Opioid therapy trajectories of patients with chronic non-cancer pain over 1 year of follow-up after initiation of short-acting opioid formulations.

OBJECTIVE: This study compared opioid utilization trajectories of persons initiating tramadol, short-acting hydrocodone, or short-acting oxycodone, and it characterized opioid dose trajectories and type of opioid in persistent opioid therapy subsamples. METHODS: A retrospective cohort study of adults with chronic non-cancer pain who were initiating opioid therapy was conducted with the IQVIA PharMetrics® Plus for Academics data (2008-2018). Continuous enrollment was required for 6 months before ("baseline") and 12 months after ("follow-up") the first opioid prescription ("index date"). Opioid therapy measures were assessed every 7 days over follow-up. Group-based trajectory modeling (GBTM) was used to identify trajectories for any opioid and total morphine milligram equivalent measures, and longitudinal latent class analysis was used for opioid therapy type. RESULTS: A total of 40 276 tramadol, 141 023 hydrocodone, and 45 221 oxycodone initiators were included. GBTM on any opioid therapy identified 3 latent trajectories: early discontinuers (tramadol 39.0%, hydrocodone 54.1%, oxycodone 61.4%), late discontinuers (tramadol 37.9%, hydrocodone 39.4%, oxycodone 33.3%), and persistent therapy (tramadol 6.7%, hydrocodone 6.5%, oxycodone 5.3%). An additional fourth trajectory, intermittent therapy (tramadol 16.4%), was identified for tramadol initiators. Of those on persistent therapy, 2687 individuals were on persistent therapy with tramadol, 9169 with hydrocodone, and 2377 with oxycodone. GBTM on opioid dose resulted in 6 similar trajectory groups in each persistent therapy group. Longitudinal latent class analysis on opioid therapy type identified 6 latent classes for tramadol and oxycodone and 7 classes for hydrocodone. CONCLUSION: Opioid therapy patterns meaningfully differed by the initial opioid prescribed, notably the presence of intermittent therapy among tramadol initiators and higher morphine milligram equivalents and prescribing of long-acting opioids among oxycodone initiators.

Effect of cannabis on opioid use in patients with cancer receiving palliative care.

OBJECTIVE: Opioids are the primary therapy for cancer-related pain in patients receiving palliative care. More states are legalizing medical cannabis, which may provide a pain management alternative for some of these patients. This study aimed to estimate the effect of cannabis on opioid use in patients with cancer receiving palliative care. METHODS: This was a retrospective cohort study of patients with cancer at an academic medical center palliative care clinic. The primary outcome was change in morphine equivalent daily dose (MEDD) from baseline to 84-day follow-up in the cannabis plus opioid group compared to that in the opioid-only group. RESULTS: A total of 83 patients were included: 61 in the opioid monotherapy group and 22 in the cannabis plus opioid group. An increase in MEDD from the baseline to 84 days was seen in both the opioid monotherapy and opioid plus cannabis group (28.8 vs. 10.8); however, the study lacked power to detect a statistical difference. CONCLUSION: A possibly meaningful difference in MEDD increase was seen when comparing the opioid monotherapy group with the opioid plus cannabis group. However, the study was not powered to test this hypothesis; the findings suggest that further research is warranted to determine the impact of cannabis use on opioid dosing in patients receiving palliative care for cancer.

A recent history of opioid use in the US: Three decades of change.

BACKGROUND: The opioid epidemic in the United States is a problem that has developed over decades. While clinical, regulatory, and legislative changes have been implemented to combat this issue, changes will not be immediate. Moreover, the changes that have been carried out may have unintended negative consequences such as increased use of illicit opioids (e.g., heroin and synthetics) and challenges in effective and appropriate pain management. OBJECTIVES: This review focuses on the last three decades and presents key changes the United States has seen in the use of opioids. Conclusions/Importance: There have been numerous policy changes and programs aimed at decreasing opioid use and abuse in the United States; however, it will take a major shift in the mindset of clinicians, the general public, and policy makers to alleviate this epidemic.

Association of the "CDC Guideline for Prescribing Opioids for Chronic Pain" With Emergency Department Opioid Prescribing.

BACKGROUND: The number of unintentional deaths due to prescription drug overdose has risen in recent years due to the increased utilization of opioid analgesics. Pain is one of the most common reasons for patients to visit an emergency department (ED) and is often treated with opioid analgesics. In 2016, the Centers for Disease Control and Prevention (CDC) released guidelines for primary care providers on prescribing opioids for chronic pain. OBJECTIVES: The objective of this study was to determine if release of the 2016 CDC guidelines for prescribing opioids for chronic pain was associated with changes in prescribing habits in the ED of an academic medical center. METHODS: The data were extracted from patient electronic health records between January 2015 and June 2017. The primary endpoint of the study was average morphine equivalent daily dose (MEDD) for the pre- and postguideline cohorts. RESULTS: A total of 8652 patients were included in the analysis (4389 in the preguideline cohort and 4263 in the postguideline cohort). The average MEDD decreased significantly from 30.6 ± 20.2 MEDD in the preguideline cohort to 29.8 ± 19.5 MEDD in the postguideline cohort (p = 0.0460). There was also a significant decrease in the rate of concomitant opioid and benzodiazepine prescribing as well as average days' supply per prescription in the postguideline cohort, as compared with the preguideline cohort. CONCLUSIONS: The average MEDD prescribed in the ED of an academic medical center decreased after the release of the CDC guidelines on opioid prescribing for chronic pain.

Pharmacists' perceived knowledge of and confidence in dispensing oral antineoplastic agents.

OBJECTIVES: To assess community pharmacists' perceived confidence with counseling patients about oral antineoplastic agents, in identifying drug and/or herbal interactions with these agents, and with identifying adverse drug events. METHODS: Four hundred pharmacists were contacted and asked to take an anonymous survey regarding 11 oral antineoplastic agents (OAAs) and the oral antineoplastic market place in general. RESULTS: With a response rate of 61.5%, there was variation with perceived overall confidence in counseling patients, identifying drug and/or herbal interactions (DHIs), and identifying adverse drug events (ADEs) with each oral antineoplastic agent (OAA). There was a trend toward more confidence in identifying DHI and ADE in those agents dispensed within the past 6 months. The majority of pharmacists reported the main barrier to counseling to be a lack of training or knowledge. Only about 22% of pharmacists who participated in this survey reported confidence in their ability to manage an influx of OAAs. CONCLUSION: Overall, there was a lack of perceived confidence among pharmacists in counseling patients and identifying DHIs as well as with identifying ADEs with the 11 OAAs chosen for this survey. One of the main barriers identified was the lack of knowledge or training. These data provide preliminary information needed to launch educational programs in the student pharmacist curriculum (e.g., elective courses) and continuing education programs to improve overall confidence among pharmacists.

Assessment of medication adherence app features, functionality, and health literacy level and the creation of a searchable Web-based adherence app resource for health care professionals and patients.

OBJECTIVES: To assess the features and level of health literacy (HL) of available medication adherence apps and to create a searchable website to assist health care providers (HCP) and patients identify quality adherence apps. PRACTICE DESCRIPTION: Medication nonadherence continues to be a significant problem and leads to poor health outcomes and avoidable health care expense. The average adherence rate for chronic medications, regardless of disease state, is approximately 50% leaving significant room for improvement. PRACTICE INNOVATION: Smartphone adherence apps are a novel resource to address medication nonadherence. With widespread smartphone use and the growing number of adherence apps, both HCP and patients should be able to identify quality adherence apps to maximize potential benefits. INTERVENTIONS: Assess the features, functionality and level of HL of available adherence apps and create a searchable website to help both HCP and patients identify quality adherence apps. EVALUATION: Online marketplaces (iTunes, Google Play, Blackberry) were searched in June of 2014 to identify available adherence apps. Online descriptions were recorded and scored based on 28 author-identified features across 4 domains. The 100 highest-scoring apps were user-tested with a standardized regimen to evaluate their functionality and level of HL. RESULTS: 461 adherence apps were identified. 367 unique apps were evaluated after removing "Lite/Trial" versions. The median initial score based on descriptions was 15 (max of 68; range: 3 to 47). Only 77 apps of the top 100 highest-scoring apps completed user-testing and HL evaluations. The median overall user-testing score was 30 (max of 73; range: 16 to 55). CONCLUSION: App design, functionality, and level of HL varies widely among adherence apps. While no app is perfect, several apps scored highly across all domains. The website www.medappfinder.com is a searchable tool that helps HCP and patients identify quality apps in a crowded marketplace.

Treatment of metastatic melanoma with pazopanib: A report of five patient cases.

Metastatic melanoma has a median length of survival after diagnosis of 6-9 months. Unfortunately, the National Comprehensive Cancer Network clinical practice guidelines for treating stage IV, unresectable, metastatic melanoma are limited with regard to treatment options. Pazopanib (Votrient™) is FDA-approved for advanced soft tissue sarcoma and advanced renal cell carcinoma. Limited research exists for using pazopanib in the treatment of metastatic melanoma. We present five cases in which pazopanib was used in combination with paclitaxel ± carboplatin for treatment of unresectable, metastatic melanoma.

The Effect of Concurrent Use of Opioids and Gabapentin on Fall Risk in Older Adults.

Falls pose a significant threat to older adults, resulting in injuries and mortality. Concurrently prescribed opioids and gabapentin for pain management may increase fall risks in older patients. This study aimed to estimate fall risks associated with the concurrent use of gabapentin and opioids, comparing them to opioid monotherapy in older adults. A retrospective case-control study of 1,813 patients aged 65-89 on chronic opioid therapy (2017-2020), excluding those with a fall history, analysis focused on the first fall occurrence. Logistic regression assessed the association between concurrent gabapentin and opioid use and fall events. Out of eligible patients, 122 (6.73%) experienced falls during opioid therapy, with 232 (12.80%) having concurrent gabapentin use. Concurrent use significantly increased fall risk (AOR = 1.73; 95% CI: 1.08-2.78). Being female, aged ≥81, and having more chronic conditions also increased risk. Mitigating fall risk in older adults requires education on prevention, exploring alternative pain management, and careful consideration of prescribing. Further research is crucial to understand adverse events linked to combined opioid and gabapentin use in the geriatric population.

Smartphone medication adherence apps: potential benefits to patients and providers.

OBJECTIVES: To provide an overview of medication adherence, discuss the potential for smartphone medication adherence applications (adherence apps) to improve medication nonadherence, evaluate features of adherence apps across operating systems (OSs), and identify future opportunities and barriers facing adherence apps. PRACTICE DESCRIPTION: Medication nonadherence is a common, complex, and costly problem that contributes to poor treatment outcomes and consumes health care resources. Nonadherence is difficult to measure precisely, and interventions to mitigate it have been largely unsuccessful. PRACTICE INNOVATION: Using smartphone adherence apps represents a novel approach to improving adherence. This readily available technology offers many features that can be designed to help patients and health care providers improve medication-taking behavior. MAIN OUTCOME MEASURES: Currently available apps were identified from the three main smartphone OSs (Apple, Android, and Blackberry). In addition, desirable features for adherence apps were identified and ranked by perceived importance to user desirability using a three-point rating system: 1, modest; 2, moderate; or 3, high. The 10 highest-rated apps were installed and subjected to user testing to assess app attributes using a standard medication regimen. RESULTS 160 adherence apps were identified and ranked. These apps were most prevalent for the Android OS. Adherence apps with advanced functionality were more prevalent on the Apple iPhone OS. Among all apps, MyMedSchedule, MyMeds, and RxmindMe rated the highest because of their basic medication reminder features coupled with their enhanced levels of functionality. CONCLUSION: Despite being untested, medication apps represent a possible strategy that pharmacists can recommend to nonadherent patients and incorporate into their practice.

The Impact of Continuous Infusion Compared to Intravenous Bolus Administration of Pantoprazole on Length of Intensive Care Unit Stay in Critically Ill Patients.

Purpose: To determine if intravenous (IV) bolus pantoprazole increases intensive care unit (ICU) length of stay compared to IV infusion pantoprazole for treatment of gastrointestinal (GI) bleeding in critically ill patients. Methods: This retrospective cohort study included adult patients admitted to the ICU with GI bleeds. Patients treated with IV pantoprazole from January 1, 2017 to December 31, 2017 were analyzed in the continuous infusion group, and patients treated from March 1, 2018 to February 28, 2019 were analyzed in the bolus only group. Patients with pregnancy, variceal bleeds, or lower GI bleeds were excluded. Intensive care unit length of stay was compared between the two cohorts using the Mann Whitney U test. Adjusted analysis was conducted using the generalized linear model with gamma log link to estimate the effect of type of infusion on ICU length of stay. Results: A total of 145 patients were included in the analysis, with 72 patients in the continuous infusion group and 73 patients in the bolus only group. The median ICU length of stay was 70.5 hours for continuous infusion and 64 hours for bolus only pantoprazole (P-value = .577). In the adjusted analysis, there was no difference in ICU length of stay between the continuous infusion and bolus only groups (RR, 1.06; 95% CI, .76-1.47). Conclusion: Intensive care unit length of stay was not prolonged with the use of IV bolus only compared to continuous infusion pantoprazole. Intravenous bolus only pantoprazole may be used in critically ill patients for treatment of upper GI bleeding.

Healthcare costs and utilization associated with pain among breast cancer survivors: a propensity score matched cohort study using SEER-Medicare data.

PURPOSE: To assess healthcare costs and utilization of treatment-related pain among breast cancer survivors. METHODS: A retrospective matched cohort study using Surveillance Epidemiology and End Results SEER-Medicare linked data was conducted. The study population included older breast cancer survivors continuously enrolled in Medicare parts A, B, and D in the baseline and 1-year follow-up periods. Survivors with pain were matched to survivors without pain using PSM. Incremental all-cause healthcare costs associated with pain were calculated using a two-part model. Incremental healthcare utilization of inpatient hospitalizations, ER, outpatient, and physician services were estimated using the negative binomial model. RESULTS: The study included 101,120 non-metastatic breast cancer patients between July 2007 and September 2013. The final analytical cohort after matching included 5891 survivors in both groups. The incremental annual all-cause total healthcare costs per patient were higher in survivors with pain as compared to survivors without pain (Δ = 4379.00 (95% CI: 4308.00-4448.80). The main cost drivers were hospitalizations at 71%, followed by ER at 16% and physician services at 9% for survivors diagnosed with pain. Annual all-cause healthcare resource utilization was also found to be higher in survivors with pain as compared to survivors without pain across all categories of use. Similar trends were observed when stratified by surgery type and subgrouped by pain type and pain-related costs. CONCLUSION: This study provided baseline data that can be used for future cost-effectiveness analysis studies and burden of illness studies. IMPLICATION FOR CANCER SURVIVORS: Treatment-related costs have a substantial burden on healthcare costs and the utilization of Medicare.

The use of gabapentinoids and opioids and risk of developing opioid-induced respiratory depression among older breast cancer survivors with neuropathic pain.

PURPOSE: To estimate the combined effect of gabapentinoid and opioid therapy compared to opioid monotherapy on the risk of developing opioid-induced respiratory depression among breast cancer survivors with neuropathic pain. METHOD: A nested case-control study of Medicare female breast cancer survivors with neuropathic pain receiving both opioids and gabapentinoids, opioid monotherapy, gabapentinoid monotherapy, and none of these drugs was conducted using SEER-Medicare between 2007 and 2015. Cases were survivors with respiratory depression and were matched with controls on the event date (± 1 year), age at diagnosis (± 5 years), and stage at diagnosis. Exposure to opioids and gabapentinoids was assessed 120 days before the event date. Conditional logistic regression was used to assess the impact of exposure among cases and controls. RESULTS: A total of 657 cases and 11,471 controls were identified. After matching, 656 cases and 5612 controls were retained, and cases were more likely to be diagnosed with mental health disorders (24.4% vs 10.5%, p < 0.0001) than controls. In the primary adjusted analysis, combined opioids and gabapentin use were associated with an increased risk of respiratory depression compared to opioid monotherapy (Adj. OR: 1.513; 95% CI: 1.473-2.350). Additionally, under secondary analysis, combined opioids and gabapentin use were associated with an increased risk of respiratory depression compared to receiving neither of these classes. (Adj. OR: 1.595; 95% CI: 1.050-2.421). CONCLUSION: There is a need for dose titration strategies of gabapentinoids and caution when co-prescribing opioids and gabapentinoids in older cancer survivors.

Comparative Study of Opioid Initiation With Tramadol, Short-acting Hydrocodone, or Short-acting Oxycodone on Opioid-related Adverse Outcomes Among Chronic Noncancer Pain Patients.

OBJECTIVE: To compare the safety profiles of low and high-dose tramadol, short-acting hydrocodone, and short-acting oxycodone therapies among chronic noncancer pain individuals. MATERIALS AND METHODS: A retrospective cohort study of individuals with back/neck pain/osteoarthritis with an initial opioid prescription for tramadol, hydrocodone, or oxycodone was conducted using IQVIA PharMetrics Plus claims for Academics database (2006 to 2020). Two cohorts were created for separately studying opioid-related adverse events (overdoses, accidents, self-inflicted injuries, and violence-related injuries) and substance use disorders (opioid and nonopioid). Patients were followed from the index date until an outcome event, end of enrollment, or data end. Time-varying exposure groups were constructed and Cox regression models were estimated. RESULTS: A total of 1,062,167 (tramadol [16.5%], hydrocodone [61.1%], and oxycodone [22.4%]) and 986,809 (tramadol [16.5%], hydrocodone [61.3%], and oxycodone [22.2%]) individuals were in the adverse event and substance use disorder cohorts. All high-dose groups had elevated risk of nearly all outcomes, compared with low-dose hydrocodone. Compared with low-dose hydrocodone, low-dose oxycodone was associated with a higher risk of opioid overdose (hazard ratio: 1.79 [1.37 to 2.33]). No difference in risk was observed between low-dose tramadol and low-dose hydrocodone (hazard ratio: 0.85 [0.64 to 1.13]). Low-dose oxycodone had higher risks of an opioid use disorder, and low-dose tramadol had a lower risk of accidents, self-inflicted injuries, and opioid use disorder compared with low-dose hydrocodone. DISCUSSION: Low-dose oxycodone had a higher risk of opioid-related adverse outcomes compared with low-dose tramadol and hydrocodone. This should be interpreted in conjunction with the benefits of pain control and functioning associated with oxycodone use in future research.

Factors Associated With Guideline-Concordant Pharmacological Treatment for Neuropathic Pain Among Breast Cancer Survivors.

PURPOSE: To identify factors associated with receiving guideline-concordant treatment among breast cancer survivors with neuropathic pain. MATERIALS AND METHODS: A retrospective case-control study was conducted using the SEER-Medicare linked database. We included female breast cancer survivors diagnosed with non-metastatic breast cancer (stages 0-III) between 2007 and 2015 who developed treatment-related neuropathic pain during their survivorship period. Guideline-concordant treatment was defined based on NCCN guidelines. Factors associated with receiving guideline-concordant treatment were assessed using multivariable logistic regression and backward selection was used to identify potential associated factors. RESULTS: Around 16.7% of breast cancer survivors in the study developed a neuropathic pain condition. The mean time to develop neuropathic pain was 1.4 years after beginning adjuvant treatment. On average, patients who developed neuropathic pain and received guideline-concordant treatment did so at 2.4 months after their neuropathic pain diagnosis. We found that survivors that are black and of other races were less likely to receive guideline-concordant treatment for breast cancer treatment-related neuropathic pain. Whereas survivors with diabetes, mental health disorders, hemiplegia, prior continuous opioid use, benzodiazepine use, nonbenzodiazepine CNS depressant use, or antipsychotic medication use were less likely to receive guideline-concordant treatment. CONCLUSION: This study suggests that minority races, prior medication use, and comorbid conditions are associated with guideline-concordant treatment among breast cancer survivors with neuropathic pain. These findings warrant attention towards minority races to prescribe them guideline-concordant treatment as well as caution when prescribing concurrent pain medications to survivors with comorbidities and prior medication use.

Prior Pharmacy Work Experience as a Predictor of Clinical and Didactic Performance for Admissions Committees.

OBJECTIVE: To investigate prior pharmacy work experience (PPWE) in admissions to predict clinical and didactic performance. METHODS: In this retrospective study, data from 3 cohorts, classes of 2020-2022, were collected. Multivariate regressions were conducted to determine the impact of PPWE on performance in first-year pharmacy (P1) Community Introductory Pharmacy Practice Experience (IPPEs), second-year pharmacy (P2) institutional IPPEs, P2 & third-year pharmacy (P3) Observed Structured Clinical Examinations (OSCEs), Drug Information class and P1, P2, P3 grade point averages (GPAs). RESULTS: Of 329 students, those who had PPWE (n = 210) worked as pharmacy technicians (78%), clerks, cashiers, drivers (10%), or other (12%). The majority worked in community settings (86%) and worked an average of 24 h weekly. PPWE was not associated with any pharmacy school GPAs. Those with PPWE scored 2.17 out of 100% points higher in Drug Information than those who did not. They also scored higher on P1 IPPE performance in communication and pharmacy operations skills; however, these notable differences did not continue in P2 IPPEs or OSCEs. Total hours worked in higher quartiles were also associated with increased scores in P1 IPPE communications skills, P1 IPPE pharmacy operations skills, and Drug Information course scores. CONCLUSION: Prior pharmacy work experience modestly improved pharmacy school performance in selected areas in the P1 year, but the effect did not continue in later years. Students who had PPWE performed better in Drug Information and P1 IPPE communication and pharmacy operations skills.

Remote smart pill cap monitoring of post-surgical pain management in thyroid and parathyroid surgery.

BACKGROUND: With recent efforts to decrease opioid use following surgery, this study aims to answer: what pain regimen do patients follow at home? Is it controlling pain? METHODS: This is a prospective, pilot study of thyroid and parathyroid surgery patients. Patients were prescribed acetaminophen, ibuprofen, and tramadol dispensed in smart pill (Pillsy) bottles that record "events" corresponding to medication use. Patients received messages querying their current pain level. Patients were compared to historical controls. RESULTS: 26 patients were in the Pillsy group and 30 in the control group. In the Pillsy group, pain scores averaged 3.67 out of 10 in the first 24 h after surgery and decreased each day. Patients took an average of 6.45 doses of acetaminophen, 6.64 doses of ibuprofen, and 1.82 doses of tramadol in the first week. CONCLUSIONS: Pain scores are highest in the first 24 h after surgery and decrease thereafter. This acceptable level of pain can be achieved with non-opioid medications.

Interprofessional Naloxone Student Training to Manage Suspected Opioid Overdose.

PURPOSE: The study purpose was to examine the effect of interprofessional naloxone training on students' knowledge, confidence, and interprofessional collaboration competency. The overarching goal was to decrease mortality related to opioid overdoses. DESIGN/METHODS: A training session for interprofessional students consisted of a lecture presentation, demonstration, and hands-on practice regarding appropriate administration of naloxone for suspected opioid overdose. A questionnaire elicited baseline and change in knowledge, confidence, and interprofessional collaboration competency scores at pretraining and posttraining. In addition, changes in knowledge and confidence were also measured 3 weeks after the training. Thematic analysis explored training components that students perceived as valuable or needing improvement. RESULTS: Participants (N = 100) were nursing (n = 33), physician assistant (n = 37), and pharmacy (n = 30) students. Pretraining and posttraining comparison demonstrated increased knowledge (P < .001), confidence (P < .001), and collaboration scores (P < .001). At 3 weeks, knowledge and confidence remained higher than pretraining (P < .001). Knowledge was trending downward compared with posttraining (P = .09). Thematic analysis identified 4 themes: (a) indications for administration of different naloxone types, (b) learning modalities, (c) knowledge application, and (d) improvements. CONCLUSIONS: An interprofessional naloxone administration training resulted in increased knowledge, confidence, and interprofessional teamwork. Educators can adapt this training for a variety of future or current healthcare professionals to improve immediate intervention and outcomes in suspected opioid overdoses.

Development of a potential opioid misuse measure from administrative dispensing data and contrasting opioid misuse among individuals on long-term tramadol, long-term short-acting hydrocodone or long-term short-acting oxycodone therapy in Arkansas.

OBJECTIVE: This study sought to: (1) construct and validate a composite potential opioid misuse score; and (2) compare potential opioid misuse among individuals prescribed long-term therapy on tramadol, short-acting hydrocodone or short-acting oxycodone. METHODS: A retrospective cohort study was conducted using Arkansas All-Payer Claims Database (APCD; 2013-2018) linked to Arkansas Prescription Drug Monitoring Program (PDMP; 2014-2017) and state death certificate data (2013-2018). The study subjects were ambulatory, cancer-free adults with incident long-term therapy on tramadol, short-acting hydrocodone or short-acting oxycodone. The number of opioid prescribers/pharmacies, cash payment for opioid prescriptions, overlapping prescribers/pharmacies and a composite misuse score (derived from opioid prescribers/pharmacies and cash payment) were assessed in two 180 day windows as potential measures of misuse. The composite score was developed based on associations observed with opioid overdose and opioid-related injuries. RESULTS: A total of 17,816 (tramadol), 23,660 (hydrocodone) and 4799 (oxycodone) persons were included. The composite score had modest discrimination for overdose (c-index = 0.65). In the first 180 day period, the average composite misuse scores were 1.28 (tramadol), 1.93 (hydrocodone) and 2.18 (oxycodone). Compared to long-term hydrocodone, long-term tramadol had lower misuse (IRR [95% CI]: 0.75 [0.73-0.76]), and long-term oxycodone had higher misuse (1.09 [1.07-1.11]) in adjusted analyses. Qualitatively similar associations were observed for nearly all individual component measures of misuse. CONCLUSION: A composite measure of potential opioid misuse had modest levels of discrimination in detecting overdose. In comparison to long-term hydrocodone therapy, long-term oxycodone had higher and tramadol had lower risk of potential opioid misuse.

Impact of Hydroxyurea Starting Dose on Pain Outcomes in Patients with Sickle Cell Disease.

In patients with sickle cell disease, hydroxyurea decreases the number of pain crises experienced. This study aimed to evaluate the difference in pain outcomes between patients started on a guideline concordant, weight-based starting dose of at least 15 mg/kg/day of hydroxyurea and those not. The first prescription of hydroxyurea was the baseline date, follow-up was a visit 60-120 days after baseline. The primary outcome was the change in opioid prescribing between baseline and follow-up. 138 patients met inclusion criteria; of these, 55 were started on a guideline concordant dose of hydroxyurea. Greater white blood cell count (9.5 vs 12.0; p < 0.01) was statistically associated with subtherapeutic dosing. Greater actual body weight (68.0 vs 72.1 kg; p = 0.16) also appeared higher in the non-guideline concordant group. No statistically significant difference in opioid prescribing was observed between those started on a guideline concordant dose of hydroxyurea and those who were not. In the guideline concordant starting dose group, 42% had a reduction in pain scores at first follow up, compared to 35% with a non-guideline recommended starting dose. (p = 0.41). While this difference is in the direction that would be expected based on the guidelines, the difference does not appear to be clinically meaningful.

Pharmacist-Delivered Patient Care in an Interdisciplinary Team-Based Institutional Palliative Care Clinic, 2012 to 2018.

Palliative care services offered in the United States have grown substantially since the year 2000. These types of services have been shown to improve a patient's quality of life when presented with a serious or life-threatening disease or illness. An important characteristic of a quality palliative care service is the presence of an interdisciplinary team to utilize different areas of expertise to address multiple aspects of patient care. An important member of this team is the pharmacist. The services presented in this interprofessional education and practice guide describe pharmacist-delivered palliative care services offered in an institutional ambulatory palliative care setting from 2012 to 2018.