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Smid MC, Clifton RG, Rood K, Srinivas S, Simhan HN, Casey BM, Longo M, Landau R, MacPherson C, Bartholomew A, Sowles A, Reddy UM, Rouse DJ, Bailit JL, Thorp JM, Chauhan SP, Saade GR, Grobman WA, Macones GA. Optimizing Opioid Prescription Quantity After Cesarean Delivery: A Randomized Controlled Trial. Obstet Gynecol 2024; 144:195-205. [PMID: 38857509 PMCID: PMC11257794 DOI: 10.1097/aog.0000000000005649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Accepted: 04/25/2024] [Indexed: 06/12/2024]
Abstract
OBJECTIVE To test whether an individualized opioid-prescription protocol (IOPP) with a shared decision-making component can be used without compromising postcesarean pain management. METHODS In this multicenter randomized controlled noninferiority trial, we compared IOPP with shared decision making with a fixed quantity of opioid tablets at hospital discharge. We recruited at 31 centers participating in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Study participants had uncomplicated cesarean births. Follow-up occurred through 12 weeks postdischarge. Individuals with complicated cesarean births or history of opioid use in the pregnancy were excluded. Participants were randomized 1:1 to IOPP with shared decision making or fixed quantity (20 tablets of 5 mg oxycodone). In the IOPP group, we calculated recommended tablet quantity based on opioid use in the 24 hours before discharge. After an educational module and shared decision making, participants selected a quantity of discharge tablets (up to 20). The primary outcome was moderate to severe pain (score 4 or higher [possible range 0-10]) on the BPI (Brief Pain Inventory) at 1 week after discharge. A total sample size of 5,500 participants was planned to assess whether IOPP with shared decision making was not inferior to the fixed quantity of 20 tablets. RESULTS From September 2020 to March 2022, 18,990 individuals were screened and 5,521 were enrolled (n=2,748 IOPP group, n=2,773 fixed-quantity group). For the primary outcome, IOPP with shared decision making was not inferior to fixed quantity (59.5% vs 60.1%, risk difference 0.67%; 95% CI, -2.03% to 3.37%, noninferiority margin -5.0) and resulted in significantly fewer tablets received (median 14 [interquartile range 4-20] vs 20, P <.001) through 90 days postpartum. CONCLUSION Compared with fixed quantity, IOPP with shared decision making was noninferior for outpatient postcesarean analgesia at 1 week postdischarge and resulted in fewer prescribed opioid tablets at discharge. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT04296396.
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Affiliation(s)
- Marcela C Smid
- Departments of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, Utah, The Ohio State University, Columbus, Ohio, University of Pennsylvania, Philadelphia, Pennsylvania, University of Pittsburgh, Pittsburgh, Pennsylvania, University of Alabama at Birmingham, Birmingham, Alabama, Brown University, Providence, Rhode Island, Columbia University, New York, New York, University of Texas Medical Branch, Galveston, Texas, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, University of Texas Health Science Center at Houston, Children's Memorial Hermann Hospital, Houston, Texas, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, Northwestern University, Chicago, Illinois, and University of Texas at Austin, Austin, Texas; the Department of Anesthesiology, Columbia University, New York, New York; the George Washington University Biostatistics Center, Washington, DC; and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
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Sarantou M, Burke ALJ, Semple T, Johnson JL. A 3-year retrospective review of hospital admissions involving opioid toxicity in South Australia. Drug Alcohol Rev 2024. [PMID: 39072905 DOI: 10.1111/dar.13913] [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: 09/09/2023] [Revised: 05/21/2024] [Accepted: 07/10/2024] [Indexed: 07/30/2024]
Abstract
INTRODUCTION This article aims to characterise hospital admissions involving opioid toxicity across South Australia to guide future implementation and evaluation of risk mitigation strategies. METHODS International Classification of Diseases, 10th Edition codes (T40.0-T40.4) were used to identify admissions involving pre-hospital opioid toxicity in public hospitals across South Australia from 1 June 2017 to 30 August 2020. Demographic and episode of care data were extracted and summarised using descriptive statistics. Admission cost estimates were calculated using Independent Hospital Pricing Authority data. RESULTS A total of 2046 cases met the criteria for inclusion; over half (56%) were female and median age on admission was 44 years (interquartile range 27 years). Where opioid toxicity was the primary diagnosis, 70% of admissions did not specify the responsible opioid and 23% were related to heroin use. One-fifth of admissions occurred outside of metropolitan Adelaide. Individuals living in an area of relative socio-economic disadvantage were over-represented. Over half of admissions required a stay >24 h; 19% were admitted for ≥5 days, 22% required intensive care and ~10% required mechanical ventilation. The total estimated cost of admissions involving opioid toxicity in South Australia over the 3-year period was $18,230,546.50, equating to $5.6 million per annum. DISCUSSIONS AND CONCLUSIONS These findings highlight the significant personal, fiscal, and systemic impacts of opioid toxicity-related hospital admissions in South Australia and provide a baseline to evaluate the effectiveness of initiatives to reduce opioid-related harm, including real-time prescription monitoring and take-home naloxone supply.
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Affiliation(s)
- Maria Sarantou
- Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Anne L J Burke
- South Australian Statewide Chronic Pain Clinical Network, Commission on Excellence and Innovation in Health, Adelaide, Australia
- Psychology Department, Central Adelaide Local Health Network, Adelaide, Australia
- Faculty of Health and Medical Sciences, School of Psychology, The University of Adelaide, Adelaide, Australia
| | - Tim Semple
- South Australian Statewide Chronic Pain Clinical Network, Commission on Excellence and Innovation in Health, Adelaide, Australia
- Pain Management Unit, Central Adelaide Local Health Network, Adelaide, Australia
| | - Jacinta L Johnson
- South Australian Statewide Chronic Pain Clinical Network, Commission on Excellence and Innovation in Health, Adelaide, Australia
- UniSA Clinical and Health Sciences, University of South Australia, Adelaide, Australia
- SA Pharmacy, Statewide Clinical Support Services, SA Health, Adelaide, Australia
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Varney B, Zoega H, Gillies MB, Gisev N, Weston Shand A, Pearson SA, Havard A. Prevalence and Persistence of Prescription Opioid Use Following Hospital Discharge After Childbirth: An Australian Population-Based Cohort Study. Anesth Analg 2024; 138:970-979. [PMID: 37319031 DOI: 10.1213/ane.0000000000006582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
BACKGROUND Opioid analgesics are used for acute postpartum pain relief but carry risks, including persistent long-term opioid use. Our primary objective was to estimate the prevalence of persistent use following hospital discharge after childbirth. METHODS We conducted a population-based cohort study of women discharged from public or private hospitals in New South Wales, Australia, between 2012 and 2018 following vaginal birth (VB) or cesarean delivery (CD). We used linked hospitalization and medicine dispensing data to calculate the prevalence of opioid use within 14 days of hospital discharge for childbirth using an external estimate of the total number of hospital admissions for childbirth per year as the denominator. Among women dispensed an opioid postdischarge, we estimated the prevalence of persistent use defined as ≥3 dispensings between 30- and 365-days postdischarge. To calculate the odds of persistent opioid use, we performed a series of logistic regressions each including a single characteristic of interest. Included characteristics were maternal and birth characteristics, maternal medical conditions, prior use of certain medicines, and the initial opioid dispensed following discharge for childbirth. RESULTS The final cohort comprised of 38,832 women who were dispensed an opioid in the 14 days following discharge after childbirth. Between 2012 and 2018, the prevalence of opioid use was increased following CD (public hospital 16.6%-21.0%; private hospital 9.8%-19.5%) compared with VB (public hospital 1.5%-1.5%; private hospital 1.2%-1.4%) and was higher following discharge from public hospitals compared with private. The most commonly dispensed opioids following discharge for childbirth were oxycodone (44.8%; 95% confidence interval [CI], 44.3-45.3), codeine (42.1%; 95% CI, 41.6-42.6), and tramadol (12.9%; 95% CI, 12.6-13.2). Among women dispensed an opioid, the prevalence of persistent opioid use was 5.4% (95% CI, 5.1-5.6). This prevalence was 11.4% (95% CI, 10.5-12.3) following a VB as compared with 4.3% (95% CI, 4.1-4.6) among those who underwent a CD ( P < .001). Characteristics associated with persistent opioid use included smoking during pregnancy, age <25 years, living in remote areas, discharged from a public hospital, history of opioid use disorder, other substance use disorder, mental health diagnosis, or prior use of prescription opioids, nonopioid analgesics, or benzodiazepines. CONCLUSIONS The results of this cohort study indicate that Australian women have a higher prevalence of opioid use following CD compared to VB. One in 19 women dispensed an opioid postdischarge used opioids persistently. Careful monitoring of opioid therapy following childbirth is warranted, particularly among women with characteristics we identified as high risk for persistent opioid use.
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Affiliation(s)
- Bianca Varney
- From the School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Helga Zoega
- From the School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
- Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Malcolm Bjørn Gillies
- From the School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Natasa Gisev
- National Drug and Alcohol Research Centre, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Antonia Weston Shand
- Department of Maternal Fetal Medicine, Royal Hospital for Women, Randwick, Sydney, Australia
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Sallie-Anne Pearson
- From the School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Alys Havard
- From the School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
- National Drug and Alcohol Research Centre, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
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Lu A, Armstrong M, Alexander R, Vest E, Chang J, Zhu M, Xiang H. Trends in pediatric prescription-opioid overdoses in U.S. emergency departments from 2008-2020: An epidemiologic study of pediatric opioid overdose ED visits. PLoS One 2024; 19:e0299163. [PMID: 38630653 PMCID: PMC11023208 DOI: 10.1371/journal.pone.0299163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 02/05/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Opioid overdose was declared a public health emergency in the United States, but much of the focus has been on adults. Child and adolescent exposure and access to unused prescription-opioid medications is a big concern. More research is needed on the trend of pediatric (age 0-17) prescription-opioid overdose emergency department (ED) visits in the United States, particularly during the COVID-19 pandemic year. METHODS This retrospective epidemiological study used the 2008-2020 Nationwide Emergency Department Sample to provide a national estimate of ED visits related to prescription-opioid overdose. Inclusion criteria were 0-17-year-old patients treated at the ED due to prescription-opioid overdose. Eligible visits were identified if their medical records included any administrative billing codes for prescription-opioid overdose. National estimates were broken down by age groups, sex, geographic region, primary payer, median household income by zip code, ED disposition, and hospital location/teaching status. Incidence rate per 100,000 U.S. children was calculated for age groups, sex, and geographic region. RESULTS Overall, the prescription-opioid overdose ED visits for patients from 0-17 years old in the United States decreased by 22% from 2008 to 2019, then increased by 12% in 2020. Most patients were discharged to home following their ED visit; however, there was a 42% increase in patients admitted from 2019 to 2020. The prescription-opioid overdose rate per 100,000 U.S. children was highest in the 0 to 1 and 12 to 17 age groups, with the 12 to 17 group increasing by 27% in 2020. ED visits in the West and Midwest saw prescription-opioid visits increase by 58% and 20%, respectively, from 2019-2020. CONCLUSIONS Prescription-opioid overdose ED visits among U.S. children and adolescents decreased over the past decade until 2019. However, there was a substantial increase in ED visits from 2019 to 2020, suggesting the potential impact due to the then-emerging COVID-19 pandemic. Findings suggest focusing on young children and adolescents to reduce further prescription-opioid overdoses in the United States.
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Affiliation(s)
- Audrey Lu
- The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Center for Pediatric Trauma Research, Columbus, OH, United States of America
| | - Megan Armstrong
- The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Center for Pediatric Trauma Research, Columbus, OH, United States of America
- The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Center for Injury Research and Policy, Columbus, OH, United States of America
| | - Robin Alexander
- Biostatistics Resource at Nationwide Children’s Hospital (BRANCH), The Ohio State University, Columbus, OH, United States of America
| | - Eurella Vest
- The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Center for Pediatric Trauma Research, Columbus, OH, United States of America
- Ohio University Heritage College of Osteopathic Medicine, Dublin Campus, Dublin, OH, United States of America
| | - Jonathan Chang
- Department of Emergency Medicine, Nationwide Children’s Hospital, Columbus, OH, United States of America
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States of America
| | - Motao Zhu
- The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Center for Injury Research and Policy, Columbus, OH, United States of America
| | - Henry Xiang
- The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Center for Pediatric Trauma Research, Columbus, OH, United States of America
- The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Center for Injury Research and Policy, Columbus, OH, United States of America
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States of America
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Chau LQ, Crawford JR. Neuroimaging features of accidental fentanyl overdose in a toddler. BMJ Case Rep 2024; 17:e258524. [PMID: 38191218 PMCID: PMC10806892 DOI: 10.1136/bcr-2023-258524] [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: 01/10/2024] Open
Abstract
The opioid epidemic has become a significant public health crisis worldwide. With the rise in popularity of fentanyl, opioid overdoses continue to rise at unprecedented rates. Unfortunately, young children have become collateral damage in the face of the opioid epidemic. Accidental exposures and ingestions are the leading cause of opioid overdose in this age group and can result in significant acute complications, long-term sequelae and even death. We present the case of a toddler with accidental fentanyl ingestion who experienced seizures and required intubation for respiratory distress. He was found to have notable diffusion restriction cerebellar changes on MRI and ultimately discharged with normal neurological function. Our case adds to the growing literature of the clinical presentation and neuroimaging features associated with opioid toxicity in young children.
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Affiliation(s)
- Lianne Q Chau
- School of Medicine, University of California San Diego, La Jolla, California, USA
| | - John Ross Crawford
- Pediatrics, University of California Irvine, Irvine, California, USA
- Pediatrics, Children's Hospital Orange County, Orange, California, USA
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Zipursky JS, Everett K, Calzavara A, Gomes T, Juurlink DN. New Persistent Opioid Use After Childbirth. Obstet Gynecol 2023; 142:1440-1449. [PMID: 37917933 DOI: 10.1097/aog.0000000000005432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/14/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVE To examine factors associated with new persistent opioid use after childbirth. METHODS We conducted a population-based cohort study of individuals who initiated opioid therapy within 7 days of discharge from hospital after delivery between September 1, 2013, and September 30, 2021. The primary outcome was new persistent opioid use , which was defined as one or more prescriptions for an opioid within 90 days of the first postpartum prescription and one or more subsequent opioid prescriptions in the 91-365 days afterward. We used multivariable logistic regression to assess patient-, pregnancy-, and prescription-related factors associated with new persistent opioid use after delivery. RESULTS We identified 118,694 unique deliveries after which opioids were initiated, including 99,399 cesarean (83.7%) and 19,295 vaginal (16.3%) deliveries. Among mothers who initiated an opioid after delivery, 1,282 (10.8/1,000 deliveries) met our definition of new persistent opioid use in the subsequent year. Rates of new persistent opioid use were appreciably higher after vaginal (16.0/1,000) compared with cesarean (9.8/1,000) deliveries. Each additional 30 morphine milligram equivalents in the initial opioid prescription was associated with an increased risk of new persistent use after cesarean (adjusted odds ratio [aOR] 1.06, 95% CI 1.04-1.08) and vaginal (aOR 1.05, 95% CI 1.02-1.08) delivery. A concomitant benzodiazepine prescription after cesarean delivery was associated with a markedly increased risk of persistent opioid use (aOR 2.69, 95% CI 1.60-4.52). CONCLUSION Among people who filled an opioid prescription after delivery, about 1% displayed evidence of persistent opioid use in the subsequent year. Initial prescriptions for large quantities of opioids and a concurrent benzodiazepine prescription may be important modifiable risk factors to prevent new persistent opioid use after delivery.
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Affiliation(s)
- Jonathan S Zipursky
- Department of Medicine, Sunnybrook Health Sciences Centre, ICES, the Sunnybrook Research Institute, the Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, and the Leslie Dan Faculty of Pharmacy and the Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Zipursky JS, Gomes T, Everett K, Calzavara A, Paterson JM, Austin PC, Mamdani MM, Ray JG, Juurlink DN. Maternal opioid treatment after delivery and risk of adverse infant outcomes: population based cohort study. BMJ 2023; 380:e074005. [PMID: 36921977 PMCID: PMC10015218 DOI: 10.1136/bmj-2022-074005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
OBJECTIVE To examine whether maternal opioid treatment after delivery is associated with an increased risk of adverse infant outcomes. DESIGN Population based cohort study. SETTING Ontario, Canada. PARTICIPANTS 865 691 mother-infant pairs discharged from hospital alive within seven days of delivery from 1 September 2012 to 31 March 2020. Each mother who filled an opioid prescription within seven days of discharge was propensity score matched to a mother who did not. MAIN OUTCOME MEASURES The primary outcome was hospital readmission of infants for any reason within 30 days of their mother filling an opioid prescription (index date). Infant related secondary outcomes were any emergency department visit, hospital admission for all cause injury, admission to a neonatal intensive care unit, admission with resuscitation or assisted ventilation, and all cause death. RESULTS 85 675 mothers (99.8% of the 85 852 mothers prescribed an opioid) who filled an opioid prescription within seven days of discharge after delivery were propensity score matched to 85 675 mothers who did not. Of the infants admitted to hospital within 30 days, 2962 (3.5%) were born to mothers who filled an opioid prescription compared with 3038 (3.5%) born to mothers who did not. Infants of mothers who were prescribed an opioid were no more likely to be admitted to hospital for any reason than infants of mothers who were not prescribed an opioid (hazard ratio 0.98, 95% confidence interval 0.93 to 1.03) and marginally more likely to be taken to an emergency department in the subsequent 30 days (1.04, 1.01 to 1.08), but no differences were found for any other adverse infant outcomes and there were no infant deaths. CONCLUSIONS Findings from this study suggest no association between maternal opioid prescription after delivery and adverse infant outcomes, including death.
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Affiliation(s)
- Jonathan S Zipursky
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto ON M4N 3M5, Canada
- ICES, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Tara Gomes
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | | | | | - J Michael Paterson
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Peter C Austin
- ICES, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Muhammad M Mamdani
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Joel G Ray
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Department of Medicine, St Michael's Hospital, Toronto, Ontario, Canada
| | - David N Juurlink
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto ON M4N 3M5, Canada
- ICES, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Yakubi H, Gac B, Apollonio DE. Industry strategies to market opioids to children and women in the USA: a content analysis of internal industry documents from 1999 to 2017 released in State of Oklahoma v. Purdue Pharma, L.P. et al. BMJ Open 2022; 12:e052636. [PMID: 36323465 PMCID: PMC9639061 DOI: 10.1136/bmjopen-2021-052636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVE Identify advertising strategies used to market opioids to women and children. DESIGN Qualitative content analysis of internal pharmaceutical industry documents released in litigation, dated between 1999 and 2017. SETTING USA. PARTICIPANTS Opioid manufacturers (Janssen, Ortho-McNeil, Purdue, Teva (Actavis), Janus, Cephalon); women; children. PRIMARY AND SECONDARY OUTCOME MEASURES Advertising campaigns, industry executive statements regarding marketing goals METHODS: We examined ((DATASET) link: https://www.industrydocuments.ucsf.edu/drug/) documents released in State of Oklahoma v. Johnson & Johnson (2019) to identify marketing strategies and campaigns developed by opioid manufacturers that focused on children and women, as well as public records, including websites developed by manufacturers and their allies, to confirm whether marketing campaigns proposed in internal industry documents were implemented. Documents identified as relevant were coded for themes based on expectations drawn from previous research on marketing using internal industry documents, which included making emotional appeals and understating the risks of addiction. RESULTS We found that opioid manufacturers sought to recruit coaches and school nurses to encourage opioid use by children, developed unbranded initiatives suggesting adolescents ask providers for pain care medications, suggested that opioid use could reduce health risks associated with untreated pain among women and advocated to policy makers that women faced unmet needs for pain medication. CONCLUSIONS The USA strictly regulates direct marketing of medications but does not place the same restrictions on indirect marketing and unbranded campaigns, which encourage people to seek treatment without indicating the names of specific products. Opioid manufacturers in the early 21st century appear to have relied largely on unbranded campaigns for marketing, which they described externally as public health promotion and internally as a way to increase sales of opioids. The rapid increase in opioid use concomitant with these campaigns suggests that additional scrutiny of this kind of marketing may be needed in order to protect vulnerable groups.
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Affiliation(s)
- Hanna Yakubi
- Department of Clinical Pharmacy, University of California, San Francisco, California, USA
| | - Brian Gac
- Department of Clinical Pharmacy, University of California, San Francisco, California, USA
| | - Dorie E Apollonio
- Department of Clinical Pharmacy, University of California, San Francisco, California, USA
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Abraham O, Rosenberger CA, Birstler J. Psychometric validation of the AOSL scale using confirmatory factor analysis: A nationally representative sample. J Am Pharm Assoc (2003) 2022; 62:1638-1643.e6. [PMID: 35450831 PMCID: PMC9680980 DOI: 10.1016/j.japh.2022.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 03/14/2022] [Accepted: 03/24/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The opioid overdose epidemic has worsened during the COVID-19 pandemic. Recent data revealed a 28.5% increase in drug-related overdose deaths from 2019 to 2020. Adolescents often misuse family members' and friends' prescription opioid medications. Furthermore, adolescents may not possess the knowledge or understanding to safely manage opioid medications. There is a need for a validated scale to effectively measure adolescents' opioid misuse knowledge, attitudes, and interest in learning about prescription opioid safety. OBJECTIVE The purpose of this study was to validate the Adolescent Opioid Safety and Learning (AOSL) scale with a nationally representative sample of adolescents and confirm the factor structure of the scale using confirmatory factor analysis (CFA). METHODS Adolescent participants (aged 13-18 years) completed the 16-item AOSL scale in Qualtrics from November to December 2020. A total of 774 responses were analyzed. A CFA was performed to determine the fit of the data to the 4-factor model proposed by a prior exploratory factor analysis of the AOSL scale. Fit was assessed using the chi-square test, comparative fit index (CFI), Tucker-Lewis index (TLI), and root mean-squared error of approximation (RMSEA). RESULTS Participants were 50% male and 62% white non-Hispanic. The CFI was 0.984, TLI was 0.980, and RMSEA was 0.048 ([95% CI 0.041-0.054], P-value that RMSEA ≤ 0.05 = 0.712). The chi-square test results were χ2 = 268.752 on 98 degrees of freedom (P < 0.001). Cronbach's alpha, a measure of internal consistency, was high within each factor. CFA indicated good fit of the current study's data to the 4-factor model. CONCLUSION We found the AOSL scale measures adolescents' knowledge of opioid misuse, knowledge of opioid harm, interest in learning about prescription opioids, and likelihood to practice misuse behaviors. This scale can help researchers understand adolescent perceptions and opinions about opioid safety.
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Affiliation(s)
| | | | - Jen Birstler
- Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin-Madison
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Keane AM, Larson EL, Payne RM, Cooke S, Zubovic E, Patel KB, Mackinnon SE, Snyder-Warwick AK. Dispose with dish soap: a simple and convenient method to increase proper opioid disposal in postoperative pediatric patients. J Plast Reconstr Aesthet Surg 2022; 75:3845-3852. [DOI: 10.1016/j.bjps.2022.06.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 03/09/2022] [Accepted: 06/08/2022] [Indexed: 10/17/2022]
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Higgins RM, Petro CC, Warren J, Perez AJ, Dews T, Phillips S, Reinhorn M. The opioid reduction task force: using the ACHQC Data Registry to combat an epidemic in hernia patients. Hernia 2022; 26:855-864. [PMID: 35039950 DOI: 10.1007/s10029-021-02556-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/27/2021] [Indexed: 11/04/2022]
Abstract
PURPOSE Post-operative opioid prescriptions contribute to prolonged opioid misuse and abuse. Using a national hernia registry, we aimed to evaluate the effectiveness of a data-driven educational intervention on surgeon prescribing behavior. METHODS After collecting opioid prescribing and patient consumption data from March 2019-December 2019 in inguinal and umbilical hernia repair, the Abdominal Core Health Quality Collaborative (ACHQC) Opioid Reduction Task Force presented data at a Quality Improvement (QI) Summit to educate surgeons on strategies to minimize opioid prescribing. Surgeons were asked to implement a multimodal pain management approach and were supported with educational tools created by the task force. Prescribing and consumption data after the summit, December 2019-March 2021, were then collected to assess the effectiveness of the QI effort. RESULTS Registry participation before and after the QI summit increased from 52 to 91 surgeons, with an increase of 353-830 umbilical hernia patients and 976-2447 inguinal hernia patients. After the summit, high (> 10 tablets) surgeon prescribers shifted toward low (≤ 10 tablets) prescribing. Yet, patients consumed less than what was prescribed, with a significant increase in patients consuming ≤ 10 tablets before and after the summit: 79-88% in umbilical hernia (p = 0.01) and 85-94% in inguinal hernia (p < 0.001). CONCLUSIONS Following an educational QI summit by the ACHQC Opioid Reduction Task Force, high opioid prescribing has shifted toward low. However, patients consume less than prescribed, highlighting the importance of continuing this effort to reduce opioid prescribing.
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Affiliation(s)
- R M Higgins
- Division of Minimally Invasive Gastrointestinal Surgery, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA.
| | - C C Petro
- Center for Abdominal Core Health, Cleveland Clinic, Cleveland, OH, USA
| | - J Warren
- The University of South Carolina School of Medicine Greenville, Greenville, SC, USA
| | - A J Perez
- Division of General, Acute Care and Trauma Surgery, The University of North Carolina, Chapel Hill, NC, USA
| | - T Dews
- Pain Management Department, Cleveland Clinic Euclid Hospital, Cleveland, OH, USA
| | - S Phillips
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - M Reinhorn
- Mass General Brigham-Newton Wellesley Hospital, Boston Hernia and Pilonidal Center, Newton, MA, USA
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12
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Champagne-Langabeer T, Cardenas-Turanzas M, Ugalde IT, Bakos-Block C, Stotts AL, Cleveland L, Shoptaw S, Langabeer JR. The Impact of Pediatric Opioid-Related Visits on U.S. Emergency Departments. CHILDREN 2022; 9:children9040524. [PMID: 35455568 PMCID: PMC9030094 DOI: 10.3390/children9040524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/25/2022] [Accepted: 03/31/2022] [Indexed: 11/16/2022]
Abstract
Background: While there is significant research exploring adults’ use of opioids, there has been minimal focus on the opioid impact within emergency departments for the pediatric population. Methods: We examined data from the Agency for Healthcare Research, the National Emergency Department Sample (NEDS), and death data from the Centers for Disease Control and Prevention. Sociodemographic and financial variables were analyzed for encounters during 2014–2017 for patients under age 18, matching diagnoses codes for opioid-related overdose or opioid use disorder. Results: During this period, 59,658 children presented to an ED for any diagnoses involving opioids. The majority (68.5%) of visits were related to overdoses (poisoning), with a mean age of 11.3 years and a majority female (53%). There was a curvilinear relationship between age and encounters, with teens representing the majority of visits, followed by infants. The highest volume was seen in the Southern U.S., with over 58% more opioid visits than the next highest region (Midwest). Charges exceeded USD 157 million, representing 2% of total ED costs, with Medicaid responsible for 54% of the total. Conclusions: With increases in substance use among children, there is a growing need for pediatric emergency physicians to recognize, refer, and initiate treatments.
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Affiliation(s)
- Tiffany Champagne-Langabeer
- Center for Health Systems Analytics, School of Biomedical Informatics, The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA; (M.C.-T.); (C.B.-B.); (J.R.L.)
- Correspondence:
| | - Marylou Cardenas-Turanzas
- Center for Health Systems Analytics, School of Biomedical Informatics, The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA; (M.C.-T.); (C.B.-B.); (J.R.L.)
| | - Irma T. Ugalde
- Department of Emergency Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA;
| | - Christine Bakos-Block
- Center for Health Systems Analytics, School of Biomedical Informatics, The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA; (M.C.-T.); (C.B.-B.); (J.R.L.)
| | - Angela L. Stotts
- Department of Family and Community Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA;
| | - Lisa Cleveland
- UTHealth San Antonio, School of Nursing, San Antonio, TX 78229, USA;
| | - Steven Shoptaw
- Center for Behavioral and Addiction Medicine, Department of Family Medicine, University of California, Los Angeles, CA 90024, USA;
| | - James R. Langabeer
- Center for Health Systems Analytics, School of Biomedical Informatics, The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA; (M.C.-T.); (C.B.-B.); (J.R.L.)
- Department of Emergency Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX 77030, USA;
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13
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Cohen N, Mathew M, Davis A, Brent J, Wax P, Schuh S, Freedman SB, Froberg B, Schwarz E, Canning J, Tortora L, Hoyte C, Koons AL, Burns MM, McFalls J, Wiegand TJ, Hendrickson RG, Judge B, Quang LS, Hodgman M, Chenoweth JA, Algren DA, Carey J, Caravati EM, Akpunonu P, Geib AJ, Seifert SA, Kazzi Z, Othong R, Greene SC, Holstege C, Tweet MS, Vearrier D, Pizon AF, Campleman SL, Li S, Aldy K, Finkelstein Y. Predictors of severe outcome following opioid intoxication in children. Clin Toxicol (Phila) 2022; 60:702-707. [PMID: 35333145 DOI: 10.1080/15563650.2022.2038188] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION While the opioid crisis has claimed the lives of nearly 500,000 in the U.S. over the past two decades, and pediatric cases of opioid intoxications are increasing, only sparse data exist regarding risk factors for severe outcome in children following an opioid intoxication. We explore predictors of severe outcome (i.e., intensive care unit [ICU] admission or in-hospital death) in children who presented to the Emergency Department with an opioid intoxication. METHODS In this prospective cohort study we collected data on all children (0-18 years) who presented with an opioid intoxication to the 50 medical centers in the US and two international centers affiliated with the Toxicology Investigators Consortium (ToxIC) of the American College of Medical Toxicology, from August 2017 through June 2020, and who received a bedside consultation by a medical toxicologist. We collected relevant demographic, clinical, management, disposition, and outcome data, and we conducted a multivariable logistic regression analysis to explore predictors of severe outcome. The primary outcome was a composite severe outcome endpoint, defined as ICU admission or in-hospital death. Covariates included sociodemographic, exposure and clinical characteristics. RESULTS Of the 165 (87 females, 52.7%) children with an opioid intoxication, 89 (53.9%) were admitted to ICU or died during hospitalization, and 76 did not meet these criteria. Seventy-four (44.8%) children were exposed to opioids prescribed to family members. Fentanyl exposure (adjusted OR [aOR] = 3.6, 95% CI: 1.0-11.6; p = 0.03) and age ≥10 years (aOR = 2.5, 95% CI: 1.2-4.8; p = 0.01) were independent predictors of severe outcome. CONCLUSIONS Children with an opioid toxicity that have been exposed to fentanyl and those aged ≥10 years had 3.6 and 2.5 higher odds of ICU admission or death, respectively, than those without these characteristics. Prevention efforts should target these risk factors to mitigate poor outcomes in children with an opioid intoxication.
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Affiliation(s)
- Neta Cohen
- Division of Paediatric Emergency Medicine, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada.,University of Toronto, Toronto, Canada
| | - Mathew Mathew
- Division of Paediatric Emergency Medicine, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada.,University of Toronto, Toronto, Canada
| | - Adrienne Davis
- Division of Paediatric Emergency Medicine, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada.,University of Toronto, Toronto, Canada
| | - Jeffrey Brent
- Department of Internal Medicine, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Paul Wax
- Southwestern School of Medicine, University of Texas, Dallas, TX, USA
| | - Suzanne Schuh
- Division of Paediatric Emergency Medicine, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada.,University of Toronto, Toronto, Canada
| | - Stephen B Freedman
- Department of Paediatrics and Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Blake Froberg
- Indiana University School of Medicine, Indianapolis, IN, USA
| | | | | | - Laura Tortora
- Banner - University Medical Centre, Phoenix, AZ, USA
| | - Christopher Hoyte
- Rocky Mountain Poison and Drug Center, Denver Health, Denver, CO, USA
| | - Andrew L Koons
- Lehigh Valley Health Network, USF Morsani College of Medicine, Allentown, PA, USA
| | | | - Joshua McFalls
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | - Bryan Judge
- Spectrum Health - Michigan State University, Grand Rapids, MI, USA
| | - Lawrence S Quang
- Arkansas Children's Hospital/University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | | | - Douglas A Algren
- University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Jennifer Carey
- University of Massachusetts Medical School, Worcester, MA, USA
| | | | | | | | | | - Ziad Kazzi
- Emory University School of Medicine, Atlanta, GA, USA
| | - Rittirak Othong
- Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | | | | | | | - David Vearrier
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Anthony F Pizon
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Shao Li
- American College of Medical Toxicology, Phoenix, AZ, USA
| | - Kim Aldy
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Yaron Finkelstein
- Division of Paediatric Emergency Medicine, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada.,University of Toronto, Toronto, Canada.,Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada
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14
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Auger N, Chadi N, Low N, Ayoub A, Lo E, Luu TM. Maternal Substance Use Disorders and Accidental Drug Poisonings in Children. Am J Prev Med 2022; 62:360-366. [PMID: 34802817 DOI: 10.1016/j.amepre.2021.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 09/07/2021] [Accepted: 09/09/2021] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Risk factors for accidental drug poisonings in children are poorly understood, including the association with maternal substance use. This study seeks to determine whether maternal substance use disorders before birth are associated with the future risk of accidental drug poisonings in young children. METHODS This study was a longitudinal cohort analysis of 1,032,209 children aged <5 years between 2006 and 2020 in Quebec, Canada. The main exposure included maternal substance use disorders before or during pregnancy. The outcome was hospitalization for drug poisonings before age 5 years, including opioids, cannabis, sedatives/hypnotics, stimulants, and other drugs. Adjusted Cox proportional hazards regression was used to compute hazard ratios and 95% CIs for the association of substance use disorders with child drug poisonings during 4,523,003 person-years of follow-up. Analyses were conducted in 2020. RESULTS Hospitalization rates for drug poisoning before age 5 years were greater for children of mothers with substance use disorders versus no substance use disorder (84.8 vs 20.7 per 100,000 person-years). Maternal substance use disorders before birth were associated with 2.28 times the risk of future drug poisonings in children (95% CI=1.63, 3.20). The association was stronger for maternal opioid use disorders (hazard ratio=4.16, 95% CI=2.38, 7.27) than other drug use disorders. Associations with child poisonings were stronger between age 1 and 2 years (hazard ratio=3.26, 95% CI=2.09, 5.10) and for poisonings involving opioids, cannabis, and sedative/hypnotic drugs. CONCLUSIONS Maternal substance use disorders before childbirth may be markers of future risk of drug poisonings in young children.
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Affiliation(s)
- Nathalie Auger
- Health Innovation and Evaluation Hub, University of Montreal Hospital Research Centre, Montreal, Quebec, Canada; Bureau d'information et d'études en santé des populations, Institut national de santé publique du Québec, Montreal, Quebec, Canada; Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada.
| | - Nicholas Chadi
- Division of Adolescent Medicine, Department of Pediatrics, Sainte-Justine University Hospital Centre, Montreal, Quebec, Canada
| | - Nancy Low
- Department of Psychiatry, McGill University, Montreal, Quebec, Canada
| | - Aimina Ayoub
- Health Innovation and Evaluation Hub, University of Montreal Hospital Research Centre, Montreal, Quebec, Canada; Bureau d'information et d'études en santé des populations, Institut national de santé publique du Québec, Montreal, Quebec, Canada
| | - Ernest Lo
- Bureau d'information et d'études en santé des populations, Institut national de santé publique du Québec, Montreal, Quebec, Canada; Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Thuy Mai Luu
- Department of Pediatrics, Sainte-Justine University Hospital Research Centre, University of Montreal, Montreal, Quebec, Canada
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15
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Russell L, Gajwani R, Turner F, Minnis H. Gender, Addiction, and Removal of Children Into Care. Front Psychiatry 2022; 13:887660. [PMID: 35722570 PMCID: PMC9201045 DOI: 10.3389/fpsyt.2022.887660] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/28/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Parental addiction can result in harm to children and removal of children by the Local Authority. Less is known about the impact of removal of children on their parents and whether gender has a role in this process. METHODS Data on 736 service users were obtained from the caseloads of 8 nurses and 12 social care workers from an Alcohol and Drug Recovery Service in Scotland. Gender differences in prevalence/patterns of child removal, associations between child removal and parental factors and the relationship between removal and suicidality were examined. RESULTS Mothers were more likely to have had one or more children removed compared to fathers (56.6 vs. 17.7%; p < 0.001) and were more likely to have a series of individual child removals (22.5 vs. 4.3%; p = 0.014). In addition to female gender, younger age, drug use, mental health and suicide attempts were also associated with child removal. Mothers who had children removed and women who were not mothers were more likely to have made an attempt to end their lives than women who had children but had not had them removed. CONCLUSION Gender differences were apparent in prevalence and patterns of child removal. Mothers were six times more likely to have children removed compared to fathers. Child removal occurred alongside other risk factors suggesting that families need holistic support for their multiple areas of need. Services should be aware of the link between child removal and suicide and provide additional support to mothers during and after removal.
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Affiliation(s)
- Lynda Russell
- Mental Health and Wellbeing, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Ruchika Gajwani
- Mental Health and Wellbeing, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Fiona Turner
- Mental Health and Wellbeing, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Helen Minnis
- Mental Health and Wellbeing, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
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16
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Cranfield E, Ashcroft E, Forget P. Mortality by opioid poisoning in children and teenagers and opioid prescriptions. BMC Pediatr 2021; 21:569. [PMID: 34903210 PMCID: PMC8667418 DOI: 10.1186/s12887-021-03061-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 12/03/2021] [Indexed: 11/15/2022] Open
Abstract
Background No comparisons between mortality from opioids in children and teenagers and opioid prescription patterns have been made in England. Aim To investigate if an association exists between mortality rates from opioid poisoning in persons aged 19 years old and under and community opioid prescription in England. Methods A retrospective analysis was undertaken for 2016 to 2019, comparing community opioid prescriptions and mortality rates from opioid poisoning. Results The number of opioid prescriptions decreased over the study period (− 2.4%, p < 0.001). Most deaths due to opioid poisoning in children and teenagers were seen in those under one year old and those aged between 15 and 19 years old (Kruskal-Wallis: p = 0.12; Dunn’s test: p = 0.01). Deaths in all age ranges did not change significantly (Poisson Regression Analysis: p > 0.05). Conclusion Despite the reduction in community opioid prescriptions, there was no decrease in the number of deaths in children and teenagers due to opioid poisoning. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-021-03061-9.
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Affiliation(s)
- Elise Cranfield
- Edinburgh Medical School, College of Medicine and Veterinary Medicine, Edinburgh, EH16 4TJ, UK
| | | | - Patrice Forget
- Institute of Applied Health Sciences, Epidemiology group, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen; Department of Anaesthesia, NHS Grampian, Aberdeen, AB25 2ZD, UK.
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17
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Sun N, Steinberg BE, Faraoni D, Isaac L. Variability in discharge opioid prescribing practices for children: a historical cohort study. Can J Anaesth 2021; 69:1025-1032. [PMID: 34904210 DOI: 10.1007/s12630-021-02160-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 08/12/2021] [Accepted: 10/13/2021] [Indexed: 11/29/2022] Open
Abstract
PURPOSE Legitimate opioid prescriptions can increase the risk of misuse, addiction, and overdose of opioids in children and adolescents. This study aimed to describe the prescribing patterns of discharge opioid analgesics following inpatient visits and to determine patient and prescriber characteristics that are associated with prolonged opioid prescription. METHODS In a historical cohort study, we identified patients discharged from hospital with an opioid analgesic prescription in a tertiary pediatric hospital from 1 January 2016 to 30 June 2017. The primary outcome was the duration of opioid prescription in number of days. We assessed the association between patient and prescriber characteristics and an opioid prescription duration > five days using a generalized estimating equation to account for clustering due to repeated admissions of the same patient. RESULTS During the 18-month study period, 15.4% of all admitted patients (3,787/24,571) were given a total of 3,870 opioid prescriptions at discharge. The median [interquartile range] prescribed duration of outpatient opioid therapy was 3.75 [3.00-5.00] days. Seventy-seven percent of the opioid prescriptions were for five days or less. Generalized estimating equation analysis revealed that hospital stay > four days, oxycodone prescription, and prescription by clinical fellows and the orthopedics service were all independently associated with a discharge opioid prescription of > five days. CONCLUSIONS Most discharge opioids for children were prescribed for less than five days, consistent with current guidelines for adults. Nevertheless, the dosage and duration of opioids prescribed at discharge varied widely.
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Affiliation(s)
- Naiyi Sun
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, 555 University Ave., Toronto, ON, M5G 1X8, Canada.
| | - Benjamin E Steinberg
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, 555 University Ave., Toronto, ON, M5G 1X8, Canada
| | - David Faraoni
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, 555 University Ave., Toronto, ON, M5G 1X8, Canada
| | - Lisa Isaac
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, 555 University Ave., Toronto, ON, M5G 1X8, Canada
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18
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Zipursky J, Juurlink DN. Opioid use in pregnancy: An emerging health crisis. Obstet Med 2021; 14:211-219. [PMID: 34880933 PMCID: PMC8646213 DOI: 10.1177/1753495x20971163] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 10/07/2020] [Indexed: 04/17/2024] Open
Abstract
Opioid use in pregnancy has increased in parallel to the opioid crisis observed in the general population. Rising rates of peripartum opioid use pose a significant public health concern for both mothers and their children. Pregnancy also represents a unique opportunity for healthcare providers to screen women for opioid use disorder and engage them in appropriate care. In the present review, we describe patterns of opioid use in pregnancy and how this relates to maternal and neonatal health outcomes. We also examine screening for and treatment of opioid use disorder in pregnancy, neonatal outcomes following maternal opioid use, and breastfeeding recommendations for women taking opioids postpartum.
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Affiliation(s)
- Jonathan Zipursky
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - David N Juurlink
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
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19
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Kelly BC, Vuolo M, Frizzell LC. Pediatric drug overdose mortality: contextual and policy effects for children under 12 years. Pediatr Res 2021; 90:1258-1265. [PMID: 34021271 PMCID: PMC8606008 DOI: 10.1038/s41390-021-01567-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 03/10/2021] [Accepted: 04/19/2021] [Indexed: 12/04/2022]
Abstract
BACKGROUND We determine trends in fatal pediatric drug overdose from 1999 to 2018 and describe the influence of contextual factors and policies on such overdoses. METHODS Combining restricted CDC mortality files with data from other sources, we conducted between-county multilevel models to examine associations of demographic and socioeconomic characteristics with pediatric overdose mortality and a fixed-effects analysis to identify how changes in contexts and policies over time shaped county-level fatal pediatric overdoses per 100,000 children under 12 years. RESULTS Pediatric overdose deaths rose from 0.08/100,000 children in 1999 to a peak of 0.19/100,000 children in 2016, with opioids accounting for an increasing proportion of deaths. Spatial patterns of pediatric overdose deaths are heterogenous. Socioeconomic characteristics are not associated with between-county differences in pediatric overdose mortality. Greater state expenditures on public welfare (B = -0.099; CI: [-0.193, -0.005]) and hospitals (B = -0.222; CI: [-.437, -.007]) were associated with lower pediatric overdose mortality. In years when a Good Samaritan law was in effect, the county-level pediatric overdose rate was lower (B = -0.095; CI: [-0.177, -0.013]). CONCLUSIONS Pediatric overdose mortality increased since 1999, peaking in 2016. Good Samaritan laws and investment in hospitals and public welfare may temper pediatric overdoses. Multi-faceted approaches using policy and individual intervention is necessary to reduce pediatric overdose mortality. IMPACT Pediatric fatalities from psychoactive substances have risen within the U.S. since 1999. Higher levels of state spending on public welfare and hospitals are significantly associated with lower pediatric overdose mortality rates. The implementation of Good Samaritan laws is significantly associated with lower pediatric overdose mortality rates. We identified no county-level sociodemographic factors associated with pediatric overdose mortality. The findings indicate that a multi-faceted approach to the reduction of pediatric overdose is necessary.
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Affiliation(s)
- Brian C Kelly
- Department of Sociology, Purdue University, West Lafayette, IN, USA
| | - Mike Vuolo
- Department of Sociology, The Ohio State University, Columbus, OH, USA.
| | - Laura C Frizzell
- Department of Sociology, The Ohio State University, Columbus, OH, USA
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20
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Hunter AA, Schwab-Reese L, DiVietro S, McCollum S. An examination of fatal child poisonings in the United States using the National Violent Death Reporting System (NVDRS), 2012-2017. Clin Toxicol (Phila) 2021; 60:342-347. [PMID: 34545746 DOI: 10.1080/15563650.2021.1955913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Fatal drug overdoses are predominantly attributed to opioids. Women of childbearing age are among those at greatest risk, underscoring the need to understand the overlapping risk of fatal poisoning in children. METHODS A retrospective analysis of fatal poisonings among decedents aged 0-9 years captured in the National Violent Death Reporting System (NVDRS) from 2012 to 2017 was employed. Poisonings were identified using International Classification of Diseases, Tenth Revision (ICD-10) codes for poisonings (T36-T50, Y10-Y19), toxic effects of substances (T51-T65), and assault (X85-X90). The frequency and types of drugs involved in poisonings were derived from toxicological analysis. Logistic regression was used to model the odds of fatal poisoning by decedent and perpetrator characteristics. Qualitative content analysis was used to contextualize the patterns of fatal poisonings. FINDINGS 1850 violent deaths were identified; 7% (n = 122) were poisoning-related, and 50% of these were attributed to opioids. Next, benzodiazepines (8%), amphetamines (7%), and antidepressants (5%) were most prevalent. Among poisoning-related deaths, 25% involved homicide-suicide. No differences in deaths were observed according to child race/ethnicity, and the risk of fatal poisoning decreased 6% with each year of child age. Following qualitative analysis, three unique categories of fatal poisoning emerged: "intentional administration without documented benign intent", "intentional administration with benign intent", and "unclear administration". CONCLUSION The high proportion of fatal poisonings in children attributed to opioids in this study suggests a need for universal dissemination and training of naloxone in households comprised of children living with parents experiencing, or in recovery for substance misuse. Findings also indicate a needed emphasis on safe storage practices and education to parents about the risk of prescription drug toxicity in children.
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Affiliation(s)
- Amy A Hunter
- Department of Public Health Sciences, School of Medicine, University of Connecticut, Farmington, CT, USA.,Department of Pediatrics, School of Medicine, University of Connecticut, Farmington, CT, USA.,Injury Prevention Center, Connecticut Children's and Hartford Hospital, Hartford, CT, USA.,Trinity College, Hartford, CT, USA
| | | | - Susan DiVietro
- Department of Pediatrics, School of Medicine, University of Connecticut, Farmington, CT, USA.,Injury Prevention Center, Connecticut Children's and Hartford Hospital, Hartford, CT, USA.,Trinity College, Hartford, CT, USA
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21
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Day E, Tach L, Fuzzell L, Mathios E, Kallaher A. The Consequences of Postnatal Parental Opioid Misuse on Child Well-Being: a Scoping Review. JOURNAL OF CHILD & ADOLESCENT SUBSTANCE ABUSE 2021. [DOI: 10.1080/1067828x.2021.1971130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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22
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Austin AE, Berkoff MC, Shanahan ME. Incidence of Injury, Maltreatment, and Developmental Disorders Among Substance Exposed Infants. CHILD MALTREATMENT 2021; 26:282-290. [PMID: 32519558 DOI: 10.1177/1077559520930818] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Recent changes to federal legislation created a requirement for states to address the needs of infants with prenatal substance exposure. Understanding clinical outcomes among substance exposed infants prior to these changes is important for establishing a baseline of risk and informing systems-level responses. Using North Carolina, Georgia, and Texas Medicaid data, we examined the incidence of inpatient and outpatient diagnoses for injury, maltreatment, and developmental disorders prior to age 12 months and compared types of diagnoses among substance exposed and unexposed infants. The cumulative incidence of maltreatment (1.2% vs. 0.2%) and developmental disorder (10.7% vs. 1.5%) diagnoses prior to age 12 months was significantly higher among substance exposed compared to unexposed infants. The incidence of injury diagnoses was similar (3.7% vs. 3.4%). We observed differences in types of maltreatment and injury diagnoses. For example, diagnoses for neglect were more common among substance exposed infants while diagnoses for physical abuse were more common among unexposed infants. Results provide insight for informing monitoring and intervention by medical and public health professionals.
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Affiliation(s)
- Anna E Austin
- Department of Maternal and Child Health, 2331University of North Carolina at Chapel Hill, NC, USA
- Injury Prevention Research Center, 2331University of North Carolina at Chapel Hill, NC, USA
| | - Molly Curtin Berkoff
- Department of Pediatrics, 2331University of North Carolina at Chapel Hill, NC, USA
| | - Meghan E Shanahan
- Department of Maternal and Child Health, 2331University of North Carolina at Chapel Hill, NC, USA
- Injury Prevention Research Center, 2331University of North Carolina at Chapel Hill, NC, USA
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Sejdiu A, Pereira KN, Joundi H, Patel YR, Basith SA, Ayala V, Mathialagan K, Majumder P. Demographic Pattern and Mortality Risk Factors for Prescription Opioid Overdose Hospitalizations: Results From Nationwide Inpatient Sample Analysis. Cureus 2021; 13:e15674. [PMID: 34277265 PMCID: PMC8281797 DOI: 10.7759/cureus.15674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2021] [Indexed: 11/05/2022] Open
Abstract
Objectives To explore the demographic patterns of hospitalizations related to prescription opioid overdose (POD) and evaluate the mortality risk of association in POD inpatients. Methodology We conducted a cross-sectional study using the Nationwide Inpatient Sample of 184,711 POD inpatients. A binomial logistic regression model was used to evaluate the odds ratio (OR) of association for mortality risk due to comorbidities (substance use disorders (SUD) and medical complications) in POD inpatients. Results POD inpatients were majorly females (54.1%), older adults aged 51-75 years (48.5%), whites (81.5%), and from lower household income quartet (32.8%). The most prevalent comorbid SUD among POD inpatients was alcohol (15.7%), followed by cannabis (5.7%), cocaine (4.2%), and amphetamine (1.8%). Comorbid alcohol use disorders had a minimally increased association with mortality but were not statistically significant (OR = 1.036; P = 0.438). POD in patients with cardiac arrest had the highest risk of mortality (OR = 103.423; P < 0.001), followed by shock (OR = 15.367; P < 0.001), coma (OR = 13.427; P < 0.001), and respiratory failure (OR = 12.051; P < 0.001). Conclusions Our study indicates that the hospitalizations related to POD were more prevalent among females, elders between 51 and 75 years of age, whites, and those in the lower household income quartet. The prevalence of prescription opioid use and the hospitalization related to POD remains a significant public health issue. POD inpatients with medical complications were at a higher risk of mortality than with comorbid SUD.
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Affiliation(s)
- Albulena Sejdiu
- Psychiatry, Saints Cyril and Methodius University, Skopje, MKD
| | | | - Hajara Joundi
- Internal Medicine, University Cadi Ayyad, Faculty of Medicine and Pharmacy, Marrakesh, MAR
| | | | - Sayeda A Basith
- Psychiatry and Behavioral Sciences, Medical University of the Americas, Charlestown, KNA
| | - Victoria Ayala
- Psychiatry, Ross University School of Medicine, Bridgetown, BRB
| | | | - Pradipta Majumder
- Psychiatry, Drexel University College of Medicine, Philadelphia, USA.,Psychiatry, WellSpan Health, York, USA
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24
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Sparks AC, Radakrishnan S, Corry NH, McDonald D, Carlson K, Carballo CE, Stander V. Associations between spouse and service member prescriptions for high-risk and long-term opioids: A dyadic study. Addict Behav Rep 2021; 14:100364. [PMID: 34189246 PMCID: PMC8219988 DOI: 10.1016/j.abrep.2021.100364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/24/2021] [Accepted: 06/08/2021] [Indexed: 11/21/2022] Open
Abstract
Military spouses were more likely to have risky opioid Rx if their spouse did. High-risk opioid therapy was linked to pain, disability, smoking, and ACES Reducing risky opioid Rx for service members may reduce similar risky Rx for spouses.
Background Estimates suggest approximately 2.4% of service members, and 15% of service members who have engaged in recent combat, report misusing pain relievers in the past year. This study explores the extent to which military spouses’ obtainment of opioids is associated with their service member partners’ obtainment of opioid prescriptions, in addition to other factors such as service member health, state prescribing patterns, and sociodemographic characteristics. Methods Data were drawn from the Millennium Cohort Family Study, a large, longitudinal survey of married spouses of service members from all service branches, and archival data analyzed from 2018 to 2020. The dependent variables were spouse long-term opioid therapy and spouse opioid prescriptions that pose a high risk of adverse outcomes. Results Seven percent of spouse and service member dyads met the criteria for high-risk opioid use, generally because they had purchased a prescription for a ≥90 Morphine Milligram Equivalents daily dose (76.7% for spouses, 72.8% for service members). Strong associations were found between spouse and service member opioid therapies (OR = 5.53 for long-term; OR = 2.20 for high-risk). Conclusions Findings suggest that reducing the number of long-term and high-risk opioid prescriptions to service members may subsequently reduce the number of similar prescriptions obtained by their spouses. Reducing the number of service members and spouses at risk for adverse events may prove to be effective in stemming the opioid epidemic and improve the overall health and safety of military spouses and thus, the readiness of the U.S. Armed Forces.
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Affiliation(s)
- Alicia C Sparks
- Division of Health and Environment, Abt Associates, Rockville, MD, United States
| | | | - Nida H Corry
- Division of Health and Environment, Abt Associates, Rockville, MD, United States
| | - Doug McDonald
- Division of Health and Environment, Abt Associates, Rockville, MD, United States
| | - Kenneth Carlson
- Division of Health and Environment, Abt Associates, Rockville, MD, United States
| | - Carlos E Carballo
- Deployment Health Research Department, Naval Health Research Center, San Diego, CA, United States.,Leidos, Reston, VA, United States
| | - Valerie Stander
- Deployment Health Research Department, Naval Health Research Center, San Diego, CA, United States
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25
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Zipursky JS, Pang A, Paterson JM, Austin PC, Mamdani M, Gomes T, Ray JG, Juurlink DN. Trends in Postpartum Opioid Prescribing: A Time Series Analysis. Clin Pharmacol Ther 2021; 110:1004-1010. [PMID: 34032277 DOI: 10.1002/cpt.2307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 04/14/2021] [Indexed: 12/22/2022]
Abstract
Opioids are commonly prescribed following childbirth, but data are lacking on trends in postpartum opioid prescribing over time. We examined whether a highly publicized 2006 case report questioning the safety of codeine during lactation was associated with changes in postpartum opioid prescribing. We conducted a cross-sectional time series analysis of all publicly funded prescriptions for opioids to postpartum women in Ontario, Canada, from April 1, 2000, to March 31, 2017. The intervention was the publication of a case report in 2006 attributing the death of a breastfeeding neonate to maternal codeine use. The primary outcome was the rate of opioid prescribing to postpartum women. Among postpartum women eligible for prescription drug coverage, 17.5% filled an opioid prescription in the third quarter of 2006 (immediately prior to the intervention), with codeine representing 89.8% of all prescriptions. By the fourth quarter of 2010, only 12.2% of postpartum women filled an opioid prescription, representing a decline of 30% (P < 0.01), with codeine representing 71.9% of all prescriptions. During this period, we observed sizeable relative increases in the proportion of opioid prescriptions filled for morphine, hydromorphone, and oxycodone. By 2017, among women prescribed opioids post partum, 39.0% filled a prescription for codeine, while the remainder filled prescriptions for oxycodone (18.6%), morphine (25.5%), and hydromorphone (16.9%). A highly publicized case report questioning the safety of maternal codeine use during breastfeeding was associated with significant changes in opioid prescribing to postpartum women, including a decline in overall opioid prescribing and a shift from codeine to stronger opioids.
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Affiliation(s)
- Jonathan S Zipursky
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Andrea Pang
- ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
| | - J Michael Paterson
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
| | - Peter C Austin
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Muhammad Mamdani
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada.,Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Tara Gomes
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada.,Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Joel G Ray
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada.,Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - David N Juurlink
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada
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26
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McCarthy DM, Kim HS, Hur SI, Lank PM, Arroyo C, Opsasnick LA, Piserchia K, Curtis LM, Wolf MS, Courtney DM. Patient-Reported Opioid Pill Consumption After an ED Visit: How Many Pills Are People Using? PAIN MEDICINE 2021; 22:292-302. [PMID: 32219431 DOI: 10.1093/pm/pnaa048] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Recent guidelines advise limiting opioid prescriptions for acute pain to a three-day supply; however, scant literature quantifies opioid use patterns after an emergency department (ED) visit. We sought to describe opioid consumption patterns after an ED visit for acute pain. DESIGN Descriptive study with data derived from a larger interventional study promoting safe opioid use after ED discharge. SETTING Urban academic emergency department (>88,000 annual visits). SUBJECTS Patients were eligible if age >17 years, not chronically using opioids, and newly prescribed hydrocodone-acetaminophen and were included in the analysis if they returned the completed 10-day medication diary. METHODS Patient demographics and opioid consumption are reported. Opioid use is described in daily number of pills and daily morphine milligram equivalents (MME) both for the sample overall and by diagnosis. RESULTS Two hundred sixty patients returned completed medication diaries (45 [17%] back pain, 52 [20%] renal colic, 54 [21%] fracture/dislocation, 40 [15%] musculoskeletal injury [nonfracture], and 69 [27%] "other"). The mean age (SD) was 45 (15) years, and 59% of the sample was female. A median of 12 pills were prescribed. Patients with renal colic used the least opioids (total pills: median [interquartile range {IQR}] = 3 [1-7]; total MME: median [IQR] = 20 [10-50]); patients with back pain used the most (total pills: median [IQR] = 12 [7-16]; total MME: median [IQR] = 65 [47.5-100]); 92.5% of patients had leftover pills. CONCLUSIONS In this sample, pill consumption varied by illness category; however, overall, patients were consuming low quantities of pills, and the majority had unused pills 10 days after their ED visit.
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Affiliation(s)
- Danielle M McCarthy
- Department of Emergency Medicine, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Howard S Kim
- Department of Emergency Medicine, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Scott I Hur
- Division of General Internal Medicine and Geriatrics, Department of, USA
| | - Patrick M Lank
- Department of Emergency Medicine, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Christine Arroyo
- Department of Emergency Medicine, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lauren A Opsasnick
- Division of General Internal Medicine and Geriatrics, Department of, USA
| | - Katherine Piserchia
- Department of Emergency Medicine, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Laura M Curtis
- Division of General Internal Medicine and Geriatrics, Department of, USA
| | - Michael S Wolf
- Division of General Internal Medicine and Geriatrics, Department of, USA
| | - D Mark Courtney
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas, USA
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27
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Wolf JP, Freisthler B, McCarthy KS. Parenting in poor health: Examining associations between parental health, prescription drug use, and child maltreatment. Soc Sci Med 2021; 277:113887. [PMID: 33873010 DOI: 10.1016/j.socscimed.2021.113887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 01/25/2021] [Accepted: 03/27/2021] [Indexed: 02/01/2023]
Abstract
RATIONALE Child maltreatment and problematic parenting are related to negative outcomes for children. Poor parental health could be a risk factor for problematic parenting through several mechanisms: 1) inadequate emotional regulation and coping; 2) impairment of parental capacity; and, 3) impairment of the parent-child relationship. OBJECTIVE This study examines relationships between self-rated parental health, prescription drug use, and a broad array of negative parenting outcomes. METHODS A sample of general population parents of children aged ten and younger was recruited from 30 mid-sized cities in California (n = 681). Weighted mixed-effects negative binomial and logistic regression models were used to examine associations between poor parental health, prescription drug use and child maltreatment (physical abuse, supervisory neglect, and physical neglect), and problematic parenting (psychological aggression and corporal punishment). RESULTS Parents in poor health used physical abuse, corporal punishment, and psychological aggression more frequently and had higher odds of supervisory neglect. Parents who were taking more prescription medications had higher odds of physical neglect. Exploratory analyses suggested that prescriptions for certain medical conditions both increased and decreased the risk of problematic parenting. CONCLUSIONS Poor health and prescription drug use are not uncommon and present largely under-recognized risk factors for a spectrum of adverse parenting outcomes. Our study provides additional evidence that parents in poor health are at heightened risk of negative parenting, and need targeted intervention supports to support family well-being.
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Affiliation(s)
- Jennifer Price Wolf
- School of Social Work, San Jose State University, One Washington Square, San Jose, CA, 95192, USA; Prevention Research Center, 2150 Shattuck Avenue, Suite 601, Berkeley, CA, 94704-1365, USA.
| | - Bridget Freisthler
- College of Social Work, Ohio State University, 340C Stillman Hall, 1947 College Rd. N, Columbus, OH, 43210, USA
| | - Karla Shockley McCarthy
- College of Social Work, Ohio State University, 340C Stillman Hall, 1947 College Rd. N, Columbus, OH, 43210, USA
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28
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Opioid prescribing is excessive and variable after pediatric ambulatory urologic surgery. J Pediatr Urol 2021; 17:259.e1-259.e6. [PMID: 33514499 DOI: 10.1016/j.jpurol.2021.01.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 01/01/2021] [Accepted: 01/07/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Acute pain after surgery is one of the most frequent indications for opioid prescribing in children. Opioids are often not stored or disposed of safely after their use, placing children and others in the home at risk for accidental ingestion or intentional misuse. We currently lack evidence-based guidelines for post-operative pain management after common ambulatory pediatric urologic procedures. Thus, each surgeon must decide if and how much opioid to prescribe based on his/her own assumptions of perceived post-operative pain. OBJECTIVES As part of an effort to establish opioid prescribing guidelines across two academic centers, the objectives of this study were to evaluate current variability in pediatric urologists' opioid prescribing factors and identify patients at greatest risk of being prescribed high doses of opioids after common ambulatory pediatric urologic procedures. METHODS We retrospectively evaluated post-operative opioid prescribing patterns after common ambulatory pediatric urology procedures (circumcision, orchiopexy, and hernia/hydrocele) at two major children's hospitals. Specifically, we evaluated if and how much opioid was prescribed for all children (18 years or younger) between 2016 and 2017. Bivariate analysis was performed using Kruskal-Wallis Test and Wilcoxon Rank Sum. Multivariable logistic regression was performed to determine patient, surgeon, and procedural factors that predicted the prescription of a high dose of opioids (greater than the median number of doses prescribed for that procedure). RESULTS Over the two-year period, 811 circumcisions and 883 inguinal surgeries (inguinal orchiopexy and hernia/hydrocele) were performed. 94% of patients undergoing circumcision and 97% of those undergoing inguinal surgery were prescribed opioid analgesia. The median number of doses prescribed for circumcision was 20; for inguinal surgeries, 23.75% of patients received 15 opioid doses or more. Patients ages 0-2 years, who represented the largest age group (41% of all patients), received significantly more opioid doses than all other age groups, followed by those >10 years (p < 0.01). There was significant variation in opioid prescribing patterns by provider (p < 0.01) (Figure 1) On multivariable logistic regression, younger age, pill form, and earlier year were all associated with a greater number of opioid doses prescribed for all surgeries. CONCLUSIONS Across two institutions without a formal post-operative opioid prescribing policy for ambulatory pediatric urologic procedures, we observed considerable variability in provider prescribing patterns, with nearly all patients receiving an opioid, and those 0-2 years receiving the highest number of doses. This highlights the need for evidence-based guidelines for post-operative pain management after ambulatory pediatric urologic surgeries.
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29
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Umukoro NN, Aruldhas BW, Rossos R, Pawale D, Renschler JS, Sadhasivam S. Pharmacogenomics of oxycodone: a narrative literature review. Pharmacogenomics 2021; 22:275-290. [PMID: 33728947 DOI: 10.2217/pgs-2020-0143] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Oxycodone is a semisynthetic μ- and κ-opioid receptor with agonist with a broad scope of use including postoperative analgesia as well as control of neuropathic and cancer pain. Advantages over other opioids include prolonged duration of action, greater potency than morphine and lack of histamine release or ceiling effect. Individual responses to oxycodone can vary due to genetic differences. This review article aims to summarize the oxycodone literature and provide context on its pharmacogenomics and pharmacokinetics. The evidence for clinical effect of genetic polymorphisms on oxycodone is conflicting. There is stronger evidence linking polymorphic genetic enzymes CYP2D6 and CYP3A with therapeutic outcomes. Further, research is needed to discern all of oxycodone's metabolites and their contribution to the overall analgesic effect.
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Affiliation(s)
- Nelly N Umukoro
- Department of Anesthesia, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, USA
| | - Blessed W Aruldhas
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Department of Pharmacology & Clinical Pharmacology, Christian Medical College, Vellore, India
| | - Ryan Rossos
- Department of Anesthesia, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, USA.,Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Dhanashri Pawale
- Department of Anesthesia, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, USA.,Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Janelle S Renschler
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Senthilkumar Sadhasivam
- Department of Anesthesia, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, USA.,Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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30
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Nguemeni Tiako MJ. Addressing racial & socioeconomic disparities in access to medications for opioid use disorder amid COVID-19. J Subst Abuse Treat 2021; 122:108214. [PMID: 33248862 PMCID: PMC7685132 DOI: 10.1016/j.jsat.2020.108214] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 10/21/2020] [Accepted: 11/20/2020] [Indexed: 12/31/2022]
Affiliation(s)
- Max Jordan Nguemeni Tiako
- Yale School of Medicine, United States of America; Center for Emergency Care and Policy Research, Perelman School of Medicine at the University of Pennsylvania, United States of America.
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31
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Feinberg AE, Acuna SA, Smith D, Kashin B, Mocon A, Yau B, Chiu J, Srikandarajah S. Optimizing opioid prescriptions after laparoscopic appendectomy and cholecystectomy. Can J Surg 2021; 64:E69-E75. [PMID: 33560737 PMCID: PMC7955819 DOI: 10.1503/cjs.001319] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background There has been an increase in opioid usage and opioid-related deaths. Opioids prescribed to surgical patients have similarly increased. The aim of this study was to assess opioid consumption in patients undergoing laparoscopic appendectomy (LA) and laparoscopic cholecystectomy (LC) and to determine whether a standardized prescription could affect opioid consumption without affecting patient satisfaction. Methods Patients undergoing LA or LC were recruited prospectively during 2 time periods (April to June 2017 and November 2017 to January 2018). In the first phase, surgeons continued their usual postoperative analgesia prescribing patterns. In the second phase, a standardized prescription was implemented. Patients were contacted by telephone and a questionnaire was completed for both phases of the study. The primary outcome was the quantity of opioids prescribed and consumed. Results In the first phase, 166 patients who underwent LC or LA were recruited. The median number of prescribed opioid tablets was 20 and the median number consumed was 2. Ninety-five percent of patients reported satisfaction with their analgesia. Based on these results, a standardized prescription for multimodal analgesia was implemented for the second phase, consisting of 10 opioid tablets. In the second phase, 129 patients who underwent LA or LC were recruited. There was a significant decrease in the median number of opioid pills filled (10) and consumed (0), with no difference in reported satisfaction with analgesia. Conclusion Patients are prescribed an excess of opioids after LA or LC. Implementation of a standardized prescription based on a quality improvement intervention was effective at decreasing the number of opioids prescribed and consumed.
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Affiliation(s)
- Adina E Feinberg
- From the Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA (Feinberg); the Department of Surgery, University of Toronto, Toronto, Ont. (Acuna); the Department of Surgery, North York General Hospital, Toronto, Ont. (Smith); the Department of Anesthesia, North York General Hospital, Toronto, Ont. (Kashin, Mocon, Yau, Srikandarajah) and the Department of Pharmacy, North York General Hospital, Toronto, Ont. (Chiu)
| | - Sergio A Acuna
- From the Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA (Feinberg); the Department of Surgery, University of Toronto, Toronto, Ont. (Acuna); the Department of Surgery, North York General Hospital, Toronto, Ont. (Smith); the Department of Anesthesia, North York General Hospital, Toronto, Ont. (Kashin, Mocon, Yau, Srikandarajah) and the Department of Pharmacy, North York General Hospital, Toronto, Ont. (Chiu)
| | - David Smith
- From the Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA (Feinberg); the Department of Surgery, University of Toronto, Toronto, Ont. (Acuna); the Department of Surgery, North York General Hospital, Toronto, Ont. (Smith); the Department of Anesthesia, North York General Hospital, Toronto, Ont. (Kashin, Mocon, Yau, Srikandarajah) and the Department of Pharmacy, North York General Hospital, Toronto, Ont. (Chiu)
| | - Brian Kashin
- From the Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA (Feinberg); the Department of Surgery, University of Toronto, Toronto, Ont. (Acuna); the Department of Surgery, North York General Hospital, Toronto, Ont. (Smith); the Department of Anesthesia, North York General Hospital, Toronto, Ont. (Kashin, Mocon, Yau, Srikandarajah) and the Department of Pharmacy, North York General Hospital, Toronto, Ont. (Chiu)
| | - Aaron Mocon
- From the Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA (Feinberg); the Department of Surgery, University of Toronto, Toronto, Ont. (Acuna); the Department of Surgery, North York General Hospital, Toronto, Ont. (Smith); the Department of Anesthesia, North York General Hospital, Toronto, Ont. (Kashin, Mocon, Yau, Srikandarajah) and the Department of Pharmacy, North York General Hospital, Toronto, Ont. (Chiu)
| | - Brian Yau
- From the Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA (Feinberg); the Department of Surgery, University of Toronto, Toronto, Ont. (Acuna); the Department of Surgery, North York General Hospital, Toronto, Ont. (Smith); the Department of Anesthesia, North York General Hospital, Toronto, Ont. (Kashin, Mocon, Yau, Srikandarajah) and the Department of Pharmacy, North York General Hospital, Toronto, Ont. (Chiu)
| | - Jenny Chiu
- From the Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA (Feinberg); the Department of Surgery, University of Toronto, Toronto, Ont. (Acuna); the Department of Surgery, North York General Hospital, Toronto, Ont. (Smith); the Department of Anesthesia, North York General Hospital, Toronto, Ont. (Kashin, Mocon, Yau, Srikandarajah) and the Department of Pharmacy, North York General Hospital, Toronto, Ont. (Chiu)
| | - Sanjho Srikandarajah
- From the Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA (Feinberg); the Department of Surgery, University of Toronto, Toronto, Ont. (Acuna); the Department of Surgery, North York General Hospital, Toronto, Ont. (Smith); the Department of Anesthesia, North York General Hospital, Toronto, Ont. (Kashin, Mocon, Yau, Srikandarajah) and the Department of Pharmacy, North York General Hospital, Toronto, Ont. (Chiu)
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32
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Neill LA, Kim HS, Cameron KA, Lank PM, Patel DA, Hur SI, Opsasnick LA, Curtis LM, Eifler MR, Courtney DM, Wolf MS, McCarthy DM. Who Is Keeping Their Unused Opioids and Why? PAIN MEDICINE 2021; 21:84-91. [PMID: 30903661 DOI: 10.1093/pm/pnz025] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To better understand patients' reasoning for keeping unused opioid pills. METHODS As part of a larger study, patients were asked their plans for their unused opioids. Responses were categorized as "dispose," "keep," and "don't know." Baseline characteristics were compared between the "keep" and "dispose" groups. Verbatim responses categorized as "keep" were analyzed qualitatively using a team-based inductive approach with constant comparison across cases. RESULTS One hundred patients planned to dispose of their pills; 117 planned to keep them. There were no differences in demographics between the groups. Among patients who planned to keep their pills, the mean age was 43 years and 47% were male. Analysis revealed four categories of patient responses: 1) plans to keep their pills "just in case," with reference to a medical condition (e.g., kidney stone); 2) plans to keep pills "just in case" without reference to any medical condition; 3) plans to dispose in delayed fashion (e.g., after pill expiration) or unsure of how to dispose; and 4) no identified plans, yet intended to keep pills. In this sample, there were no differences in characteristics of those reporting planning to keep vs dispose of pills; however, there were diverse reasons for keeping opioids. CONCLUSIONS This manuscript describes a sample of patients who kept their unused opioids and presents qualitative data detailing their personal reasoning for keeping the unused pills. Awareness of the range of motivations underpinning this behavior may inform the development of tailored education and risk communication messages to improve opioid disposal.
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Affiliation(s)
- Luke A Neill
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Howard S Kim
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kenzie A Cameron
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Patrick M Lank
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Deesha A Patel
- Health Literacy and Learning Program, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Scott I Hur
- Health Literacy and Learning Program, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lauren A Opsasnick
- Health Literacy and Learning Program, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Laura M Curtis
- Health Literacy and Learning Program, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Morgan R Eifler
- Health Literacy and Learning Program, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - D Mark Courtney
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michael S Wolf
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Health Literacy and Learning Program, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Danielle M McCarthy
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Griesler PC, Hu MC, Wall MM, Kandel DB. Assessment of Prescription Opioid Medical Use and Misuse Among Parents and Their Adolescent Offspring in the US. JAMA Netw Open 2021; 4:e2031073. [PMID: 33410876 PMCID: PMC7791357 DOI: 10.1001/jamanetworkopen.2020.31073] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 11/03/2020] [Indexed: 11/14/2022] Open
Abstract
Importance Limited information is available regarding the association between parental and adolescent medical prescription opioid use and misuse in the US. Objective To examine the associations between parental and adolescent prescription opioid medical use and misuse. Design, Setting, and Participants This cross-sectional, nationally representative study included 15 200 parent-adolescent dyads from the annual 2015-2017 National Survey on Drug Use and Health. Data were collected from January 6, 2015, to December 20, 2017, and analyzed from October 4, 2019, to October 15, 2020. Exposures Parental past 12-month exclusive medical prescription opioid use and any misuse (ie, using without a prescription or in any way not directed by a physician). Main Outcomes and Measures Adolescent past 12-month medical prescription opioid use or misuse. Multivariable regressions estimated associations between parental and offspring medical prescription opioid use or misuse, controlling for sociodemographic and psychosocial variables. Results Respondents included 9400 mother-child and 5800 father-child dyads in the same household; children were aged 12 to 17 years (52.8% male; mean [SD] age, 14.5 [1.7] years). Controlling for other factors, parental medical prescription opioid use was associated with adolescent prescription opioid medical use (adjusted odds ratio [aOR], 1.28; 95% CI, 1.06-1.53) and misuse (aOR, 1.53; 95% CI, 1.07-2.25), whereas parental misuse was not. Parental medical prescription stimulant use was associated with adolescent medical prescription opioid use (aOR, 1.40; 95% CI, 1.02-1.91). Parental marijuana use (aOR, 1.84; 95% CI, 1.13-2.99), parent-adolescent conflict (aOR, 1.26; 95% CI, 1.05-1.52), and adolescent depression (aOR, 1.75; 95% CI, 1.26-2.44) were associated with adolescent prescription opioid misuse. Adolescent delinquency (aOR, 1.55; 95% CI, 1.38-1.74) and perceived schoolmates' drug use (aOR, 2.87; 95% CI, 1.95-4.23) were also associated with adolescent misuse and more weakly with medical use (aORs, 1.13 [95% CI, 1.05-1.22] and 1.61 [95% CI, 1.32-1.96], respectively). Conclusions and Relevance Youth use of prescription opioids is in part a structural/environmental issue. The findings of this study suggest that parental medical prescription opioid use is associated with offspring prescription opioid use, whereas parental misuse is not. Restricting physicians' opioid prescribing to parents is a crucial public health goal. In addition, parents could be educated on the risks of their prescription opioid use for offspring and on practices to mitigate risk, including safe medication storage and disposal. Screening for parental prescription opioid use could be part of pediatric practice. Addressing adolescent mental health could also reduce adolescent prescription opioid misuse.
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Affiliation(s)
- Pamela C. Griesler
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
- New York State Psychiatric Institute, New York, New York
| | - Mei-Chen Hu
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Melanie M. Wall
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
- New York State Psychiatric Institute, New York, New York
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, New York
- Research Foundation for Mental Hygiene, New York, New York
| | - Denise B. Kandel
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
- New York State Psychiatric Institute, New York, New York
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, New York
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Perianesthesia Patient Education for the Promotion of Opioid Stewardship. J Perianesth Nurs 2020; 36:108-115. [PMID: 33334681 DOI: 10.1016/j.jopan.2020.06.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 06/01/2020] [Accepted: 06/07/2020] [Indexed: 11/24/2022]
Abstract
Opioid overdose deaths and opioid use disorders are a crisis in the United States and other western countries around the globe. Opioid prescriptions more than doubled after the turn of the century, particularly for postoperative patients. Unfortunately, many who have abused opioids were able to obtain those opioids from friends or family who had held on to prescribed, but unused opioids. One method to manage and decrease the opportunity for unused opioids to become black-market opioids is to educate patients and families regarding the safe use, safe storage, and proper disposal of unused prescription opioids. Perianesthesia nurses, particularly those who educate patients before and after surgery, have an excellent opportunity to educate patients and families who are discharged to home after surgery.
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Abstract
PURPOSE OF REVIEW Women with opioid use disorder (OUD) face unique challenges the moment they enter treatment. This narrative review focused on recent literature regarding sex- and gender-based issues that could affect treatment outcomes in women with OUD. RECENT FINDINGS Women respond differently to opioids based on hormonal factors, are more likely to present to treatment with mental health conditions, especially depression, and are more likely to have experienced trauma via intimate partner violence compared with men. Women also face stigma when entering OUD treatment, particularly if they have children. Future research to improve OUD treatment outcomes in women should account for sex as a biological variable and gender as a social construct. Women have a fundamentally different experience than men during the course of OUD and upon treatment entry. Programs that address childcare/family support, mental health, and trauma are warranted for women with OUD.
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Affiliation(s)
- Andrew S Huhn
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD, 21224, USA.
| | - Kelly E Dunn
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD, 21224, USA
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Toce MS, Michelson K, Hudgins J, Burns MM, Monuteaux MC, Bourgeois FT. Association of State-Level Opioid-Reduction Policies With Pediatric Opioid Poisoning. JAMA Pediatr 2020; 174:961-968. [PMID: 32658263 PMCID: PMC7358978 DOI: 10.1001/jamapediatrics.2020.1980] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 04/25/2020] [Indexed: 01/01/2023]
Abstract
Importance Opioid-reduction policies have been enacted by US states to address the opioid epidemic. Evidence of an association between policy implementation and decreased rates of pediatric opioid poisoning provides further justification for expanded implementation of these policies. Objective To examine the association of 3 state-level opioid-reduction policies with the rate of opioid poisoning in children and adolescents. Design, Setting, and Participants This interrupted time series analysis used data from the National Poison Data System (NPDS), a database of poisoning information reported to poison control centers across the US. Individuals younger than 20 years who experienced poisoning associated with 1 or more prescription opioids from January 1, 2005, to November 30, 2017, were included. The analysis focused on 3 widespread policy interventions: the prescription drug monitoring program (PDMP), pain clinic legislation, and opioid prescribing guidelines. Data analysis was performed from January 30, 2020, to March 30, 2020. Exposures Any opioid poisoning in individuals younger than 20 years that was reported to the NPDS. Main Outcomes and Measures Opioid poisoning rates per million person-months before and after implementation of each of the 3 policies, overall and stratified by age (≤4 years, 5-9 years, 10-14 years, and 15-19 years). Results A total of 338 476 opioid poisoning incidences in children and young adults were reported to the NPDS within the study period. Of this study population, the mean (SD) age was 9.74 (7.15) years, and 179 011 (52.9%) were female. The implementation of a PDMP was associated with a reduction in the monthly rate of opioid poisoning in children and adolescents (-0.07 per million person-months; 95% CI, -0.09 to -0.04) in the postimplementation period. This reduction was observed for all age groups except for the 10- to 14-year age group (-0.03 per million person-months; 95% CI, -0.05 to 0.00). Pain clinic legislation was associated with an immediate reduction in opioid poisoning (-6.22 per million person-months; 95% CI, -8.98 to -3.47). This association was statistically significant across all ages except for the 4 years or younger group. Analysis of the association of implementation of opioid prescribing guidelines was limited because of insufficient follow-up data and did not show an immediate or monthly change in the rate of opioid poisoning. Conclusions and Relevance Results of this study suggest that certain state-level opioid-reduction policies were associated with decreases in pediatric opioid exposures across age groups. Further examination of the underlying mechanisms of these associations, including age group-specific outcomes, may expand and strengthen policies that reduce opioid poisoning, misuse, and overdoses in children and adolescents.
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Affiliation(s)
- Michael S. Toce
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Harvard Medical Toxicology Program, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Kenneth Michelson
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Joel Hudgins
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Michele M. Burns
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Harvard Medical Toxicology Program, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Michael C. Monuteaux
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Florence T. Bourgeois
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Pediatric Therapeutics and Regulatory Science Initiative, Computational Health Informatics Program (CHIP), Boston Children’s Hospital, Boston, Massachusetts
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Abstract
The entire field of medicine, not just anesthesiology, has grown comfortable with the risks posed by opioids; but these risks are unacceptably high. It is time for a dramatic paradigm shift. If used at all for acute or chronic pain management, they should be used only after consideration and maximizing the use of nonopioid pharmacologic agents, regional analgesia techniques, and nonpharmacologic methods. Opioids poorly control pain, their intraoperative use may increase the risk of recurrence of some types of cancer, and they have a large number of both minor and serious side effects. Furthermore, there are a myriad of alternative analgesic strategies that provide superior analgesia, decrease recovery time, and have fewer side effects and risks associated with their use. In this article the negative consequences of opioid use for pain, appropriate alternatives to opioids for analgesia, and the available evidence in pediatric populations for both are described.
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Bethell J, Neuman MD, Bateman BT, Ladha KS, Hill A, Li G, Wijeysundera DN, Wunsch H. Association between mothers' postoperative opioid prescriptions and opioid-related events in their children: A population-based cohort study. HEALTH REPORTS 2020; 31:12-19. [PMID: 32672924 PMCID: PMC8201592 DOI: 10.25318/82-003-x202000600002-eng] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 09/29/2022]
Abstract
BACKGROUND Postoperative opioid prescriptions may be associated with risks of unintentional poisoning and drug diversion in other household members. The objective of this study was to explore the association between mothers' postoperative opioid prescriptions and incidence of opioid-related events in their children (aged 1 to 24 years). DATA AND METHODS This retrospective cohort study used individually linked administrative health data from Ontario, Canada. A population-based sample of 170,156 opioid-naïve mothers (aged 15 to 64) (see Figure 1) who underwent surgery between 2013 and 2017 in Ontario was linked through birth records to create a cohort of their 283,550 opioid-naïve children (aged 1 to 24). The association between postoperative opioid analgesic prescriptions filled by mothers within seven days of discharge after surgery and opioid-related events (emergency department presentations or inpatient admissions for opioid poisoning, or mental and behavioural disorders attributable to opioid use) in their children within one year of their mother's discharge was assessed. RESULTS Overall, 60.4% of the children in the cohort had a mother who filled a postoperative opioid prescription. The incidence of opioid-related events in children in the year after a mother's surgery was low overall (n=36/283,550, 0.01%), but higher among children whose mother filled a postoperative opioid prescription (n=29/171,139, 0.02%, vs. n=7/112,411, 0.01%, p=0.02), including in an analysis adjusting for child's age, mother's age, rural residence, neighbourhood income quintile and mother's Charlson comorbidity index score (adjusted odds ratio, 2.42 [95% confidence interval (CI), 1.05 to 5.54], p=0.04). DISCUSSION Postoperative opioid prescriptions for mothers may contribute to opioid-related events in their children. These findings further underscore the importance of safe, effective opioid prescribing, as well as of patient and public education about the use, storage and disposal of these medications.
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Affiliation(s)
- Jennifer Bethell
- Sunnybrook Research Institute, ICES, the Toronto Rehabilitation Institute at the University Health Network, and the Institute of Health Policy Management and Evaluation at the University of Toronto, Toronto, Ontario
| | - Mark D Neuman
- The Department of Anesthesiology and Critical Care, the Center for Perioperative Outcomes Research and Transformation, and the Center for Pharmacoepidemiology Research and Training at the University of Pennsylvania Perelman School of Medicine, and the Leonard Davis Institute of Health Economics at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brian T Bateman
- The Department of Anesthesia, Perioperative, and Pain Medicine, and the Division of Pharmacoepidemiology and Pharmacoeconomics in the Department of Medicine at Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Karim S Ladha
- The Department of Anesthesia at St. Michael's Hospital, and the Department of Anesthesia at the University of Toronto, Toronto, Ontario
| | - Andrea Hill
- Sunnybrook Research Institute, and the Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Guohua Li
- The Department of Epidemiology, Mailman School of Public Health, and the Department of Anesthesiology, College of Physicians and Surgeons at Columbia University, and the Center for Injury Epidemiology and Prevention, Columbia University Medical Center, New York, New York
| | - Duminda N Wijeysundera
- ICES, the Institute of Health Policy Management and Evaluation and the Department of Anesthesia at the University of Toronto, and the Department of Anesthesia at St. Michael's Hospital, Toronto, Ontario
| | - Hannah Wunsch
- Sunnybrook Research Institute, ICES, the Department of Anesthesia at the University of Toronto, the Department of Critical Care Medicine at the Sunnybrook Health Sciences Centre, and the Interdepartmental Division of Critical Care Medicine at the University of Toronto, Toronto, Ontario
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Zipursky J, Juurlink DN. The Implausibility of Neonatal Opioid Toxicity from Breastfeeding. Clin Pharmacol Ther 2020; 108:964-970. [DOI: 10.1002/cpt.1882] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 03/11/2020] [Indexed: 12/25/2022]
Affiliation(s)
- Jonathan Zipursky
- Department of Medicine Sunnybrook Health Sciences Centre Toronto Ontario Canada
- ICES Toronto Ontario Canada
- Institute of Health Policy, Management, and Evaluation University of Toronto Toronto Ontario Canada
| | - David N. Juurlink
- Department of Medicine Sunnybrook Health Sciences Centre Toronto Ontario Canada
- ICES Toronto Ontario Canada
- Institute of Health Policy, Management, and Evaluation University of Toronto Toronto Ontario Canada
- Sunnybrook Research Institute Toronto Ontario Canada
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Abstract
BACKGROUND Safe medication storage is a proven barrier to ingestions in the pediatric population, but caregivers are often unaware of the importance of safe storage practices or do not have a safe place to store medications. Caregivers may also not be fully aware that the patterns of opioid use and misuse have recently reached crisis levels. The objectives of this study were to define medication storage practices and knowledge of the opioid crisis of participants and to assess the effectiveness of an emergency department intervention on safe medication storage. METHODS This was a prospective interventional study of caregivers in an urban pediatric emergency department (ED) on safe medication storage and the opioid crisis. Questions assessed the caregivers' current perceptions and practices related to medication storage and disposal, and opioid crisis awareness. The intervention included verbal instruction about recommended safe storage methods and the opioid crisis, provision of a medication safety handout, and distribution of a medication lock box. A follow-up phone survey conducted 2 weeks later asked participants about use of and satisfaction with the lock box. Frequencies of safe storage behaviors were calculated, and the chi-square statistic was used to compare storage behavior after the intervention. RESULTS Fifty caregivers of 112 children were enrolled. Only 4% reported they currently stored medications in a locked or latched place. Thirty-eight percent reported their main barrier to storing medications safely was that they did not have a locked or latched storage location. Fifty percent were unaware of the opioid crisis. Ninety-two percent reported they would use a lock box if given one. Twenty-eight participants (56%) responded to the follow-up phone call survey 2 weeks later. At follow up 90% (25/28) reported they placed their medications within the provided lock box (p < 0.00001). Ninety-two percent reported being "very satisfied" with the lock box and how it works. CONCLUSIONS Despite widespread reporting on this issue, many caregivers remain unaware of safe medication storage practices and the opioid crisis. Providing medication lock boxes removes a commonly reported barrier to safely storing medications and improved reported practices.
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Affiliation(s)
- Alicia C. Webb
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alabama-Birmingham, Birmingham, AL 35233 USA
| | - Michele H. Nichols
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alabama-Birmingham, Birmingham, AL 35233 USA
| | - Nipam Shah
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alabama-Birmingham, Birmingham, AL 35233 USA
- Children’s of Alabama Hospital, Birmingham, USA
| | - Kathy W. Monroe
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alabama-Birmingham, Birmingham, AL 35233 USA
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Gee KM, Jones RE, Nevarez N, McClain LE, Wools G, Beres AL. No pain is gain: A prospective evaluation of strict non-opioid pain control after pediatric appendectomy. J Pediatr Surg 2020; 55:1043-1047. [PMID: 32171535 DOI: 10.1016/j.jpedsurg.2020.02.051] [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: 02/03/2020] [Accepted: 02/20/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Opiates are often prescribed after pediatric operations despite safety concerns and lack of evidence confirming superiority compared to other pain control modalities. In this study, we use daily parental surveys to prospectively evaluate a strict non-opioid pain control strategy after laparoscopic appendectomy. METHODS After IRB approval, children who underwent laparoscopic appendectomy for nonperforated acute appendicitis were recruited to the study. For these patients, our standard practice is to provide instructions to administer alternating acetaminophen and ibuprofen over-the-counter (OTC) postoperatively, and no opiate prescriptions are written. Parents of enrolled children received a daily RedCap survey via text message or e-mail on postoperative days (POD) 1 through 5 to prospectively assess pain control and medication usage. Trends were compared across postoperative days. RESULTS One hundred twenty patients were enrolled in the study, and none received opiate prescriptions. Postoperative pain survey response rates were 54% on POD1, 47% on POD2, 35% on POD3, 34% on POD4, and 29% on POD5. Pain level was 4.7 ± 2.3 (out of 10) on POD1, and down-trended significantly each postoperative day to reach 0.7 ± 1.2 by POD5. On POD1, 85% of parents administered OTC medications, which reduced significantly to 14% by POD5. Parent-reported success rates to manage pain by OTC regimen were 85% on POD1, 94% on POD2, 91% on POD3, and 100% on POD4 and POD5. CONCLUSION Strict non-opioid pain control after appendectomy exhibits high performance based upon prospective parental surveys. This strategy should be implemented as standard of care and tested for application to other surgical conditions. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Kristin M Gee
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390.
| | - R Ellen Jones
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390
| | - Nicole Nevarez
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390
| | | | - Gentry Wools
- Children's Health, 1935 Medical District Dr., Dallas, TX 75235
| | - Alana L Beres
- Department of Surgery, UC Davis Children's Hospital, 2315 Stockton Blvd., Sacramento, CA 95817
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Carrico JA, Mahoney K, Raymond KM, McWilliams SK, Mayes LM, Mikulich-Gilbertson SK, Bartels K. Predicting Opioid Use Following Discharge After Cesarean Delivery. Ann Fam Med 2020; 18:118-126. [PMID: 32152015 PMCID: PMC7062496 DOI: 10.1370/afm.2493] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 07/23/2019] [Accepted: 08/14/2019] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Although cesarean delivery is the most common surgical procedure in the United States, postoperative opioid prescribing varies greatly. We hypothesized that patient characteristics, procedural characteristics, or both would be associated with high vs low opioid use after discharge. This information could help individualize prescriptions. METHODS In this prospective cohort study, we quantified opioid use for 4 weeks following hospital discharge after cesarean delivery. Predischarge characteristics were obtained from health records, and patients self-reported total opioid use postdischarge on weekly questionnaires. Opioid use was quantified in milligram morphine equivalents (MMEs). Binomial and Poisson regression analyses were performed to assess predictors of opioid use after discharge. RESULTS Of the 233 patients starting the study, 203 (87.1%) completed at least 1 questionnaire and were included in analyses (86.3% completed all 4 questionnaires). A total of 113 patients were high users (>75 MMEs) and 90 patients were low users (≤75 MMEs) of opioids postdischarge. The group reporting low opioid use received on average 44% fewer opioids in the 24 hours before discharge compared with the group reporting high opioid use (mean = 33.0 vs 59.3 MMEs, P <.001). Only a minority of patients (11.4% to 15.8%) stored leftover opioids in a locked location, and just 31 patients disposed of leftover opioids. CONCLUSIONS Knowledge of predischarge opioid use can be useful as a tool to inform individualized opioid prescriptions, help optimize nonopioid analgesia, and reduce opioid use. Additional studies are needed to evaluate the impact of implementing such measures on prescribing practices, pain, and functional outcomes.
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Affiliation(s)
- Jacqueline A Carrico
- Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Katharine Mahoney
- Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Kristen M Raymond
- Department of Psychiatry, Division of Substance Dependence, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Shannon K McWilliams
- Department of Psychiatry, Division of Substance Dependence, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Lena M Mayes
- Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Susan K Mikulich-Gilbertson
- Department of Psychiatry, Division of Substance Dependence, University of Colorado, Anschutz Medical Campus, Aurora, Colorado.,Department of Biostatistics & Informatics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Karsten Bartels
- Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado .,Department of Psychiatry, Division of Substance Dependence, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
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Madden K, Reddy AS, De La Cruz MJ, Liu DD, Bruera E. Patterns of Storage, Use, and Disposal of Prescription Opioids by Parents of Children With Cancer. J Pain Symptom Manage 2020; 59:320-326. [PMID: 31562890 DOI: 10.1016/j.jpainsymman.2019.09.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/17/2019] [Accepted: 09/18/2019] [Indexed: 10/25/2022]
Abstract
CONTEXT Multiple studies have demonstrated that adults do not store prescription opioids safely. Increased prescription opioid rates have led to an increased incidence of opioid poisonings in children and adolescents. OBJECTIVES We investigated whether parents practiced safe storage, use, and disposal techniques of opioids that were prescribed to their child with cancer-related pain. METHODS We conducted a prospective cross-sectional survey of parents whose children were prescribed opioids and asked them about their patterns of storage, use, and disposal of prescription opioids. RESULTS Virtually, all parents (106 of 109; 97%) completed the survey. Most parents (95 of 106; 90%) did not store opioids safely. Six of 106 parents (6%) gave their child's opioid pain medication to someone else with pain, and three of 106 parents (3%) personally took some of their child's opioid. Parents who personally took their child's opioid (P = 0.01) or gave it to another person (P < 0.001) were more likely to use opioids unsafely with their child. A minority of parents (22 of 106; 21%) did not use opioids safely in their child. A small number of parents (3 of 22; 14%) did not dispose of opioids safely. CONCLUSION Universal education about the safe use and disposal of opioids should be adopted when prescribing opioids. Pediatricians need to maintain vigilance about the nonmedical use of prescription opioid use by parents of children.
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Affiliation(s)
- Kevin Madden
- Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas, M.D. Anderson Cancer Center, Houston, Texas, USA.
| | - Akhila S Reddy
- Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas, M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Maxine J De La Cruz
- Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas, M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Diane D Liu
- Department of Biostatistics, University of Texas, M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas, M.D. Anderson Cancer Center, Houston, Texas, USA
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Guan Q, Campbell T, Martins D, Tadrous M, Juurlink D, Paterson JM, Mamdani M, Mock D, Gomes T. Assessing the impact of an opioid prescribing guideline for dentists in Ontario, Canada. J Am Dent Assoc 2019; 151:43-50. [PMID: 31813472 DOI: 10.1016/j.adaj.2019.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 08/08/2019] [Accepted: 08/24/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Royal College of Dental Surgeons of Ontario introduced a new dental opioid prescribing guideline in November 2015. The authors examined whether introduction of this guideline was associated with changes in opioid prescribing patterns. METHODS The authors conducted a population-based, cross-sectional time series study of Ontarians who received opioids prescribed by dentists from July 1, 2012 through September 30, 2017. They examined the impact of the guideline on dental prescribing patterns by calculating the monthly rate of opioid dispensing from dentists per 100,000 population, as well as the population exposure to opioids expressed as milligram morphine equivalents per 100 population. RESULTS Ontario dentists issued 1,571,897 opioid prescriptions to 1,157,102 patients over the study period. The guideline was not associated with a change in opioid dispensing rates, but it was associated with a significant reduction in the volume of opioids dispensed (28.1% reduction, from 22.1 to 15.9 milligram morphine equivalents per 100 population from October 2015 through September 2017; P = .01). CONCLUSIONS Introduction of the prescribing guideline was associated with no change in the rate of opioid prescribing by dentists, but it was associated with a roughly 25% reduction in the volume of opioids prescribed. PRACTICAL IMPLICATIONS Introduction of the new opioid prescribing guideline for Ontario dentists was associated with a reduction in the overall volume of opioids dispensed.
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Gilley M, Sivilotti MLA, Juurlink DN, Macdonald E, Yao Z, Finkelstein Y. Trends of intentional drug overdose among youth: a population-based cohort study. Clin Toxicol (Phila) 2019; 58:711-715. [DOI: 10.1080/15563650.2019.1687900] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Meghan Gilley
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Marco L. A. Sivilotti
- Departments of Emergency Medicine, and of Biomedical & Molecular Sciences, Queen’s University, Kingston, Canada
- Ontario Poison Centre, Toronto, Canada
| | - David N. Juurlink
- ICES, Toronto, Canada
- Sunnybrook Research Institute, Sunnybrook Hospital, Toronto, Canada
- Departments of Medicine and Pediatrics, University of Toronto, Toronto, Canada
| | | | | | - Yaron Finkelstein
- ICES, Toronto, Canada
- Divisions of Emergency Medicine and Clinical Pharmacology and Toxicology, Hospital for Sick Children, Toronto, Canada
- Departments of Pediatrics and Pharmacology and Toxicology, University of Toronto, Toronto, Canada
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Khan NF, Bateman BT, Landon JE, Gagne JJ. Association of Opioid Overdose With Opioid Prescriptions to Family Members. JAMA Intern Med 2019; 179:1186-1192. [PMID: 31233088 PMCID: PMC6593630 DOI: 10.1001/jamainternmed.2019.1064] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Prescription opioid misuse is a public health problem that leads to overdose. Although existing interventions focus on limiting prescribing to patients at high risk, individuals may still access prescription opioids dispensed to family members. OBJECTIVE To determine whether opioid prescriptions to family members were associated with overdose for individuals who themselves did not have an opioid prescription. DESIGN, SETTING, AND PARTICIPANTS We conducted a 1:4 matched case-control study using health care utilization data from 2004 through 2015 from a large US commercial insurance company. Eligible individuals were required to have at least 12 months of continuous enrollment and 1 or more family members in the database. Individuals who experienced overdose were identified by their first opioid overdose after the baseline period and matched to control participants by time in the database, calendar time, age, sex, and number of individuals in the family unit. Both groups were restricted to individuals with no prior opioid dispensing of their own. Data analysis was conducted from January 2018 to August 2018. EXPOSURES Any prior opioid dispensing to a family member, total morphine milligram equivalents dispensed to family members, and the type of opioid product dispensed. MAIN OUTCOMES AND MEASURES Individual odds of opioid overdose resulting in an emergency department visit or hospitalization were the primary end point. The primary analysis evaluated the odds of overdose among individuals whose family members had been dispensed an opioid. Sensitivity analyses examined the odds stratified by age and timing relative to the dispensing of opioids to family members. RESULTS A total of 2303 individuals who experienced opioid overdose and 9212 matched control individuals were identified. The mean (SD) age was 23.2 (18.1) years; 1158 affected individuals and 4632 control individuals (50.3%) were female. The mean (SD) time in the database before an overdose case was 3.2 (3.3) years. Prior opioid dispensing to family members was associated with individual overdose (odds ratio [OR], 2.89 [95% CI, 2.59-3.23]). There was a significant dose-response association between increasing amounts of opioids dispensed to family members and odds of overdose (>0-<50 morphine milligram equivalents per day: OR, 2.71 [95% CI, 2.42-3.03]; 50-<90 morphine milligram equivalents per day: OR, 7.80 [95% CI, 3.63-16.78]; ≥90 morphine milligram equivalents per day: OR, 15.08 [95% CI, 8.66-26.27]). CONCLUSIONS AND RELEVANCE In this analysis, opioid prescriptions to family members were associated with overdose among individuals who do not receive opioid prescriptions. Interventions may focus on expanding access to opioid antagonists, locking prescription opioids in the home, and providing greater patient education to limit fatal overdose among family members.
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Affiliation(s)
- Nazleen F Khan
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Joan E Landon
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Joshua J Gagne
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Lawrence AE, Carsel AJ, Leonhart KL, Richards HW, Harbaugh CM, Waljee JF, McLeod DJ, Walz PC, Minneci PC, Deans KJ, Cooper JN. Effect of Drug Disposal Bag Provision on Proper Disposal of Unused Opioids by Families of Pediatric Surgical Patients: A Randomized Clinical Trial. JAMA Pediatr 2019; 173:e191695. [PMID: 31233129 PMCID: PMC6593625 DOI: 10.1001/jamapediatrics.2019.1695] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
IMPORTANCE Although opioids are an important component of pain management for children recovering from surgery, postoperative opioid prescribing has contributed to the current opioid crisis in the United States because these medications are often prescribed in excess and are rarely properly disposed. One potential strategy to combat opioid misuse is to remove excess postoperative opioids from circulation by providing patients with drug disposal products that enable safe disposal of opioids in the home garbage. OBJECTIVE To determine whether the provision of a drug disposal bag increases proper opioid disposal among the families of pediatric patients undergoing ambulatory surgery. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial enrolled 202 parents or guardians of children 1 to 17 years of age who underwent otolaryngologic or urologic surgery at the outpatient surgery centers of a tertiary children's hospital in Columbus, Ohio, from June to December 2018 and who received an opioid prescription prior to discharge. INTERVENTIONS Families randomized to intervention were provided a drug disposal bag containing activated charcoal and instructions for use plus standard postoperative discharge instructions on opioid use, storage, and disposal. Families in standard care arm received standard postoperative discharge instructions only. All participants completed a baseline survey and a follow-up survey 2 to 4 weeks postoperatively. MAIN OUTCOMES AND MEASURES Primary outcome was proper opioid disposal, defined as disposal using a drug disposal bag or a disposal method recommended by the US Food and Drug Administration. RESULTS Of 202 parents or guardians enrolled, 181 completed follow-up (92 in intervention arm and 89 in standard care arm). Most patients in both groups were white (75 [73.5%] vs 79 [80.6%]) and male (63 [61.2%] vs 54 [54.6%]), and the median (interquartile range) age was 6 (5-9) years in the intervention arm and 7 (6-10) years in the standard care arm. For intention-to-treat analyses, 92 families receiving a disposal bag and 89 families not receiving a disposal bag were included. Among them, 66 families (71.7%) randomized to receive a disposal bag reported properly disposing of their child's opioids, whereas 50 parents (56.2%) who did not receive a disposal bag reported proper opioid disposal (difference in proportions, 15.5%; 95% CI, 1.7%-29.3%; P = .03). Among only those families who filled an opioid prescription and had leftover opioids after resolution of their child's pain, 66 of 77 parents or guardians (85.7%) who had received a disposal bag and 50 of 77 parents or guardians (64.9%) who had received standard care reported properly disposing of their child's opioids (difference in proportions, 20.8%; 95% CI, 7.6%-34.0%). CONCLUSIONS AND RELEVANCE Results of this study indicated that providing drug disposal bags to families of children receiving postoperative opioids increased the likelihood of excess opioid disposal. Greater availability of disposal products may complement ongoing prescribing reduction efforts aimed at decreasing opioid misuse. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03575377.
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Affiliation(s)
- Amy E. Lawrence
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio,Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, Ohio
| | - Alex J. Carsel
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Karen L. Leonhart
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Holden W. Richards
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | | | | | - Daryl J. McLeod
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio,Section of Urology, Nationwide Children’s Hospital, Columbus, Ohio,Department of Urology, College of Medicine, The Ohio State University, Columbus
| | - Patrick C. Walz
- Department of Otolaryngology, Nationwide Children’s Hospital, Columbus, Ohio,Department of Otolaryngology, College of Medicine, The Ohio State University, Columbus
| | - Peter C. Minneci
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio,Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, Ohio,Department of Surgery, College of Medicine, The Ohio State University, Columbus
| | - Katherine J. Deans
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio,Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, Ohio,Department of Surgery, College of Medicine, The Ohio State University, Columbus
| | - Jennifer N. Cooper
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio,Department of Pediatrics, College of Medicine, The Ohio State University, Columbus,Division of Epidemiology, College of Public Health, The Ohio State University, Columbus
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Zhao S, Chen F, Feng A, Han W, Zhang Y. Risk Factors and Prevention Strategies for Postoperative Opioid Abuse. Pain Res Manag 2019; 2019:7490801. [PMID: 31360271 PMCID: PMC6652031 DOI: 10.1155/2019/7490801] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 06/25/2019] [Indexed: 02/06/2023]
Abstract
Worldwide, 80% of patients who undergo surgery receive opioid analgesics as the fundamental agent for pain relief. However, the irrational use of opioids leads to excessive drug dependence and drug abuse, resulting in an increased mortality rate and huge economic loss. The crisis of opioid overuse remains a great challenge. In this review, we summarize several key factors in opioid abuse, including race, region, income, genetic factors, age and gender, smoking and alcohol abuse, history of chronic pain and analgesic drug abuse, surgery, neuropsychiatric illness, depression and antidepressant use, human factors, national policies, hospital regulations, and health insurance under treatment of pain. Furthermore, we present several prevention strategies, such as perioperative measures, opioid substitutes, treatment of the primary illness, emotional regulation, use of opioid antagonists, efforts of the state, hospitals, doctors and pharmacy benefit managers, gene therapy, and vaccines. Greater understanding and better assessment are required of the risks associated with opioid abuse to ensure the safety and analgesic effects of pain treatment after surgery.
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Affiliation(s)
- Shuai Zhao
- Department of Anesthesiology, First Hospital of Jilin University, Changchun, China
| | - Fan Chen
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, China
| | - Anqi Feng
- Department of Anesthesiology, Second Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Wei Han
- Department of Anesthesiology, First Hospital of Jilin University, Changchun, China
| | - Yuan Zhang
- Department of Anesthesiology, First Hospital of Jilin University, Changchun, China
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Abstract
PURPOSE OF REVIEW The purpose of this review is to explore the effects of the opioid crisis on pediatric patients in the postoperative setting and provide recommendations for well-tolerated opioid prescribing practices. RECENT FINDINGS Opioid overdoses have increased among all age groups, predominantly related to overprescribing and accessibility of opioids in the home. Adverse risks of prescribed opioids include respiratory depression, gastrointestinal distress, accidental ingestion, intentional misuse, new chronic use, diversion to another user, and overdose. Well-tolerated opioid prescribing practices include multimodal pain management; prescribing guided by patient need; risk assessment for potential misuse; and comprehensive patient and family education on risks, safe storage, and disposal practices. Evolving state laws will affect varying institutional policies; thus, providers must ensure their prescribing practices are current and compliant. SUMMARY All age groups have been affected by the opioid crisis, including children and adolescents. When managing postoperative pain, clinicians must balance appropriate pain management with well-tolerated opioid stewardship to minimize harm related to postoperative care.
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Reddy A, de la Cruz M. Safe Opioid Use, Storage, and Disposal Strategies in Cancer Pain Management. Oncologist 2019; 24:1410-1415. [PMID: 31097618 DOI: 10.1634/theoncologist.2019-0242] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 04/17/2019] [Indexed: 11/17/2022] Open
Abstract
Opioids are required by a majority of patients with advanced cancer. Oncologists and palliative care clinicians are faced with the challenge of safely prescribing opioids in the current environment of an opioid crisis. Many patients with cancer use opioids unsafely, store them in unsecure locations, and do not dispose of unused opioids, leading to increased availability of these opioids for others to misuse. More than 50% of people who misuse opioids obtain the drugs from a friend or relative with or without their consent. Patient and provider education has been shown to improve safe opioid use, promote secure storage, and also increase disposal of unused opioids safely in drug take-back programs that are now widely available. This article highlights the importance of patient education and cautious opioid prescribing in patients with cancer. IMPLICATIONS FOR PRACTICE: The current opioid crisis makes it challenging to effectively manage cancer pain. Providers play a prominent role in minimizing opioid misuse. Cautious prescribing with limits enforced on the quantity of opioids prescribed, close follow-up, and consistent and frequent provision of opioid education are a must. Evidence points to the impact of patient education in promoting safety around opioid use. Most people who misuse prescription opioids obtain them from family or friends. Storing opioids in the open or not disposing of unused opioids increases the availability of these opioids for misuse by others. The importance of not sharing, always locking up, and disposing of unused and expired opioids must be highlighted as part of the opioid education that must be delivered every time that opioids are prescribed. Information about local drug take-back programs may also help increase disposal of unused opioids.
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Affiliation(s)
- Akhila Reddy
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maxine de la Cruz
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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