In long-term, higher-dose opioid use, dose tapering was linked to overdose and mental health crises.

SOURCE CITATION: Agnoli A, Xing G, Tancredi DJ, et al. Association of dose tapering with overdose or mental health crisis among patients prescribed long-term opioids. JAMA. 2021;326:411-9. 34342618.

In fibromyalgia, some therapies may provide small improvements in pain and quality of life.

SOURCE CITATION: Mascarenhas RO, Souza MB, Oliveira MX, et al. Association of therapies with reduced pain and improved quality of life in patients with fibromyalgia: a systematic review and meta-analysis. JAMA Intern Med. 2021;181:104-12. 33104162.

PEER simplified chronic pain guideline: Management of chronic low back, osteoarthritic, and neuropathic pain in primary care.

OBJECTIVE: To develop a clinical practice guideline to support the management of chronic pain, including low back, osteoarthritic, and neuropathic pain in primary care. METHODS: The guideline was developed with an emphasis on best available evidence and shared decision-making principles. Ten health professionals (4 generalist family physicians, 1 pain management-focused family physician, 1 anesthesiologist, 1 physical therapist, 1 pharmacist, 1 nurse practitioner, and 1 psychologist), a patient representative, and a nonvoting pharmacist and guideline methodologist comprised the Guideline Committee. Member selection was based on profession, practice setting, and lack of financial conflicts of interest. The guideline process was iterative in identification of key questions, evidence review, and development of guideline recommendations. Three systematic reviews, including a total of 285 randomized controlled trials, were completed. Randomized controlled trials were included only if they reported a responder analysis (eg, how many patients achieved a 30% or greater reduction in pain). The committee directed an Evidence Team (composed of evidence experts) to address an additional 11 complementary questions. Key recommendations were derived through committee consensus. The guideline and shared decision-making tools underwent extensive review by clinicians and patients before publication. RECOMMENDATIONS: Physical activity is recommended as the foundation for managing osteoarthritis and chronic low back pain; evidence of benefit is unclear for neuropathic pain. Cognitive-behavioural therapy or mindfulness-based stress reduction are also suggested as options for managing chronic pain. Treatments for which there is clear, unclear, or no benefit are outlined for each condition. Treatments for which harms likely outweigh benefits for all or most conditions studied include opioids and cannabinoids. CONCLUSION: This guideline for the management of chronic pain, including osteoarthritis, low back pain, and neuropathic pain, highlights best available evidence including both benefits and harms for a number of treatment interventions. A strong recommendation for exercise as the primary treatment for chronic osteoarthritic and low back pain is made based on demonstrated long-term evidence of benefit. This information is intended to assist with, not dictate, shared decision making with patients.

Health Care Provider Utilization of Prescription Monitoring Programs: A Systematic Review and Meta-Analysis.

OBJECTIVE: To synthesize the literature on the proportion of health care providers who access and use prescription monitoring program data in their practice, as well as associated barriers to the use of such data. DESIGN: We performed a systematic review using a standard systematic review method with meta-analysis and qualitative meta-summary. We included full-published peer-reviewed reports of study data, as well as theses and dissertations. METHODS: We identified relevant quantitative and qualitative studies. We synthesized outcomes related to prescription monitoring program data use (i.e., ever used, frequency of use). We pooled the proportion of health care providers who had ever used prescription monitoring program data by using random effects models, and we used meta-summary methodology to identify prescription monitoring program use barriers. RESULTS: Fifty-three studies were included in our review, all from the United States. Of these, 46 reported on prescription monitoring program use and 32 reported on barriers. The pooled proportion of health care providers who had ever used prescription monitoring program data was 0.57 (95% confidence interval: 0.48-0.66). Common barriers to prescription monitoring program data use included time constraints and administrative burdens, low perceived value of prescription monitoring program data, and problems with prescription monitoring program system usability. CONCLUSIONS: Our study found that health care providers underutilize prescription monitoring program data and that many barriers exist to prescription monitoring program data use.

Identifying appropriate outcomes to help evaluate the impact of the Canadian Guideline for Safe and Effective Use of Opioids for Non-Cancer Pain.

BACKGROUND: The Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain (COG) was developed in response to increasing rates of opioid-related hospital visits and deaths in Canada, and uncertain benefits of opioids for chronic non-cancer pain (CNCP). Following publication, we developed a list of evaluable outcomes to assess the impact of this guideline on practice and patient outcomes. METHODS: A working group at the National Pain Centre at McMaster University used a modified Delphi process to construct a list of clinical and patient outcomes important in assessing the uptake and application of the COG. An advisory group then reviewed this list to determine the relevance and feasibility of each outcome, and identified potential data sources. This feedback was reviewed by the National Faculty for the Guideline, and a National Advisory Group that included the creators of the COG, resulting in the final list of 5 priority outcomes. RESULTS: Five outcomes were judged clinically important and feasible to measure: 1) Effects of opioids for CNCP on quality of life, 2) Assessment of patient's risk of addiction before starting opioid therapy, 3) Monitoring patients on opioid therapy for aberrant drug-related behaviour, 4) Mortality rates associated with prescription opioid overdose and 5) Use of treatment agreements with patients before initiating opioid therapy for CNCP. Data sources for these outcomes included patient's medical charts, e-Opioid Manager, prescription monitoring programs and administrative databases. CONCLUSION: Measuring the impact of best practice guidelines is infrequently done. Future research should consider capturing the five outcomes identified in this study to evaluate the impact of the COG in promoting evidence-based use of opioids for CNCP.

Perioperative Pain and Addiction Interdisciplinary Network (PAIN) clinical practice advisory for perioperative management of buprenorphine: results of a modified Delphi process.

Until recently, the belief that adequate pain management was not achievable while patients remained on buprenorphine was the impetus for the perioperative discontinuation of buprenorphine. We aimed to use an expert consensus Delphi-based survey technique to 1) specify the need for perioperative guidelines in this context and 2) offer a set of recommendations for the perioperative management of these patients. The major recommendation of this practice advisory is to continue buprenorphine therapy in the perioperative period. It is rarely appropriate to reduce the buprenorphine dose irrespective of indication or formulation. If analgesia is inadequate after optimisation of adjunct analgesic therapies, we recommend initiating a full mu agonist while continuing buprenorphine at some dose. The panel believes that before operation, physicians must distinguish between buprenorphine use for chronic pain (weaning/conversion from long-term high-dose opioids) and opioid use disorder (OUD) as the primary indication for buprenorphine therapy. Patients should ideally be discharged on buprenorphine, although not necessarily at their preoperative dose. Depending on analgesic requirements, they may be discharged on a full mu agonist. Overall, long-term buprenorphine treatment retention and harm reduction must be considered during the perioperative period when OUD is a primary diagnosis. The authors recognise that inter-patient variability will require some individualisation of clinical practice advisories. Clinical practice advisories are largely based on lower classes of evidence (level 4, level 5). Further research is required in order to implement meaningful changes in practitioner behaviour for this patient group.

Lignes directrices simplifiées de PEER sur la douleur chronique: Gestion de la douleur chronique lombaire, arthrosique et neuropathique en première ligne.

OBJECTIF: Formuler des lignes directrices de pratique clinique pour soutenir la prise en charge de la douleur chronique, y compris la douleur lombaire, arthrosique et neuropathique, dans les soins primaires. MÉTHODES: Ces lignes directrices ont été élaborées en mettant l'accent sur les meilleures données probantes disponibles et sur les principes de décision partagée. Dix professionnels de la santé (4 omnipraticiens, 1 médecin de famille spécialisée en gestion de la douleur, 1 anesthésiste, 1 physiothérapeute, 1 pharmacienne, 1 infirmière praticienne et 1 psychologue), 1 représentant des patients, et 1 pharmacienne et spécialiste de la méthodologie des lignes directrices sans droit de vote composaient le comité des lignes directrices. Les membres ont été sélectionnés en fonction de leur profession, de leur milieu de pratique, et de l'absence d'un conflit d'intérêts de nature financière. Les lignes directrices sont le fruit d'un processus itératif incluant la détermination des questions clés, l'examen des données probantes et la formulation des recommandations des lignes directrices. Trois revues systématiques, totalisant 285 études avec répartition aléatoire et contrôlées ont été réalisées. Ces études n'étaient incluses que si elles avaient rapporté une analyse des répondants (p. ex. combien de patients ont obtenu un soulagement d'au moins 30% de la douleur). Le comité a confié à une équipe d'examen des données (composée de spécialistes des données probantes) la tâche de répondre à 11 autres questions complémentaires. Les principales recommandations découlent d'un consensus au sein du comité. Des cliniciens et des patients ont minutieusement examiné les lignes directrices et les outils de décision partagée avant leur publication. RECOMMANDATIONS: L'activité physique est recommandée comme fondement de la gestion de la douleur arthrosique et lombaire chronique; les données probantes étayant un bienfait ne sont pas concluantes dans le cas de la douleur neuropathique. La thérapie cognitivo-comportementale ou la réduction du stress basée sur la pleine conscience sont également suggérées comme des options pour gérer la douleur chronique. Les traitements pour lesquels le bienfait est clair, non concluant ou absent sont décrits sous chaque affection. Les traitements dont les préjudices surpassent probablement les bienfaits pour toutes les affections étudiées, ou la plupart d'entre elles, sont les opioïdes et les cannabinoïdes. CONCLUSION: Ces lignes directrices sur la gestion de la douleur chronique, y compris la douleur arthrosique, lombaire et neuropathique, met en lumière les meilleures données probantes disponibles, y compris les bienfaits et préjudices pour un certain nombre d'interventions thérapeutiques. Une forte recommandation en faveur de l'exercice comme principal traitement de la douleur arthrosique et lombaire chronique repose sur des données probantes ayant démontré un bienfait depuis longtemps. Cette information vise à contribuer au processus de décision partagée avec le patient et non à le dicter.

Best practice interprofessional stroke care collaboration and simulation: The student perspective.

Interprofessional practice (IPP) is the accepted standard of care for clients following a stroke. A brief, embedded and evidence-based IPP team simulation was designed to address stroke care knowledge and IPP competencies for students within limited curriculum space. Each team was required to construct a collaborative care plan for their patient during the simulation and submit the care plan for evaluation of best practice stroke care knowledge and implementation with evidence of interprofessional collaboration (IPC). A total of 302 students (274 on-site, 28 by distance technology) representing four professions comprised of 55 teams took part in this experience. Post-simulation, voluntary and anonymous programme evaluations were completed using the standardised interprofessional collaborative competency assessment scale (ICCAS) and open-ended free-text responses to five questions. There was a significant improvement for all pre-post ratings on the ICCAS regardless of profession or previous interprofessional experience. Additionally, the open-ended responses indicated perceived changes to role clarification, communication, and teamwork. The combined interpretation of the programme evaluation results supports interprofessional team simulation as an effective and efficient learning experience for students regardless of previous interprofessional experience, and demonstrated positive changes in stroke best-practice knowledge and IPC competencies.

Abuse of family physicians by patients seeking controlled substances.

OBJECTIVE: To examine family physicians' career prevalence and monthly incidence of workplace abuse by controlled substance prescription seekers. DESIGN: A 4-page cross-sectional survey. SETTING: A family medicine continuing medical education event in Halifax, NS. PARTICIPANTS: The survey was distributed to 316 family physicians attending the continuing medical education event. MAIN OUTCOME MEASURES: Career prevalence and monthly incidence of workplace abuse related to the act of prescribing controlled substances. RESULTS: Fifty-six percent (n = 178) of the 316 surveys were returned completed. Half the study participants were men (49%). Most study participants were in private practice and lived in Nova Scotia, and approximately half (51%) practised in urban settings. On average, the study participants had 20 years of practice experience. The career prevalence of abusive encounters related to controlled substance prescribing was divided into "minor," "major," and "severe" incidents. Overall, 95% of study participants reported having experienced at least 1 incident of minor abuse; 48% had experienced at least 1 incident of major abuse; and 17% had experienced at least 1 incident of severe abuse during their careers. Further, 30% reported having been abused in the past month; among those, the average number of abusive encounters was 3. Most (82%) of the abusers were male with a history of addiction (85%) and mental illness (39%). Opioids were the most frequently sought controlled substance. CONCLUSION: Abuse of family physicians by patients seeking controlled substances is substantial. Family physicians who prescribe controlled substances are at risk of being subjected to minor, major, or even severe abuse. Opioids were the most often sought controlled substance. A national discussion to deal with this issue is needed.

Self-Reported Practices in Opioid Management of Chronic Noncancer Pain: An Updated Survey of Canadian Family Physicians.

Chronic pain affects one in five Canadians, and opioids continue to be prescribed to 12.3% of the Canadian population. A survey of family physicians was conducted in 2010 as a baseline prior to the release of the Canadian Opioid Guideline. We repeated the same survey with minor modifications to reflect the updated 2017 opioid prescribing guideline. The online survey was distributed in all provinces and territories in both English and French. There were 265 responses from May 2018 to October 2019, 55% of respondents were male, 16% had advanced training in pain management, 51% had more than 20 years in practice, 54% wrote five or fewer prescriptions of opioids per month, and 58% were confident in their skills in prescribing opioids. Of the 11 knowledge questions, only two were correctly selected by more than 80% of the respondents. Twenty-nine physicians (11%) do not prescribe opioids, and the main factor affecting their decisions were concerns about long-term adverse effects and lack of evidence for effectiveness of opioids in chronic noncancer pain. Of the 12 guideline-concordant practices, only two were performed regularly by 90% or more of the respondents: explain potential harms of long-term opioid therapy and beginning dose of less than 50 mg of morphine equivalent daily. This survey represents a small proportion of family physicians in Canada and its generalizability is limited. However, we identified a number of opioid-related and guideline-specific gaps, as well as barriers and enablers to prescribing opioids and adhering to the guideline.

Overview of four prescription monitoring/review programs in Canada.

BACKGROUND: Prescription monitoring or review programs collect information about prescription and dispensing of controlled substances for the purposes of monitoring, analysis and education. In Canada, it is the responsibility of the provincial institutions to organize, maintain and run such programs. OBJECTIVE: To describe the characteristics of four provincial programs that have been in place for >6 years. METHODS: The managers of the prescription monitoring/review programs of four provinces (British Columbia, Alberta, Saskatchewan and Nova Scotia) were invited to present at a symposium at the Canadian Pain Society in May 2012. In preparation for the symposium, one author collected and summarized the information. RESULTS: Three provinces have a mix of review and monitoring programs; the program in British Columbia is purely for review and education. All programs include controlled substances (narcotics, barbiturates and psychostimulants); however, other substances are differentially included among the programs: anabolic steroids are included in Saskatchewan and Nova Scotia; and cannabinoids are included in British Columbia and Nova Scotia. Access to the database is available to pharmacists in all provinces. Physicians need consent from patients in British Columbia, and only professionals registered with the program can access the database in Alberta. The definition of inappropriate prescribing and dispensing is not uniform. Double doctoring, double pharmacy and high-volume dispensing are considered to be red flags in all programs. CONCLUSIONS: There is variability among Canadian provinces in managing prescription monitoring/review programs.

Self-reported practices in opioid management of chronic noncancer pain: a survey of Canadian family physicians.

BACKGROUND: In May 2010, a new Canadian guideline on prescribing opioids for chronic noncancer pain (CNCP) was released. To assess changes in family physicians' (FPs) prescribing of opioids following the release of the guideline, it is necessary to know their practices before the guideline was widely disseminated. OBJECTIVES: To determine FPs' practices and knowledge in prescribing opioids for CNCP in relation to the Canadian guideline, and to determine factors that hinder or enable FPs in prescribing opioids for CNCP. METHODS: An online survey was developed and FPs who manage CNCP were electronically contacted through the College of Family Physicians of Canada, university continuing medical education offices and provincial regulatory colleges. RESULTS: A total of 710 responses were received. FPs followed a precautionary approach to prescribing opioids and already practiced in accordance with Canadian guideline recommendations by discussing adverse effects, monitoring for aberrant drug-related behaviour and advising caution when driving. However, FPs seldom discontinued opioids even if they were ineffective and were unaware of the 'watchful dose' of opioids, the daily dose at which patients may need reassessment or closer monitoring. Only two of nine knowledge questions were answered correctly by more than 40% of FPs. The main enabler to optimal opioid prescribing was having access to a patient's opioid history from a provincial prescription monitoring program. The main barriers to optimal prescribing were concerns about addiction and misuse. CONCLUSIONS: While FPs follow a precautionary approach to prescribing opioids for CNCP, there are substantial practice and knowledge gaps, with implications for patient safety and costs.

Pulmonary complications after major head and neck surgery: A retrospective cohort study.

OBJECTIVES/HYPOTHESIS: Postoperative pulmonary complications (PPCs) following head and neck surgery are common. Patients undergoing tracheostomy, free tissue transfer reconstruction, and postoperative ventilation in an intensive care unit (ICU) have a high incidence of PPCs. We sought to define the incidence of PPCs in this cohort and to determine what factors PPCs correlate with. STUDY DESIGN: Retrospective cohort study. METHODS: Following institutional research ethics board approval, a retrospective review of patients undergoing major head and neck surgery at a Canadian tertiary care center was conducted. The development of PPCs was the outcome of interest. Quality assurance parameters including ICU and hospital lengths of stay, and mortality were also recorded. RESULTS: There were 105 patients enrolled, of which 47 (44.8%) sustained one or more PPCs. The most frequent PPC was respiratory failure, accounting for 39 of 94 PPCs observed. Hypertension was the only comorbidity that correlated with development of a PPC (P = .031). Those who sustained PPCs were older than those who did not (median age, 65.6 vs. 58.7 years; P = .005). Development of PPCs correlated with longer ICU and hospital stays. There was increased mortality among patients with PPCs compared to those without (12.8% vs. 1.7%, P = .04). CONCLUSIONS: Patients undergoing major head and neck surgery are at high risk of PPCs. Advanced age and hypertension significantly correlated with PPCs. PPCs correlate with prolonged ICU and hospital stays, and increased mortality. Further research is needed to define risk factors, useful investigations, and effective optimization strategies to mitigate PPCs.

Review of thromboprophylaxis in otolaryngology-head and neck surgery.

UNLABELLED: RESEARCH TYPE: Translational. OBJECTIVE: To review and tabulate the incidence of thromboembolic complications following head and neck surgery. STUDY DESIGN: Review. METHODS: Articles were identified using the MEDLINE database search engine. The relevant articles were reviewed and any thromboembolic complications were tabulated. RESULTS: Six articles, published between 1976 and 2007, were identified that reported on thromboembolic complications following head and neck surgery. Of these articles, four were retrospective reviews and two were prospective. Four of the studies looked at various methods of routine prophylaxis, which included several combinations of low-dose heparin, low-molecular-weight heparin, graduated compression stockings, and intermittent pneumatic compression devices. Two studies were simply investigating complications in general following head and neck surgery. CONCLUSIONS: Head and neck cancer patients are likely at higher risk than commonly thought, and venous thromboembolism is likely much more common that what is clinically evident. It is important to develop an institutional system of risk stratification to correspond to standardizations of thromboprophylaxis that are generally accepted. Although many institutions are already attempting to do so, such as we have outlined above by extrapolating from other surgical departments, it is important to show these relationships with head and neck patients specifically to justify the high cost of these various therapies.

Postthoracotomy shoulder pain: diagnosis and management.

PURPOSE OF REVIEW: The review will discuss postthoracotomy/scopy ipsilateral shoulder pain, a common, intense and distressing outcome of chest surgery. This review will highlight some of the diagnostic vagaries in the current literature and present an argument for the etiology of this pain. In addition, perioperative management will be discussed. Evidence will be presented that effective prevention and treatment is possible for this pain entity. A multimodal management strategy for prevention and treatment of postthoracotomy/scopy ipsilateral shoulder pain is proposed. Finally, this review will highlight potential areas for investigation. RECENT FINDINGS: Studies of postthoracotomy/scopy ipsilateral shoulder pain are few and the etiology of the pain is not clearly understood. Recent randomized studies of treatments for this pain entity have implicated the phrenic nerve in the genesis of this pain syndrome. Prospective studies of the natural history of this pain syndrome have also highlighted other sources of the pain. SUMMARY: A picture is emerging of a pain syndrome that may be intense but is relatively limited in duration. The effect of this pain on overall perioperative morbidity is not known. Potential areas for investigation including studies to determine risk factors for postthoracotomy/scopy ISP are discussed.

Postoperative tracheal rupture in a patient with a difficult airway.

PURPOSE: Tracheal rupture is an uncommon and potentially life-threatening event. This report presents a case of postoperative tracheal rupture in a patient with a known difficult airway presenting to a rural hospital. CLINICAL FEATURES: A 29-yr-old man presented to a rural hospital with sudden onset neck pain and progressive dyspnea. Five days earlier the patient had undergone tracheal resection for tracheal stenosis related to prolonged intubation. The patient informed the emergency room staff that the attending anesthesiologist had made note of a "difficult airway". The community hospital had neither a portable storage unit for difficult airway management nor a bronchoscope available. In the presence of a general surgeon, an initial attempt at an awake intubation was unsuccessful. During this time the patient developed massive subcutaneous emphysema obliterating surgical landmarks and causing stridor. A modified rapid sequence intubation was performed. Intubation was successful using a Jackson-Wisconsin #3 straight blade and styletted endotracheal tube. The patient was transferred to a tertiary care centre where he underwent a primary repair of the trachea. CONCLUSION: Management of tracheal rupture in the patient with a difficult airway is a challenging problem, especially, in a rural hospital. This case highlights the need for skilled staff and resources to manage a difficult airway in the emergency room.