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.

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.

As Opioid Prescriptions Fall, Alternate Prescriptions for Pain Relief Increase

PainRelief.com Interview with:
Lauren R. Gorfinkel MPH
New York State Psychiatric Institute
New York, NY
Department of Medicine, University of British Columbia
Vancouver, Canada

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

Response: The opioid crisis has led to clear declines in opioid prescribing across North America, however, chronic pain remains an extremely common health problem with limited treatment options. This study was therefore interested in using nationally-representative data to find out whether alternative pain medications are growing more popular as opioid prescriptions decline.

Older Adult Black Men at Disproportionate Risk of Fatal Opioid Overdose

PainRelief.com Interview with:
Maryann Mason, PhD
Department of Emergency Medicine
Northwestern University Feinberg School of Medicine
Buehler Center for Health Policy and Economics,
Northwestern University, Chicago, Illinois

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

Response: This study came about because we were looking at data for Cook County, Illinois and saw an increase in older adult opioid overdose deaths.  That made us wonder if there was a national trend or the observation was limited to our local area.  We undertook the research to determine that and found that it is indeed a national phenomenon.

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Less-is-More Approach to Pain Relief After Surgery

PainRelief.com Interview with:
Dr Deanne Jenkin PhD
UNSW Australia,
now Research Fellow at The Daffodil Centre
Sydney, Australia

Dr Jenkin

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

Response: At the time, long-term opioid use for chronic non-cancer pain was increasing and there were signs that their benefit was overestimated whilst the harms were underestimated. Our randomized trial found that after going home from fracture surgery, strong opioids were not better for pain relief compared to a milder, potentially safer opioid alternative.

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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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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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