The role of pharmacists in opioid stewardship: A scoping review

BackgroundThe opioid epidemic is an international public health concern. Pharmacists are in a strategic position to promote and implement effective opioid stewardship due to both their central role on health care teams and frequent interaction with patients. Despite this integral role, pharmacists do not have harmonized scopes of practice in opioid stewardship.ObjectivesThis scoping review was conducted to identify and critically review the role of pharmacists in opioid stewardship and identify future areas of study.MethodsThe scoping review was conducted according to the methodological framework proposed by Arksey and O'Malley, which was further modified by the Joanna Briggs Institute. Six databases were searched for original, peer-reviewed research; PubMed (MEDLINE), Ovid Embase, Ovid International Pharmaceutical Abstracts, Scopus, Cochrane Library, and APA PsycInfo.ResultsIn 92% of the included studies (n = 77), opioid stewardship interventions led by either a pharmacist or in an interdisciplinary team resulted in improvements in at least one outcome measure, with education and medication therapy adjustments being the most predominant activities. Other areas supported by evidence include community stakeholder education, policy and guideline setting, and risk assessment.ConclusionThis scoping review provides valuable insight into the various roles pharmacists can have in opioid stewardship. The findings from this review identified opioid stewardship activities that can make significant contributions towards reducing the impact of the opioid crisis. This review informs future research and has the potential to influence pharmacy practice on a national and international scale.     

Evaluation of a web-based palliative care pain management module for housestaff

The objectives of this study were to determine internal medicine residents' knowledge of outpatient palliative care pain management, describe the association of level of training with knowledge, and evaluate the impact on knowledge of a web-based, interactive, evidence-based educational module. We developed the module using established educational principles, based on review of other educational materials, guidelines, and the medical literature. The module included pretest and post-test questions, case studies, didactic sections, and web links. Six hundred twelve housestaff in 35 training programs in 19 states completed the module during the 2005–2006 academic year (196 [32.0%] postgraduate year [PGY]-1, 200 [32.7%] PGY-2, and 216 [35.3%] PGY-3). The mean pretest score was 54.4% (range 31.1%–84.6%); scores were lowest for specific pain management knowledge questions, including appropriate titration of breakthrough opioid doses (mean 31.1% correct) and appropriate initial use of opioids (40.7% correct). Pretest scores were not significantly different by level of training (52.2% for PGY-1 and 56.7% for PGY-3). The mean post-test score was 72.8%, a statistically significant increase from the pretest overall (P < 0.001) and for seven of the 10 learning objectives (P < 0.001). These findings indicate that housestaff lacked knowledge in many areas of palliative care pain management, and knowledge did not increase with time spent in residency. The large increase in test scores after the module suggests that this may be an effective component of a comprehensive palliative care curriculum.     

Differential effects of morphine on the affective and the sensory component of carrageenan-induced nociception in the rat

Pain is generally considered to have a sensory and an affective component. Clinical research has suggested that morphine more potently attenuates the affective component as compared to the sensory component. Because preclinical nociception models typically focus on the sensory component of nociception, and do not assess the affective component, it is unclear whether this potency difference of morphine can also be found in preclinical models. We therefore adapted the place conditioning paradigm to investigate negative affect accompanying carrageenan-induced (0.5% intraplantar) inflammatory nociception in rats. We found that carrageenan produced clear conditioned place aversion (CPA). Morphine (0.01-10mg/kg i.p.) dose-dependently reduced carrageenan-induced CPA with a minimal effective dose (MED) of 0.03mg/kg. Since morphine has a rewarding effect by itself, morphine-induced conditioned place preference (CPP) was also investigated. Morphine induced CPP with a MED of 1mg/kg, suggesting that the rewarding effect of morphine was not responsible for reducing carrageenan-induced CPA. We also demonstrated that morphine reduced carrageenan-induced mechanical nociception as assessed in the Randall Selitto paradigm with a MED of 1mg/kg. It is concluded that the CPA model allows for an assessment of the negative affective component of carrageenan-induced nociception. Moreover, morphine was able to reduce the affective component of nociception at doses that did not affect the sensory component of nociception, and this effect was not due to its rewarding properties. The fact that this finding mirrors the clinical situation validates the use of the CPA model for assessing the affective component of nociception.     

Alcohol and smoking behavior in chronic pain patients: The role of opioids

The primary aim of this epidemiological study was to investigate associations between chronic non-cancer pain with or without opioid treatment and the alcohol and smoking behavior. The secondary aims were to investigate self-reported quality of life, sleeping problems, oral health and the use of different health care providers.The Danish health survey of 2005 was based on a region-stratified random sample of 10.916 individuals. Data were collected via personal interviews and self-administrated questionnaires. Respondents suffering from chronic pain were identified through the question ‘Do you have chronic/long-lasting pain lasting 6 months or more?’ The question concerning alcohol intake assessed the frequency of alcohol intake and binge drinking. Smoking behavior assessed the daily number of cigarettes. Individuals reporting chronic pain were stratified into two groups (opioid users and non-opioid users).In all, 7275 individuals completed a personal interview and 5552 individuals completed and returned the self-administrated questionnaire. Responders with a self-reported earlier or present cancer diagnosis were excluded from the study. Hence, the final study population consisted of 5292 individuals.We found, that individuals suffering from chronic pain were less likely to drink alcohol. In opioid users alcohol consumption was further reduced. Cigarette smoking was significantly increased in individuals suffering from chronic pain and in opioid users smoking was further increased. Poor oral health, quality of life and sleep were markedly associated with chronic pain and opioid use. The use of opioids was associated with significantly more contacts to healthcare care providers.     

Continuous infusion of opioid drugs in the treatment of cancer pain: Guidelines for use

Continuous intravenous infusion of opioid drugs is a commonly applied approach to the management of cancer pain. Though rare studies, clinical surveys and anecdotal reports have generally concluded that the technique is both safe and efficacious, the supporting literature is meager, and neither clinical indications nor guidelines for use have been clearly defined. This report reviews the available literature on the use of continuous opioid infusion and proposes guidelines for management in the cancer population. Controlled, prospective trials of this method of drug administration are needed.     

Tolerance to the mydriatic effect of buprenorphine,butorphanol, nalbuphine,and cyclorphan,and cross-tolerance to morphine in mice

An increase in the use of opioid derivatives in the treatment of pain syndrome in clinical practice, and especially in the treatment of cancer, has added impetus to the search for an agent which does not induce tolerance and cross-tolerance to other opiodis. The mydriatic effect of opioids in mice, the correlation between analgesia and mydriasis, and tolerance to the analgesic effect of morphine in mice were evaluated previously. In the present work, tolerance to the mydriatic effect of four agonist-antagonists and cross-tolerance to morphine were examined. Measurement of the pupillary diameter was performed using a binocular operating microscope. Tolerance and cross-tolerance to morphine were developed following a chronic use of buprenorphine, nalbuphine, and cyclorphan. After chronic injection of butorphanol, no tolerance or cross-tolerance to morphine was observed.     

Chronic opioid antagonist treatment: assessment of receptor upregulation

Changes in specific brain opioid binding and opioid pharmacodynamics were determined in mice treated with the opioid antagonist naltrexone (subcutaneously implanted pellets) for 8 days. Chronic opioid antagonist treatment increased the number of binding sites (upregulation) for [³H]naloxone (+55%) and [³H][D-Ala²,D-Leu⁵]enkephalin (+41%) but did not alter the affinity of the ligands, as determined in saturation studies. Displacement studies of [³H]naloxone by morphine also indicated that there was no change in morphine's affinity. In vivo estimation of naloxone affinity (pA₂), agreed with the in vitro results indicating that chronic naltrexone treatment did not alter naloxone affinity. Chronic naltrexone treatment (0.5, 1.0, 15.0 mg pellets) increased the analgesic potency of morphine (supersensitivity) in a dose-dependent manner, up to a maximal increase in relative potency of 1.8. However, in mice tested with the naltrexone pellets still implanted, the 15 mg naltrexone pellet was able to shift the dose-response function for morphine analgesia more than 300-fold. The lowest dose naltrexone pellet (0.5 mg), produced significant antagonism of morphine analgesia, but did not produce significant supersensitivity. Thus, supersensitivity and upregulation are not proportional to the degree of antagonism of opioid effects; and supersensitivity in the mouse is related to increased binding sites and not to changes in receptor affinity as determined by in vivo and in vitro methods.     

Opioid medication and driving ability

In many European countries the use of opioids for long‐term treatment of nonmalignant pain has dramatically increased during the last decade in order to improve the patient's quality of life, to allow an active social life and the return to work. In modern society, driving is regarded as an essential activity of daily living. Since opioids are centrally acting drugs that may interfere with the ability of safely driving a motor vehicle, the question arises of whether or not and on which conditions patients under continuous opioid medication may be considered fit to drive. In this article the evidence from recent studies of opioid effects on driving ability of patients is reviewed. Based on these data, the prerequisites and restrictions for driving under chronic opioid medication are outlined and practical guidelines are proposed.