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      General practitioners and management of chronic noncancer pain: a cross-sectional survey of influences on opioid deprescribing

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          Abstract

          Background

          General practitioners’ (GPs) views about deprescribing prescription opioid analgesics (POAs) may influence the care provided for patients experiencing chronic noncancer pain (CNCP). There are limited data addressing GPs’ beliefs about deprescribing, including their decisions to deprescribe different types of POAs.

          Aim

          To determine the proportion of GPs who hold attitudes congruent with local pain stewardship, describe their deprescribing decisions, and determine whether type of POA influences deprescribing.

          Design and setting

          In 2016, a cross-sectional survey of all GPs (n=1,570) in one mixed urban and regional primary health network (PHN) in Australia was undertaken.

          Methods

          A mailed self-report questionnaire assessed agreement with local guidelines for treating CNCP; influences on deprescribing POAs and likelihood of deprescribing in a hypothetical case involving either oral codeine or oxycodone.

          Results

          A response rate of 46% was achieved. Approximately half (54%) of GPs agreed POAs should be reserved for people with acute, cancer pain or palliative care and a third (32%) did not agree that a medication focus has limited benefits for peoples’ long-term quality of life and function. Most (77%) GPs were less likely to deprescribe when effective alternate treatments were lacking, while various patient factors (eg, fear of weaning) were reported to decrease the likelihood of deprescribing for 25% of GPs. A significantly higher proportion of GPs reported being very likely to deprescribe codeine compared to the equivalent opioid dose of oxycodone for a hypothetical patient.

          Conclusions

          Many GPs in the PHN hold attitudes at odds with local guidance that opioids are a nonsuperior treatment for CNCP. Attitudinal barriers to deprescribing include: a lack of consistent approach to deprescribing opioids as a class of drugs, perceived lack of effective treatment alternatives and patient fear of deprescribing. Therefore, the next step in this target population is to appropriately train and support GPs in how to apply the evidence in practice and how to support patients appropriately.

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          Most cited references 61

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          • Article: not found

          Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms. Prepared by the International Association for the Study of Pain, Subcommittee on Taxonomy.

            (1986)
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            Risk factors for clinically recognized opioid abuse and dependence among veterans using opioids for chronic non-cancer pain.

            A central question in prescribing opioids for chronic non-cancer pain (CNCP) is how to best balance the risk of opioid abuse and dependence with the benefits of pain relief. To achieve this balance, clinicians need an understanding of the risk factors for opioid abuse, an issue that is only partially understood. We conducted a secondary data analysis of regional VA longitudinal administrative data (years 2000-2005) for chronic users of opioids for CNCP (n=15,160) to investigate risk factors for the development of clinically recognized (i.e., diagnosed) opioid abuse or dependence among these individuals. We analyzed four broad groups of possible risk factors: (i) non-opioid substance abuse disorders, (ii) painful physical health disorders, (iii) mental health disorders, and (iv) socio-demographic factors. In adjusted models, a diagnosis of non-opioid substance abuse was the strongest predictor of opioid abuse/dependence (OR=2.34, p<0.001). Mental health disorders were moderately strong predictors (OR=1.46, p=0.005) of opioid abuse/dependence. However, the prevalence of mental health disorders was much higher than the prevalence of non-opioid substance abuse disorders (45.3% vs. 7.6%) among users of opioids for CNCP, suggesting that mental health disorders account for more of the population attributable risk for opioid abuse than does non-opioid substance abuse. Males, younger adults, and individuals with greater days supply of prescription opioids dispensed in 2002 were more likely to develop opioid abuse/dependence. Clinicians need to carefully screen for substance abuse and mental health disorders in candidates for opioid therapy and facilitate appropriate treatment of these disorders.
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              Opioids compared with placebo or other treatments for chronic low back pain: an update of the Cochrane Review.

              Systematic review and meta-analysis.
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                Author and article information

                Journal
                J Pain Res
                J Pain Res
                Journal of Pain Research
                Journal of Pain Research
                Dove Medical Press
                1178-7090
                2019
                22 January 2019
                : 12
                : 467-475
                Affiliations
                [1 ]Hunter Integrated Pain Service, Hunter New England Health, Newcastle, NSW, Australia, ruth.white@ 123456hnehealth.nsw.gov.au
                [2 ]School of Medicine and Public Health, University of Newcastle, NSW, Australia, ruth.white@ 123456hnehealth.nsw.gov.au
                [3 ]Hunter Medical Research Institute, Newcastle, NSW, Australia
                Author notes
                Correspondence: Ruth White, Hunter Integrated Pain Service, Locked Bag 1, Hunter Region Mail Centre, NSW 2310, Australia, Tel +61 24 922 3435, Fax +61 24 985 5045, Email ruth.white@ 123456hnehealth.nsw.gov.au
                Article
                jpr-12-467
                10.2147/JPR.S168785
                6348964
                © 2019 White et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Categories
                Original Research

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