Prevalence of prescription and non-prescription polypharmacy by frailty and sex among middle-aged and older Canadians.

Background: Estimates of polypharmacy have primarily been derived from prescription claims, and less is known about the use of non-prescription medications (alone or in combination with prescription medications) across the frailty spectrum or by sex. Our objectives were to estimate the prevalence of polypharmacy (total, prescription, non-prescription, and concurrent prescription and non-prescription) overall, and by frailty, sex and broad age group. Data: Canadian Health Measures Survey, Cycle 5, 2016 to 2017. Methods: Among Canadians aged 40 to 79 years, all prescription and non-prescription medications used in the month prior to the survey were documented. Polypharmacy was defined as using five or more medications total (prescription and non-prescription), prescription only and non-prescription only. Concurrent prescription and non-prescription use was defined as two or more and three or more of each. Frailty was defined using a 31-item frailty index (FI) and categorized as non-frail (FI ≤ 0.1) and pre-frail or frail (FI > 0.1). Survey-weighted descriptive statistics were calculated overall and age standardized. Results: We analyzed 2,039 respondents, representing 16,638,026 Canadians (mean age of 56.9 years; 51% women). Overall, 52.4% (95% confidence interval [CI] = 47.3 to 57.4) were defined as pre-frail or frail. Age-standardized estimates of total polypharmacy, prescription polypharmacy and concurrent prescription and non-prescription medication use were significantly higher among pre-frail or frail versus non-frail adults (e.g., total polypharmacy: 64.1% versus 31.8%, respectively). Polypharmacy with non-prescription medications was common overall (20.5% [95% CI = 16.1 to 25.8]) and greater among women, but did not differ significantly by frailty. Interpretation: Polypharmacy and concurrent prescription and non-prescription medication use were common among Canadian adults, especially those who were pre-frail or frail. Our findings highlight the importance of considering non-prescribed medications when measuring the exposure to medications and the potential risk for adverse outcomes.

Creating Standardized Tools for the Pharmacist-Led Assessment and Pharmacologic Management of Adult Canadians Wishing to Quit Smoking: A Consensus-Based Approach.

Tobacco use continues to be recognized as the single most preventable cause of death worldwide. As the gatekeepers of and experts on pharmacotherapy, pharmacists play a vital role in facilitating smoking cessation. While existing frameworks have enabled pharmacists to provide smoking cessation services in Canada for many years, the way in which they are delivered vary considerably across the nation. The purpose of this initiative was to create standardized tools for the pharmacists providing cessation services to ensure all Canadians wishing to stop smoking have equal access to consistent, evidence-based care. An iterative process using repeated rounds of voting was employed to establish consensus among key opinion leaders on the most important items to include in tools for the pharmacist-led assessment and pharmacologic management of Canadian adults wishing to stop smoking. The results were used to create eight standardized documents for national use by pharmacists: a readiness to quit assessment tool, a patient consent form, a patient assessment form for past users of tobacco and/or tobacco-like products, a patient assessment form for current users of tobacco and/or tobacco-like products, a treatment algorithm, a treatment plan summary form, a prescribing documentation form, and a follow-up & monitoring documentation form. Although not described in detail in these documents, other strategies for smoking cessation (e.g., non-pharmacologic strategies (including quitting "cold turkey" and behavioural interventions), harm reduction strategies, etc.) should be considered when pharmacotherapy is inappropriate or undesired; care should be individualized based on a patient's previous experiences and current motivation. No single approach to treatment is endorsed by the authors. The consensus-based approach described here provides a suggested framework for harmonizing the pharmacist-led management of other ailments to optimize patient care.

Perioperative Opioid-sparing Strategies: Utility of Conventional NSAIDs in Adults.

PURPOSE: Opioids have long been used to treat acute postsurgical and postprocedural pain; however, opioid-related adverse events (AEs) contribute to poor patient outcomes. In addition, perisurgical exposure to opioids can potentially increase the risk for opioid-use disorder. NSAIDs reduce pain and inflammation by a mechanism different from that of opioid analgesics and may be useful in reducing the need for opioid drugs as part of a multimodal analgesia strategy. We conducted this review to assess the effectiveness and tolerability of adjunctive conventional NSAIDs given systemically in the perioperative setting in terms of opioid-sparing effects observed postoperatively. METHODS: Clinical trials published since 2000 that have assessed the opioid-sparing effects of conventional, nonselective NSAIDs were identified by a literature search using the PubMed search engine. Search terms were identified for the treatment of interest, the timing of the intervention, and the drugs of interest (NSAIDs). Data from studies that assessed opioid consumption outcomes with systemic NSAID administration were included in the review; data from studies in which NSAIDs were administered topically or via periarticular injection, local infiltration, or regional block were excluded. FINDINGS: Upon full-text review of the search results, 32 studies were chosen for inclusion in this literature review. These studies included those that assessed diclofenac, ketorolac, ibuprofen, ketoprofen, dexketoprofen, flurbiprofen, lornoxicam, tenoxicam, meloxicam, and piroxicam. In studies in which NSAIDs were associated with opioid-sparing effects within the setting of patient-controlled analgesia, opioid use was reduced by 17%-∼50% with diclofenac, 9%-66% with ketorolac, 22%-46% with ibuprofen, 34%-66% with ketoprofen, 36%-50% with dexketoprofen, 38%-41% with tenoxicam, 36%-54% with lornoxicam, and ∼50% with flurbiprofen. No opioid-sparing effect was noted with meloxicam (1 study). The majority of studies that reported on pain-score changes revealed either pain reductions with NSAIDs versus placebo or similar pain scores between groups, indicating that NSAIDs did not compromise pain control. Although many studies found no difference in the prevalence of AEs in NSAID-treated patients compared with controls, several studies noted lower rates of nausea, vomiting, sedation, and pruritus with NSAIDs versus placebo. Conversely, NSAID-related AEs were few overall but included gastrointestinal bleeding, injection site reactions, transient oliguric renal failure, and dizziness. No surgery-related bleeding complications were observed. IMPLICATIONS: NSAIDs have the potential to play an important role in reducing postoperative opioid requirements. Reducing the amount of opioids used could be expected to reduce opioid-related side effects and contribute to reversing the opioid epidemic.