Greater opioid use among nursing home residents in Ontario, Canada during the first two waves of the COVID-19 pandemic

Switching Topical Diclofenac from Higher to Lower Strength: Financial and Clinical Evaluation

Background

In February 2020, the Fraser Health Authority in British Columbia introduced an automatic therapeutic interchange policy, whereby orders for any strength of topical diclofenac would be automatically interchanged to the commercially available diclofenac 2.32% gel for twice-daily administration. The new policy was intended mainly as a cost-saving measure but had the potential for clinical impacts that needed to be considered.

Objectives

To evaluate the financial and clinical impact of the automatic therapeutic interchange policy for topical diclofenac.

Methods

A financial evaluation and a clinical evaluation were conducted. Expenditures for topical diclofenac before and after implementation of the automatic therapeutic interchange policy were compared. To obtain information about the clinical impact of the interchange, a retrospective chart review was conducted at long-term care sites. The primary outcome was a composite of 7 components that could indicate worsening of pain in 3 prespecified scenarios.

Results

The financial evaluation showed that the interchange could potentially save the health authority more than $200 000 over 12 months. The clinical evaluation showed that 25%-48% of patients met the primary outcome of worsening pain (analyzed according to 3 different scenarios) after the switch to lower-strength diclofenac, with increases in use of as-needed topical diclofenac and other analgesics being the main indicators of worsening pain.

Conclusions

An automatic therapeutic interchange policy that switched orders for higher strengths of diclofenac to the 2.32% concentration resulted in large financial savings and, in most cases (52%-75% of patients), did not appear to affect pain control. Prospective studies comparing the clinical impact of higher- and lower-strength topical diclofenac products are warranted.

Psychotropic, Anticonvulsant, and Opioid Use in Assisted Living Residents Before and During the COVID-19 Pandemic

OBJECTIVES

To examine the associations between COVID-19 pandemic waves (1-4) and prevalent antipsychotic, antidepressant, benzodiazepine, anticonvulsant, and opioid use among assisted living (AL) residents, by setting (dementia care vs other).

DESIGN

Population-based, repeated cross-sectional study.

SETTING AND PARTICIPANTS

Linked clinical and health administrative databases for residents of all publicly subsidized AL homes (N = 256) in Alberta, Canada, examined from January 2018 to December 2021. Setting-specific quarterly cohorts of residents were derived for pandemic (starting March 1, 2020) and comparable historical (2018/2019 combined) periods.

METHODS

The quarterly proportion of residents dispensed an antipsychotic, antidepressant, benzodiazepine, anticonvulsant, or opioid was examined for each setting and period. Log-binomial generalized estimating equations models estimated prevalence ratios (PR) for period (pandemic vs historical quarterly periods), setting (dementia care vs other AL), and period-setting interactions.

RESULTS

On March 1, 2020, there were 2874 dementia care and 6611 other AL residents (mean age 82.4 vs 79.9 years, 68.2% vs 66.1% female, 93.5% vs 42.6% with dementia, respectively). Antipsychotic use increased during waves 2 to 4 for residents of both settings, but this increase was significantly greater for dementia care than other AL residents during waves 3 and 4 (eg, wave 3, PR 1.21, 95% CI 1.14-1.27 vs PR 1.12, 95% CI 1.07-1.17, interaction term P = .029). In both settings, there was a significant but modest increase in antidepressant use and a significant decrease in benzodiazepine use during several pandemic waves. For other AL residents only, there was a small statistically significant increase in anticonvulsant use during waves 2 to 4. No significant pandemic effect was observed for prevalent opioid use in either setting.

CONCLUSIONS AND IMPLICATIONS

The persistence of the pandemic-associated increase in antipsychotic, antidepressant, and anticonvulsant use in AL residents, and greater increase in antipsychotic use for dementia care settings, raises concerns about the attendant risks for residents, especially those with dementia.

Trends and correlates of concurrent opioid and benzodiazepine and/or gabapentinoid use among Ontario nursing home residents

BACKGROUND

A concern with long-term opioid use is the increased risk arising when opioids are used concurrently with drugs that can potentiate their associated adverse effects. The drugs most often encountered are benzodiazepines (BZDs) and gabapentinoids. Our study objectives were to examine trends in the concurrent use of opioids and BZDs, or gabapentinoids, in a Canadian nursing home population over an 11-year period, and current resident-level correlates of this concurrent use.

METHODS

We conducted a population-based, repeated cross-sectional study among Ontario nursing home residents (>65 years) dispensed opioids between April 2009 and February 2020. For the last study year, we examined cross-sectional associations between resident characteristics and concurrent use of opioids with BZDs or gabapentinoids. Linked data on nursing home residents from clinical and health administrative databases was used. The yearly proportions of residents who were dispensed an opioid concurrently with a BZD or gabapentinoid were plotted with percent change derived from log-binomial regression models. Separate modified Poisson regression models estimated resident-level correlates of concurrent use of opioids with BZDs or gabapentinoids.

RESULTS

Over the study period, among residents dispensed an opioid there was a 53.2% relative decrease (30.7% to 14.4%) in concurrent BZD and a 505.4% relative increase (4.4% to 26.6%) in concurrent gabapentinoid use. In adjusted models, increasing age and worsening cognition were inversely associated with the concurrent use of both classes, but most other significantly related covariates were unique to each drug class (e.g., sex and anxiety disorders for BZD, pain severity and presence of pain-related conditions for gabapentinoids).

CONCLUSIONS

Co-administration of BZDs or gabapentinoids in Ontario nursing home residents dispensed opioids remains common, but the pattern of co-use has changed over time. Observed covariates of concurrent use in 2019/20 suggest distinct but overlapping resident populations requiring consideration of the relative risks versus benefits of this co-use and monitoring for potential harm.

Behavioral symptoms, depression symptoms, and medication use in Michigan nursing home residents with dementia during COVID-19

BACKGROUND

The COVID-19 pandemic significantly disrupted nursing home (NH) care, including visitation restrictions, reduced staffing levels, and changes in routine care. These challenges may have led to increased behavioral symptoms, depression symptoms, and central nervous system (CNS)-active medication use among long-stay NH residents with dementia.

METHODS

We conducted a retrospective, cross-sectional study including Michigan long-stay (≥100 days) NH residents aged ≥65 with dementia based on Minimum Data Set (MDS) assessments from January 1, 2018 to June 30, 2021. Residents with schizophrenia, Tourette syndrome, or Huntington's disease were excluded. Outcomes were the monthly prevalence of behavioral symptoms (i.e., Agitated Reactive Behavior Scale ≥ 1), depression symptoms (i.e., Patient Health Questionnaire [PHQ]-9 ≥ 10, reflecting at least moderate depression), and CNS-active medication use (e.g., antipsychotics). Demographic, clinical, and facility characteristics were included. Using an interrupted time series design, we compared outcomes over two periods: Period 1: January 1, 2018-February 28, 2020 (pre-COVID-19) and Period 2: March 1, 2020-June 30, 2021 (during COVID-19).

RESULTS

We included 37,427 Michigan long-stay NH residents with dementia. The majority were female, 80 years or older, White, and resided in a for-profit NH facility. The percent of NH residents with moderate depression symptoms increased during COVID-19 compared to pre-COVID-19 (4.0% vs 2.9%, slope change [SC] = 0.03, p < 0.05). Antidepressant, antianxiety, antipsychotic and opioid use increased during COVID-19 compared to pre-COVID-19 (SC = 0.41, p < 0.001, SC = 0.17, p < 0.001, SC = 0.07, p < 0.05, and SC = 0.24, p < 0.001, respectively). No significant changes in hypnotic use or behavioral symptoms were observed.

CONCLUSIONS

Michigan long-stay NH residents with dementia had a higher prevalence of depression symptoms and CNS active-medication use during the COVID-19 pandemic than before. During periods of increased isolation, facility-level policies to regularly assess depression symptoms and appropriate CNS-active medication use are warranted.