Implementing prescription drug monitoring and other clinical decision support for opioid risk mitigation in a military health care setting: a qualitative feasibility study.

Objective: Chronic noncancer pain is a highly prevalent condition among service members returning from deployment overseas. The US Army has a higher rate of opioid misuse than the civilian population. Although most states and many health care systems have implemented prescription drug monitoring programs (PDMPs) or other clinician decision support (CDS) to aid providers in delivering guideline-recommended opioid therapy, similar tools are lacking in military health settings. Materials and Methods: We conducted a pre-implementation feasibility and needs assessment guided by the Promoting Action Research in Health Services framework. Twenty-six semistructured interviews were conducted with providers from a large military health system (MHS) to assess baseline knowledge and practices in opioid risk mitigation and providers' preferences and needs for a military-based PDMP or other CDS. Results: Military health care providers reported complex decision-making around opioid prescribing and monitoring, varied knowledge and use of existing clinical informatics, and concerns about the feasibility of implementing a military-based PDMP in their context. However, providers indicated a need for training and CDS to support opioid risk mitigation for their patients. Discussion: This article describes providers' knowledge and behaviors around opioid risk mitigation in the MHS, and views on the potential usefulness of a military-based PDMP or other CDS. This pre-implementation study provides a model for using qualitative methods to assess feasibility and inform planning and development of CDS in complex health care settings. Conclusion: Military providers were skeptical regarding the feasibility of MHS-based PDMP implementation, but provided important recommendations for CDS to support safe and appropriate opioid prescribing in military health care.

Pain management and opioid risk mitigation in the military.

Opioid analgesics misuse is a significant military health concern recognized as a priority issue by military leadership. Opioids are among those most commonly prescribed medications in the military for pain management. The military has implemented opioid risk mitigation strategies, including the Sole Provider Program and the Controlled Drug Management Analysis and Reporting Tool, which are used to identify and monitor for risk and misuse. However, there are substantial opportunities to build on these existing systems to better ensure safer opioid prescribing and monitor for misuse. Opioid risk mitigation strategies implemented by the civilian sector include establishing clinical guidelines for opioid prescribing and prescription monitoring programs. These strategies may help to inform opioid risk mitigation in the military health system. Reducing the risk of opioid misuse and improving quality of care for our Warfighters is necessary. This must be done through evidence-based approaches with an investment in research to improve patient care and prevent opioid misuse as well as its sequelae.

The relationship between primary prescription opioid and buprenorphine-naloxone induction outcomes in a prescription opioid dependent sample.

BACKGROUND AND OBJECTIVES: This analysis aims to: (1) compare induction experiences among participants who self-reported using one of the four most commonly reported POs, and (2) examine factors associated with difficult bup-nx induction. Our hypothesis, based on previous research and current guidelines, is that those on longer-acting opioids will have experienced more difficult inductions. METHODS: The Prescription Opioid Addiction Treatment Study (POATS) was a multi-site, randomized clinical trial, using a two-phase adaptive treatment research design. This analysis examines bup-nx induction of participants who self-reported primary PO use of methadone, ER-oxycodone, IR-oxycodone, and hydrocodone (n = 69). Analyses examined characteristics associated with difficult induction, defined as increased withdrawal symptoms measured by the Clinical Opiate Withdrawal Scale (COWS) after the first bup-nx dose with higher scores denoting greater withdrawal symptoms/severity. RESULTS: Contrary to our hypothesis, difficult induction experiences did not differ by primary PO type. Those who experienced a post-induction increase in COWS score had lower pre-dose COWS scores compared to those who did not experience a post-induction increase in COWS score (10.09 vs. 12.77, t(624) = -13.56, p < .001). Demographics characteristics, depression, and pain history did not predict a difficult induction. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Difficult bup-nx inductions were not associated with participants' primary PO. Severity of withdrawal, measured with the COWS, was an important variable, reminding clinicians that bup-nx should not be commenced prior to evidence of moderate opioid withdrawal. These findings add to the evidence that with careful procedures, bup-nx can used with few difficulties in PO-dependent patients. (Am J Addict 2014;23:343-348).

Retrospective accounts of initial subjective effects of opioids in patients treated for pain who do or do not develop opioid addiction: a pilot case-control study.

This pilot case-control study retrospectively assessed between-groups differences in subjective opioid effects in patients treated for the first time with opioids for chronic pain. Cases were individuals in an inpatient substance abuse treatment center for primary prescription opioid addiction whose initial exposure to prescription opioids was reported for chronic pain. Controls had not developed prescription opioid addiction as measured in part by close monitoring on long-term opioid therapy at a pain management center. Twenty subjects in each group completed a battery of measures to capture data related to the individual's first exposure to prescription opioids. The Morphine Benzedrine Group subscale of an adapted 49-item Addiction Center Research Inventory (ARCI), designed to measure euphoria and other drug effects, showed an average score of 8.70 (+/-4.18) in cases versus 2.55 (+/-3.36) in controls (p<0.001), indicating a significantly greater "euphoric" effect of opioids in the cases compared to the controls. Differences in the subjective response to opioids suggest that: (1) a subgroup of patients does develop euphoria when taking opioids for pain, which may be a risk factor for eventual development of prescription opioid addiction; and (2) subjective effects predictive of eventual addiction may include stimulation and other experiences not typically associated with opioids.