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Background: Marijuana use is common among patients on long-term opioid therapy (LTOT) for chronic pain, but there is a lack of evidence to guide clinicians' response., Objective: To generate expert consensus about responding to marijuana use among patients on LTOT., Design: Analysis from an online Delphi study., Setting/subjects: Clinician experts in pain and opioid management across the United States., Methods: Participants generated management strategies in response to marijuana use without distinction between medical and nonmedical use, then rated the importance of each management strategy from 1 (not at all important) to 9 (extremely important). A priori rules for consensus were established, and disagreement was explored using cases. Thematic analysis of free-text responses examined factors that influenced participants' decision-making., Results: Of 42 participants, 64% were internal medicine physicians. There was consensus that it is not important to taper opioids as an initial response to marijuana use. There was disagreement about the importance of tapering opioids if there is a pattern of repeated marijuana use without clinical suspicion for a cannabis use disorder (CUD) and consensus that tapering is of uncertain importance if there is suspicion for CUD. Three themes influenced experts' perceptions of the importance of tapering: 1) benefits and harms of marijuana for the individual patient, 2) a spectrum of belief about the overall riskiness of marijuana use, and 3) variable state laws or practice policies., Conclusions: Experts disagree and are uncertain about the importance of opioid tapering for patients with marijuana use. Experts were influenced by patient factors, provider beliefs, and marijuana policy, highlighting the need for further research., (© 2019 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: High proportions of post-9/11 veterans have musculoskeletal disorders (MSDs), but engaging them in care early in their course of illness has been challenging. The service connection application is an ideal point of contact for referring veterans to early interventions for their conditions., Design: Among MSD claimants who reported risky substance use, we pilot-tested a counseling intervention targeting pain and risky substance use called Screening Brief Intervention and Referral to Treatment-Pain Module (SBIRT-PM). Veterans were randomly assigned in a 2:1:1 ratio to SBIRT-PM, Pain Module counseling only, or treatment as usual (TAU)., Methods: Participants assigned to either counseling arm were offered a single meeting with a study therapist with two follow-up telephone calls as needed. Participants completed outcome assessments at four and 12 weeks after randomization., Results: Of 257 veterans evaluated, 101 reported risky substance use and were randomized. Counseling was attended by 75% of veterans offered it and was well received. VA pain-related services were used by 51% of participants in either of the pain-focused conditions but only by 27% in TAU (P < 0.04). Starting with average pain severity ratings of 5.1/10 at baseline, only minimal changes in mean pain severity were noted regardless of condition. Self-reported risky substance use was significantly lower over time in the SBIRT-PM condition relative to the two other conditions (P < 0.02). At week 12, proportions of veterans reporting risky substance use were 0.39, 0.69, and 0.71 for the SBIRT-PM, Pain Module counseling, and TAU conditions, respectively., Conclusions: SBIRT-PM shows promise as a way to engage veterans in pain treatment and reduce substance use., (© 2018 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Dissemination of evidence-based practices that can reduce morbidity and mortality is important to combat the growing opioid overdose crisis in the USA. Research and expert consensus support reducing high-dose opioid therapy, avoiding risky opioid-benzodiazepine combination therapy, and promoting multi-modal, collaborative models of pain care. Collaborative care interventions that support primary care providers have been effective in medication tapering. We developed a patient-centered Primary Care-Integrated Pain Support (PIPS) collaborative care clinical program based on effective components of previous collaborative care interventions. Implementation facilitation, a multi-faceted and dynamic strategy involving the provision of interactive problem-solving and support during implementation of a new program, is used to support key organizational staff throughout PIPS implementation. The primary aim of this study is to evaluate the effectiveness of the implementation facilitation strategy for implementing and sustaining PIPS in the Veterans Health Administration (VHA). The secondary aim is to examine the effect of the program on key patient-level clinical outcomes-transitioning to safer regimens and enhancing access to complementary and integrative health treatments. The tertiary aim is to determine the categorical costs and ultimate budget impact of PIPS implementation., Methods: This multi-site study employs an interrupted time series, hybrid type III design to evaluate the effectiveness of implementation facilitation for a collaborative care clinical program-PIPS-in primary care clinics in three geographically diverse VHA health care systems (sites). Participants include pharmacists and allied staff involved in the delivery of clinical pain management services as well as patients. Eligible patients are prescribed either an outpatient opioid prescription greater than or equal to 90 mg morphine equivalent daily dose or a combination opioid-benzodiazepine regimen. They must also have an upcoming appointment in primary care. The Consolidated Framework for Implementation Research will guide the mixed methods work across the formative evaluation phases and informs the selection of activities included in implementation facilitation. The RE-AIM framework will be used to assess Reach, Effectiveness, Adoption, Implementation, and Maintenance of PIPS., Discussion: This implementation study will provide important insight into the effectiveness of implementation facilitation to enhance uptake of a collaborative care program in primary care, which targets unsafe opioid prescribing practices.

Introduction: Opioid prescribing and subsequent rates of serious harms have dramatically increased in the past two decades, yet there are still significant barriers to reduction of risky opioid regimens. This formative evaluation utilized a mixed-methods approach to identify barriers and factors that may facilitate the successful implementation of Primary Care-Integrated Pain Support (PIPS), a clinical program designed to support the reduction of risky opioid regimens while increasing the uptake of non-pharmacologic treatment modalities., Methods: Eighteen Department of Veterans Affairs (VA) employees across three sites completed a survey consisting of the Organizational Readiness for Implementing Change (ORIC) scale; a subset of these individuals (n = 9) then completed a semi-structured qualitative phone interview regarding implementing PIPS within the VA. ORIC results were analyzed using descriptive statistics while interview transcripts were coded and sorted according to qualitative themes., Results: Quantitative analysis based on ORIC indicated high levels of organizational readiness to implement PIPS. Interview analysis revealed several salient themes: system-level barriers such as tension among various pain management providers; patient-level barriers such as perception of support and tension between patient and provider; and facilitating factors of PIPS, such as the importance of the clinical pharmacist role., Conclusions: While organizational readiness for implementing PIPS appears high, modifications to our implementation facilitation strategy (e.g., establishing clinical pharmacists as champions; marketing PIPS to leadership as a way to improve VA opioid safety metrics) may improve capacity of the sites to implement PIPS successfully., (Published by Elsevier Ltd.)

Objective: The "stepped care model of pain management" (SCM-PM) prioritizes the role of primary care providers in optimizing pharmacological management and timely and equitable access to patient-centered, evidence-based nonpharmacological approaches, when indicated. Over the past several years, the Veterans Health Administration (VHA) has supported implementation of SCM-PM, but few data exist regarding changes in pain care resulting from implementation. We examined trends in prescribing and referral practices of primary care providers with hypotheses of decreased opioid prescribing, increased nonopioid prescribing, and increased referrals to specialty care for nonpharmacological services., Design: An initiative was designed to foster implementation and systematic evaluation of the SCM-PM over a five-year period at the VA Connecticut Healthcare System (VACHS) while fostering collaborative, partnered initiatives to promote organizational improvements in the delivery of pain care., Subjects: Participants were veterans receiving care at VACHS with at least one pain intensity rating ≥4/10 over the course of the study period (7/2008-6/2013)., Methods: We used electronic health record data to examine changes in indicators of pain care including pharmacy and health care utilization data., Results: We observed hypothesized changes in long-term opioid and nonopioid analgesic prescribing and increased utilization of nonpharmacological treatments such as physical therapy, occupational therapy, and clinical health psychology., Conclusions: Through a multifaceted comprehensive implementation approach, primary care providers demonstrated increases in guideline-concordant pain care practices. Findings suggest that engagement of interdisciplinary teams and partnerships to promote organizational improvements is a useful strategy to increase the use of integrated, multimodal pain care for veterans, consistent with VHA's SCM-PM.

Background: Despite strong evidence for the effectiveness of non-pharmacological pain treatment modalities (NPMs), little is known about the prevalence or correlates of NPM use., Objective: This study examined rates and correlates of NPM use in a sample of veterans who served during recent conflicts., Design: We examined rates and demographic and clinical correlates of self-reported NPM use (operationalized as psychological/behavioral therapies, exercise/movement therapies, and manual therapies). We calculated descriptive statistics and examined bivariate associations and multivariable associations using logistic regression., Participants: Participants were 460 veterans endorsing pain lasting ≥ 3 months who completed the baseline survey of the Women Veterans Cohort Study (response rate 7.7%., Main Measures: Outcome was self-reported use of NPMs in the past 12 months., Key Results: Veterans were 33.76 years old (SD = 10.72), 56.3% female, and 80.2% White. Regarding NPM use, 22.6% reported using psychological/behavioral, 50.9% used exercise/movement and 51.7% used manual therapies. Veterans with a college degree (vs. no degree; OR = 2.51, 95% CI = 1.46, 4.30, p = 0.001) or those with worse mental health symptoms (OR = 2.88, 95% CI = 2.11, 3.93, p < 0.001) were more likely to use psychological/behavioral therapies. Veterans who were female (OR = 0.63, 95% CI = 0.43, 0.93, p = 0.02) or who used non-opioid pain medications (OR = 1.82, 95% CI = 1.146, 2.84, p = 0.009) were more likely to use exercise/movement therapies. Veterans who were non-White (OR = 0.57, 95% CI = 0.5, 0.94, p = 0.03), with greater educational attainment (OR = 2.11, 95% CI = 1.42, 3.15, p < 0.001), or who used non-opioid pain medication (OR = 1.71, 95% CI = 1.09, 2.68, p = 0.02) were more likely to use manual therapies., Conclusions: Results identified demographic and clinical characteristics among different NPMs, which may indicate differences in veteran treatment preferences or provider referral patterns. Further study of provider referral patterns and veteran treatment preferences is needed to inform interventions to increase NPM utilization. Research is also need to identify demographic and clinical correlates of clinical outcomes related to NPM use.

Chronic pain is widely prevalent among Veterans and can have serious negative consequences for functional status and quality of life among other domains. The Veterans Health Administration (VHA) convened a state-of-the-art (SOTA) conference to develop research priorities for advancing the science and clinical practice of non-pharmacological management of chronic musculoskeletal pain. In this perspective article, we present the methods and consensus recommendations for research priorities emanating from the SOTA. In the months leading up to the SOTA, a core group of researchers defined four areas of focus: psychological/behavioral therapies; exercise/movement therapies; manual therapies; and models for delivering multi-modal pain care and divided into workgroups. Each workgroup, in their respective areas of focus, identified seminal studies capturing the state of the evidence. Herein, we present consensus recommendations ranging from efficacy to effectiveness to implementation/dissemination research depending on the state of the evidence as assessed by participants, including commentary on common elements across workgroups and future areas of innovation in study design, measurement, and outcome ascertainment.

Objective: This manuscript reviews high-impact, peer-reviewed studies published from January 2014 to March 2016 that are relevant to pain management in primary care. Given the recent release of the US Centers for Disease Control and Prevention's "Guideline for Prescribing Opioids for Chronic Pain" emphasizing the primacy of nonopioid treatment, we focused our review on nonopioid pain management., Design: Narrative review of peer-reviewed literature., Methods: We searched three article summary services and queried expert contacts for high-impact, English-language studies related to the management of pain in adults in primary care. All authors reviewed 142 study titles to arrive at group consensus on article content domains. Within article domains, individual authors selected studies approved by the larger group according to their impact on primary care clinical practice, policy, and research, as well as quality of the study methods. Through iterative discussion, 12 articles were selected for detailed review, discussion, and presentation in this narrative review., Results: We present key articles addressing each of six domains of pain management: pharmacotherapy for acute pain; interventional treatments; medical cannabis; complementary and integrative medicine; care management in chronic pain; and prevention. Within each section, we conclude with implications for pain management in primary care., Conclusions: There is growing evidence for multiple nonopioid treatment modalities available to clinicians for the management of pain in primary care. The dissemination and implementation of these studies, including innovative care management interventions, warrant additional study and support from clinicians, educators, and policy-makers., (2017 American Academy of Pain Medicine. This work is written by US Government employees and is in the public domain in the US.)

Background: Consensus guidelines recommend multi-modal chronic pain treatment with increased uptake of non-pharmacological pain treatment modalities (NPMs). We aimed to identify the barriers and facilitators to uptake of evidence-based NPMs from the perspectives of patients, nurses and primary care providers (PCPs)., Methods: We convened eight separate groups and engaged each in a Nominal Group Technique (NGT) in which participants: (1) created an individual list of barriers (and, in a subsequent round, facilitators) to uptake of NPMs; (2) compiled a group list from the individual lists; and (3) anonymously voted on the top three most important barriers and facilitators. In a separate process, research staff reviewed each group's responses and categorized them based on staff consensus., Results: Overall, 26 patients (14 women) with chronic pain participated; their mean age was 55. Overall, 14 nurses and 12 PCPs participated. Seven healthcare professionals were men and 19 were women; the mean age was 45. We categorized barriers and facilitators as related to access, patient-provider interaction, treatment beliefs and support. Top-ranked patient-reported barriers included high cost, transportation problems and low motivation, while top-ranked facilitators included availability of a wider array of NPMs and a team-based approach that included follow-up. Top-ranked provider-reported barriers included inability to promote NPMs once opioid therapy was started and patient skepticism about efficacy of NPMs, while top-ranked facilitators included promotion of a facility-wide treatment philosophy and increased patient knowledge about risks and benefits of NPMs., Conclusions: In a multi-stakeholder qualitative study using NGT, we found a diverse array of potentially modifiable barriers and facilitators to NPM uptake that may serve as important targets for program development.

Harms of opioid analgesics, especially high-dose therapy among individuals with comorbidities and older age, are increasingly recognized. However, trends in opioid receipt among HIV-infected patients are not well characterized. We examined trends, from 1999 to 2010, in any and high-dose (≥120 mg/day) opioid receipt among patients with and without HIV, by age strata, controlling for demographic and clinical correlates. Of 127,216 patients, 64 % received at least one opioid prescription. Opioid receipt increased substantially among HIV-infected and uninfected patients over the study; high-dose therapy was more prevalent among HIV-infected patients. Trends in high-dose receipt stratified by three age groups revealed an increasing trend in each age strata, higher among HIV-infected patients. Correlates of any opioid receipt included HIV, PTSD and major depression. Correlates of high-dose receipt included HIV, PTSD, major depression and drug use disorders. These findings suggest a need for appropriate balance of risks and benefits, especially as these populations age.

Background: Patients, providers, communities and health systems have struggled to achieve balance between access to opioid treatment for chronic pain and its potential harmful consequences: especially misuse, addiction and overdose. We developed an interdisciplinary clinic embedded within primary care (the Opioid Reassessment Clinic-ORC) with the goal of improving the quality of care of patients with co-occurring chronic pain and issues related to opioid safety, efficacy and/or misuse., Case Descriptions: We present three cases referred to the ORC that highlight complex clinical scenarios related to assessment and treatment of patients with chronic pain and issues related to opioid safety, efficacy and misuse., Discussion and Evaluation: In the context of the three cases, with respect to assessment, we discuss: making the diagnosis of opioid use disorder; allowing the patient space to endorse lack of efficacy; identification of co-occurring hazardous alcohol use; and recognizing barriers to multimodal pain care. With respect to treatment, we discuss: making a change in treatment with which the patient may not agree; effectiveness of buprenorphine/naloxone for the treatment of chronic pain; responding to low efficacy; and making continued opioid therapy contingent on engagement with substance abuse treatment., Conclusions: The core components of our approach-biopsychosocial assessment and multimodal treatment planning with an emphasis on promoting functional goals and safety using clear communication and a patient-centered stance-should guide providers in the management of similar clinical scenarios. More evidence is needed to definitively guide specific interventions and points of clinical equipoise.

Guidelines on long-term opioid therapy recommend frequent reassessment of harm, efficacy, and misuse of these potentially harmful and sometimes ineffective medications. In primary care, there is a need for a brief, patient-reported instrument. This report details the initial steps in the development of such an instrument. An interdisciplinary team of clinician-scientists performed four discrete steps in this study: (1) conceptualization of the purpose and function of the instrument, (2) assembly of an item pool, (3) expert rating on which items were most important to include in the instrument, and (4) modification of expert-selected items based on a reading level check and cognitive interviews with patients. A diverse panel of 47 subject matter experts was presented with 69 items to rate on a 1-9 scale in terms of importance for inclusion in the instrument. The panel highly rated 37 items: 8 related to harm, 4 related to efficacy, and 25 related to misuse. These 37 items were then tested for patient comprehension and modified as needed. Next steps in development will include further item reduction, testing against a gold standard, and assessment of the instrument's effect on clinical outcomes.

Objectives: The aims of this study were to develop and implement an interdisciplinary pain program integrated in primary care to address stakeholder-identified gaps., Design: Program development and evaluation project utilizing a Plan-Do-Study-Act (PDSA) approach to address the identified problem of insufficient pain management resources within primary care., Setting: A large Healthcare System within the Veterans Health Administration, consisting of two academically affiliated medical centers and six community-based outpatients clinics., Methods: An interprofessional group of stakeholders participated in a Rapid Process Improvement Workshop (RPIW), a consensus-building process to identify systems-level gaps and feasible solutions and obtain buy-in. Changes were implemented in 2012, and in a 1-year follow-up, we examined indicators of engagement in specialty and multimodal pain care services as well as patient and provider satisfaction., Results: In response to identified barriers, RPIW participants proposed and outlined two readily implementable, interdisciplinary clinics embedded within primary care: 1) the Integrated Pain Clinic, providing in-depth assessment and triage to targeted resources; and 2) the Opioid Reassessment Clinic, providing assessment and structured monitoring of patients with evidence of safety, efficacy, or misuse problems with opioids. Implementation of these programs led to higher rates of engagement in specialty and multimodal pain care services; patients and providers reported satisfaction with these services., Conclusions: Our PDSA cycle engaged an interprofessional group of stakeholders that recommended introduction of new systems-based interventions to better integrate pain resources into primary care to address reported barriers. Early data suggest improved outcomes; examination of additional outcomes is planned., (Wiley Periodicals, Inc.)

BackgroundThe NIH-DOD-VA Pain Management Collaboratory (PMC) supports 11 pragmatic clinical trials (PCTs) on nonpharmacological approaches to management of pain and co-occurring conditions in U.S. military and veteran health organizations. The Stakeholder Engagement Work Group is supported by a separately funded Coordinating Center and was formed with the goal of developing respectful and productive partnerships that will maximize the ability to generate trustworthy, internally valid findings directly relevant to veterans and military service members with pain, front-line primary care clinicians and health care teams, and health system leaders. The Stakeholder Engagement Work Group provides a forum to promote success of the PCTs in which principal investigators and/or their designees discuss various stakeholder engagement strategies, address challenges, and share experiences. Herein, we communicate features of meaningful stakeholder engagement in the design and implementation of pain management pragmatic trials, across the PMC.DesignOur collective experiences suggest that an optimal stakeholder-engaged research project involves understanding the following: i) Who are research stakeholders in PMC trials? ii) How do investigators ensure that stakeholders represent the interests of a study's target treatment population, including individuals from underrepresented groups?, and iii) How can sustained stakeholder relationships help overcome implementation challenges over the course of a PCT?SummaryOur experiences outline the role of stakeholders in pain research and may inform future pragmatic trial researchers regarding methods to engage stakeholders effectively.

This analysis was part of the Pain and Smoking Study (PASS), a randomized trial of a cognitive behavioral intervention (CBI) for Veterans with chronic pain who smoke. The objective of this study was to examine factors associated with participation in the walking component of the intervention. Demographics and clinical characteristics were obtained at baseline. Completion of two or more CBI counseling sessions was required to be included in analyses. Average daily step counts obtained via pedometer in the prior week were recorded in up to three telephone counseling sessions. Participants were then categorized as "sedentary" (≤ 4999 daily steps) or "not sedentary" (≥ 5000 daily steps). Multivariable logistic regression was used to model variance in activity categorization. Overall, 91.0% of participants were men, 70.5% were white, mean age was 58.4 years, mean BMI was 28.6, median pack years was 20.5, and 43.8% were depressed. Veterans reported moderate pain intensity (4.9/10) and pain interference (5.4/10). Pain locations included: lower extremity (67.4%), back (53.4%) and upper extremity (28.1%). Median daily steps were 2491 [IQR: 1720–3550] (sedentary) (n = 65), 7307 [IQR: 5952–8533] (not sedentary) (n = 24), and 3196 [IQR: 2237–5067] (overall) (n = 89). Veterans with older age (odds ratio (OR): 1.10, 95% confidence interval (CI): 1.04, 1.17) and presence of LE pain (OR: 5.98, 95% CI: 1.82, 19.65) had increased odds of being "sedentary." Integrated smoking cessation and chronic pain self-management interventions that include a walking component may need to consider the impact of age and pain location on participation. Trial registration: The trial is registered at www.ClinicalTrials.gov (NCT02971137). First posted on November 22, 2016. [ABSTRACT FROM AUTHOR]

Objective Buprenorphine is effective for chronic pain and safer than full-agonist opioids; however, limited education about and support for buprenorphine can result in under-prescribing in primary care and reduced access in specialty pain clinics. The purpose of this quality improvement initiative was to optimize and evaluate procedures for transferring patients stable on buprenorphine for chronic pain from a specialty pain clinic back to primary care. Setting Eight primary care clinics within a Veterans Health Administration health care system. Methods A standard operating procedure for facilitated transfer of prescribing was developed after a needs assessment and was introduced during an educational session with primary care providers, and providers completed a survey assessing attitudes about buprenorphine prescribing. Success of the initiative was measured through the number of patients transferred back to primary care over the course of 18 months. Results Survey results indicated that primary care providers with previous experience prescribing buprenorphine were more likely to view buprenorphine prescribing for pain as within the scope of their practice and to endorse feeling comfortable managing a buprenorphine regimen. Providers identified systemic and educational barriers to prescribing, and they identified ongoing support from specialty pain care and primary care as a facilitator of prescribing. Metrics suggested that the standard operating procedure was generally successful in transferring and retaining eligible patients in primary care. Conclusion This quality improvement initiative suggests that a facilitated transfer procedure can be useful in increasing buprenorphine prescribing for pain in primary care. Future efforts to increase primary care provider comfort and address systemic barriers to buprenorphine prescribing are needed. [ABSTRACT FROM AUTHOR]

Background: Chronic pain is among the most common conditions presenting to primary care and guideline-based care faces several challenges. A novel pain management program, Video-Telecare Collaborative Pain Management (VCPM), was established to support primary care providers and meet new challenges to care presented by the COVID-19 pandemic. Methods: The present single-arm feasibility study aimed to evaluate the feasibility and acceptability of VCPM and its components among U.S. veterans on long-term opioid therapy for chronic pain at ≥ 50 mg morphine equivalent daily dose (MEDD). VCPM consists of evidence-based interventions, including opioid reassessment and tapering, rotation to buprenorphine and monitoring, and encouraging behavioral pain and opioid-use disorder self-management. Results: Of the 133 patients outreached for VPCM, 44 completed an initial intake (33%) and 19 attended multiple VCPM appointments (14%). Patients were generally satisfied with VCPM, virtual modalities, and provider interactions. Nearly all patients who attended multiple appointments maintained a buprenorphine switch or tapered opioids (16/19; 84%), and buprenorphine switches were generally reported as acceptable by patients. Patients completing an initial intake with VCPM had reduced morphine equivalent daily dose after three months (means = 109 mg MEDD vs 78 mg), with greater reductions among those who attended multiple appointments compared to intake only (ΔMEDD = -58.1 vs. -8.40). Finally, 29 referrals were placed for evidence-based non-pharmacologic interventions. Conclusion: Pre-defined feasibility and acceptability targets for VCPM and its components were broadly met, and preliminary data are encouraging. Novel strategies to improve enrollment and engagement and future directions are discussed. [ABSTRACT FROM AUTHOR]

The article presents the discussion on quality of care for patients with chronic pain prescribing long-term opioid therapy. Topics include team based care to veterans with chronic pain exhibiting problems related to the safety, efficacy, or misuse of prescribed opioids; and addiction psychiatrist, an internist, a psychologist, a pharmacist, and a nurse, as well as trainees from several disciplines.

The authors discuss the need for a new diagnosis to expand research and treatment options for opioid use disorder (OUD). Topics include points that must be considered regarding unsuccessful efforts to cut down its corollary use for longer than intended in the context of long-term opioid therapy (LTOT), advantages of a new diagnosis for this scenario, and the need for the U.S. Food and Drug Administration (FDA) to expand the indication for sublingual buprenorphine to this scenario.

PURPOSE To understand how patients and providers weigh the risks and benefits of long-term opioid therapy (LTOT) for cancer pain. METHODS Researchers used VA approved audio-recording devices to record interviews. ATLAS t.i., a qualitative analysis software, was used for analysis of transcribed interview data. Participants included 20 Veteran patients and 20 interdisciplinary providers from primary care- and oncology-based practice settings. We conducted semistructured interviews and analyzed transcripts used thematic qualitative methods. Interviews explored factors that affect decision making about appropriateness of LTOT for cancer related pain. We saturated themes for providers and patients separately. RESULTS Factors affecting patient decision-making included influence from various information sources, persuasion from trusted providers, and sometimes deferral of the decision to their provider. Relative prioritization of pain management as the focal patient concern varied with some patients describing comparatively more fear of chemotherapy than opioid analgesics, comparatively more knowledge of opioids in relation to other drugs; patients expressed a preference to spend the limited time they have with their oncologist discussing cancer treatment rather than opioid use. Factors affecting provider decision making included prognosis, patient goals, patient characteristics, and provider experience and biases. Providers differed in how they weigh the relative importance of alleviating pain or avoiding opioids in the face of treating patients with cancer and histories of substance abuse. CONCLUSION Divergent perspectives on factors need to be considered when weighing risks and benefits. Policies and interventions should be designed to reduce variation in practice to promote equal access to adequate pain management. Improved shared decision-making initiatives will take advantage of patient decision-making factors and priorities. [ABSTRACT FROM AUTHOR]

Background The Whole Health model of the U.S. Department of Veterans Affairs (VA) emphasizes holistic self-care and multimodal approaches to improve pain, functioning, and quality of life. w HOPE (Whole Health Options and Pain Education) seeks to be the first multisite pragmatic trial to establish evidence for the VA Whole Health model for chronic pain care. Design w HOPE is a pragmatic randomized controlled trial comparing a Whole Health Team (WHT) approach to Primary Care Group Education (PC-GE); both will be compared to Usual VA Primary Care (UPC). The WHT consists of a medical provider, a complementary and integrative health (CIH) provider, and a Whole Health coach, who collaborate with VA patients to create a Personalized Health Plan emphasizing CIH approaches to chronic pain management. The active comparator, PC-GE, is adapted group cognitive behavioral therapy for chronic pain. The first aim is to test whether the WHT approach is superior to PC-GE and whether both are superior to UPC in decreasing pain interference in functioning in 750 veterans with moderate to severe chronic pain (primary outcome). Secondary outcomes include changes in pain severity, quality of life, mental health symptoms, and use of nonpharmacological and pharmacological therapies for pain. Outcomes will be collected from the VA electronic health record and patient-reported data over 12 months of follow-up. Aim 2 consists of an implementation-focused process evaluation and budget impact analysis. Summary This trial is part of the Pain Management Collaboratory, which seeks to create national-level infrastructure to support evidence-based nonpharmacological pain management approaches for veterans and military service personnel. [ABSTRACT FROM AUTHOR]

The multitude of treatments available for tens of millions of US adults with moderate/severe chronic pain have limited efficacy. Long-term opioid therapy (LTOT) is a widely available option for controlling pain among patients with chronic pain refractory to other treatments. The recent recognition of LTOT inefficacy and complications has led to more frequent opioid tapering, which in turn has revealed its own set of complications. The occurrence of the same set of symptoms—worsening pain, declining function, and clinical instability—in contrasting contexts of LTOT ineffectiveness and opioid tapering has led to increasing recognition of the utility of complex persistent opioid dependence (CPOD), a clinically distinct but biologically similar state compared with opioid use disorder as an explanatory diagnosis/heuristic. Recent guidelines for LTOT tapering have incorporated buprenorphine treatment based on CPOD concepts as a recommended treatment for problems due to opioid tapering with limited supportive evidence. The increasing utilization of buprenorphine for both LTOT ineffectiveness and opioid tapering problems raises the urgent need for a review of the clinical definition, mechanisms, and treatment of CPOD and pertinent policies. In this manuscript, we discuss various issues related to CPOD that requires further clarification through research and policy development. [ABSTRACT FROM AUTHOR]

The article discusses the observed overlap between chronic pain and psychiatric illness. Topics covered include a case of treating multimorbidity in practice, psychiatrists' non-training in the diagnosis of the underlying chronic pain generator, the use of cognitive behavioral therapy (CBT) and nonpharmacologic treatments on patients, and the need for psychiatrists to capitalize on their substance use and psychiatric disorder background in managing chronic pain.

A better understanding of predisposition to transition to high-dose, long-term opioid therapy after initial opioid receipt could facilitate efforts to prevent opioid use disorder (OUD). We extracted data on 69,268 patients in the Veterans Aging Cohort Study who received any opioid prescription between 1998 and 2015. Using latent growth mixture modelling, we identified four distinguishable dose trajectories: low (53%), moderate (29%), escalating (13%), and rapidly escalating (5%). Compared to low dose trajectory, those in the rapidly escalating dose trajectory were proportionately more European-American (59% rapidly escalating vs. 38% low); had a higher prevalence of HIV (31% vs. 29%) and hepatitis C (18% vs. 12%); and during follow-up, had a higher incidence of OUD diagnoses (13% vs. 3%); were hospitalised more often [18.1/100 person-years (PYs) vs. 12.5/100 PY]; and had higher all-cause mortality (4.7/100 PY vs. 1.8/100 PY, all p < 0.0001). These measures can potentially be used in future prevention research, including genetic discovery. [ABSTRACT FROM AUTHOR]

The article discusses that despite clinical guidelines, educational programs, and regulatory requirements, many clinicians do not follow best practices for opioid prescribing. It mentions that primary care providers (PCPs) tend to have established relationships with their patients over multiple years. It also mentions that physical therapy, yoga, or chiropractic therapy may be less accessible to uninsured or underinsured patients at community health centers (CHCs).

Introduction: Opioid prescribing and subsequent rates of serious harms have dramatically increased in the past two decades, yet there are still significant barriers to reduction of risky opioid regimens. This formative evaluation utilized a mixed-methods approach to identify barriers and factors that may facilitate the successful implementation of Primary Care-Integrated Pain Support (PIPS), a clinical program designed to support the reduction of risky opioid regimens while increasing the uptake of non-pharmacologic treatment modalities.Methods: Eighteen Department of Veterans Affairs (VA) employees across three sites completed a survey consisting of the Organizational Readiness for Implementing Change (ORIC) scale; a subset of these individuals (n = 9) then completed a semi-structured qualitative phone interview regarding implementing PIPS within the VA. ORIC results were analyzed using descriptive statistics while interview transcripts were coded and sorted according to qualitative themes.Results: Quantitative analysis based on ORIC indicated high levels of organizational readiness to implement PIPS. Interview analysis revealed several salient themes: system-level barriers such as tension among various pain management providers; patient-level barriers such as perception of support and tension between patient and provider; and facilitating factors of PIPS, such as the importance of the clinical pharmacist role.Conclusions: While organizational readiness for implementing PIPS appears high, modifications to our implementation facilitation strategy (e.g., establishing clinical pharmacists as champions; marketing PIPS to leadership as a way to improve VA opioid safety metrics) may improve capacity of the sites to implement PIPS successfully. [ABSTRACT FROM AUTHOR]

Objectives. Unsafe use of opioids prescribed for pain is a common challenge in primary care. We aimed to describe a novel clinical program designed to address this issue-the Opioid Reassessment Clinic- and evaluate preliminary efficacy. Methods. The Opioid Reassessment Clinic is a multidisciplinary care team staffed by an internist, addiction psychiatrist, advanced practice nurse, and health psychologist designed to perform enhanced assessment and longitudinal treatment of patients with unsafe use of opioids prescribed for pain. We assessed preliminary efficacy of the clinic using a priori-defined metrics at the patient, provider, clinic process, and health system levels. Results. Of referred patients (N=87), 84% had a history of substance abuse/dependence and 70% had current misuse of prescribed opioids; 22% received a new substance use disorder diagnosis, each of whom engaged in addiction treatment. Among primary care physicians, 48% referred a patient to the clinic. In terms of process metrics, high fidelity to structured clinical assessments was assisted by templated electronic progress notes. Wait time averaged 22.1 days while length of treatment averaged 137 days. Urine drug testing was performed on 91% of patients an average of 6.4 times, while assessing out-of-system opioid receipt occurred universally. Systems-level findings included evidence of institutional support: hiring a nurse case manager to help with care coordination. Conclusions. Results suggest the Opioid Reassessment Clinic was effective in the management of a small group of high-complexity patients. Wide-scale dissemination may require adapted care models. [ABSTRACT FROM AUTHOR]

Background: Expert guidelines recommend reducing or discontinuing long-term opioid therapy (LTOT) when risks outweigh benefits, but evidence on the effect of dose reduction on patient outcomes has not been systematically reviewed. Purpose: To synthesize studies of the effectiveness of strategies to reduce or discontinue LTOT and patient outcomes after dose reduction among adults prescribed LTOT for chronic pain. Data Sources: MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library from inception through April 2017; reference lists; and expert contacts. Study Selection: Original research published in English that addressed dose reduction or discontinuation of LTOT for chronic pain. Data Extraction: Two independent reviewers extracted data and assessed study quality using the U.S. Preventive Services Task Force quality rating criteria. All authors assessed evidence quality using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Prespecified patient outcomes were pain severity, function, quality of life, opioid withdrawal symptoms, substance use, and adverse events. Data Synthesis: Sixty-seven studies (11 randomized trials and 56 observational studies) examining 8 intervention categories, including interdisciplinary pain programs, buprenorphine-assisted dose reduction, and behavioral interventions, were found. Study quality was good for 3 studies, fair for 13 studies, and poor for 51 studies. Many studies reported dose reduction, but rates of opioid discontinuation ranged widely across interventions and the overall quality of evidence was very low. Among 40 studies examining patient outcomes after dose reduction (very low overall quality of evidence), improvement was reported in pain severity (8 of 8 fair-quality studies), function (5 of 5 fair-quality studies), and quality of life (3 of 3 fair-quality studies). Limitation: Heterogeneous interventions and outcome measures; poor-quality studies with uncontrolled designs. Conclusion: Very low quality evidence suggests that several types of interventions may be effective to reduce or discontinue LTOT and that pain, function, and quality of life may improve with opioid dose reduction. [ABSTRACT FROM AUTHOR]

Background: Consensus guidelines recommend multi-modal chronic pain treatment with increased uptake of nonpharmacological pain treatment modalities (NPMs). We aimed to identify the barriers and facilitators to uptake of evidence-based NPMs from the perspectives of patients, nurses and primary care providers (PCPs). Methods: We convened eight separate groups and engaged each in a Nominal Group Technique (NGT) in which participants: (1) created an individual list of barriers (and, in a subsequent round, facilitators) to uptake of NPMs; (2) compiled a group list from the individual lists; and (3) anonymously voted on the top three most important barriers and facilitators. In a separate process, research staff reviewed each group's responses and categorized them based on staff consensus. Results: Overall, 26 patients (14 women) with chronic pain participated; their mean age was 55. Overall, 14 nurses and 12 PCPs participated. Seven healthcare professionals were men and 19 were women; the mean age was 45. We categorized barriers and facilitators as related to access, patient-provider interaction, treatment beliefs and support. Top-ranked patient-reported barriers included high cost, transportation problems and low motivation, while top-ranked facilitators included availability of a wider array of NPMs and a team-based approach that included follow-up. Top-ranked provider-reported barriers included inability to promote NPMs once opioid therapy was started and patient skepticism about efficacy of NPMs, while top-ranked facilitators included promotion of a facility-wide treatment philosophy and increased patient knowledge about risks and benefits of NPMs. Conclusions: In a multi-stakeholder qualitative study using NGT, we found a diverse array of potentially modifiable barriers and facilitators to NPM uptake that may serve as important targets for program development. [ABSTRACT FROM AUTHOR]

More than one in ten adults in the USA report chronic pain,[1] and a high proportion of primary care visits involve the management of chronic pain.[2] Primary care providers frequently prescribe opioids for treatment of chronic pain despite safety concerns and minimal evidence for efficacy.[3] Safety concerns surrounding opioid therapy include the development of opioid use disorder and overdose.[4] While current guidelines discourage opioid prescribing for chronic pain,[5] randomized trials of opioid therapy reporting long-term pain and function outcomes were lacking. In patients not already on opioids, use of opioid medications for treatment of chronic pain is likely to cause more side effects without noticeable benefits when compared with non-opioid medications. [Extracted from the article]

The Veterans' Pain Care Organizational Improvement Comparative Effectiveness (VOICE) study is a 12-month pragmatic randomized comparative effectiveness trial conducted at ten United States Veterans Affairs (VA) health care sites. The overall goal was to test interventions to improve pain while reducing opioid use among VA patients with moderate-severe chronic pain despite treatment with long-term opioid therapy (LTOT). Aims were 1) to compare lower-intensity telecare collaborative pain management (TCM) versus higher-intensity integrated pain team management (IPT), and 2) to test the option of switching to buprenorphine (versus no option) in a high-dose subgroup. Recruitment challenges included secular trends in opioid prescribing and the COVID-19 pandemic. Participants were recruited over 3.5 years. Of 6966 potentially eligible patients, 4731 (67.9%) were contacted for telephone eligibility interview; of those contacted, 3398 (71.8%) declined participation, 359 (7.6%) were ineligible, 821 (24.2%) enrolled, and 820 (24.1%) were randomized. The most common reason for declining was satisfaction with pain care (n = 731). The most common reason for ineligibility was not having moderate-severe chronic pain (n = 110). Compared with the potentially eligible population, randomized participants were slightly younger, more often female, had similar prescribed opioids, and had similar or higher rates of pain and mental health diagnoses. The enrolled patient number was lower than the original target, but sufficient to power planned analyses. In conclusion, the VOICE trial enrolled a diverse sample similar to the population of VA patients receiving LTOT. Results will add substantially to limited existing evidence for interventions to improve pain while reducing opioid use. ClinicalTrials.gov identifier: NCT03026790 [ABSTRACT FROM AUTHOR]

Background Opioid use disorder and pain often co-occur, complicating the treatment of each condition. Owing to its partial agonist properties, buprenorphine/naloxone (BUP/NX) may confer advantages over full agonist opioids for treatment of both conditions. The optimal dose of BUP/NX for comorbid pain is not known. We examined dose and other factors associated with pain intensity among patients initiating BUP/NX for opioid use disorder. Methods We studied 1106 patients initiating BUP/NX treatment for opioid use disorder from 2003 to 2010. Information on pain level, diagnoses, and treatment were extracted from medical records. Eligible patients had at least one self-reported pain intensity numerical rating score (NRS) within 30 days before BUP/NX initiation (baseline) and at least one between 15 and 90 days after BUP/NX initiation (during treatment). The primary outcome was NRS decrease (2 or greater) from baseline to during treatment. We used generalized estimating equations to model odds of the primary outcome with BUP/NX dose as the independent variable of interest in the subset of patients with a baseline NRS ≥ 2. Results The sample was 94% male and 73% White. Mean age was 50. Psychiatric and non-opioid substance use comorbidities were common. The following demographic and clinical correlates were associated with a decrease in pain intensity: age 18–29 (compared to 30–39 and 40–49); absence of PTSD diagnosis and absence of a chronic pain diagnosis. BUP/NX dose was not associated with decreased pain intensity in bivariate or multivariable analysis. Conclusions BUP/NX maintenance treatment was generally consistent with improvements in pain intensity; however, factors other than BUP/NX dose contribute to improved pain intensity among those initiating the medication. [ABSTRACT FROM AUTHOR]

Objective This manuscript reviews peer-reviewed literature published from 2010-2012 relevant to the management of chronic pain in the primary care setting. Design Narrative review of peer-reviewed literature. Methods We searched MEDLINE, PubMed, and reference lists and queried expert contacts for English-language studies related to the management of chronic noncancer pain in adult patients in primary care settings. One investigator reviewed all eligible studies for relevance, and 47 studies were reviewed by all authors and rated according to their impact on 1) primary care clinical practice, 2) policy, 3) research, and 4) quality of study methods. Through iterative discussion, nine articles were selected for detailed review and discussion. Results We present articles in six topic areas: interventional pain management; opioid dose and risk of overdose death; neuropathic pain; yoga for chronic low back pain; cognitive behavioral therapy; and systematic approaches to treating back pain. We discuss implications for pain management in primary care. Conclusions There is growing evidence for the risks, benefits, and limitations of the multiple modalities available to primary care providers for the management of chronic pain. The dissemination and implementation of the evidence from these studies as well as novel system-level interventions warrant additional study and support from clinicians, educators, and policy makers. [ABSTRACT FROM AUTHOR]

Abstract: The purpose of this systematic review was to summarize and critically appraise research developing or validating instruments to assess patient-reported safety, efficacy, and/or misuse in ongoing opioid therapy for chronic pain. Our search included the following datasets: OvidSP MEDLINE (1946-August 2012), OvidSP PsycINFO (1967-August 2012), Elsevier Scopus (1947-August 2012), OvidSP HaPI (1985-August 2012), and EBSCO CINAHL (1981-August 2012). Eligible studies were published in English and pertained to adult, nonsurgical/interventional populations. Two authors independently assessed inclusion criteria. Each study was evaluated by 2 authors to assess the sources and content of items, types of psychometric tests, their results, and quality of diagnostic accuracy testing, when applicable. Of 1874 citations found in the initial search, we identified 14 studies meeting our inclusion criteria, describing 9 different instruments. Individual items were derived from surveys of content experts, literature reviews, and adapted non-patient-reported items. Misuse-related items were most prevalent (60/144; 42%), followed by safety (47/144; 33%), with efficacy having the fewest items (17/144; 12%). The studies employed a wide variety of psychometric tests, with most demonstrating statistical significance, but several potential sources of bias and generalizability limitations were identified. Lack of testing in clinical practice limited assessment of feasibility. The dearth of safety and efficacy items and lack of testing in clinical practice demonstrates areas for further research. [Copyright &y& Elsevier]

Abstract: Data on comparative safety of opioid analgesics are limited, but some reports suggest disproportionate mortality risk associated with methadone. Our objective was to compare mortality rates among patients who received prescribed methadone or long-acting morphine for pain. This is a retrospective observational cohort drawn from Department of Veterans Affairs (VA) health care databases, January 1, 2000, to December 31, 2007. We included 28,554 patients who received methadone and 79,938 who received long-acting morphine from VA pharmacies. Compared with those who received long-acting morphine, patients who received methadone were younger, less likely to have some medical comorbidities, and more likely to have psychiatric and substance use disorders. Patients were stratified into quintiles according to propensity score; the probability of receiving methadone was conditional on demographic, clinical, and VA service area variables. Overall propensity-adjusted mortality was lower for methadone than for morphine. Hazard ratios varied across propensity score quintiles; the magnitude of the between-drug difference in mortality decreased as the propensity to receive methadone increased. Mortality was significantly lower for methadone in all but the last quintile, in which there was no between-drug difference in mortality (hazard ratio=0.92, 95% confidence interval=0.74, 1.16). Multiple sensitivity analyses found either no difference in mortality between methadone and long-acting morphine or lower mortality rates among patients who received methadone. In summary, we found no evidence of excess all-cause mortality among VA patients who received methadone compared with those who received long-acting morphine. Randomized trials and prospective observational research are needed to better understand the relative safety of long-acting opioids. Among patients who received methadone or long-acting morphine for pain from Department of Veterans Affairs pharmacies in 2000–2007, no evidence of excess all-cause mortality associated with methadone was found. [Copyright &y& Elsevier]

The article reports on the study that investigates racial disparities in treating pain with opioids in the U.S. The study evaluates the physicians' use of three opioid risk reduction strategies such as urine drug testing, regular office visits, and restricted early opioid refills. It suggests that the use risk reduction strategies was very limited overall, however, black patients were more likely than white patients to receive two of three guideline-recommended strategies.

The high prevalence and societal burden of chronic pain, its undertreatment, and disparities in its management have contributed to the acknowledgment of chronic pain as a serious public-health concern. The concurrent opioid epidemic, and increasing concern about overreliance on opioid therapy despite evidence of limited benefit and serious harms, has heightened attention to this problem. The biopsychosocial model has emerged as the primary conceptual framework for understanding the complex experience of chronic pain and for informing models of care. The prominence of psychological processes as risk and resilience factors in this model has prompted extensive study of psychological treatments designed to alter processes that underlie or significantly contribute to pain, distress, or disability among adults with chronic pain. Cognitive-behavioral therapy is acknowledged to have strong evidence of effectiveness; other psychological approaches, including acceptance and commitment therapy, mindfulness, biofeedback, hypnosis, and emotional-awareness and expression therapy, have also garnered varying degrees of evidence across multiple pain conditions. Mechanistic studies have identified multiple pathways by which these treatments may reduce the intensity and impact of pain. Despite the growing evidence for and appreciation of these approaches, several barriers limit their uptake at the level of organizations, providers, and patients. Innovative methods for delivering psychological interventions and other research, practice, and policy initiatives hold promise for overcoming these barriers. Additional scientific knowledge and practice gaps remain to be addressed to optimize the reach and effectiveness of these interventions, including tailoring to address individual differences, concurrently addressing co-occurring disorders, and incorporating other optimization strategies. [ABSTRACT FROM AUTHOR]

Objectives We aimed to evaluate a novel clinical program designed to address unsafe use of opioids prescribed for pain—the Opioid Reassessment Clinic (ORC)—to inform practice and health system improvement. Design Controlled, retrospective cohort study. Setting The ORC is a multidisciplinary clinic in a primary care setting in a Veterans Health Administration hospital designed to perform longitudinal treatment of patients with unsafe use of opioids prescribed for pain, including tapering or rotating to the partial opioid agonist buprenorphine. Subjects We included patients referred to the ORC from March 1, 2016, to March 1, 2017, who had an intake appointment (intervention group) and who did not (control group). Methods We compared a priori–defined metrics at the patient, clinic process, and health system levels and compared metrics between groups. Results During the study period, 114 veterans were referred to the ORC, and 71 (62%) of these had an intake appointment. Those in the intervention group were more likely to trial buprenorphine (N = 41, 62% vs N = 1, 2%, P  < 0.01) and had greater reductions in their full agonist morphine equivalent daily dose than those in the control group (30 mg [interquartile range {IQR} = 0–120] vs 0 mg [IQR = 0–20] decrease, P  < 0.01). Of those engaging in the ORC, 20 (30%) had not transitioned chronic pain management back to their primary care providers (PCPs) by the end of follow-up. Only one patient transitioned the management of buprenorphine to the PCP. Conclusions Results suggest the ORC was effective in reducing total prescribed opioid doses and in transitioning patients to partial-agonist therapy, but PCP adoption strategies are needed. [ABSTRACT FROM AUTHOR]

Objective To examine patient sociodemographic and clinical characteristics associated with opioid use among Veterans of Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) who receive chiropractic care, and to explore the relationship between timing of a chiropractic visit and receipt of an opioid prescription. Methods Cross-sectional analysis of administrative data on OEF/OIF/OND veterans who had at least one visit to a Veterans Affairs (VA) chiropractic clinic between 2004 and 2014. Opioid receipt was defined as at least one prescription within a window of 90 days before to 90 days after the index chiropractic clinic visit. Results We identified 14,025 OEF/OIF/OND veterans with at least one chiropractic visit, and 4,396 (31.3%) of them also received one or more opioid prescriptions. Moderate/severe pain (odds ratio [OR] = 1.87, 95% confidence interval [CI] = 1.72–2.03), PTSD (OR = 1.55, 95% CI = 1.41–1.69), depression (OR = 1.40, 95% CI = 1.29–1.53), and current smoking (OR = 1.39, 95% CI = 1.26–1.52) were associated with a higher likelihood of receiving an opioid prescription. The percentage of veterans receiving opioid prescriptions was lower in each of the three 30-day time frames assessed after the index chiropractic visit than before. Conclusions Nearly one-third of OEF/OIF/OND veterans receiving VA chiropractic services also received an opioid prescription, yet the frequency of opioid prescriptions was lower after the index chiropractic visit than before. Further study is warranted to assess the relationship between opioid use and chiropractic care. [ABSTRACT FROM AUTHOR]

Objective High rates of co-occurring smoking and chronic pain are observed in the veteran population. Individuals who smoke and have chronic pain report lower self-efficacy to quit and are less successful in their attempts. Design In this pilot study, we assess the feasibility of a telephone-delivered intervention designed to integrate evidence-based smoking cessation and pain management components in a way that allows patients to understand the interplay between the two while attempting to have them build off each other and develop coping skills to address both concerns. Patients Study participants (N = 7) were veterans who received primary care in the VA Healthcare System and reported current smoking and a worst pain intensity score of 4 or greater. Intervention A five-session telephone intervention was delivered over eight weeks. Participants completed a survey at baseline and 10-week follow-up. Outcome Measures Feasibility was assessed by examining engagement with the intervention. Results Four out of seven participants completed all five sessions. Two out of seven veterans reported quitting smoking, and five out of seven reported clinically meaningful improvements in pain intensity and functional interference. Conclusions Insights gained from this study were used to modify an intervention being examined in a randomized controlled trial to test its effectiveness on both smoking and pain outcomes. [ABSTRACT FROM AUTHOR]

Background Opioid misuse is a significant public health problem. As initial exposures to opioids are frequently encountered through the management of postoperative pain, we examined patterns of opioid prescribing following surgical treatment for nephrolithiasis. Methods We identified patients with nephrolithiasis in the national Women Veterans Cohort Study (WVCS) who were treated surgically by diagnosis and procedure codes. Using standard conversion factors, we calculated the morphine milligram equivalent (MME) dose prescribed. We used descriptive statistics to characterize opioid prescription across management strategy and multivariable regression to examine clinical and demographic characteristics associated with dispensed dose. Results We identified 22,609 patients diagnosed with kidney stones during 1999–2014, 1,976 of whom were treated surgically and 1,582 (80.1%) of whom received an opioid prescription. The median age was 39 years, and 1,366 (90%) were male; 1,314 (86.3%) were treated with ureteroscopy, 172 (11.3%) with extracorporeal shockwave lithotripsy, and 36 (2.4%) with percutaneous nephrolithotomy. The median number of days supplied per opioid prescription (interquartile range) was 10 (5–14), and patients were dispensed a median of 180 (140–300) MME. A total of 6.4% of patients received ≥50 MME/d. On multivariable analysis, comorbid diagnosis of post-traumatic stress disorder (PTSD) was associated with higher total dispensed dose, whereas surgery type was not. Conclusions We observed substantial variation in opioid prescribing following surgical treatment of nephrolithiasis. Although type of surgical intervention did not impact opioid dosing, patients with a diagnosis of PTSD were more likely to receive higher doses. This work can inform efforts to improve the safety and efficacy of postoperative opioid prescribing. [ABSTRACT FROM AUTHOR]

Abstract: A challenge in clinical, research, and policy spheres is determining whether and how to apply the Diagnostic and Statistical Manual-5 Opioid Use Disorder criteria to patients receiving long-term opioid therapy (LTOT) for the management of chronic pain. This study explored perspectives on the merits of creating a new diagnostic entity to characterize the problems that arise for certain patients prescribed LTOT and develop consensus on its definition and diagnostic criteria. We conducted 3 rounds of online surveys and held one discussion-based workshop to explore a new diagnostic entity and generate consensus with subject matter experts (n = 51) in pain and opioid use disorder, including a wide range of professional disciplines. The first survey included open-ended questions and rapid qualitative analysis to identify potential diagnostic criteria. Rounds 2 and 3 involved rating potential diagnostic criteria on a Likert-type scale to achieve consensus. The workshop was a facilitated conversation aimed at further refining criteria. Three-quarters of Delphi panelists were in favor of a new diagnostic entity; consensus was reached for 19 potential diagnostic criteria including benefits of LTOT no longer outweighing harms and a criterion related to difficulty tapering. A subgroup of expert panelists further refined the new diagnostic entity definition and criteria. Consensus on potential criteria for the new diagnostic entity was reached and further refined by a subgroup of experts. This Delphi study represents the opinions of a small group of subject matter experts; perspectives from other experts and additional stakeholder groups (including patients) are warranted. [ABSTRACT FROM AUTHOR]

Chronic pain is highly prevalent among adults treated with maintenance haemodialysis (HD) and has profound negative effects. Over four decades, research has demonstrated that 50-80% of adult patients treated with HD report having pain. Half of patients with HD-dependent kidney failure (HDKF) have chronic moderate-to-severe pain, which is similar to the burden of pain in patients with cancer. However, pain management in patients with HDKF is often ineffective as most patients report that their pain is inadequately treated. Opioid analgesics are prescribed more frequently for patients receiving HD than for individuals in the general population with chronic pain, and are associated with increased morbidity, mortality and health-care resource use. Furthermore, current opioid prescribing patterns are frequently inconsistent with guideline-recommended care. Evidence for the effectiveness of opioids in pain management in general, and in patients with HDKF specifically, is lacking. Nonetheless, long-term opioid therapy has a role in the treatment of some patients when used selectively, carefully and combined with an ongoing assessment of risks and benefits. Here, we provide a comprehensive overview of the use of opioid therapy in patients with HDKF and chronic pain, including a discussion of buprenorphine, which has potential as an analgesic option for patients receiving HD owing to its unique pharmacological properties. [ABSTRACT FROM AUTHOR]

Musculoskeletal disorders (MSDs) are highly prevalent, painful, and costly disorders. The MSD Cohort was created to characterize variation in pain, comorbidities, treatment, and outcomes among patients with MSD receiving Veterans Health Administration care across demographic groups, geographic regions, and facilities. We searched electronic health records to identify patients treated in Veterans Health Administration who had ICD-9-CM codes for diagnoses including, but not limited to, joint, back, and neck disorders, and osteoarthritis. Cohort inclusion criteria were 2 or more outpatient visits occurring within 18 months of one another or one inpatient visit with an MSD diagnosis between 2000 and 2011. The first diagnosis is the index date. Pain intensity numeric rating scale (NRS) scores, comorbid medical and mental health diagnoses, pain-related treatments, and other characteristics were collected retrospectively and prospectively. The cohort included 5,237,763 patients; their mean age was 59, 6% were women, 15% identified as black, and 18% reported severe pain (NRS ≥ 7) on the index date. Nontraumatic joint disorder (27%), back disorder (25%), and osteoarthritis (21%) were the most common MSD diagnoses. Patients entering the cohort in recent years had more concurrent MSD diagnoses and higher NRS scores. The MSD Cohort is a rich resource for collaborative pain-relevant health service research. [ABSTRACT FROM AUTHOR]