Access to therapeutic opioid medications in Europe by 2011? Fifty years on from the single convention on narcotic drugs

Pharmacists opioid risk and safety counseling practices: A latent class analysis approach

BACKGROUND

The opioid crisis is a global public health issue, especially present in the United States. Limited research addresses pharmacists' opioid medication counseling practices particularly their risk and safety counseling practices.

OBJECTIVES

The objective of this paper is to categorize pharmacists based on their opioid risk and safety counseling practices to inform future interventions and research to improve practice. The percent of pharmacists falling into each of these underlying, unobservable subgroups is identified using latent class analysis.

METHODS

This study was conducted as a statewide survey of pharmacists using the modified Dilman technique. The survey consisted of ten items about pharmacists' opioid risk and safety practices when dispensing an opioid medication. Descriptive statistics were conducted followed by latent class analysis. This approach categorized pharmacists based on their responses to the survey items.

RESULTS

Responses from 216 pharmacists were used in this study. In the three-class model which was deemed the best fit, the first class shows a profile of pharmacists who counsel on almost all opioid risk and safety topics and composed 16.75% of the total respondent population. The second class shows a profile of pharmacists who hardly counsel on any opioid risks and safety topics and comprised 39.80% of the respondent population. The third class shows a profile of pharmacists counseling on opioid risk and safety topics mostly for new or long-term prescriptions, but not for refill or short-term prescriptions. This group constituted 43.45% of the respondent population.

CONCLUSION

This study identifies distinct classes of pharmacists in terms of the frequency with which their opioid counseling does or does not include key elements of risk and safety topics. A small minority usually include the risk and safety issues. Training and resource interventions targeting pharmacists who do not counsel patients about opioid risks are important to help them become more comfortable and adept as opioid risk and safety educators.

Opioid prescribing practices and medication use following urogynecological surgery

BACKGROUND

Opioid abuse is a growing epidemic in the United States, with opioid overdose becoming a leading cause of death. There is wide variation in prescription practices for post-operative opioids due to absence of guidelines. The purpose of this study is to examine postoperative opioid prescribing patterns after urogynecologic surgery and determine usage and management of opioid pills by patients.

MATERIALS AND METHODS

This is an observational, prospective study of female patients (N = 143) who underwent urogynecologic (prolapse or incontinence) surgery from June to December 2017 at a single academic center. Patients were surveyed regarding their pain medication use 30 days postoperatively. Survey questions included preoperative pain medication use, quantity of opioid pills consumed, need for additional opioid prescription, and management of remaining pills. T-test and one-way Anova were used for comparison of continuous variables and chi-squared test used for comparison of categorical variables.

RESULTS

Of 143 eligible patients, 99 (69%) responded; 62% of respondent patients underwent vaginal surgery, 22% abdominal surgery with or without vaginal surgery, and 15% underwent other procedures. Postoperatively, 81.8% of patients were prescribed opioids. The average number of tablets prescribed ranged from 12.4 to 17.4 depending on the procedure. 54.3% of patients reported using less than half of their prescribed opioid prescription. Of the patients who had excess opioid tablets, only 8.6% reported discarding their opioids.

CONCLUSION

To date, no guidelines exist on prescribing opioids postoperatively. Opioids are overprescribed post-operatively with over half of patients using less than half of the opioids prescribed to them.

Provider preferences for postoperative analgesia in obese and non-obese patients undergoing ambulatory surgery

Background

Few guidelines exist on safe prescription of postoperative analgesia to obese patients undergoing ambulatory surgery. This study examines the preferences of providers in the standard treatment of postoperative pain in the ambulatory setting.

Methods

Providers from five academic medical centers within a single US city were surveyed from May–September 2015. They were asked to provide their preferred postoperative analgesic routine based upon the predicted severity of pain for obese and non-obese patients. McNemar’s tests for paired observations were performed to compare prescribing preferences for obese vs. non-obese patients. Fisher’s exact tests were performed to compare preferences based on experience: > 15 years vs. ≤15 years in practice, and attending vs. resident physicians.

Results

A total of 452 providers responded out of a possible 695. For mild pain, 119 (26.4%) respondents prefer an opioid for obese patients vs. 140 (31.1%) for non-obese (p = 0.002); for moderate pain, 329 (72.7%) for obese patients vs. 348 (77.0%) for non-obese (p = 0.011); for severe pain, 398 (88.1%) for obese patients vs. 423 (93.6%) for non-obese (p < 0.001). Less experienced physicians are more likely to prefer an opioid for obese patients with moderate pain: 70 (62.0%) attending physicians with > 15 years in practice vs. 86 (74.5%) with ≤15 years (p = 0.047), and 177 (68.0%) attending physicians vs. 129 (83.0%) residents (p = 0.002).

Conclusions

While there is a trend to prescribe less opioid analgesics to obese patients undergoing ambulatory surgery, these medications may still be over-prescribed. Less experienced physicians reported prescribing opioids to obese patients more frequently than more experienced physicians.

Consensus building on access to controlled medicines: a four-stage Delphi consensus procedure

CONTEXT

In 2011, the World Health Organization (WHO) published the policy guidelines Ensuring Balance in National Controlled Substances Policies-Guidance for Availability and Accessibility of Controlled Medicines, presenting a revised version of the previous guidelines from 2000.

OBJECTIVES

To describe the consensus process that guided the revision of the guidelines.

METHODS

A four-stage revision process was undertaken with a panel of 29 international experts from palliative care, public health, and harm reduction: 1) a qualitative inventory of required changes by means of a structured checklist, 2) & 3) a two-round online consensus Delphi process about the draft revision of the guidelines, and 4) a WHO advisory meeting for the discussion of remaining controversies and final issues.

RESULTS

The qualitative inventory resulted in a draft revision of the guidelines meeting requirements on different levels, such as a broader focus and more accurate evidence. Operationalization of the guidelines was improved by specifying measures, procedures, and responsibilities. The Delphi procedure provided concrete indications for the rewording of both the guidelines and the associated text. During the advisory meeting, any persistent disagreements were systematically discussed to achieve consensus on the new version of the guidelines.

CONCLUSION

The four-stage multimethod consensus process resulted in a substantial revision to the WHO guidelines. This takes into account the increase in knowledge about opioid medication since the first edition of the guidelines. Disagreement emerging from the process underlines the complexity of preparing guidance because of the delicate balance between need and control.

Informatics-enabled behavioral medicine in oncology

For the practicing physician, the behavioral implications of preventing, diagnosing, and treating cancer are many and varied. Fortunately, an enhanced capacity in informatics may help create a redesigned ecosystem in which applying evidence-based principles from behavioral medicine will become a routine part of care. Innovation to support this evolution will be spurred by the "meaningful use" criteria stipulated by the Health Information Technology for Economic and Clinical Health Act of 2009 and by focused research and development efforts within the broader health information ecosystem. The implications for how to better integrate evidence-based principles in behavioral medicine into oncology care through both spheres of development are discussed within the framework of the cancer control continuum. The promise of using the data collected through these tools to accelerate discovery in psycho-oncology is also discussed. If nurtured appropriately, these developments should help accelerate successes against cancer by altering the behavioral milieu.

How well is cancer pain treated?

There are currently two indicators, Morphine Consumption Data and the Pain Management Index, that have been widely used to assess the efficacy of cancer pain treatment. Both are based on the World Health Organization guidelines for cancer pain and both have limitations in their ability to assess the quality of pain care for cancer patients. The published studies that have used these methods all report that cancer pain is generally undertreated in a wide range of clinical settings and care models.