Pain, comorbidities, and clinical decision-making: conceptualization, development, and pilot testing of the Pain in Aging, Educational Assessment of Need instrument.

Introduction: Pain is highly prevalent in older adults and often contextualized by multiple clinical conditions (pain comorbidities). Pain comorbidities increase with age and this makes clinical decisions more complex. To address gaps in clinical training and geriatric pain management, we established the Pain in Aging-Educational Assessment of Need (PAEAN) project to appraise the impacts of medical and mental health conditions on clinical decision-making regarding older adults with pain. We here report development and pilot testing of the PAEAN survey instrument to assess clinician perspectives. Methods: Mixed-methods approaches were used. Scoping review methodology was applied to appraise both research literature and selected Medicare-based data. A geographically and professionally diverse interprofessional advisory panel of experts in pain research, medical education, and geriatrics was formed to advise development of the list of pain comorbidities potentially impacting healthcare professional clinical decision-making. A survey instrument was developed, and pilot tested by diverse licensed healthcare practitioners from 2 institutions. Respondents were asked to rate agreement regarding clinical decision-making impact using a 5-point Likert scale. Items were scored for percent agreement. Results: Scoping reviews indicated that pain conditions and comorbidities are prevalent in older adults but not universally recognized. We found no research literature directly guiding pain educators in designing pain education modules that mirror older adult clinical complexity. The interprofessional advisory panel identified 26 common clinical conditions for inclusion in the pilot PAEAN instrument. Conditions fell into three main categories: "major medical", i.e., cardio-vascular-pulmonary; metabolic; and neuropsychiatric/age-related. The instrument was pilot tested by surveying clinically active healthcare providers, e.g., physicians, nurse practitioners, who all responded completely. Median survey completion time was less than 3 min. Conclusion: This study, developing and pilot testing our "Pain in Aging-Educational Assessment of Need" (PAEAN) instrument, suggests that 1) many clinical conditions impact pain clinical decision-making, and 2) surveying healthcare practitioners about the impact of pain comorbidities on clinical decision-making for older adults is highly feasible. Given the challenges intrinsic to safe and effective clinical care of older adults with pain, and attendant risks, together with the paucity of existing relevant work, much more education and research are needed.

Comparison of the Centers for Disease Control (CDC) recommendations and the risk index for overdose or serious opioid-induced respiratory depression (RIOSORD) tool for guiding naloxone coprescribing.

PURPOSE: Patients treated with ongoing opioid therapy may be at an increased risk of respiratory depression or death, which may be mitigated through prompt administration of naloxone. The Centers for Disease Control (CDC) guidelines for prescribing opioids in primary care settings recommend patients treated with ongoing opioid analgesic therapy be offered a coprescription of naloxone based on total oral morphine milligram equivalents per day or concurrent benzodiazepine therapy. Opioid overdose risk is dose-dependent, yet other patient-specific factors contribute to this risk. The risk index for overdose or serious opioid-induced respiratory depression (RIOSORD) incorporates additional risk factors to assess the risk of overdose or clinically relevant respiratory depression. OBJECTIVES: This study compared the frequency of meeting CDC, Veterans' Health Administration (VA) RIOSORD, or civilian RIOSORD criteria for naloxone coprescribing. METHODS: A retrospective chart review of 42 Federally Qualified Health Centers in Illinois was conducted for all CII-CIV opioid analgesic prescriptions. Ongoing opioid therapy was defined as patients who received seven or more CII-CIV opioid analgesic prescriptions during the 1-year study period. Patients aged 18-89, receiving opioids for nonmalignant pain, and meeting the criteria of ongoing opioid therapy were included in the analysis. RESULTS: A total of 41,777 controlled substance analgesic prescriptions were prescribed during the study period. Data from 651 individual patient charts were evaluated. Of those, 606 patients met inclusion criteria. From these data, 57.9 percent of patients (N = 351) met civilian RIOSORD criteria, 36.5 percent (N = 221) met VA RIOSORD criteria, and 22.8 percent (N = 138) met CDC guideline recommendations for naloxone coprescribing. The percentage of patients who met RIOSORD criteria compared to CDC criteria was significantly higher (p < 0.001). Of all patients meeting ongoing opioid therapy criteria, only seven had been coprescribed naloxone. CONCLUSION: Coprescribing of naloxone is significantly underutilized in patients treated with opioid therapy for nonmalignant chronic pain and should not solely be based on total oral morphine milligram equivalents per day or concurrent benzodiazepine therapy. As risk assessment improves, consideration of other risk-conferring variables, such as gabapentinoids, skeletal muscle relaxants, and sleep hypnotics, should be considered.

Patterns of Viral Arthropathy and Myalgia Following COVID-19: A Cross-Sectional National Survey.

Introduction: Viral arthropathy is an increasingly recognized sequela of several viral pathogens including alphaviruses, hepatitis, and potentially coronaviruses. Case reports of viral arthropathy and myalgia associated with SARS-CoV-2 infection (COVID-19) both during active disease and following resolution of acute COVID-19 symptoms are becoming more prevalent. We sought to describe the prevalence of viral arthropathy and myalgia associated with COVID-19, as well as to identify factors that may predict these symptoms. Methods: A national, cross-sectional survey was conducted using a questionnaire administered online. Subjects self-reporting previous confirmed COVID-19 were recruited using the Amazon Mechanical Turk crowdsourcing platform. Questionnaire items included demographics, frequency and severity of common COVID-19 symptoms, requirement for hospitalization or mechanical ventilation, subject recall of arthropathy or myalgia onset, duration, and severity, as well as WOMAC score. Binary logistic regression was used to identify potential predictive co-variates for the development of either arthropathy or myalgia. Results: A total of 3222 participants completed the arthropathy/myalgia questionnaire with 1065 responses remaining for analysis following application of exclusion criteria, data integrity review, and omission of respondents with confounding conditions. Of the 1065 cases, 282 (26.5%) reported arthralgia and 566 (53.2%) reported myalgia at some point during or after COVID-19 with 9.9% and 6.0% reporting onset of arthralgia or myalgia, respectively, after resolution of acute COVID-19 symptoms. The presence of several commonly reported COVID symptoms or indicators of disease severity was predictive of arthralgia including hospitalization (OR 3.7; 95% CI 2.4 to 5.8), sore throat (OR 2.3; 95% CI 1.5 to 3.5), fatigue (OR 2.9; 95% CI 1.7 to 4.9), and ageusia/anosmia (OR 1.7; 95% CI 1.1 to 2.7). Discussion: Based on these results, new-onset arthropathy and myalgia following COVID-19 resolution may be an increasingly encountered etiology for pain.

Pharmacist Opioid Dispensing Confidence in an Evolving Practice Landscape.

Pharmacists are increasingly called upon to make dispensing decisions when presented with prescriptions for opioids. Risk mitigation strategies have been implemented to assist pharmacists in making these decisions, but they have also increased the complexity of decision-making. The primary objective of this study was to describe change in pharmacist comfort levels with opioid prescription dispensing over the previous year. This was a cross-sectional, multi-state, 16-item survey disseminated to the general membership of 2 state-level professional pharmacy organizations in November 2018. Of 274 pharmacists who opened the questionnaire, 195 (n = 195) completed at least 80% of the survey and were included. Three-fourths (74.6%) of the respondents noted community/retail as their practice site. When asked about change in comfort with dispensing opioids, 19.6% reported an increase in comfort level, 42.5% reported a decrease in comfort level, and 38.0% reported no change. When asked about information that may increase comfort in dispensing opioids, respondents noted diagnosis, morphine milligram equivalent, prior treatments, past medical history, drug monitoring program verification, and previous treatment trials with opioids. Comfort with dispensing opioids decreased over a 12-month period among pharmacists surveyed. Improved communication between prescriber and pharmacist, as well as enhanced access to patient health information, is critical to reduce barriers to care for patients.

Comparison of Current Post-Graduate Pain Management and Palliative Care Pharmacy Residency Programs.

Post-graduate pharmacy residency training in pain management and palliative care is continuing to increase in availability. It is expected that there will be further expansion in the need for specialty trained pain and palliative care pharmacists as the population continues to age and prevalence of pain increases; however, descriptions of current post-graduate year 2 pain management and palliative care residencies are limited. The purpose of this survey is to collect program information and compare baseline characteristics of the currently available programs. Data collected included funding source, required and elective experiences, residency program director training, jobs held by residents upon completion of the program, and preceptor availability/training. Of the 15 respondents, baseline characteristics were variable. Outpatient chronic pain management was the most commonly selected required experience. Approximately 33% of residency program directors had completed a post-graduate year two residency in pain management and palliative care, and the majority of responding programs were funded by the Department of Veterans Affairs. The characteristics of responding programs illustrates the diversity of current post-graduate pain management and palliative care residency opportunities. The results of this survey help evaluate these opportunities and will provide valuable information as this specialty continues to progress.

Development of Entrustable Professional Activities for Specialist Hospice and Palliative Care Pharmacists.

CONTEXT: Entrustable professional activities (EPAs) translate competencies into explicit, practical terms that clearly state the expected roles and responsibilities of clinicians who have achieved proficiency and expertise in a field. EPAs are defined for Hospice and Palliative Medicine physicians but not for other members of Hospice and Palliative Care (HAPC) interprofessional teams, including pharmacists. OBJECTIVES: The objective of this study was to develop EPAs for HAPC pharmacists. METHODS: An 11-member workgroup of HAPC pharmacists was convened to develop candidate EPAs using nominal group and modified-Delphi methods. Content validity index was used as a measure of consensus, defined a priori at ≥ 60%. Vetting occurred via intra- and interprofessional stakeholder reactor groups and a national survey of HAPC pharmacists. RESULTS: Following an iterative process of workgroup and stakeholder consensus-building, 15 HAPC pharmacist EPAs were developed. Among the workgroup, all 15 EPAs reached ≥ 70% consensus, indicating appropriate internal validity. In a national survey of 185 HAPC pharmacists with a 20% response rate, 13 EPAs were rated by most respondents as "essential" and 2 were rated by most respondents as "important but not essential." Respondents indicated the 15 EPA set represented the core professional activities of HAPC pharmacists well (median rating of 5 on a Likert-like scale, IQR 1). CONCLUSION: Fifteen consensus EPAs describe essential activities of HAPC pharmacists in direct patient care, leadership, education, and scholarship. These EPAs will further guide pharmacist training programs, HAPC services seeking to incorporate a specialized pharmacist on the team, and currently practicing HAPC pharmacists.

Multicentered Evaluation of Palliative Care Pharmacists' Interventions and Outcomes in California.

Introduction: The palliative care (PC) pharmacist's role within PC teams is increasingly recognized with favorable outcomes being reported. Methods: Retrospective study evaluated hospitalized adults seen by PC pharmacists, as part of PC consultation team at three California institutions. The primary objective was to categorize pharmacists' interventions. Secondary end points included length from admission to PC pharmacist involvement and symptom improvement following pharmacist intervention. Results: Data were collected for a total of 557 patients. Over the study period, the PC pharmacists provided 1466 medication recommendations and 2545 nonsymptom-based interventions. Average length of stay (LOS) was 15.6 days with mean time to PC service referral of 3.6 days. PC pharmacist consult occurred after a mean of 4.3 days after PC team consulted. LOS was significantly lower if seen by PC pharmacist within 72 hours of PC consultation, 12.3 days versus 24.5 days (p < 0.001), as well as when serving as lead clinician 9.3 days versus 15.5 days (p < 0.001). Achievement of severity goal was significantly higher at 24 and 72 hours assessment periods when received a medication recommendation for pain, dyspnea, anxiety, and constipation. Conclusion: PC pharmacists provide substantial transdisciplinary interventions. Significantly decreased LOS was found when PC pharmacist was involved within 72 hours of initial PC consultation and when served as lead clinician. Improved symptom goal attainment was demonstrated for pain, dyspnea, anxiety, and constipation. In summary, integration of a PC pharmacist on a PC team can be relied upon to provide patient-centered, transdisciplinary care and enhance symptom management.

Patterns of heroin use following index prescription opioid exposure.

OBJECTIVE: This study examined the means of obtainment, indication, and prescriber of an index opioid in self-reporting heroin users. DESIGN: Cross-sectional, observational study. SETTING: A survey was submitted by participants in the United States with current or past heroin use. PARTICIPANTS: Three hundred twenty-three participants greater than 18 years of age completed the survey. MAIN OUTCOME MEASURE: Participants were surveyed regarding prescription opioid use prior to heroin initiation and spe-cifically how they were obtained. Surveys were comprehensive in nature, divulging information including which opioid(s) was/were used, how they were obtained, by which prescriber (if prescribed), and if there was a diagnosis for chronic pain. RESULTS: Roughly 47 percent of participants reported using prescription opioids prior to heroin. The most commonly used prescription opioid prior to heroin initiation was oxycodone (92.5 percent). The most common acquisition of opioids was through the prescribing of a physician, which occurred in roughly 63 percent of cases. These prescriptions were obtained most often from primary care physicians and emergency departments. Only 34 percent of participants reported being diagnosed with a chronic pain condition prior to using heroin. CONCLUSIONS: This study further supports the role that prescription opioids play in the transition to heroin use. It suggests that oxycodone is the most common prescription opioid used prior to heroin initiation. Additionally, it reports descriptive information as to how and where prescription opioids are obtained.

Interstitial Cystitis: An Update on the Disease Process and Treatment.

Interstitial cystitis (IC) is a chronic pain disorder of the bladder that is often underdiagnosed and mistreated. The difficulties in diagnosis stem from numerous theories regarding pathophysiology and etiology, including the breakdown of the glycosaminoglycan (GAG) layer, altered permeability of the urothelium, uroinflammation, and neural up-regulation. Dysfunction of the bladder increases the struggle for proper treatment and continues to prove difficult for health care providers to correctly diagnose and manage IC. If diagnosed and/or managed inappropriately, IC may contribute to increased symptom burden and decreased quality of life with respect to activities of daily living. When evaluating a patient's clinical presentation in combination with predefined risk factors, a health care provider can better establish a true diagnosis of IC, which, in turn, leads to better management of IC-associated symptoms. This review will help health care providers better understand the disease process by discussing pathophysiology, pain pathways, and common symptoms of IC, with the goal of better aiding them in the proper diagnosis and treatment of patients with IC.

Ten Tips Palliative Care Pharmacists Want the Palliative Care Team to Know When Caring for Patients.

As palliative care (PC) moves upstream in the course of serious illness and the development of drugs and their indications rapidly expand, PC providers must understand common drug indications and adverse effects to ensure safe and effective prescribing. Pharmacists, experts in the nuances of medication management, are valuable resources and colleagues for PC providers. This article will offer PC providers 10 useful clinical pharmacy tips that PC pharmacists think all PC providers should know for safe and effective symptom management. Close collaboration with or addition of a trained pharmacist to your PC team can improve clinical care for all PC patients.

Multicentered Study Evaluating Pharmacy Students' Perception of Palliative Care and Clinical Reasoning Using Script Concordance Testing.

INTRODUCTION: As the role of the pharmacist on the transdisciplinary palliative care team grows, the need for adequate instruction on palliative care and clinical reasoning skills in schools of pharmacy grows accordingly. METHODS: This study evaluates second- and third-year pharmacy students from 6 accredited schools of pharmacy that participated in surveys before and after the delivery of a didactic palliative care elective. The survey collected student demographics, perceptions of the importance of and student skill level in palliative care topics. The script concordance test (SCT) was used to assess clinical decision-making skills on patient cases. Student scores on the SCT were compared to those of a reference panel of experts. RESULTS: A total of 89 students completed the pre-/postsurveys and were included in data analysis. There was no statistically significant difference in student perceived importance of palliative care skills before and after the elective. Students from all 6 institutions showed significant increase in confidence in their palliative care skills at the end of the course. There was also a significant improvement across all institutions in clinical reasoning skills in most of the SCT questions used to assess these skills. CONCLUSIONS: Students choosing an elective in palliative care likely do so because they already have an understanding of the importance of these topics in their future practice settings. Delivery of a palliative care elective in the pharmacy curriculum significantly increases both student confidence in their palliative care skills and their clinical reasoning skills in these areas.

Elevated Transaminases with Topical Diclofenac: A Case Report.

Drug-induced liver injury (DILI) has been described with numerous nonsteroidal anti-inflammatory drugs (NSAIDs). Oral diclofenac has been associated with DILI more frequently than other NSAIDs and requires periodic monitoring of liver transaminases and judicious consideration of clinical signs and symptoms of hepatotoxicity. Here we describe a case in which elevated liver transaminases in a 79-year-old female returned to normal following discontinuation of topical diclofenac 1% gel. Using a widely accepted drug reaction causality instrument, a rating of "definite" was assigned given the temporal sequence of drug exposure and transaminase changes. Further study is warranted to better guide prescribing of topical NSAIDs.

Chronic Orofacial Pain: Burning Mouth Syndrome and Other Neuropathic Disorders.

Chronic orofacial pain is a symptom associated with a wide range of neuropathic, neurovascular, idiopathic, and myofascial conditions that affect a significant proportion of the population. While the collective impact of the subset of the orofacial pain disorders involving neurogenic and idiopathic mechanisms is substantial, some of these are relatively uncommon. Hence, patients with these disorders can be vulnerable to misdiagnosis, sometimes for years, increasing the symptom burden and delaying effective treatment. This manuscript first reviews the decision tree to be followed in diagnosing any neuropathic pain condition, as well as the levels of evidence needed to make a diagnosis with each of several levels of confidence: definite, probable, or possible. It then examines the clinical literature related to the idiopathic and neurogenic conditions that can occasion chronic orofacial pain, including burning mouth syndrome, trigeminal neuralgia, glossopharyngeal neuralgia, post-herpetic neuralgia, and atypical odontalgia. Temporomandibular disorders also are examined as are other headache conditions, even though they are not neurologic conditions, because they are common and can mimic symptoms of the latter disorders. For each of these conditions, the paper reviews literature regarding incidence and prevalence, physiologic and other contributing factors, diagnostic signs and symptoms, and empirical evidence regarding treatments. Finally, in order to improve the quality and accuracy of clinical diagnosis, as well as the efficiency with which effective treatment is initiated and delivered, criteria are offered that can be instrumental in making a differential diagnosis.

An Educational Intervention to Decrease Drug Costs Related to Terminal Secretions in a Hospice Organization.

Terminal secretions is a common symptom seen in hospice patients. Antimuscarinic drugs are commonly used to treat this symptom despite a lack of supporting data. Wide variability in cost exists among these treatments. Hospice program data were assessed to identify high-use and high-cost medications. An educational intervention (EI) was developed to target one such medication, transdermal scopolamine. The EI focused on efficacy, safety, and actual cost (by unit and total expenditure) for each possible treatment of terminal secretions. Following the EI, drug utilization data was re-evaluated. Prior to the deployment of the EI, total monthly hospice drug costs averaged $91,405 (SD 1,444) with an average drug cost per patient per day of $11.42 (SD 0.54). Monthly costs of drugs frequently employed to treat terminal secretions averaged $7,187.67 (SD 2,253) pre-intervention. Following the EI, monthly drug costs decreased 22.5%, average daily patient drug costs decreased 11.1%, and total anti-secretion costs decreased 28.5% after adjusting for difference in census. Education regarding the use and cost of medications to treat symptoms at end-of-life in hospice patients can be an intervention used to lead to significant cost savings to hospice organizations while maintaining appropriate symptom management for patients. Future interventions to target additional high-cost medications are warranted.

A Survey of Hospice Volunteer Coordinators: Training Methods and Objectives of Current Hospice Volunteer Training Programs.

INTRODUCTION: Currently more than 5800 hospice organizations operate in the United States.1 Hospice organizations are required by the Centers for Medicare and Medicaid Services (CMS) to use volunteers for services provided to patients.2 Although CMS regulates the amount of hours hospice volunteers should provide, there are currently no national requirements for objectives of training.3 The purpose of this study was to gather information from a sample of hospices regarding volunteer coordinator background, current training for volunteers, importance of training objectives, and any comments regarding additional objectives. METHODS: Representative state hospice organizations were contacted by e-mail requesting their participation and distribution of the survey throughout their member hospices. The survey asked demographical questions, along with ratings of training components based on perceived level of importance and time spent on each objective. RESULTS: A total of 90 surveys were received, and the response rate was undeterminable. Results showed the majority of hospices were nonprofit, had less than 100 currently trained volunteers, and maintained an average daily patient census of less than 50. Questions regarding training programs indicated that most use live lecture methods of approximately 19 hours or less in duration. Overall, responding hospice organizations agreed that all objectives surveyed were important in training volunteers. CONCLUSION: The small number of respondents to this survey makes generalization nationwide difficult, however it is a strong starting point for the development of further surveys on hospice volunteer training and achieving a standardized set of training objectives and delivery methods.

Differences in the Association between Depression and Opioid Misuse in Chronic Low Back Pain versus Chronic Pain at Other Locations.

Patients with chronic pain and depression are more likely to develop opioid abuse compared to patients without depression. It is not known if this association differs by pain location. We compared the strength of association between depression and opioid misuse in patients with chronic low back pain (CLBP) vs. chronic pain of other location (CPOL). Chart abstracted data was obtained from 166 patients seeking care in a family medicine clinic. Depression was measured by the PHQ-9 and opioid misuse was measured using the Current Opioid Misuse Measure. Pain severity and interference questions came from the Brief Pain Inventory. Cross-tabulations were computed to measure the association between depression and opioid misuse stratified on pain location. Exploratory logistic regression modeled the association between depression and opioid misuse after adjusting for pain location and pain severity and interference. Depression was significantly associated with opioid misuse in CPOL but not in CLBP. Regression results indicate pain interference partly accounts for the depression-opioid misuse association. These preliminary results from a small patient sample suggest depression may co-occur with opioid misuse more often in CPOL than in CLBP. Further research is needed to compare this comorbidity in specific pain diagnoses such as arthritis, fibromyalgia and CLBP.

Common questions about chronic low back pain.

More than 30% of U.S. adults report having experienced low back pain within the preceding three months. Although most low back pain is nonspecific and self-limiting, a subset of patients develop chronic low back pain, defined as persistent symptoms for longer than three months. Low back pain is categorized as nonspecific low back pain without radiculopathy, low back pain with radicular symptoms, or secondary low back pain with a spinal cause. Imaging should be reserved for patients with red flags for cauda equina syndrome, recent trauma, risk of infection, or when warranted before treatment (e.g., surgical, interventional). Prompt recognition of cauda equina syndrome is critical. Patient education should be combined with evidence-guided pharmacologic therapy. Goals of therapy include reducing the severity of pain symptoms, pain interference, and disability, as well as maximizing activity. Validated tools such as the Oswestry Disability Index can help assess symptom severity and functional change in patients with chronic low back pain. Epidural steroid injections do not improve pain or disability in patients with spinal stenosis. Spinal manipulation therapy produces small benefits for up to six months. Because long-term data are lacking for spinal surgery, patient education about realistic outcome expectations is essential.

Patient aberrant drug taking behaviors in a large family medicine residency program: a retrospective chart review of screening practices, incidence, and predictors.

INTRODUCTION: Potentially aberrant drug-taking behaviors (pADTB) are described as any departure from strict adherence to prescribed use of medications for their intended indication. There are several validated instruments, processes, and databases available to assist the clinician in screening and stratifying risk for patients in which controlled substances are being prescribed or considered. Actual utilization of these tools in nonspecialist healthcare settings is largely unknown. The primary objective of this retrospective chart review was to describe utilization patterns of these common tools within a 56 physician family medicine training program. Secondary objectives included identification of site-specific predictors of pADTB and correlation of prescribing patterns with documented aberrant behaviors. METHODS: A total of 202 chronic pain patients were identified for inclusion based on prior 12-month prescription and refill records within the electronic health record (EHR) from March 2008 through March 2009. Each patient included had at least one opioid for 30 days within the study period and had chronic pain symptoms for at least 90 days. Each chart was reviewed for predefined pADTB, controlled substance refill request, prescription drug monitoring profile, and post hoc investigator completion of the Opioid Risk Tool Clinician Form. Descriptive statistics and regression analysis was used to report results. RESULTS: Clinician documentation of risk-screening tool use of any type was limited to one patient of the 202 records reviewed. Within this sample, 203 unique pADTB were documented in the EHR records of 89 (44.1 percent) patients. Patients prescribed morphine or tramadol appeared to exhibit less use of multiple prescribers and multiple pharmacies while an association between this behavior and two or more concurrent opioid prescriptions became apparent. Those taking fentanyl or morphine exhibited unsanctioned dose escalations more frequently. CONCLUSIONS: These results suggest that routine evaluation of risk for abuse or misuse of opioid analgesics occurs infrequently in a large family medicine training program. pADTB exhibited by patients using opioids for chronic pain syndromes in this sample were consistent with those reported in other similar settings. Policies and procedures in primary care settings for improved risk evaluation and ongoing monitoring of chronic opioid therapy is needed.