Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on sleep in brain health

LIVE: Thursday 2nd May 2024, 18:00-19:30 (CEST)

Quality sleep is essential for health. But what happens to our brains when sleep patterns are disturbed? Join our experts to explore the interplay between sleep disruption and neurological diseases, and the questions that you need to be asking your patients to help you prevent the harmful effects of sleep deprivation.
ADVANCED SEARCH
Log in
Top
Addiction Science & Clinical Practice
Published in: Addiction Science & Clinical Practice 1/2016

Open Access 01-12-2016 | Case study

Management of patients with issues related to opioid safety, efficacy and/or misuse: a case series from an integrated, interdisciplinary clinic

Authors: William C. Becker, Jessica S. Merlin, Ajay Manhapra, Ellen L. Edens

Published in: Addiction Science & Clinical Practice | Issue 1/2016

Login to get access

Abstract

Background

Patients, providers, communities and health systems have struggled to achieve balance between access to opioid treatment for chronic pain and its potential harmful consequences: especially misuse, addiction and overdose. We developed an interdisciplinary clinic embedded within primary care (the Opioid Reassessment Clinic—ORC) with the goal of improving the quality of care of patients with co-occurring chronic pain and issues related to opioid safety, efficacy and/or misuse.

Case descriptions

We present three cases referred to the ORC that highlight complex clinical scenarios related to assessment and treatment of patients with chronic pain and issues related to opioid safety, efficacy and misuse.

Discussion and evaluation

In the context of the three cases, with respect to assessment, we discuss: making the diagnosis of opioid use disorder; allowing the patient space to endorse lack of efficacy; identification of co-occurring hazardous alcohol use; and recognizing barriers to multimodal pain care. With respect to treatment, we discuss: making a change in treatment with which the patient may not agree; effectiveness of buprenorphine/naloxone for the treatment of chronic pain; responding to low efficacy; and making continued opioid therapy contingent on engagement with substance abuse treatment.

Conclusions

The core components of our approach—biopsychosocial assessment and multimodal treatment planning with an emphasis on promoting functional goals and safety using clear communication and a patient-centered stance—should guide providers in the management of similar clinical scenarios. More evidence is needed to definitively guide specific interventions and points of clinical equipoise.
Literature
1.
Centers for Disease Control and Prevention. Policy impact: prescription painkiller overdoses. Atlanta: Centers for Disease Control and Prevention; 2011.
2.
3.
The Management for Opioid Therapy for Chronic Pain Working Group. VA/DoD clinical practice guideline for management of opioid therapy for chronic pain, vol. 2. 2nd ed. Washington: Department of Veterans Affairs and Department of Defense, Office of Quality and Performance; 2010.
4.
Krebs EE, et al. Barriers to guideline-concordant opioid management in primary care—a qualitative study. J Pain. 2014;15(11):1148–55.PubMedCrossRef
5.
6.
Starrels JL, et al. Low use of opioid risk reduction strategies in primary care even for high risk patients with chronic pain. J Gen Intern Med. 2011;26(9):958–64.
7.
Dorflinger LM, et al. Integrating interdisciplinary pain management into primary care: development and implementation of a Novel Clinical Program. Pain Med. 2014;15(12):2046–54.PubMedCrossRef
8.
9.
Committee on Advancing Pain Research Care and Institute of Medicine. Relieving pain in America: A blueprint for transforming prevention, care, education, and research. Washington: National Academies Press; 2011.
10.
Kahan M, et al. Canadian guideline for safe and effective use of opioids for chronic noncancer pain Clinical summary for family physicians. Part 2: special populations. Can Fam Phys. 2011;57(11):1269–76.
11.
12.
Savage SR, et al. Definitions related to the medical use of opioids: evolution towards universal agreement [see comment]. J Pain Symptom Manag. 2003;26(1):655–67.CrossRef
13.
Compton WM, Volkow ND. Abuse of prescription drugs and the risk of addiction. Drug Alcohol Depend. 2006;83(Suppl 1):S4–7.PubMedCrossRef
14.
Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Intern Med. 2006;144(2):127–34.PubMedPubMedCentralCrossRef
15.
Upshur CC, Bacigalupe G, Luckmann R. “They don’t want anything to do with you”: patient views of primary care management of chronic pain. Pain Med. 2010;11(12):1791–8.PubMedCrossRef
16.
Federation of State Medical Boards. Model policy on the use of opioid analgesics in the treatment of chronic Pain. Euless: Federation of State Medical Boards; 2013.
17.
Nicolaidis C. Police officer, deal-maker, or health care provider? Moving to a patient-centered framework for chronic opioid management. Pain Med. 2011;12(6):890–7.PubMedCrossRef
18.
Schieffer BM, et al. Pain medication beliefs and medication misuse in chronic pain. J Pain. 2005;6(9):620–9.PubMedCrossRef
19.
Lembke A. Why doctors prescribe opioids to known opioid abusers. N Engl J Med. 2012;367(17):1580–1.PubMedCrossRef
20.
Becker WC, et al. Buprenorphine/naloxone dose and pain intensity among individuals initiating treatment for opioid use disorder. J Subst Abuse Treat. 2015;48(1):128–31.PubMedCrossRef
21.
Malinoff HL, Barkin RL, Wilson G. Sublingual buprenorphine is effective in the treatment of chronic pain syndrome. Am J Ther. 2005;12(5):379–84.PubMedCrossRef
22.
Daitch J, et al. Conversion of chronic pain patients from full-opioid agonists to sublingual buprenorphine. Pain Phys. 2012;15(3 suppl):59–66.
23.
Roux P, et al. Buprenorphine/naloxone as a promising therapeutic option for opioid abusing patients with chronic pain: reduction of pain, opioid withdrawal symptoms, and abuse liability of oral oxycodone. Pain. 2013;154(8):1442–8.PubMedPubMedCentralCrossRef
24.
Rosenblum A, et al. Sublingual buprenorphine/naloxone for chronic pain in at-risk patients: development and pilot test of a clinical protocol. J Opioid Manag. 2012;8(6):369.PubMedPubMedCentralCrossRef
25.
Noble M, et al. Long-term opioid management for chronic noncancer pain. Cochrane Database Syst Rev. 2010;1(1).
26.
Weiss RD, et al. Reasons for opioid use among patients with dependence on prescription opioids: the role of chronic pain. J Subst Abuse Treat. 2014;47(2):140–5.PubMedPubMedCentralCrossRef
27.
28.
Wurst FM, et al. Ethyl glucuronide discloses recent covert alcohol use not detected by standard testing in forensic psychiatric inpatients. Alcohol Clin Exp Res. 2003;27(3):471–6.PubMedCrossRef
29.
Smith R. Medicine and the marginalised: they deserve the best, not the poorest, care. Br Med J (BMJ). 1999;319(7225):1589.CrossRef
30.
Merlin JS, et al. Common and challenging behaviors among patients taking long-term opioid therapy: Preliminary results of a Delphi study. Washington, DC: Oral presentation, The Association of Medical Education and Research in Substance Abuse; 2015.
Metadata
Title
Management of patients with issues related to opioid safety, efficacy and/or misuse: a case series from an integrated, interdisciplinary clinic
Authors
William C. Becker
Jessica S. Merlin
Ajay Manhapra
Ellen L. Edens
Publication date
01-12-2016
Publisher
BioMed Central
Published in
Addiction Science & Clinical Practice / Issue 1/2016
Electronic ISSN: 1940-0640
DOI
https://doi.org/10.1186/s13722-016-0050-0

Other articles of this Issue 1/2016

Addiction Science & Clinical Practice 1/2016 Go to the issue

Research

Emerging adults in substance misuse intervention: preintervention characteristics and responses to a motivation-enhancing program

Review

Alcohol use in opioid agonist treatment

Research

Hazardous drinking among young adults seeking outpatient mental health services

Study Protocol

Linking Infectious and Narcology Care (LINC) in Russia: design, intervention and implementation protocol

Reviewer acknowledgement

Acknowledgement of manuscript reviewers 2015

Research

Drinking to toxicity: college students referred for emergency medical evaluation