scholarly journals A Brief Screening Tool for Opioid Use Disorder: EMPOWER Study Expert Consensus Protocol

2021 ◽  
Vol 8 ◽  
Author(s):  
Dokyoung S. You ◽  
Aram S. Mardian ◽  
Beth D. Darnall ◽  
Chwen-Yuen A. Chen ◽  
Korina De Bruyne ◽  
...  
Keyword(s):  
Chronic Pain ◽  
Screening Tool ◽  
Opioid Therapy ◽  
Opioid Use Disorder ◽  
Opioid Use ◽  
Consensus Protocol ◽  
Patient Centered ◽  
Treatment Pathways ◽  
Opioid Tapering

Growing concerns about the safety of long-term opioid therapy and its uncertain efficacy for non-cancer pain have led to relatively rapid opioid deprescribing in chronic pain patients who have been taking opioid for years. To date, empirically supported processes for safe and effective opioid tapering are lacking. Opioid tapering programs have shown high rates of dropouts and increases in patient distress and suicidal ideation. Therefore, safe strategies for opioid deprescribing that are more likely to succeed are urgently needed. In response to this demand, the EMPOWER study has been launched to examine the effectiveness of behavioral medicine strategies within the context of patient-centered opioid tapering in outpatient settings (https://empower.stanford.edu/). The EMPOWER protocol requires an efficient process for ensuring that collaborative opioid tapering would be offered to the most appropriate patients while identifying patients who should be offered alternate treatment pathways. As a first step, clinicians need a screening tool to identify patients with Opioid Use Disorder (OUD) and to assess for OUD severity. Because such a tool is not available, the study team composed of eight chronic pain and/or addiction experts has extended a validated screening instrument to develop a brief and novel consensus screening tool to identify OUD and assess for OUD severity for treatment stratification. Our screening tool has the potential to assist busy outpatient clinicians to assess OUD among patients receiving long-term opioid therapy for chronic pain.

scholarly journals Impact of Spinal Cord Stimulation on Opioid Dose Reduction: A Nationwide Analysis

Neurosurgery ◽  
2020 ◽  
Vol 88 (1) ◽  
pp. 193-201
Author(s):  
Syed M Adil ◽  
Lefko T Charalambous ◽  
Charis A Spears ◽  
Musa Kiyani ◽  
Sarah E Hodges ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Chronic Pain ◽  
Dose Reduction ◽  
Spinal Cord Stimulation ◽  
Opioid Therapy ◽  
Opioid Use ◽  
Patient Centered ◽  
Opioid Dose ◽  
The Impact

Abstract BACKGROUND Opioid misuse in the USA is an epidemic. Utilization of neuromodulation for refractory chronic pain may reduce opioid-related morbidity and mortality, and associated economic costs. OBJECTIVE To assess the impact of spinal cord stimulation (SCS) on opioid dose reduction. METHODS The IBM MarketScan® database was retrospectively queried for all US patients with a chronic pain diagnosis undergoing SCS between 2010 and 2015. Opioid usage before and after the procedure was quantified as morphine milligram equivalents (MME). RESULTS A total of 8497 adult patients undergoing SCS were included. Within 1 yr of the procedure, 60.4% had some reduction in their opioid use, 34.2% moved to a clinically important lower dosage group, and 17.0% weaned off opioids entirely. The proportion of patients who completely weaned off opioids increased with decreasing preprocedure dose, ranging from 5.1% in the >90 MME group to 34.2% in the ≤20 MME group. The following variables were associated with reduced odds of weaning off opioids post procedure: long-term opioid use (odds ratio [OR]: 0.26; 95% CI: 0.21-0.30; P < .001), use of other pain medications (OR: 0.75; 95% CI: 0.65-0.87; P < .001), and obesity (OR: 0.75; 95% CI: 0.60-0.94; P = .01). CONCLUSION Patients undergoing SCS were able to reduce opioid usage. Given the potential to reduce the risks of long-term opioid therapy, this study lays the groundwork for efforts that may ultimately push stakeholders to reduce payment and policy barriers to SCS as part of an evidence-based, patient-centered approach to nonopioid solutions for chronic pain.

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.

Rating Opioid Use Disorder for Permanent Impairment

2020 ◽  
Vol 25 (1) ◽  
pp. 3-11
Author(s):  
James B. Talmage
Keyword(s):  
Treatment Compliance ◽  
Opioid Therapy ◽  
Opioid Use Disorder ◽  
Extensive Literature ◽  
Opioid Use ◽  
Work Injury ◽  
Sixth Edition ◽  
Diagnostic And Statistical Manual ◽  
History Of

Abstract The duration of opioid therapy after surgery is the strongest known predictor of ultimate misuse, and researchers have reported that the number of days for which medication was prescribed and the total number of postoperative prescriptions each predicts long-term use. This article addresses the question of rating the impairment for an individual with no history of substance use disorder before a work injury, who is prescribed opioids for this injury, and who subsequently develops opioid use disorder (OUD). The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, should be used in conjunction with the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), Sixth Edition. A person who is prescribed opioids is not yet at maximum medical improvement (MMI) and cannot be rated. Referral for substantiation of the diagnosis and for initiation of treatment are necessary before OUD is confirmed and the patient is at MMI. The AMA Guides is based on impairments of activities of daily living (ADL), so a patient's MMI should result in a happy outcome and no impairment, although the burden of treatment compliance may be a relevant consideration. The article concludes with an extensive literature review, including abstracts of published articles regarding OUD in various settings.

A Two-Year Prospective Multicenter Study of Opioid Therapy for Chronic Noncancer Pain: Prescription Trends and Predictors

Pain Medicine ◽  
2018 ◽  
Vol 20 (11) ◽  
pp. 2166-2178 ◽  
Author(s):  
Dalila R Veiga ◽  
Liliane Mendonça ◽  
Rute Sampaio ◽  
José M Castro-Lopes ◽  
Luís F Azevedo
Keyword(s):  
Chronic Pain ◽  
Clinical Outcomes ◽  
Opioid Therapy ◽  
Opioid Use ◽  
Opioid Prescription ◽  
Chronic Noncancer Pain ◽  
Noncancer Pain ◽  
Opioid Users

Abstract Objectives Opioid use in chronic pain has increased worldwide in recent years. The aims of this study were to describe the trends and patterns of opioid therapy over two years of follow-up in a cohort of chronic noncancer pain (CNCP) patients and to assess predictors of long-term opioid use and clinical outcomes. Methods A prospective cohort study with two years of follow-up was undertaken in four multidisciplinary chronic pain clinics. Demographic data, pain characteristics, and opioid prescriptions were recorded at baseline, three, six, 12, and 24 months. Results Six hundred seventy-four CNCP patients were recruited. The prevalence of opioid prescriptions at baseline was 59.6% (N = 402), and 13% (N = 86) were strong opioid prescriptions. At 24 months, opioid prescription prevalence was as high as 74.3% (N = 501), and strong opioid prescription was 31% (N = 207). Most opioid users (71%, N = 479) maintained their prescription during the two years of follow-up. Our opioid discontinuation was very low (1%, N = 5). Opioid users reported higher severity and interference pain scores, both at baseline and after two years of follow-up. Opioid use was independently associated with continuous pain, pain location in the lower limbs, and higher pain interference scores. Conclusions This study describes a pattern of increasing opioid prescription in chronic pain patients. Despite the limited improvement of clinical outcomes, most patients keep their long-term opioid prescriptions. Our results underscore the need for changes in clinical practice and further research into the effectiveness and safety of chronic opioid therapy for CNPC.

scholarly journals The conundrum of opioid tapering in long-term opioid therapy for chronic pain: A commentary

2017 ◽  
Vol 39 (2) ◽  
pp. 152-161 ◽  
Author(s):  
Ajay Manhapra ◽  
Albert J. Arias ◽  
Jane C. Ballantyne
Keyword(s):  
Chronic Pain ◽  
Opioid Therapy ◽  
Opioid Tapering

scholarly journals COVID-19 outcomes among adult patients treated with long-term opioid therapy for chronic non-cancer pain in the USA: a retrospective cohort study

BMJ Open ◽  
2021 ◽  
Vol 11 (11) ◽  
pp. e056436
Author(s):  
Wen-Jan Tuan ◽  
Hannah Spotts ◽  
Aleksandra E Zgierska ◽  
Robert P Lennon
Keyword(s):  
Retrospective Cohort ◽  
Vital Signs ◽  
Severe Infection ◽  
Healthcare Utilisation ◽  
Opioid Therapy ◽  
Opioid Use Disorder ◽  
Research Database ◽  
Opioid Use ◽  
Increased Risk

ObjectivePatients treated with long-term opioid therapy (LTOT) are known to have compromised immune systems and respiratory function, both of which make them particularly susceptible to the SARS-CoV-2 virus. The objective of this study was to assess the risk of developing severe clinical outcomes among COVID-19 non-cancer patients on LTOT, compared with those without LTOT.Design and data sourcesA retrospective cohort design using electronic health records in the TriNetX research database.Participants and setting418 216 adults diagnosed with COVID-19 in January–December 2020 from 51 US healthcare organisations: 9558 in the LTOT and 408 658 in the control cohort. They did not have cancer diagnoses; only a small proportion might have been treated with opioid maintenance for opioid use disorder.ResultsPatient on LTOT had a higher risk ratio (RR) than control patients to visit an emergency department (RR 2.04, 95% CI 1.93 to 2.16) and be hospitalised (RR 2.91, 95% CI 2.69 to 3.15). Once admitted, LTOT patients were more likely to require intensive care (RR 3.65, 95% CI 3.10 to 4.29), mechanical ventilation (RR 3.47, 95% CI 2.89 to 4.15) and vasopressor support (RR 5.28, 95% CI 3.70 to 7.53) and die within 30 days (RR 1.96, 95% CI 1.67 to 2.30). The LTOT group also showed increased risk (RRs from 2.06 to 3.98, all significant to 95% CI) of more-severe infection (eg, cough, dyspnoea, fever, hypoxaemia, thrombocytopaenia and acute respiratory distress syndrome). Statistically significant differences in several laboratory results and other vital signs appeared clinically negligible.ConclusionCOVID-19 patients on LTOT were at higher risk of increased morbidity, mortality and healthcare utilisation. Interventions to reduce the need for LTOT and to increase compliance with COVID-19 protective measures may improve outcomes and reduce healthcare cost in this population. Prospective studies need to confirm and refine these findings.

scholarly journals Comparative Effectiveness of Cognitive Behavioral Therapy for Chronic Pain and Chronic Pain Self-Management within the Context of Voluntary Patient-Centered Prescription Opioid Tapering: The EMPOWER Study Protocol

Pain Medicine ◽  
2019 ◽  
Vol 21 (8) ◽  
pp. 1523-1531 ◽  
Author(s):  
Beth D Darnall ◽  
Sean C Mackey ◽  
Kate Lorig ◽  
Ming-Chih Kao ◽  
Aram Mardian ◽  
...  
Keyword(s):  
Chronic Pain ◽  
Cognitive Behavioral Therapy ◽  
Study Protocol ◽  
Comparative Effectiveness ◽  
Behavioral Therapy ◽  
Self Management ◽  
Prescription Opioid ◽  
Patient Centered ◽  
Opioid Tapering

Abstract Objective. Evidence to date, while sparse, suggests that patients taking long-term opioids require special considerations and protections to prevent potential iatrogenic harms from opioid de-prescribing, such as increased pain or suffering. Following this study protocol, the EMPOWER study seeks to address multiple unmet needs of patients with chronic pain who desire to reduce long-term opioid therapy, and provide the clinical evidence on effective methodology. Methods. EMPOWER applies patient-centered methods for voluntary prescription opioid reduction conducted within a comprehensive, multi-state, 3-arm randomized controlled comparative effectiveness study of three study arms (1) group cognitive behavioral therapy for chronic pain; (2) group chronic pain self-management; and (3) usual care (taper only). Specialized electronic data capture systems collect patient reported symptoms and satisfaction data weekly and monthly during the taper, with real-time clinical alerts and electronic feedback loops informing, documenting, and steering needed care actions. Conclusion. The EMPOWER study seeks to provide granular evidence on patient response to voluntary opioid tapering, and will provide evidence to inform clinical systems changes, clinical care, patient satisfaction, and patient outcomes for opioid reduction.

scholarly journals Opioids and Chronic Pain: An Analytic Review of the Clinical Evidence

2021 ◽  
Vol 2 ◽  
Author(s):  
Stephen E. Nadeau ◽  
Jeffrey K. Wu ◽  
Richard A. Lawhern
Keyword(s):  
Chronic Pain ◽  
Scientific Evidence ◽  
The United States ◽  
Opioid Therapy ◽  
Opioid Use Disorder ◽  
Opioid Use ◽  
Opioid Treatment ◽  
Opioid Dose ◽  
Risk Of Death ◽  
Analytic Review

We conducted an analytic review of the clinical scientific literature bearing on the use of opioids for treatment of chronic non-cancer pain in the United States. There is substantial, albeit not definitive, scientific evidence of the effectiveness of opioids in treating pain and of high variability in opioid dose requirements and side effects. The estimated risk of death from opioid treatment involving doses above 100 MMED is ~0.25%/year. Multiple large studies refute the concept that short-term use of opioids to treat acute pain predisposes to development of opioid use disorder. The prevalence of opioid use disorder associated with prescription opioids is likely &lt;3%. Morbidity, mortality, and financial costs of inadequate treatment of the 18 million Americans with moderate to severe chronic pain are high. Because of the absence of comparative effectiveness studies, there are no scientific grounds for considering alternative non-pharmacologic treatments as an adequate substitute for opioid therapy but these treatments might serve to augment opioid therapy, thereby reducing dosage. There are reasons to question the ostensible risks of co-prescription of opioids and benzodiazepines. As the causes of the opioid crisis have come into focus, it has become clear that the crisis resides predominantly in the streets and that efforts to curtail it by constraining opioid treatment in the clinic are unlikely to succeed.

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