Managing Concerning Behaviors in Patients Prescribed Opioids for Chronic Pain: A Delphi Study

Merlin, Jessica S.; Young, Sarah; Starrels, Joanna L.; Azari, Soraya; Edelman, E. Jennifer; Pomeranz, Jamie L.; Roy, Payel; Saini, Shalini; Becker, William C.; Liebschutz, Jane M.

doi:10.1007/s11606-017-4211-y

Cited by 41 publications

(38 citation statements)

References 26 publications

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“…As prescribing behavior is influenced by laws, policies, and other environmental factors at the state and local level, it is unclear whether prescribing patterns observed in the VHA will necessarily generalize to other healthcare systems. The VA is an integrated system that has made significant efforts in recent years to reduce the prevalence and associated risks of LTO, [22][23][24][25][26][27][28] including implementing the Opioid Safety Initiative, the opioid overdose and naloxone distribution (OEND) program, the Stratification Tool for Opioid Risk Mitigation (STORM) tool, and increasing access to non-pharmacological pain management options. 22,23,25 In addition, this study was restricted to new LTO prescribing which accounted for about 15% of LTO prescribing in the VA in 2016, 29 and future research is needed to determine whether these same patterns would generalize to all prevalent LTO prescribing.…”

Section: Discussionmentioning

confidence: 99%

A Typology of New Long-term Opioid Prescribing in the Veterans Health Administration

et al. 2020

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BACKGROUND: Narrow definitions of long-term opioid (LTO) use result in limited knowledge of the full range of LTO prescribing patterns and the rates of these patterns. OBJECTIVE: To investigate a model of new LTO prescribing typologies using latent class analysis. DESIGN: National administrative data from the VA Corporate Data Warehouse were accessed using the VA Informatics and Computing Infrastructure. Characterization of the typology of initial LTO prescribing was explored using latent class analysis. PARTICIPANTS: Veterans initiating LTO during 2016 through the Veteran's Administration Healthcare System (N = 42,230). MAIN MEASURES: Opioid receipt as determined by VA prescription data, using the cabinet supply methodology. KEY RESULTS: Over one-quarter (27.7%) of the sample fell into the fragmented new long-term prescribing category, 39.8% were characterized by uniform daily new LTO, and the remaining 32.7% were characterized by uniform episodic LTO. Each of these three broad sub-groups also included two additional sub-groups (6 classes total in the model), characterized by the presence or absence of prior opioid prescriptions. CONCLUSIONS: New LTO prescribing in the VA includes uniform daily prescribing, uniform episodic prescribing, and fragmented prescribing. Future work is needed to elucidate the safety and efficacy of these prescribing patterns.

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Section: Discussionmentioning

confidence: 99%

A Typology of New Long-term Opioid Prescribing in the Veterans Health Administration

et al. 2020

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“…Importantly, early and aggressive intervention in response to aberrancy and comorbid emotional and behavioral issues potentially results in the ability to continue opioid analgesics as a treatment for these patients, which is imperative at a time in which efficacious and cost-effective chronic pain treatment options appear to be dwindling. Some of the treatments of early stage opioid aberrancy that have empirical and/or consensus support include increased patient education regarding opioids,40 switching to abuse-deterrent formulations,41 use of multimodal rather than unimodal opioid pain management strategies,42 opioid rotation,43 and the provision of behavioral services 44…”

Section: Discussionmentioning

confidence: 99%

<p>Increased frequency of urine drug testing in chronic opioid therapy: rationale for strategies for enhancing patient adherence and safety</p>

DiBenedetto¹,

Wawrzyniak²,

Schatman³

et al. 2019

JPR

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Objective To determine the average amount of time required to detect opioid aberrancy based upon varying frequencies of urine drug testing (UDT) in a community-based, tertiary care pain management center. Subjects This study was a retrospective analysis of 513 consecutive patients enrolled in a medication management program, receiving chronic opioid therapy between January 1, 2018 and December 31, 2018. Methods Data were extracted from medical records including age at start of the study period, sex, ethnicity, marital status, and smoking status. UDT was performed at each prescribing visit via semi-quantitative immunoassay, and at the discretion of the clinician, a sample was sent for external confirmation using gas chromatography or mass spectrometry testing to clarify questions of inconsistency with patients’ reports or prescribed medications. For purposes of the study, “opioid aberrancy” was defined through inconsistent UDT. Results One hundred and fifteen patients (22.4%) had at least one inconsistent UDT during the study period, and 160 (2.8%) of all UDTs were inconsistent. At this rate of inconsistency, it was determined that with monthly screening, it would require up to 36 months to detect a single aberrancy, and semi-annual testing would require as long as 216 months to detect an aberrancy. Conclusions More frequent UDT can be helpful in terms of earlier detection of opioid aberrancy. This has significant implications for helping avoid misuse, overdose, and potential diversion. Furthermore, early detection will ideally result in earlier implementation of treatment of the emotional and behavioral factors causing aberrancy. Such early intervention is more likely to be successful in terms of reducing substance misuse in a chronic pain population, providing a higher degree of patient adherence and safety, as well as producing superior overall patient outcomes. Finally, economic benefits may include substantial savings through avoidance of the necessity for drug rehabilitation and the empirically established higher costs of treating opioid misuse comorbidities.

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“…Each case was followed by several questions on appropriateness of various management strategies based on published management strategies for opioid misuse behaviours in primary care settings 20 and study team clinical expertise. These included strategies such as increasing opioids; tapering opioids; starting, splitting and stopping buprenorphine/naloxone, methadone, or other full agonist therapy and referring patients to addiction treatment.…”

Section: Methods and Analysismentioning

confidence: 99%

Consensus-based approach to managing opioids, including opioid misuse and opioid use disorder, in patients with serious illness: protocol for a modified Delphi process

et al. 2021

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IntroductionManagement of opioid misuse and opioid use disorder (OUD) among individuals with serious illness is an important yet understudied issue. Palliative care clinicians caring for individuals with serious illness, many of whom may live for months or years, describe a complex tension between weighing the benefits of opioids, which are considered a cornerstone of pain management in serious illness, and serious opioid-related harms like opioid misuse and OUD. And yet, little literature exists to inform the management of opioid misuse and OUDs among individuals with serious illness. Our objective is to provide evidence-based management guidance to clinicians caring for individuals with serious illness who develop opioid misuse or OUD.Methods and analysisWe chose a modified Delphi approach, which is appropriate when empirical evidence is lacking and expert input must be used to shape clinical guidance. We sought to recruit 60 clinicians with expertise in palliative care, addiction or both to participate in this study. We created seven patient cases that capture important management challenges in individuals with serious illness prescribed opioid therapy. We used ExpertLens, an online platform for conducting modified Delphi panels. Participants completed three rounds of data collection. In round 1, they rated and commented on the appropriateness of management choices for cases. In round 2, participants reviewed and discussed their own and other participants’ round 1 numerical responses and comments. In round 3 (currently ongoing), participants again reviewed rounds 1 and 2, and are allowed to change their final numerical responses. We used ExpertLens to automatically identify whether there is consensus, or disagreement, among responses in panels. Only round 3 responses will be used to assess final consensus and disagreement.Ethics and disseminationThis project received ethical approval from the University of Pittsburgh’s Institutional Review Board (study 19110301) and the RAND Institutional Research Board (study 2020-0142). Guidance from this work will be disseminated through national stakeholder networks to gain buy-in and endorsement. This study will also form the basis of an implementation toolkit for clinicians caring for individuals with serious illness who are at risk of opioid misuse or OUD.

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Managing Concerning Behaviors in Patients Prescribed Opioids for Chronic Pain: A Delphi Study

Abstract: This study presents clinical expert consensus on how to manage concerning behaviors among patients on LTOT. Future research is needed to investigate how implementing these management strategies would impact patient outcomes, practice and policy.

Cited by 41 publications

References 26 publications

A Typology of New Long-term Opioid Prescribing in the Veterans Health Administration

A Typology of New Long-term Opioid Prescribing in the Veterans Health Administration

<p>Increased frequency of urine drug testing in chronic opioid therapy: rationale for strategies for enhancing patient adherence and safety</p>

Consensus-based approach to managing opioids, including opioid misuse and opioid use disorder, in patients with serious illness: protocol for a modified Delphi process

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