Opioid Therapy for Chronic Noncancer Pain: Safe, Effective, Appropriate?

2016 ◽  
Author(s):  
Joseph V. Pergolizzi Jr ◽  
Robert B. Raffa ◽  
Robert Taylor ◽  
Jo Ann LeQuang
Keyword(s):  
Risk Factors ◽  
Chronic Pain ◽  
Elderly Patients ◽  
The United States ◽  
Opioid Therapy ◽  
Abuse Liability ◽  
Opioid Abuse ◽  
Individual Risk ◽  
Chronic Noncancer Pain ◽  
Routes Of Administration

In determining the appropriate role of opioids, two public health crises must be balanced: the opioid abuse epidemic and the “silent” crisis of unrelieved chronic pain. Opioids can be used safely and effectively in selected patients; however, clinicians must be aware of their abuse liability and individual risk factors for opioid misuse. A number of opioids are approved for use in the United States, and although there are class effects, there can be great variability among patients with regard to opioid response. In addition to the medication, prescribers must also determine the most appropriate dose and route of administration. Considerations must be made for special population, such as the renally impaired, those with hepatic dysfunction, and pediatric and elderly patients. Another factor is abuse-deterrent properties. Of particular interest as an opioid agent is buprenorphine, which is available in various routes of administration and because of its unique pharmacokinetics may be administered to renally compromised and elderly patients without dosing restrictions. Buprenorphine is also associated with a lower abuse liability than other opioids. Patients suffering moderate to severe pain syndromes should not be denied access to effective pain control, which in some cases may appropriately include opioid therapy. Key words: Buprenorphine, Chronic Pain, Opioid, Opioid Abuse, Opioid Prescribing, Risk Factors for Opioid Abuse

Opioid Therapy for Chronic Noncancer Pain: Safe, Effective, Appropriate?

2016 ◽  
Author(s):  
Joseph V. Pergolizzi Jr ◽  
Robert B. Raffa ◽  
Robert Taylor ◽  
Jo Ann LeQuang
Keyword(s):  
Risk Factors ◽  
Chronic Pain ◽  
Elderly Patients ◽  
The United States ◽  
Opioid Therapy ◽  
Abuse Liability ◽  
Opioid Abuse ◽  
Individual Risk ◽  
Chronic Noncancer Pain ◽  
Routes Of Administration

In determining the appropriate role of opioids, two public health crises must be balanced: the opioid abuse epidemic and the “silent” crisis of unrelieved chronic pain. Opioids can be used safely and effectively in selected patients; however, clinicians must be aware of their abuse liability and individual risk factors for opioid misuse. A number of opioids are approved for use in the United States, and although there are class effects, there can be great variability among patients with regard to opioid response. In addition to the medication, prescribers must also determine the most appropriate dose and route of administration. Considerations must be made for special population, such as the renally impaired, those with hepatic dysfunction, and pediatric and elderly patients. Another factor is abuse-deterrent properties. Of particular interest as an opioid agent is buprenorphine, which is available in various routes of administration and because of its unique pharmacokinetics may be administered to renally compromised and elderly patients without dosing restrictions. Buprenorphine is also associated with a lower abuse liability than other opioids. Patients suffering moderate to severe pain syndromes should not be denied access to effective pain control, which in some cases may appropriately include opioid therapy. Key words: Buprenorphine, Chronic Pain, Opioid, Opioid Abuse, Opioid Prescribing, Risk Factors for Opioid Abuse

scholarly journals An Analysis of Primary Care Clinician Communication About Risk, Benefits, and Goals Related to Chronic Opioid Therapy

2019 ◽  
Vol 4 (2) ◽  
pp. 238146831989257
Author(s):  
Elizabeth C. Danielson ◽  
Olena Mazurenko ◽  
Barbara T. Andraka-Christou ◽  
Julie DiIulio ◽  
Sarah M. Downs ◽  
...  
Keyword(s):  
United States ◽  
Primary Care ◽  
Chronic Pain ◽  
The United States ◽  
Opioid Therapy ◽  
Opioid Overdose ◽  
Chronic Noncancer Pain ◽  
Opioid Prescribing ◽  
Limited Effectiveness ◽  
Pain Care

Background. Safe opioid prescribing and effective pain care are particularly important issues in the United States, where decades of widespread opioid prescribing have contributed to high rates of opioid use disorder. Because of the importance of clinician-patient communication in effective pain care and recent initiatives to curb rising opioid overdose deaths, this study sought to understand how clinicians and patients communicate about the risks, benefits, and goals of opioid therapy during primary care visits. Methods. We recruited clinicians and patients from six primary care clinics across three health systems in the Midwest United States. We audio-recorded 30 unique patients currently receiving opioids for chronic noncancer pain from 12 clinicians. We systematically analyzed transcribed, clinic visits to identify emergent themes. Results. Twenty of the 30 patient participants were females. Several patients had multiple pain diagnoses, with the most common diagnoses being osteoarthritis ( n = 10), spondylosis ( n = 6), and low back pain ( n = 5). We identified five themes: 1) communication about individual-level and population-level risks, 2) communication about policies or clinical guidelines related to opioids, 3) communication about the limited effectiveness of opioids for chronic pain conditions, 4) communication about nonopioid therapies for chronic pain, and 5) communication about the goal of the opioid tapering. Conclusions. Clinicians discuss opioid-related risks in varying ways during patient visits, which may differentially affect patient experiences. Our findings may inform the development and use of more standardized approaches to discussing opioids during primary care visits.

scholarly journals Prescription Opioid Abuse in Chronic Pain: A Review of Opioid Abuse Predictors and Strategies to Curb Opioid Abuse

2012 ◽  
Vol 3S;15 (3S;7) ◽  
pp. S67-ES92 ◽  
Author(s):  
Nalini Sehgal
Keyword(s):  
Chronic Pain ◽  
Opioid Therapy ◽  
Opioid Abuse ◽  
Screening Tools ◽  
Prescription Opioid ◽  
Prescribing Practices ◽  
Chronic Noncancer Pain ◽  
The Past ◽  
Noncancer Pain ◽  
Prescription Opioid Abuse

Both chronic pain and prescription opioid abuse are prevalent and continue to exact a heavy toll on patients, physicians, and society. Individuals with chronic pain and co-occurring substance use disorders and/or mental health disorders, are at a higher risk for misuse of prescribed opioids. Opioid abuse and misuse occurs for a variety of reasons, including self medication, use for reward, compulsive use because of addiction, and diversion for profit. Treatment approaches that balance treating chronic pain while minimizing risks for opioid abuse, misuse, and diversion are much needed. The use of chronic opioid therapy for chronic noncancer pain has increased dramatically in the past 2 decades in conjunction with a marked increase in the abuse of prescribed opioids and accidental opioid overdoses. Consequently, a validated screening instrument that provides an effective and rational method of selecting patients for opioid therapy, predicting risk, and identifying problems once they arise could be of enormous benefit. Such an instrument could potentially curb the risk of iatrogenic addiction. Although several screening instruments and strategies have been introduced in the past decade, there is no single test or instrument that can reliably and accurately predict patients who are not suitable for opioid therapy or identify those who need increased vigilance or monitoring during therapy. At present, screening for opioid abuse includes assessment of premorbid and comorbid substance abuse; assessment of aberrant drug-related behaviors; risk factor stratification; and utilization of opioid assessment screening tools. Multiple opioid assessment screening tools and instruments have been developed by various authors. In addition, urine drug testing, monitoring of prescribing practices, prescription monitoring programs, opioid treatment agreements, and utilization of universal precautions are essential. Presently, a combination of strategies is recommended to stratify risk, identify and understand aberrant drug related behaviors, and tailor treatments accordingly. This manuscript will review the current state of knowledge regarding the growing problem of opioid abuse and misuse; known risk factors; and methods of predicting, assessing, monitoring, and addressing opioid abuse and misuse in patients with chronic noncancer pain. Key words: Opioids, misuse, abuse, chronic pain, prevalence, risk assessment, risk management, drug monitoring, aberrant drug-related behavior

scholarly journals Prescription Opioid Abuse in Chronic Pain: An Updated Review of Opioid Abuse Predictors and Strategies to Curb Opioid Abuse: Part 1

2017 ◽  
Vol 2 (20;2) ◽  
pp. s93-s111 ◽  
Author(s):  
Alan D. Kaye
Keyword(s):  
Chronic Pain ◽  
Cancer Pain ◽  
Drug Testing ◽  
The United States ◽  
Opioid Therapy ◽  
Opioid Abuse ◽  
Screening Tools ◽  
Prescription Opioid ◽  
Self Medication ◽  
Prescription Opioid Abuse

Chronic pain and prescription opioid abuse are extremely prevalent in the United States and worldwide. The consequences of opioid misuse can be life-threatening with significant morbidity and mortality, exacting a heavy toll on patients, physicians, and society. The risk for misuse of prescribed opioids is much higher in patients with chronic pain, especially those with concurrent substance use and /or mental health disorders. Several reasons can account for the occurrence of opioid abuse and misuse, including self-medication, use for reward, compulsive use related to addiction, and diversion for profit. There is a need, therefore, for therapeutic approaches that balance treating chronic pain, while minimizing risks for opioid abuse, misuse, and diversion. Chronic opioid therapy for chronic non-cancer pain has seen a dramatic increase throughout the past 2 decades in conjunction with associated increases in the abuse of prescribed opioids and accidental opioid overdoses. Consequently, a validated screening instrument that provides an effective and rational method for selecting patients for opioid therapy, predicting risk, and identifying problems once they have arisen, could be of enormous benefit in clinical practice. An instrument as such has the potential to attenuate the risk of iatrogenic addiction. Despite the recent introduction of various screening strategies and instruments, no single test or instrument can reliably and accurately predict those patients unsuitable for opioid therapy or pinpoint those requiring heightened degrees of surveillance and monitoring throughout their therapy. Current opioid abuse screening tactics include assessing premorbid and comorbid substance abuse; assessing aberrant drug-related behaviors; stratification of risk factors; and utilizing opioid assessment screening tools. Several authors have contributed numerous screening tools and instruments to aid the assessment of appropriate opioid therapy. Additional essential measures include urine drug testing, prescription practice monitoring programs, opioid treatment agreements, and implementing universal precautions. Presently accepted recommendations consist of a combination of strategies designed to stratify risk, to identify and to understand aberrant drug-related behaviors, and to tailor treatments accordingly. This manuscript, Part 2 of a 2 part update, builds on the 2012 opioid guidelines published in Pain Physician, and the 2016 guidelines released by the Centers for Disease Control and Prevention. It reviews screening, monitoring, and addressing opioid abuse and misuse in patients with chronic non-cancer pain. Key words: Opioids, misuse, abuse, chronic pain, prevalence, risk assessment, risk management, drug monitoring, aberrant drug-related behavior

scholarly journals Individual and Environmental Factors Associated with Recurrent Falls in Elderly Patients Hospitalized after Falls

2020 ◽  
Vol 17 (7) ◽  
pp. 2441
Author(s):  
Hai Minh Vu ◽  
Long Hoang Nguyen ◽  
Huong Lan Thi Nguyen ◽  
Giang Thu Vu ◽  
Cuong Tat Nguyen ◽  
...  
Keyword(s):  
Risk Factors ◽  
Environmental Factors ◽  
Elderly Patients ◽  
Environmental Conditions ◽  
Social Consequences ◽  
Individual Risk ◽  
Cross Sectional ◽  
Factors Associated ◽  
Recurrent Falls ◽  
The Individual

Falls and recurrent falls cause great health and social consequences in older people. However, these problems are poorly understood in Vietnam. A cross-sectional study was performed at seven hospitals in Thai Binh province, Vietnam, to investigate the individual and environmental factors associated with recurrent falls among elderly patients hospitalized due to fall injuries in Vietnam. A history of recurrent falls within the last 12 months, sociodemographic, health, and clinical characteristics, as well as environmental conditions, were obtained via self-reported interviews. Multivariate logistic and Poisson regression models were used to identify associated factors. Overall, the mean fall episodes in the last 12 months were 1.8 (Standard deviation—SD = 1.2) episodes, and the 12-month prevalence of recurrent falls was 40.5%. The individual risk factors included not receiving fall prevention guidelines, walking with devices, loss of sensation in hand or foot, and using pain relief medications. The environmental risk factors comprised having too-high stairs and not having dry, clean, and nonslippery bathrooms. This study highlights a significantly high 12-month prevalence of recurrent falls in older patients hospitalized after falls in Vietnam. Moreover, regular assessments of functional disabilities and hazardous environmental conditions, as well as the provision of prevention programs, have potential to prevent falls and recurrent falls.

Long-term opioid users with chronic noncancer pain: Assessment of opioid abuse risk and relationship with healthcare resource use

2018 ◽  
Vol 14 (2) ◽  
pp. 131 ◽  
Author(s):  
Anna D. Coutinho, BPharm, PhD ◽  
Kavita Gandhi, BPharm, MS ◽  
Rupali M. Fuldeore, BAMS, MS ◽  
Pamela B. Landsman-Blumberg, MPH, DrPH ◽  
Sanjay Gandhi, PhD
Keyword(s):  
Risk Factors ◽  
At Risk ◽  
Opioid Abuse ◽  
Low Risk ◽  
Chronic Noncancer Pain ◽  
Cart Analysis ◽  
Risk Patients ◽  
Noncancer Pain ◽  
Abuse Risk

Objective: Identify opioid abuse risk factors among chronic noncancer pain (CNCP) patients receiving long-term opioid therapy and assess healthcare resource use (HRU) among patients at elevated abuse risk.Design: Data were obtained from an integrated administrative claims database. Classification and Regression Tree (CART) analysis identified risk factors potentially predictive of opioid abuse, which were used to classify the overall population into cohorts defined by levels of abuse risk. Multivariable logistic regression compared HRU across risk cohorts.Setting: Retrospective cohort study.Patients, participants: 21,072 patients aged ≥18 years diagnosed with ≥1 of 5 types of CNCP and a prescription for Schedule II or III/IV opioid medication used long-term (≥90 days).Main outcome measures: (1) Opioid abuse risk factors; (2) HRU differences between risk cohorts.Results: CART analysis identified four groups at elevated opioid abuse risk defined by three factors (age, daily opioid dose, and total days’ supply of opioids); sensitivity: 70.3 percent, specificity: 74.1 percent, and positive predictive value: 5.6 percent. The analysis results were used to classify patients into low-risk (72.5 percent), at-risk (25.4 percent), and opioid-abuser (2.2 percent) cohorts. In multivariable analysis, emergency department (ED) use was higher among at-risk vs low-risk patients (odds ratio [OR]: 1.14; p < 0.05); hospitalization and ED visits were higher for opioid-abusers vs low-risk patients (OR: 2.33 and 2.14, respectively; p < 0.05).Conclusions: This study identifies a subpopulation of CNCP patients at risk of opioid abuse. However, limited sensitivity and specificity of criteria defining this subpopulation reinforce the importance of physician discretion in patient-level treatment decisions.

Monitoring outcomes during long-term opioid therapy for noncancer pain: Results with the Pain Assessment and Documentation Tool

2005 ◽  
Vol 1 (5) ◽  
pp. 257 ◽  
Author(s):  
Steven D. Passik, PhD ◽  
Kenneth L. Kirsh, PhD ◽  
Laurie Whitcomb, MA ◽  
Jeffrey R. Schein, PhD, MPH ◽  
Mitchell A. Kaplan, PhD ◽  
...  
Keyword(s):  
Chronic Pain ◽  
Side Effects ◽  
Pain Assessment ◽  
The United States ◽  
Opioid Therapy ◽  
Chronic Pain Patients ◽  
Noncancer Pain ◽  
Documentation Tool ◽  
Pain Patients

The increasingly common practice of long-term opioid therapy for chronic noncancer pain must be guided by ongoing assessment of four types of outcomes: pain relief, function, side effects, and drug-related behaviors. Our objective was to gather initial pilot data on the clinical application of a specialized chart note, the Pain Assessment and Documentation Tool (PADT), which was developed and tested with 27 physicians. This pilot test provided the means to collect cross-sectional outcome data on a large sample of opioid-treated chronic pain patients. Each of the physician volunteers (located in a variety of settings across the United States) completed the PADT for a convenience sample of personally treated chronic pain patients who had received at least three months of opioid therapy. Completion of the PADT required a clinical interview, review of the medical chart, and direct clinical observation. Data from the PADTs were collated and analyzed. The results suggested that the majority of patients with chronic pain achieve relatively positive outcomes in the eyes of their prescribing physicians in all four relevant domains with opioid therapy. Analgesia was modest but meaningful, functionality was generally stabilized or improved, and side effects were tolerable. Potentially aberrant behaviors were common but viewed as an indicator of a problem (i.e., addiction or diversion) in only approximately 10 percent of cases. Using the PADT, physician ratings can be developed in four domains. In this sample, outcomes suggested that opioid therapy provided meaningful analgesia.

scholarly journals The Role of Testosterone Supplemental Therapy in Opioid-Induced Hypogonadism: A Retrospective Pilot Analysis

2016 ◽  
Vol 11 (4) ◽  
pp. 1208-1213 ◽  
Author(s):  
Omer A. Raheem ◽  
Sunil H. Patel ◽  
David Sisul ◽  
Tim J. Furnish ◽  
Tung-Chin Hsieh
Keyword(s):  
Chronic Pain ◽  
Rating Scale ◽  
Numerical Rating Scale ◽  
Opioid Therapy ◽  
Total Testosterone ◽  
Chronic Noncancer Pain ◽  
Numerical Rating ◽  
Noncancer Pain ◽  
Supplemental Therapy

Chronic opioid therapy for pain management is known to induce several endocrine changes. The authors examined the effect of testosterone supplemental therapy (TST) in patients with chronic, noncancer pain undergoing opioid therapy. It was hypothesized that treatment of opioid-induced hypogonadism (OIH) can reduce opioid requirements in patients suffering from chronic pain and approve their quality of life. Over 18 months period, patients with OIH were identified in a tertiary referral pain center, Numerical Rating Scale (NRS) pain scores and daily morphine equivalent dose (MED) were the primary outcomes measured. Data were collected and comparative analysis performed between men undergoing TST versus nontreatment group. Twenty-seven OIH patients (total testosterone <300 ng/dL) were identified during the study period. TST group consists of 11 patients, while non-TST group consists of 16 patients as control cohort. Mean patient age (55 and 54.4, p = .4) and basic metabolic index (28.5 and 31.9, p = .07) in TST and non-TST groups, respectively. Mean follow-up total testosterone (ng/dL) was significantly higher after TST compared with the non-TST group (497.5 vs. 242.4 ng/dL, p = .03). Median follow-up NRS was 0 and 2 in the TST and non-TST groups ( p = .02). Mean MED (mg) decreased by 21 mg in TST group and increased by 2.5 mg in non-TST group ( p < .05). This study reports that treatment of OIH with TST can reduce opioid requirements in men with chronic pain as quantified by MED. It also confirms previous reports on the potential effects of OIH and that TST is effective in correcting opioid-induced endocrine abnormalities.

Risk factors for opioid abuse/dependence in hospitalized cancer patients in the United States.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. 11589-11589
Author(s):  
Veli Bakalov ◽  
Amy Tang ◽  
Amulya Yellala ◽  
Laila Babar ◽  
Rupin Shah ◽  
...  
Keyword(s):  
Risk Factors ◽  
Liver Cancer ◽  
Cancer Patients ◽  
Mental Disease ◽  
The United States ◽  
Opioid Abuse ◽  
Screening Tools ◽  
Inhospital Mortality ◽  
Cancer Type ◽  
Increased Risk

11589 Background: Opioid medications are the mainstay for treating cancer pain. Goal of this study was to identify risk factors for opioid abuse/dependence in patients hospitalized with cancer, explore whether risk of opioid abuse/dependence varies by cancer type and to assess whether opioid abuse/dependence in cancer patients effects the outcomes of hospitalization. Methods: The Nationwide Inpatient Sample for the years of 2011-2015 was queried for the analysis. We used ICD-9-CM codes of solid tumors as a primary diagnosis for hospitalization, and opioid abuse/dependence as a secondary diagnosis of the hospitalization. We performed univariate and multivariate logistic regression analyses to examine the association between risk factors and opioid abuse/dependence. Data were analyzed using SAS v9.4 (SAS Institute, Cary, NC). Results: Total of 524,624 patients were included in our cohort. Rate of opioid abuse/dependence was highest in patients with liver cancer (1.77%). Opioid abuse/dependence was less associated with age (>65 years old: OR 0.29, 95% CI 0.21-0.39). Patients with Medicaid insurance associated with increased risk of opioid abuse/dependence comparing to other insurances (OR 5.29, 95% CI 4.78-5.86). Strongest association with opioid abuse/dependence were in patients with liver cancer (OR 6.07, 95% CI 5.11-7.20) followed by head and neck cancer (OR 3.20, 95% CI 2.67-3.84). Substance abuse (OR 9.9, 95% CI 9.04-10.84), mental disease (OR-2.87, 95% CI 2.64-3.13) and nutrition deficiency (OR-2.09, 95% CI 1.90-2.31) were highly associated with opioid abuse dependence. Inhospital mortality rate, total cost of hospitalization, and length of stay were significantly higher in patients with opioid abuse/dependence (Table). Conclusions: We identified risk factors for opioid abuse/dependence in hospitalized patients with cancer and demonstrated that risk of opioid abuse varies by cancer type, and opioid abuse/dependence affects the outcomes of hospitalization. Findings of our study can be used for development of the screening tools with higher sensitivity and specificity for predicting the risk of opioid abuse/dependence in cancer patients.[Table: see text]

Opioid Misuse and Addiction Among Patients With Chronic Pain

2019 ◽  
pp. 339-354
Author(s):  
Marc O. Martel ◽  
Robert N. Jamison
Keyword(s):  
Chronic Pain ◽  
Opioid Therapy ◽  
Screening Tools ◽  
Prescription Opioid ◽  
Opioid Misuse ◽  
Chronic Noncancer Pain ◽  
Medication Misuse ◽  
Opioid Medications ◽  
Noncancer Pain

Chapter 20 provides an introduction to understanding the prevalence and risk factors as well as screening tools for assessing opioid misuse and addiction in patients with chronic pain. In the era of the opioid epidemic in North America and beyond, the use of prescription opioid medications to help improve function in chronic noncancer pain is frequently debated. Out of fear of iatrogenic addiction, litigation, and/or potential medication misuse, some clinicians are refusing to prescribe opioids for chronic pain. Evidence indicates that rates of opioid misuse and addiction are fairly high among chronic pain patients prescribed long-term opioid therapy, but there is consensus that opioids can be safe and effective for carefully selected and monitored patients.

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