Pain Medicine 2015; 16: 1519–1527 Wiley Periodicals, Inc.
PAIN & AGING SECTION Original Research Article Use of Opioid Analgesics in Older Australians Felicity C. Veal, MSc, Luke R. E. Bereznicki, PhD, Angus J. Thompson, MSc, and Gregory M. Peterson, PhD
Reprint requests to: Felicity Veal, MSc, Unit for Medication Outcomes Research and Education, School of Medicine, Pharmacy, University of Tasmania, Private Bag 26, Hobart, Tasmania 7001, Australia. Tel: 161 3 6226 2312; Fax: 161 3 6226 7627; E-mail: [email protected]. Conflict of interest: There is one conflict of interest to declare. Gregory Peterson has a financial share in MedscopeTM Pty Ltd which was the source of medication review data; Professor Peterson, does not participate in the administration of the business or the collection or collation of data used in the MedscopeTM database.
Abstract Objective. To identify potential medication management issues associated with opioid use in older Australians. Design. Retrospective cross-sectional review of the utilization of analgesics in 19,581 people who underwent a medication review in Australia between 2010 and 2012. Subjects. Australian residents living in the community deemed at risk for adverse medication outcomes or any resident living fulltime in an aged care facility. Methods. Patient characteristics in those taking regularly dosed opioids and not and those taking
Results. Opioids were taken by 31.8% of patients, with 22.1% taking them regularly. Several major medication management issues were identified. There was suboptimal use of multimodal analgesia, particularly a low use of non-opioid analgesics, in patients taking regular opioids. There was extensive use (45%) of concurrent anxiolytics/hypnotics among those taking regular opioid analgesics. Laxative use in those prescribed opioids regularly was low (60%). Additionally, almost 12% of patients were taking doses of opioid that exceeded Australian recommendations. Conclusions. A significant evidence to practice gap exists regarding the use of opioids amongst older Australians. These findings highlight the need for a quick reference guide to support prescribers in making appropriate decisions regarding pain management in older patients with persistent pain. This should also be combined with patient and caregiver education about the importance of regular acetaminophen to manage persistent pain. Key Words. Analgesics; Opioids; Elderly; Pain Background Up to 80% of aged care facility (ACF) residents and 50% of older persons living in the community suffer from persistent pain [1]. Persistent pain is a difficult condition to treat effectively in any population. However, pain management in older patients has a number of additional challenges, including polypharmacy [2] which increases the likelihood of drug–drug interactions, as well as comorbidities which increase the likelihood of drug–disease interactions. Management is further complicated by changes and variability in the pharmacokinetics and pharmacodynamics of analgesics [3], changes in perception of pain [4], and patient-related barriers to pain management [5]. 1519
Downloaded from http://painmedicine.oxfordjournals.org/ by guest on June 9, 2016
Unit for Medication Outcomes Research and Education, School of Medicine, Pharmacy, University of Tasmania, Tasmania 7001, Australia
opioid doses >120 mg and £ 120 mg MEQ/day were compared. Multivariable binary logistic regression was used to analyze the association between regular opioid and high dose opioid usage and key variables. Additionally, medication management issues associated with opioids were identified.
Veal et al. Opioid analgesics are not recommended as first-line treatment or in isolation of other pharmacological and nonpharmacological treatment [3,6–9]. Yet, opioid analgesics are increasingly prescribed for the management of persistent pain, demonstrated by the dramatic increase in their use [10–13] and treatment duration [11,14]. Consistent with this phenomenon, there has been a trend towards an increasing death rate associated with opioid analgesic use [14–16], proportional to the opioid dose being taken [14,17]. For noncancer pain, Australian guidelines recommended a maximum opioid dose equivalent to 100–120 mg of oral morphine (MEQ) per day [6,18]. However, the risk of overdose and adverse events, such as falls and fractures, exists at doses significantly lower than this recommended maximum [19–21].
The primary objective of this study was to assess for differences between those using regularly dosed (RD) opioids (vs those who were not); as well as for differences among those taking opioid daily doses exceeding 120 MEQ/day (versus those taking less than this amount). From this potential medication management issues were identified in relation to the use of opioids analgesics in the treatment of pain among older Australians undergoing a medication review.
The consultant pharmacist undertakes a review of the patient’s medication in their home, or ACF. This interview normally lasts for 30–60 minutes. During the interview the pharmacist inquires about any additional medical conditions or other (prescribed or over-thecounter) medications the patient may be taking. A report is then provided back to the GP, listing all medications as well as any pharmacist recommendations regarding the patient’s management. The GP will then meet with the patient and implement those recommendations they consider appropriate. A GP may request a review every 24 months for both community and ACF dwelling patients, unless there is a clear need for a shorter interval. All permanent Australian residents living in an ACF are eligible for a review. Eligibility requirements for Australian residents living in the community include; taking multiple medications, or multiple doses of medication a day; taking medications with a narrow therapeutic range; where an adverse drug reaction is suspected or the patient is or may have problems self-managing their medications [24]. MedscopeTM Database Pharmacists can choose to use different software programs to aid in assessing patient therapy and report writing. One of these programs and the one used in this study (MedscopeTM) has free text options to include the patient’s medical conditions and medications, strength, and directions. All patient records in the MedscopeTM database as of July 2012 were included in this review. The extract contained 19,996 deidentified medication reviews conducted between January 2010 and June 2012. From these records, 382 reviews were excluded as they included no medical history.
Methods Study design A retrospective cross-sectional study of patients undergoing medication reviews in Australia was undertaken evaluating who uses opioids and identifying medication management issues. Medication reviews are a government funded initiative whose principal aim is to decrease the risk of medication related adverse events. In Australia, two forms of pharmacist-conducted comprehensive medication reviews are undertaken, Home Medicines Reviews (HMR) for community dwelling patients and Residential Medication Management Reviews (RMMR) for permanent ACF residents. These reviews are collaborative between patients’ general practitioners (GPs) and specially trained consultant pharmacists, with both parties being paid by the government for their contribution. When requesting a review, the GP provides the consultant pharmacist with a list of the patient’s comorbidities and prescribed medi1520
Based on Medical Benefits Scheme (MBS) records [25], 51% of medication reviews conducted in Australia were HMRs. Of the 20,000 records reviewed for this study, a greater proportion (62%), of patients had undergone a HMR. The demographics based on the proportion of females in the MBS data compared with the study population (63.6% vs 62.1%) and proportion of patients in each age group are similar between the MBS data and the study data. MBS data show that 1.9% of the Australian population receiving a medicines review was under the age of 45% and 31.4% were 85 years or older, which is very similar to the MedscopeTM database, where 1.8% of patients were aged less than 45% and 31.9% were aged 85 or older. The 20,000 reviews included in this study equates to approximately 6.5% of all reviews conducted in Australia during the study period. Independent Variables The patient’s date of birth, date of review, gender, allergies and medical history, type of review undertaken
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In Australia, the Pharmaceutical Benefits Scheme (PBS) [22], which is the national formulary for government subsidized medicines, generally lists opioids as restricted for the management of “severe disabling pain not responding to non-narcotic analgesics.” The restriction is silent on the issue of coprescription of non-opioid analgesics. Despite this restriction, a recent Australian study evaluating the PBS prescriptions dispensed for veterans in Australia found that 34% of community patients and 20% of ACF residents commenced on oxycodone had not received non-opioid analgesics in the previous 4 months [23].
cations; and in some cases provides additional information, such as relevant pathology test results.
Opioid Analgesics in older Australians
Table 1
Characteristics by regular dosing of opioids
Variables
Those not taking regularly scheduled opioids (n 5 15246)
P value
2998 (69.2)
9155 (60.0)
P < 0.001
492 554 1008 1541 738
(11.4) (12.8) (23.3) (35.6) (17.0)
1435 2288 4036 5418 2038
(9.4) (15.0) (26.5) (35.6) (13.4)
P < 0.001
2325 1064 548 477 993
(53.6) (24.5) (12.6) (11.0) (22.9)
5961 1784 1211 1353 2767
(39.1) (11.7) (7.9) (8.9) (18.1)
P P P P P
< < < <
120 mg on average they were taking 2.3 different opioids. For this reason this section does not equal 100%. For patients taking doses 120 mg on average 1.5 different opioids IR 5 immediate release; CR 5 controlled release; MEQ 5 oral morphine equivalence/day; APAP 5 acetaminophen; NSAIDs 5 nonsteroidal anti-inflammatory drugs; TCA 5 tricyclic antidepressants; SNRI 5 serotonin noradrenalin reuptake inhibitor.
medications taken by patients using RD opioids as well as those using RD opioids at doses exceeding 120 mg MEQ/day. This table shows that adjuncts were more likely to be used in those receiving high dose therapy, similarly, more potent opioids were more frequently used by those taking doses exceeding 120 mg MEQ/ day. Hypnotics and anxiolytics were also more commonly used in those patients receiving high dose opioids. The results from a multivariable binary logistic regression analysis are shown in Table 4. Patients were more likely to take RD opioids if they were female, have a documented history of depression and/or anxiety, fractures, congestive heart failure, cancer, musculoskeletal pain or pain NOS and were less likely to be older than 60 years or have a history of diabetes. Patients were also more likely to take regular opioids at doses exceeding 120 mg MEQ/day if they had a history of depression or anxiety, pain NOS, cancer or had a history of substance or alcohol abuse and were less likely to be older than 60 years, or have a history of dementia.
Discussion This study investigated the use of analgesics in nearly 20,000 patients undergoing a medication review in Australia; 80% of these patients were taking analgesics and 22.1% were taking RD opioids. A number of important medication management issues were identified. It has been established that multimodal analgesic regimens in the treatment of acute postoperative pain, reduce opioid requirements [36]. Furthermore, current evidence suggests that acetaminophen improves pain control [37]. Despite these findings only 49.1% of patients taking RD opioids were taking optimised acetaminophen and 17.8% were taking NSAIDs. Although the effect size of acetaminophen on pain and functionality is less than that of NSAIDs [38,39] it is a more suitable treatment modality due to the side effect profile of NSAIDs. It is also important to note that there is limited evidence to support the use of opioids in chronic pain conditions and a clear dose related relationship of side effects [40]. Thus, with this older population at high risk of adverse events associated with opioids and NSAIDs, the use of 1523
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Opioid dosing Median MEQ/day Mean MEQ/day (SD) Specific opioids used (%) Buprenorphine patch Oxycodone IR Oxycodone CR Fentanyl Patch Morphine CR Morphine IR Tramadol Codeine containing Other medication that can be used for pain (%) APAP Optimised APAP NSAIDs SNRI use TCA use Gabapentin/pregabalin use Other medications (%) Laxatives Anxiolytics/hypnotics
Those taking >120mg MEQ/ day (n 5 457)
Veal et al.
Table 4
Multivariable analysis of factors associated with any RD opioid use and >120mg MEQ/day
Variables
Regularly dosed opioids >120 MEQ/day (n 5 457)†
Odds Ratio (95% CI)
Odds Ratio (95% CI)
1.51 (1.21–1.41)§ 1 0.71 (0.62–0.82)§ 0.72 (0.63–0.82)§ 0.78 (0.69–0.88)§ 0.96 (0.83–1.11) 1.64 (1.53–1.76)§ 2.26 (2.07–2.47)§ 1.45 (1.29–1.62)§ 1.31 (1.17–1.47)§ 1.09 (0.99–1.19) 1.11 (0.98–1.25) 1.40 (1.30–1.51)§ 1.25 (1.11–1.39)§
1 0.77 (0.53–1.10) 0.83 (0.60–1.14) 0.68 (0.40–0.94)‡ 0.88 (0.61–1.27)
1.81 (1.47–2.23)§ 1.79 (1.36–2.35)§
1.43 (1.17–1.75)§ 0.58 (0.42–0.80)§
0.87 (0.80–0.94)§ 1.35 (1.08–1.69)‡ 1.01 (0.93–1.09)
1.43 (0.85–2.39)
* Hosmer–lemeshow goodness-of-fit test chisq 5 12.98; df 5 8;P 5 0.112. † Hosmer–lemeshow goodness-of-fit test chisq 5 7.01; df 5 7;P 5 0.428. ‡ P < 0.05; § P < 0.001. MEQ 5 morphine equivalence.
optimised acetaminophen should be encouraged to potentially help reduce opioid and NSAID requirements. Our study also documented extensive use of anxiolytics and/or hypnotics among those taking RD opioids. This finding is not surprising and has been previously associated with opioid use [41] but is concerning given that anxiolytics and hypnotics are recommended for short term use and this combination, particularly in older people, further increases the risk of falls and fractures [28]. Another medication issue that was identified was the low (60%) use of prophylactic laxatives for people taking regular long-term opioids, despite being recommended in numerous guidelines [3,8,27]. This result suggests suboptimal management of opioid related constipation. The fourth medication problem identified was the use of high dose opioids. Nearly 12% of the population taking RD opioids were taking doses above the maximum recommended (100–120 mg MEQ/day) in Australia [6,18]. 1524
This proportion was higher than a previous US study [20] which found that 6.1–7.1% of their population used doses exceeding 120 mg MEQ/day. Patients on these high doses are at an increased risk of falls and fractures [28] as well as accidental overdose [14,15,42,43] and a number of other health related adverse events. This study highlights that there is significant room for improvement in the way pain is managed in medically complicated patients, to include those undergoing a medication review in Australia. As these patients are at high risk of opioid-associated adverse events, such as constipation, falls, fractures, respiratory depression and confusion, we need to ensure that these risks are minimized, by providing the lowest effective opioid dose in combination with optimized non-opioid analgesics. Furthermore, high risk therapy combinations, such as the use of anxiolytics and hypnotics together with opioids, should be avoided or the lowest effective dose used to minimize risk.
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Demographics Female gender Age
PAIN & AGING SECTION Original Research Article Use of Opioid Analgesics in Older Australians Felicity C. Veal, MSc, Luke R. E. Bereznicki, PhD, Angus J. Thompson, MSc, and Gregory M. Peterson, PhD
Reprint requests to: Felicity Veal, MSc, Unit for Medication Outcomes Research and Education, School of Medicine, Pharmacy, University of Tasmania, Private Bag 26, Hobart, Tasmania 7001, Australia. Tel: 161 3 6226 2312; Fax: 161 3 6226 7627; E-mail: [email protected]. Conflict of interest: There is one conflict of interest to declare. Gregory Peterson has a financial share in MedscopeTM Pty Ltd which was the source of medication review data; Professor Peterson, does not participate in the administration of the business or the collection or collation of data used in the MedscopeTM database.
Abstract Objective. To identify potential medication management issues associated with opioid use in older Australians. Design. Retrospective cross-sectional review of the utilization of analgesics in 19,581 people who underwent a medication review in Australia between 2010 and 2012. Subjects. Australian residents living in the community deemed at risk for adverse medication outcomes or any resident living fulltime in an aged care facility. Methods. Patient characteristics in those taking regularly dosed opioids and not and those taking
Results. Opioids were taken by 31.8% of patients, with 22.1% taking them regularly. Several major medication management issues were identified. There was suboptimal use of multimodal analgesia, particularly a low use of non-opioid analgesics, in patients taking regular opioids. There was extensive use (45%) of concurrent anxiolytics/hypnotics among those taking regular opioid analgesics. Laxative use in those prescribed opioids regularly was low (60%). Additionally, almost 12% of patients were taking doses of opioid that exceeded Australian recommendations. Conclusions. A significant evidence to practice gap exists regarding the use of opioids amongst older Australians. These findings highlight the need for a quick reference guide to support prescribers in making appropriate decisions regarding pain management in older patients with persistent pain. This should also be combined with patient and caregiver education about the importance of regular acetaminophen to manage persistent pain. Key Words. Analgesics; Opioids; Elderly; Pain Background Up to 80% of aged care facility (ACF) residents and 50% of older persons living in the community suffer from persistent pain [1]. Persistent pain is a difficult condition to treat effectively in any population. However, pain management in older patients has a number of additional challenges, including polypharmacy [2] which increases the likelihood of drug–drug interactions, as well as comorbidities which increase the likelihood of drug–disease interactions. Management is further complicated by changes and variability in the pharmacokinetics and pharmacodynamics of analgesics [3], changes in perception of pain [4], and patient-related barriers to pain management [5]. 1519
Downloaded from http://painmedicine.oxfordjournals.org/ by guest on June 9, 2016
Unit for Medication Outcomes Research and Education, School of Medicine, Pharmacy, University of Tasmania, Tasmania 7001, Australia
opioid doses >120 mg and £ 120 mg MEQ/day were compared. Multivariable binary logistic regression was used to analyze the association between regular opioid and high dose opioid usage and key variables. Additionally, medication management issues associated with opioids were identified.
Veal et al. Opioid analgesics are not recommended as first-line treatment or in isolation of other pharmacological and nonpharmacological treatment [3,6–9]. Yet, opioid analgesics are increasingly prescribed for the management of persistent pain, demonstrated by the dramatic increase in their use [10–13] and treatment duration [11,14]. Consistent with this phenomenon, there has been a trend towards an increasing death rate associated with opioid analgesic use [14–16], proportional to the opioid dose being taken [14,17]. For noncancer pain, Australian guidelines recommended a maximum opioid dose equivalent to 100–120 mg of oral morphine (MEQ) per day [6,18]. However, the risk of overdose and adverse events, such as falls and fractures, exists at doses significantly lower than this recommended maximum [19–21].
The primary objective of this study was to assess for differences between those using regularly dosed (RD) opioids (vs those who were not); as well as for differences among those taking opioid daily doses exceeding 120 MEQ/day (versus those taking less than this amount). From this potential medication management issues were identified in relation to the use of opioids analgesics in the treatment of pain among older Australians undergoing a medication review.
The consultant pharmacist undertakes a review of the patient’s medication in their home, or ACF. This interview normally lasts for 30–60 minutes. During the interview the pharmacist inquires about any additional medical conditions or other (prescribed or over-thecounter) medications the patient may be taking. A report is then provided back to the GP, listing all medications as well as any pharmacist recommendations regarding the patient’s management. The GP will then meet with the patient and implement those recommendations they consider appropriate. A GP may request a review every 24 months for both community and ACF dwelling patients, unless there is a clear need for a shorter interval. All permanent Australian residents living in an ACF are eligible for a review. Eligibility requirements for Australian residents living in the community include; taking multiple medications, or multiple doses of medication a day; taking medications with a narrow therapeutic range; where an adverse drug reaction is suspected or the patient is or may have problems self-managing their medications [24]. MedscopeTM Database Pharmacists can choose to use different software programs to aid in assessing patient therapy and report writing. One of these programs and the one used in this study (MedscopeTM) has free text options to include the patient’s medical conditions and medications, strength, and directions. All patient records in the MedscopeTM database as of July 2012 were included in this review. The extract contained 19,996 deidentified medication reviews conducted between January 2010 and June 2012. From these records, 382 reviews were excluded as they included no medical history.
Methods Study design A retrospective cross-sectional study of patients undergoing medication reviews in Australia was undertaken evaluating who uses opioids and identifying medication management issues. Medication reviews are a government funded initiative whose principal aim is to decrease the risk of medication related adverse events. In Australia, two forms of pharmacist-conducted comprehensive medication reviews are undertaken, Home Medicines Reviews (HMR) for community dwelling patients and Residential Medication Management Reviews (RMMR) for permanent ACF residents. These reviews are collaborative between patients’ general practitioners (GPs) and specially trained consultant pharmacists, with both parties being paid by the government for their contribution. When requesting a review, the GP provides the consultant pharmacist with a list of the patient’s comorbidities and prescribed medi1520
Based on Medical Benefits Scheme (MBS) records [25], 51% of medication reviews conducted in Australia were HMRs. Of the 20,000 records reviewed for this study, a greater proportion (62%), of patients had undergone a HMR. The demographics based on the proportion of females in the MBS data compared with the study population (63.6% vs 62.1%) and proportion of patients in each age group are similar between the MBS data and the study data. MBS data show that 1.9% of the Australian population receiving a medicines review was under the age of 45% and 31.4% were 85 years or older, which is very similar to the MedscopeTM database, where 1.8% of patients were aged less than 45% and 31.9% were aged 85 or older. The 20,000 reviews included in this study equates to approximately 6.5% of all reviews conducted in Australia during the study period. Independent Variables The patient’s date of birth, date of review, gender, allergies and medical history, type of review undertaken
Downloaded from http://painmedicine.oxfordjournals.org/ by guest on June 9, 2016
In Australia, the Pharmaceutical Benefits Scheme (PBS) [22], which is the national formulary for government subsidized medicines, generally lists opioids as restricted for the management of “severe disabling pain not responding to non-narcotic analgesics.” The restriction is silent on the issue of coprescription of non-opioid analgesics. Despite this restriction, a recent Australian study evaluating the PBS prescriptions dispensed for veterans in Australia found that 34% of community patients and 20% of ACF residents commenced on oxycodone had not received non-opioid analgesics in the previous 4 months [23].
cations; and in some cases provides additional information, such as relevant pathology test results.
Opioid Analgesics in older Australians
Table 1
Characteristics by regular dosing of opioids
Variables
Those not taking regularly scheduled opioids (n 5 15246)
P value
2998 (69.2)
9155 (60.0)
P < 0.001
492 554 1008 1541 738
(11.4) (12.8) (23.3) (35.6) (17.0)
1435 2288 4036 5418 2038
(9.4) (15.0) (26.5) (35.6) (13.4)
P < 0.001
2325 1064 548 477 993
(53.6) (24.5) (12.6) (11.0) (22.9)
5961 1784 1211 1353 2767
(39.1) (11.7) (7.9) (8.9) (18.1)
P P P P P
< < < <
120 mg on average they were taking 2.3 different opioids. For this reason this section does not equal 100%. For patients taking doses 120 mg on average 1.5 different opioids IR 5 immediate release; CR 5 controlled release; MEQ 5 oral morphine equivalence/day; APAP 5 acetaminophen; NSAIDs 5 nonsteroidal anti-inflammatory drugs; TCA 5 tricyclic antidepressants; SNRI 5 serotonin noradrenalin reuptake inhibitor.
medications taken by patients using RD opioids as well as those using RD opioids at doses exceeding 120 mg MEQ/day. This table shows that adjuncts were more likely to be used in those receiving high dose therapy, similarly, more potent opioids were more frequently used by those taking doses exceeding 120 mg MEQ/ day. Hypnotics and anxiolytics were also more commonly used in those patients receiving high dose opioids. The results from a multivariable binary logistic regression analysis are shown in Table 4. Patients were more likely to take RD opioids if they were female, have a documented history of depression and/or anxiety, fractures, congestive heart failure, cancer, musculoskeletal pain or pain NOS and were less likely to be older than 60 years or have a history of diabetes. Patients were also more likely to take regular opioids at doses exceeding 120 mg MEQ/day if they had a history of depression or anxiety, pain NOS, cancer or had a history of substance or alcohol abuse and were less likely to be older than 60 years, or have a history of dementia.
Discussion This study investigated the use of analgesics in nearly 20,000 patients undergoing a medication review in Australia; 80% of these patients were taking analgesics and 22.1% were taking RD opioids. A number of important medication management issues were identified. It has been established that multimodal analgesic regimens in the treatment of acute postoperative pain, reduce opioid requirements [36]. Furthermore, current evidence suggests that acetaminophen improves pain control [37]. Despite these findings only 49.1% of patients taking RD opioids were taking optimised acetaminophen and 17.8% were taking NSAIDs. Although the effect size of acetaminophen on pain and functionality is less than that of NSAIDs [38,39] it is a more suitable treatment modality due to the side effect profile of NSAIDs. It is also important to note that there is limited evidence to support the use of opioids in chronic pain conditions and a clear dose related relationship of side effects [40]. Thus, with this older population at high risk of adverse events associated with opioids and NSAIDs, the use of 1523
Downloaded from http://painmedicine.oxfordjournals.org/ by guest on June 9, 2016
Opioid dosing Median MEQ/day Mean MEQ/day (SD) Specific opioids used (%) Buprenorphine patch Oxycodone IR Oxycodone CR Fentanyl Patch Morphine CR Morphine IR Tramadol Codeine containing Other medication that can be used for pain (%) APAP Optimised APAP NSAIDs SNRI use TCA use Gabapentin/pregabalin use Other medications (%) Laxatives Anxiolytics/hypnotics
Those taking >120mg MEQ/ day (n 5 457)
Veal et al.
Table 4
Multivariable analysis of factors associated with any RD opioid use and >120mg MEQ/day
Variables
Regularly dosed opioids >120 MEQ/day (n 5 457)†
Odds Ratio (95% CI)
Odds Ratio (95% CI)
1.51 (1.21–1.41)§ 1 0.71 (0.62–0.82)§ 0.72 (0.63–0.82)§ 0.78 (0.69–0.88)§ 0.96 (0.83–1.11) 1.64 (1.53–1.76)§ 2.26 (2.07–2.47)§ 1.45 (1.29–1.62)§ 1.31 (1.17–1.47)§ 1.09 (0.99–1.19) 1.11 (0.98–1.25) 1.40 (1.30–1.51)§ 1.25 (1.11–1.39)§
1 0.77 (0.53–1.10) 0.83 (0.60–1.14) 0.68 (0.40–0.94)‡ 0.88 (0.61–1.27)
1.81 (1.47–2.23)§ 1.79 (1.36–2.35)§
1.43 (1.17–1.75)§ 0.58 (0.42–0.80)§
0.87 (0.80–0.94)§ 1.35 (1.08–1.69)‡ 1.01 (0.93–1.09)
1.43 (0.85–2.39)
* Hosmer–lemeshow goodness-of-fit test chisq 5 12.98; df 5 8;P 5 0.112. † Hosmer–lemeshow goodness-of-fit test chisq 5 7.01; df 5 7;P 5 0.428. ‡ P < 0.05; § P < 0.001. MEQ 5 morphine equivalence.
optimised acetaminophen should be encouraged to potentially help reduce opioid and NSAID requirements. Our study also documented extensive use of anxiolytics and/or hypnotics among those taking RD opioids. This finding is not surprising and has been previously associated with opioid use [41] but is concerning given that anxiolytics and hypnotics are recommended for short term use and this combination, particularly in older people, further increases the risk of falls and fractures [28]. Another medication issue that was identified was the low (60%) use of prophylactic laxatives for people taking regular long-term opioids, despite being recommended in numerous guidelines [3,8,27]. This result suggests suboptimal management of opioid related constipation. The fourth medication problem identified was the use of high dose opioids. Nearly 12% of the population taking RD opioids were taking doses above the maximum recommended (100–120 mg MEQ/day) in Australia [6,18]. 1524
This proportion was higher than a previous US study [20] which found that 6.1–7.1% of their population used doses exceeding 120 mg MEQ/day. Patients on these high doses are at an increased risk of falls and fractures [28] as well as accidental overdose [14,15,42,43] and a number of other health related adverse events. This study highlights that there is significant room for improvement in the way pain is managed in medically complicated patients, to include those undergoing a medication review in Australia. As these patients are at high risk of opioid-associated adverse events, such as constipation, falls, fractures, respiratory depression and confusion, we need to ensure that these risks are minimized, by providing the lowest effective opioid dose in combination with optimized non-opioid analgesics. Furthermore, high risk therapy combinations, such as the use of anxiolytics and hypnotics together with opioids, should be avoided or the lowest effective dose used to minimize risk.
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Demographics Female gender Age
