title: Inappropriate Fentanyl Prescribing Among Nursing Home Residents in the United States.
abstract: OBJECTIVE
  We quantified transdermal fentanyl prescribing in elderly nursing home residents without prior opioid use or persistent pain, and the association of individual and facility traits with opioid-naïve prescribing.
  
  
  METHODS
  Cross-sectional study.
  
  
  METHODS
  Linked Minimum Data Set (MDS) assessments; Online Survey, Certification and Reporting (OSCAR) records; and Medicare Part D claims.
  
  
  METHODS
  From a cross-section of all long-stay US nursing home residents in 2008 with an MDS assessment and Medicare Part D enrollment, we identified individuals (≥65 years old) who initiated transdermal fentanyl, excluding those with Alzheimer disease, severe cognitive impairment, cancer, or receipt of hospice care.
  
  
  METHODS
  We used Medicare Part D to select beneficiaries initiating transdermal fentanyl in 2008 and determined whether they were "opioid-naïve," defined as no opioid dispensing during the previous 60 days. We obtained resident and facility characteristics from MDS and OSCAR records and defined persistent pain as moderate-to-severe, daily pain on consecutive MDS assessments at least 90 days apart. We estimated associations of patient and facility attributes and opioid-naïve fentanyl initiation using multilevel mixed effects logistic regression modeling.
  
  
  RESULTS
  Among 17,052 residents initiating transdermal fentanyl, 6190 (36.3%) were opioid-naïve and 15,659 (91.8%) did not have persistent pain. In the regression analysis with adjustments, residents who were older (ages ≥95 odds ratio [OR] 1.69, 95% confidence interval [CI] 1.46-1.95) or more cognitively impaired (moderate-to-severe cognitive impairment, OR 1.99, 95% CI 1.73-2.29) were more likely to initiate transdermal fentanyl without prior opioid use.
  
  
  CONCLUSIONS
  Most nursing home residents initiating transdermal fentanyl did not have persistent pain and many were opioid-naïve. Changes in prescribing practices may be necessary to ensure Food and Drug Administration warnings are followed, particularly for vulnerable subgroups, such as the cognitively impaired.
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Electronic address: kfain1@jhu.edu.
authors.forename: Kevin M
authors.initials: KM
authors.lastname: Fain
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
authors.forename: Carlos
authors.initials: C
authors.lastname: Castillo-Salgado
authors.affiliation: Optum Epidemiology, Waltham, MA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI.
authors.forename: David D
authors.initials: DD
authors.lastname: Dore
authors.affiliation: Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Medicine, Johns Hopkins Medicine, Baltimore, MD.
authors.forename: Jodi B
authors.initials: JB
authors.lastname: Segal
authors.affiliation: Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI.
authors.forename: Andrew R
authors.initials: AR
authors.lastname: Zullo
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Medicine, Johns Hopkins Medicine, Baltimore, MD.
authors.forename: G Caleb
authors.initials: GC
authors.lastname: Alexander
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000701:Analgesics, Opioid / Q000627:therapeutic use*; D003430:Cross-Sectional Studies; D005260:Female; D005283:Fentanyl / Q000627:therapeutic use*; D006801:Humans; D057970:Inappropriate Prescribing / Q000706:statistics & numerical data; D008297:Male; D009735:Nursing Homes; D014481:United States; D014486:United States Food and Drug Administration
chemical_list: D000701:Analgesics, Opioid; D005283:Fentanyl
keywords: Food and Drug Administration; Nursing homes; fentanyl; prescription opioids