Electronic Real-Time Monitoring Reveals Limited Adherence to Long-Term Opioid Prescriptions in Pain Patients.

Background: Pain management physicians are increasingly focused on limiting prescription opioid abuse, yet existing tools for monitoring adherence have limited accuracy. Medication event monitoring system (MEMS) is an emerging technology for tracking medication usage in real-time but has not been tested in chronic pain patients on long-term opioid regimens. Objective: We conducted a pilot clinical trial to investigate the utility of MEMS for monitoring opioid adherence and compared to traditional methods including self-report diaries, urine drug screen (UDS), and physicians' opinions. Methods: Opioid-maintained chronic pain patients were recruited from a pain management clinic. Participants (n=28) were randomly assigned to either receive MEMS bottles containing their opioid medication for a 90-day period or to continue using standard medication bottles. MEMS bottles were configured to record and timestamp all bottle openings and the number of pills that were removed from the bottle (via measurement of weight change). Results: Participants who received MEMS demonstrated highly heterogenous dosing patterns, with a substantial number of patients rapidly removing excessive amounts of medication and/or "stockpiling" medication. By comparison, physicians rated all participants as either "totally compliant" or "mostly compliant". UDS results did not reveal any illicit drug use, but 25% of participants (n=7) tested negative for their prescribed opioid metabolite. MEMS data did not correlate with physician-rated adherence (P=0.24) and UDS results (P=0.77). MEMS data consistently revealed greater non-adherence than self-report data (P<0.001). Conclusion: These results highlight the limits in our understanding of naturalistic patterns of daily opioid use in chronic pain patients as well as support the use of MEMS for detecting potential misuse as compared to routine adherence monitoring methods. Future research directions include the need to determine how MEMS could be used to improve patient outcomes, minimize harm, and aid in clinical decision-making. Trial Registration: This study was preregistered on ClinicalTrials.gov (NCT03752411).

Next-Generation Approaches to Immuno-Oncology in GI Cancers.

Immunotherapy has only had a modest impact on the treatment of advanced GI malignancies. Microsatellite-stable colorectal cancer and pancreatic adenocarcinoma, the most common GI tumors, have not benefited from treatment with standard immune checkpoint inhibitors. With this huge unmet need, multiple approaches are being tried to overcome barriers to better anticancer outcomes. This article reviews a number of novel approaches to immunotherapy for these tumors. These include the use of novel checkpoint inhibitors such as a modified anti-cytotoxic T lymphocyte-associated antigen-4 antibody and antibodies to lymphocyte-activation gene 3, T cell immunoreceptor with immunoglobulin and ITIM domains, T-cell immunoglobulin-3, CD47, and combinations with signal transduction inhibitors. We will discuss other trials that aim to elicit an antitumor T-cell response using cancer vaccines and oncolytic viruses. Finally, we review attempts to replicate in GI cancers the frequent and durable responses seen in hematologic malignancies with immune cell therapies.

Triple Jeopardy of Minority Status, Social Stressors, and Health Disparities on Academic Performance of College Students.

Objective: In this study, we evaluated the role of minority status, as well as pandemic-related social stressors and health disparities on short- and long-term academic performances of college students. Methods: Cross-sectional analysis using descriptive and bivariate statistics were used to identify participants of minority status as well as pandemic-related prevalence of social stressors and health disparities and their roles on academic performance. Results: Poor academic performance was significantly related to being food insecure, experiences of discrimination, serious psychological distress, and low daytime wakefulness during the pandemic but only significantly based on minority status. Grade point average was significantly associated with serious psychological problems among males, independent of race/ethnicity identity. Conclusions: Institutes of higher education, when tasked with developing post-pandemic policies to address equity gaps in academic success, may benefit their students by integrating system-wide holistic approach to support, including interventions on basic needs support and health and resilience building.

Medically supervised taper for ultra high-dose opioids with significant comorbidities using a multidisciplinary approach: A case report.

INTRODUCTION: The opioid epidemic and current opioid use guidelines for chronic noncancer pain have resulted in an overwhelmingly large number of patients undergoing opioid tapers. Even though the literature for tapering guidelines is growing, there is little guidance for tapering patients on ultra high-dose opioids. CASE DESCRIPTION: This case report describes in detail the opioid tapering approach used to taper a 53-year-old male with chronic low back pain on a regimen of a morphine equivalent daily dose (MEDD) of 1,990 mg. Patient reported many side effects such as chronic nausea, irritability, psychomotor depression, and functional impairment. He was admitted for a medically supervised opioid taper for 12 days. RESULTS: The patient was discharged with an MEDD of 392 mg with additional taper as an outpatient to an MEDD of 200 mg. Adequate pain relief and resolution of side effects were achieved without the patient reporting significant withdrawal symptomatology in the outpatient setting.

COVID-19 Pandemic-Related Sleep and Mental Health Disparities among Students at a Hispanic and Minority-Serving Institution.

BACKGROUND: The COVID-19 pandemic has impacted nearly all sectors of our population, including college students, who continue to share disproportionate rate of disparities. In this study, we aimed to identity key sleep health characteristics, including markers for obstructive sleep apnea, as well as its relation to mental health, physical health, and academic performance. METHODS: A cross-sectional study design with online survey dissemination was used. Descriptive, bivariate, and multivariable binary logistic regression analyses were conducted among a predominantly minority population. RESULTS: Results show that nearly 78% of the population reported that the pandemic impacted their mental or physical health, while over 83% reported daytime tiredness/fatigue/sleepiness, and another 61% reported sleeping less than seven hours during weekdays. Among other associations, pandemic-related poor sleep health, including sleeping less than seven hours, was associated with daytime tiredness/fatigue/sleepiness, psychological distress, as well as low mental health and physical health. A severe marker for obstructive sleep apnea, having stopped breathing during sleep, was also associated with psychological distress during the pandemic. CONCLUSIONS: Sleep health interventions are critical for optimizing college student health and well-being, including improving mental health outcomes.

Analysis of Post-Transplant Lymphoproliferative Disorder (PTLD) Outcomes with Epstein-Barr Virus (EBV) Assessments-A Single Tertiary Referral Center Experience and Review of Literature.

Post-transplant lymphoproliferative disorders (PTLDs) are lymphoid or plasmacytic proliferations ranging from polyclonal reactive proliferations to overt lymphomas that develop as consequence of immunosuppression in recipients of solid organ transplantation (SOT) or allogeneic bone marrow/hematopoietic stem cell transplantation. Immunosuppression and Epstein-Barr virus (EBV) infection are known risk factors for PTLD. Patients with documented histopathologic diagnosis of primary PTLD at our institution between January 2000 and October 2019 were studied. Sixty-six patients with PTLD following SOT were followed for a median of 9.0 years. The overall median time from transplant to PTLD diagnosis was 5.5 years, with infant transplants showing the longest time to diagnosis at 12.0 years, compared to pediatric and adolescent transplants at 4.0 years and adult transplants at 4.5 years. The median overall survival (OS) was 19.0 years. In the monomorphic diffuse large B-cell (M-DLBCL-PTLD) subtype, median OS was 10.7 years, while median OS for polymorphic subtype was not yet reached. There was no significant difference in OS in patients with M-DLBCL-PTLD stratified by quantitative EBV viral load over and under 100,000 copies/mL at time of diagnosis, although there was a trend towards worse prognosis in those with higher copies.

Quantification of Opioid Prescription Practice Changes Due to Hydrocodone Combination Product Rescheduling in an Academic Pain Clinic.

PURPOSE: To determine the effect of rescheduling on prescription practices in a large academic hospital-based multidisciplinary practice comprising anesthesiologist-trained pain physicians. PATIENTS AND METHODS: We examined the number of HCP prescriptions written and quantity of tablets prescribed during a 6-month period prior to rescheduling and compared this with a 6-month period 1 year after rescheduling. We also examined the changes in prescription of tramadol and acetaminophen with codeine from one period to the next. RESULTS: Our pain clinic conducted 3,320 office visits during the 6-month period prior to HCP rescheduling and 6,003 office visits in the 6-month period 1 year after rescheduling. The charted data from each of these visits were used for our analysis. The mean number of tablets of HCPs prescribed per patient decreased from 318.48 in the pre-period to 242.27 tablets in the post-period, while the mean number of HCP prescriptions per patient decreased from 2.24 to 1.84. The mean number of acetaminophen with codeine tablets prescribed per patient increased from 3.46 to 15.27 in the pre- and post-period. Similarly, the mean number of tramadol tablets per patient increased from 47.33 to 61.97 in the pre- and post-period. The mean number of acetaminophen with codeine and tramadol prescriptions per patient increased from 0.02 to 0.15 and 0.38 to 0.51 in the pre- and post-period, respectively. In the 6-month post-period, fewer new patients were started on opioids compared to the 6-month pre-period, 16% and 27%, respectively. CONCLUSION: Our study showed a significant decrease in the mean number of HCP prescriptions written per patient, as well as a decrease in the mean number of HCP tablets prescribed. Pain physicians in our clinic increased the number of prescriptions for the non-HCPs. The number of acetaminophen with codeine and tramadol tablets prescribed significantly increased. Therefore, the rescheduling of HCPs has profoundly impacted practices within this academic pain clinic.