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Gorbaty J, Wally MK, Odum S, Yu Z, Hamid N, Hsu JR, Beuhler M, Bosse M, Gibbs M, Griggs C, Jarrett S, Karunakar M, Kempton L, Leas D, Phelps K, Roomian T, Runyon M, Saha A, Sims S, Watling B, Wyatt S, Seymour R. Patients with glenohumeral arthritis are more likely to be prescribed opioids in the emergency department or urgent care setting. J Opioid Manag 2023; 19:495-505. [PMID: 38189191 DOI: 10.5055/jom.0834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
OBJECTIVE The objective is to quantify the rate of opioid and benzodiazepine prescribing for the diagnosis of shoulder osteoarthritis across a large healthcare system and to describe the impact of a clinical decision support intervention on prescribing patterns. DESIGN A prospective observational study. SETTING One large healthcare system. PATIENTS AND PARTICIPANTS Adult patients presenting with shoulder osteoarthritis. INTERVENTIONS A clinical decision support intervention that presents an alert to prescribers when patients meet criteria for increased risk of opioid use disorder. MAIN OUTCOME MEASURE The percentage of patients receiving an opioid or benzodiazepine, the percentage who had at least one risk factor for misuse, and the percent of encounters in which the prescribing decision was influenced by the alert were the main outcome measures. RESULTS A total of 5,380 outpatient encounters with a diagnosis of shoulder osteoarthritis were included. Twenty-nine percent (n = 1,548) of these encounters resulted in an opioid or benzodiazepine prescription. One-third of those who received a prescription had at least one risk factor for prescription misuse. Patients were more likely to receive opioids from the emergency department or urgent care facilities (40 percent of encounters) compared to outpatient facilities (28 percent) (p < .0001). Forty-four percent of the opioid prescriptions were for "potent opioids" (morphine milliequivalent conversion factor > 1). Of the 612 encounters triggering an alert, the prescribing decision was influenced (modified or not prescribed) in 53 encounters (8.7 percent). All but four (0.65 percent) of these encounters resulted in an opioid prescription. CONCLUSION Despite evidence against routine opioid use for osteoarthritis, one-third of patients with a primary diagnosis of glenohumeral osteoarthritis received an opioid prescription. Of those who received a prescription, over one-third had a risk factor for opioid misuse. An electronic clinic decision support tool influenced the prescription in less than 10 percent of encounters.
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Affiliation(s)
- Jacob Gorbaty
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Meghan K Wally
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Susan Odum
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute; OrthoCarolina Research Institute, Charlotte, North Carolina
| | - Ziqing Yu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Nady Hamid
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute; OrthoCarolina, Shoulder and Elbow Center, Charlotte, North Carolina
| | - Joseph R Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Michael Beuhler
- North Carolina Poison Control, Atrium Health, Charlotte, North Carolina
| | - Michael Bosse
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Michael Gibbs
- Department of Emergency Medicine, Atrium Health, Charlotte, North Carolina
| | - Christopher Griggs
- Department of Emergency Medicine, Atrium Health, Charlotte, North Carolina
| | | | - Madhav Karunakar
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Laurence Kempton
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Daniel Leas
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Kevin Phelps
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Tamar Roomian
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Michael Runyon
- Department of Emergency Medicine, Atrium Health, Charlotte, North Carolina
| | - Animita Saha
- Department of Internal Medicine, Atrium Health, Charlotte, North Carolina
| | - Stephen Sims
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | | | | | - Rachel Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
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Rochon A, Almost J, Li W, Seitz D, Tranmer J. Opioid deprescribing in long-term care in Ontario: A comparison of resident and facility characteristics. Geriatr Nurs 2023; 53:25-32. [PMID: 37421922 DOI: 10.1016/j.gerinurse.2023.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/29/2023] [Accepted: 06/30/2023] [Indexed: 07/10/2023]
Abstract
Residents of long-term care (LTC) homes have potentially painful conditions and are prescribed opioids to manage their pain, despite the risks associated with the use of these high-risk medications. Therefore, the overall aim of this study was to describe the associations between resident and facility characteristics of residents prescribed long-term opioid therapy and those who remained on opioids or had opioids deprescribed. We conducted a retrospective cohort study utilizing health administrative databases housed within ICES. Our cohort included 26,592 of 121,564 LTC residents (21.9%) of Ontario LTC homes who were prescribed long-term opioid therapy at cohort inception. Of these residents, 4,299 (16.2%) residents had opioids deprescribed during the follow-up period. Opioid deprescribing was associated with younger age, high comorbidity, and co-prescription with benzodiazepines and gabapentinoids. Our findings suggest that there is variation in the characteristics of residents who continued long-term opioid therapy and those who subsequently had opioids deprescribed, and these characteristics need to be considered as part of individualized pain management plans of care.
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Affiliation(s)
- Andrea Rochon
- Queen's University, School of Nursing, 92 Barrie St., Kingston, Ontario, Canada K7L 3N6.
| | - Joan Almost
- Queen's University, School of Nursing, 92 Barrie St., Kingston, Ontario, Canada K7L 3N6
| | - Wenbin Li
- ICES Queen's, Queen's University, 21 Arch St., Kingston, Ontario, Canada, K7L 3L3
| | - Dallas Seitz
- Department of Psychiatry, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, Alberta, Canada, T2N 4A1; ICES Queen's, Queen's University, 21 Arch St., Kingston, Ontario, Canada, K7L 3L3
| | - Joan Tranmer
- Queen's University, School of Nursing, 92 Barrie St., Kingston, Ontario, Canada K7L 3N6; Department of Psychiatry, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, Alberta, Canada, T2N 4A1
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3
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Ong T, Thiam CN. Special consideration for pain management in the older person. Clin Med (Lond) 2022; 22:295-297. [PMID: 35882494 DOI: 10.7861/clinmed.cm-2022-0273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Pain is common among older people. However, it remains underrecognised and under-treated. A comprehensive assessment of pain involves identifying its cause, establishing its severity, determining its impact on the person experiencing it and reviewing the person's response to treatment. Addressing their pain requires a different approach compared to a younger person because there is usually concomitant frailty, multimorbidity, polypharmacy, sensory deficits and cognitive impairment. This review will summarise a comprehensive approach to pain management in the older person.
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Chiappini S, Schifano F, Martinotti G, Strasser JC, Bonnet U, Scherbaum N. Opioid painkiller dependence in a sample of elderly medical inpatients. Psychogeriatrics 2021; 21:265-271. [PMID: 33594719 DOI: 10.1111/psyg.12658] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 12/31/2020] [Accepted: 01/14/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Over the past few years, there has been a growing concern about prescription opioid misuse and dependence in the elderly. Our study aimed to investigate the prevalence of previous and current prescription opioid dependence among elderly medical inpatients recruited from a large German hospital. METHODS This cross-sectional study analyzed a cohort of inpatients aged 65 years and older who were assessed with a structured clinical interview. Levels of past and current dependence on opioids benzodiazepines, hypnotics, and non-opioid analgesics were assessed. RESULTS Of 2108 elderly inpatients admitted to the hospital during a 6-month period, 400 fulfilled the inclusion criteria and agreed to participate to the survey. Among these 400 subjects, 43 (10.8%) presented with a dependence on opioid analgesics, including 41 with current dependence and 22 (51.2%) with a de novo condition. Addiction severity was considered mild in 65.1% of cases and severe in 11.6% of cases. Tilidine and oxycodone were the most typically reported molecules. CONCLUSIONS Further research is warranted, to better understand the possible risk factors of prescription drug misuse, abuse, and addiction in this vulnerable population. Clinicians should be updated and informed regarding both prescription medication misuse potential and safe prescribing practices in the elderly.
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Affiliation(s)
- Stefania Chiappini
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Fabrizio Schifano
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Giovanni Martinotti
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK.,Department of Neurosciences, Imaging and Clinical Sciences, G. D'Annunzio University, Chieti-Pescara, Italy
| | - Johanna C Strasser
- Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, Evangelical Hospital Castrop-Rauxel, Academic Teaching Hospital of the University of Duisburg-Essen, Castrop-Rauxel, Germany
| | - Udo Bonnet
- Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, Evangelical Hospital Castrop-Rauxel, Academic Teaching Hospital of the University of Duisburg-Essen, Castrop-Rauxel, Germany.,Department of Addictive Behaviour and Addiction Medicine, LVR-Clinical Centre of Essen, Hospital of the University of Duisburg-Essen, Duisburg, Germany
| | - Norbert Scherbaum
- Department of Addictive Behaviour and Addiction Medicine, LVR-Clinical Centre of Essen, Hospital of the University of Duisburg-Essen, Duisburg, Germany
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5
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Marttinen MK, Kautiainen H, Haanpää M, Pohjankoski H, Hintikka J, Kauppi MJ. Analgesic purchases among older adults - a population-based study. BMC Public Health 2021; 21:256. [PMID: 33517898 PMCID: PMC7849135 DOI: 10.1186/s12889-021-10272-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 01/19/2021] [Indexed: 02/07/2023] Open
Abstract
Background Pain is a frequent and inevitable factor affecting the quality of life among older people. Several studies have highlighted the ineffectiveness of treating chronic pain among the aged population, and little is known about the prevalence of analgesics administration among community-dwelling older adults. The objective was to examine older adults’ prescription analgesic purchases in relation to SF-36 pain in a population-based setting. Methods One thousand four hundred twenty community-dwelling citizens aged 62–86 years self-reported SF-36 bodily pain (pain intensity and pain-related interference) scores for the previous 4 weeks. The Social Insurance Institution of Finland register data on analgesic purchases for 6 months prior to and 6 months after the questionnaire data collection were considered. Special interest was focused on factors related to opioid purchases. Results Of all participants, 84% had purchased prescription analgesics during 1 year. NSAIDs were most frequently purchased (77%), while 41% had purchased paracetamol, 32% opioids, 17% gabapentinoids, and 7% tricyclic antidepressants. Age made no marked difference in purchasing prevalence. The number of morbidities was independently associated with analgesic purchases in all subjects and metabolic syndrome also with opioid purchases in subjects who had not reported any pain. Discussion Substantial NSAID and opioid purchases emerged. The importance of proper pain assessment and individual deliberation in terms of analgesic contraindications and pain quality, as well as non-pharmacological pain management, need to be highlighted in order to optimize older adults’ pain management.
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Affiliation(s)
- Maiju K Marttinen
- Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön katu 34, 33520, Tampere, Finland. .,Department of Anesthesiology, Intensive Care and Pain Medication, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 8, 00290, Helsinki, Finland.
| | - Hannu Kautiainen
- Folkhälsan Research Center, Topeliuksenkatu 20, 00250, Helsinki, Finland.,Primary Health Care Unit, Kuopio University Hospital, Puijonlaaksontie 2, 70200, Kuopio, Finland
| | - Maija Haanpää
- Ilmarinen Mutual Pension Insurance Company, Porkkalankatu 1, 00180, Helsinki, Finland.,Department of Neurosurgery, Helsinki University Hospital, Topeliuksenkatu 5, 00270, Helsinki, Finland
| | - Heini Pohjankoski
- Department of Paediatrics, Päijät-Häme Central Hospital, Keskussairaalankatu 7, 15850, Lahti, Finland
| | - Jukka Hintikka
- Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön katu 34, 33520, Tampere, Finland.,Department of Psychiatry, Päijät-Häme Central Hospital, Keskussairaalankatu 7, 15850, Lahti, Finland
| | - Markku J Kauppi
- Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön katu 34, 33520, Tampere, Finland.,Department of Rheumatology, Päijät-Häme Central Hospital, Keskussairaalankatu 7, 15850, Lahti, Finland
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6
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Karjalainen M, Kautiainen H, Saltevo J, Haanpää M, Mäntyselkä P, Tiihonen M. Use of pain relieving drugs in community-dwelling older people with and without type 2 diabetes. Prim Care Diabetes 2020; 14:736-740. [PMID: 32980280 DOI: 10.1016/j.pcd.2020.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 11/25/2022]
Abstract
AIMS To analyze the use of pain medication among community-dwelling people aged 65 years or older with and without type 2 diabetes in primary care. METHODS A total of 187 patients with and 176 patients without diabetes were randomly selected from a primary care sample of 389 patients with diabetes and 604 age- and gender-matched controls. Pain status was defined as no pain, nociceptive pain or neuropathic pain. Pain medication (paracetamol, NSAID, opioids, neuropathic pain medication) use was based on electronic patient records and checked by a physician during a health examination. RESULTS Some pain was present in 90 (51%) patients without and in 106 (57%) patients with diabetes (p = 0.55). Of the patients without diabetes, 109 (62%) and with diabetes 123 (66%) used some pain medication (p = 0.45). The respective proportions for the regular use were 13% and 11% and for the as needed use 56% and 61%. Diabetes was not associated with any of the pain medications used. The use of pain-relieving drugs was most common for neuropathic pain. CONCLUSIONS The present study indicated that community-dwelling people with and without diabetes used pain medication similarly. Pain medication was used mostly as needed instead of being regular.
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Affiliation(s)
- Merja Karjalainen
- Institute of Public Health and Clinical Nutrition, General Practice, University of Eastern Finland, Kuopio, Finland; Inner Savo Health Center, Suonenjoki, Finland
| | - Hannu Kautiainen
- Unit of Primary Health Care, Helsinki University Central Hospital, Helsinki, Finland; Primary Health Care Unit, Kuopio University Hospital, Kuopio, Finland
| | - Juha Saltevo
- Central Finland Central Hospital, Jyväskylä, Finland
| | - Maija Haanpää
- Ilmarinen Mutual Pension Insurance Company, Finland; Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Pekka Mäntyselkä
- Institute of Public Health and Clinical Nutrition, General Practice, University of Eastern Finland, Kuopio, Finland; Primary Health Care Unit, Kuopio University Hospital, Kuopio, Finland
| | - Miia Tiihonen
- School of Pharmacy, University of Eastern Finland, P.O. Box 1627, FI-70211 Kuopio, Finland.
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Schutijser BCFM, Jongerden I, Klopotowska JE, Moesker M, Langelaan M, Wagner C, de Bruijne M. Nature of adverse events with opioids in hospitalised patients: a post-hoc analysis of three patient record review studies. BMJ Open 2020; 10:e038037. [PMID: 32998923 PMCID: PMC7528356 DOI: 10.1136/bmjopen-2020-038037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Opioids are increasingly prescribed and frequently involved in adverse drug events (ADEs). The underlying nature of opioid-related ADEs (ORADEs) is however understudied. This hampers our understanding of risks related to opioid use during hospitalisation and when designing interventions. Therefore, we provided a description of the nature of ORADEs. DESIGN A post-hoc analysis of data collected during three retrospective patient record review studies (in 2008, 2011/2012 and 2015/2016). SETTING The three record review studies were conducted in 32 Dutch hospitals. PARTICIPANTS A total of 10 917 patient records were assessed by trained nurses and physicians. OUTCOME MEASURES Per identified ORADE, we described preventability, type of medication error, attributable factors and type of opioids involved. Moreover, the characteristics of preventable and non-preventable ORADEs were compared to identify risk factors. RESULTS Out of 10 917 patient records, 357 ADEs were identified, of which 28 (8%) involved opioids. Eleven ORADEs were assessed as preventable. Of these, 10 were caused by dosing errors and 4 probably contributed to patients' death. Attributable factors identified were mainly on patient and organisational levels. Morphine and oxycodone were the most frequently involved opioids. The risk for ORADEs was higher in elderly patients. CONCLUSIONS Only 8% of ADEs identified in our sample were related to opioids. Although the frequency is low, the risk of serious consequences is high. We recommend to use our findings to increase awareness among physicians and nurses. Future interventions should focus on safe dosing of opioids when prescribing and administering, especially in elderly patients.
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Affiliation(s)
| | - Irene Jongerden
- Public and Occupational Health, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | | | - Marco Moesker
- Public and Occupational Health, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | | | - Cordula Wagner
- Public and Occupational Health, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
- NIVEL, Utrecht, The Netherlands
| | - Martine de Bruijne
- Public and Occupational Health, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
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8
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Abstract
Aim: The review aimed to identify factors influencing opioid prescribing as regular pain-management medication for older people. Background: Chronic pain occurs in 45%–85% of older people, but appears to be under-recognised and under-treated. However, strong opiate prescribing is more prevalent in older people, increasing at the fastest rate in this age group. Methods: This review included all study types, published 1990–2017, which focused on opioid prescribing for pain management among older adults. Arksey and O’Malley’s framework was used to scope the literature. PubMed, EBSCO Host, the UK Drug Database, and Google Scholar were searched. Data extraction, carried out by two researchers, included factors explaining opioid prescribing patterns and prescribing trends. Findings: A total of 613 papers were identified and 53 were included in the final review consisting of 35 research papers, 10 opinion pieces and 8 grey literature sources. Factors associated with prescribing patterns were categorised according to whether they were patient-related, prescriber-driven, or system-driven. Patient factors included age, gender, race, and cognition; prescriber factors included attitudes towards opioids and judgements about ‘normal’ pain; and policy/system factors related to the changing policy landscape over the last three decades, particularly in the USA. Conclusions: A large number of context-dependent factors appeared to influence opioid prescribing for chronic pain management in older adults, but the findings were inconsistent. There is a gap in the literature relating to the UK healthcare system; the prescriber and the patient perspective; and within the context of multi-morbidity and treatment burden.
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9
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Alamanda VK, Wally MK, Seymour RB, Springer BD, Hsu JR. Prevalence of Opioid and Benzodiazepine Prescriptions for Osteoarthritis. Arthritis Care Res (Hoboken) 2020; 72:1081-1086. [PMID: 31127868 DOI: 10.1002/acr.23933] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 05/21/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Opioids and benzodiazepines are commonly used for management of osteoarthritis, despite evidence-based recommendations to the contrary. This study aimed to quantify the prevalence of opioid and benzodiazepine prescribing for osteoarthritis. Additionally, we aimed to characterize risk factors for prescription drug misuse, abuse, and diversion among this population. METHODS We conducted a descriptive analysis of adult outpatient encounters with a primary diagnosis of osteoarthritis during a 1-year period at a large health care system, excluding cancer and outpatient procedures. Demographic data, prescription data, and patient-specific risk factors were collected. Descriptive analysis was conducted to characterize arthritis patients who received and did not receive prescription opioids. RESULTS During 1 year, our system had 31,123 outpatient encounters for osteoarthritis. Opioids and benzodiazepines were prescribed for nearly 27% of the encounters (n = 8,420). In all, 43% of the encounters involved patients age ≥65 years. Hydrocodone-acetaminophen was the most common medication prescribed (34.3%). Most prescriptions were written by pain specialists (53%). A total of 35.5% of patients had a risk factor for prescription misuse, the most prevalent being early refill and a history of receiving ≥3 prescriptions in the past month. CONCLUSION Prescriptions for opioids and benzodiazepines continue to be written for osteoarthritis. These prescriptions may pose a risk for adverse outcomes since >1 in 5 patients receiving prescriptions had a risk factor for misuse. Continued efforts to improve compliance with evidence-based guidelines as well as multimodal and alternative pain management pathways are critical to help curb the use of opioids for management of osteoarthritis-related pain. LEVEL OF EVIDENCE level IV.
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Affiliation(s)
- Vignesh K Alamanda
- Carolinas Medical Center and OrthoCarolina Hip and Knee Center, Charlotte, North Carolina
| | - Meghan K Wally
- Carolinas Medical Center and OrthoCarolina Hip and Knee Center, Charlotte, North Carolina
| | - Rachel B Seymour
- Carolinas Medical Center and OrthoCarolina Hip and Knee Center, Charlotte, North Carolina
| | - Bryan D Springer
- OrthoCarolina Hip and Knee Center and Atrium Health Musculoskeletal Institute, Atrium Health, Charlotte, North Carolina
| | - Joseph R Hsu
- Carolinas Medical Center and OrthoCarolina Hip and Knee Center, Charlotte, North Carolina
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10
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Weesie YM, Hek K, Schermer TRJ, Schellevis FG, Leufkens HGM, Rook EJ, van Dijk L. Use of Opioids Increases With Age in Older Adults: An Observational Study (2005-2017). Front Pharmacol 2020; 11:648. [PMID: 32477127 PMCID: PMC7241279 DOI: 10.3389/fphar.2020.00648] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 04/22/2020] [Indexed: 11/13/2022] Open
Abstract
Aim Pain is increasingly treated with opioids. Potential harms of opioid therapy disproportionally affect older patients. This study aims to provide information on trends, nature and duration of opioid prescribing to older adults, in primary care and to explore differences between older patients from different ages. Methods Primary care data (2005-2017) were derived from routine electronic medical records of patients in Nivel Primary Care Database. All opioid prescriptions with Anatomical Therapeutic Chemical Classification (ATC) code N02A were selected (except for codeine). Diagnoses were recorded using the International Classification of Primary Care (ICPC). Patients were categorized in three age groups (65-74, 75-84, and ≥85 years). Descriptive analyses were used to describe the trend of opioid prescriptions for specific opioids, the duration of use and underlying diagnoses. Results 283,600 patients were included of which 32,287 had at least one opioid prescription in 2017. An increase in the number of older adults who received at least one opioid was seen between 2005 and 2017. The oldest patients were more likely to be prescribed an opioid, especially when it comes to strong opioids, the increase in the volume of prescribing was highest in this group. Moreover, over 40% of the oldest patients used strong opioids chronically. Strong opioids were mostly prescribed for musculoskeletal diagnoses. Cancer was the second most common diagnosis for strong opioids in the younger subgroups, whereas less specified diagnoses were as second in the oldest subgroup. Conclusion Opioid prescription changes with increasing age in frequency, nature, and duration, despite higher harm risks among older patients. Because of the high prevalence of chronic use, it is important to monitor the patient throughout the treatment and to critically evaluate the initiation and continuation of opioid prescriptions.
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Affiliation(s)
- Yvette M Weesie
- Pharmaceutical Care, Netherlands Institute for Health Services Research (Nivel), Utrecht, Netherlands
| | - Karin Hek
- Pharmaceutical Care, Netherlands Institute for Health Services Research (Nivel), Utrecht, Netherlands
| | - Tjard R J Schermer
- Pharmaceutical Care, Netherlands Institute for Health Services Research (Nivel), Utrecht, Netherlands.,Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, Netherlands
| | - Francois G Schellevis
- Pharmaceutical Care, Netherlands Institute for Health Services Research (Nivel), Utrecht, Netherlands.,Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers location VUmc, Amsterdam, Netherlands
| | - Hubertus G M Leufkens
- Utrecht Institute for Pharmaceutical Sciences, Utrecht University (UU), Utrecht, Netherlands
| | | | - Liset van Dijk
- Pharmaceutical Care, Netherlands Institute for Health Services Research (Nivel), Utrecht, Netherlands.,Department of PharmacoTherapy,-Epidemiology & -Economics (PTEE), Faculty of Mathematics and Natural Sciences, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, Netherlands
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11
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Safer DJ. Overprescribed Medications for US Adults: Four Major Examples. J Clin Med Res 2019; 11:617-622. [PMID: 31523334 PMCID: PMC6731049 DOI: 10.14740/jocmr3906] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 07/15/2019] [Indexed: 12/24/2022] Open
Abstract
To understand possible medication overprescribing, it would be important to know which classes are the most prescribed, for which indications, for what duration, and for which age groups. Among the 10 most frequently prescribed medication classes for US adults, four were evaluated for overprescribing, and systematically assessed in relation to their primary indication. The assessment included usage patterns, trends, age of recipients, treatment duration, and benefits versus adverse consequences. The findings in this selective review are supported by an extensive search of the medical literature. The four selected medication categories and their most common indication included opioids for chronic pain, proton pump inhibitors for indigestion, levothyroxine for subclinical hypothyroidism, and antidepressants for subsyndromal levels of depression. These medications, grouped by their most frequent indication along with polypharmacy, have experienced major prescription increases in recent years, particularly among older patients. Most concerning is that they have been frequently prescribed for extended periods, usually with inadequate evidence of benefit. High drug usage patterns can aid in quantifying overprescribing within polypharmacy by age group.
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Affiliation(s)
- Daniel J Safer
- Departments of Psychiatry and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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12
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Dentino A, Medina R, Steinberg E. Pain in the Elderly: Identification, Evaluation, and Management of Older Adults with Pain Complaints and Pain-related Symptoms. Prim Care 2018; 44:519-528. [PMID: 28797377 DOI: 10.1016/j.pop.2017.04.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pain is a common and often underappreciated and undermanaged problem in older adults. This article addresses the scope of the issue of pain prevalence in older adults, types of pain and their characteristics, approach to and clinical workup of older adults with pain complaints and pain-related symptoms, nonpharmacologic and pharmacologic management strategies, and caveats with attention to medication side effects in the elderly.
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Affiliation(s)
- Andrew Dentino
- The Donald W. Reynolds Department of Geriatric Medicine, The University of Oklahoma Health Sciences Center College of Medicine, Oklahoma City, OK, USA.
| | - Roberto Medina
- The Donald W. Reynolds Department of Geriatric Medicine, The University of Oklahoma Health Sciences Center College of Medicine, Oklahoma City, OK, USA
| | - Eugene Steinberg
- The Donald W. Reynolds Department of Geriatric Medicine, The University of Oklahoma Health Sciences Center College of Medicine, Oklahoma City, OK, USA
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Maree RD, Marcum ZA, Saghafi E, Weiner DK, Karp JF. A Systematic Review of Opioid and Benzodiazepine Misuse in Older Adults. Am J Geriatr Psychiatry 2016; 24:949-963. [PMID: 27567185 PMCID: PMC5069126 DOI: 10.1016/j.jagp.2016.06.003] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 04/28/2016] [Accepted: 06/01/2016] [Indexed: 01/09/2023]
Abstract
OBJECTIVE The authors assessed the prevalence of opioid and benzodiazepine prescription drug misuse in older adults, the risk factors associated with misuse, and age-appropriate interventions. METHODS Following PRISMA guidelines, a literature search of PubMed, PsycINFO, and EMBASE for peer-reviewed journal articles in English through April 2014 with updates through November 2015 was conducted for reports on misuse of prescription benzodiazepines and opioids in older adults. Relevant publications were reviewed that included participants age ≥65 years. Reference lists were manually searched for key identified articles and geriatric journals through April 2016. Information on the study design, sample, intervention, comparators, outcome, time frame, and risk of bias were abstracted for each article. RESULTS Of 4,932 reviewed reports, 15 were included in this systematic review. Thirteen studies assessed the prevalence of prescription drug misuse and included studies related to opioid shopping behavior, assessment of morbidity and mortality associated with opioid and/or benzodiazepine use, frequency and characteristics of opioid prescribing, frequency of substance use disorders and nonprescription use of pain relievers, and health conditions and experiences of long-term benzodiazepine users. One study identified risk factors for misuse, and one study described the effects of provider education and an electronic support tool as an intervention. CONCLUSION There is a dearth of high quality research on prescription drug misuse in older adults. Existing studies are heterogeneous, making it difficult to draw broad conclusions. The need for further research specific to prescription drug misuse among older adults is discussed.
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Affiliation(s)
- RD Maree
- Department of Psychiatry, University of Pittsburgh School of Medicine
| | - ZA Marcum
- School of Pharmacy, University of Washington
| | - E Saghafi
- Department of Information Science, University of Pittsburgh School of Medicine
| | - DK Weiner
- Department of Psychiatry, University of Pittsburgh School of Medicine,Department of Anesthesiology, University of Pittsburgh School of Medicine,Department of Medicine, University of Pittsburgh School of Medicine,Geriatric Research, Education & Clinical Center, VA Pittsburgh Healthcare System
| | - JF Karp
- Department of Psychiatry, University of Pittsburgh School of Medicine,Department of Anesthesiology, University of Pittsburgh School of Medicine,Geriatric Research, Education & Clinical Center, VA Pittsburgh Healthcare System
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Abstract
When possible, chronic noncancer pain (CNCP) in older adults should be managed by nonpharmacologic modalities in conjunction with nonopioid analgesics. If moderate-to-severe pain persists despite these approaches, however, nonparenteral opioids may be considered as adjunctive therapy. This article reviews the epidemiology of opioid use and their effectiveness for CNCP in older adults and summarizes important age-related changes in opioid pharmacokinetics and pharmacodynamics that increase the risks of adverse effects in the elderly. Finally, to assist clinicians with selecting appropriate therapy, the article concludes with an evidence-based approach to optimize opioid prescribing in older adults with CNCP.
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Pharmacokinetics of Tramadol and O-Desmethyltramadol Enantiomers Following Administration of Extended-Release Tablets to Elderly and Young Subjects. Drugs Aging 2016; 32:1029-43. [PMID: 26508138 DOI: 10.1007/s40266-015-0315-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Tramadol is frequently used in geriatric patients; however, pharmacokinetic (PK) publications on tramadol and O-desmethyltramadol (ODM) in elderly patients are rare. OBJECTIVE Our objective was to characterize the PK of tramadol and ODM, including absorption processes and covariates for tramadol, in elderly and young subjects after single-dose administration of 200-mg extended-release tablets. METHODS We conducted a PK study in 15 elderly (aged ≥75 years) subjects with mild renal insufficiency and 20 young (18-40 years) subjects; blood and urine samples were collected for 48 h post-dose. Non-compartmental analysis (NCA) of each tramadol and ODM enantiomer included area under the concentration-time curve (AUC), terminal elimination rate (k el), total body clearance, volume of distribution (V area/ F), and renal clearance (Clr0-48). A one-compartment population model of total tramadol concentration was parameterized with clearance (CL/F), volume of distribution (V/F), and mixed order absorption (first-order and zero-order absorption rate constants with lag times). RESULTS NCA demonstrated comparable maximum plasma concentration (C max) and AUC between age groups for tramadol enantiomers, but significant differences in V area/ F (mean 34% higher) and k el (mean 28% lower) in the elderly. PK of ODM were significantly different in the elderly for AUC0-inf (mean 35% higher), Clr0-48 (mean 29% lower), and k el (mean 33% lower). The population analysis identified age as a covariate of V/F (young 305 L; elderly 426 L), with a 50% longer mean elimination half-life in the elderly. No differences in absorption processes were observed. CONCLUSIONS Tramadol exposure was similar between the age groups; exposure to ODM was higher in elderly subjects.
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A prospective randomized comparative study of postoperative pain control using an epidural catheter in patients undergoing posterior lumbar interbody fusion. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25:1601-1607. [PMID: 26787345 DOI: 10.1007/s00586-016-4385-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 01/08/2016] [Accepted: 01/10/2016] [Indexed: 11/27/2022]
Abstract
PURPOSE To assess the efficacy of continuous epidural infusion analgesia (ED) with 0.2 % Ropivacaine versus IV PCA (Fentanyl) in spinal fusion surgery patients. METHOD A prospective randomized comparative clinical trial. Patients were randomized into one of two groups-the epidural group (ED-51 patients) and the IV PCA group (IV-43 patients). The epidural catheter tip was placed one level cephalad to the level of the PLIF in patients in the ED group. Patients were assessed by determining the pain score, cumulative opioid requirement, adverse effects, and satisfaction. RESULTS Pain score comparisons between the ED group and the IV group, respectively, were as follows: immediate postoperative status: 2.1 ± 1.5 vs. 7.2 ± 2.1, p = 0.01; postoperative day 1: 2.3 ± 1.9 vs. 6.8 ± 2.3, p = 0.02; postoperative day 2: 1.9 ± 1.8 vs. 5.4 ± 2.1, p = 0.02; postoperative day 3: 1.5 ± 1.6 vs. 3.9 ± 1.9, p = 0.03; postoperative day 4: 3.8 ± 2.1 vs. 3.1 ± 1.9, p = 0.4. Lower levels of opioids were required in the ED group, and fewer opioid-related complications developed in the patients in this group. Complications related to the use of epidural catheters were comparable between the two groups. Patient satisfaction with postoperative pain control was higher in the ED group. CONCLUSION In comparison with the use of IV PCA only, continuous epidural infusion of Ropivacaine resulted in lower pain scores and opioid consumption and higher patient satisfaction levels after posterior lumbar interbody fusion.
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Marengoni A, Nobili A, Corli O, Djade CD, Bertoni D, Tettamanti M, Pasina L, Corrao S, Salerno F, Marcucci M, Mannucci PM. The stigma of low opioid prescription in the hospitalized multimorbid elderly in Italy. Intern Emerg Med 2015; 10:305-13. [PMID: 25248643 DOI: 10.1007/s11739-014-1131-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 09/11/2014] [Indexed: 01/05/2023]
Abstract
The primary aim of this study was to evaluate the prevalence of opioid prescriptions in hospitalized geriatric patients. Other aims were to evaluate factors associated with opioid prescription, and whether or not there was consistency between the presence of pain and prescription. Opioid prescriptions were gathered from the REgistro POliterapie Societa` Italiana di Medicina Interna (REPOSI) data for the years 2008, 2010 and 2012. 1,380 in-patients, 65+ years old, were enrolled in the first registry run, 1,332 in the second and 1,340 in the third. The prevalence of opioid prescription was calculated at hospital admission and discharge. In the third run of the registry, the degree of pain was assessed by means of a numerical scale. The prevalence of patients prescribed with opioids at admission was 3.8% in the first run, 3.6% in the second and 4.1% in the third, whereas at discharge rates were slightly higher (5.8, 5.3, and 6.6%). The most frequently prescribed agents were mild opioids such as codeine and tramadol. The number of total prescribed drugs was positively associated with opioid prescription in the three runs; in the third, dementia and a better functional status were inversely associated with opioid prescription. Finally, as many as 58% of patients with significant pain at discharge were prescribed no analgesic at all. The conservative attitude of Italian physicians to prescribe opioids in elderly patients changed very little between hospital admission and discharge through a period of 5 years. Reasons for such a low opioid prescription should be sought in physicians' and patients' concerns and prejudices.
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Affiliation(s)
- Alessandra Marengoni
- Department of Clinical and Experimental Science, University of Brescia Italy, Piazzale Spedali Civili 1, 25123, Brescia, Italy
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Sandvik RK, Selbaek G, Seifert R, Aarsland D, Ballard C, Corbett A, Husebo BS. Impact of a stepwise protocol for treating pain on pain intensity in nursing home patients with dementia: a cluster randomized trial. Eur J Pain 2014; 18:1490-500. [PMID: 24819710 PMCID: PMC4232010 DOI: 10.1002/ejp.523] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2014] [Indexed: 11/30/2022]
Abstract
Background Pain is frequent and distressing in people with dementia, but no randomized controlled trials have evaluated the effect of analgesic treatment on pain intensity as a key outcome. Methods Three hundred fifty-two people with dementia and significant agitation from 60 nursing home units were included in this study. These units, representing 18 nursing homes in western Norway, were randomized to a stepwise protocol of treating pain (SPTP) or usual care. The SPTP group received acetaminophen, morphine, buprenorphine transdermal patch and pregabalin for 8 weeks, with a 4-week washout period. Medications were governed by the SPTP and each participant's existing prescriptions. We obtained pain intensity scores from 327 patients (intervention n = 164, control n = 163) at five time points assessed by the primary outcome measure, Mobilization-Observation-Behaviour-Intensity-Dementia-2 (MOBID-2) Pain Scale. The secondary outcome was activities of daily living (ADL). We used a linear intercept mixed model in a two-way repeated measures configuration to assess change over time and between groups. Results The SPTP conferred significant benefit in MOBID-2 scores compared with the control group [average treatment effect (ATE) −1.388; p < 0.001] at week 8, and MOBID-2 scores worsened during the washout period (ATE = −0.701; p = 0.022). Examining different analgesic treatments, benefit was conferred to patients receiving acetaminophen compared with the controls at week 2 (ATE = −0.663; p = 0.010), continuing to increase until week 8 (ATE = −1.297; p < 0.001). Although there were no overall improvements in ADL, an increase was seen in the group receiving acetaminophen (ATE = +1.0; p = 0.022). Conclusion Pain medication significantly improved pain in the intervention group, with indications that acetaminophen also improved ADL function. What's already known about this topic? What does this study add?
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Affiliation(s)
- R K Sandvik
- Department of Global Public Health and Primary Care, Centre for Elderly- and Nursing Home Medicine, University of Bergen, Norway; Institute for Nursing Subjects, Bergen University College, Norway; Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway
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