Inappropriate Fentanyl Prescribing Among Nursing Home Residents in the United States

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• 作者：Kevin M. Fain ; JD ; MPH ; DrPH^a ; ^b ; ^{kfain1@jhu.edu} ; Carlos Castillo-Salgado ; MD ; JD ; MPH ; DrPH^a ; David D. Dore ; PharmD ; PhD^c ; ^d ; Jodi B. Segal ; MD ; MPH^b ; ^e ; ^f ; Andrew R. Zullo ; PharmD ; ScM^d ; G. Caleb Alexander ; MD ; MS^a ; ^b ; ^f
• 关键词：Nursing homes ; fentanyl ; prescription opioids ; Food and Drug Administration
• 刊名：Journal of the American Medical Directors Association
• 出版年：2017
• 出版时间：1 February 2017
• 年：2017
• 卷：18
• 期：2
• 页码：138-144
• 全文大小：376 K
• 卷排序：18

文摘

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.DesignCross-sectional study.SettingLinked Minimum Data Set (MDS) assessments; Online Survey, Certification and Reporting (OSCAR) records; and Medicare Part D claims.ParticipantsFrom 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.MeasurementsWe 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.ResultsAmong 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.ConclusionMost 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.