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Objective: Tapering of chronic opioids has increased, with subsequent reports of exacerbated pain among patients who tapered. We aimed to evaluate the association between opioid dose tapering and subsequent pain-related healthcare utilization (ED visits, hospitalizations and primary care visits)., Design, Setting and Subjects: We conducted a retrospective cohort study from 2015-2019 using data from the Optum Labs Data Warehouse that contains de-identified retrospective administrative claims data for commercial and Medicare Advantage enrollees in the US. Adults aged ≥18 years who were prescribed stable doses of opioids, ≥50 morphine milligram equivalents (MME)/day, during a 12-month baseline period., Methods: Tapering was defined as ≥ 15% relative reduction in mean daily opioid dose during one of 6 overlapping 60-day periods. Tapered patient-periods were subclassified as tapered-and-continued (MME > 0) vs. tapered-and-discontinued (MME = 0). We modeled monthly counts of visits for pain diagnoses up to 12 months after cohort entry using negative binomial regression as a function of tapering, baseline utilization, and patient level-covariates., Results: Among 47,033 patients, 13,793 patients tapered. Compared to no taper, any taper was associated with more ED visits for pain (adjusted incidence rate ratio [aIRR] 1.21, 95% CI: 1.11-1.30), tapered then continued status was associated with more ED visits (aIRR 1.23, CI: 1.14-1.32) and hospitalizations (aIRR 1.14, CI: 1.03-1.27) for pain, and tapered-and-discontinued was associated with fewer primary care visits for pain (aIRR 0.68, CI: 0.61-0.76)., Conclusions: These associations suggest that opioid tapering may lead to increased emergency and hospital utilization for acute pain and possibly a decreased perceived need for primary care for those whose opioids were discontinued., (© The Author(s) 2024. Published by Oxford University Press on behalf of the American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: In this systematic review, the authors examine the prevalence and extent of stigmatizing attitudes among health care professionals (HCPs) and trainees against patients with substance use disorders (SUDs), including research on interventions to reduce stigma., Method: The authors searched 7 databases for articles published from January 1, 2011, through February 15, 2023, that quantified SUD stigma among HCPs or trainees. Inclusion criteria allowed both observational and intervention studies from the United States or Canada to be included in this review. Quality assessment was applied to all included studies; studies were not excluded based on quality., Results: A total of 1,992 unique articles were identified of which 32 articles (17 observational studies and 15 intervention studies), all conducted in the United States, met the inclusion criteria. Half of the included studies (16 of 32) were published in 2020 or later. Most of the intervention studies (13 of 15) used a single-group pre-post design; interventions involved didactics and/or interactions with persons with SUDs. The 32 included studies used a total of 19 different measures of stigma. All 17 observational studies showed some degree of HCP or trainee stigma against patients with SUDs. Most intervention studies (12 of 15) found small but statistically significant reductions in stigma after intervention., Conclusions: SUD stigma exists among HCPs and trainees. Some interventions to reduce this stigma had positive impacts, but future studies with larger, diverse participants and comparison groups are needed. Heterogeneity among studies and stigma measures limits the ability to interpret results across studies. Future rigorous research is needed to determine validated, consensus measures of SUD stigma among HCPs and trainees, identify stigma scores that are associated with clinical outcomes, and develop effective antistigma interventions for HCPs and trainees., (Copyright © 2023 the Association of American Medical Colleges.)

Introduction: National guidelines recommend that patients with chronic noncancer pain prescribed long-term opioid therapy (LTOT) undergo periodic urine drug testing (UDT), yet UDT is performed inconsistently, and little evidence supports the utility of this approach. We examined patient and prescriber factors associated with UDT., Methods: A 1-year retrospective cohort study of 5690 patients prescribed LTOT by 689 clinicians in a network of 13 primary care and specialty clinics. Negative binomial regression examined patient and prescriber factors associated with the number of tests completed, and logistic regression examined prescriber and practice level testing likelihood. Analyses were adjusted for patient and clinician characteristics and accounted for patient clustering within prescribers., Results: A total of 2256 patients (39.6%) had UDT completed at least once. More UDT completion was associated with Black patient race and receipt of more opioid prescriptions, as well as with clinician testing compliance., Conclusions: UDT was relatively infrequent in patients prescribed LTOT and associated with patient factors not known to confer greater opioid-related risk, such as race. In addition, there was significant clinician-driven variation in UDT. Given the uncertain clinical utility of such testing, these findings signal the need for strategies to address potential biases in the use of UDT., Competing Interests: Conflict of interest: None., (© Copyright by the American Board of Family Medicine.)

In October of 2021, California enacted SB 428, the ACEs Equity Act, which mandates commercial insurance coverage of adverse childhood experiences (ACEs) screening in addition to ACEs screening already covered for the state's Medicaid enrollees. California is the first state to expand ACEs screening coverage, but it is possible other states may follow similar paths given the increasing interest in policy action to address ACEs. Increase in stress and trauma among Americans and evidence of the disproportionate impact ACEs have on historically marginalized and disadvantaged communities has increased the urgency with which policy makers, clinicians and researchers have sought to address ACEs and encourage trauma-informed care delivery to better meet the needs of patients. Family practice and other primary care providers are at the core of prevention and are arguably the largest group of stakeholders at the forefront of movements toward increasing ACEs screenings. However, debate persists among policy makers, clinicians, and researchers on whether the ACEs screening approach improves outcomes and avoids harms. In this health policy article, we describe key issues under debate with regards to ACEs screening and estimate potential change in screening utilization and expenditures due to the new ACEs legislation in California. The lessons being learned in California are applicable to other states and the US as a whole., Competing Interests: Conflict of interest: None., (© Copyright 2022 by the American Board of Family Medicine.)

Importance: Patients prescribed long-term opioid therapy are increasingly undergoing dose tapering. Recent studies suggest that tapering is associated with short-term risks of substance misuse, overdose, and mental health crisis, although lower opioid dose could reduce risks of adverse events over the longer term., Objective: To assess the longer-term risks of overdose or mental health crisis associated with opioid dose tapering., Design, Setting, and Participants: This is a cohort study using an exposure-crossover analysis. Data were obtained from the OptumLabs Data Warehouse, which includes deidentified medical and pharmacy claims and enrollment records for commercial insurance and Medicare Advantage enrollees, representing a diverse mixture of ages, races, ethnicities, and geographical regions across the US. Participants were US adults who underwent opioid dose tapering from 2008 to 2017 after a 12-month baseline period of stable daily dosing of 50 morphine milligram equivalents or higher and who had at least 1 month of long-term follow-up during a postinduction period beginning 12 months after taper initiation. Data analysis was performed from October 2021 to April 2022., Exposures: Opioid tapering, defined as 15% or more relative reduction in mean daily dose during any of 6 overlapping 60-day windows within a 7-month follow-up period after the stable baseline period., Main Outcomes and Measures: Emergency or hospital encounters for drug overdose or withdrawal and mental health crisis (depression, anxiety, or suicide attempt). Outcome counts were assessed in pretaper and postinduction periods (from 12 to 24 months after taper initiation)., Results: The study included 21 515 tapering events among 19 377 patients with a mean (SD) of 9.1 (2.7) months of postinduction follow-up per event (median [IQR], 10 [8-11] months). Patients had a mean (SD) age of 56.9 (11.2) years, 11 581 (53.8%) were female, and 8217 (38.2%) had commercial insurance (vs Medicare Advantage). In conditional negative binomial regression analyses, adjusted incidence rate ratios for the postinduction period compared with the pretaper period were 1.57 (95% CI, 1.42-1.74) for overdose or withdrawal and 1.52 (95% CI, 1.35-1.71) for mental health crisis., Conclusions and Relevance: These findings suggest that opioid tapering was associated with increased rates of overdose, withdrawal, and mental health crisis extending up to 2 years after taper initiation.

Background: Multimorbidity is common, and care is impacted by patient life context. Effective, efficient interventions to improve patient-centered outcomes such as perceived treatment burden are limited. There is a need for interventions that integrate patient contextual information into primary care encounters to improve such outcomes. Patient life context is a multitude of factors that influence a patient's life and healthcare, including social determinants of health and broader elements such as family and work demands., Methods: This pilot randomized controlled trial (RCT) protocol will compare standard pre-visit planning to context-informed pre-visit planning that incorporates the patient's life context, for patients with diabetes plus other chronic comorbid conditions. Primary outcomes include measures of trial protocol and intervention feasibility and acceptability: physician study and visit perceived burden, patient satisfaction, and patient, physician and staff experience with the trial. Additional measurements of intervention impact include: initial estimates of effect size on patient treatment burden and other patient-oriented outcomes, change in glycemic control, and other intermediate medical outcomes., Discussion: This intervention is novel as it collects patient life context information using a direct person-to-person approach, allows physicians to review the information prior to patient arrival at the clinic and, where appropriate, incorporate it when negotiating treatment plans, and is longitudinal, summarizing evolving contextual information over time. This pilot RCT has the potential to demonstrate trial protocol and intervention feasibility and acceptability, and estimate effect size on patient and provider outcomes, to inform for a future, definitive RCT.Trial Registration: This trial was registered at ClinicalTrials.gov prior to patient enrollment: NCT04568382., Competing Interests: Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

Importance: Opioid-related mortality and national prescribing guidelines have led to tapering of doses among patients prescribed long-term opioid therapy for chronic pain. There is limited information about risks related to tapering, including overdose and mental health crisis., Objective: To assess whether there are associations between opioid dose tapering and rates of overdose and mental health crisis among patients prescribed stable, long-term, higher-dose opioids., Design, Setting, and Participants: Retrospective cohort study using deidentified medical and pharmacy claims and enrollment data from the OptumLabs Data Warehouse from 2008 to 2019. Adults in the US prescribed stable higher doses (mean ≥50 morphine milligram equivalents/d) of opioids for a 12-month baseline period with at least 2 months of follow-up were eligible for inclusion., Exposures: Opioid tapering, defined as at least 15% relative reduction in mean daily dose during any of 6 overlapping 60-day windows within a 7-month follow-up period. Maximum monthly dose reduction velocity was computed during the same period., Main Outcomes and Measures: Emergency or hospital encounters for (1) drug overdose or withdrawal and (2) mental health crisis (depression, anxiety, suicide attempt) during up to 12 months of follow-up. Discrete time negative binomial regression models estimated adjusted incidence rate ratios (aIRRs) of outcomes as a function of tapering (vs no tapering) and dose reduction velocity., Results: The final cohort included 113 618 patients after 203 920 stable baseline periods. Among the patients who underwent dose tapering, 54.3% were women (vs 53.2% among those who did not undergo dose tapering), the mean age was 57.7 years (vs 58.3 years), and 38.8% were commercially insured (vs 41.9%). Posttapering patient periods were associated with an adjusted incidence rate of 9.3 overdose events per 100 person-years compared with 5.5 events per 100 person-years in nontapered periods (adjusted incidence rate difference, 3.8 per 100 person-years [95% CI, 3.0-4.6]; aIRR, 1.68 [95% CI, 1.53-1.85]). Tapering was associated with an adjusted incidence rate of 7.6 mental health crisis events per 100 person-years compared with 3.3 events per 100 person-years among nontapered periods (adjusted incidence rate difference, 4.3 per 100 person-years [95% CI, 3.2-5.3]; aIRR, 2.28 [95% CI, 1.96-2.65]). Increasing maximum monthly dose reduction velocity by 10% was associated with an aIRR of 1.09 for overdose (95% CI, 1.07-1.11) and of 1.18 for mental health crisis (95% CI, 1.14-1.21)., Conclusions and Relevance: Among patients prescribed stable, long-term, higher-dose opioid therapy, tapering events were significantly associated with increased risk of overdose and mental health crisis. Although these findings raise questions about potential harms of tapering, interpretation is limited by the observational study design.

Context: Health plan disenrollment has been associated with higher mortality in patients with opioid use disorder. Insurance loss and health plan disenrollment might be downstream social consequences of opioid misuse and overdose that may heighten patient mortality risks during a period of heightened need for professional assistance. Objective: To test hypotheses that: 1) overdose events in patients prescribed long-term opioids are associated with subsequent health plan disenrollment; and 2) buprenorphine initiation after overdose would attenuate this association. Study Design: Retrospective cohort study. Setting and Dataset: Data from the Optum Labs Data Warehouse which includes de-identified medical and pharmacy claims and enrollment records for commercial and Medicare Advantage enrollees. The database contains longitudinal health information on patients, representing a mixture of ages, ethnicities, and geographical regions across the United States. Population studied: Adults (aged ≥18 years) prescribed stable, opioid therapy for a 6-month baseline period (≥90% of days covered, <10% monthly fluctuation from 6-month average, average daily dose ≥10 morphine milligram equivalents). Outcome Measures: Health plan disenrollment during up to one year of follow-up. Negative binomial regression estimated adjusted incidence rate ratios of disenrollment by incident overdose and buprenorphine initiation after overdose. Results: We identified 556,676 patients who were followed up after 1,119,100 stable periods of opioid therapy. During follow-up, 17.5% of person-periods ended in health plan disenrollment. Overdose events during follow-up were associated with health plan disenrollment with a dose-response relationship [adjusted incidence rate ratio (aIRR) for 1 overdose event = 1.29 (95% CI: 1.24-1.35); aIRR for ≥2 overdose events = 1.51 (1.43-1.59)]. Among patients with overdose events, subsequent buprenorphine initiation was associated with substantially reduced risk of health plan disenrollment [aIRR 0.36 (0.17-0.74)]. Conclusions: Overdose events in patients prescribed long-term opioids may portend other social consequences, such as health insurance loss, which may exacerbate patient risk at a time of heightened need and vulnerability. Buprenorphine may mitigate the risk of health plan disenrollment in opioid-prescribed patients who overdose., Competing Interests: Authors report none, (2023 Annals of Family Medicine, Inc.)

Importance: A 2016 Centers for Disease Control and Prevention prescribing guideline cautioned against higher-dose long-term opioid therapy and recommended tapering daily opioid doses by approximately 10% per week if the risks outweigh the benefits. Warnings have since appeared regarding potential hazards of rapid opioid tapering., Objectives: To characterize US trends in opioid dose tapering among patients prescribed long-term opioids from 2008 to 2017 and identify patient-level variables associated with tapering and a more rapid rate of tapering., Design, Setting, and Participants: This retrospective cohort study used deidentified medical and pharmacy claims and enrollment records for 100 031 commercial insurance and Medicare Advantage enrollees, representing a diverse mixture of ages, races/ethnicities, and geographical regions across the United States. Adults with stable, higher-dosage (mean, ≥50 morphine milligram equivalents [MMEs]/d) opioid prescriptions for a 12-month baseline period and 2 or more months of follow-up from January 1, 2008, to December 31, 2017, were included in the study., Main Outcomes and Measures: Tapering was defined as 15% or more relative reduction in mean daily MME during any of 6 overlapping 60-day windows within a 7-month follow-up period. The rate of tapering was computed as the maximum monthly percentage dose reduction., Results: Among the 100 031 participants (53 452 [53.4%] women; mean [SD] age, 57.6 [11.8] years), from 2008 to 2015, the age- and sex-standardized percentage of patients tapering daily opioid doses increased from 10.5% to 13.7% (adjusted incidence rate ratio [aIRR] per year, 1.05 [95% CI, 1.05-1.06]) before increasing to 16.2% in 2016 and 22.4% in 2017 (aIRR in 2016-2017 vs 2008-2015, 1.20 [95% CI, 1.16-1.25]). Patient-level covariates associated with tapering included female sex (aIRR, 1.13 [95% CI, 1.10-1.15]) and higher baseline dose (aIRR for ≥300 MMEs/d vs 50-89 MMEs/d, 2.57 [95% CI, 2.48-2.65]). Among patients tapering daily opioid doses, the mean (SD) maximum dose reduction was 27.6% (17.0%) per month, and 18.8% of patients had a maximum tapering rate exceeding 40% per month (ie, faster than 10% per week). More rapid dose reduction was associated with 2016-2017 vs 2008-2015 (adjusted difference, 1.4% [95% CI, 0.8%-2.1%]) and higher baseline dose (adjusted difference, 2.7% [95% CI, 2.2%-3.3%] for 90-149 vs 50-89 MMEs/d)., Conclusions and Relevance: Patients using long-term opioid therapy are increasingly undergoing dose tapering, particularly women and those prescribed higher doses; in addition, dose tapering has become more common since 2016. Many patients undergoing tapering reduce daily doses at a rapid maximum rate.

Importance: Prior studies suggesting clinician fulfillment or denial of requests affects patient satisfaction included limited adjustment for patient confounders. The studies also did not examine distinct request types, yet patient expectations and clinician fulfillment or denial might vary among request types., Objective: To examine how patient satisfaction with the clinician is associated with clinician denial of distinct types of patient requests, adjusting for patient characteristics., Design, Setting, and Participants: Cross-sectional observational study of 1319 outpatient visits to family physicians (n = 56) by 1141 adults at one Northern California academic health center., Main Outcomes and Measures: We used 6 Consumer Assessment of Healthcare Providers and Systems Clinician and Group Adult Visit Survey items to measure patient satisfaction with the visit physician. Standardized items were averaged to form the satisfaction score (Cronbach α = 0.80), which was then percentile-transformed. Seven separate linear mixed-effects models examined the adjusted mean differences in patient satisfaction percentile associated with denial of each of the following requests (if present)-referral, pain medication, antibiotic, other new medication, laboratory test, radiology test, or other test-compared with fulfillment of the respective requests. The models adjusted for patient sociodemographics, weight, health status, personality, worry over health, prior visit with clinician, and the other 6 request categories and their dispositions., Results: The mean (SD) age of the 1141 patients was 45.6 (16.1) years, and 902 (68.4%) were female. Among 1319 visits, 897 (68.0%) included at least 1 request; 1441 (85.2%) were fulfilled. Requests by category were referral, 294 (21.1%); pain medication, 271 (20.5%); antibiotic, 107 (8.1%); other new medication, 271 (20.5%); laboratory test, 448 (34.0%); radiology test, 153 (11.6%); and other tests, 147 (11.1%). Compared with fulfillment of the respective request type, clinician denials of requests for referral, pain medication, other new medication, and laboratory test were associated with worse satisfaction (adjusted mean percentile differences, -19.75 [95% CI, -30.75 to -8.74], -10.72 [95% CI, -19.66 to -1.78], -20.36 [95% CI, -29.54 to -11.18], and -9.19 [95% CI, -17.50 to -0.87]), respectively., Conclusions and Relevance: Clinician denial of some types of requests was associated with worse patient satisfaction with the clinician, but not for others, when compared with fulfillment of the requests. In an era of patient satisfaction-driven compensation, the findings suggest the need to train clinicians to deal effectively with requests, potentially enhancing patient and clinician experiences.

The action of serotonin on growth hormone (GH) secretion is controversial because of interspecies differences and lack of specificity of serotoninergic drugs. Serotonin (5-HT) appears to inhibit GH release in the sheep and in man. We have investigated the site of action of tianeptine, a 5-HT uptake enhancer, in sheep since it is possible to collect hypophysial portal blood for the simultaneous determination of growth hormone-releasing hormone (GHRH) and somatostatin in this species under conscious, unstressed conditions. Tianeptine injection (10 mg/kg i.v.) resulted in a significant, immediate and short-lasting (30 min) increase in peripheral GH (+750%; P < 0.01) and hypophysial portal GHRH (+180%; P < 0.01). No change in the secretion of somatostatin was recorded during the same time. These data suggest that serotoninergic inputs are inhibitory to GH secretion. Tianeptine acts centrally to stimulate GH secretion in the sheep and its effect is mediated through changes in GHRH but not somatostatin release into hypophysial portal blood.

All kind of stress produce an endocrine response. These hormonal responses can serve as stress indicators. The main peripheral endocrine responses to stress are the activation of adrenal corticoids, the stimulation of Growth Hormone (GH) and prolactin secretion, and the inhibition of insulin and gonadal secretion. Except for the inhibition of insulin release, all these hormonal variations depend on the adenohypophysis activity: stimulation of Adrenocorticotrophin hormone (ACTH), GH and prolactin, and inhibition of gonadotrophins (LH-FSH) secretions. Several lines of evidence demonstrate that specific hypothalamic Neuro-hormones stimulate or inhibit the hypophysial activity in response to stress. However, due to methodological difficulties, only measurements of peripheral hormones can be used as stress indicators.