Obstructive Sleep Apnea and Chronic Opioid Use

The use of opioids has been associated with development of sleep-disordered breathing, including central apneas, nocturnal oxygen desaturations, and abnormal breathing patterns. We describe sleep-disordered breathing and its subsequent treatment in a group of obstructive sleep apneic patients on chronic opioid therapy. Clinical evaluation followed by diagnostic overnight polysomnogram was performed in subjects on chronic opioid therapy who met the study criteria. All subjects had an initial CPAP titration followed by a repeat clinical evaluation. Subjects with an apnea-hypopnea index (AHI) ≥ 5 continued to report symptoms and had follow-up titration with bilevel positive therapy; then bilevel positive-pressure therapy with a back-up rate was then performed. Age-, sex-, and disease-severity-matched obstructive sleep apnea patients served as controls. Forty-four study participants, including a large group of women (50%), and 44 controls were enrolled in the study. Opioid subjects had AHI = 43.86 ± 1.19, with a central apnea index of 0.64 ± 1.36. Two abnormal breathing patterns were seen, including decreased inspiratory effort during an obstructive event and longer than expected pauses in breathing. Despite adequate titration with CPAP and bilevel positive-pressure therapy, nocturnal awakenings and central apnea awakenings persisted (AHI and central apnea indices of 13.81 ± 2.77 and 11.52 ± 2.12, respectively). Treatment with bilevel positive-pressure therapy with a back-up rate controlled the problem. Nonobese OSA patients with opioid intake have obstructive breathing with a different pattern. In this study, bilevel positive-pressure therapy with a back-up rate was the most effective treatment.     

Opioid Overdose Risk Following Hospital Discharge Among Individuals Prescribed Long-Term Opioid Therapy: a Risk Interval Analysis

BackgroundIndividuals prescribed long-term opioid therapy (LTOT) have increased risk of readmission and death after hospital discharge. The risk of opioid overdose during the immediate post-discharge time period is unknown.ObjectiveTo examine the association between time since hospital discharge and opioid overdose among individuals prescribed LTOT.DesignSelf-controlled risk interval analysis.ParticipantsAdults prescribed LTOT with at least one hospital discharge at a safety-net health system and a non-profit healthcare organization in Colorado.Main MeasuresWe identified individuals prescribed LTOT who were discharged from January 2006 through June 2019. The outcome was a composite of fatal and non-fatal opioid overdoses during a 90-day post-discharge observation period, identified using electronic health record (EHR) and vital statistics data. Risk intervals included days 0–6 after index and subsequent hospital discharges. Control intervals ranged from days 7 to 89 after index discharge and included all other time during the observation period that did not fall within a risk interval or time readmitted during a subsequent hospitalization, which was excluded. Poisson regression was used to estimate incidence rate ratios (IRR) and 95% confidence intervals (CI) for overdose events during risk in comparison to control intervals.Key ResultsWe identified 7695 adults (63.3% over 55 years, 59.4% female, 20.3% Hispanic) who experienced 9499 total discharges during the study period. Twenty-one overdoses occurred during their observation periods (1174 per 100,000 person-years [9 in risk, 12 in control]). Overdose risk was significantly higher during the risk interval in comparison to the control interval (IRR 6.92; 95% CI 2.92–16.43).ConclusionDuring the first 7 days after hospital discharge, individuals prescribed LTOT appear to be at elevated risk for opioid overdose. Clarifying mechanisms of overdose risk may help inform in-hospital and post-discharge prevention strategies.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-022-08014-1.KEY WORDS: opioid, LTOT, overdose, hospitalization, discharge     

Pending Studies at Hospital Discharge: A Pre-post Analysis of an Electronic Medical Record Tool to Improve Communication at Hospital Discharge

Background

Achieving safe transitions of care at hospital discharge requires accurate and timely communication. Both the presence of and follow-up plan for diagnostic studies that are pending at hospital discharge are expected to be accurately conveyed during these transitions, but this remains a challenge.

Objective

To determine the prevalence, characteristics, and communication of studies pending at hospital discharge before and after the implementation of an electronic medical record (EMR) tool that automatically generates a list of pending studies.

Design

Pre-post analysis.

Patients

260 consecutive patients discharged from inpatient general medicine services from July to August 2013.

Intervention

Development of an EMR-based tool that automatically generates a list of studies pending at discharge.

Main Measures

The main outcomes were prevalence and characteristics of pending studies and communication of studies pending at hospital discharge. We also surveyed internal medicine house staff on their attitudes about communication of pending studies.

Key Results

Pre-intervention, 70 % of patients had at least one pending study at discharge, but only 18 % of these were communicated in the discharge summary. Most studies were microbiology cultures (68 %), laboratory studies (16 %), or microbiology serologies (10 %). The majority of study results were ultimately normal (83 %), but 9 % were newly abnormal. Post-intervention, communication of studies pending increased to 43 % (p < 0.001).

Conclusions

Most patients are discharged from the hospital with pending studies, but in usual practice, the presence of these studies has rarely been communicated to outpatient providers in the discharge summary. Communication significantly increased with the implementation of an EMR-based tool that automatically generated a list of pending studies from the EMR and allowed users to import this list into the discharge summary. This is the first study to our knowledge to introduce an automated EMR-based tool to communicate pending studies.KEY WORDS: Applied informatics, Care transitions, Electronic health records, Continuity of care, Health information technology, Hospital medicine, Medical informatics, Patient safety, Quality improvement, Communication     

Relationship of Opioid Use and Dosage Levels to Fractures in Older Chronic Pain Patients

Background  

Opioids have been linked to increased risk of fractures, but little is known about how opioid dose affects fracture risk.     

Training in Safe Opioid Prescribing and Treatment of Opioid Use Disorder in Internal Medicine Residencies: a National Survey of Program Directors

BackgroundTraining future clinicians in safe opioid prescribing (SOP) and treatment of opioid use disorder (OUD) is critical to address the opioid epidemic. The Accreditation Council on Graduate Medical Education requires all programs to provide instruction and experience in pain management and will mandate addiction medicine clinical experiences for internal medicine trainees.ObjectiveAssess residents’ training in SOP and treatment of OUD and identify training barriers.DesignCross-sectional nationally representative survey was emailed in 2019.ParticipantsFour hundred twenty-two Association of Program Directors in Internal Medicine members in US internal medicine residency programs.Main MeasuresProgram opportunities and challenges to developing or implementing training in SOP, treatment of OUD, and buprenorphine waiver training, and perceived curricular effectiveness.Key ResultsThe response rate was 69.4% (293/422). Most programs required didactics in SOP (94.2%) and treatment of OUD (71.7%). Few programs required clinical experiences including addiction medicine clinics (28/240, 11.7%), inpatient consult services (11/240, 4.6%), or offsite treatment rotations (8/240, 3.3%). Lack of trained faculty limited developing or implementing curricula (61.5%). Few respondents reported that their program was “very effective” in teaching SOP (80/285, 28.1%) or treatment of OUD (43/282, 15.3%). Some programs offered buprenorphine waiver training to residents (83/286, 29.0%) and faculty (94/286, 32.9%) with few mandating training (11.7% (28/240) and 5.4% (13/240) respectively). Only 60 of 19,466 (0.3%) residents completed buprenorphine waiver training. Primary care programs/tracks were more likely to offer waiver training to residents (odds ratio [OR], 3.07; 95% CI, 1.68–5.60; P < 0.001) and faculty (OR, 1.08; 95% CI, 1.01–3.22; P = 0.05).ConclusionsIn this nationally representative survey, few internal medicine residency programs provided clinical training in SOP and treatment of OUD, and training was not viewed as very effective. Lack of effective training may have adverse implications for patients, clinicians, and society.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-07102-y.KEY WORDS: graduate medical education, safe opioid prescribing, treatment of opioid use disorder     

Challenges at Care Transitions: Failure to Follow Medication Changes Made at Hospital Discharge

BackgroundIn-hospital medication reconciliation has not demonstrated reductions in adverse health outcomes, possibly because patients do not follow the changes made to their preadmission medications. Our objective was to determine the incidence of and variables associated with failure to follow newly prescribed therapies, discontinued medications, and dose changes.MethodsA prospective cohort study of patients admitted to hospitals in Montreal, Quebec between 2014 and 2016 was conducted. Failure to follow medication changes 30 days post discharge was measured by comparing prescribed and dispensed medications. Multivariable logistic regression was used to determine characteristics associated with failure to follow changes.ResultsAmong 2655 patients, mean age was 69.5 years (SD 14.7), and 1581 (60%) were males. There were 10,068 medication changes made at hospital discharge and 24% were not followed in the 30 days post discharge. Thirty percent of dose modifications were filled at the incorrect dose, 27% of new medications were not filled, and 12% of discontinued medications were filled. A number of factors increased the risk of failure to follow medication changes, including increasing out-of-pocket medication costs (adjusted odds ratio [aOR] 1.12; 95% confidence interval [CI], 1.07-1.18), discharge to long-term care facility (aOR 2.29; 95% CI, 1.63-3.08), and not having medications dispensed prior to admission (aOR 4.67; 95% CI, 3.75-5.90).ConclusionOne in 4 hospital medication changes was not followed post discharge. Health policy aimed at eliminating out-of-pocket medication costs and investigation of factors influencing failure to follow changes for those not dispensed medications prior to admission and for long-term care residents are important next steps to address this issue.     

Adherence to Clinical Guidelines for Opioid Therapy for Chronic Pain in Patients with Substance Use Disorder

BACKGROUND  

Patients with chronic non-cancer pain (CNCP) have high rates of substance use disorders (SUD). SUD complicates pain treatment and may lead to worse outcomes. However, little information is available describing adherence to opioid treatment guidelines for CNCP generally, or guideline adherence for patients with comorbid SUD.