Publications by authors named "Judith A Turner"

177 Publications

STRategies to Improve Pain and Enjoy life (STRIPE): Protocol for a pragmatic randomized trial of pain coping skills training and opioid medication taper guidance for patients on long-term opioid therapy.

Contemp Clin Trials 2021 Jul 1:106499. Epub 2021 Jul 1.

Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, United States of America.

High-dose, long-term opioid therapy (LtOT) is associated with risk for serious harms. Rapid opioid discontinuation may lead to increased pain, psychological distress, and illicit opioid use, but gradual, supported opioid taper may reduce these risks. We previously demonstrated that an opioid taper support and pain coping skills training intervention reduced opioid dose more than usual care (43% vs 19% dose reduction from baseline), with no increase in pain intensity and a significant reduction in activity interference. We aim to adapt and test this intervention in the Kaiser Permanente Washington healthcare system with STRategies to Improve Pain and Enjoy life (STRIPE), a pragmatic, randomized trial. Our goal was to randomize 215 participants on moderate-high dose (≥40 morphine milligram equivalent/day) LtOT to either cognitive-behavioral therapy-based pain coping skills training involving 18 telephone sessions over 52 weeks with optional opioid taper support or usual care. Data are collected from electronic health records, claims, and self-report. The primary outcomes are mean daily opioid dose and the pain intensity, interference with enjoyment of life, and interference with general activity (PEG) score at 12 months (primary time point) and 6 months (secondary time point). Secondary outcomes include having ≥30% opioid dose reduction from baseline, and patient-reported problem opioid use, opioid-related difficulties, pain self-efficacy, opioid craving, global impression of change, and anxiety and depressive symptoms at 6 and 12 months. If effective, this treatment could reduce opioid exposure and associated risks to patients, families, and communities while offering patients an alternative for managing pain. Trial registration: The study was first registered at Clinicaltrials.gov on November 16, 2018 (identifier: NCT03743402).
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http://dx.doi.org/10.1016/j.cct.2021.106499DOI Listing
July 2021

Expected Organizational Costs for Inserting Prevalence Information Into Lumbar Spine Imaging Reports.

J Am Coll Radiol 2021 Jun 30. Epub 2021 Jun 30.

Department of Health Services, University of Washington, Seattle, Washington.

Background: Modifying physician behavior to more closely align with guideline-based care can be challenging. Few effective strategies resulting in appropriate spine-related health care have been reported. The Lumbar Imaging With Reporting of Epidemiology (LIRE) intervention did not result in reductions in spine care but did in opioid prescriptions written.

Objectives: To estimate organizational resource needs and costs associated with implementing a pragmatic, decision support-type intervention that inserted age- and modality-matched prevalence information for common lumbar spine imaging findings, using site-based resource use data from the LIRE trial.

Research Design: Time and cost estimation associated with implementing the LIRE intervention in a health organization.

Subjects: Providers and patients assessed in the LIRE trial.

Measures: Expected personnel costs required to implement the LIRE intervention.

Results: Annual salaries were converted to daily average per person costs, ranging from $400 to $2,200 per day (base case) for personnel (range: $300-$2,600). Estimated total average cost for implementing LIRE was $5,009 (range: $2,651-$12,020), including conducting pilot testing with providers. Costs associated with a small amount of time for a radiologist (6-12 hours) and imaging-ordering providers (1-8 hours each) account for approximately 75% of the estimated total cost.

Conclusions: The process of implementing an intervention for lumbar spine imaging reports containing age- and modality-appropriate epidemiological benchmarks for common imaging findings required radiologists, imaging-ordering providers, information technology specialists, and limited testing and monitoring. The LIRE intervention seems to be a relatively low-cost, evidence-based, complementary tool that can be easily integrated into the reporting of spine imaging.
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http://dx.doi.org/10.1016/j.jacr.2021.06.010DOI Listing
June 2021

Providing Epidemiological Data in Lumbar Spine Imaging Reports Did Not Affect Subsequent Utilization of Spine Procedures: Secondary Outcomes from a Stepped-Wedge Randomized Controlled Trial.

Pain Med 2021 06;22(6):1272-1280

Clinical Learning, Evidence, and Research Center, University of Washington, Seattle, Washington, USA.

Objective: To evaluate the effect of inserting epidemiological information into lumbar spine imaging reports on subsequent nonsurgical and surgical procedures involving the thoracolumbosacral spine and sacroiliac joints.

Design: Analysis of secondary outcomes from the Lumbar Imaging with Reporting of Epidemiology (LIRE) pragmatic stepped-wedge randomized trial.

Setting: Primary care clinics within four integrated health care systems in the United States.

Subjects: 238,886 patients ≥18 years of age who received lumbar diagnostic imaging between 2013 and 2016.

Methods: Clinics were randomized to receive text containing age- and modality-specific epidemiological benchmarks indicating the prevalence of common spine imaging findings in people without low back pain, inserted into lumbar spine imaging reports (the "LIRE intervention"). The study outcomes were receiving 1) any nonsurgical lumbosacral or sacroiliac spine procedure (lumbosacral epidural steroid injection, facet joint injection, or facet joint radiofrequency ablation; or sacroiliac joint injection) or 2) any surgical procedure involving the lumbar, sacral, or thoracic spine (decompression surgery or spinal fusion or other spine surgery).

Results: The LIRE intervention was not significantly associated with subsequent utilization of nonsurgical lumbosacral or sacroiliac spine procedures (odds ratio [OR] = 1.01, 95% confidence interval [CI] 0.93-1.09; P = 0.79) or any surgical procedure (OR = 0.99, 95 CI 0.91-1.07; P = 0.74) involving the lumbar, sacral, or thoracic spine. The intervention was also not significantly associated with any individual spine procedure.

Conclusions: Inserting epidemiological text into spine imaging reports had no effect on nonsurgical or surgical procedure utilization among patients receiving lumbar diagnostic imaging.
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http://dx.doi.org/10.1093/pm/pnab065DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8185556PMC
June 2021

Effects of Including Epidemiologic Data in Lumbar Spine Imaging Reports on Prescribing Non-Opioid Medications for Pain.

J Gen Intern Med 2021 Feb 8. Epub 2021 Feb 8.

Department of Radiology, School of Medicine, University of Washington, Seattle, WA, USA.

Background: Information on the prevalence of common imaging findings among patients without back pain in spine imaging reports might affect pain medication prescribing for patients with back pain. Prior research on inserting this text suggested a small reduction in opioid prescribing.

Objective: To evaluate the effect of epidemiologic information in spine imaging reports on non-opioid pain medication prescribing for primary care patients with back pain.

Design: Post hoc analysis of the Lumbar Imaging with Reporting of Epidemiology cluster-randomized trial.

Participants: A total of 170,680 patients aged ≥ 18 years from four healthcare systems who received thoracolumbar, lumbar, or lumbosacral spine imaging from 2013 to 2016 and had not received a prescription for non-opioid pain medication in the preceding 120 days.

Intervention: Text of age- and modality-specific epidemiologic benchmarks indicating the prevalence of common findings in people without back pain inserted into thoracolumbar, lumbar, or lumbosacral spine imaging reports at intervention clinics.

Main Measures: Primary outcomes: any non-opioid prescription within 90 days after index imaging, overall, and by sub-class (skeletal muscle relaxants, NSAIDs, gabapentinoids, tricyclic antidepressants, benzodiazepines, duloxetine).

Secondary Outcomes: count of non-opioid prescriptions within 90 days, overall, and by sub-class.

Key Results: The intervention was not associated with the likelihood of patients receiving at least one prescription for new non-opioid pain-related medications, overall (adjusted OR, 1.02; 95% CI, 0.97-1.08) or by sub-class. The intervention was not associated with the number of prescriptions for any non-opioid medication (adjusted incidence rate ratio [IRR], 1.02; 95% CI, 0.99-1.04). However, the intervention was associated with more new prescriptions for NSAIDs (IRR, 1.12) and tricyclic antidepressants (IRR, 1.11).

Conclusions: Inserting epidemiologic text in spine imaging reports had no effect on whether new non-opioid pain-related medications were prescribed but was associated with the number of new prescriptions for certain non-opioid sub-classes.

Trial Registration: ClinicalTrials.gov identifier: NCT02015455.
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http://dx.doi.org/10.1007/s11606-021-06627-6DOI Listing
February 2021

The Effect of Including Benchmark Prevalence Data of Common Imaging Findings in Spine Image Reports on Health Care Utilization Among Adults Undergoing Spine Imaging: A Stepped-Wedge Randomized Clinical Trial.

JAMA Netw Open 2020 09 1;3(9):e2015713. Epub 2020 Sep 1.

Department of Biostatistics, University of Washington, Seattle.

Importance: Lumbar spine imaging frequently reveals findings that may seem alarming but are likely unrelated to pain. Prior work has suggested that inserting data on the prevalence of imaging findings among asymptomatic individuals into spine imaging reports may reduce unnecessary subsequent interventions.

Objective: To evaluate the impact of including benchmark prevalence data in routine spinal imaging reports on subsequent spine-related health care utilization and opioid prescriptions.

Design, Setting, And Participants: This stepped-wedge, pragmatic randomized clinical trial included 250 401 adult participants receiving care from 98 primary care clinics at 4 large health systems in the United States. Participants had imaging of their backs between October 2013 and September 2016 without having had spine imaging in the prior year. Data analysis was conducted from November 2018 to October 2019.

Interventions: Either standard lumbar spine imaging reports (control group) or reports containing age-appropriate prevalence data for common imaging findings in individuals without back pain (intervention group).

Main Outcomes And Measures: Health care utilization was measured in spine-related relative value units (RVUs) within 365 days of index imaging. The number of subsequent opioid prescriptions written by a primary care clinician was a secondary outcome, and prespecified subgroup analyses examined results by imaging modality.

Results: We enrolled 250 401 participants (of whom 238 886 [95.4%] met eligibility for this analysis, with 137 373 [57.5%] women and 105 497 [44.2%] aged >60 years) from 3278 primary care clinicians. A total of 117 455 patients (49.2%) were randomized to the control group, and 121 431 patients (50.8%) were randomized to the intervention group. There was no significant difference in cumulative spine-related RVUs comparing intervention and control conditions through 365 days. The adjusted median (interquartile range) RVU for the control group was 3.56 (2.71-5.12) compared with 3.53 (2.68-5.08) for the intervention group (difference, -0.7%; 95% CI, -2.9% to 1.5%; P = .54). Rates of subsequent RVUs did not differ between groups by specific clinical findings in the report but did differ by type of index imaging (eg, computed tomography: difference, -29.3%; 95% CI, -42.1% to -13.5%; magnetic resonance imaging: difference, -3.4%; 95% CI, -8.3% to 1.8%). We observed a small but significant decrease in the likelihood of opioid prescribing from a study clinician within 1 year of the intervention (odds ratio, 0.95; 95% CI, 0.91 to 1.00; P = .04).

Conclusions And Relevance: In this study, inserting benchmark prevalence information in lumbar spine imaging reports did not decrease subsequent spine-related RVUs but did reduce subsequent opioid prescriptions. The intervention text is simple, inexpensive, and easily implemented.

Trial Registration: ClinicalTrials.gov Identifier: NCT02015455.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.15713DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489827PMC
September 2020

Four decades later: what's new, what's not in our understanding of pain.

Pain 2020 09;161(9):1943-1944

Department of Health Science and Technology, Center for Pain and Neuroplasticy, School of Medicine, Aalborg University, Aalborg, Denmark.

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http://dx.doi.org/10.1097/j.pain.0000000000001991DOI Listing
September 2020

The Benefits of for Older Adults with Chronic Back Pain: A Qualitative Study.

J Altern Complement Med 2020 Jun 5;26(6):456-462. Epub 2020 May 5.

Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA.

To determine the perceived benefits of in older adults with chronic low-back pain (cLBP). A qualitative analysis from a randomized controlled feasibility trial. Eighteen participants (65+ years old) with cLBP of at least moderate intensity. A 36-week intervention beginning with twice weekly classes for 12 weeks, weekly classes for 6 weeks, biweekly classes for 6 weeks, and monthly classes for 12 weeks. Participants were asked to practice at home on nonclass days and videos were provided to assist in that process. Participants in the focus groups were asked to provide feedback on their experiences with the study as well as the benefits of their practice. We used demographic and class attendance data to describe the sample. Regarding the benefits of practice, five major themes were identified: functional benefits, pain reduction/pain relief, psychospiritual benefits, the importance of social support in learning , and the integration of into daily activities. The most common functional benefits were improvements in balance, flexibility, leg strength, and posture. Some reported pain reduction or pain relief, but others did not. Increased relaxation, mindfulness, and a sense of connectedness were subthemes that emerged from psychospiritual benefits. Social support benefits included motivation to attend class and group support while learning a new skill. Finally, improved body awareness allowed participants to integrate skills into their daily activities. This qualitative analysis demonstrates the multifaceted benefits of for older adults living with cLBP.
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http://dx.doi.org/10.1089/acm.2019.0455DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7310224PMC
June 2020

for Chronic Low Back Pain in Older Adults: A Feasibility Trial.

J Altern Complement Med 2020 Mar 3;26(3):176-189. Epub 2020 Feb 3.

Department of Psychiatry and Behavioral Sciences and Rehabilitation Medicine, University of Washington, Seattle, WA.

(TC) has been found effective for improving chronic low back pain (cLBP). However, such studies did not include adults over 65 years of age. This study was designed to evaluate the feasibility and acceptability of TC in this population compared with Health Education (HE) and with Usual Care (UC). Feasibility randomized controlled trial. Participants were recruited from Kaiser Permanente Washington and classes took place in a Kaiser facility. Adults 65 years of age and older with cLBP. Twenty-eight participants were randomized to 12 weeks of TC followed by a 24-week tapered TC program, 12 were assigned to a 12-week HE intervention and 17 were assigned to UC only. Feasibility and acceptability were determined by recruitment, retention and 12-, 26-, and 52-week follow-up rates, instructor adherence to protocol, class attendance, TC home practice, class satisfaction, and adverse events. Fifty-seven participants were enrolled in two cohorts of 28 and 29 during two 4-month recruitment periods. Questionnaire follow-up completion rates ranged between 88% and 93%. Two major class protocol deviations were noted in TC and none in HE. Sixty-two percent of TC participants versus 50% of HE participants attended at least 70% of the classes during the 12-week initial intervention period. Weekly rates of TC home practice were high among class attendees (median of 4.2 days) at 12 weeks, with fewer people practicing at 26 and 52 weeks. By 52 weeks, 70% of TC participants reported practicing the week before, with a median of 3 days per week and 15 min/session. TC participants rated the helpfulness of their classes significantly higher than did HE participants, but the groups were similarly likely to recommend the classes. The TC intervention is feasible in this population, while the HE group requires modifications in delivery.
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http://dx.doi.org/10.1089/acm.2019.0438DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7074926PMC
March 2020

Multi-site Pain Is Associated with Long-term Patient-Reported Outcomes in Older Adults with Persistent Back Pain.

Pain Med 2019 10;20(10):1898-1906

Comparative Effectiveness, Cost, and Outcomes Research Center.

Objective: To estimate the prevalence of co-occurring pain sites among older adults with persistent back pain and associations of multisite pain with longitudinal outcomes.

Design: Secondary analysis of a cohort study.

Setting: Three integrated health systems in the United States.

Subjects: Eight hundred ninety-nine older adults with persistent back pain.

Methods: Participants reported pain in the following sites: stomach, arms/legs/joints, headaches, neck, pelvis/groin, and widespread pain. Over 18 months, we measured back-related disability (Roland Morris, scored 0-24), pain intensity (11-point numerical rating scale), health-related quality of life (EuroQol-5D [EQ-5D], utility from 0-1), and falls in the past three weeks. We used mixed-effects models to test the association of number and type of pain sites with each outcome.

Results: Nearly all (N = 839, 93%) respondents reported at least one additional pain site. There were 216 (24%) with one additional site and 623 (69%) with multiple additional sites. The most prevalent comorbid pain site was the arms/legs/joints (N = 801, 89.1%). Adjusted mixed-effects models showed that for every additional pain site, RMDQ worsened by 0.65 points (95% confidence interval [CI] = 0.43 to 0.86), back pain intensity increased by 0.14 points (95% CI = 0.07 to 0.22), EQ-5D worsened by 0.012 points (95% CI = -0.018 to -0.006), and the odds of falling increased by 27% (odds ratio = 1.27, 95% CI = 1.12 to 1.43). Some specific pain sites (extremity pain, widespread pain, and pelvis/groin pain) were associated with greater long-term disability.

Conclusions: Multisite pain is common among older adults with persistent back pain. Number of pain sites was associated with all outcomes; individual pain sites were less consistently associated with outcomes.
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http://dx.doi.org/10.1093/pm/pny270DOI Listing
October 2019

Management of Pain in Elite Athletes: Identified Gaps in Knowledge and Future Research Directions.

Clin J Sport Med 2018 09;28(5):485-489

Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington.

Objective: For elite athletes to train and compete at peak performance levels, it is necessary to manage their pain efficiently and effectively. A recent consensus meeting on the management of pain in elite athletes concluded that there are many gaps in the current knowledge and that further information and research is required. This article presents the crystallization of these acknowledged gaps in knowledge.

Data Sources: Information was gathered from a wide variety of published scientific sources that were reviewed at the consensus meeting and the gaps in knowledge identified.

Main Results: Gaps have been identified in the epidemiology of analgesic use, the management of pain associated with minor injuries, and the field of play management of pain for athletes with major injuries. From a pharmacological perspective, there is a lack of information on the prescribing of opioid medications in elite athletes and more data are required on the use of local anesthetics injections, corticosteroids, and nonsteroidal anti-inflammatory drugs during training and in competition. Pain management strategies for the general population are widely available, but there are few for the elite sporting population and virtually none for elite athletes with a disability. More research is also needed in assessing cognitive-behavior therapies in improving specific outcomes and also into the new process of psychologically informed physiotherapy. A key issue is the paucity of data relating to incidence or prevalence of persistent pain and how this relates to persistent dysfunction, exercise performance, and physiological function in later life.

Conclusions: The identification of the gaps in knowledge in the management of pain in elite athletes will provide a unified direction for the retrieval of information and further research that will provide reassurance, speed return to active sport, and benefit performance.
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http://dx.doi.org/10.1097/JSM.0000000000000618DOI Listing
September 2018

Prevention and treatment of low back pain: evidence, challenges, and promising directions.

Lancet 2018 06 21;391(10137):2368-2383. Epub 2018 Mar 21.

Sydney School of Public Health, University of Sydney, NSW, Australia.

Many clinical practice guidelines recommend similar approaches for the assessment and management of low back pain. Recommendations include use of a biopsychosocial framework to guide management with initial non-pharmacological treatment, including education that supports self-management and resumption of normal activities and exercise, and psychological programmes for those with persistent symptoms. Guidelines recommend prudent use of medication, imaging, and surgery. The recommendations are based on trials almost exclusively from high-income countries, focused mainly on treatments rather than on prevention, with limited data for cost-effectiveness. However, globally, gaps between evidence and practice exist, with limited use of recommended first-line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery. Doing more of the same will not reduce back-related disability or its long-term consequences. The advances with the greatest potential are arguably those that align practice with the evidence, reduce the focus on spinal abnormalities, and ensure promotion of activity and function, including work participation. We have identified effective, promising, or emerging solutions that could offer new directions, but that need greater attention and further research to determine if they are appropriate for large-scale implementation. These potential solutions include focused strategies to implement best practice, the redesign of clinical pathways, integrated health and occupational interventions to reduce work disability, changes in compensation and disability claims policies, and public health and prevention strategies.
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http://dx.doi.org/10.1016/S0140-6736(18)30489-6DOI Listing
June 2018

Long-term outcomes of a large, prospective observational cohort of older adults with back pain.

Spine J 2018 09 31;18(9):1540-1551. Epub 2018 Jan 31.

Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, 4333 Brooklyn Ave, Seattle, WA, 98105, USA; Department of Biostatistics, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA.

Background Context: Although back pain is common among older adults, there is relatively little research on the course of back pain in this age group.

Purpose: Our primary goals were to report 2-year outcomes of older adults initiating primary care for back pain and to examine the relative importance of patient factors versus medical interventions in predicting 2-year disability and pain.

Study Design/setting: This study used a predictive model using data from a prospective, observational cohort from a primary care setting.

Patient Sample: The study included patients aged ≥65 years at the time of new primary care visits for back pain.

Outcome Measures: Self-reported 2-year disability (Roland-Morris Disability Questionnaire [RDQ]) and back pain (0-10 numerical rating scale [NRS]).

Methods: We developed our models using a machine learning least absolute shrinkage and selection operator approach. We evaluated the predictive value of baseline characteristics and the incremental value of interventions that occurred between 0 and 90 days, and the change in patient disability and pain from 0 to 90 days. Limitations included confounding by indication and unmeasured confounding.

Results: Of 4,665 patients (89%) with follow-up, both RDQ (from mean 9.6 [95% confidence interval {CI} 9.4-9.7] to mean 8.3 [95% CI 8.0-8.5]) and back pain NRS (from mean 5.0 [95% CI 4.9-5.1] to mean 3.5 [95% CI 3.4-3.6]) scores improved slightly. Only 16% (15%-18%) reported no back pain-related disability or back pain at 2 years after initial visits. Regression model parameters explained 40% of the variation (R) in 2-year RDQ scores, and the addition of 0- to 3-month change in RDQ score and pain improved prediction (R=51%). The most consistent predictors of 2-year RDQ scores and back pain NRS scores were 0- to 90-day change in each respective outcome and patient confidence in improvement. Patients experienced 50% and 43% improvement in back pain and disability, respectively, 2 years after their initial visit. However, fewer than 20% of patients had complete resolution of their back pain and disability at that time.

Conclusions: Baseline patient factors were more important than early interventions in explaining disability and pain after 2 years.
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http://dx.doi.org/10.1016/j.spinee.2018.01.018DOI Listing
September 2018

Associations of Race and Ethnicity With Patient-Reported Outcomes and Health Care Utilization Among Older Adults Initiating a New Episode of Care for Back Pain.

Spine (Phila Pa 1976) 2018 07;43(14):1007-1017

Department of Rehabilitation Medicine, University of Washington, Seattle, WA.

Study Design: Secondary analysis of the Back Pain Outcomes using Longitudinal Data (BOLD) cohort study.

Objective: To characterize associations of self-reported race/ethnicity with back pain (BP) patient-reported outcomes (PROs) and health care utilization among older adults with a new episode of care for BP.

Summary Of Background Data: No prior longitudinal studies have characterized associations between multiple race/ethnicity groups, and BP-related PROs and health care utilization in the United States.

Methods: This study included 5117 participants ≥65 years from three US health care systems. The primary BP-related PROs were BP intensity and back-related functional limitations over 24 months. Health care utilization measures included common diagnostic tests and treatments related to BP (spine imaging, spine-related relative value units [RVUs], and total RVUs) over 24 months. Analyses were adjusted for multiple potential confounders including sociodemographics, clinical characteristics, and study site.

Results: Baseline BP ratings were significantly higher for blacks vs. whites (5.8 vs. 5.0; P < 0.001). Participants in all race/ethnicity groups showed statistically significant, but modest improvements in BP over 24 months. Blacks and Hispanics did not have statistically significant improvement in BP-related functional limitations over time, unlike whites, Asians, and non-Hispanics; however, the magnitude of differences in improvement between groups was small. Blacks had less spine-related health care utilization over 24 months than whites (spine-related RVU ratio of means 0.66, 95% confidence interval [CI] 0.51-0.86). Hispanics had less spine-related health care utilization than non-Hispanics (spine-related RVU ratio of means 0.60; 95% CI 0.40-0.90).

Conclusion: Blacks and Hispanics had slightly less improvement in BP-related functional limitations over time, and less spine-related health care utilization, as compared to whites and non-Hispanics, respectively. Residual confounding may explain some of the association between race/ethnicity and health outcomes. Further studies are needed to understand the factors underlying these differences and which differences reflect disparities.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000002499DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5972040PMC
July 2018

Associations of Early Opioid Use With Patient-reported Outcomes and Health Care Utilization Among Older Adults With Low Back Pain.

Clin J Pain 2018 04;34(4):297-305

Department of Radiology, Comparative Effectiveness, Cost, and Outcomes Research Center.

Objectives: The objective of this study was to compare outcomes and health care utilization of older patients who did versus did not fill opioid prescriptions within 90 days of initiating care for low back pain.

Materials And Methods: For patients ≥65 years with new back pain visits, we used propensity scores to match those who filled no opioid prescriptions to those who filled ≥2 opioid prescriptions within 90 days (and the first opioid prescription within 30 d) of the index visit. Over 24 months, we examined patient-reported outcomes, health care utilization, and subsequent opioid prescription fills.

Results: Among 1954 patients eligible for matching, 238 (12%) filled ≥2 opioid prescriptions within 90 days; 200 of these were matched to controls. Patients with versus without early opioid prescriptions had similar patient-reported outcomes but were more likely to have filled ≥1 opioid prescription 18 to 24 months after the index visit (odds ratio [95% confidence interval]=2.4 [1.5-3.9]) and to have had ≥1 visit to the emergency department in the subsequent 24 months (OR, 1.6; 95% confidence interval, 1.0-2.5).

Discussion: Among older patients with new back pain visits, filling ≥2 opioid prescriptions within 90 days of the visit was associated with similar back pain-related outcomes but increased likelihood of filling opioid prescriptions 18 to 24 months later compared with matched patients who did not fill early opioid prescriptions.
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http://dx.doi.org/10.1097/AJP.0000000000000557DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5837891PMC
April 2018

Prescription Opioid Use and the Risk of Disability.

Clin J Pain 2018 02;34(2):190

Division of Health services Management and Policy, College of Public Health, Ohio State University Columbus, Ohio.

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http://dx.doi.org/10.1097/AJP.0000000000000548DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5754248PMC
February 2018

Pain in elite athletes-neurophysiological, biomechanical and psychosocial considerations: a narrative review.

Br J Sports Med 2017 Sep;51(17):1259-1264

Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia.

Pain is a common problem among elite athletes and is frequently associated with sport injury. Both injury and pain interfere with peak performance. Pain management should be based on the physiological, anatomical and psychosocial influences on the individual's pain and is not equivalent to injury management, which focuses on musculoskeletal recovery and return-to-play. This narrative review provides a foundation for understanding the differing causes and types of pain in elite athletes, thereby serving as a springboard for comprehensive pain management.
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http://dx.doi.org/10.1136/bjsports-2017-097890DOI Listing
September 2017

International Olympic Committee consensus statement on pain management in elite athletes.

Br J Sports Med 2017 Sep;51(17):1245-1258

International Olympic Committee, Lausanne, Switzerland.

Pain is a common problem among elite athletes and is frequently associated with sport injury. Both pain and injury interfere with the performance of elite athletes. There are currently no evidence-based or consensus-based guidelines for the management of pain in elite athletes. Typically, pain management consists of the provision of analgesics, rest and physical therapy. More appropriately, a treatment strategy should address all contributors to pain including underlying pathophysiology, biomechanical abnormalities and psychosocial issues, and should employ therapies providing optimal benefit and minimal harm. To advance the development of a more standardised, evidence-informed approach to pain management in elite athletes, an IOC Consensus Group critically evaluated the current state of the science and practice of pain management in sport and prepared recommendations for a more unified approach to this important topic.
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http://dx.doi.org/10.1136/bjsports-2017-097884DOI Listing
September 2017

Cost-effectiveness of Mindfulness-based Stress Reduction Versus Cognitive Behavioral Therapy or Usual Care Among Adults With Chronic Low Back Pain.

Spine (Phila Pa 1976) 2017 Oct;42(20):1511-1520

Kaiser Permanente Washington Health Research Institute, Seattle, WA.

Study Design: Economic evaluation alongside a randomized trial of cognitive-behavioral therapy (CBT) and mindfulness-based stress reduction (MBSR) versus usual care alone (UC) for chronic low back pain (CLBP).

Objective: To determine 1-year cost-effectiveness of CBT and MBSR compared to 33 UC.

Summary Of Background Data: CLBP is expensive in terms of healthcare costs and lost productivity. Mind-body interventions have been found effective for back pain, but their cost-effectiveness is unexplored.

Methods: A total of 342 adults in an integrated healthcare system with CLBP were randomized to receive MBSR (n = 116), CBT (n = 113), or UC (n = 113). CBT and MBSR were offered in 8-weekly 2-hour group sessions. Cost-effectiveness from the societal perspective was calculated as the incremental sum of healthcare costs and productivity losses over change in quality-adjusted life-years (QALYs). The payer perspective only included healthcare costs. This economic evaluation was limited to the 301 health plan members enrolled ≥180 days in the years pre-and postrandomization.

Results: Compared with UC, the mean incremental cost per participant to society of CBT was $125 (95% confidence interval, CI: -4103, 4307) and of MBSR was -$724 (CI: -4386, 2778)-that is, a net saving of $724. Incremental costs per participant to the health plan were $495 for CBT over UC and -$982 for MBSR, and incremental back-related costs per participant were $984 for CBT over UC and -$127 for MBSR. These costs (and cost savings) were associated with statistically significant gains in QALYs over UC: 0.041 (0.015, 0.067) for CBT and 0.034 (0.008, 0.060) for MBSR.

Conclusion: In this setting CBT and MBSR have high probabilities of being cost-effective, and MBSR may be cost saving, as compared with UC for adults with CLBP. These findings suggest that MBSR, and to a lesser extent CBT, may provide cost-effective treatment for CLBP for payers and society.

Level Of Evidence: 2.
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http://dx.doi.org/10.1097/BRS.0000000000002344DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5694631PMC
October 2017

Long-Term Effects of Repeated Injections of Local Anesthetic With or Without Corticosteroid for Lumbar Spinal Stenosis: A Randomized Trial.

Arch Phys Med Rehabil 2017 08 8;98(8):1499-1507.e2. Epub 2017 Apr 8.

Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, Seattle, WA; Department of Radiology, University of Washington, Seattle, WA; Department of Health Services, University of Washington, Seattle, WA.

Objective: To determine the overall long-term effectiveness of treatment with epidural corticosteroid injections for lumbar central spinal stenosis and the effect of repeat injections, including crossover injections, on outcomes through 12 months.

Design: Multicenter, double-blind, randomized controlled trial comparing epidural injections of corticosteroid plus lidocaine versus lidocaine alone.

Setting: Sixteen clinical sites.

Participants: Participants with imaging-confirmed lumbar central spinal stenosis (N=400).

Interventions: Participants were randomized to receive either epidural injections with corticosteroid plus lidocaine or lidocaine alone with the option of blinded crossover after 6 weeks to receive the alternate treatment. Participants could receive 1 to 2 injections from 0 to 6 weeks and up to 2 injections from 6 to 12 weeks. After 12 weeks, participants received usual care.

Main Outcome Measures: Primary outcomes were the Roland-Morris Disability Questionnaire (RDQ) (range, 0-24, where higher scores indicate greater disability) and leg pain intensity (range, 0 [no pain] to 10 [pain as bad as you can imagine]). Secondary outcomes included opioid use, spine surgery, and crossover rates.

Results: At 12 months, both treatment groups maintained initial observed improvements, with no significant differences between groups on the RDQ (adjusted mean difference, -0.4; 95% confidence interval [CI], -1.6 to 0.9; P=.55), leg pain (adjusted mean difference, 0.1; 95% CI, -0.5 to 0.7; P=.75), opioid use (corticosteroid plus lidocaine: 41.4% vs lidocaine alone: 36.3%; P=.41), or spine surgery (corticosteroid plus lidocaine: 16.8% vs lidocaine alone: 11.8%; P=.22). Fewer participants randomized to corticosteroid plus lidocaine (30%, n=60) versus lidocaine alone (45%, n=90) crossed over after 6 weeks (P=.003). Among participants who crossed over at 6 weeks, the 6- to 12-week RDQ change did not differ between the 2 randomized treatment groups (adjusted mean difference, -1.0; 95% CI, -2.6 to 0.7; P=.24). In both groups, participants crossing over at 6 weeks had worse 12-month trajectories compared with participants who did not choose to crossover.

Conclusions: For lumbar spinal stenosis symptoms, epidural injections of corticosteroid plus lidocaine offered no benefits from 6 weeks to 12 months beyond that of injections of lidocaine alone in terms of self-reported pain and function or reduction in use of opioids and spine surgery. In patients with improved pain and function 6 weeks after initial injection, these outcomes were maintained at 12 months. However, the trajectories of pain and function outcomes after 3 weeks did not differ by injectate type. Repeated injections of either type offered no additional long-term benefit if injections in the first 6 weeks did not improve pain.
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http://dx.doi.org/10.1016/j.apmr.2017.02.029DOI Listing
August 2017

Alterations in amino acid status in cats with feline dysautonomia.

PLoS One 2017 23;12(3):e0174346. Epub 2017 Mar 23.

Royal (Dick) School of Veterinary Studies and The Roslin Institute, University of Edinburgh, Roslin, Midlothian, United Kingdom.

Feline dysautonomia (FD) is a multiple system neuropathy of unknown aetiology. An apparently identical disease occurs in horses (equine grass sickness, EGS), dogs, rabbits, hares, sheep, alpacas and llamas. Horses with acute EGS have a marked reduction in plasma concentrations of the sulphur amino acids (SAA) cyst(e)ine and methionine, which may reflect exposure to a neurotoxic xenobiotic. The aim of this study was to determine whether FD cats have alterations in amino acid profiles similar to those of EGS horses. Amino acids were quantified in plasma/serum from 14 FD cats, 5 healthy in-contact cats which shared housing and diet with the FD cats, and 6 healthy control cats which were housed separately from FD cats and which received a different diet. The adequacy of amino acids in the cats' diet was assessed by determining the amino acid content of tinned and dry pelleted foods collected immediately after occurrences of FD. Compared with controls, FD cats had increased concentrations of many essential amino acids, with the exception of methionine which was significantly reduced, and reductions in most non-essential amino acids. In-contact cats also had inadequate methionine status. Artefactual loss of cysteine during analysis precluded assessment of the cyst(e)ine status. Food analysis indicated that the low methionine status was unlikely to be attributable to dietary inadequacy of methionine or cystine. Multi-mycotoxin screening identified low concentrations of several mycotoxins in dry food from all 3 premises. While this indicates fungal contamination of the food, none of these mycotoxins appears to induce the specific clinico-pathologic features which characterise FD and equivalent multiple system neuropathies in other species. Instead, we hypothesise that ingestion of another, as yet unidentified, dietary neurotoxic mycotoxin or xenobiotic, may cause both the characteristic disease pathology and the plasma SAA depletion.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0174346PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5363954PMC
August 2017

A longitudinal study of depression among middle-aged and senior patients initiating chronic opioid therapy.

J Affect Disord 2017 Mar 6;211:136-143. Epub 2017 Jan 6.

Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.

Background: Improved understanding how depressive symptoms change with sustained opioid use is needed.

Methods: We prospectively assessed patients 45 years or older initiating chronic opioid therapy (COT) at baseline and at 4 and 12 months, differentiating recent COT initiators (n=748) and continuing users (n=468). Level of opioid use before 12-month follow-up was classified as regular/higher-dose, intermittent/lower-dose, or minimal/no use. Depressive symptoms were assessed using the Patient Health Questionnaire-8 (PHQ-8).

Results: Depressive symptoms decreased, on average, from baseline to 12 months regardless of level of opioid use. COT patients with regular/higher-dose compared to those with intermittent/lower-dose opioid use (who had similar pain outcomes) did not differ in PHQ-8 scores at 12 months (adjusted mean difference -0.14, 95% CI, -1.07, 0.78 for COT initiators). At 12 months, COT patients with intermittent/lower-dose use had higher adjusted PHQ-8 scores than did those with minimal/no opioid use (adjusted mean difference 0.77, 95% CI, 0.03-1.52 for COT initiators). However, 77% of patients who discontinued opioids cited improved pain as a reason for discontinuation, while 21% cited negative emotional effects of opioids as a reason for discontinuation. Discontinuation was more common among persons who, at baseline, attributed 3 or more depressive symptoms to opioid use.

Limitations: Results are relevant to older COT patients receiving low to moderate opioid doses.

Conclusions: Depressive symptoms did not increase with sustained opioid use. Depressive symptoms were not higher with regular/higher-dose compared to intermittent/lower-dose use. Persons who perceived negative effects of opioids on emotions more often discontinued their use.
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http://dx.doi.org/10.1016/j.jad.2016.12.052DOI Listing
March 2017

Electronic Health Records to Evaluate and Account for Non-response Bias: A Survey of Patients Using Chronic Opioid Therapy.

Obs Stud 2016 1;2:24-38. Epub 2016 Feb 1.

Department of Psychiatry and Behavioral Sciences; Department of Rehabilitation Medicine; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.

Background: In observational studies concerning drug use and misuse, persons misusing drugs may be less likely to respond to surveys. However, little is known about differences in drug use and drug misuse risk factors between survey respondents and nonrespondents.

Methods: Using electronic health record (EHR) data, we compared respondents and non-respondents in a telephone survey of middle-aged and older chronic opioid therapy patients to assess predictors of interview nonresponse. We compared general patient characteristics, specific opioid misuse risk factors, and patterns of opioid use associated with increased risk of opioid misuse. Inverse probability weights were calculated to account for nonresponse bias by EHR-measured covariates. EHR-measured covariate distributions for the full sample (nonrespondents and respondents), the unweighted respondent sample, and the inverse probability weighted respondent sample are reported. We present weighted and unweighted prevalence of self-reported opioid misuse risk factors.

Results: Among 2489 potentially eligible patients, 1477 (59.3%) completed interviews. Response rates differed with age (45-54 years, 51.8%; 55-64 years, 58.7%; 65-74 years, 67.9%; and 75 years or older, 59.9%). Tobacco users had lower response rates than did nonusers (53.5% versus 60.9%). Charlson comorbidity score was also related to response rates. Individuals with a Charlson score of 2 had the highest response rate at 65.6%; response rates were lower amoung patients with the lowest (the patients with the fewest health conditions had response rates of 56.7-60.0%) and the highest Charlson scores (patients with the most health conditions had response rates of 52.2-56.0%). These bivariate relationships persisted in adjusted multivariable logistic regression models predicting survey response. Response rates of persons with and without specific opioid misuse risk factors were similar (e.g., 58.7% for persons with substance abuse diagnoses, 59.4% for those without). Opioid use patterns associated with opioid misuse did not predict response rates (e.g., 60.6% versus 59.2% for those receiving versus not receiving opioids from 3 or more physicians outside their primary care clinic). Very few patient characteristics predicted non-response; thus, inverse probability weights accounting for nonresponse had little impact on the distributions of EHR-measured covariates or self-reported measures related to opioid use and misuse.

Conclusions: Response rates differed by characteristics that predict nonresponse in general health surveys (age, tobacco use), but did not appear to differ by specific patient or drug use risk factors for prescription opioid misuse among middle- and older-aged chronic opioid therapy patients. When observational studies are conducted in health plan populations, electronic health records may be used to evaluate nonresponse bias and to adjust for variables predicting interview nonresponse, complementing other research uses of EHR data in observational studies.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5193131PMC
February 2016

Prescription Opioid Taper Support for Outpatients With Chronic Pain: A Randomized Controlled Trial.

J Pain 2017 03 28;18(3):308-318. Epub 2016 Nov 28.

Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington.

Patients receiving long-term opioid therapy for chronic pain and interested in tapering their opioid dose were randomly assigned to a 22-week taper support intervention (psychiatric consultation, opioid dose tapering, and 18 weekly meetings with a physician assistant to explore motivation for tapering and learn pain self-management skills) or usual care (N = 35). Assessments were conducted at baseline and 22 and 34 weeks after randomization. Using an intention to treat approach, we constructed linear regression models to compare groups at each follow-up. At 22 weeks, adjusted mean daily morphine-equivalent opioid dose in the past week (primary outcome) was lower in the taper support group, but this difference was not statistically significant (adjusted mean difference = -42.9 mg; 95% confidence interval, -92.42 to 6.62; P = .09). Pain severity ratings (0-10 numeric rating scale) decreased in both groups at 22 weeks, with no significant difference between groups (adjusted mean difference = -.68; 95% confidence interval, -2.01 to .64; P = .30). The taper support group improved significantly more than the usual care group in self-reported pain interference, pain self-efficacy, and prescription opioid problems at 22 weeks (all P-values < .05). This taper support intervention is feasible and shows promise in reducing opioid dose while not increasing pain severity or interference.

Perspective: In a pilot randomized trial comparing a prescription opioid taper support intervention to usual care, lower opioid doses and pain severity ratings were observed at 22 weeks in both groups. The groups did not differ significantly at 22 weeks in opioid dose or pain severity, but the taper support group improved significantly more in pain interference, pain self-efficacy, and perceived opioid problems. These results support the feasibility and promise of this opioid taper support intervention.
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http://dx.doi.org/10.1016/j.jpain.2016.11.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5337146PMC
March 2017

Mindfulness-based stress reduction and cognitive behavioral therapy for chronic low back pain: similar effects on mindfulness, catastrophizing, self-efficacy, and acceptance in a randomized controlled trial.

Pain 2016 11;157(11):2434-2444

Group Health Research Institute, Seattle, WA, USA.

Cognitive behavioral therapy (CBT) is believed to improve chronic pain problems by decreasing patient catastrophizing and increasing patient self-efficacy for managing pain. Mindfulness-based stress reduction (MBSR) is believed to benefit patients with chronic pain by increasing mindfulness and pain acceptance. However, little is known about how these therapeutic mechanism variables relate to each other or whether they are differentially impacted by MBSR vs CBT. In a randomized controlled trial comparing MBSR, CBT, and usual care (UC) for adults aged 20 to 70 years with chronic low back pain (N = 342), we examined (1) baseline relationships among measures of catastrophizing, self-efficacy, acceptance, and mindfulness and (2) changes on these measures in the 3 treatment groups. At baseline, catastrophizing was associated negatively with self-efficacy, acceptance, and 3 aspects of mindfulness (nonreactivity, nonjudging, and acting with awareness; all P values <0.01). Acceptance was associated positively with self-efficacy (P < 0.01) and mindfulness (P values <0.05) measures. Catastrophizing decreased slightly more posttreatment with MBSR than with CBT or UC (omnibus P = 0.002). Both treatments were effective compared with UC in decreasing catastrophizing at 52 weeks (omnibus P = 0.001). In both the entire randomized sample and the subsample of participants who attended ≥6 of the 8 MBSR or CBT sessions, differences between MBSR and CBT at up to 52 weeks were few, small in size, and of questionable clinical meaningfulness. The results indicate overlap across measures of catastrophizing, self-efficacy, acceptance, and mindfulness and similar effects of MBSR and CBT on these measures among individuals with chronic low back pain.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5069124PMC
http://dx.doi.org/10.1097/j.pain.0000000000000635DOI Listing
November 2016

Does association of opioid use with pain and function differ by fibromyalgia or widespread pain status?

Pain 2016 10;157(10):2208-2216

Group Health Research Institute, Seattle, WA, USA.

Many consider chronic opioid therapy (COT) to be ineffective for fibromyalgia, but empirical evidence is limited. Among patients identified as initiating COT, we examined whether fibromyalgia was associated with different relationships of opioid use to pain and activity interference outcomes 12 months later. We obtained electronic data on diagnoses and opioid prescriptions. We obtained patient self-report data, including pain and activity interference measures, at baseline, 4 months, and 12 months. Among 1218 patients, 429 (35%) met our definition of fibromyalgia. Patients with and without fibromyalgia who had intermittent/lower-dose or regular/higher-dose opioid use at 12 months had similar 12-month pain intensity scores. However, among patients with minimal/no opioid use at 12 months, 12-month pain intensity was greater for those with fibromyalgia (adjusted mean = 5.15 [95% confidence interval, 4.80-5.51]; 0-10 scale) than for those without (4.44 [4.15-4.72]). Similar patterns were observed for 12-month activity interference. Among patients who discontinued opioids by 12 months, those with fibromyalgia were more likely to report bothersome side effects and less likely to report pain improvement as important reasons for discontinuation (P < 0.05). In sum, at 12 months, among patients who had discontinued opioids or used them minimally, those with fibromyalgia had worse outcomes and were less likely to have discontinued because of pain improvement. Among patients continuing COT, pain and activity interference outcomes were worse than those of patients with minimal/no opioid use and did not differ for those with fibromyalgia vs those with diverse other chronic pain conditions.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5029856PMC
http://dx.doi.org/10.1097/j.pain.0000000000000631DOI Listing
October 2016

Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy for Chronic Low Back Pain--Reply.

JAMA 2016 Aug;316(6):663-4

Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle.

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http://dx.doi.org/10.1001/jama.2016.7951DOI Listing
August 2016

A Prospective Study of Predictors of Long-term Opioid Use Among Patients With Chronic Noncancer Pain.

Clin J Pain 2017 03;33(3):198-204

Departments of *Psychiatry and Behavioral Sciences ∥Rehabilitation Medicine ¶Anesthesiology and Pain Medicine §Biostatistics #Oral Medicine, University of Washington †Geriatric Research, Education, and Clinical Center, Puget Sound Veterans Affairs Medical Center ‡Group Health Research Institute, Seattle, WA.

Background: Chronic pain patients at increased risk of unfavorable pain and opioid misuse outcomes may be those most likely to use opioids long-term, but this has not been evaluated prospectively.

Objectives: To ascertain whether pain prognostic risk, problem opioid use risk, and depression predict opioid use 1 year later among patients recently initiating opioid therapy with a moderate likelihood of long-term opioid use.

Materials And Methods: Self-report and electronic health record data were collected from patients aged 45+ years who recently initiated opioid therapy (N=762), in an integrated health care system. Logistic regression models tested whether baseline patient chronic pain prognostic risk, problem opioid use risk, depression, and expectations concerning continued opioid use independently predicted continuing use at 1 year (≥30 d supply in the prior 4 mo).

Results: At 1 year, 46% of participants continued to use opioids. Baseline problem opioid use risk score (adjusted odds ratio, 1.15; 95% confidence interval, 1.04-1.26) and expectations about continuing opioid use, but not pain prognostic risk score or depression, were significant predictors of 1-year opioid use. Compared with patients who thought continued opioid use unlikely, those who thought it was extremely or very likely had 4 times the odds of opioid use at 1 year (adjusted odds ratio, 4.05; 95% confidence interval, 2.59-6.31).

Discussion: The strongest predictors of long-term opioid use were not patient-related or medication-related factors, but expectations about using opioids in the future. Asking about such expectations may be the easiest way to identify patients likely to continue opioid use long-term.
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http://dx.doi.org/10.1097/AJP.0000000000000409DOI Listing
March 2017
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