Opioid Prescribing Research Articles

Opportunity and Equity Costs of Multilevel Adaptive Interventions to Reduce Opioid Prescribing

Opportunity and Equity Costs of Multilevel Adaptive Interventions to Reduce Opioid Prescribing

Evidence for the Use of Opioid Medication for Pediatric Acute Pain in the Outpatient Setting: Technical Report.

This technical report summarizes the results of a systematic review designed to support the American Academy of Pediatrics' "Clinical Practice Guideline: Opioid Prescribing for Acute Pain Management in Children and Adolescents in Outpatient Settings." PubMed and Excerpta Medica Database were searched from 2010 to 2023 to identify randomized clinical trials and systematic reviews related to outpatient opioid prescribing to children. Overall, 11 randomized controlled trials were included. Although data were limited, no evidence was found that pain control by opioids is superior to nonopioid alternatives. Further, opioids are often associated with adverse events. The review also suggests that family and patient education and providing disposal methods may decrease risks associated with opioid prescription. Future studies can build on this foundation of evidence to support the appropriate use of opioids for acute pain in children treated in the outpatient setting.

Optimizing Opioid Prescriptions in Geriatric Populations at Nottingham University Hospitals Foundation Trust (NUH)

Abstract Background Severe pain is associated with adverse outcomes in the geriatric populations (Ref -Pain and Mortality in Older Adults: The Influence of Pain Phenotype - PubMed (nih.gov)). Currently it is recommended in local and national guidelines (Ref -Guidance on the management of pain in older people | Age and Ageing | Oxford Academic (oup.com), Clinical Guidelines Policy (koha-ptfs.co.uk)) that the following be implemented to geriatric patients being prescribed strong opioid medication Methods A multi-disciplinary team involving doctors, pharmacists, nurses and the NUH quality improvement team was involved in all aspects of this project. Initial data collection was done between 1st August 2023 to 1st March 2024. We intend to carry out further data collection between April and August 2024 after our proposed interventions. Data collection was carried out using the EPMA prescribing platform. Results Data collected from 1st August 2023 to 1st March 2024 only 70% of patients in health care of the elderly (HCOE) wards had correctly prescribed oxycodone as their strong opioid analgesia. It was noted that 37% of HCOE patients have had morphine incorrectly prescribed at least once during their admission. Only 11% of strong opioid prescriptions on HCOE wards in NUH had a review scheduled. A. Whilst 73% of patients had laxatives co-prescribed only 25% had anti-emetics co-prescribed. Conclusion From our initial results there is an obvious need for improvement in terms of guideline adherence. We will aim to collect further data and we will put into place interventions in a ‘PDSA’ manner to improve this.

Potentially Inappropriate Medications and De-prescribing: An Audit of STOPP/START on an Inpatient Rehabilitation Ward

Abstract Background Polypharmacy is well recognized in older adults with many adverse outcomes. Practical tools, such as the ‘STOPP/START’ criteria, aid clinicians in de-prescribing to tackle medication related morbidity. Current research suggests these tools are insufficiently implemented in clinical practice (1). Many older adults require rehabilitation after acute hospital admissions which can provide an ideal setting for medication review and de-prescribing. Methods A retrospective audit was carried out of 35 older adults in a gerontological inpatient rehabilitation facility between 8th February and 8th April 2024. Demographic and clinical data was collected using electronic and handwritten patient records. Each patients’ medication prescription was reviewed from date of admission to rehabilitation facility. Number of medications prescribed was recorded. Using the ‘STOPP/START’ criteria, potentially inappropriate medications (PIMs were identified, and de- prescribing was noted for the PIM where taken. Results 35 patients were included in the study. No patient was excluded. Mean age was 86.14 years and mean number of prescribed medications per patient was 11. The most common presenting complaint was a fall in 57.14% of patients, in which 95% had acute fracture. Other presenting complaints for acute admission included delirium and infection. Mean clinical frailty score was 5.71. 38 PIMswere identified, totalling 10% of all medication prescriptions. Of these, 12 de-prescribing opportunities were taken, one of which was a dose reduction. The most common PIMswere prescribing of PPI at full therapeutic dose (n=12), inappropriate opioid prescribing (n=4) and hypnotics (n=7) in high-risk groups. Conclusion Polypharmacy and PIMsare common in older adults and are related to adverse outcomes, especially in frail adults at risk of falls, fracture, and delirium. The rehabilitation setting is an ideal location for use of de-prescribing tools however their implementation varies. This may be improved by education and structured medication review in collaboration with trained pharmacists.

Project Lifeline-II: Feasibility of Implementing Screening, Brief Intervention, and Referral to Treatment (SBIRT) in Allegheny County, Pennsylvania.

US community pharmacies are a unique and underused health service setting for identifying and potentially intervening with patients at risk of opioid overdose or opioid use disorder with evidence-based practices such as screening, brief intervention, and referral to treatment (SBIRT). The aim of our study was to assess the feasibility of implementing SBIRT in community pharmacies in an urban county in terms of engagement, reach, and equity across the cascade of pharmacy screening and care. Patients aged 18 years or older receiving a schedule II or III opioid prescription at 1 of 17 participating community pharmacies in Allegheny County, Pennsylvania, were invited to engage in SBIRT as part of Project Lifeline-II from June 2020 through January 2023. Participants completed a prescreen and/or a full screen. We calculated the percentage of patients who participated across the cascade of pharmacy screening and care, overall and by sex (male and female) and race (Black and White). During the study period, 1952 unique adults (79.6%) were screened at least once (52.1% female; 58.0% White, 30.7% Black). Patients who identified as male (vs female) and Black (vs White) were more likely to have a positive prescreen (14.7% male vs 9.8% female; 16.4% Black vs 9.5% White), receive and complete a full screen (82.7% male vs 80.0% female; 83.6% Black vs 78.4% White), and score positively on the full screen (26.6% male vs 20.4% female; 26.8% Black vs 21.9% White). Although additional research is needed to characterize the full effect of Project Lifeline-II on patient outcomes, our findings help reinforce the benefits of multipronged public health initiatives that include community pharmacists to address the substance use disorder crisis in the United States.

Exceeding the guideline-recommended maximum daily dose of opioids for long-term treatment of non-cancer pain in Germany – a large retrospective observational study

BackgroundHigh-dose long-term opioid therapy (LTOT) has been associated with increased mortality and hospitalizations. Therefore, the evidence-based German guideline on LTOT for chronic non-cancer pain (CNCP) recommends to only exceed the maximum daily dose (MDD) of opioids in exceptional cases. This study aimed to determine the portion of LTOT patients who exceeded the guideline-recommended MDD and identify predictors of exceeding in administrative claims data.MethodsThe retrospective observational analysis of opioid prescriptions in patients receiving LTOT for CNCP was based on administrative claims by a large German statutory health insurance company. Patients with at least two quarters of opioid prescriptions between January 2018 and June 2019 were included and followed up for two years. Predictors were identified by logistic regression. In addition, the number of patients still in opioid therapy and the extent of exceeded MDDs were analyzed over time.ResultsThe sample consisted of 113,475 patients. Overall, 10.5% of the patients exceeded the guideline-recommended MDD averaged over the observation period. Strong predictors for exceeding the MDD were receiving opioid prescriptions from > 7 physicians (OR = 7.66, p < .001), receiving predominantly strong opioids (OR = 6.79, p < .001) and receiving opioids for at least one year prior to inclusion (OR = 5.35, p < .001). Within the non-exceeding group, 28.1% discontinued opioid therapy. In contrast, 9.9% of patients in the exceeding group discontinued opioid therapy, whereas the vast majority remained on treatment until the end of the observation period. Furthermore, a slight increase in prescribed doses was observed over time.ConclusionsThe results indicate that a moderate proportion of patients exceeded the guideline-recommended MDD. However, certain patient groups were more likely to receive high doses. This applied in particular to those who were already on treatment at the time of inclusion and continued to receive opioids until the end of the observation period. Further research should examine whether the continuous opioid therapy among the patients with exceeding the guideline-recommended MDD might be related to specific indications, a lack of therapeutic options or avoidance of withdrawal.Trial registrationGerman Clinical Trials Register (drks.de/search/en). Identifier: DRKS00024854. Registered 28 April 2021.

Content that Promotes Intent to Change: Asynchronous and Synchronous Professional Development for Family Doctors in Continuing Medical Education

Background In 2020, a medical school in northern Ontario launched “Overcoming Barriers to Safe Opioid Prescribing,” a continuing professional development program consisting of an asynchronous online module followed by a series of optional synchronous videoconferences, which together formed a virtual community of practice (VCoP). The videoconferences followed a structured format, where a case study was introduced by one of the participants from their practice, followed by group reflections on the case and the development of strategies for implementing the learnings in their practices. Methods Mixed methods data was collected from participants utilizing a variety of tools and at different times before, during and after their engagement in the program. Qualitative data analysis produced a list of key themes that were cross-validated by anonymized, aggregated program evaluation data to identify further, module-specific themes. Results This paper examines the learning experiences and outcomes of primary care providers that participated in the online modules and synchronous videoconferences and proposes content design strategies that led to these educational experiences. The online module created a baseline of knowledge, increased participants’ familiarity with practice guidelines, comfort and confidence in prescribing and deprescribing behaviours, and increased participants’ familiarity with tools, resources, and strategies for safe opioid prescribing in their practices. The synchronous videoconferences developed a community of learning through modeling, experiential learning and the sharing of experiences and best practices. Conclusions The combination of the online module and synchronous videoconferences led to an increase in the intent to change practice, particularly with enhanced the principles of patient-centred care through their focus on practical, real-world strategies and physician-patient communication techniques. Participants noted that the foundational knowledge and resources provided in the online course was supported and contextualized through the synchronous discussions.

Drug-drug interactions of plant alkaloids derived from herbal medicines on the phase II UGT enzymes: an introductory review.

Herbal medicines are widely used as alternative or complementary therapies to treat and prevent chronic diseases. However, these can lead to drug-drug interactions (DDIs) that affect the glucuronidation reaction of UDP glucuronosyltransferases (UGTs), which convert drugs into metabolites. Plant extracts derived from medicinal herbs contain a diverse array of compounds categorized into different functional groups. While numerous studies have examined the inhibition of UGT enzymes by various herbal compounds, it remains unclear which group of compounds exerts the most significant impact on DDIs in the glucuronidation reaction. Recently, alkaloids derived from medicinal herbs, including kratom (Mitragyna speciosa), have gained attention due to their diverse pharmacological properties. This review primarily focuses on the DDIs of plant alkaloids from medicinal herbs, including kratom on the phase II UGT enzymes. Kratom is a new emerging herbal product in Western countries that is often used to self-treat chronic pain, opioid withdrawal, or as a replacement for prescription and non-prescription opioids. Kratom is well-known for its psychoactive alkaloids, which have a variety of psychopharmacological effects. However, the metabolism mechanism of kratom alkaloids, particularly on the phase II pathway, is still poorly understood. Simultaneously using kratom or other herbal products containing alkaloids with prescribed medicines may have an impact on the drug metabolism involving the phase II UGT enzymes. To ensure the safety and efficacy of treatments, gaining a better understanding of the DDIs when using herbal products with conventional medicine is crucial.

Opioid-related mortality after occupational injury in Washington State: accounting for preinjury opioid use

ObjectivesTo estimate the impact of occupational injury and illness on opioid-related mortality while accounting for confounding by preinjury opioid use.MethodsWe employed a retrospective cohort study design using Washington State workers’...

Is Opioid Consumption Impacted by Study Participation? Maintenance of Fewer Opioid Refills With Reduced Prescription Quantity After Posterior Spinal Fusion in Adolescents With Idiopathic Scoliosis.

Opioid overprescribing can lead to nonmedical opioid use. In a previous prospective study (STUDY), we showed that a standardized protocol involving preoperative education and reduced opioid prescription quantity decreased opioid use in idiopathic scoliosis patients following posterior spinal fusion (PSF). A potential limitation was the Hawthorne effect, where participant behavior changes due to observation. At STUDY conclusion, we continued the reduced opioid prescriptions but discontinued the formal preoperative education. This retrospective study (post-STUDY) assessed if opioid refill requests increased outside of a study setting. Post-STUDY included patients aged 10 to 17 years who underwent PSF for idiopathic scoliosis between January 2022 and December 2023 and were discharged with a prescription of ≤30 oxycodone doses. Patients were excluded if they had previous spine surgery or were discharged with an opioid other than oxycodone. Demographics, perioperative variables, and opioid refill requests were compared with the data from STUDY, in which patients were aware their opioid use would be tracked. Patient-reported outcomes were collected via Scoliosis Research Society-22r (SRS-22r) surveys. The post-STUDY cohort included 67 patients (69% female). The average age at the time of PSF was 13.9 years (range, 11 to 17y). The mean number of levels fused was slightly higher (10.9 vs. 10.0, P=0.04), and intraoperative estimated blood loss was lower (211 vs. 303mL, P<0.01) compared with the STUDY cohort. Demographics, preoperative major curve magnitude, surgery duration, and length of hospital stay were similar. The percentage of patients who requested and received opioid refills between the post-STUDY and STUDY cohorts was also similar [6/67 (9%) vs. 3/49 (6%), P=0.30]. SRS-22r showed improvements in self-image, satisfaction, and mean total score from preoperative to postoperative. Reduced opioid prescriptions did not result in increased opioid refill requests in adolescents undergoing PSF for idiopathic scoliosis outside of a study setting. While formal preoperative discussions about postoperative pain control are important, other factors likely influence opioid use. Further research should explore characteristics that predispose patients to require higher amounts of postoperative opioids. Level III-therapeutic.

Adoption of clinical pharmacist roles in primary care: Longitudinal evidence from English general practice.

Over the last decade, the number of clinical pharmacists working within multidisciplinary teams in English general practice has expanded Aim: This study examines changes in quality of prescribing after the adoption of clinical pharmacists in English general practices. Two-way fixed effects regression was used to compare differences in prescribing indicators in general practices in England with and without pharmacists following implementation between September 2015 and December 2019 Results: Between September 2015 and December 2019, the proportion of practices employing a clinical pharmacist increased from 236/ 7,623 (3.10%) to 1,402/ 6,836 (20.51%). Clinical pharmacist implementation resulted in statistically significant reductions in total costs of medicines per 1,000 patients (-0.85% ,95% CI -1.50%, -0.21%), the total number of opioid prescriptions per 1,000 patients (- 1.06%, 95% CI -1.82%, -0.29%), and the average daily quantity (ADQs) of anxiolytics per 1,000 patients (-1.26%, 95% CI -2.40%, -0.12%). Clinical pharmacist implementation also resulted in reductions in the total number of prescriptions per 1,000 patients (-0.58%, 95% CI -1.30%, 0.13%), and the total number of antibiotic prescriptions per 1,000 patients (-0.51%, 95% CI -1.30%, 0.27%) that trended towards statistical significance. There were no statistically significant differences in the share of broad-spectrum versus narrow-spectrum antibiotics (0.02%, 95% CI -0.07%, 0.11%) and the oral morphine equivalence of high-dose opioids (>120mg per 24 hours) per 1,000 patients (1.19%, 95% CI -0.46%, 2.85%). Our analysis is limited by aggregate data at the practice-level but supports the hypothesis that clinical pharmacist implementation results in improvements in prescribing quality.

The Effect of Opioids and Benzodiazepines on Exacerbation Rate and Overall Survival in Patients with Chronic Obstructive Pulmonary Disease on Long-Term Non-Invasive Ventilation.

Background: There is a growing concern that opioids and benzodiazepines can depress the respiratory drive and could contribute to worsening respiratory failure and higher exacerbation frequency in COPD. However, the relationship between the exacerbation rate and medication taken is poorly understood in patients with chronic respiratory failure due to COPD. Methods: As part of a service evaluation project, we analysed 339 patients with COPD who were established on long-term non-invasive ventilation (LT-NIV) at our tertiary centre. We investigated the relationship between benzodiazepine and opioid prescription and clinical outcomes as well as their impact on the exacerbation rate and overall survival following setup. Results: Before LT-NIV setup, 40 patients took benzodiazepines and 99 patients took opioids. Neither benzodiazepine nor opioid use was associated with changes in daytime blood gases, overnight hypoxia or annual exacerbations before NIV setup, but patients taking opioids were more breathless as assessed by modified Medical Research Council scores (3.91 ± 0.38 vs. 3.65 ± 0.73, p < 0.01). Long-term NIV significantly reduced the number of yearly exacerbations (from 3.0/2.0-5.0/ to 2.8/0.71-4.57/, p < 0.01) in the whole cohort, but the effect was limited in those who took benzodiazepines (from 3.0/2.0-7.0/ to 3.5/1.2-5.5/) or opioids (3.0/2.0-6.0/ to 3.0/0.8-5.5/). Benzodiazepine use was associated with reduced exacerbation-free survival and overall survival (both p < 0.05). However, after adjustment with relevant covariates, the relationship with exacerbation-free survival became insignificant (p = 0.12). Opioids were not associated with adverse outcomes. Conclusions: Benzodiazepines and opiates are commonly taken in this cohort. Whilst they do not seem to contribute to impaired gas exchange pre-setup, they, especially benzodiazepines, may limit the benefits of LT-NIV.

Opioid Administration Patterns and Trends following Total Joint Arthroplasty: A Multi-Center Analysis

Objectives: The opioid epidemic has become a public health crisis, with orthopedic surgeons among the highest prescribers of opioids. Total joint arthroplasty (TJA) represents a large portion of orthopedic surgeries performed annually, with opioids commonly utilized in post-operative pain management. Understanding opioid administration patterns following TJA is important to better inform post-operative pain management prescribing and reduce opioid reliance in postoperative care. The purpose of this study was to characterize opioid use following TJA across various healthcare institutions and settings. Methods: A 5-year retrospective study was performed utilizing patient data collected by Avalon.ai from 3 large health systems around the US. The data was screened for patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA) between 2018 and 2022 (n=4,472). Patient records were screened for administration of opioids following TJA, defined as average morphine milligram equivalents (MME). Results: The average MME for combined TKA (n=2,913) and THA (n=1,571) increased significantly from 24 ± 18 in 2018 to 33 ± 28 in 2022 (P &lt;.0001). Average MME increased for TKA from 26 ± 19 in 2018 to 35 ± 27 in 2022 (P &lt;.0001) and THA from 23 ± 16 in 2018 to 27 ± 31 in 2022 (P &lt;0.03). Additionally, the average MME was higher following inpatient TJA than outpatient, with variation in MME amongst healthcare institutions in recent years. Conclusion: Opioid administration following TJA increased annually over the study period, with significant variation in average MME following TJA across healthcare institutions. Continued efforts are needed to deploy evidenced-based post-operative pain management after TJA to avoid over-prescribing opioids, minimize inter-institutional variability, and maximize patient experience.

Opioid Administration Patterns following Anterior Cruciate Ligament Reconstruction and Rotator Cuff Repair: A Multi-Center Analysis

Objectives Opioids are commonly administered following elective sports surgeries, contributing to the opioid epidemic. Understanding opioid administration patterns following commonly performed anterior cruciate ligament reconstruction (ACLR) and rotator cuff repair (RCR) is important to avoid inadvertent overprescribing of these drugs. The purpose of this study was to characterize opioid administration trends following these surgeries across various healthcare institutions. Methods A 5-year retrospective study was performed utilizing patient data collected by Avalon.ai from 3 large health systems around the United States. The data was screened for patients undergoing ACLR and RCR between 2018 and 2022 (n=2,129). Patient records were screened for administration of opioids following operation defined as the average morphine millimeter equivalents (MME). Results The average MME for surgeries combined increased from 23 ± 11 in 2018 to 34 ± 24 in 2022 (P&lt;.0001). ACLR has had a higher average MME than RCR in recent years, in addition to a significant variation in average MME for combined surgeries across institutions. Conclusion Opioid administration following ACLR and RCR increased annually over the study period with significant variation in average MME across healthcare institutions. Interventional efforts should continue to be made to reduce opioid prescriptions following these surgeries to mitigate long-term use and abuse.

Abstract A097: Racial and ethnic disparities in risk of persistent opioid use in a diverse cohort of breast cancer survivors and matched women without cancer

Abstract Background: Persistent opioid use (POU) in breast cancer survivors after they have completed active cancer treatment is an emerging area of concern. Disparities affecting the risk of POU remains understudied in breast cancer survivors. We evaluated disparities in examining the risk with POU in breast cancers survivors in the year after active cancer treatment along with a comparison group. Methods: We assembled a cohort of 14,347 female breast cancer (BC) survivors diagnosed in 2009-2019 treated for early-stage disease (in situ, local, regional), who had at least two opioid prescriptions after one year of survivorship and 51,369 age-matched women without cancer. Data were captured from the tumor registry, electronic health records, and pharmacy databases. The primary outcome was POU defined as continuously receiving at least 90 days supplies of opioids during follow-up. Patients were followed through the date once they met POU criteria, died, disenrolled from health plan, or reached study’s end (12/31/2021), whichever came first. We used the multivariable proportional hazard regression to estimate the association [hazard ratios (HR), 95% confidence interval (CI)] between race ethnicity and POU. Results: Overall, the cohort was diverse: 7% Asian/Pacific Islander (API); 14% Black; 28% Hispanic; and 50% White women. During a median follow-up of 6.4 years, 11134 (17%) women developed POU. Patients who developed POU had longer annualized median opioid duration, especially in Black patients (175 vs. 5 days) and were prescribed stronger opioids [median maximum daily morphine milligram equivalent (62.5 vs 42.9)], compared to those who did not develop POU. In the multivariable analyses adjusted for sociodemographic characteristics, opioid type, and other pain medications, Black, Hispanic and API women were 28%, 42% and 54% less likely to develop POU compared to White women [HR (95%CI): 0.72 (0.68-0.76), 0.58 (0.55-0.61), and 0.46 (0.42-0.52), respectively]. However, Black women were only 19% less likely [HR (95%CI): 0.81(0.72-0.92)] to develop POU compared to White women in BC survivors. Also, patients with older age, Elixhauser Comorbidity Index ≥3; smoking, type of opioid (Oxycodone and hydrocodone), and who used other psychiatric and pain medications had significantly greater POU risk. Conclusion: Findings suggest that women of color were less likely to develop POU. Further studies will include further examining clinical and pharmacological management which might have played a role in the race ethnicity groups. Citation Format: Lie Hong Chen, Rulin C. Hechter, Jiaxiao Shi, Zheng Gu, Moira Brady-Rogers, Rowan T. Chlebowski, Reina Hague. Racial and ethnic disparities in risk of persistent opioid use in a diverse cohort of breast cancer survivors and matched women without cancer [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr A097.

A novel Project ECHO curriculum on older adult pain management and opioid use disorder for outpatient clinicians

ABSTRACT Chronic pain, opioid use, and opioid use disorder (OUD) are increasingly common in older adults. Outpatient clinician education may improve outcomes. Our aim was to create and evaluate a novel curriculum for outpatient clinicians on older adult pain management, opioid prescribing, and OUD leveraging Project ECHO®, a model for delivering subspecialized medical knowledge to community outpatient clinicians via videoconferencing. The series is comprised of 8-hour-long sessions, each with an expert-led interactive lectures followed by participant-led case discussions. Topics include pain assessment & treatment, considerations in older adults (e.g. cognition, caregiver support), shared decision-making, behavioral health, and OUD diagnosis and treatment. Sixty-nine clinicians attended the series and completed the pre-series survey; 78% (n = 54) completed the post-series survey. Clinicians reported a significant increase in self-efficacy in 14/14 queried competencies and greater frequency of performing 7/10 practice behaviors regarding older adult pain management, opioid prescribing, and OUD management. The most liked curricular components were opportunities to learn with subspecialists and discussions with other community clinicians. Qualitative analysis suggests that clinicians may benefit from education on specific geriatrics-related content areas. This novel curriculum has potential to improve management of older adult chronic pain, opioid prescribing, and OUD in a virtual and scalable format.

Impact of codeine rescheduling on prescribing of codeine and other opioids: Interrupted time series analyses using Australian general practice data.

We aimed to determine the impact of codeine rescheduling on prescribing of codeine and other opioids, with a focus on demographic and diagnoses associated with codeine prescribing before and after rescheduling of codeine to prescription-only in February 2018. We used interrupted time series analysis (February 2016-February 2020) and probit regression to examine prescribing of codeine and other opioids according to primary care data from 464 general practice clinics in Victoria, Australia. The rate of codeine prescribing increased in the month following rescheduling (additional 76 people/10000, 95% confidence interval [CI] 49-103), then declined to baseline rates (slope -2.02, 95% CI 3.79, -0.25). Prescribing of other opioids did not change. Post rescheduling, females were more likely to receive codeine prescriptions compared to males (β=0.094, 95% CI 0.08-0.108) and those aged 70-79 years were more likely to receive codeine compared to those aged <30 years. Those residing in the least disadvantaged areas had a greater probability of being prescribed codeine than those in more disadvantaged areas after rescheduling (β =0.154, 95% CI 0.129-0.179). A documented mental health diagnosis (β =0.067, 95% CI 0.052-0.082) or migraine diagnosis (β =0.057, 95% CI 0.037-0.078) was associated with increased likelihood of receiving a codeine prescription after rescheduling compared to before in contrast to those without such a diagnosis. Codeine rescheduling did not result in a sustained increase in codeine prescribing nor a change in the prescribing of other opioids. Patient factors associated with increased codeine prescribing after compared to before rescheduling included female sex, older age, migraine diagnosis and comorbid mental health conditions. EU PAS Register (EUPAS43218).

The Use of Nudge Strategies in Improving Physicians’ Prescribing Behavior: A Systematic Review and Meta-analysis

Background Nudges have been proposed as a method of influencing prescribing decisions. Purpose The purpose of this article is to 1) investigate associations between nudges’ characteristics and effectiveness, 2) assess the quality of the literature, 3) assess cost-effectiveness, and 4) create a synthesis with policy recommendations. Methods We searched health and social science databases. We included studies that targeted prescribing decisions, included a nudge, and used prescribing behavior as the outcome. We recorded study characteristics, effect size of the primary outcomes, and information on cost-effectiveness. We performed a meta-analysis on the standardized mean difference of the studies’ primary outcomes, tested for associations between effect size and key intervention characteristics, and created a funnel plot evaluating publication bias. Synthesis We identified 21 studies containing 25 nudges. In total, 62 of 85 (73%) outcomes showed a statistically significant effect. The average effect size was −0.22 standardized mean difference. No studies included heterogeneity analyses. We found no associations between effects and selected study characteristics. Study quality varied and correlated with study design. A total of 7 of 21 (33%) studies included an evaluation of costs. These studies suggested that the interventions were cost-effective but considered only direct effects. We found evidence of publication bias. Limitations Heterogeneity and few studies limit the possibilities of statistical inference about effectiveness. Conclusions Nudges may be effective at directing prescribing decisions, but effects are small and health effects and cost-effectiveness are unclear. Future nudge studies should contain a rationale for the chosen nudge, prioritize the use of high-quality study designs, and include evaluations of heterogeneity, cost-effectiveness, and health outcomes to inform decision makers. Moreover, preregistration of the protocol is warranted to limit publication bias. Highlights Nudging as a method to improve prescribing decisions has gained popularity during the past decade. We find that nudging can improve prescribing decisions, but effect sizes are mostly small, and the size of derived health outcomes is unclear. Most studies use feedback and error-stopping nudges to target excessive opioid or antibiotic prescribing, making heterogeneity analyses across nudge types difficult. Further research on the cost-effectiveness of nudges and generalizability is needed to guide decision makers considering nudging as a tool to guide prescribing decisions.

Is general practitioner involvement in the initiation of opioids for chronic non-cancer pain associated with opioid dose and concurrent drug use?

Objective Is the involvement of the regular general practitioner (GP) in the decision to initiate opioid treatment for chronic non-cancer pain (CNCP) associated with two main risk factors for serious adverse events: increased opioid dose and the concomitant use of prescribed benzodiazepines or benzodiazepine-related medications? Design and setting An anonymous web-based survey was conducted in the county of Rogaland, Norway, during the spring of 2021. Subjects GPs who self-reported applying at least once for reimbursement of opioids prescribed to treat CNCP. They were asked to answer the survey based on the last patient for whom they recalled submitting a reimbursement application. Main outcome measures 1) Total opioid dose in daily oral morphine equivalents (OMEQ). 2) Concurrent use of benzodiazepines and/or benzodiazepine-related drugs. Results The daily opioid dose was lower when the surveyed GPs initiated the opioid treatment (36 OMEQ, n = 25), than when others had initiated the treatment (108 OMEQ, n = 31, p = 0.001). For concurrent use of benzodiazepine or benzodiazepine-related drugs, no significant difference was found (33%, n = 9 with GP involvement vs. 47%, n = 16, p = 0.279 with no GP involvement). Conclusions GP involvement in the initiation of opioid medication for CNCP was associated with a lower opioid dose being prescribed. Implications GP involvement in the initiation of opioid prescriptions may facilitate safer prescribing.

Long-Term Use of Muscle Relaxant Medications for Chronic Pain

Stricter opioid prescribing guidelines have increased prescriptions of skeletal muscle relaxants (SMRs) for chronic pain, but the efficacy of long-term use of SMRs for chronic pain is unknown. To systematically review the effectiveness or efficacy of long-term use of SMRs for chronic pain. Two reviewers systematically searched Ovid MEDLINE, Embase (Ovid), Web of Science, CINAHL, and Cochrane through December 4, 2023. They included articles published in English, Spanish, or Italian. Only randomized clinical trials (RCTs) and cohort studies with comparator groups evaluating at least 1-month duration of SMRs for chronic pain were included. The reviewers dually reviewed data abstraction, risk-of-bias, and quality. They characterized studies by chronic pain syndrome: low back pain, fibromyalgia, headaches, painful cramps or spasticity, and other syndromes. A total of 30 RCTs with 1314 participants and 14 cohort studies with 1168 participants assessed SMRs for chronic pain. Studies were primarily short-term (4-6 weeks). Nine unique SMRs were represented by the studies identified. Eleven studies (25%) examined baclofen, 8 (18%) examined tizanidine, and 7 (16%) examined cyclobenzaprine. Evidence for effectiveness was strongest for SMRs used for trigeminal neuralgia, neck pain, and painful cramps; evidence suggested SMRs for fibromyalgia, low back pain, and other syndromes were not more beneficial than placebo. The most common adverse effects were sedation and dry mouth. RCTs had a low to moderate risk of bias, and the quality of cohort studies was fair to good. In this systematic review of long-term use of SMRs for chronic pain, findings suggest that their long-term use may benefit patients with painful spasms or cramps and neck pain; their long-term use for low back pain, fibromyalgia, and headaches did not appear to be beneficial. Clinicians should be vigilant for adverse effects and consider deprescribing if pain-related goals are not met.