Analgesic Prescription Research Articles

Effectiveness of Pharmacological-Based Interventions, Including Education and Prescribing Strategies, to Reduce Subacute Pain After Total Hip or Knee Arthroplasty: A Systematic Review of Randomized Controlled Trials.

Total knee arthroplasty (TKA) and total hip arthroplasty (THA) surgeries are among the most common elective procedures. Moderate to severe postoperative pain during the subacute period (defined here as the period from hospital discharge to 3 months postoperatively) is a predictor of persistent pain 12 months postoperatively. This review aimed to examine the available postdischarge pharmacological interventions, including educational and prescribing strategies, and their effect on reducing pain during the subacute period after TKA or THA. We searched seven electronic databases from inception to April 22, 2021. Published randomized controlled trials of adults who underwent TKA or THA and received a pharmacological-based intervention commencing within 1 week after hospital discharge and conducted for up to 3 months postoperatively were compared with any treatment. Two reviewers independently extracted data on the primary outcome, pain intensity. This review was registered prospectively on PROSPERO (ID: CRD42021250384). Four trials involving 660 participants were included. Interventions included changing analgesic prescribing practices upon hospital discharge and education on analgesic use. Providing multimodal non-opioid analgesia in addition to reduced opioid quantity was associated with lower subacute pain (coefficient -0.81; 95% confidence interval -1.33 to -0.29; P = 0.003). Education on analgesic use during multidisciplinary home visits was effective for reducing pain intensity during the subacute period (6.25 ± 10.13 vs 35.67 ± 22.05; P < 0.001) compared with usual care. Interventions involving the provision of multimodal non-opioid analgesia and education on analgesic use show positive effects on reducing pain intensity during the subacute period after TKA and THA.

Factors that Affect Adequate Analgesia in African Americans with Cancer Pain

PURPOSE: Receiving adequate analgesia is problematic for African Americans with cancer pain. The majority of studies highlights the existing disparities between African Americans and Caucasians in pain management. There is a lack of research focusing on the etiology of these disparities, specifically on what causes prescriptions for inadequate analgesics, especially for African Americans. The purpose of this study was to characterize the adequacy of analgesia received by African Americans with cancer pain and to elucidate what patient characteristics contributed to receiving adequate analgesia. Methods: Secondary analysis of baseline data from an intervention study of African Americans with cancer pain. The Pain Management Index (PMI) was calculated for 302 African Americans with cancer pain to characterize the adequacy of the analgesics received for their reported pain score. Structure equation modeling was utilized to determine which patient factors (age, gender, presence of caregiver, employment status, educational level, cancer metastasis, perceived control over pain, pain-related distress, pain intensity, functional status) led to adequate analgesia. Results: Patients who reported worse pain received stronger analgesics. Forty percent of African Americans with cancer pain did not receive adequate analgesia based on the analgesic class prescribed. Cancer metastasis (p = .03) was the only significant predictor of a greater likelihood of receiving adequate analgesia. No other patient factors were found that affected analgesic prescriptions. Conclusions: Forty percent of African Americans with cancer pain received inadequate analgesia. No characteristics specific to African Americans with cancer pain led to receiving adequate analgesia. Cancer metastasis was the only factor that significantly contributed to receiving adequate analgesia. Future studies must be done to determine whether this is the same for other races to elucidate if the disparity identified in this study was solely based on race. Interventions must then be developed to reduce the disparities.

Epidemiology and routine care treatment of patients with hip or knee osteoarthritis and chronic lower back pain: real-world evidence from Germany

AimMusculoskeletal disorders are a major public health problem in most developed countries. As a main cause of chronic pain, they have resulted in an increasing prescription of opioids worldwide. With regard to the situation in Germany, this study aimed at estimating the prevalence of musculoskeletal diseases such as chronic low back pain (CLBP) and hip/knee osteoarthritis (OA) and at depicting the applied treatment patterns.Subject and methodsGerman claims data from the InGef Research Database were analyzed over a 6-year period (2011–2016). The dataset contains over 4 million people, enrolled in German statutory health insurances. Inpatient and outpatient diagnoses were considered for case identification of hip/knee OA and CLBP. The World Health Organization (WHO) analgesic ladder was applied to categorize patients according to their pain management interventions. Information on demographics, comorbidities, and adjuvant medication was collected.ResultsIn 2016, n = 2,693,481 individuals (50.5% female, 49.5% male) were assigned to the study population; 62.5% of them were aged 18–60 years. In 2016, n = 146,443 patients (5.4%) with CLBP and n = 307,256 patients (11.4%) with hip/knee OA were identified. Of those with pre-specified pain management interventions (CLBP: 66.3%; hip/knee OA: 65.1%), most patients received WHO I class drugs (CLBP: 73.6%; hip/knee OA: 68.7%) as the highest level.ConclusionThis study provides indications that CLBP and hip/knee OA are common chronic pain conditions in Germany, which are often subjected to pharmacological pain management. Compared to non-opioid analgesic prescriptions of the WHO I class, the dispensation of WHO class II and III opioids was markedly lower, though present to a considerable extent.

Evaluating opioid analgesic prescribing limits: A narrative review.

In response to the opioid crisis, opioid analgesic guidelines and prescribing limits have proliferated. The purpose of this narrative review is to examine evidence from studies evaluating the patient or public health impact of federal and state opioid analgesic prescribing guidelines and laws, describe gaps and challenges in current research, and highlight opportunities for improving future research. We focused on evidence from a literature review covering 2013 through 2019. We identified 30 studies evaluating opioid analgesic thresholds based on federal policies and guidelines, state laws, and Medicaid state plans that attempt to influence the course of patient care at or when the limit is exceeded (e.g., prior authorization). Most studies evaluated changes in prescribing or dispensing patterns of opioid analgesics, largely finding decreases in prescribing after policy enactment. Fewer studies evaluated patient or public health outcomes beyond changes in prescribing and dispensing patterns; results were infrequently stratified by potentially important sociodemographic and clinical factors. No studies assessed the potential for adverse patient outcomes for which we have emerging evidence of harms. We describe knowledge gaps and propose opportunities for future research to sufficiently assess the potential impact and unintended consequences of opioid analgesic prescribing laws, regulations, guidelines, and policies.

694 IMPROVING OPIATE PRESCRIBING IN OLDER ADULTS WITH HIP FRACTURES TO COMBAT THE IATROGENIC FALLOUT

Abstract Background The number of opioid prescriptions in older patients has increased dramatically and it is recognised that opioids are the fourth most likely drug to cause preventable hospital admissions. The adverse effects of opioids occur more frequently in the geriatric population. Little is known about the impact of postoperative pain in older adults. NICE recommends paracetamol with additional opioids if there is insufficient postoperative pain relief. Multidisciplinary management with early and then daily physiotherapy is critical. We have assessed pre-morbid, immediate and prolonged use of opioids in patients following hip fracture. Local problem Pre-intervention analysis identified 79% (57/72) of all patients being discharged on opiates. At 4-months, 37% (17/46) of those were still using them. This represents 28% (17/61) of all patients. Methods Analysis of all patients (excluding poly-trauma) with hip fractures over the age of 60 years admitted to St Mary’s Hospital. Interventions Development of local guideline on analgesia prescribing; particularly focusing senior geriatrician led decision making. Prescribing oxycodone for first 72-hours and initially using nerve block. Avoidance of transdermal preparations and withdrawing stronger opioids prior to discharge. Clear instructions for GP’s on a stop date and need for community review. Patient information leaflet dispensed with all discharge opioid prescriptions. Results Post-intervention cycle; 17% (11/63) of patients were taking prescribed opioids prior to admission (similar to the pre-cohort). 52% (33/63) were discharged on opiates, down from 79%. At 4-months, of those discharged on opioids, 30% (9/30) were still using them; lower than in the first cycle (37%). Overall reduction from 28% to 16% of patients on opioids at 4-months. Conclusion The use of specific hip fracture analgesia guideline, senior geriatrician decision-making and support to community colleagues can reduce in-patient and community opiate prescribing, and stem the growing problem of opioid addiction, misuse and iatrogenic re-admission.

756 ORTHOPAEDIC SURGEONS CAN PRESCRIBE LAXATIVES &amp; ANALGESICS TOO - A QUALITY IMPROVEMENT PROJECT SPANNING 7 YEARS

Abstract Background Patients admitted with age 60 years and over with a hip fracture admitted to a District General Hospital. Introduction The aim was to improve the prescribing of regular laxatives and analgesia at the time of admission to hospital. Methods There were repeated PDSA cycles. Data was collected on consecutive patients (by admission date) identified from the National Hip Fracture Database. Data was collected at baseline (10 patients in November 2013) and after Phase 1 intervention (20 patients, December 2013—January 2014), after Phase 2 (20 patients, February 2014), after Phase 3 (39 patients, April—June 2017) and after Phase 4 (September—October 2020). The interventions were as follows: Phase 1: Prompts at new doctor induction (‘Induction’) + prompts in hip fracture admission document. Phase2: Phase 1 intervention + flow diagram in fracture admission document. Phase 3: Prompts at Induction + electronic prescribing protocol (including laxatives and analgesics) + removal of flow diagram from admission document. Phase 4: Phase 3 intervention + more effort to explain to new locum doctors. Results Laxative prescribing: Baseline = 40%, Phase 1 = 80%, Phase 2 = 80%, Phase 3 = 56%, Phase 4 = 74% (24 hours post-admission = 90%). Paracetamol prescribing: Baseline 100%, Phase 1,100%, Phase 2,100%, Phase 3 64%, Phase 4 82% (24 h post-admission = 90%). Regular strong opioid prescribing: Admission: Baseline 60%, Phase 1 90%, Phase 2,100%, Phase 3 44%, Phase 4 80% (24 h post-admission = 90%). Conclusion 1. Orthopaedic Surgeons can prescribe laxatives and analgesia well—given sufficient prompts 2. The electronic solution is not always sufficient—locum doctors may not be aware of it. 3. Do not assume continued success Future Plans Re-introduce flow diagram to admission document. Acknowledgements Many people have helped with previous phases &amp; will be acknowledged.

Risk of asthma exacerbation associated with opioid and nonopioid analgesic use in children with current asthma.

BACKGROUND: In the United States, asthma occurs in a vast proportion of children and adolescents. Asthma exacerbation is an acute episodic event typically characterized by difficulty in breathing, chest tightness, coughing, or wheezing. Severe asthma exacerbation can be life-threatening and lead to service utilizations such as hospitalizations and emergency department (ED) visits. Opioid analgesic use can trigger an asthma exacerbation through 2 pharmacological mechanisms. Despite the potential mechanisms, there is lack of empirical evidence to determine the risk of asthma exacerbation and its association with opioid use. OBJECTIVE: To evaluate the risk of asthma exacerbation in children with current asthma receiving an opioid vs a nonopioid analgesic. METHODS: Eligible individuals aged under 18 years with current asthma and receiving an incident analgesic prescription were identified from a large Medicaid managed care database during 2013-2018. Current asthma was defined as receipt of an asthma diagnosis and an antiasthmatic medication in the 12 months before analgesic medication initiation. Asthma exacerbation was defined as a hospitalization or ED visit with asthma as either the primary or secondary diagnosis within 3 days of receipt of an analgesic prescription. A weighted multivariable logistic regression using inverse probability treatment weighting was performed to test the association between use of analgesic medication and risk of asthma exacerbation. RESULTS: This study included 13,359 children with current asthma who filled either an incident opioid (n = 5,363, 40.1%) or nonopioid analgesic (n = 7,996, 59.9%) prescription. Asthma exacerbation was observed in 24 (0.5%) opioid analgesic recipients and 22 (0.3%) nonopioid analgesic recipients within 3 days of analgesic initiation. Weighted logistic regression results showed that children receiving opioid analgesics (adjusted odds ratio = 1.6, 95% CI = 0.9-2.9) did not have a statistically significantly higher risk of asthma exacerbation than their nonopioid analgesic recipient counterparts in the propensity score-weighted multivariable analysis. CONCLUSIONS: Asthma exacerbation associated with analgesic use in children with current asthma was an uncommon event, and the risk was comparable among children receiving opioid vs nonopioid analgesics. DISCLOSURES: This study was supported and funded by the Agency for Healthcare Research and Quality (AHRQ), Project Number: 1R03HS026790-01A1. The study content was solely the responsibility of the authors, and AHRQ had no role in the design and conduct of the study. The authors have nothing to disclose.

Inter-Professional-Compassionate pain management during endotracheal suctioning: a valuable lesson from a Chinese surgical intensive care unit

Abstract Objective To compare the effects of a pain management program and routine suctioning methods on the level of pain presence and agitation in Chinese adults admitted to the intensive care unit. To disseminate the results from the implementation of the evidence-informed pain management interventions for reducing pain presence and agitation during endotracheal tube suctioning (ETS) and translate the key finding to clinical nursing practice. Methods A quasi-experimental study of a two-group post-test design was conducted in adults admitted after surgery to a surgical intensive care unit (SICU) of the Second Affiliated Hospital of Kunming Medical University, Yunnan, China in 2018. Fifty-two adults who met the study eligibility were included after consent, 26 in each group. Patients in the control group received usual care while patients in the intervention group received interventions to reduce agitation and pain-related ETS. The impacts of the intervention on the level of pain presence and agitation were measured at 5 measuring time points using the Chinese versions of Critical-Care Pain Observation Tool (CPOT) and Richmond Agitation Sedation Scale (RASS). Results The level of pain presence in the intervention group statistically significantly decreased during, immediately after, and 5 min after suctioning. The level of agitation in the intervention group significantly decreased during and immediately after suctioning. Conclusions The findings provide support for the positive pain-relieving effects of the evidence-informed pain-related ETS management interventions when compared with the usual ETS practice. The study interventions were sufficiently effective and safe to maintain patent airway clean and patent as standardized suctioning and helps pain relief. So, evidence-based pain-related ETS management intervention is worthy of recommending to utilize in SICU patients as well as other patients who required suctioning. It is worth noting that integrating pre-emptive analgesia prescription and administration with non-pharmacological intervention plays a critical role in achieving pain relief.

Transcultural validation of a French-European version of the Prescription Opioid Misuse Index Scale (POMI-5F).

The Prescription Opioid Misuse Index scale (POMI) is a brief questionnaire used to assess opioid prescription misuse. In view of the increase in the prescription of opioid analgesics for chronic noncancer pain (CNCP), this tool is particularly useful during medical consultations to screen opioid misuse in patients using opioids. We sought to generate and validate a French-European translation of the POMI. We conducted an observational, longitudinal, and multicenter psychometric study with crosscultural validation. All adult CNCP patients who were treated with opioids for at least three months, were followed in pain clinics, and spoke French were eligible. From September 2015 to November 2017, we included 163 patients and analyzed 154. We performed a pretest on a sample of representative patients to evaluate acceptability and understanding of translation. Study patients completed the POMI scale at a pain clinic (test phase), and we assessed test-retest reliability after two to four weeks by a second completion of the POMI scale at home by patients (retest phase). We subsequently explored psychometric properties of the POMI (acceptability, internal consistency, reproducibility, and external validity). Due to poor internal consistency and reproducibility, items 4, 7, and 8 of the original POMI scale were removed, and we proposed a five-question French-European version (POMI-5F). The internal consistency of POMI-5F was good (Cronbach's α = 0.71), as was test-retest reliability (r = 0.65 [0.55-0.67]). The external validity of POMI-5F, compared with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, was moderate but significant (r = 0.45; P < 0.001). The optimal POMI-5F cut-off score to indicate misuse was 2/5 (sensitivity = 0.95 and specificity = 0.54). We generated and validated a French-European translation of the POMI scale, POMI-5F, for use by French researchers and physicians to identify opioid misuse in CNCP patients.

93 Are NSAIDs Being Prescribed First Line to Manage Renal Colic Pain? A Complete Audit

Abstract Introduction NICE recommends NSAIDs as first line analgesia for renal colic pain. The aim of this audit was to evaluate NSAID prescribing at Salford Royal Hospital in this patient cohort against NICE guidelines. Method Using electronic patient records, patients admitted with renal colic pain over a 3-week period were identified. Data regarding the type and order of analgesia prescriptions from the time of surgical clerking were collected retrospectively. Patients with a documented contraindication to NSAIDs were excluded. A local renal colic pathway was published by the Urology Department, and we followed this with additional interventions, namely an email reminder to the juniors and a poster with a renal colic analgesia ladder illustration as an aide-memoire. Subsequently, a re-audit was undertaken. Results Cycle 1 identified 22 patients admitted with renal colic pain with most diagnoses supported radiologically. Only 38% of patients were found to be prescribed an NSAID for analgesia around the time of surgical clerking. In the re-audit, 50% of patients had an NSAID prescribed at the time of surgical clerking. Conclusions NSAIDs are clearly being underused as first line analgesia in renal colic pain despite NICE guidelines. A newly published trust renal colic pathway and targeted interventions have shown to increase their use, but further QI work is needed.

Broadband internet subscription rates and opioid prescribing via telemedicine during the COVID-19 pandemic.

PurposeIn response to the COVID‐19 pandemic, the US DEA allowed controlled substance prescriptions to be issued following a telemedicine encounter. This study evaluated changes in opioid prescribing in Kentucky counties with low and high rates of broadband subscription before, during, and after a series of statewide emergency declarations that may have affected health care access.MethodsThe study used the prescription drug monitoring program to analyze records of opioid analgesic prescriptions dispensed to opioid‐naïve individuals in high (N = 26) and low (N = 94) broadband access counties during 3 periods: before a state of emergency (SOE) and executive order (EO) limiting nonemergent health care services (January 2019‐February 2020), while the EO was active (March‐April 2020), and after health care services began reopening (May‐December 2020). Marginal generalized estimating equations‐type negative binomial models were fit to compare prescription counts by broadband access over the 3 periods.FindingsRates of opioid dispensing to opioid‐naïve individuals decreased significantly during the EO, but increased nearly to pre‐SOE levels after health care services began reopening. Dispensing rates in low broadband counties were higher than those in high broadband counties during all time periods, although these differences were negligible after adjusting for potential confounders. During the EO, prescriptions were written for longer days’ supply in both county types.ConclusionsThe overall dramatic reduction in opioid prescribing rates should be considered when evaluating annual opioid prescribing trends. However, broadband subscription rate did not appear to influence opioid prescriptions dispensed in Kentucky during the EO.

Trends in Ambulatory Analgesic Usage after Myocardial Infarction: A Nationwide Cross-Sectional Study of Real-World Data.

Although current guidelines for myocardial infarction (MI) recommend caution in using non-steroidal anti-inflammatory drugs (NSAIDs), real-world studies of ambulatory settings are rare. This study aimed to explore the patterns and trends of analgesic prescriptions (especially NSAIDs) among patients with a history of MI in ambulatory care settings in Korea. We analyzed real-world data from the Korea National Health Insurance Service database. Patients aged 20 years or older hospitalized with incident MI were identified between January 2007 and December 2015. Ambulatory analgesics were administered after discharge from incident hospitalization for MI, and annual trends in the prescriptions of individual analgesics were evaluated. Among the 93,597 patients with incident MI, 75,131 (80.3%) received a total of 2,081,705 ambulatory analgesic prescriptions. Prescriptions were mainly issued at primary care clinics (80.3%). Analgesics were most frequently prescribed for musculoskeletal diseases (often NSAIDs, 70.7%); aceclofenac (13.7%) and diclofenac injection (9.4%) were the frequently used NSAIDs. Additionally, significant changes were observed in the trends for some analgesics, such as loxoprofen. This study suggested that NSAIDs are commonly prescribed to patients with a history of MI. Future real-world studies are needed to elucidate the drug–disease interactions of NSAIDs prescribed after MI, especially for patients with musculoskeletal diseases.

Trends in Opioid Prescribing by General Dentists and Dental Specialists in the U.S., 2012–2019

Evidence suggests that U.S. dentists prescribe opioids excessively. There are limited national data on recent trends in opioid prescriptions by U.S. dentists. In this study, we examined trends in opioid prescribing by general dentists and dental specialists in the U.S. from 2012 to 2019. Dispensed prescriptions for oral opioid analgesics written by dentists were identified from IQVIA Longitudinal Prescription Data from January 2012 through December 2019. Autoregressive integrated moving average and joinpoint regression models described monthly population-based prescribing rates (prescriptions/100,000 individuals), dentist-based prescribing rates (prescriptions/1,000 dentists), and opioid dosages (mean daily morphine milligram equivalents/day). All analyses were performed in 2020. Over the 8 years, dentists prescribed >87.2 million opioid prescriptions. Population- and dentist-based prescribing rates declined monthly by -1.97 prescriptions/100,000 individuals (95% CI= -9.98, -0.97) and -39.12 prescriptions/1,000 dentists (95% CI= -58.63, -17.65), respectively. Opioid dosages declined monthly by -0.08 morphine milligram equivalents/day (95% CI= -0.13, -0.04). Joinpoint regression identified 4 timepoints (February 2016, May 2017, December 2018, and March 2019) at which monthly prescribing rate trends were often decreasing in greater magnitude than those in the previous time segment. Following national trends, dentists became more conservative in prescribing opioids. A greater magnitude of decline occurred post 2016 following the implementation of strategies aimed to further regulate opioid prescribing. Understanding the factors that influence prescribing trends can aid in development of tailored resources to encourage and support a conservative approach by dentists, to prescribing opioids.

Evaluation of Analgesics Prescription Pattern and Surgical Patients' Responses in Tertiary Hospitals in Southeast Nigeria

Background: Adequate analgesics help the patients to recover quickly from surgery with less discomfort and pain. It helps the patient breathe well, cough, turn and ambulate early to enable quick recovery. Inadequate prescribed analgesic delays recovery and leads to postoperative complications. Despite documented evidence that adequate pain control helps in the quick recovery of surgical patients, it has been reported that doctors' prescriptions of analgesics for postoperative patients are inadequate for the level of pain experienced by the patients. This informed the establishment of pain medication prescription standards by accrediting agencies in some developed countries. Nigeria has no binding standards, and patients' postoperative pain is managed by what doctors and nurses deem adequate. It has been reported that the patients' pain medication needs in Nigeria are unmet. The study, therefore, seeks to evaluate the postoperative analgesics prescription pattern and patients' responses in three tertiary hospitals in Southeast Nigeria. Objective: The study's main purpose was to evaluate the pattern of postoperative prescription of analgesics and surgical patient response to these drugs in tertiary hospitals in Southeast Nigeria. Method: A descriptive cross-sectional survey research design was used for the study. Study sample was 120 surgical patients selected equally from three randomly selected tertiary hospitals from the five States in Southeast Zone. Questionnaire and checklist were the instruments used for data collection in the study. The instrument's reliability was tested using the split-half technique and was analyzed using Spearman's rank-order correlation coefficient, which yielded a value of 0.85. All the hypotheses were tested at 0.05 level of significance. Results: The results show that drugs commonly prescribed by doctors for pain relief were pentazocine, paracetamol, diclofenac, and tramadol. The prescriptions were done mainly by Surgeons and Resident doctors. There was agreement on the pattern of prescription of analgesics by Surgeons in the southeast Nigerian hospitals. The results also show that there is a significant difference (p&lt;0.05) in the mean patients' responses to the prescribed analgesics but found no significant difference (p&gt;0.05) in pain prescription by doctors in the management of surgical patients in tertiary hospitals in Southeast Nigeria. Patients reported experiencing severe pains (41.7%) on the first, moderate pains (45.8%) on the second day, and mild pain (25%) on the third day after surgery. Conclusion: It was concluded that there is no significant difference in the pattern of the prescribed pain relief drugs and their dosages among surgeons from different tertiary hospitals. The patients' responses showed that the prescription pattern does not lead to good pain control in the first three days post-surgery. Recommendation: It was recommended that doctors review their prescription pattern for surgical patients, particularly within the first 72 hours after surgery when the pain is at its peak. Nurses should apply non-pharmacological pain management methods within this period to improve the comfort of the surgical patients.

Initiation of Opioid Prescription and Risk of Suicidal Behavior Among Youth and Young Adults.

Opioids are involved in an increasing proportion of suicide deaths. This study examined the association between opioid analgesic prescription initiation and suicidal behavior among young people. We analyzed Swedish population-register data on 1 895 984 individuals ages 9 to 29 years without prior recorded opioid prescriptions. We identified prescriptions dispensed from January 2007 onward and diagnosed self-injurious behavior and death by suicide through December 2013. We first compared initiators with demographically matched noninitiators. To account for confounding, we applied an active comparator design, which examined suicidal behavior among opioid initiators relative to prescription nonsteroidal antiinflammatory drug (NSAID) initiators while inverse-probability-of-treatment weighting with individual and familial covariates. Among the cohort, 201 433 individuals initiated opioid prescription. Relative to demographically matched noninitiators, initiators (N = 180 808) had more than doubled risk of incident suicidal behavior (hazard ratio = 2.64; 95% confidence interval [CI], 2.47-2.81). However, in the active comparator design, opioid initiators (N = 86 635) had only 19% relatively greater risk of suicidal behavior compared with NSAID initiators (N = 255 096; hazard ratio = 1.19; 95% CI,: 1.11-1.28), corresponding to a weighted 5-year cumulative incidence of 2.2% (95% CI, 2.1-2.4) for opioid and 1.9% (95% CI, 1.9-2.0) for NSAID initiators. Most sensitivity analyses produced comparable results. Opioid initiation may make only a small contribution to the elevated risk of suicidal behavior among young people receiving pharmacologic pain management. In weighing benefits and harms of opioid initiation, our results suggest that increased risk of suicidal behavior may not be a major concern.

Patterns of opioid analgesic prescribing in cancer outpatients during the last year of life in France: A pharmacoepidemiological cohort study based on the French health insurance database

Cancer pain management with adequate analgesics for cancer outpatients can be particularly challenging. This representative retrospective cohort study aimed to investigate the prevalence and timing of weak and strong opioid analgesic prescriptions in cancer outpatients during their last year of life, with a focus on factors associated to potential late strong opioid initiation. Factors associated with late strong opioid initiation were investigated through multivariate logistic regression analyses stratified by place of death. A retrospective cohort of cancer outpatients, who died between 2014 and 2016, was identified from the general sample of beneficiaries. Among N=4704 cancer patients (median age 76 years, 42.7% women), 3002 (63.8%) were prescribed and dispensed ≥1 weak or strong opioid analgesic during their last year of life; of whom, 2458 (52.3%) received ≥1 weak opioid analgesic (tramadol as single-ingredient accounting for 25.9%) and 1733 (36.8%) ≥1 strong opioid analgesic dispensation (fentanyl 21.6%). Median interval between the first prescription for any strong opioid and death was 18 weeks (interquartile range: 8-38), and for weak opioids 33 weeks (interquartile range: 20-47). Among weak opioid users, 1229 (50.0%) patients had received ≥1 weak opioid analgesic dispensation during the year n-2 before death. Among strong opioid users, 986 (56.9%) patients had received ≥1 weak opioid analgesic dispensation during the year n-2 before death and 381 (21.9%) patients ≥1 strong opioid analgesic dispensation. Patients with an outpatient death were more likely to have a late strong opioid initiation compared to patients with an inpatient death. Late strong opioid initiation (<18 weeks before death) was significantly associated with a lower number of hospitalization days and prior weak opioid exposure for patients with an inpatient death and, with older age, social, prior weak opioid exposure, and a prescription initiation by general practitioner for patients with an outpatient death. Our gained knowledge of opioid prescribing patterns in cancer patients during the last year of life might help to progress opioid analgesic treatment and to improve patient outcomes.

An overview of the use and misuse/abuse of opioid analgesics in different world regions and future perspectives.

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.

Trends in the number of patients linked to potential vet-shopping behavior in the United States (2014-2019).

To estimate the number of patients linked to vet-shopping behavior (the solicitation of controlled substance prescriptions from multiple veterinarians for misuse) in the United States using 2014-2019 data and characterize mandates for veterinarians to examine prescription drug monitoring programs (PDMPs) before prescribing controlled substances as of April 2021. National database reporting prescription dispensing from 92% of US pharmacies from 2014 through 2019. The annual number of patients with dispensed prescriptions for opioid analgesics, opioid cough-and-cold medications, or benzodiazepines from ≥ 4 veterinarians was calculated. State veterinary medical associations were contacted for information on veterinarian PDMP use mandates. From 2014 through 2019, the number of patients with prescriptions for any class of controlled substances from ≥ 4 veterinarians tripled from 935 to 2,875 (+207.5%). The number of patients with opioid cough-and-cold medication prescriptions from ≥ 4 veterinarians rose from 150 to 1,348 (+798.9%). The corresponding number for benzodiazepines rose from 185 to 440 (+137.8%). The corresponding number for opioid analgesics peaked at 868 in 2016 before decreasing to 733 in 2019. In April 2021, 10 states mandated veterinarians to examine PDMP records of owners or animals before prescribing controlled substances; 3 mandates excluded benzodiazepines. Vet shopping in the US may be increasingly common. Mandates for veterinarians to examine PDMPs before prescribing controlled substances might facilitate detection of this behavior. However, benefits of mandates should be weighed against their potential burden on veterinarians.

Long-term Cannabis-based oil therapy and pain medications prescribing patterns: an Italian observational study.

Chronic pain is one of the most common medical conditions in developed countries. The 2020 Italian National Report on Medicines shows how, in the last years, there was a light but constant increase in the prescription of pain medications. The purpose of our study was to assess the effects of long-term cannabis-based oil consumption on the distribution of patients with analgesics prescriptions for chronic pain in a Pain Medicine Unit in Northern Italy. This is a retrospective, observational study in which patients treated with long-term medical cannabis-based oils, followed between June 2016 and July 2019, were enrolled. The effects of cannabis-based oil consumption on the distribution of patients with pain medications, before and after its long-term use, were evaluated with a Related Samples McNemar Test. Subgroups analyses were performed based on sex, age, comorbidity, duration of cannabis treatment, and condition driving cannabis prescription. A significant difference in opioid non-users after a long-term cannabis-based oil therapy was identified (from 32.1% to 55.4%, p = 0.0023), while no significant differences were found in the distribution of anticonvulsant, antidepressant, and benzodiazepine users. A high benzodiazepine use prevalence was revealed, while subgroup analyses showed increased antidepressant use in people over 65 years old (from 93.7% to 56.2%; p = 0.0313). Pain medication patterns of prescribing show how necessary it is to improve prescription practices among chronic pain patients. Opioid-sparing medications represent a crucial aspect of the pain treatment process, along with deprescribing protocols. Clinicians and clinical pharmacologists must cooperate to meet the need of a guide that can represent the most possible appropriate therapy for these patients.

Association between chiropractic care and use of prescription opioids among older medicare beneficiaries with spinal pain: a retrospective observational study

BackgroundThe burden of spinal pain can be aggravated by the hazards of opioid analgesics, which are still widely prescribed for spinal pain despite evidence-based clinical guidelines that identify non-pharmacological therapies as the preferred first-line approach. Previous studies have found that chiropractic care is associated with decreased use of opioids, but have not focused on older Medicare beneficiaries, a vulnerable population with high rates of co-morbidity and polypharmacy. The purpose of this investigation was to evaluate the association between chiropractic utilization and use of prescription opioids among older adults with spinal pain.MethodsWe conducted a retrospective observational study in which we examined a nationally representative multi-year sample of Medicare claims data, 2012–2016. The study sample included 55,949 Medicare beneficiaries diagnosed with spinal pain, of whom 9,356 were recipients of chiropractic care and 46,593 were non-recipients. We measured the adjusted risk of filling a prescription for an opioid analgesic for up to 365 days following diagnosis of spinal pain. Using Cox proportional hazards modeling and inverse weighted propensity scoring to account for selection bias, we compared recipients of both primary care and chiropractic to recipients of primary care alone regarding the risk of filling a prescription.ResultsThe adjusted risk of filling an opioid prescription within 365 days of initial visit was 56% lower among recipients of chiropractic care as compared to non-recipients (hazard ratio 0.44; 95% confidence interval 0.40–0.49).ConclusionsAmong older Medicare beneficiaries with spinal pain, use of chiropractic care is associated with significantly lower risk of filling an opioid prescription.