An update on the safety of prescribing opioids in pediatrics.
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ABSTRACT:
SUBMITTER: Parikh JM
PROVIDER: S-EPMC6446903 | biostudies-literature | 2019 Feb
REPOSITORIES: biostudies-literature
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An update on the safety of prescribing opioids in pediatrics.
Parikh Jagroop M JM Amolenda Patricia P Rutledge Joseph J Szabova Alexandra A Chidambaran Vidya V
Expert opinion on drug safety 20190125 2
<h4>Introduction</h4>The opioid abuse epidemic and its toll on the adolescent population have heightened awareness for safer opioid prescribing practices in pediatric pain management. Opioids remain the mainstay of therapy for severe pain, although there is an emphasis on multimodal therapy. Areas covered: In this update, the authors present information on parenteral/oral opioids commonly used in pediatrics. Recommendations for opioid use in special circumstances including neonates and developme ...[more]
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| S-EPMC8513597 | biostudies-literature
Project description:Use of opioids during and shortly after an acute hospitalization is warranted in some clinical settings. However, given the potential of opioids for short-term adverse events and long-term physiologic tolerance, it is important to understand the frequency of opioid prescribing at hospital discharge, hospital variation, and patient and hospital factors associated with opioid prescribing, which is currently unknown in the United States.To estimate the frequency of opioid prescribing at hospital discharge among Medicare beneficiaries without an opioid prescription claim 60 days prior to hospitalization; to document hospital variation in prescribing; and to analyze patient and hospital factors associated with prescribing, including hospital average performance on pain-related Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) measures.Analysis of pharmacy claims of a 20% random sample of Medicare beneficiaries hospitalized in 2011 without an opioid prescription claim in the 60 days before hospitalization.Our main outcome was a new opioid claim within 7 days of hospital discharge. We estimated a multivariable linear probability model of patient factors associated with new opioid use and described hospital variation in adjusted rates of new opioid use. In multivariable linear regression analysis, we also analyzed hospital factors associated with average adjusted new opioid use at the hospital level, including the percentage of each hospital's patients who reported that their pain during hospitalization was always well controlled in the 2011 HCAHPS surveys.Among 623?957 hospitalizations, 92?882 (14.9%) were associated with a new opioid claim. Among those hospitalizations with an associated opioid claim within 7 days of hospital discharge, 32?731 (42.5%) of 77?092 were associated with an opioid claim after 90 days postdischarge. Across 2512 hospitals, the average adjusted rate of new opioid use within 7 days of hospitalization was 15.1% (interquartile range, 12.3%-17.4%; interdecile range, 10.5%-20.0%). A hospital's adjusted rate of new opioid use was modestly positively associated with the percentage of its inpatients reporting that their pain was always well managed (increase from 25th to the 75th percentile in the HCAHPS measure was associated with an absolute increase in new opioid use of 0.89 percentage points or a relative increase of 6.0%; P?<?.001).New opioid use after hospitalization is common among Medicare beneficiaries, with substantial variation across hospitals and a large proportion of patients using a prescription opioid 90 days after hospitalization. The degree to which observed hospital variation in short- and longer-term opioid use reflects variation in inappropriate prescribing at hospital discharge is unknown.
| S-EPMC4955877 | biostudies-literature
Project description:IntroductionWhile drug prescription should be based on established recommendations stemming from clinical trials but in pediatrics, many drugs are used without marketing authorization. Consequently recommendations are often based on clinical experience and the risk of inappropriate prescription (IP) is high. A tool for detecting IP in pediatrics-called POPI (Pediatrics: Omission of Prescriptions and Inappropriate prescriptions)-has been developed in France. However the relevance of its use at an international level is not known. Our aim has been to adapt POPI for a worldwide use.Material and methodA two-round Delphi online questionnaire was completed and validated by international experts to identify consensual items. They were asked to rate the validity of each items taking into account the recommendations and practices in their countries. Only propositions obtaining a median score in the upper tertile with an agreement of more than 75% of the panel-for the first round-and 85%-for the second round-were retained.ResultsOur panel included 11 pharmacists (55%) and 9 physicians (45%). The panelists came from 12 different countries: England, Belgium, Brazil, Canada, China, Ivory Coast, Ireland, Malaysia, Portugal, Switzerland, Turkey and Vietnam. At the end of the first round, of the 105 items of the original POPI tool, 80 items were retained including 16 items reworded and 25 items were deleted. In the second round, 14 experts participated in the study. This final international POPI tool is composed of 73 IP and omissions of prescriptions in the fields of neuropsychiatry, dermatology, infectiology, pneumology, gastroenterology, pain and fever.Discussion and conclusionThis study highlights international consensus on prescription practice in pediatrics. The use of this tool in everyday practice could reduce the risk of inappropriate prescription. The impact of the diffusion of POPI tool will be assessed in a prospective multicentric study.
| S-EPMC7535059 | biostudies-literature
Project description:ObjectivesHaving shown previously that an electronic prescription writer and decision support system improved pediatric prescribing behavior for otitis media in an academic clinic setting, we assessed whether point-of-care delivery of evidence could demonstrate similar effects for a wide range of other common pediatric conditions.DesignCluster randomized controlled trial.SettingA teaching clinic/clinical practice site and a primary care pediatric clinic serving a rural and semi-urban patient mix.ParticipantsA total of 36 providers at the teaching clinic/practice site and eight providers at the private primary pediatric clinic.InterventionAn evidence-based message system that presented real-time evidence to providers based on prescribing practices for acute otitis media, allergic rhinitis, sinusitis, constipation, pharyngitis, croup, urticaria, and bronchiolitis.Outcome measuresThe proportion of prescriptions dispensed in accordance with evidence.ResultsThe proportion of prescriptions dispensed in accordance with evidence improved four percentage points, from 38% at baseline to 42% following the intervention. The control group improved by one percentage point, from 39% at baseline to 40% at trial's conclusion. The adjusted difference between the intervention and control groups was 8% (95% confidence interval 1%, 15%). Intervention effectiveness did not decrease with time.ConclusionFor common pediatric outpatient conditions, a point-of-care evidence-based prescription writer and decision support system was associated with significant improvements in prescribing practices.
| S-EPMC1876598 | biostudies-literature
Project description:Background. Inappropriate prescribing of antibiotics, which is common in pediatric care, is a key driver of antimicrobial resistance. To mitigate the development of resistance, antibiotic stewardship programs often suggest the inclusion of feedback targeted at individual providers. Empirically, however, it is not well understood how feedback affects individual physicians' antibiotic prescribing decisions. Also, the question of how physicians' characteristics, such as clinical experience, relate to antibiotic prescribing decisions and to responses to feedback is largely unexplored. Objective. To analyze the causal effect of descriptive expert feedback (and individual characteristics) on physicians' antibiotic prescribing decisions in pediatrics. Design. We employed a randomized, controlled framed field experiment, in which German pediatricians (n=73) decided on the length of first-line antibiotic treatment for routine pediatric cases. In the intervention group (n=39), pediatricians received descriptive feedback in form of an expert benchmark, which allowed them to compare their own prescribing decisions with expert recommendations. The recommendations were elicited in a survey of pediatric department directors (n=20), who stated the length of antibiotic therapies they would choose for the routine cases. Pediatricians' characteristics were elicited in a comprehensive questionnaire. Results. Providing pediatricians with expert feedback significantly reduced the length of antibiotic therapies by 10% on average. Also, the deviation of pediatricians' decisions from experts' recommendations significantly decreased. Antibiotic therapy decisions were significantly related to pediatricians' clinical experience, risk attitudes, and personality traits. The effect of feedback was significantly associated with physicians' experience. Conclusion. Our results indicate that descriptive expert feedback can be an effective means to guide pediatricians, especially those who are inexperienced, toward more appropriate antibiotic prescribing. Therefore, it seems to be suitable for inclusion in antibiotic stewardship programs.
| S-EPMC6843625 | biostudies-literature
Project description:Study objectiveHigh prescribers of antibiotics and opioids are an important target for stewardship interventions. The goal of this study was to assess the association between high antibiotic and high opioid prescribing by provider type.DesignA national cross-sectional study.Setting2015-2017 Department of Veterans Affairs (VA) electronic health record data.PopulationPrescribers were identified as dentists (2017: n = 1346) and medical providers (physicians n = 23,072; advanced practice providers [APP] n = 7705; and other providers [pharmacists/chiropractors] n = 3674) (2017: n = 34,451).MeasurementsHigh prescribing was defined as being in the top 25% of visit-based rates of antibiotic or opioid prescribing (number of prescriptions/number of dental or medical visits). Multivariable random effects logistic regression with clustering by facility was used to assess the adjusted association between high antibiotic and opioid prescribing.ResultsMedical providers prescribed 4,348,670 antibiotic and 10,256,706 opioid prescriptions; dentists prescribed 277,170 antibiotic and 124,103 opioid prescriptions. Among all high prescribers of antibiotics, 40% were also high prescribers of opioids as compared to 18% of those who were not high antibiotic prescribers (p < 0.0001). High prescribing of antibiotics was associated with high prescribing of opioids in medical providers (adjusted odds ratio [aOR] = 2.87, 95% confidence interval [CI] = 2.72-3.04) and dentists (aOR = 8.40, 95% CI 6.00-11.76). Older provider age, specific US geographic regions, and lower VA facility complexity and rurality were also associated with high opioid prescribing by medical providers. In dentists, younger provider age, male gender, specific regions of the United States, and lower number of dentists in a facility were associated with high opioid prescribing. At the facility level, high dental prescribers of antibiotics or opioids were not at the same facilities as high medical prescribers, respectively (p < 0.0001).ConclusionsHigh antibiotic prescribing was associated with high opioid prescribing. Thus, stewardship interventions targeting both medication classes may have higher impact to efficiently reduce prescribing of medications with high public health impact. Provider-targeted interventions are needed to improve antibiotic and opioid prescribing in both dentists and medical providers.
| S-EPMC9794436 | biostudies-literature
Project description:IMPORTANCE:Primary care clinicians find managing chronic pain challenging. Evidence of long-term efficacy of opioids for chronic pain is limited. Opioid use is associated with serious risks, including opioid use disorder and overdose. OBJECTIVE:To provide recommendations about opioid prescribing for primary care clinicians treating adult patients with chronic pain outside of active cancer treatment, palliative care, and end-of-life care. PROCESS:The Centers for Disease Control and Prevention (CDC) updated a 2014 systematic review on effectiveness and risks of opioids and conducted a supplemental review on benefits and harms, values and preferences, and costs. CDC used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework to assess evidence type and determine the recommendation category. EVIDENCE SYNTHESIS:Evidence consisted of observational studies or randomized clinical trials with notable limitations, characterized as low quality using GRADE methodology. Meta-analysis was not attempted due to the limited number of studies, variability in study designs and clinical heterogeneity, and methodological shortcomings of studies. No study evaluated long-term (?1 year) benefit of opioids for chronic pain. Opioids were associated with increased risks, including opioid use disorder, overdose, and death, with dose-dependent effects. RECOMMENDATIONS:There are 12 recommendations. Of primary importance, nonopioid therapy is preferred for treatment of chronic pain. Opioids should be used only when benefits for pain and function are expected to outweigh risks. Before starting opioids, clinicians should establish treatment goals with patients and consider how opioids will be discontinued if benefits do not outweigh risks. When opioids are used, clinicians should prescribe the lowest effective dosage, carefully reassess benefits and risks when considering increasing dosage to 50 morphine milligram equivalents or more per day, and avoid concurrent opioids and benzodiazepines whenever possible. Clinicians should evaluate benefits and harms of continued opioid therapy with patients every 3 months or more frequently and review prescription drug monitoring program data, when available, for high-risk combinations or dosages. For patients with opioid use disorder, clinicians should offer or arrange evidence-based treatment, such as medication-assisted treatment with buprenorphine or methadone. CONCLUSIONS AND RELEVANCE:The guideline is intended to improve communication about benefits and risks of opioids for chronic pain, improve safety and effectiveness of pain treatment, and reduce risks associated with long-term opioid therapy.
| S-EPMC6390846 | biostudies-literature
Project description:ObjectivesTo describe the continuity of opioid prescribing and prescriber characteristics among older adults with chronic noncancer pain (CNCP) who are on long-term opioid therapy (LTOT) and to evaluate the association of continuity of opioid prescribing and prescriber characteristics with the risk of opioid-related adverse events.Study designNested case-control design.MethodsThis study employed a nested case-control design using a 5% random sample of the national Medicare administrative claims data for 2012-2016. Eligible individuals experiencing a composite outcome of opioid-related adverse events were defined as cases and matched to controls using incidence density sampling. Continuity of opioid prescribing (operationalized using the Continuity of Care Index) and prescriber specialty were assessed among all eligible individuals. Conditional logistic regression was conducted to assess the relationships of interest after accounting for known confounders.ResultsIndividuals with low (odds ratio [OR], 1.45; 95% CI, 1.08-1.94) and medium (OR, 1.37; 95% CI, 1.04-1.79) continuity of opioid prescribing were found to have greater odds of experiencing a composite outcome of opioid-related adverse events compared with individuals with high prescribing continuity. Fewer than 1 in 10 (9.2%) older adults starting a new LTOT episode received at least 1 prescription from a pain specialist. Receiving a prescription from a pain specialist was not significantly associated with the outcome in adjusted analyses.ConclusionsWe found that higher continuity of opioid prescribing, but not provider specialty, was significantly associated with fewer opioid-related adverse outcomes among older adults with CNCP.
| S-EPMC10851930 | biostudies-literature
Project description:Chronic non-cancer pain is common and long-term opioid therapy is frequently used in its management. While opioids can be effective, they are also associated with significant harm and misuse, and clinicians must weigh any expected benefits with potential risks when making decisions around prescribing. This review aimed to summarise controlled trials and systematic reviews that evaluate patient-related, provider-related, and system-related factors supporting responsible opioid prescribing for chronic non-cancer pain. A scoping review methodology was employed, and six databases were searched. Thirteen systematic reviews and nine controlled trials were included for analysis, and clinical guidelines were reviewed to supplement gaps in the literature. The majority of included studies evaluated provider-related factors, including prescribing behaviours and monitoring for misuse. A smaller number of studies evaluated system-level factors such as regulatory measures and models of healthcare delivery. Studies and guidelines emphasise the importance of careful patient selection for opioid therapy, development of a treatment plan, and cautious initiation and dose escalation. Lower doses are associated with reduced risk of harm and can be efficacious, particularly when used in the context of a multimodal interdisciplinary pain management program. Further research is needed around many elements of responsible prescribing, including instruments to monitor for misuse, and the role of policies and programs.
| S-EPMC7557364 | biostudies-literature
Project description:Co-prescribing of opioids and sedatives is a known risk factor for opioid-induced ventilatory impairment (OIVI). Prevalence data for sedative and opioid co-prescription in inpatients in Australia are unknown. Our objective was to determine the prevalence of inpatient sedative and opioid co-prescribing and to identify factors associated with co-prescription. We conducted a retrospective cross-sectional study from July 2017 to October 2017 across four South Australian hospitals utilizing a centralized electronic health record. Multivariate analysis was used to identify characteristics predictive of co-prescribing of a strong opioid (fentanyl, hydromorphone, morphine, and oxycodone) and sedative medications (benzodiazepines, antiepileptics, antipsychotics, and tricyclic antidepressants). Of the 6170 inpatients, 2795 (45.3%) were prescribed a strong opioid and of those, 1889 (30.6% of all inpatients) were co-prescribed a sedative. Of those prescribed a strong opioid, five (0.18%) developed OIVI. Patients prescribed a strong opioid had a 27-77% increased likelihood of being prescribed a sedative. Factors predictive of sedative co-prescribing included the presence of disease of the central nervous system adjusted OR (aOR) 8.66 [95% CI 5.83-12.9] and respiratory disease aOR 1.42 [95% CI 1.17-1.72]. Nearly, one third of all hospital inpatients were co-prescribed a strong opioid and a sedative medication. Patients with comorbidities resulting in increased risk of respiratory depression/OIVI were more likely to have sedative co-prescription. Clinicians should be aware of the effects of high-risk medications and ensure that systems and monitoring are in place that help mitigate adverse outcomes.
| S-EPMC7868063 | biostudies-literature