Values in Translation: How Asking the Right Questions Can Move Translational Science Toward Greater Health Impact

The speed and effectiveness of current approaches to research translation are widely viewed as disappointing given small gains in real population health outcomes despite huge investments in basic and translational science. We identify critical value questions—ethical, social, economic, and cultural—that arise at moments throughout the research pathway. By making these questions visible, and promoting discussion of them with diverse stakeholders, we can facilitate handoffs along the translational pathway and increase uptake of effective interventions. Who is involved with those discussions will determine which research projects, populations, and methods get prioritized. We argue that some upfront investment in community and interdisciplinary engagement, shaped by familiar questions in ethics, social justice, and cultural knowledge, can save time and resources in the long run because interventions and strategies will be aimed in the right direction, that is, toward health improvements for all. Clin Trans Sci 2012; Volume 5: 445–451     

Changing Opioid Use for Right Lower Quadrant Abdominal Pain in the Emergency Department

Objectives: To compare the use of opioid analgesia in the treatment of emergency department patients with acute right lower quadrant (RLQ) abdominal pain between 1998 and 2003 and to explore the relationship between opioid use and abdominal computed tomography (CT) scanning. Methods: This was a retrospective cohort study of patients presenting in 1998 and 2003 to an urban emergency department with a triage complaint of RLQ pain. The authors abstracted use and timing of abdominal CT scanning and opioid analgesia. Other predictor variables were patient demographics. Risk ratio for receiving opioids with CT scan versus without CT scan, stratifying by year, were calculated. Proportional‐hazards analysis was used to control for time in the emergency department. Results: Of the 187 patients seen in 1998, 38 (20%) underwent CT scanning and 43 (23%) received opioids. Of the 137 patients seen in 2003, 77 (56%) underwent CT scanning and 72 (53%) received opioids. In 1998, the risk ratio for receiving opioids in patients who underwent CT scanning (vs. without) was 3.7 (95% confidence interval [CI] = 2.3 to 6.1); in 2003, it was 1.5 (95% CI = 1.0 to 2.1). Opioids were overwhelmingly given before CT scanning in those patients who received both (81% in 1998 and 98% in 2003). The mean time to administration of the first opioid dose in 1998 was 155 minutes and in 2003 was 94 minutes. The proportional‐hazards analysis confirmed a strong association between CT scanning and opioid administration in 1998 (relative hazard, 2.7; 95% CI = 1.5 to 5.1) and substantial attenuation of the association in 2003 (relative hazard, 1.3; 95% CI = 0.8 to 2.1). The hospitalization rate was not significantly different in 2003 (33%) versus 1998 (27%) (p = 0.28). The risk ratio of receiving opioids in admitted patients was 2.8 (95% CI = 1.7 to 4.6) in 1998 and 2.0 (95% CI = 1.5 to 2.7) in 2003. Conclusions: Opioid administration to patients with RLQ pain has dramatically increased between 1998 and 2003. During these five years, the number of patients receiving opioids more than doubled and the time to first administration of opioids decreased by one hour. The authors show that this cannot be attributed to an increased use of CT scanning.     

PS1-07: PSA Test Use in Primary Care

Background/Aims Some professional organizations advocate for PSA testing to screen for prostate cancer while others recommend against it. Regardless of position, each advocates for consideration of individual risk factors and for patients to consult with their physician when deciding. We describe men's use of PSA testing around the time of a periodic health examination (PHE), whether test use varies by patient risk factor status, and the extent to which PSA testing occurs following patient-physician discussion of PSA testing, prostate cancer, or both. Methods Physician and patient subjects were enrolled in an observational study of patient-physician decision making in primary care. Physicians were salaried, general internal and family medicine physicians. Patients were insured, aged 50-80 years, without a history of prostate cancer, and due for colorectal cancer screening at the time of an audio-recorded office visit between 2007-2009. Office visit recordings were joined with data from pre-visit patient surveys and automated laboratory data for the 6 prior and 8 subsequent weeks. Content of patient-physician discussions was coded with a structured coding worksheet (mean Cohen's Kappa = 0.77). Generalized estimating equations were used to evaluate associations among patient-physician screening-related talk, patient risk factors, and PSA use. Results Among N=161 study-eligible men, just over half (53%) presented with at least one risk factor: 11.2% family history; 29.2% aged 65+; and 21.2% black. Eighty-one percent used PSA testing around the time of their PHE (8.3% prior and 72.7% subsequent to visit). Test use did not differ significantly by risk factor status: family history, 94.4% vs. no family history, 79.4%, (p=0.13); aged 65+, 85.1% vs. aged <65, 79.8% (p=0.39); and blacks, 76.5% vs. whites, 82.7%(p=0.49). Prostate cancer, PSA testing, or both was mentioned during 82% of visits: 34.8% mentioned prostate cancer and 79.5% PSA testing. Among men tested subsequent to visit, these percents were 92.9%, 35.0% and 89.3%, respectively. Discussion PSA testing is common among men who schedule a PHE, regardless of risk factor status. Furthermore, 7% of men who receive PSA testing subsequent to their PHE, do so in absence of any mention of prostate cancer or PSA screening during the visit.     

Cannabis Use: Change in Screening for Primary Care Preoperative Clearance

Patients are required to obtain preoperative screening 30 days before elective surgery with an emphasis on testing and screening tools to identify patients at risk for perioperative, intraoperative, and postoperative complications. Surgical complications are being reported in patients who have recently consumed cannabis before surgery. As cannabis use becomes more prevalent for both medicinal and recreational reasons, the lack of evidence-based guidelines for preoperative screening in the primary care setting and surgical setting is problematic. To prevent surgical complications, advanced practice registered nurses must obtain a thorough cannabis history with education on abstaining from use before elective surgery.     

Opioid Use in End-of-Life Care in Patients With Interstitial Pneumonia Associated With Respiratory Worsening

ABSTRACT

The authors investigated the treatment outcome of patients with severe interstitial pneumonia (IP) who received opioids during end-of-life care. Twenty-two consecutive patients were retrospectively evaluated before and after continuous administration of opioids for 24 hours. All subjects died within 21 days; the mean survival period after opioid administration was 5.6 days. Six of the 22 patients (27%) died within 24 hours after opioids were initiated. In the other 16 patients, respiratory rate was significantly decreased after opioid use and there was a small, nonsignificant improvement in dyspnea measured by the Borg scale without adequate evaluation and records (n = 6). However, hypercapnia with over 10 mm Hg of Paco₂ developed in two patients. Paco₂ tended to be elevated after opioid use in all patients, although the change was not significant. An extremely poor outcome was attributable to the disease progression of IP in six of the patients with Pao₂/F_Io₂ levels below 100. The other 16 patients showed both positive and negative effects as expected. Clinicians should assess dyspnea prior to opioid administration, since the purpose of the opioid administration is to relieve dyspnea. Dyspnea should be monitored and recorded in routine clinical practice, at least after hospitalization.     

Assessment of Chronic Pain Management in the Treatment of Opioid Use Disorder: Gaps in Care and Implications for Treatment Outcomes

Chronic pain is a significant comorbid condition among individuals with opioid use disorder (OUD). However, due to conflicting perceptions of responsibility, structural barriers, and a lack of widely applied standards of care, it is unclear what the landscape of chronic pain management looks like in addiction medicine. Using a national opioid surveillance system, we analyzed survey data from new entrants (n = 14,449) to 225 OUD treatment centers from 2013 to 2018, as well as an online survey among a subset of respondents (n = 309). While chronic pain was reported by 33.4% of the sample, two-thirds of the chronic pain group (66.0%) reported their pain was not managed through their OUD treatment program, with 47% reporting worsening pain. Pain that was managed was primarily done so through pharmaceuticals (75.2%), notably as a secondary effect of medication-assisted treatment. In addition, 43.2% reported chronic pain as a primary factor in their opioid relapse. These data suggest that chronic pain is commonly reported, yet not managed by many OUD treatment programs, increasing the likelihood of opioid relapse. In order to improve poor outcomes among OUD patients, interdisciplinary collaboration/care, along with evidence-based policies or processes for quality pain management in addiction care need to be prioritized.PerspectiveThis article suggests chronic pain is commonly reported, yet not managed by many OUD treatment programs, increasing the likelihood of opioid relapse. In order to improve low retention and success rates among OUD patients, interdisciplinary collaboration, evidence-based policies or processes (eg, referral) for quality pain management in addiction care need to be prioritized.