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.

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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Tramadol Prescriptions for Pain Relief Linked to More Complications than Codeine

PainRelief.com Interview with:
Carlen Reyes PhD
Médico de familia
Gestora de proyectos de investigación IDIAP Jordi Gol

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

Response: Tramadol and codeine are two “weak” opioids frequently prescribed for different non-cancer pain indications, however, few are the studies that compare the adverse outcomes between them using large routinely collected primary care data. We aimed to fulfil this gap by analysing the risk of adverse events with the tramadol and codeine dispensations in a large primary care health care data (SIDIAP database) from Spain. 

We found that the dispensations of tramadol were associated with a greater risk of cardiovascular events, mortality and fractures compared to the dispensations of codeine. 

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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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No Decrease in Pain Relief With Less Opioids After Surgery

PainRelief.com Interview with:
Ryan Howard, MD
Academic Development Time Year 1
Resident, General Surgery
University of Michigan

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

Response: Opioids are commonly prescribed to control pain after surgery, but they also carry significant risks such as overdose, long-term dependence, and diversion into the community. While some have advocated for decreasing or eliminating opioids from postoperative pain control regimens, others are concerned that this would lead to uncontrolled pain and dissatisfied patients. To study whether that’s true, we compared two groups of patients undergoing the same surgical procedures. One group received “opioid-sparing” prescriptions after surgery and the other group received “normal-sized” prescriptions.

Conditioned Open-Label Placebos Provide Pain Relief in Some Post-Surgical Patients

PainRelief.com Interview with:
Kristin Schreiber, MD, PhD
Neuroscientist and Clinical Regional Anesthesiologist
Brigham and Women’s Hospital
Assistant Professor of Anesthesia
Harvard Medical School

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

Response: Traditionally, the placebo effect has involved deceiving patients, where they think they may be taking a real medication. “Open-label placebos” are when placebos are given to patients, and patient are told that they are in fact a placebo. Recent research has suggested that these open-label placebos may actually reduce a number of symptoms in patients, including chronic low back pain. We were interested whether this strategy could be used to help reduce pain and opioid use around the time of surgery. We decided to combine the use of OLP with a conditioning approach, so that anytime a patient took an opioid analgesic, they would take the open-label placebo, so that the OLP pills would be associated with pain relief. That way when patients took them on their own, it would serve to trigger an expectation of pain relief, which is thought to at least partially explain the placebo effect.  

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Study Discusses Overlap of Opioid Therapy for Physical and Social Pain Relief

PainRelief.com Interview with:
Mark Sullivan, MD, PhD
Professor, Psychiatry and Behavioral Sciences
Adjunct Professor, Anesthesiology and Pain Medicine, Bioethics and Humanities
Medical Co-Director, UW Telepain

Dr. Sullivan

University of Washington
Seattle, WA 98195

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

Response: This is a review paper than synthesizes neuroscience, pharmacological and epidemiological research on the opioid epidemic. It has been known since at least the 1970s that opioids treat not only pain due to physical damage, but also separation distress.

Functional neuroimaging (fMRI) studies have shown that physical pain (tissue injury) and social pain (social rejection) activate the same limbic brain centers (insula, cingulate cortex). Both chronic pain and depression are associated with dysfunction of the endogenous opioid system in the human brain. Studies of opioid prescribing have shown that patients with chronic pain, who also have anxiety and depressive disorders are more likely to be prescribed long-term opioid therapy at high doses and with concurrent sedatives.

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Opioid Analgesic Use For Pain Relief in Chronic Noncancer Pain

PainRelief.com Interview with:
Dr Stephanie Mathieson
NHMRC Health Professional Research Early Career Fellow
The University of Sydney
Faculty of Medicine and Health, Sydney School of Public Health
Institute for Musculoskeletal Health
Royal Prince Alfred Hospital Australia

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

Response: Chronic non-cancer pain, such as chronic non-specific low back pain has a substantial impact on society by costing billions of dollars each year in health care costs and lost productivity.

Current clinical practice guidelines for the management of chronic non-cancer pain, such as those from the Centers for Disease Control and Prevention, now recommend avoiding the initial use of opioid analgesics, as the risk of harms, such as overdose and death.

We wanted to establish the extent to which opioid analgesics are used by people with chronic noncancer pain. This is important, as many studies report how many opioids are prescribed, but this may not represent the actual use of opioid analgesics.

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Traditional and Battlefield Acupuncture Provide Post-Op Pain Relief and Reduced Need for Opioids

PainRelief.com Interview with:

  • Brinda Krish, D.O., lead author of the study and an anesthesiology resident at Detroit Medical Center.
  • Padmavathi Patel, M.D., principal investigator of the study and Medical Director, Northstar Anesthesia at John D. Dingell Veteran Hospital.

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

Dr. Padmavathi Patel: Pain is a major contributor to health care costs and a common cause of long-term disability (about  $61.2 billion/year) in lost productivity due to pain.

acupuncture

76.2 million Americans (one in four) have suffered from pain that lasts longer than 24 hours (2013).

Numerous literature such as:

1. “Use of prescription opioids in the treatment of pain has increased notably over recent decades.”

2. “Rates of death from prescribed opioids increased four fold between 2000 and 2014.”

3. “16,651 opioid related deaths in 2010.”

4. “The problem of opioid overuse and dependence is seen in the military as well as in civilian.”

-Opioid-related side effects could lead to a delay in recovery.
-Pain control is more challenging for military population.
-More extensive injuries and greater pain severity is seen in survivors of combat- related blast injuries compared to those of non-blast civilians and also they require larger opioid doses.
-Pain is a very common patient complaint, both in veteran and non-veteran populations.
-Among the 5.7 million unique patients seen annually with in the Department of Veterans Affairs (DVA), more than half of these patients experience chronic pain.

In 2017, The DVA and the United States Department of Defense (DoD) published an updated guidelines on opioid therapy for chronic pain that strongly recommends against initiation of long-term opioid use and recommends alternatives, including non-pharmacologic therapy, such as Acupuncture, which has been shown to be effective for treating a variety of painful conditions.

Acupuncture techniques have been in existence for centuries, with roots tied to Eastern Asia. Traditional acupuncture involves the insertion of very thin needles at specific trigger points around the body to relieve pain. Battlefield acupuncture (BFA), developed by a U.S. Air Force doctor uses needles that are inserted at various trigger points in the ear. In 2013, $5.4 million was awarded to the Departments of Defense and Veterans Affairs to teach BFA to healthcare providers in both the military and the Department of Veterans Affairs and assess it.  In light of the opioid epidemic, there is a strong need to decrease perioperative opioid use. Opioid use due to postoperative pain along with perioperative anxiety has been linked to increased length of hospital stay, increased morbidity and mortality, and ultimately higher healthcare costs.

Battlefield acupuncture was introduced into Veterans Health Administration (VHA) in the last few years and in VHA, clinicians of various disciplines (MDs, DOs, PAs, nurse-practitioners), can currently obtain clinical privilege to provide it.

I received the Battlefield acupuncture training at John D. Dingell VA medical Center, Detroit and I was surprised with the outcomes of chronic pain patients. As an anesthesiologist I know pain after the surgery is common, often severe and largely unnecessary. I discussed these concerns with the surgeons and created the protocol to use BFA for general surgical patients and traditional acupuncture for hip replacement patients as an adjuvant to the standard protocol for acute post-surgical pain control.

Effective relief of postoperative pain is vital. Such pain probably prolongs hospital stay, as it can affect all the organ systems with side effects. Post op pain remains grossly under treated, with up to 70% of patients reporting moderate to severe pain following surgery.

Multimodal pain control not only can result in earlier discharge from hospital, but it may also reduce the onset of chronic pain syndromes.

2 studies performed TA (n=21), Controls given sham acupuncture (n=21).  BFA (n=28), Controls given sham acupuncture (n=36). Measured variables included post-operative opioid requirements, postoperative pain, the incidence of PONV, and patient satisfaction scores

Key conclusions use of Battlefield acupuncture and Traditional acupuncture reduced post-operative opioid requirements, post-operative pain scores (pain intensity) and increased patient satisfaction scores.  BFA also reduced PONV in patients.