Use Of Chronic Opioid Therapy Research Articles

Contextual Factors and Adoption of Strategies Related to Opioid Prescribing Practices in Healthcare Settings: Cross-Sectional Study.

This study aimed to examine the association between different contextual factors (e.g., facility size, rurality, and perceived needs) and the adoption of a policy or strategy related to opioid prescribing practices in healthcare settings. Cross-sectional survey data was collected from a convenience sample of physicians (N = 68). Logistic regression models were used to examine the effects of contextual factors on the dependent variables. Less than half reported having a policy restricting opioid prescribing practices, and 81% reported having one or more strategies for the safe use of chronic opioid therapy. After adjusting for other contextual factors, small practice size was positively associated with having a policy restricting opioid prescribing practices. This exploratory study provides insights for further investigation of how various contextual factors can influence policy adoption in different healthcare settings and practices to address major public health threats.

Opioid Safety: Complex Pain Case Conferences

The 2016 CDC guidelines and the 2017 Veterans Administration and the Department of Defense (VA/DoD) chronic pain guidelines discouraged the use of chronic opioid therapy for non-cancer, or non-palliative care pain. Both assert that chronic opioid use could cause potential adverse events such as depression, addiction, and death. Both encourage non-opioid interventions such as cognitive behavioral therapy, physical therapy, and various other modalities. To better manage opioid patients with chronic pain, Walter Reed Internal Medicine Department convened a multidisciplinary group composed of pharmacists, physical therapists, psychologists, social workers, internists, and addiction specialists. The group reviewed one patient monthly. Research question: what impact can a multidisciplinary team have on opioid prescribing? STUDY DESIGN: Small cohort study. A clinician performed a chart review of the patients discussed in the multi-disciplinary group. The opioid medications were converted into morphine equivalent daily doses (MEDD) and graphed per patient over time. Although there were 12 patients total, one did not use opioids, and another had not had a follow-up. Among the ten patients left, six had a decrease in their MEDD, three patients’ MEDDs remained the same, one Patient's MEDD increased. The success in lowering 6 of 10 MEDDs is likely multifactorial and based on access to a wide variety of providers and on continuity of care despite being in an institution where turnover is high due to the abundance of military providers. There was a 60% reduction in opioid utilization. In addition, there were unexpected benefits of improved continuity of care, and access to care. Although this a small study, the results demonstrate that a multi-disciplinary approach to managing pain is able to improve healthcare quality, patient safety, and help reduce reliance on opioids. We see opportunities for larger studies as our program matures.

Pain States, the Opioid Epidemic, and the Role of Radiologists.

The prevalence of chronic pain and prescription opioid abuse has resulted in epidemic problems for patients and clinicians. The consequences are taking a heavy toll on patients, physicians, and society. Specific to radiology, a significant need exists for best practice assessment and treatment approaches for pain management, as patients with chronic pain often undergo radiological tests of unclear clinical relevance. The USA is amid an opioid-prescribing epidemic and resultant overdose public health emergency. A variety of reasons, which are examined in this manuscript, have contributed to the dramatic increase in the use of chronic opioid therapy for chronic non-cancer pain. This increase of opioid prescriptions and related deaths is based on many factors including the perception that there was systemic undertreatment of pain, the philosophical approach of advocacy groups for pain relief, promotion by the pharmaceutical industry, Joint Commission's Fifth Vital Sign, and permissive regulations by boards of medical licensures promoting excessive use of opioids. Overall, opioid treatment has been based on subjective pain relief and radiographic findings, which may not correlate with the source of pain generation. Radiologists, along with interventionalists, frequently interact with patients on chronic opioid therapy and at times take responsibility for patients with chronic pain. Beyond reading studies, diagnostic radiologists provide care to larger percentages of patients taking narcotics than ever before. This manuscript focuses on chronic pain, escalating opioid therapy, and adverse consequences, including the epidemic of overdoses and deaths. Radiologists' expertise can potentially reduce unnecessary radiological tests and inappropriate prescribing of medications.

Opioid therapy for chronic non-cancer pain: guidelines for Hong Kong.

Opioids are increasingly used to control chronic non-cancer pain globally. International opioid guidelines have been issued in many different countries but a similar document is not generally available in Hong Kong. Chronic opioid therapy has a role in multidisciplinary management of chronic non-cancer pain despite insufficient evidence for its effectiveness and safety for long-term use. This document reviews the current literature to inform Hong Kong practitioners about the rational use of chronic opioid therapy in chronic non-cancer pain. It also aims to provide useful recommendations for the appropriate, effective, and safe use of such therapy in the management of chronic non-cancer pain in adults. Physicians should conduct a comprehensive biopsychosocial evaluation of patients prior to the commencement of opioid therapy. When opioid use is deemed appropriate, the patient should provide informed consent within an agreement that specifies treatment goals and expectations. A trial of opioid can be commenced and, provided there is progress towards treatment goals, then chronic therapy can be considered at a dose that minimises harm. Monitoring of effectiveness, safety, and drug misuse should be continued. Treatment should be stopped when opioids become ineffective, intolerable, or misused. The driving principles for opioid prescription in chronic pain management should be: start with a low dose, titrate slowly, and maintain within the shortest possible time.

Exploring the Use of Chronic Opioid Therapy for Chronic Pain: When, How, and for Whom?

This article provides a broad overview regarding intent to initiate and consider ongoing chronic opioid therapy (COT) for treatment of chronic noncancer pain (CNCP). COT should be an individualized decision based on a comprehensive evaluation, assessment, and monitoring. It is imperative that providers discuss various risks and benefits of COT initially and at follow-up visits, and continue appropriate monitoring and follow-up at regular intervals. The decision to initiate or continue opioid therapy is based on clinical judgment; however, it is understood that opioid and other medication therapy represent one piece of the complete treatment plan for patients with CNCP.

Sex and Age Differences in Global Pain Status Among Patients Using Opioids Long Term for Chronic Noncancer Pain.

The use of chronic opioid therapy (COT) has risen dramatically in recent years, especially among women. However, little is known about factors influencing overall pain and function (global pain status) among COT users. Characterizing the typical experiences of COT patients by age-sex group could help clinicians and patients better weigh the risks and benefits of COT. Thus, we sought to characterize global pain status among COT users in community practice by age and sex. Telephone survey of 2,163 health plan members aged 21-80 years using COT. We assessed average/usual pain (0-10 scale); pain-related interference (0-10); activity limitation days, last 3 months; and pain impact, last 2 weeks (0-11). Status on each indicator was classified as low (better pain/function), moderate, or high (worse pain/function). Global pain status was categorized as favorable if 2-4 indicators were low and 0-1 was high and unfavorable if 2-4 indicators were high and 0-1 was low. Among female COT patients, 15% (vs. 26% of males) had favorable global pain status and 59% (vs. 42% of males) had unfavorable status. Under age 65 years, women fared more poorly than men on every indicator. Among 65- to 80-year-olds, women and men had similar global pain status. Although pain and function among COT users vary considerably, only one in five reported low pain levels and high levels of function. Young and middle-aged women seem to be at particularly high risk for unfavorable global pain status. More research is needed about how to best manage pain in this group.

Doctors and patients in pain: Conflict and collaboration in opioid prescription in primary care

Use of chronic opioid therapy (COT) for chronic noncancer pain has dramatically increased in the United States. Patients seek compassionate care and relief while physicians struggle to manage patients’ pain effectively without doing harm. This study explores the narratives of chronic noncancer pain patients receiving chronic opioid therapy and those of their physicians to better understand the effects of COT on the doctor–patient relationship. A mixed method study was conducted that included in-depth interviews and qualitative analysis of 21 paired patients with chronic pain and their physicians in the following groups: patients, physicians, and patient–physician pairs. Findings revealed that patients’ narratives focus on suffering from chronic pain, with emphasis on the role of opioid therapy for pain relief, and physicians’ narratives describe the challenges of treating patients with chronic pain on COT. Results elucidate the perceptions of ideal vs difficult patients and show that divergent patterns surrounding the consequences, utility, and goals of COT can negatively affect the doctor–patient relationship. The use of paired interviews through a narrative lens in this exploratory study offers a novel and informative approach for clinical practice and research. The findings have significant implications for improving doctor–patient communication and health outcomes by encouraging shared decision making and goal-directed health care encounters for physicians and patients with chronic pain on COT. PerspectiveThis study found patterns of understanding pain, opioid pain medications, and the doctor–patient relationship for patients with chronic pain and their physicians using a narrative lens. Thematic findings in this exploratory study, which include a portrayal of collaborative vs conflictual relationships, suggest areas of future intervention and investigation.

(115) Interpretation of urine drug testing results in patients using transdermal buprenorphine preparations for the treatment of chronic non-cancer pain

The use of buprenorphine for the management of chronic pain has risen rapidly since the FDA approved a transdermal formulation of this opioid in 2010. Consensus guidelines for the use of chronic opioid therapy highlight the importance of routine monitoring for patience compliance using periodic urine drug screens. The validity of the urine buprenorphine detection assay, currently in widespread use, was established for monitoring patient compliance in patients receiving sublingual formulations (e.g. subutex, suboxone) in the outpatient addiction treatment setting. However, transdermal dosing is an order of magnitude lower (mcg range) than sublingual (mg range). This retrospective analysis of tandem LC-MS urine samples from a single reference laboratory compares the results from two different buprenorphine treatment cohorts: transdermal pain treatment and sublingual detoxification. Samples from the group (n=54) undergoing pain treatment with the transdermal formulation showed urine concentrations of buprenorphine, norbuprenorphine, buprenorphine-glucuronide, and norbuprenorphine glucuronide significantly lower than the range of those treated with sublingual preparations (often below the 5mcg/ml limit of detection). The analyte that differed the most between the two patient groups was norbuprenorphine, detected in only 16.2% of transdermal patients with an overall median concentration of < 3 ng/mL, versus 100% of sublingual patients with a median concentration of 88 ng/mL. Buprenorphine-glucuronide demonstrated the highest positive rate of detection at 97.3% in samples from the transdermal group with at least one positive detectable analyte. This study demonstrates that urine parent drug and metabolite profiles are markedly different for the distinct patient populations using sublingual and transdermal buprenorphine formulations. Failure to recognize the difference in urine concentrations may lead to a misinterpretation of noncompliance. Assays with high sensitivity for buprenorphine glucuronide will likely have greater relevance in the pain treatment setting. The use of buprenorphine for the management of chronic pain has risen rapidly since the FDA approved a transdermal formulation of this opioid in 2010. Consensus guidelines for the use of chronic opioid therapy highlight the importance of routine monitoring for patience compliance using periodic urine drug screens. The validity of the urine buprenorphine detection assay, currently in widespread use, was established for monitoring patient compliance in patients receiving sublingual formulations (e.g. subutex, suboxone) in the outpatient addiction treatment setting. However, transdermal dosing is an order of magnitude lower (mcg range) than sublingual (mg range). This retrospective analysis of tandem LC-MS urine samples from a single reference laboratory compares the results from two different buprenorphine treatment cohorts: transdermal pain treatment and sublingual detoxification. Samples from the group (n=54) undergoing pain treatment with the transdermal formulation showed urine concentrations of buprenorphine, norbuprenorphine, buprenorphine-glucuronide, and norbuprenorphine glucuronide significantly lower than the range of those treated with sublingual preparations (often below the 5mcg/ml limit of detection). The analyte that differed the most between the two patient groups was norbuprenorphine, detected in only 16.2% of transdermal patients with an overall median concentration of < 3 ng/mL, versus 100% of sublingual patients with a median concentration of 88 ng/mL. Buprenorphine-glucuronide demonstrated the highest positive rate of detection at 97.3% in samples from the transdermal group with at least one positive detectable analyte. This study demonstrates that urine parent drug and metabolite profiles are markedly different for the distinct patient populations using sublingual and transdermal buprenorphine formulations. Failure to recognize the difference in urine concentrations may lead to a misinterpretation of noncompliance. Assays with high sensitivity for buprenorphine glucuronide will likely have greater relevance in the pain treatment setting.

South African guideline for the use of chronic opioid therapy for chronic non-cancer pain

Chronic pain may have a significant impact on health-related quality of life and can be difficult to manage. In carefully selected patients, and as part of a comprehensive pain management strategy, opioid analgesia may help to achieve long-term pain control with a manageable side-effect profile and a low risk of serious adverse effects. However, appropriate evaluation, including biopsychosocial screening and risk screening is essential before initiating an opioid and during continued therapy. This guideline aims to assist practitioners in screening and selecting appropriate patients with chronic non-cancer pain to initiate, monitor and continue pain management with opioid therapy.

Risk Stratification With Opioid Therapy

The use of chronic opioid therapy for persistent headache remains controversial because of limited supporting data and potential risks. In addition to possible individual risks for the patient, society risks associated with diversion and substance abuse are well documented. Few studies directly address risk stratification for opioid therapy where a diagnosis of headache is present, making it necessary to extrapolate from other pain research when developing recommendations for screening and patient management. Considering the historical framework of opioid prescribing, relevant studies assessing risk stratification of chronic opioid therapy are reviewed. Specific risk factors that may lead to a problematic course with chronic opioid therapy are outlined. Both clinical experience and the limited empirical research underscore the need for multiple assessment tools and ongoing patient monitoring in the evaluation of these risk factors.

Prescription Opioid Abuse in Chronic Pain: A Review of Opioid Abuse Predictors and Strategies to Curb Opioid Abuse

Both chronic pain and prescription opioid abuse are prevalent and continue to exact a heavy toll on patients, physicians, and society. Individuals with chronic pain and co-occurring substance use disorders and/or mental health disorders, are at a higher risk for misuse of prescribed opioids. Opioid abuse and misuse occurs for a variety of reasons, including self medication, use for reward, compulsive use because of addiction, and diversion for profit. Treatment approaches that balance treating chronic pain while minimizing risks for opioid abuse, misuse, and diversion are much needed. The use of chronic opioid therapy for chronic noncancer pain has increased dramatically in the past 2 decades in conjunction with a marked increase in the abuse of prescribed opioids and accidental opioid overdoses. Consequently, a validated screening instrument that provides an effective and rational method of selecting patients for opioid therapy, predicting risk, and identifying problems once they arise could be of enormous benefit. Such an instrument could potentially curb the risk of iatrogenic addiction. Although several screening instruments and strategies have been introduced in the past decade, there is no single test or instrument that can reliably and accurately predict patients who are not suitable for opioid therapy or identify those who need increased vigilance or monitoring during therapy. At present, screening for opioid abuse includes assessment of premorbid and comorbid substance abuse; assessment of aberrant drug-related behaviors; risk factor stratification; and utilization of opioid assessment screening tools. Multiple opioid assessment screening tools and instruments have been developed by various authors. In addition, urine drug testing, monitoring of prescribing practices, prescription monitoring programs, opioid treatment agreements, and utilization of universal precautions are essential. Presently, a combination of strategies is recommended to stratify risk, identify and understand aberrant drug related behaviors, and tailor treatments accordingly. This manuscript will review the current state of knowledge regarding the growing problem of opioid abuse and misuse; known risk factors; and methods of predicting, assessing, monitoring, and addressing opioid abuse and misuse in patients with chronic noncancer pain. Key words: Opioids, misuse, abuse, chronic pain, prevalence, risk assessment, risk management, drug monitoring, aberrant drug-related behavior

Prescription Opioid Deaths: A Preventable Epidemic

Prescription Opioid Deaths: A Preventable Epidemic

Response to Bouloux: Use of Opioids in Long-Term Management of Temporomandibular Joint Dysfunction

Recently, Dr Gary Bouloux reviewed opioid management of chronic temporomandibular joint dysfunction-related pain. 1 Bouloux G.F. Use of opioids in long-term management of temporomandibular joint dysfunction. J Oral Maxillofac Surg. 2011; 69: 1885 Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Appropriately, the review discussed the biopsychosocial model of chronic pain, issues of risk and benefit (consistent with the guidelines), 2 Chou R. Fanciullo G.J. Fine P.G. et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009; 10: 113 Abstract Full Text Full Text PDF PubMed Scopus (1691) Google Scholar , 3 Trescot A.M. Helm S. Hansen H. et al. Opioids in the management of chronic non-cancer pain: an update of American Society of the Interventional Pain Physicians (ASIPP) Guidelines. Pain Physician. 2008; 11: S5 PubMed Google Scholar adjunct pain medications, and monitoring of use and misuse. Some available products were compared based on how well their characteristics match “the ideal opioid.” However, the regrettable reality is that no opioid remains “ideal” for a given patient indefinitely. Commonly, opioids must be periodically switched or rotated due to waning efficacy or the emergence of intolerable side effects. 4 Slatkin N.E. Opioid switching and rotation in primary care: implementation and clinical utility. Curr Med Res Opin. 2009; 25: 2133 Crossref PubMed Scopus (59) Google Scholar Response to Dr Howard SmithJournal of Oral and Maxillofacial SurgeryVol. 69Issue 11PreviewI would like to thank Dr Howard Smith for his insightful comments in regard to the use of opioids in the long-term management of temporomandibular joint dysfunction. The purpose of our review was to provide a rationale and understanding of the value of opioids in the management of chronic noncancer pain such as temporomandibular joint pain. The omission of tapentadol, transdermal buprenorphine, and oxymorphone resulted from a paucity of independent studies addressing these drugs in this patient group. Full-Text PDF

Differences in rapid-acting opioid dosage forms for cancer-related BTP: a review of comparative effectiveness studies

Differences in rapid-acting opioid dosage forms for cancer-related BTP: a review of comparative effectiveness studies

A Systematic Review of Randomized Trials of Long-Term Opioid Management for Chronic Non-Cancer Pain

Background: Even though opioids have been used for pain for thousands of years, opioid therapy for chronic non-cancer pain is controversial due to concerns regarding the long-term effectiveness and safety, particularly the risk of tolerance, dependance, or abuse. While the debate continues, the use of chronic opioid therapy for chronic non-cancer pain has increased exponentially. Even though evidence is limited, multiple expert panels have concluded that chronic opioid therapy can be effective therapy for carefully selected and monitored patients with chronic non-cancer pain. Study Design: A systematic review of randomized trials of opioid management for chronic noncancer pain. Objective: The objective of this systematic review is to evaluate the clinical efficacy of opioids in the treatment of chronic non-cancer pain. Methods: A comprehensive evaluation of the literature relating to opioids in chronic non-cancer pain was performed. The literature was evaluated according to Cochrane review criteria for randomized controlled trials (RCTs) and Jadad criteria. A literature search was conducted by using PubMed, EMBASE, Cochrane library, ECRI Institute Library, U.S. Food and Drug Administration (FDA) website, U.S. National Guideline Clearinghouse (NGC), Database of Abstracts of Reviews of Effectiveness (DARE), clinical trials, systematic reviews and cross references from systematic reviews. The level of evidence was classified as good, fair, or poor based on the quality of evidence developed by the United States Preventive Services Task Force (USPSTF) and used by other systematic reviews and guidelines. Outcome Measures: Pain relief was the primary outcome measure. Other outcome measures were functional improvement, withdrawals, and adverse effects. Results: Based on the USPSTF criteria, the indicated level of evidence was fair for Tramadol in managing osteoarthritis. For all the drugs assessed, including Tramadol, for all other conditions, the evidence was poor based on either weak positive evidence, indeterminate evidence, or negative evidence. Limitations: A paucity of literature, specifically with follow-up beyond 12 weeks for all types of opioids with controlled trials for various chronic non-cancer pain conditions. Conclusions: This systematic review illustrated fair evidence for Tramadol in managing osteoarthritis with poor evidence for all other drugs and conditions. Thus, recommendations must be based on non-randomized studies. Key words: Chronic non-cancer pain, opioids, opioid efficacy, opioid effectiveness, significant pain relief, functional improvement, adverse effects, morphine, hydrocodone, hydromorphone, fentanyl, tramadol, buprenorphine, methadone, tapentadol, oxycodone, oxymorphone, systematic reviews, randomized trials

Opioids in chronic non-cancer pain

Introduction: The use of chronic opioid therapy for chronic non-cancer pain is growing and is now accepted as an effective treatment modality.Areas covered: Although there are guidelines and reviews for chronic opioid therapy for chronic non-cancer pain patients, physicians may still have concerns and be reluctant to prescribe strong opioids for chronic non-cancer pain. Common issues and concerns when prescribing opioid for chronic pain management are reviewed and discussed. The literature search was done using Medline with key words ‘chronic non-cancer pain’, ‘chronic opioid therapy’, ‘effectiveness’, ‘opioid tolerance’, ‘opioid-induced hyperalgesia’, ‘adverse effect’, ‘opioid dependency’, ‘addiction’, ‘monitoring’, ‘opioid contract’ and various combinations with these key words. Studies from 1990 – 2010 have been included. This article helps readers to update, clarify and understand the common concerns when using opioid for chronic non-cancer pain. Clinical effectiveness and adverse effects with chronic opioid therapy, opioid tolerance and opioid-induced hyperalgesia, opioid dependency and addiction, monitoring during chronic opioid use, and opioid contact are discussed in detailed.Expert opinion: Not much strongly positive data supports the long-term use of opioids for pain relief, and the evidence for an improvement in functional activity is inconclusive. With careful selection of patients, meticulous prescription and monitoring protocol, chronic non-cancer pain patients who are likely to benefit from potent opioids should not be prevented from obtaining this treatment.

Pain: Not a Normal Part of Aging

Pain: Not a Normal Part of Aging

Risks for possible and probable opioid misuse among recipients of chronic opioid therapy in commercial and medicaid insurance plans: The TROUP Study

The use of chronic opioid therapy (COT) for chronic non-cancer pain (CNCP) has increased dramatically in the past two decades. There has also been a marked increase in the abuse of prescribed opioids and in accidental opioid overdose. Misuse of prescribed opioids may link these trends, but has thus far only been studied in small clinical samples. We therefore sought to validate an administrative indicator of opioid misuse among large samples of recipients of COT and determine the demographic, clinical, and pharmacological risks associated with possible and probable opioid misuse. A total of 21,685 enrollees in commercial insurance plans and 10,159 in Arkansas Medicaid who had at least 90 days of continuous opioid use 2000–2005 were studied for one year. Criteria were developed for possible and probable opioid misuse using administrative claims data concerning excess days supplied of short-acting and long-acting opioids, opioid prescribers and opioid pharmacies. We estimated possible misuse at 24% of COT recipients in the commercially insured sample and 20% in the Medicaid sample and probable misuse at 6% in commercially insured and at 3% in Medicaid. Among non-modifiable factors, younger age, back pain, multiple pain complaints and substance abuse disorders identify patients at high risk for misuse. Among modifiable factors, treatment with high daily dose opioids (especially >120 mg MED per day) and short-acting Schedule II opioids appears to increase the risk of misuse. The consistency of the findings across diverse patient populations and the varying levels of misuse suggest that these results will generalize broadly, but await confirmation in other studies.

Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 2009;10(2):113-30

Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 2009;10(2):113-30

2009 Clinical Guidelines from the American Pain Society and the American Academy of Pain Medicine on the use of chronic opioid therapy in chronic noncancer pain: what are the key messages for clinical practice?

Safe and effective chronic opioid therapy (COT) for chronic noncancer pain requires clinical skills and knowledge in both the principles of opioid prescribing and in the assessment and management of risks associated with opioid abuse, addiction, and diversion. The American Pain Society and the American Academy of Pain Medicine commissioned a systematic review of the evidence on COT for chronic noncancer pain and convened a multidisciplinary expert panel to review the evidence and formulate recommendations based on the best available evidence. This article summarizes key clinical messages from this guideline regarding patient selection and risk stratification, informed consent and opioid management plans, initiation and titration of COT, use of methadone, monitoring of patients, use of opioids in high-risk patients, assessment of aberrant drug-related behaviors, dose escalations and high-dose opioid therapy, opioid rotation, indications for discontinuation of therapy, prevention and management of opioid-related adverse effects, driving and work safety, identifying a medical home and when to obtain consultation, and management of breakthrough pain.