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Verma A, Chauhan A, Islam MM, Kahlon MS, Singh A. Navigating the Opioid Crisis: Exploring Innovative Approaches to Pain Management. Curr Pharm Biotechnol 2024; 25:1629-1631. [PMID: 38093445 DOI: 10.2174/0113892010277968231127072017] [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: 08/18/2023] [Revised: 10/25/2023] [Accepted: 10/31/2023] [Indexed: 09/04/2024]
Affiliation(s)
- Abhishek Verma
- Department of Pharmaceutics, ISF College of Pharmacy, Moga, Punjab, 142001, India
| | - Abhishek Chauhan
- Department of Pharmaceutics, ISF College of Pharmacy, Moga, Punjab, 142001, India
| | - Md Moidul Islam
- Department of Pharmaceutics, ISF College of Pharmacy, Moga, Punjab, 142001, India
| | - Milan Singh Kahlon
- Department of Pharmaceutics, ISF College of Pharmacy, Moga, Punjab, 142001, India
| | - Amandeep Singh
- Department of Pharmaceutics, ISF College of Pharmacy, Moga, Punjab, 142001, India
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Maharjan S, Kertesz SG, Bhattacharya K, Markland A, McGwin G, Yang Y, Bentley JP, Ramachandran S. Coprescribing of opioids and psychotropic medications among Medicare-enrolled older adults on long-term opioid therapy. J Am Pharm Assoc (2003) 2023; 63:1753-1760.e5. [PMID: 37633452 DOI: 10.1016/j.japh.2023.08.019] [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: 04/27/2023] [Revised: 08/01/2023] [Accepted: 08/17/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Pressures to reduce opioid prescribing have potential to incentivize coprescribing of opioids (at lower dose) with psychotropic medications. Evidence concerning the extent of the problem is lacking. This study assessed trends in coprescribing and characterized coprescribing patterns among Medicare-enrolled older adults with chronic noncancer pain (CNCP) receiving long-term opioid therapy (LTOT). METHODS A cohort study was conducted using 2012-2018 5% National Medicare claims data. Eligible beneficiaries were continuously enrolled and had no claims for cancer diagnoses or hospice use, and ≥ 2 claims with diagnoses for CNCP conditions within a 30-day period in the 12 months before the index date (LTOT initiation). Coprescribing was defined as an overlap between opioids and any class of psychotropic medication (antidepressants, benzodiazepines, antipsychotics, anticonvulsants, muscle relaxants, and nonbenzodiazepine hypnotics) based on their prescription fill dates and days of supply in a given year. The occurrence of coprescribing, coprescribing intensity, and number of days of overlap with psychotropic medications were calculated for each calendar year. RESULTS The eligible study population of individuals on LTOT ranged from 2038 in 2013 to 1751 in 2018. The occurrence of coprescribing among eligible beneficiaries decreased from 73.41% in 2013 to 70.81% in 2015 and then increased slightly to 71.22% in 2018. Among eligible beneficiaries with at least one overlap day, the coprescribing intensity with any class of psychotropic medications showed minimal variation throughout the study period: 74.73% in 2013 and 72.67% in 2018. Across all the years, the coprescribing intensity was found to be highest with antidepressants (2013, 49.90%; 2018, 50.33%) followed by benzodiazepines (2013, 25.42%; 2018, 19.95%). CONCLUSION Coprescribing was common among older adults with CNCP who initiated LTOT but did not rise substantially in the period studied. Future research should investigate drivers behind coprescribing and safety of various patterns of use.
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Do Formulation and Dose of Long-Term Opioid Therapy Contribute to Risk of Adverse Events among Older Adults? J Gen Intern Med 2022; 37:367-374. [PMID: 34258726 PMCID: PMC8811113 DOI: 10.1007/s11606-021-06792-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 04/01/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Chronic non-cancer pain (CNCP) is highly prevalent in older adults and long-term opioid therapy (LTOT) has been used to manage chronic pain. However, the safety of LTOT among older adults with CNCP is not well-established and there is a need to identify therapy-related risk factors of opioid-related adverse events among older adults. OBJECTIVE To evaluate the relationship between opioid dose and formulation and the risk of opioid-related adverse events among Medicare-eligible older adults on LTOT. DESIGN Nested case-control study. PARTICIPANTS Older Medicare beneficiaries (N=35,189) who received > 3 opioid prescriptions with a total days-supply of >45 days within a 90-day period for CNCP between 2012 and 2016. MAIN MEASURES This study utilized Medicare 5% medical and prescription claims data. Outcome measures included opioid-induced respiratory depression (OIRD), opioid overdose, all-cause mortality, and a composite outcome, defined as the first occurrence of any of the previous three events. Key independent variables were opioid formulation and opioid dose (measured in morphine milligram equivalents (MME)) prescribed during LTOT. KEY RESULTS Seventy-four OIRD, 133 overdose, 982 all-cause mortality, and 1122 composite outcome events were observed during follow-up. In unadjusted analyses, the use of combination opioids (OR: 4.52 [95%CI: 1.51-13.47]) was significantly associated with OIRD compared to short-acting (SA) opioids. In adjusted analyses, opioid-related adverse events were significantly associated with the use of LA (overdose OR: 13.00 [95%CI: 1.30-130.16] and combination opioids (overdose OR: 6.27 [95%CI: 1.91-20.55]; mortality OR: 2.75 [95%CI: 1.87-4.04]; composite OR: 2.82 [95%CI: 2.01-3.96]) when compared to SA opioids. When compared to an average dose of less than 20 MME, outcomes were significantly associated with doses of 20-50 MME (mortality OR: 1.61 [95%CI: 1.24-2.10]; composite OR: 1.59 [95%CI: 1.26-2.01]) and >50 MME (mortality OR: 1.99 [95%CI: 1.28-3.10]; composite OR: 2.09 [95%CI: 1.43-3.04]). CONCLUSIONS Older adults receiving medically prescribed opioids at higher doses and those using LA and combination of LA and SA opioids are at increased risks for opioid-related adverse events, highlighting the need for close patient supervision.
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Young JC, Dasgupta N, Chidgey BA, Stürmer T, Pate V, Hudgens M, Funk MJ. Impacts of Initial Prescription Length and Prescribing Limits on Risk of Prolonged Postsurgical Opioid Use. Med Care 2022; 60:75-82. [PMID: 34812786 PMCID: PMC8900903 DOI: 10.1097/mlr.0000000000001663] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND In response to concerns about opioid addiction following surgery, many states have implemented laws capping the days supplied for initial postoperative prescriptions. However, few studies have examined changes in the risk of prolonged opioid use associated with the initial amount prescribed. OBJECTIVE The objective of this study was to estimate the risk of prolonged opioid use associated with the length of initial opioid prescribed and the potential impact of prescribing limits. RESEARCH DESIGN Using Medicare insurance claims (2007-2017), we identified opioid-naive adults undergoing surgery. Using G-computation methods with logistic regression models, we estimated the risk of prolonged opioid use (≥1 opioid prescription dispensed in 3 consecutive 30-d windows following surgery) associated with the varying initial number of days supplied. We then estimate the potential reduction in cases of prolonged opioid use associated with varying prescribing limits. RESULTS We identified 1,060,596 opioid-naive surgical patients. Among the 70.0% who received an opioid for postoperative pain, 1.9% had prolonged opioid use. The risk of prolonged use increased from 0.7% (1 d supply) to 4.4% (15+ d). We estimated that a prescribing limit of 4 days would be associated with a risk reduction of 4.84 (3.59, 6.09)/1000 patients and would be associated with 2255 cases of prolonged use potentially avoided. The commonly used day supply limit of 7 would be associated with a smaller reduction in risk [absolute risk difference=2.04 (-0.17, 4.25)/1000]. CONCLUSIONS The risk of prolonged opioid use following surgery increased monotonically with increasing prescription duration. Common prescribing maximums based on days supplied may impact many patients but are associated with relatively low numbers of reduced cases of prolonged use. Any prescribing limits need to be weighed against the need for adequate pain management.
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Affiliation(s)
- Jessica C. Young
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599-7400, U.S.A
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Martin Luther King Jr. Blvd, Chapel Hill, NC 27599
| | - Nabarun Dasgupta
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, 725 Martin Luther King Jr. Blvd., Chapel Hill, NC 27599
| | - Brooke A. Chidgey
- Department of Anesthesiology and Pain Management, University of North Carolina School of Medicine, Chapel Hill, NC 27599
| | - Til Stürmer
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599-7400, U.S.A
| | - Virginia Pate
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599-7400, U.S.A
| | - Michael Hudgens
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599-7400, U.S.A
| | - Michele Jonsson Funk
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599-7400, U.S.A
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Interest of registries in neuropathic pain research. Rev Neurol (Paris) 2021; 177:843-848. [PMID: 34384628 DOI: 10.1016/j.neurol.2021.07.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/17/2021] [Accepted: 07/20/2021] [Indexed: 11/22/2022]
Abstract
Neuropathic pain is frequent in the general population, with 7 to 10% of adults presenting with chronic neuropathic pain. To date, the gold standard to evaluate treatments is based on randomized controlled trials. Nonetheless, such design is run on a limited sample and for a limited period. Moreover, many treatments will never be compared directly in sufficiently large and representative populations. A way to overcome several of these limitations is to use real-world data. Indeed, the International Association for the Study of Pain (IASP) includes a special interest group focusing on pain registries and promoting the use of such approaches. In this short narrative review, several of the main chronic pain registries are presented. The strengths and weaknesses of this approach are presented. Indication bias is frequent in observational studies because the choice of treatment is generally influenced by the patients' characteristics. However, a propensity score can be computed to adjust for these differences. The use of propensity score is briefly explained. Some data specific to neuropathic pain are discussed.
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Forrester S, Mbrah A, Lapane KL. A Latent Approach to Understanding Pain in Nursing Home Residents Who are Unable to Self-Report Pain. J Pain Res 2021; 14:2283-2293. [PMID: 34345184 PMCID: PMC8324982 DOI: 10.2147/jpr.s302305] [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: 01/21/2021] [Accepted: 06/15/2021] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Pain assessment in people with cognitive impairment is challenging. OBJECTIVE The study sought to 1) identify pain subgroups based on staff-assessed pain, agitated and reactive behavior, functional status, and symptoms of depression; and 2) understand if cognitive impairment was associated with transitions between pain subgroups at nursing home admission, 3 months, and 6 months. METHODS Using national Minimum Data Set 3.0 data (2011-2016), we included 26,816 newly admitted residents with staff-assessed pain at admission, 3 months, and 6 months. Pain subgroups were identified by latent class analysis at each time point. Transitions between pain subgroups were described using latent transition analysis. RESULTS Five latent statuses of pain were identified at admission: "Behavioral and Severe Depression" (prevalence stable, severe or worsening cognitive impairment: 11%, mild/moderate or improved cognitive impairment: 10%), "Functional" (21%; 25%), "Physical" (22%; 23%), "Behavioral" (23%, 19%), and "Low" (23%; 24%). Regardless of change in cognitive status, most residents remained in the same pain latent class. Among residents with stable, severe or worsening cognitive impairment, 11% in the "Behavioral" class transitioned to the "Behavioral and Severe Depression" class by 3 months. Fewer residents transitioned between latent classes in the 3- to 6-month period (>80% remained in their 3-month class). CONCLUSION For nursing home residents unable to self-report pain, consideration of additional indicators including functioning, depressive symptoms, and agitation may be useful in identifying pain subgroups. Longitudinal changes in the pain subgroups over 6 months post-admission highlight that residents with severe cognitive impairment may be at risk for worsening pain.
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Affiliation(s)
- Sarah Forrester
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Attah Mbrah
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Kate L Lapane
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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Haines KL, Fuller M, Antonescu I, Vaughan JG, Raghunathan K, Cox CE, Bartz RR, Ohnuma T, Agarwal S, Krishnamoorthy V. Underutilization of Acetaminophen in Older Adult Trauma Patients. Am Surg 2021; 88:2003-2010. [PMID: 34049451 DOI: 10.1177/00031348211023397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Older adults are more vulnerable to opioid-associated morbidity. The purpose of this study was to determine the frequency and timing of acetaminophen and opioid use in the postoperative period. METHODS Older adult trauma patients (≥65 years) with hip fractures requiring femur or hip fixation were reviewed (Premier Database 2008-2014). We examined rates of acetaminophen use on the day of surgery and prior to receipt of oral opioids. Mixed-effects linear regression models were used to examine the effects of an acetaminophen-first approach on opioid use the day prior to and on the day of discharge. RESULTS Of the 192 768 patients, 81.6% were Caucasian; 74.0% were female; and the mean age was 82.0 years [± 7.0]. Only 16.8% (32 291) of patients received acetaminophen prior to being prescribed opioids. 27.4% (52 779) received an acetaminophen-opioid combination, and 9.2% (17 730) received opioids without acetaminophen first. Acetaminophen first was associated with reduced opioid use on the day prior to and on the day of discharge (3.52 parenteral morphine equivalent doses (PMEs) less [95% CI: 3.33, 3.70]; P < .0001). A statistically but not clinically significant reduction in length of stay was observed in the acetaminophen-first group. CONCLUSION Nearly 37% of older adult patients did not receive acetaminophen as first-line analgesia after hip surgery. Multimodal analgesia, including non-opioid medications as first-line, should be encouraged.
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Affiliation(s)
- Krista L Haines
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA.,The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA
| | - Matthew Fuller
- The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA.,Department of Anesthesiology, 22957Duke University Medical Center, Durham, NC, USA
| | - Ioana Antonescu
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA.,The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA
| | - Justin G Vaughan
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA
| | - Karthik Raghunathan
- Department of Anesthesiology, 22957Duke University Medical Center, Durham, NC, USA
| | - Christopher E Cox
- The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA
| | - Raquel R Bartz
- The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA.,Department of Anesthesiology, 22957Duke University Medical Center, Durham, NC, USA
| | - Tetsu Ohnuma
- The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA.,Department of Anesthesiology, 22957Duke University Medical Center, Durham, NC, USA
| | - Suresh Agarwal
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA.,The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA
| | - Vijay Krishnamoorthy
- Department of Anesthesiology, 22957Duke University Medical Center, Durham, NC, USA
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Roseen EJ, Purtle J, Zhang W, Miller DW, Schwartz AW, Ramanadhan S, Sherman KJ. The Intersection of Dissemination Research and Acupuncture: Applications for Chronic Low Back Pain. Glob Adv Health Med 2021; 10:2164956120980694. [PMID: 34104573 PMCID: PMC8150432 DOI: 10.1177/2164956120980694] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 11/05/2020] [Accepted: 11/23/2020] [Indexed: 12/29/2022] Open
Abstract
Dissemination research is the study of distributing information and intervention materials to a specific clinical practice or public health audience. Acupuncture, a healthcare practice involving the stimulation of certain body points, often with thin needles, is considered an evidence-based treatment for low back pain (LBP), but is underutilized in the United States. Body: We will use the example of acupuncture for LBP to identify opportunities to leverage dissemination research to increase utilization of acupuncture. Deficits in the awareness or knowledge of acupuncture may limit its adoption by patients and other stakeholders. Thus, we summarize methods to gather data on stakeholder awareness and knowledge of acupuncture for LBP, i.e., audience research. Engaging multiple stakeholder audiences (e.g., health system leaders, primary care providers, patients), is needed to generate knowledge on promising dissemination strategies for each audience. Audience segmentation is important for identifying population subgroups for whom adoption of acupuncture may require a more intensive or tailored dissemination strategy. To illustrate potential audience ‘segments’, our research discussion focused on developing dissemination strategies by age (i.e., older adults – those age 65 years or older, and younger adults – those under age 65 ). This decision was prompted by Medicare’s recent policy covering acupuncture for chronic LBP. We leverage current knowledge of barriers and facilitators of acupuncture use to discuss how further tailoring of dissemination strategies might optimize adoption of acupuncture in both groups of adults. Experimental study designs could then be used to compare the effectiveness of such strategies to increase awareness, knowledge, or adoption of acupuncture. Conclusions: Conducting dissemination research may improve awareness and knowledge of acupuncture, and ultimately the adoption of acupuncture in biomedical settings. We anticipate that the concepts highlighted in this manuscript will also be helpful for those disseminating information about other complementary and integrative health approaches.
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Affiliation(s)
- Eric J Roseen
- Department of Family Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts.,Department of Rehabilitation Science, MGH Institute of Health Professions, Boston, Massachusetts.,New England Geriatric Research, Education, and Clinical Center, VA Boston Healthcare System, Boston, Massachusetts
| | - Jonathan Purtle
- Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - Weijun Zhang
- Department of Medicine, UCLA Center for East-West Medicine, Los Angeles, California.,Division of General Internal Medicine and Health Service Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - David W Miller
- Department of Pediatrics, Connor Integrative Health Network, University Hospitals, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Andrea Wershof Schwartz
- New England Geriatric Research, Education, and Clinical Center, VA Boston Healthcare System, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Shoba Ramanadhan
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Karen J Sherman
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington.,Department of Epidemiology, University of Washington, Seattle, Washington
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Ro JY, Zhang Y, Tricou C, Yang D, da Silva JT, Zhang R. Age and Sex Differences in Acute and Osteoarthritis-Like Pain Responses in Rats. J Gerontol A Biol Sci Med Sci 2021; 75:1465-1472. [PMID: 31412104 DOI: 10.1093/gerona/glz186] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Indexed: 12/19/2022] Open
Abstract
In this study, we investigated age and sex differences in acute and chronic pain in rats. Groups of young (3-6 months) and aged (20-24 months) male and female Fischer 344 rats were used to assess basal thermal and mechanical thresholds, capsaicin-induced acute nocifensive responses and c-Fos expression in the spinal cord, and monoiodoacetate (MIA)-induced knee osteoarthritis (OA)-like pain responses. There was a significant sex, but not age, effect on thermal threshold on the hindpaw and mechanical threshold on the knee joint. No significant age and sex differences in capsaicin-induced nocifensive and c-Fos responses were observed. MIA induced a greater peak reduction of weight-bearing responses in aged males than young rats. Aged females developed the most profound weight-bearing deficit. With knee joint sensitivity as a primary outcome measure, MIA induced more pronounced and longer-lasting hyperalgesia in older rats, with aged female rats showing the worst effect. These data suggest that age may not have significant effect on acute nociceptive processing, but it significantly impacts OA-like pain, making aged rats, especially females, more vulnerable to chronic pain conditions. These preclinical models should provide important tools to investigate basic mechanisms underlying the impact of age and sex in chronic pain conditions.
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Affiliation(s)
- Jin Y Ro
- Department of Neural and Pain Sciences, University of Maryland School of Dentistry, Baltimore
| | - Youping Zhang
- Department of Neural and Pain Sciences, University of Maryland School of Dentistry, Baltimore
| | - Christina Tricou
- Department of Neural and Pain Sciences, University of Maryland School of Dentistry, Baltimore
| | - Dan Yang
- Department of Neural and Pain Sciences, University of Maryland School of Dentistry, Baltimore
| | - Joyce T da Silva
- Department of Neural and Pain Sciences, University of Maryland School of Dentistry, Baltimore
| | - Ruixin Zhang
- Center for Integrative Medicine, University of Maryland School of Medicine, Baltimore
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Van Cleave JH, Booker SQ, Powell-Roach K, Liang E, Kawi J. A Scoping Review of Nursing's Contribution to the Management of Patients with Pain and Opioid Misuse. Pain Manag Nurs 2021; 22:58-68. [PMID: 33414010 DOI: 10.1016/j.pmn.2020.11.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 11/08/2020] [Accepted: 11/16/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Nursing brings a unique lens to care of patients with pain and opioid misuse. AIMS This scoping review describes nursing's contribution to the literature on the management of patients with pain and opioid misuse, generating evidence to guide clinical care. DESIGN The scoping review was conducted according to Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews guideline. DATA SOURCES Using combined key terms ("opioid misuse," "pain," "nursing") in systematic searches in PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) electronic databases, snowball technique, and personal knowledge resulted in 108 relevant articles, reports, and websites. ANALYSIS METHOD Summative approach to content analysis was used to quantify and describe nursing's contribution to the literature. RESULTS Contributions of nurses emerged in the areas of research, clinical practice, policy, and education. The highest number of publications addressed research (50%, 54 of 108), whereas the fewest number of publications involved education (7%, 8 of 108). CONCLUSION Results provide a picture of the breadth of expertise and crucial leadership that nurses contribute to influence management of patients with pain and opioid misuse. IMPLICATIONS FOR NURSING This scoping review indicates the importance of continued support from key stakeholders, including training and interprofessional collaboration opportunities supported by the National Institutes of Health, to sustain nursing's contribution to quality care of patients with pain and opioid misuse. Ultimately, all health care professionals must collaborate to conduct rigorous research and construct evidence-based guidelines to inform policy initiatives and education strategies to solve the complex co-occurring epidemics of pain and opioid misuse.
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Affiliation(s)
| | - Staja Q Booker
- University of Florida, College of Nursing, Gainesville, Florida
| | | | - Eva Liang
- NYU Rory Meyers College of Nursing, New York, New York
| | - Jennifer Kawi
- University of Nevada, Las Vegas, School of Nursing, Las Vegas, Nevada
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Ramachandran S, Salkar M, Bentley JP, Eriator I, Yang Y. Patterns of Long-Term Prescription Opioid Use Among Older Adults in the United States: A Study of Medicare Administrative Claims Data. Pain Physician 2021; 24:31-40. [PMID: 33400426 PMCID: PMC7789048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND Long-term opioid therapy was prescribed with increasing frequency over the past decade. However, factors surrounding long-term use of opioids in older adults remains poorly understood, probably because older people are not at the center stage of the national opioid crisis. OBJECTIVES To estimate the annual utilization and trends in long-term opioid use among older adults in the United States. STUDY DESIGN Retrospective cohort study. SETTING Data from Medicare-enrolled older adults. METHODS This study utilized a nationally representative sample of Medicare administrative claims data from the years 2012 to 2016 containing records of health care services for more than 2.3 million Medicare beneficiaries each year. Medicare beneficiaries who were 65 years of age or older and who were enrolled in Medicare Parts A, B, and D, but not Part C, for at least 10 months in a year were included in the study. We measured annual utilization and trends in new long-term opioid use episodes over 4 years (2013-2016). We examined claims records for the demographic characteristics of the eligible individuals and for the presence of chronic non-cancer pain (CNCP), cancer, and other comorbidities. RESULTS From 2013 to 2016, administrative claims of approximately 2.3 million elderly Medicare beneficiaries were analyzed in each year with a majority of them being women (~56%) and white (~82%) with a mean age of approximately 75 years. The proportion of all eligible beneficiaries with at least one new opioid prescription increased from 6.64% in 2013, peaked at 10.32% in 2015, and then decreased to 8.14% in 2016. The proportion of individuals with long-term opioid use among those with a new opioid prescription was 12.40% in 2013 and 10.20% in 2016. Among new long-term opioid users, the proportion of beneficiaries with a cancer diagnosis during the study years increased from 13.30% in 2013 to 15.67% in 2016, and the proportion with CNCP decreased from 30.25% in 2013 to 27.36% in 2016. Across all years, long-term opioid use was consistently high in the Southern states followed by the Midwest region. LIMITATIONS This study used Medicare fee-for-service administrative claims data to capture prescription fill patterns, which do not allow for the capture of individuals enrolled in Medicare Advantage plans, cash prescriptions, or for the evaluation of appropriateness of prescribing, or the actual use of medication. This study only examined long-term use episodes among patients who were defined as opioid-naive. Finally, estimates captured for 2016 could only utilize data from 9 months of the year to capture 90-day long-term-use episodes. CONCLUSIONS Using a national sample of elderly Medicare beneficiaries, we observed that from 2013 to 2016 the use of new prescription opioids increased from 2013 to 2014 and peaked in 2015. The use of new long-term prescription opioids peaked in 2014 and started to decrease from 2015 and 2016. Future research needs to evaluate the impact of the changes in new and long-term prescription opioid use on population health outcomes.
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Affiliation(s)
- Sujith Ramachandran
- Department of Pharmacy Administration, University of Mississippi School of Pharmacy
| | - Monika Salkar
- Department of Pharmacy Administration, University of Mississippi School of Pharmacy
| | - John P. Bentley
- Department of Pharmacy Administration, University of Mississippi School of Pharmacy
| | - Ike Eriator
- Department of Anesthesiology, School of Medicine, University of Mississippi Medical Center
| | - Yi Yang
- Department of Pharmacy Administration, University of Mississippi School of Pharmacy
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Kanaan SF, Melton BL, Waitman LR, Simpson MH, Sharma NK. The effect of age and gender on acute postoperative pain and function following lumbar spine surgeries. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2020; 26:e1888. [PMID: 33336861 DOI: 10.1002/pri.1888] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 10/13/2020] [Accepted: 11/21/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Understanding the factors contributing to the variability in postoperative pain and function following lumbar spine surgeries (LSS) is necessary to plan inpatient rehabilitation and optimize surgical outcomes. In particular, variability due to age and gender has not been studied. This study's aim was to evaluate the variability in postoperative pain and function, during hospital stay, due to age and gender following LSS. METHODS We conducted a retrospective analysis of 585 patients who underwent LSS during their hospital stay. Univariate ANCOVA was performed to study the differences in postoperative pain, and multivariate ANCOVA was performed to study the differences in postoperative function (gait distance, independency combined score, and balance combined score) between age groups (older adults [≥65 years of age] vs. younger adults) and gender. RESULTS Younger patients reported statistically, but not clinically, significant higher postoperative pain than older patients (β = 0.652 [95% CI (0.382-0.986)], p < 0.001), and males reported statistically, but not clinically, significant lower postoperative pain than female patients (β = -0.583 [95% CI (-0.825 to -0.252)], p < 0.001) with adjustment of covariates. Male patients walked significantly longer distance than female patients (β = 0.272 [95% CI (0.112-0.432)], p = 0.001) with adjustment of covariates. However, these were clinically insignificant. With adjustment of preoperative diagnosis, type of surgery, severity of illness, and prior level of function, there was no statistically significant difference between age groups in walking distance, and between age and gender groups in independency combined score and balance combined scores. DISCUSSION Following LSS, the difference in postoperative pain between age groups and gender are statistically but not clinically significant, suggesting patients require similar effective postoperative pain management regardless of age and gender. The apparent difference in age and gender in postoperative functional outcomes could be due to other factors.
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Affiliation(s)
- Saddam F Kanaan
- Department of Rehabilitation Sciences, Jordan University of Science and Technology, Irbid, Jordan
| | - Brittany L Melton
- Departments of Pharmacy Practice, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Lemuel R Waitman
- Department of Health Management and Informatics, University of Missouri Columbia, Columbia, Missouri, USA.,Department of Biomedical and Health Informatics, University of Missouri Kansas City, Kansas City, Missouri, USA.,Department of Health Management and Informatics, MU School of Medicine, NextGen Precision Health Initiative, Columbia, Missouri, USA
| | - Melanie H Simpson
- Pain Management, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Neena K Sharma
- Physical Therapy and Rehabilitation Science, University of Kansas Medical Center, Kansas City, Kansas, USA
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13
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Akande-Sholabi W, Agha PC, Olowookere OO, Adebusoye LA. Evaluation of prescription pattern of analgesic use among ambulatory elderly in South-Western Nigeria. Ann Afr Med 2020; 19:131-136. [PMID: 32499470 PMCID: PMC7453942 DOI: 10.4103/aam.aam_57_19] [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] [Indexed: 01/28/2023] Open
Abstract
Background: Inappropriate prescribing of analgesics has a global impact on the health of elderly patients and the society. Empirical evidence on the prescription of analgesics among elderly Nigerians is scarce. Objectives: The objective of the study was to evaluate the prescription pattern of analgesics and describe the co-prescribing of gastroprotective agents with non-steroidal anti-inflammatory drugs (NSAIDs) among elderly patients at the geriatric center, University College Hospital, Ibadan. Methods: A retrospective cross-sectional, hospital-based study was carried out among elderly patients (≥60 years) who were prescribed analgesics. Using a data extraction sheet, information on demographic characteristics, drug utilization pattern, and morbidities was obtained from patients’ case files via electronic health records. Results: A total of 337 patients case files were reviewed, the mean age was 72 ± 8.8 years, and 210 (62.3%) were females. There were a total of 2074 medications prescribed, with 733 (35.3%) being analgesics. Majority of the elderly patients (259, 76.9%) were on nonopioids, with 252 (74.8%) on NSAIDs. Paracetamol was the most commonly prescribed analgesics (181, 24.6%), followed by diclofenac/misoprostol (177, 24.1%), opioid analgesic prescribed was 88 (12.0%), with paracetamol/codeine 58 (65.9%), and tramadol 16 (18.2%) being the most prescribed opioid. A significant proportion of the hypertensive elderly patients (160, 78.8%; P < 0.036) were on NSAIDs. The oral route of administration (302, 89.6%) was the most common route of administration. Majority (310, 92%) of elderly patients taking NSAIDs had a co-prescription for gastroprotective agents. Conclusions: Majority of hypertensive patients were on NSAIDs. This calls for prompt awareness of rational analgesic use among the elderly to improve management and their survival.
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Affiliation(s)
- Wuraola Akande-Sholabi
- Department of Clinical Pharmacy and Pharmacy Administration, Faculty of Pharmacy, University of Ibadan, Ibadan, Nigeria
| | - Princess C Agha
- Department of Clinical Pharmacy and Pharmacy Administration, Faculty of Pharmacy, University of Ibadan, Ibadan, Nigeria
| | - Olufemi O Olowookere
- Chief Tony Anenih Geriatric Centre, University College Hospital, Ibadan, Nigeria
| | - Lawrence A Adebusoye
- Chief Tony Anenih Geriatric Centre, University College Hospital, Ibadan, Nigeria
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14
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Haines KL, Fuller M, Vaughan JG, Krishnamoorthy V, Raghunathan K, Kasotakis G, Agarwal S, Ohnuma T. The Impact of Nonsteroidal Anti-inflammatory Drugs on Older Adult Trauma Patients With Hip Fractures. J Surg Res 2020; 255:583-593. [PMID: 32650142 DOI: 10.1016/j.jss.2020.05.064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 04/03/2020] [Accepted: 05/05/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drug (NSAID) use is frequently recommended for multimodal analgesia to reduce opioid use. We hypothesized that increased NSAID utilization will decrease opioid requirements without leading to significant complications in older adult trauma patients undergoing hip fracture repair. METHODS An observational cross-sectional cohort study of 190,057 adult trauma patients over a 6-y period (2008-2014) in the national Premier Healthcare Database was performed. Patients aged 65 or older undergoing femur repair and hip arthroplasty following fractures due to falls were analyzed. Primary outcome was opioid use, and secondary outcomes included transfusion requirements, length of stay (LOS), and organ system dysfunction. Continuous outcomes were analyzed using mixed-effect linear regression models to assess the effect of NSAIDs on the day of surgery. Fixed effects were included for patient and hospital characteristics, comorbidities, co-treatments, and surgery. Random intercepts for each hospital were included to control for clustering. Categorical outcomes were similarly analyzed using mixed-effect logistic regression models. RESULTS NSAIDs decreased opioids prescribed (12.01 versus 11.43 morphine milligram equivalents) (odds ratio [OR], -0.23; confidence interval [CI] = -0.41, -0.06) without overall increased bleeding (40.83% versus 43.18%; OR, 1.02; CI = 0.99, 1.05). NSAIDs were associated with reduced LOS (5.61 versus 5.96 d; CI = -0.24, -0.12), intensive care unit admissions (9.73% versus 10.59%; OR, 0.91; CI = 0.86, 0.96), and pulmonary complications (OR, 0.88; CI = 0.83, 0.93). Additionally, there was a 21% prescribing variability based solely on hospital. CONCLUSIONS NSAIDs were associated with decreased opioid requirements, hospital LOS, and intensive care unit admissions in older adult trauma patients without overall increase in bleeding. NSAIDs should be considered in multimodal pain regimens, moreover, given prescribing variability guidelines are needed. LEVEL OF EVIDENCE Level III, Prognostic.
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Affiliation(s)
- Krista L Haines
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina; The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Duke University Medical Center, Durham, North Carolina.
| | - Matthew Fuller
- The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Duke University Medical Center, Durham, North Carolina; Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Justin G Vaughan
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Vijay Krishnamoorthy
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Karthik Raghunathan
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - George Kasotakis
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Suresh Agarwal
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina; The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Duke University Medical Center, Durham, North Carolina
| | - Tetsu Ohnuma
- The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Duke University Medical Center, Durham, North Carolina; Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
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15
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Lapane KL, Hume AL, Morrison RA, Jesdale BM. Prescription analgesia and adjuvant use by pain severity at admission among nursing home residents with non-malignant pain. Eur J Clin Pharmacol 2020; 76:1021-1028. [PMID: 32363421 PMCID: PMC7306024 DOI: 10.1007/s00228-020-02878-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 04/17/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We estimated the use of prescribed analgesics and adjuvants among nursing home residents without cancer who reported pain at their admission assessment, in relation to resident-reported pain severity. METHODS Medicare Part D claims were used to define 3 classes of analgesics and 7 classes of potential adjuvants on the 21st day after nursing home admission (or the day of discharge for residents discharged before that date) among 180,780 residents with complete information admitted between January 1, 2011 and December 9, 2016, with no cancer diagnosis. RESULTS Of these residents, 27.9% reported mild pain, 46.6% moderate pain, and 25.6% reported severe pain. The prevalence of residents in pain without Part D claims for prescribed analgesic and/or adjuvant medications was 47.3% among those reporting mild pain, 35.7% among those with moderate pain, and 24.8% among those in severe pain. Among residents reporting severe pain, 33% of those ≥ 85 years of age and 35% of those moderately cognitively impaired received no prescription analgesics/adjuvants. Use of all classes of prescribed analgesics and adjuvants increased with resident-reported pain severity, and the concomitant use of medications from multiple classes was common. CONCLUSION Among nursing home residents with recognized pain, opportunities to improve the pharmacologic management of pain, especially among older residents, and those living with cognitive impairments exist.
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Affiliation(s)
- Kate L Lapane
- Department of Population and Quantitative Health Science, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA.
| | - Anne L Hume
- Department of Family Medicine, Alpert Medical School, Brown University, Memorial Hospital of Rhode Island, Providence, RI, 02903, USA
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, 02881, USA
| | - Reynolds A Morrison
- Department of Population and Quantitative Health Science, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Bill M Jesdale
- Department of Population and Quantitative Health Science, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
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16
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Musich S, Wang SS, Slindee LB, Keown K, Hawkins K, Yeh CS. Using Pain Medication Intensity to Stratify Back Pain Among Older Adults. PAIN MEDICINE 2020; 20:252-266. [PMID: 29394401 PMCID: PMC6374135 DOI: 10.1093/pm/pny007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Objective To examine the prevalence of musculoskeletal back pain among older adults stratified by pain medication intensity to 1) review treatment patterns and 2) consider targeted back pain prevention interventions. Methods A random sample of older adults age 64 years and older was utilized to identify new and recurring back pain. Prescription pain medications from drug claims were used to stratify to five unique intensity levels. The characteristics of each level were determined using regression models. Results About 10% had musculoskeletal back pain. Of these, 54% (N = 20,645) had new back pain and 46% (N = 17,252) had recurring back pain. Overall, about 35% received physical therapy. Pain medication intensity levels included no prescription pain medications, nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, low-dose opioids, and high-dose opioids (new back pain: 39%, 10%, 6%, 23%, and 23%, respectively; recurring back pain 32%, 9%, 4%, 17%, and 38%, respectively). NSAID and muscle relaxant users were younger, healthier, and received physical therapy. Opioid users were younger, in poorer health, used sleep medications, received physical therapy, and had more falls and higher health care utilization and expenditures. Conclusions New and recurring back pain patients can be stratified by pain medication intensity to review treatment patterns and target back pain prevention programs. Those with back pain but taking no prescription pain medications may benefit from back pain prevention programs. More research on guidelines for treatment options for those on high levels of pain medications is warranted.
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Affiliation(s)
| | | | - Luke B Slindee
- Informatics and Data Science, Optum, Minnetonka, Minnesota
| | - Karen Keown
- UnitedHealthcare Alliances, Optum, Minneapolis, Minnesota
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17
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Khodneva Y, Richman J, Kertesz S, Safford MM. Gender differences in association of prescription opioid use and mortality: A propensity-matched analysis from the REasons for Geographic And Racial Differences in Stroke (REGARDS) prospective cohort. Subst Abus 2019; 42:94-103. [PMID: 31860382 PMCID: PMC7305051 DOI: 10.1080/08897077.2019.1702609] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Prescription opioids (PO) have been widely used for chronic non-cancer pain, with commensurate concerns for overdose. The long-term effect of these medications on non-overdose mortality in the general population remains poorly understood. This study's objective was to examine the association of prescription opioid use and mortality in a large cohort, accounting for gender differences and concurrent benzodiazepine use, and using propensity score matching. Methods: 29,025 US community-dwellers were enrolled in the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort between 2003 and 2007, and followed through December 31, 2012. At baseline there were 1907 participants with PO; 1864 of them were matched to participants without PO, based on the model-derived propensity to receive opioid prescriptions. Causes of death were expert-adjudicated. Results: Over median follow-up of 6 years there were 4428 deaths (413 among persons with PO). The risk for all-cause mortality was 12% higher, in absolute terms, for persons with PO compared to those without PO in the overall sample, with gender differences (interaction p = .0008). The risk of death was increased for women with PO (hazard ratio [HR] 1.21 [95% Confidence Interval (CI) 1.04-1.40]), but not men (HR 0.92 [95% CI 0.77-1.10]). Women with PO were at higher risk of cardiovascular disease (CVD) death (HR 1.43 [95% CI 1.12-1.84]), sudden death (HR 2.02 [95% CI 1.29-3.15]) (a subset of CVD death), and accidents (HR 2.18 [95% CI 1.03-4.60]). These risks were not observed for men with PO. Conclusion: Over 6 years of follow-up, women but not men who had opioid prescriptions were at higher risk of all-cause mortality, CVD death, sudden death, and accidents. Special caution in prescribing opioids for women may be warranted until these findings are confirmed.
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Affiliation(s)
- Yulia Khodneva
- Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Joshua Richman
- Department of Surgery, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Stefan Kertesz
- Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Birmingham Veterans Administration Health Medical Center, Birmingham, Alabama, USA
| | - Monika M Safford
- Division of Internal Medicine, Weill Cornell University, New York, New York, USA
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18
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Motter FR, Hilmer SN, Paniz VMV. Pain and Inflammation Management in Older Adults: A Brazilian Consensus of Potentially Inappropriate Medication and Their Alternative Therapies. Front Pharmacol 2019; 10:1408. [PMID: 31849664 PMCID: PMC6901010 DOI: 10.3389/fphar.2019.01408] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 11/05/2019] [Indexed: 12/19/2022] Open
Abstract
Purpose: The aim of the present study was to develop and validate a Potentially Inappropriate Medications (PIM) list and alternative therapies for treatment of pain and inflammation in older people adapted to the Brazilian context. Methods: A preliminary PIM list suitable for the Brazilian market was developed on the basis of three published international PIM lists [Beers 2015, Screening Tool of Older People’s Potentially Inappropriate Prescriptions - 2015, European Union (7) PIM list]. We used the modified Delphi technique (two-round) to validate concerns of use and alternative therapies related to PIM for treatment of pain and inflammation in older adults ≥65 years in Brazil. The panel involved nine Brazilian experts in geriatric pharmacotherapy. All items with mean Likert scale score ≥4.0 (agree) and the lower limit of 95% confidence interval ≥4.0 were considered validated in this study. Results: At the end of the consensus process, 94 (65.3%) items of 144 were validated. In total, consensus was reached for 33/35 (94.3%) concerns about drugs that should be avoided in older patients regardless of diagnosis, for 22/23 (95.7%) concerns about drugs that should be avoided in older patients with specific conditions or diseases, for 11/23 (47.8%) with special considerations of use, and for 28/63 (44.4%) of therapeutic alternatives. Conclusion: Although these criteria are not designed to replace clinical judgement, PIM and alternative therapies lists can be useful to inform prescribers, pharmacists, and health care planners and may serve as a starting point for safe and effective use of medications in older people.
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Affiliation(s)
- Fabiane Raquel Motter
- Postgraduate Program in Collective Health, University of Vale do Rio dos Sinos (UNISINOS), São Leopoldo, Brazil.,Kolling Institute of Medical Research, Royal North Shore 83 Hospital, St. Leonards, NSW, Australia
| | - Sarah Nicole Hilmer
- Kolling Institute of Medical Research, Royal North Shore 83 Hospital, St. Leonards, NSW, Australia
| | - Vera Maria Vieira Paniz
- Postgraduate Program in Collective Health, University of Vale do Rio dos Sinos (UNISINOS), São Leopoldo, Brazil
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19
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Aoyagi K, He J, Simpson M, Melton BL, Chandaka S, Waitman LR, Sharma NK. Association between Opioid Dose, Acute Post‐operative Pain and Walking Distance Following Lumbar Spine Surgery. J Clin Pharm Ther 2019; 45:169-178. [DOI: 10.1111/jcpt.13052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 08/17/2019] [Accepted: 09/02/2019] [Indexed: 12/28/2022]
Affiliation(s)
- Kosaku Aoyagi
- Department of Physical Therapy and Rehabilitation Science University of Kansas Medical Center Kansas City KS USA
| | - Jianghua He
- Department of Biostatistics University of Kansas Medical Center Kansas City KS USA
| | - Melanie Simpson
- University of Kansas Health System University of Kansas Kansas City KS USA
| | | | - Sravani Chandaka
- Center for Medical Informatics and Enterprise Analytics University of Kansas Medical Center University of Kansas Medical Center Kansas City KS USA
| | - Lemuel R. Waitman
- Center for Medical Informatics and Enterprise Analytics University of Kansas Medical Center University of Kansas Medical Center Kansas City KS USA
- Internal Medicine University of Kansas Medical Center Kansas City KS USA
| | - Neena K. Sharma
- Department of Physical Therapy and Rehabilitation Science University of Kansas Medical Center Kansas City KS USA
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20
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Gallagher RM. 20 Years of Pain Medicine: Documenting Our Progress and the Path Ahead. PAIN MEDICINE 2019; 20:1265-1272. [DOI: 10.1093/pm/pnz061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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21
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Ulbricht CM, Hunnicutt JN, Hume AL, Lapane KL. Depression, Anxiety, and Pain among Newly Admitted Nursing Home Residents. THE JOURNAL OF NURSING HOME RESEARCH SCIENCES 2019; 5:40-48. [PMID: 33748657 DOI: 10.14283/jnhrs.2019.8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Depression, anxiety, and pain are commonly experienced by older adults living in nursing homes. Objectives To describe the prevalence of depression, anxiety disorders, and pain among newly admitted nursing home residents in the United States and to describe the treatment of these disorders. Design Cross-sectional study of newly admitted residents. Setting Residents able to complete a pain assessment (n=783,826) living in Medicare- and Medicaid-certified nursing homes in the United States in 2011-2012. Measures Measures of sociodemographic, mood and behavior, pain, diagnoses, and functioning items from the Minimum Data Set (MDS) version 3.0. Results Approximately 36% of residents had a diagnosis of depression (other than bipolar disorder) and/or an anxiety disorder (n = 272,311). Of these residents, 25.2% had both depression and an anxiety disorder (95% CI = 25.0-25.4%), 54.3% (95% CI = 54.1-54.5%) had depression without an anxiety disorder, and 20.5% had an anxiety disorder without depression (95% CI = 20.3-20.6%). Fifteen percent had the triad of depression, anxiety, and pain at admission (95% CI = 9.3-23.3%). Depressive symptoms were more commonly reported by residents with pain than by those without pain. Receipt of psychological therapy (range: 0.9%-2.0%) or any psychiatric medication was lacking (range: 35.3%-48.5%), regardless of pain status. Participants reporting pain received a combination of scheduled, pro re nata (PRN)/as-needed, and non-medication pain interventions (range: 59.8% depression without anxiety to 62.9% depression and anxiety disorder). Conclusion Residents often suffer from combinations of depression, anxiety and pain at admission to nursing home. While treatment of pain is more common than treatment of psychiatric treatments, both psychiatric treatment and pain management may be suboptimal in nursing homes.
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Affiliation(s)
- Christine M Ulbricht
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA USA
| | - Jacob N Hunnicutt
- Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, University of Massachusetts Medical School, Worcester, MA USA
| | - Anne L Hume
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI USA
| | - Kate L Lapane
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA USA.,Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, University of Massachusetts Medical School, Worcester, MA USA
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22
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Malec M, Levine S. How do I best treat pain in my older patient with cancer? J Geriatr Oncol 2019; 10:841-844. [PMID: 31171495 DOI: 10.1016/j.jgo.2019.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 04/08/2019] [Accepted: 05/10/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Monica Malec
- University of Chicago, United States of America.
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23
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Chen C, Winterstein AG, Fillingim RB, Wei YJ. Body weight, frailty, and chronic pain in older adults: a cross-sectional study. BMC Geriatr 2019; 19:143. [PMID: 31126233 PMCID: PMC6534872 DOI: 10.1186/s12877-019-1149-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 04/26/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND There exists limited data on the association between unhealthy body weight and chronic pain, and whether this association is explained by frailty status of older adults. METHODS We included older adults aged ≥65 years from the 1999-2004 National Health and Nutrition Examination Survey (NHANES). Chronic pain was defined by self-reported pain lasting for ≥3 months in the past year. Body mass index (BMI) was categorized as underweight, normal, overweight, and obese. Participants were dichotomized as frail or non-frail based on a validated frailty index calculated as the proportion of the number of deficits present to a total of 45 possible deficits ascertained in NHANES. We used modified Poisson regression models to estimate prevalence ratios (PRs) and their 95% confidence intervals (CIs). RESULTS Of 3693 older participants, one in six (15.9%) experienced chronic pain, with higher prevalence among the underweight (24.6%) and obese (20.2%) group. Frailty versus non-frailty was independently associated with BMI (PR = 1.25, 95% CI = 1.16-1.36 for underweight; and PR = 1.15, 95% CI = 1.07-1.22 for obese), and chronic pain (PR = 2.84, 95% CI = 2.18-3.69). After adjustment for frailty, the association between BMI and chronic pain decreased from PR = 1.82 to 1.64 for the underweight and 1.41 to 1.33 for the obese group. We did not observe an interaction effect between frailty and BMI. CONCLUSIONS Unhealthy body weight was associated with increased chronic pain and the associations were partially explained by frailty status of older adults. Our findings generate hypotheses for further investigations of the interplay of these chronic conditions in older adults.
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Affiliation(s)
- Cheng Chen
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, USA
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, USA.,Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, USA.,Department of Epidemiology, College of Public Health and Health Professions & College of Medicine, University of Florida, Gainesville, USA
| | - Roger B Fillingim
- Department of Community Dentistry and Behavioral Science, College of Dentistry, University of Florida, Gainesville, USA
| | - Yu-Jung Wei
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, USA. .,Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, USA.
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24
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Shah R, Chou LN, Kuo YF, Raji MA. Long-Term Opioid Therapy in Older Cancer Survivors: A Retrospective Cohort Study. J Am Geriatr Soc 2019; 67:945-952. [PMID: 31026356 DOI: 10.1111/jgs.15945] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 03/29/2019] [Accepted: 04/01/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To examine the rates and predictors of long-term opioid therapy in older cancer survivors. DESIGN Retrospective cohort study. SETTING Texas, United States. PARTICIPANTS Cancer survivors (5 years or more postcancer diagnosis) diagnosed from 1995 to 2008 and who were also Medicare Parts A, B, and D beneficiaries. MEASUREMENTS We used Medicare Part D event data to calculate the proportion of cancer survivors with a prolonged opioid prescription (90-day or more supply of opioids/year). Adjusted odds ratios were calculated to identify predictors of prolonged opioid prescribing. All analyses were repeated with a subcohort of opioid-naïve cancer survivors. RESULTS The rate of prolonged opioid therapy for cancer patients diagnosed in 2008 was 7.1% prior to cancer diagnosis; it rose to 9.8% within a year of cancer treatments, and to 13.3% at 5 years postdiagnosis. The rate at the sixth year varied by cancer sites: 19.4% in lung cancer and 9.6% in prostate cancer. Among opioid-naïve survivors, the rate increased from 1.4% to 7.1%, from 5 to 18 years postcancer diagnosis. Cancer survivors diagnosed in 2004 to 2008 had higher rates of opioid prescribing compared to those diagnosed in 1995 to 1998 and 1999 to 2003. Years since diagnosis, a later year of diagnosis, female sex, urban location, lung cancer diagnosis, disability as reason for Medicare entitlement, Medicaid eligibility, one or more comorbidity, and history of depression or drug abuse were predictors of prolonged opioid therapy. Among opioid-naïve cancer survivors, diagnosis in 2004 to 2008 was the strongest predictor, while a history of drug abuse was the strongest predictor for all the survivors. CONCLUSION The rates of prolonged opioid prescribing for older cancer survivors remained high at 5 or more years after cancer diagnosis. Our findings have potential to inform the development of clinical guidelines and public policy to ensure safer and more effective pain treatment in older cancer survivors. J Am Geriatr Soc 67:945-952, 2019.
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Affiliation(s)
- Rahul Shah
- School of Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Lin-Na Chou
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas
| | - Yong-Fang Kuo
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas.,Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas.,Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas.,Institute for Translational Sciences, University of Texas Medical Branch, Galveston, Texas
| | - Mukaila A Raji
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas.,Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas.,Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas
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25
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Gilmartin-Thomas JFM, Bell JS, Liew D, Arnold CA, Buchbinder R, Chapman C, Cicuttini F, Dobbin M, Gibson SJ, Giummarra MJ, Gowan J, Katz B, Lubman DI, McCrone M, Pilgrim J, Synnot A, van Dyk E, Workman B, McNeil J. Chronic pain medication management of older populations: Key points from a national conference and innovative opportunities for pharmacy practice. Res Social Adm Pharm 2019; 15:207-213. [DOI: 10.1016/j.sapharm.2018.03.060] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 03/01/2018] [Accepted: 03/18/2018] [Indexed: 01/20/2023]
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Corsi N, Roberto A, Cortesi L, Nobili A, Mannucci PM, Corli O. Prevalence, characteristics and treatment of chronic pain in elderly patients hospitalized in internal medicine wards. Eur J Intern Med 2018; 55:35-39. [PMID: 29853269 DOI: 10.1016/j.ejim.2018.05.031] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 05/10/2018] [Accepted: 05/23/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Chronic pain is a frequent characteristic of elderly people and represents an actual and still poorly debated topic. OBJECTIVE We investigated pain prevalence and intensity, and its pharmacological therapy in elderly patients hospitalized in 101 internal medicine wards. METHODS Taking advantage of the "REgistro POliterapie Società Italiana Medicina Interna" (REPOSI), we collected 2535 patients of whom almost a quarter was older than 85 years old. Among them, 582 patients were affected by pain (either chronic or acute) and 296 were diagnosed with chronic pain. RESULTS Patients with pain showed worse cognitive status, higher depression and comorbidities, and a longer duration of hospital stay compared to those without pain (all p < .0366). Patients with chronic pain revealed lower level of independency in their daily life, worse cognitive status and higher level of depression compared to acute pain patients (all p < .0156). Moreover, most of them were not treated for pain at admission (73.4%) and half of them was not treated with any analgesic drug at discharge (50.5%). This difference affected also the reported levels of pain intensity. Patients who received analgesics at both admission and discharge remained stable (p = .172). Conversely, those not treated at admission who received an analgesic treatment during the hospital stay decreased their perceived pain (p < .0001). CONCLUSIONS Our results show the need to focus more attention on the pharmacological treatment of chronic pain, especially in hospitalized elderly patients, in order to support them and facilitate their daily life after hospital discharge.
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Affiliation(s)
- Nicole Corsi
- Pain and Palliative Care Research Unit, Oncology Department, IRCCS-Mario Negri Institute for Pharmacological Research, Milan, Italy.
| | - Anna Roberto
- Pain and Palliative Care Research Unit, Oncology Department, IRCCS-Mario Negri Institute for Pharmacological Research, Milan, Italy
| | - Laura Cortesi
- Quality Assessment of Geriatric Therapies and Services Laboratory, Neuroscience Department, IRCCS-Mario Negri Institute for Pharmacological Research, Milan, Italy
| | - Alessandro Nobili
- Quality Assessment of Geriatric Therapies and Services Laboratory, Neuroscience Department, IRCCS-Mario Negri Institute for Pharmacological Research, Milan, Italy
| | - Pier Mannuccio Mannucci
- Scientific Direction, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Oscar Corli
- Pain and Palliative Care Research Unit, Oncology Department, IRCCS-Mario Negri Institute for Pharmacological Research, Milan, Italy
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Marra EM, Mazer-Amirshahi M, Mullins P, Pines JM. Opioid Administration and Prescribing in Older Adults in U.S. Emergency Departments (2005-2015). West J Emerg Med 2018; 19:678-688. [PMID: 30013704 PMCID: PMC6040900 DOI: 10.5811/westjem.2018.5.37853] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 05/04/2018] [Accepted: 05/03/2018] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION We assess trends in opioid administration and prescribing from 2005-2015 in older adults in United States (U.S.) emergency departments (ED). METHODS We analyzed data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) survey from 2005 to 2015. ED visits for painful conditions were selected and stratified by age (18-64, 65-74, 75-84, ≥ 85 years). We analyzed trends in opioid administration in the ED and prescribing at discharge to encounters ≥ 65 and assessed predictors of use using survey-weighted chi-square tests and logistic regression. Trends in the use of five commonly prescribed opioids were also explored. RESULTS Opioid administration in the ED and prescribing at discharge for encounters with patients ≥ 65 years fell overall, but not significantly. By contrast, opioid administration in the ED and prescribing at discharge significantly declined for adult encounters 18-64 by 20% and 32%, respectively. A similar proportion of adult encounters ≥ 65 were administered opioids in the ED as 18-64, but adult encounters ≥ 85 had the lowest rates of administration. A smaller proportion of adult encounters ≥ 65 years with painful conditions were prescribed opioids at discharge compared to <65. However, this age-related disparity in prescribing narrowed over the study period. There were shifts in the specific types of opioids administered and prescribed in adult encounters ≥ 65 years over the study period, with the most notable being a 76% increase in hydromorphone administration comparing 2005-06 to 2014-15. CONCLUSION From 2005-15, 1 in 4 to 1 in 10 ED patients with painful conditions were administered or prescribed an opioid in U.S. EDs. Opioids prescribing increased from 2005-11 and then declined from 2012-15, more so among visits in the 18-64 age group compared to ≥ 65 years. Opioid administrating demonstrated a gradual rise and decline in all adult age groups. Age consistently appears to be an important consideration, where opioid prescribing declines with advancing age. Given the nationwide opioid crisis, ED providers should remain vigilant in limiting opioids, particularly in older adults who are at higher risk for adverse effects.
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Affiliation(s)
- Erin M Marra
- Aventura Hospital and Medical Center, Department of Emergency Medicine, Aventura, Florida
| | - Maryann Mazer-Amirshahi
- MedStar Washington Hospital Center, Department of Emergency Medicine, Washington, District of Columbia
| | - Peter Mullins
- The George Washington University, School of Medicine and Health Sciences, Washington, District of Columbia
| | - Jesse M Pines
- The George Washington University, School of Medicine and Health Sciences, Washington, District of Columbia
- The George Washington University, Department of Emergency Medicine, Washington, District of Columbia
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28
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Richardson JE, Lee JI, Nirenberg A, Reid MC. The Potential Role for Smartphones Among Older Adults with Chronic Noncancer Pain: A Qualitative Study. PAIN MEDICINE (MALDEN, MASS.) 2018; 19:1132-1139. [PMID: 28108642 PMCID: PMC5998946 DOI: 10.1093/pm/pnw284] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective To determine the role that smartphones may play in supporting older adults with chronic noncancer pain (CNCP) in order to improve pain management in this expanding population. Design Qualitative study. Setting One academically affiliated primary care practice serving older adults with CNCP in New York City. Subjects Thirteen older adults (age 65-85 years) with CNCP on chronic opioid therapy, that is, continuous use of opioids for at least six months. Methods One researcher conducted one-on-one telephone interviews with participants, and two researchers analyzed the transcribed data using descriptive analysis. A nurse and a physician researcher iteratively critiqued and approved the results. Results Participants provided opinions as to the effects that smartphones may have on medication management and communications with their providers. Smartphones can benefit older adults by supporting interactions with the health care system such as more effective scheduling and coordinating prescribing practices with local pharmacies. Participants expressed difficulties with isolation due to CNCP and posited that smartphones could provide a means for social support. Specifically, smartphones should support older adult needs to effectively communicate pain experiences with personal contacts and caregivers, as well as health care providers. Based on these results, we provide suggestions that can inform future smartphone interventions for older adults with CNCP. Conclusion Smartphones that focus on supporting medication management, enhancing communication with providers, and facilitating connectedness within social networks to reduce feelings of isolation may help to improve CNCP outcomes in older adults.
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Affiliation(s)
| | - Jennifer I Lee
- Division of Hospital Medicine
- NewYork-Presbyterian Hospital, New York, New York
| | - Anita Nirenberg
- Hunter–Bellevue School of Nursing, Hunter College of the City University of New York, New York, New York, USA
| | - M Carrington Reid
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, New York, NewYork
- NewYork-Presbyterian Hospital, New York, New York
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29
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Makris UE, Higashi RT, Marks EG, Fraenkel L, Gill TM, Friedly JL, Reid MC. Physical, Emotional, and Social Impacts of Restricting Back Pain in Older Adults: A Qualitative Study. PAIN MEDICINE 2018; 18:1225-1235. [PMID: 27516362 DOI: 10.1093/pm/pnw196] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Objective Back pain is the most common type of pain reported by older adults, yet current management strategies often do not address the multi-dimensional impacts on older adults who face unique challenges as compared with younger populations. The objective of this qualitative study was to assess the physical, psychological, and social impacts of back pain (severe enough to restrict activity, hereafter referred to as restricting back pain) on older adults. Design This was a qualitative study using semi-structured interviews and focus groups. Setting and Patients This study was comprised of a diverse sample of 93 community-living older adults (median age 83) with restricting back pain. Methods We used a semi-structured guide in 23 interviews and 16 focus groups to discuss the various ways that restricting back pain impacted participants. Transcripts were analyzed in an iterative process to develop thematic categories. Results Restricting back pain affected participants physically (inability to execute routine tasks, disruption of sleep and exercise), psychologically (feelings of sadness and irritability, fears about worsening health, loss of hope towards recovery or pain relief), and socially (experiences of isolation, inability to pursue hobbies). Conclusions These data inform which outcomes should be measured in studies evaluating treatments for older adults with restricting back pain.
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Affiliation(s)
- Una E Makris
- Departments of Internal Medicine.,Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas.,Department of Medicine, Division of Rheumatology, VA North Texas Health Care System, Dallas, Texas
| | - Robin T Higashi
- Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
| | - Emily G Marks
- Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
| | - Liana Fraenkel
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut.,Department of Medicine, VA Connecticut Health Care System, West Haven, Connecticut
| | - Thomas M Gill
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Janna L Friedly
- Department of Rehabilitation Medicine.,Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, Seattle, Washington
| | - M Carrington Reid
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College, New York, New York, USA
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Saïdi H, Pagé MG, Boulanger A, Ware MA, Choinière M. Effectiveness of long-term opioid therapy among chronic non-cancer pain patients attending multidisciplinary pain treatment clinics: A Quebec Pain Registry study. Can J Pain 2018; 2:113-124. [PMID: 35005371 PMCID: PMC8730575 DOI: 10.1080/24740527.2018.1451252] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 03/05/2018] [Accepted: 03/08/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The objective of this study was to investigate in a real-life context the effectiveness of long-term opioid therapy for reducing pain intensity and interference and improving health-related quality of life (QOL) in patients with chronic noncancer pain. METHODS Participants were 893 patients (age = 52.4 ± 14.1, female = 62.4%) enrolled in the Quebec Pain Registry (2008-2011) who completed questionnaires before their first visit at one of three multidisciplinary pain management clinics and 6 and 12 months thereafter. Based on their opioid use profile (OUP), patients were categorized as nonusers, non-lasting users, or lasting users. Data were analyzed using generalized estimating equations. RESULTS More than 60% of patients newly initiated on opioid therapy stopped their medication mainly because of adverse effects and/or lack of pain relief. OUP significantly predicted pain intensity and interference and physical QOL (pQOL; P values < 0.001). Lasting users of opioids reported higher levels of pain intensity and interference and poorer pQOL than nonusers and/or non-lasting users over the 12-month follow-up (P values < 0.001). However, all effect sizes were small, thus questioning the clinical significance of these group differences. Among lasting users, more than 20% of patients experienced a meaningful amelioration in pain intensity and interference as well as mental QOL (mQOL), whereas only 8% exhibited improved pQOL. DISCUSSION A significant subgroup of patients may benefit from long-term opioid therapy in terms of pain severity and mQOL but the majority do not. The challenge facing clinicians is how to identify who the responders will be.
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Affiliation(s)
- Hichem Saïdi
- Centre de recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Montreal, Quebec, Canada
- Department of Pharmacology, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - M. Gabrielle Pagé
- Centre de recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Montreal, Quebec, Canada
- Department of Biomedical Sciences, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Aline Boulanger
- Department of Anesthesiology, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
- Centre d’expertise en gestion de la douleur du Réseau universitaire intégré en santé de l’Université de Montréal, Montreal, Quebec, Canada
- Québec Pain Research Network
| | - Mark A. Ware
- Québec Pain Research Network
- Alan Edwards Center for Research on Pain, McGill University, Montreal, Quebec, Canada
- Department of Family Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
- Department of Anesthesia, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Manon Choinière
- Centre de recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Montreal, Quebec, Canada
- Québec Pain Research Network
- Alan Edwards Center for Research on Pain, McGill University, Montreal, Quebec, Canada
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Dublin S, Walker RL, Gray SL, Hubbard RA, Anderson ML, Yu O, Montine TJ, Crane PK, Sonnen JA, Larson EB. Use of Analgesics (Opioids and Nonsteroidal Anti-Inflammatory Drugs) and Dementia-Related Neuropathology in a Community-Based Autopsy Cohort. J Alzheimers Dis 2018; 58:435-448. [PMID: 28453469 DOI: 10.3233/jad-160374] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Opioids may influence the development of Alzheimer's disease (AD). Some studies have observed AD pathology in the brains of opioid abusers. No study has examined the association between prescription opioid use and dementia-related neuropathologic changes. OBJECTIVE To examine the relationship between prescription opioid or NSAID use and dementia-related neuropathologic changes. METHODS Within a community-based autopsy cohort (N = 420), we ascertained opioid and nonsteroidal anti-inflammatory drug (NSAID) use over a 10-year period from automated pharmacy data and calculated total standardized daily doses (TSDDs). A neuropathologist assessed outcomes including neuritic plaques, neurofibrillary tangles, and macroscopic infarcts. Outcome measures were dichotomized using established cutpoints. We used modified Poisson regression to calculate adjusted relative risks (RR) and 95% confidence intervals (CI), accounting for participant characteristics and using weighting to account for possible selection bias related to selection into the autopsy sample. RESULTS Heavier opioid exposure was not associated with greater neuropathologic changes. For neuritic plaques, the adjusted RR [95% CI] was 0.99 [0.64-1.47] for 91+ TSDDs of opioids versus little to no use, and for neurofibrillary tangles, 0.97 [0.49-1.78]. People with heavy NSAID use had higher risk of neuritic plaques (RR 1.39 [1.01-1.89]) than those with little to no use, as we have previously reported. Neither opioid nor NSAID use was associated with higher risk of macroscopic infarcts or with Lewy body disease. CONCLUSION Prescription opioid use is not associated with dementia-related neuropathologic changes, but heavy NSAID use may be. More research is needed examining chronic pain, its pharmacologic treatments, and neuropathologic changes.
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Affiliation(s)
- Sascha Dublin
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Rod L Walker
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Shelly L Gray
- School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Rebecca A Hubbard
- Department of Biostatistics & Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Melissa L Anderson
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Onchee Yu
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | - Paul K Crane
- Department of Medicine, Division of General Internal Medicine, University of Washington, Seattle, WA, USA
| | - Josh A Sonnen
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Eric B Larson
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA.,Department of Medicine, Division of General Internal Medicine, University of Washington, Seattle, WA, USA
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32
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Sharma NK, Olotu B, Mathew A, Waitman LR, Rasu R. Lumbar Spine Surgeries and Medication Usage During Hospital Stay: One-Center Perspective. Hosp Pharm 2017; 52:774-780. [PMID: 29276258 DOI: 10.1177/0018578717737431] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background: Pain after spine surgery is usually managed with opioid and nonopioids. The rate of lumbar spine surgeries (LSS) is rising, but current practices on LSS are not known. A current trend in LSS and medication usage by age group is needed to gain a better understanding of how LSS and its pain management vary by age. Objective: The aim of this study was to report current practices of LSS of discectomy, laminectomy, and fusion in patients aged 18 and older and to gain an understanding of medication use for management of LSS. Methods: This retrospective study analyzed data of the University of Kansas Medical Center from 2007 to 2014 of patients (>18 years of age) undergoing laminectomy, discectomy, and fusion. Results: A total of 19 463 patients underwent LSS between 2007 and 2014 at Kansas University hospital. For the purpose of this study, 3115 patients' medical records were observed. A 50% increase in LSS between 2007 and 2014 was noted. Specifically, more than 2-fold increase in LSS was observed in patients aged 65 years and older. Among those aged 65 years and older, laminectomy was the most commonly performed surgery (69.6%) while discectomy was the most common surgery performed among those aged 18 to 34 (82.9%) and those aged 35 to 44 (72%). The medication use also increased with a highest usage in opioids alone (55%), followed by opioids combined with other analgesics (42.7%), regardless of lumbar surgery type or age. Conclusion: The information of increase in both LSS and the medication usage over the 7 years can be used to gain a better understanding of quality, expenditure, and outcomes following LSS. This knowledge may help health care providers plan patient care and rehabilitation services for older adults, as the trajectory of lumbar spine surgery is likely to rise with growing prevalence of older adults. The information regarding increased opioid utilization may also help clinicians to refine opioid usage and consider alternative approaches to manage acute postoperative pain, in light of the current concerns related to overutilization of opioids.
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Affiliation(s)
- Neena K Sharma
- University of Kansas Medical Center, Kansas City, KS, USA
| | | | | | | | - Rafia Rasu
- West Coast University, Los Angeles, CA, USA.,University of Kansas, Lawrence, KS, USA
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Kaasalainen S, Zacharias R, Hill C, Wickson-Griffiths A, Hadjistavropoulos T, Herr K. Advancing the pain management in older adults agenda forward through the development of key research and education priorities: A Canadian perspective. Can J Pain 2017; 1:171-182. [PMID: 35005352 PMCID: PMC8730549 DOI: 10.1080/24740527.2017.1383139] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 09/17/2017] [Accepted: 09/18/2017] [Indexed: 11/04/2022]
Abstract
Background: The undermanagement of pain in older adults has been identified as a problem worldwide. Aims: The purpose of this research is to identify priority areas in education and research for future development with the aim of improving pain management in older persons. In addition, barriers to addressing these priorities are identified. Methods: This mixed methods study, based on a modified Delphi approach, included three distinct components: (1) a qualitative component using focus groups with key informants or experts in the field of pain management in older adults (n = 17), (2) a scoping review of the literature, and (3) a survey of ranked responses completed by the same key informants who attended the focus groups. Thematic analysis was used to identify the initial list of issues and descriptive statistics were used for ranking them. Results: A number of concerns related to both education and research were frequently endorsed by participants. For education, they identified the need for more content in both undergraduate and continuing education programs related to documenting about pain; assessing pain, and learning about the complexities of pain. Research priorities included the need to explore successful practice models; costs of untreated pain; effects of mobility on pain; and patient preferences for pain management. Key barriers to addressing these barriers included lack of staff time and resources and unfamiliarity with pain assessment tools. Conclusion: These findings highlight priority issues related to pain management in older adults from a nationwide perspective.
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Affiliation(s)
- Sharon Kaasalainen
- Department of Family Medicine, School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Ramesh Zacharias
- Chronic Pain Management Unit, Chedoke Hospital & Village of Erin Meadows, Hamilton, Ontario, Canada
| | - Courtney Hill
- School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Keela Herr
- College of Nursing, University of Iowa, Iowa City, Iowa, USA
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Taipale H, Hamina A, Lampela P, Tanskanen A, Tiihonen J, Karttunen N, Tolppanen AM, Hartikainen S. Is Alzheimer’s Disease Associated with Previous Opioid Use? PAIN MEDICINE 2017; 19:2115-2121. [DOI: 10.1093/pm/pnx210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Heidi Taipale
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Aleksi Hamina
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Pasi Lampela
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Antti Tanskanen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland
- The Impact Assessment Unit, National Institute for Health and Welfare, Helsinki, Finland
| | - Jari Tiihonen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland
| | - Niina Karttunen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
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35
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Binnekade TT, Scherder EJA, Maier AB, Lobbezoo F, Overdorp EJ, Rhebergen D, Perez RSGM, Oosterman JM. Pain in Patients with Different Dementia Subtypes, Mild Cognitive Impairment, and Subjective Cognitive Impairment. PAIN MEDICINE 2017; 19:920-927. [DOI: 10.1093/pm/pnx162] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Tarik T Binnekade
- Department of Clinical Neuropsychology, VU University, Amsterdam, the Netherlands
| | - Erik J A Scherder
- Department of Clinical Neuropsychology, VU University, Amsterdam, the Netherlands
| | - Andrea B Maier
- Department of Medicine and Aged Care, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
- Department of Human Movement Sciences, MOVE Research Institute Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Frank Lobbezoo
- Department of Oral Kinesiology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, MOVE Research Institute Amsterdam, Amsterdam, the Netherlands
| | - Eduard J Overdorp
- Department of Medical Psychology, Gelre Medical Centre, Zutphen, the Netherlands
| | - Didi Rhebergen
- GGZ InGeest/Department of Psychiatry and the EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, the Netherlands
| | - Roberto S G M Perez
- Department of Anesthesiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Joukje M Oosterman
- Radboud University, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, the Netherlands
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36
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Development and Implementation of a Registry of Patients Attending Multidisciplinary Pain Treatment Clinics: The Quebec Pain Registry. Pain Res Manag 2017; 2017:8123812. [PMID: 28280406 PMCID: PMC5322414 DOI: 10.1155/2017/8123812] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 11/28/2016] [Indexed: 01/15/2023]
Abstract
The Quebec Pain Registry (QPR) is a large research database of patients suffering from various chronic pain (CP) syndromes who were referred to one of five tertiary care centres in the province of Quebec (Canada). Patients were monitored using common demographics, identical clinical descriptors, and uniform validated outcomes. This paper describes the development, implementation, and research potential of the QPR. Between 2008 and 2013, 6902 patients were enrolled in the QPR, and data were collected prior to their first visit at the pain clinic and six months later. More than 90% of them (mean age ± SD: 52.76 ± 4.60, females: 59.1%) consented that their QPR data be used for research purposes. The results suggest that, compared to patients with serious chronic medical disorders, CP patients referred to tertiary care clinics are more severely impaired in multiple domains including emotional and physical functioning. The QPR is also a powerful and comprehensive tool for conducting research in a “real-world” context with 27 observational studies and satellite research projects which have been completed or are underway. It contains data on the clinical evolution of thousands of patients and provides the opportunity of answering important research questions on various aspects of CP (or specific pain syndromes) and its management.
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37
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Witkin LR, Zylberger D, Mehta N, Hindenlang M, Johnson C, Kean J, Horn SD, Inturrisi CE. Patient-Reported Outcomes and Opioid Use in Outpatients With Chronic Pain. THE JOURNAL OF PAIN 2017; 18:583-596. [PMID: 28088507 DOI: 10.1016/j.jpain.2016.12.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Revised: 12/17/2016] [Accepted: 12/27/2016] [Indexed: 12/26/2022]
Abstract
The Weill Cornell Medical College Pain Registry database contains patient characteristics, treatments, and outcomes for a prospective cohort of 1,159 chronic pain patients who were seen at the Weill Cornell Medical College Pain Medicine outpatient clinic from July 8, 2011 to December 10, 2014. Patients aged 45 to 64 years comprised 43% followed by age ≥ 65 years at 37%. Fifty-eight percent were female. Average pain intensity (Brief Pain Inventory) was reported as mild by 22.3% of patients, moderate by 34.7%, and severe by 43.0%. For each pain intensity category, patient's report of average percent pain relief and health state (EuroQOL 5 Dimensions) was inversely related to average pain intensity category, whereas measures of pain interference, number of worst pain locations, and physical and psychological distress were directly related to pain intensity category. Seventy-seven percent of patients received an opioid at 1 or more clinic encounters. Median daily opioid dose in morphine equivalents was 55 with a range from 2 to 1,145 morphine equivalents. Regression analysis revealed that being male was associated with greater likelihood of an opioid ordered and higher average dosage than being female. The registry can identify patient characteristics and treatments that provide new insights into chronic pain management. PERSPECTIVE This article describes results of analyses of patient-reported outcomes and patient-related electronic health record data collected under standard of care from a prospective cohort of chronic pain outpatients at a New York City pain management clinic. The registry provides an opportunity to learn how to improve individualized chronic pain management.
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Affiliation(s)
- Lisa R Witkin
- Department of Anesthesiology, Weill Cornell Medical College, New York, New York
| | - David Zylberger
- Department of Anesthesiology, Weill Cornell Medical College, New York, New York
| | - Neel Mehta
- Department of Anesthesiology, Weill Cornell Medical College, New York, New York
| | | | - Christopher Johnson
- Health System Innovation and Research Division, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jacob Kean
- Health System Innovation and Research Division, University of Utah School of Medicine, Salt Lake City, Utah
| | - Susan D Horn
- Health System Innovation and Research Division, University of Utah School of Medicine, Salt Lake City, Utah
| | - Charles E Inturrisi
- Department of Pharmacology, Weill Cornell Medical College, New York, New York.
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Patient Priority Weighting of the Roland Morris Disability Questionnaire Does Not Change Results of the Lumbar Epidural Steroid Injections for Spinal Stenosis Trial. Spine (Phila Pa 1976) 2017; 42:42-48. [PMID: 27105466 PMCID: PMC5071103 DOI: 10.1097/brs.0000000000001647] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Secondary analysis of lumbar epidural steroid injections for spinal stenosis randomized controlled trial data. OBJECTIVE To reevaluate whether outcomes for older adults receiving epidural steroid injections with or without corticosteroid improve after using patient-prioritized Roland-Morris Disability Questionnaire (RDQ) items. SUMMARY OF BACKGROUND DATA Epidural corticosteroid injections are commonly used to treat lumbar spinal stenosis symptoms, despite limited evidence for their effectiveness in clinical trials. It is unclear whether evaluating patient-prioritized outcomes would alter results of a large clinical trial. METHODS Outcomes from the trial of lumbar epidural corticosteroid injections for spinal stenosis (LESS) trial were reanalyzed using RDQ, Sickness Impact Profile (SIP) weights assigned to the RDQ items, and patient-prioritized RDQ items. Differences between corticosteroid + lidocaine versus lidocaine-alone groups and 95% confidence intervals (CI) were calculated using analysis of covariance with adjustment for baseline values of the RDQ and recruitment site. RESULTS At 6 weeks, both the corticosteroid + lidocaine group and the lidocaine-alone group had improvement in the RDQ scores (RDQ, RDQ using SIP weights, patient-prioritized RDQ) as compared with baseline scores (corticosteroid + lidocaine: -4.2 points, -4.1 points, -4.2; lidocaine-alone: -3.1 points, -2.9 points, and -3.1 points, respectively). However, there was no significant between-group difference in the RDQ or patient-prioritized RDQ (average treatment effect -1.0 points, 95% CI -2.1 to 0.1, P = 0.07; -1.0 points, 95% CI -2.0 to 0.1, P = 0.08, respectively). Although the between-group difference of RDQ using SIP weights was statistically significant (average treatment effect -1.1, 95% CI -2.2 to -0.1, P = 0.04), this was not clinically important. CONCLUSION Results of the LESS trial did not substantively differ based on reanalysis of data using RDQ with SIP weights or patient-prioritized RDQ outcomes. This provides additional evidence that epidural injection of corticosteroid + lidocaine offered minimal or no short-term benefit as compared with epidural injection of lidocaine alone for older adults with lumbar spinal stenosis. LEVEL OF EVIDENCE 2.
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Abstract
Pharmacologic management of chronic pain in older adults is one component of the multimodal, interdisciplinary management of this complex condition. In this article, we summarize several of the key barriers to effective pharmacologic management in older adults and review the existing (albeit limited) evidence for its effectiveness and safety, especially in a medically complex population with multimorbidity. This review covers topical formulations, acetaminophen, oral nonsteroidal antiinflammatory drugs, and adjuvant therapies. The article concludes with a suggested approach to managing chronic pain in the older patient, incorporating goals and expectations for treatment as well as careful monitoring of medication adjustments.
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Affiliation(s)
- Zachary A Marcum
- Department of Pharmacy, University of Washington School of Pharmacy, 1959 Northeast Pacific Avenue, Box 357630, Seattle, WA 98195, USA
| | - Nakia A Duncan
- Texas Tech University Health Sciences Center School of Pharmacy, 4500 South Lancaster Street, Building 7, Room 215, Dallas, TX, USA
| | - Una E Makris
- Division of Rheumatic Diseases, Department of Internal Medicine, VA North Texas Health Care System, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9169, USA.
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Abstract
The incidence and prevalence of rheumatologic conditions are increasing and the rheumatology workforce must be aware of aging-specific issues. This article reviews specific barriers to understanding the biology of aging and aging-related mechanisms that may underlie development of rheumatologic diseases in older adults. It summarizes gaps in the assessment, outcomes measurement, and treatment of these diseases in this unique population. It also highlights potential solutions to these barriers and suggests possible ways to bridge the gap, from a research and education standpoint, so that clinicians can be better prepared to effectively manage older adults with rheumatologic conditions.
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Beneciuk JM, Hill JC, Campbell P, Afolabi E, George SZ, Dunn KM, Foster NE. Identifying Treatment Effect Modifiers in the STarT Back Trial: A Secondary Analysis. THE JOURNAL OF PAIN 2016; 18:54-65. [PMID: 27765643 DOI: 10.1016/j.jpain.2016.10.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 09/16/2016] [Accepted: 10/05/2016] [Indexed: 12/28/2022]
Abstract
Identification of patient characteristics influencing treatment outcomes is a top low back pain (LBP) research priority. Results from the STarT Back trial support the effectiveness of prognostic stratified care for LBP compared with current best care, however, patient characteristics associated with treatment response have not yet been explored. The purpose of this secondary analysis was to identify treatment effect modifiers within the STarT Back trial at 4-month follow-up (n = 688). Treatment response was dichotomized using back-specific physical disability measured using the Roland-Morris Disability Questionnaire (≥7). Candidate modifiers were identified using previous literature and evaluated using logistic regression with statistical interaction terms to provide preliminary evidence of treatment effect modification. Socioeconomic status (SES) was identified as an effect modifier for disability outcomes (odds ratio [OR] = 1.71, P = .028). High SES patients receiving prognostic stratified care were 2.5 times less likely to have a poor outcome compared with low SES patients receiving best current care (OR = .40, P = .006). Education level (OR = 1.33, P = .109) and number of pain medications (OR = .64, P = .140) met our criteria for effect modification with weaker evidence (.20 > P ≥ .05). These findings provide preliminary evidence for SES, education, and number of pain medications as treatment effect modifiers of prognostic stratified care delivered in the STarT Back Trial. PERSPECTIVE This analysis provides preliminary exploratory findings about the characteristics of patients who might least likely benefit from targeted treatment using prognostic stratified care for LBP.
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Affiliation(s)
- Jason M Beneciuk
- Department of Physical Therapy, University of Florida, Gainesville, Florida; Brooks Rehabilitation-College of Public Health and Health Professions (University of Florida) Research Collaboration, University of Florida, Gainesville, Florida.
| | - Jonathan C Hill
- Arthritis Research UK Primary Care Centre, Research Institute of Primary Care and Health Sciences, Keele University, Staffordshire, United Kingdom
| | - Paul Campbell
- Arthritis Research UK Primary Care Centre, Research Institute of Primary Care and Health Sciences, Keele University, Staffordshire, United Kingdom
| | - Ebenezer Afolabi
- Arthritis Research UK Primary Care Centre, Research Institute of Primary Care and Health Sciences, Keele University, Staffordshire, United Kingdom
| | - Steven Z George
- Department of Physical Therapy, University of Florida, Gainesville, Florida; Brooks Rehabilitation-College of Public Health and Health Professions (University of Florida) Research Collaboration, University of Florida, Gainesville, Florida
| | - Kate M Dunn
- Arthritis Research UK Primary Care Centre, Research Institute of Primary Care and Health Sciences, Keele University, Staffordshire, United Kingdom
| | - Nadine E Foster
- Arthritis Research UK Primary Care Centre, Research Institute of Primary Care and Health Sciences, Keele University, Staffordshire, United Kingdom
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Choi NG, Snow AL, Kunik ME. Pain severity, interference, and prescription analgesic use among depressed, low-income homebound older adults. Aging Ment Health 2016; 20:804-13. [PMID: 25923452 DOI: 10.1080/13607863.2015.1037244] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Disabled, homebound individuals tend to suffer both chronic pain and depression; however, low-income, homebound older adults have been underexposed in pain and depression research. We examined the extent of pain frequency, intensity, and interference; the relationship between pain and depressive symptoms; and prescription analgesic use and its association with use of antidepressant and anxiolytic medications among these older adults. METHOD The data came from the baseline assessment of 215 homebound individuals aged 50+ who were referred to a clinical trial of depression treatment. Bivariate and multivariate analyses were used to examine the research questions. RESULTS Almost 87% (n = 186) of the participants reported having had chronic pain in the preceding three months. Of the pain reporters, the mean frequency, intensity, and interference of pain were 8.65 ± 2.05, 7.71 ± 2.10, and 7.80 ± 2.82, respectively, on a 1-10 scale, and 61% were taking a prescription analgesic. Analgesic users and nonusers did not differ in depressive symptoms and in pain frequency and intensity, but analgesic users reported higher pain interference than nonusers (8.22 ± 2.46 vs. 7.14 ± 3.22; t = 2.44, df = 184, p = .016). Pain frequency and interference were significantly associated with depressive symptoms, and pain interference was significantly associated with analgesic use in multivariate analysis. Anxiolytic medication use was also correlated with analgesic use. CONCLUSION The findings underscore the significant pain-related problems in these vulnerable individuals and the need for recognizing and treating both pain and depression more effectively using both pharmacologic and nonpharmacologic interventions.
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Affiliation(s)
- Namkee G Choi
- a The University of Texas at Austin School of Social Work , Austin , TX , USA
| | - A Lynn Snow
- b Department of Psychology , University of Alabama Center for Mental Health and Aging , Tuscaloosa , AL , USA
| | - Mark E Kunik
- c The Center for Innovations in Quality, Effectiveness and Safety (#CIN 13-413) , Michael E. DeBakey VA Medical Center , Houston , TX , USA.,d Houston VA Health Services Research and Development Center of Excellence , Houston , TX , USA.,e Department of Psychiatry , Baylor College of Medicine , Houston , TX , USA
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Abstract
Standardization of care that is derived from analysis of outcomes data can lead to improvements in quality and efficiency of care. The outcomes data should be validated, standardized, and integrated into ongoing patient care with minimal burden on the patient and health care team. This article describes the organization and workflow of a chronic pain clinic registry designed to collect and analyze patient data for quality improvement and dissemination. Future efforts in using mobile technology and integrating patient-reported outcome data in the electronic health records have the potential to offer new and improved models of comprehensive pain management.
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Affiliation(s)
- Neel Mehta
- Department of Anesthesiology, Weill Cornell Pain Medicine, Weill Cornell Medical College, 1305 York Avenue, 10th Floor, New York, NY 10021, USA
| | - Charles E Inturrisi
- Department of Pharmacology, Weill Cornell Medical College, 1300 York Avenue, LC-519A, New York, NY 10065, USA
| | - Susan D Horn
- Department of Population Health Sciences, Health System Innovation and Research Division, University of Utah, School of Medicine, 295 Chipeta Way, Room 1N461, Salt Lake City, UT 84108, USA
| | - Lisa R Witkin
- Department of Anesthesiology, Weill Cornell Pain Medicine, Weill Cornell Medical College, 1305 York Avenue, 10th Floor, New York, NY 10021, USA.
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Dobscha SK, Lovejoy TI, Morasco BJ, Kovas AE, Peters DM, Hart K, Williams JL, McFarland BH. Predictors of Improvements in Pain Intensity in a National Cohort of Older Veterans With Chronic Pain. THE JOURNAL OF PAIN 2016; 17:824-35. [PMID: 27058162 DOI: 10.1016/j.jpain.2016.03.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 03/21/2016] [Accepted: 03/24/2016] [Indexed: 12/25/2022]
Abstract
UNLABELLED Little is known about the factors associated with pain-related outcomes in older adults. In this observational study, we sought to identify patient factors associated with improvements in pain intensity in a national cohort of older veterans with chronic pain. We included 12,924 veterans receiving treatment from the Veterans Health Administration with persistently elevated numeric rating scale scores in 2010 who had not been prescribed opioids in the previous 12 months. We examined: 1) percentage decrease over 12 months in average pain intensity scores relative to average baseline pain intensity score; and 2) time to sustained improvement in average pain intensity scores, defined as a 30% reduction in 3-month scores compared with baseline. Average relative improvement in pain intensity scores from baseline ranged from 25% to 29%; almost two-thirds met criteria for sustained improvement during the 12-month follow-up period. In models, higher baseline pain intensity and older age were associated with greater likelihood of improvement in pain intensity, whereas Veterans Affairs service-connected disability, mental health, and certain pain-related diagnoses were associated with lower likelihood of improvement. Opioid prescription initiation during follow-up was associated with lower likelihood of sustained improvement. The findings call for further characterization of heterogeneity in pain outcomes in older adults as well as further analysis of the relationship between prescription opioids and treatment outcomes. PERSPECTIVE This study identified factors associated with improvements in pain intensity in a national cohort of older veterans with chronic pain. We found that older veterans frequently show improvements in pain intensity over time, and that opioid prescriptions, mental health, and certain pain diagnoses are associated with lower likelihood of improvement.
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Affiliation(s)
- Steven K Dobscha
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon; Department of Psychiatry, Oregon Health and Science University, Portland, Oregon.
| | - Travis I Lovejoy
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon; Department of Psychiatry, Oregon Health and Science University, Portland, Oregon
| | - Benjamin J Morasco
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon; Department of Psychiatry, Oregon Health and Science University, Portland, Oregon
| | - Anne E Kovas
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Dawn M Peters
- Department of Public Health and Preventive Medicine, Oregon Health and Science University, Portland, Oregon
| | - Kyle Hart
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - J Lucas Williams
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Bentson H McFarland
- Department of Psychiatry, Oregon Health and Science University, Portland, Oregon; Department of Public Health and Preventive Medicine, Oregon Health and Science University, Portland, Oregon
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Neumann-Podczaska A, Nowak T, Suwalska A, Łojko D, Krzymińska-Siemaszko R, Kozak-Szkopek E, Wieczorowska-Tobis K. Analgesic use among nursing homes residents, with and without dementia, in Poland. Clin Interv Aging 2016; 11:335-40. [PMID: 27051281 PMCID: PMC4807940 DOI: 10.2147/cia.s101475] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Many age-associated diseases are accompanied by pain. There is no doubt that pain is underrecognized among elderly nursing home residents and the diagnosing of pain is a real challenge in subjects with dementia. The aim of the study was to characterize analgesic use among nursing home residents and to delineate the putative associations between pain management and cognitive functions of elderly persons. The study involved 392 subjects (males:females - 81:311) with a mean age of 83.6±5.9 years. The residents' medical files in relation to diagnoses and drug consumption were analyzed, and the screening of cognitive functions was performed using the Mini-Mental State Examination (MMSE). One hundred and thirteen residents (28.8%) received some analgesics. Among them 84 (21.4%) used them routinely, 25 (6.4%) - pro re nata (PRN) and four (1.0%) - both routinely and PRN. Non-opioid analgesics were taken routinely by 53 residents, weak opioids by nine subjects, and one person was receiving strong opioids. Additionally, three individuals were taking a combination preparation of tramadol and acetaminophen. The rate of subjects who were not receiving any pain treatment was higher in residents with MMSE between 0 and 9 points than in those with MMSE between 24 and 30 points (P=0.0151). Furthermore, ten residents (9.1%) with severe dementia were treated with analgesics PRN. The results of our study point to a remarkably low use of analgesics in nursing home residents in Poland and indicate a need to introduce pain evaluation and monitoring of drug treatment appropriateness as a standard procedure in the geriatric assessment in nursing homes.
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Affiliation(s)
| | - Tomasz Nowak
- Department of Palliative Medicine, Laboratory of Geriatrics, Poznan University of Medical Sciences, Poznan, Poland
| | - Aleksandra Suwalska
- Department of Psychiatry, Laboratory of Neuropsychobiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Dorota Łojko
- Department of Adult Psychiatry, Poznan University of Medical Sciences, Poznan, Poland
| | - Roma Krzymińska-Siemaszko
- Department of Palliative Medicine, Laboratory of Geriatrics, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Katarzyna Wieczorowska-Tobis
- Department of Palliative Medicine, Laboratory of Geriatrics, Poznan University of Medical Sciences, Poznan, Poland
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Kuo YF, Raji MA, Chen NW, Hasan H, Goodwin JS. Trends in Opioid Prescriptions Among Part D Medicare Recipients From 2007 to 2012. Am J Med 2016; 129:221.e21-30. [PMID: 26522794 PMCID: PMC4718856 DOI: 10.1016/j.amjmed.2015.10.002] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 10/08/2015] [Accepted: 10/10/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND There is growing concern about potential overuse of, and toxicity from, opioid analgesics. No nationally representative study has examined inter-state variations in opioid use and impact of policy on opioid use among older adults. METHODS We used national Medicare data from 2007-2012 to assess temporal and geographic trends in rates of opioid prescription and relationship to opioid toxicity and different state regulations in Part D Medicare recipients. We excluded those with a cancer diagnosis. Multilevel, multivariable regression analyses evaluated rates of prolonged prescriptions for schedule II, schedule III, and combination II/III opioid for each state, adjusting for patient characteristics. RESULTS The percent of Part D recipients receiving prescriptions for combined schedule II/III opioid more than 90 days in a year increased from 4.62% in 2007 to 7.35% in 2012. Large variations existed among states in rates of opioid prescriptions: from 2.84% in New York to 10.93% in Utah, in 2012 data. The state variation was larger for schedule III than schedule II. Individual characteristics independently associated with prolonged use included older age, female gender, white race, low income, living in a lower-education area, and comorbidity of drug abuse, rheumatoid arthritis, and depression. Only state law regulating pain clinic was associated with reduction of schedule II opioid prescriptions. Prolonged opioid prescription use increased the odds of opioid overdose-related emergency room visits or hospitalization by 60%. CONCLUSIONS Analyses of Medicare Part D data demonstrated a substantial growth in opioid prescriptions from 2007 to 2011 and large variation in opioid prescriptions across states.
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Affiliation(s)
- Yong-Fang Kuo
- Department of Internal Medicine, The University of Texas Medical Branch, Galveston; Sealy Center on Aging, The University of Texas Medical Branch, Galveston; Department of Preventive Medicine and Community Health, The University of Texas Medical Branch, Galveston; Institute for Translational Science, The University of Texas Medical Branch, Galveston.
| | - Mukaila A Raji
- Department of Internal Medicine, The University of Texas Medical Branch, Galveston; Sealy Center on Aging, The University of Texas Medical Branch, Galveston
| | - Nai-Wei Chen
- Department of Preventive Medicine and Community Health, The University of Texas Medical Branch, Galveston
| | - Hunaid Hasan
- Department of Internal Medicine, The University of Texas Medical Branch, Galveston
| | - James S Goodwin
- Department of Internal Medicine, The University of Texas Medical Branch, Galveston; Sealy Center on Aging, The University of Texas Medical Branch, Galveston; Department of Preventive Medicine and Community Health, The University of Texas Medical Branch, Galveston; Institute for Translational Science, The University of Texas Medical Branch, Galveston
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Exposure to High-Risk Medications is Associated With Worse Outcomes in Older Veterans With Chronic Pain. Am J Med Sci 2015; 350:279-85. [PMID: 26418380 DOI: 10.1097/maj.0000000000000552] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Chronic pain is common, costly and leads to significant morbidity in older adults, yet there are limited data on medication safety. The authors sought to evaluate the association of incident high-risk medication in the elderly (HRME) with mortality, emergency department (ED) or hospital care among older adults with chronic pain. METHODS A retrospective Veterans Health Administration cohort study was conducted examining older veterans with chronic pain diagnoses and use of incident HRME (opioids, skeletal muscle relaxants, antihistamines and psychotropics). Outcomes evaluated included all-cause mortality, ED visits or inpatient hospital care. Descriptive statistics summarized variables for the overall cohort, the chronic pain cohort and those with and without HRME. Separate generalized linear mixed-effect regression models were used to examine the association of incident HRME on each outcome, controlling for potential confounders. RESULTS Among 1,807,404 veterans who received Department of Veterans Affairs care in 2005 to 2006, 584,066 (32.3%) had chronic pain; 45,945 veterans with chronic pain (7.9%) had incident HRME exposure. The strongest significant associations of incident HRME were for high-risk opioids with all-cause hospitalizations (odds ratio [OR] 2.08, 95% confidence interval [CI] 1.95-2.23), skeletal muscle relaxants with all-cause ED visits (OR 2.62, 95% CI 2.52-2.73) and mortality (OR 0.80, 95% CI 0.74-0.86), antihistamines with all-cause ED visits (OR 2.82 95% CI 2.72-2.95) and psychotropics with all-cause hospitalizations (OR 2.15, 95% CI 1.96-2.35). CONCLUSIONS Our data indicate that incident HRME is associated with clinically important adverse outcomes in older veterans with chronic pain and highlight the importance of being judicious with prescribing certain classes of drugs in this vulnerable population.
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Dublin S, Walker RL, Gray SL, Hubbard RA, Anderson ML, Yu O, Crane PK, Larson EB. Prescription Opioids and Risk of Dementia or Cognitive Decline: A Prospective Cohort Study. J Am Geriatr Soc 2015; 63:1519-26. [PMID: 26289681 PMCID: PMC4776316 DOI: 10.1111/jgs.13562] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES To determine whether prescription opioid use is associated with higher dementia risk or greater cognitive decline. DESIGN Prospective cohort study. SETTING Group Health, an integrated healthcare delivery system. PARTICIPANTS Community-dwelling individuals aged 65 and older without dementia with at least 10 years of Group Health enrollment at baseline (N = 3,434; median age 74). MEASUREMENTS The Cognitive Abilities Screening Instrument (CASI) was administered every 2 years. Low scores triggered detailed evaluation, and a multidisciplinary committee assigned dementia diagnoses. From computerized pharmacy data, cumulative opioid exposure was defined as total standardized doses (TSDs) dispensed over 10 years (excluding the most recent year because of possible prodromal symptoms). For comparison, use of nonsteroidal anti-inflammatory drugs (NSAIDs), characterized similarly, was examined. Dementia risk was analyzed using Cox proportional hazards models and CASI trajectory using linear regression models and generalized estimating equations. RESULTS Seven hundred ninety-seven participants (23%) developed dementia over a mean follow-up of 7.3 years; 637 (19%) had possible or probable Alzheimer's disease. For cumulative opioid use, the hazard ratios (HRs) for dementia were 1.06 (95% confidence interval (CI) = 0.88-1.26) for 11 to 30 TSDs, 0.88 (95% CI = 0.70-1.09) for 31 to 90 TSDs, and 1.29 (95% CI = 1.02-1.62) for 91 or more TSDs, versus 0 to 10 TSDs. A similar pattern was seen for NSAID use. Heavier opioid use was not associated with more-rapid cognitive decline. CONCLUSION People with the heaviest opioid or NSAID use had slightly higher dementia risk than people with little or no use. These results may reflect an effect of chronic pain on cognition or residual confounding. Although opioids have other risks, little evidence of long-term cognitive harm specific to opioids was found.
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Affiliation(s)
- Sascha Dublin
- Group Health Research Institute, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
| | - Rod L. Walker
- Group Health Research Institute, Seattle, Washington
| | - Shelly L. Gray
- School of Pharmacy, University of Washington, Seattle, Washington
| | - Rebecca A. Hubbard
- Center for Clinical Epidemiology & Biostatistics, Department of Biostatistics & Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Onchee Yu
- Group Health Research Institute, Seattle, Washington
| | - Paul K. Crane
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Eric B. Larson
- Group Health Research Institute, Seattle, Washington
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington
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Makris UE, Higashi RT, Marks EG, Fraenkel L, Sale JEM, Gill TM, Reid MC. Ageism, negative attitudes, and competing co-morbidities--why older adults may not seek care for restricting back pain: a qualitative study. BMC Geriatr 2015; 15:39. [PMID: 25887905 PMCID: PMC4392872 DOI: 10.1186/s12877-015-0042-z] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 03/25/2015] [Indexed: 12/22/2022] Open
Abstract
Background Back pain, the most common type of pain reported by older adults, is often undertreated for reasons that are poorly understood, especially in minority populations. The objective of this study was to understand older adults’ beliefs and perspectives regarding care-seeking for restricting back pain (back pain that restricts activity). Methods We used data from a diverse sample of 93 older adults (median age 83) who reported restricting back pain during the past 3 months. A semi-structured discussion guide was used in 23 individual interviews and 16 focus groups to prompt participants to share experiences, beliefs, and attitudes about managing restricting back pain. Transcripts were analyzed in an iterative process to develop thematic categories. Results Three themes for why older adults may not seek care for restricting back pain were identified: (1) beliefs about the age-related inevitability of restricting back pain, (2) negative attitudes toward medication and/or surgery, and (3) perceived importance of restricting back pain relative to other comorbidities. No new themes emerged in the more diverse focus groups. Conclusions Illness perceptions (including pain-related beliefs), and interactions with providers may influence older adults’ willingness to seek care for restricting back pain. These results highlight opportunities to improve the care for older adults with restricting back pain.
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Affiliation(s)
- Una E Makris
- Department of Internal Medicine, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9169, USA. .,Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA. .,Department of Veterans Affairs, Dallas, TX, USA.
| | - Robin T Higashi
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Emily G Marks
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Liana Fraenkel
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA. .,Department of Veterans Affairs, West Haven, CT, USA.
| | - Joanna E M Sale
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada. .,Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Canada.
| | - Thomas M Gill
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA.
| | - M Carrington Reid
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College, New York, NY, USA.
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Dobscha SK, Morasco BJ, Kovas AE, Peters DM, Hart K, McFarland BH. Short-term variability in outpatient pain intensity scores in a national sample of older veterans with chronic pain. PAIN MEDICINE 2014; 16:855-65. [PMID: 25545398 DOI: 10.1111/pme.12643] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The Department of Veterans Affairs (VA) uses the 11-point pain numeric rating scale (NRS) to gather pain intensity information from veterans at outpatient appointments. Yet, little is known about how NRS scores may vary over time within individuals; NRS variability may have important ramifications for treatment planning. Our main objective was to describe variability in NRS scores within a 1-month timeframe, as obtained during routine outpatient care in older patients with chronic pain treated in VA hospitals. A secondary objective was to explore for patient characteristics associated with within-month NRS score variability. DESIGN Retrospective cohort study. SUBJECTS National sample of veterans 65 years or older seen in VA in 2010 who had multiple elevated NRS scores indicating chronic pain. METHODS VA datasets were used to identify the sample and demographic and clinical variables including NRS scores. For the main analysis, we identified subjects with two or more NRS scores obtained in each of two or more months in a 12-month period; we examined ranges in NRS scores across the first two qualifying months. RESULTS Among 4,336 individuals in the main analysis cohort, the mean and median of the average NRS score range across the 2 months were 2.7 and 2.5, respectively. In multivariable models, main significant predictors of within-month NRS score variability were baseline pain intensity, overall medical comorbidity, and being divorced/separated. CONCLUSIONS The majority of patients in the sample had clinically meaningful variation in pain scores within a given month. This finding highlights the need for clinicians and their patients to consider multiple NRS scores when making chronic pain treatment decisions.
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Affiliation(s)
- Steven K Dobscha
- Center to Improve Veteran Involvement in Care, Portland Veterans Affairs Medical Center, Portland, Oregon, USA.,Department of Psychiatry, Oregon Health & Science University, Portland, Oregon, USA
| | - Benjamin J Morasco
- Center to Improve Veteran Involvement in Care, Portland Veterans Affairs Medical Center, Portland, Oregon, USA.,Department of Psychiatry, Oregon Health & Science University, Portland, Oregon, USA
| | - Anne E Kovas
- Center to Improve Veteran Involvement in Care, Portland Veterans Affairs Medical Center, Portland, Oregon, USA
| | - Dawn M Peters
- Department of Public Health & Preventive Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Kyle Hart
- Center to Improve Veteran Involvement in Care, Portland Veterans Affairs Medical Center, Portland, Oregon, USA
| | - Bentson H McFarland
- Department of Psychiatry, Oregon Health & Science University, Portland, Oregon, USA.,Department of Public Health & Preventive Medicine, Oregon Health & Science University, Portland, Oregon, USA
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