Opioid availability statistics from the International Narcotics Control Board do not reflect the medical use of opioids: comparison with sales data from Scandinavia

OBJECTIVES

Opioid analgesics are essential in clinical practice, but their excessive use is associated with addiction risk. Increases in opioid prescription rates have fuelled an epidemic of opioid addiction in the USA, making statistics on medical opioid use a critical warning signal. A dramatic 150% increase in Swedish opioid access 2001-2013 was recently reported based on data from the International Narcotics Control Board (INCB; Berterame et al. 2016) in conflict with other studies of opioid use in the Nordic countries. This article aims to analyse to what degree published INCB statistics on opioids in Scandinavia (Denmark, Norway and Sweden) reflect actual medical use and study the methodological reasons for putative discrepancies.

METHODS

Data on aggregated total national sales of opioids for the whole population, including hospitals, were collected from the Swedish e-Health Authority. Total sales data for Denmark and drugs dispensed at pharmacies in Norway are publicly available through the relevant authorities' websites.

RESULTS

INCB opioid statistics during the period 2001-2013 were markedly inconsistent with sales data from Scandinavia, calling the reliability of INCB data into question. INCB-data were flawed by (a) over-representing the volume of fentanyl, (b) under-reporting of codeine, and (c) by not including tramadol.

CONCLUSIONS

Opioid availability, as expressed by INCB statistics, does not reflect medical opioid use. It is crucial to underline that INCB statistics are based on the manual compilation of national production, import and export data from manufacturers and drug companies. This is not the same amount that is prescribed and consumed within the health care system. Moreover, there are methodological problems in the INCB reports, in particular concerning fentanyl, codeine and tramadol. We suggest that INCB should carefully review the quality of their data on medical opioids.

Clinical outcomes and prognostic factors associated with nonsteroidal anti-inflammatory drug overdose in dogs presented to an emergency room

OBJECTIVE

To describe case presentations, clinical signs, and outcomes following nonsteroidal anti-inflammatory drug (NSAID) overdose in a clinical population of dogs and to identify factors associated with various outcomes including death or euthanasia, acute kidney injury, and suspected gastrointestinal ulceration (GIU).

DESIGN

Retrospective study.

SETTING

University teaching hospital.

ANIMALS

One hundred twenty-five client-owned dogs presenting to an emergency room for NSAID overdose between January 2006 and December 2017.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Vomiting was the most common clinical sign, seen in 46 of 125 dogs (36.8%). Acute kidney injury and suspected GIU were seen in 17 (13.6%) and 16 dogs (12.8%), respectively. Thirty-two dogs (25.6%) ingested veterinary-formulated NSAIDs and 93 (74.4%) ingested human-formulated NSAIDs. No difference in any outcomes was seen between these two groups. One hundred twenty dogs (96%) survived to discharge. In multivariable analysis, the only significant finding was of the number of days of anorexia increased the risk of death or euthanasia with an odds ratio of 2.7 (95% confidence interval [1.14-6.5], P = 0.02).

CONCLUSIONS

Acute kidney injury and suspected GIU were seen less frequently than vomiting. Similar outcomes were seen for dogs ingesting veterinary- versus human-formulated NSAIDs. Owners presenting dogs with a longer duration of anorexia may be more apt to euthanize. As this was a clinical population of dogs presenting to an emergency room, findings may be more broadly applicable to the general population than prior studies utilizing poison control center data.

Polysubstance use in a Brazilian national sample: Correlates of co-use of alcohol and prescription drugs

Background: Responses to problem substance use have largely focused on illicit drugs, but reports on rising prescription drug misuse worldwide raise questions about their combined use with alcohol and potential consequences. The current study assessed prevalence of alcohol in conjunction with nonmedical opioid and benzodiazepine use across a nationally representative sample of adults in Brazil. Methods: Cross-sectional data on prevalence were estimated from the 2015 Brazilian Household Survey on Substance Use. We estimated past month nonmedical use of benzodiazepines and alcohol and past month nonmedical use of opioids and alcohol among adults who reported any past-year alcohol use. Zero-inflated Poisson models assessed independent correlates of alcohol and nonmedical opioid use, and alcohol and nonmedical benzodiazepine use. Results: Among adults who reported past year alcohol use, 0.4% (N = 257,051) reported past month alcohol and non-medical benzodiazepine use, and 0.5% (N = 337,333) reported past month alcohol and non-medical opioid use. Factors independently associated with co-use of alcohol and benzodiazepines included having depression (adjusted prevalence ratio (aPR):4.61 (95%CI 1.76-12.08)), anxiety (aPR:4.21 (95%CI 1.59-11.16)) and tobacco use (aPR: 5.48 (95%CI 2.26-13.27)). Factors associated with past-month alcohol and opioid use included having experienced physical or a threat of violence (aPR: 4.59 (95%CI 1.89-11.14)), and tobacco use (aPR:2.81(95%CI:1.29-6.12)). Conclusions: Co-use of prescription drugs with alcohol remains relatively rare among Brazilians, but findings point to a unique profile of persons at risk. Results of this study are important in light of changing dynamics and international markets of prescription drugs and the need for more research on use of these substances on a global scale.

The legal and ethical dimensions of direct-to-consumer advertising of prescription drugs: the case of Pfizer and Lipitor in the United States

The current study observes that while several studies have been conducted on the direct-to-consumer advertising (DTCA) of prescription drugs, none has explicitly evaluated the ethical dimension DTCA of prescriptions, as such a knowledge gap still exists with regard to the ethics of DTCAs. To contribute to filling this gap, the current study evaluates the ethical DTCA of prescription drugs using Pfizer's Lipitor ad, which because of public outcry, was terminated shortly after it was launched. The study concludes that what may be legal may not necessarily be ethical. Thus marketing decision marketers must expand their focus group testing of DTCAs to include assessment of their ethics.

Impact of Payor-Initiated Switching of Inhaled Corticosteroids on Lung Function

OBJECTIVES

To evaluate the impact of a payor-initiated formulary change in inhaled corticosteroid coverage on lung function in patients with asthma and on provider prescribing practices. This formulary change, undertaken in August 2016 by a Medicaid payor in Kentucky, eliminated coverage of beclomethasone dipropionate, a metered dose inhaler (MDI), in favor of mometasone furoate, available as MDI and dry powder inhaler (DPI).

STUDY DESIGN

A retrospective chart review was conducted on children with asthma ages 6-18 years covered by the relevant payor from a university-based pediatric practice who were seen before the formulary change (February to July 2016) and after (February to July 2017). Spirometry data from each visit was compared using the paired Student t test.

RESULTS

Fifty-eight patients were identified who were initially on beclomethasone dipropionate and had spirometry available at both visits. Those who switched from an MDI to a DPI (n = 24) saw a decline in median predicted forced expiratory volume in 1 second from 98.5% to 91% (P = .013). A decline was also seen in forced expiratory flow at 25%-75%, from 89.5% predicted to 76% predicted (P = .041). No significant changes were observed in children remaining on an MDI. Seven patients discontinued inhaled corticosteroid therapy.

CONCLUSIONS

This study suggests insurance formulary changes leading to use of a different inhaler device may have a detrimental impact on pediatric lung function, which may be a surrogate measure for overall asthma control. This could be due to a lack of adequate timely educational intervention as well as the inability of some children to use DPIs.

Utilization Management in the Medicare Part D Program and Prescription Drug Utilization

Medicare Part D has significantly enhanced access to prescription drugs among Medicare beneficiaries. However, the recent rapid rise of utilization management policies in the Medicare Part D program may have adversely affected access to prescription drugs. I study the effects of expected and observed exposure to utilization management in prescription drug utilization using Medicare Part D claims data from 2009 to 2016 and an instrumental variables strategy based on the interaction of lagged health status and the set of plans available to each beneficiary. I find that the expected share of spending subject to utilization management increases the observed share, with the smallest effect for prior authorization. Increases in the expected share of drug spending subject to prior authorization increases Part D spending by $122.27 per percentage point, with almost three-quarters of this increase being paid by the Medicare program, rather than beneficiaries or plans. Comparable increases in step therapy and quantity limit exposure increase spending by $46 and decrease spending by $31, respectively. Interestingly, increased exposure to prior authorization and quantity limits increases the average price per 30-day prescription.

Prioritising Risk Factors for Prescription Drug Overdose among Older Adults in South Korea: A Multi-Method Study

Older adults are vulnerable to drug overdose. We used a multi-method approach to prioritise risk factors for prescription drug overdose among older adults. The study was conducted in two stages. First, risk factors for drug overdose were classified according to importance and changeability through literature review, determined through 2-phase expert surveys. Second, prescription drug overdose cases during 2011–2015 were selected from a national cohort; the prevalence of ‘more important’ or ‘more changeable’ factors determined in stage one was investigated. Scores were assigned according to the Basic Priority Rating Scale formula, reflecting the problem size and seriousness and intervention effectiveness. In the first stage, polypharmacy, old-old age, female sex, chronic disease, psychiatric disease, and low socioeconomic status (SES) were selected as risk factors. In the second stage, 93.9% of cases enrolled had chronic medical disease; 78.3% were using multiple drugs. Low SES was more prevalent than other risk factors. As per the scoring formula, chronic medical disease, polypharmacy, psychiatric disease, low SES, female sex, and old-old age were the most important risk factors in order of priority. Patients with chronic medical disease and those using multiple medications should be prioritised in overdose prevention interventions among older adults.

Prospects for Enforcing Prohibitions on Off-Label Drug Promotion after United States v. Caronia: An Analysis of Litigated Cases

CONTEXT

Food and Drug Administration (FDA) rules restrict pharmaceutical manufacturers from promoting drugs for non-FDA-approved (off-label) indications. When manufacturers violate this rule, it has in many cases led to unsafe prescribing. However, in 2012, a federal circuit court ruled in United States v. Caronia that truthful off-label promotion was protected under the First Amendment, threatening government enforcement in this area.

METHODS

The authors extracted cases from the WestLawNext database that mentioned Caronia from 2012 to 2019. They collected information about plaintiff, procedural history, product and manufacturer involved, and case outcome. Cases were categorized as either "follows," "does not follow," or "distinguishes" from Caronia. The authors qualitatively reviewed the full text of each case to verify whether Caronia was given substantive discussion for perceptions of off-label promotion, application of commercial speech rights, and how courts interpreted Caronia.

FINDINGS

Among 42 cases in the study cohort, 22 (52%) followed Caronia's core holding that truthful, non-misleading off-label promotion was not actionable under FDA rules. By contrast, 20 cases (48%) treated Caronia negatively, either declining to follow (9 cases) or distinguishing it (11 cases).

CONCLUSIONS

Enforcement of restrictions on off-label marketing became more challenging after Caronia. This gives manufacturers greater flexibility to promote drugs for unapproved uses despite the substantial public health risks.

The Commonly Utilized Natural Products during the COVID-19 Pandemic in Saudi Arabia: A Cross-Sectional Online Survey

OBJECTIVES

The utilization rate of herbal and dietary supplements among the Saudi population is reported to be high. However, the utilization rate and types of herbal and dietary supplements during the COVID-19 pandemic are largely unknown.

METHODS

This was an online questionnaire-based cross-sectional study that used convenience sampling and social media platforms (Telegram®, Twitter®, and WhatsApp®) to disseminate a 12-item questionnaire across the Saudi general public aged 18 years and above. The questionnaire inquired about the sociodemographic characteristics (e.g., age, gender, education, geographical location), presence of chronic health conditions and the use of prescription medications, awareness of the viral nature of COVID-19 infection and its common symptoms, and the commonly utilized herbal and/or dietary supplements.

RESULTS

Sixty-four percent of the 1473 participants reported using herbal and/or dietary supplements for the purpose of boosting their immune system to prevent COVID-19 infection. In addition, 88.2% of the respondents were misinformed about the manifestation of COVID-19 symptoms. Most of the participants were Saudi (91.9%), aged 49 years and younger (83%), female (52%), and healthy (81%). Honey (46%), lemon (45%), ginger (36%), vitamin C (32%), black seed (26%), garlic (26%), and turmeric (19%) were the most commonly used herbal and/or dietary supplements by the participants. Saudi nationals (OR = 1.67, 95% CI: 1.08 to 2.6, p = 0.02), older adults (OR = 1.30, 95% CI:1.10 to 1.55, p = 0.002), and those taking prescription medications had higher odds of using dietary and/or herbal supplements (OR = 3.31, 95% CI: 2.61 to 4.18, p < 0.0001).

CONCLUSION

The utilization rate of herbal and dietary supplements among the Saudi public during the COVID-19 pandemic is high. Future studies should examine the impact of different public awareness campaigns aimed at improving the public knowledge of the risk and benefits associated with the use of different commonly utilized herbal and dietary products identified in this study.

Effects of the Off-Label Drug Prescription in the Paediatric Population in Spain from the Adoption of the Latest European Regulation: A Pre-Post Study

The year 2021 marks the 15th anniversary of the Paediatric Regulation (1901/2006/EC) in Europe. The main aim of the study was to conduct a pre-post comparison on the annual off-label prescription rates in the under-18 population in Spain and assess the potential influence of the Paediatric Regulation adoption. An observational study in the paediatric population was performed. Four cross-sectional annual periods, one before and the three latest periods after the adoption of the Regulation, were compared. Prescriptions in the primary health care setting were sorted by age group and drug and off-label status were determined. The number of off-label prescriptions issued by paediatricians was over two million per year. Prior to the adoption of the Paediatric Regulation, the off-label prescription rate was estimated at 7% of total prescriptions. Although the increase in the off-label rate over the study periods was mild, it was statistically significant (OR: 1.045; 95% CI: 1.043–1.046; p < 0.05). One of the most vulnerable population groups was neonates and infants up to 1 year, in which the off-label prescription rates showed the highest increase during the post follow-up period, which was statistically significant (OR: 4.270; 95% CI: 4.253–4.287; p < 0.05). The findings can help raise awareness and advocate for the development and authorization of medicines for children in the primary health care setting.

Neuroenhancement in French and Romanian University Students, Motivations and Associated Factors

This cross-sectional study aimed to determine the use of neuroenhancers, the motivations and factors associated with their use in French and Romanian university students. Students from two universities in France (Rouen and Opal Coast University) and one in Romania (Cluj-Napoca) were asked to complete a self-administered anonymous questionnaire, either online or on paper, about the use of three different categories of substance: Prescription drugs (methylphenidate, modafinil, and beta-blockers), drugs of abuse (alcohol, cannabis, cocaine, and amphetamines), and soft enhancers (coffee, vitamins, caffeine tablets, and energy drinks). In total, 1110 students were included: The users were 2.2% for prescription drugs, 4.3% for drugs of abuse, and 55.0% for soft enhancers. Students used neuroenhancement to stay awake for study (69.3%), to improve concentration (55.5%), to decrease stress (40.9%), and to improve memory (39.6%). Neuroenhancement was considered to meet expectations by 74.4% of users. The factors associated with the use of drugs of abuse were frequent binge drinking (Adjusted Odds Ratio-AOR: 6.49 [95% CI: 2.53-16.6]), smoking (AOR: 5.50 [95% CI: 2.98-10.14]), having a student job (AOR: 2.42 [95% CI 1.13-5.17]), and being male (AOR: 2.23 [95% CI:1.21-4.11]). No significant associations with eating disorders were detected for any of the three categories of substances. University students reported neuroenhancement with prescription drugs, drugs of abuse, and mainly soft enhancers. These substances were used mainly to increase the waking hours. Educational programs in universities seem to be required in order to increase student awareness of the problems caused by neuroenhancements, and to decrease the associated risks by changing students' attitudes and beliefs.

Trends in Dental Medication Prescribing in Australia during the COVID-19 Pandemic

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic and subsequent restrictions on dental services have had a significant impact on the provision of dental care in Australia and around the world.

OBJECTIVES

To investigate the impact of COVID-19 on medications prescribed by dentists under the Australian Pharmaceutical Benefits Scheme (PBS).

METHODS

Data on the number of dental prescriptions dispensed for all medications listed on the PBS Dental Schedule, from January 2019 to June 2020, were extracted from publicly available data sets. Analysis of prescription trends was performed for 1) total medications, 2) each major medication class, and 3) individual medications. The number of prescriptions dispensed in each month from January 2020 to June 2020 was compared to the same month in 2019 to determine the relative (percentage) change, and z statistics were used to determine whether changes were statistically significant.

RESULTS

There was a significant decrease in dental prescriptions in April 2020 compared to April 2019 (14,785, 18%; P < 0.05). Decreases in prescriptions for antibiotics (10,512, 16%; P < 0.05) and opioid analgesics (3,129, 18%; P < 0.05) were smaller compared to other major medication classes. There was a significant increase in June 2020, compared with June 2019, for prescriptions of amoxicillin with clavulanic acid (4,903, 20%; P < 0.05), tramadol (89, 46%; P < 0.05), and oxycodone (381, 73%; P < 0.05).

CONCLUSION

Dental service restrictions during COVID-19 likely drove an unmet need for routine dental treatment, which had significant implications for public oral health following easing of restrictions. During the initial surge and subsequent lockdown, antibiotics and opioid analgesics may have been used an as alternative to routine operative treatment. Continued professional guidance is required to ensure dental prescribing remains evidence based during the pandemic period.

KNOWLEDGE TRANSFER STATEMENT

The COVID-19 pandemic and subsequent restrictions on dental practice have had a profound impact on the provision of dental care in Australia and elsewhere in the world. In this context, population-level medication surveillance is important to identify and respond to changes in prescribing patterns that have arisen due to COVID-19 and restrictions on the provision of dental care. This research is particularly important for governments, regulators, and professional associations to ensure therapeutic guidelines and recommendations during the pandemic period remain relevant and evidence based.

International Reference Pricing for Prescription Drugs in the United States: Administrative Limitations and Collateral Effects

OBJECTIVES

Many countries use international (or external) reference pricing-benchmarking prices against those in other countries-to manage spending on prescription drugs. By contrast, the United States (US) allows manufacturers to set drug prices freely. In December 2019, a major bill passed the House of Representatives that would introduce international reference pricing to reduce US drug spending. In September 2020, President Trump issued an executive order to apply international reference pricing for drugs purchased under Medicare. As US policymakers consider adopting reference pricing, it is important to recognize four key administrative issues that have complicated other countries' experiences.

METHODS

We analyzed the US policy proposals and literature on international experience with international reference pricing to identify implementation challenges and potential effects of US adoption of international reference pricing.

RESULTS

Four key administrative issues were identified: lack of price transparency, delays in market approvals, the frequency of price revisions, and the prevalence of cross-referencing.

CONCLUSIONS

Failure to account for the key issues in the emerging US approach will lead to overspending from overestimation of prices. Policymakers also need to recognize the collateral effects that the US adoption of international reference pricing may have on other countries' prices. Given the size of the pharmaceutical market in the US and other market issues, US reference pricing will likely increase drug list and net prices in other countries. Because of limitations in implementation and collateral effects, US policymakers should consider international reference pricing as a supportive tool alongside other cost containment policies, such as value-based pricing or volume agreements. International reference pricing could limit drug spending in the US but faces implementation challenges and will negatively affect other countries.

The Effect of Changes in Cost Sharing on the Consumption of Prescription and Over-the-Counter Medicines in Catalonia

Many universal health care systems have increased the share of the price of medicines paid by the patient to reduce the cost pressure faced after the Great Recession. This paper assesses the impact of cost-sharing changes on the propensity to consume prescription and over-the-counter medicines in Catalonia, a Spanish autonomous community, affected by three new cost-sharing policies implemented in 2012. We applied a quasi-experimental difference-in-difference method using data from 2010 to 2014. These reforms were heterogeneous across different groups of individuals, so we define three intervention groups: (i) middle-income working population—co-insurance rate changed from 40% to 50%; (ii) low/middle-income pensioners—from free full coverage to 10% co-insurance rate; (iii) unemployed individuals without benefits—from 40% co-insurance rate to free full coverage. Our control group was the low-income working population whose co-insurance rate remained unchanged. We estimated the effects on the overall population as well as on the group with long-term care needs. We evaluated the effect of these changes on the propensity to consume prescription or over-the-counter medicines, and explored the heterogeneity effects across seven therapeutic groups of prescription medicines. Our findings showed that, on average, these changes did not significantly change the propensity to consume prescription or over-the-counter medicines. Nonetheless, we observed that the propensity to consume prescription medicines for mental disorders significantly increased among unemployed without benefits, while the consumption of prescribed mental disorders medicines for low/middle-income pensioners with long-term care needs decreased after becoming no longer free. We conclude that the propensity to consume medicines was not affected by the new cost-sharing policies, except for mental disorders. However, our results do not preclude potential changes in the quantity of medicines individuals consume.

Examining the bidirectional relationship between food insecurity and healthcare spending

OBJECTIVE

To improve food insecurity interventions, we sought to better understand the hypothesized bidirectional relationship between food insecurity and health care expenditures.

DATA SOURCE

Nationally representative sample of the civilian noninstitutionalized population of the United States (2016-2017 Medical Expenditure Panel Survey [MEPS]).

STUDY DESIGN

In a retrospective longitudinal cohort, we conducted two sets of analyses: (a) two-part models to examine the association between food insecurity in 2016 and health care expenditures in 2017; and (b) logistic regression models to examine the association between health care expenditures in 2016 and food insecurity in 2017. We adjusted for demographic and socioeconomic variables as well as 2016 health care expenditures and food insecurity.

DATA COLLECTION

Health care expenditures, food insecurity, and medical condition data from 10 886 adults who were included in 2016-2017 MEPS.

PRINCIPAL FINDINGS

Food insecurity in 2016, compared with being food secure, was associated with both a higher odds of having any health care expenditures in 2017 (OR 1.29, 95% CI: 1.04 to 1.60) and greater total expenditures ($1738.88 greater, 95% CI: $354.10 to $3123.57), which represents approximately 25% greater expenditures. Greater 2016 health care expenditures were associated with slightly higher odds of being food insecure in 2017 (OR 1.007 per $1000 in expenditures, 95% CI: 1.002 to 1.012, P =0.01). Exploratory analyses suggested that poor health status may underlie the relationship between food insecurity and health care expenditures.

CONCLUSIONS

A bidirectional relationship exists between food insecurity and health care expenditures, but the strength of either direction appears unequal. Higher health care expenditures are associated with a slightly greater risk of being food insecure (adjusted for baseline food insecurity status) but being food insecure is associated with substantially greater subsequent health care expenditures (adjusted for baseline health care expenditures). Interventions to address food insecurity and poor health may be helpful to break this cycle.

Determinants of prescription opioid use: population-based evidence from Finland

BACKGROUND AND AIMS

Previous studies have shown that prescription opioid use is more common in socio-economically disadvantaged communities in the United States. This study examined the area and individual-level determinants of prescription opioid use in Finland during the period 1995-2016.

DESIGN

Logistic regression analysis using nation-wide data on filled opioid-related prescriptions dispensed at Finnish pharmacies and covered by National Health Insurance. Opioid consumption was linked, using personal identification codes, to population-based data maintained by Statistics Finland, which records individual background and area-level characteristics.

SETTING AND PARTICIPANTS

Working-age population aged between 15 and 64 years in Finland during the periods 1995-2007 (n = 4 315 409) and 2009-16 (n = 4 116 992).

MEASUREMENTS

Annual prescription opioid use was measured using defined daily doses (DDD) and whether people used opioids during a year.

FINDINGS

Prescription opioid use increased in Finland from 1995 to 2016 (from less than 1 to 7%), but the increase was explained by the change in the treatment of codeine-based opioids in National Health Insurance. The area-level unemployment rate was positively correlated with the share of opioid users at the municipal level (r = 0.36; P < 0.001). In comparison with being employed, being outside the labour force was associated with increased opioid use in 1995-2007 [odds ratio (OR) = 2.22, 95% confidence interval (CI) = 2.10-2.36] and non-codeine opioid use in 2009-16 (OR = 2.16, 95% CI = 2.06-2.27), but not with codeine opioid use in 2009-16.

CONCLUSIONS

Prescription opioid use in Finland appears to be more common among low socio-economic status people, similar to the United States and the United Kingdom.

Overestimation of Prescription Pain Reliever Misuse and Heroin Use among Adults

Estimates from the National Survey on Drug Use and Health (Substance Abuse and Mental Health Services Administration [SAMHSA], 2019) suggest 3.6% of persons aged 12 and older misused prescription pain relievers in the past year and 0.3% used heroin. However, research suggests that most individuals drastically overestimate rates of substance use and misuse. Those who overestimate substance misuse are often more likely to misuse substances themselves (Kilmer et al., 2015; McCabe, 2008). Purpose: To compare perceived versus actual rates of prescription pain reliever misuse and heroin use among a statewide sample of adults and identify correlates of these differences. Methods: Participants (N = 689) recruited through social media estimated rates of prescription pain reliever misuse and heroin use. Participants also indicated whether they engaged in pain reliever misuse or heroin use, and whether they knew anyone who misused prescription pain medications or heroin. Results: Almost all participants (98.11%) overestimated the prevalence of prescription pain reliever misuse (mean estimate = 41.25%) and heroin use (99.71%, mean estimate =25.46%). Women and African Americans were more likely to overestimate prescription pain reliever misuse and heroin use. Knowing someone who misused prescription pain relievers was significantly associated with overestimating prescription pain reliever misuse. Personal use was not associated with overestimating prevalence of either substance. Conclusions: Adults consistently overestimate rates of prescription pain reliever misuse and heroin use. Overestimation may increase normative perceptions of substance use and ultimately lead to increased substance use. Social-norms based education and interventions may be particularly important among groups that are more likely to overestimate use.

The geography of prescription pharmaceuticals supplied to the USA: levels, trends, and implications

Prescription pharmaceuticals are frequently used consumer products whose manufacturing location is commonly held as a trade secret by firms and US regulatory agencies. Here we use previously non-publicly available data to describe levels and trends in the manufacturing locations of the most commonly used prescription pharmaceuticals, off-patent generic drugs, intended to be consumed by Americans. We find that the base ingredients required for the manufacturing of these prescription drugs are overwhelmingly and increasingly manufactured in non-domestic locations, specifically India and China. The manufacturing of finished prescription drugs for the American market is more equally split between domestic and foreign locations, but is increasingly foreign as well. The American reliance on non-domestic manufacturing of prescription drugs is important for stakeholders to appreciate, given current quality and pricing concerns and their potential susceptibility to interruptions in supply due to natural disasters, pandemics, and international trade negotiations. We discuss implications of these levels and trends for current domestic and international policy discussions.

The geography of prescription pharmaceuticals supplied to the USA: levels, trends, and implications

Prescription pharmaceuticals are frequently used consumer products whose manufacturing location is commonly held as a trade secret by firms and US regulatory agencies. Here we use previously non-publicly available data to describe levels and trends in the manufacturing locations of the most commonly used prescription pharmaceuticals, off-patent generic drugs, intended to be consumed by Americans. We find that the base ingredients required for the manufacturing of these prescription drugs are overwhelmingly and increasingly manufactured in non-domestic locations, specifically India and China. The manufacturing of finished prescription drugs for the American market is more equally split between domestic and foreign locations, but is increasingly foreign as well. The American reliance on non-domestic manufacturing of prescription drugs is important for stakeholders to appreciate, given current quality and pricing concerns and their potential susceptibility to interruptions in supply due to natural disasters, pandemics, and international trade negotiations. We discuss implications of these levels and trends for current domestic and international policy discussions.

Patterns of Substance Use and Associations with Mental, Physical, and Social Functioning: A Latent Class Analysis of a National Sample of U.S. Adults Ages 30-80

Trends show increased substance use among adults, yet little research on general population samples has examined differential patterns of licit and illicit substance use that can inform prevention and treatment efforts. This study identifies distinct patterns (classes) of substance use among 30- to 80-year olds, identifies demographic subgroups with the highest probability of class memberships, and compares classes on key indicators of functioning. Method: Participants (n = 1,877) were from the RAND American Life Panel. Online survey measures included current alcohol, tobacco, cannabis, and nonmedical prescription drug use, as well as mental, physical, and social functioning. Results: Latent class analysis identified four classes: "Lighter Drinking" (46.6%), "Abstaining" (33.7%), "Heavy Drinking with Cigarette/Cannabis Use" (17.1%), and "Cigarette Smoking with Prescription Drug/Cannabis Use" (2.6%). Of these classes, "Cigarette Smoking with Prescription Drug/Cannabis Use" reported the worst mental and physical functioning, and greater loneliness than the "Lighter Drinking" class. "Heavy Drinking with Cigarette/Cannabis Use" reported worse mental and physical functioning than the "Lighter Drinking" class and less social support than the "Lighter Drinking" and "Abstaining" classes. The "Abstaining" class reported consistently worse functioning than the "Lighter Drinking" class. Both polysubstance use classes were associated with younger age, less education, and lower income, and heavy drinking polysubstance use was associated with being male and unmarried. Conclusions: Although lighter drinking was the most common pattern, 20% of adults were classified into two polysubstance use classes associated with poorer functioning. Targeted efforts may be needed to reach certain subgroups of adults who are particularly susceptible to polysubstance use.

Non-medical Use of Prescription Gabapentinoids (Gabapentin and Pregabalin) in Five European Countries

Background: Non-medical use (NMU) of prescription GABA analogs (pregabalin and gabapentin) has been reported especially in opiate dependent persons. However, by now the prevalence of NMU of gabapentinoids in the general population has not been sufficiently evaluated. The aim of this research paper is to determine the prevalence of prescription GABA analog NMU and associated demographics in five European countries with special detail of Spain. Methods: The RADARS Survey of Non-Medical Use of Prescription Drugs Program (NMURx) is a harmonized series of contemporaneous cross-sectional surveys of adults conducted in multiple countries. NMURx collects data from the general population in each participating country about NMU of prescription drugs, illicit drugs, and associated demographics. NMU was defined as "using a medication without a doctor's prescription or for any reason other than what was recommended by their doctor." Responses from Spain (4Q2017, n=10,062) were analyzed in detail. Comparative data were available from France, Germany, Italy, and UK. Responses were collected using non-probability quota sampling and post-stratification population weighting was applied to reflect the national distributions of adults, based on age, gender, and census region. Rates of NMU and associated demographics were reported as rate of past 90-day NMU per 100,000 adult population with 95% confidence intervals. Results: Germany (1,197 per 100,000 adult population [95% CI: 1,004.3-1,379.1]) and United Kingdom (1,067 per 100,000 adult population [95% CI: 851.3-1,283.2]) presented the highest prevalence of gabapentinoids NMU. In Spain the prevalence of past 90 days GABA analog NMU was: 344.4, 95% (CI 204.8-484.0), with male predominance. Those who non-medically use GABA analogs had a higher prevalence of lifetime chronic pain, lifetime illicit drug use, and previous substance abuse treatment. In Spain, 20% of respondents who ever have used gabapentinoids, reported a lifetime NMU; the prevalence was higher for pregabalin 624 (6.2%) than for gabapentin 444 (4.4%). The main reasons for use were to self-treat pain and other medical conditions. Conclusions: The risk of NMU of gabapentinoids should not be neglected. Subjects with a history of chronic pain and lifetime substance use disorders had an increased risk of NMU of gabapentinoids.

Physician and patient-related factors associated with inappropriate prescribing to older patients within primary care: a cross-sectional study in Brazil

BACKGROUND

Physician and patient-related characteristics can influence prescription of medications to older patients within primary healthcare. Use of Brazilian criteria may indicate the real prevalence of prescription of potentially inappropriate medications to this population.

OBJECTIVES

To evaluate prescription of potentially inappropriate medications to older patients within primary care and identify patient-related and prescribing physician-related factors.

DESIGN AND SETTING

This cross-sectional study was conducted in 22 public primary care facilities in Brazil, among older people (≥ 60 years) who were waiting for medical consultations.

METHODS

Interviews were conducted before and after the medical consultations. If the patient received a medical prescription at the consultation, all the drugs prescribed and the physician's medical council registration number were recorded. Prevalence ratios were estimated to ascertain the magnitude of prescription of potentially inappropriate medications, along with patient and physician-related factors associated with such prescription.

RESULTS

In total, 417 older patients were included; 45.3% had received ≥ 1 potentially inappropriate medication, and 86.8% out of 53 physicians involved had prescribed ≥ 1 potentially inappropriate medication. The strongest patient-related factor associated with higher prevalence of prescription of potentially inappropriate medications was polypharmacy. Among physician-related factors, the number of patients attended, number of prescriptions and length of medical practice < 10 years were positively associated with prescription of potentially inappropriate medications.

CONCLUSIONS

High prevalence of prescription of potentially inappropriate medications was observed. Physician-related characteristics can influence prescription of medications to older people within primary healthcare. This suggests that there is a need for interventions among all physicians, especially younger physicians.

Physicians Treating Alzheimer's Disease Patients Should Be Aware that Televised Direct-to-Consumer Advertising Links More Strongly to Drug Utilization in Older Patients

BACKGROUND

US direct-to-consumer advertising spending for medicine has soared in recent decades. Advertising has been shown to impact drug utilization. Most Alzheimer's disease patients are above age 65 and may take a range of prescription medications for various disease states.

OBJECTIVE

To investigate how direct-to-consumer advertising is associated with the drug utilization of patients ≥65 years old.

METHODS

Using advertising expenditure data and Medicare Part D drug purchase claims, we performed regression analyses for each of the highest-spending drugs and age group, with cumulative monthly spending as the predictor variable and drug utilization as the response variable. For each drug, we ran a second set of regression analyses to determine if the spending-utilization correlation showed a significant difference between the two patient age groups (older than 65, younger than 65).

RESULTS

For all 14 drugs in our study, advertising spending is positively correlated with utilization (p < 0.01) in both age groups. For seven of the 14 drugs studied, the difference in the utilization of patients older than 65 and the utilization of patients younger than 65 is statistically significant at a p < 0.01 level. The 65-and-older age bracket exhibits significantly greater utilization for all seven of these drugs.

CONCLUSION

We find televised advertising for certain drugs to be associated with significantly stronger drug utilization among seniors, as compared to younger patients. Alzheimer's disease physicians should be aware of this result, in light of the medications that patients may take for other disease states, particularly mood and mental health medications.

Multimodal Treatment Patterns for Osteoarthritis and Their Relationship to Patient-Reported Pain Severity: A Cross-Sectional Survey in the United States

Purpose

The purpose of this study was to assess how patient-reported pain is related to osteoarthritis (OA) treatment patterns in routine clinical practice.

Patients and Methods

Data were collected between February and May 2017 from 153 United States (US) primary care physicians, rheumatologists, and orthopedic surgeons. Each invited up to nine consecutive patients to rate their OA pain in the last week. Physicians provided demographic, clinical, and treatment information for patients, including nonpharmacologic therapies ever recommended, currently recommended over-the-counter (OTC) medications, and currently and ever prescribed medications for the management of OA. Findings for patients with mild (0─3), moderate (4─6), and severe current pain (7─10) were compared using appropriate statistics.

Results

Among the 841 patients (61% female; mean 65 years; 57% knee OA), 45% reported mild, 36% moderate, and 19% severe current OA pain. Current treatment modalities differed by pain severity (P<0.05). Most patients (70%) had been recommended nonpharmacologic therapy and 40% were currently recommended OTC medications. More patients with moderate (81%) or severe pain (78%) currently received prescription medications, with or without nonpharmacologic therapy, versus those with mild pain (67%). Overall, 47% of patients currently received just one prescription drug, while 49% had received one prescription drug ever. Nonsteroidal anti-inflammatory drugs (NSAIDs) were the most common current (58%) and ever received (88%) prescriptions. Current NSAID prescriptions were not associated with pain severity. Acetaminophen recommendations, opioid prescriptions (current and ever), and multiple prescription medications tried were numerically highest in the severe pain group (all P<0.05 by pain severity). In all groups, >80% of treatment switches were due to lack of efficacy.

Conclusion

Real-life treatment patterns for OA in the US are significantly associated with current patient-reported pain. Combining nonpharmacologic and pharmacologic treatments is common but higher pain ratings are associated with multiple failed prescription treatments. Current use of acetaminophen and opioids, but not NSAIDs, increases alongside pain severity.