Publications by authors named "Mary Lynn McPherson"

59 Publications

Frequency and Characteristics of Patients Prescribed Antibiotics on Admission to Hospice Care.

J Palliat Med 2021 Nov 24. Epub 2021 Nov 24.

Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, Oregon, USA.

Little is known about antibiotic prescribing on hospice admission despite known risks and limited evidence for potential benefits. To describe the frequency and characteristics of patients prescribed antibiotics on hospice admission. Cross-sectional study. Adult (age ≥18 years) decedents of a national, for-profit hospice chain across 19 U.S. states who died between January 1, 2017 and December 31, 2019. The primary outcome was having an antibiotic prescription on hospice admission. Patient characteristics of interest were demographics, hospice referral location, hospice care location, census region, primary diagnosis, and infectious diagnoses on admission. We used multivariable logistic regression to quantify associations between study variables. Among 66,006 hospice decedents, 6080 (9.2%) had an antibiotic prescription on hospice admission. Fluoroquinolones (22%) were the most frequently prescribed antibiotic class. Patients more likely to have an antibiotic prescription on hospice admission included those referred to hospice care from the hospital (adjusted odds ratio [aOR] 1.13, 95% confidence interval [CI] 1.00-1.29) compared with an assisted living facility, those receiving hospice care in a private home (aOR 3.85, 95% CI 3.50-4.24), nursing home (aOR 3.65, 95% CI 3.24-4.11), assisted living facility (aOR 4.04, 95% CI 3.51-4.64), or hospital (aOR 2.43, 95% CI 2.18-2.71) compared with inpatient hospice, and those with a primary diagnosis of liver disease (aOR 2.23, 95% CI 1.82-2.74) or human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (aOR 3.89, 95% CI 2.27-6.66) compared with those without these diagnoses. Approximately 9% of hospice patients had an antibiotic prescription on hospice admission. Patients referred to hospice from a hospital, those receiving care in a noninpatient hospice facility, and those with liver disease or HIV/AIDS were more likely to have an antibiotic prescription. These results may inform future antimicrobial stewardship interventions among patients transitioning to hospice care.
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http://dx.doi.org/10.1089/jpm.2021.0062DOI Listing
November 2021

Variability among Online Opioid Conversion Calculators Performing Common Palliative Care Conversions.

J Palliat Med 2021 Oct 20. Epub 2021 Oct 20.

Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA.

Online opioid conversion calculators (OOCCs) are commonly used to aid conversion between opioids to overcome tolerance, reduce adverse effects, or challenges related to administration. The purpose of this study was to describe and characterize variability among OOCC used by health care practitioners when converting common opioids and doses encountered in the hospice and palliative care setting. We collected 58 quantitative surveys and performed sentiment analysis on 62 qualitative responses from adult learners primarily practicing in the palliative care setting and enrolled in an online palliative care Master of Science program through the University of Maryland, Baltimore, who were asked to perform opioid conversion calculations using realistic patient cases. OOCC have substantial variability leading to a wide range of outputs, which may put patients at risk for opioid-related harm. Assessing participant sentiment toward OOCC showed most participants held a "Negative Sentiment" toward these calculators after the activity. Overall, findings reveal that given the same information, clinicians can come to widely different opioid doses and these differences can be amplified by OOCC. These differences can be particularly dangerous given the higher opioid doses commonly used in the palliative care setting. Considering the significant harm that can arise from an error when converting between opioids, clinicians should avoid the routine use of OOCC in real-world patient care settings. If an OOCC is used, organizations should endorse a specific calculator, provide training and education about the algorithm that supports the calculations, and encourage clinicians to use it only after their own manual calculation, which should be documented in the medical record.
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http://dx.doi.org/10.1089/jpm.2021.0041DOI Listing
October 2021

Recommendations for Preventing Medication Diversion and Misuse in Hospice Care: A Modified Delphi Study.

J Pain Symptom Manage 2021 Jun 11. Epub 2021 Jun 11.

University of Maryland School of Social Work, Baltimore, Maryland, USA. Electronic address:

Context: Recommendations are needed to help minimize the risks of medication diversion and misuse in the hospice setting.

Objective: To identify recommendations that could help prevent medication diversion and misuse in hospice care.

Methods: A modified Delphi method was utilized. An interdisciplinary panel of ten experts engaged in three phases of online and in-person voting regarding recommendations. Consensus for recommendations required a minimum of 80% endorsement by the panel experts. After two rounds of voting and several rounds of informal voting, 15 total recommendations were endorsed.

Results: Fifteen recommendations achieved at least 80% endorsement during the final round of voting. Each of the following recommendation topics received ≥ 80% endorsement, the need to balance prevention efforts with quality care, screening clinical job candidates, family education and screening, medication monitoring, responding to missing/diverted medications, and medication disposal. Panelists rated the Patient & Family Education recommendation as most important (M = 9.7; SD = 0.7) followed closely by Responding to Medication Diversion or Misuse (M = 9.5; SD = 1.1).

Conclusion: These recommendations were created by experts in the field to reduce the risk of medication diversion and misuse. Further steps towards implementation may appropriately reduce these risks.
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http://dx.doi.org/10.1016/j.jpainsymman.2021.06.004DOI Listing
June 2021

Shared Medication PLanning In (SIMPLIfy) Home Hospice: An Educational Program to Enable Goal-Concordant Prescribing In Home Hospice.

J Pain Symptom Manage 2021 Nov 5;62(5):1092-1099. Epub 2021 Jun 5.

Ariadne Labs, Boston, Massachusetts, USA; University of Rhode Island College of Nursing, Kingston, Rhode Island, USA.

Context: Simplifying medication regimens by tapering and/or withdrawing unnecessary drugs is important to optimize quality of life and safety for patients with serious illness. Few resources are available to educate clinicians, patients and family caregivers about this process.

Objective: To describe the development of an educational program called Shared Medication PLanning In (SIMPLIfy) Home Hospice.

Methods: An environmental scan identified a state-of-the-art educational program for home hospice deprescribing that we adapted using a stakeholder panel engagement process. The stakeholder panel (two hospice administrators, three nurses, two physicians, two pharmacists, and two former family caregivers) drawn from two geographically diverse hospice agencies reviewed the educational program and recommended additional content.

Results: Iterative rounds of review and feedback resulted in: 1) a three-part clinician educational program (total duration = 1.5 hour) that presents a standardized, goal-concordant, medication review approach to align medications and conversations about regimen simplification with patient and family caregiver goals of care; 2) a patient-family caregiver medication management educational notebook that presents common symptoms, hospice medications, and medication regimen simplification principles; and 3) a brief guide including helpful phrases to use as conversation starters for key steps in the program. A professional designer created thematic coherence for all materials that was well received by stakeholder panelists and hospice staff.

Conclusion: Educational materials can support hospice programs' and clinicians' efforts to implement goal-concordant medication simplification that optimizes end-of-life outcomes for patients and family caregivers. Evaluation of outcomes including medication appropriateness and family caregiver medication administration burden are not yet available.
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http://dx.doi.org/10.1016/j.jpainsymman.2021.05.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8556298PMC
November 2021

Interprofessional Healthcare Students' Attitudes, Skills, and Knowledge After Comprehensive Pain Assessment Training in Verbal and Nonverbal Patients.

J Hosp Palliat Nurs 2021 08;23(4):386-395

A comprehensive pain assessment is the first step in safe, effective pain management. Few studies have explored variations of strategies and measures for multidimensional pain assessment education in both verbal and nonverbal patients. In this retrospective cohort study, interprofessional health care students enrolled in a palliative care curriculum completed a pain assessment training, which taught the PQRSTA ("palliating factors, precipitating factors, previous treatments, quality, region, radiation, severity, temporal factors and associated symptoms") mnemonic as a strategy for assessing pain in verbal patients and the Pain Assessment in Advance Dementia and Checklist of Nonverbal Pain Indicators measures for nonverbal patients. The purpose of this study was to compare the change in attitudes, self-perceived skills, and knowledge regarding pain assessment before and after the training. Attitudes and self-perceived skills were assessed in the pretraining and posttraining survey, which was analyzed using χ2 test or Fisher exact test. Students' knowledge responses were analyzed using Wilcoxon signed rank test to assess accuracy of responses compared with the expert defined score. One hundred eighty-two students were included. Results showed a statistically significant improvement in attitudes related to applicability of pain measures and self-perceived skills. Overall, data did not support an increase in knowledge using the PQRSTA mnemonic, or Pain Assessment in Advance Dementia and Checklist of Nonverbal Pain Indicators measures. Future pain trainings should consider training on only 1 nonverbal pain measure, incorporating bedside assessments, and integrating real-time feedback.
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http://dx.doi.org/10.1097/NJH.0000000000000771DOI Listing
August 2021

A National Survey of Challenges Faced by Hospices During the Opioid Crisis: Estimates of Pain Medication Shortages, Missing Medications, and Opioids Left in the Home Post-Death.

J Pain Symptom Manage 2021 10 27;62(4):738-746. Epub 2021 Feb 27.

Department of Epidemiology & Public Health, University of Maryland School of Medicine (J.M.G.), Baltimore, Maryland, USA.

Context: No national data exist on hospice medication shortages, the frequency that opioid medications go missing, and drug disposal practices.

Objectives: To provide national estimates for hospices on: drug shortages; frequency of missing medications; and opioids left in the home post-death.

Methods: A national survey of 600 randomly selected hospices stratified by state and profit status (data collection 2018). Sample weights were applied to adjust for non-response. Respondents were hospice representatives knowledgeable about agency policies and practices. Participants reported their knowledge and perceptions about medication shortages, frequency that opioid medications go missing, and the proportion of hospice deaths in which opioids are left in the home. Findings were stratified by agency size.

Results: 371 hospices completed surveys (response rate = 62%), half (50%) of which were mid-sized (26-100 patients), and not-for-profit. Respondents had 7.5 years (SD = 7.7) of agency experience. 42% of hospices - and 61% of large hospices - reported medication shortages. Among the full sample, 28% of agencies indicated shortages of morphine; 20% reported shortages of hydromorphone. Nearly half (43%) of hospice representatives reported that missing opioid medications occurred within the last 90 days. 52% of representatives reported employees are not allowed to dispose of medications after a home death; and, among home deaths, unused opioids were left in the home 32% of the time. This suggests opioid medications are frequently left in U.S. households after a hospice home death.

Conclusion: Hospices face numerous challenges during the national opioid crisis. Interventions are needed to ensure access to needed treatments, mitigation of diversion, and safe medication disposal.
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http://dx.doi.org/10.1016/j.jpainsymman.2021.02.023DOI Listing
October 2021

Monitoring Equianalgesic Opioid Dosing.

Am J Nurs 2021 03;121(3):60-63

Mark Curtis is director of Integrative Medicine and Complimentary Care at Innovative Care Solutions, Dayton, OH. Mary Lynn McPherson is a professor at the University of Maryland School of Pharmacy, Baltimore. Stacy M. Swagger is executive director of Canon City Pregnancy Center, Canon City, CO. Marianne Matzo is an AJN contributing editor and coordinates Perspectives on Palliative Nursing. Contact author: Marianne Matzo, The authors have disclosed no potential conflicts of interest, financial or otherwise.

This series on palliative care is developed in collaboration with the Hospice and Palliative Nurses Association (HPNA; https://advancingexpertcare.org). The HPNA aims to guide nurses in preventing and relieving suffering and in giving the best possible care to patients and families, regardless of the stage of disease or the need for other therapies. The HPNA offers education, certification, advocacy, leadership, and research.
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http://dx.doi.org/10.1097/01.NAJ.0000737312.95932.4dDOI Listing
March 2021

Confirmed Medication Diversion in Hospice Care: Qualitative Findings From a National Sample of Agencies.

J Pain Symptom Manage 2021 04 12;61(4):789-796. Epub 2020 Sep 12.

School of Medicine, University of Maryland, Baltimore, Maryland, USA.

Context: The nonmedical use of prescribed medications is a major public health concern in the U.S. Medications prescribed to hospice patients for pain management may be at risk of being diverted to be sold or used illicitly.

Objectives: Use responses from hospice agency representatives to explore the details of confirmed cases of medication diversion in the hospice setting.

Methods: This is a qualitative descriptive study based on responses from hospice agency representatives with surveys completed by phone or online. Template analysis was used to describe the context of confirmed diversion, specifically 1) means of how the diversion was confirmed, 2) clues/red flags, 3) who diverted, and 4) agency responses to the confirmed diversion.

Results: A total of n = 112 open-ended responses were analyzed. Respondents reported multiple ways in which medication diversion was confirmed, such as drug screening, witnessed firsthand by staff, and an overdose. Clues/red flags included reluctance to allow medication monitoring, family discord, and higher medication doses being requested. Those who diverted medications included informal caregiver/family member, family friend, and facility staff. Agency responses to diversion included limiting the supply of medication, restricting access to the medication, and increasing staff visit frequency.

Conclusion: Good clinical practice and vigilance may help agencies detect medication diversion. Moreover, diversion prevention techniques should not harmfully impact quality of patient care.
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http://dx.doi.org/10.1016/j.jpainsymman.2020.09.013DOI Listing
April 2021

Initiation of Transdermal Fentanyl Among US Commercially Insured Patients Between 2007 and 2015.

Pain Med 2020 10;21(10):2229-2236

Department of Pharmaceutical Health Service Research, University of Maryland School of Pharmacy, Baltimore, Maryland.

Introduction: This study examined patterns of initial transdermal fentanyl (TDF) claims among US commercially insured patients and explored the risk of 30-day hospitalization among patients with and without prior opioid exposure necessary to produce tolerance.

Design: A retrospective cohort study of initial outpatient TDF prescriptions.

Setting: A 10% random sample of commercially insured enrollees within the IQVIA Health Plan Claims Database (formerly known as PharMetrics Plus).

Subjects: Individuals with a claim for TDF between 2007 and 2015.

Methods: The primary exposure was a new transdermal fentanyl claim, and the primary outcome was guideline concordance based on time and dose exposure.

Results: Among the 24,770 patients in the cohort, 4,848 (20%) patients had sufficient time exposure to opioids before TDF. Among those with sufficient time exposure, 3,971 (82%) had adequate opioid exposure based on the US Food and Drug Administration (FDA) package insert dosing guidance. Overall, 3,971 of the 24,770 (16%) patients received guideline-consistent TDF. An exploratory analysis of 30-day hospitalization after a TDF claim did not detect a difference in odds between guideline-consistent or -inconsistent groups when adjusted for variables known to influence the risk of opioid-induced respiratory depression.

Conclusions: A majority of patients met FDA opioid dose thresholds for TDF but had insufficient time exposure based on package insert recommendations for tolerance. Exploratory analysis did not detect a difference in odds for all-cause hospitalization or respiratory-related 30-day hospitalization between guideline-consistent or -inconsistent TDF claims. Prescribers should continue to adhere to FDA TDF labeling, although certain aspects of the labeling should be reevaluated or clarified.
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http://dx.doi.org/10.1093/pm/pnaa091DOI Listing
October 2020

Recognizing and Managing Polypharmacy in Advanced Illness.

Med Clin North Am 2020 May 10;104(3):405-413. Epub 2020 Feb 10.

Advanced Post-Graduate Education in Palliative Care, Online Master of Science in Palliative Care, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy Baltimore, 20 North Pine Street, S405, Baltimore, MD 21201, USA. Electronic address:

Older adults, particularly those late in life, are at higher risk for medication misadventure, yet bear the burden of increasing polypharmacy. It is incumbent on practitioners who care for this vulnerable population to use one or more approaches to deprescribe medications that impose a greater burden than benefit, including medically futile medications. It is essential that health care providers use compassionate communication skills when explaining these interventions with patients and families, pointing out that this is a positive, patient-centric intervention.
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http://dx.doi.org/10.1016/j.mcna.2019.12.003DOI Listing
May 2020

Why equianalgesic tables are only part of the answer to equianalgesia.

Ann Palliat Med 2020 Mar 17;9(2):537-541. Epub 2020 Mar 17.

Department of Pharmacy Practice and Science, University of Maryland Baltimore, Baltimore, Maryland, USA.

Opioids are an important tool in the management of acute and chronic (cancer and non-cancer) pain. Pain and palliative care practitioners are frequently called upon to switch a patient from one opioid regimen to a different regimen either to gain better pain control, to minimize opioid-related adverse effects, to overcome opioid tolerance, or due to a change in patient status. To this end, equianalgesic tables have been published to guide practitioners in making these calculations. Despite being built on the best data available, equianalgesic tables do not tell the whole story, requiring the practitioner to thoroughly consider the patient's situation, and unknown variables. A five-step process is presented in this article that espouse a safe and effective way to switch from one opioid regimen to another. Directions for the future include better refinement of the data that informs the equianalgesic table, and perhaps inclusion of opioid utility data.
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http://dx.doi.org/10.21037/apm.2020.03.05DOI Listing
March 2020

Tapering opioids: a comprehensive qualitative review.

Ann Palliat Med 2020 Mar 16;9(2):586-610. Epub 2020 Jan 16.

Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Danville, PA, USA.

This state-of-the-art review comprehensive covers the benefits and risks of tapering opioids. The review discusses opioid strategies and pitfalls that may occur during tapering. The purpose of this review is to expand the knowledge of clinicians regarding tapering opioids and equip them to be able to successfully reduce and stop opioid therapy when appropriate.
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http://dx.doi.org/10.21037/apm.2019.12.10DOI Listing
March 2020

Nonprescription Medication Use in Hospice Patients.

Am J Hosp Palliat Care 2020 May 17;37(5):336-342. Epub 2019 Sep 17.

Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA.

Objective: Patients admitted to hospice are more vulnerable to age-related physiologic changes, polypharmacy, and inappropriate medication use and monitoring. The objective of this study was to characterize the utilization of nonprescription medications in a hospice population.

Methods: This was a retrospective study designed to characterize nonprescription or over-the-counter medication use in hospice patients. Data for this study were provided by Seasons Hospice & Palliative Care, a national hospice organization with licenses to operate in 19 states and collected from January 1 to December 31, 2016. The most frequently utilized nonprescription medications, therapeutic classes, and the frequency of patients with at least 1 claim within a therapeutic class were summarized.

Results: The final study population included 62 639 orders representing 15 164 patients. The average age was 79.31 years with a standard deviation of 13.31 years. The average length of stay was 26.80 days with a standard deviation of 44.14 days. The top 5 most common medications were as follows: acetaminophen (25.15%), bisacodyl (21.69%), senna (8.35%), omeprazole (4.51%), and docusate (4.46%). Approximately 13 714 (29.67%) of patients were exposed to analgesics, 13 469 (29.14%) to laxatives, and 3535 (7.65%) to antacids or antigas medications.

Conclusion: This study highlights numerous opportunities for improvement in the use of nonprescription medications among hospice patients. Reducing the use of nonprescription medications that are ineffective or produce unwanted side effects can contribute to improving the quality of care that patients receive.
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http://dx.doi.org/10.1177/1049909119876259DOI Listing
May 2020

Effect of a study skills course on student self-assessment of learning skills and strategies.

Curr Pharm Teach Learn 2019 07 29;11(7):664-668. Epub 2019 Mar 29.

Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, 20 N. Pine St, Baltimore, MD 21201, United States. Electronic address:

Introduction: The purpose of this study was to determine whether a study skills course taken by first professional year pharmacy students improved their self-assessment of study skills and strategies.

Methods: This study analyzed student responses to the Learning and Study Strategies Inventory (LASSI), an online assessment with questions in 10 subject areas: anxiety, motivation, concentration, test strategies, study aids, selecting main ideas, attitude, self-testing, information processing, and time management. Students in an elective study skills course in 2012-2017 completed the self-assessment prior to and at the end of the course. Wilcoxon signed-rank test was performed to compare class score pre- and post-course.

Results: Over a five-year period, 312 students completed both the pre- and post-course LASSI assessment. Average percentile scores increased significantly from the beginning to the end of the course in all 10 areas. Notably, average pre-course scores in seven subject areas (attention, concentration, self-testing, selecting main ideas, study aids, time management, and test strategies) were all below the 50th percentile, indicating a need for improvement in those skills to see increased academic success. Average post-course scores in each area increased to between the 50th and 75th percentile.

Conclusions: This evaluation shows that a study skills course improves students' self-assessment of skills and attitudes associated with success in post-secondary education. Future studies will look at the effect of such a course on academic outcomes.
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http://dx.doi.org/10.1016/j.cptl.2019.03.004DOI Listing
July 2019

A Survey of Hospice Professionals Regarding Medical Cannabis Practices.

J Palliat Med 2019 10 16;22(10):1208-1212. Epub 2019 May 16.

Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland.

With medical cannabis (MC) remaining illegal at the federal level, hospice programs are unsure how to handle requests for MC, particularly since hospice is largely funded with federal dollars. The purpose of this survey was to determine respondents' comfort level with MC use in hospice, what processes and logistics hospice programs are employing when dealing with MC, and to determine what, if any, education hospice programs are providing to their staff. An anonymous online survey assessed a variety of factors surrounding hospice staff practice, experience, and opinions regarding MC. The survey was disseminated to employees of clients of a large hospice benefit manager as well as through a national hospice and palliative medicine professional organization. Three hundred ten hospice professionals responded to the survey. More than half of the respondents were nurses followed by administrators and physicians. Regardless of legal status, hospice staff members were overwhelmingly in agreement that MC is appropriate for hospice patients to have access to and use. Several barriers to use were identified including discordant legal status between state and federal governments, concerns about clinical efficacy and safety, and a myriad of other societal factors. Wide variations in MC documentation and education practices between hospices were noted. The data suggest overwhelming support for MC use in the hospice setting. Our findings highlight important opportunities to support hospice providers and their patients through education and the development of policies around MC.
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http://dx.doi.org/10.1089/jpm.2018.0535DOI Listing
October 2019

Frequency and Documentation of Medication Decisions on Discharge from the Hospital to Hospice Care.

J Am Geriatr Soc 2019 06 10;67(6):1258-1262. Epub 2019 Mar 10.

Department of Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy, Portland, Oregon.

Objectives: To quantify the frequency and type of medication decisions on discharge from the hospital to hospice care.

Design: Retrospective cohort study.

Setting: A 544-bed academic tertiary care hospital in Portland, Oregon.

Participants: A total of 348 adult patients (age ≥18 y) discharged to hospice care between January 1, 2010, and December 31, 2016.

Measurements: Data were collected from an electronic repository of medical record data and a manual review of patients' discharge summaries. Our outcomes of interest were the frequency and type of medication decisions documented in patients' discharge summaries. Medication decisions were categorized as continuation, continuation but with changes in dose, route of administration, and/or frequency, discontinuation, and initiation of new medications. We also collected data on the frequency of patient/family in the participation of medication-related decisions.

Results: Patients were prescribed a mean of 7.1 medications (standard deviation [SD] = 4.8) on discharge to hospice care. The most prevalent medications prescribed on discharge were strong opioids (82.5%), anxiolytics/sedatives (62.9%), laxatives (57.5%), antiemetics (54.3%), and nonopioid analgesics (45.4%). However, only 67.8% (213/341) of patients who were prescribed an opioid on discharge to hospice care were also prescribed a laxative. Discharging providers made a mean of 15.0 decisions (SD = 7.2) per patient of which 28.5% were to continue medications without changes, 6.7% were to continue medications with changes, 30.3% were to initiate new medications, and 34.5% were to discontinue existing medications. Patients and/or family members were involved in medication decisions during 21.6% of discharges; patients were involved in 15.2% of decisions.

Conclusion: Patients averaged more than 15 medication decisions on discharge to hospice care. However, it was rarely documented that patients and/or their families participated in these decisions. J Am Geriatr Soc, 2019.
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http://dx.doi.org/10.1111/jgs.15860DOI Listing
June 2019

Safe and Appropriate Use of Methadone in Hospice and Palliative Care: Expert Consensus White Paper.

J Pain Symptom Manage 2019 03 20;57(3):635-645.e4. Epub 2018 Dec 20.

Division of General Internal Medicine and Geriatrics, OHSU, USA.

Methadone has several unique characteristics that make it an attractive option for pain relief in serious illness, but the safety of methadone has been called into question after reports of a disproportionate increase in opioid-induced deaths in recent years. The American Pain Society, College on Problems of Drug Dependence, and the Heart Rhythm Society collaborated to issue guidelines on best practices to maximize methadone safety and efficacy, but guidelines for the end-of-life scenario have not yet been developed. A panel of 15 interprofessional hospice and palliative care experts from the U.S. and Canada convened in February 2015 to evaluate the American Pain Society methadone recommendations for applicability in the hospice and palliative care setting. The goal was to develop guidelines for safe and effective management of methadone therapy in hospice and palliative care. This article represents the consensus opinion of the hospice and palliative care experts for methadone use at end of life, including guidance on appropriate candidates for methadone, detail in dosing, titration, and monitoring of patients' response to methadone therapy.
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http://dx.doi.org/10.1016/j.jpainsymman.2018.12.001DOI Listing
March 2019

Anticholinergic Burden in Hospice Patients With Dementia.

Am J Hosp Palliat Care 2019 Mar 13;36(3):222-227. Epub 2018 Sep 13.

School of Pharmacy, University of Maryland, Baltimore, MD, USA.

Background: End-of-life (EOL) patients with dementia have an increased risk for anticholinergic toxicities due to age-related pharmacokinetic and physiologic changes in conjunction with an increased susceptibility to drug-induced cognitive impairments. Despite this well-documented risk, the use of drugs with anticholinergic properties (DAPs) remains prevalent in EOL patients with dementia.

Objective: The aims of this study were to describe prescribing patterns and characterize anticholinergic burden among hospice patients with dementia, as measured by the Anticholinergic Cognitive Burden (ACB) scale.

Methods: This was a retrospective review of a national hospice patient information database. Patients included were admitted on January 1, 2016, discharged by death by December 31, 2016, and had a primary diagnosis of dementia. Patients' anticholinergic burden was calculated using ACB scores.

Results: A total of 1283 patients met the inclusion criteria. Of those, 37.1% (n = 476) were prescribed at least 1 DAP. Specifically, 28.9% (n = 371) were prescribed 1 DAP, 6.6% (n = 84) were prescribed 2 DAPs, 1.6% (n = 20) were prescribed 3 DAPs, and 0.08% (n = 1) were prescribed 4 DAPs. The majority of patients prescribed a DAP had an ACB score of 3 (n = 359, 75.4%) and an average ACB score of 3.8. The most common DAPs prescribed in patients with an ACB score of 2 or higher were quetiapine (n = 202, 42.4%), atropine (n = 155, 32.6%), hyoscyamine (n = 61, 12.8%), olanzapine (n = 46, 9.6%), and scopolamine (n = 35, 7.4%).

Conclusion: Due to the limited benefit and increased harms with the use of DAPs, providers should aim to maximize nonpharmacologic options. By reducing the use of the top 5 DAPs identified in this study, the quality of life and care for EOL patients with dementia can potentially be improved.
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http://dx.doi.org/10.1177/1049909118800281DOI Listing
March 2019

Ten Tips Palliative Care Pharmacists Want the Palliative Care Team to Know When Caring for Patients.

J Palliat Med 2018 07;21(7):1017-1023

6 Department of Medicine, Perelman School of Medicine and Palliative and Advanced Illness Research Center, University of Pennsylvania , Philadelphia, Pennsylvania.

As palliative care (PC) moves upstream in the course of serious illness and the development of drugs and their indications rapidly expand, PC providers must understand common drug indications and adverse effects to ensure safe and effective prescribing. Pharmacists, experts in the nuances of medication management, are valuable resources and colleagues for PC providers. This article will offer PC providers 10 useful clinical pharmacy tips that PC pharmacists think all PC providers should know for safe and effective symptom management. Close collaboration with or addition of a trained pharmacist to your PC team can improve clinical care for all PC patients.
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http://dx.doi.org/10.1089/jpm.2018.0187DOI Listing
July 2018

Does nalbuphine have a niche in managing pain?

J Opioid Manag 2018 Mar/Apr;14(2):143-151

Department of Pharmacy Practice and Science, University of Maryland, Baltimore, Maryland.

Nalbuphine has been commercially available for 40 years for the treatment of acute pain; few studies have centered on management of chronic pain. Nalbuphine unique pharmacology is an advantage in pain management. It is µ antagonist, partial κ agonist for G-proteins and beta-arrestin-2. Benefits are related to G-protein interactions resulting in less nausea, pruritus, and respiratory depression than morphine. At low doses, nalbuphine reduces side effects particularly respiratory depression without loss of analgesia when combined with potent opioids. Nalbuphine pharmacokinetics are moderately altered in renal failure. Several studies have found that nalbuphine reduces uremic pruritus. Nalbuphine has drawbacks: it is not an oral formulation, it causes withdrawal in patients on sustained released opioids, and it cannot be used to treat an opioid withdrawal syndrome. Nalbuphine, despite being a µ receptor antagonist produces a drug-liking effect and can be abused. There are very few deaths associated with nalbuphine alone in part due to the fact it is rarely used but also related to a ceiling on respiratory depression.
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http://dx.doi.org/10.5055/jom.2018.0441DOI Listing
July 2018

Methadone: Maximizing Safety and Efficacy for Pain Control in Patients with Cancer.

Hematol Oncol Clin North Am 2018 Jun 22;32(3):405-415. Epub 2018 Mar 22.

Pain Management/Palliative Care, University of Maryland School of Pharmacy, 20 North Pine Street, Baltimore, MD 21201, USA.

Methadone is a valuable opioid in the management of patients who have cancer with pain. Methadone is a mu-, kappa-, and delta-opioid agonist, and an N-methyl-D-aspartate receptor antagonist. These mechanisms of action make methadone an attractive option for complex pain syndromes. It is critically important that providers consider a patient's risk status before beginning methadone. Careful consideration must be given to dosing methadone in both opioid-naïve and opioid-tolerant patients, with vigilant monitoring for therapeutic effectiveness and potential toxicity until the patient achieves steady state.
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http://dx.doi.org/10.1016/j.hoc.2018.01.004DOI Listing
June 2018

What Parenteral Opioids to Use in Face of Shortages of Morphine, Hydromorphone, and Fentanyl.

Am J Hosp Palliat Care 2018 Aug 12;35(8):1118-1122. Epub 2018 Apr 12.

1 Department of Palliative Care, Geisinger Medical Center, Danville, PA, USA.

Parenteral potent opioid availability is becoming an issue in acute pain management. Two opioids, nalbuphine and buprenorphine, are available which can be substituted for hydromorphone, fentanyl, and morphine. There are advantages and disadvantages in using these 2 opioids which are discussed, and potential dosing strategies are outlined.
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http://dx.doi.org/10.1177/1049909118771374DOI Listing
August 2018

Knowledge, Skills, and Attitudes Regarding the Use of Medical Cannabis in the Hospice Population: An Educational Intervention.

Am J Hosp Palliat Care 2018 May 9;35(5):759-766. Epub 2017 Nov 9.

2 Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA.

Background: Currently, 28 states and the District of Columbia have legalized cannabis for medical use despite its remaining Schedule I federally. Benefits of medical cannabis (MC) have been demonstrated in nausea/vomiting associated with chemotherapy, cachexia associated with HIV/AIDS, and certain types of neuropathic pain. However, it is unclear how comfortable hospice providers are with the concept of MC.

Objective: The aim of this study is to determine changes in knowledge, self-perceived skills, and attitudes (KSA) of hospice providers regarding MC after an online educational intervention.

Methods: The educational intervention consisted of 3 learning modules covering information from 6 learning domains. Participants took a pre- and postcourse survey to assess changes in KSA. Participant demographics were analyzed using descriptive statistics. To detect any differences between pre- and postsurvey answers, a paired t test was used to reduce intersubject variability.

Results: Attitudes about the importance of cannabis knowledge were overall positive and did not change significantly after the intervention (N = 94). Both self-perceived skills and knowledge increased significantly, with providers reporting more positive skills, and >75% of respondents answering questions correctly after the intervention. There was a significant difference in attitudes in all domains in the postsurvey between participants who have practiced in hospice <3 years or ≥4 years, but no difference in perceived skills or knowledge.

Conclusion: Providers' attitudes regarding the importance of MC knowledge were strong and the same before and after. Both the self-perception of skills and direct knowledge were significantly increased after the educational intervention.
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http://dx.doi.org/10.1177/1049909117738246DOI Listing
May 2018

State survey of medical boards regarding abrupt loss of a prescriber of controlled substances.

J Opioid Manag 2017 Mar/Apr;13(2):105-110

Professor Emeritus, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland.

Objectives: The purpose of the study was to evaluate states' experiences with abrupt changes in controlled substances (CS) prescribing, to determine whether states have action plans in place to manage such situations, and describe the components of any such plans.

Methods: A survey of executive directors of 51 medical boards was conducted to evaluate states' experiences with abrupt changes in CS prescribing, the extent of consumer complaints attributed to these events, and the types of plans in place to manage these situations.

Results: Forty-six executive directors of medical boards responded. Twenty boards (43.5 percent) confirmed that their state had experienced abrupt loss of CS providers and 11 (55 percent) of these executive directors indicated that the loss resulted in increased consumer complaints. The majority of executive directors (86 percent) had no action plan. Six executive directors reported some type of action plan or process consisting of regulatory action, patient-provider connection, professional education, patient education, or public notice.

Conclusions: Most states do not have operational plans in place. However, a few have key strategies that may be useful in addressing potential problems following abrupt loss of a CS prescriber. State medical boards can play a significant role in the development of comprehensive preparedness plans to mitigate damage from the loss of CS prescribers in the community.
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http://dx.doi.org/10.5055/jom.2017.0374DOI Listing
May 2018

Symptom management challenges in heart failure: pharmacotherapy considerations.

Heart Fail Rev 2017 09;22(5):525-534

University of Maryland School of Pharmacy, Baltimore, USA.

Heart failure is a chronic, progressive illness that is increasing in prevalence in the USA. Patients with advanced heart failure experience a high symptom burden that is comparable to patients with advanced cancer. Palliative care, however, is underutilized in patients with heart failure, and symptoms may go untreated as the disease progresses. A combination of pharmacologic and non-pharmacologic interventions should be used to address symptoms and maintain quality of life. While there have been significant advances in evidence-based heart failure treatments in recent years, selection of appropriate palliative medications as symptoms progress is challenging due to limited clinical studies in this patient population. Medications that are commonly used for symptom management in other life-limiting illnesses may have little to no evidence in heart failure, or have undesirable cardiac effects that preclude use. Clinicians must extrapolate available clinical evidence and prescribing considerations relevant to heart failure to palliate symptoms as well as possible. The objectives of this paper are to review the most common and distressing symptoms in heart failure, analyze evidence, or lack thereof, for pharmacologic management of symptoms, and provide prescribing considerations based on side effect profiles and comorbid conditions.
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http://dx.doi.org/10.1007/s10741-017-9632-5DOI Listing
September 2017

Prevalence and Clinical Intentions of Antithrombotic Therapy on Discharge to Hospice Care.

J Palliat Med 2017 Nov 5;20(11):1225-1230. Epub 2017 Jun 5.

2 Department of Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy , Portland, Oregon.

Background: There are no guidelines for antithrombotic therapy on admission to hospice care. Antithrombotic therapy may offer some benefit in these patients, but is also associated with well-described risks.

Objective: We quantified the frequency and characteristics of patients prescribed antithrombotic therapy on discharge from acute care to hospice care.

Design: Retrospective cohort study. Settings/Subjects: Adult (age> = 21 years) patients discharged from acute care to hospice care between January 1, 2010 and June 30, 2014.

Measures: Our primary outcome of interest was receiving an outpatient prescription for antithrombotic therapy on discharge to hospice care.

Results: Among 1141 eligible patients, 77 (6.7%) patients received a prescription for antithrombotic therapy on discharge to hospice care, most frequently, aspirin (57.1%), enoxaparin (26.0%), and warfarin (20.8%). Patients actively treated for deep vein thromboembolism or pulmonary embolism, or with a history of atrial fibrillation or aortic/mitral valve replacement were significantly more likely to receive antithrombotic therapy. Patients with a history of cancer, cerebrovascular disease, or liver disease were significantly less likely to receive antithrombotic therapy (p < 0.05 for all). Among patients who received antithrombotic therapy, 22% were not receiving antithrombotic therapy before the index admission. Among patients previously receiving antithrombotic therapy, 55% continued on the same medication, of which 54.5% did not have any documented rationale for continuation.

Conclusions: Prescriptions for antithrombotic therapy were infrequent and often lacked a documented rationale. Further research is needed on the safety and effectiveness of antithrombotic therapy in hospice care and what drives current medication decisions in the absence of these data.
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http://dx.doi.org/10.1089/jpm.2016.0487DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5672614PMC
November 2017

Improved Learning Outcomes After Flipping a Therapeutics Module: Results of a Controlled Trial.

Acad Med 2017 12;92(12):1786-1793

K. Lockman is clinical assistant professor, Department of Pharmacy Practice and Science, Division of Applied Clinical Sciences, University of Iowa College of Pharmacy, Iowa City, Iowa; ORCID: http://orcid.org/0000-0001-8017-8084. S.T. Haines is professor and director, Division of Pharmacy Professional Development, University of Mississippi School of Pharmacy, Jackson, Mississippi; ORCID: http://orcid.org/ 0000-0001-8217-1871. M.L. McPherson is professor and executive director, Advanced Post-Graduate Education in Palliative Care, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland.

Purpose: To evaluate the impact on learning outcomes of flipping a pain management module in a doctor of pharmacy curriculum.

Method: In a required first-professional-year pharmacology and therapeutics course at the University of Maryland School of Pharmacy, the pain therapeutics content of the pain management module was flipped. This redesign transformed the module from a largely lecture-based, instructor-centered model to a learner-centered model that included a variety of preclass activities and in-class active learning exercises. In spring 2015, the module was taught using the traditional model; in spring 2016, it was taught using the flipped model. The same end-of-module objective structured clinical exam (OSCE) and multiple-choice exam were administered in 2015 to the traditional cohort (TC; n = 156) and in 2016 to the flipped cohort (FC; n = 162). Cohort performance was compared.

Results: Learning outcomes improved significantly in the FC: The mean OSCE score improved by 12.33/100 points (P < .0001; 95% CI 10.28-14.38; effect size 1.33), and performance on the multiple-choice exam's therapeutics content improved by 5.07 percentage points (P < .0001; 95% CI 2.56-7.59; effect size 0.45). Student performance on exam items assessing higher cognitive levels significantly improved under the flipped model. Grade distribution on both exams shifted, with significantly more FC students earning an A or B and significantly fewer earning a D or F compared with TC students.

Conclusions: Student performance on knowledge- and skill-based assessments improved significantly after flipping the therapeutics content of a pain management module.
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http://dx.doi.org/10.1097/ACM.0000000000001742DOI Listing
December 2017

Perceptions of Statin Discontinuation among Patients with Life-Limiting Illness.

J Palliat Med 2017 10 18;20(10):1098-1103. Epub 2017 May 18.

11 Department of Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy , Portland, Oregon.

Background: Optimal management of chronic medications for patients with life-limiting illness is uncertain. Medication deprescribing may improve outcomes in this population, but patient concerns regarding deprescribing are unclear.

Objective: The aim of this study was to quantify the perceived benefits and concerns of statin discontinuation among patients with life-limiting illness.

Design: Baseline data from a multicenter, pragmatic clinical trial of statin discontinuation were used.

Setting/subjects: Cognitively intact participants with a life expectancy of 1-12 months receiving statin medications for primary or secondary prevention were enrolled.

Measurements: Responses to a 9-item questionnaire addressing patient concerns about discontinuing statins were collected. We used Pearson chi-square tests to compare responses by primary life-limiting diagnosis (cancer, cardiovascular disease, other).

Results: Of 297 eligible participants, 58% had cancer, 8% had cardiovascular disease, and 30% other primary diagnoses. Mean (standard deviation) age was 72 (11) years. Fewer than 5% of participants expressed concern that statin deprescribing indicated physician abandonment. About one in five participants reported being told to take statins for the rest of their life (18%) or feeling that discontinuation represented prior wasted effort (18%). Many participants reported benefits of stopping statins, including spending less money on medications (63%), potentially stopping other medications (34%), and having a better quality of life (25%). More participants with cardiovascular disease as a primary diagnosis perceived that quality-of-life benefits related to statin discontinuation (52%) than participants with cancer (27%) or noncardiovascular disease diagnoses (27%) [p = 0.034].

Conclusion: Few participants expressed concerns about discontinuing statins; many perceived potential benefits. Cardiovascular disease patients perceived greater potential positive impact from statin discontinuation.
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http://dx.doi.org/10.1089/jpm.2016.0489DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5647503PMC
October 2017
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