Pain Management

41. Overdose Risk Based on Prescription Type

"Dunn et al4 found that risk of drug-related adverse events among individuals treated for chronic noncancer pain with opioids was increased at opioid doses equivalent to 50 mg/d or more of morphine. Our analyses similarly found that the risk of opioid overdose increased when opioid dose was equivalent to 50 mg/d or more of morphine.
"The present study also extended prior research in several important ways. We used a large, national sample of individuals and focused exclusively on opioid overdose deaths. Because the circumstances that lead to overdose death may vary by the condition for which the opioid is prescribed and substance use disorder status, we conducted analyses for subgroups of patients, including those with cancer, acute pain, and substance use disorders.
"The present study also extended the prior research by exploring a novel risk factor, ie, concurrent prescriptions of regularly scheduled and as-needed opioids. We found that those patients who were simultaneously treated with as-needed and regularly scheduled opioids, a strategy for treating pain exacerbations,7,8 did not have a statistically significant increased risk of opioid overdose in adjusted models. Recent treatment guidelines have indicated that the long-term safety of this strategy for pain exacerbation has not been established,5,9 and in the present study we did not find evidence of greater overdose risk associated with this treatment practice after accounting for maximum daily dose and patient characteristics."

Bohnert, Amy S.B., et al., "Association Between Opioid Prescribing Patterns and Opioid Overdose-Related Deaths," Journal of the American Medical Association, April 6, 2011, Vol 305, No. 13, pp. 1319-1320.
http://jama.jamanetwork.com/ar...

42. Undertreatment of Pain Among Those With Chemical Dependency

"The undertreatment of pain is a significant concern in populations with chemical dependency. In painful disorders for which there is a broad consensus about the role of opioid therapy, specifically cancer and AIDS-related pain, studies have documented that this treatment commonly diverges from accepted guidelines. Undertreatment is far more challenging to assess when a broad consensus concerning optimal treatment approaches does not exist. It would be difficult, therefore, to determine the extent to which the pain and functional impairments experienced by patients in this study relate to inadequate pain management. However, given the number of barriers identified as potential reasons for inadequate pain management, it is appropriate to raise concerns about undertreatment and to investigate it further."

Rosenblum, Andrew, PhD, Herman Joseph, PhD, Chunki Fong, MS, Steven Kipnis, MD, Charles Cleland, PhD, Russell K. Portenoy, MD, "Prevalence and Characteristics of Chronic Pain Among Chemically Dependent Patients in Methadone Maintenance and Residential Treatment Facilities," Journal of the American Medical Association (Chicago, IL: American Medical Association, May 14, 2003), Vol. 289, No. 18, p. 2377.
http://jama.jamanetwork.com/ar...

43. Undertreatment of Pain Among the Elderly

"Factors affecting the severity of pain in the elderly include
"• complex manifestations of pain;
"• underreporting of pain;
"• concurrent problems and multiple diseases (comorbidities), which complicate diagnosis and treatment;
"• higher rates of medication side effects; and
"• higher rates of treatment complications (American Geriatrics Society, 2009).
"In general, these same factors also contribute to the documented undertreatment of pain in the elderly, along with the lack of an evidence base concerning the pharmacokinetic and pharmacodynamic changes that occur with aging (Barber and Gibson, 2009). Similar to the situation with children in the past, elderly people rarely are included in clinical trials of medications, so clinicians have inadequate information about appropriate dosages and potential interactions with medications being taken for other chronic diseases (Barber and Gibson, 2009).
"A study of more than 13,000 people with cancer aged 65 and older discharged from the hospital to nursing homes found that, among the 4,000 who were in daily pain, those aged 85 and older were more than 1.5 times as likely to receive no analgesia than those aged 65-74; only 13 percent of those aged 85 and older received opioid medications, compared with 38 percent of those aged 65-74 (Bernabei et al., 1998). (A similar excess risk of receiving no analgesia was found among African Americans, Hispanics, and Asians compared with whites.)"

Institute of Medicine, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" (Washington, DC: National Academy of Sciences, 2011), pp. 79-80.
http://www.nap.edu/openbook.ph...

44. Barriers to Availability of Legal Opioid Analgesics in the US

"The most common reason cited as a barrier to opioid availability was low demand (93.1%). However, this did not vary by opioid analgesic sufficiency, pharmacy racial composition, pharmacy type, level of zip code urbanization, level of opioid analgesic supply, median age, household income, or proportion of residents ?65 years old. The fear that patients might use opioid analgesics for illicit purposes was the second most prevalent barrier identified (8.5%). Concern with illicit opioid analgesic use was more likely to be reported as a barrier by pharmacies with insufficient opioid analgesic supplies when compared with those with sufficient supplies (30.3% vs 4.3%; P ? .01). Again, this did not vary by pharmacy racial composition, pharmacy type, level of zip code urbanization, median age, household income, or proportion of residents ?65 years old. Too much paperwork (1%) and fear of robbery (1%) were rarely identified as potential reasons for opioid analgesic unavailability. Measures of association between covariates and barriers were not computed for the least common barriers (ie, too much paperwork, fear of robbery, and drug disposal regulations) because of empty cells. Other responses cited for failing to supply opioid analgesics (eg, pharmacy was located in a small community, pharmacy was near a major medical center, and community residents do not have adequate health insurance coverage) were of low frequency and were not analyzed further."

Carmen R. Green, S. Khady Ndao-Brumblay, Brady West, and Tamika Washington, "Differences in Prescription Opioid Analgesic Availability: Comparing Minority and White Pharmacies Across Michigan," The Journal of Pain - October 2005 (Vol. 6, Issue 10, Pages 689-699, DOI: 10.1016/j.jpain.2005.06.002), p. 694.
Abstract: http://www.ncbi.nlm.nih.gov/pu...

45. Racial and Socioeconomic Disparities in Availability of Opioid Analgesic Availability

"Disparities in pain assessment and treatment on the basis of race and ethnicity are well documented.29 Diminished ability to obtain access to opioid analgesics in local pharmacies is a significant barrier to quality pain care. The present investigation provides evidence that Michigan pharmacies in predominantly minority areas were significantly less likely to have sufficient prescription opioid analgesic supplies when compared with predominantly white areas. Regardless of median income and median age, significant differences were found in opioid analgesic availability on the basis of ethnic composition. These results support the findings of Morrison et al38 that pharmacies in predominantly minority neighborhoods stock insufficient opioid analgesic supplies more so than those in predominantly white neighborhoods. However, these results also extend their findings by demonstrating the role of both social class and income on opioid analgesic availability. More specifically, the odds for not having sufficient opioid analgesic supplies are significantly higher among pharmacies in low income areas when compared with higher income areas, regardless of race. More importantly, we identified that the odds of having insufficient supplies in minority neighborhoods changed significantly on the basis of income (ie, high or low) (OR, 13.36 vs 54.42). Thus, social class and poverty seem to play a role for whites more so than minorities. Noncorporate pharmacies were also more likely to have sufficient opioid analgesic supplies than corporate pharmacies. These results suggest that if an opioid analgesic is prescribed for pain management, persons living in minority zip codes (even in higher income areas) or those living in low income zip codes (regardless of minority status) face additional barriers to quality pain care. Thus, vulnerable populations (eg, minorities and low income individuals) are at increased risk for inefficient and lesser quality pain care."

Carmen R. Green, S. Khady Ndao-Brumblay, Brady West, and Tamika Washington, "Differences in Prescription Opioid Analgesic Availability: Comparing Minority and White Pharmacies Across Michigan," The Journal of Pain - October 2005 (Vol. 6, Issue 10, Pages 689-699, DOI: 10.1016/j.jpain.2005.06.002), p. 695.
Abstract: http://www.ncbi.nlm.nih.gov/pu...
http://www.jpain.org/article/S...

46. Global Lack of Pain Relief

"Current estimates suggest that upward of 80% of the world’s population lacks access to basic pain relief [6]. Paradoxically, those 80% are mostly in poorer countries, and their need for pain relief is heightened by a relative absence of curative care such as surgery, or treatment for both communicable and non-communicable diseases causing pain (e.g., HIV/AIDS, cancer)[7]."

Nickerson, Jason W., and Attaran, Amir, "The Inadequate Treatment of Pain: Collateral Damage from the War on Drugs," PLoS Medicine (Cambridge, United Kingdom: Public Library of Science, Jan. 2012) Vol. 9, Issue 1, p. 1.
http://www.plosmedicine.org/ar...

47. Global Medical Opiate Shortage

"We determined per capita need of strong opioids for pain related to three important pain causes for 188 countries. These needs were extrapolated to the needs for all the various types of pain by using an adequacy level derived from the top 20 countries in the Human Development Index. By comparing with the actual consumption levels for relevant strong opioid analgesics, we were able to estimate the level of adequacy of opioid consumption for each country. Good access to pain management is rather the exception than the rule: 5.5 billion people (83% of the world’s population) live in countries with low to nonexistent access, 250 million (4%) have moderate access, and only 460 million people (7%) have adequate access. Insufficient data are available for 430 million (7%). The consumption of opioid analgesics is inadequate to provide sufficient pain relief around the world. Only the populations of some industrialized countries have good access."

Marie-Josephine Seya, Susanne F. A. M. Gelders, Obianuju Uzoma Achara, Barbara Milani, and Willem Karel Scholten, "A First Comparison Between the Consumption of and the Need for Opioid Analgesics at Country, Regional, and Global Levels," Journal of Pain & Palliative Care Pharmacotherapy. 2011;25:6–18. ISSN: 1536-0288 print / 1536-0539 online. DOI: 10.3109/15360288.2010.536307
http://apps.who.int/medicinedo...

48. Global Lack of Access to Pain Medication

"Opioid medications are essential not only for drug dependence treatment but also for pain management. WHO estimates that 5 billion people live in countries with little or no access to controlled medicines that are used to treat moderate to severe pain.90 Up to 80% of the estimated 1 million patients in the end stages of AIDS are in great pain, but very few have access to pain relieving drugs91 because of insufficient knowledge among physicians, inadequate health systems, fears of addiction, antiquated laws, and unduly strict regulations.92"

Jürgens, Ralf; Csete, Joanne; Amon, Joseph J.; Baral, Stefan; and Beyrer, Chris, "People who use drugs, HIV, and human rights," The Lancet (London, United Kingdom: August 7, 2010) Vol. 376, Issue 9739, pp. 478-479.
http://www.thelancet.com/journ...

49. Psychosocial Interventions and Chronic Pain Outcomes in Older Adults

"Mean treatment results demonstrated in the present study obscure variations at the individual patient level. Some older patients with chronic pain may receive substantial benefit through psychological therapy, while others may not benefit. There is no evidence that the beneficial results identified at the completion of treatment persisted up to 6 months for outcomes other than pain reduction. There were too few studies reporting long-term outcomes to determine completely whether this finding was due to decreased power or to a tapering of treatment benefits over time.

"The observed benefits were strongest when delivered using group-based approaches. Potential mechanisms that could account for this finding include access to peer support, social facilitation of target behaviors, and public commitment to therapy goals.52 No other results of participant, intervention, or study characteristics were found. Treatment benefits were equally likely to occur in older men and women irrespective of age and duration of chronic pain."

Niknejad B, Bolier R, Henderson CR, et al. Association Between Psychological Interventions and Chronic Pain Outcomes in Older AdultsA Systematic Review and Meta-analysis. JAMA Intern Med. Published online May 07, 2018. doi:10.1001/jamainternmed.2018.0756
https://jamanetwork.com/journa...

50. Unrelieved Pain Continues To Burden Americans

"Pain remains one of the most common physical complaints upon a person’s admission into the healthcare system (Burton, Fanciullo, Beasley, & Fisch, 2007; Foley et al., 2005; Freburger et al., 2009; McCarberg, 2010; Peterlin, Rosso, Rapoport, & Scher, 2009; Schug & Chong, 2009; Weiss, Emanuel, Fairclough, & Emanuel, 2001). Pain is prevalent in cancer, especially near the end of life (Paice, 2010; Smith et al., 2010), and in other diseases and conditions such as HIV/AIDS (Breitbart & Cortes?Ladino, 2010; Tsao, Stein, & Dobalian, 2010) and sickle?cell anemia (American Pain Society, 1999; Ballas, 2010); indeed, persistent pain itself is increasingly being recognized as a disease (Institute of Medicine Committee on Advancing Pain Research, 2011). However, insufficient treatment attention often is given to appropriate pain relief, especially when pain is severe or prolonged. In extreme circumstances, pain can impair all aspects of life and sometimes contribute to a person’s wish for death (Fishman & Rathmell, 2010; Ilgen et al., 2013; Institute of Medicine Committee on Advancing Pain Research, 2011; Institute of Medicine National Cancer Policy Board, 2001; Wasan, Sullivan, & Clark, 2010). When pain relief is achieved, it can result in improved quality of living for people with prolonged pain and can decrease suffering for people at the end of life (Higginson & Evans, 2010)."

Pain & Policy Studies Group. Achieving Balance in Federal and State Pain Policy: A Guide to Evaluation (CY 2013). (University of Wisconsin Carbone Cancer Center: Madison, WI, July 2014), p. 13.
http://www.painpolicy.wisc.edu...
http://www.painpolicy.wisc.edu...

51. Prevalence of Chronic Pain

According to a survey conducted by Roper Starch Worldwide for the American Pain Society in 1999, "Chronic pain as defined by this study is a severe and ever present problem. It can be as much of a problem to middle age adults as seniors and is one women are more likely to face than men. The majority of chronic pain sufferers have been living with their pain for over 5 years. Although the more common type is pain that flares up frequently versus being constant, it is still present on average almost 6 days in a typical week.
"About one third of all chronic sufferers describe their pain as being almost the worst pain one can possibly imagine. Their pain is more likely to be constant than flaring up frequently and two-thirds of them have been living with it for over 5 years."

Roper Starch Worldwide, Inc., "Chronic Pain In America: Roadblocks To Relief," research conducted for the American Pain Society, the American Academy of Pain Medicine and Janssen Pharmaceutica, Jan. 1999.

52. Pain Management - Data - 1999 - 2-20-10

According to a public opinion poll released in 1999, "It is estimated that 9% of the U.S. adult population suffer from moderate to severe non-cancer related chronic pain."

Roper Starch Worldwide, Inc., "Chronic Pain In America: Roadblocks To Relief," research conducted for the American Pain Society, the American Academy of Pain Medicine and Janssen Pharmaceutica, Jan. 1999.

53. Reasons for Non-Prescription Use of Prescription Opioids by US High School Seniors

"Approximately 12.3% of the respondents -- high school seniors in the United States -- reported lifetime nonmedical use of prescription opioids and 8.0% reported past-year nonmedical use. Table 1 shows the prevalence of motives for nonmedical use of prescription opioids among high school seniors in the United States. The leading motives included 'to relax or relieve tension' (56.4%), 'to feel good or get high' (53.5%), 'to experiment-see what it's like' (52.4%), 'to relieve physical pain' (44.8%), and 'to have a good time with friends' (29.5%).

Sean Esteban McCabe, Phd, et al., "Motives for Nonmedical Use of Prescription Opioids among High School Seniors in the United States: Self-Treatment and Beyond," Archives of Pediatric and Adolescent Medicine, 2009 August; 163(8): 739-744. doi:10.1001/archpediatrics.2009.120.
http://www.ncbi.nlm.nih.gov/pu...
http://www.ncbi.nlm.nih.gov/pm...

54. Pain Relief and Non-Prescription Use of Prescription Opioids by US High School Seniors

"The lifetime medical use of prescription opioids was reported by approximately 14.0% of those who did not engage in past-year nonmedical use of prescription opioids, 76.1% of nonmedical users of prescription opioids motivated only by pain relief, 71.4% of those motivated by pain relief and other motives, and 46.7% of those who reported non-pain relief motives only (p < 0.001). Among past-year nonmedical users of prescription opioids, approximately 56.5% of those motivated only by pain relief as compared to 23.1% of those who reported pain relief and other motives, and 14.2% of those who reported only non-pain relief motives had initiated medical use of prescription opioids before nonmedical use of prescription opioids. In contrast, approximately 19.6% of those motivated only by pain relief as compared to 48.3% of those who reported pain relief and other motives, and 32.5% of those who reported only non-pain relief motives initiated nonmedical use of prescription opioids before medical use of prescription opioids."

Sean Esteban McCabe, Phd, et al., "Motives for Nonmedical Use of Prescription Opioids among High School Seniors in the United States: Self-Treatment and Beyond," Archives of Pediatric and Adolescent Medicine, 2009 August; 163(8): 739-744. doi:10.1001/archpediatrics.2009.120.
http://www.ncbi.nlm.nih.gov/pu...
http://www.ncbi.nlm.nih.gov/pm...

55. Prescribing Patterns and Opioid Overdose-Related Deaths

"There is some evidence that higher prescribed doses increase the risk of drug overdose among individuals treated with opioids for chronic non-cancer pain.4 Specifically, the risk of drug-related adverse events is higher among individuals prescribed opioids at doses equal to 50 mg/d or more of morphine. The association of opioid prescribing patterns with risk of over-dose may vary across groups of patients; opioid treatment recommendations for pain are typically specific to particular subgroups such as those with chronic noncancer pain,5 cancer-related pain, and substance use disorders.6 However, potential subgroup differences in opioid prescribing have not been examined."

Bohnert, Amy S.B., et al., "Association Between Opioid Prescribing Patterns and Opioid Overdose-Related Deaths," Journal of the American Medical Association, April 6, 2011, Vol 305, No. 13, p. 1315.
http://jama.jamanetwork.com/ar...

56. Estimated Prevalence of Non-Medical Use of Pain Relievers in the US, 2014

"Overall estimates of current nonmedical use of prescription psychotherapeutic drugs among the population aged 12 or older that were described previously have largely been driven by the nonmedical use of prescription pain relievers. In 2014, about two thirds of the current nonmedical users of psychotherapeutic drugs who were aged 12 or older reported current nonmedical use of pain relievers (Figure 5).
"The estimated 4.3 million people aged 12 or older in 2014 who were current nonmedical users of pain relievers represent 1.6 percent of the population aged 12 or older (Figures 5 and 6). The percentage of people aged 12 or older who were current nonmedical users of pain relievers in 2014 was lower than the percentages in most years from 2002 to 2012, but it was similar to the percentage in 2013."

Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50), p. 7.
http://www.samhsa.gov/data/sit...
http://www.samhsa.gov/data/sit...

57. Source of Pain Relievers Used Non-Medically

"Among persons aged 12 or older in 2010-2011 who used pain relievers nonmedically in the past year, 54.2 percent got the pain relievers they most recently used from a friend or relative for free (Figure 2.14). Another 12.2 percent bought them from a friend of relative (which was higher than the 9.9 percent in 2008-2009). In addition, 4.4 percent of these nonmedical users in 2010-2011 took pain relievers from a friend or relative without asking. More than one in six (18.1 percent) indicated that they got the drugs they most recently used through a prescription from one doctor. Less than 1 in 20 users (3.9 percent) got pain relievers from a drug dealer or other stranger, 1.9 percent got pain relievers from more than one doctor, and 0.3 percent bought them on the Internet. These other percentages were similar to those reported in 2008-2009."

Substance Abuse and Mental Health Services Administration, Results from the 2011 National
Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012, p. 28.
http://www.samhsa.gov/data/NSD...

58. Source For Pain Relievers Used Non-Medically Which Were Obtained From A Friend Or Relative For Free

"Among persons aged 12 or older in 2010-2011 who used pain relievers nonmedically in the past year and indicated that they most recently obtained the drugs from a friend or relative for free in the past year, 81.6 percent of the friends or relatives obtained the drugs from just one doctor (Figure 2.14). About 1 in 20 of these past year nonmedical users of pain relievers (5.5 percent) reported that the friend or relative got the pain relievers from another friend or relative for free, 3.9 percent reported that the friend or relative bought the drugs from a friend or relative, 1.9 percent reported that the friend or relative bought the drugs from a drug dealer or other stranger, and 1.8 percent reported that the friend or relative took the drugs from another friend or relative without asking."

Substance Abuse and Mental Health Services Administration, Results from the 2011 National
Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012, p. 28.
http://www.samhsa.gov/data/NSD...

59. Pain Treatment and Opioid Abuse

"Conventional wisdom suggests that the abuse potential of opioid analgesics is such that increases in medical use of these drugs will lead inevitably to increases in their abuse. The data from this study with respect to the opioids in the class of morphine provide no support for this hypothesis. The present trend of increasing medical use of opioid analgesics to treat pain does not appear to be contributing to increases in the health consequences of opioid analgesic abuse."

Joranson, David E., MSSW, Karen M. Ryan, MA, Aaron M. Gilson, PhD, June L. Dahl, PhD, "Trends in Medical Use and Abuse of Opioid Analgesics," Journal of the American Medical Association, Vol. 283, No. 13, April 5, 2000, p. 1713.
http://jama.jamanetwork.com/ar...

60. Prescription Opioid Overdose

"Among patients who are prescribed opioids, an estimated 80% are prescribed low doses (<100 mg morphine equivalent dose per day) by a single practitioner (7,8), and these patients account for an estimated 20% of all prescription drug overdoses (Figure 3). Another 10% of patients are prescribed high doses (?100 mg morphine equivalent dose per day) of opioids by single prescribers and account for an estimated 40% of prescription opioid overdoses (9,10). The remaining 10% of patients are of greatest concern. These are patients who seek care from multiple doctors and are prescribed high daily doses, and account for another 40% of opioid overdoses (11). Persons in this third group not only are at high risk for overdose themselves but are likely diverting or providing drugs to others who are using them without prescriptions. In fact, 76% of nonmedical users report getting drugs that had been prescribed to someone else, and only 20% report that they acquired the drug from their own doctor (4). Furthermore, among persons who died of opioid overdoses, a significant proportion did not have a prescription in their records for the opioid that killed them; in West Virginia, Utah, and Ohio, 25%–66% of those who died of pharmaceutical overdoses used opioids originally prescribed to someone else (11–13). These data suggest that prevention of opioid overdose deaths should focus on strategies that target 1) high-dosage medical users and 2) persons who seek care from multiple doctors, receive high doses, and likely are involved in drug diversion."

"CDC Grand Rounds: Prescription Drug Overdoses — a U.S. Epidemic" Morbidity and Mortality Weekly Report (Atlanta, GA: Centers for Disease Control and Prevention, January 13, 2012) Vol. 61, No. 1, p. 10.
http://www.cdc.gov/mmwr/pdf/wk...

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