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Powell D, Peet ED, Pacula RL. Understanding the rise in overdose deaths involving opioids and non-opioid prescription drugs in the United States. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023:104104. [PMID: 37422359 PMCID: PMC10770297 DOI: 10.1016/j.drugpo.2023.104104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/11/2023] [Accepted: 06/13/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Previous studies demonstrate that the reformulation of OxyContin in the U.S. in 2010 induced substitution to illicit opioids, causing illicit opioid markets to grow disproportionately fast in states more exposed to the reformulation. In this paper, we examine if this shift to the illicit market also led to a rise in polysubstance overdose deaths involving non-opioid prescription drugs, including gabapentinoids and "Z-drugs" and, separately, benzodiazepines. METHODS Using a difference-in-differences framework, the relationship between exposure to reformulation and overdose death rates including specific substances was studied in each year from 1999 to 2020 while accounting for fixed differences across states, common nationwide shocks, and state-level differences in pain reliever misuse prior to reformulation. Exposure to reformulation was measured as the pre-reformulation rate of OxyContin misuse. RESULTS Exposure to reformulation predicted growth in overdose deaths involving gabapentinoids and Z-drugs. There is less evidence that it predicted growth in overdose deaths involving benzodiazepines. However, for all substances, there is strong evidence that pre-reformulation OxyContin misuse rates predicted post-reformulation growth in overdose deaths concurrently involving synthetic opioids. DISCUSSION The opioid crisis has changed in radical ways. This study links a major supply-side intervention to the increase in polysubstance overdose deaths involving non-opioid prescription drugs, specifically gabapentinoids and Z-drugs.
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Affiliation(s)
- David Powell
- RAND Corporation, 1200 South Hayes Street, Arlington, VA 22202 USA.
| | - Evan D Peet
- RAND Corporation, 4570 Fifth Ave, Pittsburgh, PA 15213 USA
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Powell D, Shetty KD, Peet ED. Trends in overdose deaths involving gabapentinoids and Z-drugs in the United States. Drug Alcohol Depend 2023; 249:109952. [PMID: 37301069 DOI: 10.1016/j.drugalcdep.2023.109952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/10/2023] [Accepted: 05/27/2023] [Indexed: 06/12/2023]
Abstract
INTRODUCTION As policies have been implemented to limit access to prescription opioids, other drugs have been prescribed off-label, sometimes concurrently with opioids, to manage pain. There are concerns about the use of gabapentinoids and "Z-drugs" with opioids. As the opioid crisis transitions to illicit opioids and polysubstance use, little work quantifies the concurrent involvement of non-opioid prescription drugs and illicit opioids in overdose deaths. METHODS Data from the census of deaths in the United States for 1999-2020 were used to understand trends in deaths involving gabapentinoids/Z-drugs and opioid co-involvement. These trends were studied overall and by sex, race, age, and education. RESULTS Per capita overdose deaths involving gabapentinoids/Z-drugs increased almost continuously since 1999, averaging 15.8% annual growth. This rate increased to 32% in 2020, primarily due to overdoses involving synthetic opioids. Women typically had higher rates of overdose deaths involving both opioids and gabapentinoids/Z-drugs, though this disparity disappeared in 2020. White Americans and American Indians/Alaskan Natives historically had higher rates than other racial groups; however, Black Americans experienced over 60% annual growth in recent years. Low education groups have been disproportionately impacted. The age incidence tends to be older than overdoses involving opioids more generally. CONCLUSION Overdose deaths involving opioids and gabapentinoids/Z-drugs have tended to disproportionately affect women and older age groups compared to all opioid-involved overdoses. As deaths involving synthetic opioids likely reflect use of illicitly-obtained opioids, there may be less of a role for policies targeting the concurrent prescribing of gabapentinoids/Z-drugs with opioids to reduce these deaths.
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Affiliation(s)
- David Powell
- RAND, 1200 S. Hayes St, Arlington, VA22202, United States.
| | | | - Evan D Peet
- RAND, 4570 Fifth Ave, Pittsburgh, PA15213, United States
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Borrelli EP, Bratberg J, Hallowell BD, Kogut SJ. Benzodiazepine Dose Intensity among Patients Concurrently Prescribed Buprenorphine in Rhode Island. Subst Use Misuse 2023; 58:1038-1045. [PMID: 37129006 DOI: 10.1080/10826084.2023.2205492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Background: The concomitant use of buprenorphine and benzodiazepines has been linked to patient fatalities, with greater risk occurring with higher doses of benzodiazepines. We assessed benzodiazepine dose intensity among patients who were concurrently prescribed buprenorphine, as compared with patients prescribed benzodiazepines who were not receiving buprenorphine. Methods: We conducted a cross-sectional analysis of adult patients who received at least a 30-day supply of benzodiazepines during 2018, using data from the Rhode Island (RI) Prescription Drug Monitoring Program. Mean daily diazepam milligram equivalents (DME) were calculated overall and according to patient sex, age group, payment type, and RI county. Multivariable logistic regression analyses were conducted to assess the odds of higher-dose benzodiazepine utilization among patients with concurrent use of buprenorphine, as compared with patients not prescribed buprenorphine, adjusting for patient demographics. Results: Compared to patients prescribed benzodiazepines who were not receiving buprenorphine, those with concurrent buprenorphine utilization had a significantly higher mean DME/day (19.22, 95% CI: 18.70-19.74; vs 10.94, 95% CI: 10.93-10.95; p < 0.001). Patients who were prescribed benzodiazepines with concurrent utilization of buprenorphine also had a comparatively higher odds of a DME/day ≥15 (aOR: 2.86, 95% CI: 2.63-3.10), ≥20 DME/day (aOR: 2.98, 95% CI: 2.75-3.24), and ≥25 DME/day (aOR: 2.99, 95% CI: 2.65-3.18). Conclusion: Compared to patients prescribed benzodiazepines for at least 30 days who were not receiving buprenorphine, patients concurrently utilizing benzodiazepines and buprenorphine had more than twice the odds of higher dose benzodiazepine utilization. Future studies are needed to assess the relationship between benzodiazepine dose intensity, overdose outcomes, and treatment retention among patients receiving buprenorphine.
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Affiliation(s)
- Eric P Borrelli
- University of Rhode Island College of Pharmacy, Kingston, Rhode Island, USA
| | - Jeffrey Bratberg
- University of Rhode Island College of Pharmacy, Kingston, Rhode Island, USA
| | | | - Stephen J Kogut
- University of Rhode Island College of Pharmacy, Kingston, Rhode Island, USA
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Nguyen T, Meille G, Buchmueller T. Mandatory prescription drug monitoring programs and overlapping prescriptions of opioids and benzodiazepines: Evidence from Kentucky. Drug Alcohol Depend 2023; 243:109759. [PMID: 36621199 DOI: 10.1016/j.drugalcdep.2022.109759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 12/18/2022] [Accepted: 12/21/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND In response to the opioid epidemic, many states implemented mandates requiring providers to check prescription drug monitoring programs (PDMPs) before prescribing opioids. We examine how overlapping benzodiazepine and opioid prescriptions changed after Kentucky implemented a PDMP mandate in July 2012. METHODS We conducted an interrupted time series analysis using monthly data from Kentucky's PDMP from 2010 to 2016. Separate analyses were conducted for overlapping prescriptions from a single provider or multiple providers, and by sex and age group. We also conducted an individual-level longitudinal analysis that compared changes in utilization patterns after the mandate went into effect to changes in earlier periods during which the mandate was not in effect. RESULTS Kentucky's PDMP mandate was associated with an immediate 7.5 % decline in the rate of overlapping benzodiazepine and opioid prescriptions and a significant change in the trend from increasing to decreasing. Approximately half of the immediate effect in level terms was explained by decreases in overlapping prescriptions written by a single provider. Our longitudinal analysis suggests that over one year the mandate reduced initiation of overlapping prescriptions by 29.3 % and reduced continuation of overlapping prescriptions by 9.4 %. The effects of the policy were largest for women and men aged 36-50. CONCLUSIONS Though not the main rationale for the policy, Kentucky's PDMP mandate reduced overlapping prescriptions of benzodiazepines and opioids. Further efforts to reduce overlapping prescriptions should consider the effects on populations such as women over 50, who have high rates of overlapping prescriptions.
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Affiliation(s)
- Thuy Nguyen
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
| | - Giacomo Meille
- Agency for Healthcare Research and Quality, Rockville, MD, USA
| | - Thomas Buchmueller
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Stephen M. Ross School of Business, University of Michigan, Ann Arbor, MI, USA
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Young AM, Brown JL, Hunt T, Sprague Martinez LS, Chandler R, Oga E, Winhusen TJ, Baker T, Battaglia T, Bowers-Sword R, Button A, Fallin-Bennett A, Fanucchi L, Freeman P, Glasgow LM, Gulley J, Kendell C, Lofwall M, Lyons MS, Quinn M, Rapkin BD, Surratt HL, Walsh SL. Protocol for community-driven selection of strategies to implement evidence-based practices to reduce opioid overdoses in the HEALing Communities Study: a trial to evaluate a community-engaged intervention in Kentucky, Massachusetts, New York and Ohio. BMJ Open 2022; 12:e059328. [PMID: 36123106 PMCID: PMC9486330 DOI: 10.1136/bmjopen-2021-059328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Opioid-involved overdose deaths continue to surge in many communities, despite numerous evidence-based practices (EBPs) that exist to prevent them. The HEALing Communities Study (HCS) was launched to develop and test an intervention (ie, Communities That HEAL (CTH)) that supports communities in expanding uptake of EBPs to reduce opioid-involved overdose deaths. This paper describes a protocol for a process foundational to the CTH intervention through which community coalitions select strategies to implement EBPs locally. METHODS AND ANALYSIS The CTH is being implemented in 67 communities (randomised to receive the intervention) in four states in partnership with coalitions (one per community). Coalitions must select at least five strategies, including one to implement each of the following EBPs: (a) overdose education and naloxone distribution; expanded (b) access to medications for opioid use disorder (MOUD), (c) linkage to MOUD, (d) retention in MOUD and (e) safer opioid prescribing/dispensing. Facilitated by decision aid tools, the community action planning process includes (1) data-driven goal setting, (2) discussion and prioritisation of EBP strategies, (3) selection of EBP strategies and (4) identification of next steps. Following review of epidemiologic data and information on existing local services, coalitions set goals and discuss, score and/or rank EBP strategies based on feasibility, appropriateness within the community context and potential impact on reducing opioid-involved overdose deaths with a focus on three key sectors (healthcare, behavioural health and criminal justice) and high-risk/vulnerable populations. Coalitions then select EBP strategies through consensus or majority vote and, subsequently, suggest or choose agencies with which to partner for implementation. ETHICS AND DISSEMINATION The HCS protocol was approved by a central Institutional Review Board (Advarra). Results of the action planning process will be disseminated in academic conferences and peer-reviewed journals, online and print media, and in meetings with community stakeholders. TRIAL REGISTRATION NUMBER NCT04111939.
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Affiliation(s)
- April M Young
- College of Public Health, University of Kentucky, Lexington, Kentucky, USA
| | - Jennifer L Brown
- Department of Psychological Sciences, Purdue University, West Lafayette, Indiana, USA
| | - Timothy Hunt
- School of Social Work, Columbia University, New York, New York, USA
| | | | - Redonna Chandler
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland, USA
| | - Emmanuel Oga
- Center for Applied Public Health Research, Research Triangle Institute, Research Triangle Park, North Carolina, USA
| | - T John Winhusen
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Trevor Baker
- General Internal Medicine-CARE Unit, Boston Medical Center, Boston, Massachusetts, USA
| | - Tracy Battaglia
- Evans Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, MA, USA
| | - Rachel Bowers-Sword
- General Internal Medicine-CARE Unit, Boston Medical Center, Boston, Massachusetts, USA
| | - Amy Button
- Montefiore Hudson Valley Collaborative, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Laura Fanucchi
- College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Patricia Freeman
- College of Pharmacy, University of Kentucky, Lexington, Kentucky, USA
| | - LaShawn M Glasgow
- Community & Workplace Health, Research Triangle International, Research Triangle Park, North Carolina, USA
| | | | - Charles Kendell
- Franklin County Agency for Substance Abuse Policy Board, Frankfort, Kentucky, USA
| | - Michelle Lofwall
- College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Michael S Lyons
- Department of Emergency Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Maria Quinn
- Center for Behavioral Health, Holyoke Medical Center, Holyoke, Massachusetts, USA
| | - Bruce David Rapkin
- Epiemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Hilary L Surratt
- College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Sharon L Walsh
- College of Medicine, University of Kentucky, Lexington, Kentucky, USA
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Lin HC, Wang Z, Hu YH, Simon K, Buu A. Characteristics of statewide prescription drug monitoring programs and potentially inappropriate opioid prescribing to patients with non-cancer chronic pain: A machine learning application. Prev Med 2022; 161:107116. [PMID: 35750263 PMCID: PMC9307080 DOI: 10.1016/j.ypmed.2022.107116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 06/07/2022] [Accepted: 06/12/2022] [Indexed: 11/19/2022]
Abstract
Unnecessary/unsafe opioid prescribing has become a major public health concern in the U.S. Statewide prescription drug monitoring programs (PDMPs) with varying characteristics have been implemented to improve safe prescribing practice. Yet, no studies have comprehensively evaluated the effectiveness of PDMP characteristics in reducing opioid-related potentially inappropriate prescribing (PIP) practices. The objective of the study is to apply machine learning methods to evaluate PDMP effectiveness by examining how different PDMP characteristics are associated with opioid-related PIPs for non-cancer chronic pain (NCCP) treatment. This was a retrospective observational study that included 802,926 adult patients who were diagnosed NCCP, obtained opioid prescriptions, and were continuously enrolled in plans of a major U.S. insurer for over a year. Four outcomes of opioid-related PIP practices, including dosage ≥50 MME/day and ≥90 MME/day, days supply ≥7 days, and benzodiazepine-opioid co-prescription were examined. Machine learning models were applied, including logistic regression, least absolute shrinkage and selection operation regression, classification and regression trees, random forests, and gradient boost modeling (GBM). The SHapley Additive exPlanations (SHAP) method was applied to interpret model results. The results show that among 1,886,146 NCCP opioid-related claims, 22.8% had an opioid dosage ≥50 MME/day and 8.9% ≥90 MME/day, 70.3% had days supply ≥7 days, and 10.3% were when benzodiazepine was filled ≤7 days ago. GBM had superior model performance. We identified the most salient PDMP characteristics that predict opioid-related PIPs (e.g., broader access to patient prescription history, monitoring Schedule IV controlled substances), which could be informative to the states considering the redesign of PDMPs.
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Affiliation(s)
- Hsien-Chang Lin
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington, IN, United States of America.
| | - Zhi Wang
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington, IN, United States of America
| | - Yi-Han Hu
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington, IN, United States of America
| | - Kosali Simon
- O'Neil School of Public and Environmental Affairs, Indiana University, Bloomington, IN, United States of America
| | - Anne Buu
- Department of Health Promotion and Behavioral Sciences, School of Public Health, University of Texas Health Science Center, Houston, TX, United States of America
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Kuo YF, Liaw V, Yu X, Raji MA. Opioid and Benzodiazepine Substitutes: Impact on Drug Overdose Mortality in Medicare Population. Am J Med 2022; 135:e194-e206. [PMID: 35341773 PMCID: PMC9232943 DOI: 10.1016/j.amjmed.2022.02.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/09/2022] [Accepted: 02/10/2022] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Gabapentinoids (GABAs) and serotonergic drugs (selective serotonin reuptake inhibitors [SSRIs]/serotonin and norepinephrine reuptake inhibitors [SNRIs]) are increasingly being prescribed as potential substitutes to opioids and benzodiazepines (benzos), respectively, to treat co-occurring pain and anxiety disorders. The toxicities of these drug classes and their combinations are not well understood. METHODS We conducted a matched case-control study using 2013-2016 Medicare files linked to the National Death Index. Cases were enrollees who died from drug overdose. Controls were enrollees who died from other causes. Cases and controls were matched on patient characteristics and prior chronic conditions. Possession of any opioids, GABAs, benzos, and SSRIs/SNRIs in the month prior to death was defined as drug use. Combination drug use was defined as possessing at least 2 types of these prescriptions for an overlapping period of at least 7 days in the month prior to death. RESULTS Among 4323 matches, benzo possession was associated with twice the risk for drug overdose death in cases vs controls. Compared with opioid-benzo co-prescribing, combinations involving SSRIs/SNRIs and opioids (or GABAs) were associated with decreased risk (adjusted odds ratio 0.55; 95% confidence interval, 0.44-0.69 for opioids and SSRIs/SNRIs; adjusted odds ratio 0.59; 95% confidence interval, 0.44-0.79 for GABAs and SSRIs/SNRIs). Fatal drug overdose risk was similar in users of GABA-opioid, GABA-benzo, and opioid-benzo combinations. CONCLUSIONS Benzodiazepines, prescribed alone or in combination, were associated with an increased risk of drug overdose death. SSRIs/SNRIs were associated with lower risk of overdose death vs benzodiazepines. GABAs were not associated with decreased risk compared with opioids, raising concerns for GABAs' perceived relative safety.
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Affiliation(s)
- Yong-Fang Kuo
- Department of Internal Medicine and Sealy Center on Aging; Department of Preventive Medicine and Population Health; Institute for Translational Science; Office of Biostatistics, University of Texas Medical Branch, Galveston.
| | - Victor Liaw
- School of Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Xiaoying Yu
- Department of Preventive Medicine and Population Health; Office of Biostatistics, University of Texas Medical Branch, Galveston
| | - Mukaila A Raji
- Department of Internal Medicine and Sealy Center on Aging; Department of Preventive Medicine and Population Health
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Chen C, Lo-Ciganic WH, Winterstein AG, Tighe P, Wei YJJ. Concurrent Use of Prescription Opioids and Gabapentinoids in Older Adults. Am J Prev Med 2022; 62:519-528. [PMID: 34802816 PMCID: PMC9426287 DOI: 10.1016/j.amepre.2021.08.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Concurrent use of prescription opioids with gabapentinoids may pose risks of serious drug interactions. Yet, little is known about the trends in and patient characteristics associated with concurrent opioid-gabapentinoid use among older Medicare opioid users with chronic noncancer pain. METHODS A cross-sectional study was conducted among Medicare older beneficiaries (aged ≥65 years) with chronic noncancer pain who filled ≥1 opioid prescription within 3 months after a randomly selected chronic noncancer pain diagnosis (index date) in a calendar year between 2011 and 2018. Patient characteristics were measured in the 6-month baseline before the index date, and concurrent opioid-gabapentinoid use for ≥1 day was measured in the 3-month follow-up after the index date. Multivariable modified Poisson regression hwas used to assess the trends and characteristics of concurrent opioid-gabapentinoid use. Analyses were conducted from January to June 2021. RESULTS Among 464,721 eligible older beneficiaries with chronic noncancer pain and prescription opioids, the prevalence of concurrent opioid-gabapentinoid use increased from 17.0% in 2011 to 23.5% in 2018 (adjusted prevalence ratio=1.48, 95% CI=1.45, 1.53). Concurrent users versus opioid-only users tended to be non-Black, low-income subsidy recipients, and Southern residents. The clinical factors associated with concurrent opioid-gabapentinoid use included having a diagnosis of neuropathic pain, polypharmacy, and risk factors for opioid-related adverse events. CONCLUSIONS Concurrent opioid-gabapentinoid use among older Medicare beneficiaries with chronic noncancer pain and prescription opioids has increased significantly between 2011 and 2018. Future studies are warranted to investigate the impact of concurrent use on outcomes in older patients. Interventions that reduce inappropriate concurrent use may target older patients with identified characteristics.
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Affiliation(s)
- Cheng Chen
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida; Department of Epidemiology, College of Public Health and Health Professions & College of Medicine, University of Florida, Gainesville, Florida
| | - Patrick Tighe
- Department of Anesthesiology, College of Medicine, University of Florida, Gainesville, Florida
| | - Yu-Jung J Wei
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida.
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Pickens CM, Hoots BE, Casillas SM, Scholl L. Prevalences of and characteristics associated with single- and polydrug-involved U.S. Emergency Department Visits in 2018. Addict Behav 2022; 125:107158. [PMID: 34717272 PMCID: PMC9559594 DOI: 10.1016/j.addbeh.2021.107158] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 09/16/2021] [Accepted: 10/17/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Nonfatal and fatal drug overdoses have recently increased. There are limited data describing the range of illicit, prescribed, and over-the-counter drugs involved in overdoses presenting to U.S. emergency departments (EDs). METHODS Using 2018 Healthcare Cost and Utilization Project (HCUP) Nationwide ED Sample (NEDS) data, we calculated weighted counts and percentages by drug among overdose-related ED visits. Overdose-related ED visits were those having an International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) drug poisoning code falling under parent codes T36-T50 (codes involving alcohol were not explicitly queried). We identified the top 30 mutually exclusive polydrug combinations and compared characteristics of visits by polydrug status. RESULTS In 2018, 908,234 ED visits had a T36-T50 drug poisoning code. The most frequently reported drugs involved were opioids (30.3% of visits; heroin: 15.2%), benzodiazepines (11.0%), stimulants (7.9%), other/unspecified antidepressants (7.1%), 4-aminophenol derivatives (6.6%), and other/unspecified drugs, medicaments, and biological substances (11.8%). Overdose was uncommon for most other drug classes (e.g., antibiotics). Polydrug visits were more likely to involve females (prevalence ratio [PR]: 1.14, 95% confidence interval [CI]: 1.12-1.16), be coded intentional self-harm (PR: 1.81, 95% CI: 1.77-1.85), and result in hospitalization (PR: 1.84, 95% CI: 1.79-1.89) or death (PR: 1.37, 95% CI: 1.22-1.53) compared to single-drug overdose-related visits. Benzodiazepines, opioids, and/or stimulants were most frequently involved in polydrug overdoses. CONCLUSION Opioids, benzodiazepines, and stimulants were most commonly reported in both single-drug and polydrug overdose-involved ED visits. Other drugs involved in overdoses included antidepressants and 4-aminophenol derivatives. Jurisdictions can use data on drugs involved in overdoses to better tailor prevention strategies to emerging needs.
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Borrelli EP, Bratberg J, Hallowell BD, Greaney ML, Kogut SJ. Application of a diazepam milligram equivalency algorithm to assess benzodiazepine dose intensity in Rhode Island in 2018. J Manag Care Spec Pharm 2021; 28:58-68. [PMID: 34949119 PMCID: PMC10373022 DOI: 10.18553/jmcp.2022.28.1.58] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Benzodiazepines are indicated for the treatment of many conditions, such as anxiety disorders, muscle spasms, alcohol withdrawal, agitation, movement disorders, and epilepsy, and are one of the most frequently prescribed medication classes. This class of medication has important safety considerations, including an increased risk of dependence and addiction, falls, and death from opioid overdose. Although benzodiazepine safety and prescribing encompasses a rich and important research area, there is a lack of pharmacoepidemiologic literature addressing benzodiazepine dosing intensity in real-world settings. OBJECTIVE: To develop and apply a standardized benzodiazepine milligram equivalency conversion algorithm and assess the dose intensity of benzodiazepine use in Rhode Island (RI) in 2018. METHODS: A systematic literature review was conducted to identify the most commonly used benzodiazepine equivalency values. We then conducted a cross-sectional analysis of 2018 data from the RI Prescription Drug Monitoring Program (PDMP) to calculate the mean daily diazepam milligram equivalency (DME) based on a patient's most recent dispensing. A multivariable logistic regression analysis was conducted to determine the association between higher benzodiazepine doses (≥ 15 DME/day) and recipient characteristics, including concurrent use of opioids or stimulants. RESULTS: We identified 143,026 patients who received at least 1 prescription for a benzodiazepine in RI in 2018. The mean (SD) daily DME was 10.60 (9.05), and 26.2% of individuals had a mean DME per day of at least 15. Approximately 14% (n = 20,168) of patients prescribed a benzodiazepine had concurrent use with a prescription opioid, and 6.7% (n = 9,547) had concurrent use with a prescription stimulant. Females had a 28% lower adjusted odds of receiving a benzodiazepine dose of at least 15 DME per day compared with males (adjusted odds ratio [aOR] = 0.72, 95% CI = 0.70-0.73). The adjusted odds of receiving a benzodiazepine prescription of at least 15 DME per day was lower among the younger (aged 18-34 years) and older age groups (aged 65 years and older) compared with patients aged 35-64 years. Compared with commercial insurance, all other forms of payment had significantly higher adjusted odds of a daily benzodiazepine dose of at least 15 DME per day. The adjusted odds receiving a daily DME of at least 15 was 67% higher among those who also received a concurrent pharmacy dispensing for an opioid and 84% higher among those who also received a concurrent dispensing for a stimulant drug (aOR = 1.67, 95% CI = 1.61-1.72; aOR = 1.84, 95% CI = 1.76-1.93, respectively). CONCLUSIONS: Individuals aged 35-64 years with Medicaid insurance and those aged under 65 years with Medicare were more likely to be prescribed a benzodiazepine of at least 15 DME per day. Higher benzodiazepine DMEs were also dispensed to patients who concurrently used prescription opioids or stimulants who may be at increased risk of medication-related harm. We advocate for routine measurement of benzodiazepine dose intensity as a risk reduction strategy. DISCLOSURES: No funding supported this study. The authors have no conflicts of interest to disclose. The content and results of this study are solely the responsibility of the authors and do not necessarily represent the official views of the Rhode Island Department of Health. Kogut is partially supported by Institutional Development Award Numbers U54GM115677 and P20GM125507 from the National Institute of General Medical Sciences of the National Institutes of Health, which funds Advance Clinical and Translational Research (Advance-CTR) and the RI Lifespan Center of Biomedical Research Excellence (COBRE) on Opioids and Overdose, respectively. The content of this study is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Contents of this study were presented as a poster presentation at AMCP 2019 Nexus; October 29-November 1, 2019; National Harbor, MD.
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Affiliation(s)
| | | | | | - Mary L Greaney
- University of Rhode Island College of Health Sciences, Kingston
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11
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Chua KP, Brummett CM, Ng S, Bohnert ASB. Association Between Receipt of Overlapping Opioid and Benzodiazepine Prescriptions From Multiple Prescribers and Overdose Risk. JAMA Netw Open 2021; 4:e2120353. [PMID: 34374769 PMCID: PMC8356065 DOI: 10.1001/jamanetworkopen.2021.20353] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
IMPORTANCE The receipt of overlapping opioid and benzodiazepine prescriptions is associated with increased overdose risk. It is unknown whether this increase in risk varies when overlapping prescriptions are written by multiple prescribers vs 1 prescriber. OBJECTIVE To evaluate the association between receipt of overlapping opioid and benzodiazepine prescriptions from multiple prescribers and overdose risk. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted using 2017 to 2018 claims from the Optum deidentified Clinformatics Data Mart. Participants were patients with private insurance or Medicare Advantage aged 12 years or older with overlapping opioid and benzodiazepine prescriptions. Data were analyzed from March through November 2020. EXPOSURES For each patient, person-days on which opioid and benzodiazepine prescriptions overlapped were identified. The exposure was whether these prescriptions were written by multiple prescribers vs 1 prescriber. MAIN OUTCOMES AND MEASURES The outcome was a treated overdose, defined as the occurrence of 1 or more claims containing a diagnosis code for opioid or benzodiazepine poisoning on a person-day of opioid-benzodiazepine overlap. The association between exposure and outcome at the person-day level was estimated using logistic regression, controlling for opioid and benzodiazepine prescribing patterns, demographics, and comorbidities. The average marginal effect (AME) of the exposure, defined as the absolute difference in the probability of a treated overdose if all person-days of overlap involved prescriptions from multiple prescribers vs 1 prescriber, was calculated. RESULTS Among 529 053 patients, the mean (SD) age was 61.2 (15.6) years and 350 857 (66.3%) were female patients. Mean (SD) follow-up was 198.7 (249.8) days. During follow-up, overdose occurred on 1 or more person-days of opioid-benzodiazepine overlap for 2288 patients (0.4%, or 1 in 231 patients). There were 52 989 316 person-days of opioid-benzodiazepine overlap. Among 19 895 457 person-days (37.5%) involving prescriptions from multiple prescribers, there were 1390 overdoses (7.0 per 100 000 person-days), and among 33 093 859 person-days (62.5%) involving prescriptions from 1 prescriber, there were 1302 overdoses (3.9 per 100 000 person-days). Overdose risk was increased 1.8-fold (95% CI, 1.6-1.9) on person-days of overlap involving prescriptions from multiple prescribers vs 1 prescriber. The association between multiple prescribers and increased risk of overdose persisted in adjusted analyses (adjusted odds ratio, 1.20; 95% CI, 1.10-1.31; AME, 0.91 per 100 000 person-days of overlap; 95% CI, 0.46-1.37). CONCLUSIONS AND RELEVANCE This study found that among patients already at increased risk of overdose owing to concurrent treatment with opioids and benzodiazepines, overdose risk was increased further when multiple prescribers were responsible for this treatment regimen compared with 1 prescriber. This increased risk was not fully accounted for by differences in prescribing patterns, demographics, or comorbidities. This finding suggests that other factors, such as poor care coordination, may be associated with the increase in risk.
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Affiliation(s)
- Kao-Ping Chua
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
| | - Chad M. Brummett
- Division of Pain Medicine, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
- Michigan Opioid Prescribing Engagement Network, Ann Arbor
| | - Sophia Ng
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor
| | - Amy S. B. Bohnert
- Division of Pain Medicine, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
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12
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Bannon MJ, Lapansie AR, Jaster AM, Saad MH, Lenders J, Schmidt CJ. Opioid deaths involving concurrent benzodiazepine use: Assessing risk factors through the analysis of prescription drug monitoring data and postmortem toxicology. Drug Alcohol Depend 2021; 225:108854. [PMID: 34182374 PMCID: PMC8288032 DOI: 10.1016/j.drugalcdep.2021.108854] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 05/21/2021] [Accepted: 05/21/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND A high proportion of opioid drug deaths involve concurrent benzodiazepine use. To reduce the risk of drug overdose, various prescription drug monitoring programs have been implemented. This study examined the impact of concurrent benzodiazepine use on opioid-related deaths, and the utility of the Michigan Automated Prescription System (MAPS) in predicting risk of opioid death. METHODS Wayne County Medical Examiner's Office cases from 2018 were examined in terms of MAPS data and MAPS-derived drug risk scores, as well as postmortem toxicology. Opioid death cases with concurrent benzodiazepine use were compared to non-drug deaths. RESULTS For cases with a MAPS history for 6 months preceding death, the incidence of opioid prescriptions filled did not differ between groups. In contrast, significantly more opioid death cases had filled a benzodiazepine prescription; alprazolam prescription was the single best predictor of opioid drug death. Groups differed in MAPS-calculated drug risk scores, though these were less predictive of opioid death than some individual measures of prescription drug use. In terms of postmortem toxicology, fentanyl was the best discriminator between cohorts, with significant associations seen for morphine, benzodiazepine, or cocaine use. Similar results were obtained in the subset of subjects filling a prescription within a month of death, except that MAPS risk scores no longer predicted drug deaths. CONCLUSION MAPS scores did not adequately predict risk of opioid-related death. Contrary to expectations, prescription opioid use was not correlated with opioid-related death, whereas concurrent use of opioids and benzodiazepines represented a highly significant risk factor.
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Affiliation(s)
- Michael J. Bannon
- Department of Pharmacology, Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI, 48201, USA,Correspondence: Michael J Bannon PhD, Department of Pharmacology, Wayne State University School of Medicine, 6374 Scott Hall, 540 E Canfield St, Detroit, MI, 48201
| | - Allyson R. Lapansie
- Department of Pharmacology, Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI, 48201, USA
| | - Alaina M. Jaster
- Department of Pharmacology, Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI, 48201, USA
| | - Manal H. Saad
- Department of Pharmacology, Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI, 48201, USA
| | - Jayna Lenders
- Department of Pharmacology, Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI, 48201, USA
| | - Carl J. Schmidt
- Department of Pathology, University of Michigan School of Medicine, 2800 Plymouth Rd, Bldg. 35, Ann Arbor, MI 48109, USA,Wayne County Medical Examiner’s Office, 1300 E Warren Ave, Detroit, MI 48207, USA
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13
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Michaels NL, Spiller HA, Badeti J, Sheftall AH, Funk AR, Smith GA. Benzodiazepine exposures among women of reproductive age in the US, 2004-2018. Hum Exp Toxicol 2021; 40:1807-1816. [PMID: 33906473 DOI: 10.1177/09603271211013431] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Benzodiazepines, often used to treat anxiety, insomnia, and other conditions, are prescribed more frequently to women than men, and emergency department visits and overdose deaths involving benzodiazepines have increased significantly among women in recent years. This study describes characteristics and trends associated with benzodiazepine exposures among women of reproductive age (15-49 years old) that were reported to United States poison control centers from 2004 through 2018. The National Poison Data System recorded 258,370 first-ranked benzodiazepine exposures among women 15-49 years old during the study period. More than one-half (56.9%) of exposures involved a single-substance and one-third (34.0%) occurred among women 20-29 years old. The majority were categorized as "intentional, suspected suicide" (73.2%) or "intentional" (12.9%). Exposures frequently resulted in admission to a psychiatric facility (20.6%), critical care unit (18.1%), or non-critical care unit (9.3%). Twenty percent of cases resulted in a serious medical outcome, including 205 deaths. The substantial percentage of benzodiazepine exposures among women of reproductive age that were intentional and associated with suicide attempts or suicide deaths indicate that increased prevention efforts are needed to address this issue.
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Affiliation(s)
- N L Michaels
- Center for Injury Research and Policy, The Abigail Wexner Research Institute of 2650Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - H A Spiller
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.,Central Ohio Poison Center, Columbus, OH, USA
| | - J Badeti
- Center for Injury Research and Policy, The Abigail Wexner Research Institute of 2650Nationwide Children's Hospital, Columbus, OH, USA
| | - A H Sheftall
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.,Center for Innovation in Pediatric Practice at the Abigail Wexner Research Institute of 2650Nationwide Children's Hospital, Columbus, OH, USA
| | - A R Funk
- Central Ohio Poison Center, Columbus, OH, USA
| | - G A Smith
- Center for Injury Research and Policy, The Abigail Wexner Research Institute of 2650Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
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14
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On the rapid and non-destructive approach for barbiturates, benzodiazepines, and phenothiazines determination and differentiation using spectral combination analysis and chemometric methods. Microchem J 2021. [DOI: 10.1016/j.microc.2020.105853] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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15
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Abstract
ABSTRACT Despite the lack of evidence on the long-term effectiveness of benzodiazepines and their potential harmful effects, prescriptions of the drug have significantly increased in the US over the past decade. This article reviews best practices regarding primary care benzodiazepine prescriptions and how providers can best prevent and treat benzodiazepine use disorder and other harmful effects.
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Borrelli EP, Morphis B, Youssef R, Chambers LC, Hallowell BD, Bratberg J, Kogut SJ. Concurrent Utilization of Prescription Opioids and Non-opioid Controlled Substances: Rhode Island Prescription Drug Monitoring Program, 2018. RHODE ISLAND MEDICAL JOURNAL (2013) 2020; 103:53-58. [PMID: 33003681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To estimate the prevalence of concurrent prescription opioid and non-opioid controlled substance use in Rhode Island (RI). METHODS We conducted a cross sectional observational study using data from the RI Prescription Drug Monitoring Program on controlled substance prescriptions dispensed in 2018. We estimated the prevalence of concurrent use of other prescribed controlled substances among adults who received at least one opioid prescription. RESULTS In 2018, 142,692 RI adult residents received at least one opioid prescription, of whom 25.1% (99% confidence interval [CI]: 24.8-25.4) were concurrently prescribed at least one other controlled substance, including benzodiazepines (17.0%, 99% CI: 16.8-17.3), medications for insomnia (4.0%, 99% CI: 3.9-4.2), and stimulants (3.8%, 99% CI: 3.6-3.9). CONCLUSION The concurrent use of prescription opioids and other prescribed controlled substances is common. Our findings suggest an urgent need to implement focused initiatives to address controlled substance polypharmacy to reduce the risk of overdose.
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Affiliation(s)
- Eric P Borrelli
- PhD Candidate in Pharmaceutical Sciences, Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island
| | - Blake Morphis
- Director of Analytic Services, Healthcentric Advisors
| | - Rouba Youssef
- Health Information Analyst, Healthcentric Advisors. (during time of study)
| | | | | | - Jeffrey Bratberg
- Clinical Professor, Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island
| | - Stephen J Kogut
- Professor of Pharmacy Practice; Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island
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Delcher C, Pauly N, Moyo P. Advances in prescription drug monitoring program research: a literature synthesis (June 2018 to December 2019). Curr Opin Psychiatry 2020; 33:326-333. [PMID: 32250984 PMCID: PMC7409839 DOI: 10.1097/yco.0000000000000608] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Nearly every U.S. state operates a prescription drug monitoring program (PDMP) to monitor dispensing of controlled substances. These programs are often considered key policy levers in the ongoing polydrug epidemic. Recent years have seen rapid growth of peer-reviewed literature examining PDMP consultation and the impacts of these programs on diverse patient populations and health outcomes. This literature synthesis presents a review of studies published from June 2018 to December 2019 and provides relevant updates from the perspective of three researchers in this field. RECENT FINDINGS The analyzed studies were primarily distributed across three overarching research focus areas: outcome evaluations (n = 29 studies), user surveys (n = 23), and surveillance (n = 22). Identified themes included growing awareness of the unintended consequences of PDMPs on access to opioids, effects on benzodiazepines and stimulant prescribing, challenges with workflow integration across multiple specialties, and new opportunities for applied data science. SUMMARY There is a critical gap in existing PDMP literature assessing how these programs have impacted psychiatrists, their prescribing behaviors, and their patients. Although PDMPs have improved population-level monitoring of controlled substances from medical sources, their role in responding to a drug epidemic shifting to illicitly manufactured drugs is under scrutiny.
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Affiliation(s)
- Chris Delcher
- Institute for Pharmaceutical Outcomes and Policy, University of Kentucky College of Pharmacy, Lexington, Kentucky
| | - Nathan Pauly
- Department of Health Policy Management and Leadership, West Virginia University School of Public Health, Morgantown, West Virginia
| | - Patience Moyo
- Department of Health Services, Policy, and Practice, Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
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Wright SL. Limited Utility for Benzodiazepines in Chronic Pain Management: A Narrative Review. Adv Ther 2020; 37:2604-2619. [PMID: 32378069 PMCID: PMC7467435 DOI: 10.1007/s12325-020-01354-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Controversy and uncertainty exist about the use of benzodiazepine receptor agonists (BZRAs) in pain management. This article curates available research to determine the appropriate role of BZRAs in the course of pain management, and how prescribers might address these challenges. METHODS A narrative review was performed to determine the appropriate role of BZRAs in pain management and to develop practice recommendations. Publications were identified by a search of PubMed, references of retrieved reports, guidelines, and the author's personal files. RESULTS BZRAs were found to have analgesic benefit for two pain conditions: burning mouth syndrome and stiff person syndrome. Absence of research, heterogeneity of trials, and small sample sizes precluded drawing conclusions about efficacy of BZRAs for the other 109 pain conditions explored. Data supports the use of BZRAs to treat co-occurring insomnia and anxiety disorders but only when alternatives are inadequate and only for short periods of time (2-4 weeks). The utility of BZRAs is limited by loss of efficacy that may be seen with continued use and adverse reactions including physiologic dependence which develops in 20-100% of those who take these agents for more than a month. CONCLUSIONS BZRAs are often used inappropriately in pain management. Their initiation and duration of use should be limited to a narrow range of conditions. When prescribed for 4 weeks or more, patients should be encouraged to discontinue them through a supported, slow tapering process that may take 12-18 months or longer.
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Affiliation(s)
- Steven L Wright
- Alliance for Benzodiazepine Best Practices, Littleton, CO, USA.
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Maust DT, Lin LA, Goldstick JE, Haffajee RL, Brownlee R, Bohnert ASB. Association of Medicare Part D Benzodiazepine Coverage Expansion With Changes in Fall-Related Injuries and Overdoses Among Medicare Advantage Beneficiaries. JAMA Netw Open 2020; 3:e202051. [PMID: 32242907 PMCID: PMC7125434 DOI: 10.1001/jamanetworkopen.2020.2051] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE Benzodiazepines, which are associated with safety-related harms for older adults, were not covered when the US Medicare Part D prescription drug benefit began. Coverage was extended to benzodiazepines in 2013. OBJECTIVE To examine whether the expansion of benzodiazepine coverage among Medicare Advantage (MA) beneficiaries was associated with increases in fall-related injuries or overdoses among older adults. DESIGN, SETTING, AND PARTICIPANTS This ecological study used interrupted time-series with comparison-series analyses of MA claims data from 4 635 312 age-eligible MA beneficiaries and 940 629 commercially insured individuals (comparison group) stratified by age (65-69, 70-74, 75-79, and ≥80 years) to separately compare trends in fall-related injury and overdose before (January 1, 2010, to December 31, 2012) and after (January 1, 2013, to December 31, 2015) coverage expansion for benzodiazepines. Data analysis was performed from September 1, 2018, to August 31, 2019. EXPOSURES Expansion of benzodiazepine coverage in Medicare Part D in 2013. MAIN OUTCOMES AND MEASURES Monthly rate of fall-related injury and overdose. RESULTS In 2012 (the year before the policy change), women constituted 57.5% of the MA group and 47.4% of the comparison group. A total of 25.8% of individuals in the MA group were aged 65 to 69 years, and 29.3% were 80 years or older (mean [SD], 75.1 [6.4] years); 56.7% of individuals in the comparison group were aged 65 to 69 years, and 15.1% were 80 years or older (mean [SD] age, 70.9 [6.5] years). In the MA group, 4 635 312 individuals contributed 156 754 749 person-months from 2010 through 2015; in the comparison group, 940 629 individuals contributed 25 104 534 person-months. After coverage of benzodiazepines began, the rate (ie, slope) of fall-related injury among MA beneficiaries increased from before to after coverage among all age groups. Compared with the comparison group, the increase in rate was statistically significant for those 80 years or older (rate changes for the MA vs comparison groups: 0.12 [95% CI, 0.07 to 0.17] vs -0.01 [95% CI, -0.11 to 0.10]; P = .04 for interaction). The overdose trend changed from decreasing to increasing among MA beneficiaries after coverage for all age groups, with a statistically significant increase compared with the comparison group among those aged 65 to 69 years (rate changes for the MA vs comparison groups: 0.23 [95% CI, 0.17 to 0.30] vs 0.02 [95% CI, -0.06 to 0.11]; P < .001 for interaction) and among those 80 years or older (rate changes for the MA vs comparison groups: 0.07 [95% CI, 0.00 to 0.14] vs -0.20 [95% CI, -0.35 to -0.05]; P = .002 for interaction). Results among MA beneficiaries were consistent when stratified by sex and when limited to those prescribed opioids. CONCLUSIONS AND RELEVANCE Medicare's expansion of benzodiazepine coverage may have been associated with increases in the rates of overdose among adults ages 65 to 69 years and in the rates of overdose and fall-related injury among those 80 years or older.
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Affiliation(s)
- Donovan T. Maust
- Injury Prevention Center, University of Michigan, Ann Arbor
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Lewei Allison Lin
- Injury Prevention Center, University of Michigan, Ann Arbor
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Jason E. Goldstick
- Injury Prevention Center, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor
| | - Rebecca L. Haffajee
- Injury Prevention Center, University of Michigan, Ann Arbor
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
- Economics, Sociology, and Statistics Department, RAND Corporation, Boston, Massachusetts
| | - Rebecca Brownlee
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor
| | - Amy S. B. Bohnert
- Injury Prevention Center, University of Michigan, Ann Arbor
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
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