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      Sociodemographic, clinical and pharmacological profiles of medication misuse and dependence in hospitalised older patients in Norway: a prospective cross-sectional study

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          Abstract

          Objectives

          Timely recognition of medication misuse and dependence is crucial to avoid both adverse drug events and increasing health expenditure. Yet the detection of these disorders in older people remains challenging due to the paucity of evidence on characteristics of patients at risk. This study investigates sociodemographic, pharmacological and clinical characteristics and factors associated with prolonged medication use, misuse and dependence in hospitalised older patients, focusing on three commonly prescribed central nervous system depressants (CNSDs): opioid analgesics, benzodiazepines and z-hypnotics.

          Design

          A prospective, cross-sectional study complying with the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.

          Setting

          Somatic departments of the Akershus University Hospital, Norway.

          Participants

          246 patients aged 65–90 were included.

          Outcome measures

          Prolonged use was defined as using CNSDs for ≥4 weeks. Misuse and dependence were assessed with the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition criteria for substance abuse and dependence. We used descriptive statistics to report patients’ characteristics and logistic regression to demonstrate factors associated with prolonged use, and misuse or dependence.

          Results

          Forty per cent of participants reported using CNSDs for ≥4 weeks. The odds of prolonged use were higher for patients aged 75–84 (OR=2.32, 95% CI 1.16 to 4.65) and ≥85 (OR=3.33, 95% CI 1.25 to 8.87) vs <75 years, for pain intensity (OR=1.02, 95% CI 1.01 to 1.04), and polypharmacy versus no polypharmacy (OR=5.16, 95% CI 2.13 to 12.55). The odds were lower for patients who completed secondary education (OR=0.33, 95% CI 0.13 to 0.83) compared with those with only basic education. Factors associated with misuse or dependence were pain intensity (OR=1.02, 95% CI 1.01 to 1.04) and concurrent use of ≥2 CNSDs (OR=3.99, 95% CI 1.34 to 11.88).

          Conclusion

          CNSD overuse is prevalent among hospitalised older patients, despite clear guidelines and recommendations. Our findings underline a need for stronger focus on responsible prescribing, timely detection and prevention of this issue, with special attention towards older patients, those with enhanced pain, polypharmacy and/or concurrent use of several CNSDs.

          Trial registration number

          NCT03162081.

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          Most cited references38

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          The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction

          Annual Review of Public Health, 36(1), 559-574
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            The Link between Depression and Chronic Pain: Neural Mechanisms in the Brain

            Chronic pain, as a stress state, is one of the critical factors for determining depression, and their coexistence tends to further aggravate the severity of both disorders. Unfortunately, their association remains unclear, which creates a bottleneck problem for managing chronic pain-induced depression. In recent years, studies have found considerable overlaps between pain- and depression-induced neuroplasticity changes and neurobiological mechanism changes. Such overlaps are vital to facilitating the occurrence and development of chronic pain and chronic pain-induced depression. In this review, we summarized the role of neuroplasticity in the occurrence and development of the two disorders in question and explored individualized application strategies of analgesic drugs and antidepressants that have different pharmacological effects in the treatment of chronic pain-induced depression. Therefore, this review may provide new insights into the understanding of association between chronic pain and depression.
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              A comprehensive review of opioid-induced hyperalgesia.

              Opioid-induced hyperalgesia (OIH) is defined as a state of nociceptive sensitization caused by exposure to opioids. The condition is characterized by a paradoxical response whereby a patient receiving opioids for the treatment of pain could actually become more sensitive to certain painful stimuli. The type of pain experienced might be the same as the underlying pain or might be different from the original underlying pain. OIH appears to be a distinct, definable, and characteristic phenomenon that could explain loss of opioid efficacy in some patients. Findings of the clinical prevalence of OIH are not available. However, several observational, cross-sectional, and prospective controlled trials have examined the expression and potential clinical significance of OIH in humans. Most studies have been conducted using several distinct cohorts and methodologies utilizing former opioid addicts on methadone maintenance therapy, perioperative exposure to opioids in patients undergoing surgery, and healthy human volunteers after acute opioid exposure using human experimental pain testing. The precise molecular mechanism of OIH, while not yet understood, varies substantially in the basic science literature, as well as clinical medicine. It is generally thought to result from neuroplastic changes in the peripheral and central nervous system (CNS) that lead to sensitization of pronociceptive pathways. While there are many proposed mechanisms for OIH, 5 mechanisms involving the central glutaminergic system, spinal dynorphins, descending facilitation, genetic mechanisms, and decreased reuptake and enhanced nociceptive response have been described as the important mechanisms. Of these, the central glutaminergic system is considered the most common possibility. Another is the hypothesis that N-methyl-D-aspartate (NMDA) receptors in OIH include activation, inhibition of the glutamate transporter system, facilitation of calcium regulated intracellular protein kinase C, and cross talk of neural mechanisms of pain and tolerance. Clinicians should suspect OIH when opioid treatment's effect seems to wane in the absence of disease progression, particularly if found in the context of unexplained pain reports or diffuse allodynia unassociated with the original pain, and increased levels of pain with increasing dosages. The treatment involves reducing the opioid dosage, tapering them off, or supplementation with NMDA receptor modulators. This comprehensive review addresses terminology and definition, prevalence, the evidence for mechanism and physiology with analysis of various factors leading to OIH, and effective strategies for preventing, reversing, or managing OIH.
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                Author and article information

                Journal
                BMJ Open
                BMJ Open
                bmjopen
                bmjopen
                BMJ Open
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2044-6055
                2019
                5 September 2019
                : 9
                : 9
                : e031483
                Affiliations
                [1 ] departmentHealth Services Research Unit (HØKH) , Akershus University Hospital , Lørenskog, Norway
                [2 ] departmentInstitute of Clinical Medicine, Campus Ahus , University of Oslo , Lørenskog, Norway
                [3 ] National Addiction Centre, King's College , London, United Kingdom
                [4 ] departmentDepartment of General Practice, Institute of Health and Society , University of Oslo , Oslo, Norway
                [5 ] Department of Neurology, Akershus University Hospital , Lørenskog, Norway
                Author notes
                [Correspondence to ] Dr Socheat Cheng; Socheat.Cheng@ 123456ahus.no
                Author information
                http://orcid.org/0000-0003-2277-7585
                http://orcid.org/0000-0002-8404-0610
                http://orcid.org/0000-0002-8999-5424
                Article
                bmjopen-2019-031483
                10.1136/bmjopen-2019-031483
                6731874
                31492795
                2b118417-ad35-4faf-ac04-21d923b5ef4e
                © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/.

                History
                : 07 May 2019
                : 20 August 2019
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100006095, Helse Sør-Øst RHF;
                Award ID: Prosjektnummer 2011016
                Funded by: FundRef http://dx.doi.org/10.13039/501100005416, Norges Forskningsråd;
                Award ID: NFR-nummer 256431
                Categories
                Geriatric Medicine
                Original Research
                1506
                1698
                Custom metadata
                unlocked

                Medicine
                characteristics,geriatric patients,risk factors,addiction,prescription drug abuse
                Medicine
                characteristics, geriatric patients, risk factors, addiction, prescription drug abuse

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