| Journal of Opioid Management ® | ||||||||||||||||||||||||||||||||||||||||||||||||
|
Publications American Journal of Disaster Medicine Opioid Management
Society Journal of Neurodegeneration & Regeneration Activities Directors' Quarterly for Alzheimer's & Other Dementia Patients American Journal of Recreation Therapy |
January/February 2007; pages 5-7
Abstract FDA accepts Labopharm’s response to approvable letter for once-daily tramadol as complete. Study finds 90 percent of Actiq “lollipop” prescriptions are off-label. A quick-relief opioid: Cephalon reports positive results from Phase III trials with Fentora. Doctor frees inmate in order to administer drug.
January/February 2007; pages 11-14 Abstract The use of opioid analgesia for acute abdominal pain of unclear etiology has traditionally been thought to mask symptoms, alter physical exam findings, delay diagnosis, and increase morbidity and mortality. However, studies in children and adults have demonstrated that administering intravenous opioids to patients with acute abdominal pain induces analgesia but does not delay diagnosis or adversely affect diagnostic accuracy. This review discusses the effects of opioid administration on pain relief and diagnostic accuracy in children with moderate to severe acute abdominal pain who have been evaluated in the emergency department. We hold that current evidence supports the administration of opioids to children with acute abdominal pain, and future trials will help determine safe and effective timing and dosing related to opioid administration. Key words: opioids, children, abdominal pain, emergency department
January/February 2007; pages 16-20 Abstract The objective of this medicolegal case report is to present the details of the case of a chronic pain patient (CPP) who was placed on chronic opioid analgesic therapy (COAT) and was involved in a motor vehicle accident, alleged in litigation to be related to COAT. COAT standards are in a process of evolution, and this process is influenced by recent literature developments. We aim to present both the plaintiff’s and defendant’s expert witnesses’ opinions on whether the defendant physician fell below the “standard” in allowing the CPP to drive. Both the methadone and the driving literature are utilized to explain the defendant’s and plaintiff’s experts’ opinions and the differences between them. Based on these opinions, we have attempted to develop some recommendations on how pain physicians should approach the problem of deciding whether patients should be allowed to drive when on COAT. Key words: chronic pain, intractable pain, opioids, chronic opioid analgesic therapy, driving, motor vehicle accidents, standards of medical care, informed consent, breaches of standards, methadone
January/February 2007; pages 21-26 Abstract Objective: This study aimed to investigate factors that might lead French homecare nurses to consider the prescription of high-dose morphine to terminally ill patients to be euthanasia. Methods: The researchers conducted an anonymous telephone survey among a random sample of 602 French homecare nurses (response rate = 75 percent) in 2005. Results: Overall, 27 percent of responding home nurses considered prescribing high-dose morphine to terminally ill patients to be euthanasia. Such an opinion was more frequently held by older nurses, those who had not followed terminally ill patients during the previous three years, and those with less knowledge about pain management involving opioid analgesics. Conclusion: There is an urgent need to strengthen pain management education among French homecare nurses—especially regarding the use of morphine—in order to both improve their technical skills and correct some misconceptions about opioid analgesics. Key words: morphine, euthanasia, end of life, France
January/February 2007; pages 27-34 Abstract Objective: This study aimed to analyze illicit drug use of participants in a methadone treatment program in relation to methadone dose, counseling, and retention. Methods: This was a longitudinal study of a cohort of 204 heroin-dependent subjects admitted for the first time to a methadone program in Stockholm. The patients were admitted between 1995 and mid-2000 and were followed until December 2000 or discharge. Up to June 11, 1998, individual psychosocial counseling was provided; after this date individual counseling was replaced with group counseling. Clinical data were collected from patient records and from a laboratory database. Rates of drug-positive urine analyses during different time periods were measured. Results: The mean observation time was 2.5 years for all patients. The one-year retention rate was 84 percent, and the two-year rate was 65 percent, with no major differences between the two counseling groups. Almost all patients relapsed to illicit drug use. Discharged patients had a significantly higher rate of positive urine samples (21 percent versus 9 percent) than patients who remained in treatment. Also, low methadone dose and younger age predicted discharge from treatment. Conclusion: The frequent urine monitoring showed that illicit drug use was rather common, even in a program with structured psychosocial interventions, although it was lower than in other studies. This testing policy can be used for early identification of patients at risk for drop-out or discharge who should be offered complementary interventions. Key words: methadone maintenance treatment, urine samples, drug abuse patterns, discharge, drug abuse, methadone dose
January/February 2007; pages 35-43 Abstract This multicenter trial compared the efficacy, safety, and effect on quality of life and work limitation of once-daily extended-release morphine sulfate capsules (AVINZA®, A-MQD) and twice-daily controlled-release oxycodone HCl tablets (OxyContin®, O-ER) in subjects with chronic, moderate to severe low back pain. After randomization and a period of opioid dose titration, subjects (n = 266) underwent an eight-week evaluation phase and an optional four-month extension phase (n = 174 in extension phase). Subjects were assessed using the 12-item Short-Form Health Survey® (SF-12) and the Work Limitations Questionnaire® (WLQ). In both groups, significant improvements were observed in the SF-12 mean scores for physical functioning (p < 0.001), role physical (p < 0.0001), bodily pain (p < 0.0001), physical summary (p < 0.001), and mental component summary (p < 0.005). At the end of the titration period, greater relative improvements from baseline were seen in the SF-12 section on physical components in the A-MQD group versus the O-ER group, with significant differences observed for physical functioning (p = 0.0374), role physical (p = 0.0341), bodily pain (p = 0.0001), and physical summary (p = 0.0022). In both groups, SF-12 mean scores improved significantly for mental health (p < 0.01), role emotional (p < 0.01), social functioning (p < 0.0005), vitality (p < 0.005), and the mental component summary (p < 0.005), but no significant differences were noted between the two groups. Both groups reported improvement from baseline in WLQ physical demands scores, with no significant differences noted between the two groups. At the end of the evaluation phase, fewer subjects were unable to work due to illness or treatment in the A-MQD group than in the O-ER group (8.5 percent versus 19.4 percent, respectively; p = 0.0149). In conclusion, compared to twice-daily OxyContin, once-daily AVINZA resulted in significantly better and earlier improvement of physical function and ability to work. Key words: morphine sulfate, oxycodone HCl, AVINZA, ACTION trial, low back pain, chronic pain, physical functioning, quality of life
January/February 2007; pages 49-58 Abstract The analgesic potential of buprenorphine, a high-affinity partial m agonist, has been a subject of study for several decades. The drug is now widely recognized as being extremely effective in relieving perioperative pain, with little of the addictive potential or risk associated with pure m agonists. Studies have suggested that buprenorphine produces adequate analgesia via almost any route of administration, including transdermal and subcutaneous. It has also been used, with positive results, in the treatment of opioid addiction, and potential remains for research into other roles, e.g., as an anti-inflammatory agent or an antihyperalgesic medication. Key words: buprenorphine, opioid, m agonist, analgesia, perioperative pain, route of administration, addiction, withdrawal, detoxification
January/February 2007; pages 59-64 Abstract Recognition and treatment of pain are now important indicators of the quality of care being delivered to neonates. However, population-specific characteristics have to be considered, necessitating an integrated, population-specific approach. Such an approach starts with a systematic evaluation of pain, using a validated pain-assessment instrument, and should be followed by effective interventions, mainly based on appropriate, i.e., safe and effective, administration of analgesics. We will illustrate the impact of age on the pharmacokinetics and metabolism of opioids using recently collected and reported observations of tramadol disposition in early neonatal life. Although distribution volume and clearance display age-dependent maturation, it is important to recognize that important, unexplained interindividual variability in drug metabolism is still observed. Research questions in the field of developmental pharmacokinetics of opioids should focus on covariables of relevance in the interindividual variability of both pharmacokinetics and pharmacodynamics of opioids in neonates and on long-term outcomes in preterm and term neonates to whom opioids were administered, with regard to behavioral consequences and effects on pain thresholds. Key words: opioids, neonates, pharmacokinetics, interindividual variability Journal of Opioid Management March/April 2007, Volume 3, Number 2
March/April 2007; pages 69-70
Abstract New research findings from the AAPM annual meeting. Pain linked to some major psychiatric disorder diagnoses. Psychiatric factors linked to increased risk for misuse of opioid medications. Physicians debate link between morphine and double effect. Potential new pain drug developed at University of Leicester and Ferrara.
March/April 2007; pages 74-78 Abstract Background: This study was designed to evaluate the efficacy and safety of oral midazolam, tramadol drops, and intranasal sufentanil for premedication of pediatric patients. Methods: Sixty children, three to 10 years of age, who were designated as American Society of Anesthesiologists physical status I and who were undergoing adenotonsillectomy as inpatients were randomized to receive a dosage of 0.5 mg/kg (total of 4 mL) midazolam in cherry juice (n = 20, Group M), 3 mg/kg tramadol drops (n = 20, Group T), or 2 mg/kg intranasal sufentanil (n = 20, Group S). Clinical responses (sedation, anxiolysis, cooperation) and adverse effects (respiratory, hemodynamic, etc.) were recorded. Safety was assessed by continuous oxygen saturation monitoring and observation. Vital signs (blood pressure, pulse, oxygen saturation, respiratory rate) were recorded before drug administration (baseline) and then every 10 minutes until the induction of anesthesia. Results: Mean blood pressure decreased significantly after five minutes of intranasal sufentanil administration relative to Groups M (p < 0.01) and T (p < 0.05), whereas heart rate remained unchanged. Oxygen saturation and respiratory rate decreased significantly after 20 and 30 minutes of intranasal sufentanil administration relative to Groups M and T (p < 0.05). Anxiety scores showed rates of 45 percent in Group M, 5 percent in Group T, and 40 percent in Group S. Anxiety scores in Groups M and S were better than those of Group T (p < 0.01). Cooperation scores for face-mask acceptance showed rates of 85 percent in Group M, 45 percent in Group T, and 85 percent in Group S (p < 0.01). Conclusion: Intranasal sufentanil and oral midazolam are more appropriate premedication options than tramadol drops in children. Key words: children, oral midazolam, oral tramadol, intranasal sufentanil
March/April 2007; pages 80-86 Abstract Objective: To determine the level of urine drug test (UDT) interpretive knowledge of physicians who use these instruments to monitor adherence in their patients on chronic opioid therapy. Methods: A seven-question instrument consisting of six five-option, single-best-answer multiple choice questions and one yes/no question was completed by 114 physicians (77 who employ UDT and 37 who do not) attending one of three regional opioid education conferences. We calculated frequencies and performed c2 analyses to examine bivariate associations between UDT utilization and interpretive knowledge. Results: The instrument was completed by 80 percent of eligible respondents. None of the physicians who employ UDT answered all seven questions correctly, and only 30 percent answered more than half correctly. Physicians who employ UDT performed no better on any of the questions than physicians who do not employ UDT. Conclusions: Physicians who employ UDT to monitor patients receiving chronic opioid therapy are not proficient in test interpretation. This study highlights the need for improved physician education; it is imperative for physicians to work closely with certified laboratory professionals when ordering and interpreting these tests. Key words: urine drug test, chronic opioid therapy, interpretation, physician knowledge
March/April 2007; pages 89-100 Abstract Background: Psychopathology (depression, anxiety, somatization disorder) and substance abuse (opioid misuse and illicit drug use) are common in patients with chronic pain and present problems for public health and clinical management. Despite a body of literature describing various methods for identifying psychopathology, opioid misuse, and illicit drug use in chronic pain patients, the relationship between psychopathologies, substance abuse, and chronic pain has not been well characterized. Methods: This report describes a total of 500 consecutive pain patients prescribed and receiving stable doses of opioids. The patients were evaluated for psychopathology, opioid abuse, and illicit drug use during the course of regular pain management treatment. The relationships between psychopathology and drug abuse and/or illicit drug use in chronic pain patients were examined, and psychological evaluation for depression, anxiety, and somatization disorder was performed. Results: Depression, anxiety, and somatization disorder were documented in 59, 64, and 30 percent of chronic pain patients, respectively. Drug abuse was significantly higher in patients with depression as compared to patients without depression (12 percent with depression versus 5 percent without). Current illicit drug use was higher in women with depression (22 percent) than women without depression (14 percent) and in men with or without depression (12 percent). Current illicit drug use was also higher in men with somatization disorder (22 percent) than men without (9 percent). Conclusion: This study demonstrated that the presence of psychological features of depression and somatization disorder may be markers of substance abuse diathesis in chronic pain patients. Key words: psychopathology, substance abuse, opioid abuse, illicit drug use, MCMI, P3, DSM-IV-TR, endophenotype
March/April 2007; pages 101-106 Abstract Objective: We sought to assess the prevalence and characteristics of breakthrough pain (BTP) in patients with chronic back pain. Design: Researchers utilized a telephone survey using a pain assessment algorithm. This report represents a subset of patients from a larger survey of 228 patients with chronic pain unrelated to cancer. Participants: This study employed 117 subjects taking opioids for a primary diagnosis of back pain and receiving care at geographically dispersed pain treatment centers. Subjects had pain lasting at least six months and had “controlled” baseline pain. Results: Eighty-seven subjects (74 percent) experienced 93 types of BTP. The median number of BTP episodes per day was two; median time to maximum intensity was 10 minutes, and median duration was 55 minutes. Onset could not be predicted for 46 percent of pains. Eighty-three percent of subjects used shorter-acting opioids for BTP. Other medications used for pain included NSAIDs, antidepressants, anticonvulsants, skeletal muscle relaxants, intrathecal local anesthetics, and transdermal local anesthetics. Conclusions: These patients with opioid-treated chronic back pain commonly experienced BTP, which often had a rapid onset and a relatively short duration and was difficult to predict. Opioids were the mainstay of pharmacologic therapy, but nonopioid analgesics and adjuvant analgesics were commonly used. Key words: back pain, chronic pain, breakthrough pain, prevalence, survey methodology
March/April 2007; pages 107-111 Abstract Prescription opiate misuse is a major public health issue, especially in rural areas. The purpose of this analysis was to examine trends in prescription opiate misuse over time in a cohort of community-based rural probationers. Participants (N = 800), recruited over a four-year period, were divided into cohorts according to the year in which they were interviewed. Prescription opiate misuse increased significantly between 2001 and 2004 (p < 0.001). After adjustment for changes in demographic characteristics of the cohorts, misuse of prescription opiates was still significantly greater in 2004 compared with 2001. These data suggest changes in drug use patterns among community-based rural probationers from street to prescription drugs. Implications of the findings are discussed. Key words: opiate misuse, prescription opiates, recreational drugs, rural communities, probationers
March/April 2007; pages 113-114 Abstract A patient was treated for several years with high doses of opioids for malignant pain. During a recent hospitalization, the patient’s pain remained uncontrolled despite escalating doses of various opioids. We suspected that this patient suffered from the clinical phenomenon of opioid-induced hyperalgesia (OIH). The patient was then rotated from her other opioids to methadone, and her pain was adequately controlled within several days. Methadone, because of its NMDA antagonist properties, offers an effective treatment for OIH. The use of methadone for analgesia is complex and should be undertaken only by practitioners who have appropriate experience. Key words: opioid-induced hyperalgesia, methadone, opioid rotation, opioid tolerance Journal of Opioid Management May/June 2007, Volume 3, Number 3
May/June 2007; pages 123-126
May/June 2007; pages 127-132 Abstract Objective: We addressed the prevalence of opioid dependence (OD) in spine surgery patients and its correlation with length of stay (LOS) as the most important determinant of hospital cost. Methods: The study took place at Georgia Neurosurgical Institute and the Medical Center of Central Georgia between March 2006 and January 2007. A prospective convenience sample of 150 spine surgery patients (48 lumbar diskectomy, 60 cervical decompression and fusion, and 42 lumbar decompression and fusion [LDF]) was assembled. Patients were interviewed before surgery using a questionnaire designed in accordance with the World Health Organization and DSM-IV-TR criteria for the diagnosis of OD. The prevalence of OD was calculated based on questionnaire results. Pain intensity was quantified during admission using a 0-to-10 pain scale. We used pain intensity multiplied by duration of pain in months (WR index) as a new parameter. Lengths of stay were collected following patients’ discharge from hospital. Pearson correlation and regression analysis were performed using SPSS software. Results: Thirty (20.00 percent) patients were opioid dependent. The prevalence was highest among LDF patients (23.81 percent), females (22.78 percent), and, to a lesser degree, Caucasians (20.87 percent). There was no correlation between OD and age (r = 0.08, p > 0.1) or between OD and LOS (r = 0.09, p > 0.1). This study proved a very significant positive correlation between OD and pain intensity (r = 0.24, p < 0.01) and between OD and the WR index (r = 0.30, p < 0.01). On the other hand, there was a significant positive correlation between LOS and age (r = 0.42, p < 0.01), between LOS and the number of previous spine surgeries (r = 0.28, p < 0.01), and between LOS and duration of pain (r = 0.18, p < 0.05). Regression analysis showed that age, ethnicity, and type of surgery were the main determinants of LOS. Conclusions: Chronic pain and prolonged use of opioids raise the prevalence of OD in spine surgery patients to 20 percent. The lack of effect of OD on LOS after surgical intervention means that efforts to decrease LOS by trying to satisfy patients’ craving for opioids will not be fruitful. Older, African-American LDF patients with a lengthy history of pain and multiple spine surgeries in the past are the most likely to stay longer in hospital. Key words: opioid, dependence, spine surgery, length of stay, WR index
May/June 2007; pages 137-144 Abstract Background: Years’ worth of observations suggest that morphine has both inhibitory and excitatory actions, and that selective blockade of excitatory effects by low doses of opioid antagonists (e.g., naltrexone) may paradoxically enhance morphine analgesia. The purpose of this pilot study was to evaluate and compare the analgesic efficacy and safety of two different low doses of oral naltrexone given in addition to chronic intrathecal morphine infusions in patients with chronic nonmalignant pain (CNMP). Methods: After institutional review board approval, 15 patients with CNMP receiving continuous intrathecal morphine were admitted into a prospective, randomized, double-blind, placebo-controlled, seven-day pilot study. Patients were randomized into three treatment groups based on oral naltrexone dose: 100 mg (Group A, n = 3), 10 mg (Group B, n = 7), or placebo (Group C, n = 5). All patients continued with their constant intrathecal morphine infusion, and in addition they received one capsule of study medication every 12 hours for seven days. Other analgesics or coanalgesics were kept at a constant dose level throughout the study. Patients rated pain scores (visual analogue score [VAS]; 0 = no pain, 10 = worst pain imaginable) and side effects three times daily throughout the study period. Efficacy measures included pain intensity difference (PID) scores, constructed so that positive scores indicate a reduction in pain intensity and negative scores indicate a worsening of pain. Results: Fifteen patients (six male, nine female) with a mean (SD) age of 55 (10) years and weight of 81 (21) kg completed the study. The mean (SD) baseline VAS pain intensity rating was similar in all three groups (6.8 [1.5]). Baseline pain VAS score minus the lowest daily pain VAS score yielded the peak PID score. The peak PID score from Day 1 was statistically (p < 0.05) highest (median PID score: 5.9) in Group A compared with Group C. There was a trend in PID scores across Days 2 through 7, with median PID scores higher (i.e., greater pain relief; p = 0.07) in Group A. In the daily global pain assessments, the pain scores across Days 2 through 7 approached significance (least pain) in Group A compared to Group C (p = 0.07) or B (p = 0.08). Side effects were common (93 percent of patients), minor (headache, nausea, sedation, dry mouth), and similar across treatment groups. No serious adverse events were observed, and no evidence of opioid withdrawal was seen. Conclusions: 1) Patients with chronic pain who received oral naltrexone 100 mg BID in addition to their chronic intrathecal morphine infusions demonstrated the greatest improvement (p = 0.07) in their daily pain scores. Because of the small sample size, the results did not reach traditional levels of significance. 2) Side effects were common, minor, and similar across treatment groups. 3) No serious adverse events were recorded. 4) No evidence of opioid antagonist toxicity or opioid withdrawal was observed. Key words: chronic pain, opioid agonists, opioid antagonists, intrathecal analgesics, analgesia
May/June 2007; pages 145-154 Abstract Study objective: To investigate the effect of once-a-day extended release of morphine sulfate AVINZA® (A-MQD) on polysomnographic measures of sleep in a population of chronic osteoarthritic pain patients with sleep difficulties. Design: Single-center, single-blind, placebo-lead-in, 30 mg or 60 mg. Patients’ sleep and neurocognition were objectively measured at a sleep laboratory, and patients self-rated their pain, sleep, and other functions. Participants: Thirty-four participants (26 to 75 years old) complaining of sleep difficulties and chronic, stable pain secondary to hip or knee osteoarthritis. Interventions: Participants had a screening visit on current pain medication and then, following a single-blind placebo run-in period, received 30 mg/d of A-MQD for six days. At day 6, doses for participants with incomplete pain relief on the Brief-Pain-Inventory (BPI) pain scale were increased to 60 mg/d. Treatment continued for another eight days at the new dose level (14 days for a subgroup at 60 mg/d). Sleep was objectively measured by all-night polysomnography (PSG) at screening while on the participants’ current pain therapy, at baseline following a placebo run-in and at the end of treatment while on A-MQD. Outcome measures: PSG parameters evaluated included Total-Sleep-Time (TST), Wake-timeafter-Sleep-Onset (WASO), Sleep-Efficiency (SE), Latency-to-Persistent Sleep (LPS), Latency-to-REM-sleep, the Number-of-Awakenings (NAW), the time spent in each stage of sleep, and REM-sleep-latency. Subjective evaluations included participants’ estimations of sleep time and sleep quality, the Epworth-Sleepiness-Scale (ESS), the BPI, and participant acceptance of and relief due to current therapy. Assessments of neurocognitive function were also made. Results: Sleep initiation and maintenance tended to improve with A-MQD as demonstrated by the increases in TST and SE and decreases in WASO and NAW as compared with placebo-baseline values. Sleep architecture was preserved by the study drug and some increases in stage 2 and 3/4 sleep were seen compared with placebo baseline. Subjective ratings of sleep quality and sleep time were significantly improved with treatment, as were BPI scores and ratings of medication acceptance and pain relief. A-MQD was generally well tolerated. Conclusions: A-MQD was an effective treatment for pain, and this study treatment was associated with improvement of both objective and subjective sleep parameters in participants with chronic osteoarthritic pain. Key words: sleep, sleep quality, chronic pain, polysomnography, AVINZA® capsules
May/June 2007; pages 155-159 Abstract The authors investigated, in a randomized, placebo-controlled, double-blinded study, the efficacy and safety of lornoxicam on pain after abdominal hysterectomy and on tramadol consumption in patients. Fifty patients were randomized to receive either oral placebo or lornoxicam 8 mg one hour before surgery. Anesthesia was induced with propofol and maintained with sevoflurane in 50 percent N2O/O2 with a fresh gas flow of 2 L/min (50 percent N2O in O2) and fentanyl (2 mg/kg). All patients received patient-controlled analgesia with tramadol with loading dose of 50 mg; incremental dose of 20 mg; lock out interval of 10 minute; and four-hour limit 300 mg. The incremental dose was increased to 30 mg if analgesia was inadequate after one hour. Patients were studied at one, two, four, eight, 12, and 24 hours for visual analogue (VAS) pain scores, heart rate, mean arterial pressure, periferic oxygen saturation, sedation, tramadol consumption, and length of hospitalization. VAS scores at one hour were significantly lower in the lornoxicam group (p < 0.001). The tramadol consumption at one, two, four, eight, and 12 hours was significantly lower in the lornoxicam group when compared with the placebo group (p < 0.001, p = 0.008, p = 0.029, p = 0.034, p = 0.042, respectively). Sedation scores were similar at all the measured times in the groups. Length of hospitalization was significantly shorter in lornoxicam group (4.8 ± 0.4 day) than placebo group (5.2 ± 0.5 day) (p = 0.005). There was difference in the incidence of nausea between the groups (p = 0.047). The number of patients and the doses of antiemetics given during the first 24 hours after surgery in lornoxicam group were less than those in placebo group (p = 0.003, p = 0.034, respectively). In conclusion, a single oral dose of lornoxicam given preoperatively enhanced the analgesic effect of tramadol, decreasing tramadol consumption and side effects, and shortened the length of hospitalization. Key words: analgesics opioid, tramadol, lornoxicam, postoperative pain, hysterectomy
May/June 2007; pages 161-166
May/June 2007; pages 167-170 Abstract This article describes a case of severe opioid-induced pruritus following systemic morphine administration. Symptoms did not resolve after administration of antihistamines or rotation to fentanyl or hydromorphone, but oral oxycodone and small-dose intravenous naloxone did alleviate the patient’s itching. The pathogenesis of opioid-induced pruritus and the rationale for opioid rotation are briefly discussed. Current and possible future therapeutic options are mentioned. Key words: pruritus, systemic opioids, opioid rotation Journal of Opioid Management July/August 2007, Volume 3, Number 4
July/August 2007; pages 179-180
July/August 2007; pages 181-184
July/August 2007; pages 185-188 Abstract Compulsive intravenous opiate injectors often cause themselves recurrent physical damage, which sometimes threatens life or limb. Unsuccessful attempts to find a vein can occupy several hours of each day, during which blood may clot in the syringe, making injection even more difficult. Adding small amounts of heparin to the opiate in the syringe before injecting prevents clotting but may be only partially helpful. The authors describe the first report-ed case in which an arteriovenous fistula was created specifically to enable a compulsive injector to inject quickly, easily, and safely. Key words: arteriovenous, fistula, compulsive, opiate user, injecting, methadone, heparin, harm reduction, addiction
July/August 2007; pages 189-194 Abstract Background: Errors may be more common and more likely to be harmful with opioids than with other medications, but little research has been conducted on these errors. Methods: The authors retrospectively analyzed MED-MARX®, an anonymous national medication error reporting database, and quantitatively described harmful opioid errors on inpatient units that did not involve devices such as patient-controlled analgesia. The authors compared patterns among opioids and qualitatively analyzed error descriptions to help explain the quantitative results. Results: The authors included 644 harmful errors from 222 facilities. Eighty-three percent caused only temporary harm; 60 percent were administration errors and21 percent prescribing errors; and 23 percent caused underdosing and 52 percent overdosing. Morphine and hydromorphone had a significantly higher proportion of improper dose errors than other opioids (40 percent and41 percent compared with 22 percent with meperidine). Hydromorphone errors were significantly more likely to be overdoses (78 percent vs 47 percent with other opioids).Omission errors were significantly more common with fentanyl patches (36 percent compared with 12 percent for other opioids). Wrong route errors were significantly more common with meperidine (given intravenously when prescribed as intramuscular, 34 percent vs 3 percent for morphine). Oxycodone errors were significantly more likely to be wrong drug errors (24 percent vs 11 percent for other opioids), often because of confusion between immediate- and sustained-release formulations. Conclusions: Reported opioid errors are usually associated with administration and prescribing and frequently cause uncontrolled pain as well as overdoses. These patterns of errors should be considered when using opioids and incorporated into pain guidelines, education, and quality improvement programs. Key words: opioids, medication errors, medical errors, pain
July/August 2007; pages 195-206 Abstract Background: The use of opioids for the treatment of neuropathic pain remains somewhat controversial, since earlier studies indicate that neuropathic pain is generally less responsive to pure -opioid analgesia. A growing body of evidence now suggests that different opioids affect different pain pathways, and emerging data support the possibility of a role for buprenorphine in the management of neuropathic pain. Objective: This article reviews the preclinical and clinical data for the role of buprenorphine in the treatment of neuropathic pain. Research Design and Methods: Literature searches were carried out using PubMed (1988 to September2006). Search terms included buprenorphine and neuropathic pain, as well as neuropathy, painful neuropathy, hyperalgesia, and allodynia. Clinical studies and case studies were included. Results: Several assays, including the formalin, coldtail flick, and diffuse noxious inhibitory control tests, have revealed buprenorphine’s potential efficacy in various pain types. These findings seem to support hypotheses regarding its unique analgesic mechanisms as compared with pure -opioids. The exact mechanism of this analgesic efficacy remains unknown. Preclinical assessments of buprenorphine demonstrate its sustained antihyperalgesic effect in several models of neuropathic pain. These findings are supported in clinical studies of oral, intrathecal, intravenous, and transdermal buprenorphine. Furthermore, these studies have demonstrated that, despite there being a ceiling effect for respiratory depression, no relevant analgesic ceiling effect is found with buprenorphine. Conclusions: Further studies are certainly warranted to identify the clinical neuropathic syndromes that are most sensitive to buprenorphine treatment, and to compare buprenorphine with other opioids in head-to-head trials of neuropathic pain. Key words: buprenorphine, opioids, neuropathic pain, hyperalgesia, allodynia, sensitization
July/August 2007; pages 207-214 Abstract Objective: The purpose of this review is to summarize the results of studies on physician-related barriers to cancer pain management with opioid analgesics. Methods: A literature search was conducted in PUBMED, using a combined text word and MeSH heading search strategy. Those articles whose full texts were not available in PUBMED were retrieved from the electronic databases of specific journals. Results: Sixty-five relevant articles, published in the period from 1986 to 2006, were identified. Physicians’ barriers to cancer pain management were studied in questionnaire surveys and in the reviews of drug prescribing documents. The results of the articles found were analyzed with respect to (a) knowledge, beliefs, concerns, problems endorsed or acknowledged by physicians treating cancer pain, (b) physicians’ skills in pain assessment, and (c) adequacy of opioid prescription. Conclusions: This review revealed mostly general and common physician-related barriers to cancer pain management: concerns about side effects to opioids, prescription of not efficient doses of opioids, and very poor prescription for the treatment of side effects from opioids. In the future, the evaluation of the influence of cultural-social-economical background, as well as the differences between the various specialists involved in the care of patients with cancer, should be explored to better under-stand physicians’ barriers and more effectively address them in interventional and educational programs. Key words: cancer pain, opioid prescription, physicians, barriers
July/August 2007; pages 215-223 Abstract Aims: This study examines trends for treatment admissions for nonheroin opioid abuse from 1992 to 2004. Methods: Databases from the Substance Abuse Mental Health Services Administration (SAMHSA, USA): Treatment Episode Data Set (TEDS) were used to examine the changing characteristics of admissions to treatment for non-heroin opioid abuse. Data are collected annually from each state on characteristics of admissions to treatment forall substances abused in the United States. Using the Mann-Kendall test for examining annual trends, we deter-mined any significant trend changes by modeling data for every 2 years of TEDS information from 1992 to 2004.Results:We found significant changes for admissions to substance abuse treatment from 1992 to 2004. Overall, nonheroin opioid admissions to treatment have increased, specifically among adolescents. Other significant trends included an increase in the never-married group admitted, a higher rate of psychiatric problems for nonheroin opioid abuse admissions, changes in the treatment services and significant associations between age of first use of marijuana and methamphetamine, and sub-sequent nonheroin opioid abuse admissions. Conclusion: Characteristics of admissions to treatment are changing over time and identify an admitted treatment group that is historically different from heroin abusers. These findings will give providers information about who is seeking treatment for nonheroin opiate abuse. Altered treatment strategies that target the changing population who seek treatment for nonheroin opioid abuse need to be universally available. Key words: nonheroin opioid abuse, admissions, trends
July/August 2007; pages 225-230 Abstract Objective: Previous evidences concerning pain mechanisms, long-term opioids use, and personality traits evolve the possibility that pain perception and opioid abuse are two related phenomena and there is a need to take into account the specific personality traits as well, in examining the relationships among them. Opioid addicts(OAs) have been shown to exhibit different personality traits and pain perception as compared with healthy subjects. The aim of the present study was to examine the relations between personality traits and pain perception among in-treatment OAs in comparison with controls. Design: Participants (54 OAs, 59 controls), all males, were exposed to the cold pressor test and were evaluated for latency of pain onset (seconds); pain intensity (0-100visual analogue scale [VAS)]); and pain tolerance(time for hand withdrawal). Personality traits were evaluated using Cloninger’s Tridimensional Personality Questionnaire, TPQ; harm avoidance, HA; reward dependence, RD; novelty seeking, NS. Results: In comparison with controls, OAs exhibited longer latencies, lower VAS scores, and shorter tolerance, and significantly higher NS, higher HA, and lower RD. Control group, but not OAs, showed a significant positive correlation between HA and VAS (r 0.31, p 0.02)and significant negative correlation between HA and tolerance (r 0.29, p 0.03). Conclusions: It is concluded that in contrast to healthy population, personality traits, as measured by the TPQ, do not predict pain perception in OAs. Key words: addiction, cold pressor test, opioids, pain perception, personality traits Journal of Opioid Management September/October 2007, Volume 3, Number 5
September/October 2007; pages 239-241 Abstract The traditional relationship between physicians and drug companies is imperiled because the perceived clinical value of the sales detail is found to be increasingly barren of clinical relevancy by physicians. There is an urgent need to train physicians to more effectively mine and refine the data offered by pharma for the benefit of present and future patients. The ability of doctors to use medicines for chronic disease states such as chronic pain, diabetes, hyperlipedemias, depression would be vastly improved if doctors were in possession of clinically relevant data that pharma has, but does not share with clinicians. Doctors must take control of the detail to extract this vital clinical information
September/October 2007; pages 242-243
September/October 2007; pages 244-248 Abstract Objective: Determine if the attributes and behaviors anecdotally thought to be indicative of drug seeking have statistical association with opioid seeking. Methods: Data on variables thought to be indicative of drug seeking were retrospectively extracted and com-pared between two patient groups seen in the Emergency Department between July 1, 2006 and December 31, 2006. Group 1 was considered to have true physical pain, and Group 2 was thought to be seeking opioids. Results: Seven variables were found to have statistical associations with opioid seeking. There was no chart documentation on absence or presence of six variables. Conclusions: Significant associations were found between several variables and opioid seeking. A prospective study should be performed so that all variables of interest can be thoroughly studied and a predictive model can be developed to differentiate patients with real pain from drug seekers. Key words: drug seeking, opioid seeking, opioid prescription misuse
September/October 2007; pages 249-256 Abstract Background and objective: The patient-controlled fentanyl HCl iontophoretic transdermal system (ITS) is an analgesic modality approved for the management ofacute postoperative pain. The fentanyl ITS uses a generally imperceptible electrical field to drive fentanyl across the skin and into the bloodstream. Unlike intravenous patient-controlled analgesia (PCA), fentanyl ITS is nee-dle free and preprogrammed, eliminating the risks of needlestick injury and programming errors. Its efficacy, safety, and tolerability were assessed in several clinical trials, and this article presents the integrated safety and tolerability of fentanyl ITS using data pooled from these studies. Methods: Data were pooled from three placebo-controlled trials and one active-controlled trial (fentanyl ITS vs intravenous PCA morphine) in which patients18years or older were admitted to the postanesthesia care unit after major abdominal, orthopedic, or thoracic surgery. Results: This analysis of safety and tolerability data revealed common treatment-related adverse events: nausea, vomiting, headache, and erythema. No clinically relevant respiratory depression was observed. No significant differences were observed between elderly patients (??65years of age) and patients <65 years of age. Conclusion: The fentanyl ITS addresses certain safety issues of existing modalities while providing comparable pain relief, making it an attractive option for postoperative pain management. Key words: fentanyl, iontophoresis, patient-controlled analgesia, postoperative pain
September/October 2007; pages 257-266 Abstract The Pain Medication Questionnaire (PMQ), initially developed by Adams et al. (J Pain Symptom Manage.2004; 27: 440-459), is a 26-item self-report assessment to screen for opioid-medication misuse. The PMQ has demonstrated good reliability and validity, and was predictive of early termination from treatment and identified patients who demonstrated maximal benefit from inter-disciplinary treatment (Holmes et al. Pain Pract. 2006; 6:74-88). This study was designed to further evaluate the validity of the PMQ by exploring whether the initial PMQ score would accurately predict the development of aberrant opioid-medication use behaviors relative to specific behavioral indices (ie, request for early refills, use of a medication agreement) and a physician rating of medication misuse behaviors. Patients were grouped according to the initial score on the PMQ based on the median score of 25. Patients with higher PMQ (H-PMQ) scores reported greater levels of perceived disability and decreased physical and mental functioning. Similar to earlier studies, total scores on the PMQ were moderately correlated with initial measures of physical and psychosocial functioning, and observed problematic medication use behaviors observed by physicians during evaluation. Furthermore, excessively high PMQ scores (30) were significantly associated with the need to use a medication agreement or requests for early refills. Five patients were identified from the H-PMQ group who demonstrated problematic opioid-medication use that fell outside of the realm of just early refill requests. Thus, although a PMQ total score 25 is indicative of problematic use, a score30 suggests that a patient should be closely monitored when prescribed an opioid medication. Overall, this study again demonstrated that a patient’s self-report is significantly correlated with problematic behaviors observed by physicians. Therefore, when utilized in a busy clinic set-ting, the PMQ will aide in the identification of specific problematic behaviors and beliefs at the outset of treatment that may hinder successful treatment of a patient’s pain condition. Key words: Pain Medication Questionnaire, chronic pain, opioid medication, misuse/abuse
September/October 2007; pages 267-272 Abstract Study objective: The aim of this study is to compare plasma remifentanil concentrations and pulmonary function tests in subjects receiving remifentanil infusion(RI) versus RI with paracervical block (PCB) during transvaginal ultrasound-guided oocyte retrieval (TUGOR). Design: Prospective, randomized. Setting: Assisted Conception Unit. Patients: Forty American Society of Anesthesiologists I subjects requiring TUGOR. Intervention: After ovarian hyperstimulation, subjects were randomly allocated into two groups to receive either RI (Group RI, n = 20) or RI with PCB (Group RI + PCB, n = 20). Measurements: Heart rate (HR), mean arterial pres-sure (MAP), peripheral oxygen saturation (SpO2), end tidal carbon dioxide (ETCO2) tension, forced expiratory volume in 1 second (FEV1) and forced vital capacity(FVC), and amount of remifentanil used were collected. Plasma remifentanil concentrations were calculated with STANPUMP software. Main results: HR, MAP, ETCO2, SpO2, FEV1, and FVC did not differ between the groups. Total amount of remifentanil used were 486 ± 1.81 ?g and 321 ± 0.87 ?g in groups RI and RI + PCB, respectively, (p < 0.05). In Group RI, plasma remifentanil concentrations were 4.7 ng mL-1and 4.2 ng mL-1 during the second trans-vaginal puncture, and at the end of TUGOR, respectively, whereas corresponding plasma remifentanil concentrations were 3.1 ng mL-1and 2.6 ng mL-1 in Group RI + PCB (p < 0.05). Conclusion: Both anesthesia regimens provided satisfactory analgesia without affecting FEV1 and FVC, but significantly higher plasma remifentanil concentrations were calculated when only RI was used as an anesthetic technique. Key words: plasma remifentanil concentration, pulmonary function tests, in vitro fertilization (IVF),oocyte retrieval
September/October 2007; pages 273-280 Abstract This placebo-controlled study examined the analgesic efficacy, safety, and clinical benefit of Tramadol Contramid OAD, a once-daily formulation with both immediate- and extended-release components. Five hundred and fifty-two patients with moderate to severe pain due to osteoarthritis(OA) of the knee were randomized into this multicenter, double-blind, parallel arm study. After randomization to Tramadol Contramid OAD 100, 200, or 300 mg, or to placebo, patients’ dose was titrated to the fixed randomized dose and maintained for 12 weeks. Efficacy was evaluated with the Patients’ Global Rating of Pain Relief(median ratings at maintenance visits), and the Western Ontario and McMaster University (WOMAC) Pain and Physical Function subscales (percent difference, baseline to end of study) as coprimary endpoints. A responder analysis was conducted (percentage of patients who achieved a 30 percent improvement on their baseline WOMAC pain score). The difference from placebo on the median Patient Global Rating of Pain Relief at the four maintenance visits was statistically significant (200 and 300 mg: p ??0.001). Treatment was rated effective or very effective by 75 percent and 80 percent of patients randomized to Tramadol Contramid OAD 200 mg and 300 mg, respectively. There was a 46 percent (300-mg dose; p = 0.016) and 43 percent (200-mg dose; p = 0.05) improvement on the WOMAC pain score (baseline to the end of the study) with Tramadol Contramid OAD com-pared with 32 percent for placebo. The responder analysis demonstrated a statistically significant difference in the percentage of patients who achieved a 30 percent improvement in their baseline WOMAC pain score for both Tramadol Contramid OAD 200 mg (65 percent; p = 0.0095) and 300 mg (65 percent; p = 0.0104) compared with placebo (50 percent). The type and incidence of adverse events were typical of tramadol (nausea, dizziness/vertigo, vomiting, somnolence, and constipation) and the intensity was mild to moderate in 87 percent of patients who experienced them regardless of dose. This study shows the efficacy and safety of Tramadol Contramid OAD200mg and 300 mg in patients with moderate or severe pain of the knee due to OA. Key words: tramadol, pain, analgesia, osteoarthritis, controlled release
September/October 2007; pages 281-288 Abstract A 32-year-old woman with locally invasive and metastatic endometrial cancer was admitted to the hospital for the treatment of crescendo pain. The effectiveness of her medical and psychosocial care was mitigated by four issues: (1) the intractable nature of her pain, (2) substance abuse, (3) mental illness, and (4) interorganizational conflict. This case report is both a chronicle and review of the literature of these multiple issues that converged together to adversely effect the patient’s overall care. Key words: crescendo pain, substance abuse, communication Journal of Opioid Management November/December 2007, Volume 3, Number 6
November/December 2007; pages 295-301 Abstract Pain is one of the most common reasons patients seek out healthcare and management typically requires complex medication regimens. Pharmacists have become increasingly more involved in pain management. Historically, pharmacists and physicians have often had adversarial relationships because of regulatory influence. However, as medication experts, pharmacists can play a key role in optimizing outcomes in the management of pain and can be critical to the success of the medication regimen. Numerous opportunities for collaboration exist for pharmacists and physicians in various settings. One example is the VIGIL process, an effective risk management strategy that requires collaboration between pharmacists and physicians. The success of pharmacist-physician collaboration will depend on numerous factors, including strong physician and administrative support. A clear strategy and stepwise approach to developing a pain management pharmacist-physician collaborative practice is the key to its success. Once the collaboration is formalized, a management strategy should also be defined and should include regular chart review and regular feedback from the physician. Through physician-pharmacist collaboration, pain management outcomes can be optimized and risk can be managed. Key words: pharmacist, pain management, collaborative practice
November/December 2007; pages 302-308 Abstract Buprenorphine was approved in late 2004 for the treatment of opioid abuse and dependence in specially trained and certified physicians’ offices. At the time of the approval, there was a regulatory concern that given the anticipated wide exposure there would be unexpectedly high levels of abuse in the high-risk population for which it was intended. To assess its abuse potential, the authors recruited more than 1,000 individuals seeking treatment for prescription opioid abuse from 100 stand-alone (ie, self-payor insurance) drug abuse treatment programs around the country to determine whether they misused buprenorphine in the past 30 days to get high. The results indicate that there was a time-related increase in the number of subjects who used burprenorphine to get high, reaching 30-35 percent of individuals completing a questionnaire in the second quarter of 2006. At this time, it was equivalent to the misuse of methadone, both of which, however, were considerably lower than hydrocodone and oxycodone. Thereafter, the number of individuals using buprenorphine to get high dropped in a near linear fashion to less than 20 percent of those completing a questionnaire in the second quarter of 2007, significantly lower than that for methadone, oxycodone, and hydrocodone. The most likely interpretation of these data is that the poly-substance-abusing population, for whom buprenorphine is intended, experimented with this medication for its mood-altering effects for a period of time, but presumably because of its lack of euphorogenic properties, its use has now dissipated. Additionally, support for this conclusion is the very rare endorsement of buprenorphine as a primary drug (3 percent of the total sample). Thus, the results indicate that it is unlikely that buprenorphine abuse will ever reach the epidemic that was feared by some regulatory groups and that its use in opioid detoxification and maintenance should continue. Key words: buprenorphine abuse, buprenorphine misuse, prescription opioid abuse, treatment, opioid abuse
November/December 2007; pages 309-312 Abstract Opioids are commonly used in both cancer and non-cancer pain. Many patients who require opioids have renal impairment. This can adversely influence the safety of opioids in these patients. Objectives: The objectives of this study were to (1) determine which opioids are most commonly prescribed in patients with renal impairment, (2) to identify differences in prescribing practices between two groups of physicians, and (3) to determine how renal impairment was recognized in this setting. Design and participants: A questionnaire postal survey was sent out to renal and palliative medicine consultants in UK and Ireland. One hundred and seventy-eight (30.5 percent) questionnaires were completed. Results: A larger proportion of renal than palliative medicine physicians prescribed morphine in patients with renal impairment. A significant number of physicians did not adjust doses of morphine or codeine. Palliative medicine physicians were more likely to prescribe opioids other than morphine, with the exception of fentanyl which was widely used by both groups. Renal physicians were more likely to base their choice of opioid on glomerular filtration rate while palliative medicine physicians were more likely to be influenced by serum creatinine. Conclusions: Consensus guidelines drawing on expertise from both palliative and renal physicians are needed to promote safer use of opioids in this vulnerable patient group. Key words: renal impairment, opioid, morphine, glomerular filtration rate, creatinine
November/December 2007; pages 317-327 Abstract Objective: Sleep problems are common among patients with chronic pain (CP). Information on sleep problems and associated covariates in opioid-treated patients with CP is limited. The aim of this study was to assess the prevalence, characteristics, and risk factors of sleep and day-time sleepiness problems in this specific population. Design: Cross-sectional. Setting: Primary care outpatient clinics. Participants: Eight hundred and seventy six patients with CP treated with long-term opioids. Main Outcome Measures: Prestudy selected questionnaires: six questions from the Medical Outcomes Study Sleep Scale, Pain Inventory Survey, Pain Patient Profile, Substance Dependence Severity Scale, and medication log. Results: Insomnia-type sleep problems and combined sleep and sleepiness problems were reported by 87 percent and 49 percent of the sample, respectively. Logistic regression analysis showed that depression (adjusted OR, aOR2.8, 95% CI 2.1-3.7) and pain severity (aOR 1.4, 95% CI1.1-1.7) were the strongest independent predictors of sleep problems; only depression severity predicted daytime sleepiness (aOR 1.9, 95% CI 1.6-2.2) or combined sleep/sleepiness problems (aOR 2.2, 95% CI 1.8-2.5). Opioid dose was associated with a slight tendency toward unrefreshing sleep (aOR 1.2, 95% CI 1.0-1.4) and worse sleep maintenance (aOR 1.2, 95% CI 1.0-1.4), while use of long-acting opioids was associated with a trend toward increased napping (aOR 1.3, 95% CI 1.0-1.8). Conclusions: Sleep and daytime sleepiness problems are common among opioid-treated primary care patients with CP and seem to be related mainly to depression and pain severity. Physicians caring for opioid-treated patients with CP may want to assess them for sleep disorders as apart of routine CP care. Key words: opioid therapy, chronic pain, sleep, day-time sleepiness
November/December 2007; pages 328-332 Abstract Objectives: Heroin addiction in the United States exacts significant social, economic, medical, and public health costs, estimated at almost $22 billion in 1996. The national drug control strategy of arrest and mandatory sentencing of drug offenders over the past two decades has resulted in ever greater numbers of drug users who encounter the criminal justice system each year. No estimate of heroin use among the US incarcerated population exists. The authors attempted to estimate the proportion of heroin-using individuals who pass through the corrections system annually to determine the potential impact of interventions designed to link heroin-using individuals to addiction treatment. Methods: The authors constructed an estimate by employing the following elements: arrestee drug-testing data, total number of arrests, an estimate of the mean annual number of arrests in a drug-using population, estimates of arrestees incarcerated, and estimates of heroin use and addiction in the US population. The authors present each component of the estimate and how it was derived, and conclude by discussing the degree of uncertainty in the estimates and the implications of our results for policy makers. Results: Using a conservative estimate, the authors found that 24 percent to 36 percent of all heroin addicts pass through the corrections system each year, representing more than 200,000 individuals. Conclusions: Viewed as a public health opportunity, effective linkage to addiction treatment could ultimately reduce the costs associated with poor health, disease transmission, criminality, and recidivism that heroin use exacts on individuals and communities. Key words: heroin, addiction, prison, public health
November/December 2007; pages 333-337 Abstract Objective: To determine the proficiency in urine drug test interpretation among family medicine physicians who order these tests to monitor adherence in their patients on chronic opioid therapy. Methods: A seven-question instrument, consisting of six, five-option, single-best-answer multiple choice questions and one yes/no question was administered to 80family medicine physicians attending a University of Kentucky Family Medicine Review Course. We calculated frequencies and performed ?2 analyses to examine bivariate associations between urine drug test utilization and interpretive knowledge. Results: The instrument was completed by 60/80 (75percent) of eligible physicians (44 order urine drug testing; 16 do not). None of the physicians who order urine drug testing answered more than five of the seven questions correctly, and only 20 percent answered more than half correctly. Physicians who order urine drug testing performed better than physicians who do not order urine drug testing on only four of the seven questions, although there were no statistically significant differences between the groups on any question. Conclusions: Family medicine physicians who order urine drug testing to monitor their patients on chronic opioid therapy are not proficient in their interpretation. This study highlights the need for improved physician education in this area. It is imperative for physicians to work closely with certified laboratory professionals when ordering and interpreting urine drug tests. Key words: urine drug test, opioid, drug abuse
November/December 2007; pages 338-344 Abstract Objective: The aims of this study were to evaluate the cognitive complexity and reading demands of patient self-administered Opioid Assessment Screening Tools(OASTs) for use in adults with nonmalignant pain. Methods: Using comprehensive search strategies, we identified english-language OASTs with established validity and reliability for inclusion in our study. Cognitive complexity of individual OAST statements or questions were assessed using three techniques (number of items, number of words, and linguistic problems),whereas readability was measured using the Flesch-Kinkaid formula. Results: Four (n = 4) were identified and included in our review: Current Opioid Misuse Measure (COMM),Pain Medication Questionnaire (PMQ), Screener and Opioid Assessment for Patient with Pain, and Screening Tool for Addiction Risk (STAR). Number of total OAST statements or questions ranged from a low of 14 (STAR)to a high of 26 (PMQ), whereas number of words (length)per statement or question averaged from a low of 10.2 ±1.1 (STAR) to a high of 15.9 ± 3.8 (PMQ). The STAR (1.3 ±1.1) had the fewest number of linguistic problems per statement or question, whereas the PMQ (3.0 ± 1.4) had the most linguistic problems per statement or question. Although, readability of OASTs ranged from approximately sixth (STAR) to eighth (COMM, PMQ) grade, there was notable variation in readability across individual statements or questions. Conclusions: Our study demonstrates that formatting characteristics, including linguistic problems, and high readability of several OAST statements or questions may hinder many patients’ ability to accurately complete and comprehend OASTs independently. Keywords: aberrant drug behaviors, addiction, assessment, chronic pain, opioids, screening |
|||||||||||||||||||||||||||||||||||||||||||||||