Characterizing tramadol users with potentially inappropriate co-medications: A latent class analysis among older adults

Incidence and risk factors for potential drug-drug interactions in outpatients receiving opioid analgesics

BACKGROUND

Opioids are the most frequently used drugs to treat pain in cancer patients. However opioid analgesics can cause adverse effects and potential drug-drug interaction.

RESEARCH DESIGN AND METHODS

This cross-sectional retrospective study analyzed pDDI in 1839 patients with opioid analgesics in a large comprehensive hospital in China from January 1 to 31 December 2022. Three drug interaction databases were used to screen for pDDI including Drugs (U.S.A.), Medscape (U.S.A.), and Drug Assistant of Dingxiangyuan (China).

RESULTS

The prevalence of pDDIs among 1839 patients was around 41.27% of 759 patients, and 564 patients (74.31%) with pDDIs were diagnosed with tumor. Further, the total of 275 various pDDIs combinations were identified. The combination of oxycodone with morphine had the most frequent occurrence of 229 times, and its adverse effects mainly related to exacerbate central respiratory depression. While, gender, tumor, number of diagnoses, and the variety of opioid analgesics used were independent risk factors for pDDIs.

CONCLUSIONS

Outpatients taking opioid analgesics had a higher incidence of pDDIs. As consequently, optimized monitoring and management of patients taking opioid analgesics is recommended in order to ensure patient medication safety.

Pharmacological Pain Treatment in Older Persons

Pharmacological pain treatment in older persons is presented by a multi-disciplinary group of European pain experts. Drugs recommended for acute or chronic nociceptive pain, also for neuropathic pain and the routes of administration of choice are the same as those prescribed for younger persons but comorbidities and polypharmacy in older persons increase the risk of adverse effects and drug interactions. Not all drugs are available or authorised in all European countries. For mild-to-moderate pain, non-opioids including paracetamol and non-steroidal anti-inflammatory drugs are first-line treatments, followed by nefopam and metamizole. Codeine, dihydrocodeine and tramadol are prescribed for moderate to severe pain and 'strong' opioids, including morphine, hydromorphone, oxycodone, fentanyl, buprenorphine, methadone and tapentadol, for severe pain. Chronic neuropathic pain treatment relies on coanalgesics, including anti-epileptics (gabapentinoids) and anti-depressants with additional option of topical lidocaine and capsaicine. The choice of analgesic(s) and the route of administration should be guided by the pain characteristics, as well as by the patient's comorbidities, organ function and medications. Several directions have been highlighted to optimise pharmacological pain management in older individuals: (1) before starting pain treatment adequately detect and assess pain and always perform a full geriatric assessment, (2) consider kidney function systematically to adjust the doses of analgesics and avoid the risks of overdose, (3) start with the lowest dose of an analgesic and increase it gradually under the control of the effect, (4) involve the older persons and family in their treatment, (5) reevaluate pain regularly during treatment and (6) combine pharmacological treatment with non-pharmacological approaches.

Risk Factors for Respiratory Depression Associated with Tramadol Based on the Global Pharmacovigilance Database (VigiBase)

Tramadol, a weak μ-opioid receptor agonist, has been used worldwide for pain management. It is considered to have a favorable safety profile without serious adverse events; however, safety issues of respiratory depression were proposed by regulatory governments. We aimed to examine the risk and contributing factors associated with tramadol-related respiratory depression using a real-world database, VigiBase. Disproportionality analysis of tramadol and tramadol/paracetamol was performed using proportional reporting ratios, reporting odds ratios, and information components for all drugs and opioids. Factors related to respiratory depression, including sex, age, presence of abuse, death, and various concomitant medications, were evaluated. Among 140,721 tramadol reports, respiratory depression was reported in 1126 cases, 81.3% of which were deemed serious. Five adverse events were detected as signals of tramadol-related acute central respiratory depression (ACRD) in 882 reports. A higher proportion of ACRD cases in children and adolescents was observed than all adverse events cases of tramadol. Concomitant users of CYP2D6 inhibitors, opioids, benzodiazepines, and anti-depressant drugs showed a higher proportion in ACRD cases than non-ACRD cases. ACRD was related to drug abuse and death. This pharmacovigilance study, using VigiBase, confirmed a high risk of respiratory depression (a serious, potentially fatal adverse event) secondary to the use of tramadol, especially in pediatric patients, drug abusers, or during concomitant use of opioids, benzodiazepines, or antidepressants.

Factors associated with potentially inappropriate opioid use in community-living older adults consulting in primary care

OBJECTIVE

To study the factors associated with opioid use and potentially inappropriate opioid use (PIOU) in primary care older adults with non-cancer pain referring to the conceptual framework developed by the American Agency for Healthcare Research and Quality.

METHODS

This is a secondary analysis of health survey and medico-administrative data from Québec, Canada. Individuals aged ≥65 were recruited between 2011 and 2013 in primary care clinics to participate in face-to-face interviews. The sample included 945 older adults without a malignant tumor over the study period or any tumor in the 2 years surrounding opioid use. Opioid use within a 3 year follow-up period was identified from the public drug plan database. Potentially inappropriate opioid use (PIOU) was defined using the American Geriatrics Society Beers 2019 list. Multinomial regression analyses were performed to study the factors (patient, pain, substance use, provider, healthcare system) associated with opioid use and PIOU.

RESULTS

In this sample of older adults, 26.2% used an opioid and 18.4% were categorized as PIOU. Factors associated with PIOU compared to opioid use included female sex, higher psychological distress, number of emergency department visits, and recruitment type of healthcare practice. Factors associated with PIOU compared to no use included female sex, country of origin, presence of a trauma, physical/psychiatric multimorbidity, number of outpatient consultations, pain severity/type, and number of prescribers.

CONCLUSIONS

Mental health and health system factors were associated with PIOU. Results highlights the importance of a multidisciplinary approach for pain management, and the urgent need for implementing organizational efforts to optimize opioid use in primary care.

Potentially Inappropriate Prescribing among Elderly Outpatients: Evaluation of Temporal Trends 2012-2018 in Piedmont, Italy

Pharmacological intervention is one of the cornerstones in the treatment and prevention of disease in modern healthcare. However, a large number of drugs are often prescribed and used inappropriately, especially in elderly patients. We aimed at investigating the annual prevalence of potentially inappropriate prescriptions (PIPs) among older outpatients using administrative healthcare databases of the Piedmont Region (Italy) over a seven-year period (2012–2018). We included all Piedmont outpatients aged 65 years or older with at least one drug prescription per year. Polypharmacy and the prevalence of PIPs according to the ERD list explicit tool were measured on an annual basis. A range between 976,398 (in 2012) and 1,066,389 (in 2018) elderly were evaluated. Among them, the number of subjects with at least one PIP decreased from 418,537 in 2012 to 339,764 in 2018; the prevalence significantly reduced by ~25% over the study period. The stratified analyses by age groups and sex also confirmed the downward trend and identified several differences in the most prevalent inappropriately prescribed drugs. Overall, despite a reduction in PIP prevalence, one out of three older outpatients was still exposed to inappropriateness, highlighting the extensive need for intervention to improve prescribing.

Impact of Multimorbidity Subgroups on the Health Care Use and Clinical Outcomes of Patients With Tuberculosis: A Population-Based Cohort Analysis

Background: Multimorbidity is defined as the existence of two or more chronic health conditions in the same individual. While patients with tuberculosis commonly have multiple conditions at diagnosis, such as HIV, diabetes, and depression, to the authors' knowledge, there is limited information on the patterns of multimorbidity, and how the types and combinations of conditions could impact the healthcare utilization, expenditure, and TB outcomes.

Methods: An observational cohort study of adult patients diagnosed with tuberculosis was conducted using the Chinese Center for Disease Control and Prevention (CDC)'s National TB Information System (NTBIS) linked to the Ningbo Regional Health Care Database (NRHCD) (2015–2020). Latent class analysis was used to identify comorbidity groups among the subset with ≥2 conditions including TB. Group-level health care use, expenditure, and treatment outcomes were compared with patients without chronic conditions using multivariate regression models.

Results: A total of 9,651 patients with TB were identified, of whom approximately 61.4% had no chronic conditions, 17.4% had 1 chronic condition, and 21.3% had ≥2 chronic conditions. Among those with ≥1 chronic condition other than TB, 4 groups emerged: (1) general morbidity (54.4%); (2) cardiovascular morbidity without complications (34.7%); (3) cardiovascular morbidity with complications (5.0%); (4) respiratory morbidity (5.9%). The respiratory morbidity group experienced the highest expenditures, at 16,360 CNY more overall (95% CI, CNY 12,615–21,215) after adjustment compared with TB patients without chronic conditions. The respiratory morbidity and cardiovascular morbidity with complications group also had the lowest odds of favorable TB outcomes [adjusted odds ratio (aOR), 0.68; 95% CI, 0.49–0.93] and (aOR 0.59, 95% CI 0.42–0.83), respectively. The cardiovascular morbidity without complications group had the highest odds of successful TB treatment (aOR, 1.40; 95% CI, 1.15–1.71).

Conclusions: Multimorbidity is common among patients with TB. The current study identified four distinct comorbidity subgroups, all of which experienced high, yet differential, rates of health care use. These findings highlight the need for urgent reforms to transform current fragmented TB care delivery and improve access to other specialists and financial assistance.