Novel Protocol Reduced Use of Opioid Pain Relievers After Knee and Shoulder Surgeries

PainRelief.com Interview with:
Nicole Simunovic, MSc
On behalf of the NO PAin Principal Investigators

PainRelief.com: What is the background for this study?

Response: Orthopaedic surgeons prescribe more opioids than any other type of surgeon in North America. Opioids have the potential to be highly addictive and can cause serious harm or even death if taken in excess. The goal of our clinical study was to determine if an opioid sparing approach to postoperative pain management was safe and effective in patients undergoing arthroscopic knee and shoulder surgery.

States with Mandated Prescription Monitoring Programs Had Marked Increase in Heroin-Related Deaths

PainRelief.com Interview with:
Dr. Tongil “TI” Kim,
Assistant professor of marketing
Naveen Jindal School of Management
The University of Texas at Dallas (abbreviated UT Dallas)

PainRelief.com: What is the background for this study? What are the main findings?

Response: We examine the early deployment of mandated prescription drug monitoring program (PDMP) use (2006-2015) in the U.S., when 19 states mandated PDMP use. We find 6.37 more heroin-related deaths per million population per year—a 50.1% increase—following PDMP mandates compared to states that did not.

Uninsured Pay Higher Out-of-Pocket Costs for Opioid Antidote Naloxone

PainRelief.com Interview with:
Evan D. Peet, PhD Professor
Pardee RAND Graduate School

Dr. Peet

PainRelief.com: What is the background for this study?

Response: This study is part of a broader CDC funded project looking at access to naloxone and naloxone’s impacts on opioid-related overdose deaths. There have been increasing efforts to expand access to naloxone, with a variety of different laws being passed by states across the nation. But one part of access that has been understudied is the cost borne by patients.

High out-of-pocket costs may act as a barrier to this life-saving drug, so in this study we look at trends in out-of-pocket costs of naloxone and how they vary by payor and drug brand.

More Nonopioid Medications Prescribed for Pain Relief since CDC Released Chronic Pain Guidelines

PainRelief.com Interview with:

JASON GOLDSTICK
Dr. Goldstick

Jason E. Goldstick, PhD
Injury Prevention Center
Department of Emergency Medicine
University of Michigan, Ann Arbor

PainRelief.com:  What is the background for this study?  What are the main findings?

Response: In 2016, the CDC released the Guideline for Prescribing Opioids for Chronic Pain. A primary goal of this voluntary guideline is that individuals should receive pain management care that provides the greatest overall benefit. Among other things, this may entail beginning opioid treatment only when the clinician determines that the expected benefits outweigh the risks.

Other research has shown reductions in opioid prescribing as reduced since the guideline release; this report examines whether there were changes in nonopioid pain medication prescribing.

Our overall findings were that nonopioid prescribing increased nationally following the guideline release, above and beyond what would’ve been predicted based on the pre-guideline trends, and this finding was generally consistent across patient subpopulations (e.g., those with vs. without prior opioid exposure).

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Study Highlights Challenges of Opioid Use Disorder in Patients with Cancer Pain

PainRelief.com Interview with:
Katie Fitzgerald Jones MSN, APN
PhD candidate Connell School of Nursing
Boston College
Jonas Mental Health Scholar 2021-2023
American Academy of Nursing Jonas Policy Scholar 
Ruth L. Kirschstein National Service Award (F31NR019929-01)

PainRelief.com:  What is the background for this study? 

Response: I am a Palliative and Addiction Nurse Practitioner at VA Boston and a Ph.D. candidate at Boston College Connell School of Nursing. In my clinical practice, I regularly care for people with cancer who have a co-occurring substance use disorder. 

How to best care for people with substance use disorders, such as opioid use disorder is especially complex in people with cancer because opioid management is a standard of cancer-pain management and cancer prognoses can influence opioid decisions and vary. It is important when prescribing opioids that you attend to safety while also addressing pain. People with untreated opioid use disorder or concerning opioid behaviors (such as taking more opioids than prescribed or using opioids with unprescribed medications that increase the risk for opioid-related harm such as benzodiazepines) have an increased risk for opioid related-harms. It is also an area that lacks consensus and is absent from cancer-specific pain guidelines.

This study was conducted with leaders in palliative care including senior author, Jessica Merlin to tackle the question of what is consensus among palliative care and addiction clinicians to caring for people with opioid misuse or use disorder and cancer-related pain and how this is influenced by prognosis?

Concurrent Opioid and Benzodiazepine Prescriptions for Pain Relief Fall But Still Common

PainRelief.com Interview with:
Kun Zhang PhD
Senior Service Fellow and Health Scientist
Opioid Overdose Prevention Health Systems Team
Division of Unintentional Injury Prevention
Centers for Disease Control and Prevention

Dr. Zhang

PainRelief.com:  What is the background for this study?  are the main findings?

Response: When taken together by patients, opioids and benzodiazepines can result in synergistic respiratory depression which elevates overdose risk; however, these two medications have been commonly co-prescribed in the U.S.

Since 2016 there has been efforts to address the concurrent use of these two drugs, for example the 2016 FDA Boxed Warning and the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.

Our study aimed at tracking and analyzing recent trends in concurrent use of these two medications using national level data.

Policymakers Can Mitigate Prescription Opioid Misuse Associated with Delayed Dispensing for Pain Relief after Procedures

PainRelief.com Interview with:
Kao
Ping ChuaMD, PhD
Department of Pediatrics
Susan B. Meister Child Health Evaluation and Research Center
University of Michigan Medical School
Department of Health Management and Policy
University of Michigan School of Public Health, Ann Arbor

PainRelief.com:  What is the background for this study? 

Response: Opioid prescriptions written by dentists and surgeons are almost always written for the immediate relief of acute pain after procedures. However, current federal and state laws allow these prescriptions to be dispensed well after the time that they are written. When this occurs, that could be a potential sign that the prescription was used in a time frame or for a reason other than intended by the prescriber, both of which are forms of prescription opioid misuse.

Chronic Pain: Sex Differences in Pain Relief from High vs Low Spinal Cord Stimulation

PainRelief.com Interview with:
Imanuel Lerman MD MSc
Associate Professor 
Affiliate Electrical and Computer Engineering 
VA San Diego Healthcare System
Center for Stress and Mental Health
Center for Pain Medicine 
UC San Diego Health 
Qualcomm Institute 
California Institute for Telecommunications and Information Technology (Calit2)

Dr. Lerman

PainRelief.com:  What is the background for this study?  What are the main findings?

Response: Spinal Cord Stimulation (SCS) offers an implantable, non-pharmacologic treatment for patients with intractable chronic pain conditions.  There is extensive clinical literature that offers support for efficacy in chronic pain treatment for both Low frequency and High frequency based  spinal cord stimulation. While Low Frequency SCS has been heavily examined since its inception, High Frequency SCS paradigms have recently been clinically approved.

Emerging preclinical work also show sex may alter certain immunological pathways that contribute to chronic pain.  But to date few report have identified interactions between sex and SCS.  Therefore, we aimed to fill this knowledge gap through a single site (University of California San Diego), large (n=237) retrospective (2004–2020) analyses that compared SCS paradigm Low vs High Frequency SCS, efficacy (pain relief and opiate sparing effects) across sex.

Identification of the Muscle-Relaxant Carisoprodol (Soma) and Non-Controlled Prescription Substances in Drug-Arrests

PainRelief.com Interview with:
Maaz Siddiqui, BS
Department of Medical Education
Geisinger Commonwealth School of Medicine
Scranton, Pennsylvania

Maaz Siddiqui

PainRelief.com: What is the background for this study?

Response: Over the last twenty years, the rise of deaths due to drug overdoses have been mainly and rightfully attributed to opioids. However, many investigations identify non-opioid drugs and drug classes that additionally contribute to deaths due to polysubstance overdoses. Through the Maine Diversion Alert Program (DAP) data, we examined drugs that often escape the attention of healthcare providers and directly or indirectly contribute to substance misuse, arrests, addiction, and deaths due to overdose.

The goal of this study was to utilize a novel dataset to uncover and identify the noncontrolled drugs that have shown potential to be misused.

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Risk of AMA Hospital Discharge High Among Patient with Opioid-Related Conditions

PainRelief.com Interview with:
Peggy Compton, RN, PhD, FAAN
Professor and van Ameringen Endowed Chair
Program Director, Hillman Scholars in Nursing Innovation
Department of Family and Community Health
University of Pennsylvania School of Nursing
Philadelphia, PA 19104

Dr. Compton

PainRelief.com:  What is the background for this study? 

Response: Patients with substance use disorders are highly likely to leave the hospital against medical advice (AMA) or self-discharge, putting them at risk for poorer health outcomes including progressing illness, readmissions, and even death. Inadequate pain management is identified as a potential motivator of self-discharge in this patient population.  The objective of these secondary analyses was to describe the association between acute and chronic pain and AMA discharges among persons with opioid-related conditions.

PainRelief.com:  What are the main findings?

Response: The main findings were that 16% of the 7,972 admissions involving opioid-related conditions culminated in an AMA discharge, which was more than five times higher than in the general population. Self-directed discharge rates were positively associated with polysubstance use, nicotine dependence, depression, and homelessness. Among the 955 patients with at least one self-directed discharge, 15.4% had up to 16 additional self-directed discharges during the 12-month observation period. Those admitted with an acutely painful diagnosis were almost twice as likely to have an AMA discharge, and for patients with multiple admissions, rates of acutely painful diagnoses increased with each admission coinciding with a cascading pattern of worsening infectious morbidity over time. Chronic pain diagnoses were inconsistent for those patients with multiple admissions, appearing, for the same patient, in one admission but not others; those with inconsistent documentation of chronic pain were substantially more likely to self-discharge. 

PainRelief.com: What should readers take away from your report?

Response: These findings underscore the importance of aggressive and effective pain care in disrupting a process of self-directed discharge, intensifying harm, and preventable financial cost and suffering. Each admission represents a potential opportunity to provide harm reduction and treatment interventions addressing both substance use and pain.  

PainRelief.com: What recommendations do you have for future research as a result of this work?

Response: Future research should be aimed at evaluating approaches for effective pain management in patients with opioid related disorders.  These patients may present with high levels of opioid analgesic tolerance and opioid-induced hyperalgesia, suggesting that non-opioid analgesic approaches may be warranted to effectively manage their pain.  Regardless of the specific pain management approach employed, patients with opioid-related disorders should believe that their complaints of pain are taken seriously and managed aggressively to maximize duration of hospital stay.

Citation:

Compton, P., Aronowitz, S.V., Klusaritz, H. et al. Acute pain and self-directed discharge among hospitalized patients with opioid-related diagnoses: a cohort study. Harm Reduct J 18131 (2021). https://doi.org/10.1186/s12954-021-00581-6

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