Do Current Policies and Practices for Prescribing Opioid Medications Solve Chronic Pain Problems?

2015 ◽  
Vol 45 (10) ◽  
pp. 500-505
Author(s):  
David Maldow ◽  
Norman S. Miller ◽  
Alexandria Matthews
Keyword(s):  
Chronic Pain ◽  
Opioid Medications ◽  
Policies And Practices

scholarly journals Chronic pain diagnoses and opioid dispensings among individuals with serious mental illness

2019 ◽  
Author(s):  
Ashli Owen-Smith ◽  
Christine Stewart ◽  
Musu M. Sesay ◽  
Sheryl M. Strasser ◽  
Bobbi Jo Yarborough ◽  
...  
Keyword(s):  
Mental Health ◽  
Chronic Pain ◽  
Mental Illness ◽  
Healthcare Utilization ◽  
Serious Mental Illness ◽  
Research Network ◽  
Prescription Opioid ◽  
Medical Comorbidities ◽  
Pain Diagnosis ◽  
Opioid Medications

Abstract Background Individuals with major depressive disorder (MDD) and bipolar disorder (BD) have particularly high rates of chronic non-cancer pain (CNCP) and are also more likely to receive prescription opioids for their pain. However, there have been no known studies published to date that have examined opioid treatment patterns among individuals with schizophrenia. Methods Using electronic medical record data across 13 Mental Health Research Network sites, individuals with diagnoses of MDD (N=65,750), BD (N=38,117) or schizophrenia or schizoaffective disorder (N=12,916) were identified and matched on age, sex and Medicare status to controls with no documented mental illness. CNCP diagnoses and prescription opioid medication dispensings were extracted for the matched samples. Multivariate analyses were conducted to evaluate (1) the odds of receiving a pain-related diagnosis and (2) the odds of receiving opioids, by separate mental illness diagnosis category compared with matched controls, controlling for age, sex, Medicare status, race/ethnicity, income, medical comorbidities, healthcare utilization and chronic pain diagnoses. Results Multivariable models indicated that having a MDD (OR=1.90; 95% CI=1.85–1.95) or BD (OR=1.71; 95% CI=1.66–1.77) diagnosis was associated with increased odds of a CNCP diagnosis after controlling for age, sex, race, income, medical comorbidities and healthcare utilization. By contrast, having a schizophrenia diagnosis was associated with decreased odds of receiving a chronic pain diagnosis (OR=0.86; 95% CI=0.82– 0.90). Having a MDD (OR=2.59; 95% CI=2.44–2.75) or BD (OR=2.12; 95% CI=1.97–2.28) diagnosis was associated with increased odds of receiving chronic opioid medications, even after controlling for age, sex, race, income, medical comorbidities, healthcare utilization and chronic pain diagnosis; having a schizophrenia diagnosis was not associated with receiving chronic opioid medications. Conclusions Individuals with serious mental illness, who are most at risk for developing opioid-related problems, continue to be prescribed opioids more often than their peers without mental illness. Healthcare providers need to be especially conservative in prescribing opioids – or avoid opioid therapy altogether – for this population. Mental health clinicians may be particularly well-suited to lead pain assessment and management efforts for these patients.

Predicting chronic pain after major traumatic injury

2019 ◽  
Vol 19 (3) ◽  
pp. 453-464 ◽  
Author(s):  
Elisabeth B. Powelson ◽  
Brianna Mills ◽  
William Henderson-Drager ◽  
Millie Boyd ◽  
Monica S. Vavilala ◽  
...  
Keyword(s):  
Chronic Pain ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Traumatic Injury ◽  
Opioid Use ◽  
Post Injury ◽  
Regional Analgesia ◽  
Final Model ◽  
Opioid Medications

Abstract Background and aims Chronic pain after traumatic injury and surgery is highly prevalent, and associated with substantial psychosocial co-morbidities and prolonged opioid use. It is currently unclear whether predicting chronic post-injury pain is possible. If so, it is unclear if predicting chronic post-injury pain requires a comprehensive set of variables or can be achieved only with data available from the electronic medical records. In this prospective study, we examined models to predict pain at the site of injury 3–6 months after hospital discharge among adult patients after major traumatic injury requiring surgery. Two models were developed: one with a comprehensive set of predictors and one based only on variables available in the electronic medical records. Methods We examined pre-injury and post-injury clinical variables, and clinical management of pain. Patients were interviewed to assess chronic pain, defined as the presence of pain at the site of injury. Prediction models were developed using forward stepwise regression, using follow-up surveys at 3–6 months. Potential predictors identified a priori were: age; sex; presence of pre-existing chronic pain; intensity of post-operative pain at 6 h; in-hospital opioid consumption; injury severity score (ISS); location of trauma, defined as body region; use of regional analgesia intra- and/or post-operatively; pre-trauma PROMIS Depression, Physical Function, and Anxiety scores; in-hospital Widespread Pain Index and Symptom Severity Score; and number of post-operative non-opioid medications. After the final model was developed, a reduced model, based only on variables available in the electronic medical record was run to understand the “value add” of variables taken from study-specific instruments. Results Of 173 patients who completed the baseline interview, 112 completed the follow-up within 3–6 months. The prevalence of chronic pain was 66%. Opioid use increased from 16% pre-injury to 28% at 3–6 months. The final model included six variables, from an initial set of 24 potential predictors. The apparent area under the ROC curve (AUROC) of 0.78 for predicting pain 3–6 months was optimism-corrected to 0.73. The reduced final model, using only data available from the electronic health records, included post-surgical pain score at 6 h, presence of a head injury, use of regional analgesia, and the number of post-operative non-opioid medications used for pain relief. This reduced model had an apparent AUROC of 0.76, optimism-corrected to 0.72. Conclusions Pain 3–6 months after trauma and surgery is highly prevalent and associated with an increase in opioid use. Chronic pain at the site of injury at 3–6 months after trauma and surgery may be predicted during hospitalization by using routinely collected clinical data. Implications If our model is validated in other populations, it would provide a tool that can be easily implemented by any provider with access to medical records. Patients at risk of developing chronic pain could be selected for studies on preventive strategies, thereby concentrating the interventions to patients who are most likely to transition to chronic pain.

The Demise of Interdisciplinary Chronic Pain Management and Its Relationship to the Scourge of Prescription Opioid Diversion and Abuse

2018 ◽  
Author(s):  
Michael E. Schatman
Keyword(s):  
Chronic Pain ◽  
Pain Management ◽  
Healthcare Providers ◽  
Well Being ◽  
Insurance Companies ◽  
Prescription Opioid ◽  
Pain Medicine ◽  
Opioid Crisis ◽  
Opioid Medications ◽  
Opioid Diversion

Even though the efficacy of interdisciplinary pain management programs is supported, their numbers have decreased and the vast majority of Americans with chronic pain do not have access to them. Insurance companies do not want to pay for these services, hospitals believe they are financial losers, and the opioid crisis has placed a pall over the practice of pain medicine. The demise of these programs has left pain medicine in a fragmented state. Few healthcare providers who treat chronic pain patients have the time to coordinate care by multiple professionals The opioid crisis seen in certain areas, such as Appalachia, may be related to the lack of these interdisciplinary programs. There should be concerted efforts to increase access to and funding of these programs. Although they are not a panacea for all types of chronic pain, they can improve patients’ well-being and function and reduce their need for opioid medications.

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.

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.

scholarly journals Negative Affect–Related Factors Have the Strongest Association with Prescription Opioid Misuse in a Cross-Sectional Cohort of Patients with Chronic Pain

Pain Medicine ◽  
2019 ◽  
Vol 21 (2) ◽  
pp. e127-e138 ◽  
Author(s):  
Gadi Gilam ◽  
John A Sturgeon ◽  
Dokyoung S You ◽  
Ajay D Wasan ◽  
Beth D Darnall ◽  
...  
Keyword(s):  
Chronic Pain ◽  
Substance Use ◽  
Negative Affect ◽  
Substance Use Disorders ◽  
Opioid Misuse ◽  
Related Factors ◽  
Opioid Prescription ◽  
Increased Risk ◽  
Patient Reported ◽  
Opioid Medications

Abstract Objective Increased opioid prescription to relieve pain among patients with chronic pain is associated with increased risk for misuse, potentially leading to substance use disorders and overdose death. We aimed to characterize the relative importance and identify the most significant of several potential risk factors for the severity of self-reported prescribed opioid misuse behaviors. Methods A sample of 1,193 patients (mean age ± SD = 50.72 ± 14.97 years, 64.04% female) with various chronic pain conditions completed a multidimensional registry assessing four pain severity measures and 14 physical, mental, and social health status factors using the National Institutes of Health’s Patient-Reported Outcomes Measurement Information System (PROMIS). A validated PROMIS measure of medication misuse was completed by 692 patients who endorsed currently taking opioid medication. Patients taking opioid medications were compared across all measures with those who do not take opioid medications. Subsequently, a data-driven regression analysis was used to determine which measures best explained variability in severity of misuse. We hypothesized that negative affect–related factors, namely anxiety, anger, and/or depression, would be key predictors of misuse severity due to their crucial role in chronic pain and substance use disorders. Results Patients taking opioid medications had significantly greater impairment across most measures. Above and beyond demographic variables, the only and most significant predictors of prescribed opioid misuse severity were as follows: anxiety (β = 0.15, P = 0.01), anger (β = 0.13, P = 0.02), Pain Intensity–worst (β = 0.09, P = 0.02), and depression (β = 0.13, P = 0.04). Conclusions Findings suggest that anxiety, anger, and depression are key factors associated with prescribed opioid misuse tendencies in patients with chronic pain and that they are potential targets for therapeutic intervention.

scholarly journals Practical Advices for Treating Chronic Pain in the Time of COVID-19: A Narrative Review Focusing on Interventional Techniques

2021 ◽  
Vol 10 (11) ◽  
pp. 2303
Author(s):  
Giuliano Lo Lo Bianco ◽  
Alfonso Papa ◽  
Michael E. Schatman ◽  
Andrea Tinnirello ◽  
Gaetano Terranova ◽  
...  
Keyword(s):  
Chronic Pain ◽  
Interventional Procedures ◽  
Screening Tool ◽  
Scientific Literature ◽  
Narrative Review ◽  
Viral Spread ◽  
Promising Tool ◽  
Opioid Medications ◽  
New Treatments ◽  
Epidural Steroids

Background: Since the management of chronic pain has become even more challenging secondary to the occurrence of SARS-CoV-2 outbreaks, we developed an exhaustive narrative review of the scientific literature, providing practical advices regarding the management of chronic pain in patients with suspected, presumed, or confirmed SARS-CoV-2 infection. We focused particularly on interventional procedures, where physicians are in closer contact with patients. Methods: Narrative Review of the most relevant articles published between June and December of 2020 that focused on the treatment of chronic pain in COVID-19 patients. Results: Careful triage of patients is mandatory in order to avoid overcrowding of hospital spaces. Telemedicine could represent a promising tool to replace in-person visits and as a screening tool prior to admitting patients to hospitals. Opioid medications can affect the immune response, and therefore, care should be taken prior to initiating new treatments and increasing dosages. Epidural steroids should be avoided or limited to the lowest effective dose. Non urgent interventional procedures such as spinal cord stimulation and intrathecal pumps should be postponed. The use of personal protective equipment and disinfectants represent an important component of the strategy to prevent viral spread to operators and cross-infection between patients due to the SARS-CoV-2 outbreaks.

Gender Differences in Pain

2017 ◽  
Author(s):  
Gregory Carpenter ◽  
Meenal Patil
Keyword(s):  
Chronic Pain ◽  
Clinical Findings ◽  
Endogenous Opioid System ◽  
Endogenous Opioid ◽  
Women Studies ◽  
Pain Experience ◽  
Increased Risk ◽  
Sociocultural Differences ◽  
Opioid Medications ◽  
Pain Inhibition

Epidemiologic and clinical findings demonstrate that women are at increased risk for chronic pain, experience greater pain-related distress, and show heightened sensitivity for pain compared to men. There are differences in analgesic responses to pain and to both opioid and non-opioid medications as well as for endogenous analgesic processes. Many stress-related disorders, such as fibromyalgia and chronic pain, are more prevalent in women. Studies of experimentally induced pain show that women exhibit greater pain sensitivity, enhanced pain facilitation, and reduced pain inhibition compared to men. Mechanisms that implicated in the underlying sex differences include biological involvement of estrogen and progesterone versus testosterone. Sex-related differences in pain may also reflect differences in the endogenous opioid system. Other mechanisms include steroid action differences in adulthood, modulation of various biological systems such as the cardiovascular and inflammatory pathways, and sociocultural differences

Pain in the Bleeding Disorders Community: Patient and Caregiver Perspectives

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 2591-2591 ◽  
Author(s):  
Tyler W. Buckner ◽  
Nancy Durben ◽  
Christi Humphrey ◽  
Eric Iglewski ◽  
Jennifer Newman ◽  
...  
Keyword(s):  
Chronic Pain ◽  
Quality Improvement ◽  
Pain Management ◽  
Pain Assessment ◽  
Unmet Needs ◽  
Primary Care Providers ◽  
Advisory Council ◽  
Bleeding Disorders ◽  
Advisory Boards ◽  
Opioid Medications

Abstract Introduction:Pain negatively impacts individuals with bleeding disorders throughout their lives. Despite the high prevalence of pain in this population, the medical literature suggests that 40 to 60% of patients report that their pain is not well controlled. The bleeding disorders community has issued a call to confront this challenge through better prevention of bleeding and subsequent arthropathy and improved assessment and treatment of acute and chronic pain. Current efforts to address these issues lack input from patients and their caregivers (CGs) on how to prioritize specific elements of pain management for future quality improvement and research agendas. The Medical and Scientific Advisory Council of the National Hemophilia Foundation (NHF) created the Pain Initiative Task Force to address these shortcomings. This group aims to contribute to the national effort to improve pain management so that individuals with bleeding disorders can participate fully in their lives. Aims: To better understand the unmet needs of the bleeding disorders community regarding the evaluation and management of acute and chronic pain, and to identify and evaluate outcomes important to patients with bleeding disorders and their caregivers. Methods:We conducted a 1-hour session during the 2016 NHF Annual Meeting entitled "Pain in the Bleeding Disorders Community: A Call to Action." Attendance at the session was voluntary. We collected information from attendees using paper demographics forms, an electronic audience response system, and roundtable discussions. Discussion questions were presented to the group as a whole on pain types, methods of pain assessment, pain management, and perceived unmet needs. Participants were then divided into discussion groups based on whether they were a person with a bleeding disorder (PWBD) or a CG. Table discussions were moderated by a committee member who recorded field notes describing participant responses, topics of discussion, and general concerns expressed by the attendees. Results:36 PWBD and their CGs attended the session (50% patients, 50% CGs). 64% reported having chronic pain. 84% said their pain was assessed using either the 0-10 verbal response scale or the FACES scale. Only 38% reported that their pain was assessed at every clinic visit. Pain was reported as being managed by hematologists (45%), primary care providers (11%), and pain specialists (4%), while 30% reported managing their pain without any healthcare provider input. Fear of addiction to opioid medications was reported by 24% of patients and 15% of CGs. Only 52% of PWBD felt that pain was managed "fairly well" or "very well." PWBD and CG identified problems related to pain assessment, including limitations of the 0-10 pain scale for measuring pain, inadequacy of assessing only currentpain levels, and lack of assessment of sleep problems, mental health issues, and physical function. In addition, CGs noted the absence of assessment of pain's impact on CGs and other family members of patients. Participants identified many areas of pain management that were important to them, including a need for more non-pharmacologic pain treatments and non-opioid pain medications, use of physical therapy to treat/prevent pain, better understanding of the challenges of recognizing and treating pain in children, and concerns about opioids: lack of efficacy, risk of tolerance/dependence/addiction, and provider reluctance to prescribe opioid medications. Participants also felt that more research was needed to understand the role of cannabis. Areas of unmet needs identified by the groups included improvement in pain management education for providers, PWBD, and CGs, expansion of hemophilia treatment center teams to include providers with expertise in pain, improved communication between providers, and more research on prevention and treatment of pain in the bleeding disorders population. Conclusions:PWBD and caregivers identified limitations of the current healthcare delivery system and patient-valued unmet needs related to the assessment and management of pain in individuals with bleeding disorders. This information will serve to aid in prioritizing future quality improvement and research efforts to reduce the impact of pain in the bleeding disorders community. Disclosures Buckner: Novo Nordisk: Consultancy; Genentech: Consultancy; Baxalta: Consultancy. Newman:Novo Nordisk: Consultancy. Santaella:Genentech: Consultancy; Novo Nordisk: Consultancy; CSL Behring: Consultancy. Witkop:Novo Nordisk: Consultancy, Other: Advisory Boards, Speakers Bureau; Pfizer: Consultancy, Research Funding, Speakers Bureau; BioEmergent: Consultancy, Speakers Bureau; Baxalta: Consultancy.

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