Browsing by Subject "Analgesics, Opioid"
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Item Open Access A randomized controlled trial comparing two vaso-occlusive episode (VOE) protocols in sickle cell disease (SCD).(American journal of hematology, 2018-02) Tanabe, Paula; Silva, Susan; Bosworth, Hayden B; Crawford, Regina; Paice, Judith A; Richardson, Lynne D; Miller, Christopher N; Glassberg, JeffreyLimited evidence guides opioid dosing strategies for acute Sickle Cell (SCD) pain. We compared two National Heart, Lung and Blood (NHBLI) recommended opioid dosing strategies (weight-based vs. patient-specific) for ED treatment of acute vaso-occlusive episodes (VOE). A prospective randomized controlled trial (RCT) was conducted in two ED's. Adults ≥ 21 years of age with SCD disease were eligible. Among the 155 eligible patients, 106 consented and 52 had eligible visits. Patients were pre-enrolled in the outpatient setting and randomized to one of two opioid dosing strategies for a future ED visit. ED providers accessed protocols through the electronic medical record. Change in pain score (0-100 mm VAS) from arrival to ED disposition, as well as side effects were assessed. 52 patients (median age was 27 years, 42% were female, and 89% black) had one or more ED visits for a VOE (total of 126 ED study visits, up to 5 visits/patient were included). Participants randomized to the patient-specific protocol experienced a mean reduction in pain score that was 16.6 points greater than patients randomized to the weight-based group (mean difference 95% CI = 11.3 to 21.9, P = 0.03). Naloxone was not required for either protocol and nausea and/or vomiting was observed less often in the patient-specific protocol (25.8% vs 59.4%, P = 0.0001). The hospital admission rate for VOE was lower for patients in the patient-specific protocol (40.3% vs 57.8% P = 0.05). NHLBI guideline-based analgesia with patient-specific opioid dosing resulted in greater improvements in the pain experience compared to a weight-based strategy, without increased side effects.Item Open Access Addressing the Opioid Crisis: A Dynamic Case-Based Module Set for Interprofessional Educators, Learners, and Clinicians.(MedEdPORTAL : the journal of teaching and learning resources, 2022-01) Porter, Rachel; Barnett, Jacqueline; Blazar, Melinda; Pinheiro, Sandro; Bowlby, LynnIntroduction
In 2017, the opioid crisis was declared a public health emergency in the United States. The CDC has called for a multifaceted, collaborative approach to address the opioid epidemic. Though many resources have been made available for provider education, much of what has been published to date has focused narrowly on specific contexts and/or has become outdated.Methods
To address the need for more up-to-date and broad-based training, we designed a dynamic, module-based curriculum aligned with the 2016 CDC Opioid Prescribing Guideline. The three-part module set addresses safe opioid prescribing, recognizing and treating opioid use disorders, and opioids and pain management. Each module contains interactive content and assessments and culminates in case-based applications. The modules provide an anchor point for supplemental activities that can be utilized in various contexts.Results
As of May 2021, we recorded 3,529 module completions (≥80% performance on module assessments). A 6-month follow-up survey revealed that the majority of respondents had used the strategies they had learned to improve their prescribing practice and believed they had improved outcomes for patients.Discussion
The modules and supplementary resources can be used by clinicians and educators to combat the opioid epidemic with best practices in patient care and by meeting many state licensure requirements. Included supplemental resources are ideal for learners, providing a comprehensive understanding of the opioid crisis as well as tools for medication-assisted treatment that create capacity to immediately address these issues once learners become fully licensed.Item Open Access Amitifadine, a triple reuptake inhibitor, reduces self-administration of the opiate remifentanil in rats.(Psychopharmacology, 2020-06) Levin, Edward D; Wells, Corinne; Hawkey, Andrew; Holloway, Zade; Blair, Graham; Vierling, Alexander; Ko, Ashley; Pace, Caroline; Modarres, John; McKinney, Anthony; Rezvani, Amir H; Rose, Jed ERationale
A variety of neural systems are involved in drug addiction, and some of these systems are shared across different addictive drugs. We have found several different types of drug treatments that successfully reduce nicotine self-administration.Objectives
The current set of studies is the first in a series to determine if drug treatments that have been found to significantly reduce nicotine self-administration would reduce opiate self-administration.Methods
Amitifadine, a triple reuptake inhibitor of dopamine, norepinephrine, and serotonin, was assessed in female Sprague-Dawley rats to determine whether it significantly reduces remifentanil self-administration with either acute or chronic treatment.Results
Acutely, amitifadine doses of 5, 10, and 20 mg/kg each significantly reduced remifentanil self-administration. In a chronic study, repeated treatment with 10 mg/kg of amitifadine continued to reduce remifentanil self-administration, even after the cessation of treatment. However, amitifadine was not found to attenuate the rise in remifentanil self-administration with continued access. This study and our earlier one showed that the 10 mg/kg amitifadine dose did not significantly affect food motivated responding. Amitifadine did not attenuate remifentanil-induced antinociception as measured on the hot plate test but extended and maintained antinociceptive effects.Conclusions
These studies show the promise of amitifadine as a treatment for countering opiate self-administration for adjunctive use with opioids for analgesia. Further studies are needed to determine the possible efficacy of amitifadine for combating opiate addiction or preventing it in humans during adjunctive use with opioids for chronic pain.Item Open Access Associations between cigarette smoking and pain among veterans.(Epidemiologic reviews, 2015-01-16) Chapman, Shawna L Carroll; Wu, Li-TzyIndividuals with chronic pain often report using cigarettes to cope, and smoking and chronic pain appear prevalent among US veterans. Pain may be a barrier to cigarette cessation and abstinence in this population. Because of physiological effects, smoking cigarettes may also interfere with pain management. A better understanding of how cigarette use relates to pain may assist in veteran cigarette cessation and pain management efforts. To assist these efforts, we searched the literature using keywords, such as "pain," "smoking," and "veteran," to identify 23 journal articles published from 1993 to 2013 that reported on studies examining pain and smoking variables among military or veteran populations. Studies found that veterans reported using cigarettes to cope with pain, there was greater occurrence of pain and disability among smokers in the military, and smoking increased the odds of veterans receiving an opioid prescription for pain and misusing opioids. Studies also found increased odds of pain and smoking among Veterans Health Administration patients with post-traumatic stress disorder when compared with those without post-traumatic stress disorder. Studies support an interaction between pain and smoking among veterans. However, the mechanisms underlying this relationship remain unclear. Future studies focused on this interaction would benefit veteran populations.Item Open Access Buprenorphine compared with methadone to treat pregnant women with opioid use disorder: a systematic review and meta-analysis of safety in the mother, fetus and child.(Addiction (Abingdon, England), 2016-12) Zedler, Barbara K; Mann, Ashley L; Kim, Mimi M; Amick, Halle R; Joyce, Andrew R; Murrelle, E Lenn; Jones, Hendrée EAims
To assess the safety of buprenorphine compared with methadone to treat pregnant women with opioid use disorder.Methods
We searched PubMed, Embase and the Cochrane Library from inception to February 2015 for randomized controlled trials (RCT) and observational cohort studies (OBS) that compared buprenorphine with methadone for treating opioid-dependent pregnant women. Two reviewers assessed independently the titles and abstracts of all search results and full texts of potentially eligible studies reporting original data for maternal/fetal/infant death, preterm birth, fetal growth outcomes, fetal/congenital anomalies, fetal/child neurodevelopment and/or maternal adverse events. We ascertained each study's risk of bias using validated instruments and assessed the strength of evidence for each outcome using established methods. We computed effect sizes using random-effects models for each outcome with two or more studies.Results
Three RCTs (n = 223) and 15 cohort OBSs (n = 1923) met inclusion criteria. In meta-analyses using unadjusted data and methadone as comparator, buprenorphine was associated with lower risk of preterm birth [RCT risk ratio (RR) = 0.40, 95% confidence interval (CI) = 0.18, 0.91; OBS RR = 0.67, 95% CI = 0.50, 0.90], greater birth weight [RCT weighted mean difference (WMD) = 277 g, 95% CI = 104, 450; OBS WMD = 265 g, 95% CI = 196, 335] and larger head circumference [RCT WMD = 0.90 cm, 95% CI = 0.14, 1.66; OBS WMD = 0.68 cm, 95% CI = 0.41, 0.94]. No treatment differences were observed for spontaneous fetal death, fetal/congenital anomalies and other fetal growth measures, although the power to detect such differences may be inadequate due to small sample sizes.Conclusions
Moderately strong evidence indicates lower risk of preterm birth, greater birth weight and larger head circumference with buprenorphine treatment of maternal opioid use disorder during pregnancy compared with methadone treatment, and no greater harms.Item Open Access Buprenorphine for prescription opioid addiction in a patient with depression and alcohol dependence.(The American journal of psychiatry, 2011-07) Fishman, Marc J; Wu, Li-Tzy; Woody, George EItem Open Access Construct and differential item functioning in the assessment of prescription opioid use disorders among American adolescents.(Journal of the American Academy of Child and Adolescent Psychiatry, 2009-05) Wu, Li-Tzy; Ringwalt, Christopher L; Yang, Chongming; Reeve, Bryce B; Pan, Jeng-Jong; Blazer, Dan GOBJECTIVE:To examine the psychometric properties of diagnostic criteria for prescription analgesic opioid use disorders (OUDs) and to identify background predictors of a latent continuum for OUD liability. METHOD:Data were drawn from the adolescent sample of the 2006 National Survey of Drug Use and Health. Item response theory (IRT) and multiple indicators-multiple causes methods were used to examine DSM-IV criteria for OUDs in a subsample of adolescents who reported nonmedical prescription opioid use in the past year (N = 1,290). RESULTS:Among nonmedical users of prescription opioids, the criteria of OUDs were arrayed along a single continuum of severity. All abuse criteria were endorsed at a severity level higher than D1 (tolerance) and D5 (time spent) but lower than D3 (taking larger amounts) and D4 (inability to cut down). Differential item functioning in reports of dependence symptoms across adolescents' sex and race/ethnicity were identified: withdrawal, time spent, and continued use despite medical or psychological problems. Adjusting for the effects of differential item functioning and the demographic variables examined, female subjects were more likely than male subjects to exhibit a higher level of OUD liability. CONCLUSIONS:Study findings do not support the DSM-IV's current hierarchical distinction between abuse of and dependence on prescription opioids. Abuse symptoms in adolescents are not necessarily less severe than those of dependence. There is evidence of some differential item functioning in the assessment of OUDs.Item Open Access Development and Validation of a Model for Opioid Prescribing Following Gynecological Surgery.(JAMA network open, 2022-07) Rodriguez, Isabel V; Cisa, Paige McKeithan; Monuszko, Karen; Salinaro, Julia; Habib, Ashraf S; Jelovsek, J Eric; Havrilesky, Laura J; Davidson, BrittanyImportance
Overprescription of opioid medications following surgery is well documented. Current prescribing models have been proposed in narrow patient populations, which limits their generalizability.Objective
To develop and validate a model for predicting outpatient opioid use following a range of gynecological surgical procedures.Design, setting, and participants
In this prognostic study, statistical models were explored using data from a training cohort of participants undergoing gynecological surgery for benign and malignant indications enrolled prospectively at a single institution's academic gynecologic oncology practice from February 2018 to March 2019 (cohort 1) and considering 39 candidate predictors of opioid use. Final models were internally validated using a separate testing cohort enrolled from May 2019 to February 2020 (cohort 2). The best final model was updated by combining cohorts, and an online calculator was created. Data analysis was performed from March to May 2020.Exposures
Participants completed a preoperative survey and weekly postoperative assessments (up to 6 weeks) following gynecological surgery. Pain management was at the discretion of clinical practitioners.Main outcomes and measures
The response variable used in model development was number of pills used postoperatively, and the primary outcome was model performance using ordinal concordance and Brier score.Results
Data from 382 female adult participants (mean age, 56 years; range, 18-87 years) undergoing gynecological surgery (minimally invasive procedures, 158 patients [73%] in cohort 1 and 118 patients [71%] in cohort 2; open surgical procedures, 58 patients [27%] in cohort 1 and 48 patients [29%] in cohort 2) were included in model development. One hundred forty-seven patients (38%) used 0 pills after hospital discharge, and the mean (SD) number of pills used was 7 (10) (median [IQR], 3 [0-10] pills). The model used 7 predictors: age, educational attainment, smoking history, anticipated pain medication use, anxiety regarding surgery, operative time, and preoperative pregabalin administration. The ordinal concordance was 0.65 (95% CI, 0.62-0.68) for predicting 5 or more pills (Brier score, 0.22), 0.65 (95% CI, 0.62-0.68) for predicting 10 or more pills (Brier score, 0.18), and 0.65 (95% CI, 0.62-0.68) for predicting 15 or more pills (Brier score, 0.14).Conclusions and relevance
This model provides individualized estimates of outpatient opioid use following a range of gynecological surgical procedures for benign and malignant indications with all model inputs available at the time of procedure closing. Implementation of this model into the clinical setting is currently ongoing, with plans for additional validation in other surgical populations.Item Open Access Development and validation of an electronic health records-based opioid use disorder algorithm by expert clinical adjudication among patients with prescribed opioids.(Pharmacoepidemiology and drug safety, 2023-05) Ranapurwala, Shabbar I; Alam, Ishrat Z; Pence, Brian W; Carey, Timothy S; Christensen, Sean; Clark, Marshall; Chelminski, Paul R; Wu, Li-Tzy; Greenblatt, Lawrence H; Korte, Jeffrey E; Wolfson, Mark; Douglas, Heather E; Bowlby, Lynn A; Capata, Michael; Marshall, Stephen WBackground
In the US, over 200 lives are lost from opioid overdoses each day. Accurate and prompt diagnosis of opioid use disorders (OUD) may help prevent overdose deaths. However, international classification of disease (ICD) codes for OUD are known to underestimate prevalence, and their specificity and sensitivity are unknown. We developed and validated algorithms to identify OUD in electronic health records (EHR) and examined the validity of OUD ICD codes.Methods
Through four iterations, we developed EHR-based OUD identification algorithms among patients who were prescribed opioids from 2014 to 2017. The algorithms and OUD ICD codes were validated against 169 independent "gold standard" EHR chart reviews conducted by an expert adjudication panel across four healthcare systems. After using 2014-2020 EHR for validating iteration 1, the experts were advised to use 2014-2017 EHR thereafter.Results
Of the 169 EHR charts, 81 (48%) were reviewed by more than one expert and exhibited 85% expert agreement. The experts identified 54 OUD cases. The experts endorsed all 11 OUD criteria from the Diagnostic and Statistical Manual of Mental Disorders-5, including craving (72%), tolerance (65%), withdrawal (56%), and recurrent use in physically hazardous conditions (50%). The OUD ICD codes had 10% sensitivity and 99% specificity, underscoring large underestimation. In comparison our algorithm identified OUD with 23% sensitivity and 98% specificity.Conclusions and relevance
This is the first study to estimate the validity of OUD ICD codes and develop validated EHR-based OUD identification algorithms. This work will inform future research on early intervention and prevention of OUD.Item Open Access Differential behavioral functioning in the offspring of rats with high vs. low self-administration of the opioid agonist remifentanil.(European journal of pharmacology, 2021-10) Rezvani, Amir H; Wells, Corinne; Hawkey, Andrew; Blair, Graham; Koburov, Reese; Ko, Ashley; Schwartz, Andrea; Kim, Veronica J; Levin, Edward DOpioid use disorder (OUD) has a variety of adverse effects on both the users and their offspring. In the current study, a random group of Sprague-Dawley rats (25 females and 15 males) were tested for intravenous self-administration of the opioid agonist remifentanil to determine the range of acquisition for opioid. One-month after the end of self-administration of remifentanil, rats with the highest intake were mated together and rats with lowest intake were mated together. Then, the offspring of the two groups were tested for anxiety-like behavior, locomotor activity, nociception and intravenous remifentanil self-administration. The parents showed a range of remifentanil self-administration, especially in the female rats. The offspring of the parents with low and high remifentanil self-administration showed significant differences in specific behavioral functions. On the hotplate test of nociception, the female offspring parents with high remifentanil self-administration had significantly longer hotplate latencies, indicating reduced nociception, than the female offspring of parents with low remifentanil-self-administration, whereas there was no difference in the male offspring of low and high responding parents. In the elevated plus maze test of anxiety-like behavior, the offspring of the parents with high remifentanil intake showed more anxiety-like behavior than the offspring of the parents with low remifentanil intake regardless of sex. Locomotor activity was not significantly different. Interestingly, no significant differences in remifentanil self-administration in the offspring of parents with low and high remifentanil self-administration were detected. Overall, our data suggest a considerable range in remifentanil self-administration in rats and the offspring of rats with high opioid self-administration exhibit different behaviors vs offspring of rats with low opioid self-administration.Item Open Access Differential mechanisms of morphine antinociceptive tolerance revealed in (beta)arrestin-2 knock-out mice.(J Neurosci, 2002-12-01) Bohn, Laura M; Lefkowitz, Robert J; Caron, Marc GMorphine induces antinociception by activating mu opioid receptors (muORs) in spinal and supraspinal regions of the CNS. (Beta)arrestin-2 (beta)arr2), a G-protein-coupled receptor-regulating protein, regulates the muOR in vivo. We have shown previously that mice lacking (beta)arr2 experience enhanced morphine-induced analgesia and do not become tolerant to morphine as determined in the hot-plate test, a paradigm that primarily assesses supraspinal pain responsiveness. To determine the general applicability of the (beta)arr2-muOR interaction in other neuronal systems, we have, in the present study, tested (beta)arr2 knock-out ((beta)arr2-KO) mice using the warm water tail-immersion paradigm, which primarily assesses spinal reflexes to painful thermal stimuli. In this test, the (beta)arr2-KO mice have greater basal nociceptive thresholds and markedly enhanced sensitivity to morphine. Interestingly, however, after a delayed onset, they do ultimately develop morphine tolerance, although to a lesser degree than the wild-type (WT) controls. In the (beta)arr2-KO but not WT mice, morphine tolerance can be completely reversed with a low dose of the classical protein kinase C (PKC) inhibitor chelerythrine. These findings provide in vivo evidence that the muOR is differentially regulated in diverse regions of the CNS. Furthermore, although (beta)arr2 appears to be the most prominent and proximal determinant of muOR desensitization and morphine tolerance, in the absence of this mechanism, the contributions of a PKC-dependent regulatory system become readily apparent.Item Open Access Effect of ritonavir-induced cytochrome P450 3A4 inhibition on plasma fentanyl concentrations during patient-controlled epidural labor analgesia: a pharmacokinetic simulation.(Int J Obstet Anesth, 2014-02) Cambic, CR; Avram, MJ; Gupta, DK; Wong, CABACKGROUND: Ritonavir inhibition of cytochrome P450 3A4 decreases the elimination clearance of fentanyl by 67%. We used a pharmacokinetic model developed from published data to simulate the effect of sample patient-controlled epidural labor analgesic regimens on plasma fentanyl concentrations in the absence and presence of ritonavir-induced cytochrome P450 3A4 inhibition. METHODS: Fentanyl absorption from the epidural space was modeled using tanks-in-series delay elements. Systemic fentanyl disposition was described using a three-compartment pharmacokinetic model. Parameters for epidural drug absorption were estimated by fitting the model to reported plasma fentanyl concentrations measured after epidural administration. The validity of the model was assessed by comparing predicted plasma concentrations after epidural administration to published data. The effect of ritonavir was modeled as a 67% decrease in fentanyl elimination clearance. Plasma fentanyl concentrations were simulated for six sample patient-controlled epidural labor analgesic regimens over 24 h using ritonavir and control models. Simulated data were analyzed to determine if plasma fentanyl concentrations producing a 50% decrease in minute ventilation (6.1 ng/mL) were achieved. RESULTS: Simulated plasma fentanyl concentrations in the ritonavir group were higher than those in the control group for all sample labor analgesic regimens. Maximum plasma fentanyl concentrations were 1.8 ng/mL and 3.4 ng/mL for the normal and ritonavir simulations, respectively, and did not reach concentrations associated with 50% decrease in minute ventilation. CONCLUSION: Our model predicts that even with maximal clinical dosing regimens of epidural fentanyl over 24 h, ritonavir-induced cytochrome P450 3A4 inhibition is unlikely to produce plasma fentanyl concentrations associated with a decrease in minute ventilation.Item Open Access Effects of nociceptin (13-17) in pain modulation at supraspinal level in mice.(Neurosci Lett, 2002-10-11) Chen, Li-Xiang; Wang, Zhuan-Zi; Wu, Hua; Fang, Quan; Chen, Yong; Wang, RuiThis work was designed to observe the effects of nociceptin(13-17), one of the main metabolites of nociceptin (also termed orphanin FQ), in pain modulation at supraspinal level in mice. Intracerebroventricular (i.c.v.) administration of nociceptin/orphanin FQ(13-17) (N/OFQ(13-17)) (5, 0.5, 0.05, 0.005 nmol/mouse) dose-dependently induced potent hyperalgesic effects in the 48 degrees C warm-water tail-flick test in mice. I.c.v. pretreatment with N/OFQ(13-17) (5, 0.5, 0.05 nmol/mouse) potentiated the analgesic effects induced by morphine (i.p., 2 mg/kg) and reversed the hyperalgesic effects induced by N/OFQ (i.c.v., 5 nmol/mouse). The hyperalgesic effects induced by N/OFQ(13-17) could not be antagonized by [Nphe((1))]N/OFQ(1-13)NH((2)) or naloxone. These findings suggest that N/OFQ(13-17) may play important roles in pain modulation at supraspinal level in mice and elicits these effects through a novel mechanism independent of the N/OFQ receptor and the mu, delta and kappa opioid receptors.Item Open Access Exploring Emergency Department Provider Experiences With and Perceptions of Weight-Based Versus Individualized Vaso-Occlusive Treatment Protocols in Sickle Cell Disease.(Advanced emergency nursing journal, 2019-01) Knight, LaʼKita MJ; Onsomu, Elijah O; Bosworth, Hayden B; Crawford, Regina D; DeMartino, Theresa; Glassberg, Jeffrey; Paice, Judith A; Miller, Christopher N; Richardson, Lynne; Tanabe, PaulaTreatment of vaso-occlusive episodes (VOEs) is the most common reason for emergency department (ED) treatment of sickle cell disease (SCD). We (1) compared perceptions of the usability and ability to manage VOE pain between ED nurses and other ED provider types, ED sites, and VOE protocols (individualized vs. weight-based), and (2) identified ED nurse and other provider protocol suggestions. A secondary analysis of provider survey data collected immediately after caring for a patient enrolled in a randomized controlled trial comparing weight-based versus individualized opioid dosing for VOE. Research staff asked the ED nurses and other ED providers (nurse practitioners [NPs], physician assistants [PAs], residents, and attending physicians) 5 questions related to the protocol's ease of use and ability to manage pain. There were 236 surveys completed. Attending physicians (n = 15), residents (n = 88), PAs (n = 21), and NPs (n = l) were more satisfied than nurses (n = 111) with the clarity of the analgesic ordering (97.6% vs. 0%, p = 0.0001) and ability to manage the patient's VOE pain (91% vs. 0%, p = 0.0001). When comparing both protocols with the usual ED strategy in their ED to manage VOE, more nurses than other ED providers perceived the study patients' pain management protocol as better (100% vs. 35.2%, p = 0.0001). Other ED providers perceived the individualized versus weight-based protocol as better at managing pain than their usual ED strategy (70.3% vs. 59.5%, p = 0.04). The individualized protocol was perceived as better in managing VOE than the weight-based ED strategy. While physicians were satisfied with the clarity of the protocols, nurses were not. Improved protocol usability is required for widespread ED implementation.Item Open Access Impact of Spinal Cord Stimulation on Opioid Dose Reduction: A Nationwide Analysis.(Neurosurgery, 2020-12) Adil, Syed M; Charalambous, Lefko T; Spears, Charis A; Kiyani, Musa; Hodges, Sarah E; Yang, Zidanyue; Lee, Hui-Jie; Rahimpour, Shervin; Parente, Beth; Greene, Kathryn A; McClellan, Mark; Lad, Shivanand PBackground
Opioid misuse in the USA is an epidemic. Utilization of neuromodulation for refractory chronic pain may reduce opioid-related morbidity and mortality, and associated economic costs.Objective
To assess the impact of spinal cord stimulation (SCS) on opioid dose reduction.Methods
The IBM MarketScan® database was retrospectively queried for all US patients with a chronic pain diagnosis undergoing SCS between 2010 and 2015. Opioid usage before and after the procedure was quantified as morphine milligram equivalents (MME).Results
A total of 8497 adult patients undergoing SCS were included. Within 1 yr of the procedure, 60.4% had some reduction in their opioid use, 34.2% moved to a clinically important lower dosage group, and 17.0% weaned off opioids entirely. The proportion of patients who completely weaned off opioids increased with decreasing preprocedure dose, ranging from 5.1% in the >90 MME group to 34.2% in the ≤20 MME group. The following variables were associated with reduced odds of weaning off opioids post procedure: long-term opioid use (odds ratio [OR]: 0.26; 95% CI: 0.21-0.30; P < .001), use of other pain medications (OR: 0.75; 95% CI: 0.65-0.87; P < .001), and obesity (OR: 0.75; 95% CI: 0.60-0.94; P = .01).Conclusion
Patients undergoing SCS were able to reduce opioid usage. Given the potential to reduce the risks of long-term opioid therapy, this study lays the groundwork for efforts that may ultimately push stakeholders to reduce payment and policy barriers to SCS as part of an evidence-based, patient-centered approach to nonopioid solutions for chronic pain.Item Open Access Impacts of an opioid overdose prevention intervention delivered subsequent to acute care.(Injury prevention : journal of the International Society for Child and Adolescent Injury Prevention, 2019-06) Banta-Green, Caleb J; Coffin, Phillip O; Merrill, Joseph O; Sears, Jeanne M; Dunn, Chris; Floyd, Anthony S; Whiteside, Lauren K; Yanez, Norbert D; Donovan, Dennis MBackground
Opioid overdose is a major and increasing cause of injury and death. There is an urgent need for interventions to reduce overdose events among high-risk persons.Methods
Adults at elevated risk for opioid overdose involving heroin or pharmaceutical opioids who had been cared for in an emergency department (ED) were randomised to overdose education combined with a brief behavioural intervention and take-home naloxone or usual care. Outcomes included: (1) time to first opioid overdose-related event resulting in medical attention or death using competing risks survival analysis; and (2) ED visit and hospitalisation rates, using negative binomial regression and adjusting for time at risk.Results
During the follow-up period, 24% of the 241 participants had at least one overdose event, 85% had one or more ED visits and 55% had at least one hospitalisation, with no significant differences between intervention and comparison groups. The instantaneous risk of an overdose event was not significantly lower for the intervention group (sub-HR: 0.83; 95% CI 0.49 to 1.40).Discussion
These null findings may be due in part to the severity of the population in terms of housing insecurity (70% impermanently housed), drug use, unemployment and acute healthcare issues. Given the high overdose and healthcare utilisation rates, more intensive interventions, such as direct referral and provision of housing and opioid agonist treatment medications, may be necessary to have a substantial impact on opioid overdoses for this high-acuity population in acute care settings.Trial registration number
NCT0178830; Results.Item Open Access Implementation of mandatory opioid prescribing limits in North Carolina: healthcare administrator and prescriber perspectives.(BMC health services research, 2021-11-03) Blackburn, Natalie A; Joniak-Grant, Elizabeth; Nocera, Maryalice; Dorris, Samantha Wooten; Dasgupta, Nabarun; Chelminski, Paul R; Carey, Timothy S; Wu, Li-Tzy; Edwards, David A; Marshall, Stephen W; Ranapurwala, Shabbar IBackground
Recent increases in state laws to reduce opioid prescribing have demonstrated a need to understand how they are interpreted and implemented in healthcare systems. The purpose of this study was to explore the systems, strategies, and resources that hospital administrators and prescribers used to implement the 2017 North Carolina Strengthen Opioid Prevention (STOP) Act opioid prescribing limits, which limited initial prescriptions to a five (for acute) or seven (for post-surgical) days' supply.Methods
We interviewed 14 hospital administrators and 38 prescribers with degrees in medicine, nursing, pharmacy, business administration and public health working across North Carolina. Interview guides, informed by the Consolidated Framework for Implementation Research, explored barriers and facilitators to implementation. Interview topics included communication, resources, and hospital system support. Interviews were recorded and transcribed, then analyzed using flexible coding, integrating inductive and deductive coding, to inform analytic code development and identify themes.Results
We identified three main themes around implementation of STOP act mandated prescribing limits: organizational communication, prescriber education, and changes in the electronic medical record (EMR) systems. Administrators reflected on implementation in the context of raising awareness and providing reminders to facilitate changes in prescriber behavior, operationalized through email and in-person communications as well as dedicated resources to EMR changes. Prescribers noted administrative communications about prescribing limits often focused on legality, suggesting a directive of the organization's policy rather than a passive reminder. Prescribers expressed a desire for more spaces to have their questions answered and resources for patient communications. While hospital administrators viewed compliance with the law as a priority, prescribers reflected on concerns for adequately managing their patients' pain and limited time for clinical care.Conclusions
Hospital administrators and prescribers approached implementation of the STOP act prescribing limits with different mindsets. While administrators were focused on policy compliance, prescribers were focused on their patients' needs. Strategies to implement the mandate then had to balance patient needs with policy compliance. As states continue to legislate to prevent opioid overdose deaths, understanding how laws are implemented by healthcare systems and prescribers will improve their effectiveness through tailoring and maximizing available resources.Item Open Access Lidocaine patch for acute pain management: a meta-analysis of prospective controlled trials.(Curr Med Res Opin, 2015-03) Bai, Yaowu; Miller, Timothy; Tan, Mingjuan; Law, Lawrence Siu-Chun; Gan, Tong JooBACKGROUND: Local anesthetic is one of the cornerstones of multimodal analgesia. We investigated the efficacy of the lidocaine patch for acute pain management. METHODS: We searched MEDLINE, CINAHL, Scopus, and the Cochrane Controlled Trials Register for published prospective controlled clinical trials that evaluated the analgesic effect of the lidocaine patch for acute or postoperative pain management (1966--2014). The outcomes were postoperative opioid consumption, pain intensity and length of hospital stay. RESULTS: Five trials comparing the lidocaine patch with control (no treatment/placebo) for acute or postoperative pain treatment/management were included in this meta-analysis. Data was analyzed on 251 patients. Between the lidocaine patch group and the control group, no significant difference was found for all three outcomes (all p > 0.05). For postoperative opioid consumption, mean difference (MD) was -8.2 mg morphine equivalent (95% CI -28.68, 12.24). For postoperative pain intensity, MD was -9.1 mm visual analog scale or equivalent (95% CI -23.31, 5.20). For length of hospital stay, MD was -0.2 days (95% CI -0.80, 0.43). CONCLUSION: Application of a lidocaine patch may not be an effective adjunct for acute and postoperative pain management, in terms of pain intensity, opioid consumption and length of hospital stay. LIMITATIONS: The limitations were a small number of included studies, potential biases from some unblinded studies, clinical heterogeneity between studies, and incomplete reported data for adjunct analgesics.Item Open Access Measurement-based care using DSM-5 for opioid use disorder: can we make opioid medication treatment more effective?(Addiction (Abingdon, England), 2019-08) Marsden, John; Tai, Betty; Ali, Robert; Hu, Lian; Rush, A John; Volkow, NoraContext and purpose
Measurement-based care (MBC) is an evidence-based health-care practice in which indicators of disease are tracked to inform clinical actions, provide feedback to patients and improve outcomes. The current opioid crisis in multiple countries provides a pressing rationale for adopting a basic MBC approach for opioid use disorder (OUD) using DSM-5 to increase treatment retention and effectiveness.Proposal
To stimulate debate, we propose a basic MBC approach using the 11 symptoms of OUD (DSM-5) to inform the delivery of medications for opioid use disorder (MOUD; including methadone, buprenorphine and naltrexone) and their evaluation in office-based primary care and specialist clinics. Key features of a basic MBC approach for OUD using DSM-5 are described, with an illustration of how clinical actions are guided and outcomes communicated. For core treatment tasks, we propose that craving and drug use response to MOUD should be assessed after 2 weeks, and OUD remission status should be evaluated at 3, 6 and 12 months (and exit from MOUD treatment) and beyond. Each of the 11 DSM-5 symptoms of OUD should be discussed with the patient to develop a case formulation and guide selection of adjunctive psychological interventions, supplemented with information on substance use, and optionally extended with information from other clinical instruments. A patient-reported outcome measure should be recorded and discussed at each remission assessment.Conclusions
MBC can be used to tailor and adapt MOUD treatment to increase engagement, retention and effectiveness. MBC practice principles can help promote patient-centred care in OUD, personalized addiction therapeutics and facilitate communication of outcomes.Item Open Access Nonmedical Opioid Pain Relievers and All-Cause Mortality: A 27-Year Follow-Up From the Epidemiologic Catchment Area Study.(American journal of public health, 2016-03) Cottler, Linda B; Hu, Hui; Smallwood, Bryan A; Anthony, James C; Wu, Li-Tzy; Eaton, William WWe investigated whether nonmedical opioid pain reliever use is associated with higher mortality in the general US population.We assessed the history of nonmedical opioid pain reliever use among 9985 people interviewed at baseline of the Epidemiologic Catchment Area Program initiated in 1981 to 1983 in Baltimore, Maryland; St. Louis, Missouri; and Durham, North Carolina. We linked the data with the National Death Index through 2007.Nonmedical opioid pain reliever use was 1.4%. Compared with no nonmedical drug use, mortality was increased for nonmedical opioid pain reliever use (hazard ratio [HR] = 1.60; 95% confidence interval [CI] = 1.01, 2.53) or nonmedical use of other drugs (HR = 1.31; 95% CI = 1.07, 1.62). Mortality was also higher for males and for those beginning nonmedical opioid pain reliever use before aged 15 years.A history of nonmedical opioid pain reliever use was associated with increased mortality, in particular for males and early onset users.