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.

scholarly journals Opioid Discontinuation Among Patients Receiving High-Dose Long-Term Opioid Therapy in the Veterans Health Administration

2020 ◽  
Vol 35 (S3) ◽  
pp. 903-909
Author(s):  
Taeko Minegishi ◽  
Melissa M. Garrido ◽  
Michael Stein ◽  
Elizabeth M. Oliva ◽  
Austin B. Frakt
Keyword(s):  
Veterans Health Administration ◽  
Opioid Therapy ◽  
High Dose ◽  
Veterans Health ◽  
Health Administration

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.

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.

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

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.

Women Veterans’ Experiences with Integrated, Biopsychosocial Pain Care: A Qualitative Study

Pain Medicine ◽  
2021 ◽  
Author(s):  
Francesca M Nicosia ◽  
Carolyn J Gibson ◽  
Natalie Purcell ◽  
Kara Zamora ◽  
Jennifer Tighe ◽  
...  
Keyword(s):  
Chronic Pain ◽  
San Francisco ◽  
Women Veterans ◽  
Self Management ◽  
Veterans Health ◽  
Health Administration ◽  
Care Models ◽  
Va Health Care System ◽  
Pain Care ◽  
Gender Specific

Abstract Objectives Biopsychosocial, integrated pain care models are increasingly implemented in the Veterans Health Administration to improve chronic pain care and reduce opioid-related risks, but little is known about how well these models address women veterans’ needs. Design Qualitative, interview-based study. Setting San Francisco VA Health Care System Integrated Pain Team (IPT), an interdisciplinary team that provides short-term, personalized chronic pain care emphasizing functional goals and active self-management. Subjects Women with chronic pain who completed ≥3 IPT sessions. Methods Semistructured phone interviews focused on overall experience with IPT, perceived effectiveness of IPT care, pain care preferences, and suggested changes for improving gender-sensitive pain care. We used a rapid approach to qualitative thematic analysis to analyze interviews. Results Fourteen women veterans (mean age 51 years; range 33–67 years) completed interviews. Interviews revealed several factors impacting women veterans’ experiences: 1) an overall preference for receiving both primary and IPT care in gender-specific settings, 2) varying levels of confidence that IPT could adequately address gender-specific pain issues, 3) barriers to participating in pain groups, and 4) barriers to IPT self-management recommendations due to caregiving responsibilities. Conclusions Women veterans reported varied experiences with IPT. Recommendations to improve gender-sensitive pain care include increased provider training; increased knowledge of and sensitivity to women’s health concerns; and improved accommodations for prior trauma, family and work obligations, and geographic barriers. To better meet the needs of women veterans with chronic pain, integrated pain care models must be informed by an understanding of gender-specific needs, challenges, and preferences.

scholarly journals Predictors of Veterans Health Administration utilization and pain persistence among soldiers treated for postdeployment chronic pain in the Military Health System

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Rachel Sayko Adams ◽  
Esther L. Meerwijk ◽  
Mary Jo Larson ◽  
Alex H. S. Harris
Keyword(s):  
Mental Health ◽  
Health Care ◽  
Chronic Pain ◽  
Veterans Health Administration ◽  
First Year ◽  
Veterans Health ◽  
Health Administration ◽  
Military Health System ◽  
Military Health ◽  
The Military

Abstract Background Chronic pain presents a significant burden for both federal health care systems designed to serve combat Veterans in the United States (i.e., the Military Health System [MHS] and Veterans Health Administration [VHA]), yet there have been few studies of Veterans with chronic pain that have integrated data from both systems of care. This study examined 1) health care utilization in VHA as an enrollee (i.e., linkage to VHA) after military separation among soldiers with postdeployment chronic pain identified in the MHS, and predictors of linkage, and 2) persistence of chronic pain among those utilizing the VHA. Methods Observational, longitudinal study of soldiers returning from a deployment in support of the Afghanistan/Iraq conflicts in fiscal years 2008–2014. The analytic sample included 138,206 active duty soldiers for whom linkage to VHA was determined through FY2019. A Cox proportional hazards model was estimated to examine the effects of demographic characteristics, military history, and MHS clinical characteristics on time to linkage to VHA after separation from the military. Among the subpopulation of soldiers who linked to VHA, we described whether they met criteria for chronic pain in the VHA and pain management treatments received during the first year in VHA. Results The majority (79%) of soldiers within the chronic pain cohort linked to VHA after military separation. Significant predictors of VHA linkage included: VHA utilization as a non-enrollee prior to military separation, separating for disability, mental health comorbidities, and being non-Hispanic Black or Hispanic. Soldiers that separated because of misconduct were less likely to link than other soldiers. Soldiers who received nonpharmacological treatments, opioids/tramadol, or mental health treatment in the MHS linked earlier to VHA than soldiers who did not receive these treatments. Among those who enrolled in VHA, during the first year after linking to the VHA, 49.7% of soldiers met criteria for persistent chronic pain in VHA. Conclusions The vast majority of soldiers identified with chronic pain in the MHS utilized care within VHA after military separation. Careful coordination of pain management approaches across the MHS and VHA is required to optimize care for soldiers with chronic pain.

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

scholarly journals Automated Nationwide Benchmarking Dashboard for Antimicrobial Stewardship Programs within the Veterans’ Health Administration

2021 ◽  
Vol 1 (S1) ◽  
pp. s23-s24
Author(s):  
Michihiko Goto ◽  
Eli Perencevich ◽  
Alexandre Marra ◽  
Bruce Alexander ◽  
Brice Beck ◽  
...  
Keyword(s):  
Acute Care ◽  
Antimicrobial Stewardship ◽  
Risk Adjustment ◽  
Long Term Care ◽  
Antimicrobial Use ◽  
Veterans Health ◽  
Health Administration ◽  
Term Care ◽  
Patient Level

Group Name: VHA Center for Antimicrobial Stewardship and Prevention of Antimicrobial Resistance (CASPAR) Background: Antimicrobial stewardship programs (ASPs) are advised to measure antimicrobial consumption as a metric for audit and feedback. However, most ASPs lack the tools necessary for appropriate risk adjustment and standardized data collection, which are critical for peer-program benchmarking. We created a system that automatically extracts antimicrobial use data and patient-level factors for risk-adjustment and a dashboard to present risk-adjusted benchmarking metrics for ASP within the Veterans’ Health Administration (VHA). Methods: We built a system to extract patient-level data for antimicrobial use, procedures, demographics, and comorbidities for acute inpatient and long-term care units at all VHA hospitals utilizing the VHA’s Corporate Data Warehouse (CDW). We built baseline negative binomial regression models to perform risk-adjustments based on patient- and unit-level factors using records dated between October 2016 and September 2018. These models were then leveraged both retrospectively and prospectively to calculate observed-to-expected ratios of antimicrobial use for each hospital and for specific units within each hospital. Data transformation and applications of risk-adjustment models were automatically performed within the CDW database server, followed by monthly scheduled data transfer from the CDW to the Microsoft Power BI server for interactive data visualization. Frontline antimicrobial stewards at 10 VHA hospitals participated in the project as pilot users. Results: Separate baseline risk-adjustment models to predict days of therapy (DOT) for all antibacterial agents were created for acute-care and long-term care units based on 15,941,972 patient days and 3,011,788 DOT between October 2016 and September 2018 at 134 VHA hospitals. Risk adjustment models include month, unit types (eg, intensive care unit [ICU] vs non-ICU for acute care), specialty, age, gender, comorbidities (50 and 30 factors for acute care and long-term care, respectively), and preceding procedures (45 and 24 procedures for acute care and long-term care, respectively). We created additional models for each antimicrobial category based on National Healthcare Safety Network definitions. For each hospital, risk-adjusted benchmarking metrics and a monthly ranking within the VHA system were visualized and presented to end users through the dashboard (an example screenshot in Figure 1). Conclusions: Developing an automated surveillance system for antimicrobial consumption and risk-adjustment benchmarking using an electronic medical record data warehouse is feasible and can potentially provide valuable tools for ASPs, especially at hospitals with no or limited local informatics expertise. Future efforts will evaluate the effectiveness of dashboards in these settings.Funding: NoDisclosures: None

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