Characteristics of methadone maintenance treatment patients prescribed opioid analgesics

ABSTRACT

Background: Opioid analgesic use and disorders have dramatically increased among the general American population and those receiving methadone maintenance treatment (MMT). Most research among MMT patients focuses on opioid analgesics misuse or disorders; few studies focus on MMT patients prescribed opioid analgesics. We describe demographic, clinical, and substance use characteristics of MMT patients prescribed opioid analgesics and compare them with MMT patients not prescribed opioid analgesics. Methods: We conducted a cross-sectional secondary data analysis using screening interviews from a parent study. From 2012 to 2015, we recruited adults from 3 MMT Bronx clinics. Questionnaire data included patterns of opioid analgesic use, substance use, comorbid illnesses, and demographic characteristics. Our main dependent variable was patients' report of currently taking prescribed opioid analgesics. To compare characteristics between MMT patients prescribed and not prescribed opioid analgesics, we conducted chi-square tests, t tests, and Mann-Whitney U tests. Results: Of 611 MMT patients, most reported chronic pain (62.0%), hepatitis C virus (HCV) infection (52.1%), and current use of illicit substances (64.2%). Of the 29.8% who reported currently taking prescribed opioid analgesics, most misused their opioid analgesics (57.5%). Patients prescribed (versus not prescribed) opioid analgesics were more likely to report human immunodeficiency virus (HIV) infection (adjusted odds ratio [aOR] = 1.6, 95% confidence interval [CI]: 1.1–2.3) and chronic pain (aOR = 7.6, 95% CI: 4.6–12.6). Conclusion: Among MMT patients primarily in 3 Bronx clinics, nearly one third reported taking prescribed opioid analgesics. Compared with patients not prescribed opioid analgesics, those prescribed opioid analgesics were more likely to report chronic pain and HIV infection. However, between these patients, there was no difference in illicit substance use. These findings highlight the complexity of addressing chronic pain in MMT patients.     

Protocol for a pilot and feasibility study of nurse practitioner-pharmacist telehealth collaboration to simplify complex medication regimens

IntroductionNew and flexible multidisciplinary workforce models are needed to address unnecessary medication regimen complexity in residential aged care facilities (RACFs). This study will investigate the feasibility of a nurse practitioner-pharmacist telehealth-based collaborative care model to simplify complex medication regimens.MethodsThis is a pragmatic, non-randomized pilot and feasibility study of up to 30 permanent residents from 4 RACFs in Western Australia. Simplification will be conducted in accordance with a validated 5-step implicit process. Nurse practitioners will identify residents potentially interested in and who may benefit from simplification, including any regulatory or safety imperatives that might preclude simplification. Medication regimens will be assessed by an off-site clinical pharmacist to identify opportunities for simplification in terms of drug–drug, drug–food, or drug–time interactions, and the availability of alternative formulations. The pharmacist will communicate simplification opportunities to nurse practitioners via video case conferencing. Nurse practitioners will then discuss simplification opportunities with the resident, caregiver and the health and care team, including any unintended consequences for the resident or RACF. The primary outcome measure will be feasibility (stakeholder acceptability, protocol adherence, recruitment and retention rates). Secondary outcomes include change in the number of medication administration times per day, medication and behavioral incidents, falls and fractures, hospitalization and mortality at 4 months.Ethics and disseminationEthical approval has been obtained from the Monash University Human Research Ethics Committee. Research findings will be disseminated through industry report, lay summaries, conference presentations and peer-reviewed publications.     

Restrictive opioid prescribing policies and evolving risk environments: A qualitative study of the perspectives of patients who experienced an accidental opioid overdose

BackgroundDespite policy efforts to prevent overdose, accidental overdoses among individuals prescribed opioids continue to occur. Guided by Rhodes’ Risk Environment Framework, we examined the unintended consequences of restrictive policies by identifying macro policy and micro-level contextual factors that patients prescribed opioids for pain identified as contributing to overdose events.MethodsSemi-structured interviews were conducted with 31 patients prescribed opioids who experienced an accidental opioid overdose between April 2017 and June 2019 in two health systems.ResultsWe identified three interrelated factors that emerged within an evolving risk environment and may have increased patients’ vulnerability for an accidental opioid overdose: desperation from persistent pain and comorbidities; limited knowledge about opioid medication safety and effectiveness; and restrictive opioid prescribing policies that exacerbated stigma, fear and mistrust and prevented open patient-clinician communication. When experiencing persistent pain, patients took matters into their own hands by taking more medications or in different intervals than prescribed, mixing them with other substances, or using illicitly obtained opioids.ConclusionFor some patients, macro-level policies and guidelines designed to reduce opioid overdoses by restricting opioid supply may have paradoxically created a micro-level risk environment that contributed to overdose events in a subset of patients.     

Opioid analgesic use in Australia and The Netherlands: a cross-country comparison

Background Increasing use of opioid analgesics (OA) has been reported worldwide. Objective To compare the use of OA in two countries in order to better understand these trends. Setting Outpatient settings in Australia and The Netherlands. Method We analysed publicly available government data on outpatient OA dispensing over 15 years (2000–2014). We compared dispensing trends for specific OA and explored medical (national clinical guidelines), contextual and policy-related factors to explain differences in use between the two countries. Main outcome measure OA prescribing in Australia and The Netherlands, absolute volume of use, preferred types of opioids and changes over time. Results The average annual increase in OA prescribing was 10% in Australia and 8% in The Netherlands between 2000 and 2014. In 2014, the total use of OA was 10.0 daily defined doses (DDD)/1000 population/day in Australia and 9.4 DDD/1000 population/day in The Netherlands. In Australia, the most commonly prescribed opioids were oxycodone and tramadol, compared to fentanyl and tramadol in The Netherlands. We found differences in prescribing guidelines, culture of prescribing and regulatory frameworks that could explain some of the observed differences. Conclusion OA prescribing has increased remarkably in both countries between 2000 and 2014 but the types of prescribed OA vary. Differences in national evidence-based guidelines influenced the types of OA used. Prescribing culture as well as regulatory policies and costs, may also contribute to the different patterns of OA use.

     

Impact of pharmacist outreach on glucagon prescribing

BackgroundHypoglycemia is a major limiting factor in the glycemic management of diabetes. As a method of treating hypoglycemia, the American Diabetes Association recommends glucagon to be prescribed for all individuals at increased risk of clinically impactful hypoglycemia. Glucagon Emergency Kits have been shown to reduce emergency department visits and overall health care costs. Despite these known benefits, glucagon continues to be underprescribed. Previous pharmacist-led interventions embedded in a single clinic have been shown to positively affect the rate of glucagon prescribing in patients with diabetes.ObjectiveThis study aimed to compare the rate of glucagon prescribing between quality improvement remote pharmacist outreach to multiple primary care and endocrinology specialty clinics and the control group in 1 month following a pharmacist-led provider outreach.MethodsThis was a single-center, 2-arm study with a simple randomization design.ResultsOn pharmacist outreach, 61 of 109 patients (56.0%) in the outreach group were prescribed a glucagon product within 1 month of their primary care provider (PCP) or endocrinology appointment compared with 1 of 113 (0.9%) of patients in the control group (P < 0.001). Glucagon prescribing occurred in 25 of 35 Black patients (71.4%) compared with 36 of 73 white patients (49.3%) in the outreach group. Glucagon prescribing was associated with race (P = 0.03; chi-square test).ConclusionsThe pharmacist-led provider outreach before a PCP or endocrinology appointment has a positive and statistically significant impact on glucagon prescribing rates. The pharmacist outreach had a higher impact on Black patients than white patients, possibly because of a lower rate of glucagon prescribing in Black patients before the outreach.     

The impact of pain management changes to an inpatient general admission electronic order-set

BackgroundOpioids pose many risks, and standardized ordering processes need to be created. In May 2020, our institution implemented pain management changes to the inpatient general admission electronic order-set and increased provider education on pain management prescribing.ObjectivesThis study aimed to investigate the impact of pain management changes to the inpatient general admission electronic order-set on opioid prescribing.MethodsData were collected by retrospective chart review of 376 patients who were admitted using the inpatient general admission electronic order-set at 8 hospital locations within an integrated health system. Two cohorts were identified for comparison: patients admitted pre-electronic order-set change (n = 183; August 2019) and patients admitted post-electronic order-set change (n = 193; August 2020). The primary end points were the amount of intravenous (IV) opioids received measured in morphine milligram equivalents (MME), the quantification of opioids received for pain management, and the oral MME prescribed on discharge.ResultsThere was no statistically significant difference in the use of IV opioids. There was, however, a statistically significant difference between the IV MME 24 to 48 hours with median 0 (interquartile range [IQR] 0, 6) and 0 (IQR 0, 0) for pre- and post-electronic order-set implementation, respectively (P = 0.003). Oxycodone was more frequently prescribed in the postimplementation cohort—55 patients (29%) compared with the 31 (17%) in the preimplementation cohort (P = 0.008). Tramadol was prescribed less frequently in the postimplementation cohort (n = 12 [6%]) than in preimplementation cohort (n = 28 [15%]) (P = 0.004). There was no statistically significant difference in the oral MME prescribed on discharge (P = 0.833).ConclusionChanges to the inpatient general admission electronic order-set had relatively little impact on the prescribing of opioids. Further electronic order-set changes or other methodologies should be explored to affect inpatient opioid use.     

A prospective,multisite implementation-efficacy trial of a collaborative prescriber-pharmacist model of care for Medication Assisted Treatment for Opioid Dependence: Protocol for the EPIC-MATOD study

BackgroundMedication Assisted Treatment for Opioid Dependence (MATOD) is clinically effective and cost effective, yet a lack of MATOD prescribers in the community limits access to this treatment in Australia. These shortages are often greatest in regional and rural areas.Objective(s)The Enhancing Pharmacist Involvement in Care (EPIC)-MATOD study will evaluate clinical and implementation outcomes among people with opioid dependence receiving MATOD through a collaborative pharmacist-prescriber model of care across multiple sites in a regional location (encompassing a mix of metropolitan and non-metropolitan areas) of Victoria, Australia.Methods and analysisThe EPIC-MATOD study is a prospective, multisite, implementation trial of collaborative MATOD care. Pharmacists and prescribers will be recruited through the local network of opioid pharmacotherapy providers. Patients will be recruited through participating healthcare providers. After induction into the collaborative care model, patients and healthcare professionals will be followed up over 6- (patients) and 12-months (pharmacists and prescribers) in a hybrid implementation-efficacy study, with outcomes mapped to the RE-AIM framework. The primary clinical efficacy endpoint is patient retention in treatment at 26 weeks. The primary implementation outcome is treatment capacity, based on prescriber time required to provide treatment through collaborative care compared with traditional care. Secondary clinical endpoints include attendance for dosing and clinical reviews, substance use, mental and physical health and overall well-being. Implementation costs, acceptability, and provider engagement in collaborative care will be used as secondary implementation outcome indicators. Time and costs associated with collaborative care, and health service utilisation, will also be estimated.Project impactThe study will provide important information on outcomes and acceptability of collaborative care for MATOD, as well as the cost and key considerations in delivering a collaborative model of care in Australia and other countries where similar treatment barriers exist.