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3.
Bone Joint J ; 101-B(12): 1570-1577, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31787005

RESUMO

AIMS: The aim of this study was to characterize the relationship between pre- and postoperative opioid use among patients undergoing common elective orthopaedic procedures. PATIENTS AND METHODS: Pre- and postoperative opioid use were studied among patients from a national insurance database undergoing seven common orthopaedic procedures using univariate log-rank tests and multivariate Cox proportional hazards analyses. RESULTS: A total of 98 769 patients were included; 35 701 patients were opioid-naïve, 11 621 used opioids continuously for six months before surgery, and 4558 used opioids continuously for at least six months but did not obtain any prescriptions in the three months before surgery. Among opioid-naïve patients, between 0.76% and 4.53% used opioids chronically postoperatively. Among chronic preoperative users, between 42% and 62% ceased chronic opioids postoperatively. A three-month opioid-free period preoperatively led to a rate of cessation of chronic opioid use between 82% and 93%, as compared with between 31% and 50% with continuous preoperative use (p < 0.001 for significant changes in opioid use before and after surgery in each procedure). Between 5.6 and 20.0 preoperative chronic users ceased chronic use for every new chronic opioid user. Risk factors for chronic postoperative use included chronic preoperative opioid use (odds ratio (OR) 4.84 to 39.75; p < 0.0001) and depression (OR 1.14 to 1.55; p < 0.05 except total hip arthroplasty). With a three-month opioid-free period before surgery, chronic preoperative opioids elevated the risk of chronic opioid use only mildly, if at all (OR 0.47 to 1.75; p < 0.05 for total shoulder arthroplasty, rotator cuff repair, and carpal tunnel release). CONCLUSION: Chronic preoperative opioid use increases the risk of chronic postoperative use, but an opioid-free period before surgery decreases this risk compared with continuous preoperative use Cite this article: Bone Joint J 2019;101-B:1570-1577.


Assuntos
Uso de Medicamentos/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos , Transtornos Relacionados ao Uso de Opioides/etiologia , Procedimentos Ortopédicos , Dor Pós-Operatória/tratamento farmacológico , Complicações Pós-Operatórias/etiologia , Bases de Dados Factuais , Humanos , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Período Pós-Operatório , Período Pré-Operatório , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco
4.
J Opioid Manag ; 15(6): 479-485, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31850509

RESUMO

INTRODUCTION: In response to the US opioid epidemic, the Centers for Disease Control and Prevention issued a guideline (CDCG) for prescribing opioids for chronic pain. Successful implementation of the CDCG requires identification of the information, skills, and support physicians need to carry out its recommendations. However, such data are currently lacking. METHODS: The authors performed one-on-one interviews with nine practicing physicians regarding their needs and perspectives for successful CDCG implementation, including the perceived barriers, focusing on communication strategies. Interviews were audio recorded, transcribed, and a thematic qualitative analysis was performed. FINDINGS: Three major themes were identified: communication, knowledge, and information technology (IT). Physicians reported that open communication with patients about opioids was difficult and burdensome, but essential; they shared their communication strategies. Knowledge gaps included patient-specific topics (eg, availability of/insurance coverage for non-opioid treatments) and more general areas (eg, opioid dosing/equivalencies, prescribing naloxone). Finally, physicians discussed the importance of innovation in IT, focusing on the electronic medical record for decision support and to allow safer opioid prescribing within the time constraints of clinical practice. DISCUSSION: These qualitative data document practical issues that should be considered in the development of implementation plans for safer opioid prescribing practices. Specifically, healthcare systems may need to provide opioid-relevant communication strategies and training, education on key topics such as naloxone prescribing, resources for referrals to appropriate nonpharmacologic treatments, and innovative IT solutions. Future research is needed to establish that such measures will be effective in producing better outcomes for patients on opioids for chronic pain.


Assuntos
Analgésicos Opioides , Comunicação , Registros Eletrônicos de Saúde , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Padrões de Prática Médica , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/efeitos adversos , Tomada de Decisões , Humanos , Naloxona , Médicos , Pesquisa Qualitativa
5.
BMC Health Serv Res ; 19(1): 784, 2019 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-31675963

RESUMO

BACKGROUND: In order to address the opioid crisis in North America, many regions have adopted preventative strategies, such as prescription drug monitoring programs (PDMPs). PDMPs aim to increase patient safety by certifying that opioids are prescribed in appropriate quantities. We aimed to synthesize the literature on changes in opioid-related harms and consequences, an important measure of PDMP effectiveness. METHODS: We completed a systematic review. We conducted a narrative synthesis of opioid-related harms and consequences from PDMP implementation. Outcomes were grouped into categories by theme: opioid dependence, opioid-related care outcomes, opioid-related adverse events, and opioid-related legal and crime outcomes. RESULTS: We included a total of 22 studies (49 PDMPs) in our review. Two studies reported on illicit and problematic use but found no significant associations with PDMP status. Eight studies examined the association between PDMP status and opioid-related care outcomes, of which two found that treatment admissions for prescriptions opioids were lower in states with PDMP programs (p < 0.05). Of the thirteen studies that reported on opioid-related adverse events, two found significant (p < 0.001 and p < 0.05) but conflicting results with one finding a decrease in opioid-related overdose deaths after PDMP implementation and the other an increase. Lastly, two studies found no statistically significant association between PDMP status and opioid-related legal and crime outcomes (crime rates, identification of potential dealers, and diversion). CONCLUSION: Our study found limited evidence to support overall associations between PDMPs and reductions in opioid-related consequences. However, this should not detract from the value of PDMPs' larger role of improving opioid prescribing.


Assuntos
Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Programas de Monitoramento de Prescrição de Medicamentos , Humanos , Avaliação de Programas e Projetos de Saúde , Ensaios Clínicos Controlados Aleatórios como Assunto
6.
J Opioid Manag ; 15(4): 267-271, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31637678

RESUMO

OBJECTIVE: Assess relationships between patient health literacy and formal education and use of opioids during and following an emergency department (ED) visit. DESIGN: Prospective, cross-sectional study. SETTING: Academic ED. PARTICIPANTS: Adults aged ≥ 60 years presenting to the ED with musculoskeletal pain. MAIN OUTCOME MEASURES: Opioid use during and after an ED visit. RESULTS: In a sample of 136 patients, patients with low health literacy were more likely to receive an opioid in the ED than patients with high health literacy (70 percent vs 52 percent; 18 percent difference, 95% confidence interval [CI]: -1 percent, 35 percent), receive an opioid prescription (63 percent vs 44 percent; 19 percent difference, 95% CI: 1 percent, 37 percent), and take opioids during the week following the ED visit (48 percent vs 29 percent; 18 percent difference, 95% CI: 0 percent, 36 percent). CONCLUSIONS: A greater proportion of older adults receiving ED care for musculoskeletal pain with low health literacy receive and use opioids during and following an ED visit.


Assuntos
Analgésicos Opioides/uso terapêutico , Serviço Hospitalar de Emergência , Alfabetização em Saúde , Idoso , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Manejo da Dor , Estudos Prospectivos
7.
J Opioid Manag ; 15(4): 272-274, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31637679

RESUMO

OBJECTIVE: To determine the utility of the screener and opioid assessment for patients with pain-revised (SOAPP-R) for patients with cancer-related pain. DESIGN: The authors performed a retrospective analysis of cancer patients screened with the SOAPP-R. Opiate abuse was determined using a combination of urine drug screens and analysis of patients' electronic medical records. SETTING/PATIENTS: Patients who were seen at a palliative care clinic presenting with pain or needing an opioid prescription at an academic medical center with any type of cancer were screened using the SOAPP-R (N = 69). OUTCOME MEASURES: Aberrant opioid-related behavior was determined using a combination of provider notes and urine drug screens. RESULTS: A positive SOAPP-R score (⩾18) was observed in 27 participants (39.1 percent). The sensitivity and specificity of the SOAPP-R in the study population was 0.75 and 0.80, respectively. CONCLUSIONS: The SOAPP-R, in its current form, may have value in screening patients with cancer for substance abuse. Incorporation of the screening tool in palliative and oncology settings may help reduce opioid abuse in cancer patients.


Assuntos
Analgésicos Opioides , Neoplasias/complicações , Transtornos Relacionados ao Uso de Opioides , Dor/tratamento farmacológico , Inquéritos e Questionários/normas , Analgésicos Opioides/uso terapêutico , Humanos , Programas de Rastreamento/métodos , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Dor/etiologia , Manejo da Dor , Reprodutibilidade dos Testes , Estudos Retrospectivos , Medição de Risco , Sensibilidade e Especificidade
8.
J Opioid Manag ; 15(4): 275-283, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31637680

RESUMO

OBJECTIVE: Inform readers of the use of a clinical pathway that includes initiation of methadone in hospitalized patients with acute pain who have untreated opioid use disorder (OUD). DESIGN: A retrospective chart review with frequency distributions and descriptive statistics calculated to describe demo-graphic and clinical characteristics of the sample. SETTING: Urban academic hospital. PATIENTS: One hundred twenty consecutive patients with untreated OUD cared for by the Acute Pain Service (APS). INTERVENTIONS: APS leadership spearheaded development of a clinical pathway to standardize pain management and optimize outcomes. The authors outline pathway development and describe 120 patients managed using this pathway, initiated on methadone for OUD. RESULTS: The sample included patients, average age 40 years, predominantly non-Hispanic white (74.2 percent), male (61.7 percent), unemployed (88.2 percent), and on Medicaid (84.2 percent). 96.7 percent had a history of heroin use, and 52.1 percent had engaged in previous medication-assisted treatment (MAT). Methadone or other opioids were held for signs of intoxication/sedation in 10.9 percent or for prolonged corrected QT interval in 1.7 percent. The majority received at least one other analgesic agent. For those prescribed opioids upon discharge, the average maximum morphine equivalent dose was 68.2 mg/day for approximately 3 days. 68.3 percent agreed to schedule post-discharge MAT, and of these, 68 percent attended their intake appointment. A small percentage (4.7 percent) left the hospital against medical advice. CONCLUSION: This pathway provides an example of an effective and safe response to address the opioid epidemic and pro-vide quality care to patients with OUD and pain.


Assuntos
Dor Aguda , Analgésicos Opioides/uso terapêutico , Metadona/uso terapêutico , Transtornos Relacionados ao Uso de Opioides , Dor Aguda/tratamento farmacológico , Adulto , Feminino , Humanos , Masculino , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Clínicas de Dor , Estudos Retrospectivos
9.
J Opioid Manag ; 15(4): 323-331, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31637684

RESUMO

OBJECTIVE: To develop a survey instrument to identify adult sickle cell disease (SCD) patients on chronic opioid therapy who are at-risk for opioid abuse. DESIGN: Prospective survey and interview. SETTING: Adult SCD clinic in a large urban teaching facility. PATIENTS/PARTICIPANTS: Convenience sampling of adult patients presenting to the sickle cell clinic. INTERVENTIONS: None. MAIN OUTCOME: Primary outcome was "at-risk for opioid misuse," defined as at least 3/8 "yes" answers (a positive composite score) on the Prescription Opioid Misuse Index (POMI) questionnaire. Secondary outcome was DSM-IV criteria for substance abuse using the DSM IV Diagnostic Interview Schedule. RESULTS: Of the 99 patients who completed the POMI, the mean age was 36 years; 58.6 percent were female, 48 percent were hemoglobin SS (47/99), and 26 percent were SC (26/99). Twenty-four percent (24/99) were identified as at-risk for opioid misuse using the POMI. There were no differences in demographic, SCD genotype, or socioeconomic variables for at-risk versus not-at-risk patients. CONCLUSION: Twenty-four percent of unselected adult SCD patients on opioids were identified as at-risk for opioid misuse using a quick survey. This may represent as much as 2.5-7 times the national misuse rate. This group of patients may benefit from additional diagnostic and therapeutic interventions to help understand and manage their opioid usage.


Assuntos
Analgésicos Opioides/efeitos adversos , Anemia Falciforme , Transtornos Relacionados ao Uso de Opioides , Inquéritos e Questionários/normas , Adulto , Analgésicos Opioides/uso terapêutico , Anemia Falciforme/tratamento farmacológico , Feminino , Humanos , Masculino , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Estudos Prospectivos , Medição de Risco
10.
J Opioid Manag ; 15(4): 333-341, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31637685

RESUMO

BACKGROUND: The use of opioid analgesics in the United States has increased nearly fourfold since 1999 resulting in a similar increase in opioid-related overdose deaths. Although the Centers for Disease Control published guidelines for prescribing chronic opioids, there is a lack of guidance for prescribing postoperative opioids. OBJECTIVE: To offer an evidence-based approach to prescribing opioids for post-operative pain management in the orthopedic setting. METHODS: A narrative review was performed of studies evaluating and quantifying opioid use in orthopedic patients in the postoperative setting, as well as studies analyzing patient satisfaction and perception with regards to opioid use. RESULTS: Studies show that postoperative pain may not be the largest contributing factor to developing an opioid use disorder, but rather patient factors such as tobacco and substance use disorder, mental health disorders, anxiety, mood disorders, pre-existing chronic pain, and recent opioid use may play a role. The review also found that most patients do not utilize significant portions of prescribed opioids and most do not require a refill. This trend leaves patients with thousands of unused pills, which are either retained, shared, or diverted. Although there is no guideline for prescribing opioids postoperatively, data suggest that clinicians can prescribe smaller dosages and fewer quantities of opioids initially. There are also non-opioid strategies that can be employed to reduce opioid consumption. CONCLUSION: There is a need for more high quality research to be conducted to standardize postoperative opioid prescribing patterns and create best practice guidelines to guide clinicians. Orthopedic practices should consider creating institutional guidelines to reduce the amount of opioids prescribed.


Assuntos
Analgésicos Opioides , Prescrições de Medicamentos/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides , Padrões de Prática Médica , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/uso terapêutico , Humanos , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Procedimentos Ortopédicos , Manejo da Dor/métodos , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/prevenção & controle , Padrões de Prática Médica/estatística & dados numéricos , Estados Unidos
11.
Lancet ; 394(10208): 1560-1579, 2019 10 26.
Artigo em Inglês | MEDLINE | ID: mdl-31657732

RESUMO

We summarise the evidence for medicinal uses of opioids, harms related to the extramedical use of, and dependence on, these drugs, and a wide range of interventions used to address these harms. The Global Burden of Diseases, Injuries, and Risk Factors Study estimated that in 2017, 40·5 million people were dependent on opioids (95% uncertainty interval 34·3-47·9 million) and 109 500 people (105 800-113 600) died from opioid overdose. Opioid agonist treatment (OAT) can be highly effective in reducing illicit opioid use and improving multiple health and social outcomes-eg, by reducing overall mortality and key causes of death, including overdose, suicide, HIV, hepatitis C virus, and other injuries. Mathematical modelling suggests that scaling up the use of OAT and retaining people in treatment, including in prison, could avert a median of 7·7% of deaths in Kentucky, 10·7% in Kiev, and 25·9% in Tehran over 20 years (compared with no OAT), with the greater effects in Tehran and Kiev being due to reductions in HIV mortality, given the higher prevalence of HIV among people who inject drugs in those settings. Other interventions have varied evidence for effectiveness and patient acceptability, and typically affect a narrower set of outcomes than OAT does. Other effective interventions focus on preventing harm related to opioids. Despite strong evidence for the effectiveness of a range of interventions to improve the health and wellbeing of people who are dependent on opioids, coverage is low, even in high-income countries. Treatment quality might be less than desirable, and considerable harm might be caused to individuals, society, and the economy by the criminalisation of extramedical opioid use and dependence. Alternative policy frameworks are recommended that adopt an approach based on human rights and public health, do not make drug use a criminal behaviour, and seek to reduce drug-related harm at the population level.


Assuntos
Analgésicos Opioides/uso terapêutico , Overdose de Drogas/mortalidade , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Analgésicos Opioides/envenenamento , Overdose de Drogas/epidemiologia , Saúde Global , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Transtornos Relacionados ao Uso de Opioides/terapia , Prevalência , Fatores de Risco
12.
Urology ; 134: 103-108, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31536742

RESUMO

OBJECTIVE: To measure the incidence of persistent opioid use following ureteroscopy (URS). Over 100 Americans die every day from opioid overdose. Recent studies suggest that many opioid addictions surface after surgery. METHODS: Using claims data, we identified adults who underwent outpatient URS for treatment of upper tract stones between January 2008 and December 2016 and filled an opioid prescription attributable to URS. We then measured the rate of new persistent opioid use-defined as continued use of opioids 91-180 days after URS among those who were previously opioid-naive. Finally, we fit multivariable models to assess whether new persistent opioid use was associated with the amount of opioid prescribed at the time of URS. RESULTS: In total, 27,740 patients underwent outpatient URS, 51.2% of whom were opioid-naïve. Nearly 1 in 16 (6.2%) opioid-naïve patients developed new persistent opioid use after URS. Six months following surgery, beneficiaries with new persistent opioid use continued to fill prescriptions with daily doses of 4.2 oral morphine equivalents. Adjusting for measured sociodemographic and clinical differences, patients in the highest tercile of opioids prescribed at the time of URS had 69% higher odds of new persistent opioid use compared to those in the lowest tercile (odds ratio, 1.69; 95% CI, 1.41-2.03). CONCLUSION: Nearly 1 in 16 opioid-naive patients develop new persistent opioid use after URS. New persistent opioid use is associated with the amount of opioid prescribed at the time of URS. Given these findings, urologists should re-evaluate their post-URS opioid prescribing patterns.


Assuntos
Analgésicos Opioides , Transtornos Relacionados ao Uso de Opioides , Dor Pós-Operatória , Padrões de Prática Médica , Ureteroscopia , Cálculos Urinários/cirurgia , Adulto , Procedimentos Cirúrgicos Ambulatórios/estatística & dados numéricos , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/efeitos adversos , Demografia , Feminino , Humanos , Revisão da Utilização de Seguros , Masculino , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/etiologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/epidemiologia , Dor Pós-Operatória/etiologia , Fatores de Risco , Fatores Socioeconômicos , Estados Unidos/epidemiologia , Ureteroscopia/efeitos adversos , Ureteroscopia/métodos , Urologistas/estatística & dados numéricos
13.
West J Emerg Med ; 20(5): 804-809, 2019 Aug 20.
Artigo em Inglês | MEDLINE | ID: mdl-31539338

RESUMO

INTRODUCTION: Screening of patients for opioid risk has been recommended prior to opioid prescribing. Opioids are prescribed frequently in the emergency department (ED) setting, but screening tools are often of significant length and therefore limited in their utility. We describe and evaluate three approaches to shortening a screening tool: creation of a short form; curtailment; and stochastic curtailment. METHODS: To demonstrate the various shortening techniques, this retrospective study used data from two studies of ED patients for whom the provider was considering providing an opioid prescription and who completed the Screener and Opioid Assessment for Patients with Pain-Revised, a 24-item assessment. High-risk criteria from patients' prescription drug monitoring program data were used as an endpoint. Using real-data simulation, we determined the sensitivity, specificity, and test length of each shortening technique. RESULTS: We included data from 188 ED patients. The original screener had a test length of 24 questions, a sensitivity of 44% and a specificity of 76%. The 12-question short form had a sensitivity of 41% and specificity of 75%. Curtailment and stochastic curtailment reduced the question length (mean test length ranging from 8.1-19.7 questions) with no reduction in sensitivity or specificity. CONCLUSION: In an ED population completing computer-based screening, the techniques of curtailment and stochastic curtailment markedly reduced the screening tool's length but had no effect on test characteristics. These techniques can be applied to improve efficiency of screening patients in the busy ED environment without sacrificing sensitivity or specificity.


Assuntos
Analgésicos Opioides/efeitos adversos , Serviço Hospitalar de Emergência , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Padrões de Prática Médica , Programas de Monitoramento de Prescrição de Medicamentos/organização & administração , Adulto , Feminino , Humanos , Masculino , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Reprodutibilidade dos Testes , Estudos Retrospectivos , Inquéritos e Questionários
14.
Br J Anaesth ; 123(5): 627-636, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31563269

RESUMO

BACKGROUND: Excessive opioid prescribing after surgery has been recognised as a contributor to the current crisis of opioid addiction and overdose. Clinicians may potentially tackle this crisis by using opioid-free postoperative analgesia; however, the scientific literature addressing this approach is sparse and heterogeneous, thereby limiting robust conclusions. A scoping review was conducted to systematically map the extent, range, and nature of the literature addressing postoperative opioid-free analgesia. METHODS: Eight bibliographic databases were searched for studies addressing opioid-free analgesia after a major surgery. We extracted the study characteristics, including design, country, year, surgical procedure(s), and interventions. Results were organised thematically according to surgical specialty and targeted phase of recovery: in hospital (early recovery, ≤24 h after operation; intermediate recovery, >24 h) and post-discharge (late recovery). Reporting was according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement for scoping reviews. RESULTS: We identified 424 studies addressing postoperative opioid-free analgesia. The number of studies conducted in countries where the opioid crisis is primarily focused was remarkably low (USA, n=11 [3%]; Canada, n=5 [1%]). Many RCTs compared opioid-free vs opioid analgesia during hospital stay (n=117), but few targeted analgesia post-discharge (n=8). Studies were predominantly focused on procedures in orthopaedic, general, and gynaecological/obstetric surgery. Limited attention has been directed towards non-pharmacological pain interventions. We did not identify knowledge synthesis studies (i.e. systematic reviews and meta-analyses) focused on the comparative effectiveness of opioid-free vs opioid analgesia. CONCLUSIONS: Opioids remain a mainstay analgesic for managing pain after surgery, but alternative analgesia strategies should not be overlooked. This scoping review indicates numerous opportunities for future research targeting opioid-free postoperative analgesia. REVIEW REGISTRATION: http://www.researchregistry.com; ID: reviewregistry576.


Assuntos
Analgésicos não Entorpecentes/administração & dosagem , Analgésicos Opioides/administração & dosagem , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Dor Pós-Operatória/prevenção & controle , Padrões de Prática Médica/estatística & dados numéricos , Uso de Medicamentos/estatística & dados numéricos , Humanos , Manejo da Dor/métodos , Cuidados Pós-Operatórios/métodos
15.
Am J Health Syst Pharm ; 76(11): 829-834, 2019 May 17.
Artigo em Inglês | MEDLINE | ID: mdl-31415689

RESUMO

PURPOSE: Describe patient-, clinician-, system-, and community-level interventions for pain management developed and employed by 9 healthcare systems across the United States and report on lessons learned from the implementation of these interventions. SUMMARY: The high cost associated with pain coupled with the frequent use of opioid analgesics as primary treatment options has made novel pain management strategies a necessity. Interventions that target multiple levels within healthcare are needed to help combat the opioid epidemic and improve strategies to manage chronic pain. Patient-level interventions implemented ranged from traditional paper-based educational tools to videos, digital applications, and peer networks. Clinician-level interventions focused on providing education, ensuring proper follow-up care, and establishing multidisciplinary teams that included prescribers, pharmacists, nurses, and other healthcare professionals. System- and community-level interventions included metric tracking and analytics, electronic health record tools, lockbox distribution for safe storage, medication return bins for removal of opioids, risk assessment tool utilization, and improved access to reversal agents. CONCLUSION: Strategies to better manage pain can be implemented within health systems at multiple levels and on many fronts; however, these changes are most effective when accepted and widely used by the population for which they are targeted.


Assuntos
Analgésicos Opioides/efeitos adversos , Dor Crônica/tratamento farmacológico , Prestação Integrada de Cuidados de Saúde/organização & administração , Manejo da Dor/métodos , Assistência Farmacêutica/organização & administração , Implementação de Plano de Saúde , Humanos , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Manejo da Dor/efeitos adversos , Farmacêuticos/organização & administração , Estados Unidos/epidemiologia
16.
Expert Opin Pharmacother ; 20(16): 1993-2005, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31418602

RESUMO

Introduction: Opioid addiction is a worldwide disease with a significant impact. A multitude of physical and mental comorbidities are associated with opioid addiction, pain being one of the most relevant. Insufficient pain management may lead to a disruption in medical treatment, self-medication, and subsequent harm to patients. Areas covered: In this review, the authors provide a general overview of opioid addiction. A literature search for pain management and opioid maintenance treatment was conducted. Different settings of acute or chronic pain and situations specific to patients addicted to opioids are described. Pain management therapy in addiction is also addressed with an emphasis on treatment strategies such as the optimization of methadone and buprenorphine medication, additional opioid analgesia, and multimodal pain management. Expert opinion: Opioid addiction is a growing global health concern, and maintenance therapy remains an effective and lifesaving treatment option. However, there remains uncertainty on the appropriate pain management for this patient group. The backbone of pain management in opiate-addicted patients remains maintenance therapy while adjunctive treatment such as regional analgesia, non-opioid analgesia, antidepressants, steps to improve sleep, acceptance and commitment therapy, biofeedback, and hypnosis should be considered. Additional opioid medication is possible as well.


Assuntos
Analgésicos Opioides/uso terapêutico , Dor Crônica/tratamento farmacológico , Manejo da Dor/métodos , Anti-Inflamatórios não Esteroides/uso terapêutico , Antidepressivos/uso terapêutico , Humanos , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides/patologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle
17.
Nurs Older People ; 31(3): 40-48, 2019 May 23.
Artigo em Inglês | MEDLINE | ID: mdl-31468789

RESUMO

There is little doubt that opiates have transformed healthcare, particularly in relation to pain management. However, many patients prescribed this type of drug develop problems such as dependency. Although we do not know how many older people have developed such problems due to opiate use we know that some will. It is important for nurses to understand the context in which opiates are used, as well as the specific needs of older people and how to respond to them.


Assuntos
Enfermagem Geriátrica , Alcaloides Opiáceos/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Manejo da Dor/enfermagem , Idoso , Humanos , Alcaloides Opiáceos/efeitos adversos , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Medição de Risco
19.
Surgery ; 166(4): 593-600, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31326187

RESUMO

BACKGROUND: Opioid-prescribing practices for minimally injured trauma patients are unknown. We hypothesized that opioid-prescribing frequency and morphine-equivalent doses prescribed have decreased in recent years, specifically surrounding an acute prescribing limit implemented in August 2017 mandating opioid prescriptions not exceed 210 morphine-equivalent doses. METHODS: A single-center retrospective study was performed in the month of May during the years 2015 to 2018 on minimally injured trauma patients in a level I trauma center. Minimally injured trauma patients included patients discharged within 2 midnights of trauma evaluation without surgical intervention. Primary outcomes were discharge opioid-prescribing frequency and dosing in morphine-equivalent doses. Secondary outcomes were occurrence and timing of postdischarge follow-up. RESULTS: For 673 minimally injured trauma patients, opioid-prescribing frequency and morphine-equivalent doses prescribed decreased between 2015 and 2017 (49.3% to 31.5%, P = .006, mean 229 to 146 morphine-equivalent doses, P = .007). Decreases between 2017 and 2018 were not statistically significant. Acute prescribing limit compliance was 97% in 2018. After the acute prescribing limit was implemented, outpatient opioid prescribing did not increase and time to earliest follow-up did not decrease. CONCLUSION: Opioid-prescribing frequency and morphine-equivalent doses prescribed to minimally injured trauma patients decreased dramatically between 2015 and 2018. These changes occurred primarily before the implementation of an acute prescribing limit; however, incremental improvement and high compliance since implementation are demonstrated. Patients did not have significantly earlier follow-up encounters for pain or additional opioid prescriptions. Prospective research on pain control for minimally injured trauma patients is needed.


Assuntos
Analgésicos Opioides/administração & dosagem , Uso de Medicamentos/legislação & jurisprudência , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Padrões de Prática Médica/legislação & jurisprudência , Ferimentos e Lesões/tratamento farmacológico , Estudos de Coortes , Continuidade da Assistência ao Paciente , Relação Dose-Resposta a Droga , Esquema de Medicação , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Determinação de Necessidades de Cuidados de Saúde , Manejo da Dor , Alta do Paciente , Estudos Retrospectivos , Centros de Traumatologia , Estados Unidos , Ferimentos e Lesões/diagnóstico
20.
J Opioid Manag ; 15(3): 183-191, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31343720

RESUMO

OBJECTIVE: To characterize primary care physicians' (PCPs') perceptions of the reasons patients receive opioid medications from both VA and non-VA healthcare systems. DESIGN: Qualitative. SETTING: Department of Veterans Affairs (VA). PARTICIPANTS: Forty-two VA PCPs who prescribed opioids to at least 15 patients and who practiced in Massachusetts, Illinois, or Pennsylvania. METHODS: Thirty-minute, semistructured telephone interviews were conducted in 2016, addressing topics regarding PCPs' experiences and perspectives on patients who use both VA and non-VA healthcare systems to obtain prescription opioids. The analysis focused on two questions: attributes that PCPs believe characterize dual-use patients and reasons that PCPs believe patients obtain opioids from both VA and non-VA sources. RESULTS: PCPs identified multiple attributes of, and reasons for, patients obtaining opioid medications from both VA and non-VA healthcare systems, including pain issues, opioid misuse, having healthcare managed through multiple healthcare systems, and transferring care between systems. More than half of the PCPs identified addiction and diversion as key attributes and reasons why patients obtain prescription opioids from multiple sources. PCPs also identified several behavioral and psychological factors as attributes of these patients. CONCLUSIONS: PCPs within the VA have varying perceptions of patients obtaining opioid medications from multiple healthcare systems, with pain complaints and opioid misuse as the primary themes. This knowledge about PCPs' perceptions can be incorporated into interventions to better manage pain and prescription opioid use by VA patients.


Assuntos
Analgésicos Opioides/administração & dosagem , Transtornos Relacionados ao Uso de Opioides , Médicos de Atenção Primária/psicologia , Veteranos , Humanos , Massachusetts , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Percepção , Veteranos/estatística & dados numéricos
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