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Simpson A, Levy N, Mariano E. Opioid stewardship. BJA Educ 2023; 23:389-397. [PMID: 37720559 PMCID: PMC10501885 DOI: 10.1016/j.bjae.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2023] [Indexed: 09/19/2023] Open
Affiliation(s)
- A.K. Simpson
- University Hospitals Bristol and Weston, Bristol, UK
| | - N. Levy
- West Suffolk Hospital, Bury St. Edmunds, UK
| | - E.R. Mariano
- Stanford University School of Medicine, Stanford, CA, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
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2
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Klimkiewicz J, Wysocka M, Hordowicz M, Jarosz J, Gutowski M, Paryż K, Kieszkowska-Grudny A, Klimkiewicz A. Factors related to opioid misuse among patients undergoing elective surgery in Poland. J Addict Dis 2023:1-9. [PMID: 37776897 DOI: 10.1080/10550887.2023.2252721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Abstract
In many countries, the consumption of illicit opioids is rising, becoming a major public health issue called the "opioid crisis". Many reasons contribute to this phenomenon. One of them is opioid misuse, defined as the use of legally prescribed opioids for a purpose different than pain treatment. This matter has not been well studied in Poland, where the opioid crisis has not been identified so far. This study was conducted among patients admitted for elective surgery with opioid-based postoperative pain treatment. The frequency of opioid misuse was found to be 10.8% in a sample comprising 92 patients. The group of individuals with potential opioid use disorder had a more frequent history of inadequately controlled postoperative pain compared to the group of non-misusers (p = 0.023). Furthermore, this group asked to receive additional pain treatment almost six times more often than the control group (p < 0.000). Also, patients declaring opioid misuse reported substantial differences concerning their knowledge and opinions about pain treatment and opioid analgesics: supporting the administration of opioids for pain when needed, finding opioids less harmful, and supporting messages that opioids are safe, effective, well-tolerated, easy to cutoff more often than control. There is an urgent need for the education of patients to avoid the spreading of the opioid crisis.
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Affiliation(s)
- Jakub Klimkiewicz
- Department of Anesthesiology and Intensive Care, Military Institute of Medicine - National Research Institute, Legionowo Hospital, Warsaw, Poland
| | - Maria Wysocka
- Department of Medical Ethics and Palliative Medicine, Medical University of Warsaw, Warsaw, Poland
| | | | - Jerzy Jarosz
- EWDOMED Science and Education Center, Konstancin-Jeziorna, Poland
| | - Mateusz Gutowski
- Department of Anesthesiology and Intensive Care, Military Institute of Medicine - National Research Institute, Warsaw, Poland
| | - Kamil Paryż
- Department of Anesthesiology and Intensive Care, Military Institute of Medicine - National Research Institute, Warsaw, Poland
| | | | - Anna Klimkiewicz
- Department of Psychiatry, Medical University of Warsaw, Warsaw, Poland
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Sng DDD, Uitenbosch G, de Boer HD, Carvalho HN, Cata JP, Erdoes G, Heytens L, Lois FJ, Pelosi P, Rousseau AF, Forget P, Nesvadba D. Developing expert international consensus statements for opioid-sparing analgesia using the Delphi method. BMC Anesthesiol 2023; 23:62. [PMID: 36849928 PMCID: PMC9969386 DOI: 10.1186/s12871-023-01995-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 01/25/2023] [Indexed: 03/01/2023] Open
Abstract
INTRODUCTION The management of postoperative pain in anaesthesia is evolving with a deeper understanding of associating multiple modalities and analgesic medications. However, the motivations and barriers regarding the adoption of opioid-sparing analgesia are not well known. METHODS We designed a modified Delphi survey to explore the perspectives and opinions of expert panellists with regard to opioid-sparing multimodal analgesia. 29 anaesthetists underwent an evolving three-round questionnaire to determine the level of agreement on certain aspects of multimodal analgesia, with the last round deciding if each statement was a priority. RESULTS The results were aggregated and a consensus, defined as achievement of over 75% on the Likert scale, was reached for five out of eight statements. The panellists agreed there was a strong body of evidence supporting opioid-sparing multimodal analgesia. However, there existed multiple barriers to widespread adoption, foremost the lack of training and education, as well as the reluctance to change existing practices. Practical issues such as cost effectiveness, increased workload, or the lack of supply of anaesthetic agents were not perceived to be as critical in preventing adoption. CONCLUSION Thus, a focus on developing specific guidelines for multimodal analgesia and addressing gaps in education may improve the adoption of opioid-sparing analgesia.
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Affiliation(s)
- Daniel Da Der Sng
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, AB25 2ZD, UK.
| | - Giulia Uitenbosch
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Hans D de Boer
- Department of Anesthesiology Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital Groningen, Groningen, Netherlands
| | - Hugo Nogueira Carvalho
- Anesthesiology and Perioperative Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Jette, Belgium
| | - Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, Division of Anesthesiology, Critical Care, and Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, USA
| | - Gabor Erdoes
- University Department of Anaesthesiology and Pain Medicine, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Luc Heytens
- Department of Anesthesia, Department of Neurology and Instituut Born-Bunge, University of Antwerp (UA), Antwerpen, Belgium
| | - Fernande Jane Lois
- Centre Hospitalier Universitaire de Liège, Anesthesiology, Liège, Belgium
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), IRCCS San Martino Policlinico Hospital, Genova GE, Italy
| | | | - Patrice Forget
- Department of Anaesthesia, Institute of Applied Health Sciences, Epidemiology Group, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen; NHS Grampian, Aberdeen, AB25 2ZD, UK.,Pain and Opioids After Surgery (PANDOS) European Society of Anaesthesiology and Intensive Care (ESAIC) Research Group, ESAIC, Brussels, Belgium
| | - David Nesvadba
- Department of Anaesthesia, NHS Grampian, Aberdeen, AB25 2ZD, UK
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Zhang NM, Daly D, Terblanche M, Joshi S, Tacey M, Vesty G, Zheng Z. Doctors' and Nurses' Attitudes of Acupuncture and Acupressure use in Perioperative Care: An Australian National Survey. Pain Manag Nurs 2022; 23:800-810. [PMID: 36153218 DOI: 10.1016/j.pmn.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 08/07/2022] [Accepted: 08/13/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Acupuncture and acupressure are not being systematically used in the management of postoperative nausea and vomiting and pain, despite being included in the guidelines. AIM To examine the beliefs, attitudes, and knowledge of Australian nurses/midwives and doctors toward the perioperative use of AA for the management of postoperative nausea and vomiting and pain; to explore the barriers and enablers influencing acupuncture and acupressure integration into hospital setting. METHODS A mixed-mode approach was undertaken for data collection. An online approach was used to recruit respondents from Australian College of Perioperative Nurses. Three hospitals from three different Australian states were selected via convenience sampling. RESULTS A total of 421 usable surveys were included in data analysis. The respondents comprised 14.3% doctors and 72.9% nurses/midwives. Overall, 69.4% were female, 85% were trained in Australia with 35% and 51.4% having knowledge or personal exposure to AA in general respectively. Over 60% of the respondents agreed AA should be routinely integrated into perioperative care, and over 80% would recommend AA to their patients if it was provided at their hospital, and, 75% would be willing to receive further education. The three main reported barriers included: perceived lack of scientific evidence (80.9%), unavailability of credentialed provider (77.2%) and lack of reimbursement (60.4%). CONCLUSIONS Positive attitudes are reported by Australian doctors and nurses toward AA. This is despite of low levels of knowledge or personal exposure to AA. Further studies are required to explore the implementation of barriers and address respondent calls for further education.
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Affiliation(s)
- Nancy Ming Zhang
- School of Health and Biomedical Science, RMIT University, Bundoora, Melbourne, Australia; School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Melbourne, Australia
| | - David Daly
- Department of Anaesthesia and Perioperative Medicine, The Alfred Hospital, Melbourne, Australia
| | - Morne Terblanche
- Department of Anaesthesia and Perioperative Medicine, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Sumati Joshi
- Operating Theatre, Shoalhaven District Memorial Hospital, Nowra, New South Wales, Australia
| | - Mark Tacey
- Northern Health, Epping, Victoria, Australia; School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Gillian Vesty
- School of Accounting, RMIT University, Melbourne, Australia
| | - Zhen Zheng
- School of Health and Biomedical Science, RMIT University, Bundoora, Melbourne, Australia.
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5
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Klenø AN, Sørensen HT, Pedersen AB. Time trends in use of non-steroidal anti-inflammatory drugs and opioids one year after total hip arthroplasty due to osteoarthritis during 1996-2018: a population-based cohort study of 103,209 patients. Osteoarthritis Cartilage 2022; 30:1376-1384. [PMID: 35918050 DOI: 10.1016/j.joca.2022.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/10/2022] [Accepted: 07/14/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To examine time trends in the use of NSAIDs and opioids for patients with osteoarthritis undergoing total hip arthroplasty (THA) during 1996-2018. METHOD Using Danish population-based medical databases, we identified 103,209 THA patients. Prevalence rates of NSAID and opioid use among preoperative users and non-users were calculated in four quarters (Q1-Q4) after THA by calendar periods (1996-2000, 2001-2006, 2007-2012 and 2013-2018). Prevalence rate ratios (PRR) were adjusted for age and gender. RESULTS Among preoperative NSAID users and non-users, NSAID use in Q1 increased from 32.6% in 1996-2000 to 48.0% in 2013-2018 (PRR = 1.49, 95% CI: 1.42-1.55) and from 12.9% to 32.0% (PRR = 2.49 (2.32-2.67)), respectively. Among preoperative opioid users and non-users, opioid use in Q1 increased from 42.7% in 1996-2000 to 76.9% in 2013-2018 (PRR = 1.81 (1.73-1.89)) and from 15.2% to 58.2% (PRR = 3.85 (3.65-4.05)), respectively. NSAID use in Q4 decreased from 24.5% in 1996-2000 to 21.4% in 2013-2018 (PRR = 0.88 (0.83-0.93)) and from 6.9% to 5.6% (PRR = 0.81 (0.73-0.91)) in preoperative NSAIDs users and non-users, respectively. Opioid use in Q4 increased from 26.6% in 1996-2000 to 28.6% (PRR = 1.08 (1.02-1.15)) in 2013-2018 and from 4.1% to 5.0% (PRR = 1.25 (1.11-1.40)) in preoperative opioid users and non-users, respectively. CONCLUSION We observed up to a 4-fold increase in NSAID and opioid use in Q1 during 1996-2018, while usage in Q4 did not change substantially. However, 5-6% of the preoperative non-users of NSAIDs and opioids were users in Q4, which might relate to inaccurate indication for or timing of THA and the post-surgical phasing out of analgesics use.
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Affiliation(s)
- A N Klenø
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Århus N, Denmark.
| | - H T Sørensen
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Århus N, Denmark.
| | - A B Pedersen
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Århus N, Denmark.
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Opioid Use Disorder and Racial/Ethnic Health Disparities: Prevention and Management. Curr Pain Headache Rep 2022; 26:129-137. [PMID: 35179723 DOI: 10.1007/s11916-022-01010-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW This review aims to summarize risks and disparities associated with the prevalence and treatment of opioid use disorder in the perioperative and long-term setting, as well as evidence-based treatment and prevention targeted toward specific vulnerable populations. RECENT FINDING There are significant demographic disparities in pain management and development and management of OUD in the chronic and surgical setting. While White patients traditionally receive more pain management, they are also at higher risk of developing OUD. Hispanic and Latin populations have the largest proportion of youth with OUD and often lack culturally appropriate translation services that allow for effective treatment. Native Americans have the second highest rate of OUD and often receive care in communities and healthcare settings that lack funding and resources to combat OUD. African Americans tend to suffer from the criminalization of OUD and are less able to seek treatment due to this, and furthermore, often lack community services that would benefit them. Additional vulnerable populations include homeless individuals that lack access to healthcare or health insurance. In addition, incarcerated individuals often lack access to naloxone and suffer from high rates of fatal overdose soon after being released to the community. People in rural settings lack needle-exchange programs and community-based interventions/support groups. Patients in the perioperative setting lack standard screening and pain management protocols. Interventions targeted toward each appropriate group can help decrease the rate of OUD and improve its treatment, and overarching interventions such as protocols, targeted funding, education and regulation can combat OUD for all populations.
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Mayoral V. An overview of the use and misuse/abuse of opioid analgesics in different world regions and future perspectives. Pain Manag 2022; 12:535-555. [PMID: 35118876 DOI: 10.2217/pmt-2021-0094] [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: 11/21/2022] Open
Abstract
Opioids are an important therapeutic option for severe resistant chronic pain but, in the absence of proper oversight, their use has risks. The level of prescription opioid misuse/abuse differs among countries, due to differences in healthcare systems and pain management approaches. However, evaluating the true dimension of prescription opioid misuse/abuse is complicated by statistical reporting which often does not differentiate between prescription and illicit opioid use, or between prescription opioid use by patients and nonpatients, highlighting a need for greater uniformity. Parallel efforts to educate patients and the general public about opioid risks, facilitate appropriate analgesic prescribing and identify alternative formulations or options to use instead of or with opioids, may contribute to optimizing prescription opioid use for pain management.
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Affiliation(s)
- Victor Mayoral
- Pain Unit, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
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8
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Opioid Prescription Following Wrist and Ankle Fracture Fixation in Scotland—Tradition Prevails. J Clin Med 2022; 11:jcm11020468. [PMID: 35054162 PMCID: PMC8781195 DOI: 10.3390/jcm11020468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/22/2021] [Accepted: 01/10/2022] [Indexed: 12/10/2022] Open
Abstract
The American ‘opioid crisis’ is rapidly spreading internationally. Perioperative opioid use increases the risk of long-term opioid use. We review opioid use following wrist and ankle fracture fixation across Scotland, establishing prescribing patterns and associations with patient, injury, or perioperative factors. Six Scottish orthopedic units contributed. A total of 598 patients were included. Patient demographics were similar across all sites. There was variation in anesthetic practice, length of stay, and AO fracture type (p < 0.01). For wrist fractures, 85.6% of patients received a discharge opioid prescription; 5.0% contained a strong opioid. There was no significant variation across the six units in prescribing practice. For ankle fractures, 82.7% of patients received a discharge opioid prescription; 17% contained a strong opioid. Dundee and Edinburgh used more strong opioids; Inverness and Paisley gave the least opioids overall (p < 0.01). Younger patient age, location, and length of stay were independent predictors of increased prescription on binary regression. Despite variability in perioperative practices, discharge opioid analgesic prescription remains overwhelmingly consistent. We believe that the biggest influence lies with the prescriber-institutional ‘standard practice’. Education of these prescribing clinicians regarding the risk profile of opioids is key to reducing their use following surgery, thus lowering long-term opioid dependence.
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Mallow PJ, Belk KW. Cost-utility analysis of single nucleotide polymorphism panel-based machine learning algorithm to predict risk of opioid use disorder. J Comp Eff Res 2021; 10:1349-1361. [PMID: 34672212 DOI: 10.2217/cer-2021-0115] [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: 11/21/2022] Open
Abstract
Aim: To conduct a cost-utility analysis of a novel genetic diagnostic test (OUDTEST) for risk of developing opioid use disorder for elective orthopedic surgery patients. Materials & Methods: A simulation model assessed cost-effectiveness and quality-adjusted life-years (QALYs) for OUDTEST from private insurer and self-insured employer perspectives over a 5-year time horizon for a hypothetical patient population. Results: OUDTEST was found to cost less and increase QALYs, over a 5-year period for private insurance (savings US$2510; QALYs 0.02) and self-insured employers (-US$2682; QALYs 0.02). OUDTEST was a dominant strategy in 71.1% (private insurance) and 72.7% (self-insured employer) of model iterations. Sensitivity analyses revealed robust results except for physician compliance. Conclusion: OUDTEST was expected to be a cost-effective solution for personalizing postsurgical pain management in orthopedic patients.
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Affiliation(s)
- Peter J Mallow
- Department of Health Services Administration, Xavier University, 3800 Victory Parkway, Cincinnati, OH 45207, USA
| | - Kathy W Belk
- Health Clarity Solutions, LLC, Mooresville, NC 28115, USA
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10
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Daliya P, Adiamah A, Roslan F, Theophilidou E, Knaggs RD, Levy N, Lobo DN. Opioid prescription at postoperative discharge: a retrospective observational cohort study. Anaesthesia 2021; 76:1367-1376. [PMID: 33768532 DOI: 10.1111/anae.15460] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 12/31/2022]
Abstract
Opioid misuse is now considered a major public health epidemic in North America, with substantial social and financial consequences. As well as socio-economic and commercial drivers, modifiable risk-factors that have resulted in this crisis have been identified. The purpose of this study was to identify whether, within England, modifiable drivers for persistent postoperative opioid use were present. This was a retrospective cohort study of practice at 14 National Health Service hospitals across England. Data were collected retrospectively and validated for adult patients undergoing elective intermediate and major or complex major general surgical procedures between 1 and 31 March 2019. Of the 509 patients enrolled from 14 centres, 499 were included in the data analysis. In total, 31.5% (157/499) patients were in the intermediate surgery cohort and 68.5% (342/499) were in the major or complex major surgery cohort, with 21.0% (33/157) and 21.6% (74/342) discharged with opioid medicines to be taken at regular intervals, respectively. There were similar median oral morphine equivalent doses prescribed at discharge. Of patients prescribed regular opioid medicines, 76.6% (82/107) had a specified duration at discharge. However, 72.9% (78/107) had no written deprescribing advice on discharge. Similarly, of patients prescribed 'when required' opioids, 59.6% (93/156) had a specified duration of their prescription and 33.3% (52/156) were given written deprescribing advice. This study has identified a pattern of poor prescribing practices, a lack of guidance and formal training at individual institutions and highlights opportunities for improvement in opioid-prescribing practices within England.
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Affiliation(s)
- P Daliya
- East Midlands Surgical Academic Network, Queen's Medical Centre, Nottingham, UK
- Gastro-intestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research, Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - A Adiamah
- East Midlands Surgical Academic Network, Queen's Medical Centre, Nottingham, UK
- Gastro-intestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research, Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - F Roslan
- East Midlands Surgical Academic Network, Queen's Medical Centre, Nottingham, UK
- Gastro-intestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research, Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - E Theophilidou
- East Midlands Surgical Academic Network, Queen's Medical Centre, Nottingham, UK
- Gastro-intestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research, Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - R D Knaggs
- School of Pharmacy, Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
| | - N Levy
- Department of Anaesthesia and Peri-operative Medicine, West Suffolk Hospital, Bury St. Edmunds, UK
| | - D N Lobo
- East Midlands Surgical Academic Network, Queen's Medical Centre, Nottingham, UK
- Gastro-intestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research, Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
- David Greenfield Metabolic Physiology Unit, MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK
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11
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Abstract
BACKGROUND In the United States, postoperative opioid prescriptions have been implicated in the so-called 'opioid epidemic'. In Europe, the extent of overprescribing or misuse of opioids is not known. OBJECTIVES To describe the proportion of persistent postoperative opioid use in adults (>18 years) in European countries. DESIGN Systematic review of the published data. DATA SOURCES We searched the electronic literature databases MEDLINE (Ovid), Embase (Ovid), PubMed/MEDLINE and Scopus. ELIGIBILITY CRITERIA Studies describing opioid use in adult patients (>18 years) at least 3 months after surgery. RESULTS One thousand three hundred and seven studies were found, and 12 studies were included in this review. The rate of opioid use after 3 to 6 months was extracted from the studies and categorised by the type of surgery. Nine studies investigated opioid use after total hip or total knee arthroplasties (THA and TKA) and reported opioid user rates between 7.9 and 41% after 3 months. In all the included studies, a proportion between 2 and 41% of patients were opioid users 3 months after surgery. The level of evidence varied from high to very low. CONCLUSION To describe persistent opioid use in relation to specific countries or types of surgery is not possible. Because of the wide ranges observed, we can neither confirm nor rule out a possible public health problem linked to the persistent use of opioids in Europe. STUDY REGISTRATION PROSPERO: CRD42019154292.
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Affiliation(s)
- Taalke Sitter
- From the Epidemiology group, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen (TS, PF) and Department of Anaesthesia, NHS Grampian, Aberdeen, UK (PF)
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12
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Levy N, Quinlan J, El-Boghdadly K, Fawcett WJ, Agarwal V, Bastable RB, Cox FJ, de Boer HD, Dowdy SC, Hattingh K, Knaggs RD, Mariano ER, Pelosi P, Scott MJ, Lobo DN, Macintyre PE. An international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients. Anaesthesia 2021; 76:520-536. [PMID: 33027841 DOI: 10.1111/anae.15262] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2020] [Indexed: 01/01/2023]
Abstract
This international multidisciplinary consensus statement was developed to provide balanced guidance on the safe peri-operative use of opioids in adults. An international panel of healthcare professionals evaluated the literature relating to postoperative opioid-related harm, including persistent postoperative opioid use; opioid-induced ventilatory impairment; non-medical opioid use; opioid diversion and dependence; and driving under the influence of prescription opioids. Recommended strategies to reduce harm include pre-operative assessment of the risk of persistent postoperative opioid use; use of an assessment of patient function rather than unidimensional pain scores alone to guide adequacy of analgesia; avoidance of long-acting (modified-release and transdermal patches) opioid formulations and combination analgesics; limiting the number of tablets prescribed at discharge; providing deprescribing advice; avoidance of automatic prescription refills; safe disposal of unused medicines; reducing the risk of opioid diversion; and better education of healthcare professionals, patients and carers. This consensus statement provides a framework for better prescribing practices that could help reduce the risk of postoperative opioid-related harm in adults.
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Affiliation(s)
- N Levy
- Department of Anaesthesia and Peri-operative Medicine, West Suffolk Hospital, Bury St. Edmunds, UK
| | - J Quinlan
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - K El-Boghdadly
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - W J Fawcett
- Department of Anaesthesia and Pain Medicine, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - V Agarwal
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | | | - F J Cox
- Pain Management Service, Critical Care and Anaesthesia, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - H D de Boer
- Department of Anaesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital Groningen, Groningen, The Netherlands
| | - S C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN, USA
| | - K Hattingh
- Bendigo Health, Bendigo, Victoria, Australia
| | - R D Knaggs
- School of Pharmacy, Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
| | - E R Mariano
- Department of Anesthesiology, Peri-operative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Anesthesiology and Peri-operative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - P Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- IRCCS for Oncology and Neurosciences, San Martino Policlinico Hospital, Genoa, Italy
| | - M J Scott
- Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - D N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
- David Greenfield Metabolic Physiology Unit, MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - P E Macintyre
- Department of Anaesthesia, Pain Medicine and Hyperbaric Medicine, Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, Australia
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Hyland SJ, Brockhaus KK, Vincent WR, Spence NZ, Lucki MM, Howkins MJ, Cleary RK. Perioperative Pain Management and Opioid Stewardship: A Practical Guide. Healthcare (Basel) 2021; 9:333. [PMID: 33809571 PMCID: PMC8001960 DOI: 10.3390/healthcare9030333] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/02/2021] [Accepted: 03/10/2021] [Indexed: 12/20/2022] Open
Abstract
Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a "roadmap" for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.
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Affiliation(s)
- Sara J. Hyland
- Department of Pharmacy, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA
| | - Kara K. Brockhaus
- Department of Pharmacy, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
| | | | - Nicole Z. Spence
- Department of Anesthesiology, Boston University School of Medicine, Boston Medical Center, Boston, MA 02118, USA;
| | - Michelle M. Lucki
- Department of Orthopedics, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Michael J. Howkins
- Department of Addiction Medicine, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Robert K. Cleary
- Department of Surgery, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
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Srivastava D, Wilkinson P. Surgery and opioids: some cracks in an enduring romance. Br J Anaesth 2021; 126:1088-1092. [PMID: 33707092 DOI: 10.1016/j.bja.2021.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 02/02/2021] [Accepted: 02/03/2021] [Indexed: 10/22/2022] Open
Affiliation(s)
| | - Paul Wilkinson
- Department of Anaesthesia, Newcastle Pain Management Unit, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, UK.
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Mendes A. Managing postoperative pain and risk in opioid use. Br J Community Nurs 2021; 26:152-153. [PMID: 33719555 DOI: 10.12968/bjcn.2021.26.3.152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Aysha Mendes
- Freelance journalist specialising in healthcare, psychology and nursing
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Shah RF, Gwilym SE, Lamb S, Williams M, Ring D, Jayakumar P. Factors associated with persistent opioid use after an upper extremity fracture. Bone Jt Open 2021; 2:119-124. [PMID: 33595348 PMCID: PMC7925210 DOI: 10.1302/2633-1462.22.bjo-2020-0167.r1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Aims The increase in prescription opioid misuse and dependence is now a public health crisis in the UK. It is recognized as a whole-person problem that involves both the medical and the psychosocial needs of patients. Analyzing aspects of pathophysiology, emotional health, and social wellbeing associated with persistent opioid use after injury may inform safe and effective alleviation of pain while minimizing risk of misuse or dependence. Our objectives were to investigate patient factors associated with opioid use two to four weeks and six to nine months after an upper limb fracture. Methods A total of 734 patients recovering from an isolated upper limb fracture were recruited in this study. Opioid prescription was documented retrospectively for the period preceding the injury, and prospectively at the two- to four-week post-injury visit and six- to nine-month post-injury visit. Bivariate and multivariate analysis sought factors associated with opioid prescription from demographics, injury-specific data, Patient Reported Outcome Measurement Instrumentation System (PROMIS), Depression computer adaptive test (CAT), PROMIS Anxiety CAT, PROMIS Instrumental Support CAT, the Pain Catastrophizing Scale (PCS), the Pain Self-efficacy Questionnaire (PSEQ-2), Tampa Scale for Kinesiophobia (TSK-11), and measures that investigate levels of social support. Results A new prescription of opioids two to four weeks after injury was independently associated with less social support (odds ratio (OR) 0.26, p < 0.001), less instrumental support (OR 0.91, p < 0.001), and greater symptoms of anxiety (OR 1.1, p < 0.001). A new prescription of opioids six to nine months after injury was independently associated with less instrumental support (OR 0.9, p < 0.001) and greater symptoms of anxiety (OR 1.1, p < 0.001). Conclusion This study demonstrates that potentially modifiable psychosocial factors are associated with increased acute and chronic opioid prescriptions following upper limb fracture. Surgeons prescribing opioids for upper limb fractures should be made aware of the screening and management of emotional and social health. Cite this article: Bone Jt Open 2021;2(2):119–124.
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Affiliation(s)
- Romil Fenil Shah
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Texas, USA
| | - Stephen E Gwilym
- Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, Oxford University Hospitals, Oxford, UK
| | - Sarah Lamb
- Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, Oxford University Hospitals, Oxford, UK
| | - Mark Williams
- Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, Oxford University Hospitals, Oxford, UK
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Texas, USA
| | - Prakash Jayakumar
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Texas, USA.,Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, Oxford University Hospitals, Oxford, UK
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Guillou Landreat M, Baillot M, Le Goff D, Le Reste JY. Acute pain management among patients with opioid maintenance therapy: specificities and difficulties identified in primary care: a qualitative study. BMJ Open 2021; 11:e044433. [PMID: 33468504 PMCID: PMC7817820 DOI: 10.1136/bmjopen-2020-044433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES In the last 30 years, opioid maintenance treatment prescription (OMT) has changed patients' and also changed physicians' practices. General practitioners (GPs) have to deal with patients on OMT who are in acute pain. The objective of this qualitative study was to explore medical care challenges and solutions identified by GPs in the management of acute pain among patients receiving OMT. DESIGN AND SETTING Qualitative study with semistructured interviews were used as a data collection technique with a sampling strategy using a snowball sampling method to obtain a purposive sample of practicing GPs. Analysis was undertaken using a thematic analysis method. PARTICIPANTS Twelve GPs, working in France (Brittany) who prescribe OMT were interviewed. RESULTS The thematic analysis resulted in two main themes relating to specificities and difficulties identified: (1) Medical care and training challenges identified by GPs treating patients on OMT with acute pain, with four subthemes : management of these situations not concerning primary care, lack of training prompts GPs to rely on peer and specialist support, lack of guidelines and conflicting recommendations between clinicians in different settings (2) linked to the patient-GP relationship, with six subthemes: Implementing an individualised centred approach, acute pain management during OMT relies on a relationship based on trust, GPs found difficulties in evaluating and treating pain, difficulties in care adherence, fear of patients destabilisation, fear of misuse and diversion. CONCLUSION The complexity of acute pain and OMT entails significant challenges for clinicians and patients. In primary care, it is hard to achieve a balance between pain relief and opioid use disorder treatment, in a global patient-centred approach. Fear of misuse or diversion was not a important factor, except for patients not known to the practitioners, but GPs were concerned with the risks of patient destabilisation in situations of acute pain.
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Affiliation(s)
- Morgane Guillou Landreat
- EA SPURBO, Universite de Bretagne Occidentale, Brest, France
- addictologie, CHRU de Brest, Brest, France
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Abstract
In terms of antinociceptive action, the main mode of action of magnesium involves its antagonist action at the N-methyl-d-aspartate (NMDA) receptor, which prevents central sensitization and attenuates preexisting pain hypersensitivity. Given the pivotal function of NMDA receptors in pain transduction, magnesium has been investigated in a variety of pain conditions. The oral and parenteral administration of magnesium via the intravenous, intrathecal, or epidural route may alleviate pain and perioperative anesthetic and analgesic requirements. These beneficial effects of magnesium therapy have also been reported in patients with neuropathic pain, such as malignancy-related neurologic symptoms, diabetic neuropathy, postherpetic neuralgia, and chemotherapy-induced peripheral neuropathy. In addition, magnesium treatment is reportedly able to alleviate fibromyalgia, dysmenorrhea, headaches, and acute migraine attacks. Although magnesium plays an evolving role in pain management, better understanding of the mechanism underlying its antinociceptive action and additional clinical studies is required to clarify its role as an adjuvant analgesic.
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Richards GC, Mahtani KR, Muthee TB, DeVito NJ, Koshiaris C, Aronson JK, Goldacre B, Heneghan CJ. Factors associated with the prescribing of high-dose opioids in primary care: a systematic review and meta-analysis. BMC Med 2020; 18:68. [PMID: 32223746 PMCID: PMC7104520 DOI: 10.1186/s12916-020-01528-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 02/12/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The risks of harms from opioids increase substantially at high doses, and high-dose prescribing has increased in primary care. However, little is known about what leads to high-dose prescribing, and studies exploring this have not been synthesized. We, therefore, systematically synthesized factors associated with the prescribing of high-dose opioids in primary care. METHODS We conducted a systematic review of observational studies in high-income countries that used patient-level primary care data and explored any factor(s) in people for whom opioids were prescribed, stratified by oral morphine equivalents (OME). We defined high doses as ≥ 90 OME mg/day. We searched MEDLINE, Embase, Web of Science, reference lists, forward citations, and conference proceedings from database inception to 5 April 2019. Two investigators independently screened studies, extracted data, and appraised the quality of included studies using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. We pooled data on factors using random effects meta-analyses and reported relative risks (RR) or mean differences with 95% confidence intervals (CI) where appropriate. We also performed a number needed to harm (NNTH) calculation on factors when applicable. RESULTS We included six studies with a total of 4,248,119 participants taking opioids, of whom 3.64% (n = 154,749) were taking high doses. The majority of included studies (n = 4) were conducted in the USA, one in Australia and one in the UK. The largest study (n = 4,046,275) was from the USA. Included studies were graded as having fair to good quality evidence. The co-prescription of benzodiazepines (RR 3.27, 95% CI 1.32 to 8.13, I2 = 99.9%), depression (RR 1.38, 95% CI 1.27 to 1.51, I2 = 0%), emergency department visits (RR 1.53, 95% CI 1.46 to 1.61, I2 = 0%, NNTH 15, 95% CI 12 to 20), unemployment (RR 1.44, 95% CI 1.27 to 1.63, I2 = 0%), and male gender (RR 1.21, 95% CI 1.14 to 1.28, I2 = 78.6%) were significantly associated with the prescribing of high-dose opioids in primary care. CONCLUSIONS High doses of opioids are associated with greater risks of harms. Associated factors such as the co-prescription of benzodiazepines and depression identify priority areas that should be considered when selecting, identifying, and managing people taking high-dose opioids in primary care. Coordinated strategies and services that promote the safe prescribing of opioids are needed. STUDY REGISTRATION PROSPERO, CRD42018088057.
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Affiliation(s)
- Georgia C Richards
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK. .,Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
| | - Kamal R Mahtani
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Tonny B Muthee
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Nicholas J DeVito
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.,EBMDatalab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Jeffrey K Aronson
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Ben Goldacre
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.,EBMDatalab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Carl J Heneghan
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
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20
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Emmanuel A. Progress requires change from the norm. Clin Med (Lond) 2019; 19:433. [PMID: 31732578 DOI: 10.7861/clinmed.ed.19.6.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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