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Miroshnychenko A, Ibrahim S, Azab M, Roldan Y, Martinez J, Tamilselvan D, He L, Little J, Urquhart O, Tampi M, Polk D, Moore P, Hersh E, Claytor B, Carrasco-Labra A, Brignardello-Petersen R. Acute Postoperative Pain Due to Dental Extraction in the Adult Population: A Systematic Review and Network Meta-analysis. J Dent Res 2023; 102:391-401. [PMID: 36631957 PMCID: PMC10031629 DOI: 10.1177/00220345221139230] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
This study compares the effectiveness of pharmacological treatments to develop guidelines for the management of acute pain after tooth extraction. We searched Medline, EMBASE, CENTRAL, and US Clinical Trials registry on November 21, 2020. We included randomized clinical trials (RCTs) of participants undergoing dental extractions comparing 10 interventions, including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and combinations to placebo. After duplicate screening and data abstraction, we conducted a frequentist network meta-analysis for each outcome at 6 h (i.e., pain relief, total pain relief [TOTPAR], summed pain intensity difference [SPID], global efficacy rating, rescue analgesia, and adverse effects). We assessed the risk of bias using a modified Cochrane RoB 2.0 tool and the certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation approach. We implemented the analyses in RStudio version 3.5.3 and classified interventions from most to least beneficial or harmful. We included 82 RCTs. Fifty-six RCTs enrolling 9,095 participants found moderate- and high-certainty evidence that ibuprofen 200 to 400 mg plus acetaminophen 500 to 1,000 mg (mean difference compared to placebo [MDp], 1.68; 95% confidence interval [CI], 1.06-2.31), acetaminophen 650 mg plus oxycodone 10 mg (MDp, 1.19; 95% CI, 0.85-1.54), ibuprofen 400 mg (MDp, 1.31; 95% CI, 1.17-1.45), and naproxen 400-440 mg (MDp, 1.44; 95% CI, 1.07-1.80) were most effective for pain relief on a 0 to 4 scale. Oxycodone 5 mg, codeine 60 mg, and tramadol 37.5 mg plus acetaminophen 325 mg were no better than placebo. The results for TOTPAR, SPID, global efficacy rating, and rescue analgesia were similar. Based on low- and very low-certainty evidence, most interventions were classified as no more harmful than placebo for most adverse effects. Based on moderate- and high-certainty evidence, NSAIDs with or without acetaminophen result in better pain-related outcomes than opioids with or without acetaminophen (except acetaminophen 650 mg plus oxycodone 10 mg) or placebo.
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Affiliation(s)
- A. Miroshnychenko
- Department of Health Research Methods,
Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - S. Ibrahim
- Faculty of Health Sciences, McMaster
University, Hamilton, Ontario, Canada
| | - M. Azab
- Faculty of Health Sciences, McMaster
University, Hamilton, Ontario, Canada
| | - Y. Roldan
- Department of Health Research Methods,
Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - J.P.D. Martinez
- Department of Health Research Methods,
Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - D. Tamilselvan
- Faculty of Health Sciences, McMaster
University, Hamilton, Ontario, Canada
| | - L. He
- Faculty of Health Sciences, McMaster
University, Hamilton, Ontario, Canada
| | - J.W. Little
- Division of Oral and Craniofacial
Health Sciences, Adams School of Dentistry, Chapel Hill, NC, USA
| | - O. Urquhart
- ADA Science and Research Institute,
Chicago, Illinois, USA
| | - M. Tampi
- Department of Cariology, University of
Michigan School of Dentistry, Ann Arbor, MI, USA
| | - D.E. Polk
- Department of Dental Public Health,
University of Pittsburgh, Pittsburgh, PA, USA
| | - P.A. Moore
- Department of Dental Public Health,
University of Pittsburgh, Pittsburgh, PA, USA
| | - E.V. Hersh
- Department of Oral Surgery and
Pharmacology, University of Pennsylvania, Philadelphia, PA, USA
| | - B. Claytor
- N.C. Caring Dental Professionals,
Aberdeen, NC, USA
| | - A. Carrasco-Labra
- Department of Preventative and
Restorative Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - R. Brignardello-Petersen
- Department of Health Research Methods,
Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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Kurteva S, Abrahamowicz M, Weir D, Gomes T, Tamblyn R. Determinants of long-term opioid use in hospitalized patients. PLoS One 2022; 17:e0278992. [PMID: 36520865 PMCID: PMC9754198 DOI: 10.1371/journal.pone.0278992] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 11/07/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Long-term opioid use is an increasingly important problem related to the ongoing opioid epidemic. The purpose of this study was to identify patient, hospitalization and system-level determinants of long term opioid therapy (LTOT) among patients recently discharged from hospital. DESIGN To be eligible for this study, patient needed to have filled at least one opioid prescription three-months post-discharge. We retrieved data from the provincial health insurance agency to measure medical service and prescription drug use in the year prior to and after hospitalization. A multivariable Cox Proportional Hazards model was utilized to determine factors associated with time to the first LTOT occurrence, defined as time-varying cumulative opioid duration of ≥ 60 days. RESULTS Overall, 22.4% of the 1,551 study patients were classified as LTOT, who had a mean age of 66.3 years (SD = 14.3). Having no drug copay status (adjusted hazard ratio (aHR) 1.91, 95% CI: 1.40-2.60), being a LTOT user before the index hospitalization (aHR 6.05, 95% CI: 4.22-8.68) or having history of benzodiazepine use (aHR 1.43, 95% CI: 1.12-1.83) were all associated with an increased likelihood of LTOT. Cardiothoracic surgical patients had a 40% lower LTOT risk (aHR 0.55, 95% CI: 0.31-0.96) as compared to medical patients. Initial opioid dispensation of > 90 milligram morphine equivalents (MME) was also associated with higher likelihood of LTOT (aHR 2.08, 95% CI: 1.17-3.69). CONCLUSIONS AND RELEVANCE Several patient-level characteristics associated with an increased risk of ≥ 60 days of cumulative opioid use. The results could be used to help identify patients who are at high-risk of continuing opioids beyond guideline recommendations and inform policies to curb excessive opioid prescribing.
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Affiliation(s)
- Siyana Kurteva
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada
- Clinical and Health Informatics Research Group, McGill University, Montreal, Canada
- Science, Aetion, Inc., Barcelona, Spain
- * E-mail:
| | - Michal Abrahamowicz
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada
| | - Daniala Weir
- Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
| | - Tara Gomes
- Institute of Health Policy Management and Evaluation, Toronto, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada
- ICES, Toronto, Canada
| | - Robyn Tamblyn
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada
- Clinical and Health Informatics Research Group, McGill University, Montreal, Canada
- Department of Medicine, McGill University Health Center, Montreal, Canada
- McGill University Health Centre, Montreal, Canada
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Delaney LD, Bicket MC, Hu HM, O'Malley M, McLaughlin E, Flanders SA, Vaughn VM, Waljee JF. Opioid and benzodiazepine prescribing after COVID-19 hospitalization. J Hosp Med 2022; 17:539-544. [PMID: 35621024 PMCID: PMC9347718 DOI: 10.1002/jhm.12842] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 03/22/2022] [Accepted: 04/15/2022] [Indexed: 11/08/2022]
Abstract
Opioid and benzodiazepine prescribing after COVID-19 hospitalization is not well understood. We aimed to characterize opioid and benzodiazepine prescribing among naïve patients hospitalized for COVID and to identify the risk factors associated with a new prescription at discharge. In this retrospective study of patients across 39 Michigan hospitals from March to November 2020, we identified 857 opioid- and benzodiazepine-naïve patients admitted with COVID-19 not requiring mechanical ventilation. Of these, 22% received opioids, 13% received benzodiazepines, and 6% received both during the hospitalization. At discharge, 8% received an opioid prescription, and 3% received a benzodiazepine prescription. After multivariable adjustment, receipt of an opioid or benzodiazepine prescription at discharge was associated with the length of inpatient opioid or benzodiazepine exposure. These findings suggest that hospitalization represents a risk of opioid or benzodiazepine initiation among naïve patients, and judicious prescribing should be considered to prevent opioid-related harms.
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Affiliation(s)
- Lia D. Delaney
- University of Michigan Medical SchoolAnn ArborMichiganUSA
- Center for Healthcare Outcomes and PolicyAnn ArborMichiganUSA
| | - Mark C. Bicket
- Department of AnesthesiologyUniversity of Michigan Health SystemAnn ArborMichiganUSA
- Michigan Opioid Prescribing Engagement NetworkInstitute for Healthcare Policy and InnovationAnn ArborMI
| | - Hsou Mei Hu
- Michigan Opioid Prescribing Engagement NetworkInstitute for Healthcare Policy and InnovationAnn ArborMI
- Department of SurgeryUniversity of Michigan Health SystemAnn ArborMichiganUSA
| | - Megan O'Malley
- The Division of Hospital Medicine, Department of Internal MedicineUniversity of Michigan Health SystemAnn ArborMichiganUSA
- The Hospital Medicine Safety Consortium Coordinating CenterAnn ArborMichiganUSA
| | - Elizabeth McLaughlin
- The Division of Hospital Medicine, Department of Internal MedicineUniversity of Michigan Health SystemAnn ArborMichiganUSA
- The Hospital Medicine Safety Consortium Coordinating CenterAnn ArborMichiganUSA
| | - Scott A. Flanders
- The Division of Hospital Medicine, Department of Internal MedicineUniversity of Michigan Health SystemAnn ArborMichiganUSA
- The Hospital Medicine Safety Consortium Coordinating CenterAnn ArborMichiganUSA
| | - Valerie M. Vaughn
- The Division of Hospital Medicine, Department of Internal MedicineUniversity of Michigan Health SystemAnn ArborMichiganUSA
- Division of General Internal Medicine, Department of Internal MedicineUniversity of UtahSalt Lake CityUtahUSA
- Division of Health System Innovation & ResearchUniversity of UtahSalt Lake CityUtahUSA
| | - Jennifer F. Waljee
- Center for Healthcare Outcomes and PolicyAnn ArborMichiganUSA
- Michigan Opioid Prescribing Engagement NetworkInstitute for Healthcare Policy and InnovationAnn ArborMI
- Department of SurgeryUniversity of Michigan Health SystemAnn ArborMichiganUSA
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Holloway GL, Weymiller AJ, Allemand A. Goal-Directed Opioid Stewardship in Acute-on-Chronic Nonmalignant Pain Management. J Nurse Pract 2022. [DOI: 10.1016/j.nurpra.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Characteristics of Opioid Prescribing in Non-surgical Medicine Patients with Acute Pain at Hospital Discharge. J Gen Intern Med 2022; 37:565-572. [PMID: 34382139 PMCID: PMC8858354 DOI: 10.1007/s11606-021-07092-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 07/30/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND The opioid epidemic and new Joint Commission standards around opioid stewardship have made the appropriate prescribing of opioids a priority. A knowledge gap exists pertaining to the short-term prescription of opioids at hospital discharge for acute pain in non-surgical patients. OBJECTIVE To characterize the quantity, type, and indication of opioids prescribed for non-surgical patients on hospital discharge and subsequent patient utilization. DESIGN This multicenter, single-health system retrospective cohort study was conducted for quality improvement purposes from December 2019 to May 2020 with patient follow-up 15 to 29 days after hospital discharge. PARTICIPANTS Patients discharged from a medicine service with new opioid prescriptions, defined as no opioid prescription documented within the past 90 days, were identified as eligible through the electronic health record. Surveys were attempted until a total of 200 were completed, with 374 surveys attempted and a 53% response rate. INTERVENTION Patients were contacted via phone and surveyed post-discharge. Surveys consisted of 28 questions and assessed opioid consumption, duration of use, refills, patient satisfaction, and opioid disposal. MAIN MEASURES Prescribing indications and morphine milligram equivalents (MME) quantities were collected for patients at discharge. Subsequently, the quantity of prescribed opioids utilized, remaining, and disposed of post-discharge were collected via patient self-reported survey responses. KEY RESULTS Indications for opioid prescribing for 200 surveyed patients were grouped into eight broad prescribing categories. A median of 112.5 total MME was prescribed to patients at hospital discharge. Median MME consumed for surveyed patients was 45. The median total MME remaining at time of survey was 35 MME. Only 5.9% of patients who had leftover opioids reported disposal of the medication. CONCLUSIONS Given the observed variation in opioid prescribing and utilization data, standardized indication-based opioid prescribing guidance in the non-surgical medical population would help curb the amount of opioids that remain unused post-discharge.
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Deshpande BR, McCarthy EP, Jung Y, Anderson TS, Herzig SJ. Initiation of Long-Acting Opioids Following Hospital Discharge Among Medicare Beneficiaries. J Hosp Med 2021; 16:724-726. [PMID: 34797996 PMCID: PMC8626058 DOI: 10.12788/jhm.3721] [Citation(s) in RCA: 1] [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: 10/08/2021] [Accepted: 10/08/2021] [Indexed: 11/20/2022]
Abstract
Guidelines recommend against initiating long-acting opioids during acute hospitalization, owing to higher risk of overdose and morbidity compared to short-acting opioid initiation. We investigated the incidence of long-acting opioid initiation following hospitalization in a retrospective cohort of Medicare beneficiaries with an acute care hospitalization in 2016 who were ≥65 years old, did not have cancer or hospice care, and had not filled an opioid prescription within the preceding 90 days. Among 258,193 hospitalizations, 47,945 (18.6%) were associated with a claim for a new opioid prescription in the week after hospital discharge: 817 (0.3%) with both short- and long-acting opioids, 125 (0.1%) with long-acting opioids only, and 47,003 (18.2%) with short-acting opioids only. Most long-acting opioid claims occurred in surgical patients (770 out of 942; 81.7%). Compared with beneficiaries prescribed short-acting opioids only, beneficiaries prescribed long-acting opioids were younger, had a higher prevalence of diseases of the musculoskeletal system and connective tissue, and had more known risk factors for opioid-related adverse events, including anxiety disorders, opioid use disorder, prior long-term high-dose opioid use, and benzodiazepine co-prescription. These findings may help target quality-improvement initiatives.
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Affiliation(s)
| | - Ellen P McCarthy
- Harvard Medical School, Boston, Massachusetts
- Linda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Yoojin Jung
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Timothy S Anderson
- Harvard Medical School, Boston, Massachusetts
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Shoshana J Herzig
- Harvard Medical School, Boston, Massachusetts
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Corresponding Author: Shoshana J Herzig, MD, MPH; ; Telephone: 617-754-1413; Twitter: @ShaniHerzig
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Vien A, Shyh G, Jannat-Khah D, Chen S, Kuang X, Gerber LM, Lee JI. Impact of a Novel Hospital-Based Opioid Stewardship Program on Nonsurgical Acute Pain Management in the Hospital. J Gen Intern Med 2021; 36:3608-3610. [PMID: 33469760 PMCID: PMC8606386 DOI: 10.1007/s11606-020-06404-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 12/06/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Alexis Vien
- Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA. .,New York-Presbyterian Weill Cornell Medical Center, New York, NY, USA.
| | - Grace Shyh
- Clinical Pharmacy, New York-Presbyterian Lower Manhattan Hospital, New York, NY, USA
| | - Deanna Jannat-Khah
- Division of General Internal Medicine, Department of Rheumatology, Weill Cornell Medicine and Hospital for Special Surgery, New York, NY, USA
| | - Stephanie Chen
- New York-Presbyterian Weill Cornell Medical Center, New York, NY, USA.,Department of Anesthesiology, Columbia University School of Medicine, New York, NY, USA
| | - Xiao Kuang
- Department of Nursing, New York-Presbyterian Lower Manhattan Hospital, New York, NY, USA
| | - Linda M Gerber
- Division of Nephrology and Hypertension, Weill Cornell Medicine, New York, NY, USA.,Department of Healthcare Policy and Research, Division of Biostatistics and Epidemiology, Weill Cornell Medicine, New York, NY, USA
| | - Jennifer I Lee
- Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA.,New York-Presbyterian Weill Cornell Medical Center, New York, NY, USA
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Herzig SJ, Anderson TS, Jung Y, Ngo L, Kim DH, McCarthy EP. Relative risks of adverse events among older adults receiving opioids versus NSAIDs after hospital discharge: A nationwide cohort study. PLoS Med 2021; 18:e1003804. [PMID: 34570810 PMCID: PMC8504723 DOI: 10.1371/journal.pmed.1003804] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 10/11/2021] [Accepted: 09/09/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Although analgesics are initiated on hospital discharge in millions of adults each year, studies quantifying the risks of opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) among older adults during this transition are limited. We sought to determine the incidence and risk of post-discharge adverse events among older adults with an opioid claim in the week after hospital discharge, compared to those with NSAID claims only. METHODS AND FINDINGS We performed a retrospective cohort study using a national sample of Medicare beneficiaries age 65 and older, hospitalized in United States hospitals in 2016. We excluded beneficiaries admitted from or discharged to a facility. We derived a propensity score that included over 100 factors potentially related to the choice of analgesic, including demographics, diagnoses, surgeries, and medication coadministrations. Using 3:1 propensity matching, beneficiaries with an opioid claim in the week after hospital discharge (with or without NSAID claims) were matched to beneficiaries with an NSAID claim only. Primary outcomes included death, healthcare utilization (emergency department [ED] visits and rehospitalization), and a composite of known adverse effects of opioids or NSAIDs (fall/fracture, delirium, nausea/vomiting, complications of slowed colonic motility, acute renal failure, and gastritis/duodenitis) within 30 days of discharge. After propensity matching, there were 13,385 beneficiaries in the opioid cohort and 4,677 in the NSAID cohort (mean age: 74 years, 57% female). Beneficiaries receiving opioids had a higher incidence of death (1.8% versus 1.1%; relative risk [RR] 1.7 [1.3 to 2.3], p < 0.001, number needed to harm [NNH] 125), healthcare utilization (19.0% versus 17.4%; RR 1.1 [1.02 to 1.2], p = 0.02, NNH 59), and any potential adverse effect (25.2% versus 21.3%; RR 1.2 [1.1 to 1.3], p < 0.001, NNH 26), compared to those with an NSAID claim only. Specifically, they had higher relative risk of fall/fracture (4.5% versus 3.4%; RR 1.3 [1.1 to 1.6], p = 0.002), nausea/vomiting (9.2% versus 7.3%; RR 1.3 [1.1 to 1.4], p < 0.001), and slowed colonic motility (8.0% versus 6.2%; RR 1.3 [1.1 to 1.4], p < 0.001). Risks of delirium, acute renal failure, and gastritis/duodenitis did not differ between groups. The main limitation of our study is the observational nature of the data and possibility of residual confounding. CONCLUSIONS Older adults filling an opioid prescription in the week after hospital discharge were at higher risk for mortality and other post-discharge adverse outcomes compared to those filling an NSAID prescription only.
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Affiliation(s)
- Shoshana J. Herzig
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - Timothy S. Anderson
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Yoojin Jung
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
| | - Long Ngo
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Dae H. Kim
- Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, United States of America
| | - Ellen P. McCarthy
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, United States of America
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Dijkers MP, Ward I, Annaswamy T, Dedrick D, Hoffecker L, Millis SR. What Determines the Quality of Rehabilitation Clinical Practice Guidelines?: An Overview Study. Am J Phys Med Rehabil 2021; 100:790-797. [PMID: 33214385 PMCID: PMC8265547 DOI: 10.1097/phm.0000000000001645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of the study was to determine what factors determine the quality of rehabilitation clinical practice guidelines. DESIGN Six databases were searched for articles that had applied the Appraisal of Guidelines for Research & Evaluation II quality assessment tool to rehabilitation clinical practice guidelines. The 573 deduplicated abstracts were independently screened by two authors, resulting in 81 articles, the full texts of which were independently screened by two authors for Appraisal of Guidelines for Research & Evaluation II application to rehabilitation clinical practice guidelines, resulting in a final selection of 40 reviews appraising 504 clinical practice guidelines. Data were extracted from these by one author and checked by a second. Data on each clinical practice guideline included the six Appraisal of Guidelines for Research & Evaluation II domain scores, as well as the two Appraisal of Guidelines for Research & Evaluation II global evaluations. RESULTS All six Appraisal of Guidelines for Research & Evaluation II domain scores were statistically significant predictors of overall clinical practice guideline quality rating; D3 (rigor of development) was the strongest and D1 (scope and purpose) the weakest (overall model P < 0.001, R2 = 0.53). Five of the six domain scores were significant predictors of the clinical practice guideline use recommendation, with D3 the strongest predictor and D5 (applicability) the weakest (overall model P < 0.001, pseudo R2 = 0.53). CONCLUSIONS Quality of rehabilitation clinical practice guidelines may be improved by addressing key domains such as rigor of development.
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Ahmed A, Yakah W, Freedman SD, Kothari DJ, Sheth SG. Evaluation of Opioid Use in Acute Pancreatitis in Absence of Chronic Pancreatitis: Absence of Opioid Dependence an Important Feature. Am J Med 2020; 133:1209-1218. [PMID: 32272099 DOI: 10.1016/j.amjmed.2020.03.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/06/2020] [Accepted: 03/09/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Chronic opioid use and dependence is common in patients with chronic pancreatitis. Patients with acute pancreatitis are frequently treated with opioids, but their risk for ongoing use is not well known. The aim of our study is to characterize opioid use in patients after an episode of acute pancreatitis and to assess persistent, chronic, and daily opioid use in such patients in the absence of chronic pancreatitis. METHODS This is a single-center review of prospectively enrolled patients with acute pancreatitis. Using the Massachusetts Prescription Awareness Tool, we recorded all opioid prescriptions (ie, frequency, duration, and amount) for patients from December 2016 to September 2019, after index hospitalization for acute pancreatitis. Patients with chronic pancreatitis were excluded. We used univariate and multivariate analysis to determine predictors of opioid use at discharge and subsequent follow-up over 18 months. RESULTS Of 235 enrolled patients who were opioid-naïve, 123 patients (52.3%) received opioids at discharge after index hospitalization. In follow-up over 18 months, 40 patients (17.0%) received additional opioid prescriptions. These patients had more severe disease, longer length of stay, and higher pain score at discharge. Patients with prior history of acute pancreatitis, local complications, and higher pain scores were twice as likely to subsequently be prescribed opioids. Persistent opioid use was seen only in recurrent acute pancreatitis. There was no daily or chronic opioid use. CONCLUSIONS In the absence of chronic pancreatitis, there was no daily or chronic use of opioids in patients with acute pancreatitis. Persistent use was only seen in patients with recurrent acute pancreatitis. These patients are at increased risk of chronic opioid use and dependence.
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Affiliation(s)
- Awais Ahmed
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
| | - William Yakah
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Steven D Freedman
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Darshan J Kothari
- Department of Medicine, Division of Gastroenterology, Duke University, Durham, NC
| | - Sunil G Sheth
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
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Dijkers MP, Ward I, Annaswamy T, Dedrick D, Feldpausch J, Moul A, Hoffecker L. Quality of Rehabilitation Clinical Practice Guidelines: An Overview Study of AGREE II Appraisals. Arch Phys Med Rehabil 2020; 101:1643-1655. [DOI: 10.1016/j.apmr.2020.03.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/20/2020] [Accepted: 03/24/2020] [Indexed: 12/30/2022]
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Abstract
Nurses caring for critically ill adults are challenged to balance patient comfort with the risk of complications associated with analgesic therapy. Evidence gathered since 2013, when the Society of Critical Care Medicine (SCCM) published the Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit, known as the PAD guidelines, gave rise to the SCCM 2018 publication of the Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU, known as the PADIS guidelines. This article discusses how the PADIS guidelines go beyond the PAD guidelines, providing specific guidance related to risk factors for pain, the assessment and management of pain in critical illness, and the ways in which the experience of pain in critical illness is intertwined with that of agitation, delirium, immobility, and sleep disruption. Tables summarize the key points in the PADIS guidelines, clarify the distinctions between PADIS and PAD, and describe the implications for nurses.
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Witcraft EJ, Gonzales JP, Seung H, Watt I, Tata AL, Yeung SYA, Heavner MS, Qato DM, Gulati MS, Millstein LS. Continuation of Opioid Therapy at Transitions of Care in Critically Ill Patients. J Intensive Care Med 2020; 36:879-884. [PMID: 32552281 DOI: 10.1177/0885066620933798] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Opioids are one of the high-risk medication classes that are administered to critically ill patients during their intensive care unit (ICU) stay. However, little attention has been given to inpatient opioid prescribing practices, especially in critically ill patients. The purpose of our study was to characterize opioid prescribing practices across 2 transitions of care during an inpatient hospital stay: medical ICU (MICU)/intermediate care unit (IMC) to floor and floor to hospital discharge and identify potential patient-specific factors that impact opioid continuation. METHODS This is a retrospective cohort study evaluating opioid-naive adult patients with new opioid therapy initiated in MICU/IMC at a tertiary care academic medical center from December 1, 2016, to November 30, 2017. Opioid continuation rate was assessed twice: transition 1 (MICU/IMC to floor) and transition 2 (floor to hospital discharge). RESULTS In total, 112 opioid-naive patients with initial opioid administration in the MICU/IMC were included. Opioid therapy was continued in 56.1% (37/66) at transition 1 and 56.8% of patients (21/37) at transition 2. Patients with opioids continued at transition 1 had a longer hospital length of stay compared to those not continued on opioids, 22 (interquartile range [IQR] 11-36) vs 8 (IQR 6-14; P = .0004). Among the patients continued on opioids at hospital discharge, intubation during hospital stay and cumulative opioid dosage were greater than those not continued on opioids (17 [80.9%] vs 7 [43.8%], P = .019; and 3482 mcg [IQR 1690-9530] vs 732.5 mcg [IQR 187.5-1360.9], P = .0018, respectively). CONCLUSIONS Opioid-naive patients receiving opioid therapy in the MICU/IMC had a continuation rate of >56% during transitions of care, including hospital discharge. Factors that contributed to the continuation of opioids at transitions of care included longer hospital length of stay, intubation, and cumulative hospital opioid dosage. These findings may help to provide health systems with guidance on targeted opioid stewardship programs.
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Affiliation(s)
- Emily J Witcraft
- Department of Pharmacy, 2334University of North Carolina Medical Center, Chapel Hill, NC, USA
| | | | - Hyunuk Seung
- Department of Pharmacy Practice and Science, 15513University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Ian Watt
- Department of Pharmacy Practice and Science, 15513University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Asha L Tata
- Department of Pharmacy Services, 21668University of Maryland Medical Center, Baltimore, MD, USA
| | - Siu Yan Amy Yeung
- Department of Pharmacy Services, 21668University of Maryland Medical Center, Baltimore, MD, USA
| | - Mojdeh S Heavner
- Department of Pharmacy Practice and Science, 15513University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Danya M Qato
- Department of Pharmacy Practice and Science, 15513University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Mangla S Gulati
- Department of General Internal Medicine, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Leah S Millstein
- Department of General Internal Medicine, 12264University of Maryland School of Medicine, Baltimore, MD, USA
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Díaz S, Zhao J, Cronin S, Jaglal S, Bombardier C, Furlan AD. Changes in Opioid Prescribing Behaviors among Family Physicians Who Participated in a Weekly Tele-Mentoring Program. J Clin Med 2019; 9:jcm9010014. [PMID: 31861584 PMCID: PMC7019354 DOI: 10.3390/jcm9010014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 12/10/2019] [Accepted: 12/17/2019] [Indexed: 11/29/2022] Open
Abstract
A weekly tele-mentoring program was implemented in Ontario to help address the growing opioid crisis through teaching and mentoring family physicians on the management of chronic pain and opioid prescribing. This study assessed opioid prescribing behaviours among family physicians who attended the tele-mentoring program compared to two groups of Ontario family physicians who did not attend the program. We conducted a retrospective cohort study with two control groups: a matched cohort, and a random sample of 3000 family physicians in Ontario. Each physician was followed from one year before the program, which is the index date, and one year after. We examined the number and proportion of patients on any opioid, on high dose opioids, and the average daily morphine equivalent doses prescribed to each patient. We included 24 physicians who participated in the program (2760 patients), 96 matched physicians (11,117 patients) and 3000 random family doctors (374,174 patients). We found that, at baseline, the tele-mentoring group had similar number of patients on any opioid, but more patients on high dose opioids than both control groups. There was no change in the number of patients on any opioid before and after the index date, but there was a significant reduction in high-dose opioid prescriptions in the extension for community healthcare outcomes (ECHO) group, compared to a non-significant increase in the matched cohort, and a non-significant reduction in the Ontario group during the same comparable periods. Participation in the program was associated with a greater reduction in high-dose opioid prescribing.
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Affiliation(s)
- Santana Díaz
- Institute of Medical Sciences, University of Toronto, Toronto, ON M5S, Canada
| | - Jane Zhao
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON M5G1L7, Canada
| | - Shawna Cronin
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5S, Canada
| | - Susan Jaglal
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5S, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON M5S, Canada
| | - Claire Bombardier
- Institute of Medical Sciences, University of Toronto, Toronto, ON M5S, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5S, Canada
- Department of Medicine, University of Toronto, Toronto, ON M5S, Canada
- Mount Sinai Hospital, Toronto, ON M5G1X5, Canada
- Institute for Work & Health, Toronto, ON M5G2E9, Canada
| | - Andrea D. Furlan
- Institute of Medical Sciences, University of Toronto, Toronto, ON M5S, Canada
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON M5G1L7, Canada
- Department of Medicine, University of Toronto, Toronto, ON M5S, Canada
- Institute for Work & Health, Toronto, ON M5G2E9, Canada
- Correspondence:
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15
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Abstract
OBJECTIVES Opioids are commonly used in the management of acute pancreatitis (AP). Inpatient opioid exposure is known to increase the risk of chronic opioid use after discharge. Prescription patterns for opioids at discharge for AP are unknown. METHODS Medical records of adult AP patients who presented to the emergency department from September 1, 2013, to August 31, 2016, were reviewed. Opioid prescription at discharge was defined as a prescription for opioids in a patient who was opioid naive at admission. Multivariable logistic regression was performed to identify predictors of opioid prescription at discharge. RESULTS A total of 259 opioid-naive AP patients were identified. Of these, 108 (41.6%) of 259 were discharged with an opioid prescription and 61 (56.5%) of 108 had discharge pain scores of 3 or lower. Two hundred twenty-two (85.7%) received opioids during admission and 105 (47.3%) of 222 were discharged with an opioid prescription. On multivariable analysis, predictors of discharge opioid prescription included inpatient use of opioids, female sex, and discharge pain score greater than 3. CONCLUSIONS In opioid-naive AP patients, 41.6% were discharged from the hospital with a new prescription for opioids, even though a significant proportion had pain scores of 3 or lower. Guidelines are needed for opioid prescriptions at discharge for AP.
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Stanley B, Collins LJ, Norman AF, Karro J, Jung M, Bonomo YA. Opioid prescribing in the emergency department of a tertiary hospital: A retrospective audit of hospital discharge data. Emerg Med Australas 2019; 32:33-38. [DOI: 10.1111/1742-6723.13331] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 05/05/2019] [Accepted: 05/14/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Beata Stanley
- Department of Addiction MedicineSt Vincent's Hospital Melbourne Melbourne Victoria Australia
| | - Lisa J Collins
- Department of Addiction MedicineSt Vincent's Hospital Melbourne Melbourne Victoria Australia
| | - Amanda F Norman
- Department of Addiction MedicineSt Vincent's Hospital Melbourne Melbourne Victoria Australia
| | - Jonathon Karro
- Department of Emergency MedicineSt Vincent's Hospital Melbourne Melbourne Victoria Australia
| | - Monica Jung
- Department of Addiction MedicineSt Vincent's Hospital Melbourne Melbourne Victoria Australia
| | - Yvonne A Bonomo
- Department of Addiction MedicineSt Vincent's Hospital Melbourne Melbourne Victoria Australia
- Department of MedicineThe University of Melbourne Melbourne Victoria Australia
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17
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Herzig SJ, Mosher HJ, Calcaterra SL, Nuckols TK. Reply to "In Reference to 'Improving the Safety of Opioid Use for Acute Noncancer Pain in Hospitalized Adults: A Consensus Statement from the Society of Hospital Medicine'". J Hosp Med 2018; 13:728. [PMID: 30261091 PMCID: PMC7556321 DOI: 10.12788/jhm.3058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Shoshana J Herzig
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
- Harvard Medical School, Boston, Massachusetts, USA
| | - Hilary J Mosher
- The Comprehensive Access and Delivery Research and Evaluation Center at the Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa, USA
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Susan L Calcaterra
- Department of Medicine, Denver Health Medical Center, Denver, Colorado, USA
- Department of Medicine, Division of General Internal Medicine, University of Colorado, Aurora, Colorado, USA
| | - Teryl K Nuckols
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
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