Reducing opioid use for chronic non-cancer pain in primary care using an evidence-based, theory-informed, multistrategic, multistakeholder approach: a single-arm time series with segmented regression.

BACKGROUND: Many countries have high opioid use among people with chronic non-cancer pain. Knowledge about effective interventions that could be implemented at scale is limited. We designed a national intervention that included audit and feedback, deprescribing guidance, information on catastrophising assessment, pain neuroscience education and a cognitive tool for use by patients with their healthcare providers. METHOD: We used a single-arm time series with segmented regression to assess rates of people using opioids before (January 2015 to September 2017), at the time of (October 2017) and after the intervention (November 2017 to August 2019). We used a cohort with historical comparison group and log binomial regression to examine the rate of psychologist claims in opioid users not using psychologist services prior to the intervention. RESULTS: 13 968 patients using opioids, 8568 general practitioners, 8370 pharmacies and accredited pharmacists and 689 psychologists were targeted. The estimated difference in opioid use was -0.51 persons per 1000 persons per month (95% CI -0.69, -0.34; p<0.001) as a result of the intervention, equating to 25 387 (95% CI 24 676, 26 131) patient-months of opioid use avoided during the 22-month follow-up. The targeted group had a significantly higher rate of incident patient psychologist claims compared with the historical comparison group (rate ratio: 1.37, 95% CI 1.16, 1.63; p<0.001), equating to an additional 690 (95% CI 289, 1167) patient-months of psychologist treatment during the 22-month follow-up. CONCLUSIONS: Our intervention addressed the cognitive, affective and sensory factors that contribute to pain and consequent opioid use, demonstrating it could be implemented at scale and was associated with a reduction in opioid use and increasing utilisation of psychologist services.

Medicine-Induced Acute Kidney Injury Findings from Spontaneous Reporting Systems, Sequence Symmetry Analysis and a Case-Control Study with a Focus on Medicines Used in Primary Care.

INTRODUCTION: Primary care provides an opportunity to prevent community acquired, medicine or drug-induced acute kidney injury. One of the barriers to proactive prevention of medicine-induced kidney injury in primary care is the lack of a list of nephrotoxic medicines that are most problematic in primary care, particularly one that provides a comparison of risks across medicines. OBJECTIVE: The aim of this study was to consolidate evidence on the risks associated with medicines and acute kidney injury, with a focus on medicines used in primary care. METHOD: We searched the MEDLINE and EMBASE databases to identify published studies of all medicines associated with acute kidney injury identified from spontaneous report data. For each medicine positively associated with acute kidney injury, as identified from spontaneous reports, we implemented a sequence symmetry analysis (SSA) and a case-control design to determine the association between the medicine and hospital admission with a primary diagnosis of acute kidney injury (representing community-acquired acute kidney injury). Administrative claims data held by the Australian Government Department of Veterans' Affairs for the study period 2005-2019 were used. RESULTS: We identified 89 medicines suspected of causing acute kidney injury based on spontaneous report data and a reporting odds ratio above 2, from Japan, France and the US. Spironolactone had risk estimates of 3 or more based on spontaneous reports, SSA and case-control methods, while furosemide and trimethoprim with sulfamethoxazole had risk estimates of 1.5 or more. Positive association with SSA and spontaneous reports, but not case control, showed zoledronic acid had risk estimates above 2, while candesartan telmisartan, simvastatin, naproxen and ibuprofen all had risk estimates in SSA between 1.5 and 2. Positive associations with case-control and spontaneous reports, but not SSA, were found for amphotericin B, omeprazole, metformin, amlodipine, ramipril, olmesartan, ciprofloxacin, valaciclovir, mycophenolate and diclofenac. All with the exception of metformin and omeprazole had risk estimates above 2. CONCLUSION: This research highlights a number of medicines that may contribute to acute injury; however, we had an insufficient sample to confirm associations of some medicines. Spironolactone, furosemide, and trimethoprim with sulfamethoxazole are medicines that, in particular, need to be used carefully and monitored closely in patients in the community at risk of acute kidney injury.

Impact of a patient-specific national programme aimed at increasing the use of emollient moisturisers to reduce the risk of skin tears: a longitudinal cohort study.

OBJECTIVES: To evaluate the impact of a patient-specific national programme targeting older Australians and health professionals that aimed to increase use of emollient moisturisers to reduce to the risk of skin tears. DESIGN: A prospective cohort intervention. PARTICIPANTS: The intervention targeted 52 778 Australian Government's Department of Veterans' Affairs patients aged over 64 years who had risk factors for wound development, and their general practitioners (GPs) (n=14 178). OUTCOME MEASURES: An interrupted time series model compared the rate of dispensing of emollients in the targeted cohort before and up to 23 months after the intervention. Commitment questions were included in self-report forms. RESULTS: In the first month after the intervention, the rate of claims increased 6.3-fold (95% CI: 5.2 to 7.6, p<0.001) to 10 emollient dispensings per 1000 patients in the first month after the intervention. Overall, the intervention resulted in 10 905 additional patient-months of treatment. The increased rate of dispensing among patients who committed to talking to their GP about using an emollient was six times higher (rate ratio: 6.2, 95% CI: 4.4 to 8.7) than comparison groups. CONCLUSIONS: The intervention had a sustained effect over 23 months. Veterans who responded positively to commitment questions had higher uptake of emollients than those who did not.

Determinants of usefulness in professional behaviour change interventions: observational study of a 15-year national program.

OBJECTIVE: Educational, and audit and feedback interventions are effective in promoting health professional behaviour change and evidence adoption. However, we lack evidence to pinpoint which particular features make them most effective. Our objective is to identify determinants of quality in professional behaviour change interventions, as perceived by participants. DESIGN: We performed a comparative observational study using data from the Veterans' Medicines Advice and Therapeutics Education Services program, a nation-wide Australian Government Department of Veterans' Affairs funded program that provides medicines advice and promotes physician adoption of best practices by use of a multifaceted intervention (educational material and a feedback document containing individual patient information). SETTING: Primary care practices providing care to Australian veterans. PARTICIPANTS: General practitioners (GPs) targeted by 51 distinct behaviour change interventions, implemented between November 2004 and June 2018. PRIMARY AND SECONDARY OUTCOME MEASURES: We extracted features related to presentation (number of images, tables and characters), content (polarity and subjectivity using sentiment analysis, number of external links and medicine mentions) and the use of five behaviour change techniques (prompt/cues, goal setting, discrepancy between current behaviour and goal, information about health consequences, feedback on behaviour). The main outcome was perceived usefulness, extracted from postintervention survey. RESULTS: On average, each intervention was delivered to 9667 GPs. Prompt and goal setting strategies in the audit and feedback were independently correlated to perceived usefulness (p=0.030 and p=0.005, respectively). The number of distinct behaviour change techniques in the audit and feedback was correlated with improved usefulness (Pearson's coefficient 0.45 (0.19, 0.65), p=0.001). No presentation or content features in the educational material were correlated with perceived usefulness. CONCLUSIONS: The finding provides additional evidence encouraging the use of behaviour change techniques, in particular prompt and goal setting, in audit and feedback interventions.

Comorbidities in an Australian sample of chronic and new opioid users.

INTRODUCTION AND AIMS: Mental health disorders and substance abuse are risk factors that both precede and follow chronic opioid use. We predicted that incident opioid users would have lower rates of mental health comorbidities than chronic opioid users, but that incident chronic opioid users would have lower rates of mental health comorbidities than prevalent chronic users. DESIGN AND METHODS: We used administrative health claims data to evaluate differences in lifetime mental health and substance abuse comorbidity profiles of people who were prevalent and incident chronic opioid users, as well as those who used opioids acutely. Results were stratified by age. RESULTS: Over 5,188 people were prevalent chronic opioid users at study entry. Of the 10,079 people who initiated opioids, 10.2 per-cent had a subsequent chronic episode (incident chronic) and the remainder stopped within 90 days (incident acute). In prevalent chronic users compared to incident chronic users, rates of depression and anxiety were higher across all age groups (odds ratio (OR) across age groups range from = 1.60, 95 percent confidence interval (CI) = 1.35,1.89, to OR = 6.66, 95 percent CI = 3.02, 14.69) and prevalence of alcohol abuse was higher in those aged 55 to 74 years (OR = 5.11, 95 percent CI = 1.83, 14.24, p = 0.002). Acute users were less likely than incident chronic users to have depression and anxiety in those aged over 74 years (depression OR = 0.82, 95 per-cent CI = 0.70, 0.95; anxiety OR = 0.82, 95% CI 0.70, 0.98). CONCLUSIONS: Mental health morbidities commonly associated with chronic opioid use increase in prevalence as chronic use continues.

Reduction in Use of Risperidone for Dementia in Australia Following Changed Guidelines.

Background: Risperidone is the only antipsychotic approved in Australia for the management of the behavioural and psychological symptoms of dementia (BPSD). In June 2015, the Australian Government Therapeutic Goods Administration (TGA) amended the indication to restrict use in BPSD to patients with Alzheimer's dementia for a maximum twelve-week duration. We aimed to determine whether the rate and duration of risperidone use for BPSD decreased following the regulatory changes. Methods: we conducted a study using the Australian Government Department of Veterans' Affairs administrative claims data and Pharmaceutical Benefits Scheme (PBS) 10% sample data. We included people aged 65 years or older and compared the rate and duration of risperidone use before and after the TGA labelling changes. Results: There was a sustained decrease in the trend of risperidone use for BPSD following the TGA labelling changes, with a monthly decrease of 1.7% in the aged care population, 0.5% in the community living population and 1.5% in the general older Australian population. Overall, in the 24 months post the TGA changes the reduction in the rate of use of risperidone ranged from 20% to 28% lower than compared to what the rate would have been without the TGA changes. The median duration of use of risperidone in aged-care residents decreased from 338 days in the year prior to the TGA labelling changes, to 240 days per person in the year after the changes. Conclusion: The TGA labelling changes were associated with a significant reduction in the rate of use of risperidone for BPSD in veterans living in both the aged care and community settings, and in the general older Australian population. The labelling changes were also associated with a reduced duration of risperidone use in aged care residents, although for most people the duration of use still exceeded the recommended 12-week maximum duration.

Persistence with opioids post discharge from hospitalisation for surgery in Australian adults: a retrospective cohort study.

OBJECTIVE: To determine time to opioid cessation post discharge from hospital in persons who had been admitted to hospital for a surgical procedure and were previously naïve to opioids. DESIGN, SETTING AND PARTICIPANTS: Retrospective cohort study using administrative health claims database from the Australian Government Department of Veterans' Affairs (DVA). DVA gold card holders aged between 18 and 100 years who were admitted to hospital for a surgical admission between 1 January 2014 and 30 December 2015 and naïve to opioid therapy prior to admission were included in the study. Gold card holders are eligible for all health services that DVA funds. MAIN OUTCOME MEASURES: The outcome of interest was time to cessation of opioids, with follow-up occurring over 12 months. Cessation was defined as a period without an opioid prescription that was equivalent to three times the estimated supply duration. The proportion who became chronic opioid users was defined as those who continued taking opioids for greater than 90 days post discharge. Cumulative incidence function with death as a competing event was used to determine time to cessation of opioids post discharge. RESULTS: In 2014-2015, 24 854 persons were admitted for a surgical admission. In total 3907 (15.7%) were discharged on opioids. In total 3.9% of those discharged on opioids became chronic users of opioids. The opioid that the patients were most frequently discharged with was oxycodone; oxycodone alone accounted for 43%, while oxycodone with naloxone accounted for 8%. CONCLUSIONS: Opioid initiation post-surgical hospital admission leads to chronic use of opioids in a small percentage of the population. However, given the frequency at which surgical procedures occur, this means that a large number of people in the population may be affected. Post-discharge assessment and follow-up of at-risk patients is important, particularly where psychosocial elements such as anxiety and catastrophising are identified.

Prevalence of Psychotropic Medicine Use in Australian Children with Autism Spectrum Disorder: A Drug Utilization Study Based on Children Enrolled in the Longitudinal Study of Australian Children.

Based on data from the Longitudinal Study of Australian Children linked with pharmacy dispensing data from the Australian Government's Pharmaceutical Benefits Scheme, we calculated the 1-year prevalence of psychotropic medicine supply in children and adolescents with Autism Spectrum Disorder (ASD) as reported by parents in 2014. The majority of children and adolescents with ASD in Australia were not treated with psychotropic medicine. One-third had claims for at least one psychotropic medication, most commonly medications for attention-deficit/hyperactivity disorder (ADHD), and antidepressants. Antipsychotics were supplied to less than one in twenty children and approximately one in ten adolescents. In line with findings from North America, psychotropic medicine was more often supplied to children and adolescents with ASD and comorbid ADHD.

Risk of chronic opioid use in older persons with pre-existing anxiety.

OBJECTIVE: Work that has shown a relationship between anxiety and chronic opioid use has not focused on older people specifically, despite the additional risks in older populations. This study aimed to understand whether anxiety prior to opioid initiation increased the likelihood of chronic opioid use over time in persons aged 60 years or older. DESIGN: Administrative claims data were used to calculate time between initiation of opioids and a first chronic episode of opioid use. Patients were classified as having a history of anxiety if they were dispensed medicines in the anxiolytics class or had a hospitalization event for anxiety prior to treatment with an opioid. Proportional hazards models were used to compare the likelihood of experiencing a chronic episode of opioid use between those with and without a history of anxiety. RESULTS: The cohort was 15,000 persons, of which, 5,076 (34 percent) had history of anxiety. Those with anxiety prior to their first opioid dispensing were 30 percent more likely to have an episode of chronic use after adjustment for age, gender, number of comorbidities, and prior surgery (HR = 1.30, 95% CI = 1.16-1.47). The risk of a chronic episode in patients who had surgery prior to initiation of an opioid was 60 percent greater in those with anxiety compared to no anxiety (HR = 1.60, 95% CI = 1.21-2.11) and 24 percent greater in those with anxiety but no prior surgery (HR = 1.24, 95% CI = 1.08-1.42). CONCLUSIONS: A significant proportion of older people will have a chronic episode of opioid use. This risk is increased where a history of anxiety is present.

Gathering tips from carers to support people with dementia: an adaptation of the TOP 5 program for community use.

AIM: Behavioral and psychological symptoms of dementia are often managed inappropriately with antipsychotic medicines. The TOP 5 program, which involves recording up to five relevant and meaningful tips that assist in personalizing care for the person with dementia, has been tested in the hospital setting and transitions of care in Australia, and has been found to be useful. Our study aimed to adapt the TOP 5 program as a strategy to support people with dementia in a primary care setting and to test the acceptability of our adapted TOP 5 program materials. METHODS: The adapted TOP 5 program materials were delivered as part of a larger intervention by the Australian Government Department of Veterans' Affair's Veterans' Medicines Advice & Therapeutic Education Services program to reduce inappropriate antipsychotic use in veterans with dementia. This study focuses on the acceptability of our adapted TOP 5 program materials for ascertaining carer or family members' advice about what actions might help to calm their relative when she or he is agitated. Educational materials relating to the resources for implementing the adapted TOP 5 program together with the one-page survey response to evaluate acceptability of our adapted TOP 5 program materials were mailed to 4827 general practitioners (GPs), 8381 accredited pharmacists, and 2510 Residential Aged Care Facilities. RESULTS: We received survey response forms from 350 (7%) GPs, 366 (4%) pharmacists, and 196 (8%) residential aged care facilities. Although the response rate was low, 90% of respondents in all groups indicated they were very likely or moderately likely to assist family members and carers of patients with dementia to identify their top tips to personalize care. GPs who found the information useful more frequently indicated that they were likely to assist family members and carers in identifying their top tips. Approximately one-third of respondents reported they had received positive feedback from families regarding the helpfulness of sharing their practical tips for care of their loved one. Pharmacists indicated having the tips would assist them when undertaking medicines reviews. CONCLUSIONS: Our findings suggest that the TOP 5 program, or an adaptation of the TOP 5 program, such as ours, has potential to improve the health and care of people with dementia and their carers by using patient centerd nonpharmacological approaches and avoiding the unnecessary use of antipsychotics for behavioral and psychological symptoms of dementia. Longer-term follow-up would help to establish whether the apparent benefits persist.

Is having a family member with chronic health concerns bad for young people's health? Cross-sectional evidence from a national survey of young Australians.

OBJECTIVES: Young people's perspectives on the association between having a family member with a chronic health concern (FHC) and their own health are under-researched. This study used young people's reports to assess the prevalence of FHCs and their association with negative health outcomes, with an aim of identifying potential inequalities between marginalised and non-marginalised young people. Family cohesion was examined as a moderating factor. DESIGN: Cross-sectional data from the Australian Child Wellbeing Project survey were used. Respondents were asked whether someone in their family experienced one or more FHCs (disability, mental illness or drug/alcohol addiction). In addition, their experience of different psychosomatic symptoms (headache, sleeplessness, irritability, etc), aspects of family relationships and social and economic characteristics (disability, materially disadvantaged and Indigenous) were documented. SETTING: Nationally representative Australian sample. PARTICIPANTS: 1531 students in school years 4 and 6 and 3846 students in year 8. RESULTS: A quarter of students reported having an FHC (years 4 and 6: 23.96% (95% CI 19.30% to 28.62%); year 8: 25.35% (95% CI 22.77% to 27.94%)). Significantly, more students with FHCs than those without reported experiencing 2 or more negative health symptoms at least weekly (OR=1.78; 95% CI 1.19 to 2.65; p<0.01). However, an independent relationship between FHCs and symptom load was only found in the case of FHC-drug/alcohol addiction. Marginalised students and students reporting low family cohesion had an increased prevalence of FHCs and notably higher symptom loads where FHCs were present. Level of family cohesion did not impact the relationship between FHCs and symptom load. CONCLUSIONS: The burden of FHCs is inequitably distributed between marginalised and non-marginalised groups, and between young people experiencing different levels of family cohesion. More work is required regarding appropriate targets for community and family-level interventions to support young people in the context of FHCs.