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1.
PLoS Med ; 18(11): e1003829, 2021 11.
Article in English | MEDLINE | ID: covidwho-1595916

ABSTRACT

BACKGROUND: The opioid epidemic in North America has been driven by an increase in the use and potency of prescription opioids, with ensuing excessive opioid-related deaths. Internationally, there are lower rates of opioid-related mortality, possibly because of differences in prescribing and health system policies. Our aim was to compare opioid prescribing rates in patients without cancer, across 5 centers in 4 countries. In addition, we evaluated differences in the type, strength, and starting dose of medication and whether these characteristics changed over time. METHODS AND FINDINGS: We conducted a retrospective multicenter cohort study of adults who are new users of opioids without prior cancer. Electronic health records and administrative health records from Boston (United States), Quebec and Alberta (Canada), United Kingdom, and Taiwan were used to identify patients between 2006 and 2015. Standard dosages in morphine milligram equivalents (MMEs) were calculated according to The Centers for Disease Control and Prevention. Age- and sex-standardized opioid prescribing rates were calculated for each jurisdiction. Of the 2,542,890 patients included, 44,690 were from Boston (US), 1,420,136 Alberta, 26,871 Quebec (Canada), 1,012,939 UK, and 38,254 Taiwan. The highest standardized opioid prescribing rates in 2014 were observed in Alberta at 66/1,000 persons compared to 52, 51, and 18/1,000 in the UK, US, and Quebec, respectively. The median MME/day (IQR) at initiation was highest in Boston at 38 (20 to 45); followed by Quebec, 27 (18 to 43); Alberta, 23 (9 to 38); UK, 12 (7 to 20); and Taiwan, 8 (4 to 11). Oxycodone was the first prescribed opioid in 65% of patients in the US cohort compared to 14% in Quebec, 4% in Alberta, 0.1% in the UK, and none in Taiwan. One of the limitations was that data were not available from all centers for the entirety of the 10-year period. CONCLUSIONS: In this study, we observed substantial differences in opioid prescribing practices for non-cancer pain between jurisdictions. The preference to start patients on higher MME/day and more potent opioids in North America may be a contributing cause to the opioid epidemic.


Subject(s)
Analgesics, Opioid/therapeutic use , Drug Prescriptions/statistics & numerical data , Pain/drug therapy , Adolescent , Adult , Aged , Canada , Cohort Studies , Dose-Response Relationship, Drug , Female , Humans , Male , Middle Aged , Morphine/administration & dosage , Morphine/therapeutic use , Taiwan , United Kingdom , United States , Young Adult
3.
Eur Rev Med Pharmacol Sci ; 24(24): 13062-13064, 2020 12.
Article in English | MEDLINE | ID: covidwho-1000852

ABSTRACT

Cytokine storm in COVID-19 is linked to disease severity and mortality. 40% of patients with severe COVID-19 require mechanical ventilation. Analgesia and sedation are used for treatment of pain, facilitation of mechanical ventilation, or management of acute agitation. Herein, we present the immunomodulating actions of morphine that may either improve or worsen the clinical course of COVID-19 once cytokine storm develops. A literature search was performed to find articles on potential immunomodulatory effects of morphine. Taken together, the results of in vitro and in vivo models in non-COVID-19 conditions suggest that morphine could have a beneficial effect by mitigating the cytokine storm in the early stages of severe COVID-19. In contrast, it could be potentially harmful in late stages of severe COVID-19, especially in the presence of septic shock.


Subject(s)
Analgesics, Opioid/adverse effects , COVID-19/therapy , Cytokine Release Syndrome/immunology , Immunomodulation , Morphine/adverse effects , Analgesics, Opioid/therapeutic use , COVID-19/immunology , Cytokines/immunology , Humans , Morphine/therapeutic use , Respiration, Artificial , SARS-CoV-2 , Shock, Septic/immunology
4.
Palliat Med ; 34(9): 1249-1255, 2020 10.
Article in English | MEDLINE | ID: covidwho-690192

ABSTRACT

BACKGROUND: The literature contains limited information on the problems faced by dying patients with COVID-19 and the effectiveness of interventions to manage these. AIM: The aim of this audit was to assess the utility of our end-of-life care plan, and specifically the effectiveness of our standardised end-of-life care treatment algorithms, in dying patients with COVID-19. DESIGN: The audit primarily involved data extraction from the end-of-life care plan, which includes four hourly nursing (ward nurses) assessments of specific problems: patients with problems were managed according to standardised treatment algorithms, and the intervention was deemed to be effective if the problem was not present at subsequent assessments. SETTING/PARTICIPANTS: This audit was undertaken at a general hospital in England, covered the 8 weeks from 16 March to 11 May 2020 and included all inpatients with COVID-19 who had an end-of-life care plan (and died). RESULTS: Sixty-one patients met the audit criteria: the commonest problem was shortness of breath (57.5%), which was generally controlled with conservative doses of morphine (10-20 mg/24 h via a syringe pump). Cough and audible respiratory secretions were relatively uncommon. The second most common problem was agitation/delirium (55.5%), which was generally controlled with standard pharmacological interventions. The cumulative number of patients with shortness of breath, agitation and audible respiratory secretions increased over the last 72 h of life, but most patients were symptom controlled at the point of death. CONCLUSION: Patients dying of COVID-19 experience similar end-of-life problems to other groups of patients. Moreover, they generally respond to standard interventions for these end-of-life problems.


Subject(s)
Coronavirus Infections/mortality , Delirium/drug therapy , Drug Therapy/standards , Dyspnea/drug therapy , Hospice Care/standards , Palliative Care/standards , Pneumonia, Viral/mortality , Terminal Care/standards , Aged , Aged, 80 and over , Analgesics, Opioid/therapeutic use , Betacoronavirus , COVID-19 , Coronavirus Infections/epidemiology , Coronavirus Infections/nursing , Drug Therapy/statistics & numerical data , Female , Hospice Care/statistics & numerical data , Humans , Hypnotics and Sedatives/therapeutic use , Male , Middle Aged , Morphine/therapeutic use , Palliative Care/statistics & numerical data , Pandemics , Pneumonia, Viral/epidemiology , Pneumonia, Viral/nursing , Practice Guidelines as Topic , SARS-CoV-2 , Terminal Care/statistics & numerical data , United Kingdom/epidemiology
5.
Palliat Med ; 34(9): 1235-1240, 2020 10.
Article in English | MEDLINE | ID: covidwho-616769

ABSTRACT

BACKGROUND: Hospital clinicians have had to rapidly develop expertise in managing the clinical manifestations of COVID-19 including symptoms common at the end of life, such as breathlessness and agitation. There is limited evidence exploring whether end-of-life symptom control in this group requires new or adapted guidance. AIM: To review whether prescribing for symptom control in patients dying with COVID-19 adhered to existing local guidance or whether there was deviation which may represent a need for revised guidance or specialist support in particular patient groups. DESIGN/SETTING: A retrospective review of the electronic patient record of 61 hospital inpatients referred to the specialist palliative care team with swab-confirmed COVID-19 who subsequently died over a 1-month period. Intubated patients were excluded. RESULTS: In all, 83% (40/48) of patients were prescribed opioids at a starting dose consistent with existing local guidelines. In seven of eight patients where higher doses were prescribed, this was on specialist palliative care team advice. Mean total opioid dose required in the last 24 h of life was 14 mg morphine subcutaneous equivalent, and mean total midazolam dose was 9.5 mg. For three patients in whom non-invasive ventilation was in place higher doses were used. CONCLUSION: Prescription of end-of-life symptom control drugs for COVID-19 fell within the existing guidance when supported by specialist palliative care advice. While some patients may require increased doses, routine prescription of higher starting opioid and benzodiazepine doses beyond existing local guidance was not observed.


Subject(s)
Biopharmaceutics/statistics & numerical data , Coronavirus Infections/drug therapy , Delirium/drug therapy , Dyspnea/drug therapy , Pneumonia, Viral/drug therapy , Practice Guidelines as Topic , Terminal Care/methods , Terminal Care/standards , Adult , Aged , Aged, 80 and over , Analgesics, Opioid/therapeutic use , Betacoronavirus , COVID-19 , Female , Humans , Hypnotics and Sedatives/therapeutic use , Male , Midazolam/therapeutic use , Middle Aged , Morphine/therapeutic use , Pandemics , Retrospective Studies , SARS-CoV-2
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