Use of chronic opioid therapy for chronic noncancer pain has increased substantially. The American Pain Society and the American Academy of Pain Medicine commissioned a systematic review of the ...evidence on chronic opioid therapy for chronic noncancer pain and convened a multidisciplinary expert panel to review the evidence and formulate recommendations. Although evidence is limited, the expert panel concluded that chronic opioid therapy can be an effective therapy for carefully selected and monitored patients with chronic noncancer pain. However, opioids are also associated with potentially serious harms, including opioid-related adverse effects and outcomes related to the abuse potential of opioids. The recommendations presented in this document provide guidance on patient selection and risk stratification; informed consent and opioid management plans; initiation and titration of chronic opioid therapy; use of methadone; monitoring of patients on chronic opioid therapy; dose escalations, high-dose opioid therapy, opioid rotation, and indications for discontinuation of therapy; prevention and management of opioid-related adverse effects; driving and work safety; identifying a medical home and when to obtain consultation; management of breakthrough pain; chronic opioid therapy in pregnancy; and opioid-related polices.
Safe and effective chronic opioid therapy for chronic noncancer pain requires clinical skills and knowledge in both the principles of opioid prescribing and on the assessment and management of risks associated with opioid abuse, addiction, and diversion. Although evidence is limited in many areas related to use of opioids for chronic noncancer pain, this guideline provides recommendations developed by a multidisciplinary expert panel after a systematic review of the evidence.
A staggering number of Americans are dying from overdoses attributed to prescription opioid medications (POMs). In response, states are creating policies related to POM harm reduction strategies, ...overdose prevention, and alternative therapies for pain management, such as cannabis (medical marijuana). However, little is known about how the use of cannabis for pain management may be associated with POM use.
The purpose of this article is to examine state medical cannabis (MC) use laws and policies and their potential association with POM use and related harms.
A systematic literature review was conducted to explore United States policies related to MC use and the association with POM use and related harms. Medline, PubMed, CINAHL, and Cochrane databases were searched to identify peer-reviewed articles published between 2010 and 2017. Using the search criteria, 11,513 records were identified, with 789 abstracts reviewed, and then 134 full-text articles screened for eligibility.
Of 134 articles, 10 articles met inclusion criteria. Four articles were cross-sectional online survey studies of MC substitution for POM, six were secondary data analyses exploring state-level POM overdose fatalities, hospitalizations related to MC or POM harms, opioid use disorder admissions, motor vehicle fatalities, and Medicare and Medicaid prescription cost analyses. The literature suggests MC laws could be associated with decreased POM use, fewer POM-related hospitalizations, lower rates of opioid overdose, and reduced national health care expenditures related to POM overdose and misuse. However, available literature on the topic is sparse and has notable limitations.
Review of the current literature suggests states that implement MC policies could reduce POM-associated mortality, improve pain management, and significantly reduce health care costs. However, MC research is constrained by federal policy restrictions, and more research related to MC as a potential alternative to POM for pain management, MC harms, and its impact on POM-related harms and health care costs should be a priority of public health, medical, and nursing research.
•A staggering number of Americans are dying from overdoses attributed to prescription opioid medications (POMs).•Alternative therapies are being used for pain management, such as medical cannabis (MC) (medical marijuana). However, little is known about how the use of cannabis for pain management may be associated with POM use and related harms.•States that implement MC policies could potentially reduce POM-associated mortality, improve pain management, and significantly reduce health care costs.•MC research is constrained by federal policy restrictions.•Research related to MC as a potential alternative to POM for pain management, MC harms, and its impact on POM-related harms and health care costs should be a priority of public health, medical, and nursing research.
Abstract Context Morphine has been considered the gold standard for treating moderate-to-severe pain, although many new opioid products and formulations have been marketed in the last two decades and ...should be considered when examining opioid consumption. Understanding opioid consumption is improved by using an equianalgesic measure that controls for the strengths of all examined opioids. Objectives The research objective was to use a morphine equivalence (ME) metric to determine the extent that morphine consumption relates to the total consumption of all other study opioids. Methods An ME metric was created for morphine and the aggregate consumption of each study opioid (Total ME), adjusted for country population to allow for uniform equianalgesic comparisons. Graphical and statistical evaluations of morphine use and Total ME consumption trends (between 1980 and 2009) were made for the global and geographic regional levels and selected developed and developing countries. Results Global morphine consumption rose dramatically in the early 1980s but has been significantly outpaced by Total ME since 1996. As expected, the extent of morphine and Total ME consumption varied notably among regions, with the Americas, Europe, and Oceania regions accounting for the highest morphine use and Total ME in 2009. Developing and least developed countries, compared with developed countries, demonstrated lower overall Total ME consumption. Conclusion Generally, worldwide morphine use has not increased at the rate of Total ME, especially in recent years. Examining a country's ability to effectively manage moderate-to-severe pain should extend beyond morphine to account for all available potent opioids.
Although opioid prescribing has recently trended downward, opioid-related overdoses and deaths have drastically increased. Community pharmacists are accessible health care providers who are well ...positioned to disseminate information on opioid safety and to educate and counsel on medication use, managing adverse events, and proper medication disposal. Patient callbacks facilitate appropriate medication usage. We developed an opioid callback program that provides a framework for pharmacists to follow up with patients with an opioid prescription.
This study aimed to (1) describe the development of the opioid callback initiative and (2) report results from a pilot test in 2 community pharmacies.
The opioid callback process and data collection forms were collaboratively developed with community pharmacists at each site. Data recorded on the opioid callback forms were descriptively analyzed and chi-square test of independence explored differences by pain durations related to opioid disposal, security, and safety. Participating pharmacy staff were interviewed to identify facilitators and barriers to implementation, as well as opportunities for improvement.
Forty-one opioid callbacks were attempted and 36 were completed (87.8%). Pharmacists were statistically significantly more likely to discuss naloxone with patients with chronic pain (89.5%) than those with acute pain (46.2%). Pharmacists reported that the program successfully raised awareness of opioid disposal opportunities and safe opioid practices, including storage and naloxone ownership. They expressed patients' willingness to answer questions and appreciation for the extra attention and care.
Community pharmacists are well positioned to address the opioid crisis as access points for medication questions, opioid safety education, opioid disposal, naloxone, and medications for people with an opioid use disorder. This study presents a proof of concept for a pharmacist-led opioid callback program. Expansion could help inform patients about how to use opioids safely, how to treat an opioid overdose, and where to dispose of unused medications.
Advanced practice registered nurses (APRNs) are essential partners in the management of pain, both in primary care and in pain specialty practices. One of the more controversial treatment practices ...surrounds the use of opioid analgesic medication for the relief of pain in persons with chronic pain. Although several guidelines have been developed, the extent and impact of APRN knowledge, attitudes, and values about pain management and opioid prescribing practices are not known. In addition, regulatory mandates may encumber APRN scope of pain management practice.
This manuscript describes the development and pilot testing of the Achieving Effective & Safe Opioid Prescribing–APRN (AESOP-APRN) Survey conceptualized to address these topics.
Instrument development.
Advanced practice registered nurses.
Phase I addressed development, content validity determination, and survey refinement. APRN-focused discussion groups, expert review, and analysis of content were conducted. In phase II, pilot testing was conducted to determine reliability.
APRNs are aware of regulatory restrictions to practice and potential implications on patient outcomes. The Initial Content Validity Index suggested refinement of survey questions. After content revision, final ratings were acceptable. A sample of APRNs (N = 23) completed the survey. Cronbach's α range (.65-.91) suggests acceptable internal consistency for a new survey.
Even at this initial phase, the newly developed AESOP-APRN Survey accurately represents the underlying thematic concepts of interest; however further psychometric analyses are required, and instrument refinement is possible. Additional study should include analysis of members from a variety of health care disciplines, as was the intention of the development of the Core Competencies for Pain Management from which many items were derived.
This study updates a previous analysis of trends in medical use and abuse of opioid analgesics, and provides data from 1997 through 2002. Two research questions were evaluated: 1) What are the trends ...in the medical use and abuse of frequently prescribed opioid analgesics used to treat severe pain, including fentanyl, hydromorphone, meperidine, morphine, and oxycodone? 2) What is the abuse trend for opioid analgesics as a class compared to trends in the abuse of other drug classes? Results demonstrated marked increases in medical use and abuse of four of the five studied opioid analgesics. In 2002, opioid analgesics accounted for 9.85% of all drug abuse, up from 5.75% in 1997. Increase in medical use of opioids is a general indicator of progress in providing pain relief. Increases in abuse of opioids is a growing public health problem and should be addressed by identifying the causes and sources of diversion, without interfering with legitimate medical practice and patient care.
This study used an innovative information-gathering approach to provide insight into the nature and structure of pharmacy staff encounters with patients seeking over-the-counter (OTC) medications and ...revealed specific activities of pharmacy staff around these encounters.
A multistep process was used to develop and standardize an 8-item OTC Encounter Form to document the characteristics of pharmacy staff-patient encounters. The OTC Form contained several domains, including topics discussed and the problems or symptoms identified during the encounter, staff functions during the encounter, and approximate time spent with the patient. Nine pharmacists and 8 technicians used the OTC Form to document patient encounters over 7 consecutive days. Frequency distributions for each OTC Form item are reported.
One hundred eleven OTC Forms were completed. Adults aged 65 years or older were involved in 46% of all encounters. Pharmacists provided the only assistance in 41% of encounters and worked in partnership with other pharmacy staff for another 25% of encounters. Many encounters required the pharmacy staff to leave the prescription department, involved discussions about a variety of problems or symptoms, and lasted less than 3 minutes. Although the most prevalent encounter topic was locations of a particular product, about one-third of encounters involved either recommendations about a product or providing information about a product, and 41% involved communications about 2 or more topics. Finally, 11% of encounters generated a nondrug recommendation, and 8% resulted in a referral to a physician.
Pharmacists play a key role in ensuring that the benefits of OTC medications outweigh the risks, thereby providing an important resource for patient engagement about safe medication selection and use. Examining the features of OTC encounters creates an evidence base to promote best practices for OTC encounters, increasing pharmacists' ability to help people, especially older adults, navigate the intricacies of OTC medication use, without significantly increasing pharmacy staff workload.
Pain often is inadequately treated due in part to reluctance about using opioid analgesics and fear that they will be abused. Although international and national expert groups have determined that ...opioid analgesics are essential for the relief of pain, little information has been available about the health consequences of the abuse of these drugs.
To evaluate the proportion of drug abuse related to opioid analgesics and the trends in medical use and abuse of 5 opioid analgesics used to treat severe pain: fentanyl, hydromorphone, meperidine, morphine, and oxycodone.
Retrospective survey of medical records from 1990 to 1996 stored in the databases of the Drug Abuse Warning Network (source of abuse data) and the Automation of Reports and Consolidated Orders System (source of medical use data).
Nationally representative sample of hospital emergency department admissions resulting from drug abuse.
Medical use in grams and grams per 100,000 population and mentions of drug abuse by number and percentage of the population.
From 1990 to 1996, there were increases in medical use of morphine (59%; 2.2 to 3.5 million g), fentanyl (1168%; 3263 to 41,371 g), oxycodone (23%; 1.6 to 2.0 million g), and hydromorphone (19%; 118,455 to 141,325 g), and a decrease in the medical use of meperidine (35%; 5.2 to 3.4 million g). During the same period, the total number of drug abuse mentions per year due to opioid analgesics increased from 32,430 to 34,563 (6.6%), although the proportion of mentions for opioid abuse relative to total drug abuse mentions decreased from 5.1% to 3.8%. Reports of abuse decreased for meperidine (39%; 1335 to 806), oxycodone (29%; 4526 to 3190), fentanyl (59%; 59 to 24), and hydromorphone (15%; 718 to 609), and increased for morphine (3%; 838 to 865).
The trend of increasing medical use of opioid analgesics to treat pain does not appear to contribute to increases in the health consequences of opioid analgesic abuse.
The purpose of this study is to determine the types of content and to what extent that individual State Boards of Nursing (SBON) in the U.S. are providing information and education for nurses to ...mitigate prescription opioid misuse and diversion by patients and the public.
A descriptive, cross-sectional, survey research design was selected.
A survey of the SBON by two investigators, who independently reviewed each SBON website, was completed over a four-week time-period. The websites were explored for resources related to opioids. Links and descriptions were reviewed, then compared for accuracy.
All but two SBON had at least some information on the mitigation of prescription opioid misuse and diversion. Minimal information was available regarding the mitigation of opioid misuse and diversion in 18 of the 50 states and DC (35%).
SBON have a responsibility to educate licensees to enable them to assist in the mitigation of opioid misuse and diversion. States have resources like PDMPs, opioid tool-kits, newsletters, announcements, and prescriber guidelines that need to be more numerous, of higher quality, and easier to access. SBON should be commended for the resources that they currently provide, but more can be done for nurses to aid in this endeavor. SBON are positioned to provide education and information for nurses to reduce opioid misuse, and diversion. The SBON websites need to have a link to their PDMP, opioid toolkit, OD treatment, and opioid prescribing guidelines readily accessible by nurses and especially APRNs.
Objective. Opioid analgesics are the drugs of choice for the treatment of moderate to severe acute and cancer pain. Although their role in the management of chronic pain not related to cancer is ...controversial, there is increasing evidence for their benefit in certain patient populations.
Design. A 32‐item survey to assess Wisconsin physicians' knowledge, beliefs, and attitudes toward opioid analgesic use was mailed to 600 randomly selected licensed physicians, resulting in a 36% response rate.
Results. Half of the respondents considered diversion a moderate or severe problem in Wisconsin. A majority considered addiction to be a combination of physiological and behavioral characteristics, rather than defining it solely as a behavioral syndrome. Most physicians felt it lawful and acceptable medical practice to prescribe opioids for chronic cancer pain, but only half held this view if the pain was not related to cancer. Fewer physicians considered such prescribing as lawful and generally accepted medical practice if the patient had a history of substance abuse. About two‐thirds of physicians were not concerned about being investigated for their opioid prescribing practices, but some admitted that fear of investigation led them to lower the dose prescribed, limit the number of refills, or prescribe a Schedule III or IV rather than a Schedule II opioid.
Conclusion. Wisconsin physicians who responded to this survey held many misconceptions about the prescribing of opioids. Such views, coupled with a lack of knowledge about laws and regulations governing the prescribing of controlled substances, may result in inadequate prescribing of opioids with resultant inadequate management of pain.
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