Overprescribing and rational therapeutics: Barriers to change and opportunities to improve

Advances in Pharmacy Practice: A Look towards the Future

This review looks at the factors that may influence practice in the future. Transformation could occur at 3 levels. Firstly, the traditional profession of the pharmacist as a dispenser of medicines is expanding. Secondly, the pharmacist’s activities are progressing into new healthcare fields. Thirdly, other changes are stimulated by global developments. This review may be helpful for pharmacy and healthcare leaders looking at the future configuration and aims of their pharmacy services.

Potential inappropriate use of strong opioid analgesics in cancer outpatients during the last year of life in France and associated factors

AIMS

A better knowledge of opioid prescribing patterns would help to identify areas of potential improvement in cancer pain management. This study aimed to identify potential inappropriate use (PIU) of strong opioid analgesics in cancer outpatients in their last year of life.

METHODS

A retrospective cohort of cancer patients who died between 2011 and 2014 and were exposed as outpatient to a strong opioid analgesic in the last year of life was identified in the Echantillon Généraliste de Bénéficiaires (a 1/97th random sample of the French general population). Prescribing patterns of strong opioids were analysed and PIU was defined by at least 1 of these criteria: overlapping prescriptions; contraindicated prescriptions; lack of laxatives; potential drug interactions; prescription in patients hospitalized for opioid-related disorders. Factors associated with PIU were investigated through a multiple logistic regression model.

RESULTS

One third of the 2236 patients (median age 72 years [interquartile range: 61-82], 44.1% women) presented a PIU (insufficient laxative prescription [19.6% of patients], insufficient background treatment with transmucosal fentanyl [14.8%], overlapping prescriptions [2.6%]). The rate of PIU significantly decreased from 37.6% (2011) to 29.8% (2014). For patients with a duration of opioid use ≥3 months, factors associated with PIU were fentanyl prescription (adjusted odds ratio = 2.36; 95% confidence interval [1.86-3.00]) and previous use of strong opioid (adjusted odds ratio = 1.88; [1.50-2.36]).

CONCLUSION

In France, 1/3 of cancer patients exposed to strong opioids experienced PIU and this proportion tended to decrease over time. There is still room for progress in cancer pain management at the end of life.

Opioid medicines management in primary care settings: A scoping review of quantitative studies of pharmacist activities

To undertake a scoping review of pharmacist activities in opioid medicines management in primary care settings, including those developed or led by pharmacists, or in which pharmacists were members of broader multidisciplinary teams, and to collate the activities, models of care and settings, and reported outcomes. The bibliographic databases MEDLINE, EMBASE, International Pharmaceutical Abstracts, CINAHL, SCOPUS and Web of Science were searched. Studies with quantitative evaluation and published in English were eligible. Participants were patients with any pain category or an opioid use disorder, and healthcare providers. Studies originating in hospitals or involving supply functions were not included. Screening of literature and data charting of results were undertaken by two researchers. The 51 studies included in the scoping review occurred in primary care settings collated into four categories: general practice or primary care clinics, healthcare organisations, community pharmacies and outreach services. Studies were primarily of opioid use in chronic, noncancer pain. Other indications were opioid use disorder, cancer and dental pain. Pharmacist activities targeted risk mitigation, patient and provider education and broader, strategic approaches. Patient-related outcomes included reduced opioid load, improved functionality and symptom management, enhanced access to services and medication-assisted treatments, and engagement in risk-mitigation strategies. Behaviour change of providers was demonstrated. The review has identified the significant contribution that pharmacists working in primary care settings can make to minimise harm from opioids. Strategies implemented in isolation have the potential to further reduce adverse clinical outcomes with greater collaboration and coordination, such as opioid stewardship.

Why deprescribing instead of not prescribing?

Prescribing medications involves complex cognitive processes, and mistakes in prescription can cause serious adverse events. Deprescribing is one of the last opportunities to prevent patient harm from the use of drugs that should be avoided, especially among older patients. This viewpoint article aims to discuss the prescription process and some essential concepts, such as polypharmacy, prescription of potentially inappropriate medications, and, particularly, the relevance of deprescribing and its relationship with the appropriate prescription of medications in older people.