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Thompson HM, Govindarajulu U, Doucette J, Nabeel I. Short-acting opioid prescriptions and Workers' Compensation using the National Ambulatory Medical Care Survey. Am J Ind Med 2024; 67:474-482. [PMID: 38491940 DOI: 10.1002/ajim.23581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 02/20/2024] [Accepted: 02/29/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND Short-acting opioids have been utilized for pain management with little known about their use in patients on Workers' Compensation (WC) insurance. Our goal was to investigate this association in the ambulatory care setting. METHODS Using the National Ambulatory Medical Care Survey, visits from patients aged 18-64 during the years 2010 until 2018 were evaluated (excluding 2017 due to data availability). Demographic and co-morbidity data from each visit was obtained along with the visit year. The first short-acting opioid medication prescribed in the database was considered. Survey-weighted frequencies were evaluated. Logistic regression estimated the crude and adjusted odds ratios (OR) with 95% confidence intervals for the use of short-acting opioid prescription. RESULTS There were 155,947 included visits with 62.5% for female patients. Most patients were White with 11.7% identifying as Black, and 6% identifying as another race. Over 13% of the sample was of Hispanic descent. WC was the identified insurance type in 1.6% of the sample population. Of these patients, 25.6% were prescribed a short-acting opioid, compared with 10.1% of those with another identified insurance. On multivariable regression, Black patients had increased odds of being prescribed a short-acting opioid compared to white patients (OR: 1.22, 95% CI: 1.11-1.34). Those on WC had 1.7-fold higher odds of being prescribed short-acting opioids (95% CI: 1.46-2.06). CONCLUSION Certain patient characteristics, including having WC insurance, increased the odds of a short-acting opioid prescription. Further work is needed to identify prescribing patterns in specific high-risk occupational groups, as well as to elicit potential associated health outcomes.
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Affiliation(s)
- Hannah M Thompson
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Usha Govindarajulu
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, Center for Biostatistics, New York, New York, USA
| | - John Doucette
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ismail Nabeel
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Michalowski A, Cavanaugh KL, Hamm M, Wilkie C, Olejniczak DM, Eneanya ND, Colditz J, Jhamb M, Bulls HW, Liebschutz JM. Stakeholder-Driven Intervention Development for Dialysis Trials Using a Design Sprint Methodology. Kidney Med 2023; 5:100729. [PMID: 38028030 PMCID: PMC10630159 DOI: 10.1016/j.xkme.2023.100729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
Rationale & Objective Stigma contributes to ineffective treatment for pain among individuals with kidney failure on dialysis, particularly with buprenorphine pain treatment. To address stigma, we adapted a Design Sprint, an industry-developed structured exercise where an interdisciplinary group works over 5 days to clarify the problem, identify and choose a solution, and build and test a prototype. Study Design Adapted Design Sprint which clarified the problem to be solved, proposed solutions, and created a blueprint for the selected solution. Settings & Participants Five individuals with pain and kidney disease receiving dialysis, 5 physicians (nephrology, palliative care, and addiction medicine) and 4 large dialysis organization leaders recruited for specific expertise or experience. Conducted through online platform (Zoom) and virtual white board (Miro board). Analytical Approach Descriptions of the Design Sprint adaptations and processes. Results To facilitate patient comfort, a patient-only phase included four 90-minute sessions over 2-weeks, during which patient participants used a mapping process to define the critical problem and sketch out solutions. In a physician-only phase, consisting of two 120-minute sessions, participants accomplished the same tasks. During a combined phase of two 120-minute sessions, patients, physicians, and large dialysis organization representatives vetted and developed solutions from earlier phases, leading to an intervention blueprint. Videoconferencing technology allowed for geographically diverse representation and facilitated participation from patients experiencing medical illness. The electronic whiteboard permitted interactive written contributions and voting on priorities instead of only verbal discussion, which may privilege physician participants. A skilled qualitative researcher facilitated the sessions. Limitations Challenges included the time commitment of the sessions, absences owing to illness or emergencies, and technical difficulties. Conclusions An adapted Design Sprint is a novel method of efficiently and rapidly incorporating multiple stakeholders to develop solutions for clinical challenges in kidney disease. Plain Language Summary Stigma contributes to ineffective treatment for pain among individuals with kidney failure on dialysis, particularly when using buprenorphine, an opioid pain medicine with a lower risk of sedation used to treat addiction. To develop a stigma intervention, we adapted a Design Sprint, an industry-developed structured exercise where an interdisciplinary group works over 5 days to clarify the problem, identify and choose a solution, and build and test a prototype. We conducted 3 sprints with (1) patients alone, (2) physicians alone, and (3) combined patients, physicians, and dialysis organization representatives. This paper describes the adaptations and products of sprints as a method for gathering diverse stakeholder voices to create an intervention blueprint efficiently and rapidly.
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Affiliation(s)
- Allison Michalowski
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA
| | - Kerri L. Cavanaugh
- Division of Nephrology & Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Megan Hamm
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA
| | | | - Donna M. Olejniczak
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA
| | - Nwamaka D. Eneanya
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA
| | - Jason Colditz
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA
| | - Manisha Jhamb
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA
| | - Hailey W. Bulls
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, UPMC, Pittsburgh, PA
| | - Jane M. Liebschutz
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA
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Hall RK, Rutledge J, Lucas A, Liu CK, Clair Russell JS, Peter WS, Fish LJ, Colón-Emeric C. Stakeholder Perspectives on Factors Related to Deprescribing Potentially Inappropriate Medications in Older Adults Receiving Dialysis. Clin J Am Soc Nephrol 2023; 18:1310-1320. [PMID: 37499693 PMCID: PMC10578639 DOI: 10.2215/cjn.0000000000000229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 07/21/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Potentially inappropriate medications, or medications that generally carry more risk of harm than benefit in older adults, are commonly prescribed to older adults receiving dialysis. Deprescribing, a systematic approach to reducing or stopping a medication, is a potential solution to limit potentially inappropriate medications use. Our objective was to identify clinicians and patient perspectives on factors related to deprescribing to inform design of a deprescribing program for dialysis clinics. METHODS We conducted rapid qualitative analysis of semistructured interviews and focus groups with clinicians (dialysis clinicians, primary care providers, and pharmacists) and patients (adults receiving hemodialysis aged 65 years or older and those aged 55-64 years who were prefrail or frail) from March 2019 to December 2020. RESULTS We interviewed 76 participants (53 clinicians [eight focus groups and 11 interviews] and 23 patients). Among clinicians, 24 worked in dialysis clinics, 18 worked in primary care, and 11 were pharmacists. Among patients, 13 (56%) were aged 65 years or older, 14 (61%) were Black race, and 16 (70%) reported taking at least one potentially inappropriate medication. We identified four themes (and corresponding subthemes) of contextual factors related to deprescribing potentially inappropriate medications: ( 1 ) system-level barriers to deprescribing (limited electronic medical record interoperability, time constraints and competing priorities), ( 2 ) undefined comanagement among clinicians (unclear role delineation, clinician caution about prescriber boundaries), ( 3 ) limited knowledge about potentially inappropriate medications (knowledge limitations among clinicians and patients), and ( 4 ) patients prioritize symptom control over potential harm (clinicians expect resistance to deprescribing, patient weigh risks and benefits). CONCLUSIONS Challenges to integration of deprescribing into dialysis clinics included siloed health systems, time constraints, comanagement behaviors, and clinician and patient knowledge and attitudes toward deprescribing.
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Affiliation(s)
- Rasheeda K. Hall
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Medicine Service, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Jeanette Rutledge
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Anika Lucas
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Medicine Service, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Christine K. Liu
- Section of Geriatric Medicine, Stanford University School of Medicine, Stanford, California
- Geriatric Research Education and Clinical Center, Palo Alto VA Health Care System, Palo Alto, California
| | - Jennifer St. Clair Russell
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Dimensions of Care, LLC, Rockville, Maryland
| | - Wendy St. Peter
- Department of Pharmaceutical Care and Health Systems, University of Minnesota College of Pharmacy, Minneapolis, Minnesota
| | - Laura J. Fish
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, North Carolina
- Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina
| | - Cathleen Colón-Emeric
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Medicine Service, Durham Veterans Affairs Medical Center, Durham, North Carolina
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Liu X, Wang X, Ma H, Zhang W. Mechanisms underlying acupuncture therapy in chronic kidney disease: A narrative overview of preclinical studies and clinical trials. FRONTIERS IN NEPHROLOGY 2022; 2:1006506. [PMID: 37675019 PMCID: PMC10479635 DOI: 10.3389/fneph.2022.1006506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 10/18/2022] [Indexed: 09/08/2023]
Abstract
Chronic kidney disease (CKD) is associated with high incidence, low awareness, and high disability rates among the population. Moreover, the disease significantly affects the physical and mental health of patients. Approximately 25% of patients with CKD develop end-stage renal disease (ESRD) within 20 years of diagnosis and have to rely on renal replacement therapy, which is associated with high mortality, heavy economic burden, and symptoms including fatigue, pain, insomnia, uremia pruritus, and restless leg syndrome. Currently, the means to delay the progress of CKD are insufficient; therefore, developing strategies for delaying CKD progression has important practical implications. In recent years, more and more people are accepting the traditional Chinese medical technique "acupuncture." Acupuncture has been shown to improve the uncomfortable symptoms of various diseases through stimulation (needling, medicinal moxibustion, infrared radiation, and acupressure) of acupoints. Its application has been known for thousands of years, and its safety and efficacy have been verified. As a convenient and inexpensive complementary therapy for CKD, acupuncture has recently been gaining interest among clinicians and scientists. Nevertheless, although clinical trials and meta-analysis findings have demonstrated the efficacy of acupuncture in reducing albuminuria, improving glomerular filtration rate, relieving symptoms, and improving the quality of life of patients with CKD, the underlying mechanisms involved are still not completely understood. Few studies explored the correlation between acupuncture and renal pathological diagnosis. The aim of this study was to conduct a literature review summarizing the currently known mechanisms by which acupuncture could delay the progress of CKD and improve symptoms in patients with ESRD. This review help provide a theoretical basis for further research regarding the influence of acupuncture on renal pathology in patients with CKD, as well as the differences between specific therapeutic mechanisms of acupuncture in different renal pathological diagnosis. The evidence in this review indicates that acupuncture may produce marked effects on blocking and reversing the critical risk factors of CKD progression (e.g., hyperglycemia, hypertension, hyperlipidemia, obesity, aging, and anemia) to improve the survival of patients with CKD via mechanisms including oxidative stress inhibition, reducing inflammatory effects, improving hemodynamics, maintaining podocyte structure, and increasing energy metabolism.
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Affiliation(s)
- Xinyin Liu
- The First Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Xiaoran Wang
- Department of Nephrology, The First People’s Hospital of Hangzhou Lin’An District, Hangzhou, China
| | - Hongzhen Ma
- Department of Nephrology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, China
| | - Wen Zhang
- Department of Nephrology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, China
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Opioids for chronic pain management in patients with dialysis-dependent kidney failure. Nat Rev Nephrol 2022; 18:113-128. [PMID: 34621058 PMCID: PMC8792317 DOI: 10.1038/s41581-021-00484-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2021] [Indexed: 12/30/2022]
Abstract
Chronic pain is highly prevalent among adults treated with maintenance haemodialysis (HD) and has profound negative effects. Over four decades, research has demonstrated that 50-80% of adult patients treated with HD report having pain. Half of patients with HD-dependent kidney failure (HDKF) have chronic moderate-to-severe pain, which is similar to the burden of pain in patients with cancer. However, pain management in patients with HDKF is often ineffective as most patients report that their pain is inadequately treated. Opioid analgesics are prescribed more frequently for patients receiving HD than for individuals in the general population with chronic pain, and are associated with increased morbidity, mortality and health-care resource use. Furthermore, current opioid prescribing patterns are frequently inconsistent with guideline-recommended care. Evidence for the effectiveness of opioids in pain management in general, and in patients with HDKF specifically, is lacking. Nonetheless, long-term opioid therapy has a role in the treatment of some patients when used selectively, carefully and combined with an ongoing assessment of risks and benefits. Here, we provide a comprehensive overview of the use of opioid therapy in patients with HDKF and chronic pain, including a discussion of buprenorphine, which has potential as an analgesic option for patients receiving HD owing to its unique pharmacological properties.
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Paik JM, Zhuo M, York C, Tsacogianis T, Kim SC, Desai RJ. Medication Burden and Prescribing Patterns in Patients on Hemodialysis in the USA, 2013-2017. Am J Nephrol 2021; 52:919-928. [PMID: 34814147 DOI: 10.1159/000520028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 09/30/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The medication burden of patients with end-stage renal disease (ESRD) on hemodialysis, a patient population with a high comorbidity burden and complex care requirements, is among the highest of any of the chronic diseases. The goal of this study was to describe the medication burden and prescribing patterns in a contemporary cohort of patients with ESRD on hemodialysis in the USA. METHODS We used the United States Renal Data System database from January 1, 2013, and December 31, 2017, to quantify the medication burden of patients with ESRD on hemodialysis aged ≥18 years. We calculated the average number of prescription medications per patient during each respective year (January-December), number of medications within classes, including potentially harmful medications, and trends in the number of medications and classes over the 5-year study period. RESULTS We included a total of 163,228 to 176,133 patients from 2013 to 2017. The overall medication burden decreased slightly, from a mean of 7.4 (SD 3.8) medications in 2013 to 6.8 (SD 3.6) medications in 2017. Prescribing of potentially harmful medications decreased over time (74.0% with at least one harmful medication class in 2013-68.5% in 2017). In particular, the prescribing of non-benzodiazepine hypnotics, benzodiazepines, and opioids decreased from 2013 to 2017 (12.2%-6.3%, 23.4%-19.3%, and 60.0%-53.4%, respectively). This trend was consistent across subgroups of age, sex, race, and low-income subsidy status. CONCLUSIONS Patients with ESRD on hemodialysis continued to have a high overall medication burden, with a slight reduction over time accompanied by a decrease in prescribing of several classes of harmful medications. Continued emphasis on assessment of appropriateness of high medication burden in patients with ESRD is needed to avoid exposure to potentially harmful or futile medications in this patient population.
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Affiliation(s)
- Julie M Paik
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Min Zhuo
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Renal Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Cassandra York
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Theodore Tsacogianis
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Seoyoung C Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Daubresse M, Alexander GC, Crews DC, Segev DL, Lentine KL, McAdams-DeMarco MA. High-dose opioid utilization and mortality among individuals initiating hemodialysis. BMC Nephrol 2021; 22:65. [PMID: 33622271 PMCID: PMC7901089 DOI: 10.1186/s12882-021-02266-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 02/09/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Individuals undergoing hemodialysis in the United States frequently report pain and receive three-fold more opioid prescriptions than the general population. While opioid use is appropriate for select patients, high-dose utilization may contribute to an increased risk of death due to possible accumulation of opioid metabolites. METHODS We studied high-dose opioid utilization (≥120 morphine milligram equivalents [MME] per day) among adults initiating hemodialysis in the United States between 2007 and 2014 using national registry data. We calculated the cumulative incidence (%) of high-dose utilization and depicted trends in the average percentage of days individuals were exposed to opioids. We used adjusted Cox proportional hazards models to identify which opioid doses were associated with mortality. RESULTS Among 327,344 adults undergoing hemodialysis, the cumulative incidence of high-dose utilization was 14.9% at 2 years after initiating hemodialysis. Among patients with ≥1 opioid prescription during follow-up, the average percentage of days exposed to high-dose utilization increased from 13.9% in 2007 to 26.1% in 2014. Compared to 0MME per day, doses < 60MME were not associated with an increased risk of mortality, but high-dose utilization was associated with a 1.63-fold (95% CI, 1.57, 1.69) increased risk of mortality. The risk of mortality associated with opioid dose was highest in the first year after hemodialysis initiation. CONCLUSIONS The risk of mortality associated with opioid utilization among individuals on hemodialysis increases as doses exceed 60MME per day and is greatest during periods of high-dose utilization. Patients and clinicians should carefully weigh the risks and benefits of opioid doses exceeding 60MME per day.
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Affiliation(s)
- Matthew Daubresse
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street W6033, Baltimore, MD, 21205, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA
| | - G Caleb Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street W6033, Baltimore, MD, 21205, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Deidra C Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street W6033, Baltimore, MD, 21205, USA
- Division of Surgery, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Krista L Lentine
- Division of Nephrology, Department of Internal Medicine, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Mara A McAdams-DeMarco
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street W6033, Baltimore, MD, 21205, USA.
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA.
- Division of Surgery, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Abstract
Chronic pain and prescription opioid use are prevalent among patients with end-stage kidney disease treated with hemodialysis. Vulnerabilities to complications from opioid use are high in this patient population, as shown in many recent, well-conducted, patient-oriented studies. Such studies have highlighted the need for a balanced approach to pain management in hemodialysis patients that includes careful assessment of the risks and benefits of opioid prescriptions in this population. In this article, we review the available literature and experience regarding opioid prescriptions among hemodialysis patients, discuss clinical implications, and outline ongoing research.
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Affiliation(s)
- Sahir Kalim
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Karen S Lyons
- William F. Connell School of Nursing, Boston College, Boston, MA
| | - Sagar U Nigwekar
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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Roy PJ, Weltman M, Dember LM, Liebschutz J, Jhamb M. Pain management in patients with chronic kidney disease and end-stage kidney disease. Curr Opin Nephrol Hypertens 2020; 29:671-680. [PMID: 32941189 PMCID: PMC7753951 DOI: 10.1097/mnh.0000000000000646] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW This review evaluates current recommendations for pain management in chronic kidney disease (CKD) and end-stage kidney disease (ESKD) with a specific focus on evidence for opioid analgesia, including the partial agonist, buprenorphine. RECENT FINDINGS Recent evidence supports the use of physical activity and other nonpharmacologic therapies, either alone or with pharmacological therapies, for pain management. Nonopioid analgesics, including acetaminophen, topical analgesics, gabapentinoids, serotonin-norepinephrine reuptake inhibitors, and TCA may be considered based on pain cause and type, with careful dose considerations in kidney disease. NSAIDs may be used in CKD and ESKD for short durations with careful monitoring. Opioid use should be minimized and reserved for patients who have failed other therapies. Opioids have been associated with increased adverse events in this population, and thus should be used cautiously after risk/benefit discussion with the patient. Opioids that are safer to use in kidney disease include oxycodone, hydromorphone, fentanyl, methadone, and buprenorphine. Buprenorphine appears to be a promising and safer option due to its partial agonism at the mu opioid receptor. SUMMARY Pain is poorly managed in patients with kidney disease. Nonpharmacological and nonopioid analgesics should be first-line approaches for pain management. Opioid use should be minimized with careful monitoring and dose adjustment.
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Affiliation(s)
- Payel Jhoom Roy
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine
| | - Melanie Weltman
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy
| | - Laura M. Dember
- Renal, Electrolyte and Hypertension Division, Department of Medicine, and Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine
| | - Jane Liebschutz
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine
| | - Manisha Jhamb
- Division of Renal-Electrolyte, Department of Medicine, University of Pittsburgh
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Muzaale AD, Daubresse M, Bae S, Chu NM, Lentine KL, Segev DL, McAdams-DeMarco M. Benzodiazepines, Codispensed Opioids, and Mortality among Patients Initiating Long-Term In-Center Hemodialysis. Clin J Am Soc Nephrol 2020; 15:794-804. [PMID: 32457228 PMCID: PMC7274292 DOI: 10.2215/cjn.13341019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 03/16/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Mortality from benzodiazepine/opioid interactions is a growing concern in light of the opioid epidemic. Patients on hemodialysis suffer from a high burden of physical/psychiatric conditions, which are treated with benzodiazepines, and they are three times more likely to be prescribed opioids than the general population. Therefore, we studied mortality risk associated with short- and long-acting benzodiazepines and their interaction with opioids among adults initiating hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The cohort of 69,368 adults initiating hemodialysis (January 2013 to December 2014) was assembled by linking US Renal Data System records to Medicare claims. Medicare claims were used to identify dispensed benzodiazepines and opioids. Using adjusted Cox proportional hazards models, we estimated the mortality risk associated with benzodiazepines (time varying) and tested whether the benzodiazepine-related mortality risk differed by opioid codispensing. RESULTS Within 1 year of hemodialysis initiation, 10,854 (16%) patients were dispensed a short-acting benzodiazepine, and 3262 (5%) patients were dispensed a long-acting benzodiazepine. Among those who were dispensed a benzodiazepine during follow-up, codispensing of opioids and short-acting benzodiazepines occurred among 3819 (26%) patients, and codispensing of opioids and long-acting benzodiazepines occurred among 1238 (8%) patients. Patients with an opioid prescription were more likely to be subsequently dispensed a short-acting benzodiazepine (adjusted hazard ratio, 1.66; 95% confidence interval, 1.59 to 1.74) or a long-acting benzodiazepine (adjusted hazard ratio, 1.11; 95% confidence interval, 1.03 to 1.20). Patients dispensed a short-acting benzodiazepine were at a 1.45-fold (95% confidence interval, 1.35 to 1.56) higher mortality risk compared with those without a short-acting benzodiazepine; among those with opioid codispensing, this risk was 1.90-fold (95% confidence interval, 1.65 to 2.18; Pinteraction<0.001). In contrast, long-acting benzodiazepine dispensing was inversely associated with mortality (adjusted hazard ratio, 0.84; 95% confidence interval, 0.72 to 0.99) compared with no dispensing of long-acting benzodiazepine; there was no differential risk by opioid dispensing (Pinteraction=0.72). CONCLUSIONS Codispensing of opioids and short-acting benzodiazepines is common among patients on dialysis, and it is associated with higher risk of death.
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Affiliation(s)
- Abimereki D. Muzaale
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Matthew Daubresse
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sunjae Bae
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Nadia M. Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Krista L. Lentine
- Department of Medicine, St. Louis University School of Medicine, St. Louis, Missouri
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Mara McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Davison SN, Rathwell S, George C, Hussain ST, Grundy K, Dennett L. Analgesic Use in Patients With Advanced Chronic Kidney Disease: A Systematic Review and Meta-Analysis. Can J Kidney Health Dis 2020; 7:2054358120910329. [PMID: 35186302 PMCID: PMC8851133 DOI: 10.1177/2054358120910329] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 01/19/2020] [Indexed: 12/27/2022] Open
Abstract
Background: Pain is common in patients with chronic kidney disease (CKD). Analgesics may be appropriate for some CKD patients. Objectives: To determine the prevalence of overall analgesic use and the use of different types of analgesics including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), adjuvants, and opioids in patients with CKD. Design: Systematic review and meta-analysis. Setting: Interventional and observational studies presenting data from 2000 or later. Exclusion criteria included acute kidney injury or studies that limited the study population to a specific cause, symptom, and/or comorbidity. Patients: Adults with stage 3-5 CKD including dialysis patients and those managed conservatively without dialysis. Measurements: Data extracted included title, first author, design, country, year of data collection, publication year, mean age, stage of CKD, prevalence of analgesic use, and the types of analgesics prescribed. Methods: Databases searched included MEDLINE, CINAHL, EMBASE, and Cochrane Library. Two reviewers independently screened all titles and abstracts, assessed potentially relevant articles, and extracted data. We estimated pooled prevalence of analgesic use and the I2 statistic was computed to measure heterogeneity. Random-effects models were used to account for variations in study design and sample populations, and a double arcsine transformation of the prevalence variables was used to accommodate potential overweighting of studies with very large or very small prevalence measurements. Sensitivity analyses were performed to determine the magnitude of publication bias and assess possible sources of heterogeneity. Results: Forty studies were included in the analysis. The prevalence of overall analgesic use in the random-effects model was 50.8%. The prevalence of acetaminophen, NSAIDs, and adjuvant use was 27.5%, 17.2%, and 23.4%, respectively, while the prevalence of opioid use was 23.8%. Due to the possibility of publication bias, the actual prevalence of acetaminophen use in patients with advanced CKD may be substantially lower than this meta-analysis indicates. A trim-and-fill analysis decreased the pooled prevalence estimate of acetaminophen use to 5.4%. The prevalence rate for opioid use was highly influenced by 2 large US studies. When these were removed, the estimated prevalence decreased to 17.3%. Limitations: There was a lack of detailed information regarding the analgesic regimen (such as specific analgesics used within each class and inconsistent accounting for patients on multiple drugs and the use of over-the-counter analgesics such as acetaminophen and NSAIDs), patient characteristics, type of pain being treated, and the outcomes of treatment. Data on adjuvant use were very limited. These results, therefore, must be interpreted with caution. Conclusions: There was tremendous variability in the prescribing patterns of both nonopioid and opioid analgesics within and between countries suggesting widespread uncertainty about the optimal pharmacological approach to treating pain. Further research that incorporates robust reporting of analgesic regimens and links prescribing patterns to clinical outcomes is needed to guide optimal clinical practice.
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Affiliation(s)
- Sara N. Davison
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Sarah Rathwell
- Kidney Supportive Care Research Group and Department of Medicine, University of Alberta, Edmonton, Canada
| | - Chelsy George
- Kidney Supportive Care Research Group and Department of Medicine, University of Alberta, Edmonton, Canada
| | - Syed T. Hussain
- Kidney Supportive Care Research Group and Department of Medicine, University of Alberta, Edmonton, Canada
| | | | - Liz Dennett
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, Canada
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Lister JJ, Ellis JD, Yoon M. Opioid prescribing and opioid-overdose deaths in Michigan: Urban-rural comparisons and changes across 2013-2017. Addict Behav Rep 2019; 11:100234. [PMID: 32467830 PMCID: PMC7244930 DOI: 10.1016/j.abrep.2019.100234] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 11/12/2019] [Accepted: 11/12/2019] [Indexed: 01/17/2023] Open
Abstract
Examined opioid prescribing and opioid-overdose death rates in Michigan counties. Conducted urban-rural county comparisons and tested for changes across 2013–2017. Higher rates of overdose deaths in urban, and higher rates of prescribing in rural. Opioid-overdose death rates rose in both urban and rural counties across 2013–2017. Opioid prescribing rates did not change in urban or rural counties across 2013–2017.
Background Opioid-overdose deaths and opioid prescriptions have increased substantially within the past decade, leading to examinations of urban-rural differences for these opioid-related outcomes, and whether annual trends differ by urban-rural status. Most investigations have examined differences using national data, whereas few studies have identified patterns in hard-hit regions. Therefore, we examined urban-rural differences for opioid-related outcomes in Michigan, a state with overdose death and prescribing rates above the national average. Methods This study used county-level public data on opioid prescribing and opioid-overdose death rates in Michigan. Bivariate and joinpoint regression analyses tested for annual differences and annual changes in opioid-related outcomes across 2013–2017. Rural Urban Continuum Codes classified urban-rural county status. Results Bivariate analyses demonstrated that urban counties had consistently higher opioid-overdose death rates than rural, whereas rural counties had consistently higher opioid prescribing rates than urban. Joinpoint regression (2013–2017) revealed opioid-overdose death rates increased in urban (Annual Percent Change = 25.0%, p = .001) and rural counties (Annual Percent Change = 21.7%, p = .002), though no changes for opioid prescribing rates were observed among urban or rural counties. Conclusions Our study highlights nuanced urban-rural patterns in Michigan, a hard-hit state, compared to trends in national data. Both urban and rural counties experienced rising rates of opioid-overdose deaths, and rural counties experienced higher opioid prescribing rates than urban. Though urban counties experienced higher opioid-overdose death rates than rural, the rise in both county types was similar. Future research directions, implications for public health, and healthcare policy recommendations are discussed.
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Affiliation(s)
- Jamey J Lister
- Rutgers, The State University of New Jersey, School of Social Work, USA.,Wayne State University, School of Medicine, Department of Psychiatry and Behavioral Neurosciences, USA
| | - Jennifer D Ellis
- Wayne State University, School of Medicine, Department of Psychiatry and Behavioral Neurosciences, USA.,Wayne State University, Department of Psychology, USA
| | - Miyoung Yoon
- Case Western Reserve University, Jack, Joseph and Morton Mandel School of Applied Social Sciences, USA
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