Abuse of prescription of narcotics in primary care and its prevention - Dissertation Example

?"Abuse of prescription of narcotics in primary care and its prevention" Theme Lack of education of primary care providers about pain management. Unique Identifier: Upshur 1 Authors: Upshur, C. C., Luckman, R. S., Savageau, J. A. Title: Primary Care Providers Concerns about Management of Chronic Pain in Community Clinic Populations. Journal Issue, Pages: Journal of General Internal Medicine Vol. 21 No. 6 Pages 652-655. Year published Years data collected: Published in 2006. Purpose: To determine in community health care environments the level of satisfaction with regard to training received on current practices in the management of pain among the care providers. Methodology, Variables Design, Sample, Instruments: Qualitative study. Variables Design: Issues involving reaching optimal control of pain in patients and approaches that would assist in improving prescribing of opioids in managing chronic pain. Sample: 67 attending physicians, 19 nurse practitioners, 3 physician assistants, and 22 family practice residents, making a total of 111 participants from 178 selected. Instruments: Survey questionnaire relating to satisfaction with training and care delivery with regards to chronic pain, issues concerning chronic pain management, possibility of prescribing opioids, and estimation of the probability of psycho-social co-morbidities Findings: From a wide perspective there was low satisfaction among primary care providers in satisfaction of the treatment of chronic pain. For most of the attending physicians the training received in chronic pain treatment during their medical education and residency training was insufficient. For most of the care providers the major barriers to optimal pain treatment were patient self-management, patient, psychological factors, and patient compliance. There was a low rate of willingness to prescribe opioids, with the factor of the patients selling the opioids being the main barrier. Moe frequent visits raised the likelihood of willingness to prescribe opioids. Comments, Implications, Limitations: Primary care providers hold the view that the patients are the biggest barrier to optimal chronic care in primary care settings. Implications: The findings of the study suggest that education and training of primary care providers in chronic pain treatment should have a greater focus on patient oriented approaches in the management of chronic pain, and how to deal with substance abuse and addiction. Strengths: Survey questionnaire grounded in earlier studies, with assistance from a group consisting of primary care providers, researchers, and a pain specialist. Limitation: Small sample size limits the generalization of the findings of the study. Theme – 1: Lack of education of primary care providers about pain management. Unique Identifier: Sullivan 2 Authors: Sullivan, M. D., Edlund, M. J., Zhang, L., Unutzer, J. & Wells, K. B. Title: Association Between Mental Health Disorders, Problem Drug Use, and Regular Prescription Opioid Use. Journal Issue, Pages: Archives of Internal Medicine Vol. 166 Pages 2087-2093. Year published Years data collected: Published in 2006. 1998 and 2001. Purpose: To investigate whether mental disorders enhance the risk of opioid use or whether opioid enhances the risk for mental disorders from a large cross section of the population. Methodology, Variables Design, Sample, Instruments: Cross-sectional Qualitative study. Variables: Dependent Variables – Regular prescription opioid use. Independent Variables – Mental health and problem drug use. Sample: 6439 individuals matching the inclusion criteria from the 1998 and 2001 waves of the population-base survey Health-care for Communities (HCC). Instruments: Data from the 1998 and 2001 waves of the population-base survey Health-care for Communities (HCC). Findings: Patients on regular prescription opioids had the higher risk probability by two to three times to seek mental health assistance. Continued use of opioids by patients from 1998-2001 was associated with a higher risk for common mental disorders. Continued use of opioids was associated with opioid misuse. Comments, Implications, Limitations: This study is the first to elicit evidence of the association between common mental disorders and substance use disorders and continuous use of prescribed opioids from a large prospective population based data study. Implications: Greater attention has been given to the probability of substance abuse in patients prescribed opioids on a regular basis. Yet, the findings of this study indicate that the association between opioid use and common mental disorders may be of greater clinical significance. The greater emphasis on substance abuse than mental disorders in the use of opioids reflects lacunae in the knowledge of physicians. There is the need for the development of guidelines to incorporate the association of opioid use and common mental disorders to provide assistance for physicians and also incorporate the same during the imparting of knowledge and skills in the use of opioids. Strengths: Large sample size from a large prospective population base. Limitations: Self-reporting basis of data in the large prospective population study, poor response rate, and lack of information on why the opioids were prescribed. Theme – 1: Lack of education of primary care providers about pain management. Unique Identifier: Ahles 3 Authors: Ahles, T. A., Wasson, J. H., Seville, J. L., Johnson, D. J., Cole, B. F., Hanscom, B., Stukel, T. A. & McKinstry, E. Title: A Controlled Trial of Methods for Managing Pain in Primary Care Patients With or Without Co-occurring Psychosocial Problems. Journal Issue, Pages: Annals of Family Medicine Vol. 4 No. 4 Pages 341-350. Year published Years data collected: Published in 2006. Purpose: To ascertain the appropriate and effective pain management measures for primary care providers. Methodology, Variables Design, Sample, Instruments: Randomised Comparative Cohort study. Variables Design: Variables consisted of usual care group and interventions group. Interventions for the interventions group consisted of information in keeping with their problems and concerns (INFO), feedback of the problems and concerns to their physicians FEED), and nurse-educator (NE) counselling on problem solving strategies and basic pain management skills. Sample: Randomised 644 patients with diverse pain problems and psychosocial problems, 693 patients without psychosocial problems, and 47 physicians from 14 rural primary care centers. Instruments: Medical outcome studies 36-Item Short-Form and Functional Interference Estimate. Findings: Patients with pain and psychosocial problems demonstrated significant improvement in reduction of pain experienced enhanced physical ability, vitality and emotional functioning over six month and 12 month periods, when their information and counselling needs were met more effectively. Comments, Implications, Limitations: Training on cognitive-behavioral approaches to chronic pain management enhances the quality of pain management interventions by primary care providers. The nurse-educator approach provides a new interesting approach in pain management strategies. Implications: Education on obtaining tailored information from patients with chronic pain and feedback for physicians, along with nurse-educator intervention enhancing the effectiveness of pain management in primary needs to be done. Strengths: Control and randomization of samples and large sample size. Limitation: Samples belonged mostly to the white population in northern New England. Clinician’s response to INFOFEED was not ascertained, and data obtained was based on self-reporting. Theme –2: Opioids in management of chronic pain Unique Identifier: Bhamb 4 Authors: Bhamb, B., David, B., Hariharan, J., Anderson, J., Balousek, S. & Fleming, M. F. Title: Survey of select practice behaviours by primary care physicians on the use of opioids for chronic pain. Journal Issue, Pages: Current Medical Research Opinion Vol. 22 No.9 Pages 1859-1865. Year published Years data collected: Published in 2006. Years data collected 2004-2005. Purpose: To determine opioids use in the management of chronic pain by primary care physicians. Methodology, Variables Design, Sample, Instruments: Cross-sectional quantitative study. Design: Four-page cross-sectional written survey. Variables Design: Demographics, concerns on prescribing narcotics, and management of narcotics. Sample: 248 primary care physicians in six health care systems of University of Wisconsin Medical Foundation, the Medical College of Wisconsin, Aurora Health Care, Dean Health care, Group Health Cooperative of Wisconsin, and Mercy Health System. Instruments: Pilot tested and refined questionnaire with five primary questions. Findings: Most frequently employed narcotics in primary care for the treatment of pain consisted of codeine, hydrocodone, oxycodone, morphine continuous release, and oxycodone extended release. Urine toxicology screening was rarely used either prior to initiation of opioid treatment or after. The concerns of physicians in the use of opioids related primarily to abuse of opioids and addiction, with side effects, tolerance, interaction with other medications, and poor knowledge of how to use narcotics being the other areas of concern. Poor confidence of prescribing narcotics among primary care physicians, and physicians who had put in place a system to monitor patients demonstrated more probability of conducting screening tests. Comments, Implications, Limitations: High level of concern among primary physicians in prescribing opioids for the treatment of pain and low confidence in using opioids. Implications: Hesitance to use opioids among primary care physicians, lack of confidence to use opioids and the practice of seldom use of urine screening all reflect poor knowledge and skills in the use of opioids for the treatment of pain. Strengths: Pilot tested questionnaire. Limitations: Single geographic location and as with other surveys reliance on reported behavior rather than observed behavior, wherein responses are likely to be more in line with what the respondent believes is the desirable response instead a reflection of true opinion. Theme –2: Opioids in management of chronic pain Unique Identifier: Spitz 5 Authors: Spitz, A., Moore, A. A., Papaleontiou, M., Granien, E., Turner, B. J. & Reid, M. C. Title: Primary care providers’ perspective on prescribing opioids to older adults in chronic non-cancer pain: A qualitative study. Journal Issue, Pages: BMC Geriatrics Vol. 11 No. 35 Pages 1-9. Year published Years data collected: Published in 2011. Purpose: To ascertain barriers and facilitators in the perception of primary care providers in the use of opioids for managing pain among older adults. Methodology, Variables Design, Sample, Instruments: Quantitative study Design: Focus groups. Variables Design: Barriers to prescribing opioids and facilitators to prescribing opioids. Sample: 23 physicians and 3 nurse practitioners from primary care practices with academic affiliation (2) and three community centers within New York City. Instruments: Semi-structured discussion using open-ended questions and follow-up probes. Findings: Majority of the participants prescribed opioids in the treatment older patients with chronic, but hardly ever as the first line of treatment. Barriers to the use of opioids in the treatment of older patients with chronic pain included causing harm, the subjective nature of pain, deficient education, issues in converting opioids, and stigma. Fresh barriers that are emerging include reluctance of patients or their family members to try opioid treatment and concerns of opioid abuse by family members or care givers. Comments, Implications, Limitations: Finding of the issue of opioid abuse by family members and care givers as a barrier to opioid prescribing in primary care is a fresh observation on barriers to use of opioids in the treatment of chronic pain in primary care. Implications: Mandates and guidelines put in place for enhancing the effectiveness of treating chronic pain in older adults will only frustrate primary care providers, if the barriers that they experience in their use of opioids are not adequately addressed. Strengths: Focus groups based study. Limitations: Small sample size and single geographical site limits generalization of the findings of the study Theme –2: Opioids in management of chronic pain Unique Identifier: Hariharan 6 Authors: Hariharan, J., Lamb, C. & Neuner, J. M. Title: Long-Term Opioid Contract Use for Chronic Pain Management in Primary Care Practice: A Five Year Experience Journal Issue, Pages: Journal of General Internal Medicine Vol. 22 No. 4, Pages 485-490. Year published Years data collected: Published in 2007. January 1998 to December 2003. Purpose: To provide details of long-term outcomes for patients on opioid medications through a medication contract agreement in primary care environments. Methodology, Variables Design, Sample, Instruments: Retrospective cohort study. Variables Design: Independent variable - Long term outcomes and Dependent variable – Medication contract agreement. Sample: 330 patients that were on a contract for opioid medication between the time period of 1998 and 2003 at the General Internal Medicine Clinic at the Medical College of Wisconsin. Instruments: Demographics, diagnoses, opiates prescribed urine drug screens, and causes of contract cancellation from patient records. Findings: Patients placed on contract agreement constituted 4% of the patient population. During the period of the study 60% of the patients adhered to the contract. Cancellation of contracts due to physician initiatives was 17%, of which half the termination were due to toxicology screen reports and a quarter were owing to drug abuse. Voluntary cancellation of contract amounted to 20%, which was higher than physician initiated contract cancellations. Though many aspects of regarding the contract system seemed to have been successful, lacunae of monitoring of contract adherence was observed, as less than 45% of the patients on contract received UTS. Oxycodone and acetaminophen were the most commonly prescribed opioids. Comments, Implications, Limitations: This study is the first to evaluate long-term outcomes of a medication contract system in primary care settings. Implications: Opioid contract use in primary settings provides the benefits of structure, support, and monitoring for long-term chronic pain treatment in primary care environments. Further studies are required to determine the effective use of UTS for managing chronic pain, with the possibility of improved adherence monitoring providing the benefit of enhanced control over pharmacological and psychological toxicity. Strengths: Long-term outcome study. Limitations: Study conducted at a single site and so influence of local culture and trends could have affected the findings of the study. The decisions of opioids used, type of opioids use, and use of contract agreements were not under the control of the study. Theme –3: Predictors for opioid misuse or abuse. Unique Identifier: Edlund 7 Authors: Edlund, M. J., Sullivan, M., Steffick, D., Harris, K. M. & Wells, K. B. Title: Do Users of Regularly Prescribed Opioids Have Higher Rates of Substance Use Problems than Nonusers? Journal Issue, Pages: Pain Medicine Vol. 8 No. 8 Pages 647-656. Year published Years data collected: Published in 2007. Purpose: To ascertain whether use of prescription opioids for chronic noncancer pain generates higher rates of opioid misuse. Methodology, Variables Design, Sample, Instruments: Cross sectional study. Variables: Dependable Variables- any opioid misuse, problem opioid misuse, any non-opioid illicit drug use, non-opioid problem drug use, and problem alcohol use. Independent Variables – use of prescribed opioids and probable 12-month mental disorders, physical health, and other covariates. Sample: 9,279 respondents from a nationally representative survey. Instruments: Short Form Health Questionnaire. Findings: In unadjusted models there were significantly higher rates of any opioid misuse, problem opioid misuse, non-opioid illicit drug use, non-opioid problem drug use, and problem alcohol use with users of prescription opioids in comparison with non-users of prescription opioids. When adjusted models were used significantly higher rates of opioid misuse and problem opioid misuse was seen with users of prescription opioids in comparison with non-users of prescription opioids. There were no significantly higher rates in the case of the other outcomes. Comments, Implications, Limitations: There is clear indication that users of prescribed opioids have greater possibility of opioid and non-opioid abuse problems in comparison to non-users of prescribed opioids. However, these higher rates could seem to be partially mediated by depressive and anxiety disorders. Implications: Literature on users of prescribed opioids have tended to highlight the risk of opioid abuse or dependence and the requirement for balancing risk of opioid abuse and dependence with the provision of adequate and appropriate pain relief. This study introduces the new element of non-opioid drug abuse and the need for its evaluation in the clinical encounter with patients. In addition, this study points to the need in the clinical environment to be alert for the possibility of mental health disorders, as treatable mental health disorders may partially mediate the interaction between prescribed opioid drug use and drug problems. Strengths: Large sample size and nationally representative sample mix. Limitations: Cross sectional data is not useful in identify issues of causality. There are no details on why opioids were prescribed. Self-reporting may lead to recall bias resulting in the findings underestimating the true rates. Theme –3: Predictors for opioid misuse or abuse. Unique Identifier: Boscarino 8 Authors: Boscarino, J. A., Rukstalis, M., Hoffman, S. N., Han, J. J., Erlich, P. M., Gerhard, G. S. & Walter, F. S. Title: Risk factors for drug dependence among out-patients an opioid therapy in a large US health-care system. Journal Issue, Pages: Addiction Vol. 105, Pages 1776 -1782 Year published Years data collected: Published in 2010. Purpose: To determine the risk factors of opioids dependence and its prevalence among out-patients put on long-term opioid medications. Methodology, Variables Design, Sample, Instruments: Quantitative study using telephone interviews for data collection. Variables Design: Long-term opioid treatment and risk factors of opioids dependence. Sample: 705 opioid prescription patients from a randomly selected pool of 2459. Instruments: Structured diagnostic telephone interviews Findings: 36% of the participants met the criteria for life-time opioid dependence, while 26% met the criteria for current dependence. The highest risk factor for opioid dependence for both lifetime dependence and current dependence was having a history of opioid abuse. Other risk factors found to be associated with opioid dependence were younger are, level of pain discomfort, higher severity of drug dependence, more frequent opioid orders in EHR, and a history related to anti-social behavior. Comments, Implications, Limitations: Combination of risk factors enhances the risk for current addiction. Limitations of the study are that the diagnostic data received was based on self-reporting by patients; survey completion was less than optimal, introducing the possibility of bias; and participants mostly taken from the Caucasian race, reducing the possibility of generalization of the findings to all races. Strengths: Random selection of sample pool, assessment of drug dependence was the basis of DSM-IV, and identification of subjects on the basis of drug orders in EHR and not relying on patient self-reporting or treatment records. Implications: Physicians prescribing opioids in the treatment of chronic pain will find it useful to conduct a screening based on the information of mental history of the patient, current use of psychotropic medication, and pain status prior to prescribing opioids to mitigate the risks for lifetime dependence and current dependence of opioids. Additional studies are required to confirm and expand on the findings of this study. Theme –3: Predictors for opioid misuse or abuse. Unique Identifier: Becker 9 Authors: Becker, W. C., Starrels, J. L., Heo, M., Li, X., Weiner, M. G. & Turner, B. J. Title: Racial Differences in Primary Care Opioid Risk Reduction Strategies. Journal Issue, Pages: Annals of Family Medicine Vol. 9 Pages 219-225 Year published Years data collected: Published in 2011. Purpose: To determine the presence of racial bias in the employment of opioid misuse risk reduction strategies. Methodology, Variables Design, Sample, Instruments: Observational study. Variable Design: Independent variable – race Dependent variable – Risk reduction strategies. Sample: 1,612 patients with chronic noncancer pain on opioid analgesics of which 62.1% were from the black population and the rest from the white population. Instruments: Dependent variables – Three opioid risk reduction strategies of urine drug testing, regular office visits, and restricted early refills. Independent variables – The other most important independent variable was self-identified race categorising into black or white. Other independent variables included the demographic variables of age, sex, and median household income, derived from patient zip code based census data. Findings: Each of the opioid risk reduction strategies were significantly more likely to be applied to black patients than white patients. Females living in neighborhoods of low income zip code were more likely to be present among the black patients than among the white patients. Prevalence of risk factors of misuse of tobacco use and substance use were more likely to be present in black patients, but were not likely to be diagnosed with mental disorders. Painful conditions like osteoarthritis and lumbago were more prevalent in blacks and whites and so too were the case with co-morbidities. Comments, Implications, Limitations: Inability to demonstrate causality. Likely bias by clinicians who were more likely to code substance use disorder for blacks than whites is present. In spite of relatively large cohort, low prevalence of urine testing limited the ability to uncover significant association. Cohort from single urban university-affiliated health restricting extension to more generalized settings. Evaluation of dose of opioids used in patients was not done. Implications: A universal precaution approach is the advocated in the use of opioids in pain management. The findings of this study demonstrate that this is not the case in real treatment situations. This evidence should give cause for initiatives in the clinical and educational environments to make sure that every patient is monitored appropriately without any bias due to race or ethnicity. Further studies are required to determine a systematic approach for enhancing the rates of monitoring. Strengths: Relatively large cohort. Control of potential confounding variables like diagnosed substance abuse and mental health disorders was maintained. Limitations: Observational study limits demonstration of causality, low prevalence of urine testing, sample from a single health care environment, and dosage of opioids not evaluated. Theme –4: Monitoring, Documentation and Support. Unique Identifier: Krebs 10 Authors: Krebs, E. E., Ramsey, D. C., Mioshoff, J. M. & Bair, M. J. Title: Primary Care Monitoring of Long-Term Opioid Therapy among Veterans with Chronic Pain. Journal Issue, Pages: Pain Medicine Vol. 12 No. 5, Pages 740-746. Year published Years data collected: Published in 2011. 2006-2007 Purpose: To determine in primary care environments the long-term opioid prescribing and monitoring practices. Methodology, Variables Design, Sample, Instruments: Retrospective medical record review. Variables Design: Opioid monitoring practices and risk factors for opioid misuse. Sample: 155 adult patients from primary clinics attached to Veteran Affairs medical center, who received prescriptions for opioids. Instruments: Patient medical records, indicators for potential abuse of opioids, and documentation pertaining to guidelines for opioid monitoring processes. Findings: 57% of the patients received prescriptions for long-acting opioids. 72% of the patients received prescriptions for short-acting opioids. Potential for opioid misuse was entered into the medical records of 33% of the patients. Reassessment for pain was the most used documentation process, while documentation of an opioid treatment agreement was the least employed documentation process. Potential for opioid misuse was linked with the deficiency in documented guideline-recommended processes. Comments, Implications, Limitations: Implications: Guideline-recommended opioid management practices were quite often not documented, leading to poor monitoring of patients on opioid treatment for chronic pain. However, there was better documentation initiative for patients with potential for opioid misuse. More studies are required to ascertain optimal means of monitoring treatment of chronic pain with opioids. Strengths: Data collected from actual patient records. Limitations: Study did not go into whether there was any association between guideline-concordant opioid management and patient care of high quality, and so the findings of the study have no bearing on this important aspect of opioid management practices in primary care. Theme –4: Monitoring, Documentation and Support. Unique Identifier: Wilsey 11 Authors: Wilsey, B. L., Fishman, S. M., Casamalhuapa, C & Gupta, A. Title: Documenting and Improving Opioid Treatment: The Prescription Opioid Documentation and Surveillance (PODS) System Journal Issue, Pages: Pain Medicine Vol. 10 No. 5 Pages 866-877. Year published Years data collected: Published in 2009. May 2005 to September 2008. Purpose: To show that evaluation of patients before starting opioid treatment can be effectively done with the assistance of computer assisted survey instruments. Methodology, Variables Design, Sample, Instruments: Comparative. Variable: Dependent variable - Prescription Opioid Documentation and Surveillance (PODS) System. Independent variable - pen and paper documentation and surveillance system. Sample: 1,400 patients at the Veterans Administration Pain Clinic. Instruments: Pain intensity, function, mental health status, addiction history and potential for prescription opioid misuse indices were developed for immediate addition to the medical record of the patient. Findings: Computer aided survey instruments have the capacity for gathering vital clinical information in an efficient, timely and cost-effective manner to evaluate patients prior to initiation of opioid treatment. Comments, Implications, Limitations: Implications: Computer aided survey instrument demonstrate the potential to access evaluation data of patients with regard to pain treatment in a uniform and timely manner to assist in effective decision making of the appropriate pain treatment. The PODS system suggests that a personal history of drug and alcohol abuse stand out among the factors that predict opioid abuse. Computer aided survey systems may reduce the barriers to initiating appropriate analgesic therapies, but this will have to be confirmed by future studies. In addition further studies will have to be conducted to confirm whether such computer aided survey instruments really add to effective pain management through more efficient decision making. Strengths: Large sample size and long duration of study. Limitations: Single site, and sampling characterized by veteran population limits generalization of the findings of the study. Lack of any evaluation on the impact of computer aided survey systems on the efficacy of decision making. Theme –4: Monitoring, Documentation and Support. Unique Identifier: Mangione 12 Authors: Mangione, M. P. & Crowley-Matoka, M. Title: Improving Pain Management Communication: How Patients Understand the Terms “Opioid” and “Narcotic”. Journal Issue, Pages: Journal of General Internal Medicine Vol. 23 No.9 Pages 1336-1338. Year published Years data collected: Published in 2008. Purpose: The use of the terms “narcotic” and “opioid” in pain management communication has become an area of debate, and this study aims to contribute empirical data to this debate. Methodology, Variables Design, Sample, Instruments: Quantitative study using brief anonymous surveys. Variables Design: The terms “narcotic” and “opioid”. Sample: 100 outpatients. Instruments: Two similar close-ended questionnaires written at eighth grade level one containing the term “narcotic and the other containing the term “opioid”. Findings: 86% of the participating outpatients were not familiar with the term “opioid”, while 88% of the participants were familiar with the term narcotic (p Read More