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Anil N, Smallwood N, Dunn S. Opioids and driving: education gaps in advanced cancer. BMJ Support Palliat Care 2023; 13:315-317. [PMID: 33722812 DOI: 10.1136/bmjspcare-2020-002824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 02/23/2021] [Accepted: 02/24/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Opioids may impair the ability to drive safely, particularly when first prescribed or with dose titration. We investigated whether clinicians evaluate driving status and provide opioid-related driving advice when initiating opioids among people with advanced lung cancer. METHODS A retrospective medical record review of outpatients with advanced non-small cell lung cancer seen at an Australian tertiary referral centre between 1 January 2015 and 31 December 2019 was undertaken to determine frequency of opioid prescription and documentation of driving status and education regarding driving safety while taking opioids. RESULTS Of 1022 patients screened, 205 were commenced on opioid therapy. Forty-seven (23%) patients had driving status documented. According to medical records, education about driving safety while on opioids was provided to two (1%) patients on opioid initiation. Ten (5%) patients received opioid-related driving education at least once at follow-up appointments. The content of the education was infrequently documented, and when documented, focused on opioid side effects impacting driving. Opioid doses were often escalated at follow-up appointments. CONCLUSIONS According to documentation in medical records, clinicians infrequently assessed driving status on opioid initiation and rarely provided education regarding opioid-related driving risks. Further research and clearer guidance regarding opioids and driving safety in the cancer population are required.
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Affiliation(s)
- Nagtha Anil
- The University of Melbourne Melbourne Medical School, Melbourne, Victoria, Australia
| | - Natasha Smallwood
- Department of Respiratory and Sleep Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Medicine (Royal Melbourne Hospital), University of Melbourne Faculty of Medicine, Dentistry and Health Sciences, Melbourne, Victoria, Australia
| | - Sadie Dunn
- Department of Palliative Care, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Palliative Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Ismail-Callaghan S, Howarth M, Allan R, Davey N, Meddick-Dyson SA. Driving communication forward: improving communication for palliative care patients around driving and opioids - a quality improvement report. BMJ Open Qual 2023; 12:bmjoq-2022-002138. [PMID: 36754541 PMCID: PMC9923252 DOI: 10.1136/bmjoq-2022-002138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 02/01/2023] [Indexed: 02/10/2023] Open
Abstract
INTRODUCTION The number of people requiring palliative care is increasing with an ageing comorbid population. Pain is a prevalent symptom for palliative care patients and is often managed with opioids. Opioids reduce reaction time and can cause drowsiness and visual disturbance. Evidence recommends that driving should be avoided until a stable dose of opioids has been reached. It is vital for patient and public safety that these facts are communicated to patients who are prescribed opioids, as well as the legal consequences if guidance is not followed. These discussions facilitate joint decisions, optimising patient freedom and quality of life. Surprisingly though these important discussions around driving and opioids do not always occur, and so this project sought to develop a systematic approach to integrating them into practice. DESIGN Retrospective case note analysis and prospective interventional quality improvement study. SETTING A 16 bedded specialist palliative care inpatient unit. POPULATION Hospice inpatients with an Eastern Council Oncology Group performance score of 0-3 who had been prescribed opioids. INTERVENTION Three plan-do-study-act cycles were performed. First, the issue was discussed in the daily multidisciplinary team meeting to raise awareness, second a prompt was added to a pre-existing clerking proforma. Finally, a reminder poster was placed in the ward office to promote discussion prior to discharge. OUTCOME MEASURES Primary measures were the proportion of patients with the presence of documented driving status, and the presence of a documented discussion surrounding driving and opioids. RESULTS Baseline data found that 11.5% of patients had a documented driving status and 11.5% had a documented discussion surrounding driving and opioids. Over the course of the study, the proportion improved to 65.2% and 60.9%, respectively. CONCLUSION Use of quality improvement change methods have resulted in the successful integration of new interventions to increase discussions around driving when prescribed opioids. A previously overlooked issue in this facility, thus improving clinical and patient information sharing, and patient empowerment to take charge of their own health.
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Affiliation(s)
| | - Megan Howarth
- University Hospitals Dorset NHS Foundation Trust, Poole, UK
| | - Rebecca Allan
- University Hospitals Dorset NHS Foundation Trust, Poole, UK
| | - Nicola Davey
- Quality Improvement Coaching, Quality Improvement Clinic Ltd, Shedfield, UK
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Nguyen TNM, Laetsch DC, Chen LJ, Haefeli WE, Meid AD, Brenner H, Schöttker B. Pain severity and analgesics use in the community-dwelling older population: a drug utilization study from Germany. Eur J Clin Pharmacol 2020; 76:1695-1707. [PMID: 32648116 PMCID: PMC7661425 DOI: 10.1007/s00228-020-02954-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 07/03/2020] [Indexed: 01/23/2023]
Abstract
Purpose Chronic pain is common in the older population and a significant public health concern. However, comprehensive studies on analgesics use in this age group from Germany are scarce. This study aims to give a comprehensive overview on the use of the most common therapeutic groups of analgesics in community-dwelling older adults from Germany. Methods A cross-sectional study was carried out using data from a German cohort of 2038 community-dwelling adults aged 63–89 years. Descriptive statistics and logistic regression models were applied to assess the utilization of analgesics by age, sex, pain severity, pain duration, and locations. Results One out of four study participants was suffering from high-intensity or disabling pain. Approximately half of those taking analgesics still reported to suffer from high-intensity or disabling pain. Among analgesics users, occasional non-steroidal anti-inflammatory drugs (NSAIDs) use was the most frequent pain therapy (in 43.6% of users), followed by metamizole (dipyrone) use (16.1%), regular NSAIDs use (12.9%), strong opioids use (12.7%), and weak opioids use (12.0%). In multivariate logistic regression models, higher age, higher pain severity, longer pain duration, abdominal pain, and back pain were statistically significantly associated with opioids use. Metamizole use was also statistically significantly associated with higher pain severity but inversely associated with pain duration. Conclusions A significant number of older German adults are affected by high-intensity and disabling chronic pain despite receiving analgesics. Long-term studies are needed to compare the effectiveness and safety of different treatments for chronic pain in older adults. Electronic supplementary material The online version of this article (10.1007/s00228-020-02954-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Thi Ngoc Mai Nguyen
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Network Aging Research, University of Heidelberg, Heidelberg, Germany
| | - Dana Clarissa Laetsch
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Li-Ju Chen
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Network Aging Research, University of Heidelberg, Heidelberg, Germany
| | - Walter Emil Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Network Aging Research, University of Heidelberg, Heidelberg, Germany
| | - Ben Schöttker
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.
- Network Aging Research, University of Heidelberg, Heidelberg, Germany.
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Newberry CI, McCrary HC, Cerrati EW. The Efficacy of Oral Celecoxib Following Surgical Rhinoplasty. Facial Plast Surg Aesthet Med 2020; 22:100-104. [PMID: 32069423 DOI: 10.1089/fpsam.2019.29014.new] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Importance: Exploring potential methods of controlling postoperative rhinoplasty pain with non-narcotic medications. Objective: To examine the effects of celecoxib in reducing pain and possible opioid consumption after rhinoplasty surgery. Design, Setting, and Participants: This is a prospective cohort study of 51 consecutive patients who had undergone rhinoplasty surgery between July 2018 and May 2019 by a single facial plastic surgeon. A questionnaire regarding pain medication usage and complications was given to each patient at his or her initial 1-week postoperative visit. Patients were separated into groups based on whether celecoxib had been used perioperatively or not. Main Outcomes and Measures: In addition to demographic information, the following outcome measures were recorded for each group: type(s) of pain medications used, total opioid consumption, refills required, surgical complications, and related analgesic adverse effects. Results: Of the 51 patients included, 17 patients were provided celcoxib. Mean oxycodone-acetaminophen tablets taken in the celecoxib cohort was 4.2 (CI = 2.4-6.1), whereas mean tablets taken among controls was 14.8 (CI = 11.1-18.4) (p = 0.0006). Mean oxycodone-acetaminophen dose taken in the celecoxib cohort was 17.6 mg (CI = 9.0-26.3), whereas the mean among controls was 73.8 mg (CI = 55.5-92.0) (p = 0.0001). Mean total oral morphine equivalents (OMEs) were also reduced with an average of 26.5 OME (CI = 13.5-39.4) in the celecoxib cohort and 110.7 OMEs (CI = 83.3-138.0) in the control group (p = 0.001). Postoperative nausea and vomiting were significantly reduced in the celecoxib cohort versus the control group (p = 0.02). Overall, with the addition of celecoxib, there was a 76.2% decrease in milligrams of opioid use and an 83.4% decrease in incidence of nausea/vomiting. Conclusions and Relevance: Oral celecoxib appears to be effective in decreasing opioid consumption and nausea/vomiting rates after rhinoplasty without increasing surgical complications. Level of Evidence: 2.
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Affiliation(s)
- Christopher Ian Newberry
- Department of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Hilary C McCrary
- Department of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Eric W Cerrati
- Department of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah.,Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine Salt Lake City, Utah
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Boland JW, Johnson M, Ferreira D, Berry DJ. In silico (computed) modelling of doses and dosing regimens associated with morphine levels above international legal driving limits. Palliat Med 2018; 32:1222-1232. [PMID: 29724154 PMCID: PMC6041735 DOI: 10.1177/0269216318773956] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Morphine can cause central nervous system side effects which impair driving skills. The legal blood morphine concentration limit for driving is 20 µg/L in France/Poland/Netherlands and 80 µg/L in England/Wales. There is no guidance as to the morphine dose leading to this concentration. AIM The in silico (computed) relationship of oral morphine dose and plasma concentration was modelled to provide dose estimates for a morphine plasma concentration above 20 and 80 µg/L in different patient groups. DESIGN A dose-concentration model for different genders, ages and oral morphine formulations, validated against clinical pharmacokinetic data, was generated using Simcyp®, a population-based pharmacokinetic simulator. SETTING/PARTICIPANTS Healthy Northern European population parameters were used with age, gender and renal function being varied in the different simulation groups. In total, 36,000 simulated human subjects (100 per modelled group of different ages and gender) received repeated simulated morphine dosing with modified-release or immediate-release formulations. RESULTS Older age, women, modified-release formulation and worse renal function were associated with higher plasma concentrations. Across all groups, morphine doses below 20 mg/day were unlikely to result in a morphine plasma concentration above 20 µg/L; this was 80 mg/day with the 80 µg/L limit. CONCLUSION This novel study provides predictions of the in silico (computed) dose-concentration relationship for international application. Individualised morphine prescribing decisions by clinicians must be informed by clinical judgement considering the individual patient's level of impairment and insight irrespective of the blood morphine concentration as people who have impaired driving will be breaking the law. Taking into account expected morphine concentrations enables improved individualised decision making.
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Affiliation(s)
- Jason W Boland
- 1 Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Miriam Johnson
- 1 Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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Weir N, Fischer A, Good P. Assessing the practice of palliative care doctors: what driving advice do they give patients with advanced disease? Intern Med J 2017; 47:1161-1165. [PMID: 28762600 DOI: 10.1111/imj.13571] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 07/26/2017] [Accepted: 07/26/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND There is little research and no clear guidelines for clinicians to follow when instructing patients with advanced disease about driving. AIMS To investigate current practice in providing advice to patients with advanced disease and identify areas of consensus or variation with the Australian driving guidelines. METHODS An online survey was distributed to Australian members of the Australian and New Zealand Society of Palliative Medicine. Responses were analysed using descriptive statistics. RESULTS The survey was distributed to 322 Australian and New Zealand Society of Palliative Medicine members and received 92 responses (29% response rate). Most respondents were aware of the driving guidelines (76%) and about half of the respondents had read the driving guidelines (55%). The majority of respondents had been asked to provide advice about driving to their patient or patient's caregiver (91%). Most respondents had asked a patient to stop driving (94%), but only 27% had reported a patient to the Driver Licensing Authority. Only 14% of respondents were in consensus with the guidelines in providing driving advice to a patient with asymptomatic brain metastases. Most doctors (64%) advise patients to refrain temporarily from driving post-short-acting oral morphine, with 4 h (36%) being the most common time period for not driving. CONCLUSIONS This is the first survey investigating the practice of Australian doctors in assessing fitness to drive of patients with advanced disease. The survey found wide variability in practice and substantial discordance with current driving guidelines.
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Affiliation(s)
- Nashringi Weir
- Department of Palliative Care, St Vincent's Private Hospital Brisbane, Brisbane, Queensland, Australia
| | - Amanda Fischer
- Department of Palliative Care, St Vincent's Private Hospital Brisbane, Brisbane, Queensland, Australia
| | - Phillip Good
- Department of Palliative Care, St Vincent's Private Hospital Brisbane, Brisbane, Queensland, Australia.,Mater Research Institute, University of Queensland, Brisbane, Queensland, Australia.,Department of Palliative and Supportive Care, Mater Health Services, Brisbane, Queensland, Australia
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A Survey of Hospice and Palliative Nurses Association Nurse Educators’ Teaching Practices and Attitudes Toward Driving Safety in Hospice and Palliative Care Patients. J Hosp Palliat Nurs 2017. [DOI: 10.1097/njh.0000000000000323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Nagpal A, Xu R, Pangarkar S, Dworkin I, Singh JR. Driving Under the Influence of Opioids. PM R 2016; 8:698-705. [DOI: 10.1016/j.pmrj.2016.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 05/27/2016] [Indexed: 01/26/2023]
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Moore RJ, Groninger H. Chemotherapy-Induced Peripheral Neuropathy in Pediatric Cancer Patients. Cureus 2013; 5:e124. [PMID: 25144779 PMCID: PMC4094363 DOI: 10.7759/cureus.124] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Chemotherapy-induced peripheral neuropathies (CIPNs) are an increasingly common neuropathic and pain syndrome in adult and pediatric cancer patients and survivors [1-69]. However, symptoms associated with CIPNs are often undiagnosed, under-assessed, and communications problems between clinicians, family members, and patients have been observed [70-73]. Less is known about the prevalence and impact of CIPNs on pediatric cancer populations [70-71]. This article aims to provide a brief understanding of CIPNs in pediatric populations, and to review the evidence for both its prevention and treatment.
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Affiliation(s)
- Rhonda J Moore
- FDA, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Hunter Groninger
- FDA, Clinical Center, National Institutes of Health, Bethesda, MD
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Rogers E, Mehta S, Shengelia R, Reid MC. Four Strategies for Managing Opioid-Induced Side Effects in Older Adults. CLINICAL GERIATRICS 2013; 21:http://www.consultant360.com/articles/four-strategies-managing-opioid-induced-side-effects-older-adults. [PMID: 25949094 PMCID: PMC4418642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
| | - Sonal Mehta
- Department of Medicine, Division of Geriatrics and Gerontology, Weill Cornell Medical College, New York, NY
| | - Rose Shengelia
- Department of Medicine, Division of Geriatrics and Gerontology, Weill Cornell Medical College, New York, NY
| | - Manney Carrington Reid
- Department of Medicine, Division of Geriatrics and Gerontology, Weill Cornell Medical College, New York, NY
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Teoh PJ, Camm CF. NICE Opioids in Palliative Care (Clinical Guideline 140) - A Guideline Summary. Ann Med Surg (Lond) 2012; 1:44-8. [PMID: 26257908 PMCID: PMC4523168 DOI: 10.1016/s2049-0801(12)70013-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Accepted: 07/28/2012] [Indexed: 11/24/2022] Open
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