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 <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.

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.

scholarly journals Project MIMIC (Maximizing Implementation of Motivational Incentives in Clinics): A cluster-randomized type 3 hybrid effectiveness-implementation trial

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Sara J. Becker ◽  
Cara M. Murphy ◽  
Bryan Hartzler ◽  
Carla J. Rash ◽  
Tim Janssen ◽  
...  
Keyword(s):  
Public Health ◽  
Patient Outcomes ◽  
The United States ◽  
Opioid Use Disorder ◽  
Treatment Programs ◽  
Opioid Use ◽  
Opioid Treatment ◽  
Implementation Outcomes ◽  
Cluster Randomized ◽  
Type 3

Abstract Background Opioid-related overdoses and harms have been declared a public health emergency in the United States, highlighting an urgent need to implement evidence-based treatments. Contingency management (CM) is one of the most effective behavioral interventions when delivered in combination with medication for opioid use disorder, but its implementation in opioid treatment programs is woefully limited. Project MIMIC (Maximizing Implementation of Motivational Incentives in Clinics) was funded by the National Institute on Drug Abuse to identify effective strategies for helping opioid treatment programs improve CM implementation as an adjunct to medication. Specific aims will test the impact of two different strategies on implementation outcomes (primary aim) and patient outcomes (secondary aims), as well as test putative mediators of implementation effectiveness (exploratory aim). Methods A 3-cohort, cluster-randomized, type 3 hybrid design is used with the opioid treatment programs as the unit of randomization. Thirty programs are randomized to one of two conditions. The control condition is the Addiction Technology Transfer Center (ATTC) Network implementation strategy, which consists of three core approaches: didactic training, performance feedback, and on-going consultation. The experimental condition is an enhanced ATTC strategy, with the same core ATTC elements plus two additional theory-driven elements. The two additional elements are Pay-for-Performance, which aims to increase implementing staff’s extrinsic motivations, and Implementation & Sustainment Facilitation, which targets staff’s intrinsic motivations. Data will be collected using a novel, CM Tracker tool to document CM session delivery, session audio recordings, provider surveys, and patient surveys. Implementation outcomes include CM Exposure (number of CM sessions delivered per patient), CM Skill (ratings of CM fidelity), and CM Sustainment (number of patients receiving CM after removal of support). Patient outcomes include self-reported opioid abstinence and opioid-related problems (both assessed at 3- and 6-months post-baseline). Discussion There is urgent public health need to improve the implementation of CM as an adjunct to medication for opioid use disorder. Consistent with its hybrid type 3 design, Project MIMIC is advancing implementation science by comparing impacts of these two multifaceted strategies on both implementation and patient outcomes, and by examining the extent to which the impacts of those strategies can be explained by putative mediators. Trial registration: This clinical trial has been registered with clinicaltrials.gov (NCT03931174). Registered April 30, 2019. https://clinicaltrials.gov/ct2/show/NCT03931174?term=project+mimic&draw=2&rank=1

scholarly journals Kratom Use Within the Context of the Evolving Opioid Crisis and the COVID-19 Pandemic in the United States

2021 ◽  
Vol 12 ◽  
Author(s):  
Walter C. Prozialeck ◽  
Peter C. Lamar ◽  
Michael Krupp ◽  
Matthew Moon ◽  
Laura E. Phelps ◽  
...  
Keyword(s):  
United States ◽  
Chronic Pain ◽  
Southeast Asia ◽  
The United States ◽  
Opioid Use Disorder ◽  
Opioid Withdrawal ◽  
Opioid Use ◽  
Potential Harm ◽  
History Of ◽  
Chronic Pain Conditions

Kratom (Mitragyna speciosa, Korth.) is an evergreen tree that is indigenous to Southeast Asia. When ingested, kratom leaves or decoctions from the leaves have been reported to produce complex stimulant and opioid-like effects. For generations, native populations in Southeast Asia have used kratom products to stave off fatigue, improve mood, alleviate pain and manage symptoms of opioid withdrawal. Despite the long history of kratom use in Asia, it is only within the past 10–20 years that kratom has emerged as an important herbal agent in the United States, where it is being used for the self-treatment of pain, opioid withdrawal symptoms, and mood disorders. The increase in the use of kratom in the United States has coincided with the serious epidemic of opioid abuse and dependence. Since 2015, efforts to restrict access to prescription opioids have resulted in a marked increase in the use of “street” opioids such as heroin and illicit fentanyl. At the same time, many patients with chronic pain conditions or opioid use disorder have been denied access to appropriate medical help. The lack of access to care for patients with chronic pain and opioid use disorder has been magnified by the emergence of the COVID-19 pandemic. In this report, we highlight how these converging factors have led to a surge in interest in kratom as a potential harm reduction agent in the treatment of pain and opioid use disorder.

scholarly journals Chronic Opioid Therapy for Chronic Non-Cancer Pain: A Review and Comparison of Treatment Guidelines

2014 ◽  
Vol 5;17 (5;9) ◽  
pp. 401-414
Author(s):  
Chi-Wai Cheung
Keyword(s):  
Chronic Pain ◽  
Adverse Effects ◽  
Cancer Pain ◽  
Practice Guidelines ◽  
Scientific Evidence ◽  
Opioid Therapy ◽  
Scientific Data ◽  
Drug Misuse ◽  
Opioid Use ◽  
Chronic Opioid Therapy

Background: Long-term opioid use for chronic non-cancer pain has increased substantially in recent years despite the paucity of strong supporting scientific data and concerns regarding adverse effects and potential misuse. Study Design: Review and summary of practice guidelines available on PubMed and Cochrane databases as well as on the Internet on chronic opioid therapy from June 2004 to June 2013. Objective: To review expert-developed practice guidelines on chronic opioid therapy, published in different countries over the past decade in order to reveal similar principles of therapy and to provide useful information and references for future development of opioid guidelines to identify adequately supported practice points and areas in need of further scientific evidence. Method: Seven guidelines were identified as pertaining specifically to the long-term use of opioids for general chronic non-cancer pain from an initial search of the PubMed/Medline and Cochrane databases using combinations of the search terms “opioid,” “chronic opioid therapy,” “chronic pain,” “chronic non-cancer pain,” “chronic non-malignant pain,” “guidelines,” “practice guidelines,” and “clinical practice guidelines,” filtered to include only articles on humans published in the English language over the past 10 years. Results: All guidelines espouse an individual approach to management, beginning with a comprehensive patient evaluation, with particular focus on eliciting factors that may indicate potential drug misuse and abuse, and a trial of therapy to determine the course of treatment. Goals of treatment should be adequately discussed with and consented to by the patient. Opioids are generally not recommended as first-line therapy but, when used, clinicians should closely monitor patients for loss of response, adverse effects or aberrant behavior, and revise the treatment plan accordingly. Urine drug testing (UDT) may be used as a tool to monitor for aberrant behavior or drug misuse; opioid rotation may be considered when loss of response or adverse effects are a concern, at a starting dose lower than the calculated equianalgesic dose. Limitations: Information on some African nations, countries in the Middle-East, and Pacific Islands is not available and therefore was not included in this review. Conclusion: There is a growing body of scientific evidence to support opioid use in chronic pain. Future work should focus on continuing to generate good-quality evidence on the longterm benefits of opioid therapy, as well as scientific data to guide drug choice and dosing for specific conditions, populations, and situations. Key words: Chronic pain, opioid, non-cancer pain, guidelines, opioid rotation, pain management, opioid therapy

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 Current status of opioid epidemic in the United Kingdom and strategies for treatment optimisation in chronic pain

2020 ◽  
Author(s):  
Aziza Alenezi ◽  
Asma Yahyouche ◽  
Vibhu Paudyal
Keyword(s):  
Chronic Pain ◽  
United Kingdom ◽  
The United States ◽  
Opioid Use Disorder ◽  
Morbidity And Mortality ◽  
Current Status ◽  
Opioid Epidemic ◽  
Opioid Use ◽  
The United Kingdom ◽  
Treatment Optimisation

AbstractThe increase in opioid prescriptions in the United States has been accompanied by an increase in misuse as well as overdose and toxicity related morbidity and mortality. However, the extent of the increased opioid use, including misuse in the United Kingdom, currently remains less debated. Recent studies in the United Kingdom have shown a rise in opioid use and attributed deaths, particularly in areas with higher deprivation. There are also large variations amongst the devolved nations; Scotland has the highest drug-related deaths and year-on-year increase within Europe. Better clinical guidelines that can enable person-centred management of chronic pain, medicines optimisation, and early diagnosis and treatment of opioid use disorder are crucial to addressing opioid-related morbidity and mortality in the United Kingdom.

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 &gt;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 &lt; .001), use of other pain medications (OR: 0.75; 95% CI: 0.65-0.87; P &lt; .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 Trends in Urine Drug Monitoring Among Persons Receiving Long-Term Opioids and Persons with Opioid Use Disorder in the United States

2021 ◽  
pp. E249-E256
Keyword(s):  
Chronic Pain ◽  
Drug Monitoring ◽  
Opioid Analgesics ◽  
The United States ◽  
Opioid Use Disorder ◽  
Prescription Opioid ◽  
Administrative Claims ◽  
Opioid Use ◽  
Urine Drug ◽  
Prescription Opioid Analgesics

BACKGROUND: Practice guidelines recommend urine drug monitoring (UDM) at least annually in the setting of chronic opioid therapy as an objective assessment of substance use. However, empirical evidence on who gets tested and how often testing occurs is lacking. OBJECTIVES: This study investigates 10-year UDM trends in the United States based on 2 factors: (1) the duration of prescription opioid treatment, and (2) having an opioid use disorder (OUD) diagnosis and medications for opioid use disorder (MOUD) prescriptions. STUDY DESIGN: Observational cross-sectional study. SETTING: Research was conducted using administrative claims data from Optum’s deidentified Clinformatics Data Mart Database for the period 2007 to 2016. The dataset contained information on the plan enrollment and health care claims from 50 states and the District of Columbia. METHODS: To examine trends in UDM based on the duration of prescription opioid treatment, persons receiving prescription opioid analgesics were categorized into 4 groups based on the number of days covered: (a) less than 90 days, (b) 90 to 179 days, (c) 180 to 269 days, and (d) at least 270 days. To examine trends based on an OUD diagnosis and MOUD prescriptions, persons diagnosed with OUD were identified and categorized based on the presence of MOUD prescriptions as follows: (a) OUD with buprenorphine (BPN) and naltrexone (NTX) in the same year; (b) OUD with BPN only; (c) OUD with NTX only; (d) OUD with chronic prescription opioid analgesics (≥ 90 days); (e) OUD without prescription opioid analgesics, BPN, or NTX; and (f) chronic prescription opioid analgesics (≥ 90 days) without an OUD diagnosis. For analysis, the percent receiving UDM was estimated per group per year. Then the data were restricted to those receiving at least one UDM to estimate the average number of UDM per person. RESULTS: Data included an average of 364,485 persons per year receiving prescription opioid analgesics for chronic use, and 10,277 per year receiving an OUD diagnosis. Among those receiving prescription opioid analgesics, less than 50% received UDM. For those receiving at least one UDM, one additional UDM was performed per person as the duration of opioids increased by 90 days. Among persons with OUD, the percent receiving UDM was the highest for those receiving both BPN and NTX (87%), followed by those receiving BPN only (80%), chronic opioids (79%), NTX only (72%), and those not receiving any MOUD/opioids (54%). LIMITATIONS: Methadone dispensing for OUD treatments was not captured in administrative claims data. CONCLUSIONS: Although recommended for patients with chronic pain, UDM is provided less than half of the time for these patients. However, once patients received at least one UDM, they would continue to receive it on a fairly regular basis. Compared with those with chronic pain, persons diagnosed with OUD are more likely to receive UDM at a more frequent interval. KEY WORDS: Urine drug monitoring, urine drug testing, urine drug screening, chronic pain, opioid use disorder, prescription opioid analgesic, buprenorphine, naltrexone, medications for opioid use disorder

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