Guideline for Prescribing Opioids for Chronic Pain

Improving the way opioids are prescribed through clinical practice guidelines can ensure patients have access to safer, more effective chronic pain treatment while reducing the number of people who misuse, abuse, or overdose from these drugs. The Centers for Disease Control and Prevention (CDC) developed and published the Guideline for Prescribing Opioids for Chronic Pain to provide recommendations for the prescribing of opioid pain medication for patients 18 and older in primary care settings. Recommendations focus on the use of opioids in treating chronic pain (pain lasting longer than 3 months or past the time of normal tissue healing) outside of active cancer treatment, palliative care, and end-of-life care.     

Preoperative Management of Opioid and Nonopioid Analgesics: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement

There is a lack of guidelines for preoperative dosing of opioid and nonopioid pain medications for surgical patients, which can lead to suboptimal preoperative pain control. The Society for Perioperative Assessment and Quality Improvement identified preoperative dosing of opioid and nonopioid analgesics as an area in which consensus could improve patient care. The aim of this guideline is to provide consensus that will allow perioperative physicians to make optimal recommendations regarding preoperative pain medication dosing. Six categories of pain medications were identified: opioid agonists, opioid antagonists, opioid agonist-antagonists, acetaminophen, muscle relaxants, and triptans/headache medications. We then used a Delphi survey technique to develop consensus recommendations for preoperative dosing of individual medications in each of these groups.     

The trilateral opioid contract. Bridging the pain clinic and the primary care physician through the opioid contract

We have extended the traditional use of opioid contracts to involve the primary care physician (PCP). The PCP was asked to collaborate with the pain specialist's decision to use opioids by cosigning an opioid contract. Explicit in the agreement was the understanding that the primary care physician would assume prescribing the refills for these medications once the opioid regimen had become stabilized. The present study was a retrospective chart review of the first 81 patients with non-malignant chronic pain who received an opioid agreement requiring the participation of the primary care physician. Sixty-nine of the 81 patients (85%) agreed to the terms of the contract initially, but only 50 of these 69 individuals (72%) successfully obtained their PCP's written agreement for the prescribing of opioids for chronic pain management. Despite expecting reluctance on the part of the PCP to enter into this agreement, the low compliance rate was due to lack of commitment on the part of the patient, who either refused to sign the contract outright or, after initially agreeing to sign the contract, did not have it signed by the PCP. If the PCP did not agree to sign the opioid contract, the patient was tapered off the medication. If the contract was approved and signed by the PCP, there were no subsequent reversals by this physician in terms of agreeing to continue to prescribe opioids. In all cases in which a contract was completed, the patient was successfully stabilized on an appropriate opioid regimen and then discharged back to the care of the PCP for long-term opioid treatment. The opioid contract may be an effective tool for networking specialty and primary care services in the delivery of chronic opioid therapy.     

Misuse of over the counter medicines in community pharmacies in Scotland

The general public are taking more responsibility for their health, using community pharmacy as a source to access medication. There are a reported increase and change in the misuse of OTC medication from community pharmacies in Scotland (Wright et al, 2015). This article was designed to examine the self-reported use of medication from a small sample of community pharmacies in Scotland. The questionnaire gathered patient demographics and details of medicines used. The study concentrated on two treatment areas, opioid analgesics, and sedative antihistamines licensed as a sleep aid. Both previously identified as the most prevalent OTC medications that were perceived to being misused (Matheson et al, 2007). Data were collected over a short time period in 2015 from 15 community pharmacies. The data demonstrate the widespread misuse of OTC. The most prevalent group identified as females, 41–60 years old and employed. It was most commonly reported that the recommended treatment duration is exceeded rather than the maximum recommended daily dose. The recommendations from the article are that there needs to be greater awareness for pharmacists, pharmacy staff, and general public on the potential dangers of misusing OTC medications and the importance of adhering to the recommended dosing and duration guidelines.     

Beliefs about antidepressant medications in primary care patients: relationship to self-reported adherence

BACKGROUND: Adherence to medication is unacceptably low in both medical and psychiatric disorders. Explanatory models of illness beliefs and behaviors suggest that an individual's beliefs about a disorder and its treatment will influence their adherence. Given that beliefs about medications may influence adherence to antidepressants, we examined beliefs about medications in relation to antidepressant adherence in a primary care sample. OBJECTIVE: The purpose of this report is to 1) describe beliefs about medication in primary care patients prescribed antidepressants for depression; 2) examine the factor structure of the Beliefs about Medicines Questionnaire (BMQ) and compare it with the previously reported factor structure of the BMQ in medical conditions; and 3) examine the association of medication beliefs with self-reported medication adherence. RESULTS: Factor analysis indicates that the BMQ is valid in a sample of primary care patients receiving treatment for depression and has a similar factor structure to that obtained in samples of patients with chronic medical conditions. Beliefs about medications are significantly associated with self-reported adherence. Severity of depressive symptoms and specific concerns about antidepressants are significantly associated with self-reported medication-taking behavior. Findings suggest that in addition to telling patients how to take their medications, primary care physicians should also educate patients about the short- and long-term effects of the medication, how the medication works, and that antidepressants are not addictive.     

Knowledge assessment and information needs of oncology nurses regarding inpatient medication

Although several studies have evaluated the frequency and consequences of medication errors, few have explored their causes. In particular, nurses' knowledge regarding medications has been evaluated minimally. This survey was conducted to determine how nurses master medications prescribed to their patients to determine problems nurses may have with prescribed drugs and identify possible support tools. A questionnaire was created and presented to nurses in a French cancer center. A majority of the respondents correctly identified pharmaceutical classes and medications, as well as administration and storage conditions. However, side effects, contraindications, and drug-drug interactions were not adequately identified. Nurses reported facing problems mainly related to drug administration, drug storage, and generic drugs and their therapeutic equivalence. Multiple tools are in development to help nurses in these areas. This collaborative study between pharmacy and care wards identifies some difficulties nurses have regarding drugs and will help to establish improvement measures within the hospital.     

Health insurance status, cost-related medication underuse, and outcomes among diabetes patients in three systems of care

BACKGROUND: Chronically ill patients often experience difficulty paying for their medications and, as a result, use less than prescribed. OBJECTIVES: The objectives of this study were to determine the relationship between patients with diabetes' health insurance coverage and cost-related medication underuse, the association between cost-related underuse and health outcomes, and the role of comorbidity in this process. RESEARCH DESIGN: We used a patient survey with linkage to insurance information and hemoglobin A1C (A1C) test results. PATIENTS: We studied 766 adults with diabetes recruited from 3 Veterans Affairs (VA), 1 county, and 1 university healthcare system. MAIN OUTCOMES: Main outcomes consisted of self-reported medication underuse as a result of cost, A1C levels, symptom burden, and Medical Outcomes Study 12-Item Short-Form physical and mental functioning scores. RESULTS: Fewer VA patients reported cost-related medication underuse (9%) than patients with private insurance (18%), Medicare (25%), Medicaid (31%), or no health insurance (40%; P <0.0001). Underuse was substantially more common among patients with multiple comorbid chronic illnesses, except those who used VA care. The risk of cost-related underuse for patients with 3+ comorbidities was 2.8 times as high among privately insured patients as VA patients (95% confidence interval, 1.2-6.5), and 4.3 to 8.3 times as high among patients with Medicare, Medicaid, or no insurance. Individuals reporting cost-related medication underuse had A1C levels that were substantially higher than other patients (P <0.0001), more symptoms, and poorer physical and mental functioning (all P <0.05). CONCLUSIONS: Many patients with diabetes use less of their medication than prescribed because of the cost, and those reporting cost-related adherence problems have poorer health. Cost-related adherence problems are especially common among patients with diabetes with comorbid diseases, although the VA's drug coverage may protect patients from this increased risk.     

Risk and Liabilities of Prescribing Compounded Medications

Abstract

Complications resulting from the use of compounded medications have become a troubling trend nationwide. There is a significant potential for patients to suffer serious harm from the use of substandard medications prepared by compounding pharmacies, and the reality of this problem has been demonstrated in several well-publicized incidences of serious medical complications, including patient deaths, that directly resulted from the use of medications prepared at compounding pharmacies. Unlike US Food and Drug Administration (FDA)-approved drugs, compounded products are not required to meet evidentiary standards for establishing safety and efficacy. Moreover, these products are not held to Good Manufacturing Practices, which require regular inspections, quality control testing, and rejection of material not meeting specifications. Physicians, as well as other prescribers, need to be aware that when a patient suffers harm from using a compounded medication, those injured patients may bring negligence and malpractice claims, not only against the pharmacy and the pharmacist responsible for preparing the medication, but also against the prescribing physician and the physician's practice. Consequently, the best way for physicians to manage professional risk and avoid both litigation and potential negative patient outcomes related to compounded pharmaceuticals is to not use these products if there is an FDA-approved product available. However, if the use of a compounded medication is medically necessary, then physicians should adhere to the FDA guidance concerning traditional compounding. Moreover, it would be prudent for any physician who intends to either resell or participate in the distribution of compounded products beyond the direct treatment of their patients to consider obtaining the appropriate insurance coverage for this activity.     

Chief complaints, diagnoses, and medications prescribed seven weeks post-Katrina in New Orleans

BACKGROUND: In the aftermath of Hurricane Katrina, widespread flooding devastated the New Orleans healthcare system. Prior studies of post-hurricane healthcare do not consistently offer evidence-based recommendations for re-establishing patient care post-disaster. The primary objective of this study is to examine associations between patient characteristics, chief complaints, final diagnoses, and medications prescribed at a post-Katrina clinic to better inform strategic planning for post-disaster healthcare delivery (e.g., charitable donations of medications and medical supplies). METHODS: This study is a retrospective chart review of 465 patient visits from 02 September 2005 to 22 October 2005 at a post-Katrina clinic in New Orleans, Louisiana that was open for seven weeks, providing urgent care services in the central business district. Using logistic regression, the relationships between patient characteristics (date of visit, gender, age, evacuation status), type of chief complaint, final diagnosis, and type of medication prescribed was examined. RESULTS: Of 465 patients, 49.2% were middle-aged, 62.4% were men, 35% were relief workers, and 33.3% were evacuees; 35% of visits occurred in week five. Of 580 chief complaints, 71% were illnesses, 21% were medication refill requests, and 8.5% were injuries. Among 410 illness complaints, 25% were ears, nose, and throat (ENT)/dental, 17% were dermatologic, and 11% were cardiovascular. Most requested classes of medication refills for chronic medical conditions (n = 121) were cardiovascular (52%) and endocrine (24%). Most illness-related diagnoses (n = 400) were ENT/dental (18.2%), dermatologic (14.8%), cardiovascular (10.2%), and pulmonary (10.2%). Thirty-six percent of these diagnoses were infectious. Among 667 medications prescribed, 21% were cardiac agents, 13% pulmonary, 13% neurologic/musculoskeletal/pain, 11% antibiotics, 10% endocrine, and 9.3% anti-allergy. The likelihood of certain chief complaints, diagnoses, and medications prescribed varied with patient characteristics. CONCLUSIONS: Donations of certain classes of medications were more useful than others. Prevalence of select co-morbidities, the nature of patient involvement in recovery activities in the disaster area, and post-disaster health hazards may explain variations in chief complaints, diagnoses, and medications prescribed by patient characteristics.     

Migraine treatment with rizatriptan and non-triptan usual care medications: a pharmacy-based study

OBJECTIVE: To compare the effectiveness of rizatriptan to other non-triptan medications in the relief of migraine headache in usual care settings. BACKGROUND: Although rizatriptan has been shown to provide effective relief of migraine symptoms in clinical trials, limited data exist directly comparing its effectiveness with non-triptan medications. METHODS: Migraineurs aged 18 to 55 who had been prescribed a new antimigraine drug (rizatriptan 10 mg or a selected class of non-triptan oral medications) were recruited to participate in the study through a national retail pharmacy chain. Participants completed a baseline questionnaire at the enrollment and reported their treatment experiences by filling out the treatment diary after using the newly prescribed medication. The treatment outcomes of patients receiving rizatriptan were compared with those receiving non-triptan medications. Logistic regression analysis was applied to test statistical significance with adjustment for potential confounding factors. RESULTS: Of the 728 patients who entered the study, 693 (95.2%) completed the treatment diary. Patients treated with rizatriptan (192) and non-triptans (501) reported the following outcomes, respectively--onset of headache relief within 30 minutes post-dose: 25% versus 18%; self-defined significant headache relief within 2 hours post-dose: 71% versus 54%; pain free or mild pain at 2 hours post-dose: 58% versus 47%; completely symptom-free within 2 hours of post-dose: 32% versus 20%; return to usual activities within 2 hours post-dose: 39% versus 35%; and satisfied with treatment: 67% versus 55% (P <.05 in all comparisons with exception of returning to usual activities). CONCLUSION: Rizatriptan was significantly more effective than non-triptans in the relief of migraine headaches for patients obtaining prescribed migraine medications from a retail pharmacy. Additional studies at other usual care settings may be needed to confirm the findings.     

Knowledge and compliance with medications in South East Asian refugees

We evaluated knowledge about prescribed medications and compliance with taking those medications in 96 South East Asian refugees of different ethnic backgrounds seen in a primary care clinic. Two hundred and thirty (88%) of 262 prescribed medications were currently being taken by the patients. Although 97% of the medications were either named or described correctly, the correct rationale for taking the medication was known for only 79% and the correct dosage regimen for only 63%. Thirty–two (33%) of the 96 patients were not taking one or more of their prescribed medications, 17 (18%) were taking one or more medications not prescribed, 5 (5%) were taking duplicate forms of the same medication, and 4 (4%) were taking a medication that had been discontinued by the clinic provider. Seventy–two (75%) patients were taking one or more medications at an incorrect dose. Only 12 (12%) patients were fully compliant with all prescribed medications. We conclude that knowledge about and compliance with medications is a major problem among South East Asian patients attending a primary care refugee clinic.