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Gholamrezaei A, Magee MR, McNeilage AG, Dwyer L, Sim A, Ferreira ML, Darnall BD, Brake T, Aggarwal A, Craigie M, Hollington I, Glare P, Ashton-James CE. A digital health intervention to support patients with chronic pain during prescription opioid tapering: a pilot randomised controlled trial. Pain Rep 2024; 9:e1128. [PMID: 38352024 PMCID: PMC10863948 DOI: 10.1097/pr9.0000000000001128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 09/02/2023] [Accepted: 12/03/2023] [Indexed: 02/16/2024] Open
Abstract
Introduction Recent changes in opioid prescribing guidelines have led to an increasing number of patients with chronic pain being recommended to taper. However, opioid tapering can be challenging, and many patients require support. Objectives We evaluated the feasibility, acceptability, and potential efficacy of a codesigned digital health intervention to support patients with chronic pain during voluntary prescription opioid tapering. Methods In a pilot randomised controlled trial, participants received a psychoeducational video and 28 days of text messages (2 SMS/day) in addition to their usual care (intervention) or usual care alone (control). The feasibility, acceptability, and potential efficacy of the intervention were evaluated. The primary outcome was opioid tapering self-efficacy. Secondary outcomes were pain intensity and interference, anxiety and depression symptom severity, pain catastrophising, and pain self-efficacy. Results Of 28 randomised participants, 26 completed the study (13 per group). Text message delivery was high (99.2%), but fidelity of video delivery was low (57.1%). Most participants rated the messages as useful, supportive, encouraging, and engaging; 78.5% would recommend the intervention to others; and 64.2% desired a longer intervention period. Tapering self-efficacy (Cohen d = 0.74) and pain self-efficacy (d = 0.41) were higher, and pain intensity (d = 0.65) and affective interference (d = 0.45) were lower in the intervention group at week 4. Conclusion First evidence supports the feasibility, acceptability, and potentially efficacy of a psychoeducational video and SMS text messaging intervention to support patients with chronic pain during voluntary prescription opioid tapering. Definitive trials with longer intervention duration are warranted.
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Affiliation(s)
- Ali Gholamrezaei
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Michael R. Magee
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Amy G. McNeilage
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Leah Dwyer
- Consumer Advisory Group, Painaustralia, Deakin, Victoria, Australia
| | - Alison Sim
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Manuela L. Ferreira
- Sydney Musculoskeletal Health, Kolling Institute, School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Beth D. Darnall
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Timothy Brake
- Pain Management Centre, Royal Prince Alfred Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Arun Aggarwal
- Pain Management Centre, Royal Prince Alfred Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Meredith Craigie
- Pain Management Unit, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia
| | - Irina Hollington
- Pain Management Unit, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia
| | - Paul Glare
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Claire E. Ashton-James
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, New South Wales, Australia
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2
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Alderson S, Ivers NM, Foy R. The opioid prescribing problem: an opportunity to embed rigorous evaluation within initiatives to improve population healthcare. BMJ Qual Saf 2023; 32:617-619. [PMID: 37369577 DOI: 10.1136/bmjqs-2023-016239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 06/29/2023]
Affiliation(s)
- Sarah Alderson
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Noah Michael Ivers
- Family and Community Medicine, Women's College Hospital-University of Toronto, Toronto, Ontario, Canada
| | - Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Gholamrezaei A, Magee MR, McNeilage AG, Dwyer L, Jafari H, Sim AM, Ferreira ML, Darnall BD, Glare P, Ashton-James CE. Text messaging intervention to support patients with chronic pain during prescription opioid tapering: protocol for a double-blind randomised controlled trial. BMJ Open 2023; 13:e073297. [PMID: 37879692 PMCID: PMC10603486 DOI: 10.1136/bmjopen-2023-073297] [Citation(s) in RCA: 2] [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: 03/01/2023] [Accepted: 10/03/2023] [Indexed: 10/27/2023] Open
Abstract
INTRODUCTION Increases in pain and interference with quality of life is a common concern among people with chronic non-cancer pain (CNCP) who are tapering opioid medications. Research indicates that access to social and psychological support for pain self-management may help people to reduce their opioid dose without increasing pain and interference. This study evaluates the efficacy of a text messaging intervention designed to provide people with CNCP with social and psychological support for pain self-management while tapering long-term opioid therapy (LTOT) under the guidance of their prescriber. METHODS AND ANALYSIS A double-blind randomised controlled trial will be conducted. Patients with CNCP (n=74) who are tapering LTOT will be enrolled from across Australia. Participants will continue with their usual care while tapering LTOT under the supervision of their prescribing physician. They will randomly receive either a psychoeducational video and supportive text messaging (two Short Message Service (SMS) per day) for 12 weeks or the video only. The primary outcome is the pain intensity and interference assessed by the Pain, Enjoyment of Life and General Activity scale. Secondary outcomes include mood, self-efficacy, pain cognitions, opioid dose reduction, withdrawal symptoms, and acceptability, feasibility, and safety of the intervention. Participants will complete questionnaires at baseline and then every 4 weeks for 12 weeks and will be interviewed at week 12. This trial will provide evidence for the efficacy of a text messaging intervention to support patients with CNCP who are tapering LTOT. If proven to be efficacious and safe, this low-cost intervention can be implemented at scale. ETHICS AND DISSEMINATION The study protocol was reviewed and approved by the Northern Sydney Local Health District (Australia). Study results will be published in peer-reviewed journals and presented at scientific and professional meetings. TRIAL REGISTRATION NUMBER ACTRN12622001423707.
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Affiliation(s)
- Ali Gholamrezaei
- Pain Management Research Institute, Kolling Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael Reece Magee
- Pain Management Research Institute, Kolling Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Amy Gray McNeilage
- Pain Management Research Institute, Kolling Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Leah Dwyer
- Consumer Advisory Group, Painaustralia, Deakin, Victoria, Australia
| | - Hassan Jafari
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Alison Michelle Sim
- Pain Management Research Institute, Kolling Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Manuela L Ferreira
- Sydney Musculoskeletal Health, Kolling Institute, The University of Sydney, Saint Leonards, New South Wales, Australia
| | - Beth D Darnall
- Department of Anaesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Paul Glare
- Pain Management Research Institute, Kolling Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Claire Elizabeth Ashton-James
- Pain Management Research Institute, Kolling Institute, The University of Sydney, Sydney, New South Wales, Australia
- Pain Management Research Institute, Kolling Institute, The University of Sydney, Sydney, New South Wales, Australia
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4
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Haas R, Gorelik A, Busija L, O’Connor D, Pearce C, Mazza D, Buchbinder R. Prevalence and characteristics of musculoskeletal complaints in primary care: an analysis from the population level and analysis reporting (POLAR) database. BMC PRIMARY CARE 2023; 24:40. [PMID: 36739379 PMCID: PMC9898983 DOI: 10.1186/s12875-023-01976-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 01/06/2023] [Indexed: 02/06/2023]
Abstract
BACKGROUND Electronic health record datasets have been used to determine the prevalence of musculoskeletal complaints in general practice but not to examine the associated characteristics and healthcare utilisation at the primary care level. AIM To describe the prevalence and characteristics of patients presenting to general practitioners with musculoskeletal complaints. DESIGN AND SETTING A five-year analysis within three Primary Health Networks (PHNs) in Victoria, Australia. METHOD We included patients with at least one face-to-face consultation 2014 to 2018 inclusive and a low back (≥ 18 years), and/or neck, shoulder or knee (≥ 45 years) complaint determined by SNOMED codes derived from diagnostic text within the medical record. We determined prevalence, socio-demographic characteristics and diagnostic codes for patients with an eligible diagnosis; and number of consultations within one year of diagnosis. RESULTS 324,793/1,294,021 (25%) presented with at least one musculoskeletal diagnosis, of whom 41% (n = 133,279) fulfilled our inclusion criteria. There were slightly more females (n = 73,428, 55%), two-thirds (n = 88,043) were of working age (18-64 years) and 83,816 (63%) had at least one comorbidity. Over half had a low back diagnosis (n = 76,504, 57%) followed by knee (n = 33,438, 25%), shoulder (n = 26,335, 20%) and neck (n = 14,492, 11%). Most codes included 'pain' and/or 'ache' (low back: 58%, neck: 41%, shoulder: 32%, knee 26%). Median (IQR) all-cause consultations per patient within one year of diagnosis was 7 (4-12). CONCLUSION The burden of MSK complaints at the primary care level is high as evidenced by the prevalence of people with musculoskeletal complaints presenting to a general practitioner, the preponderance of comorbidities and the numerous consultations per year. Identification and evaluation of strategies to reduce this burden are needed.
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Affiliation(s)
- Romi Haas
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia. .,Cabrini Health, Malvern, VIC, 3144, Australia.
| | - Alexandra Gorelik
- grid.1002.30000 0004 1936 7857School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004 Australia ,Cabrini Health, Malvern, VIC 3144 Australia
| | - Ljoudmila Busija
- grid.1002.30000 0004 1936 7857School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004 Australia
| | - Denise O’Connor
- grid.1002.30000 0004 1936 7857School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004 Australia ,Cabrini Health, Malvern, VIC 3144 Australia
| | | | - Danielle Mazza
- grid.1002.30000 0004 1936 7857Department of General Practice, Monash University, Notting Hill, VIC 3168 Australia
| | - Rachelle Buchbinder
- grid.1002.30000 0004 1936 7857School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004 Australia ,Cabrini Health, Malvern, VIC 3144 Australia
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Woodman RJ, Horwood C, Kunnel A, Hakendorf P, Mangoni AA. Using electronic admission data to monitor temporal trends in local medication use: Experience from an Australian tertiary teaching hospital. Front Pharmacol 2022; 13:888677. [PMID: 36313311 PMCID: PMC9614045 DOI: 10.3389/fphar.2022.888677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 10/03/2022] [Indexed: 11/13/2022] Open
Abstract
Background and aims: Medication usage varies according to prescribing behavior, professional recommendations, and the introduction of new drugs. Local surveillance of medication usage may be useful for understanding and comparing prescribing practices by healthcare providers, particularly in countries such as Australia that are in the process of enhancing nationwide data linkage programs. We sought to investigate the utility of electronic hospital admission data to investigate local trends in medication use, to determine similarities and differences with other Australian studies, and to identify areas for targeted interventions. Methods: We performed a retrospective longitudinal analysis using combined data from a hospital admissions administrative dataset from a large tertiary teaching hospital in Adelaide, South Australia and a hospital administrative database documenting medication usage matched for the same set of patients. All adult admissions over a 12-year period, between 1 January 2007 and 31st December 2018, were included in the study population. Medications were categorized into 21 pre-defined drug classes of interest according to the ATC code list 2021. Results: Of the 692,522 total admissions, 300,498 (43.4%) had at least one recorded medication. The overall mean number of medications for patients that were medicated increased steadily from a mean (SD) of 5.93 (4.04) in 2007 to 7.21 (4.98) in 2018. Results varied considerably between age groups, with the older groups increasing more rapidly. Increased medication usage was partly due to increased case-complexity with the mean (SD) Charlson comorbidity index increasing from 0.97 (1.66) in 2007-to-2012 to 1.17 (1.72) in 2013-to-2018 for medicated patients. Of the 21 medication classes, 15 increased (p < 0.005), including antithrombotic agents; OR = 1.18 [1.16–1.21], proton pump inhibitors; OR = 1.14 [1.12–1.17], statins; OR = 1.12; [1.09–1.14], and renin-angiotensin system agents; OR = 1.06 [1.04–1.08], whilst 3 decreased (p < 0.005) including anti-inflammatory drugs (OR = 0.55; 99.5% CI = 0.53–0.58), cardiac glycosides (OR = 0.81; 99.5% CI = 0.78–0.86) and opioids (OR = 0.82; 99.5% CI = 0.79–0.83). The mean number of medications for all admissions increased between 2007 and 2011 and then declined until 2018 for each age group, except for the 18-to-35-year-olds. Conclusion: Increased medication use occurred in most age groups between 2007 and 2011 before declining slightly even after accounting for increased comorbidity burden. The use of electronic hospital admission data can assist with monitoring local medication trends and the effects of initiatives to enhance the quality use of medicines in Australia.
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Affiliation(s)
- Richard J. Woodman
- Centre of Epidemiology and Biostatistics, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Chris Horwood
- Department of Clinical Epidemiology, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, SA, Australia
| | - Aline Kunnel
- School of Mathematical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Paul Hakendorf
- Department of Clinical Epidemiology, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, SA, Australia
| | - Arduino A. Mangoni
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
- Department of Clinical Pharmacology, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, SA, Australia
- *Correspondence: Arduino A. Mangoni,
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Rodríguez-Espinosa S, Coloma-Carmona A, Pérez-Carbonell A, Román-Quiles JF, Carballo JL. Differential Experience of Interdose Withdrawal During Long-Term Opioid Therapy and its Association With Patient and Treatment Characteristics: A Latent Class Analysis in Chronic Pain Population. THE JOURNAL OF PAIN 2022; 23:1427-1436. [PMID: 35429674 DOI: 10.1016/j.jpain.2022.03.236] [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: 10/25/2021] [Revised: 02/20/2022] [Accepted: 03/12/2022] [Indexed: 06/14/2023]
Abstract
Opioid withdrawal is characterized by a set of physical and psychological symptoms that depend on both opioid and patient specific characteristics. The present study aims to identify different latent classes of chronic pain patients according to the type of opioid withdrawal symptoms experienced, and to analyze the relationships between the classes and demographic, opioid therapy, psychological and substance use variables. This cross-sectional descriptive study included 391 chronic pain patients on long-term opioid therapy. A Latent Class Analysis (LCA) identified 3 classes (BIC = 7051.89, entropy = .87, LRTs P < .01). The mild withdrawal class showed low probabilities of presenting physical and psychological symptoms, the moderate withdrawal class was characterized by experiencing psychological symptoms, and the severe withdrawal class stood out for high probabilities of presenting both types of symptoms. The classes differed from each other, with higher rates of moderate-severe POUD, opioid misuse, anxiety, depression, and greater pain intensity and interference in more severe withdrawal classes (P < .05). The multinomial logistic regression showed that moderate-severe POUD and anxiety were the strongest variables related to moderate (ORPOUD = 3.34, ORAnxiety = 2.58) and severe withdrawal classes (ORPOUD = 4.26, ORAnxiety = 5.15). Considering that POUD and anxiety were strongly related to a more severe withdrawal syndrome, the inclusion of psychological interventions in pain management seems critical in this population. PERSPECTIVE: Although interdose opioid withdrawal is common in chronic pain patients, this study shows 3 different patterns in its experience (mild, moderate, and severe withdrawal). A more severe withdrawal may result in reduced effectiveness of opioids in relieving pain and increased negative consequences, such as higher risk of POUD. Findings that could help improve chronic pain management.
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Affiliation(s)
- Sara Rodríguez-Espinosa
- Center for Applied Psychology, Miguel Hernández University, Avenida Universidad, s/n, Elche, Spain
| | - Ainhoa Coloma-Carmona
- Center for Applied Psychology, Miguel Hernández University, Avenida Universidad, s/n, Elche, Spain
| | | | | | - José L Carballo
- Center for Applied Psychology, Miguel Hernández University, Avenida Universidad, s/n, Elche, Spain.
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7
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Hopkins RE, Campbell G, Degenhardt L, Lintzeris N, Larance B, Nielsen S, Gisev N. Self-reported challenges obtaining ongoing prescription opioids among Australians with chronic non-cancer pain. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 105:103708. [DOI: 10.1016/j.drugpo.2022.103708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 03/06/2022] [Accepted: 04/19/2022] [Indexed: 11/24/2022]
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8
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Daniels B, Havard A, Myton R, Lee C, Chidwick K. Evaluating the accuracy of data extracted from electronic health records into MedicineInsight, a national Australian general practice database. Int J Popul Data Sci 2022; 7:1713. [PMID: 37650032 PMCID: PMC10464870 DOI: 10.23889/ijpds.v7i1.1713] [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: 10/17/2022] Open
Abstract
Introduction MedicineInsight is a database containing de-identified electronic health records (EHRs) from over 700 Australian general practices. Previous research validated algorithms used to derive medical condition flags in MedicineInsight, but the accuracy of data fields following EHR extractions from clinical practices and data warehouse transformation processes have not been formally validated. Objectives To examine the accuracy of the extraction and transformation of EHR fields for selected demographics, observations, diagnoses, prescriptions, and tests into MedicineInsight. Methods We benchmarked MedicineInsight values against those recorded in original EHRs. Forty-six general practices contributing data to MedicineInsight met our eligibility criteria, eight were randomly selected, and four agreed to participate. We randomly selected 200 patients >18 years of age within each participating practice from MedicineInsight. Trained staff reviewed the original EHRs for the selected patients and recorded data from the relevant fields. We calculated the percentage of agreement (POA) between MedicineInsight and EHR data for all fields; Cohen's Kappa for categorical and intra-class correlation (ICC) for continuous measures; and sensitivity, specificity, and positive and negative predictive values (PPV/NPV) for diagnoses. Results A total of 796 patients were included in our analysis. All demographic characteristics, observations, diagnoses, prescriptions and random pathology test results had excellent (>90%) POA, Kappa, and ICC. POA for most recent pathology/imaging test was moderate (81%, [95% CI: 78% to 84%]). Sensitivity, specificity, PPV, and NPV were excellent (>90%) for all but one of the examined diagnoses which had a poor PPV. Conclusions Overall, our study shows good agreement between the majority of MedicineInsight data and those from original EHRs, suggesting MedicineInsight data extraction and warehousing procedures accurately conserve the data in these key fields. Discrepancies between test data may have arisen due to how data from pathology, radiology and other imaging providers are stored in EHRs and MedicineInsight and this requires further investigation.
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Affiliation(s)
- Benjamin Daniels
- NPS MedicineWise, Level 7 / 418a Elizabeth St, Strawberry Hills, NSW, 2012, Sydney, Australia
- Medicines Policy Research Unit, Centre for Big Data Research in Health, UNSW Sydney, Australia
| | - Alys Havard
- NPS MedicineWise, Level 7 / 418a Elizabeth St, Strawberry Hills, NSW, 2012, Sydney, Australia
- Medicines Policy Research Unit, Centre for Big Data Research in Health, UNSW Sydney, Australia
- National Drug and Alcohol Research Centre, UNSW Sydney, Australia
| | - Rimma Myton
- NPS MedicineWise, Level 7 / 418a Elizabeth St, Strawberry Hills, NSW, 2012, Sydney, Australia
| | - Cynthia Lee
- NPS MedicineWise, Level 7 / 418a Elizabeth St, Strawberry Hills, NSW, 2012, Sydney, Australia
| | - Kendal Chidwick
- NPS MedicineWise, Level 7 / 418a Elizabeth St, Strawberry Hills, NSW, 2012, Sydney, Australia
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9
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Virnes RE, Tiihonen M, Karttunen N, van Poelgeest EP, van der Velde N, Hartikainen S. Opioids and Falls Risk in Older Adults: A Narrative Review. Drugs Aging 2022; 39:199-207. [PMID: 35288864 PMCID: PMC8934763 DOI: 10.1007/s40266-022-00929-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2022] [Indexed: 02/07/2023]
Abstract
Pain treatment is important in older adults but may result in adverse events such as falls. Opioids are effective for nociceptive pain but the evidence for neuropathic pain is weak. Nevertheless, both pain and opioids may increase the risk of falls. This narrative literature review aims to summarize the existing knowledge on the opioid-related fall risk in older adults, including the pharmacokinetics and pharmacodynamics, and assist clinicians in prescribing and deprescribing opioids in older persons. We systematically searched relevant literature on opioid-related fall risk in older adults in PubMed and Scopus in December 2020. We reviewed the literature and evaluated fall-related adverse effects of opioids, explaining how to optimally approach deprescribing of opioids in older adults. Opioid use increases fall risk through drowsiness, (orthostatic) hypotension and also through hyponatremia caused by weak opioids. When prescribing, opioids should be started with low dosages if possible, keeping in mind their metabolic genetic variation. Falls are clinically significant adverse effects of all opioids, and the risk may be dose dependent and highest with strong opioids. The risk is most prominent in older adults prone to falls. To reduce the risk of falls, both pain and the need for opioids should be assessed on a regular basis, and deprescribing or changing to a lower dosage or safer alternative should be considered if the clinical condition allows. Deprescribing should be done by reducing the dosage gradually and by assessing and monitoring the pain and withdrawal symptoms at the same time. Weighing the risks and benefits is necessary before prescribing opioids, especially to older persons at high risk of falls. Clinical decision tools assist prescribers in clinical decisions regarding (de-) prescribing.
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Affiliation(s)
- Roosa-Emilia Virnes
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland
| | - Miia Tiihonen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland. .,Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland.
| | - Niina Karttunen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland
| | - Eveline P van Poelgeest
- Department of Internal Medicine, Geriatrics, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Natalie van der Velde
- Department of Internal Medicine, Geriatrics, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Sirpa Hartikainen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland
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10
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Woods A, Begum M, Gonzalez-Chica D, Bernardo C, Hoon E, Stocks N. Long-term benzodiazepines and z-drug prescribing in Australian general practice between 2011 and 2018: A national study. Pharmacol Res Perspect 2021; 10:e00896. [PMID: 34918876 PMCID: PMC8929365 DOI: 10.1002/prp2.896] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 10/23/2021] [Indexed: 12/20/2022] Open
Abstract
Despite reducing benzodiazepine prescribing, benzodiazepine-involving deaths have substantially increased in Australia. This study aimed to explore patterns in long-term prescribing of medications (benzodiazepine and z-drugs [BZD]) used for sleep-issues/insomnia in Australia to better understand these changes. Open cohort study using de-identified electronic health records of 1 414 593 adult patients regularly attending 404 Australian general practices from 2011 to 2018 (MedicineInsight). We used logistic regression adjusted for patient and practice characteristics to; (1) estimate long-term BZD prescribing prevalence (≥3 prescriptions in 6 months) and the associated sociodemographic factors, and (2) Poisson regression to compute annual changes in prescribing rates. Long-term BZD prescribing changed from 4.4% in 2011 to 5.8% in 2015, remaining relatively stable until 2018 (annual increase +2.5% [95% CI +2.0%;+3.0%]). Long-term BZD prescribing in any year was up to six times more likely in elderly rather than in younger patients and 30%-43% more prevalent in females, or patients living in or attending a practice located in more disadvantaged areas. The increase was more pronounced among males, adults aged 35-49 years, and individuals living in advantaged areas. The median duration among incident cases decreased from 1183 to 322 days between 2011 and 2017, and was up to 197 days longer among elderly females than males. Despite a slight increase and recent stability in long-term BZD prescribing, the higher rates and durations among elderly patients, women, or those living in more disadvantaged areas are concerning and highlights the need for interventions that reduce the potential harms of long-term BZD use in vulnerable groups.
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Affiliation(s)
- Amelia Woods
- Discipline of General Practice, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Mumtaz Begum
- Discipline of General Practice, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - David Gonzalez-Chica
- Discipline of General Practice, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Carla Bernardo
- Discipline of General Practice, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Elizabeth Hoon
- Discipline of General Practice, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia.,Adelaide Institute for Sleep Health: A Flinders Centre of Research Excellence, College of Medicine and Public Health, Flinders University, South Australia, Australia.,School of Public Health, University of Adelaide, Adelaide, South Australia, Australia
| | - Nigel Stocks
- Discipline of General Practice, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia.,Adelaide Institute for Sleep Health: A Flinders Centre of Research Excellence, College of Medicine and Public Health, Flinders University, South Australia, Australia
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11
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A pharmacist-led intervention to improve the management of opioids in a general practice: a qualitative evaluation of participant interviews. Int J Clin Pharm 2021; 44:235-246. [PMID: 34751891 DOI: 10.1007/s11096-021-01340-0] [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: 07/27/2021] [Accepted: 10/17/2021] [Indexed: 10/19/2022]
Abstract
Background Opioid prescribing has escalated, particularly long-term in chronic noncancer pain. Innovative models of care have been recommended to augment regulatory and harm-minimisation strategies and to review the safety and benefits of opioids for the individual patient. Medication stewardship and pharmacist integration are evolving approaches for general practice. Aim To explore enablers, barriers, and outcomes of a pharmacist-led intervention to improve opioid management in general practice, from the perspectives of general practitioners (GPs) and practice personnel. Method The study was part of a mixed-methods investigation into a general practice pharmacist pilot. Qualitative data relevant to opioids were analysed. Data from 13 semi-structured interviews were coded, analysed iteratively and thematically, and interpreted conceptually through the framework of Opioid Stewardship fundamentals proposed by the National Quality Forum. Results Seven themes and 14 subthemes aligned with stewardship fundamentals. Participants considered organisational policy, supported by leadership and education, fostered collaboration and consistency and improved practice safety. Patient engagement with individualised resources, 'agreements' and 'having the conversation' with the pharmacist enabled person-centred opioid review and weaning. GPs reported greater accountability and reflection in their practices, in the broader context of opioid prescribing and dilemmas in managing patients transitioning through care. Receiving feedback on practice deprescribing outcomes encouraged participants' ongoing commitment. Patient communication was deemed an early barrier; however, learnings were applied when transferring the model to other high-risk medicines. Conclusion Improved opioid management was enabled through implementing pharmacist-led coordinated stewardship. The findings offer a practical application of guideline advice to individualise opioid deprescribing.
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