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Lv Z, Deng C. NSAID medication mediates the causal effect of genetically predicted major depressive disorder on falls: Evidence from a Mendelian randomization study. J Affect Disord 2024; 361:217-223. [PMID: 38876314 DOI: 10.1016/j.jad.2024.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 05/27/2024] [Accepted: 06/11/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND Increasing evidence supports that depression including major depressive disorder (MDD) is associated with an increased risk of falls. However, some studies suggest no association between MDD and falls. Therefore, the specific causal relationship whereby MDD affects the risk of falls remains elusive, and the potential mediators are unclear. METHODS Summary-level data for MDD and falls were collected from the Genome-wide association studies (GWAS) in this study. Mendelian randomization (MR) and multivariable MR (MVMR) analyses were performed to evaluate the causal associations between MDD and falls. A Two-step MR analysis was employed to analyze the mediating effect of nonsteroidal anti-inflammatory drugs (NSAIDs) on the causal association between MDD and the risk of falls. RESULTS Using the inverse-variance weighted (IVW) method, genetically predicted MDD was associated with an increased risk of falls (β = 0.15, SE = 0.034; P = 1.61E-5). MVMR and two-step MR analyses demonstrated that MDD was a causal determinant of increased falls independent of body mass index (BMI), smoking initiation, and alcohol consumption and that this causal relationship was mediated by NSAID medication. LIMITATIONS Extracted GWAS summary statistics are from European ancestry. Stratified analyses by sex and age were not included in our study. Therefore, it is unclear whether the results are the same for other ethnic groups, genders, and ages. CONCLUSIONS Our results demonstrate that MDD is independently associated with an increased risk of falls, in which NSAIDs mediate the association. This study suggests that avoiding the use of NSAIDs may reduce the risk of falls in patients diagnosed with MDD.
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Affiliation(s)
- Zhengtao Lv
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China.
| | - Chunchu Deng
- Department of Rehabilitation Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China.
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Metzger CE, Grecco GG, Tak LY, Atwood BK, Allen MR. Two Weeks of Continuous Opioid Treatment in an Adenine-Induced Mouse Model of Chronic Kidney Disease Exacerbates the Bone Inflammatory State and Increases Osteoclasts. Calcif Tissue Int 2024; 115:174-184. [PMID: 38856730 PMCID: PMC11246326 DOI: 10.1007/s00223-024-01239-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/24/2024] [Indexed: 06/11/2024]
Abstract
Patients with chronic kidney disease (CKD) report high pain levels, but reduced renal clearance eliminates many analgesic options; therefore, 30-50% of CKD patients have chronic opioid prescriptions. Opioid use in CKD is associated with higher fracture rates. Opioids may directly alter bone turnover directly through effects on bone cells and indirectly via increasing inflammation. We hypothesized that continuous opioid exposure would exacerbate the high bone turnover state of CKD and be associated with elevated measures of inflammation. Male C57Bl/6J mice after 8 weeks of adenine-induced CKD (AD) and non-AD controls (CON) had 14-day osmotic pumps (0.25-µL/hr release) containing either saline or 50-mg/mL oxycodone (OXY) surgically implanted in the subscapular region. After 2 weeks, all AD mice had elevated blood urea nitrogen, parathyroid hormone, and serum markers of bone turnover compared to controls with no effect of OXY. Immunohistochemical staining of the distal femur showed increased numbers of osteocytes positive for the mu opioid and for toll-like receptor 4 (TLR4) due to OXY. Osteocyte protein expression of tumor necrosis factor-α (TNF-α) and RANKL were higher due to both AD and OXY so that AD + OXY mice had the highest values. Trabecular osteoclast-covered surfaces were also significantly higher due to both AD and OXY, resulting in AD + OXY mice having 4.5-fold higher osteoclast-covered surfaces than untreated CON. These data demonstrate that opioids are associated with a pro-inflammatory state in osteocytes which increases the pro-resorptive state of CKD.
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Affiliation(s)
- Corinne E Metzger
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, 635 Barnhill Drive, MS 5045, Indianapolis, IN, 46202, USA.
| | - Gregory G Grecco
- Department of Pharmacology & Toxicology, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Landon Y Tak
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, 635 Barnhill Drive, MS 5045, Indianapolis, IN, 46202, USA
| | - Brady K Atwood
- Department of Pharmacology & Toxicology, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
- Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Matthew R Allen
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, 635 Barnhill Drive, MS 5045, Indianapolis, IN, 46202, USA
- Roudebush Veterans Administration Medical Center, Indianapolis, IN, 46202, USA
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Howell CC, Witvoet S, Scholl L, Coppolecchia A, Bhowmik-Stoker M, Chen AF. Postoperative Complications and Readmission Rates in Robotic-Assisted Versus Manual Total Knee Arthroplasty: Large, Propensity Score-Matched Patient Cohorts. J Am Acad Orthop Surg 2024:00124635-990000000-01054. [PMID: 39029449 DOI: 10.5435/jaaos-d-23-01117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 05/22/2024] [Indexed: 07/21/2024] Open
Abstract
INTRODUCTION There is a paucity of research comparing postoperative complication rates between manual total knee arthroplasty (M-TKA) and robotic-assisted total knee arthroplasty (RA-TKA). This study aims to compare 90-day postoperative complication, readmission, and emergency department rates between RA-TKA and M-TKA. METHODS A retrospective review of a multihospital database identified patients who underwent TKA between January 2016 and May 2023. Surgeons who used the robotic-assisted surgery technique in <10% or >90% of their cases annually were excluded. This resulted in 15,999 cases (8,853 RA-TKAs; 7,146 M-TKAs) from 282 surgeons. RA-TKA and M-TKA cohorts were one-to-one matched based on patient sex, age, body mass index, hospital setting, surgeon experience, primary payer, and anesthesia type. Each cohort consisted of 7,146 patients (N = 14,292). 90-day revisits, specifically readmissions, readmissions with >23 hours of observation, and ED visit rates were compared between cohorts. Complications were classified according to the Clinical Classification Software schema and compared between cohorts. Mann-Whitney U, chi-squared, and Fisher exact tests, along with Bonferroni correction, were used to statistically compare cohorts. RESULTS All-cause 90-day readmission rates were 2.4% for RA-TKA and 2.6% for M-TKA (P = 0.36). RA-TKA had fewer revisits (RA-TKA: 7.8%; M-TKA: 8.8%, P = 0.027) and rates of readmission with >23 hours of observation (RA-TKA: 1.4%; M-TKA: 2.0%, P = 0.003). RA-TKA had fewer hospital revisits due to joint stiffness (RA-TKA: 17 revisits; M-TKA: 42 revisits, P = 0.002) and chronic pain (RA-TKA: 1 revisit; M-TKA: 8 revisits, P = 0.039). Fewer readmissions were observed for acute injuries (lower extremity muscle/tendon strains) in the RA-TKA cohort (RA-TKA: 1; M-TKA: 9, P = 0.021). RA-TKA had fewer ED visits due to hematomas (RA-TKA: 0 visits; M-TKA: 7 visits, P = 0.016). CONCLUSION In this retrospective matched cohort analysis, RA-TKA was associated with markedly fewer revisits and readmissions with >23 hours of observation compared with M-TKA. No differences in all-cause 90-day readmission were observed between cohorts. LEVEL OF EVIDENCE Level III. STUDY DESIGN Retrospective review.
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Affiliation(s)
- Cole C Howell
- From the Albany Medical College, Albany, NY (Howell), Stryker, Amsterdam, the Netherlands (Witvoet), the Stryker, Mahwah, NJ (Scholl, Coppolecchia, and Bhowmik-Stoker), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA (Chen)
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Greenberg J, Curtin A, Taylor E, Fortenberry K. Fall Risk Screening in Older Adult Patients on Chronic Opioid Therapy: A Quality Improvement Project. J Healthc Qual 2024:01445442-990000000-00077. [PMID: 38976506 DOI: 10.1097/jhq.0000000000000442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
ABSTRACT Many older adults prescribed opioid pain medications may be at increased risk of falls. As a quality improvement (QI) initiative, the University of Utah Sugar House clinic initiated a 9-month fall risk screening pilot for older adult patients on chronic opioids. This QI project sought to determine the feasibility of adding screening to a busy clinical practice, examine risk of falls in this patient cohort, and examine whether there were significant clinical and demographic differences between the patients who did or did not receive screening. We observed whether conventionally understood fall risk factors, including higher opioid doses, concurrent benzodiazepine prescription, and age, correlate with high fall risk. After the screening initiative, we determined that it was possible to significantly increase fall risk screening rates with prompts in Electronic Health Record (EHR). This cohort's fall risk screening increased from 18% to 33%. In the patients who were screened, 43% were found to be at high risk of falls. We did not see a correlation with high fall risk and patients taking higher doses of opioids or concurrent benzodiazepine prescriptions. These findings emphasize the need for consistent screening in primary care because review of the medication list alone is not a reliable predictor of fall risk.
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Chen C, Hennessy S, Brensinger CM, Miano TA, Bilker WB, Dublin S, Chung SP, Horn JR, Tiwari A, Leonard CE. Comparative Risk of Injury with Concurrent Use of Opioids and Skeletal Muscle Relaxants. Clin Pharmacol Ther 2024; 116:117-127. [PMID: 38482733 PMCID: PMC11180590 DOI: 10.1002/cpt.3248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 03/02/2024] [Indexed: 05/04/2024]
Abstract
Concurrent use of skeletal muscle relaxants (SMRs) and opioids has been linked to an increased risk of injury. However, it remains unclear whether the injury risks differ by specific SMR when combined with opioids. We conducted nine retrospective cohort studies within a US Medicaid population. Each cohort consisted exclusively of person-time exposed to both an SMR and one of the three most dispensed opioids-hydrocodone, oxycodone, and tramadol. Opioid users were further divided into three cohorts based on the initiation order of SMRs and opioids-synchronically triggered, opioid-triggered, and SMR-triggered. Within each cohort, we used Cox proportional hazard models to compare the injury rates for different SMRs compared to methocarbamol, adjusting for covariates. We identified 349,543, 139,458, and 218,967 concurrent users of SMRs with hydrocodone, oxycodone, and tramadol, respectively. In the oxycodone-SMR-triggered cohort, the adjusted hazard ratios (HRs) were 1.86 (95% CI, 1.23-2.82) for carisoprodol and 1.73 (1.09-2.73) for tizanidine. In the tramadol-synchronically triggered cohort, the adjusted HRs were 0.69 (0.49-0.97) for metaxalone and 0.62 (0.42-0.90) for tizanidine. In the tramadol-SMR-triggered cohort, the adjusted HRs were 1.51 (1.01-2.26) for baclofen and 1.48 (1.03-2.11) for cyclobenzaprine. All other HRs were statistically nonsignificant. In conclusion, the relative injury rate associated with different SMRs used concurrently with the three most dispensed opioids appears to vary depending on the specific opioid and the order of combination initiation. If confirmed by future studies, clinicians should consider the varying injury rates when prescribing SMRs to individuals using hydrocodone, oxycodone, and tramadol.
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Affiliation(s)
- Cheng Chen
- Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Sean Hennessy
- Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Leonard Davis Institute of Health Economics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Colleen M. Brensinger
- Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Todd A. Miano
- Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Warren B. Bilker
- Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Sascha Dublin
- Kaiser Permanente Washington Health Research Institute (Seattle, WA, US)
- Department of Epidemiology, School of Public Health, University of Washington (Seattle, WA, US)
| | | | - John R. Horn
- Department of Pharmacy, School of Pharmacy, University of Washington (Seattle, WA, US)
| | - Anika Tiwari
- College of Arts and Sciences, University of Pennsylvania (Philadelphia, PA, US)
| | - Charles E. Leonard
- Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Leonard Davis Institute of Health Economics, University of Pennsylvania (Philadelphia, PA, US)
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Sant AM, Portelli S, Ballard C, Bezzina-Xuereb M, Scerri C, Sultana J. Prevalence of Opioid Use in Nursing Homes Over the Last Decade: A Systematic Literature Review. J Pharm Technol 2024; 40:123-133. [PMID: 38784025 PMCID: PMC11110733 DOI: 10.1177/87551225231217903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024] Open
Abstract
Background: Despite global concerns of an opioid epidemic, there is no systematic literature review on how frequently these drugs are used in nursing home (NH) populations, including those living with dementia. Objective: This systematic review aims to describe the prevalence and incidence of opioid use in NHs. A secondary objective is to describe the use of these drugs in a subset of NH residents, namely among persons living with dementia. Methods: A systematic literature review was carried out using MEDLINE and Scopus (PROSPERO registration number CRD42021254210). Screening of title and abstract was carried out by 2 persons independently for studies published between January 1, 2011 and May 19, 2021. The main outcomes were annual prevalence, period prevalence, and duration of opioid use. Results: From a total of 178 identified studies, 29 were considered eligible for inclusion. The annual prevalence of any opioid use among all NH residents without any selection criteria ranged from 6.3% to 50% with a median annual prevalence of 22.9% (Q25-Q75: 19.5%-30.2%), based on 17 studies. Five studies measured the annual prevalence in NH residents living with dementia, finding that this ranged from 10% to 39.6%. Conclusions: More evidence is needed quantifying opioid use in NH, especially among persons living with dementia. Given that opioid use in NH is still a problem, implementation of a pain management protocol in NH or nationally would help improve clinical outcomes.
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Affiliation(s)
| | | | - Clive Ballard
- Exeter College of Medicine and Health, University of Exeter, Exeter, UK
| | | | - Charles Scerri
- Department of Pathology, The University of Malta, Msida, Malta
| | - Janet Sultana
- Pharmacy Directorate, Mater Dei Hospital, Msida, Malta
- Exeter College of Medicine and Health, University of Exeter, Exeter, UK
- Department of Clinical Pharmacology and Therapeutics, The University of Malta, Msida, Malta
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Moriwaki M, Tanaka M, Toba M, Ozasa Y, Ogata Y, Obayashi S. Relationship Between Unit Characteristics and Fall Incidence: A Cross-Sectional Survey Using Administrative Data in Japan. J Nurs Res 2024; 32:e333. [PMID: 38814998 DOI: 10.1097/jnr.0000000000000615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND Falls are the most frequent accident experienced by inpatients in hospitals. As falls affect patient outcomes, high fall risk factors should be studied to prevent falls and improve patient safety. However, the relationship between hospital unit characteristics and fall risk has never been assessed. PURPOSE This study was designed to identify the unit characteristics significantly related to fall risk. METHODS A cross-sectional study was conducted on the medical records of patients hospitalized in a Japanese academic hospital between 2018 and 2019. This study quantified unit activities and utilized Diagnosis Procedure Combination data to examine unit characteristics related to falls based on unit day. RESULTS Data on 16,307 patients were included in the analysis, and 355 unit days were certified as fall events. Based on patient condition and medical treatment, the results identified antineoplastic injections, radiation therapy, aseptic treatment room, and functional status of partly assisted transfers, meals, and oral care as unit characteristics associated with increased fall events. Decreased nursing time per patient at night (odds ratio [OR] = 0.75, p = .04) and higher numbers of partially assisted transfer patients were also identified as unit characteristics associated with higher fall incidence rates (OR = 5.56, p = .01). CONCLUSIONS The results of this study are expected to assist nurses to predict falls based on unit characteristics; reducing nursing time in the units was found to be a factor associated with higher fall risk. Nurse managers must understand the unit-related fall risk factors, appropriately assign nurse staffing numbers, and demonstrate nursing leadership to prevent falls in their units.
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Affiliation(s)
- Mutsuko Moriwaki
- PhD, RN, Associate Professor, Quality Management Center, Tokyo Medical and Dental University Hospital, Japan
| | - Michiko Tanaka
- PhD, RN, Lecturer, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Japan
| | - Mikayo Toba
- PhD, MD, Associate Professor, Quality Management Center, Tokyo Medical and Dental University Hospital, Japan
| | - Yuka Ozasa
- PhD, RN, Head Nurse, Clinical Research Center, Tokyo Medical and Dental University Hospital, Japan
| | - Yasuko Ogata
- PhD, RN, Professor, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Japan
| | - Satoshi Obayashi
- PhD, MD, Professor, Department of Obstetrics & Gynecology, Dokkyo Medical University, Japan
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Krause JS, DiPiro ND, Dismuke-Greer CE, Cao Y. Relations Between Self-Reported Prescription Hydrocodone, Oxycodone, and Tramadol Use and Unintentional Injuries Among Those With Spinal Cord Injury. Arch Phys Med Rehabil 2024:S0003-9993(24)01002-5. [PMID: 38762197 DOI: 10.1016/j.apmr.2024.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/25/2024] [Accepted: 05/07/2024] [Indexed: 05/20/2024]
Abstract
OBJECTIVE To identify the relations of 3 frequently used prescription opioids (hydrocodone, oxycodone, tramadol) with unintentional injuries, including fall-related and non-fall-related injuries among adults with chronic, traumatic spinal cord injury (SCI). DESIGN Cross-sectional cohort study. SETTING Community setting; Southeastern United States. PARTICIPANTS Adult participants (N=918) with chronic traumatic SCI were identified from a specialty hospital and state population-based registry and completed a self-report assessment. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Self-reported fall-related and non-fall-related unintentional injuries serious enough to receive medical care in a clinic, emergency room, or hospital within the previous 12 months. RESULTS Just over 20% of participants reported ≥1 unintentional injury in the past year, with an average of 2.16 among those with ≥1. Overall, 9.6% reported fall-related injuries. Only hydrocodone was associated with any past-year unintentional injuries. Hydrocodone taken occasionally (no more than monthly) or regularly (weekly or daily) was related to 2.63 (95% confidence interval [CI], 1.52-4.56) or 2.03 (95% CI, 1.15-3.60) greater odds of having ≥1 unintentional injury in the past year, respectively. Hydrocodone taken occasionally was also associated with past-year non-fall-related injuries (OR, 2.20; 95% CI, 1.12-4.31). Each of the 3 opioids was significantly related to fall-related injuries. Taking hydrocodone occasionally was associated with 2.39 greater odds of fall-related injuries, and regular use was associated with 2.31 greater odds. Regular use of oxycodone was associated with 2.44 odds of a fall-related injury (95% CI, 1.20-4.98), and regular use of tramadol was associated with 2.59 greater odds of fall-related injury (95% CI, 1.13-5.90). CONCLUSIONS Injury prevention efforts must consider the potential effect of opioid use, particularly hydrocodone. For preventing fall-related injuries, each of the 3 opioids must be considered.
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Affiliation(s)
- James S Krause
- College of Health Professions, Medical University of South Carolina, Charleston, SC.
| | - Nicole D DiPiro
- College of Health Professions, Medical University of South Carolina, Charleston, SC
| | | | - Yue Cao
- College of Health Professions, Medical University of South Carolina, Charleston, SC
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Liu SY, Yang YK, Kor CT, Sun YW, Wang HY, Yang YT, Chou MC. Factors Impacting Fall Severity in Hospitalized Patients: A Retrospective Cohort Study. J Clin Med 2024; 13:2827. [PMID: 38792368 PMCID: PMC11122293 DOI: 10.3390/jcm13102827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 05/04/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
Objectives: This retrospective case-controlled study aimed to evaluate the association between the severity of fall-related injuries and fall-risk-increasing drugs (FRIDs) in hospitalized patients. Methods: Data were collected from Changhua Christian Hospital, Taiwan, of all adult inpatients who experienced falls between January 2017 and December 2021, and were divided into two groups based on whether they sustained severe fall-related injuries. Retrospective data that may affect the severity of fall-related injuries and the use of FRIDs were investigated. Results: Among 1231 documented cases of falls, 26 patients sustained severe fall-related injuries. Older patients and those with osteoporosis were more susceptible to more severe injuries from a fall. The use of mobility aids and osteoporosis medications showed protective effects against fall injuries. No significant association was observed between fall-related injuries and comorbidities or FRIDs. Multivariate analysis confirmed the inverse correlation between the use of mobility aids, osteoporosis medications, and fall severity. Patients with osteoporosis exhibited significantly higher odds of sustaining more severe injuries with a fall (odds ratio = 3.02, 95% confidence interval: 1.21-7.53). Conclusions: This study highlights the importance of addressing risk factors associated with fall severity among hospitalized patients. Providing mobility aids to persons at greater risk.
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Affiliation(s)
- Sen-Yung Liu
- Institute of Medicine, Chung Shan Medical University, Taichung 402367, Taiwan;
- Department of Physical Medicine and Rehabilitation, Changhua Christian Hospital, Changhua 500209, Taiwan;
| | - Yu-Kai Yang
- Department of Physical Medicine and Rehabilitation, Changhua Christian Hospital, Changhua 500209, Taiwan;
| | - Chew-Teng Kor
- Big Data Center, Changhua Christian Hospital, Changhua 500209, Taiwan;
| | - Yi-Wei Sun
- Department of Pharmacy, Changhua Christian Hospital, Changhua 500209, Taiwan; (Y.-W.S.); (H.-Y.W.); (Y.-T.Y.)
| | - Hsin-Yu Wang
- Department of Pharmacy, Changhua Christian Hospital, Changhua 500209, Taiwan; (Y.-W.S.); (H.-Y.W.); (Y.-T.Y.)
| | - Yuan-Ting Yang
- Department of Pharmacy, Changhua Christian Hospital, Changhua 500209, Taiwan; (Y.-W.S.); (H.-Y.W.); (Y.-T.Y.)
| | - Ming-Chih Chou
- Institute of Medicine, Chung Shan Medical University, Taichung 402367, Taiwan;
- Division of Thoracic Surgery, Department of Surgery, Chung Shan Medical University Hospital, Taichung 402367, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 402367, Taiwan
- Department of Family and Community Medicine, Chung Shan Medical University Hospital, Taichung 402367, Taiwan
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Sung ML, Eden SK, Becker WC, Crystal S, Duncan MS, Gordon KS, Kerns RD, Kundu S, Freiberg M, So-Armah KA, Edelman EJ. The Association of Prescribed Opioids and Incident Cardiovascular Disease. THE JOURNAL OF PAIN 2024; 25:104436. [PMID: 38029949 PMCID: PMC11058015 DOI: 10.1016/j.jpain.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 11/16/2023] [Accepted: 11/19/2023] [Indexed: 12/01/2023]
Abstract
Opioid prescribing remains common despite known overdose-related harms. Less is known about links to nonoverdose morbidity. We determined the association between prescribed opioid receipt with incident cardiovascular disease (CVD) using data from the Veterans Aging Cohort Study, a national prospective cohort of Veterans with/without Human Immunodeficiency Virus (HIV) receiving Veterans Health Administration care. Selected participants had no/minimal prior exposure to prescription opioids, no opioid use disorder, and no severe illness 1 year after the study start date (baseline period). We ascertained prescription opioid exposure over 3 years after the baseline period using outpatient pharmacy fill/refill data. Incident CVD ascertainment began at the end of the prescribed opioid exposure ascertainment period until the first incident CVD event, death, or September 30, 2015. We used adjusted Cox proportional hazards regression models with matching weights using propensity scores for opioid receipt to estimate CVD risk. Among 49,077 patients, 30% received opioids; the median age was 49 years, 97% were male, 49% were Black, and 47% were currently smoking. Prevalence of hypertension, diabetes, current smoking, alcohol and cocaine use disorder, and depression was higher in patients receiving opioids versus those not but were well-balanced by matching weights. Unadjusted CVD incidence rates per 1,000-person-years were higher among those receiving opioids versus those not: 17.4 (95% confidence interval [CI], 16.5-18.3) versus 14.7 (95% CI, 14.2-15.3). In adjusted analyses, those receiving opioids versus those not had an increased hazard of incident CVD (adjusted hazard ratio 1.16 [95% CI, 1.08-1.24]). Prescribed opioids were associated with increased CVD incidence, making opioids a potential modifiable CVD risk factor. PERSPECTIVE: In a propensity score weighted analysis of Veterans Administration data, prescribed opioids compared to no opioids were associated with an increased hazard of incident CVD. Higher opioid doses compared with lower doses were associated with increased hazard of incident CVD. Opioids are a potentially modifiable CVD risk factor.
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Affiliation(s)
- Minhee L Sung
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut; Department of Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut; Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Svetlana K Eden
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - William C Becker
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut; Department of Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut; Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut; Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Stephen Crystal
- Center for Health Services Research, Rutgers University, New Brunswick, New Jersey
| | - Meredith S Duncan
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Biostatistics, University of Kentucky, Lexington, Kentucky
| | - Kirsha S Gordon
- Department of Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut; Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Robert D Kerns
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut; Department of Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut; Departments of Psychiatry, Neurology and Psychology, Yale University, New Haven, Connecticut
| | - Suman Kundu
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew Freiberg
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kaku A So-Armah
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - E Jennifer Edelman
- Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut; Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut
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11
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Colón-Emeric CS, McDermott CL, Lee DS, Berry SD. Risk Assessment and Prevention of Falls in Older Community-Dwelling Adults: A Review. JAMA 2024; 331:1397-1406. [PMID: 38536167 DOI: 10.1001/jama.2024.1416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/24/2024]
Abstract
Importance Falls are reported by more than 14 million US adults aged 65 years or older annually and can result in substantial morbidity, mortality, and health care expenditures. Observations Falls result from age-related physiologic changes compounded by multiple intrinsic and extrinsic risk factors. Major modifiable risk factors among community-dwelling older adults include gait and balance disorders, orthostatic hypotension, sensory impairment, medications, and environmental hazards. Guidelines recommend that individuals who report a fall in the prior year, have concerns about falling, or have gait speed less than 0.8 to 1 m/s should receive fall prevention interventions. In a meta-analysis of 59 randomized clinical trials (RCTs) in average-risk to high-risk populations, exercise interventions to reduce falls were associated with 655 falls per 1000 patient-years in intervention groups vs 850 falls per 1000 patient-years in nonexercise control groups (rate ratio [RR] for falls, 0.77; 95% CI, 0.71-0.83; risk ratio for number of people who fall, 0.85; 95% CI, 0.81-0.89; risk difference, 7.2%; 95% CI, 5.2%-9.1%), with most trials assessing balance and functional exercises. In a meta-analysis of 43 RCTs of interventions that systematically assessed and addressed multiple risk factors among individuals at high risk, multifactorial interventions were associated with 1784 falls per 1000 patient-years in intervention groups vs 2317 falls per 1000 patient-years in control groups (RR, 0.77; 95% CI, 0.67-0.87) without a significant difference in the number of individuals who fell. Other interventions associated with decreased falls in meta-analysis of RCTs and quasi-randomized trials include surgery to remove cataracts (8 studies with 1834 patients; risk ratio [RR], 0.68; 95% CI, 0.48-0.96), multicomponent podiatry interventions (3 studies with 1358 patients; RR, 0.77; 95% CI, 0.61-0.99), and environmental modifications for individuals at high risk (12 studies with 5293 patients; RR, 0.74; 95% CI, 0.61-0.91). Meta-analysis of RCTs of programs to stop medications associated with falls have not found a significant reduction, although deprescribing is a component of many successful multifactorial interventions. Conclusions and Relevance More than 25% of older adults fall each year, and falls are the leading cause of injury-related death in persons aged 65 years or older. Functional exercises to improve leg strength and balance are recommended for fall prevention in average-risk to high-risk populations. Multifactorial risk reduction based on a systematic clinical assessment for modifiable risk factors may reduce fall rates among those at high risk.
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Affiliation(s)
- Cathleen S Colón-Emeric
- Division of Geriatrics, Duke University, Durham, North Carolina
- Durham VA Geriatric Research Education and Clinical Center, Durham, North Carolina
| | | | - Deborah S Lee
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Sarah D Berry
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Marcus Institute for Aging Research & Department of Medicine, Hebrew SeniorLife, Boston, Massachusetts
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Hwang S, Hughes TD, Niznik J, Ferreri SP. Association of Average Daily Morphine Milligram Equivalents and Falls in Older Adult Chronic Opioid Users. PHARMACY 2024; 12:62. [PMID: 38668088 PMCID: PMC11054049 DOI: 10.3390/pharmacy12020062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/19/2024] [Accepted: 03/26/2024] [Indexed: 04/29/2024] Open
Abstract
Opioids remain commonly prescribed in older adults, despite the known association with falls and fall-related injuries. This retrospective cohort study sought to determine the association of opioid use and falls in older adult opioid users. Using a one-year lookback period in electronic health records, daily morphine milligram equivalents (MMEs) were calculated using prescription orders. Fall history was based on patient self-reporting. A receiver operating characteristic (ROC) curve was used to identify the threshold of average daily MMEs at which the likelihood of falls was increased. Older opioid users were most often women and White, with 30% having fallen in the prior year. In ROC analyses (n = 590), the threshold where fall risk increased was 37 MMEs (p = 0.07). Older adults prescribed more than 37 MMEs daily may be at increased fall risk and should be targeted for deprescribing interventions. Additionally, analysis on patient characteristics and covariates suggest that sex, age, COPD, sleep apnea, cancer, and psychiatric conditions may indicate an increased risk of falls in older adults taking chronic opioids (p < 0.05). Multifactorial interventions may be needed to modify fall risk beyond medication use alone.
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Affiliation(s)
- Stephanie Hwang
- Division of Practice Advancement and Clinical Education, Eshelman School of Pharmacy, The University of North Carolina, Chapel Hill, NC 27599, USA
| | - Tamera D. Hughes
- Division of Practice Advancement and Clinical Education, Eshelman School of Pharmacy, The University of North Carolina, Chapel Hill, NC 27599, USA
| | - Joshua Niznik
- Division of Practice Advancement and Clinical Education, Eshelman School of Pharmacy, The University of North Carolina, Chapel Hill, NC 27599, USA
- Center for Aging and Health, Division of Geriatric Medicine, School of Medicine, The University of North Carolina, Chapel Hill, NC 27599, USA
| | - Stefanie P. Ferreri
- Division of Practice Advancement and Clinical Education, Eshelman School of Pharmacy, The University of North Carolina, Chapel Hill, NC 27599, USA
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Hopkins RE, Bharat C, Buizen L, Close J, Ivers R, Draper B, Pearson SA, Degenhardt L, Gisev N. Age-Related Risk of Serious Fall Events and Opioid Analgesic Use. JAMA Intern Med 2024; 184:394-401. [PMID: 38373005 PMCID: PMC10877504 DOI: 10.1001/jamainternmed.2023.8154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/10/2023] [Indexed: 02/20/2024]
Abstract
Importance Opioid analgesics may be associated with increased risk of falls, particularly among older adults. Objective To quantify the age-related risk of serious fall events among adults prescribed opioids by opioid exposure, time from initiation, and daily dose. Design, Setting, and Participants This population-based cohort study conducted in New South Wales, Australia, used data linking national pharmaceutical claims to national and state datasets, including information on sociodemographic characteristics, clinical characteristics, medicines use, health services utilization, and mortality (POPPY II study). It included adults (18 years or older) who initiated prescription opioid treatment, which was defined as no prior dispensing during the preceding 365 days, between January 1, 2005, and December 31, 2018. Data were analyzed from February to June 2023. Exposure Time-dependent periods of opioid exposure were evaluated from dispensing records. Main Outcome and Measures Serious fall events identified from emergency department, hospitalization, and mortality records. Negative binomial models were used to assess associations between time-dependent opioid exposure (overall, by time from initiation, and by dose), age, and risk of fall events. Models were adjusted for known fall risk factors, including other fall risk-increasing drugs, frailty risk, and prior serious fall events. Results The cohort comprised 3 212 369 individuals who initiated prescription opioid treatment (1 702 332 women [53%]; median [IQR] age at initiation, 49 [32-65] years). Overall, 506 573 serious fall events were identified, including 5210 fatal falls. During exposure to opioids, the risk of serious fall events was elevated among all age groups; compared with the group aged 18 to 44 years, this risk was highest among those 85 years or older (adjusted incident rate ratio, 6.35; 95% CI, 6.20-6.51). Across all age groups, the first 28 days following opioid initiation was a time of increased serious fall risk; this risk increased with age. Among individuals aged 18 to 84 years, associations were identified between higher daily opioid doses and serious fall events. Conclusions and Relevance The results of this cohort study suggest that prescription opioids were associated with increased risk of serious fall events among adults of all ages, with individuals 85 years or older at greatest risk. These risks should be considered when prescribing opioids, particularly for individuals with preexisting risk factors or when opioids are prescribed at higher doses. Targeted falls prevention efforts may be most effective within the first month following opioid initiation.
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Affiliation(s)
- Ria E. Hopkins
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, New South Wales, Australia
| | - Chrianna Bharat
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, New South Wales, Australia
| | - Luke Buizen
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, New South Wales, Australia
| | - Jacqueline Close
- Neuroscience Research Australia, UNSW Sydney, Sydney, New South Wales, Australia
| | - Rebecca Ivers
- School of Population Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Brian Draper
- School of Clinical Medicine, Discipline of Psychiatry and Mental Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Sallie-Anne Pearson
- School of Population Health, UNSW Sydney, Sydney, New South Wales, Australia
- Menzies Centre for Health Policy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, New South Wales, Australia
| | - Natasa Gisev
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, New South Wales, Australia
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14
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Khan NF, Bykov K, Katz JN, Glynn RJ, Vine SM, Kim SC. Risk of fall or fracture with concomitant use of prescription opioids and other medications in osteoarthritis patients. Pharmacoepidemiol Drug Saf 2024; 33:e5773. [PMID: 38419165 PMCID: PMC11000028 DOI: 10.1002/pds.5773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 12/10/2023] [Accepted: 02/11/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Osteoarthritis (OA) patients taking prescription opioids for pain are at increased risk of fall or fracture, and the concomitant use of interacting drugs may further increase the risk of these events. AIMS To identify prescription opioid-related medication combinations associated with fall or fracture. MATERIALS & METHODS We conducted a case-crossover-based screening of two administrative claims databases spanning 2003 through 2021. OA patients were aged 40 years or older with at least 365 days of continuous enrollment and 90 days of continuous prescription opioid use before their first eligible fall or fracture event. The primary analysis quantified the odds ratio (OR) between fall and non-opioid medications dispensed in the 90 days before the fall date after adjustment for prescription opioid dosage and confounding using a case-time-control design. A secondary analogous analysis evaluated medications associated with fracture. The false discovery rate (FDR) was used to account for multiple testing. RESULTS We identified 41 693 OA patients who experienced a fall and 24 891 OA patients who experienced a fracture after at least 90 days of continuous opioid therapy. Top non-opioid medications by ascending p-value with OR > 1 for fall were meloxicam (OR 1.22, FDR = 0.08), metoprolol (OR 1.06, FDR >0.99), and celecoxib (OR 1.13, FDR > 0.99). Top non-opioid medications for fracture were losartan (OR 1.20, FDR = 0.80), alprazolam (OR 1.14, FDR > 0.99), and duloxetine (OR 1.12, FDR = 0.97). CONCLUSION Clinicians may seek to monitor patients who are co-prescribed drugs that act on the central nervous system, especially in individuals with OA.
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Affiliation(s)
- Nazleen F Khan
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Katsiaryna Bykov
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jeffrey N Katz
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Orthopedics, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Seanna M Vine
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Seoyoung C Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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15
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Kheirabadi D, Minhas D, Ghaderpanah R, Clauw DJ. Problems with opioids - beyond misuse. Best Pract Res Clin Rheumatol 2024; 38:101935. [PMID: 38429184 DOI: 10.1016/j.berh.2024.101935] [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: 01/22/2024] [Accepted: 01/25/2024] [Indexed: 03/03/2024]
Abstract
The U.S. is grappling with an opioid epidemic, with millions of adults on long-term opioid therapy (LTOT). Although patients often report pain relief and improved daily function with opioids, research shows no significant differences in short-term outcomes between opioid and non-opioid users, as well as no long-term opioid benefits. This scoping review aims to identify lesser-known side effects of long-term opioid use and increase awareness of them, allowing healthcare providers and patients to better assess the risks and benefits of opioid use. Our data search from PubMed and Google Scholar used keywords related to opioids, chronic pain, hypogonadism, endocrinopathies, cancer progression, cardiovascular events, renovascular events, sleep disturbances, mood disorders and others, narrowing down to English-language full articles published from January 2018 to April 2023. This review emphasizes the probable serious adverse consequences of long-term opioid use on various body systems in patients with chronic pain. Given the lack of long-term benefits and significant adverse effects, our review underscores the critical need for healthcare providers to include these risks in discussions with patients when considering the long-term use of opioid therapy.
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Affiliation(s)
- Dorna Kheirabadi
- Department of Anesthesiology, Chronic Pain and Fatigue Research Center, University of Michigan Medical School, Ann Arbor, MI, United States.
| | - Deeba Minhas
- Department of Internal Medicine, Division of Rheumatology, University of Michigan Medical School, 300 North Ingalls Building, Ann Arbor, MI, 48109-5422, United States.
| | - Rezvan Ghaderpanah
- Department of Physiology and Aging, College of Medicine, University of Florida, United States.
| | - Daniel J Clauw
- Departments of Anesthesiology, Medicine (Rheumatology), and Psychiatry, Chronic Pain and Fatigue Research Center, University of Michigan Medical School, Ann Arbor, MI, United States.
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16
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Johansson MS, Pottegård A, Søndergaard J, Englund M, Grønne DT, Skou ST, Roos EM, Thorlund JB. Use of prescribed analgesics before and after exercise therapy and patient education in patients with knee or hip osteoarthritis. Rheumatol Int 2024; 44:319-328. [PMID: 37775621 PMCID: PMC10796603 DOI: 10.1007/s00296-023-05432-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 08/11/2023] [Indexed: 10/01/2023]
Abstract
The aim of this study was to investigate utilisation patterns of prescribed analgesics before, during, and after an exercise therapy and patient education program among patients with knee or hip osteoarthritis. This cohort study is based on data from the nationwide Good Life with osteoarthritis in Denmark (GLA:D®) patient-register linked with national health registries including data on prescribed analgesics. GLA:D® consists of 8-12 weeks of exercise and patient education. We included 35,549 knee/hip osteoarthritis patients starting the intervention between January 2013 and November 2018. Utilisation patterns the year before, 3 months during, and the year after the intervention were investigated using total dispensed defined daily doses (DDDs) per month per 1000 population as outcome. During the year before the intervention, use of prescribed paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), and opioids increased with 85%, 79% and 22%, respectively. During the intervention, use of paracetamol decreased with 16% with a stable use the following year. Use of NSAIDs and opioids decreased with 38% and 8%, respectively, throughout the intervention and the year after. Sensitivity analyses indicated that the prescription of most analgesics changed over time. For paracetamol, NSAIDs, and opioids, 10% of analgesic users accounted for 45%, 50%, and 70%, respectively, of the total DDDs dispensed during the study period. In general, analgesic use increased the year before the intervention followed by a decrease during the intervention and the year after. A small proportion of analgesic users accounted for half or more of all paracetamol, NSAIDs, and opioids dispensed during the study period.
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Affiliation(s)
- Melker S Johansson
- Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark.
| | - Anton Pottegård
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jens Søndergaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Martin Englund
- Clinical Epidemiology Unit, Orthopaedics, Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden
| | - Dorte T Grønne
- Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Søren T Skou
- Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- The Research Unit PROgrez, Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Slagelse, Denmark
| | - Ewa M Roos
- Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Jonas B Thorlund
- Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
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17
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Stovall R, Kersey E, Li J, Baker R, Anastasiou C, Palmowski A, Schmajuk G, Gensler L, Yazdany J. Incidence Rate and Factors Associated With Fractures Among Medicare Beneficiaries With Ankylosing Spondylitis in the United States. Arthritis Care Res (Hoboken) 2024; 76:265-273. [PMID: 37605840 PMCID: PMC10843294 DOI: 10.1002/acr.25219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 06/30/2023] [Accepted: 08/15/2023] [Indexed: 08/23/2023]
Abstract
OBJECTIVE We evaluated the incidence rate and factors associated with fractures among adults with ankylosing spondylitis (AS). METHODS We performed a retrospective cohort study with data from the Rheumatology Informatics System for Effectiveness registry linked to Medicare claims from 2016 to 2018. Patients were required to have two AS International Classification of Diseases codes 30 or more days apart and a subsequent Medicare claim. Then, 1 year of baseline characteristics were included, after which patients were observed for fractures. First, we calculated the incidence rate of fractures. Second, we constructed logistic regression models to identify factors associated with the fracture, including age, sex, race and ethnicity, body mass index, Medicare/Medicaid dual eligibility, area deprivation index, Charlson comorbidity index, smoking status, osteoporosis, historical fracture, and use of osteoporosis treatment, glucocorticoids, and opioids. RESULTS We identified 1,426 adults with prevalent AS. Mean ± SD age was 69.4 ± 9.8 years, 44.3% were female, and 77.3% were non-Hispanic White. Fractures occurred in 197 adults with AS. The overall incidence rate of fractures was 76.7 (95% confidence interval [CI] 66.4-88.6) per 1,000 person-years. Older age (odds ratio [OR] 2.8, 95% CI 1.39-5.65), historical fracture (OR 5.24, 95% CI 3.44-7.99), and use of more than 30 mg morphine equivalent (OR 1.86, 95% CI 1.08-3.19) conferred increased odds of fracture. CONCLUSIONS In this large sample of Medicare beneficiaries with AS, increasing age, historical fracture, and use of opioids had higher odds of fracture. Men and women were equally likely to have a fracture. Because opioid use was associated with fracture in AS, this high-risk population should be considered for interventions to mitigate risk.
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Affiliation(s)
- Rachael Stovall
- Division of Rheumatology, University of California San Francisco (UCSF), San Francisco, CA
| | - Emma Kersey
- Division of Rheumatology, University of California San Francisco (UCSF), San Francisco, CA
| | - Jing Li
- Division of Rheumatology, University of California San Francisco (UCSF), San Francisco, CA
| | | | - Christine Anastasiou
- Division of Rheumatology, University of California San Francisco (UCSF), San Francisco, CA
| | - Andriko Palmowski
- Division of Rheumatology, University of California San Francisco (UCSF), San Francisco, CA
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, University of Copenhagen, Copenhagen, Denmark
| | - Gabriela Schmajuk
- Division of Rheumatology, University of California San Francisco (UCSF), San Francisco, CA
- San Francisco VA Healthcare System
- UCSF Institute for Health Policy Research
| | - Lianne Gensler
- Division of Rheumatology, University of California San Francisco (UCSF), San Francisco, CA
| | - Jinoos Yazdany
- Division of Rheumatology, University of California San Francisco (UCSF), San Francisco, CA
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McDermott K, Levey N, Brewer J, Ehmann M, Hooker JE, Pasinski R, Yousif N, Raju V, Gholston M, Greenberg J, Ritchie CS, Vranceanu AM. Improving Health for Older Adults With Pain Through Engagement: Protocol for Tailoring and Open Pilot Testing of a Mind-Body Activity Program Delivered Within Shared Medical Visits in an Underserved Community Clinic. JMIR Res Protoc 2023; 12:e52117. [PMID: 38157234 PMCID: PMC10787331 DOI: 10.2196/52117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 08/25/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND Chronic musculoskeletal pain is prevalent and disabling among older adults in underserved communities. Psychosocial pain management is more effective than pharmacological treatment in older adults. However, underserved community clinics often lack psychosocial treatments, in part because of a lack of trained providers. Shared medical appointments, in which patients undergo brief medical evaluation, monitoring, counseling, and group support, are an efficacious and cost-effective method for chronic disease management in underserved clinics, reducing the need for specialized providers. However, shared medical visits are often ineffective for chronic pain, possibly owing to lack of inclusion of skills most relevant for older adults (eg, pacing to increase engagement in daily activities). OBJECTIVE We have described the protocol for the development and initial pilot effectiveness testing of the GetActive+ mind-body activity intervention for older adults with chronic pain. GetActive+ was adapted from GetActive, an evidence-based intervention that improved pain outcomes among mostly affluent White adults. We aim to establish the initial feasibility, acceptability, fidelity, and effectiveness of GetActive+ when delivered as part of shared medical appointments in a community clinic. METHODS We conducted qualitative focus groups and individual interviews with providers (n=25) and English-speaking older adults (aged ≥55 y; n=18) with chronic pain to understand the pain experience in this population, perceptions about intervention content, and barriers to and facilitators of intervention participation and implementation in this setting. Qualitative interviews with Spanish-speaking older adults are in progress and will inform a future open pilot of the intervention in Spanish. We are currently conducting an open pilot study with exit interviews in English (n=30 individuals in total). Primary outcomes are feasibility (≥75% of patients who are approached agree to participate), acceptability (≥75% of patients who enrolled complete 8 out of 10 sessions; qualitative), and fidelity (≥75% of session components are delivered as intended). Secondary outcomes include physical function-self-reported, performance based (6-minute walk test), and objective (step count)-and emotional function (depression and anxiety). Other assessments include putative mechanisms (eg, mindfulness and pain catastrophizing). RESULTS We began enrolling participants for the qualitative phase in November 2022 and the open pilot phase in May 2023. We completed the qualitative phase with providers and English-speaking patients, and the results are being analyzed using a hybrid, inductive-deductive approach. We conducted rapid analysis of these data to develop GetActive+ before the open pilot in English, including increasing readability and clarity of language, reducing the number of skills taught to increase time for individual check-ins and group participation, and increasing experiential exercises for skill uptake. CONCLUSIONS We provide a blueprint for the refinement of a mind-body activity intervention for older adults with chronic pain in underserved community clinics and for incorporation within shared medical visits. It will inform a future, fully powered, effectiveness-implementation trial of GetActive+ to help address the chronic pain epidemic among older adults. TRIAL REGISTRATION ClinicalTrials.gov NCT05782231; https://clinicaltrials.gov/study/NCT05782231. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/52117.
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Affiliation(s)
- Katherine McDermott
- Center for Health Outcomes and Interdisciplinary Research, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Nadine Levey
- Center for Health Outcomes and Interdisciplinary Research, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Julie Brewer
- Center for Health Outcomes and Interdisciplinary Research, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Madison Ehmann
- Center for Health Outcomes and Interdisciplinary Research, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Julia E Hooker
- Center for Health Outcomes and Interdisciplinary Research, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Roger Pasinski
- Massachusetts General Hospital Revere HealthCare Center, Revere, MA, United States
| | - Neda Yousif
- Massachusetts General Hospital Revere HealthCare Center, Revere, MA, United States
| | - Vidya Raju
- Massachusetts General Hospital Revere HealthCare Center, Revere, MA, United States
| | - Milton Gholston
- Massachusetts General Hospital Revere HealthCare Center, Revere, MA, United States
| | - Jonathan Greenberg
- Center for Health Outcomes and Interdisciplinary Research, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Christine S Ritchie
- Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, MA, United States
| | - Ana-Maria Vranceanu
- Center for Health Outcomes and Interdisciplinary Research, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
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19
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Langford AV, Schneider CR, Lin CC, Bero L, Collins JC, Suckling B, Gnjidic D. Patient-targeted interventions for opioid deprescribing: An overview of systematic reviews. Basic Clin Pharmacol Toxicol 2023; 133:623-639. [PMID: 36808693 PMCID: PMC10953356 DOI: 10.1111/bcpt.13844] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 02/08/2023] [Accepted: 02/13/2023] [Indexed: 02/20/2023]
Abstract
BACKGROUND Deprescribing (reduction or cessation) of prescribed opioids can be challenging for both patients and healthcare professionals. OBJECTIVE To synthesize and evaluate evidence from systematic reviews examining the effectiveness and outcomes of patient-targeted opioid deprescribing interventions for all types of pain. METHODS Systematic searches were conducted in five databases with results screened against predetermined inclusion/exclusion criteria. Primary outcomes were (i) reduction in opioid dose, reported as change in oral Morphine Equivalent Daily Dose (oMEDD) and (ii) success of opioid deprescribing, reported as the proportion of the sample for which opioid use declined. Secondary outcomes included pain severity, physical function, quality of life and adverse events. The certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. FINDINGS Twelve reviews were eligible for inclusion. Interventions were heterogeneous in nature and included pharmacological (n = 4), physical (n = 3), procedural (n = 3), psychological or behavioural (n = 3) and mixed (n = 5) interventions. Multidisciplinary care programmes appeared to be the most effective intervention for opioid deprescribing; however, the certainty of evidence was low, with significant variability in opioid reduction across interventions. CONCLUSIONS Evidence is too uncertain to draw firm conclusions about specific populations who may derive the greatest benefit from opioid deprescribing, warranting further investigation.
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Affiliation(s)
- Aili V. Langford
- Centre for Medicine Use and SafetyMonash UniversityParkvilleVictoriaAustralia
- Faculty of Medicine and Health, School of PharmacyThe University of SydneySydneyNew South WalesAustralia
| | - Carl R. Schneider
- Faculty of Medicine and Health, School of PharmacyThe University of SydneySydneyNew South WalesAustralia
| | - Chung‐Wei Christine Lin
- Institute for Musculoskeletal Health, Faculty of Medicine and Health, School of Public HealthUniversity of SydneySydneyNew South WalesAustralia
- Sydney Musculoskeletal HealthThe University of SydneySydneyNew South WalesAustralia
| | - Lisa Bero
- School of Medicine, Colorado School of Public Health and Center for Bioethics and HumanitiesUniversity of Colorado Anschutz Medical CenterDenverColoradoUSA
| | - Jack C. Collins
- Faculty of Medicine and Health, School of PharmacyThe University of SydneySydneyNew South WalesAustralia
| | - Benita Suckling
- Faculty of Medicine and Health, School of PharmacyThe University of SydneySydneyNew South WalesAustralia
- Pharmacy DepartmentCaboolture Hospital, Queensland HealthBrisbaneAustralia
| | - Danijela Gnjidic
- Faculty of Medicine and Health, School of PharmacyThe University of SydneySydneyNew South WalesAustralia
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Warren C, Rizo E, Decker E, Hasse A. A Comprehensive Analysis of Risk Factors Associated With Inpatient Falls. J Patient Saf 2023; 19:396-402. [PMID: 37186671 DOI: 10.1097/pts.0000000000001123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
OBJECTIVES The primary objective of this study was to identify the relationship between rates of falls among hospitalized patients and the use of inpatient medications associated with falls. METHODS This is a retrospective study on patients older than 60 years, hospitalized between January 1, 2021, and December 31, 2021. Ventilated patients and patients with a length of stay or fall less than 48 hours after admission were excluded. Falls were determined by assessing documented post fall assessments in the medical record. Patients who fell were matched 3:1 with control patients based on demographic data (age, sex, length of stay up to the fall time, and Elixhauser Comorbidity score). For controls, a pseudo time to fall was assigned based on matching. Medication information was gathered from barcode administration data. Statistical analysis was conducted using R and RStudio. RESULTS A total of 6363 fall patients and 19,089 controls met the inclusion and exclusion criteria. Seven drug classes were identified as statistically significant ( P < 0.001) in increasing an inpatient's rate of falling: angiotensin-converting enzyme inhibitors (unadjusted odds ratio [OR], 1.22), antipsychotics (OR, 1.93), benzodiazepines (OR, 1.57), serotonin modulators (OR, 1.2), selective serotonin-reuptake inhibitors (OR, 1.26), tricyclics and norepinephrine reuptake inhibitors (OR, 1.45), and miscellaneous antidepressants (OR, 1.54). CONCLUSIONS Hospitalized patients older than 60 years are more likely to fall while taking angiotensin-converting enzyme inhibitors, antipsychotics, benzodiazepines, serotonin modulators, selective serotonin-reuptake inhibitors, tricyclics, norepinephrine reuptake inhibitors, or miscellaneous antidepressants. Patients on opiates and diuretics had a significant decrease in rate of falls.
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Affiliation(s)
| | - Eduardo Rizo
- University of Tennessee Health Science Center/HCA Healthcare, Nashville, Tennessee
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21
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Vranceanu AM, Choukas NR, Rochon EA, Duarte B, Pietrzykowski MO, McDermott K, Hooker JE, Kulich R, Quiroz YT, Parker RA, Macklin EA, Ritchie C, Mace RA. Addressing the Chronic Pain-Early Cognitive Decline Comorbidity Among Older Adults: Protocol for the Active Brains Remote Efficacy Trial. JMIR Res Protoc 2023; 12:e47319. [PMID: 37768713 PMCID: PMC10570897 DOI: 10.2196/47319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/01/2023] [Accepted: 05/31/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Chronic pain and early cognitive decline, which are costly to treat and highly prevalent among older adults, commonly co-occur, exacerbate one another over time, and can accelerate the development and progression of Alzheimer disease and related dementias. We developed the first mind-body activity program (Active Brains [AB]) tailored to the needs of older adults with chronic pain and early cognitive decline. Results from our previous study strongly supported the feasibility of conducting AB remotely and provided evidence for improvements in outcomes. OBJECTIVE We are conducting a single-blinded, National Institutes of Health stage-2, randomized clinical trial to establish the efficacy of AB versus a time-matched and dose-matched education control (Health Enhancement Program [HEP]) in improving self-reported and objective outcomes of physical, cognitive, and emotional functions in 260 participants. The methodology described in this paper was informed by the lessons learned from the first year of the trial. METHODS Participants are identified and recruited through multidisciplinary clinician-referred individuals (eg, pain psychologists and geriatricians), the Rally Research platform, social media, and community partnerships. Interested participants complete eligibility screening and electronic informed consent. Baseline assessments include self-report, performance-based measures (eg, 6-min walk test) and objective measures (eg, Repeatable Battery for the Assessment of Neuropsychological Status). Participants are mailed a wrist-worn ActiGraph device (ActiGraph LLC) to passively monitor objective function (eg, steps) during the week between the baseline assessment and the beginning of the programs, which they continue to wear throughout the programs. After baseline assessments, participants are randomized to either AB or HEP and complete 8 weekly, remote, group sessions with a Massachusetts General Hospital psychologist. The AB group receives a Fitbit (Fitbit Inc) to help reinforce increased activity. Assessments are repeated after the intervention and at the 6-month follow-up. Coprimary outcomes include multimodal physical function (self-report, performance based, and objective). Secondary outcomes are cognitive function (self-report and objective), emotional function, and pain. RESULTS We began recruitment in July 2022 and recruited 37 participants across 4 cohorts. Of them, all (n=37, 100%) have completed the baseline assessment, 26 (70%) have completed the posttest assessment, and 9 (24%) are actively enrolled in the intervention (total dropout: n=2, 5%). In the three cohorts (26/37, 70%) that have completed the AB or HEP, 26 (100%) participants completed all 8 group sessions (including minimal makeups), and watch adherence (1937/2072, 93.48%, average across ActiGraph and Fitbit devices) has been excellent. The fourth cohort is ongoing (9/37, 24%), and we plan to complete enrollment by March 2026. CONCLUSIONS We aim to establish the efficacy of the AB program over a time-matched and dose-matched control in a live video-based trial and test the mechanisms through theoretically driven mediators and moderators. Findings will inform the development of a future multisite effectiveness-implementation trial. TRIAL REGISTRATION ClinicalTrials.gov NCT05373745; https://classic.clinicaltrials.gov/ct2/show/NCT05373745. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/47319.
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Affiliation(s)
- Ana-Maria Vranceanu
- Center for Health Outcomes and Interdisciplinary Research, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Nathaniel R Choukas
- Center for Health Outcomes and Interdisciplinary Research, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Elizabeth A Rochon
- Center for Health Outcomes and Interdisciplinary Research, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Brooke Duarte
- Center for Health Outcomes and Interdisciplinary Research, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Malvina O Pietrzykowski
- Center for Health Outcomes and Interdisciplinary Research, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Katherine McDermott
- Center for Health Outcomes and Interdisciplinary Research, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Julia E Hooker
- Center for Health Outcomes and Interdisciplinary Research, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Ronald Kulich
- Harvard Medical School, Boston, MA, United States
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Yakeel T Quiroz
- Harvard Medical School, Boston, MA, United States
- Multicultural Alzheimer's Prevention Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Robert A Parker
- Harvard Medical School, Boston, MA, United States
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, United States
| | - Eric A Macklin
- Harvard Medical School, Boston, MA, United States
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, United States
| | - Christine Ritchie
- Harvard Medical School, Boston, MA, United States
- Mongan Institute Center for Aging and Serious Illness and the Division of Palliative Care and Geriatric Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Ryan A Mace
- Center for Health Outcomes and Interdisciplinary Research, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
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Schaffer AL, Gisev N, Blyth FM, Buckley NA, Currow D, Dobbins TA, Wilson A, Degenhardt L, Pearson S. Opioid prescribing patterns among medical practitioners in New South Wales, Australia. Drug Alcohol Rev 2023; 42:1472-1481. [PMID: 37159416 PMCID: PMC10946566 DOI: 10.1111/dar.13675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 03/16/2023] [Accepted: 04/11/2023] [Indexed: 05/11/2023]
Abstract
INTRODUCTION Prescriber behaviour is important for understanding opioid use patterns. We described variations in practitioner-level opioid prescribing in New South Wales, Australia (2013-2018). METHODS We quantified opioid prescribing patterns among medical practitioners using population-level dispensing claims data, and used partitioning around medoids to identify clusters of practitioners who prescribe opioids based on prescribing patterns and patient characteristics identified from linked dispensing claims, hospitalisations and mortality data. RESULTS The number of opioid prescribers ranged from 20,179 in 2013 to 23,408 in 2018. The top 1% of practitioners prescribed 15% of all oral morphine equivalent (OME) milligrams dispensed annually, with a median of 1382 OME grams (interquartile range [IQR], 1234-1654) per practitioner; the bottom 50% prescribed 1% of OMEs dispensed, with a median of 0.9 OME grams (IQR 0.2-2.6). Based on 63.6% of practitioners with ≥10 patients filling opioid prescriptions in 2018, we identified four distinct practitioner clusters. The largest cluster prescribed multiple analgesic medicines for older patients (23.7% of practitioners) accounted for 76.7% of all OMEs dispensed and comprised 93.0% of the top 1% of practitioners by opioid volume dispensed. The cluster prescribing analgesics for younger patients with high rates of surgery (18.7% of practitioners) prescribed only 1.6% of OMEs. The remaining two clusters comprised 21.2% of prescribers and 20.9% of OMEs dispensed. DISCUSSION AND CONCLUSION We observed substantial variation in opioid prescribing among practitioners, clustered around four general patterns. We did not assess appropriateness but some prescribing patterns are concerning. Our findings provide insights for targeted interventions to curb potentially harmful practices.
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Affiliation(s)
- Andrea L. Schaffer
- School of Population HealthFaculty of Medicine and Health, UNSW SydneySydneyAustralia
| | - Natasa Gisev
- National Drug and Alcohol Research Centre, UNSW SydneySydneyAustralia
| | - Fiona M. Blyth
- School of Public Health, Faculty of Medicine and HealthThe University of SydneySydneyAustralia
| | - Nicholas A. Buckley
- Biomedical Informatics and Digital Health, Faculty of Medicine and HealthThe University of SydneySydneyAustralia
| | - David Currow
- Faculty of Science, Medicine and HealthUniversity of WollongongWollongongAustralia
| | - Timothy A. Dobbins
- School of Population HealthFaculty of Medicine and Health, UNSW SydneySydneyAustralia
| | - Andrew Wilson
- Menzies Centre for Health Policy and Economics, Faculty of Medicine and HealthThe University of SydneySydneyAustralia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW SydneySydneyAustralia
| | - Sallie‐Anne Pearson
- School of Population HealthFaculty of Medicine and Health, UNSW SydneySydneyAustralia
- Menzies Centre for Health Policy and Economics, Faculty of Medicine and HealthThe University of SydneySydneyAustralia
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23
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Wang H, Cai S, Caprio T, Goulet J, Intrator O. Fall-related Injuries and Opioid Administration Among Veterans With Dementia in US Department of Veterans Affairs Community Living Centers. Med Care 2023; 61:579-586. [PMID: 37476853 DOI: 10.1097/mlr.0000000000001889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
OBJECTIVES Opioid use is associated with fall-related injuries (FRI) among older adults, especially those with dementia. We examined FRI following changes in national opioid safety initiatives over 3 regulatory periods [preinitiatives baseline (period 1): October 2012 to June 2013; post-Veteran Affairs (VA) opioid safety initiative (period 2): January 2014 to November 2015; post-VA and CDC opioid prescribing guidelines (period 3): March 2017 to September 2018] among Department of VA Community Living Center (CLC) long-stay residents with dementia. DATA VA provided and purchased care records, Medicare claims, CLC Minimum Data Set (MDS) assessments. VA bar-code medication administration data, VA outpatient prescription refill data, and Medicare Part D data were used to capture medication from inpatient, outpatient, and Medicare sources. SETTINGS AND PARTICIPANTS A total of 12,229 long-stay CLC residents with dementia between October 2012 and September 2018. METHODS We applied Veteran-regulatory period level (1) generalized linear model to examine the unadjusted and adjusted trends of FRI, and (2) difference-in-difference model with propensity score weighting to examine the relationship between opioid safety initiatives and FRI in 3 regulatory periods. We applied propensity score weighting to enable the cohorts in periods 2 and 3 had similar indications for opioid administration as in period 1. RESULTS FRI prevalence per month among CLC residents with Alzheimer disease and related dementias decreased from 3.1% in period 1 to 1.6% and 1.2% in periods 2 and 3, and the adjusted probability of FRI was 17% and 40% lower in periods 2 and 3 compared with period 1. The any, incident, and continued opioid administration were significantly associated with higher FRI, whereas the differences in FRI probabilities between opioid and nonopioid users had no significant changes over the 3 regulatory periods. CONCLUSIONS FRI was reduced among CLC residents with Alzheimer disease and related dementias receiving care in VA CLCs over the 3 regulatory periods, but the FRI reduction was not significantly associated with opioid safety initiatives. Other interventions that potentially targeted falls are likely to have helped reduce these fall events. Future studies could examine whether opioid use reduction ultimately benefitted nursing home residents by focusing on other possible outcomes or whether such reduction only resulted in more untreated pain.
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Affiliation(s)
- Huiying Wang
- Geriatrics and Extended Care Data and Analysis Center (GECDAC), Finger Lakes Healthcare System, Canandaigua, NY
- Department of Health Services, Policy, and Practice, Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, RI
- Public Health Sciences, University of Rochester
| | - Shubing Cai
- Geriatrics and Extended Care Data and Analysis Center (GECDAC), Finger Lakes Healthcare System, Canandaigua, NY
- Public Health Sciences, University of Rochester
| | - Thomas Caprio
- Department of Medicine, University of Rochester, Rochester, NY
| | - Joseph Goulet
- VA Connecticut Healthcare System, West Haven
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Orna Intrator
- Geriatrics and Extended Care Data and Analysis Center (GECDAC), Finger Lakes Healthcare System, Canandaigua, NY
- Public Health Sciences, University of Rochester
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Soares Fonseca L, Pereira Silva J, Bastos Souza M, Gabrich Moraes Campos M, de Oliveira Mascarenhas R, de Jesus Silva H, Souza Máximo Pereira L, Xavier Oliveira M, Cunha Oliveira V. Effectiveness of pharmacological and non-pharmacological therapy on pain intensity and disability in older people with chronic nonspecific low back pain: a systematic review with meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:3245-3271. [PMID: 37464184 DOI: 10.1007/s00586-023-07857-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/30/2023] [Accepted: 07/04/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND AND PURPOSE The aim of the present systematic review was to investigate the effectiveness of pharmacological and non-pharmacological therapy on pain intensity and disability in older people with chronic nonspecific low back pain. METHODS Searches were conducted in the MEDLINE, COCHRANE LIBRARY, EMBASE, AMED, PSYCINFO, and PEDRO databases up to 2022. Risk of bias was appraised using the Cochrane Risk of Bias 2.0 tool. Estimated mean differences and respective 95% confidence intervals were presented for each paired comparison and the strength of the current evidence was assessed using the GRADE approach. RESULTS AND DISCUSSION Thirty-one original trials involving 2120 participants were included. All outcomes were self-rated. Pain intensity was measured using the Visual Analogue Scale or Numerical Rating Scale. Disability was evaluated using the Roland Morris Disability Questionnaire, Oswestry Disability Index or Hannover Functional Ability Questionnaire. Short-term: Moderate quality of evidence that mindfulness reduces disability compared to patient education (mean difference [MD] = - 1.38 [95% CI - 2.02 to - 0.73]); low-quality evidence that mixed exercise (MD = - 50.33 [95% CI - 57.11 to - 43.56]) reduces pain compared to no intervention, waiting list, placebo or sham; low quality of evidence that there is no effect for opioid compared to placebo (MD = - 8.26 [95% CI - 19.29 to 2.77]) with regards to reducing pain and opioid/acetaminophen reduces disability more compared to pregabalin (MD = 2.36 [95% CI] 1.86-2.86]). CONCLUSIONS The findings showed low or very low quality of evidence for non-pharmacological interventions with a large effect in short- and long-term follow-up. The two studies that provided moderate quality of evidence had a small clinical effect. Only two studies were found that investigated pharmacological therapies-both with low quality of evidence. However, the studies were methodologically weak and had small sample sizes. Given the adverse effects of low back pain and the scarce information on the effectiveness of pharmacological and non-pharmacological treatments for older people, future randomized trials should be encouraged.
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Affiliation(s)
- Letícia Soares Fonseca
- Postgraduate Program in Rehabilitation and Functional Performance, Universidade Federal dos Vales do Jequitinhonha e Mucuri (UFVJM), Rodovia MGT 367, Km 583, 5000, Campus JK, Diamantina, CEP 39.100-000, Brazil.
| | - Juliana Pereira Silva
- Department of Physiotherapy, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Rodovia MGT 367, Km 583, 5000, Campus JK, Diamantina, CEP 39.100-000, Brazil
| | - Mateus Bastos Souza
- Postgraduate Program in Rehabilitation and Functional Performance, Universidade Federal dos Vales do Jequitinhonha e Mucuri (UFVJM), Rodovia MGT 367, Km 583, 5000, Campus JK, Diamantina, CEP 39.100-000, Brazil
| | | | - Rodrigo de Oliveira Mascarenhas
- Department of Physiotherapy, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Rodovia MGT 367, Km 583, 5000, Campus JK, Diamantina, CEP 39.100-000, Brazil
| | - Hytalo de Jesus Silva
- Postgraduate Program in Health Sciences, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Rodovia MGT 367, Km 583, 5000, Campus JK, Diamantina, CEP 39.100-000, Brazil
| | - Leani Souza Máximo Pereira
- Postgraduate Program in Rehabilitation Sciences, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Murilo Xavier Oliveira
- Postgraduate Program in Rehabilitation and Functional Performance, Universidade Federal dos Vales do Jequitinhonha e Mucuri (UFVJM), Rodovia MGT 367, Km 583, 5000, Campus JK, Diamantina, CEP 39.100-000, Brazil
| | - Vinicius Cunha Oliveira
- Postgraduate Program in Rehabilitation and Functional Performance, Universidade Federal dos Vales do Jequitinhonha e Mucuri (UFVJM), Rodovia MGT 367, Km 583, 5000, Campus JK, Diamantina, CEP 39.100-000, Brazil
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Fennell G, Jacobson M, Grol-Prokopczyk H. Predictors of Multiwave Opioid Use Among Older American Adults. Innov Aging 2023; 7:igad068. [PMID: 38094934 PMCID: PMC10714904 DOI: 10.1093/geroni/igad068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Indexed: 02/01/2024] Open
Abstract
Background and Objectives Despite limited analgesic benefits, long-term opioid therapy (L-TOT) is common among older adults with chronic pain. Extended opioid use poses a threat to older adults as aging metabolisms retain opioids for longer, increasing the risk of injury, overdose, and other negative health outcomes. In contrast to predictors of general opioid use, predictors of L-TOT in older adults are not well documented. We aimed to identify such predictors using all available data on self-reported opioid use in the Health and Retirement Study. Research Design and Methods Using 5 waves of data, respondents (N = 10,713) aged 51 and older were identified as reporting no opioid use (n = 8,621), a single wave of use (n = 1,410), or multiple waves of use (n = 682). We conducted a multinomial logistic regression to predict both single- and multiwave opioid use relative to no use. Demographic, socioeconomic, geographic, health, and health care-related factors were included in our model. Results Multivariable findings show that, relative to nonusers, both single- and multiwave users were significantly more likely to be younger (relative risk ratio [RRR] = 1.33; RRR = 2.88); report lower household wealth (RRR = 1.47; RRR = 2.88); live in the U.S. Midwest (RRR = 1.29; RRR = 1.56), South (RRR = 1.34; RRR = 1.58), or West (RRR = 1.46; RRR = 2.34); experience interfering pain (RRR = 1.59; RRR = 3.39), back pain (RRR = 1.35; RRR = 1.53), or arthritic pain (RRR = 1.46; RRR = 2.32); and see the doctor frequently (RRR = 1.50; RRR = 2.02). Multiwave users were less likely to be Black (RRR = 0.69) or Hispanic (RRR = 0.45), and less likely to be never married (RRR = 0.52). Discussion and Implications We identified demographic, socioeconomic, geographic, and health care-related predictors of chronic multiyear opioid use. Our focus on individuals taking opioids for this extended duration is novel. Differences in opioid use by geographic region and frequency of doctor visits particularly warrant attention from policy-makers and researchers. We make additional recommendations based on a sensitivity analysis limited to 2016-2020 data.
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Affiliation(s)
- Gillian Fennell
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, California, USA
| | - Mireille Jacobson
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, California, USA
- Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, California, USA
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Yang X, Li L, Xie F, Wang Z. A prospective cohort study of the impact of chronic disease on fall injuries in middle-aged and older adults. Open Med (Wars) 2023; 18:20230748. [PMID: 37465350 PMCID: PMC10350885 DOI: 10.1515/med-2023-0748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 06/19/2023] [Accepted: 06/20/2023] [Indexed: 07/20/2023] Open
Abstract
This cohort study investigated the impact of chronic diseases on fall risk in middle-aged and older individuals, offering insights for fall prevention strategies. Analysing data from 4,670 participants aged 40+ years, we used a Cox proportional risk model to assess chronic disease types, numbers, and interactions with other factors on fall injury risk across age groups. Results showed that middle-aged adults with respiratory diseases had a 26% increased fall risk (hazard ratio [HR] = 1.26, 95% confidence interval [CI]: 1.05-1.48), and a linear dose-response relationship was observed between chronic disease number and fall risk (p < 0.001). The study also examined interaction effects of chronic diseases with gender, disability, and fall injury history. Female middle-aged and older adults with chronic diseases had a 67% higher fall risk than their male counterparts without chronic diseases (HR = 1.67, 95% CI: 1.36-1.88). In conclusion, chronically ill middle-aged and older adults have a higher fall risk, with high-risk groups including women, those with chronic diseases, and individuals with fall injury history. Fall prevention efforts should target middle-aged adults as well.
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Affiliation(s)
- Xue Yang
- Department of Geriatrics, The General Hospital of Western Theater Command,
Chengdu, P.R. China
| | - Longxin Li
- Department of Geriatrics, The General Hospital of Western Theater Command,
Chengdu, P.R. China
| | - Fang Xie
- Department of Geriatrics, The General Hospital of Western Theater Command,
Chengdu, P.R. China
| | - Zhang Wang
- Department of Geriatrics, The General Hospital of Western Theater Command,
Chengdu, P.R. China
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Riester MR, Beaudoin FL, Joshi R, Hayes KN, Cupp MA, Berry SD, Zullo AR. Evaluation of post-acute care and one-year outcomes among Medicare beneficiaries with hip fractures: a retrospective cohort study. BMC Med 2023; 21:232. [PMID: 37400841 DOI: 10.1186/s12916-023-02958-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 06/22/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND Post-acute care (PAC) services after hospitalization for hip fracture are typically provided in skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), or at home via home health care (HHC). Little is known about the clinical course following PAC for hip fracture. We examined the nationwide burden of adverse outcomes by PAC setting in the year following discharge from PAC for hip fracture. METHODS This retrospective cohort included Medicare Fee-for-Service beneficiaries > 65 years who received PAC services in U.S. SNFs, IRFs, or HHC following hip fracture hospitalization between 2012 and 2018. Individuals who had a fall-related injury (FRI) during PAC or received PAC services in multiple settings were excluded. Primary outcomes included FRIs, all-cause hospital readmissions, and death in the year following discharge from PAC. Cumulative incidences and incidence rates for adverse outcomes were reported by PAC setting. Exploratory analyses examined risk ratios and hazard ratios between settings before and after inverse-probability-of-treatment-weighting, which accounted for 43 covariates. RESULTS Among 624,631 participants (SNF, 67.78%; IRF, 16.08%; HHC, 16.15%), the mean (standard deviation) age was 82.70 (8.26) years, 74.96% were female, and 91.30% were non-Hispanic White. Crude incidence rates (95%CLs) per 1000 person-years were highest among individuals receiving SNF care for FRIs (SNF, 123 [121, 123]; IRF, 105 [102, 107]; HHC, 89 [87, 91]), hospital readmission (SNF, 623 [619, 626]; IRF, 538 [532, 544]; HHC, 418 [414, 423]), and death (SNF, 167 [165, 169]; IRF, 47 [46, 49]; HHC, 55 [53, 56]). Overall, rates of adverse outcomes generally remained higher among SNF care recipients after covariate adjustment. However, inferences about the group with greater adverse outcomes differed for FRIs and hospital readmissions based on risk ratio or hazard ratio estimates. CONCLUSIONS In this retrospective cohort study of individuals hospitalized for hip fracture, rates of adverse outcomes in the year following PAC were common, especially among SNF care recipients. Understanding risks and rates of adverse events can inform future efforts to improve outcomes for older adults receiving PAC for hip fracture. Future work should consider calculating risk and rate measures to assess the influence of differential time under observation across PAC groups.
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Affiliation(s)
- Melissa R Riester
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 200 Dyer Street, Box 2013, Providence, RI, 02912, USA.
| | - Francesca L Beaudoin
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 200 Dyer Street, Box 2013, Providence, RI, 02912, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Richa Joshi
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 200 Dyer Street, Box 2013, Providence, RI, 02912, USA
| | - Kaleen N Hayes
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 200 Dyer Street, Box 2013, Providence, RI, 02912, USA
- Graduate Department of Pharmaceutical Sciences, Faculty of Pharmacy, University of Toronto Leslie Dan, Toronto, ON, Canada
| | - Meghan A Cupp
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 200 Dyer Street, Box 2013, Providence, RI, 02912, USA
| | - Sarah D Berry
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Roslindale, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 200 Dyer Street, Box 2013, Providence, RI, 02912, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
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Roitto HM, Aalto UL, Öhman H, Saarela RKT, Kautiainen H, Salminen K, Pitkälä KH. Association of medication use with falls and mortality among long-term care residents: a longitudinal cohort study. BMC Geriatr 2023; 23:375. [PMID: 37331981 DOI: 10.1186/s12877-023-04096-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 06/07/2023] [Indexed: 06/20/2023] Open
Abstract
BACKGROUND Falls in long-term care are common. The aim of our study was to explore how medication use is associated with incidence of falls, related consequences, and all-cause mortality among long-term care residents. METHODS Five hundred thirty two long-term care residents aged 65 years or older participated in this longitudinal cohort study in 2018-2021. Data on medication use were retrieved from medical records. Polypharmacy was defined as use of 5-10 medications and excessive polypharmacy as use of > 10 medications. The numbers of falls, injuries, fractures, and hospitalizations were collected from medical records over 12 months following baseline assessment. Participants were followed for three years for mortality. All analysis were adjusted for age, sex, Charlson Comorbidity Index, Clinical dementia rating, and mobility. RESULTS A total of 606 falls occurred during the follow-up. Falls increased significantly with the number of medications used. Fall rate was 0.84/person-years (pyrs) (95% CI 0.56 to 1.13) for the non-polypharmacy group, 1.13/pyrs (95% CI 1.01 to 1.26) for the polypharmacy group, and 1.84/pyrs (95% CI 1.60 to 2.09) for the excessive polypharmacy group. Incidence rate ratio for falls was 1.73 (95% CI 1.44 to 2.10) for opioids, 1.48 (95% CI 1.23 to 1.78) for anticholinergic medication, 0.93 (95% CI 0.70 to 1.25) for psychotropics, and 0.91 (95% CI 0.77 to 1.08) for Alzheimer medication. The three-year follow-up showed significant differences in mortality between the groups, the lowest survival rate (25%) being in the excessive polypharmacy group. CONCLUSION Polypharmacy, opioid and anticholinergic medication use predicted incidence of falls in long-term care. The use of more than 10 medications predicted all-cause mortality. Special attention should be paid to both number and type of medications when prescribing in long-term care.
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Affiliation(s)
- Hanna-Maria Roitto
- Department of Geriatrics, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
- Finnish Institute for Health and Welfare, Population Health Unit, Helsinki, Finland.
- Department of Social Services and Health Care, Helsinki, Finland.
| | - Ulla L Aalto
- Department of Geriatrics, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Hanna Öhman
- Department of Geriatrics, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | - Hannu Kautiainen
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland
| | - Karoliina Salminen
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland
| | - Kaisu H Pitkälä
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland
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Dowd LA, Cross AJ, Liau SJ, Jadczak AD, Visvanathan R, Veal FC, Bell JS. Identifying Residents Who May Benefit from an Analgesic Review: Applying Analgesic Indicators in Residential Aged Care Services. Drugs Aging 2023; 40:449-459. [PMID: 37147416 DOI: 10.1007/s40266-023-01025-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND Ensuring safe and effective analgesic use in residential aged care services is important because older adults are susceptible to analgesic-related adverse drug events (ADEs). OBJECTIVE The aim of this study was to identify the proportion and characteristics of residents of aged care services who may benefit from analgesic review based on indicators in the 2021 Society for Post-Acute and Long-Term Care Medicine (AMDA) Pain Management Guideline. METHODS Cross-sectional analyses of baseline data from the Frailty in Residential Sector over Time (FIRST) study (N = 550 residents) across 12 South Australian residential aged care services in 2019 were conducted. Indicators included the proportion of residents who received > 3000 mg/day of acetaminophen (paracetamol), regular opioids without a documented clinical rationale, opioid doses > 60 mg morphine equivalents (MME)/day, more than one long-acting opioid concurrently, and a pro re nata (PRN) opioid on more than two occasions in the previous 7 days. Logistic regression was performed to investigate factors associated with residents who may benefit from analgesic review. RESULTS Of 381 (69.3%) residents charted regular acetaminophen, 176 (46.2%) were charted > 3000 mg/day. Of 165 (30%) residents charted regular opioids, only 2 (1.2%) had no prespecified potentially painful conditions in their medical record and 31 (18.8%) received > 60 MME/day. Of 153 (27.8%) residents charted long-acting opioids, 8 (5.2%) received more than one long-acting opioid concurrently. Of 212 (38.5%) residents charted PRN opioids, 10 (4.7%) received more than two administrations in the previous 7 days. Overall, 196 (35.6%) of 550 residents were identified as potentially benefiting from analgesic review. Females (odds ratio [OR] 1.87, 95% confidence interval [CI] 1.20-2.91) and residents with prior fracture (OR 1.62, 95% CI 1.12-2.33) were more likely to be identified. Observed pain (OR 0.50, 95% CI 0.29-0.88) was associated with a lower likelihood of being identified compared with residents with no observed pain. Overall, 43 (7.8%) residents were identified based on opioid-related indicators. CONCLUSIONS Up to one in three residents may benefit from a review of their analgesic regimen, including 1 in 13 who may benefit from a specific review of their opioid regimen. Analgesic indicators represent a new approach to target analgesic stewardship interventions.
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Affiliation(s)
- Laura A Dowd
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia.
| | - Amanda J Cross
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Shin J Liau
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
- National Health and Medical Research Council (NHMRC) Centre of Research Excellence in Frailty and Healthy Ageing, Adelaide, SA, Australia
| | - Agathe D Jadczak
- National Health and Medical Research Council (NHMRC) Centre of Research Excellence in Frailty and Healthy Ageing, Adelaide, SA, Australia
- Faculty of Health and Medical Sciences, Adelaide Geriatrics Training and Research with Aged Care (GTRAC) Centre, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Renuka Visvanathan
- National Health and Medical Research Council (NHMRC) Centre of Research Excellence in Frailty and Healthy Ageing, Adelaide, SA, Australia
- Faculty of Health and Medical Sciences, Adelaide Geriatrics Training and Research with Aged Care (GTRAC) Centre, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- Aged and Extended Care Services, The Queen Elizabeth Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Felicity C Veal
- Unit for Medication Outcomes Research and Education (UMORE), School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
- National Health and Medical Research Council (NHMRC) Centre of Research Excellence in Frailty and Healthy Ageing, Adelaide, SA, Australia
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Kim J, Lee E, Jung Y, Kwon H, Lee S. Patient-level and organizational-level factors influencing in-hospital falls. J Adv Nurs 2022; 78:3641-3651. [PMID: 35441709 PMCID: PMC9790490 DOI: 10.1111/jan.15254] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/24/2022] [Accepted: 03/23/2022] [Indexed: 12/30/2022]
Abstract
AIM In-hospital fall is one key safety issue in a healthcare setting. Although healthcare providers apply several strategies for preventing falls, falls still occur in hospitals. The aim of this study was to investigate patient-level and organizational-level factors influencing in-hospital falls. DESIGN A multicentre retrospective observational study. METHODS This study used the national healthcare database and supplemented with organizational data obtained through a survey. Data extraction and survey were conducted between July and August 2020. A mixed-effect logistic regression model was used to analyse factors influencing in in-hospital falls. RESULTS A total of 43,286 patients admitted in 86 hospitals were included in this study. Fall rate was 0.85 per 1000 days. Length of stay was significantly longer for fall patients than for no-fall patients. Patient-level factors (including age, mobility impairment and surgery) and organizational-level factors (including nurse staffing and proportion of new nurses) were significant factors influencing in-hospital falls. CONCLUSION Since in-hospital falls increase economic burden to patients, we should consider various fall prevention strategies to reduce falls. For a strategy to be applied stably to patients, organizational factors must be supported. IMPACT Proactive fall management in acute settings is essential to ensure patient safety. Considering that the number of patients with fall risk is increasing due to ageing, organizational factors should be supported to provide quality nursing care for fall risk patients. Therefore, nurse leaders should primarily ensure an appropriate level of nurse staffing. They also need to make efforts to strengthen clinical competency of nurses.
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Affiliation(s)
- Jinhyun Kim
- College of NursingSeoul National UniversitySeoulSouth Korea
| | - Eunhee Lee
- School of Nursing/Research Institute of Nursing ScienceHallym UniversityChuncheonGangwon‐doSouth Korea
| | - Yoomi Jung
- Korea Armed Forces Nursing AcademyDaejeonSouth Korea
| | - Hyunjeong Kwon
- College of NursingSeoul National UniversitySeoulSouth Korea
| | - Sunmi Lee
- College of NursingSeoul National UniversitySeoulSouth Korea
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31
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Bloomer A, Wally M, Bailey G, Roomian T, Karunakar M, Hsu JR, Seymour R, Beuhler M, Bosse M, Gibbs M, Griggs C, Jarrett S, Leas D, Odum S, Runyon M, Saha A, Yu Z, Watling B, Wyatt S. Balancing Safety, Comfort, and Fall Risk: An Intervention to Limit Opioid and Benzodiazepine Prescriptions for Geriatric Patients. Geriatr Orthop Surg Rehabil 2022; 13:21514593221125616. [PMID: 36250188 PMCID: PMC9561667 DOI: 10.1177/21514593221125616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 08/19/2022] [Accepted: 08/24/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction This study reports on the impact of a clinical decision support tool embedded
in the electronic medical record and characterizes the demographics,
prescribing patterns, and risk factors associated with opioid and
benzodiazepine misuse in the older adult population. Significance This study reports on prescribing patterns for patients ≥65 years-old who
presented to Emergency Departments (ED) or Urgent Care (UC) facilities
across a large healthcare system following a fall (n = 34,334 encounters; n
= 25,469 patients). This system implemented a clinical decision support
intervention which provides an alert when the patient has an evidence-based
risk factor for prescription drug misuse; prescribers can continue, amend or
cancel the prescription. Results Of older adults presenting with a fall, 31.4% (N = 7986) received an opioid
or benzodiazepine prescription. Women and younger patients (65-74) had a
higher likelihood of receiving a prescription (P <
.0001). 11% had ≥1 risk factor. Women were more likely to receive an early
refill (P = .0002) and younger (65-74) men were more likely
to have a past positive toxicology (P < .0001). A
prescription was initiated in 8,591 encounters, and 946 (9.0%) triggered an
alert. In 58 cases, the alert resulted in a prescription modification, and
in 80 the prescription was canceled. Conclusions Documented risk for opioid misuse in the elderly was 10% among patients
presenting to the ED/UC after a fall. The dangers associated with
opioid/benzodiazepine use increase with age as does fall risk. Awareness of
risk factors is an important first step; more work is needed to address
potentially hazardous prescriptions in this population.
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Affiliation(s)
- Ainsley Bloomer
- Department of Orthopaedic Surgery,
Atrium
Health, Charlotte, NC, USA
| | - Meghan Wally
- Department of Orthopaedic Surgery,
Atrium
Health, Charlotte, NC, USA
| | - Gisele Bailey
- Department of Orthopaedic Surgery,
Atrium
Health, Charlotte, NC, USA
| | - Tamar Roomian
- Department of Orthopaedic Surgery,
Atrium
Health, Charlotte, NC, USA
| | - Madhav Karunakar
- Department of Orthopaedic Surgery,
Atrium
Health, Charlotte, NC, USA
| | - Joseph R Hsu
- Department of Orthopaedic Surgery,
Atrium
Health, Charlotte, NC, USA
| | - Rachel Seymour
- Department of Orthopaedic Surgery,
Atrium
Health, Charlotte, NC, USA,Rachel B Seymour, Department of Orthopaedic
Surgery, Atrium Health, 1320 Scott Ave, Charlotte, NC 28204, USA.
| | | | - Michael Bosse
- Department of Orthopaedic Surgery,
Atrium
Health, Charlotte, NC, USA
| | - Michael Gibbs
- Department of Emergency Medicine,
Atrium
Health, Charlotte, NC, USA
| | | | | | - Daniel Leas
- Department of Orthopaedic Surgery,
Atrium
Health, Charlotte, NC, USA
| | - Susan Odum
- OrthoCarolina Research
Institute, Charlotte, NC, USA
| | - Michael Runyon
- Department of Emergency Medicine,
Atrium
Health, Charlotte, NC, USA
| | - Animita Saha
- Department of Internal Medicine,
Atrium
Health, Charlotte, NC, USA
| | - Ziquing Yu
- Department of Orthopaedic Surgery,
Atrium
Health, Charlotte, NC, USA
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Silverman S, Schepman P, Rice JB, Beck CG, Pajerowski W, White AG, Thakkar S, Robinson RL, Emir B. Risk Factors Associated with Falls and Fractures Following Prescription of Opioids Among Privately Insured Patients with Osteoarthritis. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2022; 9:47-56. [PMID: 36060224 PMCID: PMC9391074 DOI: 10.36469/001c.32584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 02/09/2022] [Indexed: 06/15/2023]
Abstract
Background: While prior research has shown that patients with osteoarthritis (OA) who are prescribed opioids have higher rates of falls and fractures following drug initiation, there is a limited body of work establishing a comprehensive model of factors that influence the risk of falls or fractures among these patients. Objective: Opioids are associated with negative clinical outcomes, including increased risk of falls and fractures. This study assessed the frequency, treatment characteristics, and risk factors associated with falls or fractures among patients with OA taking opioids. Methods: Optum Healthcare Solutions, Inc data (January 2012-March 2017) were used to identify patients over 18 with at least 2 diagnoses of hip and/or knee OA, and at least 90 days' supply of opioids. Patients with cancer were excluded. Falls or fractures outcomes were assessed in the 36-month follow-up period after the date of the first opioid prescription after first OA diagnosis. Demographic, treatment, and clinical characteristics associated with falls or fractures were assessed using logistic regression. Results: Of 16 663 patients meeting inclusion criteria, 3886 (23%) had at least 1 fall or fracture during follow-up. Of these 3886 patients, 1349 (35%) had at least 1 fall with an average of 3 fall claims, and 3299 (85%) patients had at least 1 fracture with an average of 8 claims during follow-up. Spine (15.8%) and hip (12.5%) fractures were most common. Median time to fall or fracture was 18.6 and 13.9 months, respectively. Significant (P<.05) risk factors associated with at least 1 fall or fracture during the follow-up period included alcohol use (odds ratio [OR], 3.41), history of falling (OR, 2.19), non-tramadol opioid use (OR, 1.31), age (OR, 1.03), benzodiazepine use (OR, 1.21), and at least 1 osteoporosis diagnosis (OR, 2.06). Discussion: This study is among only a few that clearly identifies the substantial impact and frequency of falls and fractures associated with prescribing non-tramadol opioids to patients with OA. Findings suggest that fall or fracture risks need to be considered when managing OA pain with opioids. Conclusion: Falls and fractures impose a major clinical burden on patients prescribed opioids for OA-related pain management. Falls or fracture risks should be an important consideration in the ongoing treatment of patients with OA.
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Affiliation(s)
- Stuart Silverman
- Cedars-Sinai Medical Center, Los Angeles, California; David Geffen School of Medicine, University of California Los Angeles
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Chu WM, Kristiani E, Wang YC, Lin YR, Lin SY, Chan WC, Yang CT, Tsan YT. A model for predicting fall risks of hospitalized elderly in Taiwan-A machine learning approach based on both electronic health records and comprehensive geriatric assessment. Front Med (Lausanne) 2022; 9:937216. [PMID: 36016999 PMCID: PMC9398203 DOI: 10.3389/fmed.2022.937216] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 07/18/2022] [Indexed: 12/03/2022] Open
Abstract
Backgrounds Falls are currently one of the important safety issues of elderly inpatients. Falls can lead to their injury, reduced mobility and comorbidity. In hospitals, it may cause medical disputes and staff guilty feelings and anxiety. We aimed to predict fall risks among hospitalized elderly patients using an approach of artificial intelligence. Materials and methods Our working hypothesis was that if hospitalized elderly patients have multiple risk factors, their incidence of falls is higher. Artificial intelligence was then used to predict the incidence of falls of these patients. We enrolled those elderly patients aged >65 years old and were admitted to the geriatric ward during 2018 and 2019, at a single medical center in central Taiwan. We collected 21 physiological and clinical data of these patients from their electronic health records (EHR) with their comprehensive geriatric assessment (CGA). Data included demographic information, vital signs, visual ability, hearing ability, previous medication, and activity of daily living. We separated data from a total of 1,101 patients into 3 datasets: (a) training dataset, (b) testing dataset and (c) validation dataset. To predict incidence of falls, we applied 6 models: (a) Deep neural network (DNN), (b) machine learning algorithm extreme Gradient Boosting (XGBoost), (c) Light Gradient Boosting Machine (LightGBM), (d) Random Forest, (e) Stochastic Gradient Descent (SGD) and (f) logistic regression. Results From modeling data of 1,101 elderly patients, we found that machine learning algorithm XGBoost, LightGBM, Random forest, SGD and logistic regression were successfully trained. Finally, machine learning algorithm XGBoost achieved 73.2% accuracy. Conclusion This is the first machine-learning based study using both EHR and CGA to predict fall risks of elderly. Multiple risk factors of falls in hospitalized elderly patients can be put into a machine learning model to predict future falls for early planned actions. Future studies should be focused on the model fitting and accuracy of data analysis.
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Affiliation(s)
- Wei-Min Chu
- Department of Family Medicine, Taichung Veterans General Hospital, sTaichung, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Post-baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Institue of Health Policy and Management, National Taiwan University, Taipei, Taiwan
- Department of Occupational Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Endah Kristiani
- Department of Computer Science, Tunghai University, Taichung, Taiwan
- Department of Informatics, Krida Wacana Christian University, Jakarta, Indonesia
| | - Yu-Chieh Wang
- Department of Computer Science, Tunghai University, Taichung, Taiwan
| | - Yen-Ru Lin
- Department of Computer Science, Tunghai University, Taichung, Taiwan
| | - Shih-Yi Lin
- Center for Geriatrics and Gerontology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wei-Cheng Chan
- Department of Occupational Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chao-Tung Yang
- Department of Computer Science, Tunghai University, Taichung, Taiwan
- Research Center for Smart Sustainable Circular Economy, Tunghai University, Taichung, Taiwan
- Chao-Tung Yang
| | - Yu-Tse Tsan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Occupational Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- *Correspondence: Yu-Tse Tsan
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Hip Fracture Surgery: Regional Anesthesia and Opioid Demand. J Am Acad Orthop Surg 2022; 30:e979-e988. [PMID: 35312633 DOI: 10.5435/jaaos-d-21-00786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 02/17/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Hip fracture surgery is painful, and regional anesthesia (RA) has been used in an attempt to reduce pain and opioid consumption after surgery. Despite potential analgesic benefits, the effect of RA on inpatient and outpatient opioid demand is not well known. We hypothesized that RA would be associated with decreased inpatient opioid demand and has little effect on outpatient opioid demand in hip fracture surgery. METHODS This study retrospectively evaluated all patients of 18 years and older undergoing hip fracture surgery from July 2013 to July 2018 at a single, level I trauma center (n = 1,659). Inpatient opioid consumption in 24-hour increments up to 72-hour postoperative and outpatient opioid prescribing up to 90-day postoperative were recorded in oxycodone 5-mg equivalents (OE's). Adjusted models evaluated the effect of RA on opioid demand after adjusting for other baseline and treatment variables. RESULTS After adjusting for baseline and treatment variables, there were small increases in inpatient opioid consumption in patients with RA (2.6 estimated OE's without RA versus three OE's with RA from 0 to 24 hours postoperatively, 2.1 versus 2.4 from 24 to 48 hours postoperatively, and 1.6 versus 2.2 from 48 to 72 hours postoperatively, all P values for RA <0.001). However, there were no notable differences in outpatient opioid demand. DISCUSSION RA did not decrease inpatient or outpatient opioid demand in patients undergoing hip fracture surgery in this pragmatic study. In fact, there were slight increases in inpatient opioid consumption, although these differences are likely clinically insignificant. These results temper enthusiasm for RA in hip fracture surgery. LEVEL OF EVIDENCE Level III, retrospective, therapeutic cohort study.
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35
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Acton EK, Hennessy S, Brensinger CM, Bilker WB, Miano TA, Dublin S, Horn JR, Chung S, Wiebe DJ, Willis AW, Leonard CE. Opioid Drug-Drug-Drug Interactions and Unintentional Traumatic Injury: Screening to Detect Three-Way Drug Interaction Signals. Front Pharmacol 2022; 13:845485. [PMID: 35620282 PMCID: PMC9127150 DOI: 10.3389/fphar.2022.845485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 04/18/2022] [Indexed: 12/02/2022] Open
Abstract
Growing evidence suggests that drug interactions may be responsible for much of the known association between opioid use and unintentional traumatic injury. While prior research has focused on pairwise drug interactions, the role of higher-order (i.e., drug-drug-drug) interactions (3DIs) has not been examined. We aimed to identify signals of opioid 3DIs with commonly co-dispensed medications leading to unintentional traumatic injury, using semi-automated high-throughput screening of US commercial health insurance data. We conducted bi-directional, self-controlled case series studies using 2000-2015 Optum Data Mart database. Rates of unintentional traumatic injury were examined in individuals dispensed opioid-precipitant base pairs during time exposed vs unexposed to a candidate interacting precipitant. Underlying cohorts consisted of 16-90-year-olds with new use of opioid-precipitant base pairs and ≥1 injury during observation periods. We used conditional Poisson regression to estimate rate ratios adjusted for time-varying confounders, and semi-Bayes shrinkage to address multiple estimation. For hydrocodone, tramadol, and oxycodone (the most commonly used opioids), we examined 16,024, 8185, and 9330 drug triplets, respectively. Among these, 75 (0.5%; hydrocodone), 57 (0.7%; tramadol), and 42 (0.5%; oxycodone) were significantly positively associated with unintentional traumatic injury (50 unique base precipitants, 34 unique candidate precipitants) and therefore deemed potential 3DI signals. The signals found in this study provide valuable foundations for future research into opioid 3DIs, generating hypotheses to motivate crucially needed etiologic investigations. Further, this study applies a novel approach for 3DI signal detection using pharmacoepidemiologic screening of health insurance data, which could have broad applicability across drug classes and databases.
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Affiliation(s)
- Emily K. Acton
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Sean Hennessy
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Colleen M. Brensinger
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Warren B. Bilker
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Todd A. Miano
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Sascha Dublin
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA, United States
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, United States
| | - John R. Horn
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA, United States
| | - Sophie Chung
- AthenaHealth, Inc., Watertown, MA, United States
| | - Douglas J. Wiebe
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States
- Penn Injury Science Center, University of Pennsylvania, Philadelphia, PA, United States
| | - Allison W. Willis
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States
| | - Charles E. Leonard
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States
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Abstract
INTRODUCTION The use of medications with anticholinergic (ACh) properties is associated with numerous adverse effects especially in older adults. Emerging evidence suggests the presence of long-term effects with ACh use. AREAS COVERED Our article presents an overview of ACh effects and falls in older individuals including examination of emerging evidence on ACh use and cumulative exposure on short-term and long-term falls risk. The databases CINAHL, MEDLINE, EMBASE, and Web of Science were searched for articles published from January 2002 to December 2021. EXPERT OPINION Anticholinergic side effects include muscle weakness, blurred vision, and mental confusion which are likely to lead to increased falls risk. Many commonly used medications such as beta-blockers, calcium-channel blockers, and antihistamines are now known to have mild ACh properties. With polypharmacy now considered unavoidable in older patients, the cumulative effects of the use of multiple drugs with mild ACh properties may also lead to increased falls risk. The relationship between ACh drugs and falls may also be irreversible as ACh effects may extend beyond the period of drug use, due to cognitive and physical deconditioning following the initial exposure to ACh drugs. Future long-term studies with accurate quantification of cumulative ACh exposure and measurement of actual falls outcomes are urgently required.
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Affiliation(s)
- Xiang Jiang Xu
- Ageing and Age-Associated Disorders Research Group, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Maw Pin Tan
- Ageing and Age-Associated Disorders Research Group, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.,Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.,Department of Medical Sciences, Faculty of Healthcare and Medical Sciences, Sunway University, Selangor, Malaysia
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Wang H, Cai S, Caprio T, Goulet J, Intrator O. Opioid administration trends among long-stay community living centers residents with dementia. J Am Geriatr Soc 2022; 70:2393-2403. [PMID: 35397116 DOI: 10.1111/jgs.17785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/14/2022] [Accepted: 03/22/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pain assessment and management of Veterans with Alzheimer's disease and Related Dementia (ADRD) living in Community Living Centers (CLCs) is challenging. Safe and effective use of opioids in the treatment of pain is of great concern to patients and providers promulgating national policies and guidelines. METHODS This study examined long-stay CLC Veterans with ADRD identified in three regulatory periods (period 1: 10/2012-6/2013, n = 3347; period 2: 1/2014-11/2015, n = 4426; period 3: 1/2017-9/2018, n = 4444; Total N = 12,217).This population-based observational study used CLC Minimum Data Set (MDS) data in Fiscal Years (FYs) 2013-2018 and VA bar-code medication administration (BCMA) data. Opioid administration measures included: any opioids, long-term opioids, high-dose opioids, and co-administration with benzodiazepine. Measures were modeled using negative binomial regression with length of stay in CLC as offset adjusting for Veteran predisposing, enabling and need measures from the MDS. RESULTS Compared to period 1, any opioid administration was 26% lower in period 2, and 34% lower in period 3. Among Veterans who received any opioid medications over the three regulatory periods, high-dose and long-term opioid administration were more than 40% lower in periods 2 and 3 compared to period 1. Co-administration of opioid with benzodiazepine versus no opioid was 11% lower in period 2 and 34% lower in period 3 after adjusting for patient level covariates. CONCLUSIONS All patterns of opioid administration decreased over the four opioid regulations periods when guidelines were promulgated across the VA health system. Further research should clarify whether decreasing opioids among patients with ADRD impacted health outcomes.
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Affiliation(s)
- Huiying Wang
- Geriatrics and Extended Care Data and Analysis Center (GECDAC), Finger Lakes Healthcare System, Canandaigua, New York, USA.,Public Health Sciences, University of Rochester, Rochester, New York, USA
| | - Shubing Cai
- Geriatrics and Extended Care Data and Analysis Center (GECDAC), Finger Lakes Healthcare System, Canandaigua, New York, USA.,Public Health Sciences, University of Rochester, Rochester, New York, USA
| | - Thomas Caprio
- Department of Medicine, University of Rochester, Rochester, New York, USA
| | - Joseph Goulet
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Orna Intrator
- Geriatrics and Extended Care Data and Analysis Center (GECDAC), Finger Lakes Healthcare System, Canandaigua, New York, USA.,Public Health Sciences, University of Rochester, Rochester, New York, USA
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Dowd LA, Reynolds L, Cross AJ, Veal F, Steeper M, Wanas Z, Wu N, Bell JS. A systematic review of opioid prevalence in Australian residential aged care facilities. Australas J Ageing 2022; 41:501-512. [PMID: 35394708 PMCID: PMC10083958 DOI: 10.1111/ajag.13071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 02/24/2022] [Accepted: 03/10/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To systematically review the prevalence of opioid prescribing, dispensing and administration in Australian residential aged care facilities (RACFs). METHODS MEDLINE, Embase, CINAHL, AgeLine, Web of Science Core Collection, InformIT and International Pharmaceutical Abstracts (inception to September 2021) were searched for studies reporting opioid prevalence in Australian RACFs. Regular and as-required (i.e. pro re nata, PRN) opioid uses were considered. Screening, data extraction and quality assessment were performed independently by two review authors. RESULTS Twenty-three studies (n = 286,141 residents) reported opioid prevalence, of which 16 provided overall regular or PRN prescribing, dispensing or administration data. Five studies reported 28%-34% of residents were prescribed regular opioids over assessment periods ranging from one week to one month. Five studies reported 11%-42% of residents were prescribed PRN opioids over assessment periods ranging from one week to 30 months. Three studies reported 27%-50% of residents were dispensed an opioid over 12 months. Five studies reported 21%-29% were administered both regular and PRN opioids over 24 hours. Two studies reported 22%-42% of residents were administered PRN opioids over 1 week to 12 months. Two studies reported 6%-13% of residents were using doses >100 mg oral morphine equivalents/day. CONCLUSIONS Up to half of the residents were dispensed opioids over 12 months. The prevalence of opioid prescribing, dispensing and administration was highly variable, suggesting the potential value of opioid quality indicators and analgesic stewardship interventions to ensure opioid appropriateness.
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Affiliation(s)
- Laura A Dowd
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Melbourne, Victoria, Australia
| | - Lorenna Reynolds
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Melbourne, Victoria, Australia
| | - Amanda J Cross
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Melbourne, Victoria, Australia
| | - Felicity Veal
- Unit for Medication Outcomes Research & Education (UMORE), School of Pharmacy and Pharmacology, University of Tasmania, Hobart, Tasmania, Australia
| | - Michelle Steeper
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Melbourne, Victoria, Australia
| | - Zainab Wanas
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Melbourne, Victoria, Australia
| | - Nancy Wu
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Melbourne, Victoria, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Melbourne, Victoria, Australia.,National Health and Medical Research Council (NHMRC), Centre of Research Excellence in Frailty and Healthy Ageing, Adelaide, South Australia, Australia
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Virnes RE, Tiihonen M, Karttunen N, van Poelgeest EP, van der Velde N, Hartikainen S. Opioids and Falls Risk in Older Adults: A Narrative Review. Drugs Aging 2022; 39:199-207. [PMID: 35288864 PMCID: PMC8934763 DOI: 10.1007/s40266-022-00929-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2022] [Indexed: 02/07/2023]
Abstract
Pain treatment is important in older adults but may result in adverse events such as falls. Opioids are effective for nociceptive pain but the evidence for neuropathic pain is weak. Nevertheless, both pain and opioids may increase the risk of falls. This narrative literature review aims to summarize the existing knowledge on the opioid-related fall risk in older adults, including the pharmacokinetics and pharmacodynamics, and assist clinicians in prescribing and deprescribing opioids in older persons. We systematically searched relevant literature on opioid-related fall risk in older adults in PubMed and Scopus in December 2020. We reviewed the literature and evaluated fall-related adverse effects of opioids, explaining how to optimally approach deprescribing of opioids in older adults. Opioid use increases fall risk through drowsiness, (orthostatic) hypotension and also through hyponatremia caused by weak opioids. When prescribing, opioids should be started with low dosages if possible, keeping in mind their metabolic genetic variation. Falls are clinically significant adverse effects of all opioids, and the risk may be dose dependent and highest with strong opioids. The risk is most prominent in older adults prone to falls. To reduce the risk of falls, both pain and the need for opioids should be assessed on a regular basis, and deprescribing or changing to a lower dosage or safer alternative should be considered if the clinical condition allows. Deprescribing should be done by reducing the dosage gradually and by assessing and monitoring the pain and withdrawal symptoms at the same time. Weighing the risks and benefits is necessary before prescribing opioids, especially to older persons at high risk of falls. Clinical decision tools assist prescribers in clinical decisions regarding (de-) prescribing.
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Affiliation(s)
- Roosa-Emilia Virnes
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland
| | - Miia Tiihonen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland. .,Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland.
| | - Niina Karttunen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland
| | - Eveline P van Poelgeest
- Department of Internal Medicine, Geriatrics, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Natalie van der Velde
- Department of Internal Medicine, Geriatrics, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Sirpa Hartikainen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland
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40
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Allahabadi S, Roostan M, Roddy E, Ward DT, Rogers S, Kim C. Operative Management of Hip Fractures Within 24 Hours in the Elderly is Achievable and Associated With Reduced Opiate Use. Geriatr Orthop Surg Rehabil 2022; 13:21514593221116331. [PMID: 37101932 PMCID: PMC10123378 DOI: 10.1177/21514593221116331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 07/11/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Morbidity and mortality benefits have been associated with prompt surgical treatment of geriatric hip fractures. The purpose of this study was to evaluate the impact of early (≤24 hr) vs delayed (>24 hr) time to operating room (TTOR) on 1) hospital length of stay and 2) total and post-operative opiate use in geriatric hip fractures. Materials and Methods This study was a retrospective review of patients ≥65 years-old at the time of admission for surgery for hip fracture at a Level II academic trauma center. Outcome measures were length of stay (LOS), oral morphine equivalents (OME) throughout hospitalization. Patients were stratified into early and delayed TTOR groups and comparisons were made between groups. Results Between the early (n = 75, 80.6%) and late (n = 18, 19.4%) groups, there were no differences in age, fracture pattern, type of treatment, preoperative opiate use, and perioperative non-oral pain management. The early group trended toward shorter total LOS (108.0 ± 67.2 hours vs 144.8 ± 103.7 hours, P = .066), but not post-operative LOS. Total OME usage was less in the early intervention group (92.5 ± 188.0 vs 230.2 ± 296.7, P = .015), in addition to reduced post-operative OME (81.3 ± 174.9 vs 213.3 ± 271.3, P = .012). There were no differences in evaluated potential delay sources such as primary language, use of surrogate decision makers, or need for advanced imaging. Discussion Surgical treatment of geriatric hip/femur fractures in ≤24 hours from presentation is achievable and may be associated with reduced total inpatient opiate use, although daily use did not differ. Conclusion Establishing institutional TTOR goals as part of an interdisciplinary hip fracture co-management clinical pathway can facilitate prompt care and contribute to recovery and less opiate use in these patients with highly morbid injuries.
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Affiliation(s)
- Sachin Allahabadi
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Mohammad Roostan
- Department of Internal Medicine, Division of Geriatrics, University of California San Francisco, San Francisco, CA, USA
| | - Erika Roddy
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Derek T. Ward
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Stephanie Rogers
- Department of Internal Medicine, Division of Geriatrics, University of California San Francisco, San Francisco, CA, USA
| | - Candace Kim
- Department of Internal Medicine, Division of Geriatrics, University of California San Francisco, San Francisco, CA, USA
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Thapa R, Garikipati A, Shokouhi S, Hurtado M, Barnes G, Hoffman J, Calvert J, Katzmann L, Mao Q, Das R. Usability of Electronic Health records in Predicting Short-term falls: Machine learning Applications in Senior Care Facilities (Preprint). JMIR Aging 2021; 5:e35373. [PMID: 35363146 PMCID: PMC9015781 DOI: 10.2196/35373] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/16/2022] [Accepted: 02/07/2022] [Indexed: 11/23/2022] Open
Abstract
Background Short-term fall prediction models that use electronic health records (EHRs) may enable the implementation of dynamic care practices that specifically address changes in individualized fall risk within senior care facilities. Objective The aim of this study is to implement machine learning (ML) algorithms that use EHR data to predict a 3-month fall risk in residents from a variety of senior care facilities providing different levels of care. Methods This retrospective study obtained EHR data (2007-2021) from Juniper Communities’ proprietary database of 2785 individuals primarily residing in skilled nursing facilities, independent living facilities, and assisted living facilities across the United States. We assessed the performance of 3 ML-based fall prediction models and the Juniper Communities’ fall risk assessment. Additional analyses were conducted to examine how changes in the input features, training data sets, and prediction windows affected the performance of these models. Results The Extreme Gradient Boosting model exhibited the highest performance, with an area under the receiver operating characteristic curve of 0.846 (95% CI 0.794-0.894), specificity of 0.848, diagnostic odds ratio of 13.40, and sensitivity of 0.706, while achieving the best trade-off in balancing true positive and negative rates. The number of active medications was the most significant feature associated with fall risk, followed by a resident’s number of active diseases and several variables associated with vital signs, including diastolic blood pressure and changes in weight and respiratory rates. The combination of vital signs with traditional risk factors as input features achieved higher prediction accuracy than using either group of features alone. Conclusions This study shows that the Extreme Gradient Boosting technique can use a large number of features from EHR data to make short-term fall predictions with a better performance than that of conventional fall risk assessments and other ML models. The integration of routinely collected EHR data, particularly vital signs, into fall prediction models may generate more accurate fall risk surveillance than models without vital signs. Our data support the use of ML models for dynamic, cost-effective, and automated fall predictions in different types of senior care facilities.
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Bogin MH, Verdoorn BP. 91-Year-Old Man With Recurrent Falls. Mayo Clin Proc 2021; 96:3153-3157. [PMID: 34736779 DOI: 10.1016/j.mayocp.2021.03.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/09/2021] [Accepted: 03/12/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Melissa H Bogin
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Brandon P Verdoorn
- Advisor to resident and Consultant in Community Internal Medicine, Mayo Clinic, Rochester, MN.
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Case AA, Kullgren J, Anwar S, Pedraza S, Davis MP. Treating Chronic Pain with Buprenorphine-The Practical Guide. Curr Treat Options Oncol 2021; 22:116. [PMID: 34791564 DOI: 10.1007/s11864-021-00910-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2021] [Indexed: 12/30/2022]
Abstract
OPINION STATEMENT Buprenorphine has unique and favorable pharmacological properties that make it useful in a variety of clinical scenarios. It has been recommended to consider buprenorphine first-line opioid for chronic pain, especially in the elderly as it may be associated with less cognitive impairment, falls, sexual dysfunction, and sarcopenia when compared with schedule II opioids. It may be useful in patients with comorbid substance use disorder or non-medical opioid use, as there is less risk of misuse, euphoria and it may improve mood. When used to treat opioid use disorder, the training and waiver was recently waived for licensed practitioners with a DEA and any provider may prescribe buprenorphine. For many reasons outlined in this article, the popularity of using buprenorphine for analgesia continues to grow and a practitioner should consider this as an excellent and safe option for chronic pain.
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Affiliation(s)
- Amy A Case
- Lee Foundation Endowed Chair Supportive and Palliative Care, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.
| | - Justin Kullgren
- Palliative Medicine Clinical Pharmacy, Ohio State University Wexner Medical Center, James Cancer Hospital, Columbus, OH, USA
| | - Sidra Anwar
- Supportive Care, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Sandra Pedraza
- Palliative Care, Sibley Memorial Hospital Johns Hopkins Medicine, Washington, DC, USA
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Davies E, Phillips CJ, Jones M, Sewell B. Healthcare resource utilisation and cost analysis associated with opioid analgesic use for non-cancer pain: A case-control, retrospective study between 2005 and 2015. Br J Pain 2021; 16:243-256. [PMID: 35419202 PMCID: PMC8998526 DOI: 10.1177/20494637211045898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective To examine differences in healthcare utilisation and costs associated with opioid prescriptions for non-cancer pain issued in primary care. Method A longitudinal, case-control study retrospectively examined Welsh healthcare data for the period 1 January 2005–31 December 2015. Data were extracted from the Secure Anonymised Information Linkage (SAIL) databank. Subjects, aged 18 years and over, were included if their primary care record contained at least one of six overarching pain diagnoses during the study period. Subjects were excluded if their record also contained a cancer diagnosis in that time or the year prior to the study period. Case subjects also received at least one prescription for an opioid analgesic. Controls were matched by gender, age, pain-diagnosis and socioeconomic deprivation. Healthcare use included primary care visits, emergency department (ED) and outpatient (OPD) attendances, inpatient (IP) admissions and length of stay. Cost analysis for healthcare utilisation used nationally derived unit costs for 2015. Differences between case and control subjects for resource use and costs were analysed and further stratified by gender, prescribing persistence (PP) and deprivation. Results Data from 3,286,215 individuals were examined with 657,243 receiving opioids. Case subjects averaged 5 times more primary care visits, 2.8 times more OPD attendances, 3 times more ED visits and twice as many IN admissions as controls. Prescription persistence over 6 months and greater deprivation were associated with significantly greater utilisation of healthcare resources. Opioid prescribing was associated with 69% greater average healthcare costs than in control subjects. National Health Service (NHS) healthcare service costs for people with common, pain-associated diagnoses, receiving opioid analgesics were estimated to be £0.9billion per year between 2005 and 2015. Conclusion Receipt of opioid prescriptions was associated with significantly greater healthcare utilisation and accompanying costs in all sectors. Extended prescribing durations are particularly important to address and should be considered at the point of initiation.
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Affiliation(s)
- Emma Davies
- College of Human and Health Sciences, Swansea University, Swansea, UK
| | - Ceri J Phillips
- College of Human and Health Sciences, Swansea University, Swansea, UK
| | - Mari Jones
- Swansea Centre for Health Economics, Swansea University College of Human and Health Sciences, Swansea, UK
| | - Bernadette Sewell
- College of Human and Health Sciences, Swansea University, Swansea, UK
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45
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Guan Q, McCormack D, Juurlink DN, Bronskill SE, Wunsch H, Gomes T. New Opioid Use and Risk of Emergency Department Visits Related to Motor Vehicle Collisions in Ontario, Canada. JAMA Netw Open 2021; 4:e2134248. [PMID: 34762109 PMCID: PMC8586904 DOI: 10.1001/jamanetworkopen.2021.34248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Opioids can impair motor skills and may affect the ability to drive; however, the association of opioid use with driving ability is not well established. OBJECTIVE To examine the risk of motor vehicle collisions (MVCs) among drivers starting opioid therapy compared with that among drivers starting nonsteroidal anti-inflammatory drug (NSAID) therapy. DESIGN, SETTING, AND PARTICIPANTS This population-based, retrospective cohort study included all residents of Ontario aged 17 years or older who started new prescription analgesic therapy between March 1, 2008, and March 17, 2019. EXPOSURES Initiation of opioid therapy or NSAID therapy, ascertained through prescription dispensing records in administrative data. MAIN OUTCOMES AND MEASURES The primary outcome was an emergency department visit for injuries sustained as a driver in an MVC during the 14 days after starting analgesic therapy. Inverse probability treatment weighting was used to balance baseline covariates, and weighted Cox proportional hazards regression models were used to assess the association between new analgesic therapy and hazard of an emergency department visit after an MVC. RESULTS Of the 1 454 824 individuals included in the study, 765 464 (52.6%) were new opioid recipients and 689 360 (47.4%) were new NSAID recipients. Most participants were aged 65 years or older (75.2%), and 55.2% were women. Of 194 individuals who had emergency department visits for injuries from an MVC within 14 days of initiating therapy, 98 (50.5%) were opioid recipients (3.41 per 1000 person-years; 95% CI, 2.80-4.15 per 1000 person-years) and 96 (49.5%) were NSAID recipients (3.64 per 1000 person-years; 95% CI, 2.98-4.45 per 1000 person-years). There was no significant difference in the risk of an emergency department visit for MVC injuries between opioid and NSAID recipients (weighted hazard ratio, 0.94; 95% CI, 0.70-1.25). CONCLUSIONS AND RELEVANCE The findings of this study suggest that the hazard of an emergency department visit for injuries relating to an MVC as a driver is similar between individuals starting prescription opioids and those starting prescription NSAIDs. These results may be useful for patients, clinicians, and caregivers when considering new analgesic therapy.
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Affiliation(s)
- Qi Guan
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Ontario, Toronto, Canada
| | | | - David N. Juurlink
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Susan E. Bronskill
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Hannah Wunsch
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology, Columbia University Medical College, New York, New York
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tara Gomes
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Ontario, Toronto, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
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46
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Dowd LA, Cross AJ, Veal F, Ooi CE, Bell JS. A Systematic Review of Interventions to Improve Analgesic Use and Appropriateness in Long-Term Care Facilities. J Am Med Dir Assoc 2021; 23:33-43.e3. [PMID: 34710365 DOI: 10.1016/j.jamda.2021.09.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/14/2021] [Accepted: 09/21/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To systematically review the effectiveness of interventions to improve analgesic use and appropriateness in long-term care facilities (LTCFs). DESIGN Systematic review. SETTING AND PARTICIPANTS MEDLINE, Embase, PsycINFO, and CINAHL Plus were searched from inception to June 2021. Randomized controlled trials (RCTs), controlled and uncontrolled prospective interventions that included analgesic optimization, and reported postintervention change in analgesic use or appropriateness in LTCFs were included. METHODS Screening, data extraction, and quality assessment were performed independently by 2 review authors. RESULTS Eight cluster RCTs, 2 controlled, and 6 uncontrolled studies comprising 9056 residents across 9 countries were included. The 16 interventions included education (n = 13), decision support (n = 7), system modifications (n = 6), and/or medication review (n = 3). Six interventions changed analgesic use or appropriateness, all of which included prescribers, 5 involved multidisciplinary collaboration, and 5 included a component of education. Education alone changed analgesic use and appropriateness in 1 study. Decision support was effective when combined with education in 3 interventions. Overall, 13 studies reported analgesic optimization as part of pain management interventions and 3 studies focused on medication optimization. Two pain management interventions reduced the percentage of residents reporting pain not receiving analgesics by 50% to 60% (P = .03 and P < .001, respectively), and 1 improved analgesic appropriateness (P = .03). One reduced nonsteroidal anti-inflammatory drugs (NSAIDs) (P < .001) and another resulted in 3-fold higher odds of opioid prescription in advanced dementia [95% confidence interval (CI) 1.1-8.7]. One medication optimization intervention reduced NSAID prescription (P = .036), and another reduced as-needed opioid (95% CI 8.6-13.8) and NSAID prescription (95% CI 1.6-4.2). CONCLUSIONS AND IMPLICATIONS Interventions involving prescribers and enhanced roles for pharmacists and nurses, with a component of education, are most effective at changing analgesic use or appropriateness. Interventions combining education and decision support are also promising. Medication review interventions can change analgesic prescription, although there is currently minimal evidence in relation to possible corresponding improvements in resident-related outcomes.
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Affiliation(s)
- Laura A Dowd
- Centre for Medicine Use and Safety (CMUS), Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia.
| | - Amanda J Cross
- Centre for Medicine Use and Safety (CMUS), Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Felicity Veal
- Unit for Medication Outcomes Research & Education (UMORE), School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS, Australia
| | - Choon Ean Ooi
- Centre for Medicine Use and Safety (CMUS), Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety (CMUS), Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia; National Health and Medical Research Council (NHMRC) Centre of Research Excellence in Frailty and Healthy Ageing, Adelaide, South Australia
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Dormosh N, Schut MC, Heymans MW, van der Velde N, Abu-Hanna A. Development and internal validation of a risk prediction model for falls among older people using primary care electronic health records. J Gerontol A Biol Sci Med Sci 2021; 77:1438-1445. [PMID: 34637510 PMCID: PMC9255681 DOI: 10.1093/gerona/glab311] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Indexed: 11/25/2022] Open
Abstract
Background Currently used prediction tools have limited ability to identify community-dwelling older people at high risk for falls. Prediction models utilizing electronic health records (EHRs) provide opportunities but up to now showed limited clinical value as risk stratification tool, because of among others the underestimation of falls prevalence. The aim of this study was to develop a fall prediction model for community-dwelling older people using a combination of structured data and free text of primary care EHRs and to internally validate its predictive performance. Methods We used EHR data of individuals aged 65 or older. Age, sex, history of falls, medications, and medical conditions were included as potential predictors. Falls were ascertained from the free text. We employed the Bootstrap-enhanced penalized logistic regression with the least absolute shrinkage and selection operator to develop the prediction model. We used 10-fold cross-validation to internally validate the prediction strategy. Model performance was assessed in terms of discrimination and calibration. Results Data of 36 470 eligible participants were extracted from the data set. The number of participants who fell at least once was 4 778 (13.1%). The final prediction model included age, sex, history of falls, 2 medications, and 5 medical conditions. The model had a median area under the receiver operating curve of 0.705 (interquartile range 0.700–0.714). Conclusions Our prediction model to identify older people at high risk for falls achieved fair discrimination and had reasonable calibration. It can be applied in clinical practice as it relies on routinely collected variables and does not require mobility assessment tests.
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Affiliation(s)
- Noman Dormosh
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC - Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Martijn C Schut
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC - Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Martijn W Heymans
- Department of Epidemiology and Biostatistics, Amsterdam UMC - Location VU, VU University Medical Center, Amsterdam, The Netherlands
| | - Nathalie van der Velde
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC - Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ameen Abu-Hanna
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC - Location AMC, University of Amsterdam, Amsterdam, The Netherlands
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Yoshikawa A, Smith ML, Ory MG. Differential risk of falls associated with pain medication among community-dwelling older adults by cognitive status. Age Ageing 2021; 50:1578-1585. [PMID: 33765121 DOI: 10.1093/ageing/afab051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Persons living with dementia have an elevated risk of falling and chronic pain. This study investigates the relationship of pain medication use with falls among community-dwelling adults based on their cognitive status. METHODS We analysed a nationally representative sample of community-dwelling Medicare beneficiaries (n = 7,491) who completed cognitive assessments used for dementia classification in the 2015 US National Health and Aging Trends Study. We performed survey-weighted logistic regression to investigate differential associations between pain medication use and a recent fall by cognitive status: no dementia, possible dementia and probable dementia, controlling for sociodemographic and health characteristics. RESULTS About 16.5% of the analytic sample was classified as possible dementia (8.3%) and probable dementia (8.2%). Pain medication use was associated with a recent fall among those with probable dementia [odds ratio (OR) = 1.86, 95% confidence interval (CI): 1.14, 3.03], controlling for sociodemographic and health characteristics. Taking medication for pain 2 days a week or more (OR = 2.14, 95% CI: 1.20, 3.81) was associated with falls among those with probable dementia. Bothersome pain and worry about falling down were also associated with falls among participants with no dementia and possible dementia, respectively. CONCLUSION Differential risk factors for falls by cognitive status imply the need for tailored pain management and fall prevention strategies. The provision of fall prevention programmes stressing balance training and medication use is important regardless of cognitive status in community-dwelling older adults. Future research should explore other modifiable factors associated with the risk of falls among community-dwelling adults.
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Affiliation(s)
- Aya Yoshikawa
- Center for Population Health and Aging, School of Public Health, Texas A&M University, College Station, TX, USA
| | - Matthew Lee Smith
- Center for Population Health and Aging, School of Public Health, Texas A&M University, College Station, TX, USA
- Department of Environmental and Occupational Health, School of Public Health, Texas A&M University, College Station, TX, USA
| | - Marcia G Ory
- Center for Population Health and Aging, School of Public Health, Texas A&M University, College Station, TX, USA
- Department of Environmental and Occupational Health, School of Public Health, Texas A&M University, College Station, TX, USA
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Dufort A, Samaan Z. Problematic Opioid Use Among Older Adults: Epidemiology, Adverse Outcomes and Treatment Considerations. Drugs Aging 2021; 38:1043-1053. [PMID: 34490542 PMCID: PMC8421190 DOI: 10.1007/s40266-021-00893-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2021] [Indexed: 11/23/2022]
Abstract
With the aging population, an increasing number of older adults (> 65 years) will be affected by problematic opioid use and opioid use disorder (OUD), with both illicit and prescription opioids. Problematic opioid use is defined as the use of opioids resulting in social, medical or psychological consequences, whereas OUD is a form of problematic use that meets diagnostic criteria as defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Problematic use of opioids by older adults is associated with a number of pertinent adverse effects, including sedation, cognitive impairment, falls, fractures and constipation. Risk factors for problematic opioid use in this population include pain, comorbid medical illnesses, concurrent alcohol use disorder and depression. Treatment of OUD consists of acute detoxification and maintenance therapy. At this time, there have been no randomized controlled trials examining the effectiveness of pharmacological interventions for OUD in this population, with recommendations based on data from younger adults. Despite this, opioid agonist therapy (OAT) is recommended for both stages of treatment in older adults with OUD. Buprenorphine is recommended as a first line agent over methadone in the older adult population, due to a more favourable safety profile and relative accessibility. Use of methadone in this population is complicated by risk of QT interval prolongation and respiratory depression. Available observational data suggests that older adults respond well to OAT and age should not be a barrier to treatment. Further research is required to inform treatment decisions in this population.
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Affiliation(s)
- Alexander Dufort
- Department of Psychiatry and Behavioural Neurosciences, St. Joseph's Healthcare Hamilton, McMaster University, West 5th Campus, Administration-B3, 100 West 5th, Hamilton, ON, L8N 3K7, Canada.
| | - Zainab Samaan
- Department of Psychiatry and Behavioural Neurosciences, St. Joseph's Healthcare Hamilton, McMaster University, West 5th Campus, Administration-B3, 100 West 5th, Hamilton, ON, L8N 3K7, Canada.,Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
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Torp HA, Skurtveit S, Skaga NO, Gustavsen I, Gran JM, Rosseland LA. Pre-injury dispensing of psychoactive prescription drugs in a ten years trauma population: a retrospective registry analysis. Scand J Trauma Resusc Emerg Med 2021; 29:125. [PMID: 34454541 PMCID: PMC8399706 DOI: 10.1186/s13049-021-00939-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/16/2021] [Indexed: 11/14/2022] Open
Abstract
Background The use of psychoactive prescription drugs is associated with increased risk of traumatic injury, and has negative impact on clinical outcome in trauma patients. Previous studies have focused on specific drugs or subgroups of patients. Our aim was to examine the extent of psychoactive drug dispensing prior to injury in a comprehensive population of trauma patients. Methods The Oslo University Hospital Trauma Registry provided data on all trauma patients admitted to the trauma centre between 2005 and 2014. We linked the data to Norwegian Prescription Database data from 2004. Opioids, benzodiazepines, z-hypnotics, gabapentinoids, and centrally acting sympathomimetics dispensed during the year before trauma of each patient were identified. We determined the pre-trauma annual prevalence of dispensing and mean annual cumulative defined daily doses (DDD) for each drug class, and compared results with corresponding figures in the general population, using standardised ratios. For each drug class, dispensing 14 days preceding trauma was analysed in patients sustaining severe injury and compared with patients sustaining non-severe injury. Results 12,713 patients (71% male) were included. Median age was 36 years. 4891 patients (38%) presented with severe injury (Injury Severity Score > 15). The ratio between annual prevalence of dispensed prescriptions for trauma patients and the general population, adjusted for age and sex, was 1.5 (95% confidence interval 1.4–1.6) for opioids, 2.1 (2.0–2.2) for benzodiazepines, 1.7 (1.6–1.8) for z-hypnotics, 1.9 (1.6–2.2) for gabapentinoids, and 1.9 (1.6–2.2) for centrally acting sympathomimetics. Compared with the general population, mean annual cumulative DDD of opioids and benzodiazepines dispensed to trauma patients were more than two and three times as high, respectively, in several age groups below 70 years. The prevalence of dispensing 14 days pre-trauma was higher in severely injured patients for opioids, benzodiazepines, and z-hypnotics compared with patients without severe injury. Conclusions Our results support previous findings that the prevalence of psychoactive drug use is high among trauma patients. In terms of both frequency and amounts, the pre-injury dispensing of psychoactive drugs to trauma patients supersedes that of the general population, especially in younger patients.
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Affiliation(s)
- Henrik Andreas Torp
- Department of Pharmacology, Division of Laboratory Medicine, Oslo University Hospital, Oslo, Norway. .,Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway. .,Division of Critical Care, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Svetlana Skurtveit
- Norwegian Centre for Addiction Research, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Mental Disorders, Norwegian Institute of Public Health, Oslo, Norway
| | - Nils Oddvar Skaga
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway.,Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Ingebjørg Gustavsen
- Department of Pharmacology, Division of Laboratory Medicine, Oslo University Hospital, Oslo, Norway
| | - Jon Michael Gran
- Department of Biostatistics, Oslo Centre for Biostatistics and Epidemiology, Institute of Basal Medical Sciences, University of Oslo, Oslo, Norway
| | - Leiv Arne Rosseland
- Division of Critical Care, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
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