Effect of lock boxes and education on safe storage of medications

Opioid Prescribing for Acute Pain Management in Children and Adolescents in Outpatient Settings: Clinical Practice Guideline

This is the first clinical practice guideline (CPG) from the American Academy of Pediatrics outlining evidence-based approaches to safely prescribing opioids for acute pain in outpatient settings. The central goal is to aid clinicians in understanding when opioids may be indicated to treat acute pain in children and adolescents and how to minimize risks (including opioid use disorder, poisoning, and overdose). The document also seeks to alleviate disparate pain treatment of Black, Hispanic, and American Indian/Alaska Native children and adolescents, who receive pain management that is less adequate and less timely than that provided to white individuals. There may also be disparities in pain treatment based on language, socioeconomic status, geographic location, and other factors, which are discussed. The document recommends that clinicians treat acute pain using a multimodal approach that includes the appropriate use of nonpharmacologic therapies, nonopioid medications, and, when needed, opioid medications. Opioids should not be prescribed as monotherapy for children or adolescents who have acute pain. When using opioids for acute pain management, clinicians should prescribe immediate-release opioid formulations, start with the lowest age- and weight-appropriate doses, and provide an initial supply of 5 or fewer days, unless the pain is related to trauma or surgery with expected duration of pain longer than 5 days. Clinicians should not prescribe codeine or tramadol for patients younger than 12 years; adolescents 12 to 18 years of age who have obesity, obstructive sleep apnea, or severe lung disease; to treat postsurgical pain after tonsillectomy or adenoidectomy in patients younger than 18 years; or for any breastfeeding patient. The CPG recommends providing opioids when appropriate for treating acutely worsened pain in children and adolescents who have a history of chronic pain; clinicians should partner with other opioid-prescribing clinicians involved in the patient's care and/or a specialist in chronic pain or palliative care to determine an appropriate treatment plan. Caution should be used when treating acute pain in those who are taking sedating medications. The CPG describes potential harms of discontinuing or rapidly tapering opioids in individuals who have been on stable, long-term opioids to treat chronic pain. The guideline also recommends providing naloxone and information on naloxone, safe storage and disposal of opioids, and direct observation of medication administration. Clinicians are encouraged to help caregivers develop a plan for safe disposal. The CPG contains 12 key action statements based on evidence from randomized controlled trials, high-quality observational studies, and, when studies are lacking or could not feasibly or ethically be conducted, from expert opinion. Each key action statement includes a level of evidence, the benefit-harm relationship, and the strength of recommendation.

Prepped and ready: educating caregivers to secure firearms and medications via webinars

BACKGROUND

Means restriction is an approach to suicide prevention that has been shown to be effective but is underutilized in the United States. For the current study, we sought to determine if a webinar-based education intervention could impact caregiver means restriction knowledge and behaviors.

METHODS

Nine webinars for caregivers were offered by a children's hospital in conjunction with community groups. Education on raising teenagers was paired with information about suicide prevention, including the importance of securing medications and firearms. Participants completed surveys prior to the presentation, immediately following and two weeks later to measure change in knowledge and storage of medications and firearms. Participants were provided a safety toolkit to secure medications and firearms.

RESULTS

Of the 327 participants who completed the baseline survey, 299 and 257 completed the second and third surveys. By the conclusion of the study, 46.6% of participants reported they had disposed of unneeded medications and 44.1% had locked up medications. Among firearm owners, use of a cable gun lock rose from 13.7% to 25.8%. In addition, 40.2% of firearm owners reported learning more about how their firearms were stored at the final survey. Most participants (88.3%) strongly agreed that the presentation provided value.

CONCLUSION

This study shows that a webinar on safe storage appears to have some impact on behavior changes for caregivers of adolescents. A controlled study could help to clarify if the webinar format or the timing during the Covid-19 pandemic might have played a role in the degree of behavior change reported.

Experience of patients on methadone maintenance treatment receiving take-home methadone doses during COVID-19 pandemic: A multi-site study from India

BACKGROUND

Methadone take-home doses for opioid dependence treatment are strictly regulated due to diversion and overdose concerns, so patients must visit the clinic daily for dispensing. This was also done in India until the COVID-19 pandemic, when lockdown restriction compelled take- home dispensing of methadone. This study examined experience of patients who received take- home methadone during COVID-19 pandemic in India.

METHODS

Observational, cross-sectional design. We contacted all consenting methadone centres in India during the lockdown and selected those that provided take-home doses for the study. Patients who received daily methadone before the lockdown and take-home doses after were interviewed using a study-specific questionnaire.

RESULTS

The study had 210 participants. Take-home methadone was dispensed for 2.5 days on average in each dispensing. When taking methadone at home, 3.3% split their dose 25% took less than the prescribed dose to save it for a rainy days, and 3.3% reported an overdose episode. Adherence improved in 58.6% participants after take-home methadone. Participants perceived many benefits from take-home methadone such as reduced hospital visits and travel time to collect methadone, improvement in work, and financial savings. About 54.3% participants reported storing their take-home doses safely, and 1.9% reported that their family consumed methadone by mistake.

CONCLUSIONS

Take-home methadone was found to be beneficial to most participants in terms of time saved and improved productivity. Preconceived concerns of providing take-home methadone in terms of its overdose, diversion, or accidental ingestion by others are not commonly seen when individuals are provided take-home doses of methadone.

Trends in Adolescent Suicide by Method in the US, 1999-2020

Importance

Adolescent suicide in the US is a major public health problem, yet temporal trends in suicide methods by demographics are understudied.

Objective

To examine national trends in suicide mortality by method (firearm, poisoning, hanging and asphyxiation, and all other means) from 1999 to 2020 by demographic characteristics.

Design, Setting, and Participants

This serial cross-sectional study used national death certificate data of adolescent (aged 10-19 years) suicide decedents compiled by the National Center for Health Statistics from January 1, 1999, to December 31, 2020. Data analysis was performed from April 1, 2023, to July 9, 2023.

Exposures

Age, sex, and race and ethnicity.

Main Outcomes and Measures

Trends in age-standardized mortality rates and average annual percent change (AAPC) in rates were estimated by age, sex, and race and ethnicity for each suicide method.

Results

This study assessed data from 47 217 adolescent suicide decedents. From 1999 to 2020, suicide by firearm (AAPC, 1.0; 95% CI, 0.1-1.9), poisoning (AAPC, 2.7; 95% CI, 1.0-4.4), hanging and asphyxiation (AAPC, 2.4; 95% CI, 0.2-4.6), and other means (AAPC, 2.9; 95% CI, 1.2-4.6) increased. Rapidly increasing rates were observed among female adolescents for poisoning (AAPC, 4.5; 95% CI, 2.3-6.7) and hanging and asphyxiation (AAPC, 5.9; 95% CI, 5.0-6.8) suicides. From 2007 to 2020, firearm suicides sharply increased among female (annual percent change [APC], 7.8; 95% CI, 6.0-9.5) and male (APC, 5.3; 95% CI, 4.3-6.3) adolescents. Firearm suicide rates increased among Black adolescents from 2012 to 2020 (APC, 14.5; 95% CI, 9.7-19.5), Asian and Pacific Islander adolescents from 2008 to 2020 (APC, 12.0; 95% CI, 9.7-14.5), American Indian and Alaska Native adolescents from 2014 to 2020 (APC, 10.6; 95% CI, 2.6-19.3), and Hispanic or Latino adolescents from 2011 to 2020 (APC, 10.2; 95% CI, 6.3-13.8). During the study period, Black adolescents had the highest average increase in hanging and asphyxiation suicides (AAPC, 4.2; 95% CI, 3.2-5.2). From 2011 to 2020, poisoning suicide deaths increased (APC, 12.6; 95% CI, 8.5-16.7) among female adolescents.

Conclusions and Relevance

Suicide rates increased across all methods from 1999 to 2020. Differences were noted by sex, age, and race and ethnicity. Increasing suicide rates among racial and ethnic minoritized youth are especially concerning, and effective prevention strategies are urgently needed.

Piloting an opioid callback program in community pharmacies

BACKGROUND

Although opioid prescribing has recently trended downward, opioid-related overdoses and deaths have drastically increased. Community pharmacists are accessible health care providers who are well positioned to disseminate information on opioid safety and to educate and counsel on medication use, managing adverse events, and proper medication disposal. Patient callbacks facilitate appropriate medication usage. We developed an opioid callback program that provides a framework for pharmacists to follow up with patients with an opioid prescription.

OBJECTIVES

This study aimed to (1) describe the development of the opioid callback initiative and (2) report results from a pilot test in 2 community pharmacies.

METHODS

The opioid callback process and data collection forms were collaboratively developed with community pharmacists at each site. Data recorded on the opioid callback forms were descriptively analyzed and chi-square test of independence explored differences by pain durations related to opioid disposal, security, and safety. Participating pharmacy staff were interviewed to identify facilitators and barriers to implementation, as well as opportunities for improvement.

RESULTS

Forty-one opioid callbacks were attempted and 36 were completed (87.8%). Pharmacists were statistically significantly more likely to discuss naloxone with patients with chronic pain (89.5%) than those with acute pain (46.2%). Pharmacists reported that the program successfully raised awareness of opioid disposal opportunities and safe opioid practices, including storage and naloxone ownership. They expressed patients' willingness to answer questions and appreciation for the extra attention and care.

CONCLUSION

Community pharmacists are well positioned to address the opioid crisis as access points for medication questions, opioid safety education, opioid disposal, naloxone, and medications for people with an opioid use disorder. This study presents a proof of concept for a pharmacist-led opioid callback program. Expansion could help inform patients about how to use opioids safely, how to treat an opioid overdose, and where to dispose of unused medications.

Safe at home: prevention of pediatric unintentional injuries

BACKGROUND

Unintentional injuries are the leading cause of death in children in the United States. Studies have shown that parent adherence to safety guidelines is improved when education is provided in conjunction with safety equipment.

METHODS

This study surveyed parents about specific injury prevention behaviors regarding medication and firearm storage and provided education and safety equipment for safe practice of these behaviors. The project took place in a pediatric emergency department (PED) and partnered with the hospital foundation and the school of medicine. Inclusion criteria were families visiting a freestanding PED in a tertiary care center. Participants completed a survey conducted by a medical student approximately 5 min in length. The student then provided each family with a medication lock box (if children ≤ 5 years old lived in the home), firearm cable lock, and education for safe storage of medications and firearms in the home.

RESULTS

The medical student researcher spent a total of 20 h in the PED from June to August 2021. 106 families were approached to participate in the study, of which 99 agreed to participate (93.4%). A total of 199 children were reached with ages ranging from less than 1 year old to 18 years old. A total of 73 medication lockboxes and 95 firearm locks were distributed. The majority (79.8%) of survey participants were the mother of the patient and 97.0% of participants lived with the patient > 50% of the time. For medication storage, 12.1% of families store medications locked and 71.7% reported never receiving medication storage education from a healthcare professional. Regarding firearms, 65.2% of participants who reported having at least 1 firearm in the home stored firearms locked and unloaded with various methods of storage. 77.8% of firearm owners reported storing ammunition in a separate location from the firearm. Of all participants surveyed, 82.8% reported never receiving firearm storage education from a healthcare professional.

CONCLUSIONS

The pediatric ED is an excellent setting for injury prevention and education. Many families are not storing medications and firearms safely, demonstrating a clear opportunity to increase knowledge in families with young children.

Motivating Behavior Change in Parents for Suicide Prevention in the Midwest, USA

Safe storage of lethal means is an evidence-based approach to suicide prevention that is underutilized. This naturalistic study investigated whether a presentation on parenting teenagers that includes education about safe storage of firearms and medications, paired with tools to enact change, can impact storage practices. Ten community presentations for parents were given between November 2018 and September 2019 in the Midwest region of the United States. Multiple topics pertinent to parenting adolescents were included with an emphasis on safe storage of firearms and medications to reduce suicide risk. Toolkits including medication storage boxes and cable gun locks were offered to help parents enact recommended changes. Surveys were completed prior to the presentation (T1), immediately following the presentation (T2), and 2 weeks after the presentation (T3). Five-hundred eighty-one parents comprised the initial study sample, of whom 410 (70.6%) completed the primary study endpoint. Generalized linear mixed models with and without worst-case imputation were used to evaluate changes in safe storage practices. Results suggested the odds of storing firearms in the safest manner possible increased 5.9 times (95% CI 2.6-13.5, p < 0.001) without imputation and increased 2.0 times (95% CI 1.1-3.4, p = 0.02) with the worst-case imputation. Among participants with unlocked medications at baseline, 56.5% reported they had disposed of old medications and 53.0% reported locking up bottles of medication by the primary study endpoint. This study provides preliminary evidence that safe storage education paired with tools for behavior change motivates parents to enact safe storage measures.

Parental perception of medications safe storage in the State of Qatar

PURPOSE

The purpose of this study is to identify parental perception of household medication storage.

METHODS

A prospective cross-sectional study utilizing a questionnaire was carried out at Hamad Medical Corporation, the solely tertiary pediatric hospital in the State of Qatar at the time of the study. Qatar is a young developing country with limited data on the awareness of medication storage among adults with children at home and on the safety practices regarding medication storage.

RESULTS

Three hundred and five questionnaires were completed. The vast majority of parents were married, one-third of them were males, and more than three quarters were college graduates and younger than 40 years of age. Almost 80% of the parents had more than three children but less than seven. In addition, 23% of participants were health-care workers. Almost 90% of the participants stored medications in a place that is easy to reach. However, the same percentage stated that those medications were stored in a locked place and that children did not have access to them. Approximately 10% of caregivers store multiple medications in one bottle, and the same percentage of participants do not check the expiration date on the medication labels. In terms of the most common medications stored at home, antihypertensives were on top of the list. Our study has shown that parental education and being a health-care worker were each associated with the difficulty in reaching medications (P = 0.006 and P = 0.011, respectively). Moreover, the percentage of participants who shared medications was significantly higher among those who were not working in the health-care section compared to those who were (P = 0.004). In addition, being a female parent and a college graduate was associated with the possibility of keeping excess or leftover medications at home (P = 0.025).

CONCLUSION

Parents residing in the State of Qatar have some deficiencies in knowledge about medication storage. Parent's attitudes and perceptions are deemed vital objectives for population's health intervention.