Society of Pain and Palliative Care Pharmacists White Paper on the Role of Opioid Stewardship Pharmacists.

Opioid stewardship is one essential function of pain and palliative care pharmacists and a critical need in the United States. In recent years, this country has been plagued by two public health emergencies: an opioid crisis and the COVID-19 pandemic, which has exacerbated the opioid epidemic through its economic and psychosocial toll. To develop an opioid stewardship program, a systematic approach is needed. This will be detailed in part here by the Opioid Stewardship Taskforce of the Society of Pain and Palliative Care Pharmacists (SPPCP), focusing on the role of the pharmacist. Many pain and palliative care pharmacists have made significant contributions to the development and daily operation of such programs while also completing other competing clinical tasks, including direct patient care. To ensure dedicated time and attention to critical opioid stewardship efforts, SPPCP recommends and endorses opioid stewardship models employing a full time, opioid stewardship pharmacist in both the inpatient and outpatient setting. Early research suggests that opioid stewardship pharmacists are pivotal to improving opioid metrics and pain care outcomes. However, further research and development in this area of practice is needed and encouraged.

Fractured Care: A Window Into Emergency Transitions in Care for LTC Residents With Complex Health Needs.

Objective: For long-term care (LTC) residents, transfers to emergency departments (EDs) can be associated with poor health outcomes. We aimed to describe characteristics of residents transferred, factors related to decisions during transfer, care received in emergency medical services (EMS), ED settings, outcomes on return to LTC, and times of transfer segments along the transition. Method: We prospectively followed 637 transitions to an ED in British Columbia and Alberta, Canada, over a 12-month period. Data were captured through an electronic Transition Tracking Tool and interviews with health care professionals. Results: Common events triggering transfer were falls (26.8%), sudden change in condition (23.5%), and shortness of breath (19.8%). Discrepancies existed between reason for transfer, EMS reported chief complaint, and ED diagnosis. Many transfers resulted in resident return directly to LTC (42.7%). Discussion: Avoidable transfers may put residents at risk of receiving inappropriate care. Standardized communication strategies to highlight changes in resident condition are warranted.

Hospital Opioid Requirements Following Continuation Versus Discontinuation of Buprenorphine for Addiction - A Retrospective Cohort Study.

Evidence guiding inpatient management of buprenorphine is lacking-this retrospective cohort study evaluated the clinical impact of hospital continuation versus discontinuation of buprenorphine at an academic medical center. The primary outcome was inpatient oral morphine equivalents (OME). Secondary outcomes included patient pain levels, functional assessment, and hospital length of stay. One hundred thirty-one patients (74 continued buprenorphine, 57 discontinued) were included in the analysis. Median OME were significantly lower among patients continued on buprenorphine versus discontinued (11 mg vs 103 mg, p < 0.001), as was maximum 24-hour opioid utilization (60 mg vs 240 mg, p < 0.001) and 24-hour pre-discharge utilization (10 mg vs 128 mg, p < 0.001). Median pain levels were similar between groups at the time of admission (8 in each group, p = 0.48), discharge (7 in each group, p = 0.26), and over the first 7 days of hospitalization (7 vs 8, p = 0.08). Hospital length of stay was similar between groups (5 days in each group, p > 0.99). Failure to reinitiate buprenorphine occurred in 31/57 patients (54.4%) in the discontinuation group. Hospital buprenorphine continuation is associated with reduced opioid requirements, while not significantly impacting pain levels, functionality, or length of admission. Failure to reinitiate buprenorphine was common and may have negative implications for addiction treatment.

The Use of Comfort Kits to Optimize Adult Cancer Pain Management.

BACKGROUND: Pain is one of the most feared of all symptoms for the cancer patient. Some studies estimate that up to 90% of all cancer patients experience pain. Advances in pharmaceuticals and expert provider knowledge have improved pain management overall for the patient with cancer; however, complementary therapies can synergize medications to provide optimal pain relief while decreasing the side effect profile. Despite this, nurses may have limited access to such resources. Many therapies can be administered directly by the bedside/chairside nurse with minimal training and the nurse can then teach the patient and family how to use the selected complementary therapy after leaving the hospital or clinic. OBJECTIVES: The oncology nurse will be able to identify several easy-to-implement complementary therapies that can supplement pharmacologic pain management for cancer patients. METHODS: As a quality project, comfort kits, containing such items as handheld massagers, guided imagery audiotapes, and aromatherapy essential oils, were distributed for use with patients through unit-based pain resource nurses. ANALYSIS: More than 500 comfort kit items were tracked by the pain clinical nurse specialist during the comfort kit trial, both by medical record review and by follow-up phone calls to patients. During the comfort kit trial, average pain intensity decreased by 2.25 points on a 0-10 scale in the 24-hour period after use of the item from the comfort kit. Patients also had an overall decrease in the use of pharmacologic pain interventions and an increase in ambulation in the 24-hour period after implementation. CONCLUSIONS: Comfort kits allow nurses easy access to inexpensive tools to supplement pharmaceutical pain management. Optimizing nonpharmacologic pain management can increase patient and nurse satisfaction, improve overall pain management, and decrease untoward side effects.

Identifying Homeless Medicaid Enrollees Using Enrollment Addresses.

OBJECTIVE: To design and test the validity of a method to identify homelessness among Medicaid enrollees using mailing address data. DATA SOURCES/STUDY SETTING: Enrollment and claims data on Medicaid expansion enrollees in Hennepin and Ramsey counties who also provided self-reported information on their current housing situation in a psychosocial needs assessment. STUDY DESIGN: Construction of address-based indicators and comparison with self-report data. PRINCIPAL FINDINGS: Among 1,677 enrollees, 427 (25 percent) self-reported homelessness, of whom 328 (77 percent) had at least one positive address indicator. Depending on the type of addresses included in the indicator, sensitivity to detect self-reported homelessness ranged from 30 to 76 percent and specificity from 79 to 97 percent. CONCLUSIONS: An address-based indicator can identify a large proportion of Medicaid enrollees who are experiencing homelessness. This approach may be of interest to researchers, states, and health systems attempting to identify homeless populations.

Soybean proteins GmTic110 and GmPsbP are crucial for chloroplast development and function.

We have identified a viable-yellow and a lethal-yellow chlorophyll-deficient mutant in soybean. Segregation patterns suggested single-gene recessive inheritance for each mutant. The viable- and lethal-yellow plants showed significant reduction of chlorophyll a and b. Photochemical energy conversion efficiency and photochemical reflectance index were reduced in the viable-yellow plants relative to the wildtype, whereas the lethal-yellow plants showed no electron transport activity. The viable-yellow plants displayed reduced thylakoid stacking, while the lethal-yellow plants exhibited failure of proplastid differentiation into normal chloroplasts with grana. Genetic analysis revealed recessive epistatic interaction between the viable- and the lethal-yellow genes. The viable-yellow gene was mapped to a 58kb region on chromosome 2 that contained seven predicted genes. A frame shift mutation, due to a single base deletion in Glyma.02g233700, resulted in an early stop codon. Glyma.02g233700 encodes a translocon in the inner membrane of chloroplast (GmTic110) that plays a critical role in plastid biogenesis. The lethal-yellow gene was mapped to an 83kb region on chromosome 3 that contained 13 predicted genes. Based on the annotated functions, we sequenced three potential candidate genes. A single base insertion in the second exon of Glyma.03G230300 resulted in a truncated protein. Glyma.03G230300 encodes for GmPsbP, an extrinsic protein of Photosystem II that is critical for oxygen evolution during photosynthesis. GmTic110 and GmPsbP displayed highly reduced expression in the viable- and lethal-yellow mutants, respectively. The yellow phenotypes in the viable- and lethal-yellow mutants were due to the loss of function of GmTic110 or GmPsbP resulting in photooxidative stress.

Carbon and nitrogen isotope fractionation of amino acids in an avian marine predator, the gentoo penguin (Pygoscelis papua).

Compound-specific stable isotope analysis (CSIA) of amino acids (AA) has rapidly become a powerful tool in studies of food web architecture, resource use, and biogeochemical cycling. However, applications to avian ecology have been limited because no controlled studies have examined the patterns in AA isotope fractionation in birds. We conducted a controlled CSIA feeding experiment on an avian species, the gentoo penguin (Pygoscelis papua), to examine patterns in individual AA carbon and nitrogen stable isotope fractionation between diet (D) and consumer (C) (Δ(13)CC-D and Δ(15)NC-D, respectively). We found that essential AA δ (13)C values and source AA δ (15)N values in feathers showed minimal trophic fractionation between diet and consumer, providing independent but complimentary archival proxies for primary producers and nitrogen sources respectively, at the base of food webs supporting penguins. Variations in nonessential AA Δ(13)CC-D values reflected differences in macromolecule sources used for biosynthesis (e.g., protein vs. lipids) and provided a metric to assess resource utilization. The avian-specific nitrogen trophic discrimination factor (TDFGlu-Phe = 3.5 ± 0.4‰) that we calculated from the difference in trophic fractionation (Δ(15)NC -D) of glutamic acid and phenylalanine was significantly lower than the conventional literature value of 7.6‰. Trophic positions of five species of wild penguins calculated using a multi-TDFG lu-Phe equation with the avian-specific TDFG lu-Phe value from our experiment provided estimates that were more ecologically realistic than estimates using a single TDFG lu-Phe of 7.6‰ from the previous literature. Our results provide a quantitative, mechanistic framework for the use of CSIA in nonlethal, archival feathers to study the movement and foraging ecology of avian consumers.

The Older Persons' Transitions in Care (OPTIC) study: pilot testing of the transition tracking tool.

BACKGROUND: OPTIC is a mixed method Partnership for Health System Improvement (http://www.cihr-irsc.gc.ca/e/34348.html) study focused on improving care for nursing home (NH) residents who are transferred to and from emergency departments (EDs) via emergency medical services (EMS). In the pilot study we tested feasibility of concurrently collecting individual resident data during transitions across settings using the Transition Tracking Tool (T3). METHODS: The pilot study tracked 54 residents transferred from NHs to one of two EDs in two western Canadian provinces over a three month period. The T3 is an electronic data collection tool developed for this study to record data relevant to describing and determining success of transitions in care. It comprises 800+ data elements including resident characteristics, reasons and precipitating factors for transfer, advance directives, family involvement, healthcare services provided, disposition decisions, and dates/times and timing. RESULTS: Residents were elderly (mean age = 87.1 years) and the majority were female (61.8%). Feasibility of collecting data from multiple sources across two research sites was established. We identified resources and requirements to access and retrieve specific data elements in various settings to manage data collection processes and allocate research staff resources. We present preliminary data from NH, EMS, and ED settings. CONCLUSIONS: While most research in this area has focused on a unidirectional process of patient progression from one care setting to another, this study established feasibility of collecting detailed data from beginning to end of a transition across multiple settings and in multiple directions.

When functional capacity and real-world functioning converge: the role of self-efficacy.

Although functional capacity is typically diminished, there is substantial heterogeneity in functional outcomes in schizophrenia. Motivational factors likely play a significant role in bridging the capacity-to-functioning gap. Self-efficacy theory suggests that although some individuals may have the capacity to perform functional behaviors, they may or may not have confidence they can successfully perform these behaviors in real-world settings. We hypothesized that the relationship between functional capacity and real-world functioning would be moderated by the individual's self-efficacy in a sample of 97 middle-aged and older adults with schizophrenia (mean age = 50.9 ± 6.5 years). Functional capacity was measured using the Brief UCSD Performance-based Skills Assessment (UPSA-B), self-efficacy with the Revised Self-Efficacy Scale, and Daily Functioning via the Specific Level of Functioning (SLOF) scale and self-report measures. Results indicated that when self-efficacy was low, the relationship between UPSA-B and SLOF scores was not significant (P = .727). However, when self efficacy was high, UPSA-B scores were significantly related to SLOF scores (P = .020). Similar results were observed for self-reported social and work functioning. These results suggest that motivational processes (ie, self-efficacy) may aid in understanding why some individuals have the capacity to function well but do not translate this capacity into real-world functioning. Furthermore, while improvement in capacity may be necessary for improved functioning in this population, it may not be sufficient when motivation is absent.

Older Persons' Transitions in Care (OPTIC): a study protocol.

BACKGROUND: Changes in health status, triggered by events such as infections, falls, and geriatric syndromes, are common among nursing home (NH) residents and necessitate transitions between NHs and Emergency Departments (EDs). During transitions, residents frequently experience care that is delayed, unnecessary, not evidence-based, potentially unsafe, and fragmented. Furthermore, a high proportion of residents and their family caregivers report substantial unmet needs during transitions. This study is part of a program of research whose overall aim is to improve quality of care for frail older adults who reside in NHs. The purpose of this study is to identify successful transitions from multiple perspectives and to identify organizational and individual factors related to transition success, in order to inform improvements in care for frail elderly NH residents during transitions to and from acute care. Specific objectives are to: 1. define successful and unsuccessful elements of transitions from multiple perspectives; 2. develop and test a practical tool to assess transition success; 3. assess transition processes in a discrete set of transfers in two study sites over a one year period; 4. assess the influence of organizational factors in key practice locations, e.g., NHs, emergency medical services (EMS), and EDs, on transition success; and 5. identify opportunities for evidence-informed management and quality improvement decisions related to the management of NH - ED transitions. METHODS/DESIGN: This is a mixed-methods observational study incorporating an integrated knowledge translation (IKT) approach. It uses data from multiple levels (facility, care unit, individual) and sources (healthcare providers, residents, health records, and administrative databases). DISCUSSION: Key to study success is operationalizing the IKT approach by using a partnership model in which the OPTIC governance structure provides for team decision-makers and researchers to participate equally in developing study goals, design, data collection, analysis and implications of findings. As preliminary and ongoing study findings are developed, their implications for practice and policy in study settings will be discussed by the research team and shared with study site administrators and staff. The study is designed to investigate the complexities of transitions and to enhance the potential for successful and sustained improvement of these transitions.

Pattern of mercury allocation into egg components is independent of dietary exposure in Gentoo penguins.

Avian eggs have become one of the most common means of evaluating mercury contamination in aquatic and marine environments and can serve as reliable indicators of dietary mercury exposure. We investigated patterns of mercury deposition into the major components of penguin eggs (shell, membrane, albumen, and yolk) using the Gentoo penguin (Pygoscelis papua) as a model species. Eggs were collected from both wild and captive populations of Gentoo penguins to compare the allocation of mercury into individual egg components of birds feeding at disparate trophic positions as inferred by stable isotope analysis. Mercury concentrations in captive penguins were an order of magnitude higher than in wild birds, presumably because the former were fed only fish at a higher trophic position relative to wild penguins that fed on a diet of 72-93% krill (Euphausia spp.). Similar to previous studies, we found the majority of total egg mercury sequestered in the albumen (92%) followed by the yolk (6.7%) with the lowest amounts in the shell (0.9%) and membrane (0.4%). Regardless of dietary exposure, mercury concentrations in yolk and membrane, and to a lesser degree shell, increased with increasing albumen mercury (used as a proxy for whole-egg mercury), indicating that any component, in the absence of others, may be suitable for monitoring changes in dietary mercury. Because accessibility of egg tissues in the wild varies, the establishment of consistent relationships among egg components will facilitate comparisons with any other study using eggs to assess dietary exposure to mercury.