDS in 5 major U.S. cities (New York, Philadelphia, San Francisco, Los Angeles, and Miami). Results indicated that the most frequently endorsed barriers to pain management were those regarding lack of knowledge about pain management or access to pain management experts, and concerns regarding potential substance abuse or addiction. Experience in the management of pain in patients with AIDS was inversely correlated with endorsement of barriers related to pain management expertise and concern regarding potential substance abuse. More experienced clinicians were significantly less likely to cite these factors as barriers to pain management. More knowledgeable respondents were significantly more likely to identify barriers to pain management and individuals with more conservative attitudes towards pain management were significantly more likely to cite substance abuse issues or medical concerns as barriers to pain management.