Literature
Academic detailing basic skills
In-person academic detailing
Saffore CD, Tilton ST, Crawford SY, Fischer MA, Lee TA, Pickard AS, Sharp LK. Identification of barriers to safe opioid prescribing in primary care: a qualitative analysis of field notes collected through academic detailing. British Journal of General Practice. 2020 Aug;70(697):e589. https://doi.org/10.3399/bjgp20X711737.
iThis article identifies six potential barriers to safe opioid prescribing for providers “on the ground” through an academic detailing intervention in the Chicago area. The barriers were identified through a thematic analysis of academic detailers’ field notes recorded after detailing sessions with primary care providers. In the notes, detailers were asked to describe the academic detailing visit content as well as any questions and concerns expressed by the provider. Several barriers to safe opioid prescribing included lack of provider knowledge about opioid and non-opioid treatments, pressure to prescribe opioids--particularly from inherited patients--and uncertainty and time constraints regarding the health system’s pain management practices and policies. Reviewing these barriers can help detailers prepare for objections providers may pose during academic detailing visits on opioid stewardship.
Bounthavong M, Shayegani R, Manning JM, Marin J, Spoutz P, Hoffman JD, Harvey MA, Himstreet JE, Kay CL, Freeman BA, Almeida A, Christopher MLD. Comparison of virtual to in-person academic detailing on naloxone prescribing rates at three U.S. Veterans Health Administration Regional Networks. International Journal of Medical Informatics. 2020 May. https://doi.org/10.1016/j.ijmedinf.2022.104712.
The aim of this evaluation was to compare virtual and in-person academic detailing on naloxone prescribing rates at the Department of Veterans Affairs. Providers who received naloxone-related in-person or virtual academic detailing had increased naloxone prescribing rates; however, there were no differences between the two types of modalities. Virtual academic detailing was shown to be an alternative way to deliver academic detailing and allowed for academic detailers to expand their reach to rural providers.
Bounthavong M, Harvey MA, Kay CL, Lau MK, Wells DL, Himstreet JE, Popish SJ, Oliva EM, Christopher MLD. Comparison of naloxone prescribing patterns due to educational outreach conducted by full-time and part-time academic detailers at the U.S. Veterans Health Administration. Journal of the American Pharmacists Association. 2019 November 21. https://doi.org/10.1016/j.japh.2019.11.010.
Allocating sufficient work time for academic detailers to complete detailing tasks and activities can be an essential consideration for program staff recruiting and hiring detailers. Providers who interacted with academic detailers with high full-time equivalent employee (FTEE) allocation (0.4 FTEE or greater, meaning at least 40% of the employee’s time is dedicated to academic detailing) had a 65% greater increase in the number of average monthly naloxone prescriptions compared to providers who interacted with academic detailers with low FTEE (less than 0.4 FTEE). The increase in naloxone prescribing highlights the potential benefit of higher FTEE allocation for detailers.
Midboe AM, Wu J, Erhardt T, Carmichael JM, Bounthavong M, Christopher MLD, Gale RC. Academic Detailing to Improve Opioid Safety: Implementation Lessons from a Qualitative Evaluation. Pain Medicine. 2018 Sep 07;19(suppl_1):S46-S53. https://doi.org/10.1093/pm/pny085.
This paper summarizes several key components of an academic detailing program through qualitative interviews with current and former academic detailers and providers with varying exposure to academic detailing. The common themes included the importance of tailoring one-on-one sessions to providers’ needs, the role leadership plays in encouraging providers’ participation in detailing programs, and tracking detailer and provider performance. Reviewing these conclusions can help academic detailing program staff and detailers better understand and identify critical components of an academic detailing intervention.
Behar E, Rowe C, Santos GM, Santos N, Coffin PO. Academic Detailing Pilot for Naloxone Prescribing Among Primary Care Providers in San Francisco. Family Medicine. 2017 Feb;49(2):122-126.
In this academic detailing intervention, based in San Francisco, California, primary care providers were detailed on safe opioid prescribing and naloxone. The providers who received the intervention had an eleven-fold increase in naloxone prescribing compared to those who did not receive the intervention. This study shows that the traditional academic detailing model of one-on-one, in-person visits can be effective in increasing naloxone prescriptions in a primary care setting.
Yeh JS, Van Hoof TJ, Fischer MA. Key Features of Academic Detailing: Development of an Expert Consensus Using the Delphi Method. American Health and Drug Benefits. 2016;9(1):42-50. PMID: 27066195
This paper identifies key principles of academic detailing training, implementation, and evaluation through developing consensus from 20 experts with the Delphi method. Experts agreed the goal of academic detailing is to 1) improve clinical performance, 2) recommend practice changes, and 3) offer decision support to providers. Other major themes included the importance of focusing on clinician behavior change and tailoring content to provider needs during detailing sessions. Experts also noted the necessity for interpersonal and communication skills in detailers to overcome providers’ barriers to behavior change. These conclusions, as well as others listed in the paper, can help guide the planning and implementation of an effective academic detailing program.
Virtual detailing (e-Detailing)
Bounthavong M, Shayegani R, Manning JM, Marin J, Spoutz P, Hoffman JD, Harvey MA, Himstreet JE, Kay CL, Freeman BA, Almeida A, Christopher MLD. Comparison of virtual to in-person academic detailing on naloxone prescribing rates at three U.S. Veterans Health Administration Regional Networks. International Journal of Medical Informatics. 2022 May. https://doi.org/10.1016/j.ijmedinf.2022.104712.
The aim of this evaluation was to compare virtual and in-person academic detailing on naloxone prescribing rates at VA. Providers who received naloxone-related in-person or virtual academic detailing had increased naloxone prescribing rates; however, there were no differences between the two types of modalities. Virtual academic detailing is a viable alternative for delivering academic detailing and allows academic detailers to expand their reach to rural providers.
Smart MH, Mandava MR, Lee TA, Pickard AS. Feasibility and acceptability of virtual academic detailing on opioid prescribing. Int J Med Inform. 2020 Dec 25;147:104365. doi: https://doi.org/10.1016/j.ijmedinf.2020.104365. PMID: 33360790.
As the first paper comparing the feasibility and acceptability of in-person academic detailing visits (conducted before the COVID-19 pandemic) to virtual visits (conducted during the COVID-19 pandemic), Smart et al. is a noteworthy addition to the virtual academic detailing (also known as eDetailing) literature. Virtual visits were either conducted via WebEx with video and screensharing or on the telephone. While providers ranked in-person visits slightly more favorable than virtual visits, provider feedback indicated that there was no significant difference in feasibility between in-person and virtual visits. There was also no significant difference in providers satisfaction between video and telephone visits, and provider satisfaction was not impacted by technical difficulties.
Brunette MF, Dzebisashvili N, Xie H, Akerman S, Ferron JC, Bartels S. Expanding Cessation Pharmacotherapy Via Videoconference Educational Outreach to Prescribers. Nicotine and Tobacco Research. 2015 Jul;17(8):960-967. https://doi.org/10.1093/ntr/ntv006.
This is one of the few studies to compare in-person and videoconferencing delivery of academic detailing (called educational outreach in the study). Providers within a state mental health program either received virtual academic detailing (25 providers) or in-person academic detailing (18 providers) on smoking cessation. There was no significant difference between the providers who received in-person versus virtual academic detailing in 1) increased smoking cessation pharmacology prescriptions, 2) satisfaction with the sessions, and 3) post-intervention knowledge and attitudes. These findings indicate videoconferencing may be a plausible delivery method for academic detailing, although further investigation is needed.
Hartung DM, Hamer A, Middleton L, Haxby D, Fagnan LJ. A pilot study evaluating alternative approaches of academic detailing in rural family practice clinics. BMC Fam Pract. 2012 Dec;13:129. https://doi.org/10.1186/1471-2296-13-129
Hartung et al.’s pilot project provided in-person and virtual academic detailing to 41 clinicians at 4 different rural family practice clinics in Oregon. Each clinic received multiple detailing sessions over eight months. Providers who received in-person academic detailing reported a higher likelihood of changing their behavior compared to providers who received virtual academic detailing; however, the impact of in-person versus virtual academic detailing on provider practices post-intervention was not measured. Additionally, many providers indicated interest in continued participation of the program, but the likelihood of participation declined slightly if only virtual academic detailing was offered. While virtual academic detailing may be satisfactory, this pilot project suggests in-person academic detailing remains more desirable if both options are available. However, survey response rates were low and may not be sufficient to adequately detect significant differences between the two groups.
Motivational interviewing
Widder R. Learning to Use Motivational Interviewing Effectively: Modules. J Contin Educ Nurs. 2017 Jul 1;48(7):312-319. doi: 10.3928/00220124-20170616-08. PMID: 28658499
Motivational interviewing (MI) is used by a variety of professionals to help clients to develop motivation for lifestyle changes. It has also been shown to be an effective way to induce health-promoting activities. Education of health professionals in MI communication techniques can be done many ways, including attending a seminar and completing online classes. In a review of the literature, support was found for a variety of methods. This article described eight steps to MI education that were used to formulate two modules for nurses and exercise physiologists. These steps include PowerPoint presentations with audio linkage, participant practice with MI techniques via response to prompts, and self-evaluation of performance.
Rubac S, Sandbaek A, Lauritzen T, Christensen B. Motivational interviewing: A systematic review and meta-analysis. The British Journal of General Practice. 2005 Apr 1; 55(513): 305–312. PMID: 15826439
Motivational Interviewing is a well-known, scientifically tested method of counseling clients and a useful intervention strategy in the treatment of lifestyle problems and disease. To evaluate the effectiveness of motivational interviewing in different areas (Yes, this language the authors used.) of disease and to identify factors shaping outcomes, a systematic review and meta-analysis of randomized controlled trials using motivational interviewing as the intervention was conducted. The authors identified 72 research articles that met predetermined criteria for study quality. This study found that motivational interviewing in a clinical setting outperforms traditional advice giving in the treatment of a broad range of behavioral problems and diseases. Large-scale studies are now needed to determine if motivational interviewing can be implemented into daily clinical work in primary and secondary health care.
Chronic pain management
Ashar YK, Gordon A, Schubiner H, Uipi C, Knight K, Anderson Z, Carlisle J, Polisky L, Geuter S, Flood TF, Kragel PA, Dimidjian S, Lumley MA, Wager TD. Effect of pain reprocessing therapy vs Placebo and usual care for patients with chronic back pain: A randomized clinical trial. JAMA Psychiatry. 2022;79(1):13-23. doi:10.1001/jamapsychiatry.2021.2669
Chronic back pain (CBP) is a leading cause of disability, and treatment is often ineffective. Approximately 85% of cases are primary CBP, for which peripheral etiology cannot be identified, and maintenance factors include fear, avoidance, and beliefs that pain indicates injury. This study is intended to test whether a psychological treatment (pain reprocessing therapy [PRT]) aiming to shift patients’ beliefs about the causes and threat value of pain provides substantial and durable pain relief from primary CBP and to investigate treatment mechanisms.
Cohen SP, Vase L, Hooten WM. Chronic pain: An update on burden, best practices, and new advances. Lancet. 2021 May 29;397(10289):2082-2097. doi: 10.1016/S0140-6736(21)00393-7. PMID: 34062143
The biopsychosocial model of pain presents physical symptoms as the denouement of a dynamic interaction between biological, psychological, and social factors. Although it is widely known that pain can cause psychological distress and sleep problems, many medical practitioners do not realise that these associations are bidirectional. While predisposing factors and consequences of chronic pain are well known, the flipside is that factors promoting resilience, such as emotional support systems and good health, can promote healing and reduce pain chronification. Quality of life indicators and neuroplastic changes might also be reversible with adequate pain management.
Pain management best practices.
https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf.
The Pain Management Best Practices Inter-Agency Task Force was convened to address acute and chronic pain in light of the ongoing opioid crisis. Specific legislation required the Task Force to identify gaps, inconsistencies, and updates and to make recommendations for improving best practices for the management of acute and chronic pain. The taskforce emphasized the development of an effective pain treatment plan after proper evaluation in order to establish a diagnosis. This diagnosis included measurable outcomes that focus on improvements, such as quality of life, improved functionality, and activities of daily living.
Stonington S, Coffa D. Structural iatrogenesis - A 43-year-Old man with "opioid misuse". The New England Journal of Medicine. 2019 Feb 21;380(8):701-704. doi: 10.1056/NEJMp1811473. PMID: 30786183
Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences of the United States of America. 2016 Apr 4;113 (16) 4296-4301. https://doi.org/10.1073/pnas.1516047113.
This article examines beliefs associated with racial bias in pain management, a critical health care domain with well-documented racial disparities. Specifically, it reveals that a substantial number of white laypeople, medical students, and residents hold false beliefs about biological differences between Blacks and Whites and demonstrates that these beliefs predict racial bias in pain perception and treatment recommendation accuracy. It also provides the first evidence that racial bias in pain perception is associated with racial bias in pain treatment recommendations. This work shows that false beliefs about biological differences between Blacks and Whites continue to shape the way we perceive and treat black people.
Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RW, Guzman J, van Tulder MW. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. BMJ 2015 Feb 18;350:h444. doi: 10.1136/bmj.h444. PMID: 25694111.
The aim of this study was to assess the long term effects of multidisciplinary biopsychosocial rehabilitation for patients with chronic low back pain. The study design consisted of a systematic review and random effects meta-analysis of randomized controlled trials. Criteria included the following: multidisciplinary rehabilitation delivered by healthcare professionals from at least two different professional backgrounds and multidisciplinary rehabilitation compared with a non-multidisciplinary intervention. This study found that multidisciplinary biopsychosocial rehabilitation interventions were more effective than usual care and physical treatments in decreasing pain and disability in people with chronic low back pain. For work outcomes, multidisciplinary rehabilitation seems to be more effective than physical treatment but not more effective than usual care.
Kroenke K, Krebs EE, Wu J, Yu Z, Chumbler NR, Bair MJ. Telecare collaborative management of chronic pain in primary care: A randomized clinical trial. JAMA. 2014 Jul 16;312(3):240-8. doi: 10.1001/jama.2014.7689. PMID: 25027139
The aim of this study was to determine the effectiveness of a telecare intervention for chronic pain. Chronic musculoskeletal pain is among the most prevalent, costly, and disabling medical disorders. The Stepped Care to Optimize Pain Care Effectiveness (SCOPE) study was a randomized trial comparing a telephone-delivered collaborative care management intervention vs usual care in 250 patients with chronic musculoskeletal pain of at least moderate intensity. The goal of SCOPE was to optimize analgesic management using a stepped care approach to drug selection, symptom monitoring, dose adjustment, and switching or adding medications. This study found that telecare collaborative management increased the proportion of primary care patients with improved chronic musculoskeletal pain. This was accomplished by optimizing non-opioid analgesic medications using a stepped care algorithm and monitoring.
Guidelines for prescribing opioids for chronic pain factsheet. https://www.cdc.gov/drugoverdose/pdf/prescribing/Guidelines_Factsheet-a.pdf.
Primary care clinicians find managing chronic pain challenging. Evidence of long-term efficacy of opioids for chronic pain is limited. Opioid use is associated with serious risks, including opioid use disorder and overdose. This set of guidelines aimed to improve communication about benefits and risks of opioids for chronic pain, improve safety and effectiveness of pain treatment, and reduce risks associated with long-term opioid therapy.
Initiating opioids for chronic pain
Klimas J, Gorfinkel L, Fairbairn N, Amato L, Ahamad K, Nolan S, Simel DL, Wood E. Strategies to Identify Patient Risks of Prescription Opioid Addiction When Initiating Opioids for Pain: A Systematic Review. JAMA Network Open. 2019 May 03;2(5):e193365. doi.org/10.1001/jamanetworkopen.2019.3365
Although prescription opioid use disorder is associated with substantial harms, strategies to identify patients with pain among whom prescription opioids can be safely prescribed have not been systematically reviewed. This study aimed to review factors associated with opioid addiction and screening tools for identifying adult patients at high vs low risk of developing symptoms of prescription opioid addiction when initiating prescription opioids. This study found that while a history of substance use disorder, certain mental health diagnoses, and concomitant prescription of certain psychiatric medications appeared useful for identifying patients at higher risk, few quality studies were available. No symptoms, signs, or screening tools were particularly useful for identifying those at lower risk.
Reducing or stopping opioids for chronic pain
Nataraj N, Strahan AE, Guy GP, Losby JL, Dowell D. Dose tapering, increases, and discontinuity among patients on long-term high-dose opioid therapy in the United States, Drug and Alcohol Dependence. 2022 May. https://doi.org/10.1016/j.drugalcdep.2022.109392.
While reduced exposure to prescription opioids may decrease risks--including overdose and opioid use disorder--abrupt tapering or discontinuation may pose new risks. The aim of this study was to examine potentially unsafe tapering and discontinuation among dosage changes in opioid prescriptions dispensed to US patients on high-dose long-term opioid therapy. This study found that dosage changes for patients on high-dose long-term opioid therapy may warrant special attention to understand how potentially sudden tapering and discontinuation can be reduced while emphasizing patient safety and shared decision-making. This study found that rapid discontinuation of opioids can increase risk of adverse outcomes including opioid withdrawal.
Hallvik SE, El Ibrahimi S, Johnston K, Geddes J, Leichtling G, Korthuis PT, Hartung DM. Patient outcomes after opioid dose reduction among patients with chronic opioid therapy. Pain. 2022 Jan;163(1)p 83-90. doi: 10.1097/j.pain.0000000000002298
This retrospective cohort study found that discontinuation of opioid use after chronic opioid therapy increased the odds of suicide while decreasing the odds of overdose.
Tami ML, Parish W. Opioid medication discontinuation and risk of adverse opioid-related health care events. J Sub Ab Treatment. 2019 Aug;103:58-63. doi.org/10.1016/j.jsat.2019.05.001. PMID: 31079950.
Between 2012 and 2017, the United States dramatically reduced opioid prescribing rates. While this may be appropriate given the opioid epidemic, there has been little research to guide the clinical practice of discontinuing patients from opioid medications. This study aimed to determine the relationship between time to opioid discontinuation and the risk of an opioid-related emergency department visit or hospitalization among high dose opioid users.This study found that faster rates of opioid tapering were associated with a greater probability of adverse events and many patients were discontinued from opioids suddenly (i.e., with no incremental reduction). Additional clinical guidance, research, and interventions are needed to ensure that patients' opioid prescriptions are discontinued safely.
Stonington, S, Coffa D. Structural Iatrogenesis — A 43-Year-Old Man with “Opioid Misuse.” The New England Journal of Medicine. 2019 Fed;380(8), 701–704. https://doi.org/10.1056/NEJMp1811473
A case study of structural iatrogenesis within primary care and the direct effect to patients on high dose opioids.
Manhapra A, Arias AJ, Ballantyne JC. The conundrum of opioid tapering in long-term opioid therapy for chronic pain: A commentary, Substance Abuse. 2018;39(2):152-161. doi.org/10.1080/08897077.2017.1381663. PMID: 28929914.
In response to the opioid epidemic, many patients on high-dose long term opioid therapy (LTOT) for chronic pain are being tapered off opioids. As a result, a unique clinical challenge is emerging: while many on LTOT have poor pain control, functional decline, psychiatric instability, aberrancies and misuse, these issues may often worsen with opioid tapering. Currently, a clear explanation and practical guidance on how to manage this perplexing clinical scenario is lacking. This article offers commentary by experts on possible mechanisms involved in this clinical phenomenon and offers practical management guidance.
Barrett K, Chang YP. Behavioral Interventions Targeting Chronic Pain, Depression, and Substance Use Disorder in Primary Care. J Nurs Scholarsh. 2016;48(4):345-353. doi.org/10.1111/jnu.12213. PMID: 27149578.
Patients with chronic pain, depression, and substance use disorder (SUD) are often treated in primary care settings. An estimated 52% of patients have a diagnosis of chronic pain, 5% to 13% have depression, and 19% have SUD. These estimates are likely low when considering the fact that 50% of primary care patients with depression and 65% with SUD are undiagnosed or do not seek help. These three conditions have overlapping neurophysiological processes, which complicate the treatment outcomes of a primary physical illness. Behavioral interventions have been widely utilized as adjunctive treatments, yet little is known about what types of behavioral interventions were effective to treat these comorbidities. This systematic review aimed to identify behavioral interventions targeting chronic pain, depression, and SUD in primary care settings.
Opioid stewardship
Tay E, Makeham M, Laba TL, Baysari M. Prescription drug monitoring programs evaluation: a systematic review of reviews. Drug and Alcohol Dependence. 2023 Apr. https://doi.org/10.1016/j.drugalcdep.2023.109887.
Prescription drug monitoring programs (PDMPs) are used to mitigate harms from high-risk medicines including misuse, prescription shopping, overdoses, and death. Previous systematic reviews report inconsistent findings. We undertook a systematic review of reviews to 1) describe and identify the methods and outcome measures used to evaluate PDMPs, 2) summarise existing evidence on outcomes and factors that influence PDMP success or benefit realization.
Sturgeon JA, Sullivan MD, Parker-Shames S, Tauben D, Coelho P. Outcomes in Long-term Opioid Tapering and Buprenorphine Transition: A Retrospective Clinical Data Analysis. Pain Medicine. 2020 Dec. https://doi.org/10.1093/pm/pnaa029.
There are significant medical risks of long-term opioid therapy (LTOT) for chronic pain. Consequently, there is a need to identify effective interventions for the reduction of high-dose full-agonist opioid medication use.
Lai B, Witt D, Thacher T, Witt T. A Proposed Opioid Tapering Tool. J Am Board Fam Med. 2020 Nov;33(6):1020-1021. https://doi.org/10.3122/jabfm.2020.06.200076.
Previous studies suggest a lack of confidence among primary care providers in managing patients on chronic opioid therapy (COT) for chronic non-cancer related pain (CNCP). The US Department of Health and Human Services (HHS) recently introduced guidelines on opioid tapering. In light of these recommendations, our group developed an opioid tapering software to assist healthcare providers in managing patients on COT.
Covington EC, Argoff CE, Ballantyne JC, Cowan P, Gazelka HM, Hooten WM, Kertesz SG, Manhapra A, Murphy JL, Santos SP, Sullivan MD. Ensuring Patient Protections When Tapering Opioids: Consensus Panel Recommendations. Mayo Clinic Proceedings. 2020 Oct;95(10):2155-2171. https://doi.org/10.1016/j.mayocp.2020.04.025.
Long-term opioid therapy has the potential for serious adverse outcomes and is often used in a vulnerable population. Because adverse effects or failure to maintain benefits is common with long-term use, opioid taper or discontinuation may be indicated in certain patients. Concerns about the adverse individual and population effects of opioids have led to numerous strategies aimed at reductions in prescribing. Although opioid reduction efforts have had generally beneficial effects, there have been unintended consequences. Abrupt reduction or discontinuation has been associated with harms that include serious withdrawal symptoms, psychological distress, self-medicating with illicit substances, uncontrolled pain, and suicide. Key questions remain about when and how to safely reduce or discontinue opioids in different patient populations. Thus, health care professionals who reduce or discontinue long-term opioid therapy require a clear understanding of the associated benefits and risks as well as guidance on the best practices for safe and effective opioid reduction.
Coffin PO, Rowe C, Oman N, Sinchek K, Santos GM, Faul M, Bagnulo R, Mohamed D, Vittinghoff E. Illicit opioid use following changes in opioids prescribed for chronic non-cancer pain. PLOS ONE. 2020 May;15(5):e0232538. https://doi.org/10.1371/journal.pone.0232538.
After decades of increased opioid pain reliever prescribing, providers are rapidly reducing prescribing. It is hypothesized that reduced access to prescribed opioid pain relievers among patients previously reliant upon opioid pain relievers would result in increased illicit opioid use. It was found that discontinuation of prescribed opioid pain relievers was associated with more frequent non-prescribed opioid pain reliever and heroin use; increased dose was also associated with more frequent heroin use. Clinicians should be aware of these risks in determining pain management approaches.
Davis MP, Digwood G, Mehta Z, McPherson ML. Tapering opioids: a comprehensive qualitative review. Ann Palliat Med. 2020 Mar;9(2):586-610. doi: 10.21037/apm.2019.12.10
This state-of-the-art review comprehensive covers the benefits and risks of tapering opioids. The review discusses opioid strategies and pitfalls that may occur during tapering. The purpose of this review is to expand the knowledge of clinicians regarding tapering opioids and equip them to be able to successfully reduce and stop opioid therapy when appropriate.
Oliva EM, Bowe T, Manhapra A, Kertesz S, Hah JM, Henderson P, Robinson A, Paik M, Sandbrink F, Gordon AJ, Traftton JA. Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation. BMJ. 2020 Mar;368:m283. https://doi.org/10.1136/bmj.m283.
The objective of this study is to examine the associations between stopping treatment with opioids, length of treatment, and death from overdose or suicide in the Veterans Health Administration. These patients were found to be at greater risk of death from overdose or suicide after stopping opioid treatment, with an increase in the risk the longer patients had been treated before stopping. Descriptive data suggested that starting treatment with opioids was also a risk period. Strategies to mitigate the risk in these periods are not currently a focus of guidelines for long term use of opioids. The associations observed cannot be assumed to be causal; the context in which opioid prescriptions were started and stopped might contribute to risk and was not investigated. Safer prescribing of opioids should take a broader view on patient safety and mitigate the risk from the patient's perspective. Factors to address are those that place patients at risk for overdose or suicide after beginning and stopping opioid treatment, especially in the first three months.
Lembke A. Tapering Long-Term Opioid Therapy. Am Fam Physician. 2020;101(1):49-52.
My patient is a 54-year-old construction worker who has been taking prescribed opioids for more than a decade for chronic knee and back pain. During the past year, he has admitted that he feels “stuck on these drugs.” His pain is not well controlled, and his wife has complained that he seems “out of it.” We have talked about reducing his prescription or stopping opioids, but he is reluctant and worried. How can I help my patient taper his regimen to minimize withdrawal and maximize his chances for success?
James JR, Scott JM, Klein JW, Jackson S, McKinney C, Novack M, Chew L, Merrill JO. Mortality After Discontinuation of Primary Care–Based Chronic Opioid Therapy for Pain: a Retrospective Cohort Study. Journal of General Internal Medicine. 2019 Dec;34(12):2749-2755. https://doi.org/10.1007/s11606-019-05301-2.
Despite known risks of using chronic opioid therapy (COT) for pain, the risks of discontinuation of COT are largely uncharacterized. This study intends to evaluate mortality, prescription opioid use, and primary care utilization of patients discontinued from COT, compared with patients maintained on opioids. In this cohort of patients prescribed COT for chronic pain, mortality was high. Discontinuation of COT did not reduce risk of death and was associated with increased risk of overdose death. Improved clinical strategies, including multimodal pain management and treatment of opioid use disorder, may be needed for this high-risk group.
Davis B, Archambault C, Davis K, Oagley CR, Schneider J, Kennedy A, Wilensky D. A patient-centered approach to tapering opioids. J Fam Pract. 2019 Dec;68(10):548-556.
Many Americans who are treated with prescription opioid analgesics would be better off with less opioid or none at all. To that end, published opioid prescribing guidelines do provide guidance on the mechanics of tapering patients off opioids1-4—but they have a major flaw: They do not adequately account for the fact that people who have a diagnosis of chronic pain are a heterogeneous group and require diagnosis-specific treatment planning. A patient-centered approach to opioid tapers must account for the reality that many people who are given a prescription for an opioid to treat pain have significant mental health conditions—for which opioids act as a psychotropic agent.
Fishbain DA, Pulikal A. Does Opioid Tapering in Chronic Pain Patients Result in Improved Pain or Same Pain vs Increased Pain at Taper Completion? A Structured Evidence-Based Systematic Review. Pain Medicine. 2019 Nov;20(11):2179-2197. https://doi.org/10.1093/pm/pny231.
This article intends to support or refute the hypothesis that opioid tapering in chronic pain patients (CPPs) improves pain or maintains the same pain level by taper completion but does not increase pain. It was found that there is consistent type 3 and 4 study evidence that opioid tapering in CPPs reduces pain or maintains the same level of pain. However, these studies represented lower levels of evidence and were not designed to test the hypothesis, with the evidence being marginal in quality with large amounts of missing data. These results then primarily reveal the need for controlled studies (type 2) to address this hypothesis.
Mark TL, Parish W. Opioid medication discontinuation and risk of adverse opioid-related health care events. Journal of Substance Abuse Treatment. 2019 May;103:58-63. https://doi.org/10.1016/j.jsat.2019.05.001.
Between 2012 and 2017, the United States dramatically reduced opioid prescribing rates. While this may be appropriate given the opioid epidemic, there has been little research to guide the clinical practice of discontinuing patients from opioid medications and opioid death rates have continued to increase. This article intends to determine the relationship between time to opioid discontinuation and the risk of an opioid-related emergency department visit or hospitalization among high dose opioid users. It was found that faster rates of opioid tapering were associated with a greater probability of adverse events and many patients discontinued opioids suddenly, with no dose reduction. Additional clinical guidance, research, and interventions are needed to ensure that patients' opioid prescriptions are discontinued safely.
Manhapra A, Arias AJ, Ballantyne JC. The conundrum of opioid tapering in long-term opioid therapy for chronic pain: A commentary. Substance Abuse. 2017;39(2):152-161. doi: 10.1080/08897077.2017.1381663.
In response to the opioid epidemic and new guidelines, many patients on high-dose long term opioid therapy (LTOT) for chronic pain are getting tapered off opioids. As a result, a unique clinical challenge is emerging: while many on LTOT have poor pain control, functional decline, psychiatric instability, aberrancies and misuse, these issues may often worsen with opioid tapering. Currently, a clear explanation and practical guidance on how to manage this perplexing clinical scenario is lacking. This article offers a commentary with our perspective on possible mechanisms involved in this clinical phenomena and offer practical management guidance, supported by available evidence.
Rasu RS, Sohraby R, Cunningham L, Knell ME. Assessing chronic pain treatment practices and evaluating adherence to chronic pain clinical guidelines in outpatient practices in the United States. The Journal of Pain. 2013 Jun;14(6):568-78. doi: 10.1016/j.jpain.2013.01.425. PMID: 23578958
Chronic pain is a major health concern in the United States. Several guidelines have been developed for clinicians to promote effective management and provide an analytical framework for evaluation of treatments for chronic pain. This study explores sample population demographics and the utilization of various therapeutic modalities in an adult population with common nonmalignant chronic pain (NMCP) indications in U.S. outpatient settings. A cross-sectional study using the National Ambulatory Medical Care Survey (NAMCS) data from 2000 to 2007 was used to analyze various treatment practices for the management of NMCP and evaluate the results in comparison with guidelines. This study, representing over 690 million patient visits, contributes to the relative paucity of data on the use of therapeutic modalities in the management of NMCP. These results may assist clinicians and healthcare policymakers in identifying areas where practices are at odds with guidelines with the goal to improve care.
Victor TW, Alvarez NA, Gould E. Opioid prescribing practices in chronic pain management: Guidelines do not sufficiently influence clinical practice. The Journal of Pain. 2009 Oct;10(10):1051-7. doi: 10.1016/j.jpain.2009.03.019. PMID: 19595639
To examine the use of extended-release (ER) opioids relative to immediate-release (IR) opioids in chronic opioid prescription episodes, pharmacy claim data from a national health plan database were analyzed.This analysis suggests that the availability of pain-treatment guidelines, recommendations, and education alone may not be enough to influence opioid-prescribing practices in the treatment of chronic pain.
Using urine drug screens to support treatment of people who use substances
Starrels JL, Becker WC, Alford DP, Kapoor A, Williams AR, Turner BJ. Systematic review: Treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. Ann Intern Med. 2010 Jun 1;152(11):712-20. doi: 10.7326/0003-4819-152-11-201006010-00004. PMID: 20513829
Experts recommend opioid treatment agreements and urine drug testing to reduce opioid analgesia misuse, but evidence of these interventions’ effectiveness has not been systematically reviewed. The aim of this article is to synthesize studies of the association between treatment agreements and urine drug testing with opioid misuse outcomes in outpatients with chronic non-cancer pain. Urine drug testing and opioid treatment agreements were not found to reduce opioid misuse in patients with chronic pain. Further research on effective ways to monitor and reduce opioid misuse is needed, especially in primary care settings.
Naloxone prescribing and use
Behar E, Rowe C, Santos GM, Murphy S, Coffin PO. Primary Care Patient Experience with Naloxone Prescription. Ann Fam Med. 2016 Sep;14(5):431–436. doi.org/10.1370/afm.1972. PMID: 27621159.
Notwithstanding a paucity of data, prescription of the opioid antagonist naloxone to patients prescribed opioids is increasingly recommended in opioid stewardship guidelines. This study intended to evaluate chronic pain patients' attitudes toward being offered a naloxone prescription and their experience with naloxone. After interviewing 60 patients who received naloxone prescriptions across 6 safety-net primary care clinics, they used a standardized questionnaire to collect information on substance use, perception of personal overdose risk, history of overdose, and experiences with naloxone prescription, including initial reaction, barriers to filling the prescription, storage and use of naloxone, associated behavioral changes, and opinions about future prescribing. It was found that primary care patients on opioids reported that receiving a prescription for naloxone was acceptable, the prescription reached patients who had not had access to naloxone, and having naloxone may be associated with beneficial changes in opioid use behaviors. Patients prescribed opioids may not interpret the terminology describing overdose to imply unintentional opioid poisoning.
Coffin PO, Behar E, Rowe C, Santos GM, Coffa D, Bald M, Vittinghoff E. Nonrandomized Intervention Study of Naloxone Coprescription for Primary Care Patients Receiving Long-Term Opioid Therapy for Pain. Ann Intern Med. 2016 Aug;165(4):245–252. doi.org/10.7326/M15-2771. PMID: 27366987.
Unintentional overdose involving opioid analgesics is a leading cause of injury-related death in the United States.
This study intended to evaluate the feasibility and effect of implementing naloxone prescription to patients prescribed opioids for chronic pain. This 2-year nonrandomized intervention study found that naloxone can be coprescribed to primary care patients prescribed opioids for pain. When advised to offer naloxone to all patients receiving opioids, providers may prioritize those with established risk factors. Providing naloxone in primary care settings may have ancillary benefits, such as reducing opioid-related adverse events.
Walley AY, Xuan Z, Hackman HH, Quinn E, Doe-Simkins M, Sorensen-Alawad A, Ruiz S, Ozonoff A. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ. 2013 Jan;346:f174. https://doi.org/10.1136/bmj.f174.
This study intended to evaluate the impact of state supported overdose education and nasal naloxone distribution (OEND) programs on rates of opioid related death from overdose and acute care utilization in Massachusetts. The study design consisted of an interrupted time series analysis of opioid related overdose death and acute care utilization rates from 2002 to 2009 comparing community-year strata with high and low rates of OEND implementation to those with no implementation. It was found that opioid overdose death rates were reduced in communities where OEND was implemented. This study provides observational evidence that by training potential bystanders to prevent, recognize, and respond to opioid overdoses, OEND is an effective intervention.
Treatment of substance use disorders
Articles coming soon.
Using buprenorphine to manage opioid use disorder
Tofighi B, McNeely J, Walzer D, Fansiwala K, Demner A, Chaudhury CS, Subudhi S, Schatz D, Reed, T, Krawczyk N. A Telemedicine Buprenorphine Clinic to Serve New York City: Initial Evaluation of the NYC Public Hospital System’s Initiative to Expand Treatment Access during the COVID-19 Pandemic. Journal of Addiction Medicine. 2022 Jan;16(1):p e40-e43. doi: 10.1097/ADM.0000000000000809.
The purpose of this study was to assess the feasibility and clinical impact of telemedicine-based opioid treatment with buprenorphine-naloxone following the Coronavirus disease 2019 pandemic.
Kohan L, Potru S, Barreveld AM, Sprintz M, Lane O, Aryal A, Emerick T, Dopp A, Chhay, S,Viscusi, E. Buprenorphine management in the perioperative period: educational review and recommendations from a multisociety expert panel. Reg Anesth Pain Med. 2021 Aug;46(10), 840–859. https://doi.org/10.1136/rapm-2021-103007.
The past two decades have witnessed an epidemic of opioid use disorder (OUD) in the USA, resulting in catastrophic loss of life secondary to opioid overdoses. Medication treatment of opioid use disorder (MOUD) is effective, yet barriers to care continue to result in a large proportion of untreated individuals. Optimal analgesia can be obtained in patients with MOUD within the perioperative period. Anesthesiologists and pain physicians can recommend and consider initiating MOUD in patients with suspected OUD at the point of care; this can serve as a bridge to comprehensive treatment and ultimately save lives.
Mehtani NJ, Ristau JT, Snyder H, Surlyn C, Eveland J, Smith-Bernardin S, Knight KR. COVID-19: A catalyst for change in telehealth service delivery for opioid use disorder management. Substance Abuse. 2021 Mar;42:2, 205-212, doi: 10.1080/08897077.2021.1890676.
COVID-19 has exacerbated income inequality, structural racism, and social isolation—issues that drive addiction and have previously manifested in the epidemic of opioid-associated overdose. The co-existence of these epidemics has necessitated care practice changes, including the use of telehealth-based encounters for the diagnosis and management of opioid use disorder (OUD).
Xu KY, Borodovsky JT, Presnall N, Mintz CM, Hartz SM, Bierut LJ, Grucza RA. Association Between Benzodiazepine or Z-Drug Prescriptions and Drug-Related Poisonings Among Patients Receiving Buprenorphine Maintenance: A Case-Crossover Analysis. Am J Psychiatry. 2021 Mar 03. https://doi.org/10.1176/appi.ajp.2020.20081174.
Persons with opioid use disorder who take benzodiazepines are at high risk for overdose. The objective of this study was to evaluate the association of benzodiazepine and Z-drug use with drug-related poisonings among patients receiving buprenorphine maintenance treatment.
Ahmed S, Bhivandkar S, Lonergan BB, Suzuki J. Microinduction of Buprenorphine/Naloxone: A Review of the Literature. Am J Addict. 2020 Dec 30:ajad.13135. https://doi.org/10.1111/ajad.13135.
Buprenorphine's high-binding affinity as a partial µ-opioid agonist displaces preexisting full agonists causing precipitated withdrawal, which requires most individuals starting buprenorphine to endure moderate withdrawal prior to induction to avoid precipitated withdrawal. A novel approach called microinduction has emerged to remove this prerequisite.
Brar R, Fairbairn N, Sutherland C, Nolan S. Use of a novel prescribing approach for the treatment of opioid use disorder: Buprenorphine/naloxone micro-dosing – a case series. Drug and Alcohol Review. 2020 Jul;39(5):588-594. https://doi.org/10.1111/dar.13113.
Buprenorphine/naloxone is an evidence-based treatment for opioid use disorder, but an identified limitation is the period of required opioid abstinence prior to induction on the medication. ‘Micro-dosing’, or using incrementally increasing doses of buprenorphine/naloxone over time, may be a way to overcome this challenge as it can be done in parallel with the ongoing use of other opioids (either illicit or prescribed).
Brunet N, Moore DT, Lendvai Wischik D, Mattocks KM, Rosen MI. Increasing buprenorphine access for veterans with opioid use disorder in rural clinics using telemedicine. Substance Abuse. 2020 Feb;43:1, 39-46, doi: 10.1080/08897077.2020.1728466.
Having prescribers use clinical video teleconferencing (telemedicine) to prescribe buprenorphine to people with opioid use disorder (OUD) has shown promise but its implementation is challenging. This article describes barriers, facilitators and lessons learned while implementing a system to remotely prescribe buprenorphine to Veterans in rural settings.
Ghosh SM, Klaire S, Tanguay R, Manek M, Azar P. A Review of Novel Methods To Support The Transition From Methadone and Other Full Agonist Opioids To Buprenorphine/Naloxone Sublingual In Both Community and Acute Care Settings. The Canadian Journal of Addiction. 2019 Dec;10(4):41-50. doi: 10.1097/CXA.0000000000000072.
Converting methadone to buprenorphine/naloxone sublingual (SL) is desirable for reasons including ease of prescribing, carries to improving function, decreased drug interactions, and decreased overdose risk. The process of conversion can be difficult given methadone's long half-life and concerns regarding the need for withdrawal before initiation. This article aims to present several unique methods of converting individuals from methadone and other full opioid agonists (prescribed and illicit) to buprenorphine/naloxone SL as well as describe novel buprenorphine induction protocols to use in community and acute care settings.
Schuckit MA. Treatment of Opioid-Use Disorders. N Engl J Med. 2016 Jul;375(4):357-368. doi: 10.1056/NEJMra1604339.
This article provides an overview of the current treatment of opioid-related conditions, including treatments provided by general practitioners and by specialists in substance-use disorders. The recent dramatic increase in misuse of prescription analgesics, the easy accessibility of opioids such as heroin on the streets, and the epidemic of opioid overdoses underscore how important it is for physicians to understand more about these drugs and to be able to tell patients about available treatments for substance-use disorders.
Hämmig R, Kemter A, Strasser J, von Bardeleben U, Gugger B, Walter M, Dursteler K, Vogel M. Use of microdoses for induction of buprenorphine treatment with overlapping full opioid agonist use: the Bernese method. SAR. 2016 Apr;7:99-105. https://doi.org/10.2147/SAR.S109919.
This paper presents two cases of successful initiation of buprenorphine treatment with the Bernese method, ie, gradual induction overlapping with full agonist use. The first patient began buprenorphine with overlapping street heroin use after repeatedly experiencing relapse, withdrawal, and trauma reactivation symptoms during conventional induction. The second patient was maintained on high doses of diacetylmorphine (ie, pharmaceutical heroin) and methadone during induction. Both patients tolerated the induction procedure well and reported only mild withdrawal symptoms.
Pierce M, Bird SM, Hickman M, Marsden J, Dunn G, Jones A, Millar T. Impact of treatment for opioid dependence on fatal drug-related poisoning: a national cohort study in England. Addiction. 2016 Feb;111(2):298-308. https://doi.org/10.1111/add.13193.
To compare the change in illicit opioid users’ risk of fatal drug-related poisoning (DRP) associated with opioid agonist pharmacotherapy (OAP) and psychological support, and investigate the modifying effect of patient characteristics, criminal justice system (CJS) referral and treatment completion.
Kimber J, Larney S, Hickman M, Randall D, Degenhardt L. Mortality risk of opioid substitution therapy with methadone versus buprenorphine: a retrospective cohort study. Lancet Psychiatry. 2015 Sep;2(10):901-908. https://doi.org/10.1016/S2215-0366(15)00366-1.
Opioid dependence increases risk of premature mortality. Opioid substitution therapy with methadone or buprenorphine reduces mortality risk, especially for drug-related overdose. Clinical guidelines recommend methadone as the first line of opioid substitution therapy. This paper aimed to test whether buprenorphine treatment has a lower mortality risk than does methadone treatment by comparing all-cause mortality and drug-related overdose mortality at treatment induction, after in-treatment medication switches, and following treatment cessation.
Daitch D, Daitch J, Novinson D, Frey M, Mitnick C, Pergolizzi J Jr. Conversion from High-Dose Full-Opioid Agonists to Sublingual Buprenorphine Reduces Pain Scores and Improves Quality of Life for Chronic Pain Patients. Pain Medicine. 2014 Dec;15(12):2087-2094. https://doi.org/10.1111/pme.12520.
This study aims to determine the effectiveness of converting patients from high doses of full-opioid agonists to sublingual (SL) buprenorphine.
Fiellin DA, Barry DT, Sullivan LE, Cutter CJ, Moore BA, O'Conner PG, Schottenfeld RS. A randomized trial of cognitive behavioral therapy in primary care-based buprenorphine. Am J Med. 2013 Jan;126(1):74.e11-17. https://doi.org/10.1016/j.amjmed.2012.07.005.
To determine the impact of cognitive behavioral therapy on outcomes in primary care, office-based buprenorphine/naloxone treatment of opioid dependence.
Cunningham CO, Giovanniello A, Li X, Kunins HV, Roose RJ, Sohler NL. A comparison of buprenorphine induction strategies: patient-centered home-based inductions versus standard-of-care office-based inductions. J Subst Abuse Treat. 2011 Feb;40(4):349-356. https://doi.org/10.1016/j.jsat.2010.12.002.
Although novel buprenorphine induction strategies are emerging, they have been inadequately studied. To examine the newly developed patient-centered home-based inductions, a subgroup analysis of 79 opioid-dependent individuals who had buprenorphine inductions at an urban community health center was conducted. Participants chose their induction strategy. Standard-of-care office-based inductions were physician driven, with multiple assessments, and observed, and the patient-centered home-based inductions emphasized patient self-management and included a “kit” for induction at home. The authors conducted interviews and extracted medical records. Using mixed nonlinear models, they examined associations between induction strategy and opioid use and any drug use.
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