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Prescribing Analgesics to Older People: A Challenge for GPs.

ABSTRACT: BACKGROUND:Due to population aging, there is an increase in the prevalence of chronic diseases, and in particular musculoskeletal diseases. These trends are associated with an increased demand for prescription analgesics and an increased risk of polypharmacy and adverse medication reactions, which constitutes a challenge, especially for general practitioners (GPs), as the providers who are most responsible for the prescription policy. OBJECTIVES:To identify patterns of analgesics prescription for older people in the study area and explore associations between a long-term analgesic prescription and comorbidity patterns, as well as the prescription of psychotropic and other common medications in a continuous use. METHODS:A retrospective study was conducted in 2015 in eastern Croatia. Patients were GP attenders ?40 years old (N = 675), who were recruited during their appointments (consecutive patients). They were divided into two groups: those who have been continuously prescribed analgesics (N = 432) and those who have not (N = 243). Data from electronic health records were used to provide information about diagnoses of musculoskeletal and other chronic diseases, as well as prescription rates for analgesics and other medications. Exploratory methods and logistic regression models were used to analyse the data. RESULTS:Analgesics have been continuously prescribed to 64% of the patients, mostly to those in the older age groups (50-79 years) and females, and they were indicated mainly for dorsalgia symptoms and arthrosis. Non-opioid analgesics were most common, with an increasing tendency to prescribe opioid analgesics to older patient groups aged 60-79 years. The study results indicate that there is a high rate of simultaneous prescription of analgesics and psychotropic medications, despite the intention of GPs to avoid prescribing psychotropic medications to patients who use any option with opioid analgesics. In general, receiving prescription analgesics does not exceed the prescription for chronic diseases over the rates that can be found in patients who do not receive prescription analgesics. CONCLUSION:Based on the analysis of comorbidities and parallel prescribing, the results of this study can improve GPs' prescription and treatment strategies for musculoskeletal diseases and chronic pain conditions.

SUBMITTER: Majnaric LT

PROVIDER: S-EPMC7312581 | biostudies-literature | 2020 Jun

REPOSITORIES: biostudies-literature

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Prescribing Analgesics to Older People: A Challenge for GPs.

Majnarić Ljiljana Trtica LT Wittlinger Thomas T Stolnik Dunja D Babič František F Bosnić Zvonimir Z Rudan Stjepan S

International journal of environmental research and public health 20200605 11

<h4>Background</h4>Due to population aging, there is an increase in the prevalence of chronic diseases, and in particular musculoskeletal diseases. These trends are associated with an increased demand for prescription analgesics and an increased risk of polypharmacy and adverse medication reactions, which constitutes a challenge, especially for general practitioners (GPs), as the providers who are most responsible for the prescription policy.<h4>Objectives</h4>To identify patterns of analgesics ...[more]

PMID: 32516932

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Project description:Context: In Italy, little is known about the territorial distribution of the frailty status. Aims: To compare frailty- and multimorbidity-prevalence in the elderly population of two Italian regions. Methods: This study examined randomized samples of elderly (both community dwelling and institutionalized) assisted by general practitioners. Frailty was evaluated through the CSHA-Scale, multimorbidity through the Charlson-Score. The relation between frailty and multimorbidity was studied through a logistic model. Both crude and standardized prevalences were calculated. Results: One hundred and sixteen physicians assisted 176,503 patients highly representative of Italian people. In a randomized sample of 4,531 older people, the sex-age-standardized prevalence of Frailty (standard population: Italy) was 25.74% (24.63-26.85%). Age-standardized prevalence for males was 20.08% (18.46-21.71%) and 30.00% (28.54-31.57%) for females. Using the sex-age-standardization pooled sample, the prevalence of frailty was significantly higher in Sicily than Veneto (28.74% [27.03-30.46%] vs 22.30% [20.94-23.67%]. This study did not find differences in the prevalence of multimorbidity: Veneto 20.76% (19.21-22.31%); Sicily 22.05% (20.33-23.77%). Both "to be female" and "to live in Sicily" were shown to be predictors of frailty OR for being female = 1.64 (1.42-1.88); OR for living in Sicily = 1.27 (1.11-1.46). Multimorbidity was an independent frailty-predictor only for those aged < 85: OR of Charlson Index ≥ 4 for ages < 85 = 3.44 (2.88-4.11), OR for ages ≥ 85 = 1.44 (0.97-2.12). Limitations: (1) This study considered patients assisted by doctors, not a random sample of the general population. (2) The cross-sectional nature of the study limits the interpretation of the relationships between frailty and multi-morbidity. (3) Few covariates were available for our multivariate models. Conclusions: More than 1/4 of elderly persons are shown to be frail (1/5 of males and 1/3 of females). Frailty is more frequent in Sicily, while multimorbidity does not differ between the two regions. This could be due to regional differences in the organization of care networks dedicated to elderly patients.

Project description:ImportanceOpioid-tolerant only (OTO) medications, such as transmucosal immediate-release fentanyl products and certain extended-release opioid analgesics, require prior opioid tolerance for safe use, as patients without tolerance may be at increased risk of overdose. Studies using insurance claims have found that many patients initiating these medications do not appear to be opioid tolerant.ObjectivesTo measure prevalence of opioid tolerance in patients initiating OTO medications and to determine whether linked electronic health record (EHR) data contribute evidence of opioid tolerance not found in insurance claims data.Design, setting, and participantsThis retrospective cohort study used a national database of deidentified longitudinal health information, including medical and pharmacy claims, insurance enrollment, and EHR data, from January 1, 2007, to December 31, 2016. Data included 131 756 US residents with at least 183 days of continuous enrollment in commercial or Medicare Advantage insurance (including medical and pharmacy benefits) who had received an OTO medication and who had no inpatient stays in the 30 days prior to starting an OTO medication; of these, 20 044 individuals had linked EHR data within the prior 183 days. Data were analyzed from July 1, 2017, to August 31, 2018.ExposuresInitiating an OTO medication.Main outcomes and measuresPrior opioid tolerance demonstrated through pharmacy fills or EHR data on prescriptions written.ResultsAmong 153 385 OTO use episodes identified, 89 029 (58.0%) occurred among women, 62 900 (41.0%) occurred among patients with Medicare Advantage insurance, 39 394 (25.7%) occurred in the Midwest, 17 366 (11.3%) occurred in the Northeast, 73 316 (47.8%) occurred in the South, and 23 309 (15.2%) occurred in the West. Less than half of use episodes (73 117 episodes [47.7%]) involved patients with evidence in claims data of opioid tolerance prior to initiating therapy with an OTO medication, including 31 392 of 101 676 episodes (30.9%) involving transdermal fentanyl, 1561 of 2440 episodes (64.0%) involving transmucosal fentanyl, 36 596 of 43 559 episodes (84.0%) involving extended-release oxycodone, and 3568 of 5710 episodes (62.5%) involving extended-release hydromorphone. Among 20 044 OTO use episodes with linked EHR and claims data, less than 1% of OTO episodes identified in claims had evidence of opioid tolerance in structured EHR data that was not present in claims data (108 episodes [0.5%]). After limiting the sample to OTO episodes identified in claims with a matching OTO prescription within 14 days in the structured EHR data, only 40 of 939 episodes (4.0%) occurred among patients with evidence of tolerance that was not present in claims data.Conclusions and relevanceThis cohort study found that most patients initiating OTO medications did not have evidence of prior opioid tolerance, suggesting they were at increased risk of opioid-related harms, including fatal overdose. Data from EHRs did not contribute substantial additional evidence of opioid tolerance beyond the data found in prescription claims. Future research is needed to understand the clinical rationale behind these observed prescribing patterns and to quantify the risk of harm to patients associated with potentially inappropriate prescribing.

Project description:BackgroundMultimorbidity and polypharmacy are common in older people. Assessment tools or lists of criteria aimed at supporting prescription decisions for older people exist, but have often been based on expert opinion with insufficient consideration of the evidence available. The present paper describes the methods we are using to systematically review the existing evidence on the efficacy and safety of the most commonly prescribed drugs for older people in the management of their chronic medical conditions and to develop recommendations to reduce inappropriate prescriptions for incorporation into the Comprehensive Medication Review (CMR) tool developed by the PRIMA-eDS European project.MethodsWe selected the 20 most relevant drugs/drug classes in terms of prescription volumes and risk of hospitalisation for older people and the most relevant indications for the most common chronic conditions among older people and a total of 35 distinct drug-indication pairs were chosen. Based on clinical considerations we collapsed some indications together, reducing the 35 pairs to a final total of 22 separate systematic reviews (SR). A common methodology will be used for each individual SR, based on the methodological manuals of the Cochrane collaboration and the PRISMA statement for reporting systematic reviews. Our search strategy will have a staged approach where we initially search for systematic reviews and meta-analyses, but if relevant reviews are not found, then search for individual studies (controlled intervention and observational studies). Our pilot work and initial scoping of the literature suggested that very few, relevant individual trials or existing systematic reviews have researched or reported exclusively on older people. Therefore, sufficient data might not be available to perform meta-analysis but we will provide a narrative synthesis describing characteristics and findings of included studies. The collected evidence will be used to construct recommendations on when not to use or to discontinue a drug, or when to reduce its dose. Recommendations will be developed in team meetings using the GRADE methodology to reflect the strength of the recommendation and the quality of the evidence. Recommendations will be built into the CMR tool.DiscussionThis protocol has been prepared for a series of systematic reviews which will provide research-based evidence to develop recommendations to reduce inappropriate polypharmacy in older people as part of the CMR tool of the PRIMA-eDS project.

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Prescribing Analgesics to Older People: A Challenge for GPs.

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Prescribing Analgesics to Older People: A Challenge for GPs.

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