Quality of opioid prescribing in older adults with or without Alzheimer disease and related dementia

Abstract Background Pain is common among individuals with Alzheimer’s disease and related dementias (ADRD), and use of opioids has been increasing over the last decade. Yet, it is unclear to what extent opioids are appropriately prescribed for patients with ADRD and whether the appropriateness of opioid prescribing differs by ADRD status. The objective of this study is to compare the quality of opioid prescribing among patients with or without ADRD who have chronic noncancer pain. Methods A nationally representative cohort study of Medicare beneficiaries aged 50 years or older who had chronic pain but who had no cancer, hospice, or palliative care from 2011 to 2015. Four indicators of potentially inappropriate opioid prescribing were measured in patients residing in communities (75,258 patients with and 435,870 patients without ADRD); five indicators were assessed in patients in nursing homes (NHs) (37,117 patients with and 5128 patients without ADRD). Each indicator was calculated as the proportion of eligible patients with inappropriate opioid prescribing in the year after a chronic pain diagnosis. Differences in proportions between ADRD and non-ADRD groups were estimated using a generalized linear model adjusting for covariates through inverse probability weighting. Results Patients with ADRD versus those without had higher concurrent use of opioids and central nervous system–active drugs (community 44.1% vs 33.3%; NH 58.8% vs 54.1%, both P < 0.001) and no opioids or scheduled pain medications for moderate or severe pain (NH 60.1% vs 52.5%, P < 0.001). The ADRD versus non-ADRD group had higher use of long-term opioids for treating neuropathic pain in communities (21.7% vs 19.5%, P = 0.003) but lower use in NHs (26.9% vs 36.0%, P < 0.001). Use of strong or high-dose opioids when naive to opioids (community 1.5% vs 2.8%; NH 2.5% vs 3.5%) and use of contraindicated opioids (community 0.08% vs 0.12%; NH 0.05% vs 0.21%) were rare for either group. Conclusion Potential inappropriate opioid prescribing in 2 areas of pain care was more common among patients with ADRD than among patients without ADRD in community or NH settings. Further studies aimed at understanding the factors and effects associated with opioid prescribing patterns that deviate from guidelines are warranted.

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

Journal of Opioid Management ◽

10.5055/jom.2021.0684 ◽

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.

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Opioid Prescribing Among Adults With Disabilities in the United States After the 2014 Federal Hydrocodone Rescheduling Regulation

Public Health Reports ◽

10.1177/0033354919892638 ◽

2019 ◽

Vol 135 (1) ◽

pp. 114-123

Author(s):

Victor Liaw ◽

Yong-Fang Kuo ◽

Mukaila A. Raji ◽

Jacques Baillargeon

Keyword(s):

United States ◽

High Risk ◽

The United States ◽

Prescribing Patterns ◽

Prescription Opioid ◽

High Dose ◽

Medicare Beneficiaries ◽

Persons With Disabilities ◽

Adults With Disabilities ◽

Opioid Prescribing

Objectives: Deaths from prescription opioid overdoses have reached an epidemic level in the United States, particularly among persons with disabilities. The 2014 federal rescheduling regulation is associated with reduced opioid prescribing in the general US population; however, to date, no data have been published on this regulation’s effect on persons with disabilities. We examined whether the 2014 hydrocodone rescheduling change was associated with reduced opioid prescribing among adult Medicare beneficiaries with disabilities. Methods: We identified 680 876 Medicare beneficiaries with disabilities aged 21-64 in 2013 and 657 687 in 2015 from a 20% national sample. We examined changes in the monthly opioid-prescribing rates from January 1, 2013, through December 31, 2015. We also compared opioid-prescribing rates in 2013 with rates in 2015. Results: In 2014, the percentage of Medicare beneficiaries with disabilities who received hydrocodone prescriptions decreased by 0.154% per month (95% confidence interval [CI], –0.186 to –0.121, P < .001). The percentage of Medicare beneficiaries with disabilities who received hydrocodone prescriptions decreased from 32.2% in 2013 to 27.7% in 2015, whereas rates of any opioid prescribing, prolonged prescribing (≥90-day supply), and high-dose prescribing (≥100 morphine milligram equivalents per day for >30 days) decreased only modestly, from 50.2% to 49.0%, from 27.4% to 26.5%, and from 7.5% to 7.0%, respectively. Conclusions: The 2014 federal rescheduling of hydrocodone was associated with only minor changes in overall and potentially high-risk opioid-prescribing rates. Neither state variation in long-term prescribing nor beneficiary characteristics explained the changes in persistently high opioid-prescribing rates among adults with disabilities after the 2014 regulation. Future studies should examine patient and provider characteristics underlying the persistent high-risk prescribing patterns in this population.

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Magnesium for the Management of Chronic Noncancer Pain in Adults: Protocol for a Systematic Review (Preprint)

10.2196/preprints.11654 ◽

2018 ◽

Author(s):

Rex Park ◽

Anthony M-H Ho ◽

Gisèle Pickering ◽

Lars Arendt-Nielsen ◽

Mohammed Mohiuddin ◽

...

Keyword(s):

Systematic Review ◽

Chronic Pain ◽

Adverse Effects ◽

Controlled Trials ◽

High Dose ◽

Number Needed To Treat ◽

Cochrane Central Register ◽

Efficacy And Safety ◽

Chronic Noncancer Pain ◽

Noncancer Pain

BACKGROUND Chronic pain is a highly prevalent and complex health problem that is associated with a severe symptom burden, as well as substantial economic and social impact. Many patients with chronic pain still suffer from unrelieved or undertreated pain due to the incomplete efficacy and dose-limiting adverse effects of current therapies. Long-term and high-dose opioid use has considerably increased in the past 20 years despite limited evidence supporting its effectiveness in several chronic pain conditions, and serious concerns have emerged regarding adverse effects and potential misuse. Until recently, the steady increase in opioid prescribing rates has been associated with rising opioid-related mortality and other serious problems, emphasizing the need for better nonopioid therapies. Emerging evidence supports the safe use of magnesium in controlling chronic pain, but its overall efficacy and safety is still unclear. OBJECTIVE This paper aims to assess the efficacy and safety of magnesium compared with a placebo for the treatment of chronic noncancer pain. METHODS We will conduct a detailed search on Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE from their inception until the date the searches are run to identify relevant randomized controlled trials. The reference lists of retrieved studies as well as Web-based trial registries will also be searched. We will include randomized double-blind trials comparing magnesium (at any dose, frequency, or route of administration) with placebo using participant-reported pain assessment. Two reviewers will independently evaluate studies for eligibility, extract data, and assess trial quality and potential bias. Risk of bias will be assessed using criteria outlined in the Cochrane Handbook for Systematic Review of Interventions. Primary outcomes for this review will include any validated measure of pain intensity or pain relief. Dichotomous data will be used to calculate the risk ratio and number needed to treat or harm. The quality of evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS This protocol is grant-funded and has undergone a peer-review process through the Queen’s University Department of Anesthesiology and Perioperative Medicine Vandewater Endowed Studentship. This project is also supported, in part, by the Chronic Pain Network of the Canadian Institutes of Health Research Strategy for Patient-Oriented Research. The electronic database search strategies are currently being developed and modified. The entire review is expected to be completed by January 1, 2019. CONCLUSIONS The completion of this review is expected to identify available high-quality evidence describing the efficacy and safety of magnesium for the treatment of chronic noncancer pain. INTERNATIONAL REGISTERED REPOR PRR1-10.2196/11654

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

British Journal of General Practice ◽

10.3399/bjgp20x711581 ◽

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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A Mapping Literature Review of Medical Cannabis Clinical Outcomes and Quality of Evidence in Approved Conditions in the USA from 2016 to 2019

Medical Cannabis and Cannabinoids ◽

10.1159/000515069 ◽

2021 ◽

pp. 1-22

Author(s):

Sebastian Jugl ◽

Aimalohi Okpeku ◽

Brianna Costales ◽

Earl J. Morris ◽

Golnoosh Alipour-Haris ◽

...

Keyword(s):

Systematic Reviews ◽

The Body ◽

Medical Cannabis ◽

High Quality ◽

Chronic Noncancer Pain ◽

High Quality Evidence ◽

Improved Outcomes ◽

Noncancer Pain ◽

Study Setting

In 2017, a National Academies of Sciences, Engineering, and Medicine (NASEM) report comprehensively evaluated the body of evidence regarding cannabis health effects through the year 2016. The objectives of this study are to identify and map the most recently (2016–2019) published literature across approved conditions for medical cannabis and to evaluate the quality of identified recent systematic reviews, published following the NASEM report. Following the literature search from 5 databases and consultation with experts, 11 conditions were identified for evidence compilation and evaluation: amyotrophic lateral sclerosis, autism, cancer, chronic noncancer pain, Crohn’s disease, epilepsy, glaucoma, human immunodeficiency virus/AIDS, multiple sclerosis (MS), Parkinson’s disease, and posttraumatic stress disorder. A total of 198 studies were included after screening for condition-specific relevance and after imposing the following exclusion criteria: preclinical focus, non-English language, abstracts only, editorials/commentary, case studies/series, and non-U.S. study setting. Data extracted from studies included: study design type, outcome definition, intervention definition, sample size, study setting, and reported effect size. Few completed randomized controlled trials (RCTs) were identified. Studies classified as systematic reviews were graded using the Assessing the Methodological Quality of Systematic Reviews-2 tool to evaluate the quality of evidence. Few high-quality systematic reviews were available for most conditions, with the exceptions of MS (9 of 9 graded moderate/high quality; evidence for 2/9 indicating cannabis improved outcomes; evidence for 7/9 indicating cannabis inconclusive), epilepsy (3 of 4 graded moderate/high quality; 3 indicating cannabis improved outcomes; 1 indicating cannabis inconclusive), and chronic noncancer pain (12 of 13 graded moderate/high quality; evidence for 7/13 indicating cannabis improved outcomes; evidence from 6/7 indicating cannabis inconclusive). Among RCTs, we identified few studies of substantial rigor and quality to contribute to the evidence base. However, there are some conditions for which significant evidence suggests that select dosage forms and routes of administration likely have favorable risk-benefit ratios (i.e., epilepsy and chronic noncancer pain). The body of evidence for medical cannabis requires more rigorous evaluation before consideration as a treatment option for many conditions, and evidence necessary to inform policy and treatment guidelines is currently insufficient for many conditions.

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Perceptions and Impact of the 2017 Canadian Guideline for Opioid Therapy and Chronic Noncancer Pain: A Cross-Sectional Study of Canadian Physicians

Pain Research and Management ◽

10.1155/2020/8380171 ◽

2020 ◽

Vol 2020 ◽

pp. 1-6

Author(s):

Jason W. Busse ◽

Joyce Douglas ◽

Tara S. Chauhan ◽

Bilal Kobeissi ◽

Jeff Blackmer

Keyword(s):

Online Survey ◽

Preliminary Evidence ◽

Opioid Therapy ◽

Cross Sectional Study ◽

High Dose ◽

Cross Sectional ◽

Chronic Noncancer Pain ◽

Canadian Guideline ◽

Opioid Tapering ◽

Noncancer Pain

Background. Physician adherence to guideline recommendations for the use of opioids to manage chronic pain is often limited. Objective. In February 2018, we administered a 28-item online survey to explore perceptions of the 2017 Canadian guideline for opioid therapy and chronic noncancer pain and if physicians had altered practices in response to recommendations. Results. We invited 34,322 Canadian physicians to complete our survey, and 1,128 responded for a response rate of 3%; 687 respondents indicated they prescribed opioids for noncancer pain and answered survey questions about the guideline and their practice. Almost all were aware of the guideline, 94% had read the document, and 89% endorsed the clarity as good or excellent. The majority (86%) felt the guideline was feasible to implement, but 66% highlighted resistance by patients, and 63% the lack of access to effective nonopioid treatment as barriers. Thirty-six percent of respondents mistakenly believed the guideline recommended mandatory tapering for patients using high-dose opioid therapy (≥90 mg morphine equivalent per day), and 58% felt they would benefit from support for opioid tapering. Seventy percent of respondents had changed practices to align with guideline recommendations, with 51% engaging some high-dose patients in opioid tapering and 43% reducing the number of new opioid starts. Conclusion. There was high awareness of the 2017 Canadian opioid guideline among respondents, and preliminary evidence that recommendations have changed practice to better align with the evidence. Ongoing education is required to avoid the misunderstanding that opioid tapering is mandatory, and research to identify effective strategies to manage chronic noncancer pain is urgently needed.

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A Review of the Use of Methadone for the Treatment of Chronic Noncancer Pain

Pain Research and Management ◽

10.1155/2005/286713 ◽

2005 ◽

Vol 10 (3) ◽

pp. 133-144 ◽

Cited By ~ 33

Author(s):

Mary E Lynch

Keyword(s):

Chronic Pain ◽

Low Cost ◽

Interindividual Variation ◽

Duration Of Action ◽

Chronic Noncancer Pain ◽

Opioid Dose ◽

Long Duration ◽

Attractive Option ◽

Noncancer Pain ◽

High Bioavailability

Methadone, although having been available for approximately half a century, is now receiving increasing attention in the management of chronic pain. This is due to recent research showing that methadone exhibits at least three different mechanisms of action including potent opioid agonism, N-methyl-D-aspartate antagonism and monoaminergic effects. This, along with methadone's excellent oral and rectal absorption, high bioavailability, long duration of action and low cost, make it a very attractive option for the treatment of chronic pain. The disadvantages of significant interindividual variation in pharmacokinetics, graduated dose equivalency ratios based on prerotation opioid dose when switching from another opioid, and the requirement for special exemption for prescribing methadone make it more complicated to use. The present review is intended to educate physicians interested in adding methadone to their armamentarium for assisting patients with moderate to severe pain.

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The effects of a multiday (10–14 days) subanesthetic dose IV ketamine infusion in the treatment of refractory chronic pain

Pain Management ◽

10.2217/pmt-2021-0064 ◽

2021 ◽

Author(s):

Amokrane Chebini ◽

Sina Marzoughi ◽

Jason Randhawa ◽

Daphne Guh ◽

Stephen Wiseman ◽

...

Keyword(s):

Chronic Pain ◽

Prospective Trial ◽

Pain Syndrome ◽

Chronic Patients ◽

Chronic Neuropathic Pain ◽

Chronic Noncancer Pain ◽

Ketamine Infusion ◽

Pain Syndromes ◽

Clinically Significant ◽

Noncancer Pain

Aim: Ketamine is an anesthetic agent that at lower doses can be a potent analgesic. There has been an interest in the use of low dose ketamine in treatment of chronic pain syndromes. Patients & methods: We report the results of a retrospective observational study for patients diagnosed with a chronic noncancer pain syndrome receiving a 2-week continuous subanesthetic IV ketamine infusion. Results & conclusion: We conclude that a 10–14 days of subanesthetic ketamine infusion in chronic patients results in clinically significant lowering of patients' numerical pain score. Further studies looking at subanesthetic ketamine infusion in a prospective trial of multi-day IV ketamine infusion in chronic refractory chronic neuropathic pain are needed to further assess the efficacy of ketamine.

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Health-Related Quality of Life among Chronic Opioid Users, Nonchronic Opioid Users, and Nonopioid Users with Chronic Noncancer Pain

Health Services Research ◽

10.1111/1475-6773.12836 ◽

2018 ◽

Vol 53 (5) ◽

pp. 3329-3349 ◽

Cited By ~ 7

Author(s):

Corey J. Hayes ◽

Xiaocong Li ◽

Chenghui Li ◽

Anuj Shah ◽

Niranjan Kathe ◽

...

Keyword(s):

Quality Of Life ◽

Health Related Quality ◽

Chronic Noncancer Pain ◽

Related Quality ◽

Health Related ◽

Noncancer Pain ◽

Opioid Users

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Systematic Pain Assessment and Management

Palliative Care in Nephrology ◽

10.1093/med/9780190945527.003.0015 ◽

2020 ◽

pp. 148-166

Author(s):

Sara N. Davison

Keyword(s):

Quality Of Life ◽

Chronic Kidney Disease ◽

Chronic Pain ◽

Pain Assessment ◽

Prescribing Patterns ◽

Symptom Screening ◽

Chronic Disorder ◽

Psychosocial Consequences ◽

Clinically Significant

Patients with chronic kidney disease suffer from high rates of pain. Pain is a highly complex, multidimensional, and personal phenomenon with far reaching physical and psychosocial consequences if the pain progresses to become a chronic disorder. Systematic integration of global symptom screening needs to be incorporated into routine kidney care, followed by a comprehensive pain assessment for those with clinically significant pain, keeping in mind the overall goal is to promote functionality and quality of life and not to necessarily completely resolve the pain. There is tremendous variability within and between countries in the management of pain, including the prescribing patterns of analgesics. This chapter outlines a systematic approach to the assessment and management of acute and chronic pain with both nonpharmacologic and pharmacologic interventions.

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