Why most opioid risk tools fail?

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ruler

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.

The Problem

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 Study

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).

Take home?

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

Diagnosing opioid addiction in people with chronic pain

As good as methadone if not better

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equal

Looking at an old drug repurposed to treat opioid addiction, a new study found long-acting formulation of morphine (SROM) promising for curbing the opioid epidemic.

Many people who overdose on fentanyl have untreated opioid addiction. Left untreated, opioid addiction can have devastating consequences. One of the reasons for the low treatment rates is that current medications have limited ability to retain people in treatment. The Canadian National Guideline for the Clinical Management of Opioid Use Disorder recommends treatment with slow-release oral morphine, also known as SROM—prescribed as a third line of therapy. In this study, we wanted to compare Kadian® and Methadone for the treatment of opioid use disorder.

QUICK FACT: Slow release oral morphine (SROM) is given once daily and has been proposed for people who do not tolerate or respond to methadone.

We looked at the scientific literature up until the May of 2018. Then, we wanted to see if SROM (brand name Kadian®) works as well as methadone in the treatment of opioid use disorder. In the study, we included people of any gender, age or ethnicity.

What did the study find?

We found four unique clinical trials that met inclusion criteria (n = 471), and compared Kadian® with methadone. Meta-analysis of existing clinical trials suggests SROM (slow release oral morphine) may be as effective in retaining patients in treatment and reducing heroin use.

This is the first meta-analysis of slow release oral morphine (Kadian®). We included new studies that increase the validity of the study. We included previously unpublished data obtained from primary trials. A pooling of data for craving and adverse events was not possible due to inconsistent reporting of outcome measures across trials

SROM seems as good as methadone for the treatment of opioid use disorder but retains people in treatment longer.

Why is SROM important?

While methadone is effective for many patients, these findings suggest SROM may provide benefits in addressing some of the limitations of methadone. We need to expand uptake and retention of people on opioid use disorder treatments. These data should compel public health agencies and decision makers to find therapeutic tools for people who have opioid addiction.

We are running out of options for helping people overcome opioid addiction and abandon contaminated fentanyl. But revisiting this medication, known from cancer treatment, can have a dramatic impact on addiction treatment success because it is not only equally effective as the current treatment options but also better tolerated by patients. Expanding treatment options responds to patients’ needs by offering drugs with fewer side effects.

Kadian® slow-release oral morphine is available in 10mg, 20mg, 50mg, and 100mg capsules, which may be combined as necessary.

Reference: Klimas, J., Gorfinkel, L., Giacomuzzi, S., Ruckes, C., Socias, E.M., Fairbairn, N., Wood, E. (2019) Slow Release Oral Morphine versus Methadone for the Treatment of Opioid Use Disorder: A Systematic Review and Meta-Analysis. BMJ Open (In Press) 0:e025799. doi:10.1136/bmjopen-2018-025799

If you enjoyed reading this blog, you may also enjoy reading about a medication for treatment of stimulant use disorder. Link here

How can we do better job in studying Topiramate?

Hospital teaching team keeps fighting opioid crisis

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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?

Hospital teaching teams confront iatrogenic opioid addiction

 

Or visit a post that talks about this research as it was presented at the Canadian Society for Addiction Medicine link here

Canadian Society of Addiction Medicine, CSAM conference

Excellent scale assesses needs across four countries

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ruler

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:

We wanted to find out whether a new tool – Training Need Assessment – does what it’s set to do, measure training needs.

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?

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

International Society of Addiction Medicine | Congress #isam2015

Closing gap between workforce needs and training provision in addiction medicine

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Substance use disorders represent a significant social and economic burden globally. While effective interventions exist, the overall treatment coverage remains limited, with lack of an adequately trained workforce as one of the prominent reasons.

World over, recent initiatives have been taken to improve the training in addiction medicine; however, further efforts are required in building curricula that are internationally applicable. Here, we present a recent paper published in the British Journal of Psychiatry – International, https://www.cambridge.org/core/journals/bjpsych-international

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