Principles for managing OUD related to chronic pain in the Nordic countries based on a structured assessment of current practice

Background: Long-term use of opioid analgesics (OA) for chronic pain may result in opioid use disorder (OUD). This is associated with adverse outcomes for individuals, families and society. Treatment needs of people with OUD related to chronic pain are different compared to dependence related to use, and also injection, of illicit opioids. In Nordic countries, day-to-day practical advice to assist clinical decision-making is insufficient. Aim: To develop principles based on expert clinical insights for treatment of OUD related to the long-term use of OA in the context of chronic pain. Methods: Current status including an assessment of barriers to effective treatment in Finland, Denmark, Iceland, Norway, Sweden was defined using a patient pathway model. Evidence to describe best practice was identified from published literature, clinical guidelines and expert recommendations from practice experience. Results: Availability of national treatment guidelines for OUD related to chronic pain is limited across the Nordics. Important barriers to effective care identified: patients unlikely to present for help, healthcare system set up limits success, diagnosis tools not used, referral pathways unclear and treatment choices not elucidated. Principles include the development of a specific treatment pathway, awareness/education programs for teams in primary care, guidance on use of diagnostic tools and a flexible treatment plan to encourage best practice in referral, treatment assessment, choice and ongoing management via an integrated care pathway. Healthcare systems and registries in Nordic countries offer an opportunity to further research and identify population risks and solutions. Conclusions: There is an opportunity to improve outcomes for patients with OUD related to chronic pain by developing and introducing care pathways tailored to specific needs of the population.Peer reviewe

Många patienter med långvarig smärta får opioider

Hos patienter med medelsvår/svår långvarig icke-malign smärta är två av fem patienter förskrivna opioida läkemedel vid undersökning 2015–2017 vilket inte ligger i linje med aktuella behandlingsriktlinjer som avråder från långvariga behandlingar med opioida läkemedel då behandlingsnytta är oklar och risker väl belagda

Doktorn frågar Doktorn. Opioidbehandling

Läkare i primärvården samtalar med expert i området opioidbehandling

Prevalence of long-term opioid therapy in a chronic non-cancer pain population attending a university-based tertiary pain clinic in Sweden. A cross-sectional study

BACKGROUND: Opioid therapy has become a common treatment for chronic pain despite accumulating evidence regarding harm and the lack of data to support efficacy for long-term treatments. The prevalence of opioid treatments in Swedish patients with chronic non-cancer pain is unknown. Hence, the present study aimed to assess a short-term period prevalence of prescribed opioid-use and long-term opioid therapy (LTOT) in a population with complex chronic non-cancer pain.METHOD: The study population consisted of 1613 patients suffering from chronic non-cancer pain and referred to a university-based tertiary pain clinic in Sweden during 2015-2017. Data from a 360-day period prior to consultation were extracted from the Swedish Quality Registry for Pain Rehabilitation (SQRP) and Swedish Prescribed Drug Register (SPDR). Milligram morphine equivalents per day (MME/day) for dispensed opioids were analysed for a 90-day period preceding consultation and long-term opioid therapy (LTOT) was determined for the entire 360-day period.RESULTS: The 90-day prevalence was 38% (CI 36-40,8) and the 360-day prevalence was 22.3% (n=360 with CI 20.4-24.4).CONCLUSION: The prescribing rates of opioids in a Swedish population with complex non-cancer chronic pain were high; two in five patients were dispensed an opioid within a 90-day period prior to consultation

Tapering of prescribed opioids in patients with long-term non-malignant pain (TOPIO)-efficacy and effects on pain, pain cognitions, and quality of life : a study protocol for a randomized controlled clinical trial with a 12-month follow-up

BACKGROUND: Opioids are still widely prescribed to long-term pain patients although they are no longer recommended for long-term treatments due to poor evidence for long-term efficacy, risks of serious side effects, and the possibility of inducing opioid hyperalgesia. In a Cochrane study from 2017, the authors identified an urgent need for more randomized controlled trials investigating the efficiency and effects of opioid tapering. The study aimed to assess (1) the efficiency of a structured intervention in causing stable reductions of opioid consumption in a population with long-term non-malignant pain and (2) effects on pain, pain cognitions, physical and mental health, quality of life, and functioning in response to opioid tapering.METHODS: The study is a randomized controlled trial. The sample size was set to a total of 140 individuals after estimation of power and dropout. Participants will be recruited from a population with long-term non-malignant pain who will be randomly allocated to (1) the start of tapering immediately or (2) the control group who return to usual care and will commence tapering of opioids 4 months later. A 12-month follow-up is included. When all follow-ups are closed, data from the Swedish drug register of the National Board of Health and Welfare will be collected and individual mean daily opioid dose in morphine equivalents will be calculated at three time points: baseline, 4 months, and 12 months after the start of the intervention. At the same time points, participants fill out the following questionnaires: Numeric Pain Rating Scale (NPRS), Tampa Scale of Kinesiophobia (TSK), Pain Catastrophizing Scale (PCS), Chronic Pain Acceptance Questionnaire (CPAQ-8), Hospital Anxiety and Depression Scale (HADS), and RAND-36. At baseline and follow-up, a clinical assessment of opioid use disorder is performed.DISCUSSION: A better understanding of the efficiency and effects of opioid tapering could possibly facilitate attempts to taper opioid treatments, which might prove beneficial for both the individual and society.TRIAL REGISTRATION: ClinicalTrials.gov NCT03485430 . Retrospectively registered on 26 March 2018, first release date. "Tapering of Long-term Opioid Therapy in Chronic Pain Population. RCT with 12 Months Follow up (TOPIO)." First patient in trial 22 March 2018

LONG-TERM OPIOID THERAPY AND SIGNS OF OPOID USE DISORDERS IN A CHRONIC NON-CANCER PAIN POPULATIONAT A TERTIARY PAIN CLINIC IN SWEDEN, A CROSS-SECTIONAL STUDY

Förekomst av kända riskfaktorer eller tecken på opioidberoende hos patienter med långvarig opioidbehandling på grund av kronisk smärta

Regionala riktlinjer vid förskrivning av beroendeframkallande läkemedel i Region Skåne

Sammanfattande kommentarer och rekommendation • Opioider och bensodiazepiner är kraftfulla läkemedel med god patientnytta i utvalda fall och under begränsade behandlingstider.• Läkare/vårdenhet som initierat förskrivning har ansvar för denna tills den upphört eller tills annaninstans accepterat övertag – Behandlingsansvar• Basbehandling – överväg alltid först alternativa behandlingsstrategier, såväl icke-farmakologiska som farmakologiska• Fortsätt med den basbehandling som fungerar även om beroendeframkallande läkemedel förskrivs• Gör Riskbedömning av beroende/överdosering före nyinsättning och vid varje förskrivningstillfälle. • Samtidig behandling med opioid och bensodiazepin innebär ökad risk för letal intoxikation. • Planera för korttidsbehandling – och var tydlig med det.• Kontinuerligt långtidsbruk medför ofta negativa effekter och har kända risker.• Vid all långtidsbehandling – överväg indikation och säkerhet regelbundet och diskutera med patienten om biverkningar och effekt.• Intermittent behandling vid recidiverande/kroniska besvär kan vara ett alternativ.• God Kontroll över förskrivningen innebäro tillgång till patientens uppgifter i Nationella läkemedelslistan utan spärrar, dvs patienten har inte dolt recept- och uttagsinformation via till exempel Läkemedelskolleno förskrivarkontinuiteto ställningstagande till behov av provtagning för alkohol/drogscreening och till korta uthämtningsintervall/dosdispensering/utdelning av mediciner • Patientinformation med nedtrappningsschema hittas i slutet av dokumentet

Book talks among people with chronic non-cancer pain : Literary meaning making in a shared reading group

This paper reports findings from a pilot study for the research project SHARP – Shared Reading After Pain Rehabilitation. SHARP explores the feasibility and effect of Shared Reading, a group-based reading intervention, as a way to improve the quality of life for people with chronic non-cancer pain who have undergone a pain rehabilitation programme (5 weeks) at Skåne University Hospital in Sweden. The paper has a methodological focus. Drawing on discursive reception studies (Eriksson Barajas 2015), it aims to explore the usefulness of Judith Langer’s theory of literary meaning making to analyse book talk in a Shared Reading chronic non-cancer pain context. Langer’s key concepts envisionment building and stances (Langer 2011) will be used to trace instances of group members taking others’ perspectives, such as those of literary characters or fellow group members

Swedish Chronic Pain Biobank: protocol for a multicentre registry and biomarker project

INTRODUCTION: About 20% of the adult population have chronic pain, often associated with psychological distress, sick leave and poor health. There are large variations in the clinical picture. A biopsychosocial approach is used in investigation and treatment. The concept of personalised medicine, that is, optimising medication types and dosages for individual patients based on biomarkers and other patient-related factors, has received increasing attention in different diseases but used less in chronic pain. This cooperative project from all Swedish University Hospitals will investigate whether there are changes in inflammation and metabolism patterns in saliva and blood in chronic pain patients and whether the changes correlate with clinical characteristics and rehabilitation outcomes. METHODS AND ANALYSIS: Patients at multidisciplinary pain centres at University Hospitals in Sweden who have chosen to participate in the Swedish Quality Registry for Pain Rehabilitation and healthy sex-matched and age-matched individuals will be included in the study. Saliva and blood samples will be collected in addition to questionnaire data obtained from the register. From the samples, proteins, lipids, metabolites and micro-RNA will be analysed in relation to, for example, diagnosis, pain characteristics, psychological distress, body weight, pharmacological treatment and clinical rehabilitation results using advanced multivariate data analysis and bioinformatics. ETHICS AND DISSEMINATION: The study is approved by the Swedish Ethical Review Authority (Dnr 2021-04929) and will be conducted in accordance with the declaration of Helsinki.The results will be published in open access scientific journals and in popular scientific relevant journals such as those from patient organisations. Data will be also presented in scientific meetings, meeting with healthcare organisations and disseminated in different lecturers at the clinics and universities