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Hines RB, Schoborg C, Sumner T, Thiesfeldt DL, Zhang S. The associations of oxaliplatin-induced peripheral neuropathy, sociodemographic characteristics, and clinical characteristics with time to fall in older adults with colorectal cancer. Am J Epidemiol 2024; 193:1271-1280. [PMID: 38751324 DOI: 10.1093/aje/kwae067] [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: 06/14/2023] [Revised: 04/03/2024] [Accepted: 05/13/2024] [Indexed: 09/04/2024] Open
Abstract
Our purpose was to investigate the associations between falls and oxaliplatin-induced peripheral neuropathy (OIPN), sociodemographic characteristics, and clinical characteristics of older patients with colorectal cancer. The study population consisted of older adults diagnosed with colorectal cancer whose data were obtained from the Surveillance, Epidemiology, and End Results database combined with Medicare claims. We defined OIPN using specific (OIPN 1) and broader (OIPN 2) definitions of OIPN, based on diagnosis codes. Extensions of the Cox regression model to accommodate repeated events were used to obtain overall hazard ratios (HRs) with 95% CIs and the cumulative hazard of fall. The unadjusted risk of fall for colorectal cancer survivors with versus without OIPN 1 at 36 months of follow-up was 19.6% versus 14.3%, respectively. The association of OIPN with time to fall was moderate (for OIPN 1, HR = 1.37; 95% CI, 1.04-1.79) to small (for OIPN 2, HR = 1.24; 95% CI, 1.01-1.53). Memantine, opioids, cannabinoids, prior history of fall, female sex, advanced age and disease stage, chronic liver disease, diabetes, and chronic obstructive pulmonary disease all increased the hazard rate of falling. Incorporating fall prevention in cancer care is essential to minimize morbidity and mortality of this serious event in older survivors of colorectal cancer.
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Affiliation(s)
- Robert B Hines
- Department of Population Health Sciences, College of Medicine, University of Central Florida, Orlando, FL 32827, United States
| | - Christopher Schoborg
- Department of Statistics and Data Science, College of Sciences, University of Central Florida, Orlando, FL 32827, United States
| | - Timothy Sumner
- Department of Statistics and Data Science, College of Sciences, University of Central Florida, Orlando, FL 32827, United States
| | - Dana-Leigh Thiesfeldt
- Department of Medical Education, College of Medicine, University of Central Florida, Orlando, FL 32827, United States
| | - Shunpu Zhang
- Department of Statistics and Data Science, College of Sciences, University of Central Florida, Orlando, FL 32827, United States
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Wu PY, Caceres AI, Chen J, Sokoloff J, Huang M, Baht GS, Nackley AG, Jordt SE, Terrando N. Vagus nerve stimulation rescues persistent pain following orthopedic surgery in adult mice. Pain 2024; 165:e80-e92. [PMID: 38422485 PMCID: PMC11247455 DOI: 10.1097/j.pain.0000000000003181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/21/2023] [Accepted: 12/13/2023] [Indexed: 03/02/2024]
Abstract
ABSTRACT Postoperative pain is a major clinical problem imposing a significant burden on patients and society. In a survey 2 years after orthopedic surgery, 57% of patients reported persisting postoperative pain. However, only limited progress has been made in the development of safe and effective therapies to prevent the onset and chronification of pain after orthopedic surgery. We established a tibial fracture mouse model that recapitulates clinically relevant orthopedic trauma surgery, which causes changes in neuropeptide levels in dorsal root ganglia and sustained neuroinflammation in the spinal cord. Here, we monitored extended pain behavior in this model, observing chronic bilateral hindpaw mechanical allodynia in both male and female C57BL/6J mice that persisted for >3 months after surgery. We also tested the analgesic effects of a novel, minimally invasive, bioelectronic approach to percutaneously stimulate the vagus nerve (termed percutaneous vagus nerve stimulation [pVNS]). Weekly pVNS treatment for 30 minutes at 10 Hz for 3 weeks after the surgery strongly reduced pain behaviors compared with untreated controls. Percutaneous vagus nerve stimulation also improved locomotor coordination and accelerated bone healing. In the dorsal root ganglia, vagal stimulation inhibited the activation of glial fibrillary acidic protein-positive satellite cells but without affecting microglial activation. Overall, these data provide novel evidence supportive of the use of pVNS to prevent postoperative pain and inform translational studies to test antinociceptive effects of bioelectronic medicine in the clinic.
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Affiliation(s)
- Pau Yen Wu
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, United States
| | - Ana Isabel Caceres
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, United States
| | - Jiegen Chen
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, United States
| | - Jamie Sokoloff
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, United States
| | - Mingjian Huang
- Department of Orthopaedic Surgery, Duke Molecular Physiology Institute, Duke University Medical Center, Durham, NC, United States
| | - Gurpreet Singh Baht
- Department of Orthopaedic Surgery, Duke Molecular Physiology Institute, Duke University Medical Center, Durham, NC, United States
| | - Andrea G. Nackley
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, United States
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, NC, United States
| | - Sven-Eric Jordt
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, United States
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, NC, United States
- Integrated Toxicology and Environmental Health Program, Duke University, Durham, United States
| | - Niccolò Terrando
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, United States
- Department of Cell Biology, Duke University Medical Center, Durham, NC, United States
- Department of Integrative Immunobiology, Duke University Medical Center, Durham, NC, United States
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DiMartino SJ, Gao H, Neogi T, Fuerst T, Zaim S, Eng S, Ho T, Manvelian G, Braunstein N, Geba GP, Dakin P. Prevalence of preexisting articular bone pathology in patients with osteoarthritis screened for fasinumab clinical trials identified by X-ray or magnetic resonance imaging. Osteoarthritis Cartilage 2024:S1063-4584(24)01274-3. [PMID: 39004211 DOI: 10.1016/j.joca.2024.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 06/27/2024] [Accepted: 07/06/2024] [Indexed: 07/16/2024]
Abstract
OBJECTIVE To examine the prevalence of preexisting articular bone pathology in patients with hip or knee pain due to osteoarthritis (OA) screened for fasinumab clinical trials. METHOD This post-hoc analysis included patients with OA screened for three phase 3 fasinumab studies (NCT02683239, NCT03161093, NCT03304379). During screening, participants who met other clinical inclusion/exclusion criteria underwent radiography of knees, hips, and shoulders. Those with Kellgren-Lawrence grade (KLG) ≥ 2 for index joint and without an exclusionary finding proceeded to magnetic resonance imaging (MRI) of index, contralateral, and KLG ≥ 3 joints. Exclusionary findings included bone fragmentation/collapse, bone loss/resorption, osteonecrosis, and fracture, by either X-ray or MRI. Participants with extensive subchondral cysts were also excluded. Prevalence of abnormalities on radiographs and MRIs are reported. RESULTS Of 27,633 participants screened, 21,997 proceeded to imaging. Of these, 1203 (5.5%) were excluded due to the presence of ≥ 1 joint with severe articular bone pathology (X-ray or MRI): bone fragmentation/collapse (2.60%), subchondral insufficiency fracture (SIF; 1.67%), osteonecrosis (1.11%), and significant bone loss (0.32%). Additionally, 3.13% screen-failed due to extensive subchondral cysts. More than half of the exclusions due to bone fragmentation/collapse (386/572), osteonecrosis (141/245) and significant bone loss (59/71), and approximately one third of SIF (133/367) and extensive subchondral cysts (229/689) were evident on X-rays. CONCLUSIONS Approximately one in 20 participants with OA who met the clinical screening criteria for fasinumab phase 3 trials were later excluded due to preexisting severe articular bone pathology findings by X-ray or MRI.
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Affiliation(s)
| | - Haitao Gao
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA
| | - Tuhina Neogi
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | | | | | - Simon Eng
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA
| | - Tina Ho
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA
| | | | | | | | - Paula Dakin
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA
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Coffee Z, Cheng K, Slebodnik M, Mulligan K, Yu CH, Vanderah TW, Gordon JS. The Impact of Nonpharmacological Interventions on Opioid Use for Chronic Noncancer Pain: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:794. [PMID: 38929040 PMCID: PMC11203961 DOI: 10.3390/ijerph21060794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 06/06/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024]
Abstract
Despite the lack of evidence, opioids are still routinely used as a solution to long-term management for chronic noncancer pain (CNCP). Given the significant risks associated with long-term opioid use, including the increased number of unregulated opioid pills at large in the opioid ecosystem, opioid cessation or reduction may be the desired goal of the patient and clinician. Viable nonpharmacological interventions (NPIs) to complement and/or replace opioids for CNCP are needed. Comprehensive reviews that address the impact of NPIs to help adults with CNCP reduce opioid use safely are lacking. We conducted a literature search in PubMed, CINAHL, Embase, PsycINFO, and Scopus for studies published in English. The initial search was conducted in April 2021, and updated in January 2024. The literature search yielded 19,190 relevant articles. Thirty-nine studies met the eligibility criteria and underwent data extraction. Of these, nineteen (49%) were randomized controlled trials, eighteen (46%) were observational studies, and two (5%) were secondary analyses. Among adults with CNCP who use opioids for pain management, studies on mindfulness, yoga, educational programs, certain devices or digital technology, chiropractic, and combination NPIs suggest that they might be an effective approach for reducing both pain intensity and opioid use, but other NPIs did not show a significant effect (e.g., hypnosis, virtual reality). This review revealed there is a small to moderate body of literature demonstrating that some NPIs might be an effective and safe approach for reducing pain and opioid use, concurrently.
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Affiliation(s)
- Zhanette Coffee
- College of Nursing, University of Arizona, Tucson, AZ 85721, USA;
| | - Kevin Cheng
- College of Medicine, University of Arizona, Tucson, AZ 85721, USA;
| | | | - Kimberly Mulligan
- Veterans Health Administration, Central California, Fresno, CA 93706, USA
| | - Chong Ho Yu
- Department of Mathematics, Hawaii Pacific University, Honolulu, HI 96813, USA;
| | - Todd W. Vanderah
- Department of Pharmacology, Comprehensive Center for Pain and Addiction, University of Arizona, Tucson, AZ 85721, USA;
| | - Judith S. Gordon
- College of Nursing, University of Arizona, Tucson, AZ 85721, USA;
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Ernst AJ, Briggs AM, Spooner R, Balazs GC, Goldman AH. Grit and postoperative opioid use after total joint arthroplasty. Hip Int 2024; 34:156-160. [PMID: 37278372 DOI: 10.1177/11207000231176507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Perioperative multimodal protocols following total joint replacements have significantly decreased the amount of perioperative and postoperative opioids. Further identification of those requiring more or less opioids through individualisation, may further aid in reducing the amount prescribed. Therefore, the purpose of the study was to evaluate whether a patient's grit, the measurable psychological strength of character to persevere during hardship, measured by postoperative opioid consumption. METHODS Consecutive patients who had undergone either primary or revision total knee arthroplasty (TKA) or total hip arthroplasty (THA) from February 2019 to August 2020 at our institution logged their opioid use for the first 2 weeks postoperatively, detailing the type, dosage, and number of narcotics they consumed. Those who completed their logs and a grit questionnaire had their average morphine equivalent dose (MED) and grit score calculated. Analysis was then performed to evaluate if any association existed between these 2 variables. RESULTS There was no correlation between grit score and postoperative opioid consumption in the first 2 weeks following discharge after total joint arthroplasty. A total of 144 patients were eligible to participate and a total of 86 patients met inclusion criteria, 48 patients in the TKA group and 38 in the THA group. Of all patients, 63% were male. The average MED was 95.5 for THAs and 192 for TKAs. The average grit score was 4.23 for THAs and 4.19 for TKAs. CONCLUSIONS There is not an apparent association between grit score and postoperative opioid consumption in the first 2 weeks after total joint arthroplasty. General psychological resiliency may not be an important predictor of postoperative opioid use with modern postoperative protocols.
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Affiliation(s)
- Andrew J Ernst
- Bone and Joint Sports Medicine Institute, Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, VA, USA
| | - Avery M Briggs
- Bone and Joint Sports Medicine Institute, Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, VA, USA
| | - Rebecca Spooner
- Bone and Joint Sports Medicine Institute, Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, VA, USA
| | - George C Balazs
- Bone and Joint Sports Medicine Institute, Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, VA, USA
| | - Ashton H Goldman
- Bone and Joint Sports Medicine Institute, Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, VA, USA
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Axon DR, Aliu O. Association between self-reported pain severity and characteristics of United States adults (age ≥50 years) who used opioids. Scand J Pain 2024; 24:sjpain-2023-0076. [PMID: 38452178 DOI: 10.1515/sjpain-2023-0076] [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: 06/06/2023] [Accepted: 11/28/2023] [Indexed: 03/09/2024]
Abstract
OBJECTIVE The aim of this study was to assess the associations between the characteristics of United States (US) adults (≥50 years) who used opioids and self-reported pain severity using a nationally representative dataset. METHODS This retrospective cross-sectional database study used 2019 Medical Expenditure Panel Survey data to identify US adults aged ≥50 years with self-reported pain within the past 4 weeks and ≥1 opioid prescription within the calendar year (n = 1,077). Weighted multivariable logistic regression analysis modeled associations between various characteristics and self-reported pain severity (quite a bit/extreme vs less/moderate pain). RESULTS The adjusted logistic regression model indicated that greater odds of reporting quite a bit/extreme pain was associated with the following: age 50-64 vs ≥65 (adjusted odds ratio [AOR] = 1.76; 95% confidence interval [CI] = 1.22-2.54), non-Hispanic vs Hispanic (AOR = 2.0; CI = 1.18-3.39), unemployed vs employed (AOR = 2.01; CI = 1.33-3.05), no health insurance vs private insurance (AOR = 6.80; CI = 1.43-32.26), fair/poor vs excellent/very good/good health (AOR = 3.10; CI = 2.19-4.39), fair/poor vs excellent/very good/good mental health (AOR = 2.16; CI = 1.39-3.38), non-smoker vs smoker (AOR = 1.80; CI = 1.19-2.71), and instrumental activity of daily living, yes vs no (AOR = 2.27; CI = 1.30-3.96). CONCLUSION Understanding the several characteristics associated with pain severity in US adults ≥50 years who used an opioid may help transform healthcare approaches to prevention, education, and management of pain severity in later life.
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Affiliation(s)
- David R Axon
- Department of Pharmacy Practice & Science, R. Ken Coit College of Pharmacy, University of Arizona, 1295 N Martin Ave, PO Box 210202, Tucson, Arizona, 85721, USA
- Center for Health Outcomes and PharmacoEconomic Research (HOPE Center), R. Ken Coit College of Pharmacy, University of Arizona, 1295 N Martin Ave, PO Box 210202, Tucson, Arizona, 85721, USA
| | - Oiza Aliu
- Department of Pharmacy Practice & Science, R. Ken Coit College of Pharmacy, University of Arizona, 1295 N Martin Ave, PO Box 210202, Tucson, Arizona, 85721, USA
- Center for Health Outcomes and PharmacoEconomic Research (HOPE Center), R. Ken Coit College of Pharmacy, University of Arizona, 1295 N Martin Ave, PO Box 210202, Tucson, Arizona, 85721, USA
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Kanis E, Gallegos P, Christman K, Vazquez D, Mullen C, Cucci MD. Impact of medication intensification on 30-day hospital readmissions in a geriatric trauma population: A multicenter cohort study. Pharmacotherapy 2024; 44:39-48. [PMID: 37926857 DOI: 10.1002/phar.2890] [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: 06/15/2023] [Revised: 09/08/2023] [Accepted: 09/29/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Fall-related injuries are a significant health issue that occur in 25% of older adults and account for a significant number of trauma-related hospitalizations. Although medication intensification may increase the risk of hospital readmissions in non-trauma patients, data on a geriatric trauma population are lacking. OBJECTIVE The primary objective was to evaluate the effect of medication intensification on 30-day hospital readmissions in geriatric patients hospitalized for fall-related injuries. METHODS This multicenter, retrospective cohort study included patients with geriatric who presented to one of three trauma centers within a large, health-system between January 1, 2018 and December 31, 2020. Patients at least 65 years old admitted with a fall-related injury were eligible for inclusion. Patients were grouped according to medication changes at discharge, which included intensified and non-intensified groups. Medication intensification included increased dose(s) or initiation of new agents. The primary outcome was the 30-day hospital readmission rate. RESULTS Of the 870 patients included (median [interquartile range, IQR] age, 82 [74-89] years, 522 (60%) female, and 220 (25%) with a previous fall), there were 471 (54%) and 399 (46%) patients in the intensified and non-intensified groups, respectively. The intensified group had a higher 30-day hospital readmission rate (21% intensified vs. 16% non-intensified, p = 0.043; number needed to harm 20) based on an unweighted analysis. According to a weighted propensity score logistic regression, medication intensification was associated with higher 30-day hospital readmissions (24% [95% confidence interval [CI] 19-31%] intensified vs. 15% [95% CI 11-20%] non-intensified, p = 0.018). These results were consistent within competing risk models accounting for death (cause-specific model: hazard ratio [HR] 1.63 [95% CI 1.07-2.49], p = 0.023; Fine-Gray model: HR 1.64 [95% CI 1.07-2.50], p = 0.022). CONCLUSIONS In a geriatric trauma population hospitalized after a fall, intensification of medications may pose an increased risk of 30-day hospital readmission.
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Affiliation(s)
- Emily Kanis
- Department of Pharmacy, Cleveland Clinic Akron General, Akron, Ohio, USA
| | - Patrick Gallegos
- Department of Pharmacy, Cleveland Clinic Akron General, Akron, Ohio, USA
- Department of Pharmacy Practice, Department of Internal Medicine, Northeast Ohio Medical Center, Rootstown, Ohio, USA
| | - Kailey Christman
- Department of Research, Cleveland Clinic Akron General, Akron, Ohio, USA
| | - Daniel Vazquez
- Department of Surgery, Cleveland Clinic Akron General, Akron, Ohio, USA
| | - Chanda Mullen
- Department of Research, Cleveland Clinic Akron General, Akron, Ohio, USA
| | - Michaelia D Cucci
- Department of Pharmacy, Cleveland Clinic Akron General, Akron, Ohio, USA
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Karayiannis PN, Warnock M, Cassidy R, Jones K, Scott CEH, Beverland D. The painful truth of waiting for hip and knee arthroplasty in Northern Ireland. Bone Joint J 2023; 105-B:783-794. [PMID: 37399093 DOI: 10.1302/0301-620x.105b7.bjj-2023-0078.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
Aims The aim of this study was to report health-related quality of life (HRQoL) and joint-specific function in patients waiting for total hip or knee arthroplasty surgery (THA or TKA) in Northern Ireland, compared to published literature and a matched normal population. Secondary aims were to report emergency department (ED) and out-of-hours general practitioner (OOH GP) visits, new prescriptions of strong opioids, and new prescriptions of antidepressants while waiting. Methods This was a cohort study of 991 patients on the waiting list for arthroplasty in a single Northern Ireland NHS trust: 497 on the waiting list for ≤ three months; and 494 waiting ≥ three years. Postal surveys included the EuroQol five-dimension five-level questionnaire (EQ-5D-5L), visual analogue scores (EQ-VAS), and Oxford Hip and Knee scores to assess HRQoL and joint-specific function. Electronic records determined prescriptions since addition to the waiting list and patient attendances at OOH GP/EDs. Results Overall, 712/991 (71.8%) responded at ≤ three months for THA (n = 164) and TKA (n = 199), and ≥ three years for THA (n = 88) and TKA (n = 261). The median EQ-5D-5L score in those waiting ≤ three months was 0.155 (interquartile range (IQR) -0.118 to 0.375) and 0.189 (IQR -0.130 to 0.377) for ≥ three years. Matched controls had a median EQ-5D-5L 0.837 (IQR 0.728 to 1.000). Compared to matched controls, EQ-5D-5L scores were significantly lower in both waiting cohorts (p < 0.001) with significant differences found in every domain. Negative scores, indicating a state "worse than death", were present in 40% at ≤ three months and 38% at ≥ three years. Patients waiting ≥ three years had significantly more opioid (28.4% vs 15.2%; p < 0.001) and antidepressant prescriptions (15.2% vs 9.9%; p = 0.034) and significantly more joint-related attendances at unscheduled care (11.7% vs 0% with ≥ one ED attendance (p < 0.001) and (25.5% vs 2.5% ≥ one OOH GP attendance (p < 0.001)). Conclusion Patients on waiting lists in Northern Ireland are severely disabled with the worst HRQoL and functional scores studied. The lack of deterioration in EQ-5D-5L and joint-specific scores between patients waiting ≤ three months and ≥ three years likely reflects floor effects of these scores. Prolonged waits were associated with increased dependence on strong opiates, depression, and attendances at unscheduled care.
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Jani M, Yimer BB, Selby D, Lunt M, Nenadic G, Dixon WG. "Take up to eight tablets per day": Incorporating free-text medication instructions into a transparent and reproducible process for preparing drug exposure data for pharmacoepidemiology. Pharmacoepidemiol Drug Saf 2023; 32:651-660. [PMID: 36718594 PMCID: PMC10947089 DOI: 10.1002/pds.5595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 12/02/2022] [Accepted: 01/25/2023] [Indexed: 02/01/2023]
Abstract
PURPOSE Routinely collected prescription data provides drug exposure information for pharmacoepidemiology, informing start/stop dates and dosage. Prescribing information includes structured data and unstructured free-text instructions, which can include inherent variability, such as "one to two tablets up to four times a day". Preparing drug exposure data from raw prescriptions to a research ready dataset is rarely fully reported, yet assumptions have considerable implications for pharmacoepidemiology. This may have bigger consequences for "pro re nata" (PRN) drugs. Our aim was, using a worked example of opioids and fracture risk, to examine the impact of incorporating narrative prescribing instructions and subsequent drug preparation assumptions on adverse event rates. METHODS R-packages for extracting free-text medication prescription instructions in a structured form (doseminer) and an algorithm for transparently processing drug exposure information (drugprepr) were developed. Clinical Practice Research Datalink GOLD was used to define a cohort of adult new opioid users without prior cancer. A retrospective cohort study was performed using data between January 1, 2017 and July 31, 2018. We tested the impact of varying drug preparation assumptions by estimating the risk of opioids on fracture risk using Cox proportional hazards models. RESULTS During the study window, 60 394 patients were identified with 190 754 opioid prescriptions. Free-text prescribing instruction variability, where there was flexibility in the number of tablets to be administered, was present in 42% prescriptions. Variations in the decisions made during preparing raw data for analysis led to marked differences impacting the event number (n = 303-415) and person years of drug exposure (5619-9832). The distribution of hazard ratios as a function of the decisions ranged from 2.71 (95% CI: 2.31, 3.18) to 3.24 (2.76, 3.82). CONCLUSIONS Assumptions made during the drug preparation process, especially for those with variability in prescription instructions, can impact results of subsequent risk estimates. The developed R packages can improve transparency related to drug preparation assumptions, in line with best practice advocated by international pharmacoepidemiology guidelines.
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Affiliation(s)
- Meghna Jani
- Centre for Epidemiology Versus ArthritisCentre for Musculoskeletal Research, The University of ManchesterManchesterUK
- NIHR Manchester Biomedical Research CentreManchester University NHS Foundation Trust, Manchester Academic Health Science CentreManchesterUK
- Salford Royal HospitalNorthern Care Alliance NHS Foundation TrustSalfordUK
| | - Belay Birlie Yimer
- Centre for Epidemiology Versus ArthritisCentre for Musculoskeletal Research, The University of ManchesterManchesterUK
| | - David Selby
- Centre for Epidemiology Versus ArthritisCentre for Musculoskeletal Research, The University of ManchesterManchesterUK
| | - Mark Lunt
- Centre for Epidemiology Versus ArthritisCentre for Musculoskeletal Research, The University of ManchesterManchesterUK
| | - Goran Nenadic
- Department of Computer ScienceUniversity of ManchesterManchesterUK
| | - William G. Dixon
- Centre for Epidemiology Versus ArthritisCentre for Musculoskeletal Research, The University of ManchesterManchesterUK
- NIHR Manchester Biomedical Research CentreManchester University NHS Foundation Trust, Manchester Academic Health Science CentreManchesterUK
- Salford Royal HospitalNorthern Care Alliance NHS Foundation TrustSalfordUK
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Wu PY, Caceres AI, Chen J, Sokoloff J, Huang M, Baht GS, Nackley AG, Jordt SE, Terrando N. Vagus nerve stimulation rescues persistent pain following orthopedic surgery in adult mice. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.05.16.540949. [PMID: 37292744 PMCID: PMC10245641 DOI: 10.1101/2023.05.16.540949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Postoperative pain is a major clinical problem imposing a significant burden on our patients and society. Up to 57% of patients experience persistent postoperative pain 2 years after orthopedic surgery [49]. Although many studies have contributed to the neurobiological foundation of surgery-induced pain sensitization, we still lack safe and effective therapies to prevent the onset of persistent postoperative pain. We have established a clinically relevant orthopedic trauma model in mice that recapitulates common insults associated with surgery and ensuing complications. Using this model, we have started to characterize how induction of pain signaling contributes to neuropeptides changes in dorsal root ganglia (DRG) and sustained neuroinflammation in the spinal cord [62]. Here we have extended the characterization of pain behaviors for >3 months after surgery, describing a persistent deficit in mechanical allodynia in both male and female C57BL/6J mice after surgery. Notably, we have applied a novel minimally invasive bioelectronic approach to percutaneously stimulate the vagus nerve (termed pVNS) [24] and tested its anti-nociceptive effects in this model. Our results show that surgery induced a strong bilateral hind-paw allodynia with a slight decrease in motor coordination. However, treatment with pVNS for 30-minutes at10 Hz weekly for 3 weeks prevented pain behavior compared to naïve controls. pVNS also improved locomotor coordination and bone healing compared to surgery without treatment. In the DRGs, we observed that vagal stimulation fully rescued activation of GFAP positive satellite cells but did not affect microglial activation. Overall, these data provide novel evidence for the use of pVNS to prevent postoperative pain and may inform translational studies to test anti-nociceptive effects in the clinic.
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Affiliation(s)
- Pau Yen Wu
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, United States
| | - Ana Isabel Caceres
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, United States
| | - Jiegen Chen
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, United States
| | - Jamie Sokoloff
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, United States
| | - Mingjian Huang
- Department of Orthopaedic Surgery, Duke Molecular Physiology Institute, Duke University Medical Center, Durham, NC, United States
| | - Gurpreet Singh Baht
- Department of Orthopaedic Surgery, Duke Molecular Physiology Institute, Duke University Medical Center, Durham, NC, United States
| | - Andrea G Nackley
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, United States
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, NC, United States
| | - Sven-Eric Jordt
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, United States
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, NC, United States
- Integrated Toxicology & Environmental Health Program, Duke University, Durham, United States
| | - Niccolò Terrando
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, United States
- Department of Cell Biology, Duke University Medical Center, Durham, NC, United States
- Department of Integrative Immunobiology, Duke University Medical Center, Durham, NC, United States
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11
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Mörttinen-Vallius HP, Huhtala HSA, Hartikainen SA, Jämsen ERK. The Association of Long-Term Opioid Use With Health Care and Home Care Service Use Among Aged Home Care Clients. J Am Med Dir Assoc 2022:S1525-8610(22)00920-3. [PMID: 36581308 DOI: 10.1016/j.jamda.2022.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 10/04/2022] [Accepted: 11/29/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To compare health care and home care service utilization, mortality, and long-term care admissions between long-term opioid users and nonusers among aged home care clients. DESIGN A retrospective cohort study based on the Resident Assessment Instrument-Home Care (RAI-HC) assessments and electronic medical records. SETTING AND PARTICIPANTS The study sample included all regular home care clients aged ≥65 years (n = 2475), of whom 220 were long-term opioid users, in one city in Finland (population base 222,000 inhabitants). METHODS Health care utilization, mortality, and long-term care admissions over a 1-year follow-up were recorded from electronic medical records, and home care service use from the RAI-HC. Negative binomial and multivariable logistic regression, adjusted for several socioeconomic and health characteristics, were used to analyze the associations between opioid use and health and home care service use. RESULTS Compared with nonusers, long-term opioid users had more outpatient consultations (incidence rate ratio 1.26; 95% CI 1.08-1.48), home visits (1.23; 1.01-1.49), phone contacts (1.38; 1.13-1.68), and consultations without a patient attending a practice (1.22; 1.04-1.43) after adjustments. A greater proportion of long-term opioid users than nonusers had at least 1 hospitalization (49% vs 41%) but the number of inpatient days did not differ after adjustments. The home care nurses' median work hours per week were 4.3 (Q1-Q3 1.5-7.7) among opioid users and 2.8 (1.0-6.1) among nonusers. Mortality and long-term care admissions were not associated with opioid use. CONCLUSIONS AND IMPLICATIONS Long-term opioid use in home care clients is associated with increased health care utilization regardless of the severity of pain and other sociodemographic and health characteristics. This may indicate the inability of health care organizations to produce alternative treatment strategies for pain management when opioids do not meet patients' needs. The exact reasons for opioid users' greater health care utilization should be examined in future.
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Affiliation(s)
| | | | - Sirpa A Hartikainen
- Research Centre of Geriatric Care, School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Esa R K Jämsen
- Faculty of Medicine (Clinicum), University of Helsinki, Helsinki, Finland; Department of Geriatrics, Helsinki University Hospital, Helsinki, Finland
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12
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Costa AC, Joaquim HPG, Pedrazzi JFC, Pain ADO, Duque G, Aprahamian I. Cannabinoids in Late Life Parkinson's Disease and Dementia: Biological Pathways and Clinical Challenges. Brain Sci 2022; 12:brainsci12121596. [PMID: 36552056 PMCID: PMC9775654 DOI: 10.3390/brainsci12121596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 11/16/2022] [Accepted: 11/18/2022] [Indexed: 11/25/2022] Open
Abstract
The use of cannabinoids as therapeutic drugs has increased among aging populations recently. Age-related changes in the endogenous cannabinoid system could influence the effects of therapies that target the cannabinoid system. At the preclinical level, cannabidiol (CBD) induces anti-amyloidogenic, antioxidative, anti-apoptotic, anti-inflammatory, and neuroprotective effects. These findings suggest a potential therapeutic role of cannabinoids to neurodegenerative disorders such as Parkinson's disease (PD) and Alzheimer. Emerging evidence suggests that CBD and tetrahydrocannabinol have neuroprotective therapeutic-like effects on dementias. In clinical practice, cannabinoids are being used off-label to relieve symptoms of PD and AD. In fact, patients are using cannabis compounds for the treatment of tremor, non-motor symptoms, anxiety, and sleep assistance in PD, and managing responsive behaviors of dementia such as agitation. However, strong evidence from clinical trials is scarce for most indications. Some clinicians consider cannabinoids an alternative for older adults bearing Parkinson's disease and Alzheimer's dementia with a poor response to first-line treatments. In our concept and experience, cannabinoids should never be considered a first-line treatment but could be regarded as an adjuvant therapy in specific situations commonly seen in clinical practice. To mitigate the risk of adverse events, the traditional dogma of geriatric medicine, starting with a low dose and proceeding with a slow titration regime, should also be employed with cannabinoids. In this review, we aimed to address preclinical evidence of cannabinoids in neurodegenerative disorders such as PD and AD and discuss potential off-label use of cannabinoids in clinical practice of these disorders.
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Affiliation(s)
- Alana C. Costa
- Laboratory of Neuroscience (LIM-27), Departamento e Instituto de Psiquiatria, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-903, Brazil
- Instituto Nacional de Biomarcadores em Neuropsiquiatria (INBioN), Conselho Nacional de Desenvolvimento Científico e Tecnológico, São Paulo 05403-010, Brazil
| | - Helena P. G. Joaquim
- Department of Psychiatry, Faculdade de Medicina da Universidade de São Paulo, São Paulo 01246-903, Brazil
| | - João F. C. Pedrazzi
- Department of Neurosciences and Behavioral Sciences, School of Medicine of Ribeirão Preto, University of São Paulo, São Paulo 05403-903, Brazil
| | - Andreia de O. Pain
- Group of Investigation on Multimorbidity and Mental Health in Aging (GIMMA), Geriatrics Division, Department of Internal Medicine, Jundiaí Medical School, Jundiaí 13202-550, Brazil
| | - Gustavo Duque
- Division of Geriatric Medicine, Research Institute of the McGill University Health Centre, Montreal, QC H4A 3J1, Canada
| | - Ivan Aprahamian
- Group of Investigation on Multimorbidity and Mental Health in Aging (GIMMA), Geriatrics Division, Department of Internal Medicine, Jundiaí Medical School, Jundiaí 13202-550, Brazil
- Department of Psychiatry, University Medical Center Groningen, University of Groningen, 9712 Groningen, The Netherlands
- Correspondence:
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13
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Hereford TE, Porter A, Stambough JB, Cherney SM, Mears SC. Prevalence of Chronic Opioid Use in the Elderly After Hip Fracture Surgery. J Arthroplasty 2022; 37:S530-S535. [PMID: 35219575 DOI: 10.1016/j.arth.2022.01.071] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/18/2022] [Accepted: 01/24/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND While interest has focused on opioid use after total hip arthroplasty, little research has investigated opioid use in elderly patients after hip fracture. We hypothesize that a substantial number of opioid-naïve elderly patients go on to chronic opioid use after hip fracture surgery. METHODS We reviewed a consecutive series of 219 patients 65 years and older who underwent surgical fixation between January 1, 2016 and February 28, 2019 for a native hip fracture. Patients were excluded for polytrauma, periprosthetic or pathologic fractures, recent major surgery, or death within 90 days of their hip surgery. The state prescription monitoring database was used to determine opioid use. RESULTS Overall, 58 patients (26%) were postoperative chronic opioid users. Of the initial 188 opioid-naïve patients, 43 (23%) became chronic users. Of the 31 preoperative opioid users, 15 (48%) continued as chronic users. Chronic postoperative users were more likely to be White (76% vs 91%, P = .04), younger (78 vs 82 years, P = .003), and preoperative opioid users (odds ratio 3.3, P = .007). Arthroplasty vs fixation did not affect the rate of chronic opioid use (P = .22). CONCLUSION Chronic opioid use is surprisingly common after hip fracture repair in the elderly. Twenty-three percent of opioid-naïve hip fracture patients became chronic users after surgery. Continued vigilance is needed by orthopedic surgeons to limit the amount and duration of postoperative narcotic prescriptions and to monitor for continued use.
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Affiliation(s)
- Timothy E Hereford
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Austin Porter
- Fay W. Boozman College of Public Health, Department of Health Policy and Management, University of Arkansas for Medical Sciences, Little Rock, AR; Arkansas Department of Health, Little Rock, AR
| | - Jeffrey B Stambough
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Steven M Cherney
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Simon C Mears
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
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Kotlińska-Lemieszek A, Żylicz Z. Less Well-Known Consequences of the Long-Term Use of Opioid Analgesics: A Comprehensive Literature Review. Drug Des Devel Ther 2022; 16:251-264. [PMID: 35082488 PMCID: PMC8784970 DOI: 10.2147/dddt.s342409] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 12/07/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The adverse effects of short-term opioid analgesics are well known and acknowledged; however, the spectrum of the sequelae of long-term use seems less clear. Some effects may remain undetected but still have the potential to cause harm and reduce patients' quality of life. OBJECTIVE To review the literature on the adverse effects of long-term opioid therapy. METHODS We performed a quasi-systematic search, analyzing articles published in the MEDLINE database between January 2000 and March 2021 that identified adverse effects of opioids used for chronic pain treatment. RESULTS Growing evidence indicates that there are multiple serious adverse effects of opioid treatment. Long-term opioid use may have significant effects on the endocrine, immune, cardiovascular, respiratory, gastrointestinal, and neural systems. Studies show that long-term opioid treatment increases the risk of fractures, infections, cardiovascular complications, sleep-disordered breathing, bowel dysfunction, overdose, and mortality. Opioids may potentially affect cancer development. Most consequences of the long-term use of opioids have been identified in studies of patients with non-malignant pain. CONCLUSION Studies indicate that long-term use of opioids increases the risk of drug-related events in a significant number of patients. Clinicians should be aware of these complications associated with prescribing opioids, discuss them with patients, prevent complications, if possible, and diagnose them early and manage adequately. More human studies are needed to assess the risk, including trials with individual opioids, because they have different adverse effect profiles.
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Affiliation(s)
- Aleksandra Kotlińska-Lemieszek
- Chair and Department of Palliative Medicine, Pharmacotherapy in Palliative Care Laboratory, Poznan University of Medical Sciences, Poznan, Poland.,Heliodor Święcicki University Hospital, Poznan, Poland
| | - Zbigniew Żylicz
- Institute of Medical Sciences, Medical College, University of Rzeszów, Rzeszów, Poland
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15
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Lim WB, Al-Dadah O. Conservative treatment of knee osteoarthritis: A review of the literature. World J Orthop 2022; 13:212-229. [PMID: 35317254 PMCID: PMC8935331 DOI: 10.5312/wjo.v13.i3.212] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/29/2021] [Accepted: 01/29/2022] [Indexed: 02/06/2023] Open
Abstract
Knee osteoarthritis (KOA) is a common chronic debilitating disease with an estimated prevalence of 23.9% in the general adult population. The condition is characterised by joint pain, functional impairment and significant reduction in quality of life. Management for KOA can generally be divided into conservative (non-operative) and surgical (operative) measures. Conservative management broadly compromises pharmacological and non-pharmacological options and is conventionally the first line treatment to avoid or delay the need for surgical management. The aim of this study is to provide an overview of the current recommendations, efficacy and safety profile of different conservative treatments through a review of the literature.
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Affiliation(s)
- Wei Boon Lim
- The Medical School, Newcastle University, Newcastle-upon-Tyne NE2 4HH, United Kingdom
| | - Oday Al-Dadah
- Department of Trauma and Orthopaedic Surgery, South Tyneside District Hospital, South Tyneside NE34 0PL, United Kingdom
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle-upon-Tyne NE2 4HH, United Kingdom
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16
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Brooks JM, Umucu E, Fortuna KL, Reid MC, Tracy K, Poghosyan L. Prevalence of lifetime nonmedical opioid use among U.S. Health Center Patients aged 45 years and older with psychiatric disorders. Aging Ment Health 2022; 26:179-185. [PMID: 33291958 PMCID: PMC8187460 DOI: 10.1080/13607863.2020.1855105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 11/15/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Despite recent concerns over the increase in opioid misuse among aging adults, little is known about the prevalence of lifetime nonmedical opioid use in underserved, vulnerable middle-aged and older patients with psychiatric disorders. This study aims to determine the lifetime prevalence of nonmedical opioid use among underserved, vulnerable U.S. adults aged ≥45 years with psychiatric disorders. METHOD A nationally representative sample (n = 3,294) was obtained from the 2014 Health Center Patient Survey which collects data on psychiatric disorders, opioid use, and other health information from underserved, vulnerable U.S. primary care populations. Predictor variables included self-reported panic disorder, generalized anxiety disorder, schizophrenia, or bipolar disorder. The outcome variable was self-reported lifetime nonmedical opioid use. Frequencies, counts, and unadjusted and adjusted logistic regression models were conducted with the cross-sectional survey dataset. RESULTS Patients with bipolar disorder had the highest lifetime nonmedical opioid use rate (20.8%), followed by schizophrenia (19.3%), panic disorder (16.5%), and generalized anxiety disorder (14.5%). Nonmedical opioid use was significantly associated with bipolar disorder (OR 3.46, 95% CI [1.33, 8.99]) and generalized anxiety disorder (OR 2.03 95% CI [1.08, 3.83]). CONCLUSION Our findings demonstrate a high prevalence of lifetime nonmedical opioid use in underserved, vulnerable middle-aged and older health center patients with psychiatric disorders. Given the prevalence, health center professionals should monitor, prevent, and treat new or reoccurring signs and symptoms of nonmedical opioid use in this high-risk group of aging patients with psychiatric disorders.
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Affiliation(s)
- Jessica M. Brooks
- Department of Psychiatry, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Emre Umucu
- Department of Rehabilitation Sciences, University of Texas at El Paso, El Paso, TX, USA
| | - Karen L. Fortuna
- Geisel School of Medicine, Dartmouth College, Concord, NH, USA
- CDC Health Promotion Research Center at Dartmouth, Lebanon, NH, USA
| | - M. Carrington Reid
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Kathlene Tracy
- Psychosocial Division, Addiction Institute within Icahn School of Medicine at Mount Sinai (AIMS), New York, NY, USA
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17
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Martinez P, Zemore SE, Pinedo M, Borges G, Orozco R, Cherpitel C. Understanding differences in prescription drug misuse between two Texas border communities. ETHNICITY & HEALTH 2021; 26:1028-1044. [PMID: 31116033 PMCID: PMC6872923 DOI: 10.1080/13557858.2019.1620175] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 05/11/2019] [Indexed: 06/09/2023]
Abstract
Objectives: The misuse of prescription drugs in the U.S. is an alarming public health crisis. Prior research at the U.S.-Mexico border has found high rates of prescription drug misuse, but with rates varying significantly across border communities. We aimed to examine a model of permissive climate measures and stress exposures as potential mediators of community differences in prescription drug misuse at the U.S.-Mexico border.Design: We analyzed data from the U.S.-Mexico Study of Alcohol and Related Conditions (UMSARC). Household, in-person interviews were conducted with Mexican-origin residents of the Texas border cities Laredo (n = 751) and Brownsville/McAllen (n = 814). Interviews assessed past-year misuse of any and pain-reliever prescription drugs. Drug availability, neighborhood safety, exposure to violence/crime, and social support were examined as potential mediators. Analyses were stratified by gender and employed regressions and mediation analysis with Mplus.Results: The past-year prevalence of any prescription drug misuse in Laredo was 26.3% among women and 24.4% among men, and in Brownsville/McAllen was 12.4% among men, and 6.7% among women. Mediation analysis revealed site effects via some of the hypothesized risk factors for men, but not for women. Specifically, for men, site effects on any and pain reliever prescription drug misuse were partially mediated via high drug availability and low family support.Conclusions: Past-year prescription drug misuse was over 3 times the 2015 national prevalence among both men and women in Laredo and calls for immediate attention. Findings regarding the model suggest drug availability and social support may be relevant to understanding community differences in prescription drug misuse among men living at the border, and that additional factors should be investigated to understand misuse among women living at the border.
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Affiliation(s)
| | - Sarah E. Zemore
- Alcohol Research Group, Public Health Institute, Emeryville, CA
| | | | - Guilherme Borges
- Instituto Nacional de Psiquiatria Ramon de la Fuente, Mexico City, Mexico
| | - Ricardo Orozco
- Instituto Nacional de Psiquiatria Ramon de la Fuente, Mexico City, Mexico
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18
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Herrera AV, Wastila L, Brown JP, Chen H, Gambert SR, Albrecht JS. Effects of Prescription Opioid Use on Traumatic Brain Injury Risk in Older Adults. J Head Trauma Rehabil 2021; 36:388-395. [PMID: 34489389 PMCID: PMC8428555 DOI: 10.1097/htr.0000000000000716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to estimate the risk of traumatic brain injury (TBI) associated with opioid use among older adult Medicare beneficiaries. SETTING Five percent sample of Medicare administrative claims obtained for years 2011-2015. PARTICIPANTS A total of 50 873 community-dwelling beneficiaries 65 years and older who sustained TBI. DESIGN Case-crossover study comparing opioid use in the 7 days prior to TBI with the control periods of 3, 6, and 9 months prior to TBI. MAIN MEASURES TBI cases were identified using ICD-9 (International Classification of Diseases, Ninth Revision) and ICD-10 (International Classification of Diseases, Tenth Revision) codes. Prescription opioid exposure and concomitant nonopioid fall risk-increasing drug (FRID) use were determined by examining the prescription drug event file. RESULTS The 8257 opioid users (16.2%) were significantly younger (mean age 79.0 vs 80.8 years, P < .001). Relative to nonusers, opioid users were more likely to be women (77.0% vs 70.0%, P < .001) with a Charlson Comorbidity Index of 2 or more (43.7% vs 30.9%, P < .001) and higher concomitant FRID use (94.0% vs 82.7%, P < .001). Prescription opioid use independently increased the risk of TBI compared with nonusers (OR = 1.34; 95% CI, 1.28-1.40). In direct comparisons, we did not observe evidence of a significant difference in adjusted TBI risk between high- (≥90 morphine milligram equivalents) and standard-dose opioid prescriptions (OR = 1.01; 95% CI, 0.90-1.14) or between acute and chronic (≥90 days) opioid prescriptions (OR = 0.93; 95% CI, 0.84-1.02). CONCLUSIONS Among older adult Medicare beneficiaries, prescription opioid use independently increased risk for TBI compared with nonusers after adjusting for concomitant FRID use. We found no significant difference in adjusted TBI risk between high-dose and standard-dose opioid use, nor did we find a significant difference in adjusted TBI risk between acute and chronic opioid use. This analysis can inform prescribing of opioids to community-dwelling older adults for pain management.
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Affiliation(s)
- Anthony V Herrera
- Departments of Epidemiology and Public Health (Mr Herrera and Drs Brown, Chen, and Albrecht) and Medicine (Dr Gambert), School of Medicine, and Department of Pharmaceutical Health Services Research, School of Pharmacy (Dr Wastila), University of Maryland, Baltimore
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19
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Iloanusi S, Mgbere O, Essien EJ. Polypharmacy among COVID-19 patients: A systematic review. J Am Pharm Assoc (2003) 2021; 61:e14-e25. [PMID: 34120855 PMCID: PMC8149164 DOI: 10.1016/j.japh.2021.05.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 05/10/2021] [Accepted: 05/11/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Polypharmacy, the concomitant use of 5 or more medications, is highly prevalent among older adults and individuals with multimorbid conditions and has been linked to suboptimal clinical outcomes in various diseases. However, little is known about the impact of polypharmacy on clinical outcomes among coronavirus disease 2019 (COVID-19) patients. OBJECTIVE This systematic review summarizes the available literature on the association between polypharmacy and specific drug classes, and clinical outcomes among COVID-19 patients. METHODS We conducted an electronic database search on Embase, Medline, Cochrane, Scopus, Google Scholar, clinicaltrials.gov, LITCOVID, PubMed, PubMed Central (PMC), and China national knowledge infrastructure for studies on Polypharmacy among COVID-19 patients using relevant combinations of the keywords. Only studies published between November 2019 to September 2020 were included. Seven articles out of 1502 unique articles met the inclusion criteria and were used for the current study. We adopted the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline in conducting and reporting this systematic review. RESULTS The total sample size of all studies was 474,342, out of which 10,519 patients were COVID-19 positive, and 4818 COVID-19 positive patients experienced polypharmacy. Five out of the 7 included studies found associations between polypharmacy and negative clinical outcomes among COVID-19 patients. Polypharmacy was associated with increase in the relative risk of a positive COVID-19 test result (P < 0.01), death among male COVID-19 patients (P < 0.001), increase in the rate of acute kidney injury (P = 0.003), and adverse drug reactions (P < 0.001). Antipsychotic drugs were associated with severe COVID-19 morbidity (OR = 2.79; 95% CI 2.23-3.49) and increased risk of death among COVID-19 infected men (OR = 1.71; 95% CI 1.18-2.48) and women (OR = 1.96; 95% CI 1.41-2.73). CONCLUSION Polypharmacy and selected drug classes are associated with increased risk of adverse clinical outcomes among COVID-19 patients. Understanding these relationships can enhance risk stratification and evidence-based decision-making that may improve care and clinical outcomes of COVID-19 patients.
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Kaboré JL, Pagé MG, Martel MO, Dassieu L, Hudspith M, Moor G, Sutton K, Roy JS, Williamson OD, Choinière M. Impact of the Opioid Epidemic and Associated Prescribing Restrictions on People Who Live With Chronic Noncancer Pain in Canada. Clin J Pain 2021; 37:607-615. [PMID: 34054062 DOI: 10.1097/ajp.0000000000000951] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 03/18/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Little is known about the consequences of the opioid epidemic on people living with chronic noncancer pain (CNCP). This study examined this issue in people who lived in the most impacted province by opioid overdoses in Canada (British Columbia [BC]) or one of the least impacted (Quebec [QC]), and examined the factors associated with opioid use. MATERIALS AND METHODS This cross-sectional study was carried out in adults living in BC (N=304) and QC (N=1071) who reported CNCP (≥3 months) and completed an online questionnaire that was tailored to their opioid status. RESULTS Almost twice as many participants in BC as in QC were proposed to cease their opioid medication in the past year (P<0.001). The proportion who reported having hoarded opioids in fear of not being able to get more in the future was also significantly higher in BC (P<0.001) compared with QC. In addition, they were significantly more likely to have had their opioid dose decreased than those in QC (P=0.001). No significant association was found between opioid discontinuation and province of residence. Two-thirds of the BC participants felt that the media coverage of the opioid crisis was very to extremely detrimental to CNCP patients in general, this percentage being significantly higher than in QC (P<0.001). DISCUSSION The opioid epidemic and associated prescribing restrictions have had harmful effects on Canadians with CNCP. The clinical community, the general public, and the media need to be aware of these negative consequences to decrease patients' stigmatization and minimize inadequate treatment of CNCP.
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Affiliation(s)
- Jean-Luc Kaboré
- Departments of Pharmacology and Physiology
- Research Centre of the University of Montreal Hospital Centre (CRCHUM)
| | - M Gabrielle Pagé
- Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal
- Research Centre of the University of Montreal Hospital Centre (CRCHUM)
| | - Marc O Martel
- Department of Anesthesia, Faculty of Medicine, Faculty of Dentistry
- Alan Edwards Center for Research on Pain, McGill University, Montreal
| | - Lise Dassieu
- Research Centre of the University of Montreal Hospital Centre (CRCHUM)
| | | | | | | | - Jean-Sébastien Roy
- Centre for Interdisciplinary Research in Rehabilitation and Social Integration (CIRRIS)
- Department of Rehabilitation, Faculty of Medicine, Université Laval, Quebec, QC
| | - Owen D Williamson
- JPOCSC Pain Management Clinic, Fraser Health Authority, Surrey, BC, Canada
- Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Vic., Australia
| | - Manon Choinière
- Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal
- Research Centre of the University of Montreal Hospital Centre (CRCHUM)
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Mörttinen-Vallius H, Hartikainen S, Huhtala H, Seinelä L, Jämsen E. Factors associated with daily opioid use among aged home care clients: a cross-sectional analysis of Resident Assessment Instrument data. Eur Geriatr Med 2021; 13:185-194. [PMID: 34241822 PMCID: PMC8860789 DOI: 10.1007/s41999-021-00533-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 06/21/2021] [Indexed: 11/28/2022]
Abstract
Aim To examine which client characteristics and other factors, including possible adverse effects, identified in the Resident Assessment Instrument-Home Care (RAI-HC) are associated with daily opioid use among aged home care clients. Findings After adjustment for pain-related diseases, disabilities, depressive symptoms and the estimated severity of pain, daily opioid use was associated with osteoporosis, cancer within previous 5 years and greater disabilities in Instrumental Activities of Daily Living, and cognitive impairment was associated with less frequent opioid use. Constipation was the only adverse effect identified in the RAI-HC associated with daily opioid use. Message The pain of home care clients with cognitive impairment may not be treated optimally, whereas there might be prolonged opioid use without a sufficient evaluation of current pain among clients with osteoporosis, cancer within previous 5 years and disabilities in Instrumental Activities of Daily Living. Purpose To examine which client characteristics and other factors, including possible adverse effects, identified in the Resident Assessment Instrument—Home Care (RAI-HC) are associated with daily opioid use among aged home care clients. Methods The study sample comprised 2584 home care clients aged ≥ 65 years, of which 282 persons used opioids daily. Clients using opioids less than once daily were excluded. The cross-sectional data were gathered from each client’s first assessment with the RAI-HC during 2014. Multivariable logistic regression was used to study associations of daily opioid use with the clients’ characteristics and symptoms. Results Cognitive impairment was associated with less frequent opioid use after adjusting for pain-related diseases, disabilities and depressive symptoms (OR 0.43, 95% CI 0.32–0.58). The association was not explained by the estimated severity of pain. Osteoporosis, cancer within previous 5 years and greater disabilities in Instrumental Activities of Daily Living (IADL) were associated with daily opioid use regardless of the estimated severity of pain. Depressive symptoms and Parkinson’s disease were associated with daily opioid use only among clients with cognitive impairment, and disabilities in Activities of Daily Living, cancer, arthritis, fractures and pressure ulcers only among clients without cognitive impairment. Constipation was the only adverse effect associated with daily opioid use. Conclusion The pain of home care clients with cognitive impairment may not be treated optimally, whereas there might be prolonged opioid use without a sufficient evaluation of current pain among clients with osteoporosis, cancer within previous 5 years and disabilities in IADLs.
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Affiliation(s)
| | - Sirpa Hartikainen
- Research Centre of Geriatric Care, School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, N33014, Tampere, Finland
| | - Lauri Seinelä
- Faculty of Medicine and Health Technology, Tampere University, N33014, Tampere, Finland
| | - Esa Jämsen
- Faculty of Medicine and Health Technology and Gerontology Research Centre GEREC, Tampere University, FIN-33014, Tampere, Finland.,Tampere University Hospital, P.O. Box 2000, FIN-33521, Tampere, Finland
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Taqi A, Gran S, Knaggs RD. Current use of analgesics and the risk of falls in people with knee osteoarthritis: A population-based cohort study using primary care and hospital records. OSTEOARTHRITIS AND CARTILAGE OPEN 2021; 3:100165. [DOI: 10.1016/j.ocarto.2021.100165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 03/31/2021] [Accepted: 04/06/2021] [Indexed: 11/25/2022] Open
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de Amorim JSC, Rocha VTM, Lustosa LP, Pereira LSM. Use of healthcare services and therapeutic measures associated with new episodes of acute low back pain-related disability among elderly people: a cross-sectional study on the Back Complaints in the Elders - Brazil cohort. SAO PAULO MED J 2021; 139:137-143. [PMID: 33825772 PMCID: PMC9632518 DOI: 10.1590/1516-3180.2020.0414.r1.0712020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/03/2020] [Accepted: 12/07/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Patients with low back pain frequently undergo a variety of diagnostic and therapeutic interventions, but some of these have uncertain effectiveness. This highlights the importance of the association of healthcare services and therapeutic measures relating to disability. OBJECTIVE To analyze the use of healthcare services and therapeutic measures among Brazilian older adults with disability-related low back pain. DESIGN AND SETTING Observational cross-sectional study on baseline assessment data from the Back Complaints in the Elders - Brazil (BACE-B) cohort. METHODS The main analyses were based on a consecutive sample of 602 older adult participants in BACE-B (60 years of age and over). The main outcome measurement for disability-related low back pain was defined as a score of 14 points or more in the Roland Morris Questionnaire. RESULTS Visits to doctors in the previous six weeks (odds ratio, OR = 1.82; 95% confidence interval, CI 1.22-2.71) and use of analgesics in the previous three months (OR = 1.57; 95% CI 1.07-2.31) showed statistically significant associations with disability-related low back pain. The probability of disability-related low back pain had an additive effect to the combination of use of healthcare services and therapeutic measures (OR = 2.57; 95% CI 1.52-4.36). The analyses showed that this association was significant among women, but not among men. CONCLUSIONS Occurrence of the combined of consultations and medication use was correlated with higher chance of severe disability among these elderly people with nonspecific low back pain. This suggested that overuse and "crowding-in" effects were present in medical services for elderly people.
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Affiliation(s)
- Juleimar Soares Coelho de Amorim
- PhD. Physiotherapist and Associate Professor, Physical Therapy Course, Instituto Federal de Educação Ciência e Tecnologia do Rio de Janeiro (IFRJ), Rio de Janeiro (RJ), Brazil.
| | - Vitor Tigre Martins Rocha
- MD. Physiotherapist, Postgraduate Program on Rehabilitation Sciences, Department of Physical Therapy, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte (MG), Brazil.
| | - Lygia Paccini Lustosa
- PhD. Physiotherapist and Associate Professor, Postgraduate Program on Rehabilitation Sciences, Department of Physical Therapy, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte (MG), Brazil.
| | - Leani Souza Máximo Pereira
- PhD. Physiotherapist and Associate Professor, Postgraduate Program on Rehabilitation Sciences, Department of Physical Therapy, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte (MG), Brazil.
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Vyas MV, Watt JA, Yu AYX, Straus SE, Kapral MK. The association between loneliness and medication use in older adults. Age Ageing 2021; 50:587-591. [PMID: 32931548 DOI: 10.1093/ageing/afaa177] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Loneliness is common in older adults, and it is associated with unhealthy behaviours, including substance use. We evaluated the association between loneliness and self-reported use of opioids and benzodiazepines in older adults. METHODS We used data from the Canadian Community Health Survey's 'Healthy Aging' sub-survey and included adults 65 years or older who administered their own medications. We classified individuals as lonely if they scored 6 or more on the three -item University of California, Los Angeles's Loneliness Scale. We used multinomial logistic regression models, adjusting for demographics and self-reported comorbidities, to describe the association between loneliness and daily or occasional use of opioids, benzodiazepines and non-opioid analgesics. We also explored the association between loneliness and polypharmacy. RESULTS Our cohort included 15,302 older adults, of whom 2,096 (13.7%) were classified as lonely. Daily use of opioids (4.1%) and benzodiazepines (1.7%) were less common than daily use of non-opioid analgesics (33.9%). Lonely older adults had higher daily use of opioids (odds ratio [OR] 1.61, 1.31-1.98) and benzodiazepines (OR 1.66, 1.21-2.28), but not non-opioid analgesics (OR 1.05, 0.92-1.19). Loneliness was not associated with occasional use of opioids, benzodiazepines or non-opioid analgesics in older adults, but was associated with polypharmacy (OR 1.27, 1.06-1.52). CONCLUSIONS Loneliness in older adults is associated with increased daily use of opioids and benzodiazepines. Further research should evaluate patient- and physician-level factors that mediate this association, and develop strategies to mitigate loneliness and its attendant adverse outcomes.
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Affiliation(s)
- Manav V Vyas
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Jennifer A Watt
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, Canada
| | - Amy Y X Yu
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Sharon E Straus
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, Canada
| | - Moira K Kapral
- Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Canada
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25
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van den Driest JJ, Schiphof D, de Wilde M, Bindels PJE, van der Lei J, Bierma-Zeinstra SMA. Opioid prescriptions in patients with osteoarthritis: a population-based cohort study. Rheumatology (Oxford) 2021; 59:2462-2470. [PMID: 31960046 PMCID: PMC7449800 DOI: 10.1093/rheumatology/kez646] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 11/29/2019] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVES To examine the incidence, prevalence and trends for opioid prescriptions in patients with OA. Furthermore, types of opioids prescribed and long-term prescription rates were examined. Finally, the patient characteristics associated with the prescription of opioids were assessed. METHODS A population-based cohort study was conducted using the Integrated Primary Care Information database. Incidence and prevalence of opioid prescriptions were calculated for the period 2008-2017. Logistic regression was used to assess which patient characteristics were associated with opioid prescriptions. RESULTS In total, 157 904 OA patients were included. The overall prescription rate remained fairly stable, at around 100 incident and 170 prevalent prescriptions per 1000 person years. However, the incident prescription rate for oxycodone increased from 7.1 to 40.7 per 1000 person years and for fentanyl from 4.2 to 7.4 per 1000 person years. The incident prescription rate for paracetamol/codeine decreased from 63.0 to 13.3 per 1000 person years. Per follow-up year, long-term use was found in 3% of the patients with incident OA. Finally, factors associated with more prescriptions were increasing age, OA in ≥2 joint groups [odds ratio (OR) 1.56; 95% CI: 1.51, 1.65] and the presence of other musculoskeletal disorders (OR 4.91; 95% CI: 4.76, 5.05). Men were less likely to be prescribed opioids (OR 0.78; 95% CI: 0.76, 0.80). CONCLUSION Prescription rates for opioids remained stable, but types of opioids prescribed changed. Oxycodone and fentanyl were increasingly prescribed, while prescriptions of paracetamol/codeine decreased. Since the benefit of opioids for OA pain is questionable and side effects are common, opioids should be prescribed with caution.
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Affiliation(s)
- Jacoline J van den Driest
- Department of General PracticeErasmus MC, University Medical Center, Rotterdam, The Netherlands
- Correspondence to: J. J. van den Driest, Department of General Practice, Erasmus MC, Wytemaweg 80, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands. E-mail:
| | - Dieuwke Schiphof
- Department of General PracticeErasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Marcel de Wilde
- Department of Medical Informatics Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Patrick J E Bindels
- Department of General PracticeErasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Johan van der Lei
- Department of Medical Informatics Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Sita M A Bierma-Zeinstra
- Department of General PracticeErasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Orthopedics, University Medical Center, Erasmus MC, Rotterdam, The Netherlands
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26
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Al-Qurain AA, Gebremichael LG, Khan MS, Williams DB, Mackenzie L, Phillips C, Russell P, Roberts MS, Wiese MD. Prevalence and Factors Associated with Analgesic Prescribing in Poly-Medicated Elderly Patients. Drugs Aging 2020; 37:291-300. [PMID: 32016823 DOI: 10.1007/s40266-019-00742-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pain is common in older patients and management guidelines rarely consider the effect of multiple comorbidities and concurrent medications on analgesic selection. OBJECTIVES The objectives of this study were to identify the prevalence and pattern of analgesic prescribing and associated factors in older patients with polypharmacy. METHODS Older patients (aged ≥ 75 years) admitted to the Royal Adelaide Hospital between September 2015 and August 2016 and with polypharmacy were included and their comorbidities and medications prescribed at discharge were recorded. Drug Burden Index and Charlson Comorbidity Index were calculated. The number of medications that increased the risk of orthostatic hypotension were recorded. Logistic regression was used to compute the association between analgesic use and participant characteristics, and results were presented as odds ratios and 95% confidence intervals, adjusted for age, sex, Charlson Comorbidity Index, Drug Burden Index and orthostatic hypotension. RESULTS Over 15,000 admissions were identified, of which 1192 patients were included, 824 (69%) of whom were prescribed an analgesic medication. Paracetamol (used by 89% of analgesic users), opioids (34%) and adjuvants (17%) were used more frequently than non-steroidal anti-inflammatory drugs (8%). Analgesic users had a higher Drug Burden Index, were prescribed more medications and were less likely to be male compared with non-users. Charlson Comorbidity Index across the cohort was high (7.3 ± 1.9) but there was no difference between analgesic users and non-users, but analgesic users were more likely to have a documented diagnosis of osteoarthritis, osteoporosis and falls. Opioid use was associated with the Drug Burden Index, while adjuvant use was associated with orthostatic hypotension. Opioid use was associated with having a diagnosis of osteoporosis and falls. CONCLUSIONS In our cohort of poly-medicated elderly patients, prescription of analgesic medications was common, and these patients are likely to have an increased rate of adverse drug reactions and falls compared with those who were not prescribed analgesic medications.
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Affiliation(s)
- Aymen Ali Al-Qurain
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia.,Basil Hetzel Institute for Translational Research, The Queen Elizabeth Hospital, Woodville, Australia.,Saudi Arabian Cultural Mission, Ministry of Education, Riyadh, Saudi Arabia
| | - Lemlem G Gebremichael
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia.,Basil Hetzel Institute for Translational Research, The Queen Elizabeth Hospital, Woodville, Australia
| | - Muhammad Suleman Khan
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia.,Basil Hetzel Institute for Translational Research, The Queen Elizabeth Hospital, Woodville, Australia
| | - Desmond B Williams
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - Lorraine Mackenzie
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia.,Basil Hetzel Institute for Translational Research, The Queen Elizabeth Hospital, Woodville, Australia
| | - Craig Phillips
- School of Nursing and Midwifery, University of South Australia, Adelaide, Australia
| | | | - Michael S Roberts
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia.,Basil Hetzel Institute for Translational Research, The Queen Elizabeth Hospital, Woodville, Australia.,Therapeutics Research Centre, Diamantina Institute, Translational Research Institute, The University of Queensland, Brisbane, Australia
| | - Michael D Wiese
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia.
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27
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Treatment Effectiveness and Medication Use Reduction for Older Adults in Interdisciplinary Pain Rehabilitation. Mayo Clin Proc Innov Qual Outcomes 2020; 4:276-286. [PMID: 32542219 PMCID: PMC7283568 DOI: 10.1016/j.mayocpiqo.2020.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Objective To examine the effectiveness of an interdisciplinary pain rehabilitation program (IPRP) that incorporates medication tapering on improving pain-related and performance-based outcomes for older adults with chronic noncancer pain and determine the proportion who demonstrated reliable improvement in outcome. Patients and Methods This 2-year retrospective clinical cohort study examined treatment outcomes of 134 older adult patients 65 years or older with chronic noncancer pain who completed a 3-week IPRP with physician-supervised medication tapering between January 1, 2015, and December 31, 2017. Pain, pain catastrophizing, depressive symptoms, and quality of life were assessed at pretreatment, posttreatment, and follow-up. Physical performance and medication use were assessed pre- and posttreatment. Outcomes were examined using a series of repeated-measures analyses of variance, examining effect size and reliable change. Results Significant treatment effects (P<.001) with large effect sizes were observed for all self-report and physical performance outcome measures at posttreatment and 6-month follow-up (42.5% response rate). There were no significant differences in outcome based on opioid use status at admission. Reliable change analyses revealed that 76.9% (n=103 of 134) evidenced improvement in at least 1 pain-related outcome measure at posttreatment, and 87.7% (n=50 of 57), at follow-up. Patients also had significant reductions (P<.01) in medications at posttreatment (opioids, benzodiazepines, sedative-hypnotics, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and anticonvulsants). Conclusion Older adults with chronic noncancer pain demonstrated improved pain-related outcomes, physical performance, and decreased medication use following IPRP treatment. Results support the effectiveness of IPRPs in enhancing the physical and emotional functioning of older adults with chronic pain while also facilitating the reduction of medications that place them at risk for adverse events.
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Key Words
- ANCOVA, analysis of covariance
- ANOVA, analysis of variance
- BZD, benzodiazepine
- CES-D, Center for Epidemiologic Studies- Depression Scale
- CNP, chronic noncancer pain
- IPRP, interdisciplinary pain rehabilitation program
- MME, morphine milligram equivalent
- OA, older adult
- PCS, Pain Catastrophizing Scale
- PHQ-9, Patient Health Questionnaire-9
- PI, pain interference
- PRC, Mayo Clinic Pain Rehabilitation Center
- PS, pain severity
- QOL, quality of life
- Sdiff, standard error of the difference
- WYMHPI, West Haven-Yale Multidimensional Pain Inventory
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28
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Leoni MLG, Schatman ME, Demartini L, Lo Bianco G, Terranova G. Genicular Nerve Pulsed Dose Radiofrequency (PDRF) Compared to Intra-Articular and Genicular Nerve PDRF in Knee Osteoarthritis Pain: A Propensity Score-Matched Analysis. J Pain Res 2020; 13:1315-1321. [PMID: 32581573 PMCID: PMC7280065 DOI: 10.2147/jpr.s240138] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 03/07/2020] [Indexed: 11/23/2022] Open
Abstract
Background Chronic knee osteoarthritic (OA) pain is a common and debilitating complaint in elderly patients. Despite numerous pharmaceutical options, the majority of patients still experience long-term pain. Genicular nerve (GN) radiofrequency has become increasingly popular as a treatment for knee pain. This retrospective study aimed to evaluate the effects of pulse dose radiofrequency (PDRF) in patients with chronic knee OA pain. Patients and Methods Propensity score matching analysis was performed in a retrospective cohort of 78 patients with moderate-severe knee OA pain unresponsive to conservative treatment who underwent PDRF GN or intra-articular (IA) and PDRF GN. Pain relief was measured using the numeric rating scale (NRS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Patient Global Impression of Change (PGIC) at 3 and 6 months post-intervention. Results A significant reduction in NRS scores was reported at 3 (p<0.001) and 6 months (p<0.001) after PDRF in both groups. NRS was lower in PDRF IA + GN than PDRF GN (p<0.0001). WOMAC pain was significantly reduced at 3 months in PDRF IA + GN group (baseline: 10.12±3.14, 3 months: 6.25±2.44, p=0.0001). WOMAC stiffness and function were improved only at 3 months in PDRF IA + GN compared to baseline (p=0.007 and p=0.006, respectively). A longer period of pain relief was reported after PDRF IA + GN (6.75±2.42 months) compared to PDRF GN (4.31±2.85 months, p<0.001) in association with higher PGIC scores. Conclusion This is the first study that compared two different PDRF techniques. PDRF GN and PDRF IA + GN were both effective in reducing pain at 3 and 6 months follow-up. However, only PDRF IA + GN was able to improve WOMAC scores at 3 months after the treatment with a longer period of efficacy compared to PDRF GN alone.
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Affiliation(s)
| | - Michael E Schatman
- Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA, USA.,Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Laura Demartini
- Pain Unit, Istituti Clinici Scientifici Maugeri, Pavia, Italy
| | - Giuliano Lo Bianco
- Basildon and Thurrock University Hospital, Essex, London, Orsett Hospital, Pain Management and Neuromodulation, London, Essex, UK.,IRCCS Centro Regionale Oncologico Basilicata, Rionero in Vulture, Italy.,Department of Biomedical and Biotechnological Sciences (Biometec), Università di Catania, Catania, Italy
| | - Gaetano Terranova
- Anaesthesia and Intensive Care Department, Asst Gaetano Pini, Milano, Italy
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29
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Abbs E, Brown R, Guzman D, Kaplan L, Kushel M. Risk Factors for Falls in Older Adults Experiencing Homelessness: Results from the HOPE HOME Cohort Study. J Gen Intern Med 2020; 35:1813-1820. [PMID: 31965522 PMCID: PMC7280424 DOI: 10.1007/s11606-020-05637-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 11/13/2019] [Accepted: 01/03/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND More than half of homeless adults are of age ≥ 50 years. Falls are a common cause of morbidity in older adults in the general population. Risk factors for falls in the general population include poor health, alcohol use, and exposure to unsafe environments. Homeless adults aged ≥ 50 have a high prevalence of known risk factors and face additional potential risks. OBJECTIVES To examine the prevalence of and risk of falling in a cohort of older homeless adults. DESIGN Longitudinal cohort study with participant interviews every 6 months for 3 years; data were analyzed using generalized estimating equations (GEEs). PARTICIPANTS Three hundred fifty adults aged ≥ 50, homeless at study entry, recruited via population-based sampling. MEASURES The dependent variable is any falls in prior 6 months; independent variables include individual (i.e., illness, behaviors) and social/environmental (i.e., social support, experiencing violence, living unsheltered) factors. RESULTS Over three quarters of participants were men (77.1%) and Black (79.7%). The median age was 58 (IQR 54, 61). At baseline, one third (33.7%) reported a fall in the prior 6 months. At follow-up visits, 23.1% to 31.2% of participants reported having fallen. In GEE models, individual risk factors (non-Black race, being a women, older age, functional impairment, urinary incontinence, history of stroke, and use of assistive devices, opioid, and marijuana) were associated with increased odds of falls. Environmental and social factors (spending any nights unsheltered (adjusted odds ratio (AOR) = 1.42, CI = 1.10-1.83) and experiencing physical assault (AOR = 1.67, CI = 1.18-2.37) were also associated. CONCLUSIONS Older homeless adults fall frequently. Likely contributors include having a high prevalence of conditions that increase the risk of falls, compounded by heightened exposure to unsafe environments. Fall prevention in this population should target those at highest risk and address modifiable environmental conditions. Providing shelter or housing and addressing substance use could reduce morbidity from falls in homeless older adults.
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Affiliation(s)
- Elizabeth Abbs
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Rebecca Brown
- Division of Geriatrics, University of California, San Francisco, San Francisco, CA, USA.,Division of Geriatric Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, San Francisco, CA, USA
| | - David Guzman
- UCSF Division of General Internal Medicine at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA.,Center for Vulnerable Populations, University of California, San Francisco, UCSF Box 1364, San Francisco, CA, 94143, USA
| | - Lauren Kaplan
- UCSF Division of General Internal Medicine at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA.,Center for Vulnerable Populations, University of California, San Francisco, UCSF Box 1364, San Francisco, CA, 94143, USA
| | - Margot Kushel
- UCSF Division of General Internal Medicine at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA. .,Center for Vulnerable Populations, University of California, San Francisco, UCSF Box 1364, San Francisco, CA, 94143, USA.
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30
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Lalic S, Gisev N, Bell JS, Ilomäki J. Transition to high-dose or strong opioids: a population-based study of people initiating opioids in Australia. Addiction 2020; 115:1088-1097. [PMID: 31814212 DOI: 10.1111/add.14926] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 08/06/2019] [Accepted: 11/29/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Strong and high-dose opioids are associated with opioid overdose and death. The objective of this study was to determine the rate and predictors of transitioning to high-dose or strong opioids among people initiating opioids. DESIGN Retrospective cohort study. SETTING Australia. PARTICIPANTS People initiating opioid analgesics from July 2013 to January 2018 were identified from a random 10% sample of Australia's Pharmaceutical Benefits Scheme eligible population. MEASUREMENTS Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated for the predictors of escalating to ≥ 50 mg oral morphine equivalents (OMEs)/day (cohort 1); ≥ 90 mg OMEs/day (cohort 2) and transitioning from weak opioids to strong opioids (cohort 3) over 12 months of follow-up. Predictors included age, sex, number of comorbidities, history of depression, prior treatment for cancer and selected other medication use. FINDINGS In total, 861 691 people initiated opioids at average doses < 50 mg OMEs/day (cohort 1), 874 401 at < 90 mg OMEs/day (cohort 2) and 603 884 initiated weak opioids (cohort 3). Overall, 1.4% of people escalated to doses ≥ 50 mg OMEs/day, 0.8% to doses ≥ 90 mg OMEs/day and 7.3% transitioned to strong opioids. The strongest predictors of transitioning included prior treatment for cancer [cohort 1: HR = 3.19, 95% CI = 3.00-3.40; cohort 2: HR = 4.19, 95% CI = 3.90-4.51; cohort 3: HR = 2.07, 95% CI = 1.95-2.18] and age ≥ 75 years (cohort 1: HR = 3.04, 95% CI = 2.73-3.38; cohort 2: HR = 2.51, 95% CI = 2.17-2.89; cohort 3: HR = 1.88, 95% CI = 1.80-1.96). Females transitioned to high doses and strong opioids less rapidly than males (cohort 1: HR = 0.79, 95% CI = 0.76-0.82; cohort 2: HR = 0.70, 95% CI = 0.66-0.73; cohort 3: HR = 0.95, 95% CI = 0.93-0.96). CONCLUSIONS In Australia, more than one in every 13 people initiating weak opioids transition to strong opioids. By extrapolation, more than 26 000 Australian adults initiating opioids escalate to high doses each year. People with cancer treatment history, older people and males transition to strong and high-dose opioids more rapidly than others.
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Affiliation(s)
- Samanta Lalic
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical, Sciences, Monash University, Melbourne, Australia.,Pharmacy Department, Monash Health, Melbourne, Australia
| | - Natasa Gisev
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical, Sciences, Monash University, Melbourne, Australia
| | - Jenni Ilomäki
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical, Sciences, Monash University, Melbourne, Australia
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Blanshan N, Krug H. The Use of Botulinum Toxin for the Treatment of Chronic Joint Pain: Clinical and Experimental Evidence. Toxins (Basel) 2020; 12:toxins12050314. [PMID: 32397671 PMCID: PMC7291335 DOI: 10.3390/toxins12050314] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/25/2020] [Accepted: 05/05/2020] [Indexed: 12/11/2022] Open
Abstract
Chronic osteoarthritis pain is an increasing worldwide problem. Treatment for osteoarthritis pain is generally inadequate or fraught with potential toxicities. Botulinum toxins (BoNTs) are potent inhibitors of neuropeptide release. Paralytic toxicity is due to inhibition at the neuromuscular junction, and this effect has been utilized for treatments of painful dystonias. Pain relief following BoNT muscle injection has been noted to be more significant than muscle weakness and hypothesized to occur because of the inhibition of peripheral neuropeptide release and reduction of peripheral sensitization. Because of this observation, BoNT has been studied as an intra-articular (IA) analgesic for chronic joint pain. In clinical trials, BoNT appears to be effective for nociceptive joint pain. No toxicity has been reported. In preclinical models of joint pain, BoNT is similarly effective. Examination of the dorsal root ganglion (DRG) and the central nervous system has shown that catalytically active BoNT is retrogradely transported by neurons and then transcytosed to afferent synapses in the brain. This suggests that pain relief may also be due to the central effects of the drug. In summary, BoNT appears to be safe and effective for the treatment of chronic joint pain. The long-term effects of IA BoNT are still being determined.
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Affiliation(s)
- Nicole Blanshan
- Minneapolis VA Health Care System, Minneapolis, MN 55455, USA;
| | - Hollis Krug
- Minneapolis VA Health Care System, Minneapolis, MN 55455, USA;
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
- Correspondence: ; Tel.: +1-612-467-4190
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Mathieson S, Wertheimer G, Maher CG, Christine Lin CW, McLachlan AJ, Buchbinder R, Pearson SA, Underwood M. What proportion of patients with chronic noncancer pain are prescribed an opioid medicine? Systematic review and meta-regression of observational studies. J Intern Med 2020; 287:458-474. [PMID: 32100394 DOI: 10.1111/joim.13026] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 12/09/2019] [Accepted: 01/15/2020] [Indexed: 01/01/2023]
Abstract
Guidelines now discourage opioid analgesics for chronic noncancer pain because the benefits frequently do not outweigh the harms. We aimed to determine the proportion of patients with chronic noncancer pain who are prescribed an opioid, the types prescribed and factors associated with prescribing. Database searches were conducted from inception to 29 October 2018 without language restrictions. We included observational studies of adults with chronic noncancer pain measuring opioid prescribing. Opioids were categorized as weak (e.g. codeine) or strong (e.g. oxycodone). Study quality was assessed using a risk of bias tool designed for observational studies measuring prevalence. Individual study results were pooled using a random-effects model. Meta-regression investigated study-level factors associated with prescribing (e.g. sampling year, geographic region as per World Health Organization). The overall evidence quality was assessed using Grading of Recommendations Assessment, Development and Evaluation criteria. Of the 42 studies (5,059,098 participants) identified, the majority (n = 28) were from the United States of America. Eleven studies were at low risk of bias. The pooled estimate of the proportion of patients with chronic noncancer pain prescribed opioids was 30.7% (95% CI 28.7% to 32.7%, n = 42 studies, moderate-quality evidence). Strong opioids were more frequently prescribed than weak (18.4% (95% CI 16.0-21.0%, n = 15 studies, low-quality evidence), versus 8.5% (95% CI 7.2-9.9%, n = 15 studies, low-quality evidence)). Meta-regression determined that opioid prescribing was associated with year of sampling (more prescribing in recent years) (P = 0.014) and not geographic region (P = 0.056). Opioid prescribing for patients with chronic noncancer pain is common and has increased over time.
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Affiliation(s)
- S Mathieson
- From the, Institute for Musculoskeletal Health, Sydney, NSW, Australia.,Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - G Wertheimer
- School of Medicine, University of Notre Dame, Sydney, NSW, Australia
| | - C G Maher
- From the, Institute for Musculoskeletal Health, Sydney, NSW, Australia.,Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - C-W Christine Lin
- From the, Institute for Musculoskeletal Health, Sydney, NSW, Australia.,Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - A J McLachlan
- Faculty of Medicine and Health, Sydney Pharmacy School, The University of Sydney, Sydney, NSW, Australia
| | - R Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Institute, Malvern, Vic.,, Australia.,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia
| | - S-A Pearson
- Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - M Underwood
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK.,University Hospitals of Coventry and Warwickshire, Coventry, UK
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Potential for Harm Associated with Discharge Opioids After Hospital Stay: A Systematic Review. Drugs 2020; 80:573-585. [DOI: 10.1007/s40265-020-01294-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Rao T, Kiptanui Z, Dowell P, Triebwasser C, Alexander GC, Harris I. Association of Formulary Exclusions and Restrictions for Opioid Alternatives With Opioid Prescribing Among Medicare Beneficiaries. JAMA Netw Open 2020; 3:e200274. [PMID: 32119095 PMCID: PMC7052746 DOI: 10.1001/jamanetworkopen.2020.0274] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Although there are many pharmacologic alternatives to opioids, it is unclear whether the structure of Medicare Part D formularies discourages use of the alternatives. OBJECTIVES To quantify the coverage of opioid alternatives and prevalence of prior authorization, step therapy, quantity limits, and tier placement for these drugs, and test whether these formulary exclusions and restrictions are associated with increased opioid prescribing to older adults at the county level. DESIGN, SETTING, AND PARTICIPANTS County fixed-effect models were estimated using a panel of counties across the 50 US states and the District of Columbia over calendar years 2015 and 2016. Data analysis was conducted from July 1 to September 23, 2019. The sample included 2721 counties in 2015 and 2671 counties in 2016 with sufficient data on Medicare Part D formulary design and opioid prescribing. MAIN OUTCOMES AND MEASURES County-level opioid prescribing rate (number of opioid claims divided by the number of overall claims) and counts of excluded opioid alternatives and opioid alternatives with prior authorization, step therapy, quantity limits, and high-tier placements. RESULTS A total of 30 nonopioid analgesics were examined across 28 997 Medicare plans in 2015 and 30 390 plans in 2016. Medicare plans did not cover a mean of 7% of these drugs (interquartile range, 10%; lower to upper limit, 0%-23%). Among covered nonopioids, prior authorization and step therapy were uncommon, with fewer than 5% affected by prior authorization and 0% by step therapy. However, 13% of covered nonopioids had quantity limits (interquartile range, 10%; lower to upper limit, 0%-31%) and 22% were in high-cost tiers (interquartile range, 38%; lower to upper limit, 0%-50%). Increases in the number of nonopioids excluded on Medicare plans in a county were associated with increased opioid prescribing (effect size relative to mean, 2.2%-3.7%; P = .004). Conversely, increases in the number of opioids not covered on Medicare plans in a county was found to be associated with decreased opioid prescribing (effect size relative to mean, 0.8%-1.5%; P = .02). None of the utilization management strategies (prior authorization, step therapy, and quantity limits) examined or high-cost tier placements of nonopioids were associated with increased opioid prescribing. CONCLUSIONS AND RELEVANCE Lack of Medicare coverage for pharmacologic alternatives to opioids may be associated with increased opioid prescribing.
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Affiliation(s)
- Tanvi Rao
- IMPAQ International LLC, Washington, District of Columbia
| | | | | | | | - G. Caleb Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Kern KU, Sohns M, Heckes B, Elling C. Tapentadol prolonged release for severe chronic osteoarthritis pain in the elderly: improvements in daily functioning and quality of life. Pain Manag 2020; 10:85-95. [DOI: 10.2217/pmt-2019-0041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Background: Chronic osteoarthritis (OA) pain leads to severe impairments in physical functioning and quality of life. Patients & methods: Data of patients with severe chronic knee and/or hip OA pain were extracted from the database of a prospective, noninterventional trial to assess the benefits of tapentadol prolonged release (PR) in elderly patients (>65 years of age; n = 1162) compared with younger patients (≤65 years of age; n = 498). Results: Tapentadol PR treatment (up to 3 months) significantly reduced pain intensity and pain-related restrictions on daily functioning and significantly improved physical and mental quality of life in both patient groups. The incidence of adverse drug reactions was low. Conclusion: Tapentadol PR is a useful strong analgesic to improve pain intensity, physical functioning and quality of life in elderly OA patients.
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Affiliation(s)
- Kai-Uwe Kern
- Institute for Pain Medicine/Pain Practice, Wiesbaden, 65193, Germany
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Kong SH, Ahn D, Kim BR, Srinivasan K, Ram S, Kim H, Hong AR, Kim JH, Cho NH, Shin CS. A Novel Fracture Prediction Model Using Machine Learning in a Community-Based Cohort. JBMR Plus 2020; 4:e10337. [PMID: 32161842 PMCID: PMC7059838 DOI: 10.1002/jbm4.10337] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/16/2019] [Accepted: 01/03/2020] [Indexed: 11/11/2022] Open
Abstract
The prediction of fracture risk in osteoporotic patients has been a topic of interest for decades, and models have been developed for the accurate prediction of fracture, including the fracture risk assessment tool (FRAX). As machine-learning methodologies have recently emerged as a potential model for medical prediction tools, we aimed to develop a novel fracture prediction model using machine-learning methods in a prospective community-based cohort. In this study, 2227 participants (1257 females) with a baseline bone mineral density (BMD) and trabecular bone score were enrolled from the Ansung cohort. The primary endpoint was the fragility fractures reported by patients or confirmed by X-rays. We used 3 different models: CatBoost, support vector machine (SVM), and logistic regression. During a mean 7.5-year follow-up (range, 2.5 to 10 years), fragility fractures occurred in 537 (25.6%) of participants. In predicting total fragility fractures, the area under the curve (AUC) values of the CatBoost, SVM, and logistic regression models were 0.688, 0.500, and 0.614, respectively. The AUC value of CatBoost was significantly better than that of FRAX (0.663; p < 0.001), whereas the the SVM and logistic regression models were not. Compared with the conventional models such as SVM and logistic regression, the CatBoost model had the best performance in predicting total fragility fractures (p < 0.001). According to feature importance in the CatBoost model, the top predicting factors (listed in order) were total hip, lumbar spine, and femur neck BMD, subjective arthralgia score, serum creatinine, and homocysteine. The latter three factors were listed higher than conventional predictors such as age or previous fracture history. In summary, we hereby report the development of a prediction model for fragility fractures using a machine-learning method, CatBoost, which outperforms the FRAX model as well as two conventional machine-learning models. The model was also able to propose novel high-ranking predictors. © 2020 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Sung Hye Kong
- Department of Internal Medicine Seoul National University College of Medicine Seoul Republic of Korea
| | - Daehwan Ahn
- Department of Operations, Information and Decisions, Wharton School University of Pennsylvania Philadelphia PA USA
| | - Buomsoo Raymond Kim
- Department of Management Information Systems, Eller College of Management University of Arizona Tucson AZ USA
| | - Karthik Srinivasan
- Department of Management Information Systems, Eller College of Management University of Arizona Tucson AZ USA
| | - Sudha Ram
- Department of Management Information Systems, Eller College of Management University of Arizona Tucson AZ USA
| | - Hana Kim
- Department of Internal Medicine Seoul National University College of Medicine Seoul Republic of Korea
| | - A Ram Hong
- Department of Internal Medicine Chonnam National University Hwasun Hospital Chonnam
| | - Jung Hee Kim
- Department of Internal Medicine Seoul National University College of Medicine Seoul Republic of Korea
| | - Nam H Cho
- Department of Preventive Medicine Ajou University School of Medicine Suwon Republic of Korea
| | - Chan Soo Shin
- Department of Internal Medicine Seoul National University College of Medicine Seoul Republic of Korea
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Pain management in trauma patients affected by the opioid epidemic: A narrative review. J Trauma Acute Care Surg 2020; 87:430-439. [PMID: 30939572 DOI: 10.1097/ta.0000000000002292] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Acute and chronic pain in trauma patients remains a challenging entity, particularly in the setting of the escalating opioid epidemic. It has been reported that chronic opioid use increases the likelihood of hospital admissions as a result of traumatic injuries. Furthermore, patients admitted with traumatic injuries have a greater than average risk of developing opioid use disorder after discharge. Practitioners providing care to these patients will encounter the issue of balancing analgesic goals and acute opioid withdrawal with the challenge of reducing postdischarge persistent opioid use. Additionally, the practitioner is faced with the worrisome prospect that inadequate treatment of acute pain may lead to the development of chronic pain and overtreatment may result in opioid dependence. It is therefore imperative to understand and execute alternative nonopioid strategies to maximize the benefits and reduce the risks of analgesic regimens in this patient population. This narrative review will analyze the current literature on pain management in trauma patients and highlight the application of the multimodal approach in potentially reducing the risks of both short- and long-term opioid use. LEVEL OF EVIDENCE: Narrative review, moderate to High.
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Lee EA, Brettler JW, Kanter MH, Steinberg SG, Khang P, Distasio CC, Martin J, Dreskin M, Thompson NH, Cotter TM, Thai K, Yasumura L, Gibbs NE. Refining the Definition of Polypharmacy and Its Link to Disability in Older Adults: Conceptualizing Necessary Polypharmacy, Unnecessary Polypharmacy, and Polypharmacy of Unclear Benefit. Perm J 2019; 24:18.212. [PMID: 31905333 DOI: 10.7812/tpp/18.212] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The term polypharmacy in older adults is generally used in a pejorative context in the medical literature. Because of its link to geriatric syndromes and disability, the avoidance of polypharmacy is usually recommended in older adults as a strategy to optimize functional status. However, there are many polypharmacy regimens based on high-quality trials that clearly reduce the risk of disability in older adults. Other guidelines for older adults recommend the use of additional medications that may or may not be evidence based and that may or may not reduce disability. Therefore, we propose that, in the geriatric literature, polypharmacy now be categorized as "necessary polypharmacy," "unnecessary polypharmacy," or "polypharmacy of unclear benefit." In this article, we discuss the 3 categories of polypharmacy and give examples on each polypharmacy regimen and its potential relationship to disability in older adults.
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Affiliation(s)
- Eric A Lee
- Department of Internal Medicine, West Los Angeles Medical Center, CA
| | | | - Michael H Kanter
- Department of Clinical Science, Kaiser Permanente School of Medicine, Pasadena, CA
| | | | - Peter Khang
- Department of Geriatrics, Palliative Medicine, and Continuing Care, Los Angeles Medical Center, CA
| | | | - John Martin
- Department of Internal Medicine, Los Angeles Medical Center, CA
| | - Mark Dreskin
- Department of Integrated Behavioral Health, Los Angeles Medical Center, CA.,Urgent Care Division, Los Angeles Medical Center, CA
| | | | | | - Kim Thai
- Department of Physical Medicine and Rehabilitation, Baldwin Park Medical Center, CA
| | - Lyn Yasumura
- Department of Obstetrics and Gynecology, Baldwin Park Medical Center, CA
| | - Nancy E Gibbs
- Department of Geriatrics, Kaiser Permanente Southern California, Pasadena, CA
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Magidson PD, Thoburn AK, Hogan TM. Emergency Orthogeriatrics: Concepts and Therapeutic Considerations for the Geriatric Patient. Emerg Med Clin North Am 2019; 38:15-29. [PMID: 31757248 DOI: 10.1016/j.emc.2019.09.002] [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] [Indexed: 11/19/2022]
Abstract
Appropriate recognition of the physiologic, psychological, and clinical differences among geriatric patients, with respect to orthopedic injury and disease, is paramount for all emergency medicine providers to ensure they are providing high-value care for this vulnerable population.
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Affiliation(s)
- Phillip D Magidson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, A1 East Suite 150, Baltimore, MD 21224, USA.
| | - Allison K Thoburn
- Department of Medicine, Section of Geriatrics and Palliative Medicine, University of Chicago Medicine, 5841 South Maryland Avenue, MC 6098, Chicago, IL 60637, USA
| | - Teresita M Hogan
- Department of Medicine, Division of Emergency Medicine, University of Chicago School of Medicine, 5841 South Maryland Avenue, MC 6098, Chicago, IL 60637, USA
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40
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Schear S, Patel K, Deng LX, Miaskowski C, Maravilla I, Garrigues SK, Thompson N, Auerbach AD, Ritchie CS. Multimorbidity and Opioid Prescribing in Hospitalized Older Adults. J Palliat Med 2019; 23:475-482. [PMID: 31689152 DOI: 10.1089/jpm.2019.0260] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Background: Multimorbidity and pain are both common among older adults, yet pain treatment strategies for older patients with multimorbidity have not been well characterized. Objectives: To assess the prevalence and relationship between multimorbidity and opioid prescribing in hospitalized older medical patients with pain. Methods: We collected demographic, morbidity, pain, and analgesic treatment data through structured review of the electronic medical records of a consecutive sample of 238 medical patients, aged ≥65 years admitted between November 2014 and May 2015 with moderate-to-severe pain by numerical pain rating scale (range 4-10). We used the Cumulative Illness Rating Scale for Geriatrics (CIRS-G) to assess multimorbidity and cumulative illness burden. We examined the relationship between morbidity measures and opioid prescribing at hospital discharge using multivariate regression analysis. Results: The mean age was 75 ± 8 years, 57% were female and 50% were non-White. Mean CIRS-G total score was 17 ± 6, indicating high cumulative illness burden. Ninety-nine percent of patients had multimorbidity, defined as moderate-to-extremely severe morbidity in ≥2 organ systems. Sixty percent of patients received an opioid prescription at discharge. In multivariate analyses adjusted for age, race, and gender, patients with a discharge opioid prescription were significantly more likely to have higher cumulative illness burden and chronic pain. Conclusion: Among older medical inpatients, multimorbidity was nearly universal, and patients with higher cumulative illness burden were more likely to receive a discharge opioid prescription. More studies of benefits and harms of analgesic treatments in older adults with multimorbidity are needed to guide clinical practice.
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Affiliation(s)
- Sarah Schear
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Kanan Patel
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Lisa X Deng
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Christine Miaskowski
- Department of Physiological Nursing, School of Nursing, University of California San Francisco, San Francisco, California
| | - Ingrid Maravilla
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Sarah K Garrigues
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Nicole Thompson
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Andrew D Auerbach
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Christine S Ritchie
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California
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Day BF, Rosenthal GL. Social isolation proxy variables and prescription opioid and benzodiazepine misuse among older adults in the U.S.: A cross-sectional analysis of data from the National Survey on Drug Use and Health, 2015-2017. Drug Alcohol Depend 2019; 204:107518. [PMID: 31494444 DOI: 10.1016/j.drugalcdep.2019.06.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 06/13/2019] [Accepted: 06/13/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Prescription drug misuse in older adults is a growing public health problem. It is important to understand factors which predispose older adults to misuse prescription drugs, and social isolation may play an important role. In this study, we examined the association between social isolation proxy variables (living alone, being unmarried, and not attending religious services) and prescription opioid/benzodiazepine misuse in older adults. METHODS With pooled cross-sectional data from the National Survey on Drug Use and Health (2015-2017), we used multinomial multiple logistic regression models to analyze the association between each social isolation proxy variable and past-year prescription opioid/benzodiazepine misuse. We controlled for potentially confounding variables including sociodemographic, physical/mental health, and substance use variables. RESULTS Being unmarried was associated with approximately three times increased odds of combined opioid and benzodiazepine misuse (OR 2.98, 95% CI 1.75, 5.08), a finding that persisted after adjusting for multiple potential confounders. Further analysis showed this finding persisted for divorced/separated and never married individuals, but not widowed. Not attending religious services was also associated with prescription opioid/benzodiazepine misuse, but only in unadjusted analyses. There was no association between living alone and opioid/benzodiazepine misuse. CONCLUSION Increased odds of combined opioid and benzodiazepine prescription drug misuse was observed among unmarried older adults. Given the susceptibility of older adults to the harms of these medications, further exploration of the role of marital relationships and other forms of social connectedness in prescription drug misuse in this vulnerable population is indicated.
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Affiliation(s)
- Brendan F Day
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, 655 W. Baltimore Street, Baltimore, MD, 21201 United States.
| | - Geoffrey L Rosenthal
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, 655 W. Baltimore Street, Baltimore, MD, 21201 United States; Department of Pediatrics, University of Maryland School of Medicine, 655 W. Baltimore Street, Baltimore, MD, 21201 United States
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Brooks JM, Petersen C, Kelly SM, Reid MC. Likelihood of depressive symptoms in US older adults by prescribed opioid potency: National Health and Nutrition Examination Survey 2005-2013. Int J Geriatr Psychiatry 2019; 34:1481-1489. [PMID: 31134673 PMCID: PMC6742518 DOI: 10.1002/gps.5157] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 05/22/2019] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To investigate the relationships between depressive symptoms and opioid potency among adults aged 50 years and older reporting use of one or more prescription opioids in the past 30 days. MATERIALS/DESIGN Adjusted multiple linear regression models were conducted with 2005-2013 files from a secondary cross-sectional dataset, the National Health and Nutrition Examination Survey (NHANES). Respondents were community-dwelling, noninstitutionalized adults 50 years or older (n = 1036). Predictor variables included a positive screen for minor depression symptoms (Patient Health Questionnaire [PHQ-9] score greater than or equal to 5 and less than or equal to 9), moderate depression symptoms (PHQ-9 greater than or equal to 10 and less than or equal to 14), and severe depression symptoms (PHQ-9 greater than or equal to 15). Criterion variables included weaker-than-morphine analgesics (eg, codeine and tramadol) and morphine-equivalent opioids (eg, morphine and hydrocodone), which served as the reference category, as well as stronger-than-morphine opioid analgesics (eg, fentanyl and oxycodone). RESULTS Prevalence rates for symptoms of minor depression, moderate depression, and severe depression were n = 236 (22.8%), n = 135 (13.0%), and n = 122 (11.8%), respectively. Severe depression was significantly associated with high-potency opioid use (odds ratio [OR]: 2.27; confidence interval [CI], 1.16-4.46). In post hoc tests, severe depression remained significantly associated with high-potency opioid use only among respondents without arthritis (OR: 5.80; CI, 1.59-21.13). CONCLUSIONS Compared with older adults without depressive symptoms, older adults with severe depressive symptoms are more likely to be taking high-potency opioid medications. Future prescription opioid medication research should prioritize investigations among older adults with pain-related diagnoses, other than arthritis, reporting preexisting or new symptoms of severe depression.
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Affiliation(s)
- Jessica M. Brooks
- Geriatric Research, Education, and Clinical Center, James J. Peters VA, Medical Center, Bronx, NY
| | - Curtis Petersen
- Quantiative Biomedical Sciences, Geisel School of Medicine at Dartmouth College, Lebanon, NH
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, NH
| | - Stephanie M. Kelly
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, NH
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Daoust R, Paquet J, Moore L, Émond M, Gosselin S, Lavigne G, Choinière M, Boulanger A, Mac-Thiong JM, Chauny JM. Recent opioid use and fall-related injury among older patients with trauma. CMAJ 2019; 190:E500-E506. [PMID: 29685910 DOI: 10.1503/cmaj.171286] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Evidence for an association between opioid use and risk of falls or fractures in older adults is inconsistent. We examine the association between recent opioid use and the risk, as well as the clinical outcomes, of fall-related injuries in a large trauma population of older adults. METHODS In a retrospective, observational, multicentre cohort study conducted on registry data, we included all patients aged 65 years and older who were admitted (hospital stay > 2 d) for injury in 57 trauma centres in the province of Quebec, Canada, between 2004 and 2014. We looked at opioid prescriptions filled in the 2 weeks preceding the trauma in patients who sustained a fall, compared with those who sustained an injury through another mechanism. RESULTS A total of 67 929 patients were retained for analysis. Mean age was 80.9 (± 8.0) years and 69% were women. The percentage of patients who had filled an opioid prescription in the 2 weeks preceding an injury was 4.9% (95% confidence interval [CI] 4.7%-5.1%) for patients who had had a fall, compared with 1.5% (95% CI 1.2%-1.8%) for those who had had an injury through another mechanism. After we controlled for confounding variables, patients who had filled an opioid prescription within 2 weeks before injury were 2.4 times more likely to have a fall rather than any other type of injury. For patients who had a fall-related injury, those who used opioids were at increased risk of in-hospital death (odds ratio 1.58; 95% CI 1.34-1.86). INTERPRETATION Recent opioid use is associated with an increased risk of fall and an increased likelihood of death in older adults.
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Affiliation(s)
- Raoul Daoust
- Department of Emergency Medicine (Daoust, Paquet, Chauny), Research Centre, Hôpital du Sacré-Coeur de Montréal; Faculté de Médecine (Daoust, Mac-Thiong, Chauny), Université de Montréal; Montréal, Que.; Département de médecine sociale et préventive (Moore), Faculté de médecine, Université Laval; Axe de recherche en traumatologie-urgence-soins intensifs du Centre de recherche FRQS du CHU-Québec (Moore); Département de médecine familiale et de médecine d'urgence (Émond), Faculté de médecine, Université Laval, Québec, Que.; Department of Emergency Medicine (Gosselin), McGill University Health Centre, McGill University; Faculties of Dental Medicine and Medicine (Lavigne), Université de Montréal; Center for Advanced Research in Sleep Medicine (Lavigne), Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal); Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM) (Choinière, Boulanger); Département d'anesthésiologie (Choinière), Faculté de médecine, Université de Montréal; Research Centre (Daoust, Paquet, Mac-Thiong, Chauny), Hôpital du Sacré-Coeur (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Que.
| | - Jean Paquet
- Department of Emergency Medicine (Daoust, Paquet, Chauny), Research Centre, Hôpital du Sacré-Coeur de Montréal; Faculté de Médecine (Daoust, Mac-Thiong, Chauny), Université de Montréal; Montréal, Que.; Département de médecine sociale et préventive (Moore), Faculté de médecine, Université Laval; Axe de recherche en traumatologie-urgence-soins intensifs du Centre de recherche FRQS du CHU-Québec (Moore); Département de médecine familiale et de médecine d'urgence (Émond), Faculté de médecine, Université Laval, Québec, Que.; Department of Emergency Medicine (Gosselin), McGill University Health Centre, McGill University; Faculties of Dental Medicine and Medicine (Lavigne), Université de Montréal; Center for Advanced Research in Sleep Medicine (Lavigne), Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal); Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM) (Choinière, Boulanger); Département d'anesthésiologie (Choinière), Faculté de médecine, Université de Montréal; Research Centre (Daoust, Paquet, Mac-Thiong, Chauny), Hôpital du Sacré-Coeur (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Que
| | - Lynne Moore
- Department of Emergency Medicine (Daoust, Paquet, Chauny), Research Centre, Hôpital du Sacré-Coeur de Montréal; Faculté de Médecine (Daoust, Mac-Thiong, Chauny), Université de Montréal; Montréal, Que.; Département de médecine sociale et préventive (Moore), Faculté de médecine, Université Laval; Axe de recherche en traumatologie-urgence-soins intensifs du Centre de recherche FRQS du CHU-Québec (Moore); Département de médecine familiale et de médecine d'urgence (Émond), Faculté de médecine, Université Laval, Québec, Que.; Department of Emergency Medicine (Gosselin), McGill University Health Centre, McGill University; Faculties of Dental Medicine and Medicine (Lavigne), Université de Montréal; Center for Advanced Research in Sleep Medicine (Lavigne), Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal); Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM) (Choinière, Boulanger); Département d'anesthésiologie (Choinière), Faculté de médecine, Université de Montréal; Research Centre (Daoust, Paquet, Mac-Thiong, Chauny), Hôpital du Sacré-Coeur (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Que
| | - Marcel Émond
- Department of Emergency Medicine (Daoust, Paquet, Chauny), Research Centre, Hôpital du Sacré-Coeur de Montréal; Faculté de Médecine (Daoust, Mac-Thiong, Chauny), Université de Montréal; Montréal, Que.; Département de médecine sociale et préventive (Moore), Faculté de médecine, Université Laval; Axe de recherche en traumatologie-urgence-soins intensifs du Centre de recherche FRQS du CHU-Québec (Moore); Département de médecine familiale et de médecine d'urgence (Émond), Faculté de médecine, Université Laval, Québec, Que.; Department of Emergency Medicine (Gosselin), McGill University Health Centre, McGill University; Faculties of Dental Medicine and Medicine (Lavigne), Université de Montréal; Center for Advanced Research in Sleep Medicine (Lavigne), Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal); Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM) (Choinière, Boulanger); Département d'anesthésiologie (Choinière), Faculté de médecine, Université de Montréal; Research Centre (Daoust, Paquet, Mac-Thiong, Chauny), Hôpital du Sacré-Coeur (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Que
| | - Sophie Gosselin
- Department of Emergency Medicine (Daoust, Paquet, Chauny), Research Centre, Hôpital du Sacré-Coeur de Montréal; Faculté de Médecine (Daoust, Mac-Thiong, Chauny), Université de Montréal; Montréal, Que.; Département de médecine sociale et préventive (Moore), Faculté de médecine, Université Laval; Axe de recherche en traumatologie-urgence-soins intensifs du Centre de recherche FRQS du CHU-Québec (Moore); Département de médecine familiale et de médecine d'urgence (Émond), Faculté de médecine, Université Laval, Québec, Que.; Department of Emergency Medicine (Gosselin), McGill University Health Centre, McGill University; Faculties of Dental Medicine and Medicine (Lavigne), Université de Montréal; Center for Advanced Research in Sleep Medicine (Lavigne), Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal); Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM) (Choinière, Boulanger); Département d'anesthésiologie (Choinière), Faculté de médecine, Université de Montréal; Research Centre (Daoust, Paquet, Mac-Thiong, Chauny), Hôpital du Sacré-Coeur (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Que
| | - Gilles Lavigne
- Department of Emergency Medicine (Daoust, Paquet, Chauny), Research Centre, Hôpital du Sacré-Coeur de Montréal; Faculté de Médecine (Daoust, Mac-Thiong, Chauny), Université de Montréal; Montréal, Que.; Département de médecine sociale et préventive (Moore), Faculté de médecine, Université Laval; Axe de recherche en traumatologie-urgence-soins intensifs du Centre de recherche FRQS du CHU-Québec (Moore); Département de médecine familiale et de médecine d'urgence (Émond), Faculté de médecine, Université Laval, Québec, Que.; Department of Emergency Medicine (Gosselin), McGill University Health Centre, McGill University; Faculties of Dental Medicine and Medicine (Lavigne), Université de Montréal; Center for Advanced Research in Sleep Medicine (Lavigne), Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal); Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM) (Choinière, Boulanger); Département d'anesthésiologie (Choinière), Faculté de médecine, Université de Montréal; Research Centre (Daoust, Paquet, Mac-Thiong, Chauny), Hôpital du Sacré-Coeur (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Que
| | - Manon Choinière
- Department of Emergency Medicine (Daoust, Paquet, Chauny), Research Centre, Hôpital du Sacré-Coeur de Montréal; Faculté de Médecine (Daoust, Mac-Thiong, Chauny), Université de Montréal; Montréal, Que.; Département de médecine sociale et préventive (Moore), Faculté de médecine, Université Laval; Axe de recherche en traumatologie-urgence-soins intensifs du Centre de recherche FRQS du CHU-Québec (Moore); Département de médecine familiale et de médecine d'urgence (Émond), Faculté de médecine, Université Laval, Québec, Que.; Department of Emergency Medicine (Gosselin), McGill University Health Centre, McGill University; Faculties of Dental Medicine and Medicine (Lavigne), Université de Montréal; Center for Advanced Research in Sleep Medicine (Lavigne), Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal); Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM) (Choinière, Boulanger); Département d'anesthésiologie (Choinière), Faculté de médecine, Université de Montréal; Research Centre (Daoust, Paquet, Mac-Thiong, Chauny), Hôpital du Sacré-Coeur (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Que
| | - Aline Boulanger
- Department of Emergency Medicine (Daoust, Paquet, Chauny), Research Centre, Hôpital du Sacré-Coeur de Montréal; Faculté de Médecine (Daoust, Mac-Thiong, Chauny), Université de Montréal; Montréal, Que.; Département de médecine sociale et préventive (Moore), Faculté de médecine, Université Laval; Axe de recherche en traumatologie-urgence-soins intensifs du Centre de recherche FRQS du CHU-Québec (Moore); Département de médecine familiale et de médecine d'urgence (Émond), Faculté de médecine, Université Laval, Québec, Que.; Department of Emergency Medicine (Gosselin), McGill University Health Centre, McGill University; Faculties of Dental Medicine and Medicine (Lavigne), Université de Montréal; Center for Advanced Research in Sleep Medicine (Lavigne), Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal); Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM) (Choinière, Boulanger); Département d'anesthésiologie (Choinière), Faculté de médecine, Université de Montréal; Research Centre (Daoust, Paquet, Mac-Thiong, Chauny), Hôpital du Sacré-Coeur (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Que
| | - Jean-Marc Mac-Thiong
- Department of Emergency Medicine (Daoust, Paquet, Chauny), Research Centre, Hôpital du Sacré-Coeur de Montréal; Faculté de Médecine (Daoust, Mac-Thiong, Chauny), Université de Montréal; Montréal, Que.; Département de médecine sociale et préventive (Moore), Faculté de médecine, Université Laval; Axe de recherche en traumatologie-urgence-soins intensifs du Centre de recherche FRQS du CHU-Québec (Moore); Département de médecine familiale et de médecine d'urgence (Émond), Faculté de médecine, Université Laval, Québec, Que.; Department of Emergency Medicine (Gosselin), McGill University Health Centre, McGill University; Faculties of Dental Medicine and Medicine (Lavigne), Université de Montréal; Center for Advanced Research in Sleep Medicine (Lavigne), Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal); Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM) (Choinière, Boulanger); Département d'anesthésiologie (Choinière), Faculté de médecine, Université de Montréal; Research Centre (Daoust, Paquet, Mac-Thiong, Chauny), Hôpital du Sacré-Coeur (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Que
| | - Jean-Marc Chauny
- Department of Emergency Medicine (Daoust, Paquet, Chauny), Research Centre, Hôpital du Sacré-Coeur de Montréal; Faculté de Médecine (Daoust, Mac-Thiong, Chauny), Université de Montréal; Montréal, Que.; Département de médecine sociale et préventive (Moore), Faculté de médecine, Université Laval; Axe de recherche en traumatologie-urgence-soins intensifs du Centre de recherche FRQS du CHU-Québec (Moore); Département de médecine familiale et de médecine d'urgence (Émond), Faculté de médecine, Université Laval, Québec, Que.; Department of Emergency Medicine (Gosselin), McGill University Health Centre, McGill University; Faculties of Dental Medicine and Medicine (Lavigne), Université de Montréal; Center for Advanced Research in Sleep Medicine (Lavigne), Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal); Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM) (Choinière, Boulanger); Département d'anesthésiologie (Choinière), Faculté de médecine, Université de Montréal; Research Centre (Daoust, Paquet, Mac-Thiong, Chauny), Hôpital du Sacré-Coeur (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Que
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Anticholinergic and sedative medications exposure in older patients: a cross-sectional study. Int J Clin Pharm 2019; 41:1152-1158. [DOI: 10.1007/s11096-019-00885-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 07/27/2019] [Indexed: 10/26/2022]
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Shindo Y, Iwasaki S, Yamakage M. Efficacy and Practicality of Opioid Therapy in Japanese Chronic Noncancer Pain Patients. Pain Manag Nurs 2019; 20:222-231. [PMID: 31126747 DOI: 10.1016/j.pmn.2018.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 08/06/2018] [Accepted: 09/30/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND Many Japanese adults suffer from chronic pain. However, 50% of these individuals discontinue treatment despite the persistence of pain. Both clinicians and patients in Japan tend to be concerned about the safety and efficacy of opioid therapy, and the use of opioids in chronic non-cancer pain remains less common in Japan than elsewhere. AIMS This study examined the effects of opioid therapy on the daily lives of patients with chronic noncancer pain in Japan, where use of opioids for this type of pain remains uncommon. DESIGN Prospective cross-sectional questionnaire study. SETTING Data were collected over two periods, between March and April 2014 at one hospital, and between February and April 2015 at the other hospital. Subjects were recruited at the respective clinics by the study interviewer between March 1, 2014 and April 15, 2014 and between February 1, 2015 and April 15, 2015. PARTICIPANTS/SUBJECTS This study included 34 outpatients with chronic non-cancer pain who were being treated with opioid analgesics at pain clinics in two hospitals in Sapporo. METHODS Thirty-four Japanese patients receiving opioid medications for chronic noncancer pain in outpatient pain clinics were enrolled. Participants underwent interviews and completed the Japanese versions of the Short Form 36 (SF-36v2) and the Coping Strategies Questionnaire (CSQ). RESULTS Sleep disruption, claiming compensation for work-related accidents, and current pain level were negatively correlated with opioid effectiveness (p < .05). Additionally, opioid effectiveness was negatively correlated with the catastrophizing subscale of the CSQ (r = -0.50, p < .01). The effects of opioid therapy had a low positive correlation with the emotional functioning role subscale of the SF-36v2 (r = 0.38, p < .05). Daily equivalent morphine dose was positively correlated with opioid therapy duration, interference with appetite, and current pain intensity. Morphine dose was also positively correlated with scores for the catastrophizing subscale of the CSQ (r = 0.36, p < .05) and negatively correlated with scores in all subdomains of the SF-36v2. CONCLUSIONS It is important to focus on adaptive, cognitive, and emotional factors, such as emotional role functioning, to determine the efficacy of opioid treatment for chronic noncancer pain. Moreover, patients with catastrophizing significantly increased their morphine doses, resulting in an increased risk of overdose.
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Affiliation(s)
- Yukari Shindo
- The Faculty of Health Sciences, Hokkaido University, Sapporo, Hokkaido, Japan.
| | - Soushi Iwasaki
- Sapporo Medical University School of Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
| | - Michiaki Yamakage
- Sapporo Medical University School of Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
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Weinheimer K, Michelotti B, Silver J, Taylor K, Payatakes A. A Prospective, Randomized, Double-Blinded Controlled Trial Comparing Ibuprofen and Acetaminophen Versus Hydrocodone and Acetaminophen for Soft Tissue Hand Procedures. J Hand Surg Am 2019; 44:387-393. [PMID: 30502019 DOI: 10.1016/j.jhsa.2018.10.014] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 08/24/2018] [Accepted: 10/16/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the efficacy of opioid versus nonopioid analgesic regimens after elective, soft tissue hand surgery. We hypothesized that there would be no difference in patient-perceived pain relief between these 2 groups. METHODS This prospective, randomized, double-blinded controlled trial included patients undergoing elective soft tissue hand procedures (carpal tunnel release, trigger finger release, first dorsal compartment release, or ganglion cyst excision). Patients were randomized before surgery into 2 treatment groups: acetaminophen/hydrocodone 325/5 mg (AH, opioid group) or acetaminophen/ibuprofen 500/400 mg (AIBU, nonopioid group) and followed for 2 weeks after surgery evaluating daily pain intensity scores-visual analog scale (VAS), medication pain relief (Likert pain relief score), need for rescue opioid prescription at 1 week, and days until pain-free. RESULTS Sixty patients were randomized, 30 in the AH group and 30 in the AIBU group. There was no difference in the average VAS score. There was improved pain relief in the AIBU group, but the difference did not reach significance. There was no difference in time until pain-free, with a median of 5 days in the AH group and 3 days in the AIBU group. Two patients in each group required rescue opioid medication. Side effects were significantly more common in the AH group (n = 7; 23%) than the AIBU group (n = 1; 3%), but none were severe. CONCLUSIONS We recommend surgeons consider a combination of acetaminophen and ibuprofen as a safe and effective postoperative pain regimen for soft tissue hand surgery procedures. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic I.
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Affiliation(s)
- Kent Weinheimer
- Department of Orthopaedic Surgery, Penn State Hershey Medical Center, Hershey, PA.
| | - Brett Michelotti
- Division of Plastic Surgery, Penn State Hershey Medical Center, Hershey, PA
| | - Jeremy Silver
- Department of Orthopaedic Surgery, Penn State Hershey Medical Center, Hershey, PA
| | - Kenneth Taylor
- Department of Orthopaedic Surgery, Penn State Hershey Medical Center, Hershey, PA
| | - Alexander Payatakes
- Department of Orthopaedic Surgery, Penn State Hershey Medical Center, Hershey, PA
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Associations of Early Opioid Use With Patient-reported Outcomes and Health Care Utilization Among Older Adults With Low Back Pain. Clin J Pain 2019; 34:297-305. [PMID: 28915153 DOI: 10.1097/ajp.0000000000000557] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The objective of this study was to compare outcomes and health care utilization of older patients who did versus did not fill opioid prescriptions within 90 days of initiating care for low back pain. MATERIALS AND METHODS For patients ≥65 years with new back pain visits, we used propensity scores to match those who filled no opioid prescriptions to those who filled ≥2 opioid prescriptions within 90 days (and the first opioid prescription within 30 d) of the index visit. Over 24 months, we examined patient-reported outcomes, health care utilization, and subsequent opioid prescription fills. RESULTS Among 1954 patients eligible for matching, 238 (12%) filled ≥2 opioid prescriptions within 90 days; 200 of these were matched to controls. Patients with versus without early opioid prescriptions had similar patient-reported outcomes but were more likely to have filled ≥1 opioid prescription 18 to 24 months after the index visit (odds ratio [95% confidence interval]=2.4 [1.5-3.9]) and to have had ≥1 visit to the emergency department in the subsequent 24 months (OR, 1.6; 95% confidence interval, 1.0-2.5). DISCUSSION Among older patients with new back pain visits, filling ≥2 opioid prescriptions within 90 days of the visit was associated with similar back pain-related outcomes but increased likelihood of filling opioid prescriptions 18 to 24 months later compared with matched patients who did not fill early opioid prescriptions.
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Fritsch MA, Shelton PS. Geriatric Polypharmacy: Pharmacist as Key Facilitator in Assessing for Falls Risk: 2019 Update. Clin Geriatr Med 2019; 35:185-204. [PMID: 30929882 DOI: 10.1016/j.cger.2019.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
This article highlights the significant health impact of falls among older adults. An emphasis is placed on the vital role of the pharmacist, regardless of practice setting, in assessing and reducing falls risk for this growing population. In addition, the importance of a stepwise comprehensive approach to falls assessment by pharmacists in collaboration with other clinicians is elucidated.
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Affiliation(s)
| | - Penny S Shelton
- North Carolina Association of Pharmacists, 1101 Slater Road, Suite 110, Durham, NC 27703, USA
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Cooper C, Chapurlat R, Al-Daghri N, Herrero-Beaumont G, Bruyère O, Rannou F, Roth R, Uebelhart D, Reginster JY. Safety of Oral Non-Selective Non-Steroidal Anti-Inflammatory Drugs in Osteoarthritis: What Does the Literature Say? Drugs Aging 2019; 36:15-24. [PMID: 31073921 PMCID: PMC6509083 DOI: 10.1007/s40266-019-00660-1] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are widely recommended and prescribed to treat pain in osteoarthritis. While measured to have a moderate effect on pain in osteoarthritis, NSAIDs have been associated with wide-ranging adverse events affecting the gastrointestinal, cardiovascular, and renal systems. Gastrointestinal toxicity is found with all NSAIDs, which may be of particular concern when treating older patients with osteoarthritis, and gastric adverse events may be reduced by taking a concomitant gastroprotective agent, although intestinal adverse events are not ameliorated. Cardiovascular toxicity is associated with all NSAIDs to some extent and the degree of risk appears to be pharmacotherapy specific. An increased risk of acute myocardial infarction and heart failure is observed with all NSAIDs, while an elevated risk of hemorrhagic stroke appears to be restricted to the use of diclofenac and meloxicam. All NSAIDs have the potential to induce acute kidney injury, and patients with osteoarthritis with co-morbid conditions including hypertension, heart failure, and diabetes mellitus are at increased risk. Osteoarthritis is associated with excess mortality, which may be explained by reduced levels of physical activity owing to lower limb pain, presence of comorbid conditions, and the adverse effects of anti-osteoarthritis medications especially NSAIDs. This narrative review of recent literature identifies data on the safety of non-selective NSAIDs to better understand the risk:benefit of using NSAIDs to manage pain in osteoarthritis.
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Affiliation(s)
- Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD UK
- National Institute for Health Research Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK
- WHO Collaborating Centre for Public Heath Aspects of Musculoskeletal Health and Aging, Liège, Belgium
| | - Roland Chapurlat
- INSERM, UMR 1033, Université de Lyon, Hôpital E Herriot, Lyon, France
| | - Nasser Al-Daghri
- Chair for Biomarkers of Chronic Diseases, Biochemistry Department, College of Science, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Gabriel Herrero-Beaumont
- Rheumatology Service, Joint and Bone Research Unit, Autonomous University of Madrid, Fundación Jiménez Díaz, Madrid, Spain
| | - Olivier Bruyère
- WHO Collaborating Centre for Public Heath Aspects of Musculoskeletal Health and Aging, Liège, Belgium
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - François Rannou
- Division of Physical Medicine and Rehabilitation, Department of Rheumatology, AP-HP Cochin Hospital, INSERM U1124, Université Paris Descartes Sorbonne Paris Cité, Paris, France
| | - Roland Roth
- Max-Reger-Strasse 17-19, Essen-Suedviertel, Germany
| | - Daniel Uebelhart
- Division of Musculoskeletal, Internal Medicine and Oncological Rehabilitation, Department of Orthopaedics and Traumatology, Hôpital du Valais, Centre Hospitalier du Valais Romand, CVP, Crans-Montana, Switzerland
| | - Jean-Yves Reginster
- WHO Collaborating Centre for Public Heath Aspects of Musculoskeletal Health and Aging, Liège, Belgium
- Chair for Biomarkers of Chronic Diseases, Biochemistry Department, College of Science, King Saud University, Riyadh, Kingdom of Saudi Arabia
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
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50
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Davison SN. Clinical Pharmacology Considerations in Pain Management in Patients with Advanced Kidney Failure. Clin J Am Soc Nephrol 2019; 14:917-931. [PMID: 30833302 PMCID: PMC6556722 DOI: 10.2215/cjn.05180418] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Pain is common and poorly managed in patients with advanced CKD, likely due to both under and over prescription of appropriate analgesics. Poorly managed pain contributes to patients' poor quality of life and excessive health care use. There is tremendous variability within and between countries in prescribing patterns of analgesics, suggesting that factors other than patient characteristics account for these differences. This article discusses the pharmacologic management of acute and chronic pain in patients with advanced CKD, and the role analgesics, including opioids, play in the overall approach to pain management.
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Affiliation(s)
- Sara N Davison
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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