Opioids and Other Central Nervous System-Active Polypharmacy in Older Adults in the United States

Chronic Pain Self-Management Strategies for Older Adults: An Integrative Review

INTRODUCTION

Due to the complex nature of chronic pain, especially in older adults, a biopsychosocial approach is more effective than an isolated approach for its management. Furthermore, when patients are actively engaged in their pain management, they are more likely to be successful than relying totally on others.

OBJECTIVE

To analyze the self-management strategies currently used by older adults with chronic pain.

METHOD

An integrative review was conducted through seven online databases, searching for scientific studies on this topic published in the last 10 years.

RESULTS AND CONCLUSION

Fifty-eight studies were included in the final sample. Research on chronic pain self-management for older adults has increased in recent years. Although a diversity of chronic physical painful conditions are being investigated, many conditions are still under-investigated. Online and in-person strategies are currently adopted, demonstrating similar results. Positive results are evidenced by strategies including health promotion, mind control, social participation and take-action fields. Major results come from a combination of strategies focusing on biopsychosocial aspects of pain management. Results include not only the reduction of pain itself, but increased self-efficacy, adoption of health behaviors and improvement of functionality, among others, i.e., improved QoL, despite pain.

Prescribing Benzodiazepines and Opioids and Clinical Characteristics Associated With 30-Day Hospital Return in Patients Aged ≥75 Years: Secondary Data Analysis

PURPOSE

The current study compared prevalence of opioid or benzodiazepine (BZD) prescription and co-prescription of opioids and BZD at discharge and return to a community hospital within 30 days, as well as identified clinical characteristics associated with hospital return in patients aged ≥75 years.

METHOD

A secondary analysis of a database created during implementation of the Safe Transitions for At Risk Patients program at a 400-bed community teaching hospital in south Florida was conducted. Multivariable logistic regression analyses were performed to identify significant demographic and clinical characteristics associated with return to the hospital within 30 days of discharge.

RESULTS

A total of 24,262 participants (52.6% women) with a mean age of 85.3 (SD = 6.42) years were included. More than 20% in each central nervous system prescription group (i.e., opioids only, BZD only, opioids and BZD) returned to the hospital within 30 days of discharge. Demographic and chronic conditions (e.g., congestive heart failure, chronic obstructive pulmonary disease, diabetes) and poly-pharmacy were significant factors of a 30-day return to the hospital.

CONCLUSION

Findings highlight the importance of hospital nurses' role in identifying high-risk patients, educating patients and caregivers, monitoring them closely, communicating with primary care physicians and specialists, and conducting intensive follow up via telephone to avoid 30-day rehospitalization. [Journal of Gerontological Nursing, 50(4), 25-33.].

Prevalence and trend of central nervous system-active medication polypharmacy among US commercially insured adults with vs without early-onset dementia: a multi-year cross-sectional study

BACKGROUND

Limited data exist on the prevalence and trend of central nervous system (CNS)-active medication polypharmacy among adults with early-onset dementia (EOD) and whether these estimates differ for adults without EOD but with chronic pain, depression, or epilepsy, conditions managed by CNS-active medications.

METHODS

A multi-year, cross-sectional study using 2012-2021 MarketScan Commercial Claims data was conducted among adults aged 30 to 64 years with EOD and those without EOD but having a diagnosis of chronic pain, depression, or epilepsy as comparison groups. For each disease cohort, the primary outcome was CNS-active medication polypharmacy defined as concurrent use of ≥ 3 CNS-active medications on the US Beers Criteria list that overlapped for > 30 consecutive days during 12 months following a randomly selected medical encounter with the disease diagnosis. A separate multivariate modified Poisson regression model was used to estimate time trends in CNS polypharmacy in each disease cohort. Differences in trend estimates between EOD and non-EOD disease cohorts were examined by an interaction between EOD status and yearly time.

RESULTS

From 2013 to 2020, the annual crude prevalence of CNS polypharmacy was higher among adults with EOD (21.2%-25.0%) than adults with chronic pain (5.1%-5.9%), depression (14.8%-21.7%), or epilepsy (20.0%-22.3%). The adjusted annual prevalence of CNS polypharmacy among patients with EOD did not significantly change between 2013 and 2020 (adjusted prevalence rate ratio [aPRR], 0.94; 95% CI, 0.88-1.01), whereas a significant decreasing trend was observed among non-EOD cohorts with chronic pain (aPRR, 0.66; 95% CI, 0.63-0.69), depression (aPRR, 0.81; 95% CI, 0.77-0.85), and epilepsy (aPRR, 0.86; 95% CI, 0.83-0.89). The interaction analysis indicated that patients with epilepsy and depression (vs with EOD) had a decreasing probability of CNS-active medication polypharmacy over time (aPRR, 0.98 [95% CI, 0.98-0.99]; P < .001 for interaction for both conditions).

CONCLUSIONS

The prevalence of CNS polypharmacy among US commercially insured adults with EOD (vs without) was higher and remained unchanged from 2013 to 2021. Medication reviews of adults with EOD and CNS polypharmacy are needed to ensure that benefits outweigh risks associated with combined use of these treatments.

Interaction between benzodiazepines and prescription opioids on incidence of hard braking events in older drivers

BACKGROUND

Polypharmacy use among older adults is of increasing concern for driving safety. This study assesses the individual and joint effects of benzodiazepines and prescription opioids on the incidence of hard braking events in older drivers.

METHODS

Data for this study came from the Longitudinal Research on Aging Drivers project-a multisite, prospective cohort study of 2990 drivers aged 65-79 years at enrollment (2015-2017). Adjusted incidence rate ratios (aIRRs) and 95% confidence intervals (CIs) of hard braking events (defined as maneuvers with deceleration rates ≥0.4 g and commonly known as near-crashes) were estimated through multivariable negative binominal modeling.

RESULTS

Of the 2929 drivers studied, 167 (5.7%) were taking benzodiazepines,  163 (5.6%) prescription opioids, and 23 (0.8%) both drugs at baseline. The incidence rates of hard braking events per 1000 miles driven were 1.14 (95% CI 1.10-1.18) for drivers using neither benzodiazepines nor prescription opioids, 1.25 (95% CI 1.07-1.43) for those using benzodiazepines only, 1.55 (95% CI 1.35-1.76) for those using prescription opioids only, and 1.63 (95% CI 1.11-2.16) for those using both medications. Multivariable modeling revealed that the use of prescription opioids was associated with a 19% increased risk of hard braking events (aIRR 1.19, 95% CI 1.03-1.36). There existed a positive interaction between the two drugs on the additive scale but not on the multiplicative scale.

CONCLUSION

Concurrent use of benzodiazepines and prescription opioids by older drivers appears to affect driving safety through increased incidence of hard braking events.

Patient Perceptions of Opioids and Benzodiazepines and Attitudes Toward Deprescribing

BACKGROUND

Opioids and benzodiazepines (BZDs) pose a public health problem. Older adults are especially susceptible to adverse events from opioids and BZDs owing to an increased usage of opioids and BZDs, multiple comorbidities, and polypharmacy. Deprescribing is a possible, yet challenging, solution to reducing opioid and BZD use.

OBJECTIVE

We aimed to explore older adult patients' knowledge of opioids and BZDs, perceived facilitators and barriers to deprescribing opioids and BZDs, and attitudes toward alternative treatments for opioids and BZDs.

METHODS

We conducted 11 semi-structured interviews with patients aged 65+ years with long-term opioid and/or BZD prescriptions. The interview guide was developed by an interprofessional team and focused on patients' knowledge of opioids and BZDs, perceived ability to reduce opioid or BZD use, and attitudes towards alternative treatments.

RESULTS

Three patients had taken opioids, either currently or in the past, three had taken BZDs, and five had taken both opioids and BZDs. Generally, knowledge of opioids and BZDs was variable among patients; yet facilitators and barriers to deprescribing both opioids and BZDs were consistent. Facilitators of deprescribing included patient-provider trust and slow tapering of medications, while barriers included concerns about re-emergence of symptoms and a lack of motivation, particularly if medications and symptoms were stable. Patients were generally unenthusiastic about pursuing alternative pharmacologic and non-pharmacologic alternatives to opioids and BZDs for symptom management.

CONCLUSIONS

Our findings indicate that patients are open to deprescribing opioids and BZDs under certain circumstances, but overall remain hesitant with a lack of enthusiasm for alternative treatments. Future studies should focus on supportive approaches to alleviate older adults' deprescribing concerns.

Coprescribing of opioids and psychotropic medications among Medicare-enrolled older adults on long-term opioid therapy

BACKGROUND

Pressures to reduce opioid prescribing have potential to incentivize coprescribing of opioids (at lower dose) with psychotropic medications. Evidence concerning the extent of the problem is lacking. This study assessed trends in coprescribing and characterized coprescribing patterns among Medicare-enrolled older adults with chronic noncancer pain (CNCP) receiving long-term opioid therapy (LTOT).

METHODS

A cohort study was conducted using 2012-2018 5% National Medicare claims data. Eligible beneficiaries were continuously enrolled and had no claims for cancer diagnoses or hospice use, and ≥ 2 claims with diagnoses for CNCP conditions within a 30-day period in the 12 months before the index date (LTOT initiation). Coprescribing was defined as an overlap between opioids and any class of psychotropic medication (antidepressants, benzodiazepines, antipsychotics, anticonvulsants, muscle relaxants, and nonbenzodiazepine hypnotics) based on their prescription fill dates and days of supply in a given year. The occurrence of coprescribing, coprescribing intensity, and number of days of overlap with psychotropic medications were calculated for each calendar year.

RESULTS

The eligible study population of individuals on LTOT ranged from 2038 in 2013 to 1751 in 2018. The occurrence of coprescribing among eligible beneficiaries decreased from 73.41% in 2013 to 70.81% in 2015 and then increased slightly to 71.22% in 2018. Among eligible beneficiaries with at least one overlap day, the coprescribing intensity with any class of psychotropic medications showed minimal variation throughout the study period: 74.73% in 2013 and 72.67% in 2018. Across all the years, the coprescribing intensity was found to be highest with antidepressants (2013, 49.90%; 2018, 50.33%) followed by benzodiazepines (2013, 25.42%; 2018, 19.95%).

CONCLUSION

Coprescribing was common among older adults with CNCP who initiated LTOT but did not rise substantially in the period studied. Future research should investigate drivers behind coprescribing and safety of various patterns of use.

Association of medication use with falls and mortality among long-term care residents: a longitudinal cohort study

BACKGROUND

Falls in long-term care are common. The aim of our study was to explore how medication use is associated with incidence of falls, related consequences, and all-cause mortality among long-term care residents.

METHODS

Five hundred thirty two long-term care residents aged 65 years or older participated in this longitudinal cohort study in 2018-2021. Data on medication use were retrieved from medical records. Polypharmacy was defined as use of 5-10 medications and excessive polypharmacy as use of > 10 medications. The numbers of falls, injuries, fractures, and hospitalizations were collected from medical records over 12 months following baseline assessment. Participants were followed for three years for mortality. All analysis were adjusted for age, sex, Charlson Comorbidity Index, Clinical dementia rating, and mobility.

RESULTS

A total of 606 falls occurred during the follow-up. Falls increased significantly with the number of medications used. Fall rate was 0.84/person-years (pyrs) (95% CI 0.56 to 1.13) for the non-polypharmacy group, 1.13/pyrs (95% CI 1.01 to 1.26) for the polypharmacy group, and 1.84/pyrs (95% CI 1.60 to 2.09) for the excessive polypharmacy group. Incidence rate ratio for falls was 1.73 (95% CI 1.44 to 2.10) for opioids, 1.48 (95% CI 1.23 to 1.78) for anticholinergic medication, 0.93 (95% CI 0.70 to 1.25) for psychotropics, and 0.91 (95% CI 0.77 to 1.08) for Alzheimer medication. The three-year follow-up showed significant differences in mortality between the groups, the lowest survival rate (25%) being in the excessive polypharmacy group.

CONCLUSION

Polypharmacy, opioid and anticholinergic medication use predicted incidence of falls in long-term care. The use of more than 10 medications predicted all-cause mortality. Special attention should be paid to both number and type of medications when prescribing in long-term care.

Design, synthesis, and biological evaluation of low-toxic lappaconitine derivatives as potential analgesics

The C₁₈-diterpenoid alkaloid lappaconitine (LA) is a non-addictive analgesic used in China. The toxicity (LD₅₀ = 11.7 mg/kg) limits its application. Two series of LA derivatives, including amides and sulfonamides (1-93), were designed and synthesized by modification on their C4 acetamidobenzoate side chains in this work. In vivo analgesic activity and toxicity of all derivatives were evaluated, and the structure-activity relationship was summarized. Six lead compounds (35, 36, 39, 49, 70, and 89) exhibited approximate analgesic activity to LA but with significantly reduced toxicity. The therapeutic index of these compounds is 14-30 times that of LA. In vivo metabolism study of the lead compounds 39, 49, 70, and 89 were conducted by UPLC-MS^E, indicating the reason for the low toxicity of the potential derivatives might be they are difficult to metabolize to toxic metabolite N-deacetyllappaconitine compared to LA. The effects of lead compounds on sodium channels and hERG channels were also studied by ion channel reader (ICR) which further revealed their analgesic and toxicity-attenuating mechanisms. Sodium channel assay revealed that the analgesic mechanism of these lead compounds was inhibiting the Na_v 1.7 channels. Taken together, compound 39 was provided as a new analgesic lead compound with significantly low toxicity and comparable activity to LA.

Opioid Initiation and the Hazard of Falls or Fractures Among Older Adults with Varying Levels of Central Nervous System Depressant Burden

BACKGROUND

Co-prescription of opioids with other central nervous system (CNS) depressants is common but the combination may increase the risk for adverse events such as falls and fractures, particularly among older adults. We explored the risk of fall- or fracture-related hospital visits after opioid initiation among older adults with varying degrees of concomitant CNS depressant burden.

METHODS

We used population-based administrative health data from Ontario, Canada, to examine the relationship between hospital visits for falls or fractures at different levels of CNS burden among individuals aged 66 and older who started prescription opioids between March 1, 2008, and March 31, 2019. For comparison, we identified individuals starting prescription non-steroidal anti-inflammatory drugs (NSAIDs). The outcome was a hospital visit for falls or fractures within 14 days after starting analgesic therapy. We stratified the cohort according to additional CNS burden: none, low (one concurrent CNS depressant drug class) and high (≥ 2 concurrent CNS depressant classes) on the index date. We balanced opioid and NSAID recipients using inverse probability of treatment weighting and reported weighted hazard ratios from Cox proportional hazards models. We then used pairwise comparisons to determine differences between hazard ratios at different levels of CNS burden.

RESULTS

The cohort included 1,066,692 older adults, with 562,692 new opioid recipients and 504,000 new NSAID recipients. Among opioid recipients, 83 % had no additional CNS burden, 13 % had low burden and 4 % had high burden. The short-term rate of falls or fractures for new opioid recipients increased by CNS burden from 97 per 1000 person-years (no burden) to 233 per 1000 person-years (high CNS burden). Opioid recipients had a similarly elevated hazard of falls or fractures within each CNS burden level compared to NSAID recipients (adjusted hazard ratio [aHR] 1.62, 95 % CI 1.50-1.76 for no burden; aHR 1.69, 95 % CI 1.45-1.97 for low burden; aHR 1.40, 95 % CI 1.08-1.82 for high burden).

CONCLUSION

Among older adults, initiation of opioids is associated with an increased hazard of falls; however, this hazard is not modified by different levels of CNS depressant burden. This suggests that it remains important for physicians, patients, and caregivers to be vigilant when starting new opioid therapy regardless of other CNS medications taken concurrently.

Pharmacist interventions to deprescribe opioids and benzodiazepines in older adults: A rapid review

BACKGROUND

Many older adults are prescribed opioids and benzodiazepines (BZDs), despite increased susceptibility to adverse events. Challenges of deprescribing include fragmented care and lack of knowledge or time. Pharmacists are well-positioned to overcome these challenges and facilitate deprescribing of these medications.

OBJECTIVES

We sought to evaluate interventions utilizing pharmacists to deprescribe opioids and BZDs in older adults.

METHODS

We conducted a rapid review following a comprehensive literature search to identify interventions with pharmacist involvement for deprescribing opioids and BZDs in older adults. Studies were included based on: (1) inclusion of patients ≥ 65 years old receiving BZDs and/or opioids, (2) evaluation of feasibility or outcomes following deprescribing (3) pharmacists as part of the intervention. We included randomized, observational, cohort, and pilot studies. Studies that did not report specific results for BZD or opioids were excluded.

RESULTS

We screened 687 abstracts and included 17 studies. Most (n = 13) focused on BZD deprescribing. Few studies focused on opioids (n = 2) or co-prescribing of opioids and BZDs (n = 2). The most common intervention was educational brochures (n = 8), majority being the EMPOWER brochure for deprescribing BZDs. Other interventions included chart review with electronic notes (n = 4), pharmacist-led programs/services (n = 2), and multifactorial interventions (n = 3). Many studies were underpowered or lacked suitable control groups. Generally speaking, interventions utilizing educational materials and those in which pharmacists engaged with patients and providers were more effective. Interventions relying on electronic communication by pharmacists were less successful, due to low acceptance or acknowledgement.

CONCLUSIONS

We identified a number of feasible interventions to reduce BZD use, but fewer interventions to reduce opioid use in older adults. An optimal approach for deprescribing likely requires pharmacists to engage directly with patients and providers. Larger well-designed studies are needed to evaluate the effectiveness of deprescribing interventions beyond feasibility.

Opioid Drug-Drug-Drug Interactions and Unintentional Traumatic Injury: Screening to Detect Three-Way Drug Interaction Signals

Growing evidence suggests that drug interactions may be responsible for much of the known association between opioid use and unintentional traumatic injury. While prior research has focused on pairwise drug interactions, the role of higher-order (i.e., drug-drug-drug) interactions (3DIs) has not been examined. We aimed to identify signals of opioid 3DIs with commonly co-dispensed medications leading to unintentional traumatic injury, using semi-automated high-throughput screening of US commercial health insurance data. We conducted bi-directional, self-controlled case series studies using 2000-2015 Optum Data Mart database. Rates of unintentional traumatic injury were examined in individuals dispensed opioid-precipitant base pairs during time exposed vs unexposed to a candidate interacting precipitant. Underlying cohorts consisted of 16-90-year-olds with new use of opioid-precipitant base pairs and ≥1 injury during observation periods. We used conditional Poisson regression to estimate rate ratios adjusted for time-varying confounders, and semi-Bayes shrinkage to address multiple estimation. For hydrocodone, tramadol, and oxycodone (the most commonly used opioids), we examined 16,024, 8185, and 9330 drug triplets, respectively. Among these, 75 (0.5%; hydrocodone), 57 (0.7%; tramadol), and 42 (0.5%; oxycodone) were significantly positively associated with unintentional traumatic injury (50 unique base precipitants, 34 unique candidate precipitants) and therefore deemed potential 3DI signals. The signals found in this study provide valuable foundations for future research into opioid 3DIs, generating hypotheses to motivate crucially needed etiologic investigations. Further, this study applies a novel approach for 3DI signal detection using pharmacoepidemiologic screening of health insurance data, which could have broad applicability across drug classes and databases.

Frailty Risks of Prescription Analgesics and Sedatives across Frailty Models: the Health and Retirement Study

INTRODUCTION

Limited evidence for incident frailty risks associated with prescription analgesics and sedatives in older (≥ 65 years) community-living adults prompted a more comprehensive investigation.

METHODS

We used data from older Health and Retirement Study respondents and three frailty models (frailty index, functional domain, frailty phenotype with 8803, 10,470, and 6850 non-frail individuals, respectively) and estimated sub-hazard ratios of regular prescription drug use (co-use, analgesic use, and sedative use), by frailty model. We addressed confounding with covariate adjustment and propensity score matching approaches.

RESULTS

The baseline prevalence of analgesic and sedative co-use, analgesic use, and sedative use among non-frail respondents was 1.8%, 12.8%, and 4.7% for the frailty index model, 4.2%, 16.2%, and 5.3% for the functional domain model, and 4.3%, 15.4%, and 6.1% for the frailty phenotype model, respectively. Cumulative frailty incidence over 10 years was 39.3%, 36.1%, and 14.2% for frailty index, functional domain, and frailty phenotype models, respectively; covariate-adjusted sub-hazard ratio estimates were 2.00 (1.63-2.45), 1.83 (1.57-2.13), and 1.68 (1.21-2.33) for co-use; 1.72 (1.56-1.89), 1.38 (1.27-1.51), and 1.51 (1.27-1.79) for analgesic use; and 1.46 (1.24-1.72), 1.25 (1.07-1.46), and 1.31 (0.97-1.76) for sedative use. Frailty risk ranking (co-use > analgesic use > sedative use) persisted across all model sensitivity analyses.

DISCUSSION

Consistently significant frailty risk estimates of regular prescription analgesic and sedative co-use and of prescription analgesic use support existing clinical, public health, and regulatory guidance on opioid and benzodiazepine co-prescription, on opioid prescription, and on NSAID prescription. Frailty phenotype measurement administration limited power to detect significant frailty risks. Research into specific pharmaceutical exposures and comparison of results across cohorts will be required to contribute to the deprescribing evidence base.

The impact of high-risk medications on mortality risk among older adults with polypharmacy: evidence from the English Longitudinal Study of Ageing

BACKGROUND

Polypharmacy is common among older people and is associated with an increased mortality risk. However, little is known about whether the mortality risk is related to specific medications among older adults with polypharmacy. This study therefore aimed to investigate associations between high-risk medications and all-cause and cause-specific mortality among older adults with polypharmacy.

METHODS

This study included 1356 older adults with polypharmacy (5+ long-term medications a day for conditions or symptoms) from Wave 6 (2012/2013) of the English Longitudinal Study of Ageing. First, using the agglomerative hierarchical clustering method, participants were grouped according to the use of 14 high-risk medication categories. Next, the relationship between the high-risk medication patterns and all-cause and cause-specific mortality (followed up to April 2018) was examined. All-cause mortality was assessed by Cox proportional hazards model and competing-risk regression was employed for cause-specific mortality.

RESULTS

Five high-risk medication patterns-a renin-angiotensin-aldosterone system (RAAS) inhibitors cluster, a mental health drugs cluster, a central nervous system (CNS) drugs cluster, a RAAS inhibitors and antithrombotics cluster, and an antithrombotics cluster-were identified. The mental health drugs cluster showed increased risks of all-cause (HR = 1.55, 95%CI = 1.05, 2.28) and cardiovascular disease (CVD) (SHR = 2.11, 95%CI = 1.10, 4.05) mortality compared with the CNS drug cluster over 6 years, while others showed no differences in mortality. Among these patterns, the mental health drugs cluster showed the highest prevalence of antidepressants (64.1%), benzodiazepines (10.4%), antipsychotics (2.4%), antimanic agents (0.7%), opioids (33.2%), and muscle relaxants (21.5%). The findings suggested that older adults with polypharmacy who took mental health drugs (primarily antidepressants), opioids, and muscle relaxants were at higher risk of all-cause and CVD mortality, compared with those who did not take these types of medications.

CONCLUSIONS

This study supports the inclusion of opioids in the current guidance on structured medication reviews, but it also suggests that older adults with polypharmacy who take psychotropic medications and muscle relaxants are prone to adverse outcomes and therefore may need more attention. The reinforcement of structured medication reviews would contribute to early intervention in medication use which may consequently reduce medication-related problems and bring clinical benefits to older adults with polypharmacy.

Prevalence of psychotropic polypharmacy in nursing home residents with dementia: a meta-analysis

OBJECTIVES

Nursing home (NH) residents with dementia is exposed to high rates of psychotropic prescriptions. Our objectives were to: (1) pool the prevalence estimates of psychotropic polypharmacy from the existing literature and (2) examine potentially influential factors that are related to a higher or lower prevalence.

DESIGN

Meta-analysis of data collected from randomized trials, quasi-experimental, prospective or retrospective cohort, and cross-sectional studies. English-language searches of PubMed and PsycINFO were completed by November 2020. Included studies reported prevalence estimates of psychotropic polypharmacy (i.e. defined as either two-or-more or three-or-more medications concurrently) in NH residents with dementia.

SETTING AND PARTICIPANTS

NH residents with dementia.

MEASUREMENTS

Random-effects models were used to pool the prevalence of psychotropic polypharmacy in NH residents with dementia across studies. Estimates were provided for both two-or-more and three-or-more concurrent medications. Heterogeneity and publication bias were measured. Meta-regression examined the influence of the percentage of the sample who were male, mean age of the sample, geographic region (continent), sample size, and study year on the prevalence of psychotropic polypharmacy.

RESULTS

Twenty-five unique articles were included comprising medications data from 92,370 NH residents with dementia in 12 countries. One-in-three (33%, [95% CI: 28%, 39%]) NH residents with dementia received two-or-more psychotropic medications concurrently. One-in-eight (13%, [95% CI: 10%, 17%]) received three-or-more psychotropic medications concurrently. Estimates were highly variable across both definitions of psychotropic polypharmacy (p < 0.001). Among study-level demographics, geographic region, sample size, or study year, only male sex was associated with greater use of two-or-more psychotropic medications (Unadjusted OR = 1.02, p = 0.006; Adjusted OR = 1.04, p = 0.07).

CONCLUSIONS

Psychotropic polypharmacy is common among NH residents with dementia. Identifying the causes of utilization and the effects on resident health and well-being should be prioritized by federal entities seeking to improve NH quality.

Risk of fall-related injury and all-cause hospitalization of select concomitant central nervous system medication prescribing in older adult persistent opioid users: A case-time-control analysis

BACKGROUND

Concomitant use of central nervous system (CNS) medications frequently occurs in older adults with persistent opioid use. The risks of adverse outcomes associated with combinations of opioids, sedative hypnotics, or skeletal muscle relaxants have not been sufficiently described in this population.

OBJECTIVE

To compare the overall and incremental risk of (1) fall-related injury and (2) all-cause hospitalization associated with sedative hypnotics and skeletal muscle relaxants among older persistent opioid users.

METHODS

A case-time-control study was conducted using administrative claims of adults ages ≥66 years with a history of persistent (≥90 days) opioid use. Cases included those with first (1) emergency department, hospital, or outpatient visit for a fall-related injury, or (2) all-cause hospitalization. Exposure to CNS medications prior to the case event versus earlier periods, and the risk associated with CNS drug class combinations and sequence of use, was estimated using conditional logistic regression, adjusted for time trends and time-varying covariates.

RESULTS

Among 140,101 older persistent opioid users, 20,723 experienced fall-related injury and 39,444 were hospitalized during follow-up. Skeletal muscle relaxant use was associated with an increased risk of fall-related injury (Odds ratio [OR] 1.28) and all-cause hospitalization (OR 1.11). Statistically significant associations were observed for the joint effects of interactions involving skeletal muscle relaxants on fall-related injury (with opioid: OR 1.25; with sedative hypnotic: OR 1.24), and interactions involving opioids on all-cause hospitalization (with sedative hypnotic: OR 1.10; with skeletal muscle relaxant: OR 1.17). The addition of a skeletal muscle relaxant to an opioid regimen was associated with a 25% increased risk of fall-related injury. Additions of other CNS medications did not have apparent incremental effects on the risk of all-cause hospitalization.

CONCLUSION

The excess risks of fall-related injury and hospitalization associated with various combinations of CNS medications among older persistent opioid users should be considered in therapeutic decision making. Further research is needed to confirm these findings.

Chronic Pain, Opioid Use Disorder, and Clinical Management Among Older Adults

Because of unique factors related to physiological changes and altered metabolism in advanced age, special attention is needed concerning chronic pain, opioid use, and opioid use disorder among older adults. Clinicians need to follow the most updated clinical guidelines regarding opioid prescribing. Routine screening and awareness are the keys to identifying opioid use disorder. Comprehensive assessments often require both pain assessment (including functional status) and substance use assessment, including the use of urine toxicological testing and structured, validated screening tools and instruments. Comprehensive, interdisciplinary efforts are critical in managing the care of older adults with chronic pain and opioid use disorder. A collaborative approach that includes substance abuse treatment and pain management (including pain subspecialty care) is often recommended. Medications for opioid use disorder have been extensively studied and have the most convincing evidence to date, and psychosocial treatments may be beneficial in some circumstances.

Low Back Pain and Substance Use: Diagnostic and Administrative Coding for Opioid Use and Dependence Increased in U.S. Older Adults with Low Back Pain

OBJECTIVE

Low back pain (LBP) is a leading cause of pain and disability. Substance use complicates the management of LBP, and potential risks increase with aging. Despite implications for an aging, diverse U.S. population, substance use and LBP comorbidity remain poorly defined. The objective of this study was to characterize LBP and substance use diagnoses in older U.S. adults by age, gender, and race.

DESIGN

Cross-sectional study of a random national sample.

SUBJECTS

Older adults including 1,477,594 U.S. Medicare Part B beneficiaries.

METHODS

Bayesian analysis of 37,634,210 claims, with 10,775,869 administrative and 92,903,649 diagnostic code assignments.

RESULTS

LBP was diagnosed in 14.8±0.06% of those more than 65 years of age, more in females than in males (15.8±0.08% vs. 13.4±0.09%), and slightly less in those more than 85 years of age (13.3±0.2%). Substance use diagnosis varied by substance: nicotine, 9.6±0.02%; opioid, 2.8±0.01%; and alcohol, 1.3±0.01%. Substance use diagnosis declined with advancing age cohort. Opioid use diagnosis was markedly higher for those in whom LBP was diagnosed (10.5%) than for those not diagnosed with LBP (1.5%). Most older adults (54.9%) with an opioid diagnosis were diagnosed with LBP. Gender differences were modest. Relative rates of substance use diagnoses in LBP were modest for nicotine and alcohol.

CONCLUSIONS

Older adults with LBP have high relative rates of opioid diagnoses, irrespective of gender or age. Most older adults with opioid-related diagnoses have LBP, compared with a minority of those not opioid diagnosed. In caring for older adults with LBP or opioid-related diagnoses, health systems must anticipate complexity and support clinicians, patients, and caregivers in managing pain comorbidities. Older adults may benefit from proactive incorporation of non-opioid pain treatments. Further study is needed.

Quality of opioid prescribing in older adults with or without Alzheimer disease and related dementia

Background

Pain is common among individuals with Alzheimer’s disease and related dementias (ADRD), and use of opioids has been increasing over the last decade. Yet, it is unclear to what extent opioids are appropriately prescribed for patients with ADRD and whether the appropriateness of opioid prescribing differs by ADRD status. The objective of this study is to compare the quality of opioid prescribing among patients with or without ADRD who have chronic noncancer pain.

Methods

A nationally representative cohort study of Medicare beneficiaries aged 50 years or older who had chronic pain but who had no cancer, hospice, or palliative care from 2011 to 2015. Four indicators of potentially inappropriate opioid prescribing were measured in patients residing in communities (75,258 patients with and 435,870 patients without ADRD); five indicators were assessed in patients in nursing homes (NHs) (37,117 patients with and 5128 patients without ADRD). Each indicator was calculated as the proportion of eligible patients with inappropriate opioid prescribing in the year after a chronic pain diagnosis. Differences in proportions between ADRD and non-ADRD groups were estimated using a generalized linear model adjusting for covariates through inverse probability weighting.

Results

Patients with ADRD versus those without had higher concurrent use of opioids and central nervous system–active drugs (community 44.1% vs 33.3%; NH 58.8% vs 54.1%, both P < 0.001) and no opioids or scheduled pain medications for moderate or severe pain (NH 60.1% vs 52.5%, P < 0.001). The ADRD versus non-ADRD group had higher use of long-term opioids for treating neuropathic pain in communities (21.7% vs 19.5%, P = 0.003) but lower use in NHs (26.9% vs 36.0%, P < 0.001). Use of strong or high-dose opioids when naive to opioids (community 1.5% vs 2.8%; NH 2.5% vs 3.5%) and use of contraindicated opioids (community 0.08% vs 0.12%; NH 0.05% vs 0.21%) were rare for either group.

Conclusion

Potential inappropriate opioid prescribing in 2 areas of pain care was more common among patients with ADRD than among patients without ADRD in community or NH settings. Further studies aimed at understanding the factors and effects associated with opioid prescribing patterns that deviate from guidelines are warranted.

Unhealthy Opioid Use and COVID-19 Mortality Incidence in Older Adults: A Multicenter Research Network Study

Opioid use has the potential to influence infectious respiratory diseases. The purpose of this research is to examine if there is an association of deaths from the respiratory infection, COVID-19, and unhealthy opioid use in older adults. Data about patients, ages ≥65 years, who had a COVID-19 infection between 1/20/2020 to 12/23/2020 (n = 533,153) were extracted using the TriNetX system. Mortality incidence between initial diagnosis and ninety days after contracting COVID-19 were determined. Comparisons were made between people with and without unhealthy opioid use. There were 7,547 COVID-19 patients with unhealthy opioid use (mean age, 71.8 years; standard deviation 6.3 years) and 525,606 COVID-19 patients (mean age, 74.1 years; standard deviation 7.3 years) without unhealthy opioid use. Of the total, 15,852 (3.0%) died within 3 months of COVID-19 diagnosis. The unadjusted risk ratio of the cohort with unhealthy opioid use compared with the cohort that did not have unhealthy opioid uses was 1.18 (95% CI: 1.05,1.33); p = 0.0069. The relationship failed to remain significant in analysis with propensity score matching (risk ratio = 0.96; 95% CI: 0.82, 1.14; p = 0.6606, ns). The public health implication is that although older adults are more vulnerable to COVID-19 than younger adults, a difference between older adults with or without unhealthy opioid use did not increase vulnerability to death from COVID-19 and should be not be considered if rationing of care becomes necessary.

Patterns of Psychoactive Medication Use in Community-Dwelling Older Adults in the US in 2016: A Descriptive Cross-Sectional Study

Objectives: We aim to quantify any use and long-term use patterns of psychoactive medications and explore differences in use by sociodemographic factors in older adults (60-85 years) using the 2016 Medical Expenditure Panel Survey. Methods: Prevalence estimates of any use and long-term use were calculated. Chi-square and crude odds ratios were calculated to estimate differences in any use and long-term use of psychoactive medication by sociodemographic characteristics of respondents. Results: Thirty percent of older adults in the US reported any use of psychoactive medications. Long-term use was significantly higher in women (28.3% [95% confidence interval: 26.5, 30.2]), white (27.8 [26.1, 29.7]), presently unmarried (27.5 [25.4, 29.7]), and low-income (30.3 [27.7, 32.9]) subgroups than in men (20.5 [18.4, 22.5]), Black (14.7 [12.3, 17.1]), presently married (22.8 [20.7, 24.9]), and high-income (21.1 [19.1, 23.1]) subgroups, respectively. Discussion: Despite continued risks associated with use, long-term use of psychoactive medications is prevalent in the older adult population in the US. Given the increased complexity of pharmacotherapy regimens in this population, enhanced efforts at improving use of psychoactive medications should be intensified.

Central nervous system (CNS) medications and polypharmacy in later life: cross-sectional analysis of the English Longitudinal Study of Ageing (ELSA)

OBJECTIVES

Many central nervous system (CNS) medications are considered potentially inappropriate for prescribing in older people; however, these medications are common in polypharmacy (≥5 medicines) regimens. This paper aims to determine the prevalence of CNS drug classes commonly taken by older people. Furthermore, this paper aims to determine whether polypharmacy and other factors, previously found to be associated with overall polypharmacy, are associated with the most common CNS drug classes.

DESIGN

Cross-sectional study.

SETTING

English Longitudinal Study of Ageing (wave 6).

PARTICIPANTS

7730 participants (≥50 years).

MAIN OUTCOME MEASURES

Adjusted Odds Ratios (OR) and 95% confidence intervals (CI) for CNS drug classes.

RESULTS

31% of the sample were currently taking ≥5 medications (polypharmacy), of whom 58% (n=1362/2356) were taking CNS medicines as part of their regimen. The most common CNS drug classes in polypharmacy regimens were non-opioid analgesics, opioid analgesics, tricyclic and related antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) (34.6%, 13.2%, 10.9% and 10.4%, respectively). Compared with people currently taking 1-4 prescribed medicines, polypharmacy was associated with adjusted ORs of 5.71 (95% CI: 4.29 to 7.61, p<0.01) for opioid analgesics, 3.80 (95% CI: 3.25 to 4.44, p<0.01) for non-opioid analgesics, 3.11 (95% CI: 2.43 to 3.98, p<0.01) for TCAs and 2.30 (95% CI: 1.83 to 2.89, p<0.01) for SSRIs. Lower wealth was also associated with the aforementioned CNS drug classes.

CONCLUSION

Opioid and non-opioid analgesics were the most prevalent classes of CNS medicines in this study. Polypharmacy is strongly associated with the aforementioned classes of analgesics. Polypharmacy is also associated with TCAs and SSRIs, although to a lesser extent than for analgesics. For all CNS medicine classes, polypharmacy may need to be considered in relation to reducing the risk of potential adverse events. After adjustment, lower wealth is associated particularly with analgesics, highlighting that socioeconomic factors may play a role in the prescribing of CNS medicines. These findings provide a baseline for future research into this area.

Opioids, Polypharmacy, and Drug Interactions: A Technological Paradigm Shift Is Needed to Ameliorate the Ongoing Opioid Epidemic

Polypharmacy is a common phenomenon among adults using opioids, which may influence the frequency, severity, and complexity of drug–drug interactions (DDIs) experienced. Clinicians must be able to easily identify and resolve DDIs since opioid-related DDIs are common and can be life-threatening. Given that clinicians often rely on technological aids—such as clinical decision support systems (CDSS) and drug interaction software—to identify and resolve DDIs in patients with complex drug regimens, this narrative review provides an appraisal of the performance of existing technologies. Opioid-specific CDSS have several system- and content-related limitations that need to be overcome. Specifically, we found that these CDSS often analyze DDIs in a pairwise manner, do not account for relevant pharmacogenomic results, and do not integrate well with electronic health records. In the context of polypharmacy, existing systems may encourage inadvertent serious alert dismissal due to the generation of multiple incoherent alerts. Future technological systems should minimize alert fatigue, limit manual input, allow for simultaneous multidrug interaction assessments, incorporate pharmacogenomic data, conduct iterative risk simulations, and integrate seamlessly with normal workflow.

[Association Suvorexant and Ramelteon Use with the Risk of Falling: A Retrospective Case-control Study]

Sedative hypnotics are among the classes of drugs reported to influence falls. However, the effects of the sedative hypnotic drugs, suvorexant and ramelteon, on falls are not well known. Therefore, we conducted this retrospective case-control study to examine the association of the use of these two sedative hypnotics with the risk of falls. Conducted at the Sapporo Medical University Hospital in Japan, our study included 360 patients with fall incidents and 819 randomly selected control patients. Patients in the fall group were significantly older with a lower body mass index, and had a history of falls, disabilities in activities of daily living, cognitive impairment, and delirium. Monovariate analysis revealed that patients in the fall group frequently used ramelteon [odds ratio (OR) 2.38, 95% confidence interval (CI): 1.49-3.81, p<0.001], but rarely used suvorexant (OR 0.66, 95% CI: 0.29-1.39, p=0.317), compared with control patients. Furthermore, multivariate analysis revealed that ramelteon use did not increase the risk of falls (adjusted OR 1.43, 95% CI: 0.82-2.48, p=0.207), whereas suvorexant use significantly decreased the risk of falls (adjusted OR 0.32, 95% CI: 0.13-0.76, p=0.009). Although ramelteon tends to be used in patients at a high risk of falls, it may not increase the risk of falls. In contrast, the use of suvorexant may reduce the risk of falls.

Predictors of CNS-Active Medication Use and Polypharmacy Among Homebound Older Adults With Depression

OBJECTIVE

The authors assessed central nervous system (CNS) polypharmacy among low-income, racially diverse homebound older adults with depression (N=277) and its associations with the participants' ratings of depressive symptoms and pain.

METHODS

CNS-active and other psychotropic and analgesic medications intake was collected from patients' medication containers. Depressive symptoms were assessed with the 24-item Hamilton Depression Rating Scale, and pain intensity was measured on an 11-point numerical rating scale. Covariates were disability (World Health Organization Disability Assessment Schedule 2.0) and perceived social support (Multidimensional Scale of Perceived Social Support).

RESULTS

Of the patients, 16% engaged in CNS polypharmacy, taking three or more CNS-active medications. Of these, 69%, 69%, and 89% were using selective serotonin reuptake inhibitors, benzodiazepines, and opioids, respectively. Higher pain intensity ratings were associated with CNS polypharmacy. Benzodiazepine users were more likely than nonusers to use opioids.

CONCLUSIONS

Medication reviews and improved access to evidence-based psychotherapeutic treatments are needed for these older individuals with depression.

Pain Management for the Otolaryngologist: Overview of Perioperative Analgesia and Introduction to Opioids

Nearly 50,000 US adults experience opioid-overdose deaths annually and 1.7 million experience a substance use disorder from prescription opioids. Hence, understanding analgesia strategies is of utmost importance. A pre-operative analgesic plan can consist of a brief conversation between the surgeon, patient, and anesthesiologist in an uncomplicated case or range all the way to an involved, multidisciplinary plan for a chronic pain patient. Over the past several decades, there have been myriad studies examining perioperative analgesic regimens for otolaryngologic procedures, many of which have demonstrated the efficacy of nonopioid analgesics.

Treatment Effectiveness and Medication Use Reduction for Older Adults in Interdisciplinary Pain Rehabilitation

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.

Special High-Risk Populations in Dentistry: The Adolescent Patient, the Elderly Patient, and the Woman of Childbearing Age

Comprehensive and compassionate treatment of vulnerable patients is an important service to the community, although dental treatment of special populations can represent a challenge. The dental provider must be able to recognize the issues surrounding substance use and abuse, coordinate care with medical providers, and build a trusting provider-patient relationship to achieve success. Open conversations regarding expectations of pain, and the risks, benefits, and alternatives to opioids are important aspects of the best care of these patients.

The Benefits of T'ai Chi for Older Adults with Chronic Back Pain: A Qualitative Study

Objective: To determine the perceived benefits of t'ai chi in older adults with chronic low-back pain (cLBP). Design: A qualitative analysis from a randomized controlled feasibility trial. Subjects: Eighteen participants (65+ years old) with cLBP of at least moderate intensity. Intervention: A 36-week intervention beginning with twice weekly classes for 12 weeks, weekly classes for 6 weeks, biweekly classes for 6 weeks, and monthly classes for 12 weeks. Participants were asked to practice at home on nonclass days and videos were provided to assist in that process. Outcome Measures: Participants in the focus groups were asked to provide feedback on their experiences with the study as well as the benefits of their t'ai chi practice. We used demographic and class attendance data to describe the sample. Results: Regarding the benefits of t'ai chi practice, five major themes were identified: functional benefits, pain reduction/pain relief, psychospiritual benefits, the importance of social support in learning t'ai chi, and the integration of t'ai chi into daily activities. The most common functional benefits were improvements in balance, flexibility, leg strength, and posture. Some reported pain reduction or pain relief, but others did not. Increased relaxation, mindfulness, and a sense of connectedness were subthemes that emerged from psychospiritual benefits. Social support benefits included motivation to attend class and group support while learning a new skill. Finally, improved body awareness allowed participants to integrate t'ai chi skills into their daily activities. Conclusions: This qualitative analysis demonstrates the multifaceted benefits of t'ai chi for older adults living with cLBP.

Psychotropic and Opioid-Based Medication Use among Economically Disadvantaged African-American Older Adults

African-American older adults, particularly those who live in economically deprived areas, are less likely to receive pain and psychotropic medications, compared to Whites. This study explored the link between social, behavioral, and health correlates of pain and psychotropic medication use in a sample of economically disadvantaged African-American older adults. This community-based study recruited 740 African-American older adults who were 55+ yeas-old in economically disadvantaged areas of South Los Angeles. Opioid-based and psychotropic medications were the outcome variables. Gender, age, living arrangement, socioeconomic status (educational attainment and financial strain), continuity of medical care, health management organization membership, sleeping disorder/insomnia, arthritis, back pain, pain severity, self-rated health, depressive symptoms, and major chronic conditions were the explanatory variables. Logistic regression was used for data analyses. Arthritis, back pain, severe pain, and poor self-rated health were associated with opioid-based medications. Pain severity and depressive symptoms were correlated with psychotropic medication. Among African-American older adults, arthritis, back pain, poor self-rated health, and severe pain increase the chance of opioid-based and psychotropic medication. Future research should test factors that can reduce inappropriate and appropriate use and prescription of opioid-based and psychotropic medication among economically disadvantaged African-American older adults.

Trends, Patient and Prescriber Characteristics in Gabapentinoid Use in a Sample of United States Ambulatory Care Visits from 2003 to 2016

Increasing gabapentinoid use has raised concerns of misuse and abuse in the United States (US). Little is known about the characteristics of gabapentinoid use in general clinical practice over time. This cross-sectional study used data from the National Ambulatory Medical Care Survey. We examined the trends of patient and prescriber characteristics and the diagnoses associated with US ambulatory care visits involving gabapentinoids for adult visits from 2003 to 2016. Using multivariable logistic regression, we estimated the adjusted proportion of gabapentinoid-involved visits among all visits and tested for trend significance. Among the weighted estimate of 260.1 million gabapentinoid-involved visits (aged 18–64 years: 61.8%; female: 61.9%; white: 85.5%), the adjusted annual proportion of gabapentinoid-involved visits nearly quadrupled from 2003 to 2016 (9.1 to 34.9 per 1000 visits; P_trend < 0.0001), driven mainly by gabapentin. Nearly half had concurrent use with opioids (32.9%) or benzodiazepines (15.3%). Primary care physicians (45.8%), neurologists (8.2%), surgeons (6.2%), and psychiatrists (4.8%) prescribed two-thirds of the gabapentinoids. Most (96.6%) of the gabapentinoid visits did not have an approved indication for gabapentinoids among the first three diagnoses. Among US ambulatory care visits from 2003 to 2016, gabapentinoid use increased substantially, commonly prescribed by primary care physicians.

Concurrent Use of Opioids with Other Central Nervous System-Active Medications Among Older Adults

The primary objective was to determine the prevalence and characteristics of older adults concurrently using opioids and other central nervous system (CNS)-active medications, and the specialties of providers who ordered the medications. A secondary objective was to document medication-related adverse effects associated with such concurrent drug use. Study populations were identified as older adults aged ≥65 years with 1 year continuous medical and drug plan enrollment during 2017 and opioid use of ≥2 prescriptions for ≥15 days' supply. CNS-active medications included benzodiazepines, non-benzodiazepine hypnotics, muscle relaxants, antipsychotics, and gabapentinoids. Provider specialties were identified from the National Provider Identification database. Characteristics associated with opioids only, opioids plus 1, and opioids plus ≥2 additional CNS-active medications were determined using multinomial logistic regression. Outcome measures during 2017 included injurious falls/fractures and ≥3 emergency room (ER) visits. Among eligible insureds (N = 209,947), 57% used opioids only, 28% used opioids plus 1 additional CNS medication, and 15% used ≥2 additional medications. About 60% of opioids and other concurrent CNS medications were prescribed by the same provider, generally a primary care provider. Benzodiazepines and gabapentinoids were most often used concurrently with opioids. Health status, insomnia, anxiety, depression, and low back pain had the strongest associations with concurrent medication use. Overall, concurrent use with ≥2 CNS medications increased the likelihood of injurious falls/fractures or ≥3 ER visits in this population by about 18% and 21%, respectively. Both patients and providers may benefit from an awareness of adverse outcomes associated with concurrent opioid and other CNS-active medication use.

Self-Reported Prescription Drug Use for Pain and for Sleep and Incident Frailty

OBJECTIVES

We aimed to estimate incident frailty risks of prescription drugs for pain and for sleep in older US adults.

DESIGN

Longitudinal cohort.

SETTING

Health and Retirement Study.

PARTICIPANTS

Community-living respondents aged 65 years and older, excluding individuals who received recent treatment for cancer (N = 14 208). Our longitudinal analysis sample included respondents who were not frail at baseline and had at least one follow-up wave with complete information on both prescription drug use and frailty, or date of death (N = 7201).

MEASUREMENTS

Prescription drug use for pain and sleep, sociodemographics, other drug and substance use, and Burden frailty model components. Multivariable drug use stratified hazard models with death as a competing risk evaluated frailty risks associated with co-use and single use of prescription drugs for pain and for sleep.

RESULTS

Proportions endorsing prescription drug use were 22.1% for pain only, 6.8% for sleep only, and 7.7% for both indications. Burden frailty model prevalence was 41.0% and varied significantly by drug use. Among non-frail individuals at baseline, proportions endorsing prescription drug use were 14.9%, 5.6%, and 2.2% for the three indications. Prescription drug use was associated with increased risk of frailty (co-use adjusted subhazard ratio [sHR] = 1.95; 95% confidence interval [CI] = 1.6-2.4; pain only adjusted sHR = 1.58; CI = 1.4-1.8; sleep-only adjusted sHR = 1.35; CI = 1.1-1.6; no use = reference group). Cumulative incidence of frailty over 8 years for the four groups was 60.6%, 50.9%, 45.8%, and 34.1%. Sensitivity analyses controlling for chronic diseases associated with persistent pain resulted in minor risk reductions.

CONCLUSION

Prescription pain and sleep drug use is significantly associated with increased incidence of frailty. Research to estimate effects of pain and sleep indications and of drug class-specific dosage and duration on incident frailty is indicated before advocating deprescribing based on these findings. J Am Geriatr Soc 67:2474-2481, 2019.

An examination of opioid prescription for Medicare Part D patients among family practice prescribers

BACKGROUND

In the USA, opioid overdose accounted for more than 60% of drug overdose deaths in 2015. Of these deaths, 40% were due to use of prescription opioids.

OBJECTIVES

The aims of the study were to (i) study family medicine physician opioid-prescribing rate and duration of prescription, (ii) study the distribution of prescription by medication potency, (iii) study opioid-prescribing trends in health care shortage areas and (iv) study the association between extreme high prescribing rates and medical board discipline.

METHODS

This is a retrospective cross-sectional study of the 2015 Medicare Part D claim data.

RESULTS

Family practitioners have opioid prescription rates (5.6%) similar to medical subspecialists (6.0%), but lower than pain specialists (53.2%) and surgical specialists (36.6%). Family practitioners have an average opioid prescription duration (21.5 days) similar to medical subspecialists (23.1 days) and pain specialists (27.1 days), but longer than surgical specialists (8.9 days). Family practitioners tend to prescribe lower potency opioids. Family practitioners in rural health care shortage areas have a higher opioid prescription rate than other family practitioners (6.5% versus 5.6%). Among the 52 family practitioners who prescribed opioids as frequently as pain specialists, 26 of the 52 (50%) were certified in pain management or worked with a partner certified in pain management. Of the other 26 family practitioners, 3 (12%) had medical board disciplinary actions regarding opioid prescription.

CONCLUSIONS

While monitoring extreme prescribers is important and needs to be continued, the next step in policies to reduce prescription opioids will require systemic change, especially providing support for family practitioners in rural health care shortage areas.

Psychoactive medication use among older community-dwelling Americans

BACKGROUND

Falls are a common and serious health issue among older Americans. A common fall risk factor is the use of psychoactive medications. There is limited recent information on the national prevalence of psychoactive medication use among older Americans.

OBJECTIVES

To estimate the prevalence of psychoactive medication use among community-dwelling older Americans and compare it with previous estimates from 1996.

METHODS

The data source was the 2013 Cost and Use Data files combining Medicare claims data and survey data from the Medicare Current Beneficiary Survey, an in-person nationally representative survey of Medicare beneficiaries. Participants were included if they were 65 years of age and older, lived in the community, and had a complete year of prescription use data. Medication use was examined for 7 classes of psychoactive medications categorized by the 2015 American Geriatric Society Beers criteria as increasing fall risk. These include opioids, benzodiazepines, selective serotonin reuptake inhibitors, anticonvulsants, nonbenzodiazepine sedative hypnotics, antipsychotics, and tricyclic antidepressants. Data on participant demographic factors were also collected.

RESULTS

Among the 6959 community-dwelling older adults studied, representing 33,268,104 community-dwelling Medicare beneficiaries, 53.3% used at least 1 psychoactive medication linked to falls in 2013. The most frequently used medication classes were opioids (34.9%), benzodiazepines (15.4%), selective serotonin reuptake inhibitors (14.3%), and anticonvulsants (13.3%). These estimates are considerably higher for all classes except tricyclic antidepressants than previous reports from 1996 that used the same data source. Among most psychoactive medication classes observed, women had higher usage than men.

CONCLUSION

More than half of all older Americans used at least 1 psychoactive medication in 2013. Health care providers, including pharmacists, play a vital role in managing older adults' exposure to psychoactive medications. Medication management can optimize health and reduce older adult falls.

High-risk opioid prescribing trends in the outpatient setting prior to issuance of federal guidance

Co-prescription of opioid and benzodiazepine products increases the risk of overdose-related mortality four-fold due to respiratory depression. Accordingly, prevention of high-risk opioid prescribing (HROP) has become a focus over the past two decades and was the subject of a black-box warning (BBW) issued by the U.S. Food and Drug Administration (FDA) on August 31, 2016. Because older patients are at increased risk for these outcomes, we compared rates of HROP for older (aged ≥65 years) and younger (aged 18–64 years) adults using a repeated cross-sectional cohort design. Data from the National Ambulatory Medical Care Survey of U.S. office-based physician visits were accessed for 2006–2016 August. From 2006 to 2016, the opioid-prescribing rate increased by 40% among those aged 18–64 years and by 54% among those aged ≥65 years. From 2012–2013 to 2014–2016, the HROP rate, expressed as a proportion of all opioid-prescribing visits, increased to 26.6% among those aged 18–64 years but declined to 21.0% among those aged ≥65 years, primarily because of changes for patients aged ≥75 years. Prior to the FDA-issued BBW, the HROP prescribing rate trended upward for all adults, except in 2014–2016 when it began to decline among older adults.

•

From 2006–07 to 2014–16, opioid prescribing rates increased among U.S. adults.

•

Opioid use decreased for adults aged ≥75 in 2014–16 but grew for those aged 65–74 years.

•

High-risk opioid-prescribing (HROP) for older adults began to decline in 2014–16.

•

From 2012–13 to 2014–16, HROP continued to increase for those aged 18–64 years.

Patterns in Outpatient Benzodiazepine Prescribing in the United States

IMPORTANCE

Benzodiazepines are implicated in a growing number of overdose-related deaths.

OBJECTIVES

To quantify patterns in outpatient benzodiazepine prescribing and to compare them across specialties and indications.

DESIGN, SETTING, AND PARTICIPANTS

This serial cross-sectional study (January 1, 2003, through December 31, 2015) used nationally representative National Ambulatory Medical Care Survey data. The yearly population-based sample of outpatient visits among adults, ranging from 20 884 visits in 2003 (representing 737 million visits) to 24 273 visits in 2015 (representing 841 million visits) was analyzed. Prescribing patterns were examined by specialty and indication and used to calculate the annual coprescribing rate of benzodiazepines with other sedating medications. Data were analyzed from July 1, 2017, through November 30, 2018.

MAIN OUTCOMES AND MEASURES

Annual benzodiazepine visit rate.

RESULTS

Among the 386 457 ambulatory care visits from 2003 through 2015, a total of 919 benzodiazepine visits occurred in 2003 and 1672 in 2015, nationally representing 27.6 million and 62.6 million visits, respectively. The benzodiazepine visit rate doubled from 3.8% (95% CI, 3.2%-4.4%) to 7.4% (95% CI, 6.4%-8.6%; P < .001) of visits. Visits to primary care physicians accounted for approximately half of all benzodiazepine visits (52.3% [95% CI, 50.0%-54.6%]). The benzodiazepine visit rate did not change among visits to psychiatrists (29.6% [95% CI, 23.3%-36.7%] in 2003 to 30.2% [95% CI, 25.6%-35.2%] in 2015; P = .90), but increased among all other physicians, including primary care physicians (3.6% [95% CI, 2.9%-4.4%] to 7.5% [95% CI, 6.0%-9.5%]; P < .001). The benzodiazepine visit rate increased slightly for anxiety and depression (26.6% [95% CI, 22.6%-31.0%] to 33.5% [95% CI, 28.8%-38.6%]; P = .003) and neurologic conditions (6.8% [95% CI, 4.8%-9.5%] to 8.7% [95% CI, 6.2%-12.1%]; P < .001), but more so for back and/or chronic pain (3.6% [95% CI, 2.6%-4.9%] to 8.5% [95% CI, 6.0%-11.9%]; P < .001) and other conditions (1.8% [95% CI, 1.4%-2.2%] to 4.4% [95% CI, 3.7%-5.2%]; P < .001); use did not change for insomnia (26.9% [95% CI, 19.3%-36.0%] to 25.6% [95% CI, 15.3%-39.6%]; P = .72). The coprescribing rate of benzodiazepines with opioids quadrupled from 0.5% (95% CI, 0.3%-0.7%) in 2003 to 2.0% (95% CI, 1.4%-2.7%) in 2015 (P < .001); the coprescribing rate with other sedating medications doubled from 0.7% (95% CI, 0.5%-0.9%) to 1.5% (95% CI, 1.1%-1.9%) (P < .001).

CONCLUSIONS AND RELEVANCE

The outpatient use of benzodiazepines has increased substantially. In light of increasing rates of overdose deaths involving benzodiazepines, understanding and addressing prescribing patterns may help curb the growing use of benzodiazepines.

A hidden aspect of the U.S. opioid crisis: Rise in first-time treatment admissions for older adults with opioid use disorder

BACKGROUND

Older adults with opioid use disorder (OUD) are a medically complex population. The current study evaluated trends in older adults seeking treatment for OUD, with a focus on primary heroin versus prescription opioid use. This study also compared older adults with OUD to the younger OUD population on demographics and drug use behaviors.

METHODS

Publicly available data from state-certified addiction treatment centers were collected via the Treatment Episode Data Set - Admissions (TEDS-A) between 2004-2015. This study utilized Joinpoint Regression to conduct a cross-sectional, longitudinal analysis of trends in first-time treatment admissions for OUD in adults 55 and older (older adults; n = 400,421) versus adults under the age of 55 (n = 7,795,839). Given the rapid increase in older adults seeking treatment for OUD between 2013-2015, secondary outcomes include changes in demographics and drug use between 2012 (as a baseline year) and 2015.

RESULTS

The proportion of older adults seeking treatment for OUD rose steadily between 2004-2013 (41.2% increase; p-trend = 0.046), then rapidly between 2013-2015 (53.5% increase; p-trend = 0.009). The proportion of older adults with primary heroin use more than doubled between 2012-2015 (p < 0.001); these individuals were increasingly male (p < 0.001), African American (p < 0.001), and using via the intranasal route of administration (p < 0.001).

CONCLUSIONS

There has been a recent surge in older adults seeking treatment for OUD, particularly those with primary heroin use. Specialized treatment options for this population are critically needed, and capacity for tailored elder care OUD treatments will need to increase if these trends continue.

Update on Medication Use Quality and Safety in Older Adults, 2017

Improving the quality of medication use and medication safety in older adults is an important public health priority and is of paramount importance for clinicians who care for them. We selected four important articles from 2017 that address these issues to annotate and critique, and we discuss the broader implications for optimizing medication use. A longer list of articles is given in an online appendix. The first study provides national data on the prevalence of central nervous system-active medication polypharmacy in older adults and how this has changed over a 9-year period (2004-2013). The second study characterizes prevalence of and factors associated with nonadherence to antiepileptic drugs in 36,912 older adults with epilepsy, with an emphasis on minorities. The third study describes the extent of antibiotic use in residents of 381 long-term care facilities (LTCF) in British Columbia, Canada, from 2007 to 2014. Finally, we discuss a meta-analysis of 42 studies that evaluated the prevalence of hospital admissions caused by adverse drug reactions in older adults. This article is intended to provide a narrative review of important publications on medication use quality and safety for clinicians and researchers committed to optimizing medication use in older adults. J Am Geriatr Soc 66:2254-2258, 2018.

Changes in Australian Early-Career General Practitioners' Benzodiazepine Prescribing: a Longitudinal Analysis

BACKGROUND

Australian and international guidelines recommend benzodiazepines and related drugs (hereafter "benzodiazepines") as second-line, short-term medications only. Most benzodiazepines are prescribed by general practitioners (GPs; family physicians). Australian GP registrars ("trainees" or "residents" participating in a post-hospital training, apprenticeship-like, practice-based vocational training program), like senior GPs, prescribe benzodiazepines at high rates. Education within a training program, and experience in general practice, would be expected to reduce benzodiazepine prescribing.

OBJECTIVE

To establish if registrars' prescribing of benzodiazepines decreases with time within a GP training program DESIGN: Longitudinal analysis from the Registrar Clinical Encounters in Training multi-site cohort study PARTICIPANTS: Registrars of five of Australia's 17 Regional Training Providers. Analyses were restricted to patients ≥ 16 years.

MAIN MEASURES

The main outcome factor was prescription of a benzodiazepine. Conditional logistic regression was used, with registrar included as a fixed effect, to assess within-registrar changes in benzodiazepine-prescribing rates. The "time" predictor variable was "training term" (6-month duration Terms 1-4). To contextualize these "within-registrar" changes, a mixed effects logistic regression model was used, including a random effect for registrar, to assess within-program changes in benzodiazepine-prescribing rates over time. The "time" predictor variable was "year" (2010-2015).

KEY RESULTS

Over 12 terms of data collection, 2010-2015, 1161 registrars (response rate 96%) provided data on 136,809 face-to-face office-based consultations. Two thousand six hundred thirty-two benzodiazepines were prescribed (for 1.2% of all problems managed). In the multivariable model, there was a significant reduction in within-program benzodiazepine prescribing over time (year) (p = < 0.001, OR = 0.94, CI = 0.90, 0.97). However, there was no significant change in 'within-registrar' prescribing over time (registrar Term) (p = 0.92, OR = 1.00 [95% CI = 0.94-1.06]).

CONCLUSIONS

Despite a welcome temporal trend for reductions in overall benzodiazepine prescribing from 2010 to 2015, there is still room for improvement and our findings suggest a lack of effect of specific GP vocational training program education and, thus, an opportunity for targeted education.

Examining patterns in opioid prescribing for non-cancer-related pain in Wales: preliminary data from a retrospective cross-sectional study using large datasets

Objectives

To examine trends in strong opioid prescribing in a primary care population in Wales and identify if factors such as age, deprivation and recorded diagnosis of depression or anxiety may have influenced any changes noted.

Design

Trend, cross-sectional and longitudinal analyses of routine data from the Primary Care General Practice database and accessed via the Secure Anonymised Information Linkage (SAIL) databank.

Setting

A total of 345 Primary Care practices in Wales.

Participants

Anonymised records of 1,223,503 people aged 18 or over, receiving at least one opioid prescription between 1 January 2005 and 31 December 2015 were analysed. People with a cancer diagnosis (10.1%) were excluded from the detailed analysis.

Results

During the study period, 26,180,200 opioid prescriptions were issued to 1,223,503 individuals (55.9% female, 89.9% non-cancer diagnoses). The greatest increase in annual prescribing was in the 18-24 age group (10,470%), from 0.08 to 8.3 prescriptions/1000 population, although the 85+ age group had the highest prescribing rates across the study period (from 149.9 to 288.5 prescriptions/1000 population). The number of people with recorded diagnoses of depression or anxiety and prescribed strong opioids increased from 1.2 to 5.1 people/1000 population (328%). The increase was 366.9% in areas of highest deprivation compared to 310.3 in the least. Areas of greatest deprivation had more than twice the rate of strong opioid prescribing than the least deprived areas of Wales.

Conclusion

The study highlights a large increase in strong opioid prescribing for non-cancer pain, in Wales between 2005 and 2015. Population groups of interest include the youngest and oldest adult age groups and people with depression or anxiety particularly if living in the most deprived communities. Based on this evidence, development of a Welsh national guidance on safe and rational prescribing of opioids in chronic pain would be advisable to prevent further escalation of these medicines.

Summary points

This is the first large-scale, observational study of opioid prescribing in Wales.Over 1 million individual, anonymised medical records have been searched in order to develop the study cohort, thus reducing recall bias.Diagnosis and intervention coding in the Primary Care General Practice database is limited at input and may lead to under-reporting of diagnoses.There are limitations to the data available through the Secure Anonymised Information Linkage databank because anonymously linked dispensing data (what people collect from the pharmacy) are not currently available. Consequently, the results presented here could be seen as an 'intention to treat' and may under- or overestimate what people in Wales actually consume.

Medication Profiles of Patients with Cognitive Impairment and High Anticholinergic Burden

BACKGROUND

Drugs with anticholinergic properties are considered potentially inappropriate in patients with cognitive impairment because harms-including delirium, falls, and fractures-may outweigh benefits.

OBJECTIVE

To highlight opportunities to improve clinical decision making and care for patients with cognitive impairment and multiple chronic conditions, we identified distinct subgroups of patients with mild cognitive impairment (MCI) and dementia who had high cumulative anticholinergic burden and specific patterns of anticholinergic use.

PATIENTS AND METHODS

We conducted a retrospective cohort study in a not-for-profit, integrated delivery system. Participants included community-dwelling adults aged 65 years and older (n = 13,627) with MCI or dementia and at least two other chronic diseases. We calculated the Anticholinergic Cognitive Burden (ACB) score for each participant from pharmacy and electronic health record (EHR) data. Among individuals with a mean 12-month ACB score ≥ 2, we used agglomerative hierarchical clustering to identify groups or clusters of individuals with similar anticholinergic prescription patterns.

RESULTS

Twenty-four percent (3257 participants) had high anticholinergic burden, defined as an ACB score ≥ 2. Clinically meaningful clusters based upon anchoring medications or drug classes included a cluster of cardiovascular medications (n = 1497; 46%); two clusters of antidepressant medications (n = 633; 20%); and a cluster based on use of bladder antimuscarinics (n = 431; 13%). Several clusters comprised multiple central nervous system (CNS)-active drugs.

CONCLUSIONS

Cardiovascular and CNS-active medications comprise a substantial portion of anticholinergic burden in people with cognitive impairment and multiple chronic conditions. Antidepressants were highly prevalent. Clinical profiles elucidated by these clusters of anticholinergic medications can inform targeted approaches to care.