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Patients with rheumatoid arthritis (RA) experience pain from inflammation, joint destruction, and neuropathy. Antidepressants may play a role among patients with RA and depression, fibromyalgia, or neuropathy to achieve desired outcomes. This commentary evaluated evidence for medications individually and identified important variables for future research. While we await the results of well-designed studies, a trial of duloxetine or milnacipran may be considered for patients with remnant pain and RA remission. Research is needed to evaluate the efficacy and safety of serotonin–norepinephrine reuptake inhibitors and tricyclic antidepressants in patients with RA and associated comorbid conditions.

Objectives: To describe the effectiveness of medications for the treatment of opioid use disorder (OUD) and attention deficit/hyperactivity disorder (ADHD). Data Sources: Literature search of PubMed, Embase, Web of Science, CINAHL, Medline, PsycINFO, and Google Scholar was performed for studies published from inception to October 25, 2022. Study Selection and Data Extraction: Studies were included if patients were diagnosed with OUD and ADHD and had pharmacotherapy for either condition. Abstracts, commentaries, reviews, case reports, case series, non-English articles, and animal studies were omitted. Data Synthesis: This review found 18 studies. Treatment of ADHD was evaluated for impact on ADHD and OUD outcomes, while treatment of OUD was evaluated for OUD-related outcomes. Outcomes assessed included markers for symptom intensity, adherence, and treatment failure. While results were mixed, treatment of ADHD was largely associated with improvements in ADHD severity and retention in OUD treatment programs. ADHD severity was associated with higher rates of illicit substance abuse and worse OUD-related outcomes. It could not be determined which medications for treatment of OUD should be prioritized. Relevance to Patient Care and Clinical Practice: This review summarized key findings from studies that treated ADHD or OUD among dually diagnosed patients and highlighted methodological considerations for future research. Conclusions: Treatment of ADHD is warranted among patients with OUD and ADHD to improve retention in OUD treatment programs and reduce illicit substance abuse. Pharmacotherapy for the treatment of ADHD or OUD should continue to be determined based on patients' characteristics and the capabilities of the treatment program.

A limited number of studies have analyzed prescribing among Medicare-enrolled adults at risk for opioid overdoses. The objectives of this study were to evaluate prescribing for naloxone and central nervous system (CNS) active medications and to determine the relationships of patient characteristics with exposure to these medications.This was a retrospective cross-sectional analysis of a Medicare-enrolled medication therapy management eligible cohort. Patients were stratified into two cohorts, individuals with a mean daily morphine milligram equivalent (MME) dose50 and individuals with MME ≥50. Medications assessed included benzodiazepines, skeletal muscle relaxants (SMR), hypnotics, gabapentanoids, selective-serotonin reuptake inhibitors (SSRI), serotonin-norepinephrine reuptake inhibitors (SNRI), tricyclic antidepressants (TCA), antipsychotics, barbiturates, other antiepileptics, hydroxyzine, and naloxone. Chi-square with odds ratios and logistic regressions determined the relationships of medications and patient characteristics with mean daily MME ≥50. Relationship between medications and opioid dose was adjusted for age and sex.There were 3452 patients with a daily MME50 and 1116 with a daily MME ≥50. After adjusting for age and sex, patients with a daily MME ≥50 were more likely to be prescribed hypnotics (OR: 1.41, 95% CI 1.17-1.70), SNRIs (OR: 1.39, 95% CI 1.17-1.64), and naloxone (OR: 3.21, 95% CI 2.49-4.12) (p 0.001). Nine percent of eligible patients received naloxone. Age groups of persons85 years of age had 1.58-4.04 (p ≤ 0.004) times the odds of being prescribed a mean daily MME ≥50.Nearly one-fourth of patients were prescribed a mean daily opioid therapy of MME ≥50. These patients were more likely to be prescribed hypnotics, SNRIs, and naloxone. Patients receiving chronic high-dose opioid therapy were more likely to be in age groups of persons85 years. Naloxone may be underprescribed among eligible adults. Targeted medication services may ensure optimal prescribing among Medicare patients with chronic opioid therapies.

PurposeTablet formulations fail to meet the needs of patients unable to swallow tablets such as pediatric, elderly, and patients that must receive medications via feeding tubes. Our aim was to develop and test a new, simple device (XTEMP-R™) and the methodology for converting tablets into a homogeneous suspension for medication administration.MethodsWe developed a new device comprised of a flexible receptacle, a tight-fitting cap, and a suction cup bottom to convert tablets into liquid preparations. TB treatment drugs, TBAJ-876 and TBI-223, were dispersed within the device utilizing water and commonly available suspending vehicles. We investigated the effectiveness of the XTEMP-R device in dispersing tablets. This was accomplished by visual observations, determining the fineness of dispersion, and measuring the total drug recovery from the dispersions in XTEMP-R. We investigated the accuracy and reproducibility of delivering aliquots from these suspensions by determining the dose reproducibility upon suspension and upon redispersion after 24 hours. The effectiveness of the device was also evaluated using commercially available tablets of acetaminophen, amlodipine, glimepiride, metformin and valsartan.ResultsThe suspensions were visually uniform without any large particles. The suspensions passed through #18 sieve confirming that the particles were less than 1000 μm. Average total dose recovery of three suspensions each was determined to be 101.3% and 99.2% for TBI-223 and TBAJ-876, respectively. Reproducibility from aliquots of 2 mL each were 98.9-99.7% for three replicates of TBI-223 suspensions, and 102.6-103.2% for TBAJ-876 suspensions. Aliquots tested after 24 hours confirmed uniform re-dispersibility.ConclusionWe have demonstrated that XTEMP-R can be utilized to prepare homogeneous suspensions can be prepared conveniently and efficiently in less than 10 minutes without any drug loss. Aliquots for partial dose delivery can be withdrawn accurately. These findings demonstrate that XTEMP-R can be used to accurately deliver doses of suspensions for patients who cannot swallow tablets.

Background Potentially inappropriately prescribed medications (PIPMs) among patients with chronic kidney disease (CKD) may vary among clinical settings. Rates of PIPM are unknown among Medicare-enrolled Medication Therapy Management (MTM) eligible patients. Objectives Determine prevalence of PIPM among patients with CKD and evaluate characteristics of patients and providers associated with PIPM. Design An observational cross-sectional investigation of a Medicare insurance plan for the year 2018. Patients Medicare-enrolled MTM eligible patients with stage 3–5 CKD. Main Measures PIPM was identified utilizing a tertiary database. Logistic regression assessed relationship between patient characteristics and PIPM. Key Results Investigation included 3624 CKD patients: 2856 (79%), 548 (15%), and 220 (6%) patients with stage 3, 4, and 5 CKD, respectively. Among patients with stage 3, stage 4, and stage 5 CKD, 618, 430, and 151 were with at least one PIPM, respectively. Logistic regression revealed patients with stage 4 or 5 CKD had 7–14 times the odds of having a PIPM in comparison to patients with stage 3 disease (p < 0.001). Regression also found PIPM was associated with increasing number of years qualified for MTM (odds ratio (OR) 1.46–1.74, p ≤ 0.005), female gender (OR 1.25, p = 0.008), and increasing polypharmacy (OR 1.30–1.57, p ≤ 0.01). Approximately 14% of all medications (2879/21093) were considered PIPM. Majority of PIPMs (62%) were prescribed by physician primary care providers (PCPs). Medications with the greatest percentage of PIPM were spironolactone, canagliflozin, sitagliptin, levetiracetam, alendronate, pregabalin, pravastatin, fenofibrate, metformin, gabapentin, famotidine, celecoxib, naproxen, meloxicam, rosuvastatin, diclofenac, and ibuprofen. Conclusion Over one-third of Medicare MTM eligible patients with CKD presented with at least one PIPM. Worsening renal function, length of MTM eligibility, female gender, and polypharmacy were associated with having PIPM. Majority of PIPMs were prescribed by PCPs. Clinical decision support tools may be considered to potentially reduce PIPM among Medicare MTM–enrolled patients with CKD.

Background: Background:Finding ways to reduce prescribing of potentially inappropriate medications (PIMs) among patients with dementia is necessary. Objectives: To evaluate an automated targeted medication review (TMR) service to reduce PIM prescribing among patients with dementia. Methods: This was a retrospective observational analysis of patients in a Medication Therapy Management (MTM) program for year 2017. Patients included if Medicare enrolled, MTM eligible, had dementia, and with PIM prescribing. Descriptive statistics described reduced PIM prescribing. Odds ratios (ORs) assessed prescriber relationship with PIM prescribing. Regression evaluated relationship between patient characteristics and discontinued PIMs. Results: A total of 33 696 TMRs were triggered for 17 933 patients. Four months later, 11 608 TMRs led to a discontinued PIM among 8002 patients. Medications with the largest discontinuations were antihistamines (56%), muscle relaxants (53%), antiemetics (53%), and typical antipsychotics (40%). Physician primary care providers (PCPs) were more likely than nonphysician PCPs (OR = 4.54; 95% CI = 4.15-4.97; P < 0.001), psychiatrists (OR = 1.64; 95%CI = 1.44-1.86; P < 0.001), and neurologists (OR = 4.48; 95% CI = 4.07-4.93; P < 0.001) to prescribe medications to treat dementia and PIMs. Regression showed that younger age, female gender, higher poverty level, and a greater number of pharmacies, medications, and prescribers were associated with discontinued PIMs. Conclusions and Relevance: TMRs were effective in reducing PIM prescribing. Younger patients, individuals living in higher poverty levels, and patients with multiple prescribers or pharmacies may benefit most from this service. TMRs in primary care offices may reduce PIM prescribing.

The unintentional prescribing of medications harmful for patients with heart failure (HF) remains an ongoing problem. The American Heart Association published a scientific statement detailing a list of medications that may worsen or exacerbate a patient’s HF. The use of potentially harmful medications has not been studied in Medicare patients with HF. The aim of this study was to assess the prevalence of prescribing these harmful medications in a Medicare-enrolled medication therapy management (MTM)-eligible population with HF and to identify the characteristics associated with this potentially harmful prescribing. This cross-sectional analysis involved utilization of a national MTM provider’s database for the 2018 calendar year. Eligible patients were included if they were Medicare enrolled, MTM eligible, and with International Classification of Disease 9/10 codes for HF. Counts and percentages were used to describe the prevalence of potentially harmful medication use and prescribing, by physician specialty. Exploratory logistic regression assessed the relationship between unique patient characteristics and potentially harmful prescribing. A total of 13,250 patients were included, of whom 7017 (53%) were prescribed at least one potentially harmful medication. The most frequently prescribed medications in this cohort were nonsteroidal anti-inflammatory drugs (NSAIDs; 3357, 25%), dipeptidyl peptidase-4 (DPP4) inhibitors (3117, 24%), and non-dihydropyridine calcium channel blockers (CCBs; 936, 7%). A logistic regression found female sex, increasing polypharmacy, years qualified for MTM, higher poverty level, number of prescribers, and number of pharmacies were associated with potentially harmful medication prescribing. Of 17,548 potentially harmful medications encountered in a 4-month span, 9433 (54%) were prescribed by physician primary care providers. Over one-half of patients with HF were prescribed one or more potentially harmful medication(s). Automated monitoring of prescription claims and implementation of alerts in electronic health records in primary care is warranted to reduce potentially harmful medication use among Medicare MTM-eligible patients.

Introduction: Sodium glucose cotransporter-2 (SGLT-2) inhibitors and glucagon-like peptide 1 receptor (GLP-1) agonists are recommended for patients with type two diabetes (T2D) and atherosclerotic cardiovascular disease (ASCVD) or heart failure (HF) to reduce cardiovascular-related mortality. The objective of this study was to evaluate a telehealth targeted medication review (TMR) program to identify patients for uptake of these evidence-based medications. Methods: This was an observational descriptive study of a TMR program for Medicare-enrolled, Medication Therapy Management-eligible patients in one insurance plan. Prescription claims and patient interviews identified individuals who would benefit from SGLT-2 inhibitors or GLP-1 agonists. Facsimiles were sent to providers of patients with educational information about the targeted medications. Descriptive statistics described characteristics and proportion of patients prescribed targeted medications after 120 days. Bivariate statistical tests evaluated associations between age, sex, number of medications, number of providers, and poverty level with adoption of targeted medications. Results: A total of 1106 of 1127 had a facsimile sent to their provider after a conversation with the patient. Among patients with a provider facsimile, 69 (6%) patients filled a prescription for a targeted medication after 120 days. There was a significant difference in age between individuals who started a targeted medication (67 ± 10 years) compared with patients who did not (71 ± 10 years) (p = 0.001). Conclusions: A TMR efficiently identified patients with T2D and ASCVD or HF who would benefit from evidence-based medications. Although younger patients were more likely to receive these medications, the overall uptake of these medications within four months of the intervention was lower than expected.

Objectives: To describe the pharmacology, efficacy, safety, and potential role of vonoprazan with amoxicillin or amoxicillin and clarithromycin for the treatment of Helicobacter pylori infection in adults. Data Sources: PubMed, Embase, Cochrane Library, and ClinicalTrials.gov were searched using the terms: (vonoprazan OR voquezna) AND (“ H. pylori” OR “ Helicobacter pylori”) AND amoxicillin with no date limitations up to November 3, 2022. Study Selection and Data Extraction: Studies assessing the efficacy and safety of vonoprazan with amoxicillin and/or clarithromycin were included and divided into 3 groups based on different comparisons between treatment regimens used in each group. Data Synthesis: Ten clinical trials and 17 observational studies were included. Vonoprazan-based therapy demonstrated greater acid inhibition and similar or higher efficacy than proton-pump inhibitor (PPI)-based therapy in treatment-naïve patients and with clarithromycin-resistant infections. Relevance to Patient Care and Clinical Practice: Proton-pump inhibitor-based therapies have not reached the desired successful eradication rate of 90% for H. pylori infection. Vonoprazan-based therapies being at least as effective as PPI-based therapies offer an alternative for patients with H. pylori infection. Conclusion: Vonoprazan-based therapies were effective and well tolerated for the treatment of H. pylori infection in adults. These regimens provide an important alternative with prolonged acid inhibition, lower potential for CYP2C19 polymorphism, and at least comparable efficacy and safety versus PPI-based therapies in patients with H. pylori infections. Thus, vonoprazan-based therapy should be considered for certain patients, for example, those with failure to PPI-based treatments.

Data regarding medication adherence in older adults with asthma before and during the coronavirus disease 2019 (COVID-19) pandemic are lacking.To evaluate medication adherence and determine factors associated with adherence in Medicare-enrolled older adults with asthma before and during the COVID-19 pandemic.This was a retrospective cohort analysis of Medicare-enrolled patients with asthma. Medication adherence was measured using rates of proportion of days covered for dates January to July 2019 and January to July 2020. Patients less than 65 years of age, with chronic obstructive pulmonary disease, or with cystic fibrosis were excluded. Paired t tests assessed change in adherence between 2019 and 2020. Logistic regression evaluated association of age, sex, depression, moderate or severe asthma, use of a 90-day supply, having 3 or more albuterol fills, number of medications, medication-related problems, prescribers, pharmacies, controller medication classes, and systemic corticosteroid fills with high adherence (proportion of days covered ≥ 80%).Mean adherence to asthma controller medications ranged from 75% to 90%, in 2019. Adherence significantly decreased (P.001) from 51% to 70% for all controller medications, except theophylline in 2020. Similar results were observed among patients with moderate or severe asthma. In 2019 and 2020, number of controller medications, 3 or more albuterol fills, and having a 90-day supply were associated with high adherence (P.001).Adherence to asthma controller medications decreased considerably during the COVID-19 pandemic among Medicare-enrolled patients with asthma. Patients with markers for more severe asthma, overuse of albuterol, and a 90-day supply of controller medications were more likely to have high adherence. These findings can be used to identify opportunities to improve adherence and prescribing among adult patients with asthma.

Study objectives To assess chronic potentially unsafe medication use among older adults using opioids chronically versus those who did not, to assess the likelihood of chronically using medications to treat adverse effects associated with chronic opioid use, and to characterize the differences in chronic potentially unsafe medication use at three morphine equivalent dose (MED) levels/day (less than 50MED, 50-90MED, and more than 90MED). Design Retrospective cross-sectional analysis. Data source Prescription claims data from a national telehealth Medication Therapy Management (MTM) provider for the year 2015. Patients All Medicare Part D beneficiaries (65 years and older [older adults]) from one Medicare Part D plan provider in one state who were eligible to receive MTM services. Measurements and main results Medication claims were limited to refills in a 120-day window from one Medicare Part D provider. Chronic medication use was defined as having a total days' medication supply of 84 days or more. Odds ratios (ORs) and χ2 tests were used to compare chronic medication use among beneficiaries who were chronic opioid users versus nonopioid users. Analyses were repeated among chronic opioid users at the less than 50MED, 50-90MED, and more than 90MED levels. Unpaired t tests and Welch's analysis of variance paired with Games-Howell post hoc tests were used for continuous variables. Older adult (mean age 76 years) chronic opioid users were more likely to use muscle relaxants chronically (OR 2.67, 95% confidence interval [CI] 2.20-3.25), benzodiazepines (OR 2.08, 95% CI 1.87-2.31), hypnotics (OR 1.98, 95% CI 1.67-2.34), antidepressants (OR 1.64, 95% CI 1.51-1.77), and nonsteroidal antiinflammatory drugs (OR 1.78, 95% CI 1.59-1.98) versus nonopioid users. Further, chronic opioid users were 3.04 times (95% CI 2.05-4.51) more likely to use muscle relaxants and benzodiazepines concomitantly chronically and also more likely to use medications chronically to treat gastrointestinal reflux disease, constipation, estrogen loss, nausea and vomiting, and edema. Very high-dose (more than 90MED/day) chronic opioid users were more likely than low-dose users (less than 50MED) to use antidepressants (OR 1.51, 95% CI 1.15-1.97, p=0.003). Conclusion Older adults with chronic opioid use were more likely to use potentially unsafe medications chronically. These data demonstrated discordance between national prescribing guidelines and real-world practice among older adults with chronic pain in one Medicare Part D plan.

Heart failure (HF) is associated with significant morbidity, mortality, compromised quality of life and socioeconomic burden worldwide. This chronic condition is becoming an increasingly important concern given the increased prevalence of HF among aging populations. Significant contributors toward escalating health care costs are emergency room visits and hospitalizations associated with HF. An important strategy to improve health care outcomes and reduce unnecessary costs is to identify and reduce the prescribing of potentially harmful medications (PHMs) among adults with HF. Previous studies in patients with HF found roughly 10–50% of them were prescribed at least one PHM in ambulatory care and inpatient health care settings. This opinion highlights recent findings from studies assessing prevalence of PHMs, associations between PHM prescribing and characteristics, and what can be done to improve patient outcomes and reduce the use of PHMs and associated health care costs in adults with HF.

Objective To assess the relationship between patient characteristics and completion of telehealth comprehensive medication reviews (CMRs). Design Cross-sectional analysis of a national telehealth medication therapy management program. A negative binomial regression assessed the relationship between number of phone calls to complete a CMR and age, sex, number of medications, poverty level, geographic region, limited English proficiency (LEP), years eligible for CMR services, and if a caregiver completed the CMR. Setting and participants Patients included in the analysis were Medicare enrolled, medication therapy management eligible, and completed a CMR in 2017. Patients excluded if they were younger than 65 years, they had incomplete data, they had participated in an employer-sponsored plan, or completed a CMR with their provider. Outcome measures Number of phone calls reflected number of outgoing phone calls needed to complete a CMR. Results Analysis included 222,163 patients. Females needed 9% more calls to complete a CMR than males (incident rate ratio 1.09 [95% CI 1.08–1.10]). Adults older than 75 years compared with patients between age 65 and 74 years needed 7% fewer calls (0.93 [0.92–0.94]). Patients needing a caregiver to complete the CMR required 33% more calls than individuals who did not (1.33 [1.31–1.35]). Patients eligible for CMR services longer than 1 year required 12%-45% fewer calls to complete a CMR than recently eligible patients. A statistically significant interaction was detected between LEP and poverty quintile. Conclusions This study found that poverty level inversely affected the number of phone calls to complete a CMR between those considered LEP and English language-speakers. Female sex and caregiver presence were associated with number of phone calls needed to complete a CMR. Older age and length of CMR eligibility were inversely associated with the number of phone calls needed. Future research is warranted to evaluate whether targeted approaches may improve CMR completion rates.

Supplemental material, online_appendices for Impact of Automated Targeted Medication Review Electronic Alerts to Reduce Potentially Inappropriate Medication Prescribing Among Medicare Enrolled Patients With Dementia by Armando Silva-Almodóvar, Andrea Malfara and Milap C. Nahata in Annals of Pharmacotherapy

Exposure to medication therapy management (MTM) courses has demonstrated to increase student pharmacist's confidence in the application of patient care skills. The purpose of this study was to evaluate the effects of student pharmacists' work experience in a telehealth MTM program, versus hospital or community settings, on their confidence in skills applied in patient care.This was a cross-sectional multicenter survey. Confidence in patient care among student pharmacists was assessed between those who worked in a telehealth MTM program versus other settings. The data was evaluated using Chi-Square, Fisher exact, unpaired-t, Kruskal-Wallis, and Mann-Whitney U tests.282 surveys were completed. First-year student pharmacists who worked in the telehealth MTM programs, versus other settings, were more confident in the provision of a comprehensive medication review (CMR) (p.001), interviewing patients (p.001), identifying medication errors (p.001), and making therapeutic recommendations to patients (p = .04) and prescribers (p = .04). Second and third-year student pharmacists who worked in telehealth MTM programs, versus other settings, were more confident in the provision of a CMR (p ≤ .005). Fourth-year student pharmacists who worked in the telehealth MTM programs, versus other settings, were more confident in the provision of a CMR (p = .003), interviewing patients (p = .02), and identifying medication errors (p = .04).Student pharmacists' participation in a telehealth MTM program may markedly increase their confidence in skills applied in patient care. MTM work experience should be offered to student pharmacists during their PharmD programs to enhance their confidence in the provision of patient care.

Purpose The use of nebulized opioids for the palliation of dyspnea in terminally ill patients is reviewed. Summary More than 50% of patients with advanced diseases experience dyspnea during their final stages of life. Systemically administered opioids are recommended for the management of dyspnea in these patients, but adverse effects may limit their use. Nebulization offers an alternative route for administering opioids, providing relief of dyspnea while minimizing adverse events. An extensive literature search was conducted to identify publications evaluating nebulized opioids for the palliation of dyspnea in patients at end-of-life. Ten studies that evaluated nebulized morphine, fentanyl, hydromorphone, and morphine-6-glucuronide were reviewed; 1 of these studies evaluated 4 different opioids. Of these 10 studies, 2 had double-blind, placebo-controlled, randomized crossover designs; 1 was retrospective, and the remaining 7 were prospective studies. A total of 181 patients, all adults, were evaluated. Subjective improvement in dyspnea from baseline was observed in 9 of the 10 studies. Nebulized morphine 20 mg every 4 hours was the most common opioid studied. Other doses of nebulized opioids included fentanyl 25 and 100 μg and hydromorphone 5 mg. Nine studies reported subjective improvement of dyspnea from baseline after administering nebulized opioids. Six studies evaluated objective outcomes and showed decreased respiratory rate (morphine, fentanyl, and hydromorphone) and heart rate (hydromorphone) and increased oxygen saturation (fentanyl). Mild-to-moderate adverse effects such as claustrophobia due to nebulizer mask, drowsiness, cough, and bitter taste were described. Conclusion Nebulized opioids may provide subjective relief of dyspnea in terminally ill patients with mild-to-moderate adverse effects.

With more than 1.6 million new cases of cancer occurring each year, anticancer medications are in high demand. Escalating prescription drug prices have become a significant concern. Anticancer medications are among the most expensive prescription medications, many of them exceeding $100 000 a year. The survival benefits of certain newer anticancer medications may be a few months more than that from the existing treatment but at a much higher price tag. Drug cost may play a substantial role in making treatment choices. Multiple factors leading to high prices and some potential solutions to lower them have been highlighted.

To determine if engagement in office-based opioid treatment decreases emergency department, urgent care visits, and hospitalizations for acute opioid-related events (OREs) among adolescents with opioid use disorder.This retrospective cohort study identified all emergent and outpatient visits among adolescents, age 10-19 years, referred for office-based opioid treatment between January 1, 2006 and December 31, 2016. Patients were dichotomized into 2 cohorts: those who did and did not engage in office-based opioid treatment. The primary end point was the difference in the proportion of visits over the study period for acute OREs between cohorts and within the office-based opioid treatment cohort before and after referral. Secondary end points assessed change in the proportion of outpatient visits for treatment unrelated to opioid use disorder.Four hundred five emergent and outpatient visits were identified: 285 (70.4%) in the office-based opioid treatment cohort and 120 (29.6%) in the non-office-based opioid treatment cohort. After office-based opioid treatment engagement, 27.8% of visits in the office-based opioid treatment cohort were for acute OREs vs 80.8% in the non-office-based opioid treatment cohort (OR, 0.092; 95% CI, 0.052-0.160; P .001). Outpatient visits in the office-based opioid treatment cohort were 10.9 times that of non-office-based opioid treatment (OR, 10.9; 95% CI, 6.23-19.16; P .001). Within the office-based opioid treatment cohort, emergent visits decreased from 76.1% to 27.8% (OR, 0.121; 95% CI, 0.070-0.210; P .001) and the odds of outpatient services was 8.3 times more after engagement (OR, 8.27; 95% CI, 4.78-14.4, P .001).The absolute decrease in emergent visits for acute OREs was 53% in adolescents engaged in office-based opioid treatment, representing a relative decrease of 65.6% compared with adolescents not engaged. An analysis of visits before and after office-based opioid treatment demonstrated similar decreases, suggesting that office-based opioid treatment has a significant impact in decreasing acute OREs in the adolescent population.

Mismanaged polypharmacy among older adults costs the health care system approximately $2 billion each year. Medication therapy management (MTM), a service designed to optimize medication use, improve health outcomes, and reduce associated costs, is available to eligible Medicare beneficiaries. Yet, it remains unclear which beneficiaries benefit most from this service.To assess associations between patient characteristics, chronic disease, polypharmacy, and medication-related problems (MRPs) in a sample population of Medicare beneficiaries.This study was a retrospective cross-sectional analysis of 1 Medicare Part D plan provider for the year 2015. Medicare beneficiaries were included if they were eligible to receive MTM services and excluded if they were aged under 65 years or the dataset had no count of MRPs for the beneficiary. A negative binomial regression assessed the relationship between age, sex, and chronic health conditions with MRPs. Second and third negative binomial regressions assessed the relationship between age, sex, and polypharmacy with MRPs.A sample of 27,765 Medicare beneficiaries had a mean (SD) age of 76 (±7) years, were predominantly female (59%), and used a mean (SD) of 11 (±4) chronic medications. Beneficiaries with certain conditions were more likely to incur an MRP than those without, including depression (OR = 1.58; 95% CI = 1.51-1.64), congestive heart failure (OR = 1.26; 95% CI = 1.20-1.31), diabetes (OR = 1.24; 95% CI = 1.18-1.29), end-stage renal disease (OR = 1.38; 95% CI = 1.25-1.52), respiratory conditions (OR = 1.25; 95% CI = 1.19-1.31), and hypertension (OR = 1.09; 95% CI = 1.01-1.18). Medicare beneficiaries with polypharmacy (11 or more medications) were 1.86 (95% CI = 1.80-1.93) times more likely to experience an MRP than those taking fewer medications. For every additional medication, the odds of incurring an MRP increased by 10% (OR = 1.11; 95% CI = 1.10-1.1.11).The diagnosis of depression presented with the strongest association with MRPs. Diabetes, congestive heart failure, end-stage renal disease, respiratory conditions, and hypertension also presented with significant associations with MRPs. Beneficiaries with polypharmacy (11 or more medications) were almost 2 times more likely to experience an MRP than those taking fewer medications. Addition of a chronic medication resulted in a 10% increase in the odds of incurring an MRP. MTM programs may find a greater number of MRPs among those diagnosed with depression in their MTM-eligible patient populations.No outside funding supported this research. Silva Almodóvar reports fees from SinfoniaRx, outside the submitted work. Nahata has nothing to disclose.

Pharmacy residents must complete research as part of their program, however, challenges exist in providing experiences that result in successful research dissemination outcomes. A university-based research team, integrated into an ambulatory care pharmacy residency program aimed to improve presentation and publication rates of pharmacy resident research projects. Data on the number of postgraduate year-2 (PGY2) residents and their productivity were collected and summarized to assess progress. A total of 13 residents completed their residency over seven years. Each resident produced one regional presentation, and one national presentation beginning in year four. To date, three peer-reviewed papers have been published, with another one in-press. Responses from residents found lack of guidance, lack of data availability for projects and feedback fatigue were barriers to a positive research experience. To address these problems, a university-based research team was integrated to provide research mentor guided support, ensure study feasibility, and provide structured feedback. This program evaluation highlighted the integration of a PGY2 ambulatory care pharmacy residency with a designated, interprofessional university-based research team. Future work is warranted to reduce research-related barriers and formally evaluate resident post-program knowledge, skills, and subsequent dissemination rates.

Background Appropriate antibiotic treatment of cat scratch disease (CSD) in pediatrics is not well established. Objective The purpose of this study was to evaluate the response rates of antibiotic therapy in pediatrics with CSD. Methods The electronic medical records of a cohort of pediatric patients with confirmed diagnosis of CSD (2006–2016) were reviewed, retrospectively. Data collection included patient demographics, clinical and laboratory results, antibiotic treatment and follow-up evaluations. Results One hundred and seventy-five patients (aged 7.4 ± 4.4 years) had confirmed CSD. Azithromycin and trimethoprim/sulfamethoxazole (TMP/SMX) were the largest groups with documented effectiveness at follow-up visits. Resolution and improvement of CSD was observed in 51.4% and 61.5% of patients with azithromycin and TMP/SMX, respectively among those with follow-up assessment. The effectiveness of azithromycin and TMP/SMX was comparable (p = 0.56). Conclusion Azithromycin and TMP/SMX were most frequently prescribed antibiotics. Azithromycin appeared to be an appropriate option for the treatment of CSD. TMP/SMX may be considered as an alternative antibiotic when azithromycin cannot be used.

Introduction: Options for the treatment of the behavioral and psychological symptoms of dementia (BPSD) are limited. Atypical antipsychotics are often used but have questionable efficacy and are generally considered high risk. Therefore, the objective of this study is to evaluate the efficacy and safety of using any atypical antipsychotic for the treatment of BPSD among outpatients. Methods: Retrospective observational study of an academic outpatient memory disorders clinic. Participants included any community-dwelling patient with a diagnosis of dementia, not trauma induced, with documented BPSD treated with an atypical antipsychotic for at least 2 weeks. Medical records were reviewed from January 1, 1990 to March 23, 2010. Safety outcomes were documented from the time of antipsychotic initiation, and behavioral/psychological efficacy outcomes were documented beginning 2 weeks after antipsychotic therapy was initiated, until the last documentation available. Results: A total of 87 distinct antipsychotic treatment periods for 81 unique patients were included. Antipsychotic treatment was continued for more than a year in 33% of patients and only 17% of patients discontinued antipsychotic treatment over the entire period. The behavioral/psychological outcomes improved for 24 (28%) treatments, remained stable for 17 (20%) treatments, and worsened for 46 (53%) treatments. Adverse events were reported by 53% of patients, with the most common adverse events being metabolic, fall related, type, and vascular. Few adverse events were severe. The odds ratio of adverse events per every 90-day increase in duration of treatment was 1.20 ( P = 0.02). Conclusion: Antipsychotic treatment improved behavioral/psychological symptoms for less than one-third of patients and increased the potential risk of adverse events for more than half of patients.

In 2007, the Centers for MedicareMedicaid Services (CMS) instituted a star rating system using performance outcome measures to assess Medicare Advantage Prescription Drug (MAPD) and Prescription Drug Plan (PDP) providers.To assess the relationship between 2 performance outcome measures for Medicare insurance providers, comprehensive medication reviews (CMRs), and high-risk medication use.This cross-sectional study included Medicare Part C and Part D performance data from the 2014 and 2015 calendar years. Performance data were downloaded per Medicare contract from the CMS. We matched Medicare insurance provider performance data with the enrollment data of each contract. Mann Whitney U and Spearman rho tests and a hierarchical linear regression model assessed the relationship between provider characteristics, high-risk medication use, and CMR completion rate outcome measures.In 2014, an inverse correlation between CMR completion rate and high-risk medication use was identified among MAPD plan providers. This relationship was further strengthened in 2015. No correlation was detected between the CMR completion rate and high-risk medication use among PDP plan providers in either year. A multivariate regression found an inverse association with high-risk medication use among MAPD plan providers in comparison with PDP plan providers in 2014 (beta = -0.358, P0.001) and 2015 (beta = -0.350, P0.001), the CMR completion rate in 2015 (beta = -0.221, P0.001), and enrollee population size in 2015 (beta = -0.203, P = 0.001).This study found that MAPD plan providers and higher CMR completion rates were associated with lower use of high-risk medications among beneficiaries.No outside funding supported this study. Silva Almodovar reports a fellowship funded by SinfoniaRx, Tucson, Arizona, during the time of this study. The other authors have nothing to disclose.

The majority of studies on medication therapy management (MTM) have focused on the conduct of in-person comprehensive medication reviews (CMRs). Although face-to-face MTM services may be the most well-known mode of delivery, there are other ways CMRs can be implemented as part of an MTM service. Specifically, telephonic CMR is an alternative method of offering MTM services that many patients may welcome. The purpose of this commentary was to highlight current findings regarding the impact of telephonic CMRs as a component of MTM services on health outcomes.Review of available literature analyzing the impact of telephonic CMRs on health outcomes.PubMed was used to identify studies published between January 1980 and December 2016 using the search terms medication therapy management (MTM), telephonic MTM, comprehensive medication reviews, and targeted medication reviews. This search was limited to publications in English. Case reports were excluded.CMRs conducted telephonically as part of an MTM program may potentially reduce healthcare expenditures, hospitalizations, and mortality.Although study results have shown telephonic CMRs to be an effective way to enhance patient care and reduce healthcare expenditures, the components of telephonic MTM programs that make them most effective and the population on which they have the greatest impact are unknown. Moving forward, further evaluation of these programs is necessary to determine which specific factors, such as access to patient electronic health records, patient follow-up frequency, and the use of collaborative practice agreements, are most vital to improving patient outcomes.

Objective: To discuss the risk factors, microbial resistance rates, and pharmacotherapy, including antimicrobial choices and medication dosage regimens, for urinary tract infections (UTIs) in pediatric patients. Data Sources: A MEDLINE literature search (1985 to December 2017) was performed using the following keywords and associated medical subject headings: urinary tract infection, antimicrobial, treatment, and children. Study Selection and Data Extraction: Search was conducted to identify clinical trials, systematic reviews, and guidelines. Search was filtered to include studies with age range between birth and 18 years and published in English. Additional references were identified from selected review articles. Data Synthesis: In total, 27 studies investigating microbial resistance, 31 studies assessing antimicrobial efficacy, 34 studies describing prophylaxis, and 6 systematic reviews were included. The resistance patterns differed across age groups and affected the choice of empirical therapy. If pyelonephritis is suspected, empiric antimicrobials should have high urinary and sufficient parenchymal concentrations. Nitrofurantoin has low microbial resistance rates and can generally be used empirically for treating uncomplicated cystitis in children >1 month of age. Trimethoprim-sulfamethoxazole resistance has increased and should be avoided unless local susceptibility data are available. Certain patients with recurrent UTIs or renal abnormalities may require antimicrobial prophylaxis, which may be associated with adverse effects, such as intolerability or an increased risk of microbial resistance. Conclusion: The resistance pattern of uropathogens should be considered prior to initiating therapy. Controlled trials with large samples are needed to compare the treatment duration of various antimicrobial regimens and the specific role of prophylactic antimicrobials.

Health information technologies, such as computerized clinical decision support (CDS) systems, are being utilized increasingly in pediatric health care institutions as a means of medication error prevention. Most studies have suggested a positive impact of CDS on medication safety, but others have identified complexities that have prevented full optimization of these systems. Recent studies regarding the implementation of pediatric dosing alerts have illustrated the complexities that can be associated with the design, implementation, and refinement of CDS systems. Although CDS dosing alerts have likely improved the safety of medication use in pediatric patients, it is important to be aware of certain limitations of the dosing alert systems. A collaborative effort is required to optimize the effectiveness of CDS dosing alerts.

Information technology (IT) has the potential to prevent medication errors. While many studies have analyzed specific IT technologies and preventable adverse drug events, no studies have identified risk factors for errors still occurring that are not preventable by IT. The objective of this study was to categorize reported or trigger tool-identified errors and adverse events (AEs) at a pediatric tertiary care institution. Also, we sought to identify medication errors preventable by IT, determine why IT-preventable errors occurred, and to identify risk factors for errors that were not preventable by IT. This was a retrospective analysis of voluntarily reported or trigger tool-identified errors and AEs occurring from 1 July 2011 to 30 June 2012. Medication errors reaching the patients were categorized based on the origin, severity, and location of the error, the month in which they occurred, and the age of the patient involved. Error characteristics were included in a multivariable logistic regression model to determine independent risk factors for errors occurring that were not preventable by IT. A medication error was defined as a medication-related failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. An IT-preventable error was defined as having an IT system in place to aid in prevention of the error at the phase and location of its origin. There were 936 medication errors (identified by voluntarily reporting or a trigger tool system) included and analyzed. Drug administration errors were identified most frequently (53.4% ), but prescribing errors most frequently caused harm (47.2 % of harmful errors). There were 470 (50.2 %) errors that were IT preventable at their origin, including 155 due to IT system bypasses, 103 due to insensitivity of IT alerting systems, and 47 with IT alert overrides. Dispensing, administration, and documentation errors had higher odds than prescribing errors for being not preventable by IT [odds ratio (OR) 8.0, 95 % CI 4.4–14.6; OR 2.4, 95 % CI 1.7–3.7; and OR 6.7, 95 % CI 3.3–14.5, respectively; all p

Objectives To determine dosing alert rates based on prescription order characteristics and identify prescription order risk factors for the occurrence of dosing alerts. Methods A retrospective analysis of inpatient medication orders and dosing alerts occurring during October 2011 and January, April, and July 2012 at a pediatric institution. Prescription orders and alerts were categorized by: medication class, patient age, route of administration, and month of the year. Results There were 228,259 orders during the studied period, with 11,072 alerted orders (4.9%). The most frequently alerted medication class was the non-analgesic central nervous system agent class (14% of alerts). Age, route, medication class, and month all independently affected dosing alert rates. The alert rate was highest for immunosuppressive agents (54%), neonates (6.7%), and orders for rectal administration (9.5%). The alert rate was higher in adult patients receiving their care at a pediatric institution (5.7%) compared to children (4.7%), but after multivariate analysis, pediatric orders had higher odds for an alert (OR 1.1, 95% CI 1.05–1.16). Mercaptopurine had the highest alert rate when categorized by active ingredient (73.9%). Albuterol 2.5 mg/mL continuous aerosol and heparin 1000 units in 0.9% sodium chloride injection solution were the unique medications with the highest alert rates (100.0% and 97.7%, respectively). Conclusions Certain types of prescription orders have a higher risk for causing dosing alerts than others. Patient age, medication class, route of administration, and the month of year can affect dosing alert rates. Design and customization efforts should focus on these medications and prescription order characteristics that increase the risk for dosing alerts.

BACKGROUND Inadequacies in mental health care coverage remain an enormous problem in the United States. Barriers include scarcity of accessible mental health care professionals. Use of a mental health mobile app incorporating social cognitive theory may help improve confidence in coping skills and improve anxiety and depression. Sinasprite is a mobile app that recruited users via self-referral and clinician referral. Users completed questionnaires to obtain demographic and medical histories. At baseline and 6-week follow-up, users completed the Patient Health Questionnaire 8 (PHQ-8), General Anxiety Disorder 7-Item (GAD-7), and the Coping Self-Efficacy Scale (CSE). It is unknown how self-directed use of a mobile app improves confidence in coping skills and its effects on self-reported depression and anxiety. OBJECTIVE The objective of this study was to evaluate the Sinasprite database to assess self-directed engagement and how use of this mobile app impacted self-reported confidence in coping skills and severity of depression and anxiety. METHODS This retrospective longitudinal study involved users recruited via clinician referral and self-referral through social media and news media. Questionnaires were used to record demographic, medical, and prescription medication histories. Mental health status was assessed via PHQ-8, GAD-7, and CSE questionnaires. A deidentified dataset reporting mobile app use data was provided to investigators. Individuals with verifiable usage data and at least one completed questionnaire at 6 weeks of use were included. Mann–Whitney U and Kruskal-Wallis tests were used to assess whether demographic data and psychotherapy were related to baseline questionnaire scores and usage. A Spearman rho (ρ) test was used to assess the relationship between improvement in the CSE and GAD-7 and PHQ-8 questionnaires. Changes in mental health status were assessed using Wilcoxon signed-rank test. A mixed-effects repeated-measures linear regression model assessed the main effects of time, concomitant counseling, and psychotropic prescription medication use on mental health status. RESULTS Thirty-four users were eligible for inclusion in the analysis. Users were predominantly female, white, married, and college educated. At baseline, 35% (12/34) of respondents reported the use of individual/group counseling, and 38% (19/34) reported using prescription medications for their mental health. The median user completed 5.7 (interquartile range 2.7-14.1) trackable activities per week. Statistically significant improvements using a Wilcoxon signed-ranked test were observed in the PHQ-8 (P CONCLUSIONS This 6-week retrospective study showed that self-directed use of the mobile app, Sinasprite, resulted in significant improvements in self-reported questionnaire scores reflecting depression, anxiety, and confidence in coping skills.

Morphine and sildenafil are commercially available at high concentrations which may lead to errors in measuring small volumes to provide low doses needed in infants. The purpose of this study was to assess the stability of morphine sulfate and sildenafil citrate in extemporaneously prepared suspensions for oral use. Morphine (0.2 mg/mL) was prepared from dilution of morphine elixir (2 mg/mL) with distilled water and stored in amber, plastic syringes at 25°C for 60 days. The mean concentration of morphine exceeded 95% of the initial concentration for the entire 60-day study period. No marked changes in pH or physical appearance were observed. Sildenafil (2.5 mg/mL) was prepared from Revatio tablets in two groups of suspensions: one group in 1% methylcellulose:simple syrup (1:7) and another in OraPlus:OraSweet (1:1). These were stored in plastic prescription bottles at 4°C and 25°C for a period of 91 days. The mean concentrations of sildenafil exceeded 95% of the original concentrations throughout the 91-day study period. No substantial changes were seen in the pH or physical appearance of the suspensions. These results indicate that the diluted morphine was stable for at least 60 days at room temperature. In addition, sildenafil was stable for 91 days in each of the two suspensions prepared from Revatio tablets and stored under refrigeration or at room temperature.