How many of you had a flu this winter? Anyone took antibiotics for that? But some people can’t take them because they are allergic. Now, imagine someone suffering from pain, being prescribed opioids and having a negative reaction to them. What if this reaction was addiction to opioids? What if we could measure the risk for addiction the same way we can measure allergy to antibiotics? This article describes why opioid addiction is not an allergy to opioids and that we should not think about it that way, nor try to measure it using opioid risk tools.
We wanted to find out whether we can tell which adult will go into opioid addiction when prescribed opioids for pain. Why? Prescription opioid addiction can have devastating consequences but it is not clear how to identify patients with pain among whom prescription opioids can be safely prescribed.
The Journal of the American Medical Association – JAMA Network Open – commissioned us to do a very special kind of review that is called Diagnostic Accuracy Review. For this study, we chose only the best studies. To illustrate diagnostic performance, data from higher quality studies were extracted and used to calculate likelihood ratios (LR). What are likelihood ratios? Likelihood Ratios bigger than 1 increase the probability of a disease. Likelihood ratio of 1 equals roughly zero increase. Likelihood of 2 equals just about 15% increase.
Opioid Risk Tools
The opioid risk screening tools that are in widespread use are based on low quality studies and are not helpful in identifying patients at higher risk. Among them, the pain medication questionnaire had likelihood ratio of 2.6 (slight increase in likelihood, about 15%). Some risk factors were found in a single high quality study:
A history of opioid or non-opioid use disorder, a mental health diagnosis and concomitant prescription of certain psychiatric medications may increase the risk of prescription opioid addiction.
However, only the absence of a mood disorder appeared useful for identifying lower risk patients (and assessment tools incorporating combinations of patient characteristics and risk factors were not useful).
There are few valid ways to identify patients who can be safely prescribed opioid analgesics. Given the lack of good tools and the mounting evidence that opioids are not effective for chronic pain, such as the recent JAMA trial called Space, prescribers should be aware of tools’ limitations when prescribing opioids for pain. Opioid addiction is not an allergic reaction. Don’t try to measure risk for it and whether it’s safe to prescribe. De-implement opioid risk tools!
|Reference: Klimas, J., Gorfinkel, L., Fairbairn, N., Amato, L., Ahamad, K., Nolan, S., Simel, D., Wood, E. (2019) Strategies to identify patient risks of prescription opioid addiction when initiating opioids for pain: A Systematic review. JAMA Network Open. 2(5):e193365. Doi: 10.1001/jamanetworkopen.2019.3365|
If you enjoyed reading this article, you may also wish reading the article about diagnosing opioid use disorder link here
Which student learns best with hospital teams fighting opioid crisis? Understanding how students learn is perhaps the most important way to improve addiction training.
In a new article published by the Substance Abuse journal, we report findings suggesting that the completion of an elective with a hospital-based Addiction Medicine Consult Team appeared to improve knowledge of medical students more than of other types of students. Read more below or listen to the podcast.
Firstly, we found that both emerging and established physicians appear to be responsive to this type of training. Secondly, the learner self-assessment can provide valuable feedback to the consultants. Then, consultants can focus more on the students who learn less.
Keep fighting opioid crisis through training
The study sample was drawn from medical students, residents and physicians who took part in a month-long rotation with a hospital-based addiction medicine consult team in Vancouver, Canada. The addiction rotation includes full-time clinical training involving intake assessment and treatment planning. And referrals to community agencies and starting people on evidence-based medications for substance use disorders. The students take part in didactic lectures, bedside teaching, journal clubs and some prepare papers for submission to peer-reviewed journals. Each year, about 80 learners go through the program. Furthermore, learners rate their knowledge before and after the training.
At the end, all learners reported increased knowledge. One group, however, learned more than the others – the medical students. This two-year study confirms that a structured clinical training program can lead to an increased knowledge on addiction and that medical students benefit from it the most.
For more info read the full article at:
Gorfinkel, L., Klimas, J., Ahamad, K., Mead, A., McLean, M., Fairgrieve, C., Nolan, S., Small, W., Cullen, W., Wood, E., Fairbairn, N. (2019) In-hospital training in addiction medicine: A mixed methods study of health care provider benefits and differences. Substance Abuse (Published online Jan 28) doi: 10.1080/08897077.2018.1561596
If interested, you can also read: What can hospital teams teach medical students about addiction to help curb the opioid overdose epidemic?
Or visit a post that talks about this research as it was presented at the Canadian Society for Addiction Medicine link here
What is the smartest scale for asking clinicians about their training needs?
In a new article published by the Journal of Substance Abuse Treatment, we report findings from a study that looked at a new scale, the training needs assessment. Read more or watch podcast below:
|QUICK FACT: Addiction Medicine (AM) rarely uses Training Need Assessments (TNA).|
How we did the study?
We did a cross-sectional study in four countries (Indonesia, Ireland, Lithuania and the Netherlands). 483 health professionals working in addiction care completed AM-TNA. To assess the factor structure, we used explorative factor analysis. Reliability was tested using Cronbach’s Alpha, ANOVA determined the discriminative validity.
What has the scale found?
- Tailored training of health professionals is one of the elements to narrow the “scientific knowledge-addiction treatment” gap. Addiction Medicine (AM) rarely uses Training Need Assessments (TNA). The AM-TNA scale is a reliable, valid instrument to measure addiction medicine training needs. The AM-TNA helps to determine the profile of future addiction specialist.
The Training Need Assessment is a reliable, valid instrument to measure addiction medicine training needs.
Why is the scale important?
The AM-TNA proved reliable and valid. Additionally, the AM training needs in the non-clinical domain appeared positively related to the overall level of AM proficiency. Furthermore, researchers should study whether the AM-TNA can also measure changes in AM competencies over time and compare different health professionals. Finally, the AM-TNA assists tailoring training to national, individual and group addiction priorities.
|Reference: Pinxten, W.J.L. et al. (2019) Excellent reliability and validity of the Addiction Medicine Training Need Assessment Scale across four countries. Journal of Substance Abuse Treatment , Volume 99 , 61 – 66|
For more info read the full article in the Journal of Substance Abuse Treatment 99 (2019) 61–66 https://doi.org/10.1016/j.jsat.2019.01.009
Read more about this topic in a post from 2017: What are the core skills of an addiction expert?
You can also read a related post from 2015: International Society of Addiction Medicine | Congress #isam2015
Frequent drug tests in addiction treatment have become a common practice despite proven benefits of such testing. When do tests become the end instead of the means to health and wellness?
In a previous post, I have explained how there was no agreement on the frequency of drug testing in Canada. Not until March 2018, when the British Columbia Centre on Substance use released the National guidelines for opioid use disorder. This article looks at the scientific evidence (or the lack of it) for frequent drug testing in addiction treatment. Read more or watch podcast below:
What is the study about?
We wanted to find out whether frequent urine drug tests correspond with better outcomes of treatment with opioid agonists such as methadone or buprenorphine.
How we did the study ?
We looked at the scientific literature from 1995 up until the end of 2017.
Then, we wanted to see how often the screening should be done while in the opiod agonist treatment. In the study, we included people of any gender, age or ethnicity.
Frequent drug tests lack evidence
We found only one higher quality studies with patients from USA
The study compared weekly and monthly urine drug testing with take-home doses of opioid agonists
Our review identified an urgent gap in research evidence underpinning an area of clinical importance and that is routinely reported by patients as an area of concern
Why is the study important?
Opioid use disorder is a chronic condition impacting the reward, motivation and memory pathways of the brain (ASAM, 2017).
Opioid agonist therapy is a first-line treatment for opioid use disorder.
The frequency and role of urine drug screening in opioid agonist treatment has received little research attention.
Although prior evidence suggests that testing frequency reflects philosophy and practice context, rather than differences in patient characteristics or clinical need, frequent urine testing remains under-researched.
Finally, the editorial of the Canadian Journal of Addiction featured this study as important for bringing additional management aspects for consideration:
McEachern J, Adye-White L, Priest KC, Moss E, Gorfinkel L, Wood E, Cullen W, Klimas J: Lacking evidence for the association between frequent urine drug screening and health outcomes of persons on opioid agonist therapy. International Journal of Drug Policy 2019, 64:30-33.
Diagnosing opioid addiction in people with chronic pain requires a fully validated alternative to DSM-5.
Over the past two decades, a steep rise in the number of opioids dispensed for pain treatment has been accompanied by a dramatic rise in overdose deaths in the United States. In 2016, up to 32 000 deaths reportedly involved prescription opioids. Besides that, the economic burden of prescription opioid overdose exceeds $78bn (£59bn; €67bn) annually.
Despite all the evidence of harm, it remains unclear exactly how to determine if a patient with chronic pain has opioid addiction. What criteria should serve as a gold standard in making a diagnosis of opioid use disorder (OUD) in this context? This is an important gap in the literature. It hinders both evidence based care and research on the links between prescription opioids and OUD. Therefore, we discuss the limitations of diagnosing OUD in people with chronic pain, and make several recommendations for further research.
Diagnosing opioid addiction in people with chronic pain
The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) provides a widely used set of diagnostic criteria for OUD. But these criteria do not always apply to patients who are prescribed opioids for chronic pain. According to DSM-5, if a patient presents with 2 out of 9 specific symptoms, it may indicate …
Diagnosing opioid addiction in people with chronic pain