Collaboration between adult patients and practitioners when making decisions about prescribing opioid medicines for chronic non-cancer pain in primary care: a scoping review

Background: Long-term opioid therapy (>12 months) is not effective for improving chronic non-cancer pain and function. Where patients are not experiencing pain relief with long-term opioids, the opioid should be tapered and discontinuation considered. Practitioners may find it challenging to tell patients experiencing pain that they are better off reducing or not taking medicines that do not help. This review aims to ascertain what is published about: (1) the interaction and (2) the nature of the relationship between practitioners and patients when prescribing opioids for chronic non-cancer pain in primary care. Method: A scoping review of English-language qualitative, quantitative or mixed-method studies in databases including: MEDLINE, Embase, PsycINFO, AMED, BNI, CINALH EMCARE and HMIC. The identified papers were reviewed to provide a descriptive summary of the literature. Results: The review identified 20 studies. The studies used a range of methods including interviews, focus groups, audio and video recordings of clinical consultations, telephone survey and data from patient records. One study reported that researchers had engaged with a patient advisory group to guide their research. Patients expressed the importance of being treated as individuals, not being judged and being involved in prescribing decisions. Practitioners expressed difficulty in managing patient expectations and establishing trust. Opioid risk and practitioner suspicion shape opioid prescribing decisions. There is a paucity of literature about how precisely practitioners overcome interactional challenges and implement personalised care in practice. Conclusion: The studies in this review ascertain that practitioners and patients often find it challenging to achieve shared decisions in opioid review consultations. Effective communication is essential to achieve good clinical practice. Collaborative research with PPI partners should be aimed at identifying communication practices that support practitioners to achieve shared decisions with patients when reviewing opioids for chronic non-cancer pain.

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Identifying appropriate outcomes to help evaluate the impact of the Canadian Guideline for Safe and Effective Use of Opioids for Non-Cancer Pain

10.21203/rs.2.9200/v3 ◽

2019 ◽

Author(s):

Michael Allen ◽

Beth Sproule ◽

Peter MacDougall ◽

Andrea Furlan ◽

Laura Murphy ◽

...

Keyword(s):

Cancer Pain ◽

Patient Outcomes ◽

Opioid Therapy ◽

Data Sources ◽

Prescription Opioid ◽

Advisory Group ◽

Opioid Overdose ◽

Canadian Guideline ◽

Effective Use ◽

The Impact

Abstract Background: The Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain (COG) was developed in response to increasing rates of opioid-related hospital visits and deaths in Canada, and uncertain benefits of opioids for chronic non-cancer pain (CNCP). Following publication, we developed a list of evaluable outcomes to assess the impact of this guideline on practice and patient outcomes . Methods: A working group at the National Pain Centre at McMaster University used a modified Delphi process to construct a list of clinical and patient outcomes important in assessing the uptake and application of the COG. An advisory group then reviewed this list to determine the relevance and feasibility of each outcome, and identified potential data sources. This feedback was reviewed by the National Faculty for the Guideline, and a National Advisory Group that included the creators of the COG, resulting in the final list of 5 priority outcomes. Results: Five outcomes were judged clinically important and feasible to measure: 1) Effects of opioids for CNCP on quality of life, 2) Assessment of patient’s risk of addiction before starting opioid therapy, 3) Monitoring patients on opioid therapy for aberrant drug-related behaviour, 4) Mortality rates associated with prescription opioid overdose and 5) Use of treatment agreements with patients before initiating opioid therapy for CNCP. Data sources for these outcomes included patient’s medical charts, e-Opioid Manager, prescription monitoring programs and administrative databases. Conclusion: Measuring the impact of best practice guidelines is infrequently done. Future research should consider capturing the five outcomes identified in this study to evaluate the impact of the COG in promoting evidence-based use of opioids for CNCP.

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A Systematic Review of Randomized Trials of Long-Term Opioid Management for Chronic Non-Cancer Pain

January 2018 - Pain Physician ◽

10.36076/ppj.2011/14/91 ◽

2011 ◽

Vol 3;14 (2;3) ◽

pp. 91-121

Author(s):

Laxmaiah Manchikanti

Keyword(s):

Systematic Review ◽

Cancer Pain ◽

Systematic Reviews ◽

Randomized Trials ◽

Opioid Therapy ◽

Functional Improvement ◽

Controlled Trials ◽

Chronic Opioid Therapy ◽

Level Of Evidence

Background: Even though opioids have been used for pain for thousands of years, opioid therapy for chronic non-cancer pain is controversial due to concerns regarding the long-term effectiveness and safety, particularly the risk of tolerance, dependance, or abuse. While the debate continues, the use of chronic opioid therapy for chronic non-cancer pain has increased exponentially. Even though evidence is limited, multiple expert panels have concluded that chronic opioid therapy can be effective therapy for carefully selected and monitored patients with chronic non-cancer pain. Study Design: A systematic review of randomized trials of opioid management for chronic noncancer pain. Objective: The objective of this systematic review is to evaluate the clinical efficacy of opioids in the treatment of chronic non-cancer pain. Methods: A comprehensive evaluation of the literature relating to opioids in chronic non-cancer pain was performed. The literature was evaluated according to Cochrane review criteria for randomized controlled trials (RCTs) and Jadad criteria. A literature search was conducted by using PubMed, EMBASE, Cochrane library, ECRI Institute Library, U.S. Food and Drug Administration (FDA) website, U.S. National Guideline Clearinghouse (NGC), Database of Abstracts of Reviews of Effectiveness (DARE), clinical trials, systematic reviews and cross references from systematic reviews. The level of evidence was classified as good, fair, or poor based on the quality of evidence developed by the United States Preventive Services Task Force (USPSTF) and used by other systematic reviews and guidelines. Outcome Measures: Pain relief was the primary outcome measure. Other outcome measures were functional improvement, withdrawals, and adverse effects. Results: Based on the USPSTF criteria, the indicated level of evidence was fair for Tramadol in managing osteoarthritis. For all the drugs assessed, including Tramadol, for all other conditions, the evidence was poor based on either weak positive evidence, indeterminate evidence, or negative evidence. Limitations: A paucity of literature, specifically with follow-up beyond 12 weeks for all types of opioids with controlled trials for various chronic non-cancer pain conditions. Conclusions: This systematic review illustrated fair evidence for Tramadol in managing osteoarthritis with poor evidence for all other drugs and conditions. Thus, recommendations must be based on non-randomized studies. Key words: Chronic non-cancer pain, opioids, opioid efficacy, opioid effectiveness, significant pain relief, functional improvement, adverse effects, morphine, hydrocodone, hydromorphone, fentanyl, tramadol, buprenorphine, methadone, tapentadol, oxycodone, oxymorphone, systematic reviews, randomized trials

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Identifying appropriate outcomes to help evaluate the impact of the Canadian Guideline for Safe and Effective Use of Opioids for Non-Cancer Pain

BMC Anesthesiology ◽

10.1186/s12871-020-0930-4 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Michael Allen ◽

Beth Sproule ◽

Peter MacDougall ◽

Andrea Furlan ◽

Laura Murphy ◽

...

Keyword(s):

Cancer Pain ◽

Patient Outcomes ◽

Opioid Therapy ◽

Data Sources ◽

Prescription Opioid ◽

Advisory Group ◽

Opioid Overdose ◽

Canadian Guideline ◽

Effective Use ◽

The Impact

Abstract Background The Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain (COG) was developed in response to increasing rates of opioid-related hospital visits and deaths in Canada, and uncertain benefits of opioids for chronic non-cancer pain (CNCP). Following publication, we developed a list of evaluable outcomes to assess the impact of this guideline on practice and patient outcomes. Methods A working group at the National Pain Centre at McMaster University used a modified Delphi process to construct a list of clinical and patient outcomes important in assessing the uptake and application of the COG. An advisory group then reviewed this list to determine the relevance and feasibility of each outcome, and identified potential data sources. This feedback was reviewed by the National Faculty for the Guideline, and a National Advisory Group that included the creators of the COG, resulting in the final list of 5 priority outcomes. Results Five outcomes were judged clinically important and feasible to measure: 1) Effects of opioids for CNCP on quality of life, 2) Assessment of patient’s risk of addiction before starting opioid therapy, 3) Monitoring patients on opioid therapy for aberrant drug-related behaviour, 4) Mortality rates associated with prescription opioid overdose and 5) Use of treatment agreements with patients before initiating opioid therapy for CNCP. Data sources for these outcomes included patient’s medical charts, e-Opioid Manager, prescription monitoring programs and administrative databases. Conclusion Measuring the impact of best practice guidelines is infrequently done. Future research should consider capturing the five outcomes identified in this study to evaluate the impact of the COG in promoting evidence-based use of opioids for CNCP.

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All-cause mortality in patients with long-term opioid therapy compared with non-opioid analgesics for chronic non-cancer pain: a database study

BMC Medicine ◽

10.1186/s12916-020-01644-4 ◽

2020 ◽

Vol 18 (1) ◽

Author(s):

Winfried Häuser ◽

Tino Schubert ◽

Tobias Vogelmann ◽

Christoph Maier ◽

Mary-Ann Fitzcharles ◽

...

Keyword(s):

Cancer Pain ◽

Opioid Analgesics ◽

Opioid Therapy ◽

Database Study ◽

All Cause Mortality

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Health service utilisation by people living with chronic non-cancer pain: findings from the Pain and Opioids IN Treatment (POINT) study

Australian Health Review ◽

10.1071/ah15047 ◽

2016 ◽

Vol 40 (5) ◽

pp. 490 ◽

Cited By ~ 3

Author(s):

Suzanne Nielsen ◽

Gabrielle Campbell ◽

Amy Peacock ◽

Kimberly Smith ◽

Raimondo Bruno ◽

...

Keyword(s):

Health Insurance ◽

Cancer Pain ◽

Private Health Insurance ◽

Healthcare Services ◽

Opioid Therapy ◽

Limited Evidence ◽

Financial Barriers ◽

Different Types ◽

Before And After

Objective The aims of the present study were to describe the use, and barriers to the use, of non-medication pain therapies and to identify the demographic and clinical correlates of different non-opioid pain treatments. Methods The study was performed on a cohort (n = 1514) of people prescribed pharmaceutical opioids for chronic non-cancer pain (CNCP). Participants reported lifetime and past month use of healthcare services, mental and physical health, pain characteristics, current oral morphine equivalent daily doses and financial and access barriers to healthcare services. Results Participants reported the use of non-opioid pain treatments, both before and after commencing opioid therapy. Services accessed most in the past month were complementary and alternative medicines (CAMs; 41%), physiotherapy (16%) and medical and/or pain specialists (15%). Higher opioid dose was associated with increased financial and access barriers to non-opioid treatment. Multivariate analyses indicated being younger, female and having private health insurance were the factors most commonly associated with accessing non-opioid treatments. Conclusions Patients on long-term opioid therapy report using multiple types of pain treatments. High rates of CAM use are concerning given limited evidence of efficacy for some therapies and the low-income status of most people with CNCP. Financial and insurance barriers highlight the importance of considering how different types of treatments are paid for and subsidised. What is known about the topic? Given concerns regarding long-term efficacy, adverse side-effects and risk of misuse and dependence, prescribing guidelines recommend caution in prescribing pharmaceutical opioids in cases of CNCP, typically advising a multidisciplinary approach to treatment. There is a range of evidence supporting different (non-drug) treatment approaches for CNCP to reduce pain severity and increase functioning. However, little is known about the non-opioid treatments used among those with CNCP and the demographic and clinical characteristics that may be associated with the use of different types of treatments. Understanding the use of non-drug therapy among people with CNCP is crucial given the potential to improve pain control for these patients. What does this paper add? The present study found that a wide range of non-opioid treatments was accessed by the study sample, both before and after commencing opioids, indicating that in this sample opioids were not the sole strategy used for pain management. The most common treatment (other than opioids) was CAM, reported by two-fifths of the sample. Having private health insurance was associated with increased use of non-opioid treatments for pain, highlighting the importance of considering how treatments are paid for and potential financial barriers to effective treatments. What are the implications for practitioners? Patients’ beliefs and financial barriers may affect the uptake of different treatments. Many patients may be using complementary and alternative approaches with limited evidence to support their use, highlighting the need for clinicians to discuss with patients the range of prescribed and non-prescribed treatments they are accessing and to help them understand the benefits and risks of treatments that have not been tested sufficiently, or have inconsistent evidence, as to their efficacy in improving pain outcomes.

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Primary care interventions and current service innovations in modifying long-term outcomes after stroke: a protocol for a scoping review

BMJ Open ◽

10.1136/bmjopen-2016-012840 ◽

2016 ◽

Vol 6 (10) ◽

pp. e012840 ◽

Cited By ~ 2

Author(s):

Dominika M Pindus ◽

Lisa Lim ◽

A Viona Rundell ◽

Victoria Hobbs ◽

Noorazah Abd Aziz ◽

...

Keyword(s):

Primary Care ◽

Scoping Review ◽

Long Term Outcomes

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Capsule Commentary on Behar et al., Acceptability of Naloxone Co-Prescription Among Primary Care Providers Treating Patients on Long-Term Opioid Therapy for Pain

Journal of General Internal Medicine ◽

10.1007/s11606-016-3947-0 ◽

2016 ◽

Vol 32 (3) ◽

pp. 313-313

Author(s):

William Cheung

Keyword(s):

Primary Care ◽

Primary Care Providers ◽

Opioid Therapy ◽

Care Providers

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Improving Adherence to Long-term Opioid Therapy Guidelines to Reduce Opioid Misuse in Primary Care

JAMA Internal Medicine ◽

10.1001/jamainternmed.2017.2468 ◽

2017 ◽

Vol 177 (9) ◽

pp. 1265 ◽

Cited By ~ 52

Author(s):

Jane M. Liebschutz ◽

Ziming Xuan ◽

Christopher W. Shanahan ◽

Marc LaRochelle ◽

Julia Keosaian ◽

...

Keyword(s):

Primary Care ◽

Opioid Therapy ◽

Opioid Misuse ◽

Therapy Guidelines

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Evaluating health and well-being outcomes following the South Gloucestershire Pain Review pilot for patients on long-term opioids for chronic non-cancer pain

British Journal of General Practice ◽

10.3399/bjgp19x703445 ◽

2019 ◽

Vol 69 (suppl 1) ◽

pp. bjgp19X703445

Author(s):

Jo Kesten ◽

Lauren Scott ◽

Kevin Bache ◽

Rosie Closs ◽

Sabi Redwood ◽

...

Keyword(s):

Primary Care ◽

Pain Management ◽

Cancer Pain ◽

Management Strategies ◽

Well Being ◽

Service Users ◽

Opioid Use ◽

The South ◽

Health And Well Being

BackgroundThe South Gloucestershire Pain Review pilot is an individually-tailored service to help primary care patients on long-term (>3 months) treatment with opioid painkillers for chronic non-cancer pain understand their relationship with opioids and support alternative non-drug-based pain management strategies. The pilot was based in two GP practices in South Gloucestershire.AimTo evaluate the health and well-being outcomes and perceived impact of the pilot service to inform future service development.MethodQuantitative data were collected for all enrolled patients on demographics; opioid use, misuse and dose; and pre-post intervention changes in health, well-being, quality of life (QoL), pain intensity/relief, and interference with life measures. Twenty-five semi-structured interviews (18 service users, seven service providers) explored experiences of the pilot including perceived impacts.ResultsFifty-nine patients were invited to use the service and 34 (58%) enrolled. The median prescribed opioid dose reduced from 90 mg (interquartile range [IQR] 60–240) at baseline to 72 mg (IQR 30–160) at follow-up (P<0.001). On average, service users showed improvement on all health, well-being, and QoL outcomes except pain relief. The service was received positively. Perceived benefits related to well-being and QoL, use of pain management strategies (for example pacing), changes in medication use and changes in primary care use.ConclusionThe pilot has shown promising results. The service was viewed as acceptable and health and well-being outcomes suggest a benefit. Following further development of the service, a randomised controlled trial is needed to formally test the effects of this type of care pathway on pain management and reducing long-term opioid use.

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