Samanta Lalic

Prioritizing interventions to manage polypharmacy in Australian aged care facilities

Background: Polypharmacy is highly prevalent in residential aged care facilities (RACFs). Although polypharmacy is sometimes unavoidable, polypharmacy has been associated with increased morbidity and mortality. Objective: To identify and prioritize a range of potential interventions to manage polypharmacy in RACFs from the perspectives of health care professionals, health policy and consumer representatives. Methods: Two nominal group technique (NGT) sessions were convened in August 2015. A purposive sample (n = 19) of clinicians, researchers, managers and representatives of consumer, professional and health policy organizations were asked to nominate interventions to address the prevalence and appropriateness of medication use. Participants were then asked to prioritize five interventions suitable for possible implementation at the system level. Results: Six of 16 potential interventions were prioritized highest for possible implementation in clinical practice, with two interventions prioritized as second highest. The top interventions in rank order were ‘implementation of a pharmacist‐led medication reconciliation service for new residents,’ ‘conduct facility‐level audits and feedback to staff and health care professionals,’ ‘develop deprescribing scripts to assist clinician‐resident discussion,’ ‘develop or revise prescribing guidelines specific to older people with multimorbidity in RACFs,’ ‘implement electronic medication charts and records’ and ‘better support Medication Advisory Committees (MACs) to address medication appropriateness.’ Conclusion: This study prioritized a range of potential interventions that may be used to assist clinicians and policy makers develop a comprehensive strategy to manage polypharmacy in RACFs.

Frailty, Hospitalization, and Mortality in Residential Aged Care

Background Frailty predicts mortality in residential aged care, but the relationship with hospitalization is inconsistent. The purpose of this study was to investigate and compare whether frailty is associated with hospitalization and mortality among residents of aged care services. Methods A prospective cohort study of 383 residents aged 65 years and older was conducted in six Australian residential aged care services. Frailty was assessed using the FRAIL-NH scale and a 66-item frailty index. Results Overall, 125 residents were hospitalized on 192 occasions and 85 died over the 12-month follow-up. Over this period, less than 3% of the nonfrail/vulnerable residents but more than 20% of the most frail residents died at the facility without hospitalization. Using the FRAIL-NH, residents with mild/moderate frailty had higher numbers of hospitalizations (adjusted incidence rate ratio 1.57, 95% confidence interval [CI] 1.11-2.20) and hospital days (incidence rate ratio 1.48, 95% CI 1.32-1.66) than nonfrail residents. Residents who were most frail had lower numbers of hospitalizations (incidence rate ratio 0.65, 95% CI 0.42-0.99) and hospital days (incidence rate ratio 0.39, 95% CI 0.33-0.46) than nonfrail residents. Similar patterns of associations with number of hospital days were observed for the frailty index. Most frail residents had a higher risk of death than nonfrail residents (for FRAIL-NH, adjusted hazard ratio 2.96, 95% CI 1.50-5.83; for frailty index, hazard ratio 5.28, 95% CI 2.05-13.59). Conclusions Residents with mild/moderate frailty had higher risk of hospitalization and death than nonfrail residents. Residents who were most frail had higher risk of death but lower risk of hospitalization than nonfrail residents.

Harms associated with extramedical use of prescription opioid analgesics in Australia: A scoping review

BACKGROUND Evidence is accumulating globally on harms from extramedical prescription opioid analgesic (POA) use. OBJECTIVE The aim of this scoping review was to explore harms and documented risk factors associated with extramedical POA use in Australia. METHODS MEDLINE, EMBASE, PsycINFO and CINAHL were searched for original studies published between January 2000 and February 2018. Studies were eligible for inclusion if: 1) POA use was explicitly reported, 2) extramedical use was evident 3) harm was explicitly reported, 4) data were collected in/after 2000, 5) conducted in adults and 6) undertaken in Australia. RESULTS We identified 560 articles and 16 met the inclusion criteria. Harms reported from extramedical POA use included: increased health service utilization (n = 5), non-fatal overdose (n = 6), fatal overdose (n = 5), injection-related injuries or diseases (n = 4), engagement in crime (n = 2), loss of employment (n = 1), and foreign body pulmonary embolization (n = 1). Multiple drug toxicity was reported as the cause of death in up to 83% of fatal overdose cases. Risk factors for harm included being male, aged 31-49 years, a history of chronic non-cancer pain, mental health disorders and/or substance abuse, and concomitant use of benzodiazepines, antidepressants or other centrally-acting substances. CONCLUSION Extramedical use of POAs is associated with a range of harms, including fatal and non-fatal overdose. Polysubstance use with other centrally-acting substances was often implicated. No published studies used linked data sources to provide a comprehensive overview of the extent of POA use or harm in Australia. Future research should focus on undertaking longitudinal cohort studies with linked data sources.

Spontaneously reported adverse drug events related to tapentadol and oxycodone/naloxone in Australia

Background: The rapid increase in prescribing and use of opioids for noncancer pain has coincided with an increase in opioid-related adverse drug events (ADEs). The objective of our study was to describe ADEs related to tapentadol and oxycodone/naloxone spontaneously reported to the Australian Therapeutic Goods Administration (TGA). Methods: Public case detail reports for tapentadol (September 2013–March 2017) and oxycodone/naloxone (April 2011–March 2017) were sourced from the TGA. The total number of public case detail reports for tapentadol were 104 and 249 for oxycodone/naloxone. Demographic characteristics of patients, concomitant medications, causality assessment and outcome were described for each opioid according to the Medical Dictionary for Regulatory Activities (MedDRA) system organ class. Results: The most prevalent ADEs for tapentadol were nervous system disorders (n = 52, 50%), psychiatric (n = 34, 32.7%), gastrointestinal (n = 18, 17.3%), and general disorders and administration site conditions (n = 21, 20.2%). Sixteen (23.2%) of 69 nervous system disorders reaction terms were consistent with serotonin syndrome of which 14 (87.5%) involved documented coadministration with another serotonergic medication. The most prevalent ADEs for oxycodone/naloxone were psychiatric disorders (n = 78, 31.3%), gastrointestinal (n = 73, 29.3%), general disorders and administration site conditions (n = 87, 35%), and nervous system disorders (n = 62, 24.9%). There were 40 (16%) public case detail reports for oxycodone/naloxone with the MedDRA reaction terms ‘drug withdrawal syndrome’ and ‘withdrawal syndrome’. Conclusion: The profiles of spontaneous ADE reports for tapentadol and oxycodone/naloxone are largely consistent with their premarketing randomized controlled studies and profiles of opioids in general. Further research into the risk of serotonin syndrome with tapentadol use is warranted. The ADEs suggest clinicians should be cautious when switching patients to oxycodone/naloxone from other opioids.

Current Opioid Access, Use, and Problems in Australasian Jurisdictions

Purpose of ReviewTo summarize current patterns of pharmaceutical opioid use, extra-medical use, and harms across Australasia, with a focus on Australia and New Zealand. Treatment for opioid dependence and recent changes to the regulatory environment governing opioid access and treatment are also discussed.Recent FindingsA fourfold increase in opioid use has occurred across Australia and New Zealand between 2001–2003 and 2011–2013, with significant increases in the use of strong opioids. Documented harms include opioid dependence, hospitalization and other health service use, and non-fatal and fatal overdose. Pharmaceutical opioids account for the majority of opioid-related deaths.SummaryThere is an ongoing need for timely and proactive responses to the opioid problem in Australia and New Zealand. Although several strategies have been implemented in Australia, the effectiveness of these strategies is currently unknown, and given the magnitude of the problem, it is likely that additional strategies will be needed.

Predictors of persistent prescription opioid analgesic use among people without cancer in Australia

To identify patterns of opioid analgesic use and determine predictors of persistent opioid use among people without cancer.

Prevalence and incidence of prescription opioid analgesic use in Australia: Prevalence and incidence of opioid analgesic use in Australia

The aims of the current study were to determine the prevalence and incidence of prescription opioid analgesic use in Australia and compare the characteristics of people with and without cancer initiating prescription opioid analgesics.