Cannabis Use Is Associated with Pain Severity and Interference Among Cancer Survivors.

Context: Cannabis use for symptom management among individuals with cancer is increasingly common. Objectives: We sought to describe the (1) prevalence and characteristics of cannabis use, (2) perceived therapeutic benefits of cannabis use, and (3) examine how use of cannabis was associated with self-reported pain, mood, and general health outcomes in a representative sample of patients treated at a National Cancer Institute (NCI)-designated Oregon Health and Science University Knight Cancer Institute. Methods: We conducted a population-based, cross-sectional survey developed in conjunction with 11 other NCI-designated cancer centers and distributed to eligible individuals. The survey inquired about characteristics of cannabis use, perception of therapeutic benefits, pain, mood, and general health. Responses were population weighted. We examined the association of cannabis use with self-reported pain, mood, and general health using logistic regression controlling for relevant sociodemographic and clinical characteristics. Results: A total of 523 individuals were included in our analytic sample. A total of 54% endorsed using cannabis at any time since their cancer diagnosis and 42% endorsed using cannabis during active treatment. The most commonly endorsed reasons for use included the following: sleep disturbance (54.7%), pain (47.1%), and mood (42.6%). We found that moderate pain was associated with more than a twofold (odds ratio = 2.4 [95% confidence interval = 1.3-4.6], p = 0.002) greater likelihood of self-reported cannabis use. Depressed mood and general health were not associated with cannabis use. Conclusions: In a state that had early adoption of medical and recreational cannabis legislation, a high number of cancer survivors report cannabis use. Moderate or more severe pain was associated with an increased likelihood to use cannabis, while mood and general health were not associated. Oncologists should be aware of these trends and assess use of cannabis when managing long-term symptoms of cancer and its treatments.

Cannabis and opioid perceptions, co-use, and substitution among patients across 4 NCI-Designated Cancer Centers.

Prescription opioids are used for managing pain in persons with cancer, however, there are socioeconomic and racial disparities in medication access. Cannabis is increasingly used for cancer symptom management and as an opioid alternative. Limited data are available about patterns of opioid and cannabis use among patients with cancer. We used survey data from 4 National Cancer Institute-designated cancer centers in 3 states (n = 1220) to assess perceptions, use of cannabis and opioids for pain, their substitution, and racial and ethnic differences in each outcome. Compared with White patients, Black patients were less likely to use opioids for pain (odds ratio [OR] = 0.66; P = .035) and more likely to report that cannabis was more effective than opioids (OR = 2.46; P = .03). Race effects were mitigated (P > .05) after controlling for socioeconomic factors. Further research is needed to understand cannabis and opioid use patterns and how overlapping social determinants of health create a disadvantage in cancer symptom management for Black patients.

Dispensary Staff Perceptions About the Benefits, Risks, and Safety of Cannabis for Medical Purposes.

BACKGROUND: Therapeutic use of cannabis is common in the United States (up to 18.7% of Americans aged ≥12), and dispensaries in the US are proliferating rapidly. However, the efficacy profile of medical cannabis is unclear, and customers often rely on dispensary staff for purchasing decisions. The objective was to describe cannabis dispensary staff perceptions of medical cannabis benefits and risks, as well as its safety in high-risk populations. METHODS: Online Survey study conducted using Qualtrics from February 13, 2020 to October 2, 2020 with a national sample of dispensary staff who reportedinteracting with customers in a cannabis dispensary selling tetrahydrocannabinol-containing products. Participants were queried about benefits ("helpfulness") and risks ("worry") about cannabis for a variety of medical conditions, and safety in older adults and pregnant women on a five-point Likert scale. These results were then collapsed into three categories including "neutral" (3/5). "I don't know" (uncertainty) was a response option for helpfulness and safety. RESULTS: Participants (n = 434) were from 29 states and included patient-facing dispensary staff (40%); managers (32%); pharmacists (13%); and physicians, nurse practitioners, or physician assistants (5%). Over 80% of participants perceived cannabis as helpful for post-traumatic stress disorder (88.7%), epilepsy (85.3%) and cancer (83.4%). Generally, participants were not concerned about potential cannabis risks, including increased use of illicit drugs (76.3%), decreases in intelligence (74.4%), disrupted sleep (71.7%), and new/worsening health problems from medical cannabis use (70.7%). Cannabis was considered safe in older adults by 81.3% of participants, though there was much less consensus on safety in pregnancy. CONCLUSIONS: Cannabis dispensary staff generally view medical cannabis as beneficial and low-risk. However, improvements in dispensary staff training, an increased role for certifying clinicians, and interventions to reduce dispensary staff concerns (e.g., cost, judgment) may improve evidence-based staff recommendations to patients seeking medical cannabis.

Cannabis use is associated with pain severity and interference among cancer survivors.

Context: Cannabis use for symptom management among individuals with cancer is increasingly common. Objectives: We sought to describe the 1) prevalence and characteristics of cannabis use, 2) perceived therapeutic benefits of cannabis use, and 3) examine how use of cannabis was associated with self-reported pain, mood, and general health outcomes among a representative sample of patients treated at NCI designated OHSU Knight Cancer Institute. Methods: We conducted a population-based, cross-sectional survey developed in conjunction with 11 other NCI designated cancer centers and distributed to eligible individuals. The survey inquired about characteristics of cannabis use, perception of therapeutic benefits, pain, mood, and general health. Responses were population weighted. We examined the association of cannabis use with self-reported pain, mood, and general health using logistic regression controlling for relevant sociodemographic and clinical characteristics. Results: 523 individuals were included in our analytic sample. 54% endorsed using cannabis at any time since their cancer diagnosis and 42% endorsed using cannabis during active treatment. The most endorsed reasons for use included: sleep disturbance (54.7%), pain (47.1%), and mood (42.6%). We found moderate pain was associated with more than a 2-fold (OR = 2.4 [95% CI = 1.3-4.6], p = 0.002) greater likelihood of self-reported cannabis use. Depressed mood or general health were not associated with cannabis use. Conclusions: In a state with medical and recreational cannabis legislation, a high number of cancer survivors report cannabis use. Those with pain were more likely to use cannabis. Oncologists should be aware of this trend and assess use of cannabis when managing long-term symptoms of cancer and its treatments.

Prevalence and correlates of high-dose opioid use among survivors of head and neck cancer.

BACKGROUND: We characterized prescription opioid medication use up to 2 years following the head and neck cancer (HNC) diagnosis and examined associations with moderate or high daily opioid prescription dose. METHODS: Using administrative data from Veterans Health Administration, we conducted a retrospective cohort analysis of 5522 Veterans treated for cancers of the upper aerodigestive tract between 2012 and 2019. Data included cancer diagnosis and treatments, pain severity, prescription opioid characteristics, demographics, and other clinical factors. RESULTS: Two years post-HNC, 7.8% (n = 428) were receiving moderate or high-dose opioid therapy. Patients with at least moderate pain (18%, n = 996) had 2.48 times higher odds (95% CI = 1.94-3.09, p < 0.001) to be prescribed a moderate opioid dose or higher at 2 years post diagnosis. CONCLUSIONS: Survivors of HNC with at least moderate pain were at elevated risk of continued use of moderate and high dose opioids.

"I'm Clean and Sober, But Not Necessarily Free": Perceptions of Buprenorphine Among Patients in Long-Term Treatment.

BACKGROUND: Patients receiving buprenorphine for the treatment of opioid use disorder (OUD) experience a roughly 50% reduction in mortality risk relative to those not receiving medication. Longer periods of treatment are also associated with improved clinical outcomes. Despite this, patients often express desires to discontinue treatment and some view taper as treatment success. Little is known about the beliefs and medication perspectives of patients engaged in long-term buprenorphine treatment that may underlie motivations to discontinue. METHODS: This study was conducted at the VA Portland Health Care System (2019-2020). Qualitative interviews were conducted with participants prescribed buprenorphine for ≥2 years. Coding and analysis were guided by directed qualitative content analysis. RESULTS: Fourteen patients engaged in office-based buprenorphine treatment completed interviews. While patients expressed strong enthusiasm for buprenorphine as a medication, the majority expressed the desire to discontinue, including patients actively tapering. Motivations to discontinue fell into 4 categories. First, patients were troubled by perceived side effects of the medication, including effects on sleep, emotion, and memory. Second, patients expressed unhappiness with being "dependent" on buprenorphine, framed in opposition to personal strength/independence. Third, patients expressed stigmatized beliefs about buprenorphine, describing it as "illicit," and associated with past drug use. Finally, patients expressed fears about buprenorphine unknowns, including potential long-term health effects and interactions with medications required for surgery. CONCLUSIONS: Despite recognizing benefits, many patients engaged in long-term buprenorphine treatment express a desire to discontinue. Findings from this study may help clinicians anticipate patient concerns and can be used to inform shared decision-making conversations regarding buprenorphine treatment duration.

Patient-Provider Shared Decision-Making, Trust, and Opioid Misuse Among US Veterans Prescribed Long-Term Opioid Therapy for Chronic Pain.

BACKGROUND: Patient-provider shared decision-making is associated with better treatment adherence and pain outcomes in opioid-specific pain management. One possible mechanism through which shared decision-making may impact pain management outcomes is trust in one's prescribing provider. Elucidating relationships between factors that enhance the patient-provider relationship, such as shared decision-making and trust, may reduce risks associated with opioid treatment, such as opioid misuse. OBJECTIVE: The purpose of this study was to investigate the mediating effect of trust in one's prescribing provider on the relationship between shared decision-making and current opioid misuse. DESIGN: A secondary analysis of data from a prospective cohort study of US Veterans (N = 1273) prescribed long-term opioid therapy (LTOT) for chronic non-cancer pain. PARTICIPANTS: Eligibility criteria included being prescribed LTOT, ability to speak and read English, and access to a telephone. Veterans were excluded if they had a cancer diagnosis, received opioid agonist therapy for opioid use disorder, or evidence of pending discontinuation of LTOT. Stratified random sampling was employed to oversample racial and ethnic minorities and women veterans. MAIN MEASURES: Physician Participatory Decision-Making assessed level of patient involvement in medical decision-making, the Trust in Provider Scale assessed interpersonal trust in patient-provider relationships, and the Current Opioid Misuse Measure assessed opioid misuse. KEY RESULTS: Patient-provider shared decision-making had a total significant effect on opioid misuse, in the absence of the mediator (c = - 0.243, p < 0.001), such that higher levels of shared decision-making were associated with lower levels of reported opioid misuse. When trust in provider was added to the mediation model, the indirect effect of shared decision-making on opioid misuse through trust in provider remained significant (c' = - 0.147, p = 0.007). CONCLUSIONS: Shared decision-making is associated with less prescription opioid misuse through the trust that is fostered between patients and providers.

Risk of Suicidal Self-directed Violence Among US Veteran Survivors of Head and Neck Cancer.

Importance: Head and neck cancer (HNC) survivors are about twice as likely to die by suicide compared with other cancer survivors. Objective: To examine the associations between precancer mental health and pain and postcancer receipt of mental health, substance use disorder (SUD), or palliative care services with risk of suicidal self-directed violence (SSDV). Design, Setting, and Participants: This retrospective cohort study used the Veterans Health Administration data of 7803 veterans with a diagnosis of HNC (stage I-IVB) who received cancer treatment between January 1, 2012, and January 1, 2018. Data were analyzed between May 2020 and July 2021. Exposures: Presence of precancer chronic pain and SUD diagnoses, and postcancer SUD, mental health, or palliative care treatment. Exposures were defined using International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes in Veterans Health Administration administrative data. Main Outcomes and Measures: Documented SSDV event, including suicide attempt or death by suicide, after HNC diagnosis. Results: Among the cohort of 7803 veterans (7685 [98.4%] male; mean [SD] age, 65 [10.7] years), 72 (0.9%) had at least 1 documented SSDV event following their cancer diagnosis, and 51 (0.7%) died by suicide. Four adjusted modified Poisson regression analyses identified that precancer chronic pain (incidence rate ratio [IRR], 2.58; 95% CI 1.54-4.32) or mood disorder diagnoses (IRR, 1.95; 95% CI, 1.17-3.24) were associated with higher risk of postcancer SSDV. Those who had at least 1 documented mental health (IRR, 2.73; 95% CI, 1.24-6.03) or SUD (IRR, 3.92; 95% CI, 2.46-6.24) treatment encounter in the 90 days following HNC diagnosis were at higher risk for SSDV. A palliative care encounter within 90 days of postcancer diagnosis was associated with decreased risk of SSVD (IRR, 0.49; 95% CI, 0.31-0.78). Conclusions and Relevance: In this cohort study, a high proportion of HNC survivors with an SSVD event died from their injuries. Identification of risk factors for SSDV among HNC survivors may help direct additional resources to those who are at high risk. Referral to palliative care appears to be an important component of supportive oncologic care to reduce the risk of SSDV.

Factors Related to Prescription Drug Monitoring Program Queries for Veterans Receiving Long-Term Opioid Therapy.

OBJECTIVE: State prescription drug monitoring programs (PDMPs) identify controlled medications dispensed across providers and systems. Department of Veterans Affairs (VA) policy requires electronic health record documentation of PDMP queries at least annually for VA patients receiving controlled medications; however, queries are not uniformly conducted. We examined factors associated with PDMP queries for veterans receiving long-term opioid therapy. METHODS: Veterans with a VA provider who received long-term opioid therapy between August 2015 and August 2016 within a four-state region were identified; 9,879 were due for a PDMP query between August 2016 and February 2017. Likelihood of veterans' PDMP queries during this follow-up period was modeled as a function of patient, provider, and facility characteristics of interest in mixed-effects modified Poisson models estimating relative risk and 95% confidence intervals. Multivariable models controlled for potential confounders identified through the use of directed acyclic graphs. RESULTS: PDMP queries were documented for 62.1% of veterans that were due for a PDMP query. Veterans were more likely to be queried if they were Hispanic or if they received methadone, had average daily milligram morphine equivalents >20, or received urine drug screening during the studied period. Veterans were less likely to be queried if they had a rural address, mail order medication, or cancer diagnosis. Likelihood of PDMP queries was also lower for veterans whose opioid-prescribing provider was an oncologist or working in a low-complexity facility. CONCLUSIONS: Adherence to PDMP query policy within the VA varied by patient, clinician, and facility factors. Mechanisms to standardize the conduct of PDMP queries may be needed.

Prospective Investigation of Factors Associated with Prescription Opioid Dose Escalation among Patients in Integrated Health Systems.

BACKGROUND: Prior research has identified factors associated with prescription opioid initiation, but little is known about the prevalence or predictors of dose escalation among patients already prescribed long-term opioid therapy (LTOT). OBJECTIVE: This was a 2-year prospective cohort study to examine patient and clinician factors associated with opioid dose escalation. DESIGN: A prospective cohort study. Participants were seen at baseline and every 6 months for a total of 2 years. PARTICIPANTS: Patients prescribed a stable dose of LTOT for musculoskeletal pain were recruited from two integrated health systems (Kaiser Permanente and the Department of Veterans Affairs, respectively). MAIN MEASURES: The prescription opioid dose was based on pharmacy records and self-report. Administrative data were gathered on characteristics of the opioid-prescribing clinician and healthcare utilization. Participants completed measures of pain, functioning, and quality of life. KEY RESULTS: Of enrolled participants (n = 517), 19.5% had an opioid dose increase. In multivariate analyses, patient variables associated with dose escalation were lower opioid dose (hazard ratio [HR] = 0.86, 95% confidence interval [CI] = 0.79-0.94, for every 10-mg increase in baseline dose) and greater pain catastrophizing (HR = 1.03, 95% CI = 1.01-1.05). Other variables associated with dose escalation were as follows: receiving medications from a nurse practitioner primary care provider (HR = 2.10, 95% CI = 1.12-3.96) or specialty physician (HR = 3.18, 95% CI = 1.22-8.34), relative to a physician primary care provider, and having undergone surgery within the past 6 months (HR = 1.80, 95% CI = 1.10-2.94). Other variables, including pain intensity, pain disability, or depression, were not associated with dose escalation. CONCLUSIONS: In this 2-year prospective cohort study, variables associated with opioid dose escalation were lower opioid dose, higher pain catastrophizing, receiving opioids from a medical specialist (rather than primary care clinician) or nurse practitioner, and having recently undergone surgery. Study findings highlight intervention points that may be helpful for reducing the likelihood of future prescription opioid dose escalation.

CE: Implementing Guidelines for Treating Chronic Pain with Prescription Opioids.

Chronic pain, stemming primarily from musculoskeletal conditions and severe headaches, is a growing problem in the United States, affecting as many as 43% of adults. Opioids are frequently prescribed to manage chronic pain despite limited data on their long-term efficacy and the potential risks of long-term use. In 2017, more than 47,000 people died as a result of an opioid overdose involving illicit opioids (such as heroin), illicitly manufactured opioids, diverted opioids, prescription opioids, or some combination thereof. Although it's been more than three years since the nationwide opioid crisis prompted the Centers for Disease Control and Prevention (CDC) to release a guideline outlining safe practices for prescribing opioids to patients with chronic pain (unrelated to active cancer or palliative and end-of-life care), opioid misuse remains a significant concern. Historically, physicians have been tasked with the primary responsibility for implementing opioid safety measures, but nurses in the primary care setting are being increasingly relied on to incorporate these measures as part of their practice. In this article, we discuss the use of five tools outlined in the CDC guideline: prescription opioid treatment agreements, urine drug screening, prescription drug monitoring program databases, calculation of morphine milligram equivalents, and naloxone kits. Primary care nurses can use these tools to promote opioid safety among patients receiving opioid therapy for chronic pain.

Setting Expectations, Following Orders, Safety, and Standardization: Clinicians' Strategies to Guide Difficult Conversations About Opioid Prescribing.

BACKGROUND: Evidence has continued to accumulate regarding the potential risks of treating chronic pain with long-term opioid therapy (LTOT). Clinical practice guidelines now encourage clinicians to implement practices designed to reduce opioid-related risks. Yet how clinicians implement these guidelines within the context of the patient encounter has received little attention. OBJECTIVE: This secondary analysis aimed to identify and describe clinicians' strategies for managing prescription opioid misuse and aberrant behaviors among patients prescribed LTOT for chronic pain. DESIGN: Individual interviews guided by a semi-structured interview protocol probed: (1) methods clinicians utilize to reduce prescription opioid misuse and address aberrant opioid-related behaviors; (2) how clinicians respond to misuse; and (3) resources and constraints faced in managing and treating misuse among their patients. PARTICIPANTS: Interviews were conducted with 24 physicians and nurse practitioners, representing 22 Veterans Health Administration (VA) facilities across the USA, who had one or more patients in their clinical panels who were prescribed LTOT for the treatment of chronic non-cancer pain. APPROACH: Qualitative content analysis was the analytic approach utilized. A codebook was developed iteratively following group coding and discussion. All transcripts were coded with the finalized codebook. Quotes pertaining to key themes were retrieved and, following careful review, sorted into themes, which were then further categorized into sub-themes. Quotes that exemplified key sub-themes were selected for inclusion. KEY RESULTS: We detail the challenges clinicians describe in navigating conversations with patients around prescription opioid misuse, which include patient objection as well as clinician ambivalence. We identify verbal heuristics as one strategy clinicians utilize to structure these difficult conversations, and describe four heuristics: setting expectations, following orders, safety, and standardization. CONCLUSION: Clinicians frequently use verbal heuristics to routinize and increase the efficiency of care management discussions related to opioid prescribing, redirect responsibility, and defuse the potential emotional charge of the encounter.

Marijuana Use Is Not Associated With Changes in Opioid Prescriptions or Pain Severity Among People Living With HIV and Chronic Pain.

BACKGROUND: People living with HIV (PLWH) commonly report marijuana use for chronic pain, although there is limited empirical evidence to support its use. There is hope that marijuana may reduce prescription opioid use. Our objective was to investigate whether marijuana use among PLWH who have chronic pain is associated with changes in pain severity and prescribed opioid use (prescribed opioid initiation and discontinuation). METHODS: Participants completed self-report measures of chronic pain and marijuana use at an index visit and were followed up for 1 year in the Center for AIDS Research Network of Integrated Clinical Systems (CNICS). Self-reported marijuana use was the exposure variable. Outcome variables were changes in pain and initiation or discontinuation of opioids during the study period. The relationship between exposure and outcomes was assessed using generalized linear models for pain and multivariable binary logistic regression models for opioid initiation/discontinuation. RESULTS: Of 433 PLWH and chronic pain, 28% reported marijuana use in the past 3 months. Median pain severity at the index visit was 6.3/10 (interquartile range 4.7-8.0). Neither increases nor decreases in marijuana use were associated with changes in pain severity, and marijuana use was not associated with either lower odds of opioid initiation or higher odds of opioid discontinuation. CONCLUSIONS: We did not find evidence that marijuana use in PLWH is associated with improved pain outcomes or reduced opioid prescribing. This suggests that caution is warranted when counseling PLWH about potential benefits of recreational or medical marijuana.

Development of an Algorithm to Identify Cannabis Urine Drug Test Results within a Multi-Site Electronic Health Record System.

With the rapid changes in the legalization of cannabis in the U.S., there is an urgent need to understand clinical outcomes and processes of care among patients who use cannabis, particularly among patients with chronic pain who are high utilizers of cannabis. Electronic health records (EHRs) are a common and convenient mechanism for examining processes of care; however, there is not an indication for cannabis use that does not meet criteria for a diagnostic disorder. We used urine drug test (UDT) results identified through EHRs to identify patients with confirmed cannabis use. We developed and tested an algorithm to identify outcomes of UDT results for cannabis because there is wide variability in reporting methodology, including in multi-site health systems. Among all patients receiving care in the Department of Veterans Affairs (VA) who were prescribed long-term opioid therapy for chronic pain, we identified a random sample who completed UDT for cannabis. Through an iterative process, we developed an algorithm to identify UDT cannabis results. Manual review of EHR data was conducted to verify accuracy of UDT results. The final UDT algorithm correctly identified 99% of cannabis positive UDT results and 100% of cannabis negative UDT results among 200 randomly sampled patients. Study findings suggest a high degree of accuracy for using an algorithm to identify samples of patients with positive cannabis UDT results across multiple institutions with disparate UDT reporting practices. The methodology for testing this algorithm is feasible and may be applied to other multi-site health systems.

The Effects of Cannabis Among Adults With Chronic Pain and an Overview of General Harms: A Systematic Review.

BACKGROUND: Cannabis is increasingly available for the treatment of chronic pain, yet its efficacy remains uncertain. PURPOSE: To review the benefits of plant-based cannabis preparations for treating chronic pain in adults and the harms of cannabis use in chronic pain and general adult populations. DATA SOURCES: MEDLINE, Cochrane Database of Systematic Reviews, and several other sources from database inception to March 2017. STUDY SELECTION: Intervention trials and observational studies, published in English, involving adults using plant-based cannabis preparations that reported pain, quality of life, or adverse effect outcomes. DATA EXTRACTION: Two investigators independently abstracted study characteristics and assessed study quality, and the investigator group graded the overall strength of evidence using standard criteria. DATA SYNTHESIS: From 27 chronic pain trials, there is low-strength evidence that cannabis alleviates neuropathic pain but insufficient evidence in other pain populations. According to 11 systematic reviews and 32 primary studies, harms in general population studies include increased risk for motor vehicle accidents, psychotic symptoms, and short-term cognitive impairment. Although adverse pulmonary effects were not seen in younger populations, evidence on most other long-term physical harms, in heavy or long-term cannabis users, or in older populations is insufficient. LIMITATION: Few methodologically rigorous trials; the cannabis formulations studied may not reflect commercially available products; and limited applicability to older, chronically ill populations and patients who use cannabis heavily. CONCLUSION: Limited evidence suggests that cannabis may alleviate neuropathic pain in some patients, but insufficient evidence exists for other types of chronic pain. Among general populations, limited evidence suggests that cannabis is associated with an increased risk for adverse mental health effects. PRIMARY FUNDING SOURCE: U.S. Department of Veterans Affairs. (PROSPERO: CRD42016033623).

Care management practices for chronic pain in veterans prescribed high doses of opioid medications.

BACKGROUND: There is growing interest in the primary care management of patients with chronic non-cancer pain (CNCP) who are prescribed long-term opioid therapy. OBJECTIVE: The aim of this study was to examine the care management practices and medical utilization of patients prescribed high doses of opioids relative to patients prescribed traditional doses of opioids. METHODS: We conducted a retrospective cohort study of veterans who had CNCP in 2008 and reviewed medical care for the prior 2 years. Patients with CNCP who were prescribed high-dose opioid therapy (≥180mg morphine equivalent per day for 90+ consecutive days; n = 60) were compared with patients prescribed traditional dose opioid therapy (5-179mg morphine equivalent per day for 90+ consecutive days; n = 60). RESULTS: Patients in the high-dose group had several aspects of documented care that differed from patients in the traditional dose group, including more medical visits, attempting an opioid taper, receiving a urine drug screen and developing a pain goal. The majority of variables that were assessed did not differ between groups, including documented assessments of functional status or co-morbid psychopathology, opioid rotation, discussion of treatment side effects, non-pharmacological treatments or collaboration with mental health or pain specialists. CONCLUSIONS: Further work is needed to identify mechanisms for optimizing care management for patients with CNCP who are prescribed high doses of opioid medications.

Sex differences in the medical care of VA patients with chronic non-cancer pain.

OBJECTIVE: Despite a growing number of women seeking medical care in the veterans affairs (VA) system, little is known about the characteristics of their chronic pain or the pain care they receive. This study sought to determine if sex differences are present in the medical care veterans received for chronic pain. DESIGN: Retrospective cohort study using VA administrative data. SUBJECTS: The subjects were 17,583 veteran patients with moderate to severe chronic non-cancer pain treated in the Pacific Northwest during 2008. METHODS: Multivariate logistic regression assessed for sex differences in primary care utilization, prescription of chronic opioid therapy, visits to emergency departments for a pain-related diagnosis, and physical therapy referral. RESULTS: Compared with male veterans, female veterans were more often diagnosed with two or more pain conditions, and had more of the following pain-related diagnoses: fibromyalgia, low back pain, inflammatory bowel disease, migraine headache, neck or joint pain, and arthritis. After adjustment for demographic characteristics, pain diagnoses, mental health diagnoses, substance use disorders, and medical comorbidity, women had lower odds of being prescribed chronic opioid therapy (adjusted OR [AOR] 0.67, 95% CI 0.58-0.78), greater odds of visiting an emergency department for a pain-related complaint (AOR 1.40, 95% CI 1.18-1.65), and greater odds of receiving physical therapy (AOR 1.19, 95% CI 1.05-1.33). Primary care utilization was not significantly different between sexes. CONCLUSIONS: Sex differences are present in the care female veterans receive for chronic pain. Further research is necessary to understand the etiology of the observed differences and their associations with clinical outcomes.

Prescription opioids for back pain and use of medications for erectile dysfunction.

STUDY DESIGN: Cross-sectional analysis of electronic medical and pharmacy records. OBJECTIVE: To examine associations between use of medication for erectile dysfunction or testosterone replacement and use of opioid therapy, patient age, depression, and smoking status. SUMMARY OF BACKGROUND DATA: Males with chronic pain may experience erectile dysfunction related to depression, smoking, age, or opioid-related hypogonadism. The prevalence of this problem in back pain populations and the relative importance of several risk factors are unknown. METHODS: We examined electronic pharmacy and medical records for males with back pain in a large group model health maintenance organization during 2004. Relevant prescriptions were considered for 6 months before and after the index visit. RESULTS: There were 11,327 males with a diagnosis of back pain. Males who received medications for erectile dysfunction or testosterone replacement (n = 909) were significantly older than those who did not and had greater comorbidity, depression, smoking, and use of sedative-hypnotics. In logistic regressions, the long-term use of opioids was associated with greater use of medications for erectile dysfunction or testosterone replacement compared with no opioid use (odds ratio, 1.45; 95% confidence interval, 1.12-1.87, P < 0.01). Age, comorbidity, depression, and use of sedative-hypnotics were also independently associated with the use of medications for erectile dysfunction or testosterone replacement. Patients prescribed daily opioid doses of 120 mg of morphine-equivalents or more had greater use of medication for erectile dysfunction or testosterone replacement than patients without opioid use (odds ratio, 1.58; 95% confidence interval, 1.03-2.43), even with adjustment for the duration of opioid therapy. CONCLUSION: Dose and duration of opioid use, as well as age, comorbidity, depression, and use of sedative-hypnotics, were associated with evidence of erectile dysfunction. These findings may be important in the process of decision making for the long-term use of opioids. LEVEL OF EVIDENCE: 4.

Vulnerability to somatic symptoms of depression during interferon-alpha therapy for hepatitis C: a 16-week prospective study.

OBJECTIVE: This study evaluated the distinctive clinical and biological manifestations of depressive symptom subtypes (i.e., cognitive-affective and somatic) in Veterans with hepatitis C viral infection (HCV) before and during interferon-alpha (IFN) based antiviral therapy. METHODS: Thirty-two Veterans with HCV and no prior history of IFN therapy were followed prospectively during the first 16weeks of therapy to evaluate depressive symptoms and to determine if baseline cytokine and serotonin levels predicted subsequent changes in depressive scores. RESULTS: IFN therapy resulted in a significant increase in total depressive symptoms from baseline (week 0) to week 16, with neurovegetative and somatic symptoms of depression including loss of appetite, fatigue and irritability increasing within the first two weeks of therapy and continuing to increase throughout IFN therapy. When depressive symptoms were evaluated using a two-factor (i.e., Cognitive-Affective and Somatic) model, the Cognitive-Affective factor score did not change significantly following IFN therapy initiation, while the Somatic factor score showed a significant increase from week 0 to week 16. Veterans with the largest increases in somatic symptoms from week 0 to week 2 had significantly higher levels of tumor necrosis factor-alpha (TNF-α) and lower levels of serotonin at baseline, as compared to Veterans with minimal or no increase in somatic symptoms. CONCLUSION: Somatic symptoms of depression can be significantly exacerbated during IFN therapy and may be predicted by higher TNF-α levels and lower serotonin levels at baseline.