Consensus-based recommendations for titrating cannabinoids and tapering opioids for chronic pain control.

AIMS: Opioid misuse and overuse have contributed to a widespread overdose crisis and many patients and physicians are considering medical cannabis to support opioid tapering and chronic pain control. Using a five-step modified Delphi process, we aimed to develop consensus-based recommendations on: 1) when and how to safely initiate and titrate cannabinoids in the presence of opioids, 2) when and how to safely taper opioids in the presence of cannabinoids and 3) how to monitor patients and evaluate outcomes when treating with opioids and cannabinoids. RESULTS: In patients with chronic pain taking opioids not reaching treatment goals, there was consensus that cannabinoids may be considered for patients experiencing or displaying opioid-related complications, despite psychological or physical interventions. There was consensus observed to initiate with a cannabidiol (CBD)-predominant oral extract in the daytime and consider adding tetrahydrocannabinol (THC). When adding THC, start with 0.5-3 mg, and increase by 1-2 mg once or twice weekly up to 30-40 mg/day. Initiate opioid tapering when the patient reports a minor/major improvement in function, seeks less as-needed medication to control pain and/or the cannabis dose has been optimised. The opioid tapering schedule may be 5%-10% of the morphine equivalent dose (MED) every 1 to 4 weeks. Clinical success could be defined by an improvement in function/quality of life, a ≥30% reduction in pain intensity, a ≥25% reduction in opioid dose, a reduction in opioid dose to <90 mg MED and/or reduction in opioid-related adverse events. CONCLUSIONS: This five-stage modified Delphi process led to the development of consensus-based recommendations surrounding the safe introduction and titration of cannabinoids in concert with tapering opioids.

Healthcare provider knowledge, beliefs, and attitudes regarding opioids for chronic non-cancer pain in North America prior to the emergence of COVID-19: A systematic review of qualitative research.

Background: Balance between benefits and harms of using opioids for the management of chronic noncancer pain (CNCP) must be carefully considered on a case-by-case basis. There is no one-size-fits-all approach that can be executed by prescribers and clinicians when considering this therapy. Aim: The aim of this study was to identify barriers and facilitators for prescribing opioids for CNCP through a systematic review of qualitative literature. Methods: Six databases were searched from inception to June 2019 for qualitative studies reporting on provider knowledge, attitudes, beliefs, or practices pertaining to prescribing opioids for CNCP in North America. Data were extracted, risk of bias was rated, and confidence in evidence was graded. Results: Twenty-seven studies reporting data from 599 health care providers were included. Ten themes emerged that influenced clinical decision making when prescribing opioids. Providers were more comfortable to prescribe opioids when (1) patients were actively engaged in pain self-management, (2) clear institutional prescribing policies were present and prescription drug monitoring programs were used, (3) long-standing relationships and strong therapeutic alliance were present, and (4) interprofessional supports were available. Factors that reduced likelihood of prescribing opioids included (1) uncertainty toward subjectivity of pain and efficacy of opioids, (2) concern for the patient (e.g., adverse effects) and community (i.e., diversion), (3) previous negative experiences (e.g., receiving threats), (4) difficulty enacting guidelines, and (5) organizational barriers (e.g., insufficient appointment duration and lengthy documentation). Conclusions: Understanding barriers and facilitators that influence opioid-prescribing practices offers insight into modifiable targets for interventions that can support providers in delivering care consistent with practice guidelines.

Contexte: L'équilibre entre les avantages et les inconvénients de l'utilisation d'opioïdes pour la prise en charge de la douleur chronique non cancéreuse (CNCP) doit être soigneusement examiné au cas par cas. Il n'existe pas d'approche uniforme pouvant être adoptée par les prescripteurs et les cliniciens lorsqu'ils envisagent cette thérapie.Objectif: L'objectif de cette étude était de recenser les obstacles et les facilitateurs pour la prescription d'opioïdes pour la douleur chronique non cancéreuse par une revue systématique de la littérature qualitative.Méthodes: Six bases de données ont été consultées pour la période allant de leur création jusqu'en juin 2019 afin d'y repérer les rapports d'études qualitatives sur les connaissances, les attitudes, les croyances ou les pratiques des prestataires en matière de prescription d'opioïdes pour la douleur chronique non cancéreuse en Amérique du Nord. Les données ont été extraites, le risque de biais a été évalué et la confiance envers les données probantes a été notée.Résultats: Vingt-sept études faisant état de données provenant de 599 prestataires de soins de santé ont été incluses. Dix thèmes influençant la prise de décision clinique lors de la prescription d'opioïdes ont émergé. Les prestataires étaient plus à l'aise pour prescrire des opioïdes lorsque (1) les patients étaient activement engagés dans la prise en charge de la douleur, (2) des politiques de prescription institutionnelles claires et des programmes de surveillance des médicaments d'ordonnance étaient en place, (3) des relations de longue date et une alliance thérapeutique forte étaient présentes, et (4) du soutien interprofessionnel était disponible. Les facteurs qui réduisaient la probabilité de la prescription d'opioïdes comprenaient (1) l'incertitude à l'égard de la subjectivité de la douleur et de l'efficacité des opioïdes, (2) une préoccupation pour le patient (p. ex., effets indésirables) et la collectivité (p. ex., détournement), (3) des expériences négatives antérieures (p. ex., recevoir des menaces), (4) des difficultés à adopter des lignes directrices et (5) des obstacles organisationnels (p. ex., durée insuffisante des rendez-vous et longueur de la documentation).Conclusions: La compréhension des obstacles et des facilitateurs qui influencent les pratiques de prescription d'opioïdes permet d'avoir un aperçu des cibles modifiables pour les interventions qui peuvent aider les prestataires à fournir des soins conformes aux directives de pratique.

Evaluating the efficacy of intranasal oxytocin on pain and function among individuals who experience chronic pain: a protocol for a multisite, placebo-controlled, blinded, sequential, within-subjects crossover trial.

INTRODUCTION: Current treatments for chronic pain (eg, opioids) can have adverse side effects and rarely result in resolution of pain. As such, there is a need for adjuvant analgesics that are non-addictive, have few adverse side effects and are effective for pain management across several chronic pain conditions. Oxytocin is a naturally occurring hormone that has gained attention for its potential analgesic properties. The objective of this trial is to evaluate the efficacy of intranasal oxytocin on pain and function among adults with chronic pain. METHODS AND ANALYSIS: This is a placebo-controlled, triple-blind, sequential, within-subject crossover trial. Adults with chronic neuropathic, pelvic and musculoskeletal pain will be recruited from three Canadian provinces (British Columbia, Alberta and Newfoundland and Labrador, respectively). Enrolled patients will provide one saliva sample pretreatment to evaluate basal oxytocin levels and polymorphisms of the oxytocin receptor gene before being randomised to one of two trial arms. Patients will self-administer three different oxytocin nasal sprays twice daily for a period of 2 weeks (ie, 24 IU, 48 IU and placebo). Patients will complete daily diaries, including standardised measures on day 1, day 7 and day 14. Primary outcomes include pain and pain-related interference. Secondary outcomes include emotional function, sleep disturbance and global impression of change. Intention-to-treat analyses will be performed to evaluate whether improvement in pain and physical function will be observed posttreatment. ETHICS AND DISSEMINATION: Trial protocols were approved by the Newfoundland and Labrador Health Research Ethics Board (HREB #20227), University of British Columbia Clinical Research Ethics Board (CREB #H20-00729), University of Calgary Conjoint Health Research Ethics Board (REB20 #0359) and Health Canada (Control # 252780). Results will be disseminated through publication in peer-reviewed journals and presentations at scientific conferences. TRIAL REGISTRATION NUMBER: NCT04903002; Pre-results.

Interventions to Influence Opioid Prescribing Practices for Chronic Noncancer Pain: A Systematic Review and Meta-Analysis.

CONTEXT: This study is a systematic review of interventions to improve adherence to guideline recommendations for prescribing opioids for chronic noncancer pain. EVIDENCE ACQUISITION: Investigators searched CINAHL, Embase, MEDLINE, PsycINFO, the Cochrane Library, and Joanna Briggs Institute Evid Based Pract database from inception until June 3, 2019. Interventional studies to improve adherence to recommendations made by opioid guidelines for chronic noncancer pain in North America were eligible if outcomes included adherence to guideline recommendations or change in quantity of opioids prescribed. Data were extracted independently and in duplicate. Quantitative synthesis was performed using random effects meta-analysis. Confidence in evidence was determined using the Grades of Recommendation, Assessment, Development, and Evaluation. EVIDENCE SYNTHESIS: A total of 20 studies (8 controlled and 12 prospective cohort) involving 1,491 providers and 72 clinics met inclusion. Interventions included education, audit and feedback, interprofessional support, shared decision making, and multifaceted strategies. Multifaceted interventions improved the use of urine drug testing (n=2, or =2.31, 95% CI=1.53, 3.49, z=3.98, p<0.01; high-certainty evidence), treatment agreements (n=2, or =1.96, 95% CI=1.47, 2.61, z=4.56, p<0.01; moderate-certainty evidence), and mental health screening (n=2, 2.57-fold, 95% CI=1.56, 4.24, z=2.32, p=0.02; low-certainty evidence) when prescribing opioids for chronic noncancer pain. Very low-certainty evidence suggests that several interventions improved the use of treatment agreements, urine drug testing, and prescription drug monitoring programs. CONCLUSIONS: Mostly very low-certainty evidence supports a number of interventions for improving adherence to risk management strategies when prescribing opioids for chronic noncancer pain; however, the effect on patient important outcomes (e.g., overdose, addiction, death) is uncertain.

The INternet ThERapy for deprESsion Trial (INTEREST): protocol for a patient-preference, randomised controlled feasibility trial comparing iACT, iCBT and attention control among individuals with comorbid chronic pain and depression.

INTRODUCTION: Approximately one-third of adults with chronic pain also report clinically relevant levels of depression. Internet-delivered psychological therapies such as Cognitive Behavioural Therapy (iCBT) and Acceptance and Commitment Therapy (iACT) have been developed to overcome barriers of access to services and ensure the timely delivery of care. The objective of this trial is to collect data on feasibility, acceptability and range of probable effect sizes for iCBT and iACT interventions tailored towards the treatment of depression and chronic pain using a randomised controlled patient-preference design. METHODS AND ANALYSIS: Community dwelling adults with chronic non-cancer pain (CNCP) and major depression will be recruited from pain clinics and primary care providers in Newfoundland and Labrador, Canada. The study is a randomised controlled patient-preference trial. Eligible patients will be randomly assigned to a 'preference' or 'no-preference' arm during the first step of randomisation and to intervention or control in the second step of randomisation. Two interventions (ie, iCBT or iACT) will be evaluated relative to attention control. iCBT and iACT involve the completion of 7-weekly online modules augmented with one session of motivational enhancement and weekly therapy sessions. Primary outcomes include (1) feasibility and acceptability parameters and (2) change in symptoms of depression. Secondary outcomes include pain, physical function, emotional function and quality of life. We will recruit 60 participants and examine the range of effect sizes obtained from the trial but will not conduct significance testing as per recommendations for behavioural trial development. ETHICS AND DISSEMINATION: Ethics was approved by the provincial Health Research Ethics Board. Dissemination of results will be published in a peer-reviewed academic journal and presented at scientific conferences. TRIAL REGISTRATION NUMBER: NCT04009135.

Prescriber adherence to guidelines for chronic noncancer pain management with opioids: Systematic review and meta-analysis.

OBJECTIVE: This review quantified prescriber adherence to opioid prescribing guidelines for chronic noncancer pain (CNCP). METHOD: We searched CINAHL, Embase, MEDLINE, PsycINFO, the Cochrane Library, and the Joanna Briggs Institute EBP Database from inception until June 3, 2019. Studies that focused on provider adherence to opioids guidelines for CNCP in North America were eligible. Four reviewers screened studies, extracted data, and assessed study quality. RESULTS: Thirty-eight studies were eligible, comprising 17 cross-sectional studies (n = 11,835 providers) and 22 chart reviews (n = 22,512 patients). Survey data indicated that adherence was 49% (95% CI [40, 59]) for treatment agreements, 33% (95% CI [19%, 47%]) for urine drug testing, 48% (95% CI [26%, 71%]) for consultation with drug monitoring program, 57% (95% CI [35%, 79%]) for assessing risk of aberrant medication-taking behavior, and 61% (95% CI [35%, 87%]) for mental health screening. Chart review data indicated that the proportion of patients with documentation was 40% (95% CI [29, 51]) for treatment agreements, 41% (95% CI [32%, 50%]) for urine drug testing, 40% (95% CI [2%, 78%]) for consultation with drug monitoring program, 41% (95% CI [20%, 64%]) for assessing risk of aberrant medication-taking behavior, and 22% (95% CI [9%, 33%]) for mental health screening. Year of publication, practice guideline referenced, and risk of bias explained significant heterogeneity. No study evaluated whether nonadherence to recommendations reflected well-justified deviations to care. CONCLUSIONS: Adherence to guideline recommendations for opioids for CNCP is low. It is unclear whether nonadherence reflects thoughtful deviations in care. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Healthcare provider knowledge, attitudes, beliefs, and practices surrounding the prescription of opioids for chronic non-cancer pain in North America: protocol for a mixed-method systematic review.

BACKGROUND: Evidence from diverse areas of medicine (e.g., cardiovascular disease, diabetes) indicates that healthcare providers (HCPs) often do not adhere to clinical practice guidelines (CPGs) despite a clear indication to implement recommendations-a phenomenon commonly termed clinical inertia. There are a variety of reasons for clinical inertia, but HCP-related factors (e.g., knowledge, motivation, agreement with guidelines) are the most salient and amenable to intervention aimed to improve adherence. CPGs have been developed to support the safe and effective prescription of opioid medication for the management of chronic non-cancer pain. The extent of physician uptake and adherence to such guidelines is not yet well understood. The purpose of this review is to synthesize the published evidence about knowledge, attitudes, beliefs, and practices that HCPs hold regarding the prescription of opioids for chronic non-cancer pain. METHODS: An experienced information specialist will perform searches of CINAHL, Embase, MEDLINE, and PsycINFO bibliographic databases. The Cochrane library, PROSPERO, and the Joanna Briggs Institute will be searched for systematic reviews. Searches will be performed from inception to the present. Quantitative and qualitative study designs that report on HCP knowledge, attitudes, beliefs, or practices in North America will be eligible for inclusion. Studies reporting on interventions to improve HCP adherence to opioid prescribing CPGs will also be eligible for inclusion. Two trained graduate-level research assistants will independently screen articles for inclusion, perform data extraction, and perform risk of bias and quality assessment using recommended tools. Confidence in qualitative evidence will be evaluated using the Grades of Recommendation, Assessment, Development, and Evaluation-Confidence in the Evidence from Qualitative Reviews (GRADE-CERQual) approach. Confidence in quantitative evidence will be assessed using the GRADE approach. DISCUSSION: The ultimate goal of this work is to support interventions aiming to optimize opioid prescribing practices in order to prevent opioid-related morbidity and mortality without restricting a HCP's ability to select the most appropriate treatment for an individual patient. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018091640 .