Development of a self-report screening instrument for assessing potential opioid medication misuse in chronic pain patients

Background: Sublingual buprenorphine-naloxone (buprenorphine SL) is a preparation that is used to treat opioid dependence. In addition, the Drug Enforcement Administration (DEA) has acknowledged the legality of an off-label use to treat pain with a sublingual buprenorphine preparation. Buprenorphine SL is unique among the opioid class of analgesics; this compound has a high affinity for the mu-receptor, yet only partially activates it. Thus, buprenorphine SL can provide analgesia, yet minimize opioid side effects. Many patients on high doses of traditional opioid medication develop tolerance. Despite escalating medication dosage, a subset of patients had a paradoxical increase in pain, which has been characterized as opioid-induced hyperalgesia (OIH). Buprenorphine SL, on the other hand, may even be anti-hyperalgesic and may have utility in treating these challenging patients. Objective: To determine the effectiveness of converting patients from traditional full agonist opioid medication to sublingual buprenorphine, as well as to identify patient groups that are most likely to benefit from this therapy. Patients who underwent conversion either had developed tolerance with diminished analgesia or were experiencing side effects on their opioid medications. Study Design: An observational report of outcomes assessment. Setting: An interventional pain management practice setting in the United States. Methods: Retrospective data from clinical records was compiled on 104 de-identified chronic pain patients whose personal information had been redacted (60 men and 44 women, aged 21-78) and who had previously been treated with opioid-agonist drugs; they were converted to buprenorphine SL in tablet form during the study. Chronic pain was defined as persistent pain for at least 6 months. Data collected from patient profiles included age, sex, diagnosis, medication history, pre-induction opioid intake, reason for detoxification, preinduction Clinical Opiate Withdrawal Score (COWS), and if applicable, cause of buprenorphine SL cessation. Pain levels and Quality of Life scores were recorded before and after conversion to buprenorphine SL. Outcome Measures: Level of analgesia for patients who continued conversion to sublingual buprenorphine for more than 2 months. Results: After initiation of buprenorphine SL therapy for more than 2 months, the mean pain scores on a scale from 0-10 decreased by 2.3 points (P < 0.001). Patient Quality of Life (QoL scale) was not significantly affected by buprenorphine SL therapy (P = 0.14). The success rate was highest for patients using morphine, oxycodone, and fentanyl before buprenorphine SL induction. These patient groups had a 3.7 point decrease in pain for those taking morphine, a 2.5 point decrease in pain for those taking oxycodone, and a 2.2 point decrease for those taking fentanyl. The smallest pain reduction was seen in the patient group using oxymorphone before conversion with a 1.1 point decrease in pain. Patients taking between 100-199 mg morphine equivalent per day experienced the greatest reduction (2.7 points) in pain scores. Patients taking between 200 and 299 mg morphine equivalent before buprenorphine SL induction exhibited a decrease of over 2 points on average. Patients taking > 400mg morphine equivalent reported the smallest reduction in pain scores, on average a 1.1 point decrease. Limitations: This study is limited by its observational nature. Conclusions: Patients continuing buprenorphine SL therapy for more than 60 days reported significant decreases in pain (2.3 points). Patients on doses of opioid medication between 100-199 mg morphine equivalents seemed to fare better with conversion to buprenorphine SL than patients on the highest doses (> 400 mg morphine equivalents). The opioid drug used by the patient before buprenorphine SL induction appears to have some effect on buprenorphine SL conversion success. Patients previously taking morphine, oxycodone, and fentanyl had the greatest decrease in pain after conversion to buprenorphine SL. Key Words: Sublingual buprenorphine-naloxone, buprenorphine, buprenorphine SL, opioid dependence, opioid conversion, opioid-induced hyperalgesia, analgesia, full agonist opioids, opioid tolerance.

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Medical Cannabis for the Management of Pain and Quality of Life in Chronic Pain Patients: A Prospective Observational Study

Pain Medicine ◽

10.1093/pm/pnaa163 ◽

2020 ◽

Vol 21 (11) ◽

pp. 3073-3086 ◽

Cited By ~ 1

Author(s):

Ramin Safakish ◽

Gordon Ko ◽

Vahid Salimpour ◽

Bryan Hendin ◽

Imrat Sohanpal ◽

...

Keyword(s):

Quality Of Life ◽

Chronic Pain ◽

Observational Study ◽

Medication Use ◽

Medical Cannabis ◽

Opioid Medication ◽

Chronic Pain Patients ◽

Pain Patients ◽

Observation Period

Abstract Objective To evaluate the short-term and long-term effects of plant-based medical cannabis in a chronic pain population over the course of one year. Design A longitudinal, prospective, 12-month observational study. Setting Patients were recruited and treated at a clinic specializing in medical cannabis care from October 2015 to March 2019. Subjects A total of 751 chronic pain patients initiating medical cannabis treatment. Methods Study participants completed the Brief Pain Inventory and the 12-item Short Form Survey (SF-12), as well as surveys on opioid medication use and adverse events, at baseline and once a month for 12 months. Results Medical cannabis treatment was associated with improvements in pain severity and interference (P < 0.001) observed at one month and maintained over the 12-month observation period. Significant improvements were also observed in the SF-12 physical and mental health domains (P < 0.002) starting at three months. Significant decreases in headaches, fatigue, anxiety, and nausea were observed after initiation of treatment (P ≤ 0.002). In patients who reported opioid medication use at baseline, there were significant reductions in oral morphine equivalent doses (P < 0.0001), while correlates of pain were significantly improved by the end of the study observation period. Conclusions Taken together, the findings of this study add to the cumulative evidence in support of plant-based medical cannabis as a safe and effective treatment option and potential opioid medication substitute or augmentation therapy for the management of symptoms and quality of life in chronic pain patients.

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Brief, Self-Report Fibromyalgia Screener Evaluated in a Sample of Chronic Pain Patients

Pain Medicine ◽

10.1111/pme.12114 ◽

2013 ◽

Vol 14 (5) ◽

pp. 730-735 ◽

Cited By ~ 9

Author(s):

Dawn A. Marcus ◽

Cheryl Bernstein ◽

Kara L. Albrecht

Keyword(s):

Chronic Pain ◽

Self Report ◽

Chronic Pain Patients ◽

Pain Patients

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Does validation and alliance during the multimodal investigation affect patients’ acceptance of chronic pain? An experimental single case study

Scandinavian Journal of Pain ◽

10.1515/sjpain-2018-0051 ◽

2019 ◽

Vol 19 (1) ◽

pp. 73-82 ◽

Cited By ~ 1

Author(s):

Mikael Svanberg ◽

Ann-Christin Johansson ◽

Katja Boersma

Keyword(s):

Chronic Pain ◽

Therapeutic Effect ◽

Pain Catastrophizing ◽

Single Case ◽

Rehabilitation Program ◽

Self Report ◽

Pain Coping ◽

Chronic Pain Patients ◽

Before And After ◽

Pain Patients

Abstract Background and aims Among chronic pain patients who are referred to participation in a multimodal rehabilitation program (MMRP), pain catastrophizing and dysfunctional pain coping is common. In many cases it may have driven the patient to a range of unsuccessful searches for biomedical explanations and pain relief. Often these efforts have left patients feeling disappointed, hopeless and misunderstood. The MMRP process can be preceded by a multimodal investigation (MMI) where an important effort is to validate the patient to create a good alliance and begin a process of change towards acceptance of the pain. However, whether the MMI has such therapeutic effect is unclear. Using a repeated single case experimental design, the purpose of this study was to investigate the therapeutic effect of MMI by studying changes in patients’ experience of validation, alliance, acceptance of pain, coping, catastrophizing, and depression before and during the MMI process. Methods Participants were six chronic pain patients with high levels of pain catastrophizing (>25 on the Pain Catastrophizing Scale) and risk for long term disability (>105 on the Örebro Musculoskeletal Pain Screening Questionnaire) who were subjected to MMI before planned MMRP. For each patient, weekly self-report measures of validation, alliance and acceptance of pain were obtained during a 5–10-weeks baseline, before the MMI started. Subsequently, these measures were also obtained during a 6–8 weeks MMI process in order to enable comparative analyses. Additionally, pain coping, depression and pain catastrophizing were measured using standardized questionnaires before and after the MMI. Results Irrespective of experiences of validation and alliance before MMI, all six patients felt validated and experienced a good alliance during MMI. Acceptance of pain improved only in one patient during MMI. None of the patients showed clinically relevant improvement in pain coping, depression or catastrophizing after the MMI. Conclusions The patients did not change their acceptance and pain coping strategies despite of good alliance and experience of validation during the MMI process. Even if the design of this study precludes generalization to chronic pain patients in general, the results suggest that MMI may not have a therapeutic effect.

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