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ABSTRACTBackgroundThe relation between emergency department opioid prescribing and subsequent harm is complex and poorly studied. We sought to quantify adverse outcomes, incremental risk, and rates of prolonged opioid use among emergency department patients receiving an opioid prescription and propensity-matched controls. MethodsWe used administrative data to sample all Alberta emergency department visits over 10 years, excluding patients with cancer, palliative care, or concurrent opioid use. Treated patients filled an opioid prescription within 72 hours after their index visit; untreated patients did not. We generated propensity scores to identify matched controls among untreated patients. The 1-year primary composite outcome included opioid-related emergency visits (e.g., overdoses), new opioid agonist therapy, all-cause hospital admission, or death. The secondary outcome was prolonged opioid use. ResultsAfter 13 028 575 eligible visits, 689 074 patients (5.3%) filled an opioid prescription. The mean age was 43.9 years, and 49.8% of patients were female. Most were high-acuity patients with traumatic, gastrointestinal–genitourinary, or musculoskeletal complaints. Patients who received opioids experienced 1.4% more primary outcome events (17.1% v. 15.7%), driven by all-cause hospital admissions (16.4% v. 15.1%; number needed to harm [NNH] = 53) and prolonged opioid use (4.5% v. 3.3%; NNH = 59). Opioid-related visits, new opioid agonist treatment, and mortality were unaffected. Incremental risk was low for patients with documented mental health conditions or substance use, and was highest for opioid-naive patients, older patients, and males. InterpretationEmergency department opioid prescriptions were associated with small increases in subsequent opioid prescription use and hospital admission, particularly in older and opioid-naive patients, and males; they were not associated with overdoses, new opioid agonist therapy, or mortality. Physicians should understand patient-specific incremental risks when prescribing opioids for acute pain.

Objective Documenting cannabis use is important for patient care, but no formal requirements for consistent reporting exist in primary care. The objective of this study was to understand how cannabis use is documented in primary care electronic medical record (EMR) data. Results This was a cross-sectional study using de-identified EMR data from over 398,000 patients and 333 primary care providers in Alberta, Canada. An automated pattern-matching algorithm was developed to identify text and ICD-9 diagnostic codes indicating cannabis use in the EMR. There was a total of 11,724 records indicating cannabis use from 4652 patients, representing approximately 1.2% of the patient sample. Commonly used terms and ICD-9 codes included cannabis , marijuana/marihuana, THC, 304.3 and 305.2. Nabilone was the most frequently prescribed cannabinoid medication. Slightly more males and those with a chronic condition had cannabis use recorded more often. Overall, very few patients have cannabis use recorded in primary care EMR data and this is not captured in a systematic way. We propose several strategies to improve the documentation of cannabis use to facilitate more effective clinical care, research, and surveillance.

Background Long-term prescription of opioids by healthcare professionals has been linked to poor individual patient outcomes and high resource utilization. Supportive strategies in this population regarding acute healthcare settings may have substantial impact. Methods We performed a systematic review and meta-analysis of primary studies. The studies were included according to the following criteria: 1) age 18 and older; 2) long-term prescribed opioid therapy; 3) acute healthcare setting presentation from a complication of opioid therapy; 4) evaluating a supportive strategy; 5) comparing the effectiveness of different interventions; 6) addressing patient or healthcare related outcomes. We performed a qualitative analysis of supportive strategies identified. We pooled patient and system related outcome data for each supportive strategy. Results A total of 5664 studies were screened and 19 studies were included. A total of 9 broad categories of supportive strategies were identified. Meta-analysis was performed for the “supports for patients in pain” supportive strategy on two system-related outcomes using a ratio of means. The number of emergency department (ED) visits were significantly reduced for cohort studies ( n  = 6, 0.36, 95% CI [0.20–0.62], I 2 = 87%) and randomized controlled trials (RCTs) ( n  = 3, 0.71, 95% CI [0.61–0.82], I 2 = 0%). The number of opioid prescriptions at ED discharge was significantly reduced for RCTs ( n  = 3, 0.34, 95% CI [0.14–0.82], I 2 = 78%). Conclusion For patients presenting to acute healthcare settings with complications related to long-term opioid therapy, the intervention with the most robust data is “supports for patients in pain”.

BACKGROUND: The impact of telephone consultations between pain specialists and primary care physicians regarding the care of patients with chronic pain is unknown. OBJECTIVES: To evaluate the impact of telephone consultations between pain specialists and primary care physicians regarding the care of patients with chronic pain. METHODS: Patients referred to an interdisciplinary chronic pain service were randomly assigned to either receive usual care by the primary care physician, or to have their case discussed in a telephone consultation between a pain specialist and the referring primary care physician. Patients completed a numerical rating scale for pain, the Pain Disability Index and the Short Form‐36 on referral, as well as three and six months later. Primary care physicians completed a brief survey to assess their impressions of the telephone consultation. RESULTS: Eighty patients were randomly assigned to either the usual care group or the standard telephone consultation group, and 67 completed the study protocol. Patients were comparable on baseline pain and demographic characteristics. No differences were found between the groups at six months after referral in regard to pain, disability or quality of life measures. Eighty percent of primary care physicians indicated that they learned new patient care strategies from the telephone consultation, and 97% reported that the consultation answered their questions and helped in the care of their patient. DISCUSSION: Most primary care physicians reported that a telephone consultation with a pain specialist answered their questions, improved their patients’ care and resulted in new learning. Differences in patient status compared with a usual care control group were not detectable at six‐month follow‐up. CONCLUSIONS: While telephone consultations are clearly an acceptable strategy for knowledge translation, additional strategies may be required to actually impact patient outcomes.

Introduction Opioids are routinely used to treat a variety of chronic conditions associated with pain. However, they are a class of medications with a significant potential for adverse health effects, with and without misuse. Opioid misuse, as defined as inappropriate use of appropriately prescribed opioids, is becoming more well-recognized publicly but does not have clear treatment options. Opioid misuse has been linked to variety of poor outcomes and its consequences have a significant impact on healthcare resource utilization. The evidence on harm reduction strategies to mitigate adverse events prompting presentation to acute care settings for patients presenting with long-term opioid use is sparse. Methods and analysis We will perform a systematic review and meta-analysis to catalog effective harm reduction strategies and identify the most effective ones to reduce avoidable healthcare utilization in patients on long-term opioid therapy who present to acute health care settings with complications attributed to opioid misuse. A search strategy will be developed and executed by an information specialist; electronic databases (MEDLINE, EMBASE, CINAHL, Cochrane Library) and additional sources will be searched. Search themes will include opioids, chronic drug use, and acute healthcare settings. Citation screening, selection, quality assessment, and data abstraction will be performed in duplicate. A comprehensive inventory of harm reduction strategies will be developed. Data will be collected on patient-related outcomes associated with each identified harm reduction strategy. When sufficiently homogeneous data on interventions, population, and outcomes is available, it will be pooled for aggregate analysis. Evaluation of the methodological quality of individual studies and of the quality of the body of evidence will be performed. Our primary objective will be to identify harm reduction strategies that have been shown to result in clinically relevant and statistically significant improvements in patient outcomes and/or decreased healthcare utilization. Discussion This study will better characterize harm reduction strategies for patients on long-term prescribed opioids presenting to acute healthcare settings. It will also add new knowledge and generate greater understanding of key knowledge gaps of the long-term prescribed opioid use and its impact on healthcare utilization. Systematic review registration CRD42018088962 .

ObjectivesTo describe how the development of a clinical practice guideline on the management of chronic pain (including back pain, osteoarthritis, and neuropathic pain) can potentially lead to better pain control with fewer medications.MethodsBased on the needs of family physicians, the guideline emphasized use of best available evidence and shared decision making. A guideline panel (10 health professionals and a patient representative) with no financial conflicts of interest identified key clinical questions and later created practice recommendations based on evidence review. Systematic reviews of randomized, controlled trials (RCTs) were performed by an experienced evidence team. RCTs were included if they reported a responder analysis (ie. how many patients had a meaningful reduction in pain). Additional rapid reviews were completed to answer supplemental questions. GRADE methodology was used in evidence review and recommendation creation, and the guideline was reviewed by clinicians and patients.ResultsThree published comprehensive reviews including 35 systematic reviews (285 randomized, controlled trials) of individual treatments for osteoarthritis, chronic low back and neuropathic pain were completed. Based on evidence review, treatments were divided into those with clear evidence of benefit, those with unclear benefit, those with no evidence of benefit, and those where the potential harms likely outweigh the benefits. Absolute benefits and risks were presented in knowledge translation tools and decision aids to encourage shared decision making with patients. Due to the nature of chronic pain, treatments were not aligned in a stepwise hierarchy to prevent eventual treatment with opioids or other potentially harmful treatments; rather, they are presented in a way that allows dialogue between patients and providers regarding various options. Physical activity is recommended as the foundation for treating osteoarthritis and low back pain. Cognitive-behavioural therapy or mindfulness-based stress reduction are also potential non-drug options. Opioids and cannabinoids are examples of treatments where the potential harms likely outweigh the benefits for most conditions studied. Patient resources for understanding chronic pain and increasing physical activity were also identified and shared.ConclusionsThis guideline, utilizing the best available evidence, highlights the role of effective non-drug options for managing chronic pain in primary care, and minimizes the role of treatments where the potential harms likely exceed the benefits. The provision of absolute benefits and risks of various treatments allows the principles of shared decision making to be used throughout the treatment process. More research is needed on the management of patients with complex chronic pain.