Ensuring Patient Protections When Tapering Opioids: Consensus Panel Recommendations.

Long-term opioid therapy has the potential for serious adverse outcomes and is often used in a vulnerable population. Because adverse effects or failure to maintain benefits is common with long-term use, opioid taper or discontinuation may be indicated in certain patients. Concerns about the adverse individual and population effects of opioids have led to numerous strategies aimed at reductions in prescribing.

Challenges with Implementing the Centers for Disease Control and Prevention Opioid Guideline: A Consensus Panel Report.

Background: A national crisis of opioid-related morbidity, mortality, and misuse has led to initiatives to address the appropriate role of opioids to treat pain. Deployment of a guideline from the Centers for Disease Control and Prevention to reduce the risks of opioid therapy has raised substantial clinical and public policy challenges. The agency anticipated implementation challenges and committed to reevaluating the guideline for intended and unintended effects on clinician and patient outcomes.

Rational Urine Drug Monitoring in Patients Receiving Opioids for Chronic Pain: Consensus Recommendations.

Objective: To develop consensus recommendations on urine drug monitoring (UDM) in patients with chronic pain who are prescribed opioids.

Methods: An interdisciplinary group of clinicians with expertise in pain, substance use disorders, and primary care conducted virtual meetings to review relevant literature and existing guidelines and share their clinical experience in UDM before reaching consensus recommendations.

Results: Definitive (e.

Strategies for Combating Opioid-Induced Constipation: Targeted Mechanisms to Maintain Pain Control Without Compromise.

Opioid-induced constipation (OIC) is a common side effect of opioid use and can occur from the outset of opioid therapy (Online access: http://courses.elseviercme.com/aapmr2016/638e).

Consensus Recommendations on Initiating Prescription Therapies for Opioid-Induced Constipation.

Objective: Aims of this consensus panel were to determine (1) an optimal symptom-based method for assessing opioid-induced constipation in clinical practice and (2) a threshold of symptom severity to prompt consideration of prescription therapy.

Methods: A multidisciplinary panel of 10 experts with extensive knowledge/experience with opioid-associated adverse events convened to discuss the literature on assessment methods used for opioid-induced constipation and reach consensus on each objective using the nominal group technique.

Results: Five validated assessment tools were evaluated: the Patient Assessment of Constipation-Symptoms (PAC-SYM), Patient Assessment of Constipation-Quality of Life (PAC-QOL), Stool Symptom Screener (SSS), Bowel Function Index (BFI), and Bowel Function Diary (BF-Diary).

Topical therapies in the management of chronic pain.

Chronic pain, whether localized or generalized, is a widespread, often debilitating condition affecting > 25% of adults in the United States. Oral agents are the cornerstone of chronic pain treatment, but their use may be limited in certain patients, particularly the elderly. Topical therapies offer advantages over systemically administered medications, including the requirement of a lower total systemic daily dose for patients to achieve pain relief, site-specific drug delivery, and avoidance of first-pass metabolism, major drug interactions, infections, and systemic side effects.

Ethnicity and interdisciplinary pain treatment.

Objective: The purpose of this study was to identify ethnic differences in interdisciplinary pain treatment outcome and whether these differences occur while controlling for the effects of demographics, psychosocial, and secondary gain.

Methods: We assessed a sample of 116 (Caucasian, African American, and Latino/a) chronic pain patients who participated a 4-week interdisciplinary pain treatment program. Outcome measure included pretreatment, post-treatment, and change scores on the Multidimensional Pain Inventory, Pain Anxiety Symptom Scale 20, Chronic Pain Acceptance Questionnaire, Coping Strategies Questionnaire-revised, and the Center for Epidemiologic Studies Depression Scale-short form.

Validity testing of patient objections to acceptance of tamper-resistant opioid formulations.

Background: Tamper-resistant formulations (TRFs) of oral opioid drugs are intended to prevent certain types of abuse (eg, intranasal, intravenous). Patients raising objections to receiving a TRF may have valid concerns or may be seeking a formulation that can be more easily misused.

Methods: US clinicians experienced in pain management met in October 2011 to discuss common patient objections to being switched from a non-TRF opioid to a TRF of the same opioid.

Osteoarthritis guidelines: a progressive role for topical nonsteroidal anti-inflammatory drugs.

Current treatment guidelines for the treatment of chronic pain associated with osteoarthritis reflect the collective clinical knowledge of international experts in weighing the benefits of pharmacologic therapy options while striving to minimize the negative effects associated with them. Consideration of disease progression, pattern of flares, level of functional impairment or disability, response to treatment, coexisting conditions such as cardiovascular disease or gastrointestinal disorders, and concomitant prescription medication use should be considered when creating a therapeutic plan for a patient with osteoarthritis. Although topical nonsteroidal anti-inflammatory drugs historically have not been prevalent in many of the guidelines for osteoarthritis treatment, recent evidence-based medicine and new guidelines now support their use as a viable option for the clinician seeking alternatives to typical oral formulations.

Treatment outcomes for workers compensation patients in a U.S.-based interdisciplinary pain management program.

Objectives:  Assess the efficacy of an outpatient-based interdisciplinary pain rehabilitation program for patients with active workers compensation claims.

Patients:  Data were available for 101 patients, primarily with chronic low back pain (75%), who participated in the program.

Methods: Treatment included a 4-week (Monday to Friday), 8-hours/day graded progressive program that included individual and group therapies (pain psychology, physical therapy, occupational therapy, relaxation training/biofeedback, aerobic conditioning, pool therapy, vocational counseling, patient education and medical management).

Strategies to reduce the tampering and subsequent abuse of long-acting opioids: potential risks and benefits of formulations with physical or pharmacologic deterrents to tampering.

Increased prescribing of opioid analgesics for chronic noncancer pain may reflect acceptance that opioid benefits outweigh risks of adverse events for a broadening array of indications and patient populations; however, a parallel increase in the abuse, misuse, and diversion of prescription opioids has resulted. There is an urgent need to reduce opioid tampering and subsequent abuse without creating barriers to safe, effective analgesia. Similar to the "magic bullet" concept of antibiotic development (kill the bacteria without harming the patient), the idea behind reformulating opioid analgesics is to make them more difficult to tamper with and abuse by drug abusers but innocuous to the compliant patient.

Guideline warfare over interventional therapies for low back pain: can we raise the level of discourse?

Unlabelled: As guidelines proliferate and are used to inform efforts to improve the quality and efficiency of care, disputes over guideline recommendations are likely to become more common and contentious. It is appropriate for guidelines to come under close scrutiny, given their important clinical and policy implications, and critiques that point out missing evidence, improper methods, or errors in interpretation can be valuable. But for critiques to be valid, they should be based on accurate information and a sound scientific basis.

Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society.

Study Design: Clinical practice guideline.

Objective: To develop evidence-based recommendations on use of interventional diagnostic tests and therapies, surgeries, and interdisciplinary rehabilitation for low back pain of any duration, with or without leg pain.

Summary Of Background Data: Management of patients with persistent and disabling low back pain remains a clinical challenge.

Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline.

Study Design: Systematic review.

Objective: To systematically assess benefits and harms of nonsurgical interventional therapies for low back and radicular pain.

Summary Of Background Data: Although use of certain interventional therapies is common or increasing, there is also uncertainty or controversy about their efficacy.

Physical medicine rehabilitation approach to pain.

A physical medicine and rehabilitation approach to acute and chronic pain syndromes includes a wide spectrum of treatment focus. Management includes an assessment and treatment model based on a biopsychosocial approach. Assessment includes a focus on pain behaviors, posture, muscle imbalances, and gait impairments.

Topical agents for the management of musculoskeletal pain.

The recent recognition of the magnitude of cardiovascular risk of both nonselective nonsteroidal anti-inflammatory drugs and COX-2 selective inhibitors, in addition to the persistent concerns about the use of opioids, has brought increased attention to nonsystemic, topical analgesics. These agents have a favorable safety profile and there is increasing evidence indicating their efficacy for a variety of pain disorders. The use of topical analgesics in the treatment of the most prevalent musculoskeletal pain syndromes is described, with a focus on mechanisms for drug delivery and clinical trials data.