Fain Kevin M, Castillo-Salgado Carlos, Dore David D, Segal Jodi B, Zullo Andrew R, Alexander G Caleb
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
J Am Med Dir Assoc. 2017 Feb 1;18(2):138-144. doi: 10.1016/j.jamda.2016.08.015. Epub 2016 Oct 6.
We quantified transdermal fentanyl prescribing in elderly nursing home residents without prior opioid use or persistent pain, and the association of individual and facility traits with opioid-naïve prescribing.
Cross-sectional study.
Linked Minimum Data Set (MDS) assessments; Online Survey, Certification and Reporting (OSCAR) records; and Medicare Part D claims.
From a cross-section of all long-stay US nursing home residents in 2008 with an MDS assessment and Medicare Part D enrollment, we identified individuals (≥65 years old) who initiated transdermal fentanyl, excluding those with Alzheimer disease, severe cognitive impairment, cancer, or receipt of hospice care.
We used Medicare Part D to select beneficiaries initiating transdermal fentanyl in 2008 and determined whether they were "opioid-naïve," defined as no opioid dispensing during the previous 60 days. We obtained resident and facility characteristics from MDS and OSCAR records and defined persistent pain as moderate-to-severe, daily pain on consecutive MDS assessments at least 90 days apart. We estimated associations of patient and facility attributes and opioid-naïve fentanyl initiation using multilevel mixed effects logistic regression modeling.
Among 17,052 residents initiating transdermal fentanyl, 6190 (36.3%) were opioid-naïve and 15,659 (91.8%) did not have persistent pain. In the regression analysis with adjustments, residents who were older (ages ≥95 odds ratio [OR] 1.69, 95% confidence interval [CI] 1.46-1.95) or more cognitively impaired (moderate-to-severe cognitive impairment, OR 1.99, 95% CI 1.73-2.29) were more likely to initiate transdermal fentanyl without prior opioid use.
Most nursing home residents initiating transdermal fentanyl did not have persistent pain and many were opioid-naïve. Changes in prescribing practices may be necessary to ensure Food and Drug Administration warnings are followed, particularly for vulnerable subgroups, such as the cognitively impaired.
我们对未使用过阿片类药物或无持续性疼痛的老年疗养院居民中透皮芬太尼的处方情况进行了量化，并研究了个体和机构特征与未使用过阿片类药物的处方之间的关联。
横断面研究。
关联的最低数据集（MDS）评估；在线调查、认证和报告（OSCAR）记录；以及医疗保险D部分索赔。
从2008年所有接受MDS评估和医疗保险D部分登记的美国长期疗养院居民中选取一个横断面，我们确定了开始使用透皮芬太尼的个体（≥65岁），排除患有阿尔茨海默病、严重认知障碍、癌症或接受临终关怀的患者。
我们使用医疗保险D部分来选择2008年开始使用透皮芬太尼的受益人，并确定他们是否“未使用过阿片类药物”，定义为在过去60天内未使用过阿片类药物。我们从MDS和OSCAR记录中获取居民和机构特征，并将持续性疼痛定义为至少间隔90天的连续MDS评估中出现的中度至重度每日疼痛。我们使用多级混合效应逻辑回归模型估计患者和机构属性与未使用过阿片类药物的芬太尼起始之间的关联。
在17052名开始使用透皮芬太尼的居民中，6190名（36.3%）未使用过阿片类药物，15659名（91.8%）没有持续性疼痛。在进行调整的回归分析中，年龄较大（≥95岁，比值比[OR]1.69，95%置信区间[CI]1.46 - 1.95）或认知障碍程度较高（中度至重度认知障碍，OR 1.99，95% CI 1.73 - 2.29）的居民更有可能在未使用过阿片类药物的情况下开始使用透皮芬太尼。
大多数开始使用透皮芬太尼的疗养院居民没有持续性疼痛，且许多人未使用过阿片类药物。可能需要改变处方做法，以确保遵循美国食品药品监督管理局的警告，特别是对于认知障碍等脆弱亚组。
