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Wright RC, Polivka BJ, Villwock JA. Inpatient pain assessment and decision-making in internal medicine and general surgery residents: A qualitative analysis. Heliyon 2024; 10:e30537. [PMID: 38756564 PMCID: PMC11096894 DOI: 10.1016/j.heliyon.2024.e30537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 04/22/2024] [Accepted: 04/29/2024] [Indexed: 05/18/2024] Open
Abstract
Background Understanding physician approaches to pain treatment is a critical component of opioid and analgesic stewardship. Practice patterns learned in residency often persist longitudinally into practice. Objective This study sought to identify salient factors and themes in how resident physicians assess and manage pain. Methods Video-recorded focus groups of internal medicine and general surgery residents were conducted via videoconferencing software. Data were analyzed using a ground theory approach and constant comparative method to identify themes and subthemes. Focus groups occurred in September and October 2020. Results 10 focus groups including 35 subjects were conducted. Four general themes emerged: (1) Assessment considerations; (2) Education & Expectations; (3) Systems Factors; and (4) Management considerations. Participants indicated that while it is important to treat pain, its inherently subjective nature makes it difficult to objectively quantify it. The 0-10 numeric rating scale was problematic and infrequently utilized. Patient expectations of no pain following procedures was viewed as particularly challenging. The absence of formal best practices to guide pain assessment and management was noted in every group. Management approaches overall very highly variable, often relying on word-of-mouth relay of the preferences of specific attending physicians. Conclusions Pain is highly nuanced and resident physicians struggle to balance pain's subjectivity with a desire to quantify and appropriately treat it. The 0-10 numeric rating pain scale, though ubiquitous, is problematic. Priority areas of improvement identified include education for both patients and physicians, functional pain scales, and expansion of existing effective resources like the nursing pain team.
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Affiliation(s)
- Robert C. Wright
- Department of Otolaryngology, Head and Neck Surgery, University of Kansas Medical Center, 3901 Rainbow Blvd, Mailstop 3010, Kansas City, KS 66160, USA
| | - Barbara J. Polivka
- School of Nursing, University of Kansas Medical Center, 3901 Rainbow Blvd, Mailstop 2029, Kansas City, KS 66160, USA
| | - Jennifer A. Villwock
- School of Nursing, University of Kansas Medical Center, 3901 Rainbow Blvd, Mailstop 2029, Kansas City, KS 66160, USA
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Fong ISH, Yiu CH, Abelev MD, Allaf S, Begley DA, Bugeja BA, Khor KE, Rimington J, Penm J. Supply of opioids and information provided to patients after surgery in an Australian hospital: A cross-sectional study. Anaesth Intensive Care 2023; 51:340-347. [PMID: 37688434 PMCID: PMC10493037 DOI: 10.1177/0310057x231163890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
Opioids are commonly prescribed to manage pain after surgery. However, excessive supply on discharge can increase patients' risk of persistent opioid use and contribute to the reservoir of unused opioids in the community that may be misused. This study aimed to evaluate the use of opioids in Australian surgical patients after discharge and patient satisfaction with the provision of opioid information after discharge. This prospective cohort study was conducted at a tertiary referral and teaching hospital. Surgical patients were called 7-28 days after discharge to identify their opioid use and the information that they received after discharge. In total, 66 patients responded. Most patients underwent orthopaedic surgery (45.5%; 30/66). The median days of opioids supplied on discharge was 5 (IQR 3-5). In total, 40.9% (27/66) of patients had >50% of their opioids remaining. Patients undergoing orthopaedic surgery were less likely to have >50% of their opioids remaining (P = 0.045), whilst patients undergoing urological or renal surgeries were significantly more likely (P = 0.009). Most patients recalled receiving information about their opioids (89.4%; 59/66). However, the majority (51.5%; 34/66) did not recall receiving any information about the signs of opioid toxicity and interactions between opioids and alcohol. In conclusion, around 40% of patients had more than half of their opioid supply remaining after they ceased taking their opioid. Although most patients recalled receiving information about their opioids, more than half did not recall receiving any information about the signs of opioid toxicity or interactions between opioids and alcohol.
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Affiliation(s)
- Ian SH Fong
- Department of Pharmacy, Prince of Wales Hospital, Randwick, Australia
| | - Chin Hang Yiu
- School of Pharmacy, The University of Sydney Faculty of Medicine and Health, Camperdown, Australia
| | - Matthew D Abelev
- School of Pharmacy, The University of Sydney Faculty of Medicine and Health, Camperdown, Australia
| | - Sara Allaf
- School of Pharmacy, The University of Sydney Faculty of Medicine and Health, Camperdown, Australia
| | - David A Begley
- Department of Pain Management. Prince of Wales Hospital, Randwick, Australia
| | - Bernadette A Bugeja
- Department of Pain Management. Prince of Wales Hospital, Randwick, Australia
| | - Kok Eng Khor
- Department of Pain Management. Prince of Wales Hospital, Randwick, Australia
| | - Joanne Rimington
- District Pharmacy Services, South Eastern Sydney Local Health District, Randwick, Australia
| | - Jonathan Penm
- Department of Pharmacy, Prince of Wales Hospital, Randwick, Australia
- School of Pharmacy, The University of Sydney Faculty of Medicine and Health, Camperdown, Australia
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Swain S, Fernandes GS, Sarmanova A, Valdes AM, Walsh DA, Coupland C, Doherty M, Zhang W. Comorbidities and use of analgesics in people with knee pain: a study in the Nottingham Knee Pain and Health in the Community (KPIC) cohort. Rheumatol Adv Pract 2022; 6:rkac049. [PMID: 35784017 PMCID: PMC9245392 DOI: 10.1093/rap/rkac049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/23/2022] [Indexed: 11/27/2022] Open
Abstract
Objectives The aims were to examine the prevalence of comorbidities and role of oral analgesic use in people with knee pain (KP) compared with those without. Methods The Knee Pain and related health In the Community (KPIC) cohort comprises community-derived adults aged ≥40 years, irrespective of knee pain. Thirty-six comorbidities across 10 systems were compared between people with KP and controls without KP or knee OA. Multivariable logistic regression analysis was used to determine the adjusted odds ratio (aOR) and 95% CI for multimorbidity (at least two chronic conditions) and each specific comorbidity. Both prescribed and over-the-counter analgesics were included in the model, and their interactions with KP for comorbidity outcomes were examined. Results Two thousand eight hundred and thirty-two cases with KP and 2518 controls were selected from 9506 baseline participants. The mean age of KP cases was 62.2 years, and 57% were women. Overall, 29% of the total study population had multimorbidity (KP cases 34.4%; controls 23.8%). After adjustment for age, sex, BMI and analgesic use, KP was significantly associated with multimorbidity (aOR 1.35; 95% CI 1.17, 1.56) and with cardiovascular (aOR 1.25; 95% CI 1.08, 1.44), gastrointestinal (aOR 1.34; 95% CI 1.04, 1.92), chronic widespread pain (aOR 1.54; 95% CI 1.29, 1.86) and neurological (aOR 1.32; 95% CI 1.01, 1.76) comorbidities. For multimorbidity, the use of paracetamol and opioids interacted positively with KP, whereas the use of NSAIDs interacted negatively for seven comorbidities. Conclusion People with KP are more likely to have other chronic conditions. The long-term benefits and harms of this change remain to be investigated. Trial registration ClinicalTrials.gov, http://clinicaltrials.gov, NCT02098070.
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Affiliation(s)
- Subhashisa Swain
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham City Hospital
- Pain Centre Versus Arthritis, University of Nottingham
- NIHR Nottingham Biomedical Research Centre, Nottingham
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | | | - Aliya Sarmanova
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol
| | - Ana M Valdes
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham City Hospital
- Pain Centre Versus Arthritis, University of Nottingham
- NIHR Nottingham Biomedical Research Centre, Nottingham
| | - David A Walsh
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham City Hospital
- Pain Centre Versus Arthritis, University of Nottingham
- NIHR Nottingham Biomedical Research Centre, Nottingham
| | - Carol Coupland
- Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Michael Doherty
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham City Hospital
- Pain Centre Versus Arthritis, University of Nottingham
- NIHR Nottingham Biomedical Research Centre, Nottingham
| | - Weiya Zhang
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham City Hospital
- Pain Centre Versus Arthritis, University of Nottingham
- NIHR Nottingham Biomedical Research Centre, Nottingham
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Naughton M, Redmond P, Durbaba S, Ashworth M, Molokhia M. Determinants of long-term opioid prescribing in an urban population- a cross sectional study. Br J Clin Pharmacol 2022; 88:3172-3181. [PMID: 35018644 PMCID: PMC9305420 DOI: 10.1111/bcp.15231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 04/12/2021] [Accepted: 12/07/2021] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Opioid prescribing has more than doubled in the UK between 1998 and 2016. Potential adverse health implications include dependency, falls and increased health expenditure. AIM To describe the predictors of long-term opioid prescribing (LTOP), (≥3 opioid prescriptions in a 90-day period). DESIGN AND SETTING A retrospective cross-sectional study in 41 General Practices in South London. METHOD Multi-level multivariable logistic regression to investigate the determinants of LTOP. RESULTS 2,679 (0.8%) out of 320,639 registered patients ≥18 years were identified as having LTOP. Patients Were most likely to have LTOP, if: they had ≥5 long term conditions (LTCs) (adjusted odds ratio [AOR] 36.5, 95% confidence interval [CI] 30.4-43.8) or 2-4 LTCs (AOR 13.8, CI 11.9-16.1), in comparison to no LTCs, ≥75 years compared to 18-24 years (AOR 12.31, CI 7.1-21.5), smokers compared to non-smokers (AOR 2.2, CI 2.0-2.5), females compared to males (AOR 1.9, CI 1.7-2.0) and in the most deprived deprivation quintile (AOR 1.6, CI 1.4-1.8) compared to the least deprived. In a separate model examining individual long-term conditions (LTCs), the strongest associations for LTOP were noted for sickle cell disease (SCD) (AOR 18.4, CI 12.8-26.4), osteoarthritis (AOR 3.0, CI 2.8-3.3), rheumatoid arthritis (AOR 2.8, CI 2.2-3.4), depression (AOR 2.6, CI 2.3-2.8) and multiple sclerosis (OR 2.5, CI 1.4-4.4). CONCLUSION LTOP was significantly higher in those aged ≥75 years, with multi-morbidity or specific LTCs: sickle cell disease, osteoarthritis, rheumatoid arthritis, depression, and multiple sclerosis. These characteristics may enable the design of targeted interventions to reduce LTOP.
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Affiliation(s)
- Michael Naughton
- Department of Population Health Sciences & Environmental Sciences, King's College London
| | - Patrick Redmond
- School of Population Health & Environmental Sciences, King's College London
| | - Stevo Durbaba
- Department of Population Health Sciences, King's College London
| | - Mark Ashworth
- Department of Population Health Sciences, King's College London
| | - Mariam Molokhia
- Department of Population Health Sciences, King's College London
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Huang YT, Steptoe A, Wei L, Zaninotto P. The impact of high-risk medications on mortality risk among older adults with polypharmacy: evidence from the English Longitudinal Study of Ageing. BMC Med 2021; 19:321. [PMID: 34911547 PMCID: PMC8675465 DOI: 10.1186/s12916-021-02192-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 11/18/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Polypharmacy is common among older people and is associated with an increased mortality risk. However, little is known about whether the mortality risk is related to specific medications among older adults with polypharmacy. This study therefore aimed to investigate associations between high-risk medications and all-cause and cause-specific mortality among older adults with polypharmacy. METHODS This study included 1356 older adults with polypharmacy (5+ long-term medications a day for conditions or symptoms) from Wave 6 (2012/2013) of the English Longitudinal Study of Ageing. First, using the agglomerative hierarchical clustering method, participants were grouped according to the use of 14 high-risk medication categories. Next, the relationship between the high-risk medication patterns and all-cause and cause-specific mortality (followed up to April 2018) was examined. All-cause mortality was assessed by Cox proportional hazards model and competing-risk regression was employed for cause-specific mortality. RESULTS Five high-risk medication patterns-a renin-angiotensin-aldosterone system (RAAS) inhibitors cluster, a mental health drugs cluster, a central nervous system (CNS) drugs cluster, a RAAS inhibitors and antithrombotics cluster, and an antithrombotics cluster-were identified. The mental health drugs cluster showed increased risks of all-cause (HR = 1.55, 95%CI = 1.05, 2.28) and cardiovascular disease (CVD) (SHR = 2.11, 95%CI = 1.10, 4.05) mortality compared with the CNS drug cluster over 6 years, while others showed no differences in mortality. Among these patterns, the mental health drugs cluster showed the highest prevalence of antidepressants (64.1%), benzodiazepines (10.4%), antipsychotics (2.4%), antimanic agents (0.7%), opioids (33.2%), and muscle relaxants (21.5%). The findings suggested that older adults with polypharmacy who took mental health drugs (primarily antidepressants), opioids, and muscle relaxants were at higher risk of all-cause and CVD mortality, compared with those who did not take these types of medications. CONCLUSIONS This study supports the inclusion of opioids in the current guidance on structured medication reviews, but it also suggests that older adults with polypharmacy who take psychotropic medications and muscle relaxants are prone to adverse outcomes and therefore may need more attention. The reinforcement of structured medication reviews would contribute to early intervention in medication use which may consequently reduce medication-related problems and bring clinical benefits to older adults with polypharmacy.
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Affiliation(s)
- Yun-Ting Huang
- Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.
| | - Andrew Steptoe
- Department of Behavioural Science and Health, University College London, London, UK
| | - Li Wei
- School of Pharmacy, University College London, London, UK
| | - Paola Zaninotto
- Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
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Cheng S, Siddiqui TG, Gossop M, Wyller TB, Kristoffersen ES, Lundqvist C. The patterns and burden of multimorbidity in geriatric patients with prolonged use of addictive medications. Aging Clin Exp Res 2021; 33:2857-2864. [PMID: 33599959 PMCID: PMC8531043 DOI: 10.1007/s40520-021-01791-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 01/11/2021] [Indexed: 01/12/2023]
Abstract
Background Multimorbidity and prolonged use of addictive medications are prevalent among older patients, and known to increase the risk of adverse drug events. Yet, the relationship between these two entities has remained understudied. Aims This study explored the association between multimorbidity burden and prolonged use of addictive medications in geriatric patients, adjusted for clinically important covariates. Furthermore, we identified comorbidity patterns in prolonged users. Methods We conducted a cross-sectional study on a consecutive sample of 246 patients, aged 65–90 years, admitted to a large public university hospital in Norway. We defined prolonged use of addictive medications as using benzodiazepines, opioids and/or z-hypnotics beyond the duration recommended by clinical guidelines (≥ 4 weeks). Multimorbidity was assessed with the Cumulative Illness Rating Scale for Geriatrics (CIRS-G), based on diagnoses made by independent physicians. Results Compared to non-prolonged use, prolonged use was significantly more common among patients who had psychiatric (19/27, 70%), liver (19/22, 86%), upper gastrointestinal tract (21/32, 66%), musculoskeletal (52/96, 54%), or nervous system disorders (46/92, 50%). Patients with prolonged use had a higher multimorbidity burden than those without such use (CIRS-G score, mean = 7.7, SD = 2.7 versus mean = 4.6, SD = 2.2, p < 0.001). Multivariable logistic regression indicated a significant association between multimorbidity burden and prolonged addictive medication use (OR = 1.72, 95% CI 1.42–2.08). Predictive margins postestimation showed a systematic increase in the predicted CIRS-G scores when the number of addictive drug used increases. Conclusions Multimorbidity is strongly associated with prolonged use of addictive medications. Multiple substance use may aggravate disease burden of older patients. Supplementary Information The online version contains supplementary material available at 10.1007/s40520-021-01791-5.
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Affiliation(s)
- Socheat Cheng
- Division of Health Services Research and Psychiatry (AHUSKHP), Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, PO Box 1000, 1478, Lørenskog, Norway.
- Health Services Research Unit (HØKH), Akershus University Hospital, Lørenskog, Norway.
| | - Tahreem Ghazal Siddiqui
- Division of Health Services Research and Psychiatry (AHUSKHP), Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, PO Box 1000, 1478, Lørenskog, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Campus Ahus, Lørenskog, Norway
| | - Michael Gossop
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Torgeir Bruun Wyller
- Department of Geriatric Medicine, Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Espen Saxhaug Kristoffersen
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| | - Christofer Lundqvist
- Health Services Research Unit (HØKH), Akershus University Hospital, Lørenskog, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Campus Ahus, Lørenskog, Norway
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
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Hubsky AR, Noble BN, Hartung DM, Tjia J, Lapane KL, Furuno JP. Opioid prescribing on discharge to skilled nursing facilities. Pharmacoepidemiol Drug Saf 2020; 29:1183-1188. [PMID: 32725962 DOI: 10.1002/pds.5075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/17/2020] [Accepted: 06/19/2020] [Indexed: 11/07/2022]
Abstract
PURPOSE Skilled nursing facility (SNF) residents are at increased risk for opioid-related harms. We quantified the frequency of opioid prescribing among patients discharged from an acute care hospital to SNFs. METHODS This was a retrospective cohort study among adult (≥18 years) inpatients discharged from a quaternary-care academic referral hospital in Portland, OR to a SNF between January 1, 2017 and December 31, 2018. Our primary outcome was receipt of an opioid prescription on discharge to a SNF. Our exposures included patient demographics (eg, age, sex), comorbid illnesses, surgical diagnosis related group (DRG), receiving opioids on the first day of the index hospital admission, and inpatient hospital length of stay. RESULTS Among 4374 patients discharged to a SNF, 3053 patients (70%) were prescribed an opioid on discharge. Among patients prescribed an opioid, 61% were over the age of 65 years, 50% were male, and 58% had a surgical Medicare severity diagnosis related group (MS-DRG). Approximately 70% of patients discharged to a SNF were prescribed an opioid on discharge, of which 68% were for oxycodone, and 52% were for ≥90 morphine milligram equivalents per day. Surgical DRG, diagnoses of cancer or chronic pain, last pain score, and receipt of an opioid on first day of the index hospital admission were independently associated with being prescribed an opioid on discharge to a SNF. CONCLUSION Opioids were frequently prescribed at high doses to patients discharged to a SNF. Efforts to improve opioid prescribing safety during this transition may be warranted.
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Affiliation(s)
- Ashlee R Hubsky
- Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, Oregon, USA
| | - Brie N Noble
- Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, Oregon, USA
| | - Daniel M Hartung
- Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, Oregon, USA
| | - Jennifer Tjia
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Kate L Lapane
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Jon P Furuno
- Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, Oregon, USA
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