Optimizing Pain Management in Medically Complex Long-Term Care Residents
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AbstractProblem statement: While much needed clinical research has emphasized appropriate opioid stewardship in the general population, the needs of long-term nursing home care (LTC) residents remain largely ignored. Methods: This dissertation identified emerging trends in opioid therapy and initial opioid dosing patterns among LTC Medicare beneficiaries using Medicare Parts A, B and D claims, the Minimum Data Set 3.0 (MDS) and LTCFocus datasets. Aim 1 is a repeat cross-section study using resident and facility adjusted generalized estimating equations (GEE) to examine patterns of opioid use alone and in conjunction with pain-adjuvant medications among general, hospice, cancer, non-cancer chronic pain and dementia-related LTC stays from 2011 to 2015. Aim 2 identifies common patterns of average morphine equivalent daily dosing (MEDD) across six 30-day intervals starting with the first opioid prescription using latent class growth modeling (LCGM). Multivariate multinomial regression quantifies associations between different opioid use patterns over time and resident characteristics. Aim 3 accesses the odds of falls among residents with the highest probability of belonging to each of the commonly identified opioid dosing patterns with a facility clustered GEE model. Results: From 2011 to 2015, adjusted analyses found no constant significant changes in dose, duration, or frequency of opioid use. Increased use of anticonvulsant and skeletal muscle relaxants in opioid-related stays, particularly among residents with dementia, were found. LCGM identified four common opioid dosing patterns; extended high, short-term, intermittent and restart. Almost half of LTC residents received extended high opioid dosing. Multinomial regression found significant associations between sex, race, U.S. geographical region, pain diagnosis and receipt of other pain treatments with receipt of extended high dose therapy. Fall odds were found to be similar in the extended high and short-term groups. Models did find increased odds of falls in groups with less opportunity to develop tolerance (i.e., the restart and intermittent groups). Findings were not consistently significant in stratified analyses. Conclusions: Opioid use varies by resident characteristics. Opioid dosing varies over the course of therapy. More research on what factors lead to decisions regarding pain treatment and the impact of opioid dosing strategies on health-related outcomes are warranted.
DescriptionPharmaceutical Health Services Research
University of Maryland, Baltimore
Keywordlong-term care residents