scholarly journals Quantifying prescribed high dose opioids in the community and risk of overdose

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Joe Schofield ◽  
Deborah Steven ◽  
Rebecca Foster ◽  
Catriona Matheson ◽  
Alexander Baldacchino ◽  
...  
Keyword(s):  
Risk Factors ◽  
Service Improvement ◽  
High Dose ◽  
Opioid Overdose ◽  
Opioid Prescribing ◽  
Patient Level ◽  
Strong Opioid ◽  
High Doses ◽  
Strong Opioids ◽  
Very High

Abstract Background Opioid prescribing for a range of health issues is increasing globally. The risk of fatal and non-fatal overdose is increased among people prescribed strong opioids: in high doses in the context of polypharmacy (the use of multiple medications at the same time), especially with other sedatives; and among people with multiple morbidities including cardiorespiratory, hepatic and renal conditions. This study described and quantified the prescribing of strong opioids, comorbidities and other overdose risk factors among those prescribed strong opioids, and factors associated with high/very high opioid dosage in a regional health authority in Scotland as part of a wider service improvement exercise. Methods Participating practices ran searches to identify patients prescribed strong opioids and their characteristics, polypharmacy, and other overdose risk factors. Data were anonymised before being analysed at practice and patient-level. Morphine Equivalent Doses were calculated for patients based on drug/dose information and classed as Low/Medium/High/Very High. Descriptive statistics were generated on the strong opioid patient population and overdose risk factors. The relationship between the prescribing of strong opioids and practice/patient-level factors was investigated using linear and logistic regression models. Results Eighty-five percent (46/54) of GP practices participated. 12.4% (42,382/341,240) of individuals in participating practices were prescribed opioids and, of these, one third (14,079/42,382) were prescribed strong opioids. The most common comorbidities and overdose risk factors among strong opioid recipients were pain (67.2%), cardiovascular disease (43.2%), and mental health problems (39.3%). There was a positive significant relationship between level of social deprivation among practice caseload and level of strong opioid prescribing (p < 0.001). People prescribed strong opioids tended to be older (mean 59.7 years) and female (8638, 61.4%) and, among a subset of patients, age, gender and opioid drug class were significantly associated with prescribing of High/Very High doses. Conclusions Our findings have identified a large population at potential risk of prescription opioid overdose. There is a need to explore pragmatic models of tailored interventions which may reduce the risk of overdose within this group and clinical practice may need to be tightened to minimise overdose risk for individuals prescribed high dose opioids.

scholarly journals Evaluation of a Medicaid performance improvement project to reduce high-dose opioid prescriptions

2022 ◽  
Vol 22 (1) ◽  
Author(s):  
Daniel M. Hartung ◽  
Jonah Geddes ◽  
Sara E. Hallvik ◽  
P. Todd Korthuis ◽  
Luke Middleton ◽  
...  
Keyword(s):  
Performance Improvement ◽  
Emergency Department Visits ◽  
Prescription Opioid ◽  
High Dose ◽  
Opioid Overdose ◽  
Opioid Use ◽  
Improvement Project ◽  
Opioid Prescribing ◽  
Percentage Points ◽  
Prescription Opioid Use

Abstract Background In 2015, Oregon’s Medicaid program implemented a performance improvement project to reduce high-dose opioid prescribing across its 16 coordinated care organizations (CCOs). The objective of this study was to evaluate the effect of that program on prescription opioid use and outcomes. Methods Using Medicaid claims data from 2014 to 2017, we conducted interrupted time-series analyses to examine changes in the prescription opioid use and overdose rates before (July 2014 to June 2015) and after (January 2016 to December 2017) implementation of Oregon’s high-dose policy initiative (July 2015 to December 2015). Prescribing outcomes were: 1) total opioid prescriptions 2) high-dose [> 90 morphine milligram equivalents per day] opioid prescriptions, and 3) proportion of opioid prescriptions that were high-dose. Opioid overdose outcomes included emergency department visits or hospitalizations that involved an opioid-related poisoning (total, heroin-involved, non-heroin involved). Analyses were performed at the state and CCO level. Results There was an immediate reduction in high dose opioid prescriptions after the program was implemented (− 1.55 prescription per 1000 enrollee; 95% CI − 2.26 to − 0.84; p < 0.01). Program implementation was also associated with an immediate drop (− 1.29 percentage points; 95% CI − 1.94 to − 0.64 percentage points; p < 0.01) and trend reduction (− 0.23 percentage point per month; 95% CI − 0.33 to − 0.14 percentage points; p < 0.01) in the monthly proportion of high-dose opioid prescriptions. The trend in total, heroin-involved, and non-heroin overdose rates increased significantly following implementation of the program. Conclusions Although Oregon’s high-dose opioid performance improvement project was associated with declines in high-dose opioid prescriptions, rates of opioid overdose did not decrease. Policy efforts to reduce opioid prescribing risks may not be sufficient to address the growing opioid crisis.

scholarly journals High-dose N-acetylcysteine therapy in the treatment of pneumonia

2021 ◽  
Vol 4 (1) ◽  
pp. 4-10
Author(s):  
Dmytro Dmytriiev ◽  
Oleksandr Nazarchuk ◽  
Yuliana Babina
Keyword(s):  
Risk Factors ◽  
Cystic Fibrosis ◽  
Antioxidant Properties ◽  
Individual Risk ◽  
High Dose ◽  
Review Of The Literature ◽  
The World ◽  
High Doses ◽  
Individual Risk Factors ◽  
Epidemiological Situation

The article presents modern data on the use of N-acetylcysteine in the treatment of infectious diseases of the respiratory tract in the practice of a physician. Its antioxidant, mucolytic, anti-inflammatory, pulmoprotective and antitoxic properties are described. The emphasis is placed on the antioxidant properties of N-acetylcysteine, which are expressed when used in high doses of 1200 mg/day or more. There is a review of the literature on the use of high doses of N-acetylcysteine in the treatment of pneumonia, cystic fibrosis, COPD, ARDS. The effect of N-acetylcysteine on individual risk factors for prolonged pneumonia is analyzed. Given the epidemiological situation around the world, the antioxidant properties of N-acetylcysteine in the treatment of pneumonia, including complicated COVID-19, are relevant and require further study.

scholarly journals Unintended Consequence of High-Dose Vitamin C Therapy for an Oncology Patient: Evaluation of Ascorbic Acid Interference With Three Hospital-Use Glucose Meters

2020 ◽  
pp. 193229682093218
Author(s):  
Brooke M. Katzman ◽  
Brandon R. Kelley ◽  
Gayle R. Deobald ◽  
Nikki K. Myhre ◽  
Sean A. Agger ◽  
...  
Keyword(s):  
Ascorbic Acid ◽  
Vitamin C ◽  
High Dose ◽  
Oncology Patient ◽  
Glucose Meter ◽  
High Doses ◽  
The Impact ◽  
Very High ◽  
High Dose Vitamin ◽  
Hospital Use

The use of high-dose vitamin C in cancer care has offered promising results for some patients. However, the intravenous (IV) doses used for these patients can reach concentrations that interfere with some strip-based glucose meters. We characterized the impact of vitamin C interference, from standard to the very high doses used for some cancer protocols, using three different hospital-use glucose meters. For two of the three devices tested, increasing concentrations of ascorbic acid caused false elevations in the glucose measurements. The third glucose meter did not provide inaccurate results, regardless of the vitamin C concentration present. Rather, above a certain threshold, the device generated error messages and no results could be obtained.

High-dose thiotepa: Neurotoxicity and risk factors in children with solid tumors.

2012 ◽  
Vol 30 (15_suppl) ◽  
pp. 9572-9572
Author(s):  
Christophe Maritaz ◽  
Francois Lemare ◽  
Amani Cherif ◽  
Sylvie Demirdjian ◽  
Dominique Valteau Couanet ◽  
...  
Keyword(s):  
Risk Factors ◽  
Solid Tumors ◽  
Median Time ◽  
Biological Data ◽  
High Dose ◽  
Blurred Vision ◽  
Exact Test ◽  
High Doses ◽  
Opsoclonus Myoclonus Syndrome ◽  
Method Analysis

9572 Background: Thiotepa (TTP) is a cytotoxic agent used in children with solid tumors at high doses followed by autologous stem cell transplantation (ASCT). During these treatments, neurological adverse events (NAE) were observed. Causal relationships and risk factors were investigated. Methods: Patients with solid tumors treated with high-dose thiotepa with ASCT between May 1987 and March 2011 were retrospectively identified. Clinico-biological data were collected and NAE were identified from medical and nursing records. Toxicity was graded according to the NCI CTCAE v4.03 classification. Imputability of thiotepa was assessed according to Begaud et al. method. Analysis of risk factors was assessed with Fisher's exact test (alpha 0.05) and relative risk was estimated by calculating odds ratios with their 95% confidence interval. Results: 251 patients received 307 courses (56 patients received twice) of high-dose thiotepa (600 mg/m²: 82 courses; 720 mg/m²: 76 courses; 900 mg/m²: 149 courses) with ASCT. The median age was 8.33 years (range, 1 - 31.2 years). 81 NAE (26.4%) were described. NAE were considered “possibly” related to TTP in 9 courses, “likely” related to TTP in 35 courses and “very likely” related to TTP in 13 courses. Other NAE were assessed “doubtful” or “incompatible”. In these 57 NAE, neurological symptoms appeared at a median time of 2 days (range, 0 - 4 days) after the introduction of TTP. Symptoms were headache, tremor, dizziness and confusion, blurred vision, seizure, pyramidal tract syndrome, cerebellar syndrome, opsoclonus-myoclonus syndrome and coma. These events disappeared without sequelea in a median time of 3 days (range, 1 - 8 days). TTP was reintroduced in 21 cases. NAE reappeared in 12 cases. For 3 patients with seizure during the first course, premedication with clonazepam prevented NAE during the second course. The use of analgesic for moderate to severe pain, such as tramadol or codeine, increased the probabiblity to have NAE (OR 5.6467; 95CI [1.5523-21.2786]; p 0.037). Conclusions: In our study, the incidence of NAE related to TTP was 18.6%. The outcome was favorable without sequelea in all cases. TTP could be reintroduced after NAE. The association of TTP with tramadol increases the risk of neurotoxicity.

scholarly journals Severe Infusion-Related Adverse Events and Renal Failure in Patients Receiving High-Dose Intravenous Polymyxin B

2017 ◽  
Vol 62 (1) ◽  
Author(s):  
Josiane F. John ◽  
Diego R. Falci ◽  
Maria Helena Rigatto ◽  
Renata D. Oliveira ◽  
Thaysa G. Kremer ◽  
...  
Keyword(s):  
Renal Failure ◽  
Adverse Event ◽  
Body Weight ◽  
Adverse Events ◽  
Total Dose ◽  
Polymyxin B ◽  
High Dose ◽  
Daily Dose ◽  
High Doses ◽  
Very High

ABSTRACT The use of very high doses of polymyxin B (PMB) against carbapenem-resistant Gram-negative bacilli has been addressed in in vitro experiments as a strategy to improve bacterial killing and suppress resistance emergence. However, the toxicities of very high doses in patients are unknown. We conducted a retrospective cohort study assessing patients receiving PMB at >3 mg/kg of body weight/day or a total dose of ≥250 mg/day. The main outcomes were severe infusion-related adverse events according to the Common Terminology Criteria for Adverse Events and the renal failure category of RIFLE criteria for acute kidney injury (AKI) during treatment. A total of 222 patients were included for analysis of infusion-related events. The mean PMB dose was 3.61 ± 0.97 mg/kg/day (median total dose/day = 268 mg). Severe infusion-related adverse events occurred in two patients, resulting in an incidence of 0.9% (95% confidence interval, 0.2 to 3.2%); one was classified as a life-threatening adverse event, and one was classified as a severe adverse event. Renal failure was analyzed in 115 patients, and 25 (21.7%) patients presented renal failure (54 [47.0%] developed any degree of AKI, categorized as risk [27.8%], injury [25.9%], and failure [46.3%]). Treatment with a vasoactive drug, concomitant treatment with nephrotoxic drugs, and baseline creatinine clearance were independent risk factors for renal failure. Neither the PMB daily dose scaled by body weight nor the total daily dose was associated with renal failure. The in-hospital mortality rate was 60% (134 patients): 26% of deaths (57 patients) occurred during treatment, and none occurred during infusion. Our data suggest that high-dose schemes have an acceptable safety profile and could be further tested in clinical trials assessing strategies to improve patient outcomes and minimize the emergence of PMB resistance.

Very high-dose methylprednisolone for treatment of nivolumab-induced limbic encephalitis: A case report

2020 ◽  
Vol 26 (6) ◽  
pp. 1538-1543 ◽  
Author(s):  
Vincent-Thierry Taillefer ◽  
Marjorie Pigeon ◽  
Michelle Chen ◽  
Catherine Larochelle ◽  
Marie Florescu ◽  
...  
Keyword(s):  
Case Report ◽  
Limbic Encephalitis ◽  
Oral Prednisone ◽  
Neurological Impairment ◽  
Immune Checkpoint Blockade ◽  
High Dose ◽  
Life Threatening ◽  
Autoimmune Limbic Encephalitis ◽  
High Doses ◽  
Very High

Introduction Nivolumab is a programmed death 1 (PD-1) inhibitor approved by the Food and Drug Administration (FDA) for the treatment of eight different cancers including metastatic melanoma. Immune checkpoint blockade may lead to a range of neurologic immune-related adverse events (irAEs) with severity varying from mild to life-threatening, including encephalitis. Case report We describe a case of a 68-year-old man who developed alteration in mental status, physical weakness and fatigue after nine cycles of nivolumab 3 mg/kg every two weeks. These symptoms were compatible with a clinical diagnosis of autoimmune limbic encephalitis, although no specific antibodies were detected and the initial MRI was normal. Management and outcome The patient received intravenous methylprednisolone 1 g daily for 5 days, which was then converted to a maintenance dose of oral prednisone. The patient made a full clinical recovery but relapsed clinically upon steroid tapering, while hypersignal in the left mesial temporal suggestive of limbic encephalitis was observed on repeated MRI. Discussion Because of the prevailing usage of nivolumab in many cancer protocols, this case highlights the importance of rapidly recognising neurological impairment in patients treated with nivolumab and of initiating very high doses of corticosteroids.

scholarly journals High National Rates of High-Dose Dopamine Agonist Prescribing for RLS

SLEEP ◽  
2021 ◽  
Author(s):  
John W Winkelman
Keyword(s):  
Dopamine Agonist ◽  
Daily Maximum ◽  
High Dose ◽  
Patient Age ◽  
Dose Rates ◽  
Patient Âgé ◽  
Related Symptom ◽  
Icd 10 ◽  
High Doses ◽  
Very High

Abstract Study Objectives Long-term dopamine agonist (DA) use in restless legs syndrome (RLS) is associated with augmentation, a dose-related symptom worsening leading to further dose escalation to manage RLS. This study investigated rates and factors of high-dose DA prescribing in US RLS patients. Methods This retrospective analysis examined data from a US longitudinal prescriptions database (October 2017–September 2018). Patients diagnosed with RLS (ICD-10 G255.81) without Parkinson’s disease who were prescribed ropinirole, pramipexole, and/or rotigotine were included. Daily DA dosage was categorized: LOW/MID (FDA-approved/guideline or slightly above FDA-approved [pramipexole]); HIGH (101%–149%); VERY HIGH (&gt;150%). Patient counts were converted to US national estimates. Logistic regression of patient counts evaluated factors associated with HIGH/VERY HIGH DA dosing. Results Of 670,404 RLS patients (131,289,331 therapy days), 58.8% were prescribed DA therapy. Overall, 19.1% of RLS patients were prescribed DAs above maximum FDA-approved/guideline daily doses—over half of these were &gt;150% maximum recommended doses; 67.6% of HIGH/VERY HIGH-dose prescriptions were pramipexole (OR [95% CI] pramipexole vs ropinirole, 5.8 [5.7–6.0]). The highest 1% of DA prescriptions were ≥10× the FDA-recommended maximum daily dose. Rates of HIGH/VERY HIGH DA dosing increased with patient age. Twice as many neurologists (31.1%) prescribed HIGH/VERY HIGH doses vs other specialties (OR [95%CI], 2.1 [1.2–2.0]). Conclusions Approximately 20% of DA-treated RLS patients were prescribed doses above the approved and guideline daily maximum. Pramipexole, Neurology as specialty, and patient age were independently associated with HIGH/VERY HIGH DA dosing. Increased education is warranted regarding risks of high-dose DA exposure in RLS.

Platelet Transfusion: A Dose-Response Study

Blood ◽  
1998 ◽  
Vol 92 (4) ◽  
pp. 1448-1453 ◽  
Author(s):  
Françoise Norol ◽  
Philippe Bierling ◽  
Françoise Roudot-Thoraval ◽  
Françoise Ferrer Le Coeur ◽  
Claire Rieux ◽  
...  
Keyword(s):  
Body Weight ◽  
Dose Response ◽  
Dose Effect ◽  
High Dose ◽  
Platelet Concentrates ◽  
Clinical Factors ◽  
Platelet Recovery ◽  
High Doses ◽  
Very High ◽  
Medium Dose

Early recommendations on prophylactic transfusion of thrombocytopenic patients involved a standard platelet dose of about 0.5 × 1011/10 kg body weight. Given the lack of data supporting this dose, we prospectively studied the dose response to platelet transfusions in adults and children with hematologic malignancies. Each patient received, in similar clinical conditions, a medium, high, and very high dose of fresh (< 24 hours old) ABO-compatible platelets, in the form of apheresis platelet concentrates (APC). For the adults, the medium dose was defined as APC containing between 4 and 6 × 1011 platelets, the high dose between 6 and 8 × 1011, and the very high dose > 8 × 1011; for the children, the three doses corresponded to 2 to 4, 4 to 6, and > 6 × 1011 platelets. The end points were the platelet increment, platelet recovery, and the transfusion interval, and the results were compared with a paired t-test. Sixty-nine adults and 13 children could be assessed. Recoveries in the adults were similar with the three doses (from 28% to 30%), but the high and very high doses led to a significantly better platelet increment (52 and 61 × 109/L, respectively) than the medium dose (33 × 109/L, P < .01). The main difference was in the transfusion interval, which increased with the dose of platelets transfused, from 2.6 days with the medium dose to 3.3 and 4.1 days with the high and very high doses, respectively (P< .01). The positive effect of the high dose was observed regardless of pretransfusional clinical status, but was more marked in patients with no clinical factors known to impair platelet recovery. In these patients, a platelet dose of 0.07 × 1011 per kg of body weight led to a transfusion interval of more than 2 days in 95% of cases. In patients with clinical factors favoring platelet consumption, the proportion of transfusions yielding an optimal platelet increment and transfusion interval increased with the dose of platelets.The platelet dose-effect was also significant in the children, in whom the high and very high doses led to 1.5-fold to twofold higher posttransfusion platelet counts and transfusion intervals. We conclude that transfusion of high platelet doses can reduce the number of platelet concentrates required by thrombocytopenic patients and significantly reduce donor exposure. © 1998 by The American Society of Hematology.

Platelet Transfusion: A Dose-Response Study

Blood ◽  
1998 ◽  
Vol 92 (4) ◽  
pp. 1448-1453 ◽  
Author(s):  
Françoise Norol ◽  
Philippe Bierling ◽  
Françoise Roudot-Thoraval ◽  
Françoise Ferrer Le Coeur ◽  
Claire Rieux ◽  
...  
Keyword(s):  
Body Weight ◽  
Dose Response ◽  
Dose Effect ◽  
High Dose ◽  
Platelet Concentrates ◽  
Clinical Factors ◽  
Platelet Recovery ◽  
High Doses ◽  
Very High ◽  
Medium Dose

Abstract Early recommendations on prophylactic transfusion of thrombocytopenic patients involved a standard platelet dose of about 0.5 × 1011/10 kg body weight. Given the lack of data supporting this dose, we prospectively studied the dose response to platelet transfusions in adults and children with hematologic malignancies. Each patient received, in similar clinical conditions, a medium, high, and very high dose of fresh (&lt; 24 hours old) ABO-compatible platelets, in the form of apheresis platelet concentrates (APC). For the adults, the medium dose was defined as APC containing between 4 and 6 × 1011 platelets, the high dose between 6 and 8 × 1011, and the very high dose &gt; 8 × 1011; for the children, the three doses corresponded to 2 to 4, 4 to 6, and &gt; 6 × 1011 platelets. The end points were the platelet increment, platelet recovery, and the transfusion interval, and the results were compared with a paired t-test. Sixty-nine adults and 13 children could be assessed. Recoveries in the adults were similar with the three doses (from 28% to 30%), but the high and very high doses led to a significantly better platelet increment (52 and 61 × 109/L, respectively) than the medium dose (33 × 109/L, P &lt; .01). The main difference was in the transfusion interval, which increased with the dose of platelets transfused, from 2.6 days with the medium dose to 3.3 and 4.1 days with the high and very high doses, respectively (P&lt; .01). The positive effect of the high dose was observed regardless of pretransfusional clinical status, but was more marked in patients with no clinical factors known to impair platelet recovery. In these patients, a platelet dose of 0.07 × 1011 per kg of body weight led to a transfusion interval of more than 2 days in 95% of cases. In patients with clinical factors favoring platelet consumption, the proportion of transfusions yielding an optimal platelet increment and transfusion interval increased with the dose of platelets.The platelet dose-effect was also significant in the children, in whom the high and very high doses led to 1.5-fold to twofold higher posttransfusion platelet counts and transfusion intervals. We conclude that transfusion of high platelet doses can reduce the number of platelet concentrates required by thrombocytopenic patients and significantly reduce donor exposure. © 1998 by The American Society of Hematology.

Higher naloxone dosing may be required for opioid overdose

2019 ◽  
Vol 76 (22) ◽  
pp. 1835-1837 ◽  
Author(s):  
Russell Bardsley
Keyword(s):  
Emergency Department ◽  
Case Report ◽  
New Hampshire ◽  
Community Hospital ◽  
High Dose ◽  
Opioid Overdose ◽  
Small Community ◽  
Emergency Personnel ◽  
High Doses ◽  
Small Community Hospital

Abstract Purpose Carfentanil is a synthetic opioid with an estimated potency that is 10,000 times more than that of morphine and 100 times more than that of fentanyl. Although there is a paucity of evidence, when considering the potency of carfentanil, it is reasonable to speculate that larger doses of naloxone may be required to resuscitate patients after carfentanil ingestion. This case report discusses the use of high-dose naloxone in 2 patients with suspected carfentanil overdose presenting to a small community hospital. Summary Two patients with suspected carfentanil overdose presented to a 30-bed emergency department at a community hospital in New Hampshire. Cyanosis and respiratory distress were noted in both instances, and airway intervention was ultimately deemed necessary. Patient 1 required a total of 12 mg of naloxone to be successfully resuscitated, while patient 2 required a total of 10 mg for resuscitation. Both patients were successfully resuscitated with high doses of naloxone. The use of high-dose naloxone prevented the need for intubation in these patients. Conclusion While more robust studies should be considered, emergency personnel should be comfortable using higher-than-standard doses of naloxone in appropriate cases.

Sign in / Sign up

Export Citation Format

Share Document