Unsafe Medication Use Research Articles

Receipt of Concurrent VA and Non-VA Opioid and Sedative-Hypnotic Prescriptions Among Post-9/11 Veterans With Traumatic Brain Injury.

Receipt of concurrent psychotropic prescription medications from both US Department of Veterans Affairs (VA) and non-VA healthcare providers may increase risk of adverse opioid-related outcomes among veterans with traumatic brain injury (TBI). Little is known about patterns of dual-system opioid or sedative-hypnotic prescription receipt in this population. We estimated the prevalence and patterns of, and risk factors for, VA/non-VA prescription overlap among post-9/11 veterans with TBI receiving opioids from VA providers in Oregon. Oregon VA and non-VA outpatient care. Post-9/11 veterans in Oregon with TBI who received an opioid prescription from VA providers between the years of 2014 and 2019. Historical cohort study. Prescription overlap of VA opioids and non-VA opioids or sedative-hypnotics; proportions of veterans who received VA or non-VA opioid, benzodiazepine, and nonbenzodiazepine sedative-hypnotic prescriptions were also examined by year and by veteran characteristics. Among 1036 veterans with TBI receiving opioids from the VA, 210 (20.3%) received an overlapping opioid prescription from a non-VA provider; 5.3% received overlapping benzodiazepines; and none received overlapping nonbenzodiazepine sedative-hypnotics. Proportions of veterans with prescription overlap tended to decrease over time. Veterans with other than urban versus urban addresses (OR = 1.4; 95% CI, 1.0-1.8), high versus medium average annual VA visits (OR = 1.7; 95% CI, 1.1-2.6), and VA service connection of 50% or more versus none/0% to 40% (OR = 4.3; 95% CI, 1.3-14.0) were more likely to have concurrent VA/non-VA prescriptions in bivariable analyses; other than urban remained associated with overlap in multivariable models. Similarly, veterans with comorbid posttraumatic stress disorder diagnoses were more likely to have concurrent VA/non-VA prescriptions in both bivariable and multivariable (OR = 2.1; 95% CI, 1.0-4.1) models. Among post-9/11 veterans with TBI receiving VA opioids, a considerable proportion had overlapping non-VA prescription medications. Providers and healthcare systems should consider all sources of psychotropic prescriptions, and risk factors for overlapping medications, to help mitigate potentially unsafe medication use among veterans with TBI.

Insurance Coverage and Use of Hormones Among Transgender Respondents to a National Survey.

We undertook a study to assess the associations between barriers to insurance coverage for gender-affirming hormones (either lack of insurance or claim denial) and patterns of hormone use among transgender adults. We used data from the US Transgender Survey, a large national sample of 27,715 transgender adults, collected from August to September 2015. We calculated weighted proportions and performed multivariate logistic regression analyses. Of 12,037 transgender adults using hormones, 992 (9.17%) were using nonprescription hormones. Among insured respondents, 2,528 (20.81%) reported that their claims were denied. Use of nonprescription hormones was more common among respondents who were uninsured (odds ratio = 2.64; 95% CI, 1.88-3.71; P <.001) or whose claims were denied (odds ratio = 2.53; 95% CI, 1.61-3.97; P <.001). Uninsured respondents were also less likely to be using hormones (odds ratio = 0.37; 95% CI, 0.24-0.56; P <.001). Lack of insurance coverage for gender-affirming hormones is associated with lower overall odds of hormone use and higher odds of use of nonprescription hormones; such barriers may thus be linked to unmonitored and unsafe medication use, and increase the risks for adverse health outcomes. Ensuring access to hormones can decrease the economic burden transgender people face, and is an important part of harm-reduction strategies.

Views and experiences of decision-makers on organisational safety culture and medication errors.

In 2017, the World Health Organization published "Medication Without Harm, WHO Global Patient Safety Challenge," to reduce patient harm caused by unsafe medication use practices. While the five objectives emphasise the need to create a framework for action, engaging key stakeholders and others, most published research has focused on the perspectives of health professionals. The aim was to explore the views and experiences of decision-makers in Qatar on organisational safety culture, medication errors and error reporting. Qualitative, semi-structured interviews were conducted with healthcare decision-makers (policy-makers, professional leaders and managers, lead educators and trainers) in Qatar. Participants were recruited via purposive and snowball sampling, continued to the point of data saturation. The interview schedule focused on: error causation and error prevention; engendering a safety culture; and initiatives to encourage error reporting. Interviews were digitally recorded, transcribed and independently analysed by two researchers using the Framework Approach. From the 21 interviews conducted, key themes were the need to: promote trust within the organisation through articulating a fair blame culture; eliminate management, professional and cultural hierarchies; focus on team building, open communication and feedback; promote professional development; and scale-up successful initiatives. There was recognition that the current medication error reporting processes and systems were suboptimal, with suggested enhancements in themes of promoting a fair blame culture and open communication. These positive and negative aspects of organisational culture can inform the development of theory-based interventions to promote patient safety. Central to these will be the further development and sustainment of a "fair" blame culture in Qatar and beyond.

The key challenges of deprescribing

Doctors have prescribed medicines for thousands of years. The ancient Greek physician Dioscorides authored De Materia Medica, one of the first pharmacopoeias, in the first century AD, and it was used to guide therapeutics for over a millennium. Fast forward to the 20th century: the tome had changed to the British National Formulary, and the Medicines Act of 1968 introduced legislation governing prescription-only medicines – but the prescriber remained the doctor. Indeed, the fundamental skills necessary to prescribe medicines have always been a core part of medical school teaching – the basic principles of pharmacology, the diagnostic and therapeutic process, the essentials of evidence-based clinical practice. The significance of prescribing is even reflected in doctors’ notorious reputation for illegible handwriting, which owes itself to writing scrips in Latin. The prescription is a tool not just with pharmacological purpose, but one that impacts patient trust and confidence in the doctor, that influences health-seeking behaviour, and can even act as a symbol that signifies the end of the consultation. As prescribing has grown, however, there have been increasing concerns about the overuse of medicines. Perhaps all those medicines we are handing out aren't always the best thing for the patient? The concept of deprescribing is now well established, yet there are no clear strategies for its implementation in practice; barriers include a lack of education and training, an absence of robust evidence, a tendency towards defensive practice, and pressure to adhere to single-disease evidence-based guidelines that frequently promote adding more medications. Shifting doctors away from a culture of prescribing that has been established for so long is not an easy thing to do. Although this is something the medical profession is only just getting to grips with, there are, of course, many other professionals who can now prescribe – and as a result, need also to consider the challenges of deprescribing. Although this might come more readily to pharmacists, given their expertise in reducing potentially unsafe medication use, the experiences of nurses are not well understood; Emma Crowe discusses this perspective on page 29 of this month's Prescriber. Non-medical prescribing only began in the 1990s, and so the weight of history may be somewhat easier to deal with when it comes to pharmacist and nurse deprescribing. But there are other key challenges, including overcoming inter-professional boundaries (it's still doctors who initiate most medicines, after all), and dealing with the clinical uncertainty deprescribing is often associated with but that many non-medical prescribers feel inadequately prepared for. Deprescribing is not going to go away any time soon. For all health professions involved in prescribing, medical or otherwise, there is a growing need to foster strategies – whether those are grounded in training, guidelines, policy, or something else – to help clinicians deliver this core aspect of good therapeutic management in the most effective and safe manner possible.

&lt;p&gt;Medication Use During Pregnancy in Mainland China: A Cross-Sectional Analysis of a National Health Insurance Database&lt;/p&gt;

PurposeThis study aims to illustrate the prevalence and patterns of medication use among pregnant women in mainland China.Patients and methodsHospital and drugstore service data for a nationally representative sample of basic medical insurance (BMI) beneficiaries in 2015 were obtained from the China Health Insurance Association (CHIRA) database. A total of 7946 women who had singleton deliveries in 2015, aged between 12 and 54, and whose records in the CHIRA database covered at least one trimester were included in this study. We conducted descriptive analyses of sample characteristics, medication use prevalence, and number and types of medications used.ResultsWe found that 11.7% of women used at least one medication during the course of pregnancy (median number of medications used = 6.7). Medication use was more common among those who were older, residing in Eastern China, or employed. Most commonly used medication groups by the Anatomical Therapeutic Chemical Classification System were B (Blood and blood forming organs, 49.3%), A (Alimentary tract and metabolism, 48.1%), G (Genito urinary system and sex hormones, 38.1%) and J (Antiinfectives for systemic use, 31.6%). Intravenous solutions, vitamins and minerals, progestogens, and beta-lactam antibacterials were the most frequently used medications from each of these four ATC groups, respectively. Moreover, 7.1% used at least one medication contraindicated in pregnancy.ConclusionThis study showed that around one in 10 women used medication during pregnancy in mainland China and found possible cases of inappropriate or unsafe medication use.

Usability and feasibility of consumer-facing technology to reduce unsafe medication use by older adults.

Mobile health technology can improve medication safety for older adults, for instance, by educating patients about the risks associated with anticholinergic medication use. This study's objective was to test the usability and feasibility of Brain Buddy, a consumer-facing mobile health technology designed to inform and empower older adults to consider the risks and benefits of anticholinergics. Twenty-three primary care patients aged ≥60 years and using anticholinergic medications participated in summative, task-based usability testing of Brain Buddy. Self-report usability was assessed by the System Usability Scale and performance-based usability data were collected for each task through observation. A subset of 17 participants contributed data on feasibility, assessed by self-reported attitudes (feeling informed) and behaviors (speaking to a physician), with confirmation following a physician visit. Overall usability was acceptable or better, with 100% of participants completing each Brain Buddy task and a mean System Usability Scale score of 78.8, corresponding to "Good" to "Excellent" usability. Observed usability issues included higher rates of errors, hesitations, and need for assistance on three tasks, particularly those requiring data entry. Among participants contributing to feasibility data, 100% felt better informed after using Brain Buddy and 94% planned to speak to their physician about their anticholinergic related risk. On follow-up, 82% reported having spoken to their physician, a rate independently confirmed by physicians. Consumer-facing technology can be a low-cost, scalable intervention to improve older adults' medication safety, by informing and empowering patients. User-centered design and evaluation with demographically heterogeneous clinical samples uncovers correctable usability issues and confirms the value of interventions targeting consumers as agents in shared decision making and behavior change.

Potentially Unsafe Chronic Medication Use Among Older Adult Chronic Opioid Users.

To assess chronic potentially unsafe medication use among older adults using opioids chronically versus those who did not, to assess the likelihood of chronically using medications to treat adverse effects associated with chronic opioid use, and to characterize the differences in chronic potentially unsafe medication use at three morphine equivalent dose (MED) levels/day (less than 50MED, 50-90MED, and more than 90MED). Retrospective cross-sectional analysis. Prescription claims data from a national telehealth Medication Therapy Management (MTM) provider for the year 2015. All Medicare Part D beneficiaries (65years and older [older adults]) from one Medicare Part D plan provider in one state who were eligible to receive MTM services. Medication claims were limited to refills in a 120-day window from one Medicare Part D provider. Chronic medication use was defined as having a total days' medication supply of 84days or more. Odds ratios (ORs) and χ2 tests were used to compare chronic medication use among beneficiaries who were chronic opioid users versus nonopioid users. Analyses were repeated among chronic opioid users at the less than 50MED, 50-90MED, and more than 90MED levels. Unpaired t tests and Welch's analysis of variance paired with Games-Howell post hoc tests were used for continuous variables. Older adult (mean age 76years) chronic opioid users were more likely to use muscle relaxants chronically (OR 2.67, 95% confidence interval [CI] 2.20-3.25), benzodiazepines (OR 2.08, 95% CI 1.87-2.31), hypnotics (OR 1.98, 95% CI 1.67-2.34), antidepressants (OR 1.64, 95% CI 1.51-1.77), and nonsteroidal antiinflammatory drugs (OR 1.78, 95% CI 1.59-1.98) versus nonopioid users. Further, chronic opioid users were 3.04 times (95% CI 2.05-4.51) more likely to use muscle relaxants and benzodiazepines concomitantly chronically and also more likely to use medications chronically to treat gastrointestinal reflux disease, constipation, estrogen loss, nausea and vomiting, and edema. Very high-dose (more than 90MED/day) chronic opioid users were more likely than low-dose users (less than 50MED) to use antidepressants (OR 1.51, 95% CI 1.15-1.97, p=0.003). Older adults with chronic opioid use were more likely to use potentially unsafe medications chronically. These data demonstrated discordance between national prescribing guidelines and real-world practice among older adults with chronic pain in one Medicare Part D plan.

Medication Use During Pregnancy in the Netherlands: A Population-Based Study

The objective of this study was to assess medication use during pregnancy in a population-based setting in the Netherlands. A cross-sectional analysis was conducted using pharmacy dispensing records linked to pregnancy records. Community pharmacy dispensing records were obtained from the Out-patient Pharmacy Database of the PHARMO Database Network (PHARMO) – a population-based network of electronic healthcare databases combining data from different healthcare settings in the Netherlands. Pregnancy records were obtained from the Perinatal Registry of the Netherlands (Perined) – a nationwide registry containing maternal and neonatal characteristics and data on perinatal care. Pregnancies between 1999 and 2015 of women registered in Perined as well as PHARMO were included in the study. Use of unsafe medication was defined according to 5 categories of the Dutch classification of medication in pregnancy: A) medication with pharmacological effects that (A1) should be monitored when used or (A2) should be (temporarily) avoided; B) medication with teratogenic effects that (B1) should be monitored when used or (B2) should be (temporarily) avoided and C) medication with unknown risks due to insufficient experience. The PHARMO-Perined cohort included 475,332 pregnancies of 343,783 women (mean (±SD) age at delivery 30.3 (±4.8) years, 81% with Dutch ethnicity). A total of 335,017 (70%) pregnancies were identified during which women were dispensed medication at least once. Among all pregnancies, 137,893 (29%) were exposed to unsafe medication with the highest use for medication in category C (79,416 pregnancies, 58%) followed by category A2 (48,584 pregnancies, 35%), category A1 (38,084 pregnancies, 28%), category B2 (13,094 pregnancies, 9%) and category B1 (1,952 pregnancies, 1%). Nearly one third of all pregnancies were exposed to medication not indicated as safe. Future interventions in the Netherlands should focus on the prevention of unsafe medication use during pregnancy.

How Clinicians Use Prescription Drug Monitoring Programs: A Qualitative Inquiry

Prescription drug monitoring programs (PDMPs) are now active in most states to assist clinicians in identifying potential controlled drug misuse, diversion, or excessive prescribing. Little is still known about the ways in which they are incorporated into workflow and clinical decision making, what barriers continue to exist, and how clinicians are sharing PDMP results with their patients.Qualitative data were collected through online focus groups and telephone interviews.Clinicians from pain management, emergency and family medicine, psychiatry/behavioral health, rehabilitation medicine, internal medicine and dentistry participated.Thirty-five clinicians from nine states participated.We conducted two online focus groups and seven telephone interviews. A multidisciplinary team then used a grounded theory approach coupled with an immersion-crystallization strategy for identifying key themes in the resulting transcripts.Some participants, mainly from pain clinics, reported checking the PDMP with every patient, every time. Others checked only for new patients, for new opioid prescriptions, or for patients for whom they suspected abuse. Participants described varied approaches to sharing PDMP information with patients, including openly discussing potential addiction or safety concerns, avoiding discussion altogether, and approaching discussion confrontationally. Participants described patient anger or denial as a common response and noted the role of patient satisfaction surveys as an influence on prescribing.Routines for accessing PDMP data and how clinicians respond to it vary widely. As PDMP use becomes more widespread, it will be important to understand what approaches are most effective for identifying and addressing unsafe medication use.

Work System Barriers to Providing Safe Over-the-Counter (OTC) Medication Recommendations for Older Adults

Background: Unsafe medication use represents a major public health concern, especially for older adults. OTC medications, those that can be purchased without a formal prescription or advice from a health care professional, are one contributor to unsafe use because of their perceived safety and accessibility. Despite the recognition of pharmacists’ ability to help patients make safe OTC medication choices, the prevalence of older adult misuse of OTC medications is well documented. Objective: To identify barriers to pharmacists providing safe OTC medication recommendations to older adults. Methods: Twenty-one retail pharmacists in three focus groups with questions developed using the critical incident technique. Analysis was guided by the Input-Performance-Output Model for Health Care Professional Performance. Results: Thematic analysis revealed barriers within all of the input categories of the work system model, including provider, patient, work system, organizational factors, and external environment. The results provide support that any intervention to improve safe OTC medication use in older adults should take into consideration the role of individual and interacting components of the work system.

Potentially inappropriate medicines in a cohort of community‐dwelling older people in New Zealand

To examine independent factors associated with potentially inappropriate medicines (PIM) among 316 community-dwelling people aged ≥75 years living in Dunedin. People aged ≥75 years living in the community in Dunedin, New Zealand, taking ≥1 prescription medicines, randomly sampled from the electoral roll, were interviewed about their medicine-taking practices. A medication inventory comprising prescription and non-prescription medicines was taken from each participant at the time of the interview. Participants used a median of seven prescription medicines (range 1-19) and one non-prescription medicine (0-14). PIM were identified using the updated 2012 Beers criteria. PIM were identified in 42.7% (n = 135) older people. A total of 23 (7.2%) took two PIM, five (1.5%) took three PIM, four (1.2%) took four PIM and one (0.3%) took five PIM. Of the 184 total PIM identified, the top three drug classes were non-COX-selective non-steroidal anti-inflammatory drugs (24.0%), tricyclic antidepressants (16.8%) and benzodiazepines (14.6%). Polypharmacy (adjusted odds ratio [OR] 2.06, 95% confidence interval [CI] 1.03-4.12) and the use of any psychotropic drug use (OR 22.05, 95% CI 5.80-83.84) were associated with PIM exposure. In the Poisson regression model, the risk of taking a PIM significantly decreased with age (OR 0.95, CI 0.91-0.99) and increased as the number of drugs prescribed increased (OR 1.11, CI 1.08-1.15). The prevalence of PIM is relatively high in community-dwelling older people aged ≥75 years living in New Zealand. PIM defined by the Beers criteria might be a useful initial screening tool, before efforts to stop unsafe medication use or replace with safer alternatives are initiated.

Over-the-counter analgesic use by urban Aboriginal people in South Australia.

Despite recent health gains for Australian Aboriginal people their significantly poorer health status compared with that of non-Aboriginal Australians remains significant. Within the context of high levels of mortality and morbidity, research highlights significant barriers to timely health-care, access and safe use of prescribed and over-the-counter medicines. The risks to Aboriginal people's health due to unsafe medication use are preventable. The purpose of this article is to present the findings from qualitative research focused on Aboriginal people's knowledge, use and experience of over-the-counter analgesics. The study was conducted in the north-western metropolitan area of Adelaide, which has the largest urban Aboriginal population in South Australia. The employment of an Aboriginal Elder as Cultural Advisor enabled engagement with Aboriginal participants. Purposive 'snow ball' sampling was used to recruit participants for four focus groups [n = 30] and one participant opting for a personal semi-structured interview. Participants worked with the researchers to develop the findings and formulate recommendations. The 25 women and 6 men, aged 20-80 years reported various chronic medical conditions. Focus groups/interview elicited accounts of critical issues concerning safe selection and use of over-the-counter analgesics. Serious health risks were evident due to limited knowledge about safe analgesic use and over-reliance on information from family, friends and advertising. Extremely poor access was reported by participants to culturally and linguistically appropriate information, education and advice from a range of doctors and other health professionals including Aboriginal health workers.