Managing Concerning Behaviors in Patients Prescribed Opioids for Chronic Pain: A Delphi Study

Background

Current guideline-recommended monitoring of patients prescribed long-term opioid therapy (LTOT) for chronic pain will likely result in increased identification of behaviors of concern for misuse and addiction, but there is a dearth of empiric evidence about how these behaviors should be managed.

Objective

To establish expert consensus about treatment approaches for common and challenging concerning behaviors that arise among patients on LTOT.

Design

We used a Delphi approach, which allows for generation of consensus.

Participants

Participants were clinical experts in chronic pain and opioid prescribing recruited from professional societies and other expert groups.

Main Measures

The Delphi process was conducted online, and consisted of an initial brainstorming round to identify common and challenging behaviors, a second round to identify management strategies for each behavior, and two rounds to establish consensus and explore disagreement/uncertainty.

Key Results

Forty-two participants completed round 1, 22 completed round 2, 30 completed round 3, and 28 completed round 4. Half of round 1 participants were female (52%), and the majority were white (83%). Most (71%) were physicians, and most participants practiced in academic primary (40%) or specialty care (19%).The most frequently cited common and challenging behaviors were missing appointments, taking opioids for symptoms other than pain, using more opioid medication than prescribed, asking for an increase in opioid dose, aggressive behavior, and alcohol and other substance use. Across behaviors, participants agreed that patient education and information gathering were important approaches. Participants also agreed that stopping opioids is not important initially, but if initial approaches do not work, tapering opioids and stopping opioids immediately may become important approaches.

Conclusions

This study presents clinical expert consensus on how to manage concerning behaviors among patients on LTOT. Future research is needed to investigate how implementing these management strategies would impact patient outcomes, practice and policy.

     

Prevalence of Interpersonal Abuse in Primary Care Patients Prescribed Opioids for Chronic Pain

Background Interpersonal abuse is associated with clinical problems including chronic pain disorders. Objectives The objective of this study is to describe 30-day and lifetime prevalence of emotional, physical, and sexual abuse found in men and women prescribed opioids for chronic pain. Design Cross-sectional interview is the design of this study. Participants Patients, 1,009, currently prescribed opioids for chronic noncancer pain. They were recruited from the practices of 235 Family Physicians and Internists in Wisconsin. The most common pain diagnoses were arthritis, low back pain, headache, and fibromyalgia/myofascial pain. Measurement Data for this secondary analysis on rates of interpersonal abuse were based on 3 questions from the Addiction Severity Index (ASI) regarding 30-day and lifetime emotional, physical, and sexual abuse. Results Forty-seven percent of women and 22% of men reported a history of lifetime physical abuse. Thirty -five percent of women and 10% of men reported lifetime sexual abuse. Binary logistic regression identified the following variables associated with lifetime physical abuse: female gender (RR 2.81, CI 2.01–3.94), age 31–50 (RR1.77, CI 1.30–2.41), Caucasian (RR1.67, CI 1.19–2.35), increased psychiatric symptoms as measured by the ASI (RR 2.14, CI 1.56–2.94), and lifetime suicide attempts (RR 3.98, CI 2.76–5.74). Conclusions This study reports prevalence of abuse in both men and women prescribed opioids for chronic pain in primary care settings. Subjects who report experiencing interpersonal abuse also report significantly higher rates of suicide attempts and score higher on the ASI psychiatric scale. Screening patients taking opioids for chronic pain for interpersonal abuse may lead to a better understanding of contributors to their physical and mental health.     

Botulinum Toxin A: Evolving Treatment Strategies for the Chronic Pelvic Pain Patient

Chronic pelvic pain syndrome (CPPS) is defined as pain perceived within the structures of the male or female pelvis of at least 6-month duration. The management of CPPS in both men and women poses a challenge to both the clinician and the patient. Botulinum toxin type A (BoNT-A) is known to block the release of neurotransmitters at the neuromuscular junction but also appears to have anti-nociceptive and anti-inflammatory effects. BoNT-A has been used for over two decades to treat conditions associated with pathological muscle hyperactivity. There is emerging evidence that BoNT-A may play a role in treating CPPS when alternate treatments and more conservative measures have been ineffective. Moving forward, well-designed clinical trials are needed to further investigate the utility of BoNT-A use in the treatment of CPPS.     

Influence of Patient Race on Physician Prescribing Decisions: A Randomized On-Line Experiment

BACKGROUND  

Prior research reports black patients have lower medication use for hypercholesterolemia, hypertension, and diabetes.     

Provider Beliefs and Practices Relating to Tobacco Use in Patients Living with HIV/AIDS: A National Survey

The entire online HIV Medical Association US registry was invited to complete a questionnaire regarding beliefs and practices related to smoking in persons living with HIV/AIDS (PLWHAs). 363/486 returned completed questionnaires. Respondents from 43 states reported caring for 76,570 PLWHAs. Only 22.9% had ever received formal tobacco treatment training. Respondents generally agreed that smoking is an important issue in PLWHAs, but reported low levels of cessation-promoting activities. Providers with larger patient panels, “primarily HIV” practices, and formal cessation training had higher questionnaire scores, indicating stronger beliefs in the harms of smoking, benefits of quitting, and effectiveness of cessation strategies.     

HIV Provider Documentation and Actions Following Patient Reports of At-risk Behaviors and Conditions When Identified by a Web-Based Point-of-Care Assessment

We compared same-day provider medical record documentation and interventions addressing depression and risk behaviors before and after delivering point-of-care patient-reported outcomes (PROs) feedback for patients who self-reported clinically relevant levels of depression or risk behaviors. During the study period (1 January 2006–15 October 2010), 2289 PRO assessments were completed by HIV-infected patients. Comparing the 8 months before versus after feedback implementation, providers were more likely to document depression (74% before vs. 87% after feedback, p = 0.02) in patients with moderate-to-severe depression (n = 317 assessments), at-risk alcohol use (41 vs. 64%, p = 0.04, n = 155) and substance use (60 vs. 80%, p = 0.004, n = 212). Providers were less likely to incorrectly document good adherence among patients with inadequate adherence after feedback (42 vs. 24%, p = 0.02, n = 205). While PRO feedback of depression and adherence were followed by increased provider intervention, other domains were not. Further investigation of factors associated with the gap between awareness and intervention are needed in order to bridge this divide.