Publications by authors named "Peggy Compton"

64 Publications

The Opioid Crisis and the CRNA: Providing Emergency Care for Patients With Opioid Use Disorder.

AANA J 2021 Apr;89(2):103-107

is an internationally known researcher in pain and opioid use disorder. She is an associate professor in the Department of Family and Community Health, and the van Ameringen Chair in Psychiatric and Mental Health Nursing at the University of Pennsylvania, School of Nursing, Philadelphia, Pennsylvania.

Certified Registered Nurse Anesthetists (CRNAs) care for patients with opioid use disorder frequently. Goals are to support recovery, prevent relapse, and effectively and safely treat perioperative pain. During emergencies, care may be urgent to prevent patient harm, potentially interfering with helpful interventions. This article discusses care principles that CRNAs should follow to assure that the anesthetic care goals are achieved during emergent care of patients with opioid use disorder.
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April 2021

Opportunities and challenges presented by recent pedagogical innovations in doctoral nursing education.

J Prof Nurs 2021 Jan-Feb;37(1):228-234. Epub 2020 Sep 2.

NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, 418 Curie Boulevard, Philadelphia, PA 19104, United States of America.

The demand to expand the nurse scientist pipeline over the past decade has generated numerous pedagogical innovations in nursing doctoral education. A PhD nursing education summit was held at the University of Pennsylvania in October 2019 to discuss pedagogical innovations. The main pedagogical innovations discussed by Summit attendees included: 1) the expansion of both 3-year PhD programs and BSN to PhD programs; 2) changes in learning opportunities and curricula content; and 3) the role of postdoctoral fellowships. This overview examines the numerous opportunities and challenges generated by these innovations. Opportunities include producing scholars with research careers that are potentially longer than historically seen in the nursing profession, as well as the emergence of unique educational and mentoring opportunities both during and after doctoral studies. Challenges involve the impact condensed program timelines have had on both the content and delivery of curricula, as well as the research expertise and skillsets of nursing PhD program graduates. There is a need to conduct a national coordinated evaluation of PhD program using shared metrics in order to better evaluate the effect of these pedagogical innovations on the development of nurse scientists, and ultimately, the discipline.
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http://dx.doi.org/10.1016/j.profnurs.2020.09.003DOI Listing
September 2020

Perceived social support in patients with chronic pain with and without opioid use disorder and role of medication for opioid use disorder.

Drug Alcohol Depend 2021 Apr 15;221:108619. Epub 2021 Feb 15.

Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Suite 500, Philadelphia, PA, 19104, United States. Electronic address:

Background: A significant predictor of treatment outcomes for patients with chronic non-cancer pain (CNCP) and opioid use disorder (OUD) is the degree and quality of social support they receive. Specifically, in patients with CNCP and on long-term opioid therapy, the development of OUD tends to be associated with losses in social support, while engagement in treatment for OUD improves support networks. Delivery of the evidence-based OUD treatment medications, methadone and buprenorphine, occurs in clinical environments which patently differ with respect to social support resources. The aims of this study were to describe perceived social support in patients with CNCP without OUD (no-OUD), with OUD and on buprenorphine (OUD-BP), and with OUD and on methadone (OUD-methadone).

Methods: Using the Duke Social Support Index (DSSI), perceived social support in a sample of Caucasian patients with CNCP and on opioid therapy was compared between no-OUDs (n = 834), OUD-methadone (n = 83) and OUD-BP (n = 99) therapy. Average DSSI scores were compared across groups and a linear regression model computed to describe association between group and perceived social support.

Results: No difference was observed in DSSI scores between no-OUDs and OUD-methadone, however scores were lower among OUD-BP participants than those receiving methadone (x = -5.2; 95% CI: -7.5, -2.9) and (x = -6.5, 95% CI: -8.2, -4.9).

Conclusions: Patients with CNCP and OUD on methadone therapy endorse levels of social support comparable to those without OUD, however those on buprenorphine therapy report significantly less support, bringing implications for OUD treatment outcomes.
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http://dx.doi.org/10.1016/j.drugalcdep.2021.108619DOI Listing
April 2021

Revisiting the Fetal Assault Law in Tennessee: Implications and the Way Forward.

Policy Polit Nurs Pract 2021 Feb 10:1527154421989994. Epub 2021 Feb 10.

The University of Tennessee, Knoxville, United States.

The rising prevalence of opioid use disorder (OUD) among those living in the United States has demanded a collaborative response from health care and policy spheres. Addressing OUD among pregnant women is especially difficult, given the controversies surrounding the medical and ethical balance between meeting maternal versus fetal/newborn needs. Most medical organizations discourage the criminalization of drug use in pregnancy due to the adverse public health outcomes of such an approach. Despite this recommendation, many states continue to use punitive law to address drug use in pregnancy. In 2014, the Fetal Assault Law in Tennessee (TN) became the first law in the United States to directly allow women to be prosecuted for drug use in pregnancy. Since its expiration in 2016, this law has been re-introduced several times to the TN legislature in support of permanent implementation. This article outlines the impact of the initial Fetal Assault Law on maternal/newborn health in TN and provides alternative immediate, short-term, and long-term health policy strategies through which health care providers and legislators can better advocate for the well-being of both mothers with OUD and their infants.
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http://dx.doi.org/10.1177/1527154421989994DOI Listing
February 2021

Is It "True" Pain? Pain Treatment Discharge Planning for Seriously Injured Patients.

Ethn Dis 2021 21;31(1):139-148. Epub 2021 Jan 21.

University of Pennsylvania School of Nursing, Philadelphia, PA.

Background: The United States is experiencing an opioid overdose crisis accounting for as many as 130 deaths per day. As a result, health care providers are increasingly aware that prescribed opioids can be misused and diverted. Prescription of pain medication, including opioids, can be influenced by how health care providers perceive the trustworthiness of their patients. These perceptions hinge on a multiplicity of characteristics that can include a patient's race, ethnicity, gender, age, and presenting health condition or injury. The purpose of this study was to identify how trauma care providers evaluate and plan hospital discharge pain treatment for patients who survive serious injuries.

Methods: Using a semi-structured guide from November 2018 to January 2019, we interviewed 12 providers (physicians, nurse practitioners, physician assistants) who prescribe discharge pain treatment for injured patients at a trauma center in Philadelphia, PA. We used thematic analysis to interpret these data.

Results: Participants identified the importance of determining "true" pain, which was the overarching theme that emerged in analysis. Subthemes included perceptions of the influence of reliable methods for pain assessment, the trustworthiness of their patient population, and the consequences of not getting it right.

Conclusions: Trauma care providers described a range of factors, beyond patient-elicited pain reports, in order to interpret their patients' analgesic needs. These included consideration of both the risks of under treatment and unnecessary suffering, and overtreatment and contribution to opioid overdoses.
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http://dx.doi.org/10.18865/ed.31.1.139DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7843056PMC
January 2021

The influence of sleep disturbances and sleep disorders on pain outcomes among veterans: A systematic scoping review.

Sleep Med Rev 2021 Apr 30;56:101411. Epub 2020 Nov 30.

University of Pennsylvania School of Nursing, Philadelphia, PA, USA; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA; University of Pennsylvania Perelman School of Medicine Center for Sleep and Circadian Neurobiology, Philadelphia, PA, USA. Electronic address:

Chronic nonmalignant pain, sleep disturbances and sleep disorders are highly prevalent conditions among U.S. military veterans. Evidence summaries highlight the influence of sleep on pain outcomes in the general adult population but not for the military veteran population. This is a significant gap as U.S. military veterans are an exceedingly high-risk population for both chronic pain and sleep disturbances and/or disorders. We aimed to review the influence of sleep disturbances and sleep disorders on pain outcomes among veterans with chronic nonmalignant pain. A systematic scoping review was conducted using PubMed/Medline, EMBASE, Scopus, CINAHL, and PsycINFO. Twenty-six out of 1450 studies from initial search were included in this review resulting in a combined sample size of N = 923,434 participants. Sleep disturbances and sleep disorders were associated with worse pain outcomes among veterans with chronic pain. Treatment-induced sleep improvements ameliorated pain outcomes in veterans with sleep disorders and sleep disturbances. Research is indicated to address an overlooked pain treatment opportunity - that of sleep disturbance and sleep disorder management.
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http://dx.doi.org/10.1016/j.smrv.2020.101411DOI Listing
April 2021

Evaluating Pain, Opioids, and Delirium in Critically Ill Older Adults.

Clin Nurs Res 2020 Nov 20:1054773820973123. Epub 2020 Nov 20.

University of Pennsylvania, Philadelphia, USA.

Untreated pain and pain management with opioids are independent precipitating factors for delirium. This retrospective study evaluated the relationships among pain severity, its management with opioids, and the onset of delirium in older adult patients admitted to the surgical intensive care unit (SICU). Consecutive patients aged 65 or greater admitted to the SICU over a 5-month period were examined ( = 172). When assessed using a multivariable general estimating equation model, opioids (chi-square [χ], 12.34,  = .0004), but not pain (χ, 3.31,  = .0688) were significant in predicting next-day delirium status. Controlling for pain, patients exposed to opioids were 2.5 times more likely to develop delirium than patients not exposed (95% Confidence Interval: 1.44-4.36). Our data shows that opioid administration predicted the onset of next-day delirium. In an effort to prevent delirium, future research should focus on opioid-sparing pain management approaches to mitigate pain and delirium.
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http://dx.doi.org/10.1177/1054773820973123DOI Listing
November 2020

The Impact of Intentionality of Injury and Substance Use History on Receipt of Discharge Opioid Medication in a Cohort of Seriously Injured Black Men.

J Racial Ethn Health Disparities 2020 Oct 14. Epub 2020 Oct 14.

School of Nursing, University of Pennsylvania, 418 Curie Blvd., Philadelphia, PA, 19104, USA.

Black patients are less likely than white patients to receive pain treatment, especially opioids, for both acute and chronic pain. Black men are at higher risk than other populations of being "assumed criminal" regardless of any involvement in criminal activity. Additionally, certain injury and patient characteristics such as intentionality of injury and substance use history may lead providers to suspect criminal involvement and impact pain treatment decisions. The purpose of this study was to describe factors that predict receipt of opioid prescription at hospital discharge. We conducted a secondary analysis of data from a cohort of 623 seriously injured Black men treated at trauma centers in Philadelphia between 2013 and 2017. Regression models were used to examine relationships between discharge opioid prescriptions, injury intent, and substance use history. Controlling for age, injury severity, pain score, length of hospital stay (LOS), insurance type, and year of study, receipt of opioids was not impacted by injury intent. However, patients who self-reported substance overuse were less likely to receive opioids than those who did not. Patients with higher injury severity, pain scores, and longer LOS were more likely to receive opioids. Of patients who received opioids, patients with higher pain scores and longer LOS received higher dosages than those with lower scores and shorter LOS. While previous research highlights stigmatization experienced by intentionally injured patients, injury intent did not impact receipt of discharge opioid prescriptions in this study. Future research should continue to explore the effect of injury intent on patients' experiences in the healthcare system.
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http://dx.doi.org/10.1007/s40615-020-00896-3DOI Listing
October 2020

Pharmacological treatment of pain among persons with opioid addiction: A systematic review and meta-analysis with implications for drug development.

Addict Biol 2020 Sep 24:e12964. Epub 2020 Sep 24.

VA Connecticut Healthcare System, West Haven, Connecticut, USA.

The clinical features and neurobiology of pain and opioid use disorder (OUD) are inextricably linked. Despite emerging evidence supporting the negative impact of ongoing pain in the treatment of OUD, the pharmacological management of pain in the presence of OUD has received limited attention. We sought to systematically review the studies investigating pharmacotherapies for pain among persons with OUD. Eligible studies had participants with OUD and outcomes including evoked or spontaneous pain. We searched Scopus, Cochrane Database of Systematic Reviews, Medline, and Embase. Out of 1,097 studies that met the search criteria, 12 studies provided data relevant to the research question-five laboratory studies and seven clinical trials. Random effects pooled estimates suggested no significant difference between groups at baseline but a response favoring the active treatment group over placebo, with nonsignificant heterogeneity between studies. Findings from these studies provide preliminary evidence for analgesic and antihyperalgesic effects of gabapentin, GABA agonists, and NMDA antagonists among persons with OUD. To establish the tradeoffs between the analgesic effects and abuse liability of these compounds, further well-controlled clinical trials are required among persons with OUD. This review also underscores the need for methodological enhancement in drug development for pain in OUD. Future research should address the clinical and neurobiological overlap between pain- and addiction-related phenomena. Transdisciplinary approaches may identify biomarkers of these shared phenomena and their neural substrates. The development of novel therapeutics for pain in OUD may be accelerated by such integration of pain and addiction research.
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http://dx.doi.org/10.1111/adb.12964DOI Listing
September 2020

Innovative Approaches to Educating Future Clinicians about Opioids, Pain, Addiction and Health Policy.

Pain Manag Nurs 2021 Feb 3;22(1):11-14. Epub 2020 Aug 3.

Department of Biobehavioral Health Sciences, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

Background: Opioid use disorder and overdose have reached unprecedented levels in many countries across the globe, including the United States, and pain is one of the most common reasons American adults seek healthcare. To address the interrelated public health crises of opioid use disorder and chronic pain, it is vital that clinicians practicing in diverse roles and settings possess the ability and knowledge to effectively manage pain, responsibly prescribe and monitor opioid analgesics, educate patients about harm reduction techniques, and treat opioid use disorder. However, future healthcare professionals are not receiving the training needed to competently provide this care. This gap in curriculum may lead to clinicians being unwilling and unprepared to address the current opioid and overdose crises, which requires a clinical understanding of pain and substance use disorders as well as knowledge about public health and policy interventions. To address this gap, we designed and are teaching an innovative transdisciplinary elective course titled "Opioids: From Receptors to Epidemic" for undergraduate nursing and premedical students.

Aim: In this paper, we present the course curriculum in detail, with the hope that educators at other institutions will design similar courses for their health professions students.
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http://dx.doi.org/10.1016/j.pmn.2020.07.001DOI Listing
February 2021

Increased Experimental Pain Sensitivity in Chronic Pain Patients Who Developed Opioid Use Disorder.

Clin J Pain 2020 09;36(9):667-674

Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia.

Objective: Although the great majority of individuals who take opioids for chronic pain use them appropriately and to good effect, a certain minority will develop the problematic outcome of opioid use disorder (OUD). Characteristics associated with the development of OUD in individuals with chronic pain have been described; however, relatively unexplored is how sensitivity to pain is associated with OUD outcomes.

Materials And Methods: We examined for differences in response to static and dynamic experimental pain stimuli between individuals with chronic nonmalignant pain who developed OUD after starting opioid therapy (n=20) and those on opioid therapy who did not (n=20). During a single experimental session, participants underwent cold pressor and quantitative sensory testing pain assays, and objective and subjective responses were compared between groups; the role of pain catastrophizing in mediating pain responses was examined.

Results: Results suggested that both groups of opioid-dependent patients were similarly hyperalgesic to the cold pressor pain stimulus, with nonparametric testing revealing worsened central pain sensitization (temporal summation) in those who developed OUD. Significant group differences were evident on subjective ratings of experimental pain, such that those who developed OUD rated the pain as more severe than those who did not. Pain catastrophizing was unrelated to pain responses.

Discussion: Despite the small sample size and cross-sectional design, these findings suggest that experimental pain testing may be a novel technique in identifying patients with chronic pain likely to develop OUD, in that they are likely to evidence exacerbated temporal summation and to rate the associated pain as more severe.
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http://dx.doi.org/10.1097/AJP.0000000000000855DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7429335PMC
September 2020

Evaluating delirium outcomes among older adults in the surgical intensive care unit.

Heart Lung 2020 Sep - Oct;49(5):578-584. Epub 2020 May 17.

School of Nursing, University of Pennsylvania, 418 Curie Blvd, Philadelphia, PA, 19104, United States; Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, United States.

Background: Delirium is prevalent in hospitalized older adults. Little is known about delirium among older adults admitted to the surgical intensive care unit (SICU).

Objectives: The purpose of this study was to describe the incidence of delirium, length of stay, 30-day readmission and mortality rates experienced by older adults in the SICU before and after a nurse-driven protocol for delirium-informed care.

Methods: This study employed a retrospective observational cohort design. Consecutive patients 65 years or older admitted to the SICU over six-month periods were compared before (n = 101) and following (n = 172) a nurse-driven protocol for delirium-informed care. Patient-level outcomes included incidence delirium, SICU and hospital length of stay, 30-day readmission and mortality rates. All measures were collected using medical record review.

Results: In the pre- and post-intervention cohorts, 37% (37/101) and 33% (56/172) of patients screened positive for delirium, respectively. Following implementation of the delirium-informed care intervention, the number of days where no CAM-ICU assessment was performed significantly decreased (Pre 1.1 ± 1.4; Post 0.45 ± 0.65; p <0.001) and the number of negative assessments significantly increased (Pre 2.45 ± 1.66; Post 2.94 ± 1.69; p < 0.0178), indicating that nurses post-intervention were more consistently assessing for delirium.

Conclusions: This study failed to show improvements in patient outcomes (SICU and hospital length of stay, 30-day readmission and mortality rates), before and following a delirium-informed care intervention. However, positive trends in the data suggest that delirium-informed care has the potential to increase rates of assessment and delirium identification, thereby providing the foundation for reducing the consequences of delirium and improve patient-level outcomes. Further better controlled prospective work is needed to validate this intervention.
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http://dx.doi.org/10.1016/j.hrtlng.2020.04.009DOI Listing
March 2021

School nurse reported supply and administration of naloxone in schools.

Public Health Nurs 2020 05 24;37(3):347-352. Epub 2020 Feb 24.

Penn Injury Science Center, University of Pennsylvania, Philadelphia, PA, USA.

Objective: To describe school nurse reported naloxone supply and administration in Pennsylvania, as well as nurse and school-level characteristics associated with naloxone availability.

Methods: Cross-sectional, online survey with school nurses in Pennsylvania. Data were collected (3/14/18-6/5/18) on school nurse demographic and professional characteristics, school characteristics, naloxone supply and administration, and when not available, reasons for not having a naloxone supply.

Results: A total of 362 school nurses met inclusion criteria, representing schools in 56 of the 67 Pennsylvania counties. Over half of the school nurses reported a naloxone supply in their school building (53.6%, n = 194). Additionally, 5.2% of those who had a naloxone supply reported that it had been administered in their school or at a school sponsored activity. The most common reasons for not having naloxone available included lack of support and the belief that naloxone was not needed in their school.

Conclusion: Although many school nurses reported having a naloxone supply in their school, and a small percentage reported administration, particular barriers to access and use remain.
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http://dx.doi.org/10.1111/phn.12715DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7376294PMC
May 2020

Acute Pain Management for Patients Receiving Medication-Assisted Therapy.

Authors:
Peggy Compton

AACN Adv Crit Care 2019 Dec;30(4):335-342

Peggy Compton is Associate Professor, School of Nursing, University of Pennsylvania, 418 Curie Blvd, Room 402, Philadelphia, PA 19104

Evidence-based approaches for the treatment of opioid use disorder include the use of opioid medications (methadone, buprenorphine, or naltrexone), collectively referred to as medication-assisted therapy. Patients receiving medication-assisted therapy may present in the acute care setting with pain, often related to planned surgical procedures to treat health issues that were not addressed before entering treatment. Because these medications act on the same receptors as do analgesic opioids-and, in the cases of methadone and buprenorphine, have analgesic properties - managing acute pain in these patients can be challenging. Principles of effective pain management for these patients include continuing the usual medication-assisted therapy dose; using nonpharmacological and nonopioid pain management strategies as possible and immediate-release opioids, titrating to effect and monitoring for toxicity; anticipating tolerance and hyperalgesia; and establishing a collaborative treatment relationship with the medication-assisted therapy provider. Providing effective pain treatment supports ongoing recovery in patients with opioid use disorder.
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http://dx.doi.org/10.4037/aacnacc2019328DOI Listing
December 2019

The Opioid Crisis and the Certified Registered Nurse Anesthetist: Caring for Patients With Opioid Use Disorder in Drug-Free Recovery.

AANA J 2018 Oct;86(5):82-87

is an associate professor and van Ameringen Endowed Chair in the Department of Family and Community Health at the University of Pennsylvania School of Nursing. Her ongoing research programs explore pain and opioid addiction, with a specific focus on opioid-induced hyperalgesia in chronic pain and opioid-dependent individuals.

Opioid Use Disorder (OUD), the diagnostic term for opioid addiction, is estimated to affect millions of Americans and cost those who suffer it enormously. Given that opioid analgesics are a common component of anesthesia, how can we deliver safe and effective care to those who are in drug-free remission? This editorial will provide a background of this disorder, and will focus specifically on recommendations and guidelines available to the nurse anesthetist on the appropriate anesthetic care for the surgical patient population with OUD in recovery and not on maintenance therapy.
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October 2018

Nursing Education in the Midst of the Opioid Crisis.

Pain Manag Nurs 2020 02 26;21(1):35-42. Epub 2019 Jul 26.

College of Nursing and Health Professions, Drexel University, Philadelphia, Pennsylvania.

Objectives: The current opioid addiction crisis highlights two chronic health conditions which have traditionally received relatively little emphasis in nursing curricula: addiction and chronic pain. In an effort to provide direction to nursing programs in the US on the curriculum needed to prepare students to care for patients and meaningfully intervene in the opioid crisis, this paper presents an overview of the curricular elements which require integration.

Design And Data Sources: Specifically, the state of current nursing education in pain and addiction are reviewed, followed by foundational knowledge for nursing practice to address the opioid crisis.

Review/analysis Methods: Practice competencies for generalist registered nurses as well as advanced practice nurses will then be detailed, and, recognizing the role nurses play in policy development and implementation, policy interventions to address the opioid crisis will also be presented.

Result And Conclusions: Both addiction and chronic pain are sources of suffering for patients; the key role nursing can play in reducing the experience of these illnesses in these vulnerable populations is critical to addressing the opioid addiction crisis.
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http://dx.doi.org/10.1016/j.pmn.2019.06.006DOI Listing
February 2020

Chronic pain and addiction: worry about the worrier.

Authors:
Peggy Compton

Am J Drug Alcohol Abuse 2019 12;45(5):430-431. Epub 2019 Jul 12.

a School of Nursing, University of Pennsylvania , Philadelphia , PA.

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http://dx.doi.org/10.1080/00952990.2019.1642342DOI Listing
July 2020

Nursing interventions for sexual dysfunction: An integrative review for the psychiatric nurse.

Arch Psychiatr Nurs 2019 08 23;33(4):389-399. Epub 2019 Apr 23.

The University of Pennsylvania, School of Nursing, 418 Curie Blvd, Room 402, Philadelphia, PA 19104, United States of America. Electronic address:

Sexual dysfunctions are prevalent disorders in psychiatric patients that too often are not addressed by psychiatric-mental health nurses. An integrative review was conducted using PubMed, Joanna Briggs Institute, SCOPUS, PsycINFO and CINAHL databases to evaluate the evidence for independent, nursing interventions for sexual dysfunction across all nursing literature that could be implemented by psychiatric-mental health nurses. Out of 2448 articles, nine papers met inclusion criteria and were synthesized. Best available evidence was found for sexual teaching interventions for female sexual dysfunction. The implications for psychiatric-mental health nursing practice and recommendations for future research are discussed.
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http://dx.doi.org/10.1016/j.apnu.2019.04.003DOI Listing
August 2019

Development of the Revised Opioid Risk Tool to Predict Opioid Use Disorder in Patients with Chronic Nonmalignant Pain.

J Pain 2019 07 26;20(7):842-851. Epub 2019 Jan 26.

Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

The Opioid Risk Tool (ORT) is a commonly used measure of risk of aberrant drug-related behaviors in patients with chronic pain prescribed opioid therapy. In this study, the discriminant predictive validity of the ORT was evaluated in a unique cohort of patients with chronic nonmalignant pain (CNMP) on long-term opioid therapy who displayed no evidence of developing an opioid use disorder (OUD) and a sample of patients with CNMP who developed an OUD after commencing opioid therapy. Results revealed that the original ORT was able to discriminate between patients with and without OUDs (odds ratio = 1.624; 95% confidence interval [CI] = 1.539-1.715, P < .001). A weighted ORT eliminating the gender-specific history of preadolescent sexual abuse item revealed comparable results (odds ratio = 1.648, 95% CI = 1.539-1.742, P < .001). A revised unweighted ORT removing the history of preadolescent sexual abuse item was notably superior in predicting the development of OUD in patients with CNMP on long-term opioid therapy (odds ratio = 3.085; 95% CI = 2.725-3.493; P < .001) with high specificity (.851; 95% CI = .811-.885), sensitivity (.854; 95% CI = .799-.898), positive predictive value (.757; 95% CI = .709-.799), and negative predictive value (.914; 95% CI = .885-.937). Perspective: The revised ORT is the first tool developed on a unique cohort to predict the risk of developing an OUD in patients with CNMP receiving opioid therapy, as opposed to aberrant drug-related behaviors that can reflect a number of other issues. The revised ORT has clinical usefulness in providing clinicians a simple, validated method to rapidly screen for the risk of developing OUD in patients on or being considered for opioid therapy.
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http://dx.doi.org/10.1016/j.jpain.2019.01.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6768552PMC
July 2019

Minocycline does not affect experimental pain or addiction-related outcomes in opioid maintained patients.

Psychopharmacology (Berl) 2019 Oct 18;236(10):2857-2866. Epub 2018 Dec 18.

Department of Psychiatry, Yale University School of Medicine, West Haven, CT, USA.

Rationale: Minocycline, a tetracycline antibiotic, inhibits activation of microglia. In preclinical studies, minocycline prevented development of opioid tolerance and opioid-induced hyperalgesia (OIH). The goal of this study was to determine if minocycline changes pain threshold and tolerance in individuals with opioid use disorder who are maintained on agonist treatment.

Methods: In this double-blind, randomized human laboratory study, 20 participants were randomized to either minocycline (200 mg/day) or placebo treatment for 15 days. The study had three test sessions (days 1, 8, and 15 of treatment) and one follow-up visit 1 week after the end of treatment. In each test session, participants were assessed on several subjective and cognitive measures, followed by assessment of pain sensitivity using the Cold Pressor Test (CPT). Daily surveys and cognitive measures using Ecological Momentary Assessment (EMA) were also collected four times a day on days 8 through 14 of treatment, and proinflammatory serum cytokines were assessed before and on the last day of treatment.

Results: Minocycline treatment did not change pain threshold or tolerance on the CPT. Similarly, minocycline did not change severity of pain, opioid craving, withdrawal, or serum cytokines. Minocycline treatment increased accuracy on a Go/No-Go task.

Conclusions: While these findings do not support minocycline's effects on OIH, minocycline may have a potential use as a cognitive enhancer for individuals with opioid use disorder, a finding that warrants further systematic studies.
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http://dx.doi.org/10.1007/s00213-018-5146-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6581631PMC
October 2019

Evaluating the use of dexmedetomidine for the reduction of delirium: An integrative review.

Heart Lung 2018 11 25;47(6):591-601. Epub 2018 Sep 25.

University of Pennsylvania, School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104, United States.

Delirium, an acute change in cognition and attention not secondary to a pre-existing condition or dementia, affects nearly 40,000 hospitalized older adults in the United States every day. Delirium is associated with increased healthcare costs of $16,303 to $64,421 per patient. To date, no single pharmacological intervention is effective in preventing or treating delirium in critically ill patients. Evidence suggests the alpha-2 agonist, dexmedetomidine, may reduce or prevent delirium. An integrative review examined whether dexmedetomidine was associated with a lower incidence of delirium compared to other analgesic and sedation strategies. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guided this review and 16 publications met quality criteria for inclusion. These studies support that postoperative administration of dexmedetomidine may reduce delirium in patients, particularly following cardiac surgery. Further research is needed to determine the benefits of dexmedetomidine in patients on mechanical ventilation and optimal timing and duration of administration.
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http://dx.doi.org/10.1016/j.hrtlng.2018.08.007DOI Listing
November 2018

Antagonists in the medical management of opioid use disorders: Historical and existing treatment strategies.

Am J Addict 2018 04;27(3):177-187

Baylor College of Medicine, Houston, Texas.

Background And Objectives: Opioid use disorder (OUD) is a chronic condition with potentially severe health and social consequences. Many who develop moderate to severe OUD will repeatedly seek treatment or interact with medical care via emergency department visits or hospitalizations. Thus, there is an urgent need to develop feasible and effective approaches to help persons with OUD achieve and maintain abstinence from opioids. Treatment that includes one of the three FDA-approved medications is an evidence-based strategy to manage OUD. The purpose of this review is to address practices for managing persons with moderate to severe OUD with a focus on opioid withdrawal and naltrexone-based relapse-prevention treatment.

Methods: Literature available on PubMed was used to review the evolution of treatment strategies from the 1960s onward to manage opioid withdrawal and initiate treatment with naltrexone.

Results: Emerging practices for extended-release naltrexone induction include the use of agonist tapers and adjuvant medications. Clinical challenges frequently encountered when initiating this therapy include managing withdrawal and ongoing opioid use during treatment. Clinical factors may inform decisions regarding patient selection and length of naltrexone treatment, such as recent opioid use and patient preferences.

Conclusions And Scientific Significance: Treatment strategies to manage opioid withdrawal have evolved, but many patients with OUD do not receive medication for the prevention of relapse. Clinical strategies for induction onto extended-release naltrexone are now available and can be safely and effectively implemented in specialty and select primary care settings. (© 2018 The Authors. The American Journal on Addictions Published by Wiley Periodicals, Inc. on behalf of The American Academy of Addiction Psychiatry (AAAP);27:177-187).
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http://dx.doi.org/10.1111/ajad.12711DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5900907PMC
April 2018

Addressing the Potential for Perioperative Relapse in Those Recovering from Opioid Use Disorder.

Pain Med 2018 10;19(10):1908-1915

Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA.

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http://dx.doi.org/10.1093/pm/pnx277DOI Listing
October 2018

Providing chronic pain management in the "Fifth Vital Sign" Era: Historical and treatment perspectives on a modern-day medical dilemma.

Drug Alcohol Depend 2017 Apr;173 Suppl 1:S11-S21

Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia PA, USA. Electronic address:

Background: Over 100 million Americans are living with chronic pain, and pain is the most common reason that patients seek medical attention. Despite the prevalence of pain, the practice of pain management and the scientific discipline of pain research are relatively new fields compared to the rest of medicine - contributing to a twenty-first century dilemma for health care providers asked to relieve suffering in the "Fifth Vital Sign" era.

Methods: This manuscript provides a narrative review of the basic mechanisms of chronic pain and history of chronic pain management in the United States - including the various regulatory, health system and provider factors that contributed to the decline of multidisciplinary pain treatment in favor of the predominant opioid treatment strategy seen today. Multiple non-opioid pain treatment strategies are then outlined. The manuscript concludes with three key questions to help guide future research at the intersection of pain and addiction.

Conclusions: The assessment and treatment of chronic pain will continue to be one of the most common functions of a health care provider. To move beyond an over reliance on opioid medications, the addiction and pain research communities must unite with chronic pain patients to increase the evidence base supporting non-opioid analgesic strategies.
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http://dx.doi.org/10.1016/j.drugalcdep.2016.12.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5771233PMC
April 2017

Substance Abuse and Addiction: Implications for Pain Management in Patients With Cancer
.

Clin J Oncol Nurs 2017 04;21(2):203-209

State University of New York at Buffalo.

Background: Substance use disorders (SUDs) are chronic diseases that may complicate the nursing care of patients with cancer, affecting their ability to adhere to treatment protocols, responses to cancer pain, and use of opioids for analgesia.

Objectives: This article explores how the presence of an SUD may affect oncology nursing care and pain management.

Methods: The PubMed and CINAHL® databases were searched for articles from 1980-2016 using the keywords cancer, cancer pain, addiction, substance abuse, and alcoholism.
.

Findings: SUD is a common comorbidity in patients with cancer that may play a role in disease etiology. Practice guidelines are suggested for the assessment and management of addiction to improve overall outcomes for patients. Effective treatments for SUDs and cancer pain exist, and recovery can lead to improvements in multiple aspects of patients' lives.
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http://dx.doi.org/10.1188/17.CJON.203-209DOI Listing
April 2017

Opioid Misuse/Abuse and Quality Persistent Pain Management in Older Adults.

J Gerontol Nurs 2016 Dec;42(12):21-30

The United States is amid an epidemic of prescription opioid drug abuse, bringing with it not only high rates of overdose, but growing rates of heroin abuse and addiction. Liberal opioid drug prescribing on the part of well-meaning clinicians has in part fueled this epidemic, being correlated to opioid death and addiction treatment admission rates. Misuse and abuse of prescription opioid drugs is greatest among young adults (ages 18 to 25); however, the fastest growing age group for opioid drug misuse/abuse is older (ages 50 to 64). Prescription opioid drug use issues may emerge in the context of persistent pain, and risk factors for misuse/abuse and overdose in older patients with pain require further description. In keeping with national initiatives to combat prescription opioid drug abuse and overdose, current clinical guidelines reflect an "opioid-sparing" approach. To the degree that these guidelines improve persistent pain and opioid drug misuse/abuse outcomes, significant public health benefits will be accrued. Efforts to reduce both require action and are national priorities. [Journal of Gerontological Nursing, 42(12), 21-30.].
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http://dx.doi.org/10.3928/00989134-20161110-06DOI Listing
December 2016

Use of risk mitigation practices by family nurse practitioners prescribing opioids for the management of chronic nonmalignant pain.

Subst Abus 2017 Jan-Mar;38(1):95-104

b Department of Advanced Nursing Practice , Georgetown University , Washington , DC , USA.

Background: Ongoing opioid analgesic use in patients suffering from chronic nonmalignant pain (CNMP) has been associated with the development of opioid misuse, abuse, addiction, and overdose. To prevent these adverse outcomes, it is important that family nurse practitioners (FNPs) implement recommended risk mitigation practices (RMPs) when treating CNMP patients with opioids.

Methods: A national sample of 856 FNPs was invited to answer an online survey about their utilization of opioids and RMPs in treating CNMP.

Results: One hundred sixty-eight FNPs responded (20% response rate), of whom 51.2% affirmed that they prescribe opioids for CNMP. Of the 86 FNPs who prescribe opioids, 66.7% said that less than 25% of their patients were receiving ongoing opioid therapy. The most frequently prescribed opioids were hydrocodone (77.9%) and oxycodone (58.1%). With respect to RMPs, 50 of the 86 opioid-prescribing FNPs (58.8%) reported using treatment contracts with their CNMP patients. Far fewer (20.9%) used formal screening tools to gauge the risk of opioid abuse and misuse. Most respondents (54.94%) reported using prescription monitoring programs, whereas only 33.0% reported using urine toxicology to monitor opioid use. Of the prescribing FNPs, 15.1% reported using abuse-deterrent opioid formulations. Age was found to be a correlate for prescribing opioids for CNMP, with those under 40 years of age less likely to use urine toxicology than those over 41 (45.2% vs. 4.2%; χ(6) = 11.90, P = .06). Additionally, respondents who did not use treatment contracts reported significantly fewer years in practice (10.5 years, SD = 6.1) than those who did (13.6 years, SD = 1.54, df = 2.82, P = .02).

Conclusions: Although RMPs are recommended for use in all CNMP patients receiving ongoing opioid therapy, FNPs do not consistently implement them. In the midst of the current opioid epidemic, FNPs must be vigilant about using appropriate opioid prescription practices.
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http://dx.doi.org/10.1080/08897077.2016.1265038DOI Listing
February 2018

Diffusion Tensor Imaging and Neurobehavioral Outcome in Children With Brain Tumors Treated With Chemotherapy.

J Pediatr Oncol Nurs 2016 Mar-Apr;33(2):119-28. Epub 2015 Jul 27.

David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.

Background: Childhood brain tumor survivors (CBTS) often experience treatment-related neurocognitive deficits affecting quality of life (QOL), but systemic chemotherapy contributions to outcomes are unclear. Our objective was to relate brain tissue changes to neurocognitive and QOL effects after systemic myeloablative chemotherapy with autologous hematopoietic progenitor cell rescue in CBTS.

Procedure: Regional brain volumes and diffusion tensor indices were correlated with neurocognitive, behavioral, and QOL measures, and compared between 8 CBTS (mean age 8.5 years, mean age at diagnosis 32 months), and 9 healthy controls (mean 9.3 years).

Results: Overall QOL, school, and psychosocial functioning were significantly lower in patients (P < .05). Most patients scored within normative ranges on neurocognitive and behavioral assessment. Elevated mean diffusivity and decreased fractional anisotropy, indicating gray and white matter injury, respectively, appeared in memory and executive functioning areas. Low scores on Inhibition on the Neuropsychological Assessment-II were correlated with elevated mean diffusivity in prefrontal cortex.

Conclusions: Brain injury, decreased QOL, and to a lesser extent, executive functioning deficits appear in CBTS treated with myeloablative chemotherapy and autologous hematopoietic progenitor cell rescue. Early cognitive and psychological assessment and intervention are warranted in this population.
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http://dx.doi.org/10.1177/1043454215590104DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5960591PMC
November 2016

Responsible opioid use.

J Pain Palliat Care Pharmacother 2015 Jun;29(2):166-8

Editor's Note The journal is delighted to introduce a new feature in this issue that focuses on the complex and multifaceted issue of managing pain and related symptoms while responsibly attending to minimizing substance abuse. How should the seemingly disparate disciplines of drug abuse and symptom control interact? Should these be two separate fields or should practitioners/investigators in one also be qualified in the other? Is that even feasible? We are honored to have two leading, academically based clinician scientists coordinating this new feature. Peggy Compton is Professor and Associate Dean for Academic Affairs at the School of Nursing & Health Studies, Georgetown University in Washington, DC. Many readers know of Peggy's work from her years on the faculty of the University of California at Los Angeles (UCLA). Peggy brings both clinical and scientific addictionology expertise as well as the invaluable perspective of nursing to this arena. Her collaborator is Michael F. Weaver. Mike is Professor of Psychiatry and Behavioral Sciences, and Medical Director of the Center for Neurobehavioral Research on Addictions, at the University of Texas Health Sciences Center at Houston. Prior to moving to Texas, Dr. Weaver became internationally known for his work in addiction medicine at the Medical College of Virginia. We look forward to detailed explorations of many interacting issues in symptom control and substance abuse in the articles featured in this new journal feature in coming issues. The commentary below, the article by Kanouse and Compton, the Issue Brief issued by the U.S. Department of Health and Human Services, and my editorial, all of which appear in this journal issue, introduce the new feature, which I am confident will make valuable contributions to the pain management and substance abuse literature. Arthur G. Lipman, Editor ABSTRACT Abusers of prescription opioids represent two distinct populations: those who develop addiction via opioids prescribed for pain, and those for whom prescription opioids represent a primary drug of abuse. Regardless of the pathway to abuse, outcomes for patients with untreated opioid addiction are poor, and consideration of the contextual factors surrounding their problematic use is critical to effective treatment. Reviewed are patterns of prescription opioid abuse among particularly vulnerable populations in underserved rural communities, and in an effort to prevent problematic use, principles of responsible opioid prescription for chronic pain are outlined so as to decrease the risk for developing addiction.
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http://dx.doi.org/10.3109/15360288.2015.1037522DOI Listing
June 2015

The epidemic of prescription opioid abuse, the subsequent rising prevalence of heroin use, and the federal response.

J Pain Palliat Care Pharmacother 2015 Jun;29(2):102-14

Opioids are a mainstay in the treatment of pain both chronically and acutely. In the past 20 years, the prescribing of opioids has increased exponentially. As the population for whom opioids are indicated has grown, with the number of opioid prescriptions written increased, so have indicators of opioid misuse, abuse, morbidity, and mortality. The purpose of this article is to review and explore the combination of factors of events that led to the current "epidemic" of prescription opioid abuse and overdose deaths, as well as the subsequent resurgence of heroin use among opioid addicts. Federal initiatives to mount war on prescription opioid abuse are reviewed, including responses from the White House, Drug Enforcement Agency (DEA), Food and Drug Administration (FDA), and interagency initiatives. Many initiatives are currently in place to combat the rising rates of morbidity and mortality associated with opioids, and those involved are hopeful in their efforts to curb the epidemic of this deadly phenomenon.
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http://dx.doi.org/10.3109/15360288.2015.1037521DOI Listing
June 2015