Pain Agreements and Time-to-Event Analysis of Substance Misuse in a Primary Care Chronic Pain Program

Pain Medicine ◽  
2020 ◽  
Vol 21 (10) ◽  
pp. 2154-2162
Author(s):  
Ameer Ghodke ◽  
Timothy J Ives ◽  
Anna E Austin ◽  
William C Bennett ◽  
Naishal Y Patel ◽  
...  
Keyword(s):  
Primary Care ◽  
Chronic Pain ◽  
Substance Misuse ◽  
Clinical Epidemiology ◽  
A Priori ◽  
General Medicine ◽  
Patient Characteristics ◽  
Event Analysis ◽  
Controlled Substances ◽  
Opioid Prescribing

Abstract Background Types and correlates of pain medication agreement (PMA) violations in the primary care setting have not been analyzed. Methods A retrospective analysis was completed to examine patient characteristics and correlates of PMA violations, a proxy for substance misuse, over a 15-year period in an outpatient General Medicine Pain Service within the Division of General Medicine and Clinical Epidemiology, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill. Patients who signed the PMA were managed for chronic pain from 2002 through 2017 (N = 1,210). The incidence of PMA violations was measured over a 15-year span. Substance misuse was defined a priori in the study as urine toxicology screen positive for illicit or nonprescribed controlled substances, patient engagement in prescription alteration, doctor-shopping, or diversion. Results Most patients received a prescription for a controlled substance (77.4%). During enrollment, 488 (40.3%) patients had one or more violations of their PMA. One-third (33.4%) of pain service patients had a violation within 365 days of signing the agreement. Active tobacco smokers had double the incidence of agreement violation within the first 30 days of enrollment. Almost one-half (49.8%) of violations were due to inconsistent use of controlled substances. Patients with any prior DWI/DUI or drug-related offense had a significantly increased rate of substance misuse (P < 0.0001). Conclusions PMA violations were common among a population of patients managed for chronic nonmalignant pain. Universal opioid prescribing precautions, including PMAs, require further investigation to assess their roles in mitigating the potential patient and societal harms associated with opioid prescribing.

How opioid prescribing policies influence primary care clinicians’ treatment decisions and conversations with patients with chronic pain

2021 ◽  
Vol 17 (6) ◽  
pp. 499-509
Author(s):  
Elizabeth C. Danielson, PhD ◽  
Christopher A. Harle, PhD ◽  
Sarah M. Downs, MPH ◽  
Laura Militello, MA ◽  
Olena Mazurenko, MD, PhD
Keyword(s):  
Primary Care ◽  
Chronic Pain ◽  
Treatment Decisions ◽  
Healthcare Organizations ◽  
Chronic Noncancer Pain ◽  
Opioid Prescribing ◽  
Prevention Guideline ◽  
Multistep Process ◽  
Primary Care Clinicians ◽  
Noncancer Pain

Objective: The 2016 Centers for Disease Control and Prevention guideline for prescribing opioids for chronic pain aimed to assist primary care clinicians in safely and effectively prescribing opioids for chronic noncancer pain. Individual states, payers, and health systems issued similar policies imposing various regulations around opioid prescribing for patients with chronic pain. Experts argued that healthcare organizations and clinicians may be misapplying the federal guideline and subsequent opioid prescribing policies, leading to an inadequate pain management. The objective of this study was to understand how primary care clinicians involve opioid prescribing policies in their treatment decisions and in their conversations with patients with chronic pain.Design: We conducted a secondary qualitative analysis of data from 64 unique primary care visits and 87 post-visit interviews across 20 clinicians from three healthcare systems in the Midwestern United States. Using a multistep process and thematic analysis, we systematically analyzed data excerpts addressing opioid prescribing policies.Results: Opioid prescribing policies influenced clinicians’ treatment decisions to not initiate opioids, prescribe fewer opioids overall (theme #1), and begin tapering and discontinuation of opioids (theme #2) for most patients with chronic pain. Clinical precautions, described in the opioid prescribing policies to monitor use, were directly invoked during visits for patients with chronic pain (theme #3).Conclusions: Opioid prescribing policies have multidimensional influence on clinician treatment decisions for patients with chronic pain. Our findings may inform future studies to explore mechanisms for aligning pressures around opioid prescribing, stemming from various opioid prescribing policies, with the need to deliver individualized pain care.

scholarly journals Barriers and facilitators to implementing changes in opioid prescribing in rural primary care clinics

2020 ◽  
Vol 4 (5) ◽  
pp. 425-430
Author(s):  
Michael L. Parchman ◽  
Brooke Ike ◽  
Katherine P Osterhage ◽  
Laura-Mae Baldwin ◽  
Kari A Stephens ◽  
...  
Keyword(s):  
Primary Care ◽  
Chronic Pain ◽  
Rural Areas ◽  
Building Blocks ◽  
Rural Practice ◽  
Barriers And Facilitators ◽  
External Support ◽  
Rural Setting ◽  
Opioid Prescribing ◽  
Patient Resources

AbstractBackground:Opioids are more commonly prescribed for chronic pain in rural settings in the USA, yet little is known about how the rural context influences efforts to improve opioid medication management.Methods:The Six Building Blocks is an evidence-based program that guides primary care practices in making system-based improvements in managing patients using long-term opioid therapy. It was implemented at 6 rural and rural-serving organizations with 20 clinic locations over a 15-month period. To gain further insight about their experience with implementing the program, interviews and focus groups were conducted with staff and clinicians at the six organizations at the end of the 15 months and transcribed. Team members used a template analysis approach, a form of qualitative thematic analysis, to code these data for barriers, facilitators, and corresponding subcodes.Results:Facilitators to making systems-based changes in opioid management within a rural practice context included a desire to help patients and their community, external pressures to make changes in opioid management, a desire to reduce workplace stress, external support for the clinic, supportive clinic leadership, and receptivity of patients. Barriers to making changes included competing demands on clinicians and staff, a culture of clinician autonomy, inadequate data systems, and a lack of patient resources in rural areas.Discussion:The barriers and facilitators identified here point to potentially unique determinants of practice that should be considered when addressing opioid prescribing for chronic pain in the rural setting.

scholarly journals An Analysis of Primary Care Clinician Communication About Risk, Benefits, and Goals Related to Chronic Opioid Therapy

2019 ◽  
Vol 4 (2) ◽  
pp. 238146831989257
Author(s):  
Elizabeth C. Danielson ◽  
Olena Mazurenko ◽  
Barbara T. Andraka-Christou ◽  
Julie DiIulio ◽  
Sarah M. Downs ◽  
...  
Keyword(s):  
United States ◽  
Primary Care ◽  
Chronic Pain ◽  
The United States ◽  
Opioid Therapy ◽  
Opioid Overdose ◽  
Chronic Noncancer Pain ◽  
Opioid Prescribing ◽  
Limited Effectiveness ◽  
Pain Care

Background. Safe opioid prescribing and effective pain care are particularly important issues in the United States, where decades of widespread opioid prescribing have contributed to high rates of opioid use disorder. Because of the importance of clinician-patient communication in effective pain care and recent initiatives to curb rising opioid overdose deaths, this study sought to understand how clinicians and patients communicate about the risks, benefits, and goals of opioid therapy during primary care visits. Methods. We recruited clinicians and patients from six primary care clinics across three health systems in the Midwest United States. We audio-recorded 30 unique patients currently receiving opioids for chronic noncancer pain from 12 clinicians. We systematically analyzed transcribed, clinic visits to identify emergent themes. Results. Twenty of the 30 patient participants were females. Several patients had multiple pain diagnoses, with the most common diagnoses being osteoarthritis ( n = 10), spondylosis ( n = 6), and low back pain ( n = 5). We identified five themes: 1) communication about individual-level and population-level risks, 2) communication about policies or clinical guidelines related to opioids, 3) communication about the limited effectiveness of opioids for chronic pain conditions, 4) communication about nonopioid therapies for chronic pain, and 5) communication about the goal of the opioid tapering. Conclusions. Clinicians discuss opioid-related risks in varying ways during patient visits, which may differentially affect patient experiences. Our findings may inform the development and use of more standardized approaches to discussing opioids during primary care visits.

scholarly journals Association of opioid prescribing practices with chronic pain and benzodiazepine co-prescription: a primary care data linkage study

2018 ◽  
Vol 120 (6) ◽  
pp. 1345-1355 ◽  
Author(s):  
N. Torrance ◽  
R. Mansoor ◽  
H. Wang ◽  
S. Gilbert ◽  
G.J. Macfarlane ◽  
...  
Keyword(s):  
Primary Care ◽  
Chronic Pain ◽  
Data Linkage ◽  
Linkage Study ◽  
Prescribing Practices ◽  
Opioid Prescribing ◽  
Primary Care Data

scholarly journals Veterans Affairs Primary Care Clinicians' Attitudes toward Chronic Pain and Correlates of Opioid Prescribing Rates

Pain Medicine ◽  
2008 ◽  
Vol 9 (5) ◽  
pp. 564-571 ◽  
Author(s):  
Steven K. Dobscha ◽  
Kathryn Corson ◽  
Jennifer A. Flores ◽  
Erin C. Tansill ◽  
Martha S. Gerrity
Keyword(s):  
Primary Care ◽  
Chronic Pain ◽  
Veterans Affairs ◽  
Opioid Prescribing ◽  
Primary Care Clinicians

scholarly journals Opioid use disorder from poppy seed tea successfully treated with buprenorphine in primary care: a case report

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Scott Hagan ◽  
Carol E. Achtmeyer ◽  
Carly Hood ◽  
Eric J. Hawkins ◽  
Emily C. Williams
Keyword(s):  
Primary Care ◽  
Chronic Pain ◽  
Care Provider ◽  
Primary Care Provider ◽  
Puget Sound ◽  
Opioid Use Disorder ◽  
Opioid Use ◽  
Poppy Seed ◽  
Opioid Prescribing ◽  
Support Team

Abstract Background Poppy seeds contain morphine and other opioid alkaloids and are commercially available in the United States. Users of poppy seed tea (PST) can consume several hundred morphine milligram equivalents per day, and opioid dependence from PST use can develop. We report a case of a patient with chronic pain and PST use leading to opioid use disorder (OUD). This case represents the first published report of OUD from PST successfully treated with buprenorphine (BUP) in a primary care setting. The provider in this case used a unique model of care with an opioid prescribing support team to deliver safe and effective care. Case presentation A 47-year-old man with chronic pain and prescription opioid use presented to primary care to discuss a flare of shoulder pain, and revealed in subsequent conversation a long-standing use of PST to supplement pain control. Attempts at cessation resulted in severe withdrawal symptoms, leading to return to PST use. The primary care provider consulted the VA Puget Sound SUpporting Primary care Providers in Opioid Risk reduction and Treatment (SUPPORT) team to evaluate the patient for OUD. The patient discontinued all opioids, and initiated BUP under the supervision of the primary care provider. He remained on a stable dosage, without relapse, 24 months later. Conclusions PST, which can be made through purchase of readily available poppy pods, carries risk for development of OUD and overdose. Herein we highlight the utility of a primary care opioid prescribing support team in empowering a primary care provider to prescribe BUP to treat a patient with complex OUD.

Opioid crisis in primary care? An audit of high-dose opioid prescribing at Bangholm GP Practice

2020 ◽  
Vol 70 (suppl 1) ◽  
pp. bjgp20X711581
Author(s):  
Charlotte Greene ◽  
Alice Pearson
Keyword(s):  
Chronic Pain ◽  
Back Pain ◽  
Practice Guidelines ◽  
Best Practice ◽  
Evidence Base ◽  
High Dose ◽  
Opioid Prescription ◽  
Opioid Prescribing ◽  
Best Practice Guidelines

BackgroundOpioids are effective analgesics for acute and palliative pain, but there is no evidence base for long-term pain relief. They also carry considerable risks such as overdose and dependence. Despite this, they are increasingly prescribed for chronic pain. In the UK, opioid prescribing more than doubled between 1998 and 2018.AimAn audit at Bangholm GP Practice to understand the scale of high-strength opioid prescribing. The aim of the audit was to find out if indications, length of prescription, discussion, and documentation at initial consultation and review process were consistent with best-practice guidelines.MethodA search on Scottish Therapeutics Utility for patients prescribed an average daily dose of opioid equivalent ≥50 mg morphine between 1 July 2019 and 1 October 2019, excluding methadone, cancer pain, or palliative prescriptions. The Faculty of Pain Medicine’s best-practice guidelines were used.ResultsDemographics: 60 patients (37 females), average age 62, 28% registered with repeat opioid prescription, 38% comorbid depression. Length of prescription: average 6 years, 57% >5 years, 22% >10 years. Opioid: 52% tramadol, 23% on two opioids. Indications: back pain (42%), osteoarthritis (12%), fibromyalgia (10%). Initial consultation: 7% agreed outcomes, 35% follow-up documented. Review: 56% 4-week, 70% past year.ConclusionOpioid prescribing guidelines are not followed. The significant issues are: long-term prescriptions for chronic pain, especially back pain; new patients registering with repeat prescriptions; and no outcomes of treatment agreed, a crucial message is the goal is pain management rather than relief. Changes have been introduced at the practice: a patient information sheet, compulsory 1-month review for new patients on opioids, and in-surgery pain referrals.

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