Switching to Buprenorphine Might Provide Pain Relief for Poorly Controlled Pain

PainRelief.com Interview with:
Victoria D. Powell, MD, FACP
Clinical Lecturer – Geriatric and Palliative Medicine
University of Michigan
Staff Physician, Palliative Care
LTC Charles S. Kettles VA Medical Center
Ann Arbor, MI

Dr. Powell

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

Response: People with chronic pain who use long-term opioids face a number of health risks, and often do not have optimally controlled pain.

Buprenorphine acts on the opioid receptor with a different effect than drugs like morphine or oxycodone, and as a result is less associated with the risks of long-term opioid use, such as accidental overdose. While buprenorphine has been successfully used in patients with opioid use disorder for several years, certain experts have proposed using buprenorphine for pain management in people with chronic pain. We found low quality evidence supporting pain control that may be superior to traditional opioids, but much more research is needed to confirm.

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Physicians Differently Prescribe Pain Relief Medications to White and Minority Patients

PainRelief.com Interview with:
Dan P. Ly M.D., M.P.P., Ph.D.
Division of General Internal Medicine and Health Services Research
David Geffen School of Medicine
University of California, Los Angeles

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

Response: We know that minority patients were less likely to receive opioids than white patients, but this could have been due to minority patients seeing lower opioid-prescribing physicians. As far as I could tell, nobody had been able to examine whether the same physician prescribed opioids differently to their minority patients.

I find that this is the case: the same physician was less likely to prescribe opioids to their minority patients with new low back pain, and instead was more likely to prescribe NSAIDs to their minority patients. And unfortunately, this differential prescribing may have had the consequence of leading to more chronic opioid use in white patients.  

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Overdose Rates Increased When Pain Meds Prescribed by Multiple Providers

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

Dr. Kao-Ping Chua

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

Response: Having overlapping opioid and benzodiazepine prescriptions is a strong risk factor for opioid overdose even if these prescriptions are written by the same prescriber.

In this study of privately insured and Medicare Advantage patients, we show that the risk of overdose is even greater when the prescriptions are written by multiple prescribers. Specifically, the unadjusted risk of overdose on a day of overlap was 1.8 times higher when the prescriptions were written by multiple prescribers. After controlling for patient demographic characteristics, clinical co-morbidities, and prescribing patterns, the adjusted odds of overdose was 1.2 times higher, corresponding roughly to a 20% higher adjusted risk.

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Opioid Use Disorder: Treatment Among US Medicaid Enrollees

PainRelief.com Interview with:
Julie Donohue, Ph.D., Chair and Professor
University of Pittsburgh Graduate School of Public Health Department of Health Policy and Management.
Lead, Medicaid Outcomes Distributed Research Network

Dr. Donohue

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

Response: Medicaid plays an incredibly important role in our health system, and the population it serves overlaps with those most likely to have opioid use disorder. But Medicaid is 50-plus separate programs that can’t easily share data, so it can be difficult to draw evidence-based conclusions about the impact of interventions to prevent and treat opioid use disorder in this population.

PainRelief.com: What are the main findings?

Response: For the first time, we’ve pooled a large part of that data, enabling us to draw powerful conclusions that could better enable our country to address the opioid epidemic, which has only grown more intense during the COVID-19 pandemic. We found that the prevalence of opioid use disorder increased from 3.3% of enrollees in 2014 to 5% in 2018. Notably, the share of enrollees with opioid use disorder enrolled in Medicaid due to the ACA expansion grew from 27.3% to 50.7% in the same time period.

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Multimodal Analgesia For Pain Relief After Joint Replacement

PainRelief.com Interview with:

Joseph Albert Karam, MD
Assistant Professor of Clinical Orthopaedic Surgery
Associate Program Director, Orthopaedic Surgery Residency
The University of Illinois at Chicago

Joseph-Karam
Dr. Karam

PainRelief.com:  What is the background for this study?Would you describe the multimodal pain plan?

Response: Pain after joint replacement surgery has been historically managed by protocols centered on opioid medication. Given the side effects associated with these medications, the risk for long term addiction and evidence showing that opioids are not necessarily the best at treating pain perioperatively in joint replacement, multimodal pain management protocols have been established. These protocols utilize different families of medications that target pain at different steps in the pain pathway.

The exact protocol varies from one institution to the other but typically include systemic agents such as acetaminophen, non-steroidal anti-inflammatories/COX-2 inhibitors, gabapentinoids, corticosteroids, as well as loco-regional interventions such as local infiltration analgesia and regional nerve blocks. ‘Pre-emptive analgesia’ which most commonly uses a nonsteroidal anti-inflammatory, acetaminophen and/or a gabapentinoid has also been demonstrated to play a key role. Additional measures such as NMDA antagonists and epidural catheters can also be used in select cases. Non-pharmacological treatments such as cryotherapy, cryoneurolysis and electrical nerve stimulation have also been described. Our preferred institutional protocol is detailed in the paper.

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Prescription Opioids for Pain Relief in Youth Decreased in Recent Years

PainRelief.com Interview with:

Madeline H. Renny, MD
Postdoctoral Fellow, Department of Population Health
Clinical Instructor, Department of Emergency Medicine and Pediatrics
New York University Grossman School of Medicine
New York, New York

Dr. Renny

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

Response: Prescription opioids are involved in over half of opioid overdoses among youth.  Additionally, prescription opioid use is associated with risks of future misuse, adverse events, and unintentional exposures by young children.  While there are several studies on opioid prescribing in adults, few studies have focused on the pediatric and adolescent population.  In the last year, postoperative guidelines for opioid prescribing for children and adolescents were released, but there remain no national guidelines on general opioid prescribing for youth. 

To our knowledge, no prior national studies have examined trends in important opioid prescribing practices, including amount prescribed, duration, high-dosage, and extended-release/long-acting (ER/LA) opioid prescriptions, in this subset of the population; a necessary step in understanding the opioid epidemic and in developing targeted interventions for youth. 

Therefore, we performed a cross-sectional analysis of U.S. opioid prescription data to investigate temporal trends in several key opioid prescribing practices in children, adolescents, and younger adults in the U.S. from 2006-2018.


PainRelief.com: What are the main findings?

Response: We found that opioid dispensing rates declined significantly for children, adolescents, and younger adults since 2013. When examining trends in opioid prescribing practices, there were differences based on age group. For adolescents and young adults, rates of long-duration and high-dosage opioid prescriptions decreased during the study period, whereas there were increases in these rates for younger children.  

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

Response: Dispensed opioid prescriptions for youth have significantly decreased in recent years.  These findings are consistent with prior studies in children and adults, suggesting that opioid prescribing practices may be improving. Additionally, the decrease in rates of high-dosage and long-duration prescriptions in adolescents and young adults is encouraging in the context of research showing associations with these prescribing practices and opioid use disorder and overdose. However, opioids remain commonly dispensed to youth and potential high-risk prescribing practices (long-duration, high-dosage, and ER/LA prescriptions) appear to be common, especially in younger children.  

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

Response: The increase in rates of potential high-risk prescribing practices in young children was an unexpected finding and warrants future study. Due to the limitations of our database (no clinical information, including diagnoses or indications for prescription), we were unable to determine the appropriateness of opioid prescribing practices (e.g., whether a prescription was for a child with cancer or for a child with an acute injury).  Our two sensitivity analyses were performed to try to identify a subset of patients with chronic illness and both showed no differences in trends.  However, it will be important to further investigate these opioid prescribing practices using a database with clinical information to better understand these findings in young children.

Further research investigating specific opioid prescribing practices may inform targeted interventions, including pediatric and adolescent-specific opioid prescribing guidelines, to ensure appropriate opioid prescribing in this population. 

No disclosures

Citation:

Renny MH, Yin HS, Jent V, Hadland SE, Cerdá M. Temporal Trends in Opioid Prescribing Practices in Children, Adolescents, and Younger Adults in the US From 2006 to 2018. JAMA Pediatr. Published online June 28, 2021. doi:10.1001/jamapediatrics.2021.1832

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Tapentadol Provided Pain Relief and Improved Sleep in Patients with Chronic Musculoskeletal Pain

PainRelief.com Interview with:
Dr Renato Vellucci
Contract Professor University of Florence
Pain and Palliative care Clinic
University Hospital of Careggi
Florence, Italy

Dr. Vellucci

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

Response: Chronic low back pain (CLBP) is the most prevalent chronic pain (CP) condition and the leading global cause of years lived with disability. According to the axiom pain as a biopsychosocial issue, mood and sleep disturbances represent key issues. However, the impact of different analgesic therapies on quality of life (QoL) and functional recovery has been poorly assessed to date. Focusing on combination of chronic pain and sleep, they both perform a mutual reinforcement.

Pain disorganizes the sleep architecture, and disturbed and unrefreshed sleep increases spontaneous pain and lowers pain thresholds. Sleep disorders may augment stress levels, thus making it difficult for patients to perform simple tasks impairing their cognitive ability. Poor sleep may predict the growth and intensification of pain over time, with increased insomnia symptoms being both a predictor and an indicator of worse pain outcomes and physical functioning status over time. Epidemiology of chronic pain unequivocally demonstrates the role of sleep quality in the development of chronic pain.

Notwithstanding this strong two-way relationship between chronic pain and sleep, little knowledge is available about the neurochemical determinants of this interplay and therapeutical strategies to break this vicious circle. Fifty percent of people with chronic low back pain have sleeping disturbances, with an 18-fold increase in insomnia versus healthy people. A recent study investigated the relationship between sleep disturbances and back pain and found that it is two sided with sleep disturbance being associated with risk of back pain whilst back pain can also lead to sleep disturbances. Thus, it can be hypothesized that, by reducing pain and physical dysfunction, sleep quality could be improved, thus enriching the QoL of people with CLBP.

Similarly, improvements in sleep after cognitive behavioral therapy in patients with chronic pain due to osteoarthritis were associated with reduced pain. Earlier evidence suggested that tapentadol prolonged-release treatment ameliorate in parallel QoL and sleep quality in a greater proportion of patients compared to that of patients following oxycodone/naloxone prolonged- release treatment (50% versus 37.7%). Other tapentadol studies conducted in a real-life context documented, along with effective pain control, similar improvements in mental and physical health and suggested beneficial effects in terms of less night awakenings and greater percentages of patients reporting restful sleep.

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New Class of Drugs May Provide Pain Relief Without Need for Opioids

PainRelief.com Interview with:
John Traynor, PhD
Edward F Domino Research Professor
Professor and Associate Chair for Research
Department of Pharmacology, Medical School
Professor of Medicinal Chemistry, College of Pharmacy
University of Michigan, Ann Arbor MI

Dr. Traynor

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

Response: Response: Morphine and related drugs acting at the mu-opioid receptor are the most effective treatment for moderate to severe pain, yet their use is limited by serious on-target side effects including respiratory depression, and physical and psychological dependence that has led to the opioid crisis.  Current opioid drugs are required because our own endogenous pain relieving chemicals, the enkephalins and endorphins opioid peptides, cannot efficiently relieve pain.  

We have discovered a class of drugs (positive allosteric modulators, PAMs) that bind to the mu-opioid receptor to enhance the activity of endogenous opioids.  These “enkephalin amplifiers” afford pain relief in mouse models without the need for morphine-like compounds and do so with a much reduced side-effect profile.

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Dental Opioid Prescriptions Raises Risk of Overdose in Patients and Their Families

PainRelief.com Interview with:

Kao-Ping Chua, MD, PhD
Susan B. Meister Child Health Evaluation and Research Center
Department of Pediatrics, University of Michigan Medical School
Ann Arbor MI 48109.

Dr. Kao-Ping Chua

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

ResponsePrior studies suggest that opioid prescriptions for surgical procedures are associated with increased overdose risk in patients. Additionally, studies suggest that opioid prescriptions are associated with increased overdose risk in patients’ family members, who often have access to patients’ opioids. However, studies have not specifically assessed whether opioid prescriptions for dental procedures are associated with increased overdose risk in patients and their family members.

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Chronic Low Back Pain: Spinal Manipulation Therapy May Reduce Opioid-Related Adverse Effects

PainRelief.com Interview with:
Jim Whedon DC, MS
Director of Health Services Research
SCU Health System
Southern California University of Health Sciences
Whittier, CA

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

Response:    Current evidence-based guidelines for clinical management of chronic low back pain (cLBP) include both pharmacological and non-pharmacological approaches.

Both Opioid Analgesic Therapy (OAT and Spinal Manipulative Therapy (SMT) are effective treatments for cLBP and are provided under Medicare for older adults with cLBP, but the long-term safety of OAT is uncertain, and the dangers of opioid misuse are well known. Older adults are at particularly high risk of adverse drug events (ADEs),but they nevertheless receive more opioid analgesics than any other age group. SMT is established as an effective non-pharmacologic treatment for cLBP, but little is known about the safety of long-term treatment with SMT. The objective of our study was to compare SMT and OAT to determine the impact of SMT on the risk of ADEs among older adults receiving long-term care for cLBP.

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