Improving Adherence to Long-term Opioid Therapy Guidelines to Reduce Opioid Misuse in Primary Care

Objective: Sleep problems are common among patients with chronic pain (CP). Information on sleep problems and associated covariates in opioid-treated patients with CP is limited. The aim of this study was to assess the prevalence, characteristics, and risk factors of sleep and daytime sleepiness problems in this specific population.Design: Cross-sectional.Setting: Primary care outpatient clinics.Participants: Eight hundred and seventy six patients with CP treated with long-term opioids.Main Outcome Measures: Prestudy selected questionnaires: six questions from the Medical Outcomes Study Sleep Scale, Pain Inventory Survey, Pain Patient Profile, Substance Dependence Severity Scale, and medication log.Results: Insomnia-type sleep problems and combined sleep and sleepiness problems were reported by 87 percent and 49 percent of the sample, respectively. Logistic regression analysis showed that depression (adjusted OR, aOR 2.8, 95% CI 2.1-3.7) and pain severity (aOR 1.4, 95% CI 1.1-1.7) were the strongest independent predictors of sleep problems; only depression severity predicted daytime sleepiness (aOR 1.9, 95% CI 1.6-2.2) or combined sleep/sleepiness problems (aOR 2.2, 95% CI 1.8-2.5). Opioid dose was associated with a slight tendency toward unrefreshing sleep (aOR 1.2, 95% CI 1.0-1.4) and worse sleep maintenance (aOR 1.2, 95% CI 1.0-1.4), while use of long-acting opioids was associated with a trend toward increased napping (aOR 1.3, 95% CI 1.0-1.8).Conclusions: Sleep and daytime sleepiness problems are common among opioid-treated primary care patients with CP and seem to be related mainly to depression and pain severity. Physicians caring for opioid-treated patients with CP may want to assess them for sleep disorders as a part of routine CP care.

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Opioid Misuse and Addiction Among Patients With Chronic Pain

Pain Care Essentials ◽

10.1093/med/9780199768912.003.0021 ◽

2019 ◽

pp. 339-354

Author(s):

Marc O. Martel ◽

Robert N. Jamison

Keyword(s):

Chronic Pain ◽

Opioid Therapy ◽

Screening Tools ◽

Prescription Opioid ◽

Opioid Misuse ◽

Chronic Noncancer Pain ◽

Medication Misuse ◽

Opioid Medications ◽

Noncancer Pain

Chapter 20 provides an introduction to understanding the prevalence and risk factors as well as screening tools for assessing opioid misuse and addiction in patients with chronic pain. In the era of the opioid epidemic in North America and beyond, the use of prescription opioid medications to help improve function in chronic noncancer pain is frequently debated. Out of fear of iatrogenic addiction, litigation, and/or potential medication misuse, some clinicians are refusing to prescribe opioids for chronic pain. Evidence indicates that rates of opioid misuse and addiction are fairly high among chronic pain patients prescribed long-term opioid therapy, but there is consensus that opioids can be safe and effective for carefully selected and monitored patients.

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Acceptability of Naloxone Co-Prescription Among Primary Care Providers Treating Patients on Long-Term Opioid Therapy for Pain

Journal of General Internal Medicine ◽

10.1007/s11606-016-3911-z ◽

2016 ◽

Vol 32 (3) ◽

pp. 291-295 ◽

Cited By ~ 18

Author(s):

Emily Behar ◽

Christopher Rowe ◽

Glenn-Milo Santos ◽

Diana Coffa ◽

Caitlin Turner ◽

...

Keyword(s):

Primary Care ◽

Primary Care Providers ◽

Opioid Therapy ◽

Care Providers

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Understanding Clinicians’ Decisions to Assume Prescriptions for Inherited Patients on Long-term Opioid Therapy: A Qualitative Study

Pain Medicine ◽

10.1093/pm/pnaa045 ◽

2020 ◽

Vol 21 (11) ◽

pp. 3187-3198 ◽

Cited By ~ 1

Author(s):

Michelle S Keller ◽

Alma Jusufagic ◽

Teryl K Nuckols ◽

Jack Needleman ◽

MarySue Heilemann

Keyword(s):

Primary Care ◽

Qualitative Study ◽

Primary Care Physicians ◽

Quality Care ◽

Opioid Therapy ◽

Outpatient Setting ◽

Specialized Training ◽

Primary Care Clinicians ◽

Opioid Medications

Abstract Objective Given the changing political and social climate around opioids, we examined how clinicians in the outpatient setting made decisions about managing opioid prescriptions for new patients already on long-term opioid therapy. Methods We conducted in-depth interviews with 32 clinicians in Southern California who prescribed opioid medications in the outpatient setting for chronic pain. The study design, interview guides, and coding for this qualitative study were guided by constructivist grounded theory methodology. Results We identified three approaches to assuming a new patient’s opioid prescriptions. Staunch Opposers, mostly clinicians with specialized training in pain medicine, were averse to continuing opioid prescriptions for new patients and often screened outpatients seeking opioids. Cautious and Conflicted Prescribers were wary about prescribing opioids but were willing to refill prescriptions if they perceived the patient as trustworthy and the medication fell within their comfort zone. Clinicians in the first two groups felt resentful about other clinicians “dumping” patients on opioids on them. Rapport Builders, mostly primary care physicians, were the most willing to assume opioid prescriptions and were strategic in their approach to transitioning patients to safer doses. Conclusions Clinicians with the most training in pain management were the least willing to assume responsibility for opioid prescriptions for patients already on long-term opioid therapy. In contrast, primary care clinicians were the most willing to assume this responsibility. However, primary care clinicians face barriers to providing high-quality care for patients with complex pain conditions, such as short visit times and less specialized training.

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Day-to-day hedonic and calming effects of opioids, opioid craving, and opioid misuse among patients with chronic pain prescribed long-term opioid therapy

Pain ◽

10.1097/j.pain.0000000000002220 ◽

2021 ◽

Vol Publish Ahead of Print ◽

Author(s):

Leah Frimerman ◽

Maria Verner ◽

Amanda Sirois ◽

Katherine Scott ◽

Alice Bruneau ◽

...

Keyword(s):

Chronic Pain ◽

Opioid Therapy ◽

Opioid Misuse

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Visit Linearity in Primary Care Visits for Patients with Chronic Pain on Long-term Opioid Therapy

Journal of General Internal Medicine ◽

10.1007/s11606-021-06917-z ◽

2021 ◽

Author(s):

Anne Elizabeth Clark White ◽

Eve Angeline Hood-Medland ◽

Richard L. Kravitz ◽

Stephen G. Henry

Keyword(s):

Primary Care ◽

Chronic Pain ◽

Opioid Therapy

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Nonrandomized Intervention Study of Naloxone Coprescription for Primary Care Patients Receiving Long-Term Opioid Therapy for Pain

Journal of Vascular Surgery ◽

10.1016/j.jvs.2016.10.061 ◽

2016 ◽

Vol 64 (6) ◽

pp. 1889 ◽

Cited By ~ 1

Author(s):

P.O. Coffin ◽

E. Behar ◽

C. Rowe

Keyword(s):

Primary Care ◽

Intervention Study ◽

Opioid Therapy ◽

Primary Care Patients

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Development and field testing of primary care screening tools for harms of long-term opioid therapy continuation and tapering to discontinuation: a study protocol

BMJ Open ◽

10.1136/bmjopen-2021-053524 ◽

2021 ◽

Vol 11 (10) ◽

pp. e053524

Author(s):

Christine Timko ◽

Kurt Kroenke ◽

Andrea Nevedal ◽

Mai Chee Lor ◽

Elizabeth Oliva ◽

...

Keyword(s):

Primary Care ◽

San Francisco ◽

Study Protocol ◽

Discriminant Validity ◽

Field Testing ◽

Opioid Therapy ◽

Assessment Tools ◽

Screening Tools ◽

Institutional Review Boards

IntroductionDespite calls for screening tools to help providers monitor long-term opioid therapy (LTOT) harms, and identify patients likely to experience harms of discontinuation, such screening tools do not yet exist. Current assessment tools are infeasible to use routinely in primary care and focus mainly on behaviours suggestive of opioid use disorder to the exclusion of other potential harms. This paper describes a study protocol to develop two screening tools that comprise one integrated instrument, Screen to Evaluate and Treat (SET). SET1 will indicate if LTOT may be harmful to continue (yes or no), and SET2 will indicate if tapering to discontinue opioids may be harmful to initiate (yes or no). Patients receiving LTOT who screen positive on the SET tools should receive subsequent additional assessment. SET will give providers methods that are feasible to implement routinely to facilitate more intensive and comprehensive monitoring of patients on LTOT and decision-making about discontinuation.Methods and analysisWe will develop the screening tools, SET1 and SET2, concurrently. Tool development will be done in stages: (1) comprehensive literature searches to yield an initial item pool for domains covered by each screening tool; (2) qualitative item analyses using interviews, expert review and cognitive interviewing, with subsequent item revision, to yield draft versions of each tool; and (3) field testing of the draft screening tools to assess internal consistency, test–retest reliability and convergent and discriminant validity.Ethics and disseminationEthical approval was obtained from the Institutional Review Boards of Stanford University and the University of California, San Francisco for the VA Palo Alto Health Care System, and the VA San Francisco Healthcare System, respectively. Findings will be disseminated through peer-reviewed manuscripts and presentations at research conferences.

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Examining the Effect of a Whole Health Primary Care Pain Education and Opioid Monitoring Program on Implementation of VA/DoD-Recommended Guidelines for Long-term Opioid Therapy in a Primary Care Chronic Pain Population

Pain Medicine ◽

10.1093/pm/pnaa155 ◽

2020 ◽

Vol 21 (10) ◽

pp. 2146-2153

Author(s):

Deanna Marszalek ◽

Amber Martinson ◽

Andrew Smith ◽

William Marchand ◽

Caroline Sweeney ◽

...

Keyword(s):

Primary Care ◽

Informed Consent ◽

Drug Monitoring ◽

Monitoring Program ◽

Opioid Therapy ◽

Pain Education ◽

Prescription Drug Monitoring Program ◽

Urine Drug ◽

Recommended Guidelines

Abstract Objective To describe the core elements of a Whole Health Primary Care Pain Education and Opioid Monitoring Program (PC-POP) and examine its effectiveness at increasing adherence to six of the Veteran Affairs/Department of Defense (VA/DoD) recommended guidelines for long-term opioid therapy (LOT) among chronic noncancer patients seen in primary care (i.e., urine drug screens [UDS], prescription drug monitoring program [PDMP] queries, informed consent, naloxone education/prescriptions, morphine equivalent daily dose [MEDD], and referrals to nonpharmacological pain interventions). Design/Methods A within-subjects comparison of outcomes was conducted between pre- and post-PC-POP enrollees (N = 25), as was a a between-subjects comparison to a comparison group (N = 25) utilizing a six-month range post–index date of 10/1/2018 (i.e., between-subjects comparison at Time 2). Subjects A convenience sample of adult veterans with chronic noncancer pain receiving opioid therapy consecutively for the past three months in primary care. Results Results showed increased concordance with VA/DoD guidelines among those enrolled in the PC-POP, characterized by increased documentation of urine drug screens, prescription drug monitoring program queries, informed consent, naloxone education/prescriptions, and a decrease in MEDD among patients enrolled in the PC-POP. Conclusions The PC-POP shows promise for increasing guideline-concordant care for providers working in primary care.

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