A Pharmacist-Assisted Initiative to Improve Chronic Pain Management and Reduce Opioid Use in Primary Care

Background– Since publication of the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain, there have been growing concerns that providers, including those in primary care, are tapering opioids too quickly and without concomitant use of non-opioid strategies for pain, leading to inadequate pain management. As a result, in November 2022 the CDC published Clinical Practice Guidelines for Prescribing Opioids for Pain, emphasizing the importance of creating comprehensive care plans for pain management and developing a consensual plan between provider and patient when tapering opioids. Objective–Determine the impact of a pharmacist-assisted approach aimed at helping primary care providers minimize opioid use while improving management of chronic, non-malignant pain (CNMP).  Methods – This quality improvement project focused on one primary care provider partnering with a pharmacist to reassess the management of patients on long-term opioid therapy (LTOT) for CNMP. The intervention included a letter informing patients of the provider’s intent, pharmacist outreach to intervention patients, and pharmacist development of a patient registry, updated regularly with clinical data, recommendations, and outcomes for the provider to reference throughout the project. The intervention group was compared to patients prescribed opioids for CNMP by the remaining providers at the clinic who did not engage in the quality initiative.    Results – The intervention group had a mean effective daily morphine milligram equivalent (MME) reduction of 73.7% (17.2% control) after 18 months and 60% of patients discontinued opioids (14.3% control). In a subset of patients with functional assessment scores, 93.3% were either improved or unchanged, despite a 62.5% decrease in their mean effective daily MME. In both groups, one patient transferred care to a new provider.   Conclusions – With targeted recommendations and assistance from a pharmacist, a primary care provider can make significant progress in improving management of CNMP while reducing opioid prescribing

Cellulose-Enriched Microbial Communities from Leaf-Cutter Ant (Atta colombica) Refuse Dumps Vary in Taxonomic Composition and Degradation Ability

Deconstruction of the cellulose in plant cell walls is critical for carbon flow through ecosystems and for the production of sustainable cellulosic biofuels. Our understanding of cellulose deconstruction is largely limited to the study of microbes in isolation, but in nature, this process is driven by microbes within complex communities. In Neotropical forests, microbes in leaf-cutter ant refuse dumps are important for carbon turnover. These dumps consist of decaying plant material and a diverse bacterial community, as shown here by electron microscopy. To study the portion of the community capable of cellulose degradation, we performed enrichments on cellulose using material from five Atta colombica refuse dumps. The ability of enriched communities to degrade cellulose varied significantly across refuse dumps. 16S rRNA gene amplicon sequencing of enriched samples identified that the community structure correlated with refuse dump and with degradation ability. Overall, samples were dominated by Bacteroidetes, Gammaproteobacteria, and Betaproteobacteria. Half of abundant operational taxonomic units (OTUs) across samples were classified within genera containing known cellulose degraders, including Acidovorax, the most abundant OTU detected across samples, which was positively correlated with cellulolytic ability. A representative Acidovorax strain was isolated, but did not grow on cellulose alone. Phenotypic and compositional analyses of enrichment cultures, such as those presented here, help link community composition with cellulolytic ability and provide insight into the complexity of community-based cellulose degradation.Biological and Environmental Research/[DE-FC02-07ER64494]/BER/Estados UnidosNational Science Foundation/[DGE-1256259]/NSF/Estados UnidosNational Science Foundation/[DEB-0747002]/NSF/Estados UnidosNational Science Foundation/[MCB-0702025]/NSF/Estados UnidosNational Institutes of Health/[T32 GM07215]/NIH/Estados UnidosUniversidad de Costa Rica/[]/UCR/Costa RicaMinisterio de Ciencia, Tecnología y Telecomunicaciones/[]/MICITT/Costa RicaUniversity of Wisconsin-Madison's Hilldale Undergraduate Faculty Research Fellowship/[]//Estados UnidosUCR::Vicerrectoría de Investigación::Unidades de Investigación::Ciencias Básicas::Centro de Investigación en Biología Celular y Molecular (CIBCM

PCoA clustering of Morisita-Horn Diversity Index.

<p>Sample shape indicates colony. Sample color indicates degradation (<b>A</b>) or layer (<b>B</b>). Panel <b>C</b> shows the correlation analysis. The vectors indicate the correlation of each OTU and the percentage of cellulose degradation with the principal coordinates shown.</p

Correlation between number of reads and cellulose degradation by the community for OTU1 (<i>Acidovorax</i>) and OTU9 (<i>Ferruginibacter</i>) across sequenced samples.

<p>Correlation between number of reads and cellulose degradation by the community for OTU1 (<i>Acidovorax</i>) and OTU9 (<i>Ferruginibacter</i>) across sequenced samples.</p

Comparison of degradation ability across colonies and layers.

<p><b>(A and B</b>) Qualitative Assay Data. Test tubes containing carbon-free minimal media and a strip of cellulosic filter paper were used to enrich for cellulolytic communities. Failure plots, indicating when the filter paper broke apart in each culture, were fit with Kaplan Meier curves and analyzed using the Wilcoxon method to determine significant differences among colonies (indicated by letters A-C) and layers (no significant differences). (<b>C and D)</b> Quantitative Assay Data. Pre-weighed, submerged cellulosic filter paper allowed quantification of cellulose degradation after 10 days. Samples are grouped by colony or dump layer. Error bars represent one standard error from the mean. Significant differences were determined using Tukey’s HSD test and are indicated above the data. <b>Photo credits:</b> Gina Lewin (A, C).</p

Electron microscopy of leaf-cutter ant refuse dumps.

<p><b>(A and B)</b> Scanning electron microscopy shows the ultrastructure of refuse dump leaf material and different bacterial morphologies. <b>(C)</b> Transmission electron microscopy shows leaf cells and surrounding bacteria. Red boxes indicate degraded plant cell wall and abnormal, clumped internal cell structure. <b>Photo credits:</b> Rolando Moreira Soto.</p

Degradation, sequencing depth, and alpha diversity metrics for sequenced samples at a 97% OTU definition.

<p>Degradation, sequencing depth, and alpha diversity metrics for sequenced samples at a 97% OTU definition.</p

Morisita-Horn Beta Diversity Clustering of Samples.

<p>The corresponding percentage of cellulose degradation, colony, layer, and taxonomic classification of OTUs are shown for each sample.</p