Abstract
In a primary care population of 327 older adults (age 60+) with chronic osteoarthritis (OA) pain and insomnia, we examined the relationship between short-term improvement in sleep or pain ...and long-term sleep, pain, depression, and fatigue by secondary analyses of randomized controlled trial data. Study participants, regardless of trial arm, were classified as Sleep or Pain Improvers with ≥30% baseline to 2-month reduction on the Insomnia Severity Index or the Brief Pain Inventory, respectively, or Sleep or Pain Non-Improvers. After controlling for trial arm and potential confounders, both Sleep and Pain Improvers showed significant (p < .01) sustained improvements across 12 months compared to respective Non-Improvers for the Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index, Brief Pain Inventory-short form (total, Interference, and Severity subscales), Patient Health Questionnaire, and Flinders Fatigue Scale. The effect sizes (Cohen’s f2) for the sustained benefits in both Sleep and Pain Improvers compared to their respective Non-Improvers for all variables were small (<0.15) with the exception of medium effect size for sustained reduction in insomnia symptoms for the Sleep Improvers. We conclude that short-term sleep improvements in pain populations with comorbid insomnia precede benefits not only for long-term improvement in sleep but also for reduced pain over the long-term, along with associated improvements in depression and fatigue. Short-term improvements in pain appear to have similar long-term sequelae. Successfully improving sleep in pain populations with comorbid insomnia may have the additional benefits of improving both short- and long-term pain, depression, and fatigue.
Trial Registration: OsteoArthritis and Therapy for Sleep (OATS) NCT02946957: https://clinicaltrials.gov/ct2/show/NCT02946957.
Abstract Purpose Opioid misuse in the context of chronic opioid therapy (COT) is a growing concern. Depression may be a risk factor for opioid misuse, but it has been difficult to tease out the ...contribution of co-occurring substance abuse. This study aims to examine whether there is an association between depression and opioid misuse in patients receiving COT who have no history of substance abuse. Methods A telephone survey was conducted at Group Health Cooperative and Kaiser Permanente of Northern California. We interviewed 1,334 patients on COT for noncancer pain who had no history of substance abuse. Patients were asked about 3 forms of opioid misuse: (1) self-medicating for symptoms other than pain, (2) self-increasing doses, and (3) giving to or getting opioids from others. Depression was evaluated by the 8-item Patient Health Questionnaire (PHQ-8). Results Compared with patients who were not depressed (PHQ-8 score 0 to 4), patients with moderate depression (PHQ-8 score 10 to 14) and severe depression (PHQ-8 score 15 or higher) were 1.8 and 2.4 times more likely, respectively, to misuse their opioid medications for non–pain symptoms. Patients with mild (PHQ-8 score 5 to 9), moderate, and severe depression were 1.9, 2.9, and 3.1 times more likely, respectively, to misuse their opioid medications by self-increasing their dose. There was no statistically significant association between depression and giving opioids to or getting them from others. Conclusion In patients with no substance abuse history, depressive symptoms are associated with increased rates of some forms of self-reported opioid misuse. Clinicians should be alert to the risk of patients with depressive symptoms using opioids to relieve these symptoms and thereby using more opioids than prescribed.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
In this trial, an intervention involving a medically supervised nurse providing guideline-based management, as compared with usual care, resulted in improved medical outcomes in patients who had ...depression and diabetes, coronary heart disease, or both.
Evidence-based care management for single conditions improves outcomes among patients with diabetes,
1
coronary heart disease,
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and depression,
3
but organizing diagnosis-specific programs is complex and costly, so such programs are not routinely available.
4
,
5
Care for patients with multiple chronic illnesses is expensive, and coordination of care among specialties can be inadequate.
5
,
6
In previous trials involving high-risk Medicare patients with diabetes, heart disease, or both, nurse care-management interventions did not improve patient outcomes.
7
However, these interventions were primarily delivered by telephone, had no physician supervision, did not include medication recommendations to primary care physicians, and were not integrated into primary . . .
OBJECTIVESThis paper describes characteristics of opioid use episodes for noncancer pain and defines thresholds for de facto long-term opioid therapy.
METHODSCONSORT (CONsortium to Study Opioid Risks ...and Trends) includes adult members of 2 health plans serving over 1% of the US population. Opioid use episodes beginning in the years 1997 to 2005 were classified as acute, episodic, long-term/lower dose, or long-term/higher dose.
RESULTSOn the basis of evaluation of the likelihood of opioid use continuing, long-term opioid therapy was defined by episodes lasting longer than 90 days with 10+ opioid prescriptions or 120+ days supply of opioids dispensed. Long-term/higher dose episodes (<1.5% of all opioid use episodes) were characterized by daily or near daily use, a mean duration of about 1000 days, and an average daily dose of about 55 mg. They accounted for more than half the total morphine equivalents dispensed from the years 1997 to 2006. Short-acting, non-Schedule II opioids (eg, hydrocodone with acetaminophen) were, by far, the most commonly prescribed medications for acute, episodic, and long-term episodes. Long-acting (sustained-release) opioids were the predominately prescribed medication in a minority of long-term episodes (6% to 12%).
DISCUSSIONLong-term opioid therapy was characterized by the diversity in medications prescribed, dosage levels, and frequency of use. The proposed threshold for long-term opioid therapy provides a checkpoint for physicians to review whether an explicit decision to sustain opioid therapy has been reached, and to ensure that a documented treatment plan and provisions for monitoring medication use and patient outcomes are in place.
Objective
To examine independent and combined effects of pain with concurrent insomnia and depression symptoms on the use of health care services in older adults with osteoarthritis (OA).
Methods
...Patients were Group Health Cooperative (GHC) patients with a primary diagnosis of OA (n = 2,976). We used survey data on pain (Graded Chronic Pain Scale), insomnia (Insomnia Severity Index), and depression (Patient Health Questionnaire‐8), and health care use extracted from GHC electronic health records (office visits, length of stay, outpatient and inpatient costs, and hip or knee replacement) for 3 years after the survey. Negative binomial, logistic, and generalized linear models were used to assess predictors of health care use.
Results
Approximately 34% and 29% of patients displayed at least subclinical insomnia and at least subclinical depression symptoms, respectively, in addition to moderate‐to‐severe pain. Pain had the greatest independent effects on increasing all types of health care use, followed by depression (moderate effects) on increased office visits, length of stay, outpatient and inpatient costs, and insomnia (mild effects) on decreased length of stay. No synergistic effects of the 3 symptoms on use of health care services were observed. The combined effects of pain plus insomnia and pain plus depression were significant for all types of health care use and increased greatly with increasing severity of insomnia and depression, except for hip/knee replacement.
Conclusion
Pain is the main driver for health care use in patients with OA. In addition to pain, insomnia plus depression jointly increased diverse types of health care use, and these combined effects increased greatly with increasing severity of insomnia and depression. These findings indicate the important role that concurrent symptomatic conditions may play in increasing use of health care services.
Objectives
To examine whether use of opioids or benzodiazepines is associated with risk of community‐acquired pneumonia in older adults.
Design
Population‐based case–control study.
Setting
An ...integrated healthcare delivery system.
Participants
Community‐dwelling, immunocompetent adults aged 65 to 94 from 2000 to 2003. Presumptive pneumonia cases were identified from health plan automated data and validated through medical record review. Two controls were selected for each case with pneumonia, matched on age, sex, and calendar year.
Measurements
Information about opioid and benzodiazepine use came from computerized pharmacy data. Information on covariates including comorbid illnesses and functional and cognitive status came from medical record review and electronic health data.
Results
One thousand thirty‐nine validated cases of pneumonia and 2,022 matched controls were identified. One hundred forty‐four (13.9%) cases and 161 (8.0%) controls used prescription opioids (adjusted odds ratio (OR) = 1.38, 95% confidence interval (CI) = 1.08–1.76 vs nonuse). Risk was highest for opioids categorized as immunosuppressive based on immunological studies (OR = 1.88, 95% CI = 1.26–1.79 vs nonuse), whereas for nonimmunosuppressive opioids the OR was 1.23 (95% CI = 0.89–1.69). Risk was highest in the first 14 days of use (OR = 3.24, 95% CI = 1.64–6.39 vs nonuse). For long‐acting opioids, the OR was 3.43 (95% CI = 1.44–8.21) versus nonuse, whereas for short‐acting opioids, it was 1.27 (95% CI = 0.98–1.64). No greater risk was seen for current benzodiazepine use compared to nonuse (OR = 1.08, 95% CI = 0.80–1.47).
Conclusion
Use of opioids but not benzodiazepines was associated with pneumonia risk. The differences in risk seen for different opioid regimens warrant further study.
Objectives
To assess whether older persons with osteoarthritis (OA) pain and insomnia receiving cognitive–behavioral therapy for pain and insomnia (CBT‐PI), a cognitive–behavioral pain coping skills ...intervention (CBT‐P), and an education‐only control (EOC) differed in sleep and pain outcomes.
Design
Double‐blind, cluster‐randomized controlled trial with 9‐month follow‐up.
Setting
Group Health and University of Washington, 2009 to 2011.
Participants
Three hundred sixty‐seven older adults with OA pain and insomnia.
Interventions
Six weekly group sessions of CBT‐PI, CBT‐P, or EOC delivered in participants' primary care clinics.
Measurements
Primary outcomes were insomnia severity and pain severity. Secondary outcomes were actigraphically measured sleep efficiency and arthritis symptoms.
Results
CBT‐PI reduced insomnia severity (score range 0–28) more than EOC (adjusted mean difference = −1.89, 95% confidence interval = −2.83 to −0.96; P < .001) and CBT‐P (adjusted mean difference = −2.03, 95% CI = −3.01 to −1.04; P < .001) and improved sleep efficiency (score range 0–100) more than EOC (adjusted mean difference = 2.64, 95% CI = 0.44–4.84; P = .02). CBT‐P did not improve insomnia severity more than EOC, but improved sleep efficiency (adjusted mean difference = 2.91, 95% CI = 0.85–4.97; P = .006). Pain severity and arthritis symptoms did not differ between the three arms. A planned analysis in participants with severe baseline pain revealed similar results.
Conclusion
Over 9 months, CBT of insomnia was effective for older adults with OA pain and insomnia. The addition of CBT for insomnia to CBT for pain alone improved outcomes.
CONTEXT Both antidepressant medication and structured psychotherapy have been
proven efficacious, but less than one third of people with depressive disorders
receive effective levels of either ...treatment. OBJECTIVE To compare usual primary care for depression with 2 intervention programs:
telephone care management and telephone care management plus telephone psychotherapy. DESIGN Three-group randomized controlled trial with allocation concealment
and blinded outcome assessment conducted between November 2000 and May 2002. SETTING AND PARTICIPANTS A total of 600 patients beginning antidepressant treatment for depression
were systematically sampled from 7 group-model primary care clinics; patients
already receiving psychotherapy were excluded. INTERVENTIONS Usual primary care; usual care plus a telephone care management program
including at least 3 outreach calls, feedback to the treating physician, and
care coordination; usual care plus care management integrated with a structured
8-session cognitive-behavioral psychotherapy program delivered by telephone. MAIN OUTCOME MEASURES Blinded telephone interviews at 6 weeks, 3 months, and 6 months assessed
depression severity (Hopkins Symptom Checklist Depression Scale and the Patient
Health Questionnaire), patient-rated improvement, and satisfaction with treatment.
Computerized administrative data examined use of antidepressant medication
and outpatient visits. RESULTS Treatment participation rates were 97% for telephone care management
and 93% for telephone care management plus psychotherapy. Compared with usual
care, the telephone psychotherapy intervention led to lower mean Hopkins Symptom
Checklist Depression Scale depression scores (P =
.02), a higher proportion of patients reporting that depression was "much
improved" (80% vs 55%, P<.001), and a higher proportion
of patients "very satisfied" with depression treatment (59% vs 29%, P<.001). The telephone care management program had smaller
effects on patient-rated improvement (66% vs 55%, P =
.04) and satisfaction (47% vs 29%, P = .001); effects
on mean depression scores were not statistically significant. CONCLUSIONS For primary care patients beginning antidepressant treatment, a telephone
program integrating care management and structured cognitive-behavioral psychotherapy
can significantly improve satisfaction and clinical outcomes. These findings
suggest a new public health model of psychotherapy for depression including
active outreach and vigorous efforts to improve access to and motivation for
treatment.
Long-term use of opioids for complex chronic pain Von Korff, Michael R
Baillière's best practice and research in clinical rheumatology/Baillière's best practice & research. Clinical rheumatology,
10/2013, Letnik:
27, Številka:
5
Journal Article
Recenzirano
Odprti dostop
Abstract Increased opioid prescribing for back pain and other chronic musculoskeletal pain conditions has been accompanied by dramatic increases in prescription-opioid addiction and fatal overdose. ...Opioid-related risks appear to increase with dose. Although short-term randomised trials of opioids for chronic pain have found modest analgesic benefits (a one-third reduction in pain intensity on average), the long-term safety and effectiveness of opioids for chronic musculoskeletal pain remains unknown. Given the lack of large, long-term randomised trials, recent epidemiologic data suggest the need for caution when considering long-term use of opioids to manage chronic musculoskeletal pain, particularly at higher dosage levels. Principles for achieving more selective and cautious use of opioids for chronic musculoskeletal pain are proposed.
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