Evaluation of Chronic,Noncancer Pain Management Initiative in a Multidisciplinary Pain Clinic

BackgroundChronic pain management is a major challenge for primary care providers (PCPs). PCPs manage many patients with chronic pain and other comorbidities including mental health problems like post-traumatic stress disorder (PTSD) and depression. Chronic pain and opioid problems are a national crisis, particularly among veterans (U.S. Department of Veterans Affairs, 2019). There are many veterans with chronic non-cancer pain who are being treated with opioids. Chronic opioid use has contributed to an epidemic of opioid-related adverse events (VA, 2017). Opioids not only result in poor pain control, but have associated risks such as misuse, overdose, and diversion which may be fatal (Frieden & Houry, 2016).AimsThe aim of this project was to evaluate chronic non-cancer pain management of veterans using an advanced practice registered nurse (APRN)-led multidisciplinary team approach to incorporate non-opioid and non-pharmacologic modalities to affect self-reported pain and use of prescribed opioids.MethodsA retrospective quality improvement (QI) project was conducted in the multidisciplinary pain (MDP) clinic. The APRN used a biopsychosocial approach for chronic pain management guided by the Plan, Do, Study, Act (PDSA) cycle framework. Thirty-four patients who were utilizing opioids for pain management were included using convenience sampling from the MDP clinic. The APRN educated and treated patients with non-opioid medications and non-pharmacolog therapies. A 10-point pain scale and morphine equivalent daily dose (MEDD) were utilized pre- and post-intervention to evaluate the MDP clinic.ResultsParticipants were predominantly male (91.8%), with a mean age of 63.18 ± 15.39 years, and 36.4% of whom were retired. Only 20.6% of the participants reported the use of opioids for <12 months. Low back pain (93%) was the most common pain location. The mean baseline MEDD was 41.04 and the post tapered MEDD was 23.05; this revealed a significant decline in MEDD (p < .0001). A decline was also found between pre- and post-pain scores (ranges 0-8). There was a significant reported decline in pain scores with a baseline of 6.11 to post tapering pain of 3.1 (t = 4.99, df = 28, p < .0001). Participants preferred non-opioid medications 94% and non-pharmacologic therapy 86%, like physical therapy, yoga, and acupuncture. Fifty-one percent of patients were referred for injections and 46% were referred to primary care behavior health, which includes pain school, sleep hygiene classes, and cognitive behavior therapy.ConclusionsAPRNs are in a key position to assess and treat patients based on current evidence while facilitating opioid titration. This initiative highlights that safe tapering of opioids is possible when utilizing a multidisciplinary approach for chronic pain management. Findings support the use of non-pharmacologic and non-opioid therapy for chronic pain management which can result in reduced patient-reported pain. Further research is warranted to examine both pharmacologic (non-opioid) and non-pharmacologic strategies that promote pain management while tapering opioids.     

Risks for possible and probable opioid misuse among recipients of chronic opioid therapy in commercial and medicaid insurance plans: The TROUP Study

The use of chronic opioid therapy (COT) for chronic non-cancer pain (CNCP) has increased dramatically in the past two decades. There has also been a marked increase in the abuse of prescribed opioids and in accidental opioid overdose. Misuse of prescribed opioids may link these trends, but has thus far only been studied in small clinical samples. We therefore sought to validate an administrative indicator of opioid misuse among large samples of recipients of COT and determine the demographic, clinical, and pharmacological risks associated with possible and probable opioid misuse. A total of 21,685 enrollees in commercial insurance plans and 10,159 in Arkansas Medicaid who had at least 90 days of continuous opioid use 2000–2005 were studied for one year. Criteria were developed for possible and probable opioid misuse using administrative claims data concerning excess days supplied of short-acting and long-acting opioids, opioid prescribers and opioid pharmacies. We estimated possible misuse at 24% of COT recipients in the commercially insured sample and 20% in the Medicaid sample and probable misuse at 6% in commercially insured and at 3% in Medicaid. Among non-modifiable factors, younger age, back pain, multiple pain complaints and substance abuse disorders identify patients at high risk for misuse. Among modifiable factors, treatment with high daily dose opioids (especially >120 mg MED per day) and short-acting Schedule II opioids appears to increase the risk of misuse. The consistency of the findings across diverse patient populations and the varying levels of misuse suggest that these results will generalize broadly, but await confirmation in other studies.     

Patient Patterns and Perspectives on Using Opioid Regimens for Chronic Cancer Pain

ContextWith increasing attention to the undertreatment of cancer pain in parallel with concerns about opioid misuse, little is known about how patients with advanced cancer adhere to opioid regimens for chronic cancer pain.ObjectivesWe explored patient approaches to managing chronic cancer pain with long-acting opioids.MethodsIn a multimethods study at an academic medical center, adult patients with chronic cancer pain (n = 17) used electronic pill caps to record adherence to prescribed long-acting opioid regimens. After eight weeks, patients viewed their adherence records and completed a semistructured interview about their opioid use. With a framework approach, we coded interview data (Kappa >0.95) and identified themes in how patients perceived and used opioids to manage cancer pain.ResultsPatients (59% female; 94% non-Hispanic white; median age = 65 years) felt grateful about pain benefit from opioids yet concerned about opioid side effects and addiction/tolerance. Main reasons for nonadherence included both intentional decisions (e.g., skipping doses) and unintentional barriers (e.g., missing doses due to inconsistent sleep schedules). Overall, patients set their own opioid adherence goals and developed routines to achieve them. Residual pain varied and was not consistently linked with opioid adherence.ConclusionPatients commonly felt conflicted about using prescribed long-acting opioids to manage cancer pain due to concurrent perceptions of their risks and benefits, and they set their own parameters for opioid-taking practices. Intentional and unintentional deviations from prescribed opioid schedules highlight the need to enhance adherence communication, education, and counseling, to optimize the use of long-acting opioids as a component of cancer pain management.     

The effects of depression and smoking on pain severity and opioid use in patients with chronic pain

Depression and smoking are common comorbid conditions among adults with chronic pain. The aim of this study was to determine the independent effects of depression on clinical pain and opioid use among patients with chronic pain according to smoking status. A retrospective design was used to assess baseline levels of depression, clinical pain, opioid dose (calculated as morphine equivalents), and smoking status in a consecutive series of patients admitted to a 3-week outpatient pain treatment program from September 2003 through February 2007. Depression was assessed using the Centers for Epidemiologic Studies-Depression scale, and clinical pain was assessed using the pain severity subscale of the Multidimensional Pain Inventory. The study cohort (n = 1241) included 313 current smokers, 294 former smokers, and 634 never smokers. Baseline depression (P = .001) and clinical pain (P = .001) were greater among current smokers compared to former and never smokers, and the daily morphine equivalent dose was greater among smokers compared to never smokers (P = .005). In multivariate linear regression analyses, baseline pain severity was independently associated with greater levels of depression, but not with smoking status. However, status as a current smoker was independently associated with greater opioid use (by 27 mg/d), independent of depression scores. The relationship between depression, smoking status, opioid use, and chronic pain is complex, and both depression and smoking status may be potentially important considerations in the treatment of patients with chronic pain who utilize opioids.     

Traumatic Brain Injury and Receipt of Prescription Opioid Therapy for Chronic Pain in Iraq and Afghanistan Veterans: Do Clinical Practice Guidelines Matter?

Clinical practice guidelines admonish against prescribing opioids for individuals with chronic pain and traumatic brain injury (TBI) because of increased risk for adverse outcomes, yet no studies have described opioid prescribing patterns in these higher-risk patients. Between October 2007 and March 2015, 53,124 Iraq and Afghanistan veterans with chronic pain not prescribed opioids in the previous year were followed for 1 year after completing a Comprehensive TBI Evaluation within the Department of Veterans Affairs health care facilities. Veterans reporting the most severe TBI sequelae (eg, loss of consciousness?>30 minutes) were significantly more likely to receive short-term and long-term opioid therapy than those with less severe or no TBI sequelae (P values?<?.001). In analyses adjusted for sociodemographic characteristics, military service, pain disability, and previous nonopioid treatment modalities, veterans with moderate to severe TBI had a significantly increased risk of receiving opioid therapy. Veterans with moderate to severe TBI and comorbid post-traumatic stress disorder and depression had an even greater risk of initiating long-term opioid therapy in the year after the Comprehensive TBI Evaluation (adjusted relative risk?=?3.57 [95% confidence interval?=?2.85–4.47]). Higher-risk patients with chronic pain and TBI with mental health comorbidities may benefit from improved access to behavioral health and nonpharmacological therapies for chronic pain.

Comparative mortality among Department of Veterans Affairs patients prescribed methadone or long-acting morphine for chronic pain

Data on comparative safety of opioid analgesics are limited, but some reports suggest disproportionate mortality risk associated with methadone. Our objective was to compare mortality rates among patients who received prescribed methadone or long-acting morphine for pain. This is a retrospective observational cohort drawn from Department of Veterans Affairs (VA) health care databases, January 1, 2000, to December 31, 2007. We included 28,554 patients who received methadone and 79,938 who received long-acting morphine from VA pharmacies. Compared with those who received long-acting morphine, patients who received methadone were younger, less likely to have some medical comorbidities, and more likely to have psychiatric and substance use disorders. Patients were stratified into quintiles according to propensity score; the probability of receiving methadone was conditional on demographic, clinical, and VA service area variables. Overall propensity-adjusted mortality was lower for methadone than for morphine. Hazard ratios varied across propensity score quintiles; the magnitude of the between-drug difference in mortality decreased as the propensity to receive methadone increased. Mortality was significantly lower for methadone in all but the last quintile, in which there was no between-drug difference in mortality (hazard ratio = 0.92, 95% confidence interval = 0.74, 1.16). Multiple sensitivity analyses found either no difference in mortality between methadone and long-acting morphine or lower mortality rates among patients who received methadone. In summary, we found no evidence of excess all-cause mortality among VA patients who received methadone compared with those who received long-acting morphine. Randomized trials and prospective observational research are needed to better understand the relative safety of long-acting opioids.     

Efficacy and Practicality of Opioid Therapy in Japanese Chronic Noncancer Pain Patients

BackgroundMany Japanese adults suffer from chronic pain. However, 50% of these individuals discontinue treatment despite the persistence of pain. Both clinicians and patients in Japan tend to be concerned about the safety and efficacy of opioid therapy, and the use of opioids in chronic non-cancer pain remains less common in Japan than elsewhere.AimsThis study examined the effects of opioid therapy on the daily lives of patients with chronic noncancer pain in Japan, where use of opioids for this type of pain remains uncommon.DesignProspective cross-sectional questionnaire study.SettingData were collected over two periods, between March and April 2014 at one hospital, and between February and April 2015 at the other hospital. Subjects were recruited at the respective clinics by the study interviewer between March 1, 2014 and April 15, 2014 and between February 1, 2015 and April 15, 2015.Participants/SubjectsThis study included 34 outpatients with chronic non-cancer pain who were being treated with opioid analgesics at pain clinics in two hospitals in Sapporo.MethodsThirty-four Japanese patients receiving opioid medications for chronic noncancer pain in outpatient pain clinics were enrolled. Participants underwent interviews and completed the Japanese versions of the Short Form 36 (SF-36v2) and the Coping Strategies Questionnaire (CSQ).ResultsSleep disruption, claiming compensation for work-related accidents, and current pain level were negatively correlated with opioid effectiveness (p < .05). Additionally, opioid effectiveness was negatively correlated with the catastrophizing subscale of the CSQ (r = −0.50, p < .01). The effects of opioid therapy had a low positive correlation with the emotional functioning role subscale of the SF-36v2 (r = 0.38, p < .05). Daily equivalent morphine dose was positively correlated with opioid therapy duration, interference with appetite, and current pain intensity. Morphine dose was also positively correlated with scores for the catastrophizing subscale of the CSQ (r = 0.36, p < .05) and negatively correlated with scores in all subdomains of the SF-36v2.ConclusionsIt is important to focus on adaptive, cognitive, and emotional factors, such as emotional role functioning, to determine the efficacy of opioid treatment for chronic noncancer pain. Moreover, patients with catastrophizing significantly increased their morphine doses, resulting in an increased risk of overdose.     

Do sex differences exist in opioid analgesia? A systematic review and meta-analysis of human experimental and clinical studies

Although a contribution of sex in opioid efficacy has garnered much attention, the confirmation and direction of any such difference remain elusive. We performed a systematic review of the available literature on sex differences in μ and mixed μ/κ opioid effect on acute and experimental pain. Fifty unique studies (including three unpublished studies) were included in the analyses. Across the 25 clinical studies on μ-opioids there was no significant sex-analgesia association. Restricting the analysis to patient-controlled analgesia (PCA) studies (irrespective of the opioid) yielded greater analgesia in women (n = 15, effect size 0.22, 95% c.i. 0.02-0.42, P = 0.028). Further restricting the analysis to PCA morphine studies yielded an even greater effect in women (n = 11, effect size = 0.36, 95% c.i. 0.17-0.56, P = 0.003). Meta-regression indicated that the longer the duration of PCA, the difference in effect between the sexes further increased. Across experimental pain studies on μ-opioids women had greater antinociception from opioids (n = 11, effect size = 0.35; 95% c.i. 0.01-0.69, P = 0.047), which was predominantly due to 6 morphine studies. Female patients had greater μ/κ opioid analgesia (n = 7, effect size 0.84; 95% c.i. 0.25-1.43, P = 0.005), but no sex-analgesia association was present in experimental studies (n = 7). Sex differences exist in morphine-induced analgesia in both experimental pain studies and clinical PCA studies, with greater morphine efficacy in women. The data on non-morphine μ and mixed μ/κ-opioids are less convincing and require further study.     

Time-scheduled vs. pain-contingent opioid dosing in chronic opioid therapy

Some expert guidelines recommend time-scheduled opioid dosing over pain-contingent dosing for patients receiving chronic opioid therapy (COT). The premise is that time-scheduled dosing results in more stable opioid blood levels and better pain relief, fewer adverse effects, less reinforcement of pain behaviors, and lower addiction risk. We report results of a survey of 1781 patients receiving COT for chronic noncancer pain, in which 967 reported time-scheduled opioid dosing only and 325 reported pain-contingent opioid dosing only. Opioid-related problems and concerns were assessed with the Prescribed Opioids Difficulties Scale. We hypothesized that respondents using time-scheduled opioid dosing would report significantly fewer problems and concerns than those using pain-contingent dosing. Patients receiving time-scheduled dosing received substantially higher average daily opioid doses than those using pain-contingent dosing (97.2 vs. 37.2 mg average daily dose morphine equivalents, P < .0001). Contrary to expectation, time-scheduled opioid dosing was associated with higher levels of patient opioid control concerns than pain-contingent dosing (6.2 vs. 4.8, P = .008), after adjusting for patient and drug regimen differences. Opioid-related psychosocial problems were somewhat greater among patients using time-scheduled dosing, but this difference was nonsignificant after controlling for patient and drug regimen differences (5.9 vs. 5.0, P = .14). Time-scheduled dosing typically involved higher dosage levels and was associated with higher levels of patient concerns about opioid use. Controlled comparative effectiveness research is needed to assess benefits and risks of time-scheduled opioid dosing relative to pain-contingent opioid dosing among COT patients in ambulatory care.