Opioid prescribing and social deprivation: A retrospective analysis of prescribing for CNCP in Liverpool CCG.

BACKGROUND: Treating Chronic Non-Cancer Pain (CNCP) with long-term, high dose and more potent opioids puts patients at increased risk of harm, whilst providing limited pain relief. Socially deprived areas mapped from Index of Multiple Deprivation (IMD) scores show higher rates of high dose, strong opioid prescribing compared to more affluent areas. OBJECTIVE: To explore if opioid prescribing is higher in more deprived areas of Liverpool (UK) and assess the incidence of high dose prescribing to improve clinical pathways for opioid weaning. DESIGN AND SETTING: This retrospective observational study used primary care practice and patient level opioid prescribing data for N = 30,474 CNCP patients across Liverpool Clinical Commissioning Group (LCCG) between August 2016 and August 2018. METHOD: A Defined Daily Dose (DDD) was calculated for each patient prescribed opioids. DDD was converted into a Morphine Equivalent Dose (MED) and patients stratified according to high (≥120mg) MED cut off. The association between prescribing and deprivation was analysed by linking GP practice codes and IMD scores across LCCG. RESULTS: 3.5% of patients were prescribed an average dose above 120mg MED/day. Patients prescribed long-term, high dose, strong opioids were more likely to be female, aged 60+, prescribed three opioids and reside in the North of Liverpool where there is a higher density of areas in the IMD most deprived deciles. CONCLUSION: A small but significant proportion of CNCP patients across Liverpool are currently prescribed opioids above the recommended dose threshold of 120mg MED. Identification of fentanyl as a contributor to high dose prescribing resulted in changes to prescribing practice, and reports from NHS pain clinics that fewer patients require tapering from fentanyl. In conclusion, higher rates of high dose opioid prescribing continue to be evident in more socially deprived areas further increasing health inequalities.

Feasibility study of a Behavioural Intervention for Opioid Reduction (BIOR) for patients with chronic non-cancer pain in primary care: a protocol.

INTRODUCTION: Around 30%-50% of adults suffer moderate to severe chronic pain not caused by cancer. Significant numbers are treated with opioids which over time may cease to be effective and produce side effects (eg, nausea, drowsiness and constipation). Stopping taking opioids abruptly can cause unpleasant withdrawal effects. Tapering in small steps is recommended, though some patients might struggle and need support, particularly if they have limited access to pain management alternatives. Awareness of the potential risks as well as benefits of tapering should be explored with patients. METHODS AND ANALYSIS: A randomised controlled pilot feasibility study to investigate the effectiveness and feasibility of reducing high doses of opioids through a tapering protocol, education and support in primary care. Working with NHS Knowsley Place, we will identify patients taking 50 mg or above morphine equivalent dose of opioids per day to be randomly allocated to either the tapering group or tapering with support group. At an initial joint appointment with a pain consultant and General Practitioner (GP) GP tapering will be discussed and negotiated. Both groups will have their opioid reduced by 10% per week. The taper with support group will have access to additional support, including motivational counselling, realistic goal setting and a toolkit of resources to promote self-management. Some patients will successfully reduce their dose each week. For others, this may be more difficult, and the tapering reduction will be adjusted to 10% per fortnight. We assess opioid use, pain and quality of life in both groups at the start and end of the study to determine which intervention works best to support people with chronic pain who wish to stop taking opioids. ETHICS AND DISSEMINATION: The Behavioural Intervention for Opioid Reduction feasibility study has been granted full approval by Liverpool Central Research Ethics Committee on 7 April 2022 (22/NW/0047). The current protocol version is V.1.1, date 6 July 2022. Results will be published in peer-reviewed journals and disseminated to patient stakeholders in a lay summary report available on the project website and in participating GP surgeries. TRIAL REGISTRATION NUMBER: ISRCTN 30201337.

Neuropathic pain intensity, unpleasantness, coping strategies, and psychosocial factors after spinal cord injury: an exploratory longitudinal study during the first year.

OBJECTIVE: To determine the temporal relationship between pain-related coping strategies and psychosocial factors with non-evoked neuropathic pain (NP) intensity and unpleasantness in patients during the subacute phase of spinal cord injury (SCI). DESIGN: Exploratory longitudinal study of NP from 2 to 12 months. SETTING: Hospital Nacional de Parapléjicos, Toledo, Spain. SUBJECTS: A maximum of 26 patients with early symptoms of NP after SCI with a neurological level above the Th10 spinal level. OUTCOME MEASURES: Multidimensional Pain Inventory-Spinal Cord Injury Version, Coping Strategies Questionnaire, General 7-day pain intensity and unpleasantness rated with a visual analog scale, Spearman correlation analysis. RESULTS: PAIN-related coping strategies and psychosocial factors remained stable from 2 to 12 months after SCI. Initially pain intensity and unpleasantness were rated independently, but at 6 months were intercorrelated along with "pain severity,""life interference," and "catastrophizing.""Coping self-statements" and "solicitous responses from others" were frequently adopted, compared with "ignoring pain sensations" and "catastrophising." Perception of "pain severity" correlated with "support,""solicitous responses from others,""distracting responses from others," and "life control" at 6 months, while pain intensity and unpleasantness were related to "coping self-statements,""catastrophizing,""distancing from pain," and "praying." CONCLUSIONS: Pilot longitudinal data suggest that pain-related coping strategies are adopted early after subacute SCI, and correlate with both pain intensity and unpleasantness. Future longitudinal studies of SCI with sufficient sample size will be instrumental to determine the causal relationship between psychosocial factors and coping strategies on pain.

A cognitive-perceptual model of symptom perception in males and females: the roles of negative affect, selective attention, health anxiety and psychological job demands.

Kolk et al.'s model of symptom perception underlines the effects of trait negative affect, selective attention and external stressors. The current study tested this model in 263 males and 498 females from an occupational sample. Trait negative affect was associated with symptom reporting in females only, and selective attention and psychological job demands were associated with symptom reporting in both genders. Health anxiety was associated with symptom reporting in males only. Future studies might consider the inclusion of selective attention, which was more strongly associated with symptom reporting than negative affect. Psychological job demands appear to influence symptom reporting in both males and females.

Development and preliminary validation of the NePIQoL: a quality-of-life measure for neuropathic pain.

Neuropathic pain is frequently associated with negative effects on quality of life (QoL), affecting physical, social, and psychological functioning. Of many existing scales used to measure QoL, none have been validated in a neuropathic pain patient population. This study reports on the development and preliminary psychometric evaluation of the Neuropathic Pain Impact on Quality-of-Life questionnaire (NePIQoL), a measure to assess QoL in neuropathic pain. In Phase I, focus groups with 27 patients and a panel of experts identified QoL issues for inclusion in the measure. Initial items (152) and response categories were pretested using cognitive interviewing (18 patients). Following this, the number of items was reduced to 91. In Phase II, the 91-item version of the NePIQoL was administered to a further 112 patients, poorly performing items were identified, and internal consistency was examined. In Phase III, the revised NePIQoL was administered to a further 110 patients on two occasions to examine validity and test-retest reliability. Qualitative and quantitative pretesting led to extensive revision, resulting in a final measure of 42 items. Finally, Phase IV tested the concurrent validity and responsiveness of the NePIQoL. The authors conclude that the NePIQoL is an acceptable, patient-derived, neuropathic pain-specific measure with evidence of reliability, validity, and temporal stability.