Trends in the consumption of opioid analgesics in Taiwan from 2002 to 2007: a population-based study

Ultrasound-Guided Femoral Nerve Block in Geriatric Patients with Hip Fracture in the Emergency Department

Background and Objectives: Systemic analgesics, including opioids, are commonly used for acute pain control in traumatic hip fracture patients in the emergency department (ED). However, their use is associated with high rates of adverse reactions in the geriatric population. As such, the aim of this study was to investigate the impact of lidocaine-based single-shot ultrasound-guided femoral nerve block (USFNB) on the standard care for acute pain management in geriatric patients with traumatic hip fracture in the ED. Methods: This retrospective, single-center, observational study included adult patients aged ≥60 years presenting with acute traumatic hip fracture in the ED between 1 January 2017 and 31 December 2020. The primary outcome measure was the difference in the amount of opioid use, in terms of morphine milligram equivalents (MME), between lidocaine-based single-shot USFNB and standard care groups. The obtained data were evaluated through a time-to-event analysis (time to meaningful pain relief), a time course analysis, and a multivariable analysis. Results: Overall, 607 adult patients (USFNB group, 66; standard care group, 541) were included in the study. The patients in the USFNB group required 80% less MME than those in the standard care group (0.52 ± 1.47 vs. 2.57 ± 2.53, p < 0.001). The multivariable Cox proportional hazards regression models showed that patients who received USFNB achieved meaningful pain relief 2.37-fold faster (hazard ratio (HR) = 2.37, 95% confidence intervals (CI) = 1.73−3.24, p < 0.001). Conclusions: In geriatric patients with hip fractures, a lidocaine-based single-shot USFNB can significantly reduce opioid consumption and provide more rapid and effective pain reduction.

Prevalence of opioid prescriptions in Taiwan (2008-2018)

BACKGROUND

Opioids are effective for severe pain; however, the safety issue is also a primary concern. To better understand the opioid use in Taiwan, we conducted this study.

METHODS

Data on patients with opioid prescriptions, including morphine, fentanyl, pethidine, codeine, oxycodone, hydromorphone, and buprenorphine were collected using the Taiwan National Health Insurance Database (NHID).

RESULTS

Our analysis of opioid prescriptions from 2008 to 2018 in Taiwan indicated that (1) A slow increase in prevalence of opioid prescription was found during the study period. Among the drugs studied, morphine accounted for the majority of the prescriptions written, with a gradual increase annually. Pethidine prescriptions showed a significant and rapid decline over the years; (2) medical centers prescribed the largest number of opioids, followed by regional hospitals, local hospitals, and clinics; (3) the number of prescriptions per year per capita in cancer group was much higher than that in noncancer group. In noncancer group, most of the prescriptions were used in acute pain service (98.7%); and (4) use of opioids increased with age in both cancer and noncancer patients.

CONCLUSION

The total number of opioid prescriptions in Taiwan gradually increased annually, among which morphine was the most commonly used opioid. Cancer patients consumed more opioid prescriptions than noncancer patients and most of the prescriptions in noncancer patients were used in acute pain service. The number of prescriptions increased with the age of the patients in both cancer and noncancer patients. The low prescription rate of opioids in chronic pain in Taiwan is not similar as those in high opioid-consuming countries, such as United States.

Global, regional, and national trends in opioid analgesic consumption from 2015 to 2019: a longitudinal study

BACKGROUND

Previous studies have reported an extremely unbalanced global access to opioid analgesics. We aimed to determine contemporary trends and patterns of opioid analgesic consumption at the global, regional, and national levels.

METHODS

We analysed the global pharmaceutical sales data of 66 countries or regions from the IQVIA-Multinational Integrated Data Analysis System database on opioid analgesics between 2015 and 2019. Opioid analgesic consumption was measured in milligram morphine equivalent per 1000 inhabitants per day (MME per 1000/day). The global, regional, and national trend changes were estimated using linear regressions. Factors associated with consumption patterns and trend changes were explored in multivariable linear regression analyses.

FINDINGS

Overall opioid analgesic sales in the 66 countries or regions increased from 27·52 MME per 1000/day (16·63-45·54) in 2015 to 29·51 MME per 1000/day (17·85-48·79) in 2019 (difference per year 3·96%, 95% CI 0·26 to 7·80). Sales reduced yearly in North America (-12·84%; 95% CI -15·34 to -10·27) and Oceania (-2·96%; -4·20 to -1·70); increased in South America (28·69%; 7·18 to 54·53), eastern Europe (7·68%; 3·99 to 11·49), Asia (5·74%; 0·61 to 11·14), and western and central Europe (1·64%; 0·52 to 2·78); and did not differ in Africa or central America and the Caribbean. The global opioid consumption patterns were associated with country-level Human Development Index (p=0·040), cancer death rate excluding leukaemia (p=0·0072), and geographical location (p<0·0001). In 2019, opioid analgesic consumption ranged from 0·01 MME per 1000/day to 5·40 MME per 1000/day in the 17 countries and regions in the lowest consumption quartile, despite high income levels and cancer death rates in some of them.

INTERPRETATION

Global opioid analgesic consumption increased from 2015 to 2019. The trend changes were distinctive across regions, which could reflect the different actions in response to known issues of opioid use and misuse. Disparities in opioid analgesic consumption remained, indicating potential inadequate access to essential pain relief in countries with low consumption.

FUNDING

None.

Opioid Use at End-Of-Life Among Nova Scotia Patients With Cancer

Purpose: To determine the factors associated with opioid analgesic prescriptions as measured by community pharmacy dispensations to all Nova Scotia (NS) patients with cancer at end-of-life from 2005 to 2009.

Methods: The NS Cancer Registry and the NS Prescription Monitoring Program (NSPMP) were used to link Nova Scotians who had a cancer diagnosis and received a prescription for opioids in their last year of life (n = 6,186) from 2005 to 2009. The association of factors with opioid dispensations at end-of-life were determined (e.g., patient demographics, type of prescriber, type of cancer, and opioid type, formulation, and dose).

Results: Almost 54% (n = 6,186) of the end-of-life study population with cancer (n = 11,498) was linked to the NSPMP and therefore dispensed opioids. Most prescriptions were written by general practitioners (89%) and were for strong opioids (81%). Immediate-release formulations were more common than modified-release formulations. Although the annual average parenteral morphine equivalents (MEQ) did not change during the study period, the number of opioid prescriptions per patient per year increased from 5.9 in 2006 to 7.0 in 2009 (p < 0.0001). Patients age 80 and over received the fewest prescriptions (mean 3.9/year) and the lowest opioid doses (17.0 MEQ) while patients aged 40–49 received the most prescriptions (mean 14.5/year) and the highest doses of opioid (80.2 MEQ).

Conclusion: Our study examined opioid analgesic use at end-of-life in patients with cancer for a large real-world population and determined factors, trends and patterns associated with type and dose of opioid dispensed. We provide information regarding how general practitioners prescribe opioid therapy to patients at end-of-life. Our data suggest that at the time of this study, there may have been under-prescribing of opioids to patients with cancer at end-of-life. This information can be used to increase awareness among general practitioners, and to inform recommendations from professional regulatory bodies, to aid in managing pain for cancer patients at end-of-life. Future work could address how opioid prescribing has changed over time, and whether efforts to reduce opioid prescribing in response to the opioid crisis have affected patients with cancer at end-of-life in Nova Scotia.

Analgesic use and associated adverse events in patients with chronic kidney disease: a systematic review and meta-analysis

BACKGROUND

Treating pain in the context of chronic kidney disease (CKD) is challenging because of altered pharmacokinetics and pharmacodynamics, with an increased risk of toxicity and drug adverse events in this population. The aims of this systematic review and meta-analysis were to assess the prevalence of analgesic use and establish the risk of analgesics-related adverse events, in patients with CKD.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Medline, Embase, CINAHL, and CENTRAL were searched until January 2021. Random-effects meta-analyses and meta-regression were conducted to pool and summarise prevalence data and measures of association between analgesic use and adverse events.

RESULTS

Sixty-two studies relevant to the prevalence of analgesic use and 33 to analgesic-related adverse events were included, combining data on 2.3 and 3 million individuals, respectively. Pooled analyses found that 41% (95% confidence interval [CI], 35-48) of the CKD population regularly use analgesia. The annual period prevalence was estimated at 50% for opioids and 21% for nonsteroidal anti-inflammatory drugs (NSAID). Overall, 20% and 7% of patients with CKD are on chronic opioid or NSAID therapy, respectively. Opioid use was associated with an increased risk of death (1.61; 95% CI, 1.12-2.31; n= 7, I²= 91%), hospitalisation (1.38; 95% CI, 1.32-1.45; n=2, I²=0%), and fractures (1.51; 95% CI, 1.16-1.96; n=3, I²=54%).

CONCLUSION

High levels of analgesic consumption and related serious adverse outcomes were found in patients with CKD. Consideration needs to be given to how these patients are assessed and managed in order to minimise harms and improve outcomes.

CLINICAL TRIAL REGISTRATION

CRD42019156491 (PROSPERO).

Population-Based Study on the All-Cause and Cause-Specific Risks of Mortality among Long-Term Opioid Analgesics Users without Cancer in Taiwan

(1) Background: The prevalence of opioid use in Taiwan increased by 41% between 2002 and 2014. However, little is known regarding the risk of mortality among long-term opioid analgesics users who do not have cancer. This study investigated this mortality risk with an emphasis on the calendar year and patients’ age and sex. (2) Methods: This retrospective cohort study included 12,990 adult individuals without cancer who were long-term users of opioid analgesics and were randomly selected from the data set of Taiwan’s National Health Insurance program from 2000 to 2012. They were then followed up through 2013. Information on the underlying causes of death was retrieved from the Taiwan Death Registry. Age, sex, and calendar year-standardized mortality ratios (SMRs) of all-cause and cause-specific mortality were calculated with reference to those of the general population. (3) Results: With up to 14 years of follow-up, 558 individuals had all-cause mortality in 48,020 person-years (cumulative mortality: 4.3%, mortality rate: 11.62 per 1000 person-years). Compared with the general population, the all-cause SMR of 4.30 (95% confidence interval (95% CI): 3.95–4.66) was significantly higher: it was higher in men than in women, declined with calendar year and age, and was significantly higher for both natural (4.15, 95% CI: 3.78–4.53) and unnatural (5.04, 95% CI: 3.88–6.45) causes. (4) Conclusions: Long-term opioid analgesics use among individuals without cancer in Taiwan was associated with a significantly increased risk of mortality. The notably increased mortality in younger adults warrants attention. Strategies to reduce long-term opioid analgesics use, especially their overuse or misuse, are in an urgent need.

Gender Differences in Depression and Sex Hormones among Patients Receiving Long-Term Opioid Treatment for Chronic Noncancer Pain in Taiwan-A Multicenter Cross-Sectional Study

Background: Long-term use of opioids for chronic noncancer pain is associated with sex hormone disturbances. The interferences with sex hormones, sexual function, and depression were investigated in patients with chronic noncancer pain. Methods: A cross-sectional multicenter survey was conducted on 170 officially registered outpatients receiving long-term opioid treatment in nine medical centers in Taiwan between October 2018 and July 2019. Serum sex hormone levels were examined after the collection of self-administered questionnaires containing the Taiwanese version of the Brief Pain Inventory, depressive status, and sexual function interference. Results: Among 117 (68.8%) questionnaire responses from 170 enrolled outpatients, 38 women and 62 men completed the sex hormone tests, among whom only 23 (23%) had previously received blood hormone tests. Low serum total testosterone levels were detected in 34 (89.5%) women (<30 ng/dL) and 31 (50%) men (<300 ng/dL). Over 60% of women and men reported reduced sexual desire and function despite a nearly 50% reduction in pain intensity and daily function interference over the previous week after opioid treatment. Women generally had higher risks of a depression diagnosis (p = 0.034) and severe depressive symptoms (p = 0.003) and nonsignificantly lower opioid treatment duration (median 81 vs. 120 months) and morphine milligram equivalent (median 134 vs. 165 mg/day) compared with men. Conclusions: This survey demonstrated the high prevalence of depression diagnosis, low sex hormone levels, and reduced sexual function among Taiwanese patients with chronic noncancer pain receiving prolonged opioid therapy. Regular hypogonadal screenings are recommended for further management.

Clinical Consumption of Compound Opioid Analgesics in China: A Retrospective Analysis of National Data 2015-2018

Compound opioid analgesics (COA) are widely used for cancer pain relief, but few studies investigated the use of that. We aimed to report the characteristics and trend of COA consumption in different regions and health facilities in China. The procurement data of two types of COA, compound codeine phosphate (CCP) and oxycodone and acetaminophen (OAA), in all medical institutions of 20 provinces from 2015 to 2018 were used. Data were presented as defined daily dose for statistical purpose (SDDD) and expenditures per million inhabitants per day. The annual consumption of COA and ratio of two combinations were compared among regions and institutions. We found, during 2015-2018, COA consumption increased at an average rate of 7.32% in SDDD and 19.19% in expenditures, while OAA accounted for most of the consumption. Highest COA consumption appeared in Northern China, with 121.72 SDDD and 1689.87 RMB (2015), whereas the lowest COA consumption was only 11.28 SDDD appearing in Southern China. The ratio of OAA and CCP (in SDDD) was highest in Southern China (53.14 in 2018), whereas lowest in West North (0.37 in 2018). In terms of institutions, tertiary had the highest COA consumption, with 16.74 SDDD and 292.73 RMB (2018). The SDDD of OAA was 27.44 times of that of CCP in tertiary, while it was only 0.11 in primary. Overall, COA consumption is on an upward trend and different among regions and health institutions in either amount or types of COA. These findings call for establishment of COA management regulations.

Knowledge, attitude, and barriers regarding prescribing long-term opioids among Taiwan physicians treating officially registered patients with chronic noncancer pain

BACKGROUND

Prescribing opioids for patients with chronic noncancer pain (CNCP) remains controversial. This study surveyed Taiwanese physicians who were clinically treating CNCP outpatients with long-term opioids.

METHODS

Anonymous questionnaires investigating the clinical practices, opioid knowledge, attitude, and barriers regarding the prescription of long-term opioids were delivered to 66 physicians treating CNCP outpatients who were officially registered and monitored by the Taiwan Food and Drug Administration in 2011.

RESULTS

All 66 (100%) physicians responded to the survey, comprising 41 (62%) board-certified pain specialists and 25 (38%) nonpain board-certified physicians. Pain specialists treated a greater number of CNCP outpatients and attended more CNCP training courses than nonpain board-certified physicians (97.6% vs. 56.0%, p < 0.001). Most of pain specialists stated that they were familiar with the Taiwan's narcotic regulations for CNCP patients (92.7% vs. 68.0%, p = 0.015). In addition, pain specialists were less likely to skip or reduce the dosage and duration of opioid prescriptions (22.0% vs. 36.0%, p < 0.001). By contrast, nonpain board-certified physicians had significantly less knowledge and a more negative attitude toward opioid prescription. The major perceived barriers were physician's reluctance to prescribe opioids (78% vs. 92%) and an inadequate knowledge of pain management (73% vs. 84%) among all physicians.

CONCLUSION

Among the Taiwanese physicians treating the officially registered CNCP patients, nonpain board-certified physicians had fewer patients, less knowledge, and an increased negative attitude toward long-term opioid prescriptions. Better education on chronic pain management is needed for improvement of clinical practice.

Frailty modifies the association between opioid use and mortality in chronic kidney disease patients with diabetes: a population-based cohort study

The prevalence of chronic pain in patients with chronic kidney disease (CKD) and diabetes mellitus is high and correlates with higher frailty risk, but satisfactory pain control frequently fails, necessitating opioid initiation. We aimed to examine whether opioid use affected their outcomes and whether such a relationship was modified by frailty. From the longitudinal cohort of diabetes patients (n = 840,000), we identified opioid users with CKD (n = 26,029) and propensity score-matched them to opioid-naïve patients in a 1:1 ratio. We analyzed the associations between opioid use and long-term mortality according to baseline frailty status, defined by the modified FRAIL scale. Among all, 20.3% did not have any FRAIL items, while 57.2%, 20.6%, and 1.9% had 1, 2, and at least 3 positive FRAIL items, respectively. After 4.2 years, 16.4% died. Cox proportional hazard regression showed that opioid users exhibited an 18% higher mortality risk (HR 1.183, 95% CI 1.13-1.24) with a dose- and duration-responsive relationship, compared to opioid-naive ones. Furthermore, the mortality risk posed by opioids was observed only in CKD patients without frailty but not in those with frailty. In conclusion, opioid use increased mortality among patients with CKD, while this negative outcome influence was not observed among frail ones.

Patterns of opioid use in older people diagnosed with cancer in New South Wales, Australia

PURPOSE

Opioids provide effective analgesia for most cancer patients, but little is known about individual-level opioid use after cancer diagnosis. We examined the patterns of and factors associated with opioid use in older people diagnosed with cancer.

METHODS

We used the Department of Veterans' Affairs (DVA) client data linked with the New South Wales (NSW) Cancer Registry and the Repatriation Pharmaceutical Benefits Scheme data. We included people aged ≥65 years diagnosed with cancer in NSW, Australia in 2005 to 2015. We examined patterns of opioid use in the 12 months after cancer diagnosis and used cause-specific hazards models to examine factors associated with opioid use.

RESULTS

Of 13 527 people diagnosed with cancer, 51% were dispensed opioids after their diagnosis. We observed the highest proportions of use in people diagnosed with pancreas, liver, or lung cancers. Opioid use was associated with female sex, younger age, more advanced degree of cancer spread, opioid use before cancer diagnosis, and multimorbidity. Forty-four percentages of all people dispensed opioids had a history of opioid use in the 12 months before their cancer diagnosis; these people had higher median number of different opioids and opioid dispensings, and a shorter time to first opioid dispensing than opioid-naive people.

CONCLUSION

Our study suggests that many older cancer patients were dispensed opioids before their cancer diagnosis. Previously opioid-treated people had more intense opioid use patterns after diagnosis than opioid-naïve people. Acknowledging the history of opioid use is important as it may complicate pain treatment in clinical practice.

Knowledge, Attitude and Practice Survey of Prescribing Opioids for Chronic Noncancer Pain in Taiwan-Comparison of Pain and Non-Pain Physicians

BACKGROUND

Prescribing opioids for chronic noncancer pain (CNCP) has been strictly regulated in Taiwan. This study was undertaken to survey pain and non-pain related physicians' knowledge, attitudes, and practices regarding prescribing opioids for CNCP.

METHODS

A questionnaire survey was conducted in this comparison study. All 66 physicians who were treating officially registered CNCP outpatients were visited and completed anonymous questionnaires. The other physicians (anesthesiologists, oncologists, and non-pain physicians) were surveyed by a mailed questionnaire.

RESULTS

A total of 266 (75%) questionnaires were received from 355 board-certified physicians. More CNCP physicians (81.8%) and anesthesiologists (69.7%) had received prior CNCP-related training courses than had oncologists (21.2%) and non-pain physicians (10.3%). Varied proportions of physicians by type were unfamiliar with the Taiwan opioid regulations (16.7-86.8%) and would accordingly skip or reduce dosage of opioid prescriptions (27.3-73.5%). In addition, non-pain physicians had a significantly lower knowledge level, more negative attitudes, and greater hesitation about prescribing opioids compared to the pain-related physicians (P < 0.001). CNCP physicians who had received CNCP-related training courses had a higher knowledge score than did those not receiving training (P = 0.002). Overall, the leading barriers for prescribing opioids were inadequate knowledge of pain management (76%), physician reluctance (73%), and family reluctance (78%).

CONCLUSION

There are substantial knowledge gaps, negative attitudes, and hesitation toward prescribing long-term opioids for CNCP patients by physicians in Taiwan, suggesting that efforts are needed to improve postgraduate education regarding adequate opioid management for CNCP.

Nonmedical prescription drug use of analgesics and sedatives/hypnotics in Taiwan: Results from the 2014 National Survey of Substance Use

Nonmedical prescription drug use (NMPDU) has become a major public health issue but little is known in Asian populations. This study aimed to investigate the prevalence and correlates of NMPDU in Taiwan. Participants from the 2014 national survey of 17,837 individuals, aged 12 to 64 year, completed anonymously a computer-assisted self-interview. Past-year prescription drug use was divided into medical use only (MUO) and nonmedical use (NMU), defined as using the drug without a prescription, or more frequently, or in larger doses than prescribed. Problematic alcohol use was measured using the Alcohol Use Disorders Identification Test (AUDIT), problematic drug use using the 20-item Drug Abuse Screening Test (DAST), and depressive symptoms using the Center for Epidemiological Study-Depression (CES-D). The prevalence of past-year NMU was 3.02% for analgesics, 0.71% for sedatives/hypnotics, and 3.66% for either drug, with a very small overlap of NMU between analgesics and sedatives/hypnotics (0.07%). When individuals with NMU were compared to those without NMU (Non-NMU) and those with MUO, respectively, some correlates consistently identified, including young adulthood, tobacco smoking, alcohol drinking, and greater AUDIT's scores for analgesics, as well as hard drug use and greater DAST's scores for sedatives/hypnotics. NMU was associated with greater CES-D's scores for both analgesics and sedatives/hypnotics when compared to Non-NMU but not to MUO. Robust correlates of NMPDU could offer implications for development of prevention strategies of NMPDU.

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A 3.66% of Taiwanese aged 12 to 64 had past-year nonmedical prescription drug use.

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Nonmedical use of analgesics correlated with tobacco use and problematic alcohol use.

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Nonmedical use of sedatives/hypnotics correlated with problematic drug use.

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The correlates of nonmedical drug use offer useful clues for prevention strategies.

Consumption trends and prescription patterns of opioids from 2011 to 2016: a survey in a Chinese city

OBJECTIVE

Opioid consumption in China has been very less and has varied widely since 1995. The representatively high level of consumption in Mainland China has never been reported. Our aim was to describe the consumption trends and prescription patterns of opioids in Nanjing, a highly developed city of Mainland China, and compare the results with selected worldwide regions.

METHODS

Application data of opioids in 2011-2016 were extracted from the Jiangsu Medicine Information Institute. Six opioids were included. Consumption was expressed in terms of defined daily doses (DDDs), morphine equivalents (MEs) and expenditure. The correlation between consumption of opioids and gross domestic product (GDP), Human Development Index (HDI) and cancer incidence was analysed by Pearson's correlation test.

RESULTS

DDDs, expenditure and MEs of opioids were, respectively, 256.04, $599.24 and 13.07 g in 2011, and increased to 361.27, $1041.79 and 18.09 g in 2016. DDDs in Nanjing were 2.80-fold that in Mainland China, 1.42-fold that in East and South-East Asia, but only equivalent to 8.89% of the worldwide average level. From 2011 to 2016, the consumption had a linear correlation with GDP, HDI and cancer incidence (p<0.05). However, DDDs varied greatly in countries with similar GDP or HDI. Within 45 Asian countries, the GDP only contributed to 10.47% of change in DDDs, while the HDI contributed to 20.32%. Consumption of non-intravenous opioids or strong opioids always comprised majority of the total consumption. The opioids prescribed predominantly were fentanyl, oxycodone and morphine. Fentanyl and oxycodone account for most of the increase in consumption.

CONCLUSION

Opioid consumption has increased >40% from 2011 to 2016, with consumption of fentanyl and oxycodone accounting for most of that increase. The consumption in Nanjing was higher than the average Chinese level, but lower than the global average. An increase in pain control services might be needed, but this need should be highly regulated.

Gender difference in long-term use of opioids among Taiwan officially registered patients with chronic noncancer pain

Research regarding sex or gender difference in chronic pain proliferated in this decade. This study was to analyze gender difference in Taiwan patients receiving long-term opioids for chronic noncancer pain.An observational cross-sectional survey was conducted among the registered outpatients by the Taiwan Food and Drug Administration. Participants completed a self-report questionnaire, including the Taiwanese version of Brief Pain Inventory and enquiry regarding sexual activities, depressive symptoms, and misuse behaviors.In total, 68 female and 142 male patients were analyzed. Both pain intensity and daily function interference reduced comparably (around 50%) between women and men after taking opioids in the past 1 week. The opioid-related adverse effects, including constipation, decreased sexual desire and satisfaction, and misuse behaviors were not significantly different. Women were exceedingly diagnosed with depression (67.7% vs 49.3%, P = .012) and had a higher mean depressive symptom score in the past 1 month, especially among those age <40 years (23.3 vs 11.9, P = .009), as compared with men. In addition, women had a lower mean self-rated health score (37.9 vs 44.3, P = .047). The mean morphine equivalent dose was significantly lower in women (131.6 vs 198.2 mg/day, P = .008), which was not correlated with their depressive scores.Gender differences in the effectiveness and adverse effects of long-term opioids were not found among Taiwan registered outpatients with chronic noncancer pain. However, more female patients inclined to have a coexisting depression diagnosis, depressive symptoms, and a lower perceived health score, needing regular screening and closer monitoring.

Medication appropriateness for patients with dementia approaching the end of their life

AIM

To examine medication use among patients with dementia towards the end of their life and to evaluate the appropriateness of medication use by using a nationwide database.

METHODS

Using Taiwan's National Health Insurance Research Database, we identified 6532 people with dementia that died between 2008 and 2012. For each person with dementia, data of medication use in the last month of outpatient setting (vs -12th month [baseline]) and last hospitalization (vs -3rd hospitalization [baseline]) before death were retrieved for study. The medications of interest were selected according to a consensus recommendation, which included five categories defining their appropriateness (i.e. always, sometimes, rarely and never appropriate, as well as no consensus). Multivariable logistic regression was carried out to analyze the determinants for use of "never appropriate" medications.

RESULTS

Approximately 10% of the study participants were prescribed medications categorized as "never appropriate" in the last month of life in the outpatient settings, which was significantly lower than their baseline (-12th month: 17.5%; P < 0.0001). A similar pattern was identified in the last hospitalization before death. Older age was associated with a lower likelihood of being prescribed "never appropriate" medications (age 75-84: aOR 0.34 [0.29-0.41], P < 0.0001; age ≥85: aOR 0.34 [0.28-0.40], P < 0.0001). In contrast, patients with a history of diabetes mellitus (aOR 1.31 [1.10-1.55], P = 0.0018) were associated with a higher likelihood of being prescribed "never appropriate" medications.

CONCLUSIONS

This is the first study to sophisticatedly describe medications use, particularly according to their appropriateness for palliative care, in Asian people with dementia at the end of their life. Approximately 10% of all patients were prescribed "never appropriate" medications at the end of their life, which deserves further study to evaluate the clinical impact of the quality of care. Geriatr Gerontol Int 2017: 17 (Suppl. 1): 65-74..

Consumption trend and prescription pattern of opioid analgesics in China from 2006 to 2015

Objectives

To investigate the consumption trend and prescription pattern of opioids in China from 2006 to 2015, and compare the results with those of selected countries and regions, and identify the pain relief level of China.

Methods

Nine different opioid drugs were included in our survey, based on the whole population of China. Consumption of each type of opioid was calculated in grams in reports of the Chinese Food and Drug Administration and the International Narcotics Control Board. Then it was converted to the terms of defined daily doses and morphine equivalents. The correlation between consumption of opioids and gross domestic product, human development index and cancer incidence was analysed by Pearson's correlation test.

Results

Defined daily doses increased by 7.89% per year since 2006, and reached 91.05 in 2015. Morphine equivalents increased by 10.57% per year since 2006, and reached 7.24 g in 2015. The average defined daily doses and morphine equivalents were 85.44 and 5.70 g respectively in 2006-2015. Annual defined daily doses of China were lower than the global average. Consumption was related to gross domestic product, but not human development index and cancer incidence. Furthermore, defined daily doses varied greatly in countries with similar gross domestic product or the human development index. Strong opioids or non-intravenous opioids always constituted the majority of opioids, and sustained an increasing tendency in consumption. The predominantly prescribed opioids were fentanyl and morphine. Consumption of oxycodone had a tendency to increase, whereas pethidine tended to decrease.

Conclusion

Consumption of opioids has shown an increasing tendency and in the meantime the prescription pattern has changed, indicating the progress of pain relief in China, though it remained far lower than the average global level.

Potentially high-risk medication categories and unplanned hospitalizations: a case-time-control study

Empirical data of medication-related hospitalization are very limited. We aimed to investigate the associations between 12 high risk medication categories (diabetic agents, diuretics, nonsteroidal anti-inflammatory drugs (NSAIDs), anticoagulants, antiplatelets, antihypertensives, antiarrhythmics, anticonvulsants, antipsychotics, antidepressants, benzodiazepine (BZD)/Z-hypnotics, and narcotics) and unplanned hospitalizations. A population-based case–time–control study was performed using Taiwan’s National Health Insurance Research Database. Patients who experienced an unplanned hospitalization (index visit) were identified as index subjects and matched to a randomly selected reference visit within users of a specific category of high-risk medication. An unplanned hospitalization was defined as a hospital admission immediately after an emergency department visit. Discordant exposures to the high-risk medication during the case period (1–14 days before the visit) and the control period (366–379 days before the visit) were examined in both index and reference visits. Antipsychotics was associated with the highest risk of unplanned hospitalizations (adjusted OR: 1.54, 95% CI [1.37–1.73]), followed by NSAIDs (1.50, [1.44–1.56]), anticonvulsants (1.34, [1.10–1.64]), diuretics (1.24, [1.15–1.33]), BZD/Z-hypnotics (1.23, [1.16–1.31]), antidepressants (1.17, [1.05–1.31]) and antiplatelets (1.16, [1.07–1.26]). NSAIDs and narcotics were associated with the highest risks of unplanned hospitalizations with a length of stay ≥10 days. These medication categories should be targeted for clinical and policy interventions.

End-of-life care for head and neck cancer patients: a population-based study

PURPOSE

Head and neck cancers (HNCs) usually present a poor prognosis and cause high morbidity rates. Recent surveys have demonstrated that HNC incidence rates are still on the increase in many countries. Our study objective was to assess the end-of-life care for patients with HNCs in Taiwan.

METHODS

Data was retrieved from Taiwan's National Health Insurance Research Database, where we identified patients who had been diagnosed with HNCs from January 1997 to December 2010. Each patient's annual trend of opioid use and hospice care needs, along with the distribution of place of death in the study cohort, were all analyzed.

RESULTS

A total of 98,211 HNC patients diagnosed between 1997 and 2010 were eligible for this study. The majority of HNC patients died in hospital. Patients who were male, lived in capital area, had a higher income, had received palliative hospice care, and had been prescribed opioids tended to choose to die at home or in hospice wards. Both opioid prescription and hospice care have increased during the past 10 years; however, the rate of palliative hospice care remained below 50%.

CONCLUSIONS

Our results demonstrate that greater efforts are needed to implement palliative care for HNC patients in Taiwan.

Trends in major opioid analgesic consumption in Taiwan, 2002-2014

BACKGROUND/PURPOSE

According to WHO guideline, the consumption of opioids is an important sign of national progress in cancer pain relief. However, precise data on the consumption of opioid analgesics consumption in Taiwan has not been published. We investigate opioid analgesic consumption in Taiwan between 2002 and 2014 compare the results with those in other countries to see what we could learn about other methods of pain management. To find out the different patterns between Taiwan and other country, improves the quality of pain management.

METHODS

We extracted from the Controlled Drugs Management Information System (CDMIS) database, the consumption data of morphine, fentanyl, and pethidine, three strong opioids, and of codeine and buprenorphine, two weak ones. Data were presented as defined daily doses for statistical purposes per million inhabitants per day (S-DDD/m/d). The number of inhabitants was extracted from the Taiwan Ministry of Interior Statistics population database.

RESULTS

During the thirteen studied years, the total consumption of opioids markedly increased in Taiwan. By category, the consumption of morphine, fentanyl and buprenorphine increased, but the use of pethidine and codeine decreased. Compared with the selected regions and countries, the use of opioid in Taiwan progressed in Asia, but it was still lower than in Western countries.

CONCLUSION

Opioid analgesics are probable addictive; however, they can improve a patients' quality of life if properly used. The Taiwan FDA continuously introduces new opioid analgesics and educates physicians on how to use them correctly. These measures will improve the quality of pain management in Taiwan.

The impact of pain control on physical and psychiatric functions of cancer patients: a nation-wide survey in Taiwan

OBJECTIVE

To investigate the prevalence of pain in cancer patients at different disease statuses, the impact of pain on physical and psychiatric functions of patients and the satisfaction of pain control of patients at outpatient clinic department in Taiwan.

METHODS

Short form of the Brief Pain Inventory was used as the outcome questionnaire. Unselected patients of different cancers and different disease statuses at outpatient clinic department were included. The impacts of their current pain control on physical function, psychiatric function and the satisfaction of doctors were evaluated. Logistic regression analyses were performed to evaluate whether the interference scale performed identically in the different analgesic ladders. The dependent variables were satisfaction toward physician and treatment.

RESULTS

A total of 14 sites enrolled 2075 patients in the study. One thousand and fifty-one patients reported pain within the last 1 week. In patients whose diseases deteriorated, >60% of them need analgesics for pain control. Pain influenced physical and psychiatric functions of patients, especially in the deteriorated status. More than 80% of patients were satisfied about current pain control, satisfaction rate related to disease status, pain intensities and treatments for pain.

CONCLUSION

Our study found that different cancers at different statuses had pain at variable severity. Pain can influence physical and psychological functions significantly. More than 75% of subjects reported satisfaction over physician and pain management in outpatient clinic department patients with cancer pain in Taiwan.

Pain management experience at a central Taiwan medical center

Pain management is typically more developed in western countries compared to Asia. From the accreditation standard of the Joint Commission International (JCI), there is a broad scope for pain management. In 2008, our medical center established the pain management policy, and the goal is to be a pain-free medical facility. The Framework of Pain Management Policy including: 1. the rights of patients and family members 2. Employee education 3. Assessment of pain (screening, evaluating, monitoring) 4. Patient care of pain. After implementation of pain management program, the compliance of pain assessment, the analysis of pain score before and after pain management and the analysis of Pain Management Index (PMI), all showed improvement in pain management program. The consumption of opioids usage steadily increased from 2010 to 2014. The success of our pain management program implementation could be attributed to the clear pain management policy, the firm support of higher leadership, the cooperation of IT department, and the quality control.

Morphine or oxycodone for cancer-related pain? A randomized, open-label, controlled trial

CONTEXT

There is wide interindividual variation in response to morphine for cancer-related pain; 30% of patients do not have a good therapeutic outcome. Alternative opioids such as oxycodone are increasingly being used, and opioid switching has become common clinical practice.

OBJECTIVES

To compare clinical response to oral morphine vs. oral oxycodone when used as first-line or second-line (after switching) treatment in patients with cancer-related pain.

METHODS

In this prospective, open-label, randomized, controlled trial (ISRCTN65155201) with a selected crossover phase, patients with cancer-related pain were randomized to receive either oral morphine or oxycodone as first-line treatment. Dose was individually titrated until the patient reported adequate pain control. Patients who did not respond to the first-line opioid (either because of inadequate analgesia or unacceptable adverse effects) were switched to the alternative opioid.

RESULTS

Two hundred patients were recruited. On intention-to-treat analysis (n = 198, morphine 98, oxycodone 100), there was no significant difference between the numbers of patients responding to morphine (61/98 = 62%) or oxycodone (67/100 = 67%) when used as a first-line opioid. Similarly, there was no significant difference in subsequent response when patients were switched to either morphine (8/12 = 67%) or oxycodone (11/21 = 52%). Per-protocol analysis demonstrated a 95% response rate when both opioids were available. There was no difference in adverse reaction scores between morphine and oxycodone either in first-line responders or nonresponders.

CONCLUSION

In this population, there was no difference between analgesic response or adverse reactions to oral morphine and oxycodone when used as a first- or second-line opioid. These data provide evidence to support opioid switching to improve outcomes.

Endogenous opiates and behavior: 2013

This paper is the thirty-sixth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2013 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia; stress and social status; tolerance and dependence; learning and memory; eating and drinking; alcohol and drugs of abuse; sexual activity and hormones, pregnancy, development and endocrinology; mental illness and mood; seizures and neurologic disorders; electrical-related activity and neurophysiology; general activity and locomotion; gastrointestinal, renal and hepatic functions; cardiovascular responses; respiration and thermoregulation; and immunological responses.