scholarly journals Disagreement and Uncertainty Among Experts About how to Respond to Marijuana Use in Patients on Long-term Opioids for Chronic Pain: Results of a Delphi Study

Pain Medicine ◽  
2019 ◽  
Author(s):  
Joanna L Starrels ◽  
Sarah R Young ◽  
Soraya S Azari ◽  
William C Becker ◽  
E Jennifer Edelman ◽  
...  
Keyword(s):  
Chronic Pain ◽  
Delphi Study ◽  
A Priori ◽  
Management Strategies ◽  
Marijuana Use ◽  
Initial Response ◽  
The United States ◽  
Opioid Therapy ◽  
Free Text

Abstract Background Marijuana use is common among patients on long-term opioid therapy (LTOT) for chronic pain, but there is a lack of evidence to guide clinicians’ response. Objective To generate expert consensus about responding to marijuana use among patients on LTOT. Design Analysis from an online Delphi study. Setting/Subjects Clinician experts in pain and opioid management across the United States. Methods Participants generated management strategies in response to marijuana use without distinction between medical and nonmedical use, then rated the importance of each management strategy from 1 (not at all important) to 9 (extremely important). A priori rules for consensus were established, and disagreement was explored using cases. Thematic analysis of free-text responses examined factors that influenced participants’ decision-making. Results Of 42 participants, 64% were internal medicine physicians. There was consensus that it is not important to taper opioids as an initial response to marijuana use. There was disagreement about the importance of tapering opioids if there is a pattern of repeated marijuana use without clinical suspicion for a cannabis use disorder (CUD) and consensus that tapering is of uncertain importance if there is suspicion for CUD. Three themes influenced experts’ perceptions of the importance of tapering: 1) benefits and harms of marijuana for the individual patient, 2) a spectrum of belief about the overall riskiness of marijuana use, and 3) variable state laws or practice policies. Conclusions Experts disagree and are uncertain about the importance of opioid tapering for patients with marijuana use. Experts were influenced by patient factors, provider beliefs, and marijuana policy, highlighting the need for further research.

Monitoring outcomes during long-term opioid therapy for noncancer pain: Results with the Pain Assessment and Documentation Tool

2005 ◽  
Vol 1 (5) ◽  
pp. 257 ◽  
Author(s):  
Steven D. Passik, PhD ◽  
Kenneth L. Kirsh, PhD ◽  
Laurie Whitcomb, MA ◽  
Jeffrey R. Schein, PhD, MPH ◽  
Mitchell A. Kaplan, PhD ◽  
...  
Keyword(s):  
Chronic Pain ◽  
Side Effects ◽  
Pain Assessment ◽  
The United States ◽  
Opioid Therapy ◽  
Chronic Pain Patients ◽  
Noncancer Pain ◽  
Documentation Tool ◽  
Pain Patients

The increasingly common practice of long-term opioid therapy for chronic noncancer pain must be guided by ongoing assessment of four types of outcomes: pain relief, function, side effects, and drug-related behaviors. Our objective was to gather initial pilot data on the clinical application of a specialized chart note, the Pain Assessment and Documentation Tool (PADT), which was developed and tested with 27 physicians. This pilot test provided the means to collect cross-sectional outcome data on a large sample of opioid-treated chronic pain patients. Each of the physician volunteers (located in a variety of settings across the United States) completed the PADT for a convenience sample of personally treated chronic pain patients who had received at least three months of opioid therapy. Completion of the PADT required a clinical interview, review of the medical chart, and direct clinical observation. Data from the PADTs were collated and analyzed. The results suggested that the majority of patients with chronic pain achieve relatively positive outcomes in the eyes of their prescribing physicians in all four relevant domains with opioid therapy. Analgesia was modest but meaningful, functionality was generally stabilized or improved, and side effects were tolerable. Potentially aberrant behaviors were common but viewed as an indicator of a problem (i.e., addiction or diversion) in only approximately 10 percent of cases. Using the PADT, physician ratings can be developed in four domains. In this sample, outcomes suggested that opioid therapy provided meaningful analgesia.

scholarly journals Clinical Strategies for the Treatment and Management of Patients Prescribed Long-term Opioid Therapy

Pain Medicine ◽  
2018 ◽  
Vol 20 (9) ◽  
pp. 1737-1744
Author(s):  
Jessica J Wyse ◽  
Linda Ganzini ◽  
Steven K Dobscha ◽  
Erin E Krebs ◽  
Janet Zamudio ◽  
...  
Keyword(s):  
Chronic Pain ◽  
Drug Testing ◽  
Health Care Systems ◽  
Qualitative Interviews ◽  
The United States ◽  
Opioid Therapy ◽  
Prescribing Practices ◽  
Policy And Practice ◽  
Care Systems

Abstract Objectives Across diverse health care systems, growing recognition of the harms associated with long-term opioid therapy (LTOT) for chronic pain has catalyzed substantial changes to policy and practice designed to promote safer prescribing and patient care. Although clear goals have been defined, how clinics and providers should most effectively implement these changes has been less well defined, and facilities and providers have had substantial flexibility to innovate. Methods Qualitative interviews were conducted with 24 Department of Veterans Affairs (VA) clinicians across the United States who prescribe LTOT for chronic pain. Interviews probed the practices and initiatives providers utilized to meet opioid safety requirements and address common challenges in caring for patients prescribed LTOT. Results Innovative strategies in the design and organization of clinical practice (urine drug testing, informed consent, limiting transfer requests, specialty patient panel) and resources utilized (engaged pharmacists, non-opioid pain treatments, intra-organizational collaborations) are described. Conclusions We conclude with recommendations designed to improve opioid prescribing practices, both within the VA and in other settings.

Classification of Patients for whom benefit no longer outweighs harm of long-term opioid therapy: Protocol for a Delphi study (Preprint)

2021 ◽  
Author(s):  
Raymond Van Cleve ◽  
Sara Edmond ◽  
Jennifer Snow ◽  
Anne Black ◽  
Jamie Pommeranz ◽  
...  
Keyword(s):  
Chronic Pain ◽  
Delphi Study ◽  
Opioid Therapy ◽  
High Dose ◽  
Veterans Health ◽  
Health Administration ◽  
Opioid Dependency ◽  
Modified Delphi ◽  
Modified Delphi Technique

UNSTRUCTURED Introduction: Patients with chronic pain who have been prescribed long term opioid therapies often come to a point where the benefits of their therapy are out weighted by the risks associated with taking such a high dose of opioid medication. These patients need to taper off their opioid therapy while simultaneously treating their chronic pain. At the 2019 Veterans' Health Administration State of the Art Conference, there was an acknowledgment of a lack of clinical guidance with regards to treating this subset of patients. Some of the participants believed clinicians and patients would both benefit from a new diagnostic entity describing this situation where patients needed to have their opioid dependency and chronic pain simultaneously treated. Given the ability of a Delphi method to synthesize input from a broad range of experts, we felt this technique could be used to determine if a new diagnostic entity was needed and what the criteria of the diagnostic entity would be. Methods: This would be a modified Delphi technique involving three rounds. The first round would be a series of open ended questions asking about the necessity of this diagnostic entity, how this condition is different from OUD, and what it's possible diagnostic criteria would be. After synthesizing the responses collected, a second round would be conducted to ask participants to rate the different responses offered by their peers. These ratings would be collected, analyzed, and would generate a final potential definition for this clinical phenomena. In the third round we would circulate this definition and would hopefully gain consensus. Dissemination: This protocol has been approved by the Internal Review Board at the Connecticut VA and the study is in process. We hope that other researchers can use this protocol to conduct similar studies and further explore how patients with concurrent chronic pain and opioid dependency can be best served.

Racial and Ethnic Disparities in the Treatment of Chronic Pain

Pain Medicine ◽  
2020 ◽  
Author(s):  
Mary E Morales ◽  
R Jason Yong
Keyword(s):  
Chronic Pain ◽  
Racial Differences ◽  
Current Literature ◽  
Ethnic Disparities ◽  
The United States ◽  
Cross Sectional ◽  
Effective Interventions ◽  
Sociodemographic Profile

Abstract Objective To summarize the current literature on disparities in the treatment of chronic pain. Methods We focused on studies conducted in the United States and published from 2000 and onward. Studies of cross-sectional, longitudinal, and interventional designs were included. Results A review of the current literature revealed that an adverse association between non-White race and treatment of chronic pain is well supported. Studies have also shown that racial differences exist in the long-term monitoring for opioid misuse among patients suffering from chronic pain. In addition, a patient’s sociodemographic profile appears to influence the relationship between chronic pain and quality of life. Results from interventional studies were mixed. Conclusions Disparities exist within the treatment of chronic pain. Currently, it is unclear how to best combat these disparities. Further work is needed to understand why disparities exist and to identify points in patients’ treatment when they are most vulnerable to unequal care. Such work will help guide the development and implementation of effective interventions.

scholarly journals Management of problematic behaviours among individuals on long-term opioid therapy: protocol for a Delphi study

BMJ Open ◽  
2016 ◽  
Vol 6 (5) ◽  
pp. e011619 ◽  
Author(s):  
Jessica S Merlin ◽  
Sarah R Young ◽  
Soraya Azari ◽  
William C Becker ◽  
Jane M Liebschutz ◽  
...  
Keyword(s):  
Delphi Study ◽  
Opioid Therapy ◽  
Therapy Protocol

scholarly journals Managing Chronic Pain in Cancer Survivors Prescribed Long-Term Opioid Therapy: A National Survey of Ambulatory Palliative Care Providers

2019 ◽  
Vol 57 (1) ◽  
pp. 20-27 ◽  
Author(s):  
Jessica S. Merlin ◽  
Kanan Patel ◽  
Nicole Thompson ◽  
Jennifer Kapo ◽  
Frank Keefe ◽  
...  
Keyword(s):  
Chronic Pain ◽  
Palliative Care ◽  
Cancer Survivors ◽  
National Survey ◽  
Opioid Therapy ◽  
Care Providers

Opioid Therapy for Chronic Noncancer Pain: Safe, Effective, Appropriate?

2016 ◽  
Author(s):  
Joseph V. Pergolizzi Jr ◽  
Robert B. Raffa ◽  
Robert Taylor ◽  
Jo Ann LeQuang
Keyword(s):  
Risk Factors ◽  
Chronic Pain ◽  
Elderly Patients ◽  
The United States ◽  
Opioid Therapy ◽  
Abuse Liability ◽  
Opioid Abuse ◽  
Individual Risk ◽  
Chronic Noncancer Pain ◽  
Routes Of Administration

In determining the appropriate role of opioids, two public health crises must be balanced: the opioid abuse epidemic and the “silent” crisis of unrelieved chronic pain. Opioids can be used safely and effectively in selected patients; however, clinicians must be aware of their abuse liability and individual risk factors for opioid misuse. A number of opioids are approved for use in the United States, and although there are class effects, there can be great variability among patients with regard to opioid response. In addition to the medication, prescribers must also determine the most appropriate dose and route of administration. Considerations must be made for special population, such as the renally impaired, those with hepatic dysfunction, and pediatric and elderly patients. Another factor is abuse-deterrent properties. Of particular interest as an opioid agent is buprenorphine, which is available in various routes of administration and because of its unique pharmacokinetics may be administered to renally compromised and elderly patients without dosing restrictions. Buprenorphine is also associated with a lower abuse liability than other opioids. Patients suffering moderate to severe pain syndromes should not be denied access to effective pain control, which in some cases may appropriately include opioid therapy. Key words: Buprenorphine, Chronic Pain, Opioid, Opioid Abuse, Opioid Prescribing, Risk Factors for Opioid Abuse

scholarly journals Improving physical activity, sedentary behaviour and sleep in COPD: perspectives of people with COPD and experts via a Delphi approach

PeerJ ◽  
2018 ◽  
Vol 6 ◽  
pp. e4604 ◽  
Author(s):  
Hayley Lewthwaite ◽  
Tanja W. Effing ◽  
Anke Lenferink ◽  
Tim Olds ◽  
Marie T. Williams
Keyword(s):  
Physical Activity ◽  
Sedentary Behaviour ◽  
Delphi Study ◽  
A Priori ◽  
South Australia ◽  
Chronic Obstructive ◽  
Free Text ◽  
Obstructive Pulmonary Disease ◽  
Delphi Approach ◽  
Multifactorial Approach

Background Little is known about how to achieve enduring improvements in physical activity (PA), sedentary behaviour (SB) and sleep for people with chronic obstructive pulmonary disease (COPD). This study aimed to: (1) identify what people with COPD from South Australia and the Netherlands, and experts from COPD- and non-COPD-specific backgrounds considered important to improve behaviours; and (2) identify areas of dissonance between these different participant groups. Methods A four-round Delphi study was conducted, analysed separately for each group. Free-text responses (Round 1) were collated into items within themes and rated for importance on a 9-point Likert scale (Rounds 2–3). Items meeting a priori criteria from each group were retained for rating by all groups in Round 4. Items and themes achieving a median Likert score of ≥7 and an interquartile range of ≤2 across all groups at Round 4 were judged important. Analysis of variance with Tukey’s post-hoc tested for statistical differences between groups for importance ratings. Results Seventy-three participants consented to participate in this study, of which 62 (85%) completed Round 4. In Round 4, 81 items (PA n = 54; SB n = 24; sleep n = 3) and 18 themes (PA n = 9; SB n = 7; sleep n = 2) were considered important across all groups concerning: (1) symptom/disease management, (2) targeting behavioural factors, and (3) less commonly, adapting the social/physical environments. There were few areas of dissonance between groups. Conclusion Our Delphi participants considered a multifactorial approach to be important to improve PA, SB and sleep. Recognising and addressing factors considered important to recipients and providers of health care may provide a basis for developing behaviour-specific interventions leading to long-term behaviour change in people with COPD.

Outcomes in Long-term Opioid Tapering and Buprenorphine Transition: A Retrospective Clinical Data Analysis

Pain Medicine ◽  
2020 ◽  
Vol 21 (12) ◽  
pp. 3635-3644 ◽  
Author(s):  
John A Sturgeon ◽  
Mark D Sullivan ◽  
Simon Parker-Shames ◽  
David Tauben ◽  
Paul Coelho
Keyword(s):  
Chronic Pain ◽  
Pain Intensity ◽  
Drug Prescription ◽  
Opioid Therapy ◽  
High Dose ◽  
Clinical Approach ◽  
Prevention Guideline ◽  
Effective Interventions ◽  
Opioid Medications

Abstract Background There are significant medical risks of long-term opioid therapy (LTOT) for chronic pain. Consequently, there is a need to identify effective interventions for the reduction of high-dose full-agonist opioid medication use. Methods The current study details a retrospective review of 240 patients with chronic pain and LTOT presenting for treatment at a specialty opioid refill clinic. Patients first were initiated on an outpatient taper or, if taper was not tolerated, transitioned to buprenorphine. This study analyzes potential predictors of successful tapering, successful buprenorphine transition, or failure to complete either intervention and the effects of this clinical approach on pain intensity scores. Results One hundred seven patients (44.6%) successfully tapered their opioid medications under the Centers for Disease Control and Prevention guideline target dose (90 mg morphine-equianalgesic dosage), 45 patients (18.8%) were successfully transitioned to buprenorphine, and 88 patients (36.6%) dropped out of treatment: 11 patients during taper, eight during buprenorphine transition, and 69 before initiating either treatment. Conclusions. Higher initial doses of opioids predicted a higher likelihood of requiring buprenorphine transition, and a co-occurring benzodiazepine or z-drug prescription predicted a greater likelihood of dropout from both interventions. Patterns of change in pain intensity according to treatment were mixed: among successfully tapered patients, 52.8% reported greater pain and 23.6% reported reduced pain, whereas 41.8% reported increased pain intensity and 48.8% reported decreased pain after buprenorphine transition. Further research is needed on predictors of treatment retention and dropout, as well as factors that may mitigate elevated pain scores after reduction of opioid dosing.

Poster 530 Nutrition and Eating Behavior in Patients with Chronic Pain Receiving Long-Term Opioid Therapy

PM&R ◽  
2014 ◽  
Vol 6 (9) ◽  
pp. S181
Author(s):  
Joseph Walker ◽  
Alec L. Meleger ◽  
Cameron K. Froude
Keyword(s):  
Chronic Pain ◽  
Eating Behavior ◽  
Opioid Therapy
Sign in / Sign up

Export Citation Format

Share Document