Background:
In a recent study, we showed that long-term (3 years) use of weak opioids (codeine and/or tramadol), combined with benzodiazepines/Z-drugs (BZD/Z), was associated with an increased dose-dependent risk of all-cause mortality. Therefore, preventing measures targeting this group, especially heavy drug users, by a de-prescribing approach could be of benefit for these patients. However, being multimorbid might make this approach more complicated.

Aim:
To analyse disease patterns, index conditions, and possible clustering of diseases among long-term users of weak opioids and BZD/Z-drugs.

Methods:
Of 221,804 patients contacting the primary healthcare centres in the capital area of Iceland, 124,436 were selected for further analysis. Exposure time for long-term drug use was 3 years. 88,832 participants fulfilled the inclusion criteria, aged 10–69 years, then divided into four groups: Group I, neither used BZD/Z nor opioids (N=78,248); Group II, used opioids but no BZD/Z-drugs (N=304); Group III, used BZD/Z but no opioids (N=7,881); and Group IV, used both BZ/Z and opioids (N=2,399). Chronic medical diseases were analysed according to ICD-10.

Results:
Preliminary results show that most of the long-term users of weak opioids were multimorbid, where the chronic pain-related diseases were to a great extent combined with mental diagnoses. Further subgroups, especially within mental diseases (F group) and musculoskeletal diseases (M group) with possible clustering of disease patterns will be presented at the conference.

Considerations and learning issues:
Disease patterns, multimorbidity, index diseases and index conditions, as well as polypharmacy, have to be taken into consideration among long-term users of opioids and BZD/Z, when considering de-prescribing drugs.

1. Long-term use of weak opioids (i.e. codeine and tramadol) combined with benzo/Z-drugs increase risk of all-cause mortality.
2. Long-term users of low opioids and benzo/Z-drugs are usually multimorbid
3. When de-prescribing benzo/Z-drugs, multimorbidity, and holistic approach has to be taken into consideration patients >

Introduction

Patients experiencing serious injuries are at risk of developing long-term opioid use, yet many don’t receive plans for opioid reduction when discharged from the hospital. General Practitioners (GPs) also experience lack of communication from the hospital regarding pain management plans. The opioid epidemic in the USA, characterised by opioid use disorders and addiction, has led to high mortality rates and social need. This study aims to reduce the proportion of opioid users and improve patient outcomes after accidental trauma by implementing a Pain And Coordination plan (PAC-plan).

Methods

This register-supported randomised controlled trial (RCT) will evaluate the effect of a PAC-plan compared to usual care. Patients will be recruited from Oslo University Hospital, Norway. We include adult patients in need of acute orthopaedic surgery after accidental injury and discharged to home with opioid analgesics. The participants will be randomised in patient-GP pairs and allocated into PAC-plan or control (100 patients in each group). The PAC-plan includes a) an opioid management plan to facilitate patient education and provide instructions after discharge b) a GP appointment within 2-4 weeks after discharge and c) enhanced collaboration between hospital specialists and GPs. The primary outcome is oral morphine equivalent consumption at 6 and 52 weeks after randomisation. This patient reported outcome measure (PROM) will be validated by data from the Norwegian Prescription Database. Secondary outcomes are pain, health-related quality of life (HRQoL) and other PROMs at 6 and 52 weeks.

Discussion

The intervention is expected to demonstrate efficacy in reducing harmful use of opioids, reducing pain and increasing HRQoL. If effective, the PAC-plan can be implemented into clinical practice and thereby improve patient outcomes and reduce problematic use of opioids in society.

Ethics

The project is approved by the Regional Committee for Medical Research Ethics and will be registered in ClinicalTrials.gov.

1.This register-supported randomised controlled trial aims to reduce the proportion of opioid users and improve patient outcomes after accidental trauma by implementing a Pain And Coordination plan (PAC-plan).
2. The PAC-plan focuses on a safe opioid management plan at discharge from the hospital and enhanced collaboration between patient, hospital specialists and the GP.
3. If proven effective, the PAC-plan can be implemented into clinical practice and thereby improve patient outcomes and reduce problematic use of opioids in society.

The opiate crisis has been hard on rural America. This population of patients often face stigma and barriers to care. Providing medication assisted treatment for opiate use disorder (OUD) in the patient centred medical home (PCMH) allows for comprehensive primary care management. In addition, the PCMH is the appropriate location to created access to OUD treatment, especially if care does not exist elsewhere. Population health models (aka, clinical care pathways, hub & spoke, collaborative care) make managing this population achievable in primary care. The presentation will consist of a case of a patient on medication for opiate use disorder (MOUD) whose limb-threatening ischaemia was detected early while being seen in the PCMH and treated with revascularization prior to any morbid outcomes. This care would not have been available in a treatment centre or specialty clinic. Universal access to MOUD in the primary care setting leads to decreased barriers to comprehensive health care.

1. At the conclusion of the presentation attendees will be inspired to treat patients with opiate use disorder in the medical home.
2. At the conclusion of the presentation attendees will appreciate the potential impact of stigma on accessing medical care.
3. At the conclusion of the presentation attendees will be inspired to reduce barriers to care for marginalized populations.

Background and Aim:
Musculoskeletal (MSK) pain is a common ailment that affects workers across many industries, including healthcare workers. It has the potential to affect work performance and in turn, the quality of patient care. Amongst the healthcare professions, studies (outside of Singapore) reported a prevalence of musculoskeletal pain of 20 – 91.2%. There is, however, a lack of studies looking specifically at primary care physicians. To address this knowledge gap, our study thus aimed to understand the prevalence of musculoskeletal pain and explore its associated risk factors, amongst public primary care physicians (PCPs) in Singapore.

Methods:
We conducted a cross-sectional survey among PCPs practicing in a primary healthcare cluster. Data were collected using a self-administered web-based questionnaire which included information on demographic information and the Nordic Musculoskeletal Questionnaire (NMQ).

Results:
There were 198 PCPs in the study, of which 175 (88.4%) reported the presence of musculoskeletal pain in at least one body region in the last 12 months. The most common sites of pain were the neck (70.7%), lower back (60.1%), and shoulder (49.5%). We found that females had a higher risk of musculoskeletal pain (OR 3.60; 95% CI 1.07 – 12.11) as compared to males. Participants who reported doing moderate-to-vigorous physical activity 5-7 days per week had a lower risk of musculoskeletal pain (OR 0.18; 95% CI 0.04 – 0.87) as compared to participants who were involved in moderate-to-vigorous physical activity 0-2 days per week.

Conclusion:
Our study demonstrated a high prevalence of musculoskeletal pain amongst our local primary care physicians. Female gender was associated with a higher risk of musculoskeletal pain. Participants with moderate-to-vigorous physical activity of at least 150 minutes per week had lower risk of musculoskeletal pain. Further research can be conducted to explore these risk factors for musculoskeletal pain and its impact on productivity and quality of care. This would help in the development of preventive measures with the goal of reducing musculoskeletal pain amongst PCPs

At the conclusion of my presentation, attendees will take away
1. Musculoskeletal pain is a significant burden amongst primary care doctors in Singapore
2. The associated risk and protective factors for MSK pain

Aim:
In post-war Kosovo, the magnitude of inappropriate use of benzodiazepines is unknown to date.The aim of this study was to assess the prevalence and correlates of continuation of intake of benzodiazepines beyond prescription (referred to as “inappropriate use”) in the adult population of Gjilan region in Kosovo.

Method:
A cross-sectional study was conducted in Gjilan region, including a representative sample of 780 individuals attending different pharmacies and reporting use of benzodiazepines (385 men and 395 women; age range 18–87 years; response rate: 90%). A structured questionnaire was administered to all participants inquiring about the use of benzodiazepines and socio-demographic characteristics.

Results:
Overall, the prevalence of inappropriate use of benzodiazepines was 58%. In multivariable-adjusted models, inappropriate use of benzodiazepines was significantly associated with older age (OR 1.7, 95% CI 1.1–2.7), middle education (OR 1.8, 95% CI 1.2–2.7), daily use (OR 1.4, 95% CI 1.1–2.0) and addiction awareness (OR 2.7, 95% CI 2.0–3.8). Furthermore, there was evidence of a borderline relationship with rural residence (OR 1.2, 95% CI 0.9–1.7).

Conclusion:
Our study provides novel evidence about the prevalence and selected correlates of inappropriate use of benzodiazepines in Gjilan region of Kosovo. Health professionals and policymakers in Kosovo should be aware of the magnitude and determinants of drug misuse in this transitional society.

Keywords: Addiction, Benzodiazepines, Inappropriate use of drugs, Kosovo

Prescribing opiate substitution therapy and assisting people with opiate dependence occurs primarily in the general practice setting in Victoria. This presentation will focus on the learnings of providing general practice care to people who use drugs over a period of 5 years from within one site of a large community based not-for-profit community health service. Community health services strive to improve health and wellbeing for all and lead the way in reducing health inequity in partnership with people and the communities in which they live.
The Laverton site has 2 part-time GPs treating over 100 people with opioid dependencies within a mainstream general practice setting. The service provides more than just pharmacotherapy. The introduction of a care co-ordinator role (currently is a nurse) has facilitated linking people attending the clinic with other health and social service providers both inside and outside of cohealth. The care co-ordinator and GP work together to assist complex clients and allows GP more time to focus on clinical tasks.
The development of client trust with the service has been essential in providing additional health care including heart health, chronic skin infections, sexual health, intimate partner violence and hepatitis C treatment. In settings without care co-ordinator role these aspects of health are often overlooked.
Flexibility of service delivery is key both in terms of range of treatments provided and style of care. Telephone and telehealth services have had overall a beneficial effect on service delivery. The involvement of reception staff and their understanding of drug use issues and treatments also improves the client journey. This is beyond the traditional GP service model. Community health along with Aboriginal controlled health services address specific health and social needs of individuals, families and local communities. These organisations recognise health inequities and target services for vulnerable groups.

1. flexible service delivery
2. importance of team care approach
3. engaging people who use drugs in primary care setting