Characteristics Associated With U.S. Outpatient Opioid Analgesic Prescribing and Gabapentinoid Co-Prescribing

Adjunctive Use of Gabapentinoids Increases Opioid Consumption Following One-Level to Three-Level Anterior Lumbar Interbody Fusion With Posterior Fixation: A Propensity Score-Matched Analysis

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To evaluate the impact of adjunctive gabapentinoid therapy on postoperative opioid consumption following one to three levels anterior lumbar interbody fusion (ALIF) with posterior fixation.

SUMMARY OF BACKGROUND DATA

Gabapentin and pregabalin are analogues of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) and are frequently used as adjuncts in multimodal anesthesia strategies for managing acute pain. However, the opioid-sparing effect of gabapentinoids in the context of spine surgery has yet to be consistently demonstrated.

MATERIALS AND METHODS

The PearlDiver database was queried from 2010 to 2021 for patients who underwent primary one to three levels ALIF with posterior fixation. Patients with opioid or gabapentinoid use within six months before index surgery were excluded. Patients with both gabapentinoid and opioid treatment were propensity score matched to patients with opioid-only treatment.

RESULTS

The propensity score-matching resulted in two equal groups of 2617 patients with and without adjunctive gabapentinoid treatment for pain management. Adjunctive use of gabapentinoids was associated with a modest 2.9% reduction in average morphine milligram equivalent (MME) per day [standardized mean difference (SMD): -1.33, 95% CI: -2.657 to -0.002, P =0.050]. However, this was accompanied by a 37.1% increase in the total duration of opioid prescriptions (SMD: 94.97, 95% CI: 56.976-132.967, P <0.001) and a 41.7% increase in total MME consumption per patient (SMD: 4817.23, 95% CI: 1864.410-7770.044, P =0.001). In addition, gabapentinoid use was associated with an increased risk of readmission due to pain [relative risk (RR): 1.10, 95% CI: 1.002-1.212, P =0.050] and the development of drug abuse (RR: 1.37, 95% CI: 1.016-1.833, P =0.046).

CONCLUSION

Despite the modest daily opioid-sparing effect observed, adjunctive gabapentinoid treatment appears to increase total opioid consumption due to prolonged opioid use and may compromise pain management in the context of ALIF with posterior fixation.

Opioid Treatment for Adults With and Without Systemic Autoimmune/Inflammatory Rheumatic Diseases: Analysis of 2006-2019 United States National Data

OBJECTIVES

This study compared opioid prescribing among ambulatory visits with systemic autoimmune/inflammatory rheumatic diseases (SARDs) or without and assessed factors associated with opioid prescribing in SARDs.

METHODS

This cross-sectional study used the National Ambulatory Medical Care Survey between 2006 and 2019. Adult (≥18 years) visits with a primary diagnosis of SARDs, including rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, or systemic lupus erythematosus were included in the study. Opioid prescribing was compared between those with vs without SARDs using multivariable logistic regression accounting for the complex survey design and adjusting for predisposing, enabling, and need factors within Andersen's Behavioral Model of Health Services Use. Another multivariable logistic regression examined the predictors associated with opioid prescribing in SARDs.

RESULTS

Annually, an average of 5.20 million (95% confidence interval [CI] 3.58-6.82) visits were made for SARDs, whereas 780.14 million (95% CI 747.56-812.72) visits were made for non-SARDs. The SARDs group was more likely to be prescribed opioids (22.53%) than the non-SARDs group (9.83%) (adjusted odds ratio [aOR] 2.65; 95% CI 1.68-4.18). Among the SARDs visits, patient age from 50 to 64 (aOR 1.95; 95% CI 1.05-3.65 relative to ages 18-49) and prescribing of glucocorticoids (aOR 1.75; 95% CI 1.20-2.54) were associated with an increased odd of opioid prescribing, whereas private insurance relative to Medicare (aOR 0.50; 95% CI 0.31-0.82) was associated with a decreased odds of opioid prescribing.

CONCLUSION

Opioid prescribing in SARDs was higher compared to non-SARDs. Concerted efforts are needed to determine the appropriateness of opioid prescribing in SARDs.

Standardization of continuous and categorical covariates in sparse penalized regressions

In sparse penalized regressions, candidate covariates of different units need to be standardized beforehand so that the coefficient sizes are directly comparable and reflect their relative impacts, which leads to fairer variable selection. However, when covariates of mixed data types (e.g. continuous, binary or categorical) exist in the same dataset, the commonly used standardization methods may lead to different selection probabilities even when the covariates have the same impact on or level of association with the outcome. In this paper, we propose a novel standardization method that targets at generating comparable selection probabilities in sparse penalized regressions for continuous, binary or categorical covariates with the same impact. We illustrate the advantages of the proposed method in simulation studies, and apply it to the National Ambulatory Medical Care Survey data to select factors related to the opioid prescription in the US.

Trajectories of pregabalin use and their association with longitudinal changes in opioid and benzodiazepine use

ABSTRACT

Concomitant use of pregabalin with opioids and/or benzodiazepines is common, despite the increased risks. However, clinical trials suggest pregabalin can have an opioid-sparing effect when treating acute postoperative pain. We explored how opioid and benzodiazepine use changed over time in people initiating pregabalin, using dispensing claims data for a 10% sample of Australians (2013-19). Among 142,776 people initiating pregabalin (median age = 61 years, 57% female), we used group-based trajectory modelling to identify 6 pregabalin dose trajectories in the first year postinitiation. Two trajectories involved discontinuation: after one dispensing (49%), and after 6 months of treatment (14%). Four trajectories involved persistent use with variable estimated median daily doses of 39 mg (16%), 127 mg (14%), 276 mg (5%), and 541 mg (2%). We quantified opioid and benzodiazepine use in the year before and after pregabalin initiation using generalised linear models. Over the study period, 71% were dispensed opioids and 34% benzodiazepines, with people on the highest pregabalin dose having highest rates of use. Opioid use increased postpregabalin initiation. Among people using both opioids and pregabalin, the geometric mean daily dose in oral morphine equivalents increased after pregabalin initiation in all trajectories, ranging from +5.9% (99% confidence interval 4.8%-7.0%) to +39.8% (99% confidence interval 38.3%-41.5%) in people on the highest daily pregabalin dose. Among people using both pregabalin and benzodiazepines, the dose remained constant over time for people in all trajectories. Notwithstanding its reputation as opioid-sparing, in this outpatient setting, we observed that people using opioids tended to use higher opioid daily doses after pregabalin initiation, especially those on high pregabalin doses.

Concurrent Use of Prescription Opioids and Gabapentinoids in Older Adults

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.

Association of clinical competence, specialty and physician country of origin with opioid prescribing for chronic pain: a cohort study

Background

Although little is known about why opioid prescribing practices differ between physicians, clinical competence, specialty training and country of origin may play a role. We hypothesised that physicians with stronger clinical competence and communication skills are less likely to prescribe opioids and prescribe lower doses, as do medical specialists and physicians from Asia.

Methods

Opioid prescribing practices were examined among international medical graduates (IMGs) licensed to practise in the USA who evaluated Medicare patients for chronic pain problems in 2014–2015. Clinical competence was assessed by the Educational Commission for Foreign Medical Graduates (ECFMG) Clinical Skills Assessment. Physicians in the ECFMG database were linked to the American Medical Association Masterfile. Patients evaluated for chronic pain were obtained by linkage to Medicare outpatient and prescription files. Opioid prescribing was measured within 90 days of evaluation visits. Prescribed dose was measured using morphine milligram equivalents (MMEs). Generalised estimating equation logistic and linear regression estimated the association of clinical competence, specialty, and country of origin with opioid prescribing and dose.

Results

7373 IMGs evaluated 65 012 patients for chronic pain; 15.2% received an opioid prescription. Increased clinical competence was associated with reduced opioid prescribing, but only among female physicians. For every 10% increase in the clinical competence score, the odds of prescribing an opioid decreased by 16% for female physicians (OR 0.84, 95% CI 0.75 to 0.94) but not male physicians (OR 0.99, 95% CI 0.92 to 1.07). Country of origin was associated with prescribed opioid dose; US and Canadian citizens prescribed higher doses (adjusted MME difference +3.56). Primary care physicians were more likely to prescribe opioids, but surgical and hospital-based specialists prescribed higher doses.

Conclusions

Clinical competence at entry into US graduate training, physician gender, specialty and country of origin play a role in opioid prescribing practices.

Sociodemographic and clinical correlates of gabapentin receipt with and without opioids among a national cohort of patients with HIV

Gabapentin is commonly prescribed for chronic pain, including to patients with HIV (PWH). There is growing concern regarding gabapentin's potential for harm, particularly in combination with opioids. Among PWH, we examined factors associated with higher doses of gabapentin receipt and determined if receipt varied by opioid use. We examined data from the Veterans Aging Cohort Study, a national prospective cohort including PWH, from 2002 through 2017. Covariates included prescribed opioid dose, self-reported past year opioid use, and other sociodemographic and clinical variables. We used multinomial logistic regression to determine independent predictors of gabapentin receipt. Among 3,702 PWH, 902 (24%) received any gabapentin during the study period at a mean daily dose of 1,469 mg. In the multinomial model, high-dose gabapentin receipt was associated with high-dose benzodiazepine receipt (adjusted odds ratio [aOR], 95% confidence interval [CI]= 1.53, [1.03-2.27]), pain interference (1.65 [1.39-1.95]), and hand or foot pain (1.81, [1.45-2.26]). High-dose gabapentin receipt was associated with prescribed high-dose opioids receipt (2.66 [1.95-3.62]) but not self-reported opioid use (1.03 [0.89-1.21]). PWH prescribed gabapentin at higher doses are more likely to receive high-dose opioids and high-dose benzodiazepines, raising safety concerns.

Co-prescription of gabapentinoids and opioids among adults with and without osteoarthritis in the United Kingdom between 1995 and 2017

Objectives

To produce national and regional estimates and trends for gabapentinoid–opioid co-prescribing rates in patients with OA, both in absolute terms and relative to matched controls without OA.

Methods

Using the UK Clinical Practice Research Datalink database we first constructed age–sex–practice–date 1:1 matched cohorts of patients aged ≥40 years with and without a new diagnosis of OA between 1995–2017 and estimated the relative incidence of a first gabapentinoid prescription. Incident gabapentinoid users in both cohorts were followed to estimate and compare the event rate of gabapentinoid–opioid co-prescription (prescription from both classes within the same 28-day window).

Results

The incidence of first gabapentinoid prescription was 3-fold higher in patients with OA than in matched controls [n = 215 357; incidence rate ratio (IRR) 2.93; 95% CI: 2.87, 3.00]. Among incident gabapentinoid users with OA (n = 27 374, median follow-up 3.9 years) the event rate of gabapentinoid–opioid co-prescription was 4.03 (4.02–4.05) per person-year. The rate was higher in OA patients classed as long-term gabapentinoid users (6.24; 6.22–6.26). These rates were significantly higher than in incident gabapentinoid users without OA [adjusted-IRR: 1.29 (1.28–1.30)]. This elevated risk was observed across age, sex, geographic regions, and calendar years, when restricted to strong opioids and to long-term gabapentinoid users, and when co-prescription was defined as within 14 days and same-day prescribing.

Conclusions

Patients with OA not only have a higher risk of being prescribed a gabapentinoid but, once prescribed a gabapentinoid, are also at greater risk of opioid co-prescription. Strict restriction of gabapentinoid–opioid co-prescription, and improved access to, and uptake of, effective non-pharmacological and surgical alternatives for OA are required.