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Von Korff, Michael, Andrew Kolodny, Richard A. Deyo, and Roger Chou. "Long-Term Opioid Therapy Reconsidered." Annals of Internal Medicine 155, no. 5 (September 6, 2011): 325. http://dx.doi.org/10.7326/0003-4819-155-5-201109060-00011.
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Young, Jessica C., Michele Jonsson Funk, and Nabarun Dasgupta. "Medical Use of Long-term Extended-release Opioid Analgesics in Commercially Insured Adults in the United States." Pain Medicine 21, no. 4 (July 24, 2019): 724–35. http://dx.doi.org/10.1093/pm/pnz155.
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Abstract Objectives We examined the proportion of patients initiating extended-release (ER) opioids who become long-term users and describe how pain-related diagnoses before initiation of opioid therapy vary between drugs and over time. Methods Using MarketScan (2006–2015), a US national commercial insurance database, we examined pain-related diagnoses in the 182-day baseline period before initiation of ER opioid therapy to characterize indications for opioid initiation. We report the proportion who became long-term users, the median length of opioid therapy, and the proportion with cancer and other noncancer chronic pain, by active ingredient. Results Among 1,077,566 adults initiating ER opioids, 31% became long-term users, with a median length of use of 209 days. The most common ER opioids prescribed were oxycodone (26%) and fentanyl (23%), and the most common noncancer pain diagnoses were back pain (65%) and arthritis (48%). Among all long-term users, 16% had a diagnosis of cancer. We found notable variation by drug. Eighteen percent of patients initiating drugs approved by the Food and Drug Administration >10 years ago had evidence of cancer during baseline compared with only 8% of patients who received newer drugs. Conclusions In a national sample of adults with private insurance, back pain was the most common diagnosis preceding initiation of opioid therapy. Opioids that have been approved within the last 10 years were more frequently associated with musculoskeletal pains and less frequently associated with cancer. Amid increasing concerns regarding long-term opioid therapy, our findings provide context regarding the conditions for which long-term opioid therapy is prescribed.
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Manchikanti, Laxmaiah. "Effectiveness of Long-Term Opioid Therapy for Chronic Non-Cancer Pain." Pain Physician 3;14, no. 2;3 (March 14, 2011): E133—E156. http://dx.doi.org/10.36076/ppj.2011/14/e133.
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Background: Opioids have been utilized for thousands of years to treat pain and their use continues to escalate. It is estimated that 90% of the patients who present to pain centers and receive treatment in such facilities are on opioids. However, in contrast to increasing opioid use and the lack of evidence supporting long-term effectiveness in chronic non-cancer pain, is the escalating misuse of prescription opioids, including abuse and diversion. There is also uncertainty about the incidence and clinical salience of multiple, poorly characterized adverse drug events, including endocrine dysfunction, immunosuppression, infectious disease, opioidinduced hyperalgesia, overdoses, deaths, and psychosocial and economic implications. Study Design: A comprehensive review of the literature. Objective: The objective of this comprehensive review is to evaluate the clinical effectiveness and safety of chronic opioid therapy in chronic non-cancer pain. Methods: A comprehensive review of the literature relating to chronic opioid therapy in chronic non-cancer pain. The literature was collected from various electronic and other sources. The literature that was evaluated included randomized trials, observational studies, case reports, systematic reviews, and guidelines. Outcome Measures: Pain relief was the primary outcome measure. The secondary outcome measures were functional improvement and adverse effects. Short-term effectiveness was considered to be less than 6 months; long-term effectiveness was considered to be at least one year. Results: Given the complexity and widespread nature of opioid therapy, there is a paucity of qualitative and/or quantitative literature. The available evidence is weak for pain relief combined with improvement in functional status. Only one drug, tramadol, is effective for pain relief and improvement of functional status. Limitations: This is a narrative review without application of methodologic quality assessment criteria. Even so, a paucity of literature exists concerning both controlled and observational literature for multiple drugs and multiple conditions of chronic non-cancer pain. Conclusions: This comprehensive review illustrates the lack of literature on long-term opioid therapy; thus, opioid therapy should be provided with great restraint and caution, based on the weak evidence available. Key words: Chronic non-cancer pain, opioids, opioid effectiveness, adverse effects, morphine, hydrocodone, hydromorphone, fentanyl, tramadol, methadone, oxycodone
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MOSS, CHAILEE, CARLA BOSSANO, SILKA PATEL, ANNA POWELL, RACHEL CHAN SEAY, and MOSTAFA A. BORAHAY. "Weaning From Long-term Opioid Therapy." Clinical Obstetrics and Gynecology 62, no. 1 (March 2019): 98–109. http://dx.doi.org/10.1097/grf.0000000000000425.
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Reisfield, Gary M., and Lynn R. Webster. "Benzodiazepines in Long-Term Opioid Therapy." Pain Medicine 14, no. 10 (October 2013): 1441–46. http://dx.doi.org/10.1111/pme.12236.
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Katz, Mitchell H. "Harm From Long-term Opioid Therapy." Archives of Internal Medicine 172, no. 5 (March 12, 2012): 430. http://dx.doi.org/10.1001/archinternmed.2011.1724.
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Watson, CPN, JH Watt-Watson, and ML Chipman. "Chronic Noncancer Pain and the Long Term Utility of Opioids." Pain Research and Management 9, no. 1 (2004): 19–24. http://dx.doi.org/10.1155/2004/304094.
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OBJECTIVE:To report on a long term experience in treating patients with chronic noncancer pain (CNCP).METHODS:One hundred two patients with CNCP were seen every three months and followed for one year or more (median eight years, range one to 22). Demographic data, diagnostic categories and response to therapies were recorded. The utility and safety of opioid therapy, adverse events, impact on disability and issues related to previous psychiatric or chemical dependency history were documented.RESULTS:Most patients reported a variety of neuropathic pain problems and most required chronic opioid therapy after the failure of other treatments. Although 44% reported being satisfied with pain relief despite adverse events, it is noteworthy that the remaining patients chose to continue therapy for the modest benefit of pain relief despite adverse events. Moreover, 54% were less disabled on opioid therapy.CONCLUSIONS:This is a large sample of CNCP patients, most taking opioids over a long period of time. CNCP can be treated by opioids safely and with a modest effect, with improvement in functioning in some patients who are refractory to other measures. If care is taken, opioids may even be used effectively for patients with a history of chemical dependency.
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Leroux, Timothy S., Bryan M. Saltzman, Shelby A. Sumner, Naomi Maldonado-Rodriguez, Avinesh Agarwalla, Bheeshma Ravi, Gregory L. Cvetanovich, Christian J. Veillette, Nikhil N. Verma, and Anthony A. Romeo. "Elective Shoulder Surgery in the Opioid Naïve: Rates of and Risk Factors for Long-term Postoperative Opioid Use." American Journal of Sports Medicine 47, no. 5 (April 2019): 1051–56. http://dx.doi.org/10.1177/0363546519837516.
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Background: Little is known regarding the rates and risk factors for long-term postoperative opioid use among opioid-naïve patients undergoing elective shoulder surgery. Purpose: To identify (1) the proportion of opioid-naïve patients undergoing elective shoulder surgery, (2) the rates of postoperative opioid use among these patients, and (3) the risk factors associated with long-term postoperative opioid use. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of a private administrative claims database was performed to identify those individuals who underwent elective shoulder surgery between 2007 and 2015. “Opioid-naïve” patients were identified as those patients who had not filled an opioid prescription in the 180 days before the index surgery. Within this subgroup, we tracked postoperative opioid prescription refill rates and used a logistic regression to identify patient variables that were predictive for long-term opioid use, which we defined as continued opioid refills beyond 180 days after surgery. Results were reported as odds ratios (ORs). Results: Over the study period, 79,287 patients were identified who underwent elective shoulder surgery, of whom 79.5% were opioid naïve. Among opioid-naïve patients, the rate of postoperative opioid use declined over time, and 14.6% of patients were still using opioids beyond 180 days. The greatest proportion of opioid-naïve patients still filling opioid prescriptions beyond 180 days postoperatively was seen after open rotator cuff repair (20.9%), whereas arthroscopic labral repair had the lowest proportion (9.8%). Overall, a history of alcohol abuse (OR 1.56), a history of depression (OR 1.46), a history of anxiety (OR, 1.31), female sex (OR, 1.11), and higher Charlson Comorbidity Index (OR 1.02) had the most significant influence on the risk for long-term opioid use among opioid naïve patients. Conclusions: Most patients were opioid naïve before elective shoulder surgery; however, among opioid-naïve patients, 1 in 7 patients were still using opioids beyond 180 days after surgery. Among all variables, a history of mental illness most significantly increased the risk of long-term opioid use after elective shoulder surgery.
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Elsesser, Karin, and Thomas Cegla. "Long-term treatment in chronic noncancer pain: Results of an observational study comparing opioid and nonopioid therapy." Scandinavian Journal of Pain 17, no. 1 (October 1, 2017): 87–98. http://dx.doi.org/10.1016/j.sjpain.2017.07.005.
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AbstractBackground and aimsRecent studies reveal high prevalence rates of patients receiving long-term opioids. However, well designed studies assessing effectiveness with longer than 3 months follow-up are sparse. The present study investigated the outcomes of long-term opioid therapy compared to nonopioid treatment in CNCP patients with respect to measures of pain, functional disability, psychological wellbeing, and quality of life (QoL).MethodsThree hundred and thirty three consecutive patients at our pain clinic were included and divided into patients with continuous opioid treatment for at least 3 months (51%) and patients receiving nonopioid analgesics (49%). Further, outcome of different doses of opioid (<120 mg vs. >120 mg morphine equivalents) and differences between high and low potency opioids were examined.ResultsThe opioid and nonopioid groups did not differ with regard to pain intensity or satisfaction with analgesic. Patients with continuous opioids treatment reported higher neuropathic like pain, longer duration of pain disorder, lower functional level, wellbeing, and physical QoL in comparison to patients receiving nonopioid analgesics. Higher opioid doses were associated with male gender, intake of high potency opioids and depression but there were no differences with regard to pain relief or improvement of functional level between high and low doses. Similarly, patients on high potency opioids reported more psychological impairment than patients on low potency opioids but no advantage with regard to pain relief. Overall, remaining level of pain, functional disability and poor QoL were quite high irrespective of the analgesic used or opioid dosing.ConclusionsIn the long-term no clear advantage of opioid vs. non-opioid analgesics could be revealed. In terms of remaining pain intensity, functional disability and quality of life, treatment with pain medication proved insufficient. Additionally, with higher doses of opioids the benefit to risk relationship becomes worse and patients on high potency opioids reported more psychological impairment than patients on low potency opioids but no advantage with regard to pain relief.ImplicationsOur results raise questions about the long-term effectiveness of analgesic treatment regimens irrespective of analgesics type employed and call for more multidisciplinary treatment strategies.
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Kim, Chong H. "Androgen Deficiency in Long-Term Intrathecal Opioid Administration." Pain Physician 4;17, no. 4;7 (July 14, 2014): E543—E548. http://dx.doi.org/10.36076/ppj.2014/17/e543.
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Background: Intrathecal drug delivery of opioids is an efficient and effective treatment option for pain management in the chronic nonmalignant pain population. As with all treatments, in addition to the benefits, risks and side effects exist. One such risk in intrathecal opioids is opioid-induced androgen deficiency. Objective: This study evaluates opioid-induced androgen deficiency in long-term intrathecal opioid administration in chronic nonmalignant pain. Study Design: Case series. Sixteen consecutive patients with intrathecal drug delivery with opioids were screened for androgen deficiency. Setting: Academic university-based pain management center. Method: All the subjects were seen in a 2 month period, during a scheduled maintenance refill visit. Eight consecutive men and eight consecutive women receiving intrathecal drug delivery therapy for non-malignant chronic pain were ordered blood work and asked to complete a questionnaire. Patient and patient-related data were also collected. Results: Ten of the 16 (62.5%) patients were found to have androgen deficiency, 4 of 8 men based on free testosterone levels and 6 of 8 women based on DHEA levels. In men, erectile dysfunction correlated with endocrine dysfunction (P = 0.02) while depressive symptoms correlated in women (P = .03). Overall, 2 of the 16 patients had hydromorphone as the opioid in the intrathecal system. Both patients had normal endocrine functions. Both patients with hydromorphone were men and the use of hydromorphone showed an insignificant trend (P = 0.06). Three of the 4 men with normal endocrine functions had in addition to an opioid, bupivacaine, in the intrathecal system. The presence of bupivicaine in men was significant (P = 0.02). No women had bupivicaine while one of the 8 women had clonidine in addition to the opioid. Presence of another substance in addition to the opioid showed an insignificant trend (P = 0.08). Limitations: Study limitations include the small sample size and case series nature. Additionally the symptoms data was solely based on subjective patient reports. Conclusions: Androgen deficiency is common in patients treated with intrathecal opioids for chronic nonmalignant pain. Patients experience numerous and wide ranging symptoms. Erectile dysfunction may be more suggestive for androgen deficiency in men while complaints of depressed mood may be correlative in women. Additionally, combining bupivicaine with the intrathecal opioid may provide a protective role. Key words: Androgen deficiency, endocrine dysfunction, chronic nonmalignant pain, intrathecal opioid, intrathecal drug delivery, side effects
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Hemmert, Rachael, Gabriella E. Dull, and Linda S. Edelman. "THE OPIOID EPIDEMIC IN LONG-TERM CARE: A STAFF PERSPECTIVE." Innovation in Aging 3, Supplement_1 (November 2019): S709. http://dx.doi.org/10.1093/geroni/igz038.2604.
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Abstract Opioid-based analgesic therapy is a common treatment for moderate to severe pain among long term care (LTC) residents. It has been estimated that 60% of LTC residents have an opioid prescription. Of these, 14% use opioids as part of a long term pain management strategy. LTC residents are particularly vulnerable to opioid misuse, exhibiting higher rates of adverse drug events. However, addressing pain, polypharmacological needs and resident well-being in the LTC setting is challenging. More research and education regarding opioid use in LTC is needed. The Utah Geriatric Education Consortium conducted interprofessional focus groups with LTC partners to 1) determine educational needs of staff regarding opioid use, and 2) gather qualitative data about the pain management experiences of staff when working with residents and families. Staff identified the following training needs: pain manifestation and assessment; certified nurse assistant education on opioid use; non-pharmacological options for pain management. Review of staff’s perception of the intersection of opioids, family and staff in a LTC setting revealed that 1) family is concerned about opioid use; 2) conversely, staff may not see opioid use as a problem; and 3) non-pharmacological options for pain management are often costly and unavailable to those in LTC. Identifying educational needs of LTC staff will help guide the development of educational materials and provide baseline data for future assessments of the impact of opioid education on long-term care patient outcomes.
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Keller, Michelle S., Alma Jusufagic, Teryl K. Nuckols, Jack Needleman, and MarySue Heilemann. "Understanding Clinicians’ Decisions to Assume Prescriptions for Inherited Patients on Long-term Opioid Therapy: A Qualitative Study." Pain Medicine 21, no. 11 (March 18, 2020): 3187–98. http://dx.doi.org/10.1093/pm/pnaa045.
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Abstract Objective Given the changing political and social climate around opioids, we examined how clinicians in the outpatient setting made decisions about managing opioid prescriptions for new patients already on long-term opioid therapy. Methods We conducted in-depth interviews with 32 clinicians in Southern California who prescribed opioid medications in the outpatient setting for chronic pain. The study design, interview guides, and coding for this qualitative study were guided by constructivist grounded theory methodology. Results We identified three approaches to assuming a new patient’s opioid prescriptions. Staunch Opposers, mostly clinicians with specialized training in pain medicine, were averse to continuing opioid prescriptions for new patients and often screened outpatients seeking opioids. Cautious and Conflicted Prescribers were wary about prescribing opioids but were willing to refill prescriptions if they perceived the patient as trustworthy and the medication fell within their comfort zone. Clinicians in the first two groups felt resentful about other clinicians “dumping” patients on opioids on them. Rapport Builders, mostly primary care physicians, were the most willing to assume opioid prescriptions and were strategic in their approach to transitioning patients to safer doses. Conclusions Clinicians with the most training in pain management were the least willing to assume responsibility for opioid prescriptions for patients already on long-term opioid therapy. In contrast, primary care clinicians were the most willing to assume this responsibility. However, primary care clinicians face barriers to providing high-quality care for patients with complex pain conditions, such as short visit times and less specialized training.
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Lubrano, Michael, Jonathan P. Wanderer, and Jesse M. Ehrenfeld. "Long-Term Opioid Therapy for Chronic Pain." Annals of Internal Medicine 163, no. 2 (July 21, 2015): 147. http://dx.doi.org/10.7326/l15-5109.
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Retan, J. Walden. "Long-Term Opioid Therapy for Chronic Pain." Annals of Internal Medicine 163, no. 2 (July 21, 2015): 147. http://dx.doi.org/10.7326/l15-5109-2.
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Chou, Roger. "Long-Term Opioid Therapy for Chronic Pain." Annals of Internal Medicine 163, no. 2 (July 21, 2015): 148. http://dx.doi.org/10.7326/l15-5109-3.
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&NA;. "Long-Term Opioid Therapy for Chronic Pain." Back Letter 26, no. 1 (January 2011): 1. http://dx.doi.org/10.1097/01.back.0000392987.29276.60.
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Elliott, MD, Jennifer A., Erica Horton, DO, and Eugene E. Fibuch, MD. "The endocrine effects of long-term oral opioid therapy: A case report and review of the literature." Journal of Opioid Management 7, no. 2 (January 15, 2018): 145–54. http://dx.doi.org/10.5055/jom.2011.0057.
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The negative effects of long-term opioid administration on the body’s endocrine system have been known for decades.1,2 These effects have been observed and studied with the use of intrathecal opioids and in heroin addicts.3-9 However, they have also been noted to occur with the use of oral opioids, especially in those patients who require chronic opioids for the management of nonmalignant and cancer-associated pain.2,10-13 Epidemiologic data in recent years suggest that up to five million men with chronic nonmalignant pain suffer from opioid-induced androgen deficiency (OPIAD) in the United States.14 Therefore, it is important to understand the physiologic impact of chronic opioid administration in patients. In view of the increasing use of opioids for chronic pain, we must anticipate the potential occurrence of hypogonadism during chronic opioid therapy and monitor patients accordingly. If symptoms of endocrine dysfunction are recognized during chronic opioid therapy, appropriate evaluation, treatment, and follow-up should be instituted. This article describes a case report of a patient who suffered from a clinically significant testosterone deficiency and osteoporosis related to the use of long-term oral opioids for chronic nonmalignant pain. It also includes a review of the existing literature regarding OPIAD and provides recommendations regarding the evaluation and management of OPIAD.
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Wang, Haili. "Evidence of Specific Cognitive Deficits in Patients with Chronic Low Back Pain under Long-Term Substitution Treatment of Opioids." Pain Physician 17;1, no. 1;17 (January 14, 2014): 9–19. http://dx.doi.org/10.36076/ppj.2014/17/9.
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Background: There is a growing number of patients worldwide being treated with longterm opioids for chronic non-cancer pain, although there is limited evidence for their effectiveness in improving pain and function. Opioid-use related adverse effects, especially in cognitive functioning in these patients, are rarely evaluated. Objectives: The present study investigated the cognitive functions of patients with chronic back pain who underwent long-term opioid treatment in comparison with those patients without opioid usage and healthy controls. Study Design: A prospective, nonrandomized, cross-sectional study. Setting: Multidisciplinary pain management clinic, specialty referral center, University Hospital in Germany. Methods: In a prospective cross-sectional design, 37 patients with chronic back pain who underwent long-term opioid therapy (OP) were compared with 33 patients with chronic back pain without opioid therapy (NO) and 25 healthy controls (HC). Assessment of primary outcome included cognitive function such as information processing speed, choice reaction time, pattern recognition memory, and executive function. Other data included pain, back function, depression and anxiety, use of medication, and education status. The relationship between cognitive functions and anxiety/depression was analysed. Results: Both patient groups needed significantly longer time in information processing when compared to HC (Group 1: 41.87 ± 20.47 Group 2: 38.29 ± 19.99 Group 3: 30.25 ± 14.19). Additionally, OP patients had significantly reduced spatial memory capacity, flexibility for concept change, and impaired performance in working memory assessment compared to NO patients and HC. The impaired cognitive outcomes were significantly associated with pain intensity, depression scores, and medication use. Limitations: Limitations include small number of patients with heterogeneous opioid therapy and the nonrandomized observational nature of the study. Conclusions: Our findings give a differential view into the cognitive changes from chronic back pain with and without long-term opioids treatment. Chronic back pain itself impairs some distinct cognitive functions. Long-term opioid therapy adds further cognitive impairment. Key words: Long-term opioid therapy, chronic back pain, cognitive dysfunction
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Kazis, Lewis E., Omid Ameli, James Rothendler, Brigid Garrity, Howard Cabral, Christine McDonough, Kathleen Carey, et al. "Observational retrospective study of the association of initial healthcare provider for new-onset low back pain with early and long-term opioid use." BMJ Open 9, no. 9 (September 2019): e028633. http://dx.doi.org/10.1136/bmjopen-2018-028633.
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ObjectiveThis study examined the association of initial provider treatment with early and long-term opioid use in a national sample of patients with new-onset low back pain (LBP).DesignA retrospective cohort study of patients with new-onset LBP from 2008 to 2013.SettingThe study evaluated outpatient and inpatient claims from patient visits, pharmacy claims and inpatient and outpatient procedures with initial providers seen for new-onset LBP.Participants216 504 individuals aged 18 years or older across the USA who were diagnosed with new-onset LBP and were opioid-naïve were included. Participants had commercial or Medicare Advantage insurance.ExposuresThe primary independent variable is type of initial healthcare provider including physicians and conservative therapists (physical therapists, chiropractors, acupuncturists).Main outcome measuresShort-term opioid use (within 30 days of the index visit) following new LBP visit and long-term opioid use (starting within 60 days of the index date and either 120 or more days’ supply of opioids over 12 months, or 90 days or more supply of opioids and 10 or more opioid prescriptions over 12 months).ResultsShort-term use of opioids was 22%. Patients who received initial treatment from chiropractors or physical therapists had decreased odds of short-term and long-term opioid use compared with those who received initial treatment from primary care physicians (PCPs) (adjusted OR (AOR) (95% CI) 0.10 (0.09 to 0.10) and 0.15 (0.13 to 0.17), respectively). Compared with PCP visits, initial chiropractic and physical therapy also were associated with decreased odds of long-term opioid use in a propensity score matched sample (AOR (95% CI) 0.21 (0.16 to 0.27) and 0.29 (0.12 to 0.69), respectively).ConclusionsInitial visits to chiropractors or physical therapists is associated with substantially decreased early and long-term use of opioids. Incentivising use of conservative therapists may be a strategy to reduce risks of early and long-term opioid use.
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Mizher, Hussam, Che S. Zin, Asween R. Sani, Abdul Hadi Bin Mohamed, Tan H. Ling, and Munira M. Izat. "ADHERENCE TO OPIOID THERAPY IN PATIENTS WITH CHRONIC NON-CANCER PAIN ATTENDING A PAIN CLINIC IN MALAYSIA." Asian Journal of Pharmaceutical and Clinical Research 11, no. 15 (October 3, 2018): 4. http://dx.doi.org/10.22159/ajpcr.2018.v11s3.29960.
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Objectives: This study examined the adherence to opioid therapy in patients with chronic noncancer pain (CNCP). The prevalence of opioid use and pain scores was also explored.Methods: This cross-sectional study was conducted among patients with noncancer pain attending a pain clinic at a tertiary hospital in Malaysia from August 2016 to February 2017. All patients prescribed with any of the five available opioids (morphine, oxycodone, fentanyl, buprenorphine, and dihydrocodeine) were included in the study, and their medical and prescription records were assessed for further information on opioid use such as the type of opioid, dose, frequency, and duration. The prevalence of opioid use was calculated by dividing the number of opioid users and the total number of patients attending the pain clinic during the study. Adherence was calculated for patients with long-term opioid therapy (>90 days/ year) and measured using the medication possession ratio (MPR). This was derived by sum up the total days covered with medication in the last 365 days; and then divide that by the total days, the medication was prescribed over the same period. A cutoff point of 80% or more was considered as adherence. The pain intensity score was assessed through a numerical scale from 0 (no pain) to 10 (worst possible pain) at four different points (now, on average, least in the last 24 h, and worst in the last 24 h).Results: A total of 555 patients with various noncancer pain conditions attended the pain clinic during the study. The prevalence of opioid use among these patients was 13.5% (n=74/555). Of these, 24.3% (n=18/74) of patients using opioids for long term (>90 days) and were included in the adherence measure. 78% (n=14/18) of these long-term opioid users were adherent to opioid therapy with a reported MPR >80%. 22% (n=4/18) of patients showed nonadherence to opioid therapy with a reported MPR <80%. The mean pain score for both adherent and nonadherent groups was 5/10, and there was no statistical difference between the two groups.Conclusion: The preliminary results of this study demonstrated that the majority of patients with chronic opioid use adhered to their prescribed opioids. The prevalence of opioid use among patients with noncancer pain was low, and the number of patients using opioid for the long term was ~20% which is similar to the finding from the previous study. The future research is required to evaluate the clinical outcomes in patients with CNCP using opioid for long term particularly in nonadherent patients.
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Birthi, MD, Pravardhan, Vittal R. Nagar, MD, Robert Nickerson, MD, and Paul A. Sloan, MD. "Hypogonadism associated with long-term opioid therapy: A systematic review." Journal of Opioid Management 11, no. 3 (May 1, 2015): 255. http://dx.doi.org/10.5055/jom.2015.0274.
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Background: Sexual dysfunction and Opioid-Induced Sexual Hormone Deficiency (OPISHD) have been associated with patients on long-term opioid pain therapy. There have been few comprehensive reviews to establish a relation between hypogonadism with chronic opioid pain management. The OPISHD is often not treated and literature guiding this topic is scarce.Objective: To investigate hypogonadism associated with long-term opioid therapy based on qualitative data analysis of the available literature.Study design: Systematic review.Interventions: The review included relevant literature identified through searches of PubMed, Cochrane, Clinical Trials, US National Guideline Clearinghouse, and EMBASE, for the years 1960 to September 2013. The quality assessment and clinical relevance criteria used were the Cochrane Musculoskeletal Review Group Criteria for randomized control trials and the Newcastle-Ottawa Scale Criteria for observational studies. The level of evidence was classified as good, fair, and poor, based on the quality of evidence.Main outcome measures: The primary outcome measures were clinical symptoms and laboratory markers of hypogonadism. Secondary outcome measure was management of OPISHD.Results: Thirty-one studies were identified, of which 14 studies met inclusion criteria. There were no randomized control trials and eight of 14 studies were of moderate quality. The remaining studies were of poor quality. Four studies report most patients on long-term oral opioid therapy have associated hypogonadism and three studies of patients receiving intrathecal opioid therapy suggest that hypogonadism is common.Conclusions: There is lack of high-quality studies to associate chronic opioid pain management with hypogonadism. At present, there is fair evidence to associate hypogonadism with chronic opioid pain management, and only limited evidence for treatment of OPISHD.
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Araujo-Mino, Emilio Paul, Ajaz Bulbul, Hamza Minhas, Adriana Bautista, Lisa Lentkowski, and Masoud Khorsand-Sahbaie. "LONG TERM opioid use in RURAL NON-metastatic colon cancer patients." Journal of Clinical Oncology 37, no. 15_suppl (May 20, 2019): e15174-e15174. http://dx.doi.org/10.1200/jco.2019.37.15_suppl.e15174.
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e15174 Background: Cancer related pain and subsequent long-term opioid (LTO) use worsens the opioid epidemic and facilitates abuse. Non-metastatic colon cancer (CC) is a potentially curable malignancy and prescription opioid (PO) may increase risks of adverse events when CC has been eradicated. Methods: A retrospective study evaluated stage I-III CC patients between January 2013 and January 2018 across rural cancer clinics in New Mexico who received PO during their cancer diagnosis and treatment. It excluded patients with stage IV CC, concurrent malignancies and non-cancer pain. Descriptive statistics, Chi-square and logistic regression were performed to identify correlation and predictors of LTO use. Results: Among 197 patients identified, opioids were prescribed in 24% (48/197); 22 patients met inclusion criteria. Mean age was 65.1±9.8 years; 68% male; Stage I (4.5%), II (36.3%), III (59.1%). Adjuvant chemotherapy was given in 91% (20/22). Oxaliplatin regimen was used in 63.6% (14/22). One year after therapy, 27.3% (6/22) still had neuropathy. The rate of opioid use was 72.7% (16/22) at 3 months, 54.5% (12/22) at 6 months and 41% (9/22) at 12 months; 56.2% (9/16) of opioid users at 3 months were also using opioids at 12 months from initial prescription (X2 5.71 p = 0.046). Also, 75% (9/12) of opioid users at 6 months, continued using opioids at 12 months (X2 12.7 p = 0.0001). Patients with smoking history, unemployed and PO from a surgeon, were more likely to be LTO users at 12 months; however, it was not statistically significant. Conclusions: Non-metastatic CC patients who continue to use opioids at 3 months are at a significantly higher risk of LTO use at one year. Biological and social factors in rural communities can be important determinants of this use pattern. The challenges surrounding opioid use and the need for safe and effective alternative analgesics require urgent attention and regulatory discourse.
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Ruan, Xiulu. "Drug-Related Side Effects of Long-term Intrathecal Morphine Therapy." Pain Physician 2;10, no. 3;2 (March 14, 2007): 357–65. http://dx.doi.org/10.36076/ppj.2007/10/357.
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Background: The introduction of intrathecal opioid administration for intractable chronic non-malignant pain and cancer pain is considered as one of the most important breakthroughs in pain management. Morphine, the only opioid approved by FDA for intrathecal administration, has been increasingly utilized for this purpose. For over 3 decades, there have been numerous reports on the non-nociceptive side effects associated with ever increasing long-term intrathecal morphine usage. Objectives: To review the literature on side effects due to long-term intrathecal morphine therapy with discussions of alternate treatment options. Design: English-language publications were identified through MEDLINE search and the bibliographies of identified articles were reviewed. Results: Most side effects of intrathecal morphine therapy are dose dependent and mediated by opioid receptors. Common ones include nausea, vomiting, pruritus, urinary retention, constipation, sexual dysfunction, and edema. Less common ones include respiratory depression, and hyperalgesia. Catheter tip inflammatory mass formation is a less common complication that may not be mediated by opioid receptors. Conclusion: The utilization of intrathecal morphine administration for cancer and intractable non-malignant chronic pain represents an important leap forward in pain management. Yet, a wide variety of non-nociceptive side effects may also occur in susceptible patients. The side effects due to intrathecal morphine administration are mostly mediated by opioid receptors. Treatment usually involves the utilization of opioid receptor antagonist, such as naloxone. Patients considering intrathecal opioid pump therapy should be informed and advised about the possible side effects associated with longterm intrathecal morphine administration prior to placement of a permanent morphine infusion pump. Key words: side effects, intrathecal morphine, opioid receptors
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Kurteva, Siyana, Michal Abrahamowicz, Daniala Weir, Tara Gomes, and Robyn Tamblyn. "Determinants of long-term opioid use in hospitalized patients." PLOS ONE 17, no. 12 (December 15, 2022): e0278992. http://dx.doi.org/10.1371/journal.pone.0278992.
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Background Long-term opioid use is an increasingly important problem related to the ongoing opioid epidemic. The purpose of this study was to identify patient, hospitalization and system-level determinants of long term opioid therapy (LTOT) among patients recently discharged from hospital. Design To be eligible for this study, patient needed to have filled at least one opioid prescription three-months post-discharge. We retrieved data from the provincial health insurance agency to measure medical service and prescription drug use in the year prior to and after hospitalization. A multivariable Cox Proportional Hazards model was utilized to determine factors associated with time to the first LTOT occurrence, defined as time-varying cumulative opioid duration of ≥ 60 days. Results Overall, 22.4% of the 1,551 study patients were classified as LTOT, who had a mean age of 66.3 years (SD = 14.3). Having no drug copay status (adjusted hazard ratio (aHR) 1.91, 95% CI: 1.40–2.60), being a LTOT user before the index hospitalization (aHR 6.05, 95% CI: 4.22–8.68) or having history of benzodiazepine use (aHR 1.43, 95% CI: 1.12–1.83) were all associated with an increased likelihood of LTOT. Cardiothoracic surgical patients had a 40% lower LTOT risk (aHR 0.55, 95% CI: 0.31–0.96) as compared to medical patients. Initial opioid dispensation of > 90 milligram morphine equivalents (MME) was also associated with higher likelihood of LTOT (aHR 2.08, 95% CI: 1.17–3.69). Conclusions and relevance Several patient-level characteristics associated with an increased risk of ≥ 60 days of cumulative opioid use. The results could be used to help identify patients who are at high-risk of continuing opioids beyond guideline recommendations and inform policies to curb excessive opioid prescribing.
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Bonafede, Machaon, Kathleen Wilson, and Fei Xue. "Long-term treatment patterns of prophylactic and acute migraine medications and incidence of opioid-related adverse events in patients with migraine." Cephalalgia 39, no. 9 (February 28, 2019): 1086–98. http://dx.doi.org/10.1177/0333102419835465.
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Objectives To describe long-term treatment patterns in migraine patients initiating prophylactic therapy and to evaluate acute medication use and adverse events associated with opioids. Methods This study used the 2005–2014 IBM MarketScan® databases to evaluate migraine patients initiating prophylactic medication. Outcome measures included persistence with prophylactic migraine medications over 2–5 years. Acute medication use and gastrointestinal-related adverse events and opioid abuse following opioid use were evaluated. Cox proportional hazards models were used to evaluate predictors of non-persistence and predictors of gastrointestinal-related AEs and opioid abuse associated with long-term opioid use. Results In total, 147,832 patients were analyzed. Non-persistence was observed in 90% of patients; 39% switched, 30% restarted, and 31% discontinued treatment. Over the follow-up, 59.9% of patients received triptans, 66.6% non-steroidal anti-inflammatory drugs, 77.4% opioids, and 2.6% ergotamines. Among opioid users, 16.6% experienced nausea/vomiting, 12.2% had constipation, and 10.4% had diarrhea. Opioid abuse was reported in <1% of opioid users. Gastrointestinal-related adverse events increased with increasing number of days’ supply of opioids. Conclusions Non-persistence to prophylactic treatment was frequent among migraine patients. Opioid use was common in migraine patients and the risk of gastrointestinal-related adverse events and opioid abuse increased with long-term use of opioids. These results suggest a need for more effective prophylactic migraine treatments.
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Wang, Haili. "Does Long-Term Opioid Therapy Reduce Pain Sensitivity of Patients with Chronic Low Back Pain? Evidence from Quantitative Sensory Testing." July 2012 3S;15, no. 3S;7 (July 14, 2012): ES135—ES143. http://dx.doi.org/10.36076/ppj.2012/15/es135.
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Background: Long-term opioid treatment has been used extensively in treatment of chronic low back pain (cLBP) in the last decades. However, there are serious limitations to the long-term efficacy of opioids and related side effects. Objectives: In this study we investigated whether long-term opioid treatment changes pain sensitivity of patients with cLBP. Study Design: A prospective, nonrandomized, cross-sectional study. Setting: Multidisciplinary pain management clinic, specialty referral center, university hospital in Germany. Methods: Using quantitative sensory testing (QST), we compared the pain sensitivity of the low back bilaterally among 3 groups: 35 patients with cLBP undergoing a long-term opioid therapy (OP); 35 patients with cLBP administered no opioids (ON), and 28 subjects with neither pain nor opioid intake (HC). Results: OP patients showed significantly higher bilateral thermal detection thresholds to warm stimuli on the back as compared to both ON (P = 0.009 for left low back, P = 0.008 for right low back) and HC subjects (P = 0.004 for left low back, P = 0.003 for right low back). Pain thresholds for cold and heat on the hand were similar in OP and ON groups; both showed, however, significantly reduced heat pain thresholds in comparison with HC participants (P = 0.012 for OP, P = 0.001 for ON). Factors such as age, sex, duration and dose of opioid intake, and self-reported pain intensity, but not depression and pain duration, correlated significantly with QST results. Limitations: Limitations include small numbers of patients with heterogeneous opioid therapy and the nonrandomized observational nature of the study. Conclusions: The current study demonstrated that chronic opioid intake may only reduce the temperature sensitivity but not pain sensitivity measured by QST which is a useful tool in detecting characteristic changes in pain perception of patients with chronic low back pain after long-term opioid intake. Key words: Pain sensitivity, opioid treatment, chronic low back pain (cLBP), quantitative sensory testing (QST)
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Manchikanti, Laxmaiah. "A Systematic Review of Randomized Trials of Long-Term Opioid Management for Chronic Non-Cancer Pain." Pain Physician 3;14, no. 2;3 (March 14, 2011): 91–121. http://dx.doi.org/10.36076/ppj.2011/14/91.
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Background: Even though opioids have been used for pain for thousands of years, opioid therapy for chronic non-cancer pain is controversial due to concerns regarding the long-term effectiveness and safety, particularly the risk of tolerance, dependance, or abuse. While the debate continues, the use of chronic opioid therapy for chronic non-cancer pain has increased exponentially. Even though evidence is limited, multiple expert panels have concluded that chronic opioid therapy can be effective therapy for carefully selected and monitored patients with chronic non-cancer pain. Study Design: A systematic review of randomized trials of opioid management for chronic noncancer pain. Objective: The objective of this systematic review is to evaluate the clinical efficacy of opioids in the treatment of chronic non-cancer pain. Methods: A comprehensive evaluation of the literature relating to opioids in chronic non-cancer pain was performed. The literature was evaluated according to Cochrane review criteria for randomized controlled trials (RCTs) and Jadad criteria. A literature search was conducted by using PubMed, EMBASE, Cochrane library, ECRI Institute Library, U.S. Food and Drug Administration (FDA) website, U.S. National Guideline Clearinghouse (NGC), Database of Abstracts of Reviews of Effectiveness (DARE), clinical trials, systematic reviews and cross references from systematic reviews. The level of evidence was classified as good, fair, or poor based on the quality of evidence developed by the United States Preventive Services Task Force (USPSTF) and used by other systematic reviews and guidelines. Outcome Measures: Pain relief was the primary outcome measure. Other outcome measures were functional improvement, withdrawals, and adverse effects. Results: Based on the USPSTF criteria, the indicated level of evidence was fair for Tramadol in managing osteoarthritis. For all the drugs assessed, including Tramadol, for all other conditions, the evidence was poor based on either weak positive evidence, indeterminate evidence, or negative evidence. Limitations: A paucity of literature, specifically with follow-up beyond 12 weeks for all types of opioids with controlled trials for various chronic non-cancer pain conditions. Conclusions: This systematic review illustrated fair evidence for Tramadol in managing osteoarthritis with poor evidence for all other drugs and conditions. Thus, recommendations must be based on non-randomized studies. Key words: Chronic non-cancer pain, opioids, opioid efficacy, opioid effectiveness, significant pain relief, functional improvement, adverse effects, morphine, hydrocodone, hydromorphone, fentanyl, tramadol, buprenorphine, methadone, tapentadol, oxycodone, oxymorphone, systematic reviews, randomized trials
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Coffin, Phillip O., Rebecca S. Martinez, Brian Wylie, and Bunny Ryder. "Primary care management of Long-Term opioid therapy." Annals of Medicine 54, no. 1 (September 16, 2022): 2451–69. http://dx.doi.org/10.1080/07853890.2022.2121417.
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Reisfield, Gary M., and Karen J. Maschke. "Urine Drug Testing in Long-term Opioid Therapy." Clinical Journal of Pain 30, no. 8 (August 2014): 679–84. http://dx.doi.org/10.1097/01.ajp.0000435448.34761.c9.
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Manchikanti, Laxmaiah, Mark V. Boswell, and Vijay Singh. "Monitoring of Patients Receiving Long-Term Opioid Therapy." Anesthesia & Analgesia 99, no. 1 (July 2004): 304. http://dx.doi.org/10.1213/01.ane.0000127716.40469.c4.
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Carmona-Bayonas, A., P. Jiménez-Fonseca, E. Castañón, A. Ramchandani-Vaswani, R. Sánchez-Bayona, A. Custodio, D. Calvo-Temprano, and J. A. Virizuela. "Chronic opioid therapy in long-term cancer survivors." Clinical and Translational Oncology 19, no. 2 (July 21, 2016): 236–50. http://dx.doi.org/10.1007/s12094-016-1529-6.
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Häuser, W., T. Schubert, N. Scherbaum, and T. Tölle. "Long-term opioid therapy of non-cancer pain." Der Schmerz 34, S1 (October 16, 2018): 8–15. http://dx.doi.org/10.1007/s00482-018-0331-5.
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Trescot, Andrea M. "Effectiveness of Opioids in the Treatment of Chronic Non-Cancer Pain." Pain Physician 2s;11, no. 3;2s (March 14, 2008): S181—S200. http://dx.doi.org/10.36076/ppj.2008/11/s181.
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For thousands of years, opioids have been used to treat pain, and they continue to be one of the most commonly prescribed medications for pain. It is estimated that 90% of patients presenting to pain centers and receiving treatment in such facilities are on opioids. Opioids can be considered broad-spectrum analgesics that act at multiple points along the pain pathway. Unfortunately, opioids also have the potential for great harm, with multiple side effects and potential complications, some of which are lethal. They are also uniquely addictive, which can lead to misuse and diversion. We reviewed the relevant English literature and did thorough manual searches of the bibliographies of known primary and review articles. We utilized pain relief as the primary outcome measure. Other outcome measures were functional improvement, improvement of psychological status, improvement in work status, and evidence of addiction. Shortterm use and improvement was defined as less than 6 months and long-term relief was defined as 6 months or longer. The 3 systematic reviews evaluating long-term effectiveness of opioids for chronic noncancer pain provided unclear and weak evidence. The results of this review showed that many patients in the included studies were dissatisfied with adverse events or insufficient pain relief from opioids and withdrew from the studies. For patients able to continue on opioids, evidence was weak suggesting that their pain scores were lower than before therapy and that this relief could be maintained long-term (> 6 months). There was also weak evidence that long-term opioid therapy with morphine and transdermal fentanyl not only decreases pain but also improves functioning. Limited evidence was available for the most commonly used opioids, oxycodone and hydrocodone. Evidence for the ability to drive on chronic opioid therapy was moderate without major side effects or complications. It is concluded that, for long-term opioid therapy of 6 months or longer in managing chronic non-cancer pain, with improvement in function and reduction in pain, there is weak evidence for morphine and transdermal fentanyl. However, there is limited or lack of evidence for all other controlled substances, including the most commonly used drugs, oxycodone and hydrocodone. Key words: Opioids, opioid effectiveness, pain relief, functional improvement, adverse effects, codeine, morphine, hydrocodone, hydromorphone, fentanyl, methadone.
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Yaldo, Avin, Lonnie Kent Wen, Augustina Ogbonnaya, Adriana Valderrama, Jonathan K. Kish, Michael Eaddy, Charles Kreilick, and Brian S. Seal. "Opioid use among prostate cancer patients with bone metastases." Journal of Clinical Oncology 33, no. 7_suppl (March 1, 2015): 278. http://dx.doi.org/10.1200/jco.2015.33.7_suppl.278.
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278 Background: Bone metastases (mets) occur in ≥90% of men with castrate-resistant prostate cancer (PC), causing significant pain and resource use. Opioids are frequently used in managing pain throughout the course of care, but few studies have quantified the incremental use of opioids after the onset of bone mets. This study describes treatment patterns and incremental use of opioids among PC patients diagnosed with bone mets. Methods: Prostate cancer patients (ICD9=185.xx or 233.4) newly diagnosed with bone mets (ICD9=198.5) from 2006-2012 were identified from MarketScan databases. Patients were required to be ≥40 years, continuously eligible for medical and pharmacy benefits ≥12 months pre and ≥6 months postdiagnosis, and without evidence of other primary cancers during the study period. Patients were initially categorized as non-users of opioids (<10 days use), short-term users (≥10 but <60 days use), or long-term users (≥60 days use), and further by presence of skeletal-related events (SREs). Type of opioid therapy, proportion of time on opioids, morphine equivalent dose, and NSAID use were evaluated pre and postdiagnosis. Results: There were 4,476 patients identified for inclusion; 438 (9.8%) had an SRE. Mean age was 72 and 1.6% had chronic pain at baseline. The proportion of opioid users increased from 25.2% at baseline to 32.9% after diagnosis (P<0.0001). Among opioid users, the proportion of long-term users increased from 29.9% to 45.5% (P<0.0001). Use of monotherapy short-acting opioids decreased (pre 79.0% vs post 71.9%; P<0.0001), with a corresponding increase in mixed-action opioids (pre 13.3% vs post 23.4%; P<0.0001). Mean morphine equivalent dose (pre 7.1mg vs post 9.9mg; P<0.0001) and proportion of time on opioid therapy also increased substantially (pre 28.3% vs post 54.7%; P<0.0001). NSAID use decreased after bone met onset (pre 21.9% vs post 15.5%; P<0.0001). Opioid use and radiation therapy were more evident in patients with SREs (opioids 21.9%, opioids + radiation 32.6%, radiation 29.5%), and mean morphine equivalent dose was 10.8mg. Conclusions: Long-term opioid use and dose significantly increased after bone met onset in PC. Novel strategies that mitigate bone pain and minimize opioid use should be evaluated in this population.
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Elliott, Jennifer A. "Opioid-Induced Androgen Deficiency (OPIAD)." July 2012 3S;15, no. 3S;7 (July 14, 2012): ES145—ES156. http://dx.doi.org/10.36076/ppj.2012/15/es145.
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Opioid therapy is one of the most effective forms of analgesia currently in use. In the past few decades, the use of opioids as a long-term treatment for chronic pain has increased dramatically. Accompanying this upsurge in the use of long-term opioid therapy has been an increase in the occurrence of opioid associated endocrinopathy, most commonly manifested as an androgen deficiency and therefore referred to as opioid associated androgen deficiency (OPIAD). This syndrome is characterized by the presence of inappropriately low levels of gonadotropins (follicle stimulating hormone and luteinizing hormone) leading to inadequate production of sex hormones, particularly testosterone. Symptoms that may manifest in patients with OPIAD include reduced libido, erectile dysfunction, fatigue, hot flashes, and depression. Physical findings may include reduced facial and body hair, anemia, decreased muscle mass, weight gain, and osteopenia or osteoporosis. Additionally, both men and women with OPIAD may suffer from infertility. While the literature regarding OPIAD remains limited, it is apparent that OPIAD is becoming increasingly prevalent among chronic opioid consumers but often goes unrecognized. OPIAD can have a significant negative impact on the the quality of life of opioid users, and clinicians should anticipate the potential for its occurrence whenever long-term opioid prescribing is undertaken. Once diagnosed, treatment for OPIAD may be offered utilizing a number of androgen replacement therapy options including a variety of testosterone preparations and, for female patients with OPIAD, dehydroepiandrosterone (DHEA) supplementation. Follow-up evaluation of patients receiving androgen replacement therapy should include a review of any unresolved symptoms of hypogonadism, laboratory evaluation, and surveillance for potential adverse effects of androgen replacement therapy including prostate disease in males. Key words: Opioid, hypogonadism, testosterone, endocrine, androgen
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Mason, MD, Jay W., Ullrich S. Schwertschlag, MD, PhD, Vicki Klutzaritz, BS, and Daniel M. Canafax, PharmD. "Electrocardiographic and cardiovascular diagnostic characteristics of patients receiving long-term opioid therapy for pain." Journal of Opioid Management 10, no. 2 (March 1, 2014): 103. http://dx.doi.org/10.5055/jom.2014.0199.
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Objective: To examine cardiovascular and electrocardiogram (ECG) abnormalities seen in patients with chronic pain receiving long-term opioid therapy and to compare them with findings in normal subjects.Setting: Clinical pharmaceutical drug trial in a phase I pharmacology unit (normal subjects) and multiple phase 2b study sites (pain patients).Patients: Four hundred sixty-one pain patients with constipation due to longterm opioid therapy who were screened for a clinical trial of an investigational treatment for opioid-induced constipation.Interventions: None; all data used in this study were obtained prior to drug treatment.Main outcome measures: This is a retrospective analysis of ECG abnormalities and clinical cardiovascular abnormalities in study participants compared with those in a normal reference group of 36,999 subjects.Results: Numerical ECG values were modestly but not clinically significantly different in the pain patients requiring opioids (mean heart rate +1.5 BPM, PR +5.2 milliseconds, QRS - 4.7 milliseconds, and QT corrected for heart rate using the Fridericia formula +7.2 milliseconds). The largest difference in ECG diagnoses between the two groups was a fivefold greater incidence of previous myocardial infarction in the pain patient group (4.1 percent vs 0.8 percent). In addition, 50 percent of the pain patient group had a clinical cardiovascular diagnosis.Conclusions: Patients with significant chronic pain requiring opioids have underlying clinical disorders that may be associated with abnormal cardiovascular physiology and ECGs. Clinicians who manage patients with chronic pain should be aware of the higher incidence of cardiovascular disease in this group.
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Abs, Roger, Johan Verhelst, Jan Maeyaert, Jean-Pierre Van Buyten, Frank Opsomer, Hugo Adriaensen, Jan Verlooy, Tony Van Havenbergh, Mike Smet, and Kristien Van Acker. "Endocrine Consequences of Long-Term Intrathecal Administration of Opioids." Journal of Clinical Endocrinology & Metabolism 85, no. 6 (June 1, 2000): 2215–22. http://dx.doi.org/10.1210/jcem.85.6.6615.
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Intrathecal administration of opioids is a very efficient tool in the long-term control of intractable nonmalignant pain. However, despite the well known role of opioids in endocrine regulation, few data are available about possible effects on hypothalamic-pituitary function during this treatment. Seventy-three patients (29 men and 44 women; mean age, 49.2 ± 11.7 yr) receiving opioids intrathecally for nonmalignant pain were enrolled for extensive endocrine investigation. At the time of hormonal determination, the mean duration of opioid treatment was 26.6 ± 16.3 months; the mean daily dose of morphine was 4.8 ± 3.2 mg. The control group consisted of 20 patients (11 men and 9 women; mean age, 54.2 ± 14.0 yr) with a comparable pain syndrome but not treated with opioids. Decreased libido or impotency was present in 23 of 24 men receiving opioids. The serum testosterone level was below 9 nmol/L in 25 of 29 men and was significantly lower than that in the control group (P < 0.001). The free androgen index was below normal in 18 of 29 men and was significantly lower than that in the control group (P < 0.001). The serum LH level was less than 2 U/L in 20 of 29 men and was significantly lower than that in the control group (P < 0.001). Serum FSH was comparable in both groups. Decreased libido was present in 22 of 32 women receiving opioids. All 21 premenopausal females developed either amenorrhea or an irregular menstrual cycle, with ovulation in only 1. Serum LH, estradiol, and progesterone levels were lower in the opioid group. In all 18 postmenopausal females significantly decreased serum LH (P < 0.001) and FSH (P = 0.012) levels were found. The 24-h urinary free cortisol excretion was below 20 μg/day in 14 of 71 opioid patients and was significantly lower than that in the control group (P = 0.003). The peak cortisol response to insulin-induced hypoglycemia was below 180 μg/L in 9 of 61 opioid patients and was significantly lower than that in the nonopioid group (P = 0.002). The insulin-like growth factor I sd score was below −2 sd in 12 of 73 opioid patients and was significantly lower than that in the control group (P = 0.002). The peak GH response to hypoglycemia was below 3 μg/L in 9 of 62 subjects and was significantly lower than that in the control group (P = 0.010). Thyroid function tests and PRL levels were considered normal. No metabolic disturbances were recorded, apart from significantly decreased high density lipoprotein cholesterol levels (P = 0.041) and elevated total/high density lipoprotein cholesterol ratio (P = 0.008) in the opioid group compared to the control group. Supplementation with gonadal steroids improved sexual function in most patients. In conclusion, of all patients receiving intrathecal opioids, the large majority of men and all women developed hypogonadotropic hypogonadism, about 15% developed central hypocorticism, and about 15% developed GH deficiency. These findings suggest that further investigations are required to determine the need for systematic endocrine work-up in these patients and the necessity for substitutive therapy.
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Manniche, Claus, Lonny Stokholm, Sophie L. Ravn, Tonny E. Andersen, Lars PA Brandt, Katrine H. Rubin, Berit Schiøttz-Christensen, Lars L. Andersen, and Søren G. Skousgaard. "Long-Term Opioid Therapy in Spine Center Outpatients: Protocol for the Spinal Pain Opioid Cohort (SPOC) Study." JMIR Research Protocols 9, no. 8 (August 19, 2020): e21380. http://dx.doi.org/10.2196/21380.
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Background Spinal pain is the leading cause of patient-years lived with chronic pain and disability worldwide. Although opioids are well documented as an effective short-term pain-relieving medication, more than a few weeks of treatment may result in a diminishing clinical effect as well as the development of addictive behavior. Despite recognition of opioid addiction in pain patients as a major problem commonly experienced in the clinic, no reference material exists on the scope of long-term problems in novel opioid users and the link to clinical outcomes. Objective The main aims of this study are to describe baseline and follow-up characteristics of the Spinal Pain Opioid Cohort (SPOC), to evaluate the general use of opioids in spinal pain when an acute pain episode occurs, and to demonstrate the prevalence of long-term opioid therapy (LTOT). Methods Prospective clinical registry data were collected from an outpatient spine center setting during 2012-2013 including patients with a new spinal pain episode lasting for more than 2 months, aged between 18 and 65 years who had their first outpatient visit in the center. Variables include demographics, clinical data collected in SpineData, the Danish National Patient Register, and The Danish National Prescription Registry. The primary outcome parameter is long-term prescription opioid use registered from 4 years before the first spine center visit to 5 years after. Results This is an ongoing survey. It is estimated that more than 8000 patients fulfill the SPOC inclusion criteria. In 2019, we began the intellectual process of identifying the most relevant supplementary data available from the wide range of existing national registries available in Denmark. We have now begun merging SpineData with relevant opioid data from Danish national registers and will continue to extract data up to 2021-2022. We will also be looking at data regarding somatic or psychiatric hospitalization patterns, patient usage of health care resources, as well as their working status and disability pensions. Conclusions To our knowledge, this survey will be the first to document the scope of long-term problems regarding LTOT and opioid addiction following new spinal pain episodes and comparing descriptive follow-up data between substance users and nonusers. Trial Registration ISRCTN Registry ISRCTN69685117; http://www.isrctn.com/ISRCTN69685117 International Registered Report Identifier (IRRID) DERR1-10.2196/21380
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ASIPP, ASIPP. "American Society of Interventional Pain Physicians (ASIPP) Guidelines for Responsible Opioid Prescribing in Chronic Non-Cancer Pain: Part I – Evidence Assessment." July 2012 3S;15, no. 3S;7 (July 14, 2012): S1—S66. http://dx.doi.org/10.36076/ppj.2012/15/s1.
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Background: Opioid abuse has continued to increase at an alarming rate since the 1990s. As documented by different medical specialties, medical boards, advocacy groups, and the Drug Enforcement Administration, available evidence suggests a wide variance in chronic opioid therapy of 90 days or longer in chronic non-cancer pain. Part 1 describes evidence assessment. Objectives: The objectives of opioid guidelines as issued by the American Society of Interventional Pain Physicians (ASIPP) are to provide guidance for the use of opioids for the treatment of chronic non-cancer pain, to produce consistency in the application of an opioid philosophy among the many diverse groups involved, to improve the treatment of chronic non-cancer pain, and to reduce the incidence of abuse and drug diversion. The focus of these guidelines is to curtail the abuse of opioids without jeopardizing non-cancer pain management with opioids. Results: 1) There is good evidence that non-medical use of opioids is extensive; one-third of chronic pain patients may not use prescribed opioids as prescribed or may abuse them, and illicit drug use is significantly higher in these patients. 2) There is good evidence that opioid prescriptions are increasing rapidly, as the majority of prescriptions are from non-pain physicians, many patients are on long-acting opioids, and many patients are provided with combinations of long-acting and short-acting opioids. 3) There is good evidence that the increased supply of opioids, use of high dose opioids, doctor shoppers, and patients with multiple comorbid factors contribute to the majority of the fatalities. 4) There is fair evidence that long-acting opioids and a combination of long-acting and shortacting opioids contribute to increasing fatalities and that even low-doses of 40 mg or 50 mg of daily morphine equivalent doses may be responsible for emergency room admissions with overdoses and deaths. 5) There is good evidence that approximately 60% of fatalities originate from opioids prescribed within the guidelines, with approximately 40% of fatalities occurring in 10% of drug abusers. 6) The short-term effectiveness of opioids is fair, whereas the long-term effectiveness of opioids is limited due to a lack of long-term (> 3 months) high quality studies, with fair evidence with no significant difference between long-acting and short-acting opioids. 7) Among the individual drugs, most opioids have fair evidence for short-term and limited evidence for long-term due to a lack of quality studies. 8) The evidence for the effectiveness and safety of chronic opioid therapy in the elderly for chronic non-cancer pain is fair for short-term and limited for long-term due to lack of high quality studies; limited in children and adolescents and patients with comorbid psychological disorders due to lack of quality studies; and the evidence is poor in pregnant women. 9) There is limited evidence for reliability and accuracy of screening tests for opioid abuse due to lack of high quality studies. 10) There is fair evidence to support the identification of patients who are non-compliant or abusing prescription drugs or illicit drugs through urine drug testing and prescription drug monitoring programs, both of which can reduce prescription drug abuse or doctor shopping. Disclaimer: The guidelines are based on the best available evidence and do not constitute inflexible treatment recommendations. Due to the changing body of evidence, this document is not intended to be a “standard of care.” Key words: Chronic pain, persistent pain, non-cancer pain, controlled substances, substance abuse, prescription drug abuse, dependency, opioids, prescription monitoring, drug testing, adherence monitoring, diversion
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Gupta, MS, Shaloo, Haridarshan Patel, PharmD, Justin Scopel, MD, MBA, and Reema R. Mody, MBA, PhD. "Impact of constipation on opioid therapy management among long-term opioid users, based on a patient survey." Journal of Opioid Management 11, no. 4 (July 1, 2015): 325. http://dx.doi.org/10.5055/jom.2015.0282.
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Objective: The authors sought to characterize health-related quality of life (HRQoL), medication adherence, productivity losses, and treatment satisfaction associated with modifications to opioid therapy due to opioid-induced constipation (OIC).Design: A cross-sectional, between-subjects design was used to examine health outcomes among US noncancer participants currently taking opioids.Patients, participants: Participants were adults in the 2012 US National Health and Wellness Survey, who reported currently using opioids (>30 days) and experiencing constipation. Respondents were categorized as making modifications to opioid therapy due to OIC (modifiers, n = 244) or making no modifications (nonmodifiers, n = 247).Main outcome measures: Patient Assessment of Constipation Quality of Life (PAC-QoL) and Symptoms (PAC-Sym), Morisky Medication Adherence Scale (MMAS-4), Work Productivity and Activity Impairment, and the Treatment Satisfaction Questionnaire for Medication (TSQM II) for OIC treatment were administered. Generalized linear models were adjusted to control for baseline characteristics (age, gender, comorbidities, opioid strength, etc). Results: Modifiers reported poorer HRQoL (PAC-QoL total: 1.74 vs 1.44, p < 0.001), worse constipation (PAC-Sym total: 1.56 vs 1.35, p = 0.003), more pain-related resource use (surgery: odds ratio (OR) = 3.72, p = 0.002; emergency room visits: OR = 1.88, p = 0.049; hospitalizations: OR = 2.47, p = 0.033), and lower adherence (MMAS-4 pain: OR = 0.12, p < 0.001; MMAS-4 OIC: OR = 0.39, p < 0.001) than nonmodifiers. Modifiers reported greater presenteeism (49.75 percent vs 38.28 percent, p = 0.038), but no significant differences were found for activity impairment or OIC treatment satisfaction.Conclusions: Treating OIC effectively may help prevent inadequate pain management secondary to opioid therapy modification, help increase HRQoL, lessen OIC symptoms, decrease productivity loss, and improve adherence to opioid and OIC treatments.
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Huynh, Peter, Joseph Villaluz, Harjot Bhandal, Navid Alem, and Rakhi Dayal. "Long-Term Opioid Therapy: The Burden of Adverse Effects." Pain Medicine 22, no. 9 (March 1, 2021): 2128–30. http://dx.doi.org/10.1093/pm/pnab071.
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Duarte, Rui, and Jon Raphael. "The Pros and Cons of Long-Term Opioid Therapy." Journal of Pain & Palliative Care Pharmacotherapy 28, no. 3 (August 28, 2014): 308–10. http://dx.doi.org/10.3109/15360288.2014.943383.
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