CELDAS DE COMBUSTIBLE
8.4.1. Electrocatálisis
Our study has some strengths. We used a data set of high quality that has been consistently and uniformly in use since 2002. It contains data from a clearly defined population and the long retention in care ensures a good representation of longitudinal data.
We report some limitations. First, we only used one reference day for each year. It was not possible to aggregate the data of every day to ensure complete coverage of the population. Therefore, some cases might be missing from the sample. However, we compared the data from each reference day to a second date for plausibility and did not find many discrepancies. Second, a discontinuation of therapy or an exit from the program is unapparent in the data. Additionally, the same patient may receive a different case number when re-entering OAT after dropping out. Third, we only covered medications dispensed by the OAS. The OAS is a psychiatric clinic and does not routinely investigate or prescribe treatment for somatic diseases. Hence, our results most likely underestimate the number of medications prescribed to patients, especially with regards to somatic diagnoses. Fourth, we did not have indications for treatments, for example for Methylphenidate. This information might be important to explain changes in prescription patterns. Finally, our results show a large variability, indication a high diversity and potential heterogeneity of the study population. Apart from analysis of averages, it might be worthwhile to look at the extremes and evaluate single cases.
Interpretation
Although we showed a trend towards an aging population with OAT that has been linked to an increase in chronic conditions, we did not see a general increase in somatic medications for these patients. We observed a peak in the number of substances and medications in 2008 that coincided with a higher proportion of somatic medications. It might be possible that one
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of the resident physicians put more attention towards somatic conditions compared to other years. Indeed, patients might visit other physicians and obtain additional medications from other sources. While this is likely the case for some patients, others may remain under- treated. The care for the ageing population with OAT has been reported to be insufficient
187,196. A study from Germany indicated that the supply system for those patients needs
adaption199. Moreover, Switzerland and other European countries face potential shortages of
OAT providers200-202. The consolidation of the treatment for older patients with OAT would
most likely increase the safety and effectiveness of therapies. Additionally, the declining mobility of these patients warrants changes to the supply of medication. Daily or even weekly visits to a dispensing center might not be feasible for some patients. However, legislations restrict dispensing of OAT to short intervals. Yet, studies show that takeaway doses for extended periods improves treatment outcomes and retention in care for steady
patients203,204. Moreover, many nursing homes are not prepared to care for older patients
with OAT205.
Generalizability
Our study considered only patients from one treatment center. Our results indicate a large variability of the sample in terms of age, number, and type of medications. Compared to a nationwide study reporting a mean age of 39.1 years in 2012, our sample was considerably older202. Because the OAS is specialized to treat opioid-dependent patients with mental
disorders, these may potentially show a higher complexity compared to other opioid-
dependent patients. Nevertheless, our results are relevant to other settings, as the increasing age and associated complexity is observed globally. The high standards and evidence-based practices inherent to a university hospital may be reflected in an early adoption of new treatment options, such as sustained-release Morphine or Methylphenidate for Cocaine addiction. Thus, the prevalence of these treatments might differ in other settings. Yet, novel approaches might rapidly disseminate in a small country like Switzerland, as OAT is generally provided by specialists who engage in continuous education.
Conclusion
With our database analysis, we confirmed the globally observed shift towards an older population with OAT. Furthermore, we were able to show an increase in the number of substances and medications, leading to an increased risk of drug-drug interactions, adverse events, and non-adherence. Additionally, we observed a shift from the traditional OAT with
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liquid Methadone to solid formulations, such as Buprenorphine and sustained-release Morphine. Other disorders, such as ADHD, further complicate the safe and effective therapy of the complex patients. Taken together, the developments of the past 10 years call for new care models for older patients with OAT. The increasing age and complexity of their
medication might warrant a closer collaboration of health care professionals. Alternative supply models to assist patients with their medication management and support medication adherence are needed for older patients with OAT and polypharmacy.
Acknowledgements
Many thanks to Fabienne Suppiger for her hard work during initial collection and analysis of the data. Many thanks also to Dr. Kenneth Dürsteler and Dr. med. Hannes Strasser for providing valuable support and input throughout the project, Thomas Müller for extracting the data, and the staff of the OAC for providing insight into their everyday work.
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