Prevalence and Detection of Prescription Opioid Misuse and Prescription Opioid Use Disorder Among Emergency Department Patients 50 Years of Age and Older: Performance of the Prescription Drug Use Questionnaire, Patient Version

Screening for harmful substance use in emergency departments: a systematic review

BACKGROUND

Substance use-related emergency department (ED) visits have increased substantially in North America. Screening for substance use in EDs is recommended; best approaches are unclear. This systematic review synthesizes evidence on diagnostic accuracy of ED screening tools to detect harmful substance use.

METHODS

We included derivation or validation studies, with or without comparator, that included adult (≥ 18 years) ED patients and evaluated screening tools to identify general or specific substance use disorders or harmful use. Our search strategy combined concepts Emergency Department AND Screening AND Substance Use. Trained reviewers assessed title/abstracts and full-text articles for inclusion, extracted data, and assessed risk of bias (QUADAS-2) independently and in duplicate. Reviewers resolved disagreements by discussion. Primary investigators adjudicated if necessary. Heterogeneity precluded meta-analysis. We descriptively summarized results.

RESULTS

Our search strategy yielded 2696 studies; we included 33. Twenty-one (64%) evaluated a North American population. Fourteen (42%) applied screening among general ED patients. Screening tools were administered by research staff (n = 21), self-administered by patients (n = 10), or non-research healthcare providers (n = 1). Most studies evaluated alcohol use screens (n = 26), most commonly the Alcohol Use Disorders Identification Test (AUDIT; n = 14), Cut down/Annoyed/Guilty/Eye-opener (CAGE; n = 13), and Rapid Alcohol Problems Screen (RAPS/RAPS4/RAPS4-QF; n = 12). Four studies assessing six tools and screening thresholds for alcohol abuse/dependence in North American patients (AUDIT ≥ 8; CAGE ≥ 2; Diagnostic and Statistical Manual of Mental Disorders, 4th Edition [DSM-IV-2] ≥ 1; RAPS ≥ 1; National Institute on Alcohol Abuse and Alcoholism [NIAAA]; Tolerance/Worry/Eye-opener/Amnesia/K-Cut down [TWEAK] ≥ 3) reported both sensitivities and specificities ≥ 83%. Two studies evaluating a single alcohol screening question (SASQ) (When was the last time you had more than X drinks in 1 day?, X = 4 for women; X = 5 for men) reported sensitivities 82-85% and specificities 70-77%. Five evaluated screening tools for general substance abuse/dependence (Relax/Alone/Friends/Family/Trouble [RAFFT] ≥ 3, Drug Abuse Screening Test [DAST] ≥ 4, single drug screening question, Alcohol, Smoking and Substance Involvement Screening Test [ASSIST] ≥ 42/18), reporting sensitivities 64%-90% and specificities 61%-100%. Studies' risk of bias were mostly high or uncertain.

CONCLUSIONS

Six screening tools demonstrated both sensitivities and specificities ≥ 83% for detecting alcohol abuse/dependence in EDs. Tools with the highest sensitivities (AUDIT ≥ 8; RAPS ≥ 1) and that prioritize simplicity and efficiency (SASQ) should be prioritized.

Provider beliefs about the ideal design of an opioid deprescribing and substitution intervention for older adults

PURPOSE

Opportunities exist to meaningfully reduce suboptimal prescription opioid use among older adults. Deprescribing is one possible approach to reducing suboptimal use. Appropriate interventions should outline how to carefully taper opioids, closely monitor adverse events, substitute viable alternative and affordable nonopioid pain treatments, and initiate medications for opioid use disorder to properly manage use disorders, as needed. We sought to document and understand provider perceptions to begin developing effective and safe opioid deprescribing interventions.

METHODS

We conducted 3 semistructured focus groups that covered topics such as participant perspectives on opioid deprescribing in older adults, how to design an ideal intervention, and how to identify potential barriers or facilitators in implementing an intervention. Focus group transcripts were double coded and qualitatively analyzed to identify overarching themes.

RESULTS

Healthcare providers (n = 17), including physicians, pharmacists, nurses, social workers, and administrative staff, participated in 3 focus groups. We identified 4 key themes: (1) involve pharmacists in deprescribing and empower them as leaders of an opioid deprescribing service; (2) ensure tight integration and close collaboration throughout the deprescribing process from the inpatient to outpatient settings; (3) more expansive inclusion criteria than age alone; and (4) provision of access to alternative pharmacological and nonpharmacological pain management modalities to patients.

CONCLUSION

Our findings, which highlight various healthcare provider beliefs about opioid deprescribing interventions, are expected to serve as a framework for other organizations to develop and implement interventions. Future studies should incorporate patients' and family caregivers' perspectives.

Prescription Opioid Misuse in Older Adult Surgical Patients: Epidemiology, Prevention, and Clinical Implications

ABSTRACT

The United States and many other developed nations are in the midst of an opioid crisis, with consequent pressure on prescribers to limit opioid prescribing and reduce prescription opioid misuse. This review addresses prescription opioid misuse for older adult surgical populations. We outline the epidemiology and risk factors for persistent opioid use and misuse in older adults undergoing surgery. We also address screening tools and prescription opioid misuse prevention among vulnerable older adult surgical patients (e.g., older adults with a history of an opioid use disorder), followed by clinical management and patient education recommendations. A significant plurality of older adults engaged in prescription opioid misuse obtain opioid medication for misuse from health providers. Thus, nurses can play a critical role in identifying those older adults at a higher risk for misuse and deliver quality care while balancing the need for adequate pain management against the risk for prescription opioid misuse.

Differential patterns of opioid misuse between younger and older adults - a retrospective observational study using data from South Carolina's prescription drug monitoring program

Background: Most research on opioid misuse focuses on younger adults, yet opioid-related mortality has risen fastest among older Americans over age 55.Objectives: To assess whether there are differential patterns of opioid misuse over time between younger and older adults and whether South Carolina's mandatory Prescription Drug Monitoring Program (PDMP) affected opioid misuse differentially between the two groups.Methods: We used South Carolina's Reporting and Identification Prescription Tracking System from 2010 to 2018 to calculate an opioid misuse score for 193,073 patients (sex unknown) using days' supply, morphine milligram equivalents (MME), and the numbers of unique prescribers and dispensaries. Multivariable regression was used to assess differential opioid misuse patterns by age group over time and in response to implementation of South Carolina's mandatory PDMP in 2017.Results: We found that between 2011 and 2018, older adults received 57% (p < .01) more in total MME and 25.4 days more (p < .01) in supply, but received prescriptions from fewer doctors (-0.063 doctors, p < 01) and pharmacies (-0.11 pharmacies, p < 01) per year versus younger adults. However, older adults had lower odds of receiving a high misuse score (OR 0.88, p < .01). After the 2017 legislation, misuse scores fell among younger adults (OR 0.79, p < .01) relative to 2011, but not among older adults.Conclusion: Older adults may misuse opioids differently compared to younger adults. Assessment of policies to reduce opioid misuse should take into account subgroup differences that may be masked at the population level.

Opioids and older adults: Increasing trends in opioid usage in a dental population compared to a National Database (NHANES)

Aim

To examine self‐reported opioid prevalence at a dental school clinic for patients ≥65 years old as compared to national data, comparing gender, ethnicity/race and older adult age groupings.

Methods and results

Self‐reported prescription opioid medication use was extracted from the medical record for dental patients ≥65 years old who visited the school's general dental clinic (GDC) in 2012 or 2017. This data was compared to the National Health and Nutrition Examination Survey (NHANES) data for 2011–2012 and 2017–18. There was a significant increase in prevalence of opioid use in adults ≥65 between 2012 (4.5%) and 2017 (6.5%) and for ages 65–79 (from 4.7% to 6.3%) and ≥80 (3.4% to 7.9%), women (4.8% to 7.0%), and African Americans (4.7% to 8.4%) in the GDC. Older adults at the GDC reported less opioid use than the NHANES national average for both periods no matter the gender or the age with variable results for race/ethnicity.

Conclusion

The prevalence of older adults taking opioids in our general dental school clinic population increased significantly in 2017 as compared to 2012 but was lower than the national average for the respective periods. Awareness of existing opioid usage in older adult patients and its higher adverse risk potential is critical when prescribing analgesics for dental pain for this age group.

Brief educational video plus telecare to enhance recovery for older emergency department patients with acute musculoskeletal pain: study protocol for the BETTER randomized controlled trial

BACKGROUND

Chronic musculoskeletal pain (MSP) affects more than 40% of adults aged 50 years and older and is the leading cause of disability in the USA. Older adults with chronic MSP are at risk for analgesic-related side effects, long-term opioid use, and functional decline. Recognizing the burden of chronic MSP, reducing the transition from acute to chronic pain is a public health priority. In this paper, we report the protocol for the Brief EducaTional Tool to Enhance Recovery (BETTER) trial. This trial compares two versions of an intervention to usual care for preventing the transition from acute to chronic MSP among older adults in the emergency department (ED).

METHODS

Three hundred sixty patients from the ED will be randomized to one of three arms: full intervention (an interactive educational video about pain medications and recovery-promoting behaviors, a telecare phone call from a nurse 48 to 72 h after discharge from the ED, and an electronic communication containing clinical information to the patient's primary care provider); video-only intervention (the interactive educational video but no telecare or primary care provider communication); or usual care. Data collection will occur at baseline and at 1 week and 1, 3, 6, and 12 months after study enrollment. The primary outcome is a composite measure of pain severity and interference. Secondary outcomes include physical function, overall health, opioid use, healthcare utilization, and an assessment of the economic value of the intervention.

DISCUSSION

This trial is the first patient-facing ED-based intervention aimed at helping older adults to better manage their MSP and reduce their risk of developing chronic pain. If effective, future studies will examine the effectiveness of implementation strategies.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04118595 . Registered on 8 October 2019.

Screening for Unhealthy Drug Use: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Illicit drug use is among the most common causes of preventable morbidity and mortality in the US.

OBJECTIVE

To systematically review the literature on screening and interventions for drug use to inform the US Preventive Services Task Force.

DATA SOURCES

MEDLINE, PubMed, PsycINFO, Embase, and Cochrane Central Register of Controlled Trials through September 18, 2018; literature surveillance through September 21, 2019.

STUDY SELECTION

Test accuracy studies to detect drug misuse and randomized clinical trials of screening and interventions to reduce drug use.

DATA EXTRACTION AND SYNTHESIS

Critical appraisal and data abstraction by 2 reviewers and random-effects meta-analyses.

MAIN OUTCOMES AND MEASURES

Sensitivity, specificity, drug use and other health, social, and legal outcomes.

RESULTS

Ninety-nine studies (N = 84 206) were included. Twenty-eight studies (n = 65 720) addressed drug screening accuracy. Among adults, sensitivity and specificity of screening tools for detecting unhealthy drug use ranged from 0.71 to 0.94 and 0.87 to 0.97, respectively. Interventions to reduce drug use were evaluated in 52 trials (n = 15 659) of psychosocial interventions, 7 trials (n = 1109) of opioid agonist therapy, and 13 trials (n = 1718) of naltrexone. Psychosocial interventions were associated with increased likelihood of drug use abstinence (15 trials, n = 3636; relative risk [RR], 1.60 [95% CI, 1.24 to 2.13]; absolute risk difference [ARD], 9% [95% CI, 5% to 15%]) and reduced number of drug use days (19 trials, n = 5085; mean difference, -0.49 day in the last 7 days [95% CI, -0.85 to -0.13]) vs no psychosocial intervention at 3- to 4-month follow-up. In treatment-seeking populations, opioid agonist therapy and naltrexone were associated with decreased risk of drug use relapse (4 trials, n = 567; RR, 0.75 [95% CI, 0.59 to 0.82]; ARD, -35% [95% CI, -67% to -3%] and 12 trials, n = 1599; RR, 0.73 [95% CI, 0.62 to 0.85]; ARD, -18% [95% CI, -26% to -10%], respectively) vs placebo or no medication. While evidence on harms was limited, it indicated no increased risk of serious adverse events.

CONCLUSIONS AND RELEVANCE

Several screening instruments with acceptable sensitivity and specificity are available to screen for drug use, although there is no direct evidence on the benefits or harms of screening. Pharmacotherapy and psychosocial interventions are effective at improving drug use outcomes, but evidence of effectiveness remains primarily derived from trials conducted in treatment-seeking populations.

Opioid Use and Misuse Three Months After Emergency Department Visit for Acute Pain

BACKGROUND

Studies evaluating long-term prescription opioid use are retrospective and based on filled opioid prescriptions from governmental databases. These studies cannot evaluate if opioids were really consumed and are unable to differentiate if they were used for a new pain or chronic pain or were misused. The aim of this study was to assess opioid use rate and reasons for consuming 3 months after being discharged from the emergency department (ED) with an opioid prescription.

METHODS

This is a prospective cohort study conducted in the ED of a tertiary care urban center with a convenience sample of discharged patients ≥ 18 years who consulted for an acute pain condition (≤2 weeks). Three months post-ED visit, participants were interviewed by phone on their past 2-week opioid consumption and their reasons for consuming: a) for pain related to the initial ED visit, b) for a new unrelated pain, or c) for another reason.

RESULTS

Of the 524 participants questioned at 3 months (mean ± SD age = 51 ± 16 years, 47% women), 47 patients (9%, 95% confidence interval [CI] = 7%-12%) reported consuming opioids in the previous 2 weeks. Among those, 34 (72%) reported using opioids for their initial pain, nine (19%) for a new unrelated pain and four (9%) for another reason (0.8%, 95% CI = 0.3%-2.0%, of the whole cohort). Patients who used opioids during the 2 weeks after the ED visit were 3.8 (95% CI = 1.2-12.7) times more likely to consume opioids at 3 months.

CONCLUSION

Opioid use at the 3-month follow-up in ED patients discharged with an opioid prescription for an acute pain condition is not necessarily associated with opioid misuse; 91% of those patients consumed opioids to treat pain. Of the whole cohort, less than 1% reported using opioids for reasons other than pain. The rate of long-term opioid use reported by prescription-filling database studies should not be viewed as a proxy for incidence of opioid misuse.

Screening emergency department patients for opioid drug use: A qualitative systematic review

INTRODUCTION

The opioid drug epidemic is a major public health concern and an economic burden in the United States. The purpose of this systematic review is to assess the reliability and validity of screening instruments used in emergency medicine settings to detect opioid use in patients and to assess psychometric data for each screening instrument.

METHODS

PubMed/MEDLINE, PsycINFO, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Web of Science, Cumulative Index to Nursing and Allied Health Literature and ClinicalTrials.gov were searched for articles published up to May 2018. The extracted articles were independently screened for eligibility by two reviewers. We extracted 1555 articles for initial screening and 95 articles were assessed for full-text eligibility. Six articles were extracted from the full-text assessment.

RESULTS

Six instruments were identified from the final article list: Screener and Opioid Assessment for Patients with Pain - Revised; Drug Abuse Screening Test; Opioid Risk Tool; Current Opioid Misuse Measure; an Emergency Medicine Providers Clinician Assessment Questionnaire; and an Emergency Provider Impression Data Collection Form. Screening instrument characteristics, and reliability and validity data were extracted from the six studies. A meta-analysis was not conducted due to heterogeneity between the studies.

CONCLUSIONS

There is a lack of validity and reliability evidence in all six articles; and sensitivity, specificity and predictive values varied between the different instruments. These instruments cannot be validated for use in emergency medicine settings. There is no clear evidence to state which screening instruments are appropriate for use in detecting opioid use disorders in emergency medicine patients. There is a need for brief, reliable, valid and feasible opioid use screening instruments in the emergency medicine setting.

Preventing emergency department (ED) visits and hospitalisations of older adults with cognitive impairment compared with the general senior population: what do we know about avoidable incidents? Results from a scoping review

OBJECTIVES

Older cognitively impaired adults present a higher risk of hospitalisation and mortality following a visit to the emergency department (ED). Better understanding of avoidable incidents is needed to prevent them and the associated ED presentations in community-dwelling adults. This study aimed to synthetise the actual knowledge concerning these incidents leading this population to ED presentation, as well as possible preventive measures to reduce them.

DESIGN

A scoping review was performed according to the Arksey and O'Malley framework.

METHODS

Scientific and grey literature published between 1996 and 2017 were examined in databases (Medline, Cumulative Index of Nursing and Allied Health, Ageline, Scopus, ProQuest Dissertations/theses, Evidence-based medecine (EBM) Reviews, Healthstar), online library catalogues, governmental websites and published statistics. Sources discussing avoidable incidents leading to ED presentations were included and then extended to those discussing hospitalisation and mortality due to a lack of sources. Data (type, frequency, severity and circumstances of incidents, preventive measures) was extracted using a thematic chart, then analysed with content analysis.

RESULTS

67 sources were included in this scoping review. Five types of avoidable incidents (falls, burns, transport accidents, harm due to self-negligence and due to wandering) emerged, and all but transport accidents were more frequent in cognitively impaired seniors. Differences regarding circumstances were only reported for burns, as scalding was the most prevalent mechanism of injury for this population compared with flames for the general senior population. Multifactorial interventions and implications of other professionals (eg, pharmacist, firefighters) were reported as potential interventions to reduce avoidable incidents. However, few preventive measures were specifically tested in this population.

CONCLUSIONS

Primary research that screens for cognitive impairment and involves actors (eg, paramedics) to improve our understanding of avoidable incidents leading to ED visits is greatly needed. This knowledge is essential to develop preventive measures tailored to the needs of older cognitively impaired adults.

A Systematic Review of Opioid and Benzodiazepine Misuse in Older Adults

OBJECTIVE

The authors assessed the prevalence of opioid and benzodiazepine prescription drug misuse in older adults, the risk factors associated with misuse, and age-appropriate interventions.

METHODS

Following PRISMA guidelines, a literature search of PubMed, PsycINFO, and EMBASE for peer-reviewed journal articles in English through April 2014 with updates through November 2015 was conducted for reports on misuse of prescription benzodiazepines and opioids in older adults. Relevant publications were reviewed that included participants age ≥65 years. Reference lists were manually searched for key identified articles and geriatric journals through April 2016. Information on the study design, sample, intervention, comparators, outcome, time frame, and risk of bias were abstracted for each article.

RESULTS

Of 4,932 reviewed reports, 15 were included in this systematic review. Thirteen studies assessed the prevalence of prescription drug misuse and included studies related to opioid shopping behavior, assessment of morbidity and mortality associated with opioid and/or benzodiazepine use, frequency and characteristics of opioid prescribing, frequency of substance use disorders and nonprescription use of pain relievers, and health conditions and experiences of long-term benzodiazepine users. One study identified risk factors for misuse, and one study described the effects of provider education and an electronic support tool as an intervention.

CONCLUSION

There is a dearth of high quality research on prescription drug misuse in older adults. Existing studies are heterogeneous, making it difficult to draw broad conclusions. The need for further research specific to prescription drug misuse among older adults is discussed.