Co-prescription of opioids with benzodiazepine and other co-medications among opioid users: differential in opioid doses

Purpose: This study investigated the patterns of opioid co-prescription with benzodiazepine and other concomitant medications among opioid users. Opioid dose in each type of co-prescription was also examined. Patients and methods: This cross-sectional study was conducted among opioid users receiving concomitant medications at an outpatient tertiary hospital setting in Malaysia. Opioid prescriptions (morphine, fentanyl, oxycodone, dihydrocodeine and tramadol) that were co-prescribed with other medications (opioid + benzodiazepines, opioid + antidepressants, opioid + anticonvulsants, opioid + antipsychotics and opioid + hypnotics) dispensed from January 2013 to December 2014 were identified. The number of patients, number of co-prescriptions and the individual mean opioid daily dose in each type of co-prescription were calculated. Results: A total of 276 patients receiving 1059 co-prescription opioids with benzodiazepine and other co-medications were identified during the study period. Of these, 12.3% of patients received co-prescriptions of opioid + benzodiazepine, 19.3% received opioid + anticonvulsant, 6.3% received opioid + antidepressant and 10.9% received other co-prescriptions, including antipsychotics and hypnotics. The individual mean opioid dose was <100 mg/d of morphine equivalents in all types of co-prescriptions, and the dose ranged from 31 to 66 mg/d in the coprescriptions of opioid + benzodiazepine. Conclusion: Among the opioid users receiving concomitant medications, the co-prescriptions of opioid with benzodiazepine were prescribed to 12.3% of patients, and the individual opioid dose in this co-prescription was moderate. Other co-medications were also commonly used, and their opioid doses were within the recommended dose. Future studies are warranted to evaluate the adverse effect and clinical outcomes of the co-medications particularly in long-term opioid users with chronic non-cancer pain

Prescribing of non-steroidal anti-inflammatory drugs, tramadol and opioids in children: patterns of its utilization

Background: Analgesic is commonly used in children but little is known about its patterns of utilization. This study explored the patterns of analgesic prescribing in children. Methods: This cross sectional study used prescription databases of tertiary hospital settings in Malaysia from 2010 to 2016. Prescriptions for nine NSAIDs (diclofenac, ketoprofen, etoricoxib, celecoxib, ibuprofen, indomethacin, mefenamic acid, meloxicam and naproxen), tramadol and five other opioids (morphine, oxycodone, fentanyl, buprenorphine and dihydrocodeine) prescribed for children age < 18 years old were included. Number of annual patients and prescriptions were measured and analysed using Stata v15. Results: During a 7-year study period, a total of 5040 analgesic prescriptions of the nine NSAIDs, tramadol, and five other opioids were prescribed for 2460 paediatric patients (81.8% NSAIDs patients, 17.9% tramadol patients, and 0.3% opioid patients). Ibuprofen was the primary analgesic in young children less than 12 years old (≤2 years old (y.o) (75%), 3-5 y.o (85%) and.6-12 y.o (56.3%)). While there was a wide range of analgesics used in older children (above 12 years old) with the majority for naproxen (13 to 15 y.o (28.2%) and 16 to 17 y.o (28.2%). Other frequently prescribed analgesics for older children included ibuprofen (20.6%) and diclofenac (18.2%)) for 12 to 15 y.o and diclofenac (26.7%) and tramadol (17.6%)) for 16-17 y.o. Conclusion: Ibuprofen was the primary analgesic for children less than 12 years old while there was a wide range of analgesics prescribed for children age above 12 years old including naproxen, diclofenac and tramadol

Ten years of strong opioid analgesics consumption in Malaysia and other Southeast Asian countries

Abstract Background: It was reported that opioid consumption in developing countries was stagnated or decreased but precise data on the consumption are unclear. This study examined the trends and patterns of opioid consumption in Malaysia and other four Southeast Asian countries. Methods: Data of five strong opioids consumption (morphine, oxycodone, fentanyl, pethidine and methadone) between 2005 and 2014 from Malaysia, Singapore, Indonesia, Thailand and Vietnam were extracted from the Pain & Policy Studies Group. Defined daily doses per 1000 inhabitants per day (DDD/1000 inhabitants/day) was used for calculating the annual amount of opioid use. Results: The total consumption of five strong opioids was increased in all five Southeast Asian countries during a 10-year study period. Malaysia was recorded with the largest increase of the opioid consumption (993.18%), followed by Indonesia (530.34%), Vietnam (170.17%), Singapore (116.16%) and Thailand (104.66%). Malaysia also had the highest total strong opioid consumption (11.2 DDD/1000 inhabitants/day), primarily for methadone. Among the opioids used for pain management, fentanyl was primarily used in Malaysia and Singapore but the greatest increase in these two countries was for oxycodone. Fentanyl was also primarily used in Indonesia while morphine was predominantly used in Thailand and Vietnam. Conclusion: The trends of strong opioids consumption in all five Southeast Asian countries increased steadily from 2005 to 2014. Among the opioids for pain management, fentanyl was primarily used in Malaysia, Singapore and Indonesia while morphine was predominantly used in Thailand and Vietnam

Factors associated with prescription opioid overdose deaths in patients with non-cancer pain: a literature review

Opioid analgesics have increasingly been prescribed in the treatment of non -cancer pain and this trend has accompanied increasing rates of opioid overdose deaths (ODs). Little is known about the factors that may predispose an individual to being at risk for fatal overdose from prescription opioids. This review examined factors associated with prescription opioid overdose deaths in patients with non-cancer pain. A comprehensive literature search was conducted for studies published from 2004 to 2014 using databases such as Science Direct, PubMed, Web of Science, Cochrane review and Scopus. Articles were included if they were original research studies written in English that reported deaths with prescription opioid overdose in patients with non-cancer pain. A total of 18 studies met the inclusion criteria and were included. Fndings from the review demonstrated that concomitant use of opioids with benzodiazepines (polysubstance use) was the main factor associated with opioid ODs. Codeine and oxycodone were more commonly reported to cause opioid ODs and opioid doses of more than 100 mg per day in morphine equivalents have higher risk to cause ODs. Other factors included male patients, middle aged and having mental illness. Prescription opioid overdose deaths were primarily caused by concomitant use of opioid with benzodiazepines. Further research is required to examine the trend and patterns of this co-prescribing. The guidelines on opioid prescribing and education on opioids for both patients and physicians should be emphasized to reduce fatalities from overdose while enhancing the safe prescribing of opioids

Level of agreement among various health care stakeholders on collaboration between community pharmacist (CP) and general practitioner (GP) for a ″collaborative medication therapy management″ (CMTM) model for chronic diseases (CDs) in Malaysia: a Delphi study

Objective: Current study is the first attempt to build consensus and appraise the level of agreement (or disagreement) among various health care stakeholders on the possibilities of a CMTM model for CDs in Malaysia through Delphi technique. Method: This Delph study was conducted as per the COSRT guidelines (Diamond 2014). Based on a systematic literature search, an online survey was designed on QuestionPro (an online survey tool). After face and content validity of the survey, an expert panel was constructed by inviting various health care stakeholders in different organizations and professional bodies which represent GPs, CPs, and Nurses, across Malaysia. Survey had 96 statements to rate using 5-point Likert scale (strongly agree to strongly disagree) and 36 ranking statements where experts were asked to rank in terms of feasibility of various aspects of the CMTM model. Consensus was pre-defined to be the point where >85% of the respondents falls in either agree or disagree category for each statement. Delphi operates in a reiterative fashion in rounds, where at the end of each round aggregate response (pooled opinion in the form of percent agreement among panel members) is presented to all experts and asked to reconsider their response in the light of the reasoning of other experts and aggregate response, if it appeals to them. This reiteration continues till there is a stability (no change) in the response of experts in two consecutive rounds. Response rate was 70.73% and 100% for 1st and 2nd round respectively. Results: The percentages, Median and IQR were calculated on the responses of experts at the end of the first round and it revealed that consensus was achieved on 105 statements and there was conflict over 27 statements. In round-2, 14 statements out of 27 conflicted statements reached the consensus after due considerations of the experts, while, 13 statements failed to stretch up to consensus. No further round was executed, as after round-2 stability in response of experts reached to 100% (Wilcoxon Signed Rank test). The inter-rater agreement was computed in both rounds using Intra-class correlation coefficient (ICC) (Two-way mixed model-absolute agreement, p < 0.001) that is interpreted to be in between good to excellent level of agreement. Further subgroup analysis based on profession (GP, CP, Nurses) was carried out using Kruskal Wallis H-test (p < 0.01), while differences in response based on experience and education were analyzed using Mann-Whitney U-test (p < 0.017). Conclusion: This study demonstrates a significant level of agreement among different health care professionals for a future role of CPs in CMTM model of CDs. Generally, there is a consensus to at least run a pilot trial of this CMTM model in major cities of Malaysia. It also highlights certain flash points where there were differences. However, study holds importance for policy makers, as the agreements or disagreements expressed in the survey may be utilized to foresee and generate guidelines, and strategies to lay the foundation of a CMTM model for CDs in Malaysi

Religious tourism and mass religious gatherings — the potential link in the spread of COVID-19. Current perspective and future implications

COVID-19 has exposed the fragility and preparedness of healthcare systems around the globe. Various countries have widely adopted preventive measures, such as social distancing, face masks, frequent hand wash/sanitizer and lock downs. The pandemic with shifting epicentres from Wuhan to Iran and Italy presents two relevant questions for any next outbreak or epicentre in future: a) How did COVID-19 travel from one country to another? b) To what extent are countries prepared in context of preventive measures in mass gatherings in future