Articles: opioid.
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The relationships between the initial opioid prescription characteristics and pain etiology with the probability of opioid discontinuation were explored in this retrospective cohort study using health insurance claims data from a nationally representative database of commercially insured patients in the United States. We identified 1,353,902 persons aged 14 years and older with no history of cancer or substance abuse, with new opioid use episodes and categorized them into 11 mutually exclusive pain etiologies. Cox proportional hazards models were estimated to identify factors associated with time to opioid discontinuation. ⋯ Increasing days' supply of the first prescription was consistently associated with a lower likelihood of opioid discontinuation (HRs, CIs: 3-4 days' supply = .70, .70-.71; 5-7 days' supply = .48, .47-.48; 8-10 days' supply = .37, .37-.38; 11-14 days' supply = .32, .31-.33; 15-21 days' supply = .29, .28-.29; ≥22 days supplied = .20, .19-.20). The direction of this relationship was consistent across all pain etiologies. Clinicians should initiate patients with the lowest supply of opioids to mitigate unintentional long-term opioid use.
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Pediatric opioid and benzodiazepine withdrawal are avoidable complications of pain and sedation management that is well described in the literature. To prevent withdrawal from occurring, practitioners regularly use a steady decrease of pain and sedation medications, also known as a weaning or tapering schedule. The weaning schedule is highly variable based on clinician preference and is usually dependent on the clinician. ⋯ The use of a standardized opioid-weaning protocol reduced withdrawal rates compared with nonstandardized weaning plans. Benzodiazepine weaning was inconsistently evaluated and may have affected study outcomes. Identified areas of improvement include the use of newer withdrawal assessment tools validated in the older pediatric population and standardized withdrawal assessment and reporting.
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Patient satisfaction is used to measure physician performance in hospital and governmental practice settings. There is limited understanding about factors affecting satisfaction in a chronic pain management setting for patients prescribed chronic opioids. ⋯ These results indicate that a patient's perception of a provider's engagement and concern more heavily impacts perceived satisfaction than the patient's progress. A patient's perception of his or her clinic experience is heavily influenced by the attentiveness and coordination of the entire clinic care team. Staff attentiveness and coordination may affect a patient's level of stress. Adherence to current opioid prescription guidelines did not appear to have an overall negative effect on patient satisfaction.
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In response to increases in harms associated with prescription opioids, opioid prescribing has come under greater scrutiny, leading many health care organizations and providers to consider or mandate opioid dose reductions (tapering) for patients with chronic pain. Communicating about tapering can be difficult, particularly for patients receiving long-term opioids who perceive benefits and are using their medications as prescribed. Because of the importance of effective patient-provider communication for pain management and recent health system-level initiatives and provider practices to taper opioids, this study used qualitative methods to understand communication processes related to opioid tapering, to identify best practices and opportunities for improvement. Up to 3 clinic visits per patient were audio-recorded, and individual interviews were conducted with patients and their providers. Four major themes emerged: 1) explaining-patients needed to understand individualized reasons for tapering, beyond general, population-level concerns such as addiction potential, 2) negotiating-patients needed to have input, even if it was simply the rate of tapering, 3) managing difficult conversations-when patients and providers did not reach a shared understanding, difficulties and misunderstandings arose, and 4) nonabandonment-patients needed to know that their providers would not abandon them throughout the tapering process. ⋯ Although opioid tapering can be challenging, helping patients to understand individualized reasons for tapering, encouraging patients to have input into the process, and assuring patients they would not be abandoned all appear to facilitate optimal communication about tapering.
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The Journal of urology · Nov 2017
Rates and Risk Factors for Opioid Dependence and Overdose after Urological Surgery.
Effective pain management is a critical component of the perioperative process with opioids representing a mainstay of therapy. The opioid epidemic is a growing concern in the United States. The goal of this study was to quantify the risk of opioid dependence or overdose among patients undergoing urological surgery and to identify risk factors of opioid dependence or overdose. ⋯ Postoperative opioid dependence or overdose affects 1 of 1,111 urological surgery patients. Risk factors for opioid dependence or overdose included younger age, inpatient surgery and increasing hospitalization duration, baseline depression, tobacco use and chronic obstructive pulmonary disease as well as insurance provider, including Medicaid, Medicare (age less than 65 years) and noninsured status.