Preventing and managing aberrant drug-related behavior in primary care: Systematic review of outcomes evidence

2014 ◽  
Vol 10 (2) ◽  
pp. 119 ◽  
Author(s):  
Charles E. Argoff, MD ◽  
Meldon Kahan, MD ◽  
Edward M. Sellers, MD
Keyword(s):  
Systematic Review ◽  
Risk Mitigation ◽  
Preliminary Evidence ◽  
Mitigation Strategies ◽  
Screening Tools ◽  
Dose Titration ◽  
Supporting Evidence ◽  
Opioid Dose ◽  
Levels Of Evidence ◽  
Evidence Level

Several strategies for preventing, identifying, and responding to aberrant opioid-related behaviors are recommended in pain management guidelines. This systematic review evaluated data supporting basic strategies for addressing aberrant opioid- related behaviors. Risk reduction strategies were identified via a review of available guidelines. Systematic literature searches of PubMed (May 1, 2007- January 18, 2013) identified articles with evidence relevant to nine basic strategies. Reference lists from relevant articles were reviewed for additional references of interest. Levels of evidence for articles identified were graded on a four-point scale (strongest evidence = level 1; weakest evidence = level 4) using Oxford Centre for Evidence-Based Medicine Levels of Evidence criteria. Weak to moderate evidence supports the value of thorough patient assessment, risk-screening tools, controlled substance agreements, careful dose titration, opioid dose ceilings, compliance monitoring, and adherence to practice guidelines. Moderate to strong evidence suggests that prescribing tamper-resistant opioids may help prevent misuse but may also have the unintended consequence of prompting a migration of users to other marketed opioids, heroin, or other substances. Similarly, preliminary evidence suggests that although recent regulatory and legal efforts may reduce misuse, they also impose barriers to the legitimate treatment of pain. Despite an absence of consistent, strong supporting evidence, clinicians are advised to use each of the available risk-mitigation strategies in combination in an attempt to minimize the risk of abuse in opioid treatment patients. Physicians must critically evaluate their opioid prescribing and not only increase their efforts to prevent substance

Changes in opioid type and dose among cancer patients referred to outpatient palliative care.

2016 ◽  
Vol 34 (26_suppl) ◽  
pp. 106-106
Author(s):  
Ali Haider ◽  
Joseph Baidoo ◽  
Yee Choon Meng ◽  
Donna S. Zhukovsky ◽  
Kimberson Cochien Tanco ◽  
...  
Keyword(s):  
Palliative Care ◽  
Performance Status ◽  
Symptom Assessment ◽  
Mitigation Strategies ◽  
Dose Titration ◽  
Linear Regression Method ◽  
Prescription Data ◽  
Cancer Type ◽  
Opioid Dose ◽  
Daily Dose

106 Background: Opioid prescriptions are regulated at both federal and state levels. Examples of such regulations include use of risk evaluation and mitigation strategies (REMS), mandatory sharing of prescription data with state prescription drug monitoring programs and the reclassification of hydrocodone as schedule II opioid in October 2014. One possible consequence of such changes would be earlier referral to palliative care (PC) for opioid management. Alternatively, primary oncologist may treat patients with weak opioids or use strong opioids with lower daily dose. We hypothesized that during the last six years, the number of referrals to outpatient PC has increased and the morphine equivalent daily dose (MEDD) has decreased. Methods: We reviewed 750 randomly selected patients who were seen as a new consultation from the year 2010 to 2015. Data was collected on demographics, cancer type and stage, referring specialty, symptom assessment, cancer pain classification, performance status, opioid type and MEDD. Data were also collected on first subsequent PC visit among eligible patients. MEDD over the 6 years was evaluated using general linear regression method, adjusted for covariates. Results: Hydrocodone was the most common opioid prescribed by the referring team throughout the six-year period. After reclassification, its use declined from 43% in 2014 to 33% in 2015. Tramadol use increased from 9% in 2014 to 19% in 2015 (p < 0.0001). Median MEDD upon referral was 78mg/day in 2010 and progressively decreased to 40mg/day in 2015 (p < 0.0001). Year to year referral increased 24% in the first quarter of 2015 (after hydrocodone rescheduling), compared to 17% in 2014 (p 0.0014). Conclusions: Over the past 6 years, there has been an increase in number of referrals to PC and a decline in MEDD upon referral. Likewise, an increase in weak opioids like tramadol has also been observed. These findings suggest oncologists are sending early referrals before further opioid dose titration and rotations are considered. Further opioid regulations will likely impact the integration of PC services in comprehensive cancer care.

scholarly journals Amid COVID-19 crisis, pain therapeutics telehealth services by pharmacist clinicians fill unique void and mitigate risk

2020 ◽  
Vol 4 ◽  
pp. 239920262094703
Author(s):  
Jeffrey Bettinger ◽  
Jacqueline Cleary ◽  
Jeffrey Fudin
Keyword(s):  
Chronic Pain ◽  
Risk Mitigation ◽  
Medication Management ◽  
High Risk Patient ◽  
Pharmacist Intervention ◽  
Mitigation Strategies ◽  
Specialty Area ◽  
Opioid Dose ◽  
Government Mandates ◽  
Comprehensive Evaluations

Patients with chronic pain syndromes are facing additional challenges from syndrome coronavirus 2 (SARS-CoV-2) virus compared with the general population. New reasons for compounded social isolation and commensurate opioid dose creeping and suicidality/anxiety, difficulty in obtaining legitimate medications, proper comprehensive evaluations, ongoing opioid risk stratification for opioid abuse/misuse, safe opioid tapers if necessary, and other opportunities for pharmacist intervention are clear. We discuss opportunities for pharmacist-run telehealth visits, reimbursement for services, and various aspects of interventions during this time of international emergency where all healthcare professionals have been asked to step up to help combat the mutual threat of COVID19. Clinical pharmacists in every specialty area are part of the essential healthcare workforce, but those practicing pain management in particular are in unique positions to assist all providers in adhering to chronic pain guidelines and various government mandates, and to foster optimal outcomes to complex patients with chronic pain. Furthermore, those that are available by telemedicine allow for improved access to quality and appropriate pain medication management, and additionally support opioid risk mitigation strategies, helping fill an unmet access to those at higher risk. This practice has the potential to help offset primary care provider workload, allowing for a decreased overall burden, especially in a complex, time-consuming, and high-risk patient population.

WikiRecs primary care: developing rapid recommendations for primary care through effective collaboration between systematic review and guideline teams

2018 ◽  
Vol 68 (suppl 1) ◽  
pp. bjgp18X697085
Author(s):  
Trudy Bekkering ◽  
Bert Aertgeerts ◽  
Ton Kuijpers ◽  
Mieke Vermandere ◽  
Jako Burgers ◽  
...  
Keyword(s):  
Systematic Review ◽  
Primary Care ◽  
Clinical Practice ◽  
Primary Care Physicians ◽  
Urinary Stones ◽  
Care Practice ◽  
Supporting Evidence ◽  
Supervised Exercise ◽  
Review Team ◽  
New Evidence

BackgroundThe WikiRecs evidence summaries and recommendations for clinical practice are developed using trustworthy methods. The process is triggered by studies that may potentially change practice, aiming at implementing new evidence into practice fast.AimTo share our first experiences developing WikiRecs for primary care and to reflect on the possibilities and pitfalls of this method.MethodIn March 2017, we started developing WikiRecs for primary health care to speed up the process of making potentially practice-changing evidence in clinical practice. Based on a well-structured question a systematic review team summarises the evidence using the GRADE approach. Subsequently, an international panel of primary care physicians, methodological experts and patients formulates recommendations for clinical practice. The patient representatives are involved as full guideline panel members. The final recommendations and supporting evidence are disseminated using various platforms, including MAGICapp and scientific journals.ResultsWe are developing WikiRecs on two topics: alpha-blockers for urinary stones and supervised exercise therapy for intermittent claudication. We did not face major problems but will reflect on issues we had to solve so far. We anticipate having the first WikiRecs for primary care available at the end of 2017.ConclusionThe WikiRecs process is a promising method — that is still evolving — to rapidly synthesise and bring new evidence into primary care practice, while adhering to high quality standards.

Proactive Actions Based on a Resilient Approach to Urban Seismic Risk Mitigation

2020 ◽  
Vol 14 (1) ◽  
pp. 321-335
Author(s):  
Marco Vona
Keyword(s):  
Urban Planning ◽  
Emergency Management ◽  
Seismic Risk ◽  
Risk Mitigation ◽  
Housing Stock ◽  
Mitigation Strategies ◽  
Housing System ◽  
Management Tools ◽  
Natural Risk ◽  
Seismic Risk Mitigation

Background: Seismic risk mitigation is an important issue in earthquake-prone countries, and needs to be solved in those complex communities governed by complex processes, where urban planning, socioeconomic dynamics, and, often, the need to preserve cultural assets are present simultaneously. In recent years, due to limited financial resources, mitigation activities have often been limited to post-earthquake events, and only a few in periods of inactivity, particularly in urban planning. At this point, a significant change in point of view is necessary. Methods: The seismic risk mitigation (and more generally, natural risk mitigation) must be considered as the main topic in urban planning and in the governance of communities. In fact, in several recent earthquakes, significant socioeconomic losses have been caused by the low or lack of resilience of the communities. This is mainly due to the high vulnerability of private buildings, in particular, housing units. Results: Therefore, in recent years, several studies have been conducted on the seismic resilience of communities. However, significant improvements are still needed for the resilience assessment of the housing stock, both qualitatively and quantitatively. In this study, which is applied to the housing system, a proposal regarding a change in urban planning and emergency management tools based on the concept of resilience is reported. As a first application, a case study in Italy is considered. Conclusion: The proposal is focused on defining and quantifying the improvement of the resilience of the communities and this must be obtained by modifying the current Civil Protection plan. New tools are based on a new resilience community plan by encompassing urban planning tools, resilient mitigation strategies, and consequently, emergency management planning.

Malnutrition screening tools in gastrointestinal cancer: A systematic review of concurrent validity

2021 ◽  
pp. 101627
Author(s):  
Irene Deftereos ◽  
Aleksandra Djordjevic ◽  
Vanessa M. Carter ◽  
Jacqueline McNamara ◽  
Justin MC. Yeung ◽  
...  
Keyword(s):  
Systematic Review ◽  
Gastrointestinal Cancer ◽  
Concurrent Validity ◽  
Screening Tools

Association between muscle strength and risk factors for metabolic syndrome in children and adolescents: a systematic review

2020 ◽  
Vol 0 (0) ◽  
Author(s):  
Tiago R. de Lima ◽  
Priscila C. Martins ◽  
Giuseppe L. Torre ◽  
Alice Mannocci ◽  
Kelly S. Silva ◽  
...  
Keyword(s):  
Risk Factors ◽  
Systematic Review ◽  
Metabolic Syndrome ◽  
Muscle Strength ◽  
Children And Adolescents ◽  
Lower Risk ◽  
Preliminary Evidence ◽  
Risk Of Bias ◽  
The Body ◽  
Reference List

AbstractThe aim of this systematic review was to identify and summarize evidence for the association between muscle strength (MS) and metabolic syndrome (MetS), and MS and combinations of risk factors for MetS in children and adolescents. Five databases (Medline/PubMed, EBSCO, Scielo, Scopus, and Web of Knowledge) were searched up to November 2019 with complementary reference list searches. Inclusion criteria were studies that investigated the relationship between MS and MetS or MS and combinations of risk factors for MetS in children and adolescents (≤19 years of age). Risk of bias was assessed using standard procedures. From the total of 15,599 articles initially identified, 13 articles were included, representing 11,641 children and adolescents. Higher MS values were associated with lower risk for MetS or combinations of risk factors for MetS (n=11/13 studies). Of the total of included studies, about 23.1% (03/13) were longitudinal and all included studies were classified as having a moderate risk of bias. This review provides preliminary evidence for a beneficial relationship between MS and MetS among children and adolescents. Additionally, although the body of evidence points to the beneficial relationship between higher MS and lower risk for combination of factors for MetS in children and adolescents, this relationship is inconclusive.

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