The role of opioid prescription in incident opioid abuse and dependence among individuals with chronic noncancer pain: the role of opioid prescription.
TL;DR: Patients with CNCP prescribed opioids had significantly higher rates of OUDs compared with those not prescribed opioids, and duration of opioid therapy was more important than daily dose in determining OUD risk.
Abstract: Objective
Increasing rates of opioid use disorders (abuse and dependence) among patients prescribed opioids are a significant public health concern. We investigated the association between exposure to prescription opioids and incident opioid use disorders (OUDs) among individuals with a new episode of a chronic non-cancer pain (CNCP) condition.
Citations
More filters
TL;DR: This guideline is intended to improve communication about benefits and risks of opioids for chronic pain, improve safety and effectiveness of pain treatment, and reduce risks associated with long-term opioid therapy.
Abstract: Importance Primary care clinicians find managing chronic pain challenging. Evidence of long-term efficacy of opioids for chronic pain is limited. Opioid use is associated with serious risks, including opioid use disorder and overdose. Objective To provide recommendations about opioid prescribing for primary care clinicians treating adult patients with chronic pain outside of active cancer treatment, palliative care, and end-of-life care. Process The Centers for Disease Control and Prevention (CDC) updated a 2014 systematic review on effectiveness and risks of opioids and conducted a supplemental review on benefits and harms, values and preferences, and costs. CDC used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework to assess evidence type and determine the recommendation category. Evidence Synthesis Evidence consisted of observational studies or randomized clinical trials with notable limitations, characterized as low quality using GRADE methodology. Meta-analysis was not attempted due to the limited number of studies, variability in study designs and clinical heterogeneity, and methodological shortcomings of studies. No study evaluated long-term (≥1 year) benefit of opioids for chronic pain. Opioids were associated with increased risks, including opioid use disorder, overdose, and death, with dose-dependent effects. Recommendations There are 12 recommendations. Of primary importance, nonopioid therapy is preferred for treatment of chronic pain. Opioids should be used only when benefits for pain and function are expected to outweigh risks. Before starting opioids, clinicians should establish treatment goals with patients and consider how opioids will be discontinued if benefits do not outweigh risks. When opioids are used, clinicians should prescribe the lowest effective dosage, carefully reassess benefits and risks when considering increasing dosage to 50 morphine milligram equivalents or more per day, and avoid concurrent opioids and benzodiazepines whenever possible. Clinicians should evaluate benefits and harms of continued opioid therapy with patients every 3 months or more frequently and review prescription drug monitoring program data, when available, for high-risk combinations or dosages. For patients with opioid use disorder, clinicians should offer or arrange evidence-based treatment, such as medication-assisted treatment with buprenorphine or methadone. Conclusions and Relevance The guideline is intended to improve communication about benefits and risks of opioids for chronic pain, improve safety and effectiveness of pain treatment, and reduce risks associated with long-term opioid therapy.
3,935 citations
Cites background from "The role of opioid prescription in ..."
...One fair-quality cohort study found long-term opioid therapy is associated with increased risk of an opioid abuse or dependence diagnosis versus no opioid prescription (15)....
[...]
...org/article/S0025-6196(15)00303-1/pdf, contain more detailed guidance on tapering, including management of withdrawal symptoms....
[...]
...Having a history of an opioid prescription is one of many factors that increase risk for overdose and opioid use disorder (15-17), suggesting the importance of guidance on safer prescribing practices for providers....
[...]
18 Mar 2016
TL;DR: This guideline is intended to improve communication between clinicians and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder, overdose, and death.
Abstract: This guideline provides recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care. The guideline addresses 1) when to initiate or continue opioids for chronic pain; 2) opioid selection, dosage, duration, follow-up, and discontinuation; and 3) assessing risk and addressing harms of opioid use. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework, and recommendations are made on the basis of a systematic review of the scientific evidence while considering benefits and harms, values and preferences, and resource allocation. CDC obtained input from experts, stakeholders, the public, peer reviewers, and a federally chartered advisory committee. It is important that patients receive appropriate pain treatment with careful consideration of the benefits and risks of treatment options. This guideline is intended to improve communication between clinicians and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder, overdose, and death. CDC has provided a checklist for prescribing opioids for chronic pain (http://stacks.cdc.gov/view/cdc/38025) as well as a website (http://www.cdc.gov/drugoverdose/prescribingresources.html) with additional tools to guide clinicians in implementing the recommendations.
2,819 citations
Aarhus University1, French Institute of Health and Medical Research2, Washington University in St. Louis3, Tufts Medical Center4, University of Rochester5, Queen's University6, Helsinki University Central Hospital7, Karolinska Institutet8, Oslo University Hospital9, Aarhus University Hospital10, University of the Witwatersrand11, Churchill Hospital12, Johns Hopkins University13, Chelsea and Westminster Hospital NHS Foundation Trust14, Imperial College London15, California Pacific Medical Center16, Florey Institute of Neuroscience and Mental Health17, University of Edinburgh18, Greenwich Hospital19, University of Sydney20, University of Dundee21, University of California, San Diego22
TL;DR: The results support a revision of the NeuPSIG recommendations for the pharmacotherapy of neuropathic pain and allow a strong recommendation for use and proposal as first-line treatment in neuropathicPain for tricyclic antidepressants, serotonin-noradrenaline reuptake inhibitors, pregabalin, and gabapentin.
Abstract: Summary Background New drug treatments, clinical trials, and standards of quality for assessment of evidence justify an update of evidence-based recommendations for the pharmacological treatment of neuropathic pain. Using the Grading of Recommendations Assessment, Development, and E valuation (GRADE), we revised the Special Interest Group on Neuropathic Pain (NeuPSIG) recommendations for the pharmacotherapy of neuropathic pain based on the results of a systematic review and meta-analysis. Methods Between April, 2013, and January, 2014, NeuPSIG of the International Association for the Study of Pain did a systematic review and meta-analysis of randomised, double-blind studies of oral and topical pharmacotherapy for neuropathic pain, including studies published in peer-reviewed journals since January , 1966, and unpublished trials retrieved from ClinicalTrials.gov and websites of pharmaceutical companies. We used number needed to treat (NNT) for 50% pain relief as a primary measure and assessed publication bias; NNT was calculated with the fi xed-eff ects Mantel-Haenszel method. Findings 229 studies were included in the meta-analysis. Analysis of publication bias suggested a 10% overstatement of treatment eff ects. Studies published in peer-reviewed journals reported greater eff ects than did unpublished studies (r² 9·3%, p=0·009). T rial outcomes were generally modest: in particular, combined NNTs were 6·4 (95% CI 5·2–8·4) for serotonin-noradrenaline reuptake inhibitors, mainly including duloxetine (nine of 14 studies); 7·7 (6·5–9·4) for pregabalin; 7·2 (5·9–9·21) for gabapentin, including gabapentin extended release and enacarbil; and 10·6 (7·4–19·0) for capsaicin high-concentration patches. NNTs were lower for tricyclic antidepressants, strong opioids, tramadol, and botulinum toxin A, and undetermined for lidocaine patches. Based on GRADE, fi nal quality of evidence was moderate or high for all treatments apart from lidocaine patches; tolerability and safety, and values and preferences were higher for topical drugs; and cost was lower for tricyclic antidepressants and tramadol. These fi ndings permitted a strong recommendation for use and proposal as fi rst-line treatment in neuropathic pain for tricyclic antidepressants, serotonin-noradrenaline reuptake inhibitors, pregabalin, and gabapentin; a weak recommendation for use and proposal as second line for lidocaine patches, capsaicin high-concentration patches, and tramadol; and a weak recommendation for use and proposal as third line for strong opioids and botulinum toxin A. Topical agents and botulinum toxin A are recommended for peripheral neuropathic pain only. Interpretation Our results support a revision of the NeuPSIG recommendations for the pharmacotherapy of neuropathic pain. Inadequate response to drug treatments constitutes a substantial unmet need in patients with neuropathic pain. Modest effi cacy, large placebo responses, heterogeneous diagnostic criteria, and poor phenotypic profi ling probably account for moderate trial outcomes and should be taken into account in future studies. Funding NeuPSIG of the International Association for the Study of Pain.
2,512 citations
TL;DR: In this paper, a review found that prescriptions of opioid medications for chronic pain have increased dramatically, as have opioid overdoses, abuse, and other harms and uncertainty about long-term effectiveness.
Abstract: Prescriptions of opioid medications for chronic pain have increased dramatically, as have opioid overdoses, abuse, and other harms and uncertainty about long-term effectiveness This review found s
1,223 citations
References
More filters
TL;DR: The method of classifying comorbidity provides a simple, readily applicable and valid method of estimating risk of death fromComorbid disease for use in longitudinal studies and further work in larger populations is still required to refine the approach.
39,961 citations
Oregon Health & Science University1, Dartmouth College2, University of Utah3, Harvard University4, Seattle Cancer Care Alliance5, Kaiser Permanente6, University of Miami7, Memorial Sloan Kettering Cancer Center8, Albany College of Pharmacy and Health Sciences9, University of Wisconsin-Madison10, California Health and Human Services Agency11, Yale University12, Yeshiva University13, University of California, Davis14, University of California, San Francisco15
TL;DR: Safe and effective chronic opioid therapy for chronic noncancer pain requires clinical skills and knowledge in both the principles of opioid prescribing and on the assessment and management of risks associated with opioid abuse, addiction, and diversion.
2,051 citations
Additional excerpts
...21 The 7 dosing levels were: (1) no opioid use (0 d supply, 0mg average daily dose); (2) low dose, acute; (3) low dose, chronic; (4) medium dose, acute; (5) medium dose, chronic; (6) high dose, acute; and (7) high dose, chronic....
[...]
TL;DR: The relative benefit of an active treatment over a control is usually expressed as the relative risk, the Relative risk reduction, or the odds ratio, but for clinical decision making, it is more meaningful to use the measure "number needed to treat."
Abstract: The relative benefit of an active treatment over a control is usually expressed as the relative risk, the relative risk reduction, or the odds ratio. These measures are used extensively in both clinical and epidemiological investigations. For clinical decision making, however, it is more meaningful to use the measure "number needed to treat." This measure is calculated on the inverse of the absolute risk reduction. It has the advantage that it conveys both statistical and clinical significance to the doctor. Furthermore, it can be used to extrapolate published findings to a patient at an arbitrary specified baseline risk when the relative risk reduction associated with treatment is constant for all levels of risk.
1,660 citations
TL;DR: Persistent pain was a commonly reported health problem among primary care patients and was consistently associated with psychological illness across centers, suggesting caution in drawing conclusions about the role of culture in shaping responses to persistent pain.
Abstract: Context.—There is little information on the extent of persistent pain across
cultures. Even though pain is a common reason for seeking health care, information
on the frequency and impacts of persistent pain among primary care patients
is inadequate.Objective.—To assess the prevalence and impact of persistent pain among primary
care patients.Design and Setting.—Survey data were collected from representative samples of primary care
patients as part of the World Health Organization Collaborative Study of Psychological
Problems in General Health Care, conducted in 15 centers in Asia, Africa,
Europe, and the Americas.Participants.—Consecutive primary care attendees between the age of majority (typically
18 years) and 65 years were screened (n=25916) and stratified random samples
interviewed (n=5438).Main Outcome Measures.—Persistent pain, defined as pain present most of the time for a period
of 6 months or more during the prior year, and psychological illness were
assessed by the Composite International Diagnostic Interview. Disability was
assessed by the Groningen Social Disability Schedule and by activity-limitation
days in the prior month.Results.—Across all 15 centers, 22% of primary care patients reported persistent
pain, but there was wide variation in prevalence rates across centers (range,
5.5%-33.0%). Relative to patients without persistent pain, pain sufferers
were more likely to have an anxiety or depressive disorder (adjusted odds
ratio [OR], 4.14; 95% confidence interval [CI], 3.52-4.86), to experience
significant activity limitations (adjusted OR, 1.63; 95% CI, 1.41-1.89), and
to have unfavorable health perceptions (adjusted OR, 1.26; 95% CI, 1.07-1.49).
The relationship between psychological disorder and persistent pain was observed
in every center, while the relationship between disability and persistent
pain was inconsistent across centers.Conclusions.—Persistent pain was a commonly reported health problem among primary
care patients and was consistently associated with psychological illness across
centers. Large variation in frequency and the inconsistent relationship between
persistent pain and disability across centers suggests caution in drawing
conclusions about the role of culture in shaping responses to persistent pain
when comparisons are based on patient samples drawn from a limited number
of health care settings in each culture.
1,393 citations
"The role of opioid prescription in ..." refers background or methods in this paper
...Previous studies, generally using small clinical samples from pain clinics, have investigated (1) and (2)....
[...]
...We included 2 indicator variables describing whether the patient had received (1) a preindex alcohol abuse/dependence diagnosis, or (2) a preindex nonopioid drug abuse/dependence diagnosis....
[...]
...We were interested in addressing the risk of addiction associated with exposing patients to opioid treatment for CNCP, including: (1) the magnitude of OUD risk; (2) the populations most vulnerable to OUDs; and (3) the components of opioid exposure (eg, daily dose, days used) most important in predicting OUDs....
[...]
...21 The 7 dosing levels were: (1) no opioid use (0 d supply, 0mg average daily dose); (2) low dose, acute; (3) low dose, chronic; (4) medium dose, acute; (5) medium dose, chronic; (6) high dose, acute; and (7) high dose, chronic....
[...]
01 Jan 2011
TL;DR: Wide variation among states in the nonmedical use of OPR and overdose rates cannot be explained by underlying demographic differences in state populations but is related to wide variations in OPR prescribing.
Abstract: BACKGROUND
Overdose deaths involving opioid pain relievers (OPR), also known as opioid analgesics, have increased and now exceed deaths involving heroin and cocaine combined. This report describes the use and abuse of OPR by state.
METHODS
CDC analyzed rates of fatal OPR overdoses, nonmedical use, sales, and treatment admissions.
RESULTS
In 2008, drug overdoses in the United States caused 36,450 deaths. OPR were involved in 14,800 deaths (73.8%) of the 20,044 prescription drug overdose deaths. Death rates varied fivefold by state. States with lower death rates had lower rates of nonmedical use of OPR and OPR sales. During 1999--2008, overdose death rates, sales, and substance abuse treatment admissions related to OPR all increased substantially.
CONCLUSIONS
The epidemic of overdoses of OPR has continued to worsen. Wide variation among states in the nonmedical use of OPR and overdose rates cannot be explained by underlying demographic differences in state populations but is related to wide variations in OPR prescribing.
IMPLICATIONS FOR PUBLIC HEALTH PRACTICE
Health-care providers should only use OPRs in carefully screened and monitored patients when non-OPR treatments are insufficient to manage pain. Insurers and prescription drug monitoring programs can identify and take action to reduce both inappropriate and illegal prescribing. Third-party payers can limit reimbursement in ways that reduce inappropriate prescribing, discourage efforts to obtain OPR from multiple health-care providers, and improve clinical care. Changes in state laws that focus on the prescribing practices of health-care providers might reduce prescription drug abuse and overdoses while still allowing safe and effective pain treatment.
1,298 citations