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Background: The COVID-19 pandemic disrupted how primary care patients with chronic pain received care. Our study sought to understand how long-term opioid therapy (LtOT) for chronic pain changed over the course of the pandemic overall and for different demographic subgroups., Methods: We used data from electronic health records of 64 primary care clinics across Washington state and Idaho to identify patients who had a chronic pain diagnosis and were receiving long-term opioid therapy. We defined 10-month periods in 2019 to 2021 as prepandemic, early pandemic and late pandemic and used generalized estimating equations analysis to compare across these time periods and demographic characteristics., Results: We found a proportional decrease in LtOT for chronic pain in the early months of the pandemic (OR = 0.94, P = .007 ) followed by an increase late pandemic (OR = 1.08, P = .002 ). Comparing late pandemic to prepandemic, identifying as Asian or Black, having fewer comorbidities, or living in an urban area were associated with higher likelihood of being prescribed LtOT., Discussion: The use of LtOT for chronic pain in primary care has increased from before to after the COVID-19 pandemic with racial/ethnic and geographic disparities. Future research is needed to understand these disparities in LtOT and their effect on patient outcomes., Competing Interests: Conflict of interest: None., (© Copyright 2024 by the American Board of Family Medicine.)

Background: Patients with injury may be at high risk of long-term opioid use due to the specific features of injury (e.g., injury severity), as well as patient, treatment, and provider characteristics that may influence their injury-related pain management., Objectives: Inform prescribing practices and identify high-risk populations through studying chronic prescription opioid use in the trauma population., Methods: Using the Washington State All-Payer Claims Database (WA-APCD) data, we included adults aged 18-65 years with an incident injury from October 1, 2015-December 31, 2017. We compared patient, injury, treatment, and provider characteristics by whether or not the patients had long-term (≥ 90 days continuous prescription opioid use), or no opioid use after injury., Results: We identified 191,130 patients who met eligibility criteria and were included in our cohort; 5822 met criteria for long-term use. Most had minor injuries, with a median Injury Severity Score = 1, with no difference between groups. Almost all patients with long-term opioid use had filled an opioid prescription in the year prior to their injury (95.3%), vs. 31.3% in the no-use group (p < 0.001). Comorbidities associated with chronic pain, mental health, and substance use conditions were more common in the long-term than the no-use group., Conclusion: Across this large cohort of multiple, mostly minor, injury types, long-term opioid use was relatively uncommon, but almost all patients with chronic use post injury had preinjury opioid use. Long-term opioid use after injury may be more closely tied to preinjury chronic pain and pain management than acute care pain management., (Copyright © 2022. Published by Elsevier Inc.)

Objective: To test associations between several opioid prescribing policy interventions and changes in early (acute/subacute) high-risk opioid prescribing practices., Data Sources: Population-based workers' compensation pharmacy billing and claims data, Washington State Department of Labor and Industries (January 2008-June 2015)., Study Design: We used interrupted time series analysis to test associations between three policy intervention timepoints and monthly proportions of population-based measures of high-risk, low-risk, and any workers' compensation-related opioid prescribing. We also tested associations between the policy intervention timepoints and five high-risk opioid prescribing indicators among workers prescribed any opioids within 3 months after injury: (a) >7 cumulative (not necessarily consecutive) days' supply of opioids during the acute phase, (b) high-dose opioids, (c) concurrent sedatives, (d) chronic opioids, and (e) a composite high-risk opioid prescribing indicator., Principal Findings: Within 3 months after injury, 9 percent of workers were exposed to high-risk and 12 percent to low-risk workers' compensation-related opioid prescribing; 79 percent filled no workers' compensation-related opioid prescription. Among workers prescribed any early (acute/subacute) opioids, the indicator for >7 days' supply of opioids during the acute phase was present for 30 percent, high-dose opioids for 18 percent, concurrent sedatives for 3 percent, and chronic opioids for 2 percent. Beyond a general shift toward more infrequent and lower-risk workers' compensation-related opioid prescribing, each policy intervention timepoint was significantly associated with reductions in specific acute/subacute high-risk opioid prescribing indicators; each of the four specific high-risk opioid prescribing indicators had significant reductions associated with at least one policy., Conclusions: Several state-level opioid prescribing policies were significantly associated with safer workers' compensation-related opioid prescribing practices during the first 3 months after injury (acute/subacute phase), which should in turn reduce transition to chronic opioids and associated negative health outcomes., (© 2020 Health Research and Educational Trust.)

Painful conditions affect a significant population in the United States. As the scientific understanding of the benefits and harms of opioid therapy has evolved, so too has the application of prescription opioid therapy for the treatment of pain. The rapid increase in the use of prescription and illicit opioids over the past decade has contributed to a public health crisis commonly referred to as the "opioid crisis." In this article, the ethical approaches to treating patients with opioid pharmaceuticals as well as the development of regulation of opioid therapy in Washington State are reviewed., Competing Interests: Disclosure Neither author has any commercial or financial conflicts of interest or any external funding sources., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Adults with persistent pain frequently report cannabis use to help manage their symptoms. The impact of cannabis use on cognition in the presence of concurrent symptoms of depression and anxiety is poorly understood., Aims: Our study explored how cannabis use affects relationships among symptoms of depression, anxiety, and cognition., Design: A cross-sectional survey study was conducted., Settings: Surveys were distributed at outpatient clinics treating adults for pain in the Pacific Northwestern United States., Participants: A total of 150 adults prescribed an opioid medicine for persistent pain were recruited., Methods: A pencil and paper survey was used to collect several self-reported ratings of cognition, symptoms of depression and anxiety, and the average potency of cannabis consumed as measured by the percentage of delta-9-tetrahydrocannibinol (THC) and cannabidiol (CBD), as well as frequency of cannabis use., Results: Depression, anxiety and cognition significantly worsened as the reported percentage of CBD, THC and overall frequency of cannabis use in the past 30 days increased. Depression and anxiety both significantly predicted worsening cognition in the sample. The relationship between depressive symptoms and cognition was strengthened as reported percentages of CBD use increased. The relationship was the same for anxiety and cognition, although not as strong., Conclusions: More cannabis use, particularly high CBD products, may be linked with increased symptom burdens and may strengthen relationships between negative affect and cognition. Further cannabis research within persistent pain populations is warranted to add evidence that can assist patients in managing mood and mental processes. Nurses should evaluate how negative affective health symptoms may impact cognition among adults with persistent pain using prescription opioid medications, especially in the context of concurrent cannabis use., (Copyright © 2020 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.)

Background: Prescription opioid use and opioid related deaths continue to increase nationwide. Several states have adopted legislation allowing for recreational use of cannabis. Little is known about how recreational cannabis laws impact compliance in chronic pain patients who have been prescribed opioid therapy. The goals of this study were to (1) retrospectively assess the effect of cannabis use on compliance with opioid therapy in a high-risk patient population and (2) determine the impact of legalization of recreational cannabis on patients prescribed therapeutic opioids., Methods: We conducted a retrospective cohort study on results from a "high-risk" urine drug testing panel. Results from 1 year before and 1 year after initiation of recreational cannabis legislation were analyzed. This testing panel included qualitative assays for cannabinoids and 9 other common drugs of abuse in addition to a quantitative LC-MS/MS assay for 23 different opioids and metabolites. Opioid compliance was assigned by reviewing pathologists' interpretations., Results: In the pre-legalization period, 1776 panels were performed, and in the post-legalization, 1648 panels were performed. An increase (6%) in the rate of positive cannabinoids screening results was observed after legalization of recreational cannabis; however, the overall compliance rate was consistent., Conclusions: The results of this study suggest that legalization of recreational cannabis does not affect compliance rate in patients treated with opioid therapy for chronic pain., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: This analysis examined patients' perceptions about trust within the doctor-patient relationship related to managing opioid pain medications. We compared perceptions among chronic opioid therapy (COT) patients who were and were not exposed to opioid risk reduction initiatives., Methods: Between 2014 and 2016, we surveyed 1588 adults with chronic pain receiving COT about their trust in their prescribing doctor, their perceptions of their doctor's trust in them, their concerns about opioid prescribing, and their knowledge of opioid safety concerns. The population included adults receiving care in intervention settings that implemented opioid risk reduction initiatives and control settings with similar COT patients that did not., Results: Overall, 82.2% of COT patients said they trusted their doctor's judgment, with more agreement among patients in the control clinics (86.3%; n = 653) than in the intervention clinics (77.9%; n = 935; P = .002). Similarly, slightly more patients in the control clinics believed their physician trusted how they managed their opioid pain medicines (91.1%) compared with the intervention clinics (86.2%; P = .002). The percent who worried that their doctor would stop prescribing opioid pain medicine was 29.3% in intervention clinics and 21.8% in control clinics ( P = .007)., Conclusions: Although COT patients typically reported favorable perceptions of doctor-patient trust in managing opioid pain medicines, implementation of opioid risk reduction initiatives may have reduced levels of trust for a minority of COT patients. This suggests that it may be possible to implement opioid risk-reduction initiatives while sustaining high levels of doctor-patient trust for most COT patients., Competing Interests: Conflict of interest: Ms. Saunders owns stock in Merck. The remaining authors report no conflicts., (© Copyright 2018 by the American Board of Family Medicine.)

Background: Opioid poisonings have increased as use of prescription opioid medications have increased. To reduce these poisonings, guidelines for chronic opioid use have been implemented. However, if opioid poisonings occur in individuals who do not have high prescribed doses and who are not chronic opioid users, the current guidelines may need revision., Objectives: To examine changes in rates of methadone and other opioid poisonings after implementation of the WA State Opioid Guideline in 2007 and to examine the prescription history before poisonings., Methods: The study sample consisted of individuals who had at least 1 paid claim for an opioid prescription in the Medicaid fee-for-service system between April 2006 and December 2010 and had an emergency department or inpatient hospital claim for an opioid poisoning., Results: Methadone poisonings occurred at 10 times the rate of other prescription opioid poisonings and increased between 2006 and 2010. Rates of other prescription opioid poisonings appeared to level off after implementation of the WA opioid guideline in 2007. Among individuals with nonmethadone opioid poisonings, only 44% had chronic opioid use, 17% had prescribed doses in the week before the poisoning >120 mg/d morphine-equivalent dose (MED), 28% had doses <50 mg/d MED, and 48% had concurrent sedative prescriptions., Conclusions: It may be prudent to revise guidelines to address opioid poisonings occurring at relatively low prescribed doses and with acute and intermittent opioid use. Research is needed to establish the best strategies to prevent opioid poisonings.

Background: Increased availability of prescription opioids has caused serious problems with misuse, abuse, and increased rates of morbidity and mortality. In response, Washington State enacted a law to regulate pain management and opioid prescribing practices., Objectives: The purpose of this research was to investigate healthcare professionals' practices for the care of individuals with chronic noncancer pain (CNP) who received opioid therapy before the enactment of the Washington State law., Methods: This descriptive study used a tailored design survey protocol with a 23-item questionnaire and stratified random sample of 1618 Washington State healthcare professionals. Topic areas assessed included prescribing patterns; use of best practices; consultation access; and provider education, satisfaction, and competence in prescribing opioids., Results: Only 41% of the respondents provided care for patients with CNP. Of these, nearly all (96%) managed patients with prescription opioids. Most reported "always" obtaining, evaluating, and documenting the patient's health history (86%); reviewing the patient's history for substance abuse (77.8%); and conducting ongoing interviews (57.3%). Sixty percent of the respondents self-rated being not at all, somewhat, or moderately competent to prescribe opioids. Only 8.5% reported being very or extremely satisfied working with patients with CNP., Conclusions: The enactment of Washington State's pain management law mandates all providers to adopt management and prescribing practices for patients with CNP receiving opioid medications. This study determined that these practices were not universally adopted before the law. Evaluation of the effect of this law is essential to determine if it can serve as a model for other states., Perspective: In 2010, Washington State enacted legislation on the management of CNP. The purpose of this study was to assess clinical practice among health professionals providing care to patients with CNP before implementation of the law and to discuss the potential impact of the regulation.

An epidemic of morbidity and mortality has swept across the United States related to the use of prescription opioids for chronic noncancer pain. More than 100,000 people have died from unintentional overdose, making this one of the worst manmade epidemics in history. Much of health care delivery in the United States is regulated at the state level; therefore, both the cause and much of the cure for the opioid epidemic will come from state action. We detail the strong collaborations across executive health care agencies, and between those public agencies and practicing leaders in the pain field that have led to a substantial reversal of the epidemic in Washington State.

Background: Chronic postoperative pain occurs with an appreciable incidence after elective surgery. Known risk factors include perioperative pain and posttraumatic stress disorder (PTSD). Military veterans are a population at particular risk for PTSD and hence may be at increased risk for chronic pain after surgery. Our goal was to identify risk factors for chronic postoperative pain in young veterans after minor elective surgery, including the contribution of PTSD., Methods: We reviewed the medical and pharmacy records of veterans (18-50 years old), undergoing elective knee arthroscopy from 2007 to 2010 at the Veteran's Administration Puget Sound Health Care System. The data included demographics, ASA physical status class, comorbidities, anesthesia medications, and opioid prescriptions starting 3.5 months before surgery and ending 3.5 months after surgery. We documented the presence of PTSD based on either the patient's problem list or the clinical notes. We used prolonged postoperative opioid prescription longer than 3 months after surgery as a surrogate for chronic postoperative pain., Results: We identified 145 patients who met inclusion criteria. The median age was 39 ± 8 years old. Eighty-seven percent of the patients were men. The prevalence of PTSD was 32% (95% confidence interval, 25%-41%). PTSD was associated with increased incidence of smoking (P = 0.009) and preoperative opioid use (P = 0.0006). Preoperative opioids were prescribed in 44% (63 of 145) of the patients: in 64% (30 of 47) of patients with PTSD, compared with 34% (33 of 98) in patients without PTSD (P = .0006). Chronic postoperative pain was identified in 30% (43 of 145) of patients. The strongest independent predictor of chronic postoperative pain was an opioid prescription before surgery (odds ratio = 65.3; 95% confidence interval, 014.5-293.0). In patients older than 27.5 years who did not receive opioids before surgery, PTSD may also have been a risk factor for chronic postoperative pain., Conclusions: This single-center retrospective study suggests that the most important predictor of chronic postoperative pain is preoperative opioid use. For patients not taking opioids preoperatively, PTSD may increase the risk of prolonged postoperative opioid prescriptions and chronic postoperative pain, potentially related to patient age.

Unlabelled: An opioid overdose epidemic emerged in the United States following increased opioid prescribing for chronic noncancer pain. In 2007, Washington State agencies implemented an opioid dosing guideline on safe prescribing for chronic noncancer pain. The objective of this population-based observational study was to evaluate opioid use and dosing before and after guideline implementation. We identified 161,283 workers aged 18 to 64 years with ≥1 opioid prescriptions in Washington Workers' Compensation, April 1, 2004, to December 31, 2010. Prevalence and incidence rates of opioid use were assessed. We compared pre- and postguideline chronic and high-dose use (≥120 mg/d) among incident users. The mean monthly prevalence of opioid use declined by 25.6% between 2004 (14.4%) and 2010 (10.7%). Fewer incident users went on to chronic opioid therapy in the postguideline period (4.7%; 95% confidence interval [CI], 4.5-5.0%) than in the preguideline period (6.3%; 95% CI, 6.1-6.6%). Compared with preguideline incident users, postguideline incident users were 35% less likely to receive high doses (adjusted odds ratio = .65; 95% CI, .59-.71). Although the extent to which decreases were due to the guidelines is uncertain, to our knowledge, this is the first report of significant decreases in chronic and high-dose prescription opioid use among incident users., Perspective: Evidence-based strategies for opioid risk management are needed to help abate the epidemic of opioid-related morbidity and mortality. The study findings suggest that opioid dosing guidelines that specify a "yellow flag" dosing threshold may be a useful tool in preventing escalation of doses into ranges associated with increased mortality risk., (Copyright © 2013 American Pain Society. Published by Elsevier Inc. All rights reserved.)

Purpose: To conduct a survey of primary care physicians and advanced registered nurse practitioners (ARNPs) in Washington State (WA) focused on changes in practice patterns and use of support tools in the prescription of opioids for the treatment of chronic noncancer pain (CNCP)., Methods: A convenience sample of primary care providers in WA was obtained from diverse geographic regions and health care organizations. The web-based anonymous survey was conducted in March-August 2011., Results: Among 856 provider respondents, 623 reported treating patients with CNCP and served as the analysis sample. Most providers (72%) reported concern about opioid overdose, addiction, dependence, or diversion. Only 25% indicated concern about regulatory scrutiny. Only a small proportion of providers overall (3.3%) reported that they had stopped prescribing opioids for CNCP, but twice as many ARNPs (5.8%) as physicians (MDs and osteopaths) (2.1%) reported this. A greater proportion of physicians (70.9%) than ARNPs (40.1%) reported familiarity with the Washington State opioid dosing guidelines. Physicians in a large health plan with substantial infrastructure support reported less concern about opioids compared with providers in other settings. Of providers in Spokane (the largest city in Eastern Washington), 45% reported very low capacity to access pain specialty consultation. The vast majority of providers reported a need to access more efficient, innovative means of support and education related to treating patients with CNCP, such as telemedicine consultation., Conclusions: Overall, prescribing providers in WA reported ongoing concerns regarding opioid use for CNCP, but those affiliated with a health care organization with opioid prescribing guidelines and access to pain consultation were less likely to report being concerned about opioid-related problems or to have discontinued prescribing opioids.

Background: Opioid use and dosing for patients with chronic non-cancer pain have dramatically increased over the past decade, resulting in a national epidemic of mortality associated with unintentional overdose, and increased risk of disability among injured workers. We assessed changes in opioid dosing patterns and opioid-related mortality in the Washington State (WA) workers' compensation system following implementation of a specific WA opioid dosing guideline in April, 2007., Methods: Using detailed computerized billing data from WA workers' compensation, we report overall prevalence of opioid prescriptions, average morphine-equivalent dose (MED)/day, and proportion of workers on disability compensation receiving opioids and high-dose (≥120 mg/day MED) opioids over the past decade. We also report the trend of unintentional opioid deaths during the same time period., Results: Compared to before 2007, there has been a substantial decline in both the MED/day of long-acting DEA Schedule II opioids (by 27%) and the proportion of workers on doses ≥120 md/day MED (by 35%). There was a 50% decrease from 2009 to 2010 in the number of deaths., Conclusions: The introduction in WA of an opioid dosing guideline appears to be associated temporally with a decline in the mean dose for long-acting opioids, percent of claimants receiving opioid doses ≥120 mg MED per day, and number of opioid-related deaths among injured workers., (Copyright © 2011 Wiley Periodicals, Inc.)

Purpose: To evaluate the acceptability and usefulness of the Washington State Opioid Dosing Guideline (Guideline) developed for primary care providers for the treatment of chronic noncancer pain. The Guideline contains innovative tools, such as an online dosing calculator, and recommendations to assist providers, including a "yellow flag" threshold of 120 mg/d morphine equivalent dose (MED) at which specialty consultation is recommended., Methods: Using a convenience sample, an anonymous web-based survey was conducted among primary care providers in Washington (WA) state. Physician/ administrative leaders in four regional and two statewide healthcare systems and associations distributed the electronic links to primary care providers in their organizations., Results: Six hundred fifty-five (n) providers completed the survey representing 20 percent of the total number contacted. The majority (89 percent) of providers in this sample treat chronic pain patients, and more than half (54 percent) have frequent concerns about addiction, tolerance, and diversion. Forty-five percent had read and applied the Guideline in their practice. The majority of these providers found the Guideline to be helpful and 86 percent find the threshold of 120 mg/d MED dose reasonable or too high. Some key best practices such as tracking pain and function using structured instruments and use of urine drug testing are infrequently used., Conclusions: Results from this survey suggest that the recommendations and tools given in the Guideline, including the threshold of 120 mg/day MED dose, are acceptable and useful to a large majority of primary care providers in WA state. Substantial additions to the Guideline based on needs identified in this survey were added in June 2010 and wider dissemination is planned.

Increased opioid prescribing for chronic pain that is not due to cancer has been accompanied by large increases in abuse and overdose of prescription opioids. This paper describes how Group Health, a Seattle-based nonprofit health care system, implemented a major initiative to make opioid prescribing safer. In the initiative's first nine months, clinicians developed documented care plans for almost 6,000 patients receiving long-term opioid therapy for chronic pain. Evaluation of the initiative's effects on care processes and trends in adverse events is under way.