The System Is Broken: A Qualitative Assessment of Opioid Prescribing Practices After Spine Surgery.

OBJECTIVE: To elucidate factors that influence opioid prescribing behaviors of key stakeholders after major spine surgery, with a focus on barriers to optimized prescribing. METHODS: In-person semi-structured interviews were performed with 20 surgical and medical professionals (January 23, 2019 to June 11, 2019) at a large academic medical center, including resident physicians, midlevel providers, attending physicians, and clinical pharmacists. Interviews centered on perceptions of postoperative prescribing practices were coded and analyzed using a qualitative inductive approach. RESULTS: Several unique themes emerged. First, wide interprovider variation exists in the perceived role of opioid prescribing guidelines. Second, there are important relationships between clinical experience, time constraints, and postoperative opioid prescribing. Third, opioid tapering is a major area of inconsistency. Fourth, there are serious challenges in managing analgesic expectations, particularly in those with chronic pain. Finally, there is currently no process to facilitate the hand-off or transition of opioid prescribing responsibility between surgical and primary care teams, which represents a major area for practice optimization efforts. CONCLUSION: Despite increased focus on postoperative opioid prescribing, there remain numerous areas for improvement. The development of tools and processes to address critical gaps in postoperative prescribing will be essential for our efforts to reduce long-term opioid use after major spine surgery and improve patient care.

Assessment of Potentially Inappropriate Prescribing of Opioid Analgesics Requiring Prior Opioid Tolerance.

Importance: Opioid-tolerant only (OTO) medications, such as transmucosal immediate-release fentanyl products and certain extended-release opioid analgesics, require prior opioid tolerance for safe use, as patients without tolerance may be at increased risk of overdose. Studies using insurance claims have found that many patients initiating these medications do not appear to be opioid tolerant. Objectives: To measure prevalence of opioid tolerance in patients initiating OTO medications and to determine whether linked electronic health record (EHR) data contribute evidence of opioid tolerance not found in insurance claims data. Design, Setting, and Participants: This retrospective cohort study used a national database of deidentified longitudinal health information, including medical and pharmacy claims, insurance enrollment, and EHR data, from January 1, 2007, to December 31, 2016. Data included 131 756 US residents with at least 183 days of continuous enrollment in commercial or Medicare Advantage insurance (including medical and pharmacy benefits) who had received an OTO medication and who had no inpatient stays in the 30 days prior to starting an OTO medication; of these, 20 044 individuals had linked EHR data within the prior 183 days. Data were analyzed from July 1, 2017, to August 31, 2018. Exposures: Initiating an OTO medication. Main Outcomes and Measures: Prior opioid tolerance demonstrated through pharmacy fills or EHR data on prescriptions written. Results: Among 153 385 OTO use episodes identified, 89 029 (58.0%) occurred among women, 62 900 (41.0%) occurred among patients with Medicare Advantage insurance, 39 394 (25.7%) occurred in the Midwest, 17 366 (11.3%) occurred in the Northeast, 73 316 (47.8%) occurred in the South, and 23 309 (15.2%) occurred in the West. Less than half of use episodes (73 117 episodes [47.7%]) involved patients with evidence in claims data of opioid tolerance prior to initiating therapy with an OTO medication, including 31 392 of 101 676 episodes (30.9%) involving transdermal fentanyl, 1561 of 2440 episodes (64.0%) involving transmucosal fentanyl, 36 596 of 43 559 episodes (84.0%) involving extended-release oxycodone, and 3568 of 5710 episodes (62.5%) involving extended-release hydromorphone. Among 20 044 OTO use episodes with linked EHR and claims data, less than 1% of OTO episodes identified in claims had evidence of opioid tolerance in structured EHR data that was not present in claims data (108 episodes [0.5%]). After limiting the sample to OTO episodes identified in claims with a matching OTO prescription within 14 days in the structured EHR data, only 40 of 939 episodes (4.0%) occurred among patients with evidence of tolerance that was not present in claims data. Conclusions and Relevance: This cohort study found that most patients initiating OTO medications did not have evidence of prior opioid tolerance, suggesting they were at increased risk of opioid-related harms, including fatal overdose. Data from EHRs did not contribute substantial additional evidence of opioid tolerance beyond the data found in prescription claims. Future research is needed to understand the clinical rationale behind these observed prescribing patterns and to quantify the risk of harm to patients associated with potentially inappropriate prescribing.

Pain Management Best Practices from Multispecialty Organizations During the COVID-19 Pandemic and Public Health Crises.

BACKGROUND: It is nearly impossible to overestimate the burden of chronic pain, which is associated with enormous personal and socioeconomic costs. Chronic pain is the leading cause of disability in the world, is associated with multiple psychiatric comorbidities, and has been causally linked to the opioid crisis. Access to pain treatment has been called a fundamental human right by numerous organizations. The current COVID-19 pandemic has strained medical resources, creating a dilemma for physicians charged with the responsibility to limit spread of the contagion and to treat the patients they are entrusted to care for. METHODS: To address these issues, an expert panel was convened that included pain management experts from the military, Veterans Health Administration, and academia. Endorsement from stakeholder societies was sought upon completion of the document within a one-week period. RESULTS: In these guidelines, we provide a framework for pain practitioners and institutions to balance the often-conflicting goals of risk mitigation for health care providers, risk mitigation for patients, conservation of resources, and access to pain management services. Specific issues discussed include general and intervention-specific risk mitigation, patient flow issues and staffing plans, telemedicine options, triaging recommendations, strategies to reduce psychological sequelae in health care providers, and resource utilization. CONCLUSIONS: The COVID-19 public health crisis has strained health care systems, creating a conundrum for patients, pain medicine practitioners, hospital leaders, and regulatory officials. Although this document provides a framework for pain management services, systems-wide and individual decisions must take into account clinical considerations, regional health conditions, government and hospital directives, resource availability, and the welfare of health care providers.

Response to Propoxyphene Market Withdrawal: Analgesic Substitutes, Doses, and Adverse Events.

OBJECTIVE: Experts cautioned that patients affected by the November 2010 withdrawal of the opioid analgesic propoxyphene might receive riskier prescriptions. To explore this, we compared drug receipts and outcomes among propoxyphene users before and aftermarket withdrawal. STUDY DESIGN: Using OptumLabs data, we studied 3 populations: commercial, Medicare Advantage (MA) aged (age 65+ y) and MA disabled (age below 65 y) enrollees. The exposed enrollees received propoxyphene in the 3 months before market withdrawal (n=13,622); historical controls (unexposed) received propoxyphene 1 year earlier (n=9971). Regression models estimated daily milligrams morphine equivalent (MME), daily prescription acetaminophen dose, potentially toxic acetaminophen doses, nonopioid prescription analgesics receipt, emergency room visits, and diagnosed falls, motor vehicle accidents, and hip fractures. PRINCIPAL FINDINGS: Aged MA enrollees illustrate the experience of all 3 populations examined. Following the market withdrawal, propoxyphene users in the exposed cohort experienced an abrupt decline of 69% in average daily MME, compared with a 14% decline in the unexposed. Opioids were discontinued by 34% of the exposed cohort and 18% of the unexposed. Tramadol and hydrocodone were the most common opioids substituted for propoxyphene. The proportion of each group receiving ≥4 g of prescription acetaminophen per day decreased from 12% to 2% in the exposed group but increased from 6% to 8% among the unexposed. Adverse events were rare and not significantly different in exposed versus unexposed groups. CONCLUSIONS: After propoxyphene market withdrawal, many individuals experienced abrupt discontinuation of opioids. Policymakers might consider supporting appropriate treatment transitions and monitoring responses following drug withdrawals.

Trends in opioid use in commercially insured and Medicare Advantage populations in 2007-16: retrospective cohort study.

OBJECTIVE: To describe trends in the rate and daily dose of opioids used among commercial and Medicare Advantage beneficiaries from 2007 to 2016. DESIGN: Retrospective cohort study of administrative claims data. SETTING: National database of medical and pharmacy claims for commercially insured and Medicare Advantage beneficiaries in the United States. PARTICIPANTS: 48 million individuals with any period of insurance coverage between 1 January 2007 and 31 December 2016, including commercial beneficiaries, Medicare Advantage beneficiaries aged 65 years and over, and Medicare Advantage beneficiaries under age 65 years (eligible owing to permanent disability). MAIN ENDPOINTS: Proportion of beneficiaries with any opioid prescription per quarter, average daily dose in milligram morphine equivalents (MME), and proportion of opioid use episodes that represented long term use. RESULTS: Across all years of the study, annual opioid use prevalence was 14% for commercial beneficiaries, 26% for aged Medicare beneficiaries, and 52% for disabled Medicare beneficiaries. In the commercial beneficiary group, quarterly prevalence of opioid use changed little, starting and ending the study period at 6%; the average daily dose of 17 MME remained unchanged since 2011. For aged Medicare beneficiaries, quarterly use prevalence was also relatively stable, ranging from 11% at the beginning of the study period to 14% at the end. Disabled Medicare beneficiaries had the highest rates of opioid use, the highest rate of long term use, and the largest average daily doses. In this group, both quarterly use rates (39%) and average daily dose (56 MME) were higher at the end of 2016 than the low points observed in 2007 for each endpoint (26% prevalence and 53 MME). CONCLUSIONS: Opioid use rates were high during the study period of 2007-16, with the highest rates in disabled Medicare beneficiaries versus aged Medicare beneficiaries and commercial beneficiaries. Opioid use and average daily dose have not substantially declined from their peaks, despite increased attention to opioid abuse and awareness of their risks.

Opioid Prescribing for Opioid-Naive Patients in Emergency Departments and Other Settings: Characteristics of Prescriptions and Association With Long-Term Use.

STUDY OBJECTIVE: We explore the emergency department (ED) contribution to prescription opioid use for opioid-naive patients by comparing the guideline concordance of ED prescriptions with those attributed to other settings and the risk of patients' continuing long-term opioid use. METHODS: We used analysis of administrative claims data (OptumLabs Data Warehouse 2009 to 2015) of opioid-naive privately insured and Medicare Advantage (aged and disabled) beneficiaries to compare characteristics of opioid prescriptions attributed to the ED with those attributed to other settings. Concordance with Centers for Disease Control and Prevention (CDC) guidelines and rate of progression to long-term opioid use are reported. RESULTS: We identified 5.2 million opioid prescription fills that met inclusion criteria. Opioid prescriptions from the ED were more likely to adhere to CDC guidelines for dose, days' supply, and formulation than those attributed to non-ED settings. Disabled Medicare beneficiaries were the most likely to progress to long-term use, with 13.4% of their fills resulting in long-term use compared with 6.2% of aged Medicare and 1.8% of commercial beneficiaries' fills. Compared with patients in non-ED settings, commercial beneficiaries receiving opioid prescriptions in the ED were 46% less likely, aged Medicare patients 56% less likely, and disabled Medicare patients 58% less likely to progress to long-term opioid use. CONCLUSION: Compared with non-ED settings, opioid prescriptions provided to opioid-naive patients in the ED were more likely to align with CDC recommendations. They were shorter, written for lower daily doses, and less likely to be for long-acting formulations. Prescriptions from the ED are associated with a lower risk of progression to long-term use.

Opioids for chronic pain: a knowledge assessment of nonpain specialty providers.

INTRODUCTION: Although the majority of opioids in the US are prescribed by nonpain specialists, these providers often report inadequate training in chronic pain management and opioid prescribing. The extent of health care providers' knowledge of opioid prescribing for chronic pain has not been well established. The purpose of this study was to assess knowledge about the use of opioids for chronic pain among health care providers seeking pain-focused continuing medical education. MATERIALS AND METHODS: The study participants (n=131) were recruited at a pain-focused continuing medical education conference for nonpain specialists. Upon commencement of the conference, the KnowPain-50 survey was completed. The survey comprised 50 questions, and 18 questions were related to opioid management. The focus of each opioid question was further categorized as either medicolegal (n=7) or clinical (n=11). RESULTS: The majority of study participants were male physicians with a mean age of 51.8 years. The proportion of correct responses to the 50-item survey was 72%. The proportion of correct responses to the 32 nonopioid questions was 74%, and the proportion of correct responses to the 18 opioid questions was 69% (P<0.001). Similarly, the proportion of correct responses to the seven medicolegal opioid questions was 74%, and the proportion of correct responses to the eleven clinical opioid questions was 67% (P<0.001). CONCLUSION: Health care providers demonstrated gaps in knowledge about the use of opioids for chronic pain. Lower scores on clinically based opioid questions may indicate an opportunity to provide focused educational content about this area of practice. This information could be helpful in designing future educational modules for nonpain providers.

Tobacco control in patients treated for chronic pain: a survey of pain fellowship program directors.

BACKGROUND AND OBJECTIVES: Previous studies have established the relationship between tobacco use and pain severity among patients suffering from chronic pain. Unfortunately, many physicians feel underprepared to counsel patients on smoking cessation. The purpose of this study was to identify the attitudes, beliefs, and practices of pain medicine fellowship directors in regard to tobacco control interventions and trainee education. METHODS: Program directors of ACGME-accredited pain medicine fellowships were surveyed via a web-based form to assess current practices in tobacco intervention and to gauge interest in incorporating tobacco control into their current fellowship training curriculum. RESULTS: Of the respondents, the majority indicated that they frequently asking their patients about tobacco use and advise them to quit. In addition, most agreed that presenting tobacco control is a responsibility of pain physicians. However, few consistently provided any assistance with quitting. Finally, the majority of program directors felt that pain medicine fellowships should include tobacco control training and were interested in incorporating an educational module about smoking and pain into their training program. CONCLUSIONS: This survey of pain medicine fellowship program directors indicates that although smoking cessation interventions are not being consistently applied in academic pain practices, there is a strong interest in doing so. Furthermore, the majority of program directors recognized the importance of incorporating tobacco control training into pain medicine fellowships. This recognition may provide an opportunity to develop a web-based training module that could be easily incorporated into the upcoming milestones in pain medicine training.

Utility of the NEO-FFI in multi-dimensional assessment of orofacial pain conditions.

The purpose of this study was to examine the utility of using the NEO-FFI personality assessment as part of multi-dimensional psychological assessment in orofacial pain patients during the initial diagnostic visit. All patients completed an orofacial pain questionnaire and a battery of psychological questionnaires that cover a wide range of symptoms and behaviors important to developing a comprehensive treatment plan. For purposes of the present study, the NEO-FFI was included. Personality characteristics were within normal ranges compared to NEO-FFI norms. Regression analyses demonstrated higher self-reported pain severity was associated with lower openness. Higher psychological distress was associated with higher neuroticism, lower extraversion, and lower openness. In patients reporting a traumatic life experience, neuroticism and extraversion mediated the relationship between trauma-symptoms and psychological distress. The addition of a global personality measure in standard assessment batteries may help the clinician develop coping strategies and techniques based on individual characteristics of the pain patient. Greater understanding of the individual's personality characteristics will likely influence the nature of the pain management program and predict treatment outcomes.

An assessment of the association between smoking status, pain intensity, and functional interference in patients with chronic pain.

BACKGROUND: This article examines the association between smoking and pain intensity and functional interference in a heterogeneous group of patients evaluated at a tertiary outpatient pain clinic. Current smoking is associated with less favorable clinical presentations. OBJECTIVE: This study was conducted to determine if the smoking status of patients seen in an outpatient pain clinic is associated with differences in pain intensity and interference. METHODS: Surveys were mailed to 500 consecutive new patients evaluated at an outpatient pain clinic. Measures included the Brief Pain Inventory (BPI) and the Fagerström Test for Nicotine Dependence (FTND). Univariate analyses compared BPI scores between smokers and non-smokers. Mean BPI scores were compared between smoking status via analysis of covariance (adjusted for demographic variables which differed significantly by smoking status). A p value < or = 0.05 was accepted as significant. RESULTS: Survey completion rate was 46%, and 14.7% were current smokers. Smokers were younger, and more likely to be male and unemployed. Smokers had higher scores on all the pain intensity BPI scales (p < 0.01), and higher scores (indicating greater functional impairment) on the general activity (p = 0.007), mood (p = 0.003), normal work (p = 0.02), relationships (p = 0.04), sleep (p < 0.001), and life enjoyment (p = 0.03) BPI functional impairment scales. Severe nicotine dependence was associated with greater pain now, (p = 0.05), and greater functional interference on mood (p = 0.005), normal work (p = 0.02) and life enjoyment (p = 0.04) BPI scales. CONCLUSION: In patients who completed evaluation in an outpatient pain clinic, current cigarette smokers reported significantly greater pain intensity and pain interference with functioning. Symptoms were more pronounced in smokers with more severe nicotine dependence.