scholarly journals Consensus-based approach to managing opioids, including opioid misuse and opioid use disorder, in patients with serious illness: protocol for a modified Delphi process

BMJ Open ◽  
2021 ◽  
Vol 11 (5) ◽  
pp. e045402
Author(s):  
Caroline King ◽  
Robert Arnold ◽  
Emily Dao ◽  
Jennifer Kapo ◽  
Jane Liebschutz ◽  
...  
Keyword(s):  
Palliative Care ◽  
Opioid Therapy ◽  
Opioid Use Disorder ◽  
Opioid Misuse ◽  
Opioid Use ◽  
Serious Illness ◽  
Modified Delphi ◽  
Delphi Approach ◽  
Institutional Review ◽  
Management Guidance

IntroductionManagement of opioid misuse and opioid use disorder (OUD) among individuals with serious illness is an important yet understudied issue. Palliative care clinicians caring for individuals with serious illness, many of whom may live for months or years, describe a complex tension between weighing the benefits of opioids, which are considered a cornerstone of pain management in serious illness, and serious opioid-related harms like opioid misuse and OUD. And yet, little literature exists to inform the management of opioid misuse and OUDs among individuals with serious illness. Our objective is to provide evidence-based management guidance to clinicians caring for individuals with serious illness who develop opioid misuse or OUD.Methods and analysisWe chose a modified Delphi approach, which is appropriate when empirical evidence is lacking and expert input must be used to shape clinical guidance. We sought to recruit 60 clinicians with expertise in palliative care, addiction or both to participate in this study. We created seven patient cases that capture important management challenges in individuals with serious illness prescribed opioid therapy. We used ExpertLens, an online platform for conducting modified Delphi panels. Participants completed three rounds of data collection. In round 1, they rated and commented on the appropriateness of management choices for cases. In round 2, participants reviewed and discussed their own and other participants’ round 1 numerical responses and comments. In round 3 (currently ongoing), participants again reviewed rounds 1 and 2, and are allowed to change their final numerical responses. We used ExpertLens to automatically identify whether there is consensus, or disagreement, among responses in panels. Only round 3 responses will be used to assess final consensus and disagreement.Ethics and disseminationThis project received ethical approval from the University of Pittsburgh’s Institutional Review Board (study 19110301) and the RAND Institutional Research Board (study 2020-0142). Guidance from this work will be disseminated through national stakeholder networks to gain buy-in and endorsement. This study will also form the basis of an implementation toolkit for clinicians caring for individuals with serious illness who are at risk of opioid misuse or OUD.

Incidentally Identified Opioid Misuse and Opioid Use Disorder While Inpatient

2020 ◽  
pp. 495-518
Author(s):  
Ojas Mainkar ◽  
Miranda Greiner ◽  
Jonathan Avery ◽  
Neel Mehta
Keyword(s):  
Opioid Use Disorder ◽  
Opioid Misuse ◽  
Opioid Use

scholarly journals Mindfulness-Oriented Recovery Enhancement remediates anhedonia in chronic opioid use by enhancing neurophysiological responses during savoring of natural rewards

2021 ◽  
pp. 1-10
Author(s):  
Eric L. Garland ◽  
Spencer T. Fix ◽  
Justin P. Hudak ◽  
Edward M. Bernat ◽  
Yoshio Nakamura ◽  
...  
Keyword(s):  
Chronic Pain ◽  
Skin Conductance Level ◽  
Opioid Therapy ◽  
Opioid Use Disorder ◽  
Opioid Use ◽  
Natural Reward ◽  
Before And After ◽  
Natural Rewards ◽  
Chronic Opioid Use ◽  
Opioid Users

Abstract Background Neuropsychopharmacologic effects of long-term opioid therapy (LTOT) in the context of chronic pain may result in subjective anhedonia coupled with decreased attention to natural rewards. Yet, there are no known efficacious treatments for anhedonia and reward deficits associated with chronic opioid use. Mindfulness-Oriented Recovery Enhancement (MORE), a novel behavioral intervention combining training in mindfulness with savoring of natural rewards, may hold promise for treating anhedonia in LTOT. Methods Veterans receiving LTOT (N = 63) for chronic pain were randomized to 8 weeks of MORE or a supportive group (SG) psychotherapy control. Before and after the 8-week treatment groups, we assessed the effects of MORE on the late positive potential (LPP) of the electroencephalogram and skin conductance level (SCL) during viewing and up-regulating responses (i.e. savoring) to natural reward cues. We then examined whether these neurophysiological effects were associated with reductions in subjective anhedonia by 4-month follow-up. Results Patients treated with MORE demonstrated significantly increased LPP and SCL to natural reward cues and greater decreases in subjective anhedonia relative to those in the SG. The effect of MORE on reducing anhedonia was statistically mediated by increases in LPP response during savoring. Conclusions MORE enhances motivated attention to natural reward cues among chronic pain patients on LTOT, as evidenced by increased electrocortical and sympathetic nervous system responses. Given neurophysiological evidence of clinical target engagement, MORE may be an efficacious treatment for anhedonia among chronic opioid users, people with chronic pain, and those at risk for opioid use disorder.

Predicting opioid use disorder in patients with chronic pain who present to the emergency department

2018 ◽  
Vol 25 (5) ◽  
pp. 386-391
Author(s):  
Robert Andrew Gardner ◽  
Kori L Brewer ◽  
Dennis B Langston
Keyword(s):  
Emergency Department ◽  
Chronic Pain ◽  
Opioid Therapy ◽  
Opioid Use Disorder ◽  
Small Sample ◽  
Pain Medicine ◽  
Dose Increase ◽  
Emergency Physicians ◽  
Opioid Use ◽  
Prescription Monitoring

BackgroundEmergency department (ED) patients with chronic pain challenge providers to make quick and accurate assessments without an in-depth pain management consultation. Emergency physicians need reliable means to determine which patients may receive opioid therapy without exacerbating opioid use disorder (OUD).MethodsEighty-nine ED patients with a chief complaint of chronic pain were enrolled. Researchers administered questionnaires and reviewed medical and state prescription monitoring database information. Participants were classified as either OUD or non-OUD. Statistical analysis included a bivariate analysis comparing differences between groups and multivariate logistic regression evaluating ORs.ResultsThe 45 participants categorised as OUD had a higher proportion of documented or reported psychiatric diagnoses (p=0.049), preference of opioid treatment (p=0.005), current oxycodone prescription (p=0.043), borrowed pain medicine (p=0.004) and non-authorised dose increase (p<0.001). The state prescription monitoring database revealed the OUD group to have an increased number of opioid prescriptions (p=0.005) and pills (p=0.010). Participants who borrowed pain medicine and engaged in non-authorised dose increase were 5.2 (p=0.025, 95% CI 1.24 to 21.9) and 6.1 times (p=0.001, 95% CI 1.55 to 24.1) more likely to have OUD, respectively.LimitationsMajor limitations of our study include a small sample size, self-reported measures and convenience sample which may introduce selection bias.ConclusionPatients with chronic pain with OUD have distinguishable characteristics. Emergency physicians should consider such evidence-based variables prior to opioid therapy to ameliorate the opioid crisis and limit implicit bias.

Top Ten Tips Palliative Care Clinicians Should Know About Opioid Use Disorder

2020 ◽  
Vol 23 (9) ◽  
pp. 1250-1256
Author(s):  
Erin M. Haley ◽  
Jordan Stone ◽  
Julie Childers ◽  
Amy Davis ◽  
Sarah Ehrman ◽  
...  
Keyword(s):  
Palliative Care ◽  
Opioid Use Disorder ◽  
Opioid Use

Piloting the global capacity education e-tool: can capacity be taught to health care professionals across different international jurisdictions?

2019 ◽  
pp. 1-4 ◽  
Author(s):  
Carmelle Peisah ◽  
Yaffa Lerman ◽  
Nathan Herrmann ◽  
Jeremy Rezmovitz ◽  
Kenneth Shulman
Keyword(s):  
Health Care ◽  
Palliative Care ◽  
Health Care Professionals ◽  
Test Score ◽  
Aged Care ◽  
Care Physician ◽  
Modified Delphi ◽  
Learning Platform ◽  
Delphi Approach ◽  
Post Test

ABSTRACTDetermining decision-making capacity is part of everyday business for health care professionals working with older adults. We used a modified Delphi approach to develop an inclusive curriculum for a capacity education e-tool with global application and clinical relevance to a range of disciplines. The tool comprised: (i) 25 questions forming a “pre-test” for the adaptive and personalized e-Learning platform; (ii) a learning module based on the participant’s response to the “pre-test”; (iii) a “post-test” (the same baseline 25 questions) to test knowledge translation. The tool was tested on 31 health care professionals across Israel (8), Canada (15), and Australia (8) from the following disciplines: General Practitioners (GP) (19), Internal Medicine (1), Palliative Care GP (2); Palliative Care Physician (2), Geriatrician (2); and one of each: Psychologist, Occupational Therapist, Psychiatrist, Aged Care Researcher, and Aged Care Pharmacist. The mean baseline pre-test score was 19.1/25 (S.D. =1.61; range 15–22) and post-test score 21.7/25 (S.D.= 1.42; range 18–24); with a highly significant improvement in test scores (paired t-test P &lt; 0.0001; t=10.81 on 30 df). This is the first such pilot study to demonstrate that generic capacity principles can be taught to health care professionals from different disciplines regardless of jurisdiction.

Opioid use disorder and chronic pain: challenges for palliative care practice

2019 ◽  
Vol 25 (9) ◽  
pp. 453-457
Author(s):  
Brenda Peters-Watral
Keyword(s):  
Chronic Pain ◽  
Palliative Care ◽  
Substance Use ◽  
Pain Management ◽  
Cancer Pain ◽  
Opioid Use Disorder ◽  
Care Practice ◽  
Care Providers ◽  
Opioid Use ◽  
Multiple Cancer

Along with a well-documented increase in opioid use disorder (OUD) and a rapidly escalating rate of fatal overdose in North America, inadequate management of chronic pain remains a pervasive problem. The increasing number of individuals living with OUD also experience multiple cancer risk factors, which are related to their substance use, while people with cancer diagnoses have similar risks of current or past addiction as the general population. Recent pain guidelines focus on chronic non-cancer pain and do not include recommendations for cancer pain management. Managing cancer pain at the end of life is more challenging in people with current or past substance use disorder (SUD), especially OUD. Addressing these challenges requires confronting stigmas and stereotypes, building knowledge among palliative care providers and assessing the risks and benefits of opioids for pain management on an individual basis in order to continue to provide the holistic care.

Standardizing opioid prescribing practices for cancer-related pain via a novel interactive documentation template at a public hospital.

2017 ◽  
Vol 35 (31_suppl) ◽  
pp. 253-253
Author(s):  
Maliha Nusrat ◽  
Amanda Marie Parkes ◽  
Bei Hu ◽  
Dalia Farhat ◽  
Alyssa G. Rieber ◽  
...  
Keyword(s):  
Palliative Care ◽  
Public Hospital ◽  
Improve Patient Safety ◽  
Cancer Center ◽  
Urine Drug Screen ◽  
Opioid Misuse ◽  
Opioid Use ◽  
Prescribing Practices ◽  
Record System ◽  
State Regulations

253 Background: Aberrant opioid use during treatment of cancer related pain poses serious risks for patients and society. Identifying and monitoring those at risk is challenging and time consuming. We aimed to standardize the process of managing opioids at a public hospital oncology clinic in compliance with Texas (TX) state regulations to improve patient safety. Methods: We gauged the current practices of assessing and documenting opioid efficacy, toxicity and misuse via provider survey and chart review. A process flowchart was then created and streamlined in the light of: published literature, TX Administrative Code on pain management, and practices of palliative care specialists at MD Anderson Cancer Center, TX. We made an interactive documentation template (SmartPhrase) in electronic medical record system (EPIC) to implement the standardized process. Results: Pre-intervention data showedhigh inter-provider variability in opioid misuse screening, safety monitoring and documentation. Of the 22 providers surveyed, 6 (22%) had a TX PMP Aware login; 8 (36%) ever checked the website; and 19 (86%) stated the need of a standardized process for prescribing opioids. Hence, we instituted baseline screening for aberrant behavior based on substance abuse history, TX PMP Aware query and urine drug screen; increased monitoring of high risk patients; universal screening for chemical coping at each visit; and timely referral of such patients to palliative care. We created a SmartPhrase that prompts providers to risk stratify and monitor for opioid misuse as above; assess analgesic efficacy; evaluate and manage uncontrolled pain and toxicities; and specify a refill plan. This SmartPhrase allows quick selection of options pertinent to a given patient from pre-populated lists before the encounter can be closed. Conclusions: We created a systematic approach to prescribing and monitoring opioid analgesics so as to ensure safe and judicious use of opioids to treat cancer related pain. We generated an interactive SmartPhrase for efficient documentation compliant with TX state regulations. Post-implementation review of efficacy and use of this intervention is ongoing to further refine it.

Responding to the opioid crisis in a manner that respects oncology patients: A single institution experience writing policy to promote safe opioid use.

2018 ◽  
Vol 36 (30_suppl) ◽  
pp. 132-132
Author(s):  
Cristina Cellurale ◽  
Mary Anne Fenton ◽  
Katie Cherenzia ◽  
Megan Begnoche
Keyword(s):  
Palliative Care ◽  
Policy Statement ◽  
Opioid Misuse ◽  
Opioid Use ◽  
Oncology Patients ◽  
Opioid Crisis ◽  
Pain Scores ◽  
Dramatic Shift ◽  
Oncology Practice ◽  
Safe Opioid Prescribing

132 Background: The current opioid crisis has had wide ranging implications across medicine and in particular oncology practice. Opioids have been used for centuries for their analgesic properties. As physicians and historians are aware, the abuse potential of opioids is significant. Despite this, a dramatic shift in medical education in the late 1990s and early 2000s and aggressive marketing and manufacture of opioids has led to widespread opioid misuse and abuse. Therefore, a slew of regulations has been put into effect within a brief period of time. Among practitioners, the oncologist holds a unique and arguably more challenging role, caring not only for those with acute cancer-related pain or those at the end of life, but also for cancer survivors or those who live with their cancer as a chronic condition. ASCO has put forth comprehensive guidelines for the safe use and monitoring of opioids. The ASCO policy statement also highlights the significant barriers that oncology patients face, thereby maintaining a focus on the unique needs of this patient population. Methods: The Lifespan Cancer Institute is an academic practice and writes approximately 880 opioid prescriptions each month with approximately 15% being new prescriptions. Our Multidisciplinary Quality Team implemented a safe opioid prescribing initiative including patient education sheets, an electronic patient-provider treatment agreement, and an electronic template for provider documentation. Our palliative care team monitors pain scores. Results: During month one, 16% of patients newly prescribed an opioid had a completed patient-provider treatment agreement. For the second month, the number of completed agreements increased to 29%. Conclusions: Given the prevalence of opioid misuse, there is a growing overlap between oncology patients and those with opioid misuse disorder. Given high levels of psychological distress, the cancer patient is at risk for opioid misuse. Furthermore, oncology patients can be victims of diversion. Our responsibility is to screen and educate patients on the risk of opioid addiction and diversion while providing compassionate palliative care.

scholarly journals Prevention, Diagnosis, and Management of Opioids, Opioid Misuse, and Opioid Use Disorder in Older Adults

2020 ◽  
Author(s):  
Andrew R. Zullo ◽  
Kristin J. Danko ◽  
Patience Moyo ◽  
Gaelen P. Adam ◽  
Melissa Riester ◽  
...  
Keyword(s):  
Older Adults ◽  
Opioid Use Disorder ◽  
Opioid Misuse ◽  
Opioid Use ◽  
Diagnosis And Management

How I treat pain in hematologic malignancies safely with opioid therapy

Blood ◽  
2020 ◽  
Vol 135 (26) ◽  
pp. 2354-2364
Author(s):  
Holly L. Geyer ◽  
Halena Gazelka ◽  
Ruben Mesa
Keyword(s):  
Survival Rates ◽  
Hematologic Malignancies ◽  
Opioid Therapy ◽  
Opioid Use Disorder ◽  
Screening Tools ◽  
Opioid Use ◽  
Prescribing Practices ◽  
Prescription Drug Monitoring Programs ◽  
Urine Drug ◽  
Life Threatening

Abstract The field of malignant hematology has experienced extraordinary advancements with survival rates doubling for many disorders. As a result, many life-threatening conditions have since evolved into chronic medical ailments. Paralleling these advancements have been increasing rates of complex hematologic pain syndromes, present in up to 60% of patients with malignancy who are receiving active treatment and up to 33% of patients during survivorship. Opioids remain the practice cornerstone to managing malignancy-associated pain. Prevention and management of opioid-related complications have received significant national attention over the past decade, and emerging data suggest that patients with cancer are at equal if not higher risk of opioid-related complications when compared with patients without malignancy. Numerous tools and procedural practice guides are available to help facilitate safe prescribing. The recent development of cancer-specific resources directing algorithmic use of validated pain screening tools, prescription drug monitoring programs, urine drug screens, opioid use disorder risk screening instruments, and controlled substance agreements have further strengthened the framework for safe prescribing. This article, which integrates federal and organizational guidelines with known risk factors for cancer patients, offers a case-based discussion for reviewing safe opioid prescribing practices in the hematology setting.

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