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Ashaye T, Hounsome N, Carnes D, Taylor SJC, Homer K, Eldridge S, Spencer A, Rahman A, Foell J, Underwood MR. Opioid prescribing for chronic musculoskeletal pain in UK primary care: results from a cohort analysis of the COPERS trial. BMJ Open 2018; 8:e019491. [PMID: 29880563 PMCID: PMC6009475 DOI: 10.1136/bmjopen-2017-019491] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE To establish the level of opioid prescribing for patients with chronic musculoskeletal pain in a sample of patients from primary care and to estimate prescription costs. DESIGN Secondary data analyses from a two-arm pragmatic randomised controlled trial (COPERS) testing the effectiveness of group self-management course and usual care against relaxation and usual care for patients with chronic musculoskeletal pain (ISRCTN 24426731). SETTING 25 general practices and two community musculoskeletal services in the UK (London and Midlands). PARTICIPANTS 703 chronic pain participants; 81% white, 67% female, enrolled in the COPERS trial. MAIN OUTCOME MEASURES Anonymised prescribing data over 12 months extracted from GP electronic records. RESULTS Of the 703 trial participants with chronic musculoskeletal pain, 413 (59%) patients were prescribed opioids. Among those prescribed an opioid, the number of opioid prescriptions varied from 1 to 52 per year. A total of 3319 opioid prescriptions were issued over the study period, of which 53% (1768/3319) were for strong opioids (tramadol, buprenorphine, morphine, oxycodone, fentanyl and tapentadol). The mean number of opioid prescriptions per patient prescribed any opioid was 8.0 (SD=7.9). A third of patients on opioids were prescribed more than one type of opioid; the most frequent combinations were: codeine plus tramadol and codeine plus morphine. The cost of opioid prescriptions per patient per year varied from £3 to £4844. The average annual prescription cost was £24 (SD=29) for patients prescribed weak opioids and £174 (SD=421) for patients prescribed strong opioids. Approximately 40% of patients received >3 prescriptions of strong opioids per year, with an annual cost of £236 per person. CONCLUSIONS Long-term prescribing of opioids for chronic musculoskeletal pain is common in primary care. For over a quarter of patients receiving strong opioids, these drugs may have been overprescribed according to national guidelines. TRIAL REGISTRATION NUMBER ISRCTN24426731; Post-results.
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Affiliation(s)
- Tomi Ashaye
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Natalia Hounsome
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Dawn Carnes
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Stephanie J C Taylor
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Kate Homer
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Sandra Eldridge
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Anne Spencer
- Exeter Medical School, University of Exeter, Exeter, Devon, UK
| | - Anisur Rahman
- Centre for Rheumatology Research, University College London, London, UK
| | - Jens Foell
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Martin R Underwood
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
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Mueller SR, Walley AY, Calcaterra SL, Glanz JM, Binswanger IA. A Review of Opioid Overdose Prevention and Naloxone Prescribing: Implications for Translating Community Programming Into Clinical Practice. Subst Abus 2015; 36:240-53. [PMID: 25774771 DOI: 10.1080/08897077.2015.1010032] [Citation(s) in RCA: 132] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND As physicians have increased opioid prescribing, overdose deaths from pharmaceutical opioids have substantially increased in the United States. Naloxone hydrochloride (naloxone), an opioid antagonist, is the standard of care for treatment of opioid induced respiratory depression. Since 1996, community-based programs have offered overdose prevention education and distributed naloxone for bystander administration to people who use opioids, particularly heroin. There is growing interest in translating overdose education and naloxone distribution (OEND) into conventional medical settings for patients who are prescribed pharmaceutical opioids. For this review, we summarized and classified existing publications on overdose education and naloxone distribution to identify evidence of effectiveness and opportunities for translation into conventional medical settings. METHODS For this review, we searched English language PubMed for articles on naloxone based on primary data collection from humans, including feasibility studies, program evaluations, surveys, qualitative studies, and studies comparing the effectiveness of different routes of naloxone administration. We also included cost-effectiveness studies. RESULTS We identified 41 articles that represented 5 categories: evaluations of OEND programs, effects of OEND programs on experiences and attitudes of participants, willingness of medical providers to prescribe naloxone, comparisons of different routes of naloxone administration, and the cost-effectiveness of naloxone. CONCLUSIONS Existing research suggests that people who are at risk for overdose and other bystanders are willing and able to be trained to prevent overdoses and administer naloxone. Counseling patients about the risks of opioid overdose and prescribing naloxone is an emerging clinical practice that may reduce fatalities from overdose while enhancing the safe prescribing of opioids.
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Affiliation(s)
- Shane R Mueller
- a Division of General Internal Medicine , University of Colorado School of Medicine , Aurora , Colorado , USA
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Haegerich TM, Sugerman DE, Annest JL, Klevens J, Baldwin GT. Improving injury prevention through health information technology. Am J Prev Med 2015; 48:219-228. [PMID: 25441230 PMCID: PMC4700542 DOI: 10.1016/j.amepre.2014.08.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 07/29/2014] [Accepted: 08/14/2014] [Indexed: 10/24/2022]
Abstract
Health information technology is an emerging area of focus in clinical medicine with the potential to improve injury and violence prevention practice. With injuries being the leading cause of death for Americans aged 1-44 years, greater implementation of evidence-based preventive services, referral to community resources, and real-time surveillance of emerging threats is needed. Through a review of the literature and capturing of current practice in the field, this paper showcases how health information technology applied to injury and violence prevention can lead to strengthened clinical preventive services, more rigorous measurement of clinical outcomes, and improved injury surveillance, potentially resulting in health improvement.
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Affiliation(s)
- Tamara M Haegerich
- National Center for Injury Prevention and Control, CDC, Atlanta, Georgia.
| | - David E Sugerman
- National Center for Injury Prevention and Control, CDC, Atlanta, Georgia
| | - Joseph L Annest
- National Center for Injury Prevention and Control, CDC, Atlanta, Georgia
| | - Joanne Klevens
- National Center for Injury Prevention and Control, CDC, Atlanta, Georgia
| | - Grant T Baldwin
- National Center for Injury Prevention and Control, CDC, Atlanta, Georgia
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Bagnola AJ, Escaño AK. Identifying Potential Causes of Opioid Toxicity Necessitating a Rapid Response Team Visit. J Pharm Technol 2013. [DOI: 10.1177/875512251302900303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Opioids are labeled as high-risk medications because of their propensity to cause significant harm or toxicity to patients if used inappropriately. Many incidents of opioid toxicity are the result of preventable causes. Objective: To identify and report the frequency and potential causes of opioid toxicity in the acute care setting. Methods: This single-center chart review evaluated patients receiving naloxone for presumed opioid toxicity from January 2008 through July 2010. Patients were identified for this study using rapid response team charted visits. Charts were then reviewed for opioid medications administered, possible causes of opioid toxicity, signs and symptoms of opioid toxicity, patient location by hospital floor, and prescribing physician service. Results: One hundred twenty-nine incidents of opioid toxicity met inclusion criteria and were placed in 1 or more of the applicable categories for possible causes: administration of multiple opioids (43.4%), medication errors (31.6%), and the administration of morphine to patients with impaired renal function (7.2%); 17.8% of the causes were unknown. Conclusions: Most cases of opioid toxicity were determined to be the result of preventable causes. Prevention strategies for opioid toxicity should consist of educating health care professionals as well as incorporating health information technologies shown to reduce errors. Specific areas of focus should include opioid equianalgesic dosing strategies, removal of duplicate opioid orders, and writing of clear administration guidelines for orders of as-needed opioids or multiple dosage forms of opioids.
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Affiliation(s)
- Aaron J Bagnola
- AARON J BAGNOLA PharmD BCPS, Cardiology Specialty Pharmacist, Inova Fairfax Hospital, Falls Church, VA
| | - Alisa K Escaño
- ALISA K ESCAÑO PharmD BCPS, Assistant Professor, Department of Pharmacotherapy & Outcomes Sciences, School of Pharmacy, Virginia Commonwealth University, Inova Campus, Falls Church, VA; Clinical Specialist, Internal Medicine, Inova Fairfax Hospital
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Green TC, Bowman SE, Zaller ND, Ray M, Case P, Heimer R. Barriers to medical provider support for prescription naloxone as overdose antidote for lay responders. Subst Use Misuse 2013; 48:558-67. [PMID: 23647168 DOI: 10.3109/10826084.2013.787099] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Poisonings are the leading cause of adult injury death in the United States. Over 12 weeks in 2011, 143 key informant interviews were conducted using a structured interview guide in three study sites in New England. This analysis focuses on the 24 interviews with emergency department providers, substance use treatment providers, pain specialists, and generalist/family medicine practitioners. Using an iterative coding process, we analyzed statements regarding support and concern about naloxone prescription for pain patients and drug users. The study's implications and limitations are discussed and future research suggested. The Centers for Disease Control and Prevention funded this study.
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Affiliation(s)
- Traci C Green
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island 02903, USA.
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Davis C, Webb D, Burris S. Changing law from barrier to facilitator of opioid overdose prevention. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2013; 41 Suppl 1:33-6. [PMID: 23590737 DOI: 10.1111/jlme.12035] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Opioid overdose is the leading cause of accidental injury death in the United States, taking the lives of over 16,000 Americans every year. Many of those deaths are preventable through the timely provision of naloxone, a drug that reliably and effectively reverses opioid overdose. However, that drug is often not available where and when it is needed, due in large part to laws that pre-date the overdose epidemic. Preliminary evidence suggests that amending those laws to encourage the prescription and use of naloxone will reduce opioid overdose deaths, and a number of states have done so in the past several years. Since legal amendments designed to facilitate naloxone access have no documented negative effects, can be implemented at little or no cost, and have the potential to save both lives and resources, states that have not passed them may benefit from doing so.
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Affiliation(s)
- Corey Davis
- Network for Public Health Law-Southeastern Region, National Health Law Program
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Effects of concurrent intravenous morphine sulfate and naltrexone hydrochloride on end-tidal carbon dioxide. Harm Reduct J 2012; 9:13. [PMID: 22420453 PMCID: PMC3341179 DOI: 10.1186/1477-7517-9-13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Accepted: 03/15/2012] [Indexed: 11/10/2022] Open
Abstract
Background Respiratory depression, a potentially fatal side-effect of opioid-overdose, may be reversed by timely administration of an opioid antagonist, such as naloxone or naltrexone. Tampering with a formulation of morphine sulfate and sequestered naltrexone hydrochloride extended release capsules (MS-sNT) releases both the opioid morphine and the antagonist naltrexone. A study in recreational opioid-users indicated that morphine and naltrexone injected in the 25:1 ratio (duplicating the ratio of the formulation) found MS-sNT reduced morphine-induced euphoric effects vs intravenous (IV) morphine alone. In the same study, the effects of morphine + naltrexone on end-tidal carbon dioxide (EtCO2), a measure of respiratory-depression, were evaluated and these data are reported here. Methods Single-center, placebo-controlled, double-blind crossover study. Non-dependent male opioid users were randomized to receive single IV doses of placebo, 30 mg morphine alone, and 30 mg morphine + 1.2 mg naltrexone. EtCO2 was measured by noninvasive capnography. Results Significant differences in EtCO2 least-squares means across all treatments for maximal effect (Emax) and area under the effect curve (AUE0-2, AUE0-8, AUE0-24) were detected (all p ≤ 0.0011). EtCO2 Emax values for morphine + naltrexone were significantly reduced vs morphine alone (42.9 mm Hg vs 47.1 mm Hg, p < 0.0001) and were not significantly different vs placebo (41.9 mm Hg). Median time to reach maximal effect (TEmax) was delayed for morphine + naltrexone vs morphine alone (5.0 h vs 1.0 h). Conclusions Results provide preliminary evidence that the naltrexone:morphine ratio within MS-sNT is sufficient to significantly reduce EtCO2 when administered intravenously to non-dependent male recreational opioid-users. Further studies with multiple measures of respiratory-function are warranted to determine if risk of respiratory depression is also reduced by naltrexone in the tampered formulation.
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Characteristics of an overdose prevention, response, and naloxone distribution program in Pittsburgh and Allegheny County, Pennsylvania. J Urban Health 2011; 88:1020-30. [PMID: 21773877 PMCID: PMC3232410 DOI: 10.1007/s11524-011-9600-7] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Prevention Point Pittsburgh (PPP) is a public health advocacy organization that operates Allegheny County's only needle exchange program. In 2002, PPP implemented an Overdose Prevention Program (OPP) in response to an increase in heroin-related and opioid-related overdose fatalities in the region. In 2005, the OPP augmented overdose prevention and response trainings to include naloxone training and prescription. The objective of our study is to describe the experiences of 426 individuals who participated in the OPP between July 1, 2005, and December 31, 2008. Of these, 89 individuals reported administering naloxone in response to an overdose in a total of 249 separate overdose episodes. Of these 249 overdose episodes in which naloxone was administered, participants reported 96% were reversed. The data support findings from a growing body of research on similar programs in other cities. Community-based OPPs that equip drug users with skills to identify and respond to an overdose and prescribe naloxone can help users and their peers prevent and reverse potentially fatal overdoses without significant adverse consequences.
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Abstract
Oxycodone is a major public health problem for many countries. The focus to date, however, has been on illicit drug users. Many (perhaps the majority) who are dependent on oxycodone, however, have never used illicit drugs. These people have been forgotten in public health interventions, and require urgent attention.
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Green TC, Grau LE, Carver HW, Kinzly M, Heimer R. Epidemiologic trends and geographic patterns of fatal opioid intoxications in Connecticut, USA: 1997-2007. Drug Alcohol Depend 2011; 115:221-8. [PMID: 21131140 PMCID: PMC3095753 DOI: 10.1016/j.drugalcdep.2010.11.007] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Revised: 11/07/2010] [Accepted: 11/08/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND The leading cause of injury death among adults in Connecticut (CT), USA is drug poisonings. We analyzed the epidemiology and geographic distribution of opioid-involved accidental drug-involved intoxication deaths ("overdoses") in CT over an 11-year period. METHODS We reviewed data from 1997 to 2007 on all adult accidental/undetermined drug intoxication deaths in CT that were referred to the Office of the Chief Medical Examiner (OCME). Regression analyses were conducted to uncover risk factors for fatal opioid-involved intoxications and to compare heroin- to prescription opioid- and methadone-involved deaths. Death locations were mapped to visualize differences in the geographic patterns of overdose by opioid type. RESULTS Of the 2900 qualifying deaths, 2231 (77%) involved opioids. Trends over time revealed increases in total opioid-related deaths although heroin-related deaths remained constant. Methadone, oxycodone and fentanyl, the most frequently cited prescription opioids, exhibited significant increases in opioid deaths. Prescription opioid-only deaths were more likely to involve other medications (e.g., benzodiazepines) and to have occurred among residents of a suburban or small town location, compared to heroin-involved or methadone-involved deaths. Heroin-only deaths tended to occur among non-Whites, were more likely to involve alcohol or cocaine and to occur in public locations and large cities. CONCLUSIONS The epidemiology of fatal opioid overdose in CT exhibits distinct longitudinal, risk factor, and geographic differences by opioid type. Each of these trends has implications for public health and prevention efforts.
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Affiliation(s)
- Traci C. Green
- The Warren Alpert Medical School of Brown University, Box G-1, Providence, RI 02912 USA
| | - Lauretta E. Grau
- Yale School of Medicine, 135 College Street, Suite 200, New Haven, CT 06510 USA
| | - H. Wayne Carver
- Office of the Chief Medical Examiner, 11 Shuttle Road, Farmington, CT 06032 USA
| | - Mark Kinzly
- Yale School of Medicine, 135 College Street, Suite 200, New Haven, CT 06510 USA
| | - Robert Heimer
- Yale School of Medicine, 135 College Street, Suite 200, New Haven, CT 06510 USA
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Green TC, Zaller N, Rich J, Bowman S, Friedmann P. Revisiting Paulozzi et al.'s “Prescription Drug Monitoring Programs and Death Rates from Drug Overdose”: Table 1. PAIN MEDICINE 2011; 12:982-5. [DOI: 10.1111/j.1526-4637.2011.01136.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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