Opioid and Non-opioid Therapy

Abstract Background No population-based studies have examined chronic opioid use among cancer survivors who are diverse with respect to diagnosis, age group, and insurance status. Methods We conducted a retrospective cohort study using North Carolina (NC) cancer registry data linked with claims from public and private insurance (2006–2016). We included adults with non-metastatic cancer who had no prior chronic opioid use (N = 38,366). We used modified Poisson regression to assess the adjusted relative risk of chronic opioid use in survivorship (>90-day continuous supply of opioids in the 13–24 months following diagnosis) associated with patient characteristics. Results Only 3.0% of cancer survivors in our cohort used opioids chronically in survivorship. Predictors included younger age (adjusted risk ratio [aRR], 50–59 vs 60–69 = 1.23, 95% confidence interval [CI] = 1.05–1.43), baseline depression (aRR = 1.22, 95% CI = 1.06–1.41) or substance use (aRR = 1.43, 95% CI = 1.15–1.78) and Medicaid (aRR vs Private = 1.93, 95% CI = 1.56–2.40). Survivors who used opioids intermittently (vs not at all) before diagnosis were twice as likely to use opioids chronically in early survivorship (aRR = 2.62, 95% CI = 2.28–3.02). Those who used opioids chronically (vs intermittently or not at all) during active treatment had a nearly 17-fold increased likelihood of chronic use in survivorship (aRR = 16.65, 95 CI = 14.30–19.40). Conclusions Younger and low-income survivors, those with baseline depression or substance use, and those who require chronic opioid therapy during treatment are at increased risk for chronic opioid use in survivorship. Our findings point to opportunities improve assessment of psychosocial histories and to engage patients in shared decision-making around long-term pain management, when chronic opioid therapy is required during treatment.

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Does the addition of clonidine to opioid therapy improve outcomes in infants with Neonatal Abstinence Syndrome?

Journal of Paediatrics and Child Health ◽

10.1111/jpc.15265 ◽

2021 ◽

Vol 57 (1) ◽

pp. 155-159

Author(s):

Elise D'Abaco

Keyword(s):

Opioid Therapy ◽

Neonatal Abstinence Syndrome ◽

Abstinence Syndrome

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Tapentadol results in less deterioration of gastrointestinal function and symptoms than standard opioid therapy in healthy male volunteers

Neurogastroenterology & Motility ◽

10.1111/nmo.14131 ◽

2021 ◽

Author(s):

Esben Bolvig Mark ◽

Rasmus Bach Nedergaard ◽

Tine Maria Hansen ◽

Thomas Dahl Nissen ◽

Jens Brøndum Frøkjær ◽

...

Keyword(s):

Opioid Therapy ◽

Gastrointestinal Function ◽

Healthy Male ◽

Healthy Male Volunteers ◽

Male Volunteers

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Opioid-Induced Respiratory Depression in Pediatric Palliative Care Patients with Severe Neurological Impairment—A Scoping Literature Review and Case Reports

Children ◽

10.3390/children7120312 ◽

2020 ◽

Vol 7 (12) ◽

pp. 312

Author(s):

Maximilian David Mauritz ◽

Carola Hasan ◽

Larissa Alice Dreier ◽

Pia Schmidt ◽

Boris Zernikow

Keyword(s):

Risk Factors ◽

Palliative Care ◽

Young Adults ◽

Scoping Review ◽

Pediatric Patients ◽

Case Reports ◽

Neurological Impairment ◽

Opioid Therapy ◽

Pediatric Palliative Care ◽

Severe Neurological Impairment

Pediatric Palliative Care (PPC) addresses children, adolescents, and young adults with a broad spectrum of underlying diseases. A substantial proportion of these patients have irreversible conditions accompanied by Severe Neurological Impairment (SNI). For the treatment of pain and dyspnea, strong opioids are widely used in PPC. Nonetheless, there is considerable uncertainty regarding the opioid-related side effects in pediatric patients with SNI, particularly concerning Opioid-Induced Respiratory Depression (OIRD). Research on pain and OIRD in pediatric patients with SNI is limited. Using scoping review methodology, we performed a systematic literature search for OIRD in pediatric patients with SNI. Out of n = 521 identified articles, n = 6 studies were included in the review. Most studies examined the effects of short-term intravenous opioid therapy. The incidence of OIRD varied between 0.13% and 4.6%; besides SNI, comorbidities, and polypharmacy were the most relevant risk factors. Additionally, three clinical cases of OIRD in PPC patients receiving oral or transdermal opioids are presented and discussed. The case reports indicate that the risk factors identified in the scoping review also apply to adolescents and young adults with SNI receiving low-dose oral or transdermal opioid therapy. However, the risk of OIRD should never be a barrier to adequate symptom relief. We recommend careful consideration and systematic observation of opioid therapy in this population of patients.

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Prevalence of long-term opioid therapy in spine center outpatients the spinal pain opioid cohort (SPOC)

European Spine Journal ◽

10.1007/s00586-021-06849-6 ◽

2021 ◽

Author(s):

Claus Manniche ◽

Lonny Stokholm ◽

Sophie L. Ravn ◽

Tonny A. Andersen ◽

Lars Brandt ◽

...

Keyword(s):

Spinal Pain ◽

Opioid Therapy

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Predictors of chronic opioid therapy in Medicaid beneficiaries with HIV who initiated antiretroviral therapy

Scientific Reports ◽

10.1038/s41598-021-94690-8 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

GYeon Oh ◽

Emily S. Brouwer ◽

Erin L. Abner ◽

David W. Fardo ◽

Patricia R. Freeman ◽

...

Keyword(s):

Regression Models ◽

Opioid Therapy ◽

Chronic Obstructive ◽

Chronic Opioid Therapy ◽

Hepatitis C Infection ◽

Antipsychotic Therapy ◽

Obstructive Pulmonary Disease ◽

Logistic Regression Models ◽

Factors Associated ◽

Medicaid Beneficiaries

AbstractThe factors associated with chronic opioid therapy (COT) in patients with HIV is understudied. Using Medicaid data (2002–2009), this retrospective cohort study examines COT in beneficiaries with HIV who initiated standard combination anti-retroviral therapy (cART). We used generalized estimating equations on logistic regression models with backward selection to identify significant predictors of COT initiation. COT was initiated among 1014 out of 9615 beneficiaries with HIV (male: 10.4%; female: 10.7%). Those with older age, any malignancy, Hepatitis C infection, back pain, arthritis, neuropathy pain, substance use disorder, polypharmacy, (use of) benzodiazepines, gabapentinoids, antidepressants, and prior opioid therapies were positively associated with COT. In sex-stratified analyses, multiple predictors were shared between male and female beneficiaries; however, chronic obstructive pulmonary disease, liver disease, any malignancy, and antipsychotic therapy were unique to female beneficiaries. Comorbidities and polypharmacy were important predictors of COT in Medicaid beneficiaries with HIV who initiated cART.

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Consensus-based approach to managing opioids, including opioid misuse and opioid use disorder, in patients with serious illness: protocol for a modified Delphi process

BMJ Open ◽

10.1136/bmjopen-2020-045402 ◽

2021 ◽

Vol 11 (5) ◽

pp. e045402

Author(s):

Caroline King ◽

Robert Arnold ◽

Emily Dao ◽

Jennifer Kapo ◽

Jane Liebschutz ◽

...

Keyword(s):

Palliative Care ◽

Opioid Therapy ◽

Opioid Use Disorder ◽

Opioid Misuse ◽

Opioid Use ◽

Serious Illness ◽

Modified Delphi ◽

Delphi Approach ◽

Institutional Review ◽

Management Guidance

IntroductionManagement of opioid misuse and opioid use disorder (OUD) among individuals with serious illness is an important yet understudied issue. Palliative care clinicians caring for individuals with serious illness, many of whom may live for months or years, describe a complex tension between weighing the benefits of opioids, which are considered a cornerstone of pain management in serious illness, and serious opioid-related harms like opioid misuse and OUD. And yet, little literature exists to inform the management of opioid misuse and OUDs among individuals with serious illness. Our objective is to provide evidence-based management guidance to clinicians caring for individuals with serious illness who develop opioid misuse or OUD.Methods and analysisWe chose a modified Delphi approach, which is appropriate when empirical evidence is lacking and expert input must be used to shape clinical guidance. We sought to recruit 60 clinicians with expertise in palliative care, addiction or both to participate in this study. We created seven patient cases that capture important management challenges in individuals with serious illness prescribed opioid therapy. We used ExpertLens, an online platform for conducting modified Delphi panels. Participants completed three rounds of data collection. In round 1, they rated and commented on the appropriateness of management choices for cases. In round 2, participants reviewed and discussed their own and other participants’ round 1 numerical responses and comments. In round 3 (currently ongoing), participants again reviewed rounds 1 and 2, and are allowed to change their final numerical responses. We used ExpertLens to automatically identify whether there is consensus, or disagreement, among responses in panels. Only round 3 responses will be used to assess final consensus and disagreement.Ethics and disseminationThis project received ethical approval from the University of Pittsburgh’s Institutional Review Board (study 19110301) and the RAND Institutional Research Board (study 2020-0142). Guidance from this work will be disseminated through national stakeholder networks to gain buy-in and endorsement. This study will also form the basis of an implementation toolkit for clinicians caring for individuals with serious illness who are at risk of opioid misuse or OUD.

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Evaluation of an opioid risk mitigation initiative for veterans undergoing hip or knee arthroplasty at San Francisco Veterans Affairs Heath Care System

American Journal of Health-System Pharmacy ◽

10.1093/ajhp/zxaa406 ◽

2020 ◽

Author(s):

Tessa Rife ◽

Christina Tat ◽

Mahsa Malakootian

Keyword(s):

San Francisco ◽

Knee Arthroplasty ◽

Risk Mitigation ◽

Opioid Therapy ◽

Veterans Affairs ◽

Drug Screen ◽

Urine Drug Screen ◽

Urine Drug ◽

Medication Disposal ◽

Urine Drug Screening

Abstract Purpose Guidelines recommend evaluating the risk of opioid-related adverse events prior to initiating opioid therapy. The orthopedic service at San Francisco Veterans Affairs Health Care System (SFVHCS) has not routinely used risk assessment tools such as the Stratification Tool for Opioid Risk Mitigation, prescription drug monitoring program data, and urine drug screening prior to opioid prescribing. A quality improvement project was conducted to evaluate the number of pharmacist-provided opioid risk mitigation recommendations implemented by orthopedic providers for patients who underwent total hip or knee arthroplasty at SFVHCS. Summary A pharmacist-led workflow for completing risk mitigation reviews was developed in collaboration with orthopedic providers, and urine drug screening was added to the preoperative laboratory testing protocol. The following recommendations were communicated via electronic medical record: limit postoperative opioids to a 7- or 14-day supply based on risk of suicide and/or overdose, offer naloxone and a medication disposal bag, and order a urine drug screen if not already completed. Risk reviews were completed for 75 patients. Among 64 patients with 2-month postdischarge data available, 88% (7 of 8) of 7-day and 79% (44 of 56) of 14-day opioid supply recommendations were implemented; 41% (26 of 59) of recommendations to issue a medication disposal bag, 17% (2 of 12) recommendations to order a missing urine drug screen, and 9% (5 of 55) of recommendations to offer naloxone were implemented. Conclusion Pharmacist-performed risk mitigation reviews paired with individualized recommendations led to high rates of orthopedic provider acceptance of limiting postdischarge opioid day supplies for patients who had total hip or knee arthroplasty. Alternative strategies may increase access to naloxone. Future research should examine the impact of risk mitigation tools in reducing prescribing of long-term opioid therapy and adverse events among orthopedic surgical patients.

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