Do Men and Women Have Different Pain Relief Response to Opioids? Interview with:
Roberta Agabio, M.D.
Dpt. Biomedical Sciences
University of Cagliari
Cittadella Universitaria Monserrato
Monserrato (CA) – ITALY  What is the background for this study?

Response: Pain is the leading cause for seeking medical care worldwide, and opioids are the most frequently prescribed drugs for pain relief. Differences and similarities between men and women in both effectiveness and side effects to opioids used for pain relief have been described. In addition, individuals may respond differently to these medications for other reasons for example: the intensity of pain experienced, amount and type of administration of opioids (e.g. fixed doses established by physicians or flexible doses decided by patients), mental condition, age, body weight, and use of alcohol, tobacco and/or cannabis.

However, the role of these factors in influencing sex differences and similarities in the response to opioids used for pain control has not been thoroughly investigated.

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Who Teaches Faculty to Educate Medical Residents About Opioids for Chronic Pain? Interview with:

Payel Roy, MD
Section of General Internal Medicine
Department of Medicine
Boston University School of Medicine and Boston Medical Center
Boston, Massachusetts.  What is the background for this study?  What are the main findings?

Response: Given the current opioid crisis, we know how important it is to educate physicians-in-training in safer opioid prescribing.  But we can’t educate them properly if their faculty mentors don’t feel comfortable prescribing opioids themselves.  Our study evaluated a program designed to improve faculty physicians’ comfort in prescribing opioids safely and teaching these practices to trainee physicians.  

We found that faculty development programs can improve their confidence in prescribing opioids safely and teaching their trainees about prescribing, however translating these attitudes into teaching practice remains a challenge.

Who Prescribes More Opioids for Pain Relief? Physicians or Physician Extenders?

Photo of Dr. Michael Issac Ellenbogen, M.D.

Michael Ellenbogen, MD
Assistant Professor of Internal Medicine
Johns Hopkins School of Medicine 

What is the background for this study? What are the main findings?

Nurse practitioners (NPs) and physician assistants (PAs) are becoming an increasingly important and larger part of the healthcare workforce, especially in general internal medicine. To our knowledge, differences in opioid prescribing among generalist physicians, NPs, and PAs have not been evaluated. We aimed to learn if there are differences in opioid prescribing among generalist physicians, NPs, and PAs to Medicare beneficiaries.     

We performed a serial cross-sectional analysis of prescription claims from 2013 to 2016 using publicly available data from the Centers for Medicare and Medicaid Services. All generalist physicians, NPs, and PAs who provided more than ten total prescription claims between 2013 and 2016 were included. These prescribers were subsetted as practicing in a primary care, urgent care, or hospital-based setting.

We found that the overall volume and proportion of opioid prescribing is heavily right-skewed. The mean opioid prescription proportions (as a proportion of all prescription claims) for physicians in primary care, urgent care/walk-in clinics, and hospital medicine were 4.69, 6.72, and 6.66 relative to 7.10, 11.97, and 11.01 for PAs.  The adjusted total opioid claims across these four years for physicians was 660 (95% confidence interval: 660-661), for NPs was 755 

(95% CI: 753-757), and for PAs was 812 (95% CI: 811-814). 

What should readers take away from your report?

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Nordic Countries Also See Rapid Increase in Opioid Prescriptions for Pain Relief Interview with:
Ley (Ashley) Muller, PhD
University of Oslo  What is the background for this study?  What are the main findings?

Response: The North American opioid crisis is clearly linked to the high availability of prescription opioids. In the Nordic countries of Denmark, Sweden, and Norway, the pharmaceutical industry is much more regulated, including bans on marketing to physicians, so the market isn’t flush with opioids. However, these countries have ageing populations with some of the highest rates of chronic non-cancer pain in the world, and over-prescription for this type of pain was one of the triggers of the North American crisis. 

This begs the question: how sure are we that strong pharmaceutical regulations alone can protect countries from prescription opioid problems?  

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National Trends in Prescription Opioid Risk Reduction Practices Interview with:
Daniel P. Alford, MD, MPH
Professor of Medicine
Associate Dean, Continuing Medical Education
Director, Clinical Addiction Research and Education (CARE) Unit
Director, Safe and Competent Opioid Prescribing Education (SCOPE of Pain) Program
Boston University School of Medicine
Boston Medical Center, Boston MA 02118 What is the background for this study?

Response: Boston University School of Medicine’s Safe and Competent Opioid Prescribing Education (SCOPE of Pain) is the longest-running safer opioid prescribing educational program under the FDA’s opioid Risk Evaluation and Mitigation Strategy (REMS). 

This study analyzed clinicians’, who were registering to attend a SCOPE of Pain training, self-report of performing five opioid prescribing risk-mitigation practices with patients prescribed opioids for chronic pain including:

  1. Use of patient-prescriber agreements,

2) Informing patients about taking opioids exactly as prescribed,

3) Discussing safe opioid storage and disposal,

4) Discussing risks of opioid-associated respiratory depression and overdose, and

5) Monitoring for misuse including urine drug test and/or pill counts, prior to participating in the training.

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Variety of Pain Relief Medications Reduced Opioid Usage in Trauma Patients Interview with:
Christine S. Cocanour, M.D., F.A.C.S., F.C.C.M.
Division of Trauma, Acute Care Surgery and Surgical Critical Care 
UC Davis Health  What is the background for this study?

Response: Our critical care pharmacists (Duby, Hamrick and Lee) and surgeons (Cocanour, Beyer) wanted to decrease our use of opioids without compromising pain control in our trauma patients—especially those that were admitted to the ICU.  To help make more appropriate choices we put together an order set that was a multimodal approach to pain management. 

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Opioid-Induced Constipation

Chronic Pain Patients: Opioid Induced Constipation a Serious Concern After Surgery Interview with:

Jonathan Jahr, MD, DABA, FASA

Dr. Jonathan Jahr is an anesthesiologist in Los Angeles, California and is affiliated with multiple hospitals in the area, including UCLA Medical Center and UCLA Medical Center-Santa Monica. He received his medical degree from New York Medical College and has been in practice for more than 20 years.

Dr-Jonathan-Jahr  What is the background for this study?  Why is it important?

Response: I have worked in the hospital setting for the past 25 years and have conducted multiple studies on different opioid and non-opioid strategies for managing both chronic and acute pain. I also co-edited a textbook entitled Essence of Analgesia and Analgesics. My background and the research I’ve done sets the stage for newer pain management protocols that can provide patients with significant pain relief, and improved satisfaction and outcomes due to fewer or avoided opioid related side effects (ORADS) such as opioid-induced constipation (OIC).

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EXPAREL TAP Block Provides Pain Relief For Cesarean Delivery With Less Opioids Interview with:

B. Wycke Baker, MD
Chief of Service, Anesthesiology at Texas Children’s Pavilion for Women
Clinical Professor of Anesthesiology, Obstetrics and Gynecology
Baylor College of Medicine 

pacira pharmaceuticals  What is the background for this study?  What are the main findings?

Response: For this study, we reviewed the charts of 201 women who underwent cesarean deliveries and received a multimodal pain management protocol with or without a TAP block utilizing EXPAREL, a long-acting, non-opioid option to manage pain following surgery. A TAP block, or a transversus abdominis plane block, is a field block that numbs the nerves that supply the abdominal wall. The study included patients who underwent elective, unscheduled waiting list, or emergency cesarean delivery with combined spinal-epidural anesthesia and post-cesarean pain management at Texas Children’s Hospital Pavilion for Women between 2012 and 2015.

The findings revealed many positive outcomes for patients who received a TAP block utilizing EXPAREL compared to those who received multimodal pain control without a TAP block utilizing EXPAREL. For instance, patients who received EXPAREL TAP block showed a significant decrease in postsurgical pain as well as a significant decrease in opioid consumption. On average, patients who received EXPAREL TAP block had shorter time to discharge from PACU, shorter time to readiness for discharge to home, and shorter length of stay in hospital than those who did not receive EXPAREL TAP block.

Further, a significantly higher number of patients treated with EXPAREL TAP block (12%) compared to those without EXPAREL TAP block (3%) consumed no opioids after surgery. Fewer patients treated with EXPAREL TAP block (34%) compared to those without EXPAREL TAP block (50%) reported any adverse events following the delivery.

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Online Patient Materials Unlikely to Discuss Risk of Opioids Prescribed for Pain Relief Interview with:

Edward R. Mariano, MD, MAS (Clinical Research)
Chief, Anesthesiology and Perioperative Care Service and
Associate Chief of Staff for Inpatient Surgical Services
VA Palo Alto Health Care System
Professor of Anesthesiology, Perioperative and Pain Medicine
Stanford University School of Medicine
Palo Alto, CA  94304  What is the background for this study?  What are the main findings?

Response: Today, there is so much attention on the opioid epidemic, and patients and clinicians are constantly reminded about the dangers of opioids. Guidelines have recommended the provision of patient and caregiver education on pain management, especially on how to taper (safely decrease and eventually stop taking) opioids after surgery. With over 70 fellowship programs in regional anesthesiology and acute pain medicine, we assumed that there would be plenty of information for patients on safe opioid management online since most people use the internet to find health-related information. We conducted a rigorous search for online patient education materials related to safe opioid management, evaluated to reading level and content, and compared materials produced by fellowship programs to other online educational materials. Unfortunately, the average reading level for all materials we found was above the level recommended for patients (sixth grade or lower). Most fellowship programs in regional anesthesiology and acute pain medicine did not even offer online patient education materials and were less likely to describe overdose risk and opioid disposal. Less than half of all materials mentioned tapering or cessation of opioids after surgery (see visual abstract attached).

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Pain and Substance Use Can Interact in a Vicious Cycle Interview with:

Emily L. Zale PhD Department of Psychology Syracuse University Syracuse, New York

Dr. Zale

Emily L. Zale PhD
Department of Psychology
Syracuse University
Syracuse, New York What is the background for this study? What are the main findings?

Response: When people think of pain and substance use, it’s common for opioids to come to mind. While the opioid crisis has rightfully garnered considerable attention, our research suggests that non-opioid substances, like nicotine/tobacco, alcohol, and cannabis, are also important to consider in relation to pain. In fact, nicotine/tobacco, alcohol, and cannabis are the most commonly used substances in the US, and research into associations between pain and these non-opioid substances is continuing to increase in popularity.

Research studies usually examine either how substance use affects pain or how pain affects substance use. We looked at results from over 100 studies and put these two different types of research together to understand how pain and substance use affect each other.

On one hand, substance use can be a risk factor for chronic pain and may worsen pain over time. On the other hand, experiencing pain can motivate people to use substances and might make it harder to quit. By putting these two types of studies together, we found that pain and substance use  interact in a vicious cycle that can ultimately worsen and maintain both chronic pain and addiction.

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