Literature Collection

BACKGROUND: Opioid overdose deaths have reached epidemic proportions in the United States. This problem stems from both licit and illicit opioid use. Prescribing opioids, recognizing risky use, and initiating prevention, including opioid overdose prevention training (OOPT), are key roles physicians play. The American Heart Association (AHA) modified their basic life support (BLS) algorithms to consider naloxone in high-risk populations and when a pulse is appreciated; however, the AHA did not provide OOPT. The authors' intervention filled this training deficiency by teaching medical students opioid overdose resuscitation with a Train-the-Trainer model as part of mandatory BLS training. METHODS: The authors introduced OOPT, following a Train-the-Trainer model, into the required basic life support (BLS) training for first-year medical students at a single medical school in a large urban area. The authors administered pre- and post-evaluations to assess the effects of the training on opioid overdose knowledge, self-reported preparedness to respond to opioid overdoses, and attitudes towards patients with substance use disorders (SUDs). RESULTS: In the fall 2014, 120 first-year medical students received OOPT. Seventy-three students completed both pre- and posttraining evaluations. Improvements in knowledge about and preparedness to respond to opioid overdoses were statistically significant (P < .01) and large (Cohen's D = 2.70 and Cohen's D = 2.10, respectively). There was no statistically significant change in attitudes toward patients with SUDs. CONCLUSIONS: The authors demonstrated the effectiveness of OOPT as an adjunct to BLS in increasing knowledge about and preparedness to respond to opioid overdoses; improving attitudes toward patients with SUDs likely requires additional intervention. The authors will characterize knowledge and preparedness durability, program sustainability, and long-term changes in attitudes in future evaluations. These results support dissemination of OOPT as a part of BLS training for all medical students, and potentially all BLS providers.

BACKGROUND: National guidelines advise decreasing opioids for chronic pain, but there is no guidance on implementation. OBJECTIVE: To evaluate the effectiveness of an Integrated Pain Team (IPT) clinic in decreasing opioid dose and mitigating opioid risk. DESIGN: This study prospectively compared two matched cohorts receiving chronic pain care through IPT (N = 147) versus usual primary care (UPC, N = 147) over 6 months. Patients were matched on age, sex, psychiatric diagnoses, and baseline opioid dose. PATIENTS: Veterans receiving care at a VA medical center or VA community-based clinics. INTERVENTION: Interdisciplinary IPT, consisting of a collocated medical provider, psychologist, and pharmacist embedded in VA primary care providing short-term biopsychosocial management of veterans with chronic pain and problematic opioid use. MAIN MEASURES: Change in opioid dose expressed as morphine equivalent daily dose (MEDD) and opioid risk mitigation evaluated at baseline, 3 months, and 6 months. KEY RESULTS: Compared with veterans receiving UPC, those followed by IPT had a greater mean MEDD decrease of 42 mg versus 8 mg after 3 months and 56 mg versus 17 mg after 6 months. In adjusted analysis, compared with UPC, veterans in IPT achieved a 34-mg greater mean reduction at 3 months (p = 0.002) and 38-mg greater mean reduction at 6 months (p = 0.003). Nearly twice as many patients receiving care through IPT versus UPC reduced their daily opioid dose by >/=50%, representing more than a two-fold improvement at 3 months, which was sustained at 6 months [odds ratio = 2.03; 95% CI = 1.04-3.95, p = 0.04]. Significant improvements were also demonstrated in opioid risk mitigation by 6 months, including increased urine drug screen monitoring, naloxone kit distribution, and decreased co-prescription of opioids and benzodiazepines (all p values < 0.001). CONCLUSIONS: Interdisciplinary biopsychosocial models of pain care can be embedded in primary care and lead to significant improvements in opioid dose and risk mitigation.

BACKGROUND: National guidelines advise decreasing opioids for chronic pain, but there is no guidance on implementation. OBJECTIVE: To evaluate the effectiveness of an Integrated Pain Team (IPT) clinic in decreasing opioid dose and mitigating opioid risk. DESIGN: This study prospectively compared two matched cohorts receiving chronic pain care through IPT (N = 147) versus usual primary care (UPC, N = 147) over 6 months. Patients were matched on age, sex, psychiatric diagnoses, and baseline opioid dose. PATIENTS: Veterans receiving care at a VA medical center or VA community-based clinics. INTERVENTION: Interdisciplinary IPT, consisting of a collocated medical provider, psychologist, and pharmacist embedded in VA primary care providing short-term biopsychosocial management of veterans with chronic pain and problematic opioid use. MAIN MEASURES: Change in opioid dose expressed as morphine equivalent daily dose (MEDD) and opioid risk mitigation evaluated at baseline, 3 months, and 6 months. KEY RESULTS: Compared with veterans receiving UPC, those followed by IPT had a greater mean MEDD decrease of 42 mg versus 8 mg after 3 months and 56 mg versus 17 mg after 6 months. In adjusted analysis, compared with UPC, veterans in IPT achieved a 34-mg greater mean reduction at 3 months (p = 0.002) and 38-mg greater mean reduction at 6 months (p = 0.003). Nearly twice as many patients receiving care through IPT versus UPC reduced their daily opioid dose by ≥50%, representing more than a two-fold improvement at 3 months, which was sustained at 6 months [odds ratio = 2.03; 95% CI = 1.04-3.95, p = 0.04]. Significant improvements were also demonstrated in opioid risk mitigation by 6 months, including increased urine drug screen monitoring, naloxone kit distribution, and decreased co-prescription of opioids and benzodiazepines (all p values < 0.001). CONCLUSIONS: Interdisciplinary biopsychosocial models of pain care can be embedded in primary care and lead to significant improvements in opioid dose and risk mitigation.

OBJECTIVE: The objective of this study is to examine rural hospitals' status in implementing opioid stewardship program (OSP) elements and assess differences in implementation in emergency department (ED) and acute inpatient departments. DESIGN: Health administrator survey to identify the number and type of OSP elements that each hospital has implemented. SETTING: Arizona critical access hospitals (CAHs). PARTICIPANTS: ED and acute inpatient department heads at 17 Arizona CAHs (total of 34 assessments). MAIN OUTCOME MEASURES: Implementation of 11 OSP elements, by department (ED vs inpatient) and prevention orientation (primary vs tertiary). RESULTS: The percentage of implemented elements ranged from 35 to 94 percent in EDs and 24 to 88 percent in acute care departments. Reviewing the prescription drug monitoring program database and offering alternatives to opioids were the most frequently implemented. Assessing opioid use disorder (OUD) and prescribing naloxone were among the least. The number of implemented elements tended to be uniform across departments. We found that CAHs implemented, on average, 67 percent of elements that prevent unnecessary opioid use and 54 percent of elements that treat OUD. CONCLUSIONS: Some OSP elements were in place in nearly every Arizona CAH, while others were present in only a quarter or a third of hospitals. To improve, more attention is needed to define and standardize OSPs. Equal priority should be given to preventing unnecessary opioid initiation and treating opioid misuse or OUD, as well as quality control strategies that provide an opportunity for continuous improvement.