Journal of opioid management最新文献

Background: The United States (US) is facing an opioid epidemic. Prescribed opioids are a contributor to this national issue. Strategies to reduce opioid prescriptions are a high priority. This study was designed to generate patient-level data on opioid use after surgery across different surgical specialties. We showed these data to surgeons and evaluated the impact it would have on their practice.

Methods: A cross-sectional survey-based study was performed in a teaching community hospital in the US. Adult patients who underwent an operation by a member of the Department of Surgery and the surgeons who performed these operations were surveyed. Patient-level data were obtained on opioid use after surgery. The number of opioid tablets taken and days on opioids were recorded. Patients were assessed for the frequency of recovery from surgery without opioids. Additionally, information on prescriptions filled and unused opioid disposal was collected. These data were presented to surgeons who responded on how having access to it may change their future prescribing habits.

Results: Opioid consumption after surgery was found to be far below expert panel guidelines across surgical specialties. Orthopedic surgery was found to be associated with significantly higher opioid use in the post-operative period. The small number of surgeons who responded showed that a large percentage planned to change opioid prescribing habits after gaining access to these data.

Conclusions: This project contributes to the growing body of literature showing lower than expected opioid usage for patients after surgery. Previous trends were mostly generated from large academic centers, and this community hospital data show consistent findings of patients being left with significant quantities of unused opioids routinely after surgery. It highlights the need for evidence-based prescribing recommendations as well as the need for better education and access to opioid disposal for patients.

Objective: To develop and implement a customized clinical decision support system (CDSS) in an under-resourced health region aimed at promoting appropriate and safe opioid prescribing.

Design: The Pharmaceutical Automated Reporting (PAR) tool integrates inpatient prescription data from BDM Pharmacy (version 10) and categorizes patient information using predefined logic. It operates with Python (version 3.10) and Microsoft Excel®, functioning as decision trees. Nine risk factors (absence of naloxone prescription with an opioid prescription, naloxone administration, high-frequency opioid dosing, multiple opioids prescribed, concurrent benzodiazepine and opioid coprescribed, over 7 days of intravenous route opioid use, morphine equivalent dose received over or equal to 90, possible opioid agonist therapy, possible alcohol withdrawal therapy) are assessed through a decision matrix to classify patients for opioid-related risk.

Results: Over 7 months, the PAR tool detected one opioid-related risk factor in 98.9 percent (n = 10,450) of patients prescribed an opioid and multiple risk factors in 62.4 percent (n = 6,590). The tool identified areas where data-driven interventions by the Opioid Stewardship Program could promote appropriate prescribing practices and will be used to track and promote stewardship interventions, inform policy change, and evaluate the impact on quality indicators.

Conclusion: Small, resource-scarce health systems can use open-source programming methodologies to create an internal CDSS to assist in addressing opioid-related risk factors within their healthcare facilities.

Pharmacists nationwide may play a critical role in expanding naloxone access after several states enacted legislation to allow pharmacist prescribing of opioid antagonists. This created a unique opportunity for inpatient pharmacists to participate in combating the opioid epidemic by prescribing naloxone at hospital discharge. A multifaceted intervention was developed to identify and educate hospitalized patients eligible for naloxone prescribing. After implementation, 22 of 40 eligible patients (55 percent) were prescribed naloxone by inpatient pharmacists during the 3-month study period. With this pharmacist-driven intervention, there was an 848 percent increase in the number of hospitalized chronic opioid patients with naloxone prescriptions on discharge.

Objective: Tapentadol causes fewer gastrointestinal adverse events than other potent opioid analgesics because of its low affinity for opioid receptors; however, development of symptoms related to central nervous system disorders, including delirium, has not been well-studied. This study aimed to identify the factors that influence the development of delirium after initiation of tapentadol therapy in hospitalized patients with cancer.

Design: Retrospective study.

Setting/patients: Among 93 patients, for whom treatment using tapentadol was initiated between December 1, 2017, and November 30, 2019, at a single center in Japan, 86 met the inclusion criteria and were enrolled in this study.

Main outcome measures: Delirium occurring within 2 weeks of initiation of the tapentadol treatment was diagnosed by a physician or nurse. Patient background information was obtained, including data on age, sex, medical history, adverse events, starting dose of tapentadol, and concomitant medications.

Results: Age ≥ 67 years, male sex, somnolence after initiation of tapentadol therapy, dose of ≥300 mg/day at the beginning of tapentadol therapy, switching from potent opioids, and concomitant use of duloxetine were associated with delirium occurring after tapentadol therapy initiation.

Conclusions: Among the factors associated with the incidence of delirium after the initiation of tapentadol therapy, patients whose starting dose of tapentadol was 300 mg/day or higher and those receiving concomitant duloxetine, a serotonin-noradrenaline reuptake inhibitor, were at high risk of developing delirium. These findings will help healthcare providers, including pharmacists, in development of treatment plans for preventing delirium when initiating tapentadol therapy in patients with cancer.

Objective: To implement an electronic health record best practice advisory (BPA) to promote coprescribing of naloxone to patients at high risk of serious opioid-related adverse events (ORADEs).

Design: This pre-post quasi-experimental study evaluated 9 months of opioid and naloxone prescription data before and after BPA implementation.

Setting: The Froedtert & the Medical College of Wisconsin enterprise is comprised of 45 ambulatory clinics and 10 hospitals, including the only adult Level 1 trauma center in eastern Wisconsin.

Patients: Patients who received opioid prescriptions in the preimplementation time period (n = 106,615 prescriptions) and post-implementation time period (n = 107,352 prescriptions) were included.

Interventions: BPA activation criteria included entry of a prescription with a morphine equivalent daily dose of 50 or greater with at least a 5-day supply, concomitant opioid and benzodiazepine prescription, or opioid prescription entry for a patient with a documented history of opioid overdose. The BPA defaulted to coprescribe naloxone, while also providing suppression options.

Main outcome measure: The primary endpoint was the change in naloxone prescription rate for patients on chronic opioid therapy (COT) with a morphine milligram equivalent daily dose (MEDD) per day of 50 or greater.

Results: The naloxone coprescription rate for COT patients with a MEDD of 50 or greater increased from 12.2 percent (95 percent confidence interval [CI] 10.4-14.4) to 34.79 percent (95 percent CI 31.8-38.2) after the BPA was implemented (odds ratio 2.85, 95 percent CI 2.37-3.42, p-value < 0.001).

Conclusions: Use of BPA increased the rate of naloxone coprescribing for patients at risk of serious ORADE.

Objective: The present opioid crisis has raised concern regarding the prescribing practices of physicians. However, the training of resident physicians has not been sufficiently evaluated. The proposed objective of this study was to evaluate how residents across different specialties perceived the adequacy of their training in the prescribing of opioid-based anal-gesics.

Design: Medical residents were surveyed regarding their opioid prescribing training in medical school and residency, their confidence and frequency of prescribing opioids, the indications for which they prescribed opioids, whether they utilize opioids as first-line treatment in pain management, and their perception of the effectiveness of opioids in managing a pa-tient's pain.

Setting: Medical residents across multiple years and specialties at two institutions within the same state were surveyed.

Results: The resident response rate was 26 percent (75), and of those residents, 56 percent (42) indicated that their medi-cal school training was insufficient and 37 percent (28) reported that their residency training was insufficient, which was independent of both year and specialty.

Conclusions: These findings suggest that residents perceive a lack of adequate training on the prescribing of opioids during medical school and to a lesser degree during residency. A larger study will be required to validate these findings as well as to determine which specific aspects of a resident's medical education on opioid prescribing are lacking. More importantly, the authors hope that these findings will initiate an interest in standardizing opioid prescribing education for medical students and residents with the goal of reducing the abuse and deaths related to these medications.

With the Food and Drug Administration's approval of the first over-the-counter naloxone nasal spray in 2023, it was expected that access to naloxone nasal spray would increase and that its cost would be reduced. However, the writers of this commentary found varying insurance coverage of naloxone during purchase attempts at local pharmacies. Failure to cover naloxone can reduce access and increase risk of overdose death. We suggest federal policy implementation that requires universal insurance coverage of at least one formulation of naloxone and to utilize national opioid settlement funds to pay for naloxone nasal spray to ensure equitable access to this lifesaving medication.

Objectives: Determine if physician stigma toward patients with chronic pain or opioid use disorder or physician hesitancy prescribing opioids adversely affects patient pain care. Explore the demographics associated with stigma and hesitancy.

Design: Survey, 25 questions.

Setting: Physician faculty at medical schools (80 percent), private physician Facebook® groups (15 percent), and others (5 percent), all specialties.

Participants: N = 352 attending United States physicians.

Main outcome measure: Physician self-reported patient pain care quality.

Results: Subjectively worse patient pain care was not found to be associated with stigma but had a borderline association with hesitancy (p = 0.046). Subjectively worse pain care was associated with less knowledge and experience with opioids (odds ratio [OR] 4.1, 95 percent confidence interval [CI] 3.0-5.6), practicing in the Midwest region (OR 2.1, 95 percent CI 1.2-3.4), and specialty: emergency (OR 53, 95 percent CI 20-139), other internal (OR 15, 95 percent CI 6.6-34), and general medicine (OR 12, 95 percent CI 5.4-26) compared to pain medicine. Physician stigma was more likely to be high in males (OR 2.5, 95 percent CI 1.5-4.3) and medium in physicians over 55 (OR 2.5, 95 percent CI 1.5-4.5). Compared to medium stigma, those with low stigma (General Linear Model (GLM) 0.35, 95 percent CI 0.18-0.52) and high stigma (GLM 0.22, 95 percent CI 0.01-0.44) were both more hesitant to prescribe opioids. More hesitancy was associated with less knowledge and experience (GLM 0.14, 95 percent CI 0.05-0.22) and physicians under 55 (GLM 0.24, 95 percent CI 0.08-0.40).

Conclusions: Although physician stigma was not found to affect patient pain care adversely, self-reporting bias and/or questionnaire issues may account for this. Physician specialty and knowledge and experience with opioids were important factors.

Buprenorphine was synthesized in the 1960s as a result of a search for a safe and effective opioid analgesic. Present formulations of buprenorphine are approved for the treatment of both acute and chronic pain. Its long duration of action, high affinity, and partial agonism at the µ-opioid receptor have established it as a mainstay treatment for opioid use disorder (OUD). Full agonist opioids (FAOs) remain a primary choice for perioperative pain in both opioid-naïve and opioid-tolerant patients despite well-known harms and new emphasis on multimodal analgesia strategies prioritizing nonopioid analgesics. We review the evidence supporting the use of buprenorphine as an effective analgesic alternative to more commonly prescribed FAOs in acute and chronic pain management. For the patient prescribed buprenorphine for OUD, prior conventionalism advised temporary discontinuation of buprenorphine preoperatively; this paradigm has shifted toward continuing buprenorphine throughout the perioperative period. Questions remain whether dose adjustments may improve patient outcomes.