Journal of opioid management最新文献

Objective: To examine associations between race, comorbidity, opioid and nonopioid treatment burden, and socioeconomic status (SES) in patients with chronic low back pain (CLBP).

Design: A case-control study.

Setting: Tertiary academic system.

Participants: A total of 4,193 subjects with CLBP and 4,193 age-, sex-, race-, and region-matched subjects with nonchronic low back pain participated in this study.

Main outcome measure(s): The primary outcome measures were prescription frequencies of opioid and nonopioid medications as well as nonpharmaceutical interventions. Secondary measures pertained to the prevalence of comorbidities, race, and SES traits.

Results: The median age of the subjects was 55.50 years, with 61.75 percent female distribution, 48.84 percent Black or African American, 30.65 percent White non-Hispanic, and 15.93 percent non-White Hispanic or Latino among the subjects. Black or African American and non-White Hispanic or Latino identity was associated with higher hardship compared to patients identifying as White non-Hispanic (Tukey-Kramer adjusted p-value < 0.0001). Opioid use was significantly higher in the CLBP group (Cochran-Armitage trend test p-value < 0.0001), and there was a significant positive trend between the number of comorbidities and opioids used. As hardship index group (HIG) increased by 1, the expected number of comorbidities increased by a factor of 1.09 (95 percent confidence interval [CI]: 1.06-1.11), and the expected number of treatments increased by a factor of 1.07 (95 percent CI: 1.04-1.09). Physical therapy and spine procedures had a significant negative relationship with hardship.

Conclusions: Higher opioid prescribing behavior, particularly for morphine, hydrocodone, and tramadol, exists in patients with CLBP, especially in patients facing hardship and identifying as Black or African American and non-White Hispanic or Latino. Further prospective studies are needed to strengthen causality.

Pain and addiction are persistent public health issues that can lead to serious and fatal consequences on individuals, families, and communities. With the continued development of the opioid epidemic and the subsequent rise in opioid use and misuse, it is important to recognize the need for intervention at a public health level. Opioid stewardship programs (OSPs) are promising public health interventions that aim to coordinate safe and effective pain management through evidence-based intervention strategies. This narrative literature review examined the current evidence for implementation of OSPs in emergency departments and acute care hospitals to identify best practices and gaps in evidence. We reviewed publications found through PubMed and Embase, and articles were selected for inclusion after being evaluated through the inclusion criteria. One hundred and ninety-six articles were first found via the database search, and a final 24 articles were included in the sample for full review. The results indicated that all but two studies were published within the last 4 years, and one study mentioned a rural location. Most of the studies were pre- and post-OSP implementation studies. On average, the studies implemented four of the 11 total OSP strategies of interest. Twenty-two studies included information on care coordination, with the most prevalent effect being a decrease in total morphine milligram equivalents being prescribed at discharge. Nine studies included data on patient safety measures, including adverse events such as return emergency room visits, need for naloxone administration, and increase in post-operative clinic visits. This narrative review provides us with a preliminary understanding of OSP implementation in hospital settings and provides evidence that they are feasible and accepted with a wide variety of implementation interventions and strategies. It also demonstrates a gap in the literature regarding implementation in rural settings and with some specific implementation strategies.

Background: Methadone is frequently used in opioid substitution therapies, and poisoning incidents related to its use remain a public health concern, especially in regions with high opioid dependency. In Iran, especially in the city of Kerman, there is substantial evidence regarding intentional and unintentional methadone poisoning. This raises the need for more research on the complications and treatment of methadone poisoning.

Objective: Oxidative stress is involved in methadone poisoning, but so far very few studies have been done specifically in this field. The present study aims to investigate the relationship between oxidative stress, toxicity severity, and therapeutic responses.

Methods: In this study, 51 patients who were poisoned with methadone and visited the Afzalipour Hospital in Kerman participated. Oxidative stress parameters, including lipid peroxidation rate, plasma antioxidant capacity, glutathione, protein carbonyl, and superoxide dismutase enzyme activity, were investigated in the mentioned population, and the results were compared with those of healthy -individuals.

Results: Oxidative stress was significantly higher in methadone-poisoned subjects than in the control group.

Discussion and conclusion: The use of methadone induces oxidative stress, which is correlated with the blood level of methadone.

Implications: The results of this study show that reducing the oxidative stress resulting from methadone poisoning improves the treatment of methadone poisoning. In addition, monitoring the signs of oxidative stress can be an effective tool for predicting the level of toxicity and making treatment decisions. Further research in this field can suggest new therapeutic approaches considering the reduction of oxidative stress in cases of methadone poisoning. Finally, this study emphasizes that oxidative stress is an important factor in methadone poisoning and should not be overlooked by experts.

Objective: We aimed to understand clinician perceptions of nudge interventions designed to prevent unsafe opioid prescribing for acute pain in primary care.

Design: Semistructured interviews were conducted.

Setting: Forty-eight practices across three healthcare systems were included.

Participants: Primary care clinicians who were exposed to nudge interventions as part of a randomized clinical trial were included.

Interventions: Intervention arms included an electronic health record alert upon new opioid prescribing either alone or with one or both nudge interventions (written opioid justification and/or monthly clinician comparison emails).

Main outcome measures: We used conventional content and thematic analysis to identify themes related to clinician perceptions of nudge interventions and the opioid epidemic.

Results: We conducted and analyzed 77 clinician interviews. Clinicians voiced favorable impressions of both nudge interventions, but they did not feel the nudge interventions had a direct impact on their own prescribing of opioids, perhaps due to low prescribing secondary to other opioid interventions. Clinicians felt interventions should continue to assist high opioid prescribers.

Conclusion: Nudge interventions are favorably perceived by physicians to be an additional option in the current landscape of interventions to prevent unsafe opioid prescribing for acute pain in the primary care setting.

Introduction: Opioid prescribing practices and guidelines are outlined by the United States Centers for Disease Control and Prevention (CDC), but limited data are currently available regarding their use in clinical practice. A primary care residency clinical site at an academic medical center attempted to improve compliance with the CDC best practices in 2022. As a quality improvement initiative, a policy was created, and education was provided to clinicians and patients. The clinical impact of these interventions was analyzed.

Methods: A retrospective chart review was performed for patients on chronic opiates during 2023. Extracted electronic health record data were analyzed to collect information on the prescriber (resident/faculty/advanced practice provider), opioid type and duration, concurrent benzodiazepine use, and mental health diagnoses. The main outcomes were whether these patients had an opioid agreement and/or urine drug screen (UDS) in the past 12 months.

Results: A total of 245 patients met the criteria, with 29 percent also being prescribed benzodiazepines, and 69 percent having at least one mental health diagnosis. Forty-one percent of the patients had a UDS in the electronic medical record in 2023, with the statistically significant predictors being nontramadol opioid use and a completed opioid agreement. Thirty-two percent had a completed opioid agreement, with the statistically significant predictors being a concomitant mental health diagnosis, provider type, and UDS obtained.

Discussion/conclusion: Despite policy and education, compliance with our primary outcomes remained low. Residents were the most compliant. Tramadol was also uniquely identified as having lower compliance with having a UDS on file. Next steps include continued education efforts on the risk and best practices for reducing opioid-related harms and structured chart reviews.

Objective: The objective of this study was to leverage machine learning techniques to analyze administrative claims and socioeconomic data, with the aim of identifying and interpreting the risk factors associated with high-dose opioid prescribing.

Design: We applied six machine learning algorithms to a dataset integrating Medicaid claims from Missouri (2017-2021) and 2018 United States Census Bureau data. High-dose prescribing was defined as dosages ≥120 morphine milligram equivalent/day. SHapely Additive exPlanations methods were utilized to enhance model interpretability, ensuring transparent insights into the predictors of high-dose prescription risks.

Results: Our findings reveal that sociodemographic factors like age, race, and sex, along with socioeconomic variables such as percentages of veterans, disability, and primary care physicians (PCPs) per capita, have associations with high-dose prescription risks. Notably, higher percentage of veterans and PCPs per capita within counties correspond with increased high-dose prescriptions, while older age groups and patient sex also predict a greater risk.

Conclusion: This analysis underscores the significant influence of sociodemographic variables on high-dose opioid prescriptions. The interplay of these factors highlights the need for multifaceted public health strategies to address the underlying complexities of the opioid crisis. The integration of machine learning methods with traditional epidemiological techniques represents a promising approach for gaining a comprehensive understanding of intricate patterns not captured in traditional statistical analysis, thereby enabling effective mitigation of the opioid crisis.

Objective: To observe patterns of opioid therapy among veterans with a focus on long-term opioid therapy (LTOT).

Design: A retrospective study utilizing data from the Veterans Affairs Corporate Data Warehouse.

Subjects: Veterans 18 years or older, who received at least one outpatient opioid prescription between June 1, 2008, and June 1, 2018, and had no cancer, palliative care, or hospice encounters during the study period.

Main measures: For each patient, opioid prescriptions were combined into one contiguous prescription, as long as the gap (<7, <30, <90 days) between the end of supply and the receipt of the next fill met specified intervals. When gaps exceeded the threshold, a new prescription chain began. This was done to explore patterns of opioid fills.

Results: There were 746,658 patients with a prescription gap <7 days who received 5,084,346 contiguous opioid scripts. For all gap lengths, 16-35 percent of contiguous scripts lasted at least 90 days, 3-14 percent lasted more than a year, and 1-8 percent lasted 2 years. While a relatively small proportion of contiguous scripts were long-lasting, a substantial proportion of patients received long-lasting opioid therapy.

Conclusions: Long-term, intermittent opioid therapy was common. However, the long-term, monthly, uninterrupted opioid prescriptions expected with typical LTOT was not. It is likely that LTOT in past research was more reflective of periodic use instead of continuous, monthly prescriptions, especially for multiyear studies.

Objective: Ketamine has undergone a recent resurgence of interest as an opioid-sparing agent in pain management. The purpose of this study is to evaluate the effectiveness of patient-controlled analgesia (PCA) ketamine-morphine in comparison to conventional PCA morphine alone as post-operative analgesia in colorectal surgery patients.

Design: Double-blind, randomized, controlled study.

Setting: This study was conducted at a single, tertiary hospital.

Patients: Sixty patients who underwent elective colorectal surgery were randomly assigned into two groups.

Interventions: Group A received PCA ketamine-morphine 0.5:0.5 mg mL^-1, while Group B received PCA morphine 1 mg mL^-1 as post-operative analgesia.

Main outcome measures: Patients' pain scores, total PCA demands, cumulative morphine consumption, side effects, and their overall satisfaction score were recorded and analyzed.

Results: Overall, there was no significant difference in pain score in both groups, except at 24-hour intervals where Group A had significantly lower mean pain score at rest (1.10 ± 1.37 vs 2.10 ± 1.65, p = 0.017). Total PCA demands were comparable between both groups. Cumulative morphine consumptions however were significantly lower in Group A at all intervals with 24.7 ± 15.2 vs 48.9 ± 30.4 mg (p < 0.001) at 24-hour interval and 38.3 ± 22.4 vs 77.8 ± 46.3 mg (p = 0.001) at 48-hour interval. There was no significant difference in the incidence of side effects and overall satisfaction score in both groups.

Conclusions: PCA ketamine-morphine was as effective as PCA morphine as post-operative analgesia in colorectal surgery, with comparable pain scores, PCA demands, side effects, and significant reduction in morphine consumption.

Objective: The prevention of opioid-induced constipation (OIC) in patients treated for chronic pain is important for an improved quality of life and prevention of complications. This study aims to determine whether the implementation of the Primary Care Pain Education and Opioid Monitoring Program (PC-POP) improved the management of OIC in patients receiving opioids for chronic noncancer pain. Design/measure: Pharmacy records regarding the presence of an appropriate laxative prescription, prescription fills, and laxative types were obtained. The primary outcome was the proportion of patients with an appropriate laxative prescription on file for the management of OIC.

Setting: This study was conducted in the Salt Lake City Veterans Affairs (VA) Medical Center's primary care setting.

Subjects: Patients aged 18 and older being treated with opioids for chronic noncancer pain >3 months who were enrolled in PC-POP and had attended at least two classes were compared to patients receiving standard primary care at a VA Medical Center.

Results: Of the 698 patients included, 39.2 percent of patients enrolled in PC-POP had a laxative prescription on file compared to 20.9 percent for patients receiving standard primary care from a VA provider. Presence of appropriate laxative prescription was significantly higher for the PC-POP group (p = <0.001).

Conclusion: PC-POP enrollment was associated with a significantly higher number of appropriate laxative prescription for the management of OIC. This study indicates that there is potential for improvement in prescribing practices to ensure patients receive appropriate laxatives to mitigate the impact of OIC. It also indicates that implementation of a similar program at other VA Medical Centers could improve OIC management in veterans receiving opioids for chronic noncancer pain.

Objective: The purpose of this institutional survey study was to assess the opioid tapering practices of prescribers responsible for writing post-discharge opioid refills.

Design: A prospective, cross-sectional survey study.

Setting: Urban hospital specializing in orthopedic surgery.

Participants: Participants were identified from the hospital's active directory. Out of 251 questionnaires distributed, 88 were returned and evaluated; 60 percent were surgeons and 34 percent were physician assistants.

Intervention: An anonymous, voluntary eight-item survey was devised to capture information on tapering instructions from prescribers of post-discharge opioids.

Main outcome measures: Survey responses categorized by role and primary service.

Results: All prescribers (N = 47) provide tapering instructions; 87 percent provide general, while 9 percent provide detailed plans. Most (94 percent) prescribers discuss tapering via phone calls or during office visits, and 6 percent provide written instructions.

Conclusions: Few prescribers provide detailed tapering instructions. Providers may not feel equipped to provide specific tapering plans.