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3.
J Urol ; 205(1): 264-270, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32749908

RESUMO

PURPOSE: Postoperative opioids are overprescribed in the United States. In November 2016 the State of Pennsylvania required an opioid consent for minors. Our hypothesis is that this mandate decreased postoperative opioid prescriptions in our division. MATERIALS AND METHODS: All patients who received a urological outpatient or minor emergency procedure from August 2015 to August 2019 were identified. Surgeries performed within 6 months after mandate implementation were excluded to account for the transition period. Perioperative data including case type were extracted by a clinical data warehouse from preexisting fields within the health record. The frequencies of postoperative prescriptions, delayed prescriptions and emergency department encounters were assessed. A multivariable logistic regression to identify predictors of opioid prescription at discharge was performed. RESULTS: A total of 4,349 patients were analyzed. The frequency of postsurgical opioid prescriptions decreased from 45.3% to 2.6% (p <0.001). The median morphine milligram equivalent decreased by 22.5 among children prescribed an opioid (p <0.001). Rates of an emergency department visits (3% vs 2.7%) or delayed nonopioid prescriptions (0.8% vs 1.2%) within 30 days of discharge were unchanged (p >0.05). Fewer patients received a delayed opioid prescription after mandate implementation (0.03% vs 0.5%, p <0.001). Female patients were less likely (OR 0.309, 95% CI 0.195-0.491; p <0.001) to receive opioids prior to but not after the mandate (OR 0.309, 95% CI 0.544-2.035; p=0.122). Increasing age was predictive of receiving an opioid before (OR 1.187, 95% CI 1.157-1.218; p <0.001) and after (OR 1.241, 95% CI 1.186-1.299; p <0.001) the mandate. CONCLUSIONS: A state mandated opioid consent for minors greatly reduced post-urological surgery opioid prescription rates without increasing rates of readmission or delayed prescriptions.


Assuntos
Analgésicos Opioides/efeitos adversos , Consentimento Livre e Esclarecido/legislação & jurisprudência , Manejo da Dor/normas , Dor Pós-Operatória/tratamento farmacológico , Padrões de Prática Médica/estatística & dados numéricos , Procedimentos Cirúrgicos Urológicos/efeitos adversos , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Analgésicos Opioides/normas , Criança , Pré-Escolar , Uso de Medicamentos/legislação & jurisprudência , Uso de Medicamentos/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Emergência/efeitos adversos , Tratamento de Emergência/métodos , Feminino , Humanos , Lactente , Consentimento Livre e Esclarecido/normas , Masculino , Epidemia de Opioides/prevenção & controle , Manejo da Dor/métodos , Dor Pós-Operatória/etiologia , Readmissão do Paciente/estatística & dados numéricos , Pennsylvania , Padrões de Prática Médica/legislação & jurisprudência , Padrões de Prática Médica/normas , Estudos Retrospectivos , Governo Estadual , Procedimentos Cirúrgicos Urológicos/métodos , Urologistas/legislação & jurisprudência , Urologistas/normas , Urologistas/estatística & dados numéricos
5.
N C Med J ; 81(6): 355-362, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33139463

RESUMO

BACKGROUND Deaths from unintentional opioid overdose have increased markedly over the last decade in North Carolina. In 2017 the state created a North Carolina Opioid Action Plan, which laid out a multisectoral response to the crisis that included the medical community, law enforcement, emergency medical services, and treatment professionals. It also created a website providing county-level data associated with the crisis. Using this publicly available data, we examine trends and associations between opioid-related mortality and strategies to reduce opioid prescriptions, reduce fatality of overdose, and improve treatment and recovery.METHOD We examine yearly trends from 2010-2017 for statewide unintentional opioid-related death rates, prescription of opioid pills, buprenorphine prescription rates, naloxone administrations, and number of Certified Peer Support Specialists. We compare recent opioid-related death rates for 2015-2017 with an earlier period (2010-2012) at the county level, and examine the association between death rates and rates of the supply, treatment, and recovery metrics.RESULTS Trends for all metrics increased from 2010-2017, although the number of opioid pills per capita has declined since 2015. Between 2010 and 2017, 84 of the state's 100 counties experienced an increase in opioid-related mortality. County-level mortality was positively associated with opioid prescription rate (r = +0.12, P = 0.24) and with naloxone administrations (r = +0.20, P = 0.05). Prescription of buprenorphine was associated with a reduction in opioid mortality (r = -0.27, P = 0.01). The effect of Certified Peer Support Specialists was not discernable.LIMITATIONS Data are available for only eight years and aggregated at the county level. Mortality data are based on death certificates using ICD-10 codes from the North Carolina State Center for Health Statistics, Vital Statistics, which may not capture all opioid-related fatalities. Drug-related deaths may involve multiple non-opioid substances; in addition, determining the intent of the deceased individual may be difficult (suicide versus unintentional). Naloxone administration data only includes data from emergency medical services, not community-administered naloxone, because that data was only available for 2013 and later and is based only on self-reports.CONCLUSIONS The potential efficacy of buprenorphine is promising and should be further explored. All interventions should be monitored.


Assuntos
Epidemia de Opioides , Analgésicos Opioides/envenenamento , Benchmarking , Overdose de Drogas/tratamento farmacológico , Overdose de Drogas/mortalidade , Humanos , North Carolina/epidemiologia , Epidemia de Opioides/prevenção & controle , Epidemia de Opioides/tendências
6.
Public Health Rep ; 135(1_suppl): 100S-127S, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32735190

RESUMO

OBJECTIVES: In the United States, rising rates of overdose deaths and recent outbreaks of hepatitis C virus and HIV infection are associated with injection drug use. We updated a 2014 review of systems-level opioid policy interventions by focusing on evidence published during 2014-2018 and new and expanded opioid policies. METHODS: We searched the MEDLINE database, consistent with the 2014 review. We included articles that provided original empirical evidence on the effects of systems-level interventions on opioid use, overdose, or death; were from the United States or Canada; had a clear comparison group; and were published from January 1, 2014, through July 19, 2018. Two raters screened articles and extracted full-text data for qualitative synthesis of consistent or contradictory findings across studies. Given the rapidly evolving field, the review was supplemented with a search of additional articles through November 17, 2019, to assess consistency of more recent findings. RESULTS: The keyword search yielded 535 studies, 66 of which met inclusion criteria. The most studied interventions were prescription drug monitoring programs (PDMPs) (59.1%), and the least studied interventions were clinical guideline changes (7.6%). The most common outcome was opioid use (77.3%). Few articles evaluated combination interventions (18.2%). Study findings included the following: PDMP effectiveness depends on policy design, with robust PDMPs needed for impact; health insurer and pharmacy benefit management strategies, pill-mill laws, pain clinic regulations, and patient/health care provider educational interventions reduced inappropriate prescribing; and marijuana laws led to a decrease in adverse opioid-related outcomes. Naloxone distribution programs were understudied, and evidence of their effectiveness was mixed. In the evidence published after our search's 4-year window, findings on opioid guidelines and education were consistent and findings for other policies differed. CONCLUSIONS: Although robust PDMPs and marijuana laws are promising, they do not target all outcomes, and multipronged interventions are needed. Future research should address marijuana laws, harm-reduction interventions, health insurer policies, patient/health care provider education, and the effects of simultaneous interventions on opioid-related outcomes.


Assuntos
Política de Saúde , Epidemia de Opioides/prevenção & controle , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Canadá/epidemiologia , Controle de Medicamentos e Entorpecentes/organização & administração , Educação em Saúde/organização & administração , Humanos , Naloxona/administração & dosagem , Antagonistas de Entorpecentes/administração & dosagem , Transtornos Relacionados ao Uso de Opioides/mortalidade , Guias de Prática Clínica como Assunto , Padrões de Prática Médica , Características de Residência , Estados Unidos/epidemiologia
7.
Milbank Q ; 98(3): 700-746, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32808709

RESUMO

Policy Points This article reconceptualizes our understanding of the opioid epidemic and proposes six strategies that address the epidemic's social roots. In order to successfully reduce drug-related mortality over the long term, policymakers and public health leaders should develop partnerships with people who use drugs, incorporate harm reduction interventions, and reverse decades of drug criminalization policies. CONTEXT: Drug overdose is the leading cause of injury-related death in the United States. Synthetic opioids, predominantly illicit fentanyl and its analogs, surpassed prescription opioids and heroin in associated mortality rates in 2016. Unfortunately, interventions fail to fully address the current wave of the opioid epidemic and often omit the voices of people with lived experiences regarding drug use. Every overdose death is a culmination of a long series of policy failures and lost opportunities for harm reduction. METHODS: In this article, we conducted a scoping review of the opioid literature to propose a novel framework designed to foreground social determinants more directly into our understanding of this national emergency. The "continuum of overdose risk" framework is our synthesis of the global evidence base and is grounded in contemporary theories, models, and policies that have been successfully applied both domestically and internationally. FINDINGS: De-escalating overdose risk in the long term will require scaling up innovative and comprehensive solutions that have been designed through partnerships with people who use drugs and are rooted in harm reduction. CONCLUSIONS: Without recognizing the full drug-use continuum and the role of social determinants, the current responses to drug overdose will continue to aggravate the problem they are trying to solve.


Assuntos
Analgésicos Opioides/efeitos adversos , Overdose de Drogas/etiologia , Determinantes Sociais da Saúde , Overdose de Drogas/mortalidade , Overdose de Drogas/prevenção & controle , Redução do Dano , Humanos , Modelos Teóricos , Epidemia de Opioides/mortalidade , Epidemia de Opioides/prevenção & controle , Transtornos Relacionados ao Uso de Opioides/etiologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Fatores de Risco , Estados Unidos/epidemiologia
11.
JAMA Netw Open ; 3(5): e204514, 2020 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-32391892

RESUMO

Importance: Although opioids can be effective medications in certain situations, they are associated with harms, including opioid use disorder and overdose. Studies have revealed unexplained prescribing variation and prescribing mismatched with patient-reported pain for many indications. Objective: To summarize opioid prescribing frequency, dosages, and durations, stratified across numerous painful medical indications. Design, Setting, and Participants: Retrospective cross-sectional analysis of 2017 US administrative claims data among outpatient clinical settings, including postsurgical discharge. Participants had any of 41 different indications associated with nonsurgical acute or chronic pain or postsurgical pain or pain associated with sickle cell disease or active cancer and were enrolled in either private insurance (including Medicare Advantage) in the OptumLabs Data Warehouse data set (n = 18 016 259) or Medicaid in the IBM MarketScan Multi-State Medicaid Database (n = 11 453 392). OptumLabs data were analyzed from October 2018 to March 2019; MarketScan data were analyzed from January to April 2019. Exposures: Nonsurgical acute or chronic pain or postsurgical pain; pain related to sickle cell disease or active cancer. Main Outcomes and Measures: Indication-specific opioid prescribing rates; days' supply per prescription; daily opioid dosage in morphine milligram equivalents; and for chronic pain indications, the number of opioid prescriptions. Results: During the study period, of 18 016 259 eligible patients with private insurance, the mean (95% CI) age was 42.7 (42.7-42.7) years, and 50.3% were female; of 11 453 392 eligible Medicaid enrollees, the mean (95% CI) age was 20.4 (20.4-20.4) years, and 56.1% were female. A pain-related indication under study occurred in at least 1 visit among 6 380 694 patients with private insurance (35.4%) and 3 169 831 Medicaid enrollees (27.7%); 2 270 596 (35.6% of 6 380 694) privately insured patients and 1 126 508 (35.5% of 3 169 831) Medicaid enrollees had 1 or more opioid prescriptions. Nonsurgical acute pain opioid prescribing rates were lowest for acute migraines (privately insured, 4.6% of visits; Medicaid, 6.6%) and highest for rib fractures (privately insured, 44.8% of visits; Medicaid, 56.3%), with variable days' supply but similar daily dosage across most indications. Opioid prescribing for a given chronic pain indication varied depending on a patient's opioid use history. Days' supply for postoperative prescriptions was longest for combined spinal decompression and fusion (privately insured, 9.5 days [95% CI, 9.4-9.7 days]) or spinal fusion (Medicaid, 9.1 days [95% CI, 8.9-9.2 days]) and was shortest for vaginal delivery (privately insured, 4.1 days [95% CI, 4.1-4.1 days] vs Medicaid, 4.2 days [95% CI, 4.2-4.2 days]). Conclusions and Relevance: Indication-specific opioid prescribing rates were not always aligned with existing guidelines. Potential inconsistencies between prescribing practice and clinical recommendations, such as for acute and chronic back pain, highlight opportunities to enhance pain management and patient safety.


Assuntos
Analgésicos Opioides/uso terapêutico , Medicaid , Medicare Part C , Dor/tratamento farmacológico , Padrões de Prática Médica/estatística & dados numéricos , Analgésicos Opioides/economia , Estudos Transversais , Bases de Dados Factuais , Feminino , Humanos , Revisão da Utilização de Seguros , Masculino , Pessoa de Meia-Idade , Epidemia de Opioides/prevenção & controle , Estudos Retrospectivos , Estados Unidos
12.
JAMA Netw Open ; 3(5): e204561, 2020 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-32391893

RESUMO

Importance: Treatment of opioid use disorder (OUD) with buprenorphine decreases opioid use and prevents morbidity and mortality. Emergency departments (EDs) are an important setting for buprenorphine initiation for patients with untreated OUD; however, readiness varies among ED clinicians. Objective: To characterize barriers and facilitators of readiness to initiate buprenorphine for the treatment of OUD in the ED and identify opportunities to promote readiness across multiple clinician types. Design, Setting, and Participants: Using data collected from April 1, 2018, to January 11, 2019, this mixed-methods formative evaluation grounded in the Promoting Action on Research Implementation in Health Services framework included 4 geographically diverse academic EDs. Attending physicians (n = 113), residents (n = 107), and advanced practice clinicians (APCs) (n = 48) completed surveys electronically distributed to all ED clinicians (n = 396). A subset of participants (n = 74) also participated in 1 of 11 focus group discussions. Data were analyzed from June 1, 2018, to February 22, 2020. Main Outcomes and Measures: Clinician readiness to initiate buprenorphine and provide referral for ongoing treatment for patients with OUD treated in the ED was assessed using a visual analog scale. Responders (268 of 396 [67.7%]) were dichotomized as less ready (scores 0-6) or most ready (scores 7-10). An ED-adapted Organizational Readiness to Change Assessment (ORCA) and 11 focus groups were used to assess ratings and perspectives on evidence and context-related factors to promote ED-initiated buprenorphine with referral for ongoing treatment, respectively. Results: Among the 268 survey respondents (153 of 260 were men [58.8%], with a mean [SD] of 7.1 [9.8] years since completing formal training), 56 (20.9%) indicated readiness to initiate buprenorphine for ED patients with OUD. Nine of 258 (3.5%) reported Drug Addiction Treatment Act of 2000 training completion. Compared with those who were less ready, clinicians who were most ready to initiate buprenorphine had higher mean scores across all ORCA Evidence subscales (3.50 [95% CI, 3.35-3.65] to 4.33 [95% CI, 4.13-4.53] vs 3.11 [95% CI, 3.03-3.20] to 3.60 [95% CI, 3.49-3.70]; P < .001) and on the Slack Resources of the ORCA Context subscales (3.32 [95% CI, 3.08-3.55] vs 3.0 [95% CI, 2.87-3.12]; P = .02). Barriers to ED-initiated buprenorphine included lack of training and experience in treating OUD with buprenorphine, concerns about ability to link to ongoing care, and competing needs and priorities for ED time and resources. Facilitators to ED-initiated buprenorphine included receiving education and training, development of local departmental protocols, and receiving feedback on patient experiences and gaps in quality of care. Conclusions and Relevance: Only a few ED clinicians had a high level of readiness to initiate buprenorphine; however, many expressed a willingness to learn with sufficient supports. Efforts to promote adoption of ED-initiated buprenorphine will require clinician and system-level changes.


Assuntos
Buprenorfina/uso terapêutico , Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Padrões de Prática Médica , Encaminhamento e Consulta , Adulto , Buprenorfina/administração & dosagem , Feminino , Grupos Focais , Humanos , Masculino , Pessoa de Meia-Idade , Epidemia de Opioides/prevenção & controle , Inquéritos e Questionários , Estados Unidos
13.
J Surg Res ; 252: 169-173, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32278971

RESUMO

BACKGROUND: Initial opioid exposure for most individuals with substance use disorder comes from the healthcare system, and overprescription of opioids in ambulatory operations is common. This report describes an academic medical center's experience implementing opioid-free thyroid and parathyroid operations. MATERIALS AND METHODS: This is a retrospective chart review of patients undergoing a thyroid or parathyroid operation before and after implementation of an opioid-free analgesia protocol. The primary endpoint was new postoperative opioid prescription. Secondary endpoints included prescription characteristics and predictors of new opioid prescription. RESULTS: A total of 515 patients were enrolled in the study: 240 in the control or "pre-intervention" cohort (May through October 2017) and 275 in the intervention or "post" cohort (May through October 2018). Patients in the intervention cohort were significantly less likely to receive an opioid prescription (12.0% versus 59.6%, P < 0.001). When opioids were prescribed, they were used for shorter durations and at lower doses in the intervention cohort. Among the patients prescribed opioids in the intervention cohort (N = 33), the only significant predictor of postoperative opioid use was preoperative opioid use (P = 0.001). CONCLUSIONS: Opioids may not be required after thyroidectomy and parathyroidectomy, especially for opioid-naïve patients. Future research should examine patient satisfaction with opioid-sparing analgesia.


Assuntos
Centros Médicos Acadêmicos/organização & administração , Implementação de Plano de Saúde , Manejo da Dor/métodos , Dor Pós-Operatória/tratamento farmacológico , Paratireoidectomia/efeitos adversos , Tireoidectomia/efeitos adversos , Centros Médicos Acadêmicos/normas , Centros Médicos Acadêmicos/estatística & dados numéricos , Acetaminofen/efeitos adversos , Idoso , Analgésicos Opioides/efeitos adversos , Combinação de Medicamentos , Prescrições de Medicamentos/normas , Prescrições de Medicamentos/estatística & dados numéricos , Uso de Medicamentos/normas , Uso de Medicamentos/estatística & dados numéricos , Estudos de Viabilidade , Feminino , Humanos , Hidrocodona/efeitos adversos , Masculino , Pessoa de Meia-Idade , Epidemia de Opioides/prevenção & controle , Manejo da Dor/normas , Manejo da Dor/estatística & dados numéricos , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Satisfação do Paciente , Padrões de Prática Médica/organização & administração , Padrões de Prática Médica/normas , Padrões de Prática Médica/estatística & dados numéricos , Estudos Retrospectivos , Resultado do Tratamento
14.
J Surg Res ; 252: 200-205, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32283333

RESUMO

BACKGROUND: A majority of surgical patients are prescribed opioids for pain management. Many patients have pre-existing chronic pain managed with opioids and/or opioid use disorders (OUDs), which can complicate perioperative management. Patients who use opioids prior to surgery are at increased risk of developing OUD after surgery. To date, no studies have examined the prevalence of opioid screening and electronic medical record (EMR) documentation prior to surgery. MATERIALS AND METHODS: A 40-item survey was administered to 268 patients at their first postoperative care visit at a single tertiary academic center from October 2017 to July 2018. A chart review of a random sample of 100 patients was performed to determine provider opioid screening prevalence in the presurgical setting. Log-binomial models were used to calculate prevalence ratios (PRs) to determine the provider role (surgeon, advanced practice clinicians [APC], surgical trainee) association with opioid screening documentation. Exploratory qualitative interviews were conducted with surgical providers to identify barriers to screening and screening documentation. RESULTS: Only 7% of patients were screened preoperatively for opioid use. A total of 38% of patients self-reported that they had used opioids in the past year. Of that group, only 3% had screening by a surgical provider prior to surgery documented in their EMR. Provider role was not associated with likelihood of opioid screening (surgeon versus trainee, PR = 1.2, 95% CI 0.2-8.5) (surgeons versus APCs, PR = 1.05, 95% CI 0.17-8.53). EMRs were discordant with patient survey results for patients with no ICD-10 codes for opioid use. The most common perceived barriers to preoperative screening were insufficient clinic time; logistics of who should screen/not required as part of their clinical workflow; not perceiving screening as a priority; and lack of expertise in the area of chronic opioid use and OUD. CONCLUSIONS: Preoperative screening for opioid use is uncommon, and EMRs are often discordant with patient self-reported use. Efforts to increase preoperative screening will need to address barriers screening practices and increasing health system support by incorporating screening into the clinical workflow and adding it to documentation templates.


Assuntos
Analgésicos Opioides/efeitos adversos , Programas de Rastreamento/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Dor Pós-Operatória/tratamento farmacológico , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Adulto , Idoso , Dor Crônica/tratamento farmacológico , Registros Eletrônicos de Saúde/estatística & dados numéricos , Feminino , Humanos , Masculino , Programas de Rastreamento/organização & administração , Programas de Rastreamento/normas , Pessoa de Meia-Idade , Epidemia de Opioides/prevenção & controle , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Manejo da Dor/efeitos adversos , Manejo da Dor/métodos , Dor Pós-Operatória/etiologia , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/organização & administração , Padrões de Prática Médica/normas , Padrões de Prática Médica/estatística & dados numéricos , Cuidados Pré-Operatórios/métodos , Cuidados Pré-Operatórios/normas , Cuidados Pré-Operatórios/estatística & dados numéricos , Estudos Prospectivos , Medição de Risco/métodos , Medição de Risco/estatística & dados numéricos , Autorrelato/estatística & dados numéricos , Cirurgiões/normas , Cirurgiões/estatística & dados numéricos , Fluxo de Trabalho
15.
Ann Palliat Med ; 9(2): 537-541, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32233628

RESUMO

Opioids are an important tool in the management of acute and chronic (cancer and non-cancer) pain. Pain and palliative care practitioners are frequently called upon to switch a patient from one opioid regimen to a different regimen either to gain better pain control, to minimize opioid-related adverse effects, to overcome opioid tolerance, or due to a change in patient status. To this end, equianalgesic tables have been published to guide practitioners in making these calculations. Despite being built on the best data available, equianalgesic tables do not tell the whole story, requiring the practitioner to thoroughly consider the patient's situation, and unknown variables. A five-step process is presented in this article that espouse a safe and effective way to switch from one opioid regimen to another. Directions for the future include better refinement of the data that informs the equianalgesic table, and perhaps inclusion of opioid utility data.


Assuntos
Analgésicos Opioides/uso terapêutico , Dor/tratamento farmacológico , Uso Indevido de Medicamentos sob Prescrição/prevenção & controle , Relação Dose-Resposta a Droga , Cálculos da Dosagem de Medicamento , Humanos , Metadona/uso terapêutico , Morfina/uso terapêutico , Epidemia de Opioides/prevenção & controle , Manejo da Dor/métodos
16.
PLoS One ; 15(3): e0229787, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32126120

RESUMO

OBJECTIVE: To identify the geographic, organisational, and payment correlates of buprenorphine and methadone treatment among substance abuse treatment (SAT) providers. METHODS: Secondary analyses of the National Survey of Substance Abuse Treatment Services (NSSATS) from 2007-16 were conducted. We provide bivariate descriptive statistics regarding substance abuse treatment services which offered buprenorphine and methadone treatment from 2007-16. Using multiple logistic regression, we regressed geographic, organisational, and payment correlates on buprenorphine and methadone treatment. RESULTS: Buprenorphine is increasingly offered at SAT facilities though uptake remains comparatively low outside of the northeast. SAT facilities run by tribal governments or Indian Health Service which offer buprenorphine remain low compared to privately operated SAT facilities (AOR = 0.528). The odds of offering buprenorphine among facilities offering free or no charge treatment (AOR = 0.838) or a sliding fee scale (AOR = 0.464) was lower. SAT facilities accepting Medicaid payments showed higher odds of offering methadone treatment (AOR = 2.035). CONCLUSIONS: Greater attention towards the disparities in provision of opioid agonist therapies is warranted, especially towards the reasons why uptake has been moderate among civilian providers. Additionally, the care needs of Native Americans facing opioid-related use disorders bears further scrutiny.


Assuntos
Antagonistas de Entorpecentes/uso terapêutico , Tratamento de Substituição de Opiáceos/estatística & dados numéricos , Epidemia de Opioides/prevenção & controle , Transtornos Relacionados ao Uso de Opioides/reabilitação , Centros de Tratamento de Abuso de Substâncias/estatística & dados numéricos , Analgésicos Opioides/efeitos adversos , Buprenorfina/economia , Buprenorfina/uso terapêutico , Efeitos Psicossociais da Doença , Geografia , Disparidades em Assistência à Saúde/economia , Disparidades em Assistência à Saúde/organização & administração , Disparidades em Assistência à Saúde/estatística & dados numéricos , Humanos , Medicaid/economia , Medicaid/estatística & dados numéricos , Metadona/economia , Metadona/uso terapêutico , Antagonistas de Entorpecentes/economia , Tratamento de Substituição de Opiáceos/economia , Tratamento de Substituição de Opiáceos/tendências , Transtornos Relacionados ao Uso de Opioides/economia , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/etiologia , Centros de Tratamento de Abuso de Substâncias/economia , Centros de Tratamento de Abuso de Substâncias/organização & administração , Inquéritos e Questionários/estatística & dados numéricos , Estados Unidos/epidemiologia
17.
Phys Ther ; 100(6): 995-1007, 2020 06 23.
Artigo em Inglês | MEDLINE | ID: mdl-32115638

RESUMO

The physical therapy profession has recently begun to address its role in preventing and managing opioid use disorder (OUD). This topic calls for discussion of the scope of physical therapist practice, and the profession's role, in the prevention and treatment of complex chronic illnesses, such as OUD. OUD is not just an individual-level problem. Abundant scientific literature indicates OUD is a problem that warrants interventions at the societal level. This upstream orientation is supported in the American Physical Therapy Association's vision statement compelling societal transformation and its mission of building communities. Applying a population health framework to these efforts could provide physical therapists with a useful viewpoint that can inform clinical practice and research, as well as develop new cross-disciplinary partnerships. This Perspective discusses the intersection of OUD and persistent pain using the disease prevention model. Primordial, primary, secondary, and tertiary preventive strategies are defined and discussed. This Perspective then explains the potential contributions of this model to current practices in physical therapy, as well as providing actionable suggestions for physical therapists to help develop and implement upstream interventions that could reduce the impact of OUD in their communities.


Assuntos
Dor Crônica/tratamento farmacológico , Epidemia de Opioides/prevenção & controle , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Fisioterapeutas , Humanos , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Fisioterapia , Prevenção Primária/métodos , Papel Profissional , Fatores de Risco , Prevenção Secundária/métodos , Prevenção Terciária/métodos , Estados Unidos/epidemiologia
18.
Mayo Clin Proc ; 95(5): 968-981, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32171474

RESUMO

The opioid crisis is a major concern of most health care institutions, including our large academic center. In this article, an organized approach to managing the epidemic institutionally is discussed. An Opioid Stewardship Program was instituted at our tertiary-care center with multiple sites and states of practice, which included diverse membership and expertise. Charges of the program included reviewing current practice, workflows, and external and internal guidelines and evaluating and standardizing prescribing practices. The development of an Opioid Stewardship Program resulted in: (1) an understanding of our diverse prescribing practices and the formation of patient- and procedure-specific guidelines to manage them, (2) education tools for our patients and providers, and (3) workflows and practice advisories within the electronic health record to support appropriate prescribing and monitoring of patients. This ongoing work continues to evolve in response to the needs of our patients, changing regulatory environments, and our improved understanding of our practices.


Assuntos
Instalações de Saúde , Epidemia de Opioides/prevenção & controle , Revisão de Uso de Medicamentos , Humanos
19.
J Surg Res ; 251: 6-15, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32097781

RESUMO

BACKGROUND: The devastating effects of the opioid epidemic are well documented. We implemented a surgeon/pharmacist opioid reduction initiative at an academic medical center that incorporated multimodal pain therapy in an attempt to reduce total inpatient opioids prescribed. We hypothesized that less opioids would be used postoperatively without affecting pain scores or length of stay. METHODS: This single-center observational cohort analysis included patients admitted to the acute general surgical service and had one of 10 emergent general surgical (nontrauma) procedures. Patients who underwent surgery before the opioid reduction initiative were compared with patients who underwent surgery postinitiative. The primary objective was to evaluate differences in daily oral morphine equivalents and average pain scores in patients before and after implementation of the surgeon/pharmacist initiative. RESULTS: Eighty-three patients in the preopioid reduction initiative group and 92 patients in the postopioid reduction initiative group met inclusion criteria. Oral morphine equivalents were significantly different at 24 h before discharge when comparing across both year (P = 0.032) and number of procedures (P = 0.013). Our results showed decreased opioid utilization in the postopioid reduction initiative group on all observed postoperative days with unaffected pain scores. CONCLUSIONS: An opioid reduction initiative showed promise in lowering the number of opioids used during inpatient admission without affecting pain scores in emergent general surgical procedures. This initiative can be easily reproduced at other institutions to help combat the opioid epidemic.


Assuntos
Analgésicos Opioides/administração & dosagem , Epidemia de Opioides/prevenção & controle , Manejo da Dor/métodos , Dor Pós-Operatória/tratamento farmacológico , Centros Médicos Acadêmicos , Adulto , Idoso , Estudos de Coortes , Feminino , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Ohio , Manejo da Dor/efeitos adversos , Medição da Dor , Estudos Retrospectivos , Equivalência Terapêutica
20.
Plast Reconstr Surg ; 145(3): 645-651, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32097300

RESUMO

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols have known benefits in the inpatient setting, but little is known about their impact in the subsequent outpatient setting. On discharge, multimodal analgesia has been discontinued, nerve blocks and pain pumps have worn off, and patients enter a substantially different physical environment, potentially resulting in a rebound effect. The objective of this study was to investigate the effect of ERAS protocol implementation on outpatient opioid use and recovery. METHODS: Patients who underwent abdominally based microsurgical breast reconstruction before and after ERAS implementation were reviewed retrospectively. Ohio state law mandates that no more than 7 days of opioids may be prescribed at a time, with the details of all prescriptions recorded in a statewide reporting system, from which opioid use was determined. RESULTS: A total of 105 patients met inclusion criteria, of which 46 (44 percent) were in the pre-ERAS group and 59 (56 percent) were in the ERAS group. Total outpatient morphine milligram equivalents used in the ERAS group were less than in the pre-ERAS group (337.5 morphine milligram equivalents versus 668.8 morphine milligram equivalents, respectively; p =0.016). This difference was specifically significant at postoperative week 1 (p =0.044), with gradual convergence over subsequent weeks. Although opioid use was significantly less in the ERAS group, pain scores in the ERAS group were comparable to those in the pre-ERAS group. CONCLUSIONS: The benefits of ERAS protocols appear to extend into the outpatient setting, further supporting their use to facilitate recovery, and highlighting their potential role in helping to address the prescription opioid abuse problem. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.


Assuntos
Analgésicos Opioides/uso terapêutico , Protocolos Clínicos , Recuperação Pós-Cirúrgica Melhorada/normas , Mamoplastia/efeitos adversos , Microcirurgia/efeitos adversos , Dor Pós-Operatória/tratamento farmacológico , Músculos Abdominais/transplante , Adulto , Assistência Ambulatorial/normas , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Humanos , Mamoplastia/métodos , Microcirurgia/métodos , Pessoa de Meia-Idade , Ohio/epidemiologia , Epidemia de Opioides/prevenção & controle , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/etiologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Manejo da Dor/estatística & dados numéricos , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Alta do Paciente , Retalho Perfurante/efeitos adversos , Retalho Perfurante/transplante , Estudos Retrospectivos , Resultado do Tratamento
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