1
|
Acharya PP, Joseph C. An acute phase reaction from zoledronate mimicking symptoms seen in opioid withdrawal: a case report. Addict Sci Clin Pract 2024; 19:34. [PMID: 38693547 PMCID: PMC11064307 DOI: 10.1186/s13722-024-00464-8] [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] [Received: 02/25/2024] [Accepted: 04/16/2024] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND Zoledronate, a bisphosphonate, is a potent first-line treatment for osteoporosis. It is also a preferred treatment for hypercalcemia especially when unresponsive to intravenous fluids. Bisphosphonates can cause acute phase reactions that mimic opioid withdrawal symptoms, which can confound provider decision-making. Our case highlights cognitive bias involving a patient with opioid use disorder who received zoledronate for hypercalcemia secondary to immobilization and significant bone infection. CASE PRESENTATION A 41-year-old male is admitted with a past medical history of active intravenous opioid use complicated by group A streptococcal bacteremia with L5-S1 discitis and osteomyelitis, L2-L3 osteomyelitis, and left ankle abscess/septic arthritis status post left ankle washout. His pain was well-controlled by acute pain service with ketamine infusion (discontinued earlier), opioids, acetaminophen, buprenorphine-naloxone, cyclobenzaprine, gabapentin, and naproxen. Intravenous opioids were discontinued, slightly decreasing the opioid regimen. A day later, the patient reported tachycardia, diaphoresis, myalgias, and chills, which the primary team reconsulted acute pain service for opioid withdrawal. However, the patient received a zoledronate infusion for hypercalcemia, on the same day intravenous opioids were discontinued. He had no other medications known to cause withdrawal-like symptoms per chart review. Therefore, it was suspected that an acute phase reaction occurred, commonly seen within a few days of bisphosphonate use. CONCLUSION Zoledronate, well known for causing acute phase reactions, was likely the cause of withdrawal-like symptoms. Acute phase reactions with bisphosphonates mostly occur in the first infusion, and the incidence decreases with subsequent infusions. Symptoms typically occur 24-72 h post-infusion, and last at most for 72 h. Cognitive bias led the primary team to be concerned with opioid withdrawal rather than investigating other causes for the patient's presentation. Therefore, providers should thoroughly investigate potential etiologies and rule them out accordingly to provide the best care. Health care providers should also be aware of the implicit biases that potentially impact the quality of care they provide to patients.
Collapse
Affiliation(s)
- Pankti P Acharya
- Department of Anesthesiology, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA.
| | - Crystal Joseph
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| |
Collapse
|
2
|
Horton DM, Woods DK, Garland EL, Edwards RR, Barrett B, Zgierska AE. Qualitative findings from a randomized trial of mindfulness-based and cognitive-behavioral group therapy for opioid-treated chronic low back pain. J Health Psychol 2024:13591053241247710. [PMID: 38679890 DOI: 10.1177/13591053241247710] [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] [Indexed: 05/01/2024] Open
Abstract
This article reports qualitative outcomes from a randomized controlled trial comparing eight weeks of cognitive-behavioral group therapy for chronic pain (CBT-CP) and mindfulness-based group therapy (MBT) in individuals with chronic low back pain (CLBP). Approximately 10 months post-treatment, 108 participants completed structured qualitative interviews to express how the study treatment affected their life or health. Responses were qualitatively analyzed to generate a set of themes and subthemes, with between-groups comparisons to evaluate differences (if any) in treatment-response between MBT and CBT-CP. A majority of participants (n = 88, 81.5%) across both groups reflected positively on the study intervention and outcomes, identifying benefits in pain management (31.5%), meditation and mindfulness skills (25.9%), and relaxation skills (22.2%). Perceived benefits varied widely, suggesting no one intervention may be ideal for CLBP. Future research should examine tailoring interventions to target diverse clinical presentations to achieve optimal outcomes.
Collapse
Affiliation(s)
- David M Horton
- Department of Family Medicine and Community Health, University of Wisconsin-Madison School of Medicine and Public Health, USA
| | - David K Woods
- Department of Family Medicine and Community Health, University of Wisconsin-Madison School of Medicine and Public Health, USA
| | | | - Robert R Edwards
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston, Massachusetts, Brigham and Women's Hospital, USA
| | - Bruce Barrett
- Department of Family Medicine and Community Health, University of Wisconsin-Madison School of Medicine and Public Health, USA
| | - Aleksandra E Zgierska
- Department of Family and Community Medicine, The Pennsylvania State University College of Medicine, USA
| |
Collapse
|
3
|
Fereydooni S, Lorenz K, Azarfar A, Luckett T, Phillips JL, Becker W, Giannitrapani K. Identifying provider, patient and practice factors that shape long-term opioid prescribing for cancer pain: a qualitative study of American and Australian providers. BMJ Open 2024; 14:e082033. [PMID: 38514141 PMCID: PMC10961503 DOI: 10.1136/bmjopen-2023-082033] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/28/2024] [Indexed: 03/23/2024] Open
Abstract
INTRODUCTION Prescribing long-term opioid therapy is a nuanced clinical decision requiring careful consideration of risks versus benefits. Our goal is to understand patient, provider and context factors that impact the decision to prescribe opioids in patients with cancer. METHODS We conducted a secondary analysis of the raw semistructured interview data gathered from 42 prescribers who participated in one of two aligned concurrent qualitative studies in the USA and Australia. We conducted a two-part analysis of the interview: first identifying all factors influencing long-term prescribing and second open coding-related content for themes. RESULTS Factors that influence long-term opioid prescribing for cancer-related pain clustered under three key domains (patient-related, provider-related and practice-related factors) each with several themes. Domain 1: Patient factors related to provider-patient continuity, patient personality, the patient's social context and patient characteristics including racial/ethnic identity, housing and socioeconomic status. Domain 2: Provider-related factors centred around provider 'personal experience and expertise', training and time availability. Domain 3: Practice-related factors included healthcare interventions to promote safer opioid practices and accessibility of quality alternative pain therapies. CONCLUSION Despite the differences in the contexts of the two countries, providers consider similar patient, provider and practice-related factors when long-term prescribing opioids for patients with cancer. Some of these factors may be categorised as cognitive biases that may intersect in an already disadvantaged patient and exacerbate disparities in the treatment of their pain. A more systematic understanding of these factors and how they impact the quality of care can inform appropriate interventions.
Collapse
Affiliation(s)
| | - Karl Lorenz
- Stanford University, Stanford, California, USA
| | - Azin Azarfar
- University of Florida, Gainesville, Florida, USA
| | - Tim Luckett
- IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), Faculty of Health, University of Technology, Sydney, New South Wales, Australia
| | - Jane L Phillips
- IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), University of Technology, Sydney, New South Wales, Australia
| | - William Becker
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Karleen Giannitrapani
- VA Center for Innovation to Implementation, Menlo Park, California, USA
- Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
| |
Collapse
|
4
|
Scott I, Hubinette M, van der Goes T, Kahlke R. Through a Tainted Lens: A Qualitatve Study of Medical Learners' Thinking About Patient 'Deservingness' of Health Advocacy. Perspect Med Educ 2024; 13:151-159. [PMID: 38406649 PMCID: PMC10885826 DOI: 10.5334/pme.1314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 01/31/2024] [Indexed: 02/27/2024]
Abstract
Introduction While health advocacy is a key component of many competency frameworks, mounting evidence suggests that learners do not see it as core to their learning and future practice. When learners do advocate for their patients, they characterize this work as 'going above and beyond' for a select few patients. When they think about advocacy in this way, learners choose who deserves their efforts. For educators and policymakers to support learners in making these decisions thoughtfully and ethically, we must first understand how they are currently thinking about patient deservingness. Methods We conducted qualitative interviews with 29 undergraduate and postgraduate medical learners, across multiple sites and disciplines, to discuss their experiences of and decision-making about health advocacy. We then carried out a thematic analysis to understand how learners decided when and for whom to advocate. Stemming from initial inductive coding, we then developed a deductive coding framework, based in existing theory conceptualizing 'deservingness.' Results Learners saw their patients as deserving of advocacy if they believed that the patient: was not responsible for their condition, was more in need of support than others, had a positive attitude, was working to improve their health, and shared similarities to the learner. Learners noted the tensions inherent in, and discomfort with, their own thinking about patient deservingness. Discussion Learners' decisions about advocacy deservingness are rooted in their preconceptions about the patient. Explicit curriculum and conversations about advocacy decisions are needed to support learners in making advocacy decisions equitably.
Collapse
Affiliation(s)
- Ian Scott
- Department of Family Practice and the Director of the Centre for Health Education Scholarship at the University of British Columbia, Vancouver British Columbia, Canada
| | - Maria Hubinette
- Department of Family Practice and a Scholar at the Centre for Health Education Scholarship at the University of British Columbia, Vancouver BC, Canada
| | - Theresa van der Goes
- Department of Family Practice, University of British Columbia, Vancouver BC, Canada
| | - Renate Kahlke
- Division of Education and Innovation, Department of Medicine and Scientist in the McMaster Education Research, Innovation and Theory Program at McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
5
|
Baltes A, Horton DM, Malicki J, Trevino C, Agarwal, S, Zarzaur BL, Brown RT. Pain management in trauma: the need for trauma-informed opioid prescribing guidelines. Trauma Surg Acute Care Open 2024; 9:e001294. [PMID: 38352958 PMCID: PMC10862252 DOI: 10.1136/tsaco-2023-001294] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 01/27/2024] [Indexed: 02/16/2024] Open
Abstract
Background/objectives Surgical populations and particularly injury survivors often present with complex trauma that elevates their risk for prolonged opioid use and misuse. Changes in opioid prescribing guidelines during the past several years have yielded mixed results for pain management after trauma, with a limiting factor being the heterogeneity of clinical populations and treatment needs in individuals receiving opioids. The present analysis illuminates this gap between clinical guidelines and clinical practice through qualitative feedback from hospital trauma providers and unit staff members regarding current opioid prescribing guidelines and practices in the setting of traumatic injury. Methods The parent study aimed to implement a pilot screening tool for opioid misuse in four level I and II trauma hospitals throughout Wisconsin. As part of the parent study, focus groups were conducted at each study site to explore the facilitators and barriers of implementing a novel screening tool, as well as to examine the current opioid prescribing guidelines, trainings, and resources available for trauma and acute care providers. Focus group transcripts were independently coded and analyzed using a modified grounded theory approach to identify themes related to the facilitators and barriers of opioid prescribing guidelines in trauma and acute care. Results Three major themes were identified as impactful to opioid-related prescribing and care provided in the setting of traumatic injury; these include (1) acute treatment strategies; (2) patient interactions surrounding pain management; and (3) the multifactorial nature of trauma on pain management approaches. Conclusion Providers and staff at four Wisconsin trauma centers called for trauma-specific opioid prescribing guidelines in the setting of trauma and acute care. The ubiquitous prescription of opioids and challenges in long-term pain management in these settings necessitate additional community-integrated research to inform development of federal guidelines. Level of evidence Therapeutic/care management, level V.
Collapse
Affiliation(s)
- Amelia Baltes
- Department of Family Medicine and Community Health, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - David M Horton
- Department of Family Medicine and Community Health, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Julia Malicki
- Department of Family Medicine and Community Health, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Colleen Trevino
- Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Ben L Zarzaur
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Randall T Brown
- Department of Family Medicine and Community Health, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| |
Collapse
|
6
|
Teeple S, Smith A, Toerper M, Levin S, Halpern S, Badaki-Makun O, Hinson J. Exploring the impact of missingness on racial disparities in predictive performance of a machine learning model for emergency department triage. JAMIA Open 2023; 6:ooad107. [PMID: 38638298 PMCID: PMC11025382 DOI: 10.1093/jamiaopen/ooad107] [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: 09/09/2023] [Revised: 11/15/2023] [Accepted: 12/06/2023] [Indexed: 04/20/2024] Open
Abstract
Objective To investigate how missing data in the patient problem list may impact racial disparities in the predictive performance of a machine learning (ML) model for emergency department (ED) triage. Materials and Methods Racial disparities may exist in the missingness of EHR data (eg, systematic differences in access, testing, and/or treatment) that can impact model predictions across racialized patient groups. We use an ML model that predicts patients' risk for adverse events to produce triage-level recommendations, patterned after a clinical decision support tool deployed at multiple EDs. We compared the model's predictive performance on sets of observed (problem list data at the point of triage) versus manipulated (updated to the more complete problem list at the end of the encounter) test data. These differences were compared between Black and non-Hispanic White patient groups using multiple performance measures relevant to health equity. Results There were modest, but significant, changes in predictive performance comparing the observed to manipulated models across both Black and non-Hispanic White patient groups; c-statistic improvement ranged between 0.027 and 0.058. The manipulation produced no between-group differences in c-statistic by race. However, there were small between-group differences in other performance measures, with greater change for non-Hispanic White patients. Discussion Problem list missingness impacted model performance for both patient groups, with marginal differences detected by race. Conclusion Further exploration is needed to examine how missingness may contribute to racial disparities in clinical model predictions across settings. The novel manipulation method demonstrated may aid future research.
Collapse
Affiliation(s)
- Stephanie Teeple
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19143, United States
- Palliative and Advanced Illness Research (PAIR) Center, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| | - Aria Smith
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD 21218, United States
- Clinical Decision Support Solutions, Beckman Coulter, Brea, CA 92821, United States
| | - Matthew Toerper
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD 21218, United States
- Clinical Decision Support Solutions, Beckman Coulter, Brea, CA 92821, United States
| | - Scott Levin
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD 21218, United States
- Clinical Decision Support Solutions, Beckman Coulter, Brea, CA 92821, United States
| | - Scott Halpern
- Palliative and Advanced Illness Research (PAIR) Center, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine at the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Oluwakemi Badaki-Makun
- Department of Pediatric Emergency Medicine, Johns Hopkins University, Baltimore, MD 21218, United States
| | - Jeremiah Hinson
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD 21218, United States
| |
Collapse
|
7
|
Tata V, Al Saadi R, Cho SK, Varisco TJ, Wanat M, Thornton JD. Physician perspective on the implementation of risk mitigation strategies when prescribing opioid medications: a qualitative analysis. BMC Health Serv Res 2023; 23:1185. [PMID: 37907915 PMCID: PMC10617230 DOI: 10.1186/s12913-023-10136-z] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 10/12/2023] [Indexed: 11/02/2023] Open
Abstract
OBJECTIVE To understand the physician perspective on the barriers and facilitators of implementing nine different opioid risk mitigation strategies (RMS) when prescribing opioid medications. METHODS We created and dispersed a cross-sectional online survey through the Qualtrics© data collection platform among a nationwide sample of physicians licensed to practice medicine in the United States who have prescribed an opioid medication within the past year. The responses were analyzed using a deductive thematic analysis approach based on the Consolidated Framework for Implementation Research (CFIR) to ensure a holistic approach to identifying the barriers and facilitators for each RMS assessed. In concordance with this method, the themes and codes for the thematic analysis were defined prior to the analysis. The five domains within the CFIR were used as themes and the 39 nested constructs were treated as the codes. Two members of the research team independently coded the transcripts and discussed points of disagreement until consensus was reached. All analyses were conducted in ATLAS.ti© V7. RESULTS The completion rate for this survey was 85.1% with 273 participant responses eligible for analysis. Intercoder reliability was calculated to be 82%. Deductive thematic analysis yielded 2,077 descriptions of factors affecting implementation of the nine RMS. The most salient code across all RMS was Knowledge and Beliefs about the Intervention, which refers to individuals' attitudes towards and value placed on the intervention. Patient Needs and Resources, a code referring to the extent to which patient needs are known and prioritized by the organization, also emerged as a salient code. The physicians agreed that the patient perspective on the issue is vital to the uptake of each of the RMS. CONCLUSIONS This deductive thematic analysis identified key points for actionable intervention across the nine RMS assessed and established the importance of patient concordance with physicians when deciding on a course of treatment.
Collapse
Affiliation(s)
- Vaishnavi Tata
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, 4349 Martin Luther King Jr. Blvd, Houston, TX, 77204, USA.
- Prescription Drug Misuse and Education Research (PREMIER) Center, University of Houston College of Pharmacy, Houston, TX, 77204, USA.
| | - Randa Al Saadi
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, 4349 Martin Luther King Jr. Blvd, Houston, TX, 77204, USA.
- Prescription Drug Misuse and Education Research (PREMIER) Center, University of Houston College of Pharmacy, Houston, TX, 77204, USA.
| | - Sang Kyu Cho
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, 4349 Martin Luther King Jr. Blvd, Houston, TX, 77204, USA
- Prescription Drug Misuse and Education Research (PREMIER) Center, University of Houston College of Pharmacy, Houston, TX, 77204, USA
| | - Tyler J Varisco
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, 4349 Martin Luther King Jr. Blvd, Houston, TX, 77204, USA
- Prescription Drug Misuse and Education Research (PREMIER) Center, University of Houston College of Pharmacy, Houston, TX, 77204, USA
| | - Matthew Wanat
- Prescription Drug Misuse and Education Research (PREMIER) Center, University of Houston College of Pharmacy, Houston, TX, 77204, USA
- College of Pharmacy, Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, 77204, USA
| | - J Douglas Thornton
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, 4349 Martin Luther King Jr. Blvd, Houston, TX, 77204, USA
- Prescription Drug Misuse and Education Research (PREMIER) Center, University of Houston College of Pharmacy, Houston, TX, 77204, USA
| |
Collapse
|
8
|
Nevedal AL, Timko C, Lor MC, Hoggatt KJ. Patient and Provider Perspectives on Benefits and Harms of Continuing, Tapering, and Discontinuing Long-Term Opioid Therapy. J Gen Intern Med 2023; 38:1802-1811. [PMID: 36376623 PMCID: PMC9663196 DOI: 10.1007/s11606-022-07880-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 10/24/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Given efforts to taper patients off long-term opioid therapy (LTOT) because of known harms, it is important to understand if patients and providers align in LTOT treatment goals. OBJECTIVE To investigate patient and provider perceptions about the harms and benefits of continuing and discontinuing LTOT. DESIGN Qualitative study PARTICIPANTS: Patients and providers with experiences with LTOT for pain in two Veterans Health Affairs regions. APPROACH We conducted semi-structured interviews and analyzed data using rapid qualitative analysis to describe patient and provider preferences about LTOT continuation and discontinuation and non-opioid pain treatments. KEY RESULTS Participants (n=43) included 28/67 patients and 15/17 providers. When discussing continuing LTOT, patients emphasized the benefits outweighed the harms, whereas providers emphasized the harms. Participants agreed on the benefits of continuing LTOT for improved physical functioning. Provider-reported benefits of continuing LTOT included maintaining the status quo for patients without opioid alternatives or who were at risk for illicit drug use. Participants were aligned regarding the harms of negative side-effects (e.g., constipation) from continued LTOT. In contrast, when discussing LTOT tapering and discontinuation, providers underscored how benefits outweighed the harms, citing patients' improved well-being and pain management with tapering or alternatives. Patients did not foresee benefits to potential LTOT tapers or discontinuation and were worried about pain management in the absence of LTOT. When discussing non-opioid pain treatments, participants emphasized that they were adjunctive to opioid therapy rather than a replacement (except for cannabis). Providers described the importance of mental health services to manage pain, which differed from patients who focused on treatments to improve strength and mobility and reduce pain. CONCLUSIONS Patients emphasized the benefits of continuing LTOT for pain management and well-being, which differed from providers' emphasis on the benefits of discontinuing LTOT. Patient and provider differences are important for informing patient-centered care and decisions around continuing, tapering, or discontinuing LTOT.
Collapse
Affiliation(s)
- Andrea L Nevedal
- Department of Veterans Affairs Health Care System, VA Center for Clinical Management Research, Ann Arbor, MI, 48105, USA.
| | - Christine Timko
- Department of Veterans Affairs Health Care System, Center for Innovation to Implementation, Palo Alto, CA, 94304, USA
- Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, Stanford, CA, 94305, USA
| | - Mai Chee Lor
- Department of Veterans Affairs Health Care System, Center for Innovation to Implementation, Palo Alto, CA, 94304, USA
| | - Katherine J Hoggatt
- San Francisco VA Health Care System, San Francisco, CA, 94121, USA
- Department of Medicine, University of California, San Francisco, San Francisco, CA, 94143, USA
| |
Collapse
|
9
|
Pace L, Howard M, Makar E, Lee J. The association of patient age, race, and demographic features on reported pain and sedation dosing during procedural abortion: A retrospective cohort study. Contraception 2023:110037. [PMID: 37019255 DOI: 10.1016/j.contraception.2023.110037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 03/25/2023] [Accepted: 03/29/2023] [Indexed: 04/05/2023]
Abstract
OBJECTIVES To explore impact of age, racial, demographic, and psychosocial factors on patients' dosage of analgesia and maximum pain score during procedural abortion. STUDY DESIGN We performed retrospective chart review of pregnant individuals undergoing procedural abortion at our hospital-based abortion clinic from October 2019 through May 2020. Patients were stratified into three age groups for comparison, <19 years, 19-35 years, >35 years. We conducted the Kruskal-Wallis H test to evaluate for medication dosing or maximum pain score differences among the age groups. RESULTS We included 225 patients in our study. We found no difference in fentanyl or midazolam dosing between age groups. The median fentanyl dose was 75mcg and the median dose of midazolam was 2mg in all three groups (p=0.61, p=0.99). White patients received higher median midazolam dosing than Black patients (2mg and 3mg, respectively, p<0.01) despite similar reported pain scores. Nulliparous patients reported lower maximum pain scores than parous patients (8 and 9, respectively, p=0.01). Despite no difference in pain scores, patients terminating for genetic anomaly received more fentanyl than those terminating for socioeconomic reasons (75 and 100mcg, respectively, p<0.01). CONCLUSIONS In our limited study, we found younger patients (<19 years) and older patients (>35 years) did not receive more fentanyl or midazolam. White race and induced abortion for genetic anomaly were associated with increased medication dosing. Multiple demographic and psychosocial factors, as well as perhaps provider bias, play into both a patient's perception of pain and the dosage of fentanyl and midazolam they receive during abortion procedures.
Collapse
|
10
|
Ojeda MS, Chen AMH, Miracle T, Delaney E, Freiermuth CE, Sprague JE. HealthCare educational differences in pain management, adverse childhood experiences and their relationship to substance use disorder education. Subst Abuse Treat Prev Policy 2022; 17:10. [PMID: 35130945 PMCID: PMC8819922 DOI: 10.1186/s13011-022-00436-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2022] [Indexed: 11/26/2022] Open
Abstract
Background In order to assist the State of Ohio in the United States in addressing the opioid epidemic, the Ohio Attorney General appointed experts in a variety of academic disciplines to the Scientific Committee on Opioid Prevention and Education (SCOPE). The focus of SCOPE is the application of scientific principles in the development of prevention and educational strategies for reducing substance use disorder (SUD). One area of focus for SCOPE was SUD education of healthcare professionals. The objective of the present was to identify the content and extent to which future healthcare professionals are trained in pain management, SUD, and adverse childhood experiences (ACEs). Methods In December of 2019, a survey was distributed to 49 healthcare professional schools in Ohio that included the following disciplines: medicine, pharmacy, advanced practice registered nurse (APRN), physician assistant, dentistry, and optometry. The survey included four domains: initial screening of patients, training in SUD, training in care for patients at high risk for SUD, and education in evaluating patients for ACEs. Descriptive statistics were calculated. Results Thirty one of the forty-nine schools completed the survey. Most disciplines indicated that some form of basic training in the principles of SUD were taught in their core curriculum. The training on ethical issues surrounding SUD were not as widely covered (range 0-62.5%). Medicine, APRN, physician assistant, and pharmacy schools had a “moderate” to “great” extent of pharmacologic therapy curriculum integration. Other pain management strategies were “somewhat” to “moderately” integrated. There were variations seen in training on risk of medication misuse based on various contributors to health. At least 67.7% of medicine, APRN, physician assistant, and pharmacy programs included motivational interviewing training. The extent to which schools integrated education regarding ACEs into their curriculum varied from 0 to 66.7%. Conclusions The study finding suggests a need for a unified, consistent, and expanded training requirement in the foundations of pain management, SUD, and ACEs in professional healthcare education.
Collapse
|
11
|
Essien UR, Chiswell K, Kaltenbach LA, Wang TY, Fonarow GC, Thomas KL, Turakhia MP, Benjamin EJ, Rodriguez F, Fang MC, Magnani JW, Yancy CW, Piccini JP. Association of Race and Ethnicity With Oral Anticoagulation and Associated Outcomes in Patients With Atrial Fibrillation: Findings From the Get With The Guidelines-Atrial Fibrillation Registry. JAMA Cardiol 2022; 7:1207-1217. [PMID: 36287545 PMCID: PMC9608025 DOI: 10.1001/jamacardio.2022.3704] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 09/06/2022] [Indexed: 01/13/2023]
Abstract
Importance Oral anticoagulation (OAC) is underprescribed in underrepresented racial and ethnic group individuals with atrial fibrillation (AF). Little is known of how differential OAC prescribing relates to inequities in AF outcomes. Objective To compare OAC use at discharge and AF-related outcomes by race and ethnicity in the Get With The Guidelines-Atrial Fibrillation (GWTG-AFIB) registry. Design, Setting, and Participants This retrospective cohort analysis used data from the GWTG-AFIB registry, a national quality improvement initiative for hospitalized patients with AF. All registry patients hospitalized with AF from 2014 to 2020 were included in the study. Data were analyzed from November 2021 to July 2022. Exposures Self-reported race and ethnicity assessed in GWTG-AFIB registry. Main Outcomes and Measures The primary outcome was prescription of direct-acting OAC (DOAC) or warfarin at discharge. Secondary outcomes included cumulative 1-year incidence of ischemic stroke, major bleeding, and mortality postdischarge. Outcomes adjusted for patient demographic, clinical, and socioeconomic characteristics as well as hospital factors. Results Among 69 553 patients hospitalized with AF from 159 sites between 2014 and 2020, 863 (1.2%) were Asian, 5062 (7.3%) were Black, 4058 (5.8%) were Hispanic, and 59 570 (85.6%) were White. Overall, 34 113 (49.1%) were women; the median (IQR) age was 72 (63-80) years, and the median (IQR) CHA2DS2-VASc score (calculated as congestive heart failure, hypertension, age 75 years and older, diabetes, stroke or transient ischemic attack, vascular disease, age 65 to 74 years, and sex category) was 4 (2-5). At discharge, 56 385 patients (81.1%) were prescribed OAC therapy, including 41 760 (74.1%) receiving DOAC. OAC prescription at discharge was lowest in Hispanic patients (3010 [74.2%]), followed by Black patients (3935 [77.7%]) Asian patients (691 [80.1%]), and White patients (48 749 [81.8%]). Black patients were less likely than White patients to be discharged while taking any anticoagulant (adjusted odds ratio, 0.75; 95% CI, 0.68-0.84) and DOACs (adjusted odds ratio, 0.73; 95% CI, 0.65-0.82). In 16 307 individuals with 1-year follow up data, bleeding risks (adjusted hazard ratio [aHR], 2.08; 95% CI, 1.53-2.83), stroke risks (aHR, 2.07; 95% CI, 1.34-3.20), and mortality risks (aHR, 1.22; 95% CI, 1.02-1.47) were higher in Black patients than White patients. Hispanic patients had higher stroke risk (aHR, 2.02; 95% CI, 1.38-2.95) than White patients. Conclusions and Relevance In a national registry of hospitalized patients with AF, compared with White patients, Black patients were less likely to be discharged while taking anticoagulant therapy and DOACs in particular. Black and Hispanic patients had higher risk of stroke compared with White patients; Black patients had a higher risk of bleeding and mortality. There is an urgent need for interventions to achieve pharmacoequity in guideline-directed AF management to improve overall outcomes.
Collapse
Affiliation(s)
- Utibe R. Essien
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Lisa A. Kaltenbach
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Tracy Y. Wang
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Gregg C. Fonarow
- Division of Cardiology, University of California, Los Angeles
- Associate Editor for Health Care Quality and Guidelines, JAMA Cardiology
| | - Kevin L. Thomas
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Mintu P. Turakhia
- VA Palo Alto Health Care System, Palo Alto, California
- Center for Digital Health, Stanford University School of Medicine, Stanford, California
| | - Emelia J. Benjamin
- Cardiovascular Medicine, Boston University School of Medicine, Boston, Massachusetts
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
| | - Fatima Rodriguez
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Margaret C. Fang
- Division of Hospital Medicine, University of California, San Francisco
| | - Jared W. Magnani
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Clyde W. Yancy
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Deputy Editor, JAMA Cardiology
| | - Jonathan P. Piccini
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| |
Collapse
|
12
|
Agarwal I, Joseph JW, Sanchez LD. Time on shift in the emergency department and decision to prescribe opioids to patients without chronic opioid use. Clin Exp Emerg Med 2022; 9:108-113. [PMID: 35843610 PMCID: PMC9288880 DOI: 10.15441/ceem.22.212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 04/26/2022] [Indexed: 11/23/2022] Open
Abstract
Objective To study the effect of time on shift on the opioid prescribing practices of emergency physicians among patients without chronic opioid use.Methods We analyzed pain-related visits for five painful conditions from 2010 to 2017 at a single academic hospital in Boston. Visits were categorized according to national guidelines as conditions for which opioids are “sometimes indicated” (fracture and renal colic) or “usually not indicated” (headache, low back pain, and fibromyalgia). Using conditional logistic regression with fixed effects for clinicians, we estimated the probability of opioid prescribing for pain-related visits as a function of shift hour at discharge, time of day, and patient-level confounders (age, sex, and pain score).Results Among 16,115 visits for which opioids were sometimes indicated, opioid prescribing increased over the course of a shift (28% in the first hour compared with 40% in the last hour; adjusted odds ratio, 1.06; 95% confidence interval, 1.02–1.10; adjusted P-trend <0.01). However, among visits for which opioids are usually not indicated, relative to the first hour, opioid prescriptions progressively fell (40% in the first hour compared with 23% in the last hour; adjusted odds ratio, 0.93; 95% confidence interval, 0.91–0.96; adjusted P-trend <0.01).Conclusion As shift hour progressed, emergency physicians became more likely to prescribe opioids for conditions that are sometimes indicated, and less likely to prescribe opioids for nonindicated conditions. Our study suggests that clinical decision making in the emergency department can be substantially influenced by external factors such as clinician shift hour.
Collapse
|
13
|
Ekl EA, Brooks CV. Take the Day Off: Examining the Sick Role for Chronic Back Pain by Race and Gender. Soc Psychol Q 2022. [DOI: 10.1177/01902725221078541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Research has largely overlooked the public’s willingness to validate entrance to the sick role for individuals experiencing chronic pain. To fill this gap, we conducted a survey experiment to assess how race, gender, and their intersection impact (1) the legitimation of missing work due to pain and (2) recommendations for help seeking, examining the role of both respondents and vignette characters. We find that respondent characteristics are associated with perceived acceptability of missing work due to pain, and both respondent and vignette characteristics are associated with help-seeking endorsements. White females are least likely to view pain as an acceptable excuse to miss work but are most likely to endorse help-seeking measures, while black women are recommended the most treatments for pain. We theorize how results provide evidence to counter assumptions of objectivity and linearity of the sick role and how gender and race influence the social response to pain.
Collapse
|
14
|
Gannon M, Short V, Becker M, Parikh S, McGuigan K, Hand D, Keith S, Abatemarco D. Doula engagement and maternal opioid use disorder (OUD): Experiences of women in OUD recovery during the perinatal period. Midwifery 2021; 106:103243. [PMID: 34999514 DOI: 10.1016/j.midw.2021.103243] [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] [Received: 08/10/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pregnant women who have substance use disorders (SUDs) are at increased risk of preterm birth, fetal mortality, and inadequate prenatal care and have higher rates of childhood trauma than their counterparts without SUDs. Doulas have been utilized with other vulnerable populations who experience trauma to increase perinatal healthcare utilization, provide emotional support, and improve birth outcomes. The objective of the current study was to examine, in women with opioid use disorder (OUD), perceptions of working with a doula in the perinatal period. METHODS Eligible participants were ≥ 18 years old, in OUD treatment, and were pregnant or recently delivered (child ≤ 3 months of age). Semi-structured interviews were used to collect tacit data on the woman's experience working with a doula during the perinatal period. All one-hour interviews were conducted over the phone and transcribed verbatim by a HIPAA compliant transcription service. Transcripts were reviewed independently by 4 coders using open coding procedures, constant comparative method of grounded theory, and inductive thematic analysis. Demographic data and history of childhood trauma information (Adverse Childhood Experiences Tool) were collected with a phone survey prior to the interview. RESULTS Participants' (N = 23) were 32.5 years of age (4.1 SD), with the majority Caucasian (71.4%), Non-Hispanic (71.4%) and Medicaid recipients (100%). Participants reported a mean of 5.61 (SD=2.93) adverse childhood experiences, indicating a significant trauma burden. Major themes uncovered in the interview transcripts revealed emotional and OUD recovery support provided by the doula and increased maternal health literacy and self-advocacy. The presence of a doula during labor/delivery reduced maternal perceptions of stigma they perceived from their healthcare providers. CONCLUSION Doula engagement was associated with perceptions of increased emotional support, health literacy and self-advocacy in maternal health among women with OUD, which is significant given this population's trauma histories. This preliminary research has significant implications for improving the health of the mother child dyad affected by maternal OUD.
Collapse
Affiliation(s)
- Meghan Gannon
- Department of OB/GYN, Thomas Jefferson University, 1233 Locust St, Philadelphia, PA 19107, United States.
| | - Vanessa Short
- Department of Obstetrics and Gynecology, Thomas Jefferson University, 1233 Locust St, Philadelphia, PA 19107, United States.
| | - Mariel Becker
- Thomas Jefferson University, Philadelphia, PA 19107, United States.
| | - Saloni Parikh
- Thomas Jefferson University, Philadelphia, PA 19107, United States.
| | - Kelly McGuigan
- Thomas Jefferson University, Philadelphia, PA 19107, United States.
| | - Dennis Hand
- Department of Obstetrics, Gynecology, and Psychiatry, Thomas Jefferson University, 1233 Locust St, Philadelphia, PA 19107, United States.
| | - Scott Keith
- Department of Biostatistics, Thomas Jefferson University, 1015 Chestnut St, Philadelphia, PA 19107, United States.
| | - Diane Abatemarco
- Gynecology and Pediatrics Director of Maternal Addiction Treatment, Education and Research (MATER), 1233 Locust St, Philadelphia, PA 19107, United States.
| |
Collapse
|