Unsafe Prescribing Research Articles

Unsafe Opioid Prescribing among Patients with ESKD in 2020

Unsafe Opioid Prescribing among Patients with ESKD in 2020

Role of primary care in opioid prescribing for older head and neck cancer survivors.

Older head and neck cancer (HNC) survivors have concerning rates of potentially unsafe opioid prescribing. Identifying the specialties of opioid prescribers for HNC survivors is critical for targeting the settings for opioid safety interventions. This study hypothesized that oncology and surgery providers are primarily responsible for opioid prescriptions in the year after treatment but that primary care providers (PCPs) are increasingly involved in prescribing over time. Using linked Surveillance, Epidemiology, and End Results-Medicare data, a retrospective analysis was conducted of adults aged >65 years diagnosed between 2014 and 2017 with stage I-III HNC and who had ≥6 months of treatment-free follow-up through 2019. Starting at treatment completion, opioid fills were assigned to a prescriber specialty: oncology, surgery, primary care, pain management, or other. Prescriber patterns were summarized for each year of follow-up. Multinomial logistic regression models captured the likelihood of opioids being prescribed by each specialty. Among 5135 HNC survivors, 2547 (50%) had ≥1 opioid fill (median, 2.1-year follow-up). PCPs prescribed 47% of all fills (42%-55% each year). PCPs prescribed opioids to 45% of survivors with ≥1 opioid fill, which was a greater share than other specialties. PCPs prescribed longer supplies of opioids (median, 20 days/fill; median, 30 days/year) than oncologists or surgeons. The likelihood of an opioid being prescribed by an oncology provider was four times lower than that of it being prescribed by a PCP. PCP involvement in opioid prescribing remains high throughout HNC survivorship. Interventions to improve the safety of opioid prescribing should target primary care, as is typical for opioid reduction efforts in the noncancer population.

Impacts of State-Level Opioid Review Programs on Injured Workers and Their Health Care Providers: A Qualitative Study in Washington and Ohio.

Unsafe prescribing practices have been among the central causes of improper reception of opioids, unsafe use, and overdose in the United States. Workers' compensation agencies in Washington and Ohio have implemented opioid review programs (ORPs)-a form of quality improvement based on utilization review-to curb unsafe prescribing. Evidence suggests that such regulations indeed reduce unsafe prescribing, but pharmaceutical companies and patient advocates have raised concerns about negative impacts that could also result. This study explores whether three core sets of problems have actually come to pass: (1) unmanaged pain or reduced function among patients, (2) anger or resistance to ORPs from patients or providers, and (3) damage to patient-provider relationships or clinical autonomy. In-depth semistructured interviews were conducted with 48 patients (21 from Washington, 27 from Ohio) and 32 providers (18 from Washington, 14 from Ohio) who were purposively sampled to represent a range of injury and practice types. Thematic coding was conducted with codebooks developed using both inductive and deductive approaches. The consequences of opioid regulations have been generally positive: providers report more limited prescribing and a focus on multimodal pain control; patients report satisfactory pain control and recovery alongside collaborative relationships with providers. Participants attribute these patterns to a broad environment of opioid caution; they do not generally perceive workers' compensation policies as distinctly impactful. Both patients and providers comment frequently on the difficult aspects of interacting with workers' compensation agencies; effects of these range from simple inconvenience to delays in care, unmanaged pain, and reduced potential for physical recovery. In general, the three types of feared negative impacts have not come to pass for either patients or providers. Although interacting with workers' compensation agencies involves difficulties typical of interacting with other insurers, opioid controls seem to have generally positive effects and are generally perceived of favorably.

Prescribers of opioids for head and neck cancer (HNC) survivors.

12085 Background: Older HNC survivors often experience post-treatment pain, and they have concerningly high rates of unsafe opioid prescribing per CDC guidelines (e.g., high doses, concurrent benzodiazepines). Because interventions to improve opioid safety should target providers who prescribe opioids to HNC survivors, we aimed to identify post-treatment opioid prescriber specialty. Methods: Using the national linked Surveillance, Epidemiology, and End Results (SEER) registry and Medicare claims data, we identified adults age >65 diagnosed 2014-2017 with stage I-III HNC and who had ≥6 months treatment-free follow-up prior to censoring at further treatment, new cancer, hospice, death, or end 2019. Each opioid fill was assigned to a prescriber specialty: oncology (medical, radiation), surgery, primary care (internal medicine, family practice, geriatrics), pain, or other. Prescriber patterns (number of fills, duration of fill, annual opioid receipt) were summarized across follow-up and stratified by year. Multinomial logistic regression models captured trends in prescribing, accounting for clinical and sociodemographic characteristics. Results: Among 5547 HNC survivors, 2951 (53%) had ≥1 opioid fill (median 2.1 years follow-up). Primary care providers (PCPs) prescribed 49% of all fills (46%-53% each year). PCPs prescribed opioids to 49% of survivors with ≥1 opioid fill, a greater share than other specialties. PCPs prescribed longer supplies of opioids (median 30 days/fill and median 45 days/year) than oncologists or surgeons. The likelihood of an opioid being prescribed by an oncologist or surgeon was ≥5 times lower than by a PCP. Over follow-up, rates of opioid prescribing by oncologists decreased relative to rates of prescribing by PCPs (Table). Conclusions: Primary care involvement in opioid prescribing remains high over post-treatment HNC survivorship. Interventions to address unsafe opioid prescribing for HNC survivors should target the primary care setting, as is typical for opioid-reduction efforts in the non-cancer population. [Table: see text]

The role of primary care in opioid prescribing for head and neck cancer (HNC) survivors.

480 Background: Older HNC survivors often experience post-treatment pain, and they have concerningly high rates of unsafe opioid prescribing (e.g., high doses, concurrent benzodiazepines). Interventions to improve opioid safety should target providers who prescribe opioids to HNC survivors. We hypothesized that oncologists were responsible for most opioid prescribing to HNC survivors, but that involvement of primary care providers (PCPs) as prescribers increased over time after treatment. Methods: Using linked Surveillance, Epidemiology, and End Results (SEER) registry and Medicare claims data, we identified adults age >65 diagnosed 2014-2017 with stage I-III HNC with ≥6 months treatment-free follow-up prior to censoring at further treatment, new cancer, hospice, death, or end 2019. Starting 1 month after treatment completion, all opioid fills were assigned to a prescriber specialty: oncology (medical, radiation, surgical), surgery, primary care (internal medicine, family practice, geriatrics), pain, or other. Prescriber patterns were summarized at the fill and patient levels for each year of follow-up. Results: Among 5494 HNC survivors with median 2.1 years of treatment-free follow-up, 3092 (56%) had ≥1 opioid fill. At the fill level, almost half of all opioids (47%) were dispensed in the first year after treatment completion, with fewer fills each subsequent year. Contrary to our hypothesis, only 9% of all fills were prescribed by oncologists. Half of all fills were prescribed by PCPs; 14% were prescribed by pain specialists and 9% by surgeons. At the patient level, on average, each survivor had 34% of their opioid fills prescribed by primary care providers, followed by 24% by surgeons and 10% by oncologists. The proportion of survivors’ fills prescribed by PCPs remained high (36%-42% of each survivor’s fills) across all years, while proportion of each survivor’s fills prescribed by oncologists declined from 14% to 2% over years of follow-up. (See Table). Conclusions: PCPs prescribe a greater proportion of HNC survivors’ opioids than oncologists and surgeons combined. While oncologists’ and surgeons’ role as opioid prescribers declines over time, primary care involvement in opioid prescribing remains high throughout survivorship, suggesting that PCPs manage cancer-related pain, non-cancer pain is prevalent after HNC, or both. Interventions to address unsafe opioid use among HNC survivors should target the primary care setting, as is typical for opioid-reduction efforts in the non-cancer population.[Table: see text]

Impact of unsolicited reporting notifications on providers’ prescribing behavior: An experimental study on Maryland PDMP data

BackgroundUnsolicited Reporting Notifications(URNs) have been a component of Maryland’s Prescription Drug Monitoring Program (PDMP) since 2016. We evaluated the effect of URNs on providers’ prescription behaviors. MethodsThis is a quasi-experimental study of providers who were issued at least one URN from January 2018 to April 2021. Providers for whom URNs were not successfully delivered were designated as a comparison group. The outcome variables were average daily opioid and benzodiazepine prescriptions, average morphine milligram equivalents per patient, and proportion of overlapping opioid and benzodiazepine, either with or without muscle relaxant prescriptions. Changes were compared before versus after the issuance of a URN among the intervention and comparison groups using “Generalized Estimation Equation” and “Generalized Linear” Models. We also conducted stratified analyses by types of URN, including notifications for multiple provider episodes (MPE), overdose fatality (ODF), and dangerous drug combinations (DDC). ResultsThe average daily number of opioids prescriptions (3.3% decrease in the intervention group vs 22.7% increase in the comparison group, P<0.001), co-prescription of opioids and benzodiazepines either with muscle relaxants (68.0% decrease vs. 36.1% decrease, P<0.001), or without muscle relaxants (6.0% decrease vs. 16.3% increase, P<0.001), significantly reduced after the first URN regardless of the type of URN. Stratified analysis by types of URNs showed that ODF and DDC URNs had a significant effect on most of the outcomes of interest. ConclusionThe findings suggest that unsolicited reporting, especially particular types of URNs including ODF and DDC, is associated with subsequent changes in unsafe prescribing behaviors.

APA Debuts Mental Health Innovation Exchange

APA Debuts Mental Health Innovation Exchange

Effect of Different Interventions to Help Primary Care Clinicians Avoid Unsafe Opioid Prescribing in Opioid-Naive Patients With Acute Noncancer Pain

Prescription opioids can treat acute pain in primary care but have potential for unsafe use and progression to prolonged opioid prescribing. To compare clinician-facing interventions to prevent unsafe opioid prescribing in opioid-naive primary care patients with acute noncancer pain. We conducted a multisite, cluster-randomized, 2 × 2 factorial, clinical trial in 3 health care systems that comprised 48 primary care practices and 525 participating clinicians from September 2018 through January 2021. Patient participants were opioid-naive outpatients, 18 years or older, who presented for a qualifying clinic visit with acute noncancer musculoskeletal pain or nonmigraine headache. Practices randomized to: (1) control; (2) opioid justification; (3) monthly clinician comparison emails; or (4) opioid justification and clinician comparison. All groups received opioid prescribing guidelines via the electronic health record at the time of a new opioid prescription. Primary outcome measures were receipt of an initial opioid prescription at the qualifying clinic visit. Other outcomes were opioid prescribing for more than 3 months and a concurrent opioid/benzodiazepine prescription over 12-month follow-up. Among 22 616 enrolled patient participants (9740 women [43.1%]; 64 American Indian/Alaska Native [0.3%]; 590 Asian [2.6%], 1120 Black/African American [5.0%], 1777 Hispanic [7.9%], 225 Native Hawaiian/Pacific Islander [1.0%], and 18 981 White [83.9%] individuals), the initial opioid prescribing rates at the qualifying clinic visit were 3.1% in the total sample, 4.2% in control, 3.6% in opioid justification, 2.6% in clinician comparison, and 1.9% in opioid justification and clinician comparison. Compared with control, the adjusted odds ratio (aOR) for a new opioid prescription was 0.74 (95% CI, 0.46-1.18; P = .20) for opioid justification and 0.60 (95% CI, 0.38-0.96; P = .03) for clinician comparison. Compared with control, clinician comparison was associated with decreased odds of opioid therapy of more than 3 months (aOR, 0.79; 95% CI, 0.69-0.91; P = .001) and concurrent opioid/benzodiazepine prescription (aOR, 0.85; 95% CI, 0.72-1.00; P = .04), whereas opioid justification did not have a significant effect. In this cluster randomized clinical trial, comparison emails decreased the proportion of opioid-naive patients with acute noncancer pain who received an opioid prescription, progressed to treatment with long-term opioid therapy, or were exposed to concurrent opioid and benzodiazepine therapy. Health care systems can consider adding clinician-targeted nudges to other initiatives as an efficient, scalable approach to further decrease potentially unsafe opioid prescribing. ClinicalTrials.gov Identifier: NCT03537573.

Feedback of actionable individual patient prescription data to improve asthma prescribing: pragmatic cluster randomised trial in 233 UK general practices.

BackgroundPotentially inappropriate prescribing (PIP) of asthma bronchodilator inhalers is associated with increased morbidity and mortality.AimTo evaluate the effectiveness of feedback on the PIP of bronchodilator inhalers.Design and settingPragmatic cluster randomised trial involving 235 of 244 (96.3%) GP practices in one Scottish health board.MethodPractices were randomly allocated (1:1 ratio) to individualised feedback (including visualised medication histories for each patient and action-oriented messages) on PIP of bronchodilator inhalers from prescription data; feedback reports were sent in July 2015, February 2016, and August 2016. Controls were sent feedback on an unrelated subject. The primary outcome was the change in the mean number of patients per practice with PIP of bronchodilator inhalers from the baseline period (August 2014–July 2015) until the post-feedback period (February 2016–January 2017), identified through a composite of five individual measures using prescription data.ResultsIn the analysis of the primary outcome, the mean number of patients with PIP of bronchodilator inhalers fell in the 118 practices that were sent feedback from 21.8 per practice to 17.7 per practice. Numbers fell marginally in the 115 control practices, from 20.5 per practice to 20.2 per practice, with a statistically significant difference between the two groups. There were 3.7 fewer patients per practice with PIP of bronchodilator inhalers in the intervention practices versus the control practices (95% confidence interval = −5.3 to −2.0).ConclusionIndividualised feedback of PIP of asthma bronchodilators that included background information, visualised medication histories for each patient, and action-oriented messages was effective at reducing the number of patients exposed to excess or unsafe prescribing of bronchodilator inhalers.

Safer citalopram use in primary care: Can staff education and prescribing prompts improve adherence to national guidance? A closed loop clinical audit, service evaluation and quality improvement study.

Citalopram is a drug with many important safety considerations in prescribing including dosage adjustments, pre-prescription testing and multiple interactions. Because of this, the UK government issued advice regarding the prescription of citalopram and escitalopram in its Drug Safety Update Vol 5 Issue 5, Dec 2011,[1] and the expectation is that all prescribers adhere to this. To establish the adherence to prescribing guidance of citalopram at the practice level, implement change to address the lack of adherence and then evaluate the effectiveness of the change using re-audit techniques. Patients were identified using data searching techniques on EMIS for February-April 2020. Parameters searched for included age, hepatic impairment, cardiac disease, known QT prolongation and concomitant use with other QT-prolonging medication. Following the first cycle teaching on the safer use of citalopram was delivered to all prescribers and an EMIS prompt was also set up. A second audit cycle was then carried out. Data was analysed using Statistical Package for Social Sciences software to assess the significance of the results. Following the presentation of the first cycle findings and the introduction of the EMIS safety prompt, there was a statistically significant reduction in incorrect citalopram dose prescription in the over 65s (8 vs 1), a statistically significant reduction in the incidence of dangerous drug interactions involving citalopram (44 vs 8) and a significant reduction in the incidence of unsafe prescribing of citalopram overall (47 vs 9). The introduction of an EMIS prompt and one-off prescriber teaching resulted in a statistically significant reduction in incorrect prescriptions of citalopram when re-audited a year later. These interventions resulted in improved patient safety and more effective use of resources and could easily be replicated at other practices throughout the country both for citalopram and other drugs with multiple safety considerations.

CDC Guideline For Opioid Prescribing Associated With Reduced Dispensing To Certain Patients With Chronic Pain.

The Centers for Disease Control and Prevention's 2016 Guideline for Prescribing Opioids for Chronic Pain aimed to reduce unsafe opioid prescribing. It is unknown whether the guideline influenced prescribing in the target population: patients with chronic, noncancer pain, who may be at particular risk for opioid-related harms. To study this question, we used 2014-18 data from a commercial claims database to examine associations between the release of the guideline and opioid dispensing in a national cohort of more than 450,000 patients with four common chronic pain diagnoses. We also examined whether any reductions associated with the guideline were larger for diagnoses for which there existed stronger expert consensus against opioid prescribing. Overall, the guideline was associated with substantial reductions in dispensing opioids, including a reduction in patients' rate of receiving at least one opioid prescription by approximately 20percentage points by December 2018 compared with the counterfactual, no-guideline scenario. However, the reductions in dispensing did not vary by the strength of expert consensus against opioid prescribing. These findings suggest that although voluntary guidelines can drive changes in prescribing, questions remain about how clinicians are tailoring opioid reductions to best benefit patients.

530 INTERPRETATION OF HBA1C VALUES IN GERIATRIC PATIENTS WITH TYPE 2 DIABETES: LARGE DIVERGENCE BETWEEN CLINICAL PRACTICE GUIDELINES

Abstract Introduction An individualised glycated haemoglobin (HbA1c) target according to the patients’ health status is central in the glycaemic management of geriatric people with type 2 diabetes (T2D) in order to avoid hypoglycaemic events through an appropriate management of the glucose-lowering therapy (GLT). Current clinical practice guidelines (CPGs) provide different recommendations for patients’ HbA1c targets. Using real-life data from geriatric patients, this study aimed at assessing the concordance in interpretation of HbA1c values according to three current major CPGs from the Diabetes Canada-2018 (DC18), the Endocrine Society-2019 (ES19) and the American Diabetes Association-2020 (ADA20). Introduction Retrospective study in consecutive older patients (≥75 years) with T2D admitted to a Belgian geriatric ward, with GLT before admission and HbA1c measurement during the hospital stay. Patients were classified into three categories of HbA1c values according to the CPGs recommendations: in-target HbA1c (appropriate-GLT), too-low HbA1c (GLT-overtreatment) and too-high HbA1c (GLT-undertreatment). Concordance of health status classifications and GLT categories between the three CPGs was assessed using Cohen’s and Fleiss’ κ, respectively. Results Of the 318 patients (median age 84 years, 54% women), one-third were in intermediate health and two-thirds in poor health (κ = 0.86; excellent concordance). According to the DC18, ES19 and ADA20 CPGs, HbA1c was in-target for respectively 46%, 25% and 82% of the patients, and too-low HbA1c (GLT-overtreatment) was present in 28%, 57% and 0% (κ = 0.36; low concordance). Results Patients’ HbA1c values are interpreted differently according to these major CPGs, mainly because of differences in their recommendations about HbA1c target individualisation and specifically the definition of a too-low HbA1c value. In clinical practice, these diverging interpretations regarding overtreatment may lead to unsafe GLT prescribing and thereby to hypoglycaemic events in this high-risk population.

Development of video animations to encourage patient-driven deprescribing: A Team Alice Study

ObjectivePatient-driven deprescribing initiatives aim to increase patient knowledge and strengthen self-advocacy skills. This article describes the development of three animated videos designed to educate older adults about unsafe prescribing and medication harm, based on the actionable lessons from the death, by polypharmacy, of an older adult in our community. MethodsUsing a community based participatory research approach (CBPR), members of three senior centers (n = 53) and the Deprescribing Partnership of Western New York (n = 30) were recruited and participated in two rounds of focus groups to guide the video development. ResultsStakeholder input led to changes in content, wording, and visual presentation. The final versions of the videos emphasize the following messages (1) “New medications and what you should know about the risks”, (2) “What you should do when a doctor tells you never to take a certain medication”, (3) “What you should know about medications when you are in the hospital.” ConclusionThe study highlights the successful process of using CBPR to develop a series of videos designed to provide information on the risks of polypharmacy, and empower older adults to advocate for themselves. Practice implicationsAnimated educational videos are a novel strategy to address medication harm in older adults. This research is a critical first step to increasing patient-led discussions that reduce the incidence of medication harm and inappropriate medication use among older adults.

Use of prescribing safety quality improvement reports in UK general practices: a qualitative assessment

BackgroundQuality improvement (QI) initiatives are increasingly used to improve the quality of care and reduce prescribing errors. The Royal College of General Practitioners (RCGP) and Clinical Practice Research Datalink (CPRD) QI initiative uses routinely collected electronic primary care data to provide bespoke practice-level reports on prescribing safety. The aim of this study was to explore how the QI reports were used, barriers and facilitators to use, long-term culture change and perceived impact on patient care and practices systems as a result of receiving the reports.MethodsA qualitative study using purposive sampling of practices contributing to the CPRD, semi-structured interviews and inductive thematic analysis. We interviewed general practitioners, pharmacists, practice managers and research nurses.ResultsWe conducted 18 interviews, and organised themes summarising the use of QI reports in practice: receiving the report, facilitators and barriers to acting upon the reports, acting upon the report, and how the reports contribute to a quality culture. Effective dissemination of reports, and a positive attitude to audit and the perceived relevance of the clinical topic facilitated use. Lack of time and failure to see or act upon the reports meant they were not used. Factors influencing use of the reports included the structure of the report, ease of identifying cases, and perceptions about coding accuracy. GPs and pharmacists used the reports to conduct case reviews and directly contact patients to discuss unsafe prescribing and patient medication preferences. Finally, the reports contributed to the development of a quality culture within practices through promoting audit activity and acting as a reminder of good prescribing behaviours, promoting future patient safety initiatives, contributing to continuing professional development and improving local networks.ConclusionsThis study found the reports facilitated individual case review leading to an enhanced sense of quality culture in practices where they were utilised. Our findings demonstrate that the reports were generally considered useful and have been used to support patient safety and clinical practice in specific cases.

Prospects for Enforcing Prohibitions on Off-Label Drug Promotion after United States v. Caronia: An Analysis of Litigated Cases.

Food and Drug Administration (FDA) rules restrict pharmaceutical manufacturers from promoting drugs for non-FDA-approved (off-label) indications. When manufacturers violate this rule, it has in many cases led to unsafe prescribing. However, in 2012, a federal circuit court ruled in United States v. Caronia that truthful off-label promotion was protected under the First Amendment, threatening government enforcement in this area. The authors extracted cases from the WestLawNext database that mentioned Caronia from 2012 to 2019. They collected information about plaintiff, procedural history, product and manufacturer involved, and case outcome. Cases were categorized as either "follows," "does not follow," or "distinguishes" from Caronia. The authors qualitatively reviewed the full text of each case to verify whether Caronia was given substantive discussion for perceptions of off-label promotion, application of commercial speech rights, and how courts interpreted Caronia. Among 42 cases in the study cohort, 22 (52%) followed Caronia's core holding that truthful, non-misleading off-label promotion was not actionable under FDA rules. By contrast, 20 cases (48%) treated Caronia negatively, either declining to follow (9 cases) or distinguishing it (11 cases). Enforcement of restrictions on off-label marketing became more challenging after Caronia. This gives manufacturers greater flexibility to promote drugs for unapproved uses despite the substantial public health risks.

The opioid-prescribing practices of Australian general practice registrars: an interview study.

Approximately half of the opioids prescribed by Australian GP and GP registrars are for chronic non-cancer pain-despite limited therapeutic benefit, and serious risks of harm. Understanding the factors driving non-evidence-based opioid prescribing may improve GP training and education. To explore attitudes, beliefs, knowledge and self-reported factors influencing the opioid-prescribing decisions of Australian GP registrars. Telephone interviews were undertaken with 20 GP registrars in 2018-19. Interviews were 30-60 minutes in duration, audio-recorded and de-identified. Braun and Clarke's 6-phase framework was adopted for reflexive thematic analysis of data and managed using QSR NVivo software. Twenty registrars were recruited; 8 men and 12 women. Three themes were identified. Difficult chronic pain consultations negatively affected the registrar well-being. Registrars role modelled their supervisors' opioid-prescribing practices, even if they perceived it to be unsafe. Registrars lacked confidence in initiating, prescribing and weaning opioids, recognizing drug-seeking behaviours and declining to prescribe-but felt confident in their knowledge of opioid pharmacology. Registrars were aware of evidence-based prescribing recommendations and risk reduction strategies but struggled to translate this into practice. Non-evidence-based opioid prescribing by Australian GP registrars is multifactorial. Emotionally difficult pain consultations, poor supervision and low prescriber confidence may contribute to unsafe prescribing. Improving registrar prescribing may require interventions to improve risk reduction, training in communication and role modelling by supervisors.

Combining stimulants with antipsychotics for foster children and adolescents: Do prescribers adhere to guidelines?

ObjectiveConsistent with federal requirements for states to monitor psychotropic medication use in foster children and adolescents, we assessed prescribers’ adherence to best practice guidelines. Specifically, we identified the prevalence and patterns of combined use of stimulants and antipsychotics among a sample of foster children and adolescents that received additional non-pharmacological interventions from a state-funded team. A secondary purpose of this paper was to demonstrate a method for monitoring psychotropic medication use for this vulnerable population. MethodsUsing data from a state Medicaid database and a state-funded team, we tracked medication use among a sample of 128 foster children and adolescents aged 5–19 years with varying diagnoses who received behavioral and medication review services. We extracted data for children and adolescents who received the combination of stimulants and antipsychotics, and then we visually depicted the data to show changes in medication use before, during, and after our services. ResultsOut of the larger sample, twenty-one foster children and adolescents (16%) simultaneously received stimulants and antipsychotics. Visual depictions of data show that less than 50% received stimulants alone before combined use. In addition, participants experienced limited changes in medication regimens even after receiving non-pharmacological services. ConclusionsThese findings suggest that prescribers may not adhere to practice guidelines for use of stimulants and antipsychotics, even for clients who receive other services, and highlight the need for relevant stakeholders to monitor unsafe prescribing practices.

Evaluation of a framework for safe and appropriate prescribing of psychoactive medications in a UK prison.

The widespread use of drugs in prisons leads to avoidable deaths, poorer health and a poor living environment. The contribution of psychoactive prescription drugs to this problem has received little attention in prison policy or at individual prescriber level. To determine the extent of unsafe and inappropriate prescribing of psychoactive medications in one UK prison using a newly developed medicines optimisation framework. A medicines optimisation framework was developed based on principles of good prescribing. It was initiated on the opening of a new prison-HMP Berwyn-in February 2017. During the study period, all prisoners at HMP Berwyn were transferred from other prisons. The safety and appropriateness of psychoactive medications were evaluated de novo on reception at HMP Berwyn and during follow up, using the medicines optimisation framework. About 1941 sentenced men arrived at HMP Berwyn between February 2017 and November 2018. Nearly one-third (634, 33%) were on a prescribed psychoactive medication. Seventy-five percent of these (474/634) required a prescription change due to appropriateness or safety concerns. Nearly half (295, 46.5%) received changes at reception despite having already undergone medicines reconciliation at their previous prison. Forty-three percent (275/634) received changes at follow up, most commonly those who had no prior risks identified at reception. Inappropriate and unsafe prescribing of psychoactive medications is occurring in prisons despite mandatory medication reviews. Ongoing monitoring is required to reduce the risk from these medications. A medicines optimisation framework such as this could be adopted across other prisons, worldwide, to help contribute to risk reduction from drug use in prisons. Appropriately modified, a similar framework might help reduce inappropriate and harmful prescribing in hospitals and in the community.

Impact of Electronic Health Record Interface Design on Unsafe Prescribing of Ciclosporin, Tacrolimus, and Diltiazem: Cohort Study in English National Health Service Primary Care.

BackgroundIn England, national safety guidance recommends that ciclosporin, tacrolimus, and diltiazem are prescribed by brand name due to their narrow therapeutic windows and, in the case of tacrolimus, to reduce the chance of organ transplantation rejection. Various small studies have shown that changes to electronic health record (EHR) system interfaces can affect prescribing choices.ObjectiveOur objectives were to assess variation by EHR systems in breach of safety guidance around prescribing of ciclosporin, tacrolimus, and diltiazem, and to conduct user-interface research into the causes of such breaches.MethodsWe carried out a retrospective cohort study using prescribing data in English primary care. Participants were English general practices and their respective EHR systems. The main outcome measures were (1) the variation in ratio of safety breaches to adherent prescribing in all practices and (2) the description of observations of EHR system usage.ResultsA total of 2,575,411 prescriptions were issued in 2018 for ciclosporin, tacrolimus, and diltiazem (over 60 mg); of these, 316,119 prescriptions breached NHS guidance (12.27%). Breaches were most common among users of the EMIS EHR system (breaches in 18.81% of ciclosporin and tacrolimus prescriptions and in 17.99% of diltiazem prescriptions), but breaches were observed in all EHR systems.ConclusionsDesign choices in EHR systems strongly influence safe prescribing of ciclosporin, tacrolimus, and diltiazem, and breaches are prevalent in general practices in England. We recommend that all EHR vendors review their systems to increase safe prescribing of these medicines in line with national guidance. Almost all clinical practice is now mediated through an EHR system; further quantitative research into the effect of EHR system design on clinical practice is long overdue.

The opioid-impaired provider: A call for national guidance to maximize rehabilitation while protecting patient safety.

The opioid-impaired provider: A call for national guidance to maximize rehabilitation while protecting patient safety.