Opioids
Decision-Making Capacity, Opioid Use Disorder, and the 3-Stage Model of Addiction
The assessment of decision-making capacity in hospitalized individuals with acute decompensation of chronic illness is challenging. Such decompensations are often accompanied by pathophysiologic processes that impair cognition and judgment, sometimes subtly. The standard of care has thus evolved such that assessment of decisional capacity is best performed once acute decompensation is stabilized with evidence-based treatment, a process that can take several hours to days.1,2Shell Shock and PTSD: A Tale of Two Diagnoses
Ever since human beings first went to war, the people who fight in those wars have sustained not only physical wounds but also psychological wounds, which may spare the body but scar the mind. And for almost as long as human beings have been waging war, societies have struggled with two fundamental questions about these psychological wounds. First, how do we identify and define these unseen wounds, wounds that lead to the type of consequences that defy simple physiologic explanation? Second, given that some people clearly return from war with psychological issues that impair their ability to function, how do we justly compensate those who experience these psychological wounds (an issue that becomes particularly salient as the number of people affected increases)?The System Is Broken: A Qualitative Assessment of Opioid Prescribing Practices After Spine Surgery
To elucidate factors that influence opioid prescribing behaviors of key stakeholders after major spine surgery, with a focus on barriers to optimized prescribing.An Institutional Approach to Managing the Opioid Crisis
The opioid crisis is a major concern of most health care institutions, including our large academic center. In this article, an organized approach to managing the epidemic institutionally is discussed. An Opioid Stewardship Program was instituted at our tertiary-care center with multiple sites and states of practice, which included diverse membership and expertise. Charges of the program included reviewing current practice, workflows, and external and internal guidelines and evaluating and standardizing prescribing practices.Can Pain Management be Safely Optimized in Older Adults?
Managing chronic pain is a challenging task. Older adults (OAs) (>65 years) are the fastest growing segment of our population, and are substantially affected by chronic pain of various etiologies. Chronic pain, which affects a significant proportion of community-dwelling OAs and may be nearly universal in long-term care residents, is associated with numerous other conditions, including frailty, debility, and depression.1 Optimizing its management is critical for achieving optimal health outcomes in OAs.Balancing the Risks and Benefits of Opioid Therapy: The Pill and the Pendulum
Over the past 20 years, the medicinal use of opioids has swung back and forth like a pendulum. However, unlike Edgar Allan Poe's classic short story, the likelihood of a last-second rescue seems remote. In the 1990s, a confluence of economic, medical, and governmental factors coalesced into a mutual driver of widespread prescription opioid use for chronic pain.1 The havoc wrought by this shift in prescribing practices ushered in the most devastating addiction crisis in US history. The ramifications of indiscriminate opioid prescribing are ubiquitous across the United States, and the statistics are grim.Prescription Opioid Epidemic and Trends in the Clinical Development of New Pain Medications
To evaluate trends in the clinical development of new pain and reformulated pain medications given the ongoing opioid crisis and the public health burden of inadequately controlled pain.Medication-Assisted Treatment for Opioid-Use Disorder
The United States is in the midst of a national opioid epidemic. Physicians are encouraged both to prevent and treat opioid-use disorders (OUDs). Although there are 3 Food and Drug Administration-approved medications to treat OUD (methadone, buprenorphine, and naltrexone) and there is ample evidence of their efficacy, they are not used as often as they should. We provide a brief review of the 3 primary medications used in the treatment of OUD. Using data from available medical literature, we synthesize existing knowledge and provide a framework for how to determine the optimal approach for outpatient management of OUD with medication-assisted treatments.Spinal Stimulation for the Treatment of Intractable Spine and Limb Pain: A Systematic Review of RCTs and Meta-Analysis
To synthesize the evidence regarding the effect of spinal stimulation (SS) vs medical therapy (MT) and the effect of newer SS technologies vs conventional SS on pain reduction in patients with intractable spine or limb pain.Chronic Constipation
Constipation is a common symptom that may be primary (idiopathic or functional) or associated with a number of disorders or medications. Although most constipation is self-managed by patients, 22% seek health care, mostly to primary care physicians (>50%) and gastroenterologists (14%), resulting in large expenditures for diagnostic testing and treatments. There is strong evidence that stimulant and osmotic laxatives, intestinal secretagogues, and peripherally restricted μ-opiate antagonists are effective and safe; the lattermost drugs are a major advance for managing opioid-induced constipation.In Reply—The Importance of Educational Interventions and Regional Analgesia in Tackling the Opioid Crisis in the United States
Overprescribing opioids has true risks for our patients. A study by Sanger et al1 found that more than half of patients in a methadone maintenance treatment program were introduced to opioids through a prescription. This carries particular relevance for surgeons, who prescribe a significant portion of all opioids, including many for patients without a history of exposure.2,3 Optimal prescribing practices therefore toe the delicate line between providing adequate pain control and minimizing the risk of medication misuse and abuse.The Importance of Educational Interventions and Regional Analgesia in Tackling the Opioid Crisis in the United States
Ziegelmann et al1 recently published an interesting report titled “Wide variation in opioid prescribing after urological surgery in tertiary care centers” that strives to shed light on the mounting opioid crisis in the United States. In accordance with previous studies, the analysis revealed a considerable variation in postoperative opioid prescribing patterns both for a given procedure and among procedures. This was ascribed to patient-related factors such as younger age, male sex, cancer diagnosis, and prolonged hospital stay and more importantly to lack of standardization and physician and patient expectations.Wide Variation in Opioid Prescribing After Urological Surgery in Tertiary Care Centers
To describe postoperative opioid prescribing practices in a large cohort of patients undergoing urological surgery.Management Options for Irritable Bowel Syndrome
Irritable bowel syndrome (IBS) is associated with diverse pathophysiologic mechanisms. These mechanisms include increased abnormal colonic motility or transit, intestinal or colorectal sensation, increased colonic bile acid concentration, and superficial colonic mucosal inflammation, as well as epithelial barrier dysfunction, neurohormonal up-regulation, and activation of secretory processes in the epithelial layer. Novel approaches to treatment include lifestyle modification, changes in diet, probiotics, and pharmacotherapy directed to the motility, sensation, and intraluminal milieu of patients with IBS.Advances in the Treatment of Sickle Cell Disease
Sickle cell disease (SCD) is a monogenic disorder that afflicts approximately 100,000 Americans and millions of people worldwide. It is characterized by hemolytic anemia, vaso-occlusive crises, relentless end-organ injury, and premature death. Currently, red blood cell transfusion and hydroxyurea are the major disease-modifying therapies available for SCD. Hematopoetic stem cell transplant is curative, but barriers to treatment are substantial and include a lack of suitable donors, immunologic transplant rejection, long-term adverse effects, prognostic uncertainty, and poor end-organ function, which is especially problematic for older patients.A Before and After Analysis of Health Care Utilization by Patients Enrolled in Opioid Controlled Substance Agreements for Chronic Noncancer Pain
To evaluate the impact of opioid controlled substance agreements (CSAs) enrollment on health care utilization.In Reply II—Root Causes of Opioid Crisis
Dr Pendyal highlights an important point that the opioid crisis is much bigger than just the “supply side” of the problem. It is truly a biological-psychological-social-spiritual problem that impacts both the “supply side” and the “demand side.”1 However, in his description of the social factors, of which there are many, he too fails to acknowledge many of the drivers of the opioid crisis. Many of the drivers go beyond “unemployment, poverty, and wealth inequality,” with an increasing number of those dying from opioids being employed, middle- and upper-class individuals.The Root Causes of the Current Opioid Crisis
I read with a great deal of interest the article by Rummans et al1 and the accompanying editorial by Srivastava and Gold2 in the March 2018 issue of the Mayo Clinic Proceedings.In Reply I—Root Causes of the Opioid Crisis
We thank Dr. Pendyal for the thoughtful and articulate response to our article.1 We agree that a thorough examination of opioid use disorders and overdoses includes evaluation of structural- and societal-level factors. Indeed, income inequality, social disparities, and other structural inequities are important considerations in chronic illnesses, disease management, premature deaths, infant mortality, maternal illness, and all epidemics past and present, not just the current opioid epidemic. Similarly, depression, despair, hopelessness, and suicide are not exclusively linked to the current opioid crisis but are reflective of the state of health and wellness in our society.Telemedicine’s Role in Addressing the Opioid Epidemic
Adverse health effects of the opioid epidemic continue to climb. Opioid-related overdose deaths reached an all-time high of 42,249 in 2016,1 prompting President Trump to declare an opioid public health emergency in 2017. From July 2016 to September 2017, emergency department visits associated with opioid-related overdoses spiked about 30%.2 Those with opioid use disorders (OUDs) face dramatically increased risk of early death, typically from overdose. Provision of evidence-based medication-assisted treatment (MAT), which can involve methadone, buprenorphine, or naltrexone, to those with OUDs has been shown to reduce the risk of death by as much as 50%.CAREFUL: A Practical Guide for Improving the Clinical Surveillance of Long-Term Opioid Therapy
To the Editor: National prescribing guidelines for opioid use provide recommendations for clinical surveillance aimed at enhancing the safe use of these medications in patients with chronic pain.1 However, despite the widespread availability of these guidelines, most clinicians do not follow recommendations for clinical surveillance.2 The purpose of this letter was to describe an acronym that provides a summary of many key components of clinical surveillance that have been recommended for patients receiving long-term opioid therapy.In Reply—Additional Safety Considerations Before Prescribing Opioids to Manage Restless Legs Syndrome
We thank Dr Geller for his interest in our article on the appropriate use of opioids in refractory restless legs syndrome (RLS).Additional Safety Considerations Before Prescribing Opioids to Manage Restless Legs Syndrome
Silber et al1 are commended for espousing the merit of low and stable dose opioid treatment of refractory restless legs syndrome (RLS) given the risks of suicide and severely compromised quality of life if untreated. Opioid agreements reduce risks of RLS treatment with opioids as agreements mandate drug testing as well as frequent query of prescription drug monitoring programs.Opioid-Induced Adrenal Insufficiency
One in 10 Americans experience chronic pain. Although opioids do play a role in the management of pain, long-term opioid use may lead to adverse effects. Endocrine-related adverse effects have been described but remain poorly recognized. Opioid-induced adrenal insufficiency occurs because of suppression of hypothalamic-pituitary-adrenal communication and may be challenging to diagnose but has been reported in 9% to 29% of patients receiving long-term opiate therapy. Little data exist to guide case detection and patient management.Younger Adults Initiating Hemodialysis: Antidepressant Use for Depression Associated With Higher Health Care Utilization
To examine associations between antidepressant use and health care utilization in young adults beginning maintenance hemodialysis (HD) therapy.How Good Intentions Contributed to Bad Outcomes: The Opioid Crisis
The opioid crisis that exists today developed over the past 30 years. The reasons for this are many. Good intentions to improve pain and suffering led to increased prescribing of opioids, which contributed to misuse of opioids and even death. Following the publication of a short letter to the editor in a major medical journal declaring that those with chronic pain who received opioids rarely became addicted, prescriber attitude toward opioid use changed. Opioids were no longer reserved for treatment of acute pain or terminal pain conditions but now were used to treat any pain condition.Beyond Supply: How We Must Tackle the Opioid Epidemic
The opioid epidemic is the most important and most serious public health crisis today. The effects are reported in overdose deaths but are also starkly evident in declines in sense of well-being and general health coupled with increasing all-cause mortality, particularly among the middle-aged white population.1 As exceptionally well described by Rummans et al2 in this issue of Mayo Clinic Proceedings, the cause of the epidemic is multifactorial, including an overinterpretation of a now infamous New England Journal of Medicine letter describing addiction as a rare occurrence in hospitalized patients treated with opioids, initiatives from the Joint Commission directed toward patient satisfaction and the labeling of pain as the “5th vital sign,” the advent of extended-release oxycodone (OxyContin), an aggressive marketing campaign from Purdue Pharma L.P., and the influx of heroin and fentanyl derivatives.Diagnosis and Management of Headache in Older Adults
Headache is a common, disabling neurologic problem in all age groups, including older adults. In older adults, headache is most likely a primary disorder, such as tension-type headache or migraine; however, there is a higher risk of secondary causes, such as giant cell arteritis or intracranial lesions, than in younger adults. Thus, based on the headache history, clinical examination, and presence of headache red flags, a focused diagnostic evaluation is recommended, ranging from blood tests to neuroimaging, depending on the headache characteristics.A Conceptual Framework for Understanding Unintended Prolonged Opioid Use
An urgent need exists to better understand the transition from short-term opioid use to unintended prolonged opioid use (UPOU). The purpose of this work is to propose a conceptual framework for understanding UPOU that posits the influence of 3 principal domains that include the characteristics of (1) individual patients, (2) the practice environment, and (3) opioid prescribers. Although no standardized method exists for developing a conceptual framework, the process often involves identifying corroborative evidence, leveraging expert opinion to identify factors for inclusion in the framework, and developing a graphic depiction of the relationships between the various factors and the clinical problem of interest.Clinical Interpretation of Urine Drug Tests: What Clinicians Need to Know About Urine Drug Screens
Urine drug testing is frequently used in clinical, employment, educational, and legal settings and misinterpretation of test results can result in significant adverse consequences for the individual who is being tested. Advances in drug testing technology combined with a rise in the number of novel misused substances present challenges to clinicians to appropriately interpret urine drug test results. Authors searched PubMed and Google Scholar to identify published literature written in English between 1946 and 2016, using urine drug test, screen, false-positive, false-negative, abuse, and individual drugs of abuse as key words.Understanding Palliative Care and Hospice: A Review for Primary Care Providers
Palliative care provides invaluable clinical management and support for patients and their families. For most people, palliative care is not provided by hospice and palliative medicine specialists, but rather by their primary care providers. The recognition of hospice and palliative medicine as its own medical subspecialty in 2006 highlighted the importance of palliative care to the practice of medicine, yet many health care professionals harbor misconceptions about palliative care, which may be a barrier to ensuring that the palliative care needs of their patients are identified and met in a timely fashion.Hypoactive Sexual Desire Disorder: International Society for the Study of Women's Sexual Health (ISSWSH) Expert Consensus Panel Review
The objective of the International Society for the Study of Women's Sexual Health expert consensus panel was to develop a concise, clinically relevant, evidence-based review of the epidemiology, physiology, pathogenesis, diagnosis, and treatment of hypoactive sexual desire disorder (HSDD), a sexual dysfunction affecting approximately 10% of adult women. Etiologic factors include conditions or drugs that decrease brain dopamine, melanocortin, oxytocin, and norepinephrine levels and augment brain serotonin, endocannabinoid, prolactin, and opioid levels.Anorectal and Pelvic Pain
Although pelvic pain is a symptom of several structural anorectal and pelvic disorders (eg, anal fissure, endometriosis, and pelvic inflammatory disease), this comprehensive review will focus on the 3 most common nonstructural, or functional, disorders associated with pelvic pain: functional anorectal pain (ie, levator ani syndrome, unspecified anorectal pain, and proctalgia fugax), interstitial cystitis/bladder pain syndrome, and chronic prostatitis/chronic pelvic pain syndrome. The first 2 conditions occur in both sexes, while the latter occurs only in men.Murder Liability for Prescribing Opioids: A Way Forward?
In February 2016, a California judge sentenced Dr Hsiu-Ying Tseng (“Dr Tseng”) to 30-years-to-life in prison after a jury found her guilty of second-degree murder for 3 patient drug overdose deaths.1 This marked the first time in American history that a physician was held criminally liable for the murder of a patient by means of extreme recklessness in opioid prescribing. Although Dr Tseng's unique conviction reflects her outlier prescribing practices, the recently spotlighted potential for criminal penalty may have a chilling effect on physicians treating patients for pain.Common Functional Gastroenterological Disorders Associated With Abdominal Pain
Although abdominal pain is a symptom of several structural gastrointestinal disorders (eg, peptic ulcer disease), this comprehensive review will focus on the 4 most common nonstructural, or functional, disorders associated with abdominal pain: functional dyspepsia, constipation-predominant and diarrhea-predominant irritable bowel syndrome, and functional abdominal pain syndrome. Together, these conditions affect approximately 1 in 4 people in the United States. They are associated with comorbid conditions (eg, fibromyalgia and depression), impaired quality of life, and increased health care utilization.Chronic Pain and Mental Health Disorders: Shared Neural Mechanisms, Epidemiology, and Treatment
Chronic pain and mental health disorders are common in the general population, and epidemiological studies suggest that a bidirectional relationship exists between these 2 conditions. The observations from functional imaging studies suggest that this bidirectional relationship is due in part to shared neural mechanisms. In addition to depression, anxiety, and substance use disorders, individuals with chronic pain are at risk of other mental health problems including suicide and cigarette smoking and many have sustained sexual violence.Future Directions in Pain Management: Integrating Anatomically Selective Delivery Techniques With Novel Molecularly Selective Agents
Treatment for chronic, locoregional pain ranks among the most prevalent unmet medical needs. The failure of systemic analgesic drugs, such as opioids, is often due to their off-target toxicity, development of tolerance, and abuse potential. Interventional pain procedures provide target specificity but lack pharmacologically selective agents with long-term efficacy. Gene therapy vectors are a new tool for the development of molecularly selective pain therapies, which have already been proved to provide durable analgesia in preclinical models.Opioid Use in Fibromyalgia: A Cautionary Tale
Multiple pharmacotherapies are available for the treatment of fibromyalgia (FM), including opioid analgesics. We postulate that the mechanism of action of traditional opioids predicts their lack of efficacy in FM. Literature searches of the MEDLINE and Cochrane Library databases were conducted using the search term opioid AND fibromyalgia to identify relevant articles, with no date limitations set. Citation lists in returned articles and personal archives of references were also examined for additional relevant items, and articles were selected based on the expert opinions of the authors.Advanced Innovations for Pain
Chronic pain represents one of the most important public health problems in terms of both the number of patients afflicted and health care costs. Most patients with chronic pain are treated with medications as the mainstay of therapy, and yet most medically treated patients continue to report ongoing pain. Additionally, adverse effects from pain medications represent a major challenge for clinicians and patients. Spinal cord stimulation and intrathecal drug delivery systems are well-established techniques that have been utilized for over 25 years.Interpreting Urine Drug Screen Results in the Context of Poppy Seed Use
The abuse of home opiate preparations derived from poppy seeds (PSs) is gaining popularity in the United States,1 and clinicians may increasingly encounter these patients in their practice. At least 5 American men have died after consuming poppy-based tea, most often in the context of urine drug screens (UDSs) positive for other illicit substances.1 Clinicians may find that their patients using PS tea are also using other opioids, which may present a challenge when interpreting UDSs.Evaluation and Treatment of Low Back Pain: A Clinically Focused Review for Primary Care Specialists
Low back pain (LBP) is a leading cause of disability worldwide. In the absence of a classification system for pain syndromes, classification of LBP on the basis of the distribution of pain as axial (pain generally localized to the low back) or radicular neuropathic (pain radiating to the lower extremities) is relevant to clinical practice because the distribution of pain is often a corollary of frequently occurring disease processes involving the lumbar spine. Common sources of axial LBP include the intervertebral disc, facet joint, sacroiliac joint, and paraspinal musculature, whereas common sources of radicular pain include a herniated intervertebral disc and spinal stenosis.Cancer Pain Management
Safe, effective, and evidence-based management of cancer-related pain is a cornerstone of comprehensive cancer care. Despite increasing interest in and efforts to improve its management, pain remains poorly controlled in nearly half of all patients with cancer, with little change in the past 20 years. Limited training in pain assessment and management, overestimation of providers' own skills to treat pain, and failure to refer patients to pain specialists can result in suboptimal pain management with devastating effects on quality of life, physical functioning, and increased psychological distress.Alternative Splicing of G Protein–Coupled Receptors: Relevance to Pain Management
Drugs that target G protein–coupled receptors (GPCRs) represent the primary treatment strategy for patients with acute and chronic pain; however, there is substantial individual variability in both the efficacy and adverse effects associated with these drugs. Variability in drug responses is due, in part, to individuals’ diversity in alternative splicing of pain-relevant GPCRs. G protein–coupled receptor alternative splice variants often exhibit distinct tissue distribution patterns, drug-binding properties, and signaling characteristics that may impact disease pathology as well as the extent and direction of analgesic effects.Opioid Analgesics
Chronic pain is an international health issue of immense importance that is influenced by both physical and psychological factors. Opioids are useful in treating chronic pain but have accompanying complications. It is important for clinicians to understand the basics of opioid pharmacology, the benefits and adverse effects of opioids, and related problematic issues of tolerance, dependence, and opioid-induced hyperalgesia. In this article, the role of psychiatric comorbidity and the use of validated assessment tools to identify individuals who are at the greatest risk for opioid misuse are discussed.Incidence and Risk Factors for Progression From Short-term to Episodic or Long-term Opioid Prescribing: A Population-Based Study
To determine what proportion of a geographically defined population who receive new opioid prescriptions progresses to episodic or long-term patterns of opioid prescribing and to explore the clinical characteristics associated with patterns of opioid prescribing.Peripheral Neuropathy: A Practical Approach to Diagnosis and Symptom Management
Peripheral neuropathy is one of the most prevalent neurologic conditions encountered by physicians of all specialties. Physicians are faced with 3 distinct challenges in caring for patients with peripheral neuropathy: (1) how to efficiently and effectively screen (in less than 2 minutes) an asymptomatic patient for peripheral neuropathy when they have a disorder in which peripheral neuropathy is highly prevalent (eg, diabetes mellitus), (2) how to clinically stratify patients presenting with symptoms of neuropathy to determine who would benefit from specialty consultation and what testing is appropriate for those who do not need consultation, and (3) how to treat the symptoms of painful peripheral neuropathy.Tapering Long-term Opioid Therapy in Chronic Noncancer Pain: Evidence and Recommendations for Everyday Practice
Increasing concern about the risks and limited evidence supporting the therapeutic benefit of long-term opioid therapy for chronic noncancer pain are leading prescribers to consider discontinuing the use of opioids. In addition to overt addiction or diversion, the presence of adverse effects, diminishing analgesia, reduced function and quality of life, or the absence of progress toward functional goals can justify an attempt at weaning patients from long-term opioid therapy. However, discontinuing opioid therapy is often hindered by patients’ psychiatric comorbidities and poor coping skills, as well as the lack of formal guidelines for the prescribers.Fibromyalgia and Related Conditions
Fibromyalgia is the currently preferred term for widespread musculoskeletal pain, typically accompanied by other symptoms such as fatigue, memory problems, and sleep and mood disturbances, for which no alternative cause can be identified. Earlier there was some doubt about whether there was an “organic basis” for these related conditions, but today there is irrefutable evidence from brain imaging and other techniques that this condition has strong biological underpinnings, even though psychological, social, and behavioral factors clearly play prominent roles in some patients.Neuropathic Pain: Principles of Diagnosis and Treatment
Neuropathic pain is caused by disease or injury of the nervous system and includes various chronic conditions that, together, affect up to 8% of the population. A substantial body of neuropathic pain research points to several important contributory mechanisms including aberrant ectopic activity in nociceptive nerves, peripheral and central sensitization, impaired inhibitory modulation, and pathological activation of microglia. Clinical evaluation of neuropathic pain requires a thorough history and physical examination to identify characteristic signs and symptoms.Drug Management in the Elderly Adult With Chronic Kidney Disease: A Review for the Primary Care Physician
With advancing age, the functional reserve of many organs tends to decrease. In particular, the lean body mass, the levels of serum albumin, the blood flow to the liver, and the glomerular filtration rate are reduced in elderly individuals and can be further impaired by the concomitant presence of acute or chronic kidney disease. Moreover, patients with kidney disease are often affected by comorbid processes and are prescribed multiple medications. The aging process also modifies some drug interactions, including the affinity of some drugs for their receptor, the number of receptors, and the cell responses upon receptor activation.
