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Progressive Opioid Use: Who’s At Risk?

Progressive Opioid Use: Who’s At Risk?

Throughout the United States, greater attention is being paid to accidental overdoses from the long-term use of opioids. Experts have reported that there is an urgent need to better understand patterns of opioid prescribing. In most cases, healthcare providers do not prescribe opioids with the intent of having patients use them long term, nor do they intend to provide repeat prescriptions. “Opioids are an important drug class that is used to manage short-term pain as well as pain after surgical procedures or trauma,” explains W. Michael Hooten, MD. “At the same time, it’s critical that these medications are prescribed carefully to ensure their safe use by patients.” Studies are lacking on the characteristics associated with the transition from shorter-term to longer-term opioid use, says Dr. Hooten. “When opioids are first prescribed, it’s unclear which patients are more likely to eventually receive repeat prescriptions,” he says. “A better understanding of these characteristics may help guide efforts to optimize opioid use. It could also help us anticipate the potential for inappropriate episodic or long-term use.” Exploring Recent Trends The Consortium to Study Opioid Risks and Trends (CONSORT) is an initiative supported by the National Institute of Drug Abuse that has identified trends and risks associated with long-term opioid therapy for chronic pain. CONSORT classified opioid prescribing patterns as 1) short-term use, 2) episodic use, and 3) long-term use. Dr. Hooten and colleagues had a study published in Mayo Clinic Proceedings that sought to determine how often patients receiving new opioid prescriptions progressed to episodic or long-term opioid use. It also examined associations between patient characteristics and the transition to longer-term use...
Opioid Backlash Threatens Sickle Cell Care

Opioid Backlash Threatens Sickle Cell Care

The well-meaning push to curb opioid prescribing could worsen healthcare for sickle cell patients. Clinicians tend to undertreat the substantial pain experienced by many sickle cell patients and treat them as drug addicts. However, research does not support increased risk of addiction in this patient population. Challenging Pain, Few Options A 2008 study in Annals of Internal Medicine revealed a vast undercurrent of chronic pain in sickle cell disease, with 29% of patients reporting pain—which is often severe—nearly every day. On top of that, vaso-occlusive episodes can trigger excruciating pain and life-threatening complications, such as organ damage. These crises prompt most ED visits for sickle cell disease. Hydroxyurea, the one drug approved by the FDA to treat the disease, is used infrequently despite being effective. The drug lessens the frequency of pain crises but does not eliminate them. In any case, opioids remain essential for treating sickle cell pain. Clinical trials testing these agents in sickle cell populations are lacking, but even less is known about possible alternatives. Inaccurate Assumptions of Pain A recent study found that most sickle cell patients delay seeking treatment until their pain nears 9 on a 10-point intensity scale. When they finally go to the ED, they face longer waits for care than others in less pain. In some research, these patients report that healthcare providers sometimes treat them without respect. Indeed, clinicians often wrongly suspect them of exaggerating their pain or abusing drugs. A Patient-Centered Approach to Treating Sickle Cell Pain Treating sickle cell pain starts with assessment, but no laboratory test or physiological marker can measure this pain. Nor can clinicians gauge...
Predicting Prolonged Opioid Use After Surgery

Predicting Prolonged Opioid Use After Surgery

Opioid drug use in patients with chronic pain has been linked to psychological distress and substance abuse. Studies suggest that these factors are often more influential than the intensity of pain patients are experiencing. The determinants of the duration of opioid use after surgery have not been reported in previous research. Furthermore, few analyses have explored the factors that affect ongoing use of opioids after surgery.  In Anesthesiology & Analgesia, my colleagues and I had a study published that sought to determine preoperative factors that predict continued use of opioids long after surgery. Preoperative psychological distress and prior substance use was assessed in 109 patients who were undergoing various operations. After surgery, daily use of opioids was measured until patients reported ceasing use of these drugs and having no pain. Three Important Factors According to our results, three preoperative factors were independently related to long-term opioid use: 1. Legitimate prescribed opioid use. 2. Self-perceived risk of addiction. 3. Depressive symptoms. Patients who were using opioids for pain relief before their procedure had a 73% higher likelihood of using these drugs at follow-up. Individuals who rated themselves at increased risk of developing an addiction were more likely to be long-term opioid users. The risk increased 53% for each 1-point increase on a 4-point scale of perceived addiction risk. Patients with symptoms of depression had a 42% higher risk for each 10-point increase on the Beck Depression Inventory scale. The three factors identified in our study were significant regardless of the type of surgery patients underwent. These factors were also better predictors of long-term opioid drug use than the severity of...
Patient Safety & Pain Management

Patient Safety & Pain Management

According to current estimates, more than 76 million people in the United States suffer from chronic or acute pain. Opioid analgesics are a widely accepted treatment for severe acute pain, but use of these medications to treat some types of chronic pain remains controversial. “The challenge with chronic pain is that it can occur in the context of numerous diseases and syndromes,” explains Daniel J. Castillo, MD. “The problems associated with opioid use—including underprescribing, overprescribing, tolerance, dependence, and drug abuse—highlight the importance of safe opioid use in hospitals and other healthcare settings.” Research has shown that pain is a leading cause of disability and can have deleterious effects on ability to work, functional status, and other quality-of-life domains. Unalleviated pain can impair the immune response, impede wound healing, affect gastrointestinal and pulmonary functions, suppress appetite, and delay ambulation after surgery. The number of opioid prescriptions for pain management has increased substantially over the last 20 years, in part due to a growing consensus that opioids are appropriate for some patients with pain. At the same time, there has been an increase in prescription opioid misuse and associated mortality, affecting adolescents and adults of all ages.   A Sentinel Event Alert issued by the Joint Commission in 2012 provides a number of actions that can be taken by hospitals to avoid the unintended consequences of opioid use among hospital inpatients (Table 1). It also provides clinicians with strategies for avoiding accidental opioid overuse (Table 2). “Opioids can be helpful for some patients, but it’s important that clinicians recognize and understand that there are risks to consider,” Dr. Castillo says. Joint...

Updating Osteoarthritis Treatment Recommendations

To help clinicians manage the increasing number of patients with osteoarthritis (OA), the American College of Rheumatology (ACR) revised its guidelines for using non-pharmacologic and pharmacologic therapies in OA of the hand, hip, and knee. Published in an issue of Arthritis Care & Research, the guidelines update recommendations from 2000. According to the ACR, management of OA should begin with treatments that are beneficial and have the lowest possible risk. Prior to recommending prescription medication and surgery, low-risk modalities (eg, weight loss and exercise) should be attempted. Treatments with greater risk may be used when simpler treatments fail. Hand Osteoarthritis Potential treatment modalities for hand OA include an assessment of activities of daily living, use of assistive devices, joint protection techniques, thermal agents, and trapeziometacarpal joint splinting. Oral and topical NSAIDs, topical capsaicin, and tramadol are other treatment modalities for hand OA, but opioids and intra-articular therapies are not recommended. Topical NSAIDs are preferred to oral administration in patients aged 75 and older, thus putting an emphasis on using these agents conservatively when possible. “New therapies for OA and additional information on the safety and acceptability of existing therapies have emerged.” Knee Osteoarthritis For knee OA, aerobic or resistance land-based exercise, aquatic exercise, and weight loss are strongly recommended in the guideline update. Conditionally recommended modalities include self-management programs like manual therapy with supervised exercise, tai chi, and wedged insoles. For moderate to severe pain in patients who do not wish to undergo joint replacement, acupuncture and transcutaneous electrical nerve stimulation (TENS) are recommended. Conditionally recommended pharmacologic modalities include acetaminophen, oral and topical NSAIDs, tramadol, and intra-articular corticosteroid injections....
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