Reducing Opioid Use for Patients With Chronic Pain: An Evidence-Based Perspective

Abstract Background Over the last three decades, Australian opioid-prescribing rates and related morbidity and mortality have dramatically increased. Opioids are frequently prescribed by general practitioners (GPs) to manage chronic non-cancer pain, despite evidence-based recommendations from the Centre for Disease Control, National Institute for Health and Care Excellence and World Health Organization widely cautioning their use. Little is known about the factors influencing the opioid prescribing decisions of Australian GPs, especially when not evidence based. Objective To explore the opioid prescribing knowledge, attitudes and practices of Australian GPs. Methods Semi-structured interviews with 20 GPs recruited from the Monash University practice-based research network in metropolitan, southeastern Melbourne. Thematic analysis was used to identify emergent themes. Data were managed using QSR NVivo. Ethics approval was granted by Monash University. Results Three key themes emerged. GP attitudes towards opioid use for chronic pain varied by age of patient and goals for therapy. Use of opioids for elderly patients was positively perceived. GPs were reluctant to use opioids in younger patients due to fears of addiction and difficulty weaning. GPs felt obliged to prescribe opioids recommended by specialists, even if they believed the opioids were unsafe. Conclusion This study identified and described the patient-centred nature of GP opioid prescribing decisions. Patient age and perceived age-related opioid harm were important factors influencing prescribing decisions. Future work should inform interventions that value GP autonomy while still encouraging a collaborative inter-speciality approach to managing chronic pain patients with opioids.

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Reducing opioid use for chronic pain in older adults

American Journal of Health-System Pharmacy ◽

10.1093/ajhp/zxz025 ◽

2019 ◽

Vol 76 (8) ◽

pp. 554-559 ◽

Cited By ~ 1

Author(s):

Joshana K Goga ◽

Annie Michaels ◽

Marc Zisselman ◽

Antonio DePaolo ◽

Sunil Khushalani ◽

...

Keyword(s):

Older Adults ◽

Chronic Pain ◽

Back Pain ◽

Health System ◽

Chronic Back Pain ◽

Treatment Algorithm ◽

Private Provider ◽

Evidence Based ◽

Opioid Use ◽

Alternative Medications

Abstract Purpose Implementation of the SAFE PAIN algorithm for reducing opioid use for chronic pain in older adults is described. Summary A multidisciplinary team at Sheppard Pratt Health System, the largest private provider of psychiatric care in Maryland, used lean methodology to identify the root causes for noncompliance to evidence-based practices for patients in the geropsychiatry unit treated for osteoarthritis or chronic back pain. The team collaborated to develop a facility-specific treatment algorithm, called SAFE PAIN (Sheppard Pratt Health System Algorithm For Elderly Patient Centered Analgesia Interdisciplinary Nagara), was based on the Center for Disease Control and Prevention’s evidence-based recommendations that included nonpharmacologic interventions as a first-line therapy for patients with osteoarthritis or chronic back pain. Rates of prescribing new opioids and prescribing evidence-based alternative medications via the SAFE PAIN algorithm were evaluated from March 1 to September 30, 2017 and compared with baseline (2012–2016). The lean methodology interventions led to zero new opioid orders during the study period, a significant decrease compared with previous years (p < 0.01). The rates of prescribing evidence-based alternative medications increased significantly from the baseline period to postimplementation (p < 0.01). Lean methodology interventions also decreased waste in several processes. Conclusion The prescribing rate of new opioids for osteoarthritis and chronic back pain decreased and the prescribing rate for evidence-based medications increased after implementation of the SAFE PAIN algorithm in a geropsychiatry unit.

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Prevention of Opioid Abuse in Chronic NonCancer Pain: An Algorithmic, Evidence Based Approach

January 2018 - Pain Physician ◽

10.36076/ppj.2012/15/es177 ◽

2012 ◽

Vol 3S;15 (3S;7) ◽

pp. ES177-ES189

Author(s):

Sairam Atluri

Keyword(s):

Chronic Pain ◽

Opioid Abuse ◽

Screening Tools ◽

Evidence Based ◽

Opioid Use ◽

Algorithmic Approach ◽

Prescription Monitoring ◽

Monitoring Programs ◽

Urine Drug ◽

Overdose Deaths

Background: The use of opioids for chronic non-cancer pain has grown exponentially in the last 15 years. Associated with that, dramatic increases in abuse and overdose deaths from opioid use have been noted. Objectives: Most opioid abuse stems from legitimate prescriptions, putting the onus on prescribers to use opioids responsibly for chronic pain. Very little evidence-based guidance exists for those who wish to prescribe opioids for legitimate chronic pain and at the same time prevent opioid abuse. Methods: A review of literature was performed for articles focused on guidelines for opioid use when prescribed for chronic pain, opioid abuse, and overdose, strategies to detect and prevent abuse of opioids, urine drug screens (UDS) in chronic pain settings, prescription monitoring programs (PMP), and the relationship between opioid dosing and abuse. Results: Based on the existing literature, an evidence-based algorithmic approach was developed to decrease opioid abuse in the chronic pain environment. The pillars of prevention are the screening of patients into high, medium, and low risk categories using screening tools; monitoring patients using UDS, PMP, and pill counts, and lastly, dose limitations. Conclusion: This algorithmic approach may enable physicians to prescribe opioids for patients with chronic pain and also to reduce opioid abuse. Key words: Opioids, chronic pain, abuse, prescription, overdose, deaths, overdose deaths, urine drug screens, prescription monitoring programs, opioid dose, screening, monitoring

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Chronic pain management and the development of opioid use disorder

University of Western Ontario Medical Journal ◽

10.5206/uwomj.v87i1.1907 ◽

2018 ◽

Vol 87 (1) ◽

pp. 55-57

Author(s):

Lily Robinson ◽

Richard Yu ◽

Salonee Patel

Keyword(s):

Chronic Pain ◽

Pain Management ◽

Cancer Pain ◽

Medical Management ◽

Opioid Therapy ◽

Opioid Use Disorder ◽

Medical Attention ◽

Prescription Opioid ◽

Evidence Based ◽

Opioid Use

Chronic pain is a common condition that impacts quality of life and often precipitates the need for medical attention. Despite evidence that long-term opioid use provides limited relief, prescription opioid therapy remains a cornerstone in the medical management of chronic non-cancer pain. Presently, 13% of Canadians are prescribed opioids for pain management, and physicians play a crucial role in preventing the development of opioid use disorders. However, Canadian physicians lack knowledge of and comfort with evidence-based principles of opioid stewardship. In this article, we aim to highlight ongoing Canadian efforts to address physician discomfort and improve clinical practice. We focus on 2017 Canadian guidelines that provide clinicians with evidence-based recommendations for opioid use in chronic non-cancer pain management. In addition, we call attention to provincial efforts to implement physician accountability measures. In reviewing the existing literature, we uncovered inadequacies in pain management curricula within the Canadian undergraduate and continuing medical education (CME) systems. We consulted the educational practices of the European Pain Federation and the Centers for Disease Control and Prevention to make recommendations for improvement to current Canadian pain curricula. Based on our findings, we recommend that (1) Canadian medical institutions expand upon current core pain curricula, (2) pain management education be made compulsory, (3) academic detailing be emphasized as a means of CME, and (4) multidisciplinary non-medical management of chronic pain be featured more extensively.

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A new OPIATE (Optimizing Positive Ibuprofen and Acetaminophen Treatment Expectations) model: A brief comment on “Concurrent and lagged associations of prescription opioid use with pain and negative affect in the daily lives of chronic pain patients” (Carpenter, Lane, Bruehl, & Trull, 2019).

Journal of Consulting and Clinical Psychology ◽

10.1037/ccp0000436 ◽

2019 ◽

Vol 87 (10) ◽

pp. 887-892

Author(s):

Jack Stevens ◽

Tarun Bhalla

Keyword(s):

Chronic Pain ◽

Negative Affect ◽

Prescription Opioid ◽

Opioid Use ◽

Treatment Expectations ◽

Daily Lives ◽

Chronic Pain Patients ◽

Prescription Opioid Use ◽

Pain Patients

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Evidence-Based Treatment for Opioid Use Disorder

PsycEXTRA Dataset ◽

10.1037/e503952019-001 ◽

2018 ◽

Keyword(s):

Opioid Use Disorder ◽

Evidence Based ◽

Opioid Use ◽

Evidence Based Treatment

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Faculty Opinions recommendation of Oral opioid use alters DNIC but not cold pain perception in patients with chronic pain - new perspective of opioid-induced hyperalgesia.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.1119101.575248 ◽

2008 ◽

Author(s):

Robert Edwards ◽

Claudia Campbell

Keyword(s):

Chronic Pain ◽

Pain Perception ◽

Opioid Use ◽

Cold Pain ◽

Opioid Induced Hyperalgesia ◽

New Perspective

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Retrospective analysis on the effect of spinal cord stimulation on opioid consumption

Pain Management ◽

10.2217/pmt-2020-0016 ◽

2020 ◽

Author(s):

Awinita Barpujari ◽

Michael A Erdek

Keyword(s):

Spinal Cord ◽

Chronic Pain ◽

Retrospective Analysis ◽

Spinal Cord Stimulation ◽

Alternative Therapy ◽

Opioid Consumption ◽

Opioid Use ◽

Number Of Patients ◽

Chronic Pain Conditions ◽

Post Trial

Aim: Spinal cord stimulation (SCS) is used to clinically manage and/or treat several chronic pain etiologies. A limited amount is known about the influence on patients' use of opioid pain medication. This retrospective analysis evaluated SCS effect on opioid consumption in patients presenting with chronic pain conditions. Materials & methods: Sixty-seven patients underwent a temporary trial device, permanent implant or both. Patients were divided for assessment based on the nature of their procedure(s). Primary outcome was change in morphine equivalent dose (MED), ascertained from preoperative and postoperative medication reports. Results: Postoperative MED was significantly lower in patients who received some form of neuromodulation therapy. Pretrial patients reported an average MED of 41.01 ± 10.23 mg per day while post-trial patients reported an average of 13.30 ± 5.34 mg per day (p < 0.001). Pre-implant patients reported an average MED of 39.14 ± 13.52 mg per day while post-implant patients reported an average MED of 20.23 ± 9.01 mg per day (p < 0.001). There were no significant differences between pre-trial and pre-implant MED, nor between post-trial and post-implant MED. Of the 42 study subjects who reported some amount of pre-intervention opioid use, 78.57% indicated a lower MED (n = 33; p < 0.001), 16.67% indicated no change (n = 7) and 4.76% (n = 2) indicated a higher MED, following intervention. Moreover, SCS therapy resulted in a 26.83% reduction (p < 0.001) in the number of patients with MED >50 mg per day. Conclusion: Spinal cord stimulation may reduce opioid use when implemented appropriately. Neuromodulation may represent alternative therapy for alleviating chronic pain which may avoid a number of deleterious side effects commonly associated with opioid consumption.

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