Journal of opioid management最新文献

Objective: The primary objective of this study was to evaluate the effectiveness of a discharge analgesia guideline on the number of days' supply of opioid analgesics provided among surgical patients upon hospital discharge. The secondary objective was to analyze the effect of this guideline on the provision of an analgesic discharge plan.

Design: A retrospective historical control cohort study.

Setting: A tertiary metropolitan hospital.

Interventions: A discharge analgesia guideline recommending the supply of opioid analgesics on discharge based on patient use in the 24 hours prior to discharge and the supply of an analgesic discharge plan.

Main outcome measure(s): The primary outcome measure was the number of days' supply of opioids. The secondary outcome measure was the proportion of patients receiving an analgesic discharge plan.

Results: There was no change in the number of days' supply of opioids provided on discharge (median, interquartile range: 5, 3-9.75 vs 6, 4-10; p = 0.107) and in the proportion of patients receiving an analgesic discharge plan (26 percent vs 22.2 percent; p = 0.604). The results of two multivariable regression models showed no change in the number of days' supply of opioids (adjusted incidence rate ratio, 95 percent confidence interval [CI]: 1.1, 0.9-1.2) and the provision of an analgesic discharge plan (adjusted odds ratio, 95 percent CI: 0.6, 0.2-1.4) after adjusting for confounding variables.

Conclusion: Overall, our study found no change in the number of days' supply of opioids provided on discharge and the provision of an analgesic discharge plan after implementation of a discharge analgesia guideline, but we also found that prescribing practices already aligned with the guideline before its implementation.

Objective: This study investigated the association between patient treatment capacity rates and the percentage of racial/ethnic minorities at the county level.

Design: Ecological study at the county level.

Exposure: The percentages of racial/ethnic minorities and the people living in poverty in 3,140 counties serve as the main exposure and confounder variables.

Main outcome measure: "No or low patient capacity" was defined as a patient capacity rate less than or equal to the 40th percentile of the distribution. Patient capacity rates were calculated by adding the maximum number of patients X-waivered providers could potentially treat in each county.

Result: Counties in higher racial/ethnic minority quintiles had significantly lower odds of "no or low patient capacity" than those in the lowest quintile in multiple logistic regression (adjusted odds ratio, 0.29; 95 percent CI, 0.14-0.61).

Conclusion: Since racial/ethnic minorities continue to have limited access to buprenorphine, as shown in individual-level studies, merely increasing treatment capacity is largely insufficient.

Background: Buprenorphine may be safer and better-tolerated than full mu opioid receptor (MOR) agonists. Whether it effectively controls cancer-related pain is unclear. A prior review (Cochrane 2015) did not support prioritizing buprenorphine over full MOR agonists for cancer-associated pain.

Purpose/hypothesis: We conducted an updated systematic review of buprenorphine's effect on cancer- related pain including both new studies and additional study designs. Procedures/data/observations: We searched Cochrane, OVID Medline, EMBASE, EBSCO and Web of Science for studies published in any language up to May 2023 for studies that examined buprenorphine's impact upon pain severity/intensity in patients with active cancer. Risk of bias and study quality were assessed using the Cochrane Collaboration tool for randomized controlled trials (RCTs), and the Newcastle-Ottawa Scale for cohort and casecontrol studies. Data were synthesized using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.

Conclusions/applications: 2322 publications were identified and 42 studies were included (14 RCTs, 10 pre-post uncontrolled, 5 cohort, and 2 case-control studies). All had moderate-high risk of bias. One RCT showed buprenorphine was superior to placebo. 11 RCTs (12 papers) showed buprenorphine was as effective as full MOR agonists for cancer pain. 10-30 percent of cancer patients trialing buprenorphine did not achieve adequate response.

Background: The CPG's updated recommendation is supported by buprenorphine's lower risk of overdose and misuse.(1) In comparison to full mu-opioid agonists, buprenorphine possesses a superior safety profile with respect to respiratory depression, even in non-dependent individuals, and fatal overdose, when not combined with other sedating medications.(2-5) Purpose/hypothesis: This project identifies prescribing trends of buprenorphine for chronic pain before and after implementing two pharmacy interventions. Procedures/data/observations: Patient charts were reviewed before and after removal of a drug authorization key in the electronic health record and development of an educational presentation for providers. In the pre-intervention group, 19 patients were included and 13 patients in the post-intervention group. Prescriptions for buprenorphine decreased by 31.5% from the pre-intervention to post-intervention period, but three new prescriptions were started after interventions.

Conclusions/applications: Adverse reactions were the cause of the decrease in prescriptions, most commonly nausea and vomiting. This data may be valuable to providers as they expand their knowledge about buprenorphine's analgesic use. This is a longitudinal project and identifying barriers that may limit prescribing of buprenorphine may be beneficial for future educational interventions.

Background: There is a great deal of confusion associated with conversion from CII opioid to buprenorphine products. The data presented supports that patients can be converted from high dose opioid medication to buprenorphine products safely and effectively. This presentation will provide a road map to help guide practitioners who are interested in applying this to their clinical practice.

Purpose/hypothesis: Thepurposeoftheresearchwasnotonlytodiscoverifconversiontoapartialagonist CIII medication from full agonist CII medications would be achieveable without sacrificing analgesia, but also to provide guidance to providerswhoareinterestedinpursuingthisoptioninclinicalpractice. Procedures/data/observations: Patients who met inclusion criteria were stratified into subgroups on the basis of pre- conversion morphine milligram equivalents, whether they remained on opioids for breakthrough pain postconversion, and pre- and postconversion numerical rating scale pain scores. Outcomes of interest included the differences between pre- and postconversion numerical rating scale pain scores and daily morphine milligram equivalents for each sub-group. Of 157 patients reviewed, 87.9% were successfully converted to buprenor-phine buccal film. Overall, numericalrating scale pain scores were stable after conversion. Statistically significant reductions were demonstrated in the <90 daily morphine milligram equivalent subgroup. Postconversion daily morphine milligram equivalents decreased by 85.4% from baseline. Change in daily morphine milligram equivalents is representative of patients who remained on breakthrough pain medication.

Conclusions/applications: Results demonstrate continued analgesia after conversion to buprenorphine buccal film despite reductions in daily morphine milligram equivalents. Most patients were able to convert directly from their long-acting opioid to buprenorphine buccal film and stabilized without the use of concomitant opioids for breakthrough pain. Aggressive titration strategies were associated with greater success. This data proves that conversion from full agonist CII medications is possible without sacrificing analgesia while reducing the risk of adverse events associated with full agonist CII medications.

Background: Various protocols for micro-induction of buprenorphine in patients with opioid use disorder have been published. There is a paucity of literature similarly describing micro- induction in patients converting from full agonist opioids to buprenorphine for chronic pain. As the prescription opioid epidemic continues to be problematic and more patients are being converted to buprenorphine, we are working to provide more guidance on goal dosages of buprenorphine and how to safely cross-titrate to that goal.

Purpose/hypothesis: As the prescription opioid epidemic continues to be problematic and more patients are being converted to buprenorphine, we are working to provide more guidance on goal dosages of buprenorphine and how to safely cross-titrate to that goal. Procedures/data/observations: Our cross-titration protocol resulted in roughly half (15/31) patients successfully converting to and continuing with buprenorphine at 4 weeks, with an average duration of induction of 29 days. Average end titration dose for patients on buprenorphine/naloxone SL films was 7.9 ± 5.7 mg/day. Patients previously taking >120 mg MEDD stabilized on 8-16 mg/day.

Conclusions/applications: Clinical responses were widely variable, and many required slower taper and higher end titration buprenorphine dose than anticipated. Future work is focused on determining which factors contribute to the variation and whether adjustment to the protocol is warranted.

Background: Historically, there has been limited evidence and no clear consensus suggesting best practices for perioperative buprenorphine management (PBM). Previously published PBM strategies included a wide variation in dosing, complexity, and clinical decision making points. Importantly, there are limited published algorithms reporting corresponding patient outcomes data.

Purpose/hypothesis: To review the literature for newly published perioperative PBM strategies, with the aims of identifying emerging trends and assessing patient outcomes data. Procedures/data/observations: Literature review of manuscripts published from 2020 to current containing PBM strategies.

Conclusions/applications: Pending completion of analysis, the authors will present findings of emerging trends and patient outcomes data in PBM.

Background: Opioids remain the cornerstone for the treatment of moderate to severe cancer pain. Due to benefits over full agonist opioids (FAO), buprenorphine has emerged as an alternative treatment.

Purpose/hypothesis: Buprenorphine is only approved for the treatment of pain that is chronic non-cancer. Cancer-related pain is often progressive with breakthrough pain. There is limited evidence for using short-acting FAO in combination with buprenorphine. There are concerns about withdrawal and the efficacy of pain control using buprenorphine. We hypothesize buprenorphine, in combination with short-acting FAOs, can adequately control cancer- related pain without causing withdrawal symptoms. Procedures/data/observations: Our prospective, single-arm, open-label study enrolls patients with cancer-related pain who are on buprenorphine in combination with an FAO at > 30 mg OME/day, either requiring long-acting pain relief or their pain is not controlled with an FAO alone. Our study is ongoing, with 15 patients enrolled and a target of 50. The patient's pain is self-assessed daily using a mobile application. Withdrawal is assessed regularly using a modified Clinical Opioid Withdrawal Scale (COWS) score.

Conclusions/applications: Buprenorphine appears to be effective for the treatment of cancer pain without causing withdrawal in combination with short-acting FAO >30 mg/day.

Background: Opioid overdoses continue to rise in the United States. In 2021, a record 80,411 reported overdoses occurred in the US alone, nearly double that in 2017. Buprenorphine's pharmacology is ideal for management of patients with opioid use disorder (OUD) with or without chronic pain. Within the VA, clinical pharmacist practitioners (CPP) are uniquely equipped to operate with significant scope of practice to prescribe medications including controlled substances, an opportunity to vastly increase access to care for veterans suffering from OUD, complex opioid dependency or pain.

Purpose/hypothesis: The purpose of this case series is to describe how DEA licensed pain CPP safely and effectively manages 1) Suboxone home inductions to increase access for OUD 2) rotations from traditional full mu opioids to chronic pain buprenorphine products and 3) off label use of Suboxone for pain. Procedures/data/observations: Cases were collected in usual workload for clinical pharmacist. High rate of tolerability and efficacy noted with buprenorphine across all products.

Conclusions/applications: DEA licensed Pain CPPs can make an immediate positive impact for veterans with OUD and/or complex pain and may be more comfortable with buprenorphine than many other providers.