A survey assessment of clinician perceptions of opioid supply and monitoring requirement policy changes

Objective: Florida-mandated Prescription Drug Monitoring Program (PDMP) use and restricted Schedule II opioid dispensing for acute pain to 3-day supply in 2018. This study assessed physician perception of these policies.Design: A cross-sectional study design.Setting: Large academic medical center.Patients/participants: Physicians in inpatient and outpatient practice, as stratified by physician specialty for psychiatry or addiction medicine (Psych/AM), primary care, and others.Interventions: A survey was administered electronically from July to September 2019, with survey items adapted from published opioid policy evaluations.Main outcome measure: Assessment of physician reason for the use of PDMP and perception of PDMP clinical utility. Responses by specialty were compared via chi square testing.Results: There were N = 214 responses (response rate ~10.9 percent), representing n = 15 from Psych/AM, n = 58 primary care, and n = 143 from other specialties. The most frequently reported reason for PDMP use across specialties was to examine prescribing history for patients currently using opioid analgesics (6.7 percent Psych/AM; 50.1 percent primary care; 38.6 percent others; p = 0.027). Fewer Psych/AM physicians agreed that the policy hinders the clinical work day as compared with primary care physicians (46.7 percent vs. 58.6 percent). More primary care agreed the policy was a good idea relative to Psych/AM (62.1 percent vs. 53.3 percent). More primary care than Psych/AMs agreed that the policy made it more challenging for chronic pain patients to access opioid therapies (77.6 percent vs. 53.3 percent).Conclusions: The perceived workflow burden and unintended consequence of decreased chronic pain patient access to opioid pharmacotherapies suggest further opportunities for pharmacist–physician collaboration in managing affected patients.

Development and Validation of a Predictive Model of Pain Modulation Profile to Guide Chronic Pain Treatment: A Study Protocol

Introduction: Quantitative sensory testing is frequently used in research to assess endogenous pain modulation mechanisms, such as Temporal Summation (TS) and Conditioned Pain Modulation (CPM), reflecting excitatory and inhibitory mechanisms, respectively. Numerous studies found that a dysregulation of these mechanisms is associated with chronic pain conditions. In turn, such a patient's “profile” (increased TS and/or weakened CPM) could be used to recommend different pharmacological treatments. However, the procedure to evaluate these mechanisms is time-consuming and requires expensive equipment that is not available in the clinical setting. In this study, we aim to identify psychological, physiological and socio-demographic markers that could serve as proxies to allow healthcare professionals to identify these pain phenotypes in clinic, and consequently optimize pharmacological treatments.Method: We aim to recruit a healthy participant cohort (n = 360) and a chronic pain patient cohort (n = 108). Independent variables will include psychological questionnaires, pain measurements, physiological measures and sociodemographic characteristics. Dependent variables will include TS and CPM, which will be measured using quantitative sensory testing in a single session. We will evaluate one prediction model and two validation models (for healthy and chronic pain participants) using multiple regression analysis between TS/CPM and our independent variables. The significance thresholds will be set at p = 0.05, respectively.Perspectives: This study will allow us to develop a predictive model to compute the pain modulation profile of individual patients based on their biopsychosocial characteristics. The development of the predictive model is the first step toward the overarching goal of providing clinicians with a set of quick and cheap tests, easily applicable in clinical practice to orient pharmacological treatments.

Clinical Challenges and Considerations in Management of Chronic Pain Patients During a COVID-19 Pandemic

Since the coronavirus disease 2019 (COVID-19) was deemed a pandemic on 11 March 2020, we have seen exponential increases in the number of cases and deaths worldwide. The rapidly evolving COVID-19 situation requires revisions to clinical practice to defer non-essential clinical services to allocate scarce medical resources to the care of the COVID-19 patient and reduce risk to healthcare workers. Chronic pain patients require long-term multidisciplinary management even during a pandemic. Fear of abandonment, anxiety and depression may increase during this period of social isolation and aggravate pain conditions.Whilst physical consults for chronic pain patients were reduced, considerations including continuity of support and analgesia, telemedicine, allied health support and prioritising necessary pain services and interventions, were also taken to ensure biopsychosocial care for them. Chronic pain patients are mostly elderly with multiple comorbidities, and are more susceptible to morbidity and mortality from COVID-19. It is imperative to review pain management practices during the COVID-19 era with respect to infection control measures, re-allocation of healthcare resources, community collaborations, and analgesic use and pain interventions. The chronic pain patient faces a potential risk of functional and emotional decline during a pandemic, increasing healthcare burden in the long term. Clinical decisions on pain management strategies should be based on balancing the risks and benefits to the individual patient. In this commentary, we aim to discuss the basis behind some of the decisions and safeguards that were made at our tertiary pain centre over the last 6 months during the COVID-19 outbreak.

Assessment and Monitoring of Patients With Chronic Pain and Co-occurring Substance Use and Abuse

Substance abuse complicates pain management. The comorbidity of substance abuse and pain is particularly problematic in the United States and Canada, substantially more than in most countries with advanced health care systems. Treatment of pain with long-term opioids, particularly in high doses, is known to be associated with substantial medical comorbidity, unintentional overdoses, and death. Treatment of opioid dependence in the chronic pain patient is necessary for effective pain management, whether or not the patient uses drugs illicitly. Opioids, particularly in high doses, produce central nervous system neuroadaptations that reduce or eliminate analgesic effectiveness and enhance sensitivity to pain in general. The neuroadaptations often result in opioid dependency and, in the long-term, craving. Weaning patients from chronic opioids can be exquisitely difficult if simple dose reduction is attempted. The process can be quite successful and gratifying, however, if certain principles are followed. These include education, comfortable detoxification using long-acting opioids, usually methadone or buprenorphine, nonopioid pain management, psychological support, and coordinated care.