The Association of Long-Term Opioid Use With Health Care and Home Care Service Use Among Aged Home Care Clients.

OBJECTIVES: To compare health care and home care service utilization, mortality, and long-term care admissions between long-term opioid users and nonusers among aged home care clients. DESIGN: A retrospective cohort study based on the Resident Assessment Instrument-Home Care (RAI-HC) assessments and electronic medical records. SETTING AND PARTICIPANTS: The study sample included all regular home care clients aged ≥65 years (n = 2475), of whom 220 were long-term opioid users, in one city in Finland (population base 222,000 inhabitants). METHODS: Health care utilization, mortality, and long-term care admissions over a 1-year follow-up were recorded from electronic medical records, and home care service use from the RAI-HC. Negative binomial and multivariable logistic regression, adjusted for several socioeconomic and health characteristics, were used to analyze the associations between opioid use and health and home care service use. RESULTS: Compared with nonusers, long-term opioid users had more outpatient consultations (incidence rate ratio 1.26; 95% CI 1.08-1.48), home visits (1.23; 1.01-1.49), phone contacts (1.38; 1.13-1.68), and consultations without a patient attending a practice (1.22; 1.04-1.43) after adjustments. A greater proportion of long-term opioid users than nonusers had at least 1 hospitalization (49% vs 41%) but the number of inpatient days did not differ after adjustments. The home care nurses' median work hours per week were 4.3 (Q1-Q3 1.5-7.7) among opioid users and 2.8 (1.0-6.1) among nonusers. Mortality and long-term care admissions were not associated with opioid use. CONCLUSIONS AND IMPLICATIONS: Long-term opioid use in home care clients is associated with increased health care utilization regardless of the severity of pain and other sociodemographic and health characteristics. This may indicate the inability of health care organizations to produce alternative treatment strategies for pain management when opioids do not meet patients' needs. The exact reasons for opioid users' greater health care utilization should be examined in future.

Pioglitazone and bladder cancer risk: a multipopulation pooled, cumulative exposure analysis.

AIMS/HYPOTHESIS: The evidence on the association between pioglitazone use and bladder cancer is contradictory, with many studies subject to allocation bias. The aim of our study was to examine the effect of exposure to pioglitazone on bladder cancer risk internationally across several cohorts. The potential for allocation bias was minimised by focusing on the cumulative effect of pioglitazone as the primary endpoint using a time-dependent approach. METHODS: Prescription, cancer and mortality data from people with type 2 diabetes were obtained from six populations across the world (British Columbia, Finland, Manchester, Rotterdam, Scotland and the UK Clinical Practice Research Datalink). A discrete time failure analysis using Poisson regression was applied separately to data from each centre to model the effect of cumulative drug exposure on bladder cancer incidence, with time-dependent adjustment for ever use of pioglitazone. These were then pooled using fixed and random effects meta-regression. RESULTS: Data were collated on 1.01 million persons over 5.9 million person-years. There were 3,248 cases of incident bladder cancer, with 117 exposed cases and a median follow-up duration of 4.0 to 7.4 years. Overall, there was no evidence for any association between cumulative exposure to pioglitazone and bladder cancer in men (rate ratio [RR] per 100 days of cumulative exposure, 1.01; 95% CI 0.97, 1.06) or women (RR 1.04; 95% CI 0.97, 1.11) after adjustment for age, calendar year, diabetes duration, smoking and any ever use of pioglitazone. No association was observed between rosiglitazone and bladder cancer in men (RR 1.01; 95% CI 0.98, 1.03) or women (RR 1.00; 95% CI 0.94, 1.07). CONCLUSIONS/INTERPRETATION: The cumulative use of pioglitazone or rosiglitazone was not associated with the incidence of bladder cancer in this large, pooled multipopulation analysis.

Persistence of noncancer-related musculoskeletal chronic pain among community-dwelling older people: a population-based longitudinal study in Finland.

OBJECTIVE: To determine the persistence of chronic pain among community-dwelling older persons and to identify factors related to persistent chronic pain. METHODS: In this prospective longitudinal study, a random sample of Finnish community-dwelling people aged 76 years and older (n=256) were interviewed annually by a trained nurse at 3 time points. Data on prevalence, duration, location, and intensity of musculoskeletal pain, analgesic use, demographics, and health characteristics were collected during the interviews. RESULTS: Chronic pain was reported by 48.9% of the participants at baseline, with 74.4% of them experiencing persistent chronic pain, that is, they reported chronic pain at all 3 study points. Persistent chronic pain was associated with poor self-rated health (adjusted odds ratio [AOR]=2.26, 95% confidence interval [95% CI] 1.03-4.98), mobility difficulties (AOR=2.80, 95% CI, 1.22-6.43), and arthrosis or rheumatoid arthritis (AOR=3.07, 95% CI, 1.47-6.42) when compared with persons without chronic pain. However, only 15% of the persons with persistent chronic pain were using analgesics on a regular basis, and one out of every 5 was not taking any analgesics. CONCLUSIONS: Chronic musculoskeletal pain is a highly persistent condition among community-dwelling older persons and it is related to poor health and mobility difficulties. In addition, the use of daily analgesic is low despite the continuous nature of chronic pain.

Analgesic use and frailty among community-dwelling older people: a population-based study.

BACKGROUND: Frail older people have a decreased ability to respond to stressors and may therefore be more susceptible to adverse events related to inadequately treated pain. Conversely, aging- and frailty-related changes in pharmacokinetics and pharmacodynamics may predispose frail older people to adverse events of analgesics. OBJECTIVE: The aim of this study was to explore whether analgesic use is associated with frailty status and whether there are differences in the types of analgesics used between frailty groups among community-dwelling older people. METHODS: The study population consisted of 605 community-dwelling people aged >75 years. Demographic, diagnostic and drug use data were collected during standardized nurse interviews. Participants were classified as frail, pre-frail or robust using the Cardiovascular Health Study frailty criteria (weight loss, weakness, exhaustion, slowness and low physical activity). RESULTS: Overall, 11.4 % (n = 69) of the study participants were frail and 49.4 % (n = 299) were pre-frail. The prevalence of prescription and non-prescription analgesic use was higher among frail (68.1 %) than among pre-frail (54.5 %) and robust (40.5 %) older people (p < 0.001). In multivariate analyses, frailty was positively associated with analgesic use (odds ratio 2.96; 95 % CI 1.38-6.36). However, frail analgesic users (46.7 %) were more likely to want their physicians to pay greater attention to pain management than robust (23.2 %) analgesic users. The most prevalent analgesic was acetaminophen (paracetamol) among frail (78.7 %) and pre-frail (63.2 %), and NSAIDs among robust (60.4 %) analgesic users. Frail (60.3 %) and pre-frail (58.1 %) participants were more likely to report musculoskeletal pain than robust (44.7 %) participants. Of robust, pre-frail and frail older people 33.0 %, 23.1 % and 4.9 % (respectively) did not use any analgesics to treat their pain. CONCLUSIONS: Frailty was associated with a higher prevalence of analgesic use. As frail older people may be more susceptible to adverse events, careful selection of analgesics is warranted. Clinicians should pay more attention to pain management to ensure adequate pain relief.

Balancing pain and analgesic treatment in the home-dwelling elderly.

BACKGROUND: In elderly persons, pain is a common problem, and analgesic medicines are among the most frequently used drugs. OBJECTIVE: To describe the use of analgesic medication and its relation to daily pain and morbidity in home-dwelling elderly people aged at least 75 years. METHODS: A random sample of 700 subjects aged at least 75 years was drawn from the total population of Kuopio, Finland. A geriatrician and nurse carried out structured clinical examinations and interviews with 601 persons, 523 of whom were living at home. RESULTS: Seventy percent (n = 364) of the elderly people were taking at least one analgesic, including most of those who suffered from daily interfering pain (85%) and nearly all of those experiencing daily pain at rest (93%). Nonsteroidal antiinflammatory drugs (NSAIDs; n = 226, 51%) and acetaminophen (n = 118, 23%) were the most commonly used analgesics. The use of opioids became more common with age, accounting for 16% of the drugs in the oldest patients (> or =85 y) and 6% among those aged 75-79 years. Analgesics were mainly taken when needed. Only 13% of NSAID users, 18% of acetaminophen users, and 21% of opioid users took these preparations regularly. CONCLUSIONS: Although analgesics are commonly used by elderly patients, it appeared that many patients were still experiencing daily interfering pain and pain at rest.

Sedative drug use in the home-dwelling elderly.

BACKGROUND: The elderly use more sedatives than other populations. Reports on the sedative load of drugs and their associations with health items are scarce. OBJECTIVE: To investigate the prevalence of sedatives and drugs with sedative properties and the associations between those drugs and demographic or health items in the home-dwelling elderly in a cross-sectional community survey. METHODS: Information was obtained from 1197 persons (43% men) aged >or=64 years in the Finnish municipality of Lieto in 1998-1999. The brand names of the prescription drugs taken by each interviewee during one week prior to the interview were recorded. The classification created in a previous study, where the drugs used in Finland were divided into 4 groups by their sedative properties, was utilized to determine associations with health items. RESULTS: A total of 88% (n = 1056) of the participants used some drug. Forty percent (n = 422 persons) of the drug users took sedatives or drugs with sedative properties. The oldest individuals (>or=80 y), women, those with low education, smokers, those with poor self-perceived health, people with dementia and mobility problems, and especially those with depression had an independent association with the simultaneous use of many (>or=2) sedatives or drugs with sedative properties. CONCLUSIONS: In a population of home-dwelling elderly patients, abundant sedative drug use was common and especially associated with high age, female gender, poor basic education, poor health habits (eg, smoking), depression, dementia, or impaired mobility. Users also had poor self-perceived health. The need to further develop the classification will be a major challenge, and the classification needs to be updated every year. More studies are needed in this field.