How do contraindications to non-opioid analgesics and opioids affect the likelihood that patients with back pain diagnoses in the primary care setting receive an opioid prescription? An observational cross-sectional study.

BACKGROUND: Given the risks of opioids, clinicians are under growing pressure to treat pain with non-opioid medications. Yet non-opioid analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) have their own risks: patients with kidney disease or gastrointestinal diseases can experience serious adverse events. We examined the likelihood that patients with back pain diagnoses and contraindications to NSAIDs and opioids received an opioid prescription in primary care. METHODS: We identified office visits for back pain from 2012 to 2017 and sampled the first office visit per patient per year (N = 24,543 visits). We created indicators reflecting contraindications for NSAIDs (kidney, liver, cardiovascular/cerebrovascular, and gastrointestinal diseases; concurrent or chronic use of anticoagulants/antiplatelets, chronic corticosteroid use) and opioids (depression, anxiety, substance use (SUD) and bipolar disorders, and concurrent benzodiazepines) and estimated four logistic regression models, with the one model including all patient visits and models 2-4 stratifying for previous opioid use. We estimated the population attributable risk for each contraindication. RESULTS: In our model with all patients-visits, patients received an opioid prescription at 4% of visits. The predicted probability (PP) of receiving an opioid was 4% without kidney disease vs. 7% with kidney disease; marginal effect (ME): 3%; 95%CI: 1-4%). For chronic or concurrent anticoagulant/antiplatelet prescriptions, the PPs were 4% vs. 6% (ME: 2%; 95%CI: 1-3%). For concurrent benzodiazepines, the PPs were 4% vs. 11% (ME: 7%, 95%CI: 5-9%) and for SUD, the PPs were 4% vs. 5% (ME: 1%, 95%CI: 0-3%). For the model including patients with previous long-term opioid use, the PPs for concurrent benzodiazepines were 25% vs. 24% (ME: -1%; 95%CI: - 18-16%). The population attributable risk (PAR) for NSAID and opioid contraindications was small. For kidney disease, the PAR was 0.16% (95%CI: 0.08-0.23%), 0.44% (95%CI: 0.30-0.58%) for anticoagulants and antiplatelets, 0.13% for substance use (95%CI: 0.03-0.22%) and 0.20% for concurrent benzodiazepine use (95%CI: 0.13-0.26%). CONCLUSIONS: Patients with diagnoses of kidney disease and concurrent use of anticoagulants/antiplatelet medications had a higher probability of receiving an opioid prescription at a primary care visit for low back pain, but these conditions do not explain a large proportion of the opioid prescriptions.

Cumulative Update of a Systematic Overview Evaluating Interventions Addressing Polypharmacy.

Importance: Polypharmacy is associated with mortality, falls, hospitalizations, and functional and cognitive decline. The study of polypharmacy-related interventions has increased substantially, prompting the need for an updated, more focused systematic overview. Objective: To systematically evaluate and summarize evidence across multiple systematic reviews (SRs) examining interventions addressing polypharmacy. Evidence Review: A search was conducted of MEDLINE, the Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effects for articles published from January 2017-October 2022, as well as those identified in a previous overview (January 2004-February 2017). Systematic reviews were included regardless of study design, setting, or outcome. The evidence was summarized by 4 categories: (1) medication-related process outcomes (eg, potentially inappropriate medication [PIM] and potential prescribing omission reductions), (2) clinical and functional outcomes, (3) health care use and economic outcomes, and (4) acceptability of the intervention. Findings: Fourteen SRs were identified (3 from the previous overview), 7 of which included meta-analyses, representing 179 unique published studies. Nine SRs examined medication-related process outcomes (low to very low evidence quality). Systematic reviews using pooled analyses found significant reductions in the number of PIMs, potential prescribing omissions, and total number of medications, and improvements in medication appropriateness. Twelve SRs examined clinical and functional outcomes (very low to moderate evidence quality). Five SRs examined mortality; all mortality meta-analyses were null, but studies with longer follow-up periods found greater reductions in mortality. Five SRs examined falls incidence; results were predominantly null save for a meta-analysis in which PIMs were discontinued. Of the 8 SRs examining quality of life, most (7) found predominantly null effects. Ten SRs examined hospitalizations and readmissions (very low to moderate evidence quality) and 4 examined emergency department visits (very low to low evidence quality). One SR found significant reductions in hospitalizations and readmissions among higher-intensity medication reviews with face-to-face patient components. Another meta-analysis found a null effect. Of the 7 SRs without meta-analyses for hospitalizations and readmissions, all had predominantly null results. Two of 4 SRs found reductions in emergency department visits. Two SRs examined acceptability (very low evidence quality), finding wide variation in the adoption of polypharmacy-related interventions. Conclusions and Relevance: This updated systematic overview noted little evidence of an association between polypharmacy-related interventions and reduced important clinical and health care use outcomes. More evidence is needed regarding which interventions are most useful and which populations would benefit most.

Implementation of an intervention aimed at deprescribing benzodiazepines in a large US healthcare system using patient education materials: a pre/post-observational study with a control group.

OBJECTIVES: Long-term benzodiazepine use is common despite known risks. In the original Eliminating Medications Through Patient Ownership of End Results (EMPOWER) Study set in Canada, patient education led to increased rates of benzodiazepine cessation. We aimed to determine the effectiveness of implementing an adapted EMPOWER quality improvement (QI) initiative in a US-based healthcare system. DESIGN: We used a pre-post design with a non-randomised control group. SETTING: A network of primary care clinics. PARTICIPANTS: Patients with ≥60 days' supply of benzodiazepines in 6 months and ≥1 risk factor (≥65 years of age, a concurrent high-risk medication prescribed or a diazepam equivalent daily dose ≥10) were eligible. INTERVENTION: In March 2022, we engaged 22 primary care physicians (PCPs), and 308 of their patients were mailed an educational brochure, physician letter and flyer detailing benzodiazepine risks; the control group included 4 PCPs and 291 of their patients. PRIMARY AND SECONDARY MEASURES: The primary measure was benzodiazepine cessation by 9 months. We used logistic regression and a generalised estimating equations approach to control for clustering by PCP, adjusting for demographics, frailty, number of risk factors, and diagnoses of arthritis, depression, diabetes, falls, and pain. RESULTS: Patients in the intervention and control groups were comparable across most covariates; however, a greater proportion of intervention patients had pain-related diagnoses and depression. By 9 months, 26% of intervention patients (81 of 308) had discontinued benzodiazepines, compared with 17% (49 of 291) of control patients. Intervention patients had 1.73 greater odds of benzodiazepine discontinuation compared with controls (95% CI: 1.09, 2.75, p=0.02). The unadjusted number needed to treat was 10.5 (95% CI: 6.30, 34.92) and the absolute risk reduction was 0.095 (95% CI: 0.03 to 0.16). CONCLUSIONS: Results from this non-randomised QI initiative indicate that patient education programmes using the EMPOWER brochures have the potential to promote cessation of benzodiazepines in primary care.