Relationship of opioid prescription sales and overdoses, North Carolina

Effects of Opioid-Limiting Legislation in the State of Ohio on Opioid Prescriptions After Shoulder Arthroscopy

Background

Recent studies have shown that legislation regulating opioid prescriptions in the United States has been successful in reducing the morphine milligram equivalent (MME) prescribed after certain orthopaedic procedures.

Purpose

To (1) determine the effect of Ohio's legislation limiting opioid prescriptions after shoulder arthroscopy and (2) identify risk factors associated with prolonged opioid use and increased postoperative opioid dosing.

Study Design

Cohort study; Level of evidence, 3.

Methods

We reviewed the data of patients who underwent shoulder arthroscopy between January 1, 2016, and March 31, 2020. Patients were classified according to the date of legislation passage (August 31, 2017) as before legislation (PRE) or on/after legislation (POST). Patients were also classified based on the number of opioid prescriptions filled within 30 days of surgery as opioid-tolerant (at least 1 prescription) or opioid-naïve (zero prescriptions). We recorded patient characteristics, medical comorbidities, and surgical details, as well as the number of opioid prescriptions, MME per prescription from 30 days preoperatively to 90 days postoperatively, and the number of gamma-aminobutyric acid (GABA) analogues and benzodiazepine prescriptions from 30 days preoperatively to the date of surgery. Differences between cohorts were compared with the Fisher exact test and Wilcoxon test. A covariate-adjusted regression analysis was used to evaluate risk factors associated with increased postoperative opioid dosing.

Results

Overall, 279 patients (n = 97 PRE; n = 182 POST; n = 42 opioid-tolerant; n = 237 opioid-naïve) were included in the final analysis. There was a significant reduction in the cumulative MME prescribed in the immediate (0-7 days) postoperative period (PRE, 450 MME vs POST, 315 MME), the first 30 postoperative days (PRE, 590 MME vs POST, 375 MME), and the first 90 postoperative days (PRE, 600 MME vs POST, 420 MME) (P < .001 for all). The opioid-tolerant cohort had higher MME at every time point in the postoperative period (P < .001). Consumption of preoperative opioid (β = 1682.5; P < .001), benzodiazepine (β = 468.09; P < .001), and GABA analogue (β = 251.37; P = .04) was associated with an increase in the cumulative MME prescribed.

Conclusion

Opioid prescription-limiting legislation in Ohio significantly reduced the cumulative MME prescribed in the first 30 days postoperatively for both opioid-naïve and opioid-tolerant patients after shoulder arthroscopy. Consumption of opioids, benzodiazepines, and GABA analogues preoperatively was associated with increased postoperative opioid dosage.

Opioid utilization after lower extremity amputation for peripheral vascular disease and discharge prescribing recommendations

OBJECTIVES

Opioids are commonly used for pain control after lower extremity amputations (LEA)-below the knee amputations (BKA) and above the knee amputations (AKA). Well-defined benchmarks for prescription requirements after amputation are deficient. This analysis evaluated opioid utilization after amputation to identify high-risk patients and provide recommendations for post-hospitalization opioid prescriptions at discharge.

METHODS

Patients undergoing LEA (2008-2016) with identified peripheral vascular disease were selected from Cerner's Health Facts® database using ICD-9 and 10 diagnosis and procedure codes. Patient demographics, disease severity, comorbidities, and hospital characteristics were evaluated. Post-operative opioid medications administered intravenously and orally during the hospital stay were identified from the data and converted to Morphine Milligram Equivalent per day (MME/d) for an evaluation and comparison during the index hospitalization. Descriptive statistics were used to report continuous and dichotomous variables. Dichotomous variables are reported as n (%) and continuous variables are reported as mean ± standard deviation (SD). Chi-square and T-tests were used as appropriate.

RESULTS

2399 patients who underwent AKA or BKA with peripheral vascular disease were evaluated. Sixty-three percent of the cohort was male, 67% Caucasian, and 42% married, and 58% had a Charlson index >3. The majority of patients had an average length of hospital stay of 5.7 days (M = 5.72, SD = 4.56). Patient groups that used significantly higher MME/d in the early postop period included: BKA (29.2 vs 20.7, p = 0.006), males (62.6 vs 54.0, p < 0.0001), Caucasians (64.3 vs 44.7, p < 0.0001), younger patients (69.6 vs 54.0, p < 0.0001), and those at non-training institutions (66.7 vs 56.7, p < 0.0001). Patients whose hospital stay was greater than 6 days were found to have increased opioid utilization likely secondary to index complications. For those discharged by post-operative day 7, the mean MME utilized on postop day 1 was 59.5 and decreased to a mean MME/d utilization prior to discharge of 17.6.

CONCLUSIONS

This analysis demonstrates that younger patients, males, patients with BKAs, and those who receive amputations for vascular disease at non-training institutions have higher post-operative opioid utilization during the hospital stay. At the time of discharge, patients utilized an average of 17.6 MME/d which equates to approximately three hydrocodone/acetaminophen 5/325 mg tablets per day. Based on these findings, vascular surgeons are likely over prescribing opioids at discharge and must be cognizant of appropriate dosing quantities. Prescriptions at discharge should reflect the daily utilization described from this analysis and tapered to avoid chronic utilization, overdose, and possible death.

A Bayesian Spatio-temporal Model to Optimize Allocation of Buprenorphine in North Carolina

The opioid epidemic is an ongoing public health crisis. In North Carolina, overdose deaths due to illicit opioid overdose have sharply increased over the last 5-7 years. Buprenorphine is a U.S. Food and Drug Administration approved medication for treatment of opioid use disorder and is obtained by prescription. Prior to January 2023, providers had to obtain a waiver and were limited in the number of patients that they could prescribe buprenorphine. Thus, identifying counties where increasing buprenorphine would yield the greatest overall reduction in overdose death can help policymakers target certain geographical regions to inform an effective public health response. We propose a Bayesian spatiotemporal model that relates yearly, county-level changes in illicit opioid overdose death rates to changes in buprenorphine prescriptions. We use our model to forecast the statewide count and rate of illicit opioid overdose deaths in future years, and we use nonlinear constrained optimization to identify the optimal buprenorphine increase in each county under a set of constraints on available resources. Our model estimates a negative relationship between death rate and increasing buprenorphine after accounting for other covariates, and our identified optimal single-year allocation strategy is estimated to reduce opioid overdose deaths by over 5.

Examining Increasing Racial Inequities in Opioid Overdose Deaths: a Spatiotemporal Analysis of Black and White Decedents in St. Louis, Missouri, 2011-2021

The third wave of the opioid overdose crisis-defined by the proliferation of illicit fentanyl and its analogs-has not only led to record numbers of overdose deaths but also to unprecedented racial inequities in overdose deaths impacting Black Americans. Despite this racialized shift in opioid availability, little research has examined how the spatial epidemiology of opioid overdose death has also shifted. The current study examines the differential geography of OOD by race and time (i.e., pre-fentanyl versus fentanyl era) in St. Louis, Missouri. Data included decedent records from the local medical examiners suspected to involve opioid overdose (N = 4420). Analyses included calculating spatial descriptive analyses and conducting hotspot analyses (i.e., Gettis-Ord Gi*) stratified by race (Black versus White) and time (2011-2015 versus 2016-2021). Results indicated that fentanyl era overdose deaths were more densely clustered than pre-fentanyl era deaths, particularly those among Black decedents. Although hotspots of overdose death were racially distinct pre-fentanyl, they substantially overlapped in the fentanyl era, with both Black and White deaths clustering in predominantly Black neighborhoods. Racial differences were observed in substances involved in cause of death and other overdose characteristics. The third wave of the opioid crisis appears to involve a geographic shift from areas where White individuals live to those where Black individuals live. Findings demonstrate racial differences in the epidemiology of overdose deaths that point to built environment determinants for future examination. Policy interventions targeting high-deprivation communities are needed to reduce the burden of opioid overdose on Black communities.

Understanding the differential effect of local socio-economic conditions on the relation between prescription opioid supply and drug overdose deaths in US counties

BACKGROUND AND AIMS

Both local socio-economic conditions and prescription opioid supply are associated with drug overdose deaths, which exhibit substantial geographical heterogeneity across the United States. We measured whether the associations of prescription opioid supply with drug overdose deaths vary by local socio-economic conditions.

DESIGN

Ecological county-level study, including 3109 US counties between 2006 and 2019 (n = 43 526 county-years) using annual mortality data.

SETTING

United States.

CASES

A total of 711 447 drug overdose deaths.

MEASUREMENTS

We modeled overdose counts using Bayesian hierarchical Poisson models, estimating associations between four types of drug overdose deaths (deaths involving any drugs, any opioid, prescription opioids only and heroin), prescription opioid supply and five socio-economic indicators: unemployment, poverty rate, income inequality, Rey index (components include mean household income, % high school graduates, % blue-collar workers and unemployment rate), and American human development index (HDI; an indicator of community wellbeing).

FINDINGS

Drug overdose deaths and all substance-specific overdose deaths were higher in counties with higher income inequality [adjusted odds ratios (aORs) = 1.09-1.13], Rey index (aORs = 1.15-1.21) and prescription opioid supply (aORs = 1.14-1.21), and lower in counties with higher HDI scores (aORs = 0.75-0.92). Poverty rate, income inequality and HDI scores were found to modify the effect of prescription opioid supply on heroin overdose deaths. The plot of the interactions showed that when disadvantage is high, increasing prescription opioid supply does not increase heroin overdose deaths. The less disadvantage there is, indicated by lower poverty rates, higher HDI scores and lower income inequality, the greater the effect of increasing prescription opioid supply relative to population size on heroin overdose deaths in US counties.

CONCLUSIONS

In the United States, prescription opioid supply is associated with higher drug overdose deaths; associations are stronger in counties with less disadvantage and less income inequality, but only for heroin overdose deaths.

Effects of Opioid-Limiting Legislation and Increased Provider Awareness on Postoperative Opioid Use and Complications After Hip Arthroscopy

Background

On August 31, 2017, Ohio passed legislation that regulates how opioids can be prescribed postoperatively. Studies have shown that such legislation is successful in reducing the morphine milligram equivalents (MMEs) prescribed after certain orthopaedic procedures.

Purpose

(1) To determine if the opioid prescription-limiting legislation in Ohio reduced the cumulative MMEs prescribed after hip arthroscopy without significantly affecting the rates of emergency department (ED) visits, hospital readmissions, and reoperations within 90 days postoperatively, and (2) to assess risk factors associated with increased postoperative opioid dosing.

Study Design

Cohort study; Level of evidence, 3.

Methods

This study included patients who underwent primary and revision hip arthroscopy at a single institution over a 4-year period. The prelegislation (PRE) and postlegislation (POST) groups were defined as patients who underwent surgery before August 31, 2017, and on/after this date, respectively. The Ohio Automated Rx Reporting System was queried for controlled-substance prescriptions from 30 days preoperatively to 90 days postoperatively, and patient medical records were reviewed to collect demographic, medical, surgical, and readmission data. Inverse probability weighting-adjusted mean treatment effect regression models were used to measure the difference in mean outcomes between the PRE and POST cohorts.

Results

A total of 546 patients (228 PRE, 318 POST) were identified. There was a 25% reduction in the cumulative MMEs prescribed to the POST group as compared with the PRE group during the first 90 days postoperatively (840 vs 1125 MME, respectively; P < .01). The legislation was associated with a significant decrease in the cumulative MMEs prescribed in the first 90 postoperative days (mean treatment effect = -280.6; P < .01), and there were no significant between-group differences in the frequency of ED encounters (8.8% PRE, 11.6% POST; P = .32), hospital readmissions (1.3% PRE, 0.9% POST; P = .70), or reoperations (0.9% PRE, 0.6% POST; P ≥ .99) during this period. Preoperative opioid use was a significant independent risk factor for increased cumulative MMEs in the first 90 days postoperatively (β = 275; P < .01).

Conclusion

Opioid prescription-limiting legislation in Ohio was associated with significant reductions in opioid MMEs dosing in the 90-day period following hip arthroscopy. This legislation had no significant effect on ED utilization, hospital readmissions, or reoperations within the same period. Preoperative opioid use was a significant risk factor for increased MME dosing after hip arthroscopy.

Narrative minireview of the spatial epidemiology of substance use disorder in the United States: Who is at risk and where?

Drug overdose is the leading cause of death by injury in the United States. The incidence of substance use disorder (SUD) in the United States has increased steadily over the past two decades, becoming a major public health problem for the country. The drivers of the SUD epidemic in the United States have changed over time, characterized by an initial heroin outbreak between 1970 and 1999, followed by a painkiller outbreak, and finally by an ongoing synthetic opioid outbreak. The nature and sources of these abused substances reveal striking differences in the socioeconomic and behavioral factors that shape the drug epidemic. Moreover, the geospatial distribution of the SUD epidemic is not homogeneous. The United States has specific locations where vulnerable communities at high risk of SUD are concentrated, reaffirming the multifactorial socioeconomic nature of this epidemic. A better understanding of the SUD epidemic under a spatial epidemiology framework is necessary to determine the factors that have shaped its spread and how these patterns can be used to predict new outbreaks and create effective mitigation policies. This narrative minireview summarizes the current records of the spatial distribution of the SUD epidemic in the United States across different periods, revealing some spatiotemporal patterns that have preceded the occurrence of outbreaks. By analyzing the epidemic of SUD-related deaths, we also describe the epidemic behavior in areas with high incidence of cases. Finally, we describe public health interventions that can be effective for demographic groups, and we discuss future challenges in the study and control of the SUD epidemic in the country.

Population-Based Opioid Prescribing and Overdose Deaths in the USA: an Observational Study

BACKGROUND

Rising opioid-related death rates have prompted reductions of opioid prescribing, yet limited data exist on population-level associations between opioid prescribing and opioid-related deaths.

OBJECTIVE

To evaluate population-level associations between five opioid prescribing measures and opioid-related deaths.

DESIGN

An ecological panel analysis was performed using linear regression models with year and commuting zone fixed effects.

PARTICIPANTS

People ≥10 years aggregated into 886 commuting zones, which are geographic regions collectively comprising the entire USA.

MAIN MEASURES

Annual opioid prescriptions were measured with IQVIA Real World Longitudinal Prescription Data including 76.5% (2009) to 90.0% (2017) of US prescriptions. Prescription measures included opioid prescriptions per capita, percent of population with ≥1 opioid prescription, percent with high-dose prescription, percent with long-term prescription, and percent with opioid prescriptions from ≥3 prescribers. Outcomes were age- and sex-standardized associations of change in opioid prescriptions with change in deaths involving any opioids, synthetics other than methadone, heroin but not synthetics or methadone, and prescription opioids, but not other opioids.

KEY RESULTS

Change in total regional opioid-related deaths was positively correlated with change in regional opioid prescriptions per capita (β=.110, p<.001), percent with ≥1 opioid prescription (β=.100, p=.001), and percent with high-dose prescription (β=.081, p<.001). Change in total regional deaths involving prescription opioids was positively correlated with change in all five opioid prescribing measures. Conversely, change in total regional deaths involving synthetic opioids was negatively correlated with change in percent with long-term opioid prescriptions and percent with ≥3 prescribers, but not for persons ≥45 years. Change in total regional deaths in heroin was not associated with change in any prescription measure.

CONCLUSIONS

Regional decreases in opioid prescriptions were associated with declines in overdose deaths involving prescription opioids, but were also associated with increases in deaths involving synthetic opioids (primarily fentanyl). Individual-level inferences are limited by the ecological nature of the analysis.

Geographic information science and the United States opioid overdose crisis: A scoping review of methods, scales, and application areas

BACKGROUND

The Opioid Overdose Crisis (OOC) continues to generate morbidity and mortality in the United States, outpacing other prominent accident-related reasons. Multiple disciplines have applied geographic information science (GIScience) to understand geographical patterns in opioid-related health measures. However, there are limited reviews that assess how GIScience has been used.

OBJECTIVES

This scoping review investigates how GIScience has been used to conduct research on the OOC. Specific sub-objectives involve identifying bibliometric trends, the location and scale of studies, the frequency of use of various GIScience methodologies, and what direction future research can take to address existing gaps.

METHODS

The review was pre-registered with the Open Science Framework ((https://osf.io/h3mfx/) and followed the PRISMA-ScR guidelines. Scholarly research was gathered from the Web of Science Core Collection, PubMed, IEEE Xplore, ACM Digital Library. Inclusion criteria was defined as having a publication date between January 1999 and August 2021, using GIScience as a central part of the research, and investigating an opioid-related health measure.

RESULTS

231 studies met the inclusion criteria. Most studies were published from 2017 onward. While many (41.6%) of studies were conducted using nationwide data, the majority (58.4%) occurred at the sub-national level. California, New York, Ohio, and Appalachia were most frequently studied, while the Midwest, north Rocky Mountains, Alaska, and Hawaii lacked studies. The most common GIScience methodology used was descriptive mapping, and county-level data was the most common unit of analysis across methodologies.

CONCLUSIONS

Future research of GIScience on the OOC can address gaps by developing use cases for machine learning, conducting analyses at the sub-county level, and applying GIScience to questions involving illicit fentanyl. Research using GIScience is expected to continue to increase, and multidisciplinary research efforts amongst GIScientists, epidemiologists, and other medical professionals can improve the rigor of research.

Variation in adverse drug events of opioids in the United States

Background: The United States (US) ranks high, nationally, in opioid consumption. The ongoing increase in the misuse and mortality amid the opioid epidemic has been contributing to its rising cost. The worsening health and economic impact of opioid use disorder in the US warrants further attention. We, therefore, assessed commonly prescribed opioids to determine the opioids that were over-represented versus under-represented for adverse drug events (ADEs) to better understand their distribution patterns using the Food and Drug Administration's Adverse Event Reporting System (FAERS) while correcting for distribution using the Drug Enforcement Administration's Automation of Reports and Consolidated Orders System (ARCOS). Comparing the ratio of the percentage of adverse drug events as reported by the FAERS relative to the percentage of distribution as reported by the ARCOS database is a novel approach to evaluate post-marketing safety surveillance and may inform healthcare policies and providers to better regulate the use of these opioids. Methods: We analyzed the adverse events for 11 prescription opioids, when correcting for distribution, and their ratios for three periods, 2006-2010, 2011-2016, and 2017-2021, in the US. The opioids include buprenorphine, codeine, fentanyl, hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, oxymorphone, and tapentadol. Oral morphine milligram equivalents (MMEs) were calculated by conversions relative to morphine. The relative ADEs of the selected opioids, opioid distributions, and ADEs relative to distribution ratios were analyzed for the 11 opioids. Results: Oxycodone, fentanyl, and morphine accounted for over half of the total number of ADEs (n = 667,969), while meperidine accounted for less than 1%. Opioid distributions were relatively constant over time, with methadone repeatedly accounting for the largest proportions. Many ADE-to-opioid distribution ratios increased over time, with meperidine (60.6), oxymorphone (11.1), tapentadol (10.3), and hydromorphone (7.9) being the most over-represented for ADEs in the most recent period. Methadone was under-represented (<0.20) in all the three periods. Conclusion: The use of the FAERS with the ARCOS provides insights into dynamic changes in ADEs of the selected opioids in the US. There is further need to monitor and address the ADEs of these drugs.

Dispensed Opioid Prescription Patterns, by Racial/Ethnic Groups, Among South Carolina Medicaid-Funded Children Experiencing Limb Fracture Injuries

OBJECTIVE

To examine dispensed opioid prescription patterns for limb fractures across racial/ethnic groups in a pediatric population.

METHODS

We used South Carolina's Medicaid claims data 2000 to 2018 for pediatric limb fracture cases (under age 19) discharged from the emergency department. The key independent variable was the child's race/ethnicity. The outcomes were: 1) whether the patient had a dispensed opioid prescription; and 2) whether dispensed opioid supply was longer than 5 days among cases with any dispensed opioid prescriptions. Logistic regression models were used to test the association between race/ethnicity and the outcomes. Covariates included age-at-service, gender, service year, and having multiple fracture injuries.

RESULTS

Compared with non-Hispanic White cases (NHW), the odds of receiving dispensed opioid prescriptions were lower for cases of non-Hispanic Black (NHB) (OR = 0.73; 95% confidence interval [CI]: 0.71, 0.75), Asian (OR = 0.69; CI: 0.53, 0.90), Other/Unknown (OR = 0.86; CI: 0.80, 0.92), and Hispanic (OR = 0.84; CI: 0.79, 0.90) race/ethnicity. The odds of receiving >5 days of dispensed opioid prescription supply did not differ significantly among race/ethnic categories.

CONCLUSIONS

Our study confirms previous findings that as compared to NHW, the NHB children were less likely to receive dispensed opioid prescriptions. Also, it reveals that the different minority race/ethnic groups are not homogenous in their likelihoods of receiving dispensed opioid prescriptions after a limb fracture compared to NHW, findings underreported in previous studies. Children in the Other/Unknown race/ethnicity category have prescribing patterns different from those of other minority race/ethnic groups and should be analyzed separately.

Effects of County-Level Opioid Dispensing Rates on Individual-Level Patterns of Prescription Opioid and Heroin Consumption: Evidence From National U.S. Data

OBJECTIVE

The authors examined directly whether county-level changes in opioid dispensing rates affect individual-level prescription opioid misuse, frequency of use, and dependence, as well as the same outcomes for heroin.

METHODS

Using data from the restricted-access National Survey on Drug Use and Health, the Centers for Disease Control and Prevention's retail opioid prescription database, the Prescription Drug Abuse Policy System, and the U.S. Census, the authors applied fixed-effects models to determine whether county-level dispensing rates affected prescription opioid outcomes as intended and whether changes in rates adversely affected heroin use outcomes. Bayes factors were used to confirm evidence for null findings.

RESULTS

The sample included 748,800 respondents age 12 and older from 2006 to 2016. The odds of prescription opioid misuse, increased frequency of misuse, and dependence were 7.2%, 3.5%, and 10.4% higher, respectively, per standard deviation increase in the county-level opioid dispensing rate per 100 persons. There was no evidence for any association between opioid dispensing rates and the three heroin outcomes. The odds ratio was nonsignificant according to frequentist techniques in fixed-effects models, and Bayesian techniques confirmed very strong support for the null hypothesis.

CONCLUSIONS

County-level opioid dispensing rates are directly associated with individual-level prescription opioid misuse, frequency of misuse, and dependence. Changes in dispensing were not associated with population shifts in heroin use. Reductions in opioid dispensing rates have contributed to stemming prior increases in prescription opioid misuse while not adversely affecting heroin use. Physicians and other health care providers can take action to minimize opioid dispensing for tangible benefits regarding prescription opioid misuse without adverse effects on heroin use.

Intoxication related to substances use in patients presenting to Ain Shams University Poisoning Treatment Center, Cairo, Egypt (2015-2019)

INTRODUCTION

Illicit drug use may result in several emergencies. Hospital emergency data can help to detect new patterns of substance use and high-risk trends of drug use. This epidemiological study aimed to investigate the pattern and outcome of cases with substance use intoxication who presented to Ain Shams University Poisoning Treatment Centre, Cairo, Egypt.

METHODS

This retrospective study included all cases of acute intoxication due to use/misuse of substances who presented to the centre during the period (2015-2019).

RESULTS

The study included 11 281 cases; young adults (aged 20-40 years) represented the greatest proportion of cases (6519, 57.8%). Males were the predominant gender in all age groups (representing 79.2% of the cases). Tramadol was the most common substance of exposure in all age groups except for children and adolescents where cannabis was the most common one. There were 162 fatalities (1.4% of all cases) and opioids had the greatest case fatality rate.

DISCUSSION AND CONCLUSIONS

Tramadol was the most used drug that resulted in acute intoxication, followed by cannabis. A total of 43.6% of the cases of acute intoxications were due to recreational use/misuse of prescription drugs.

Effects of opioid-limiting legislation on postoperative opioid use in shoulder arthroplasty in an epidemic epicenter

BACKGROUND

The current opioid epidemic in the United States has become a public health crisis with an estimated 150 daily deaths and nearly 47,000 opioid-related deaths in the United States in 2017 alone. Sensible prescriber practice changes have been a focus of policymakers to decrease the total number of narcotic pain medications in circulation. In the state of Ohio, opioid prescription limits for acute pain were enacted in August 2017. However, given the association of acute opioid exposure with long-term use and lack of assessment of these policies, there is an unmet need to evaluate the effects of similar legislation in Ohio on postoperative opioid dosing after shoulder arthroplasty. This study evaluates the effects of opioid prescription-limiting legislation in Ohio on postoperative opioid dosing in shoulder arthroplasty and assesses risk factors related to long-term opioid use.

METHODS

All patients undergoing primary and revision shoulder arthroplasty over a 5-year period performed by a single surgeon were included. The pre-legislation (PRE) and post-legislation (POST) groups were defined as patients undergoing shoulder arthroplasty before August 31, 2017 and on or after August 31, 2017, respectively. The Ohio Automated Rx Reporting System was queried for controlled-substance prescriptions from 30 days preoperatively to 90 days postoperatively. Patients were designated as opioid tolerant if they had filled an opioid prescription within 30 days of surgery. A binary logistic regression analysis was applied to assess factors related to long-term opioid use.

RESULTS

A total of 334 patients were categorized into 2 cohorts: PRE (n = 99) and POST (n = 235). Accounting for legislative effects, we observed significant reductions in cumulative morphine milligram equivalent (MME) dosing in the opioid-naive patients in the 7-day and 30-day postoperative periods (450.0 MMEs in PRE group vs. 210.0 MMEs in POST group, P < .001) and in the opioid-tolerant patients in the 7-day postoperative period (450.0 MMEs in PRE group vs. 250.0 MMEs in POST group, P = .001). Among the opioid-naive patients, the POST group had a significant MME reduction in the 90-day postoperative period relative to the PRE cohort (P < .001). Preoperative opioid tolerance and benzodiazepine tolerance were independent risk factors for increased MME dosing at 90 days postoperatively (P < .001 and P = .02, respectively).

CONCLUSION

Opioid prescription-limiting legislation for acute pain in the state of Ohio is associated with a notable reduction in opioid MME dosing in the 90-day postoperative period after shoulder arthroplasty, particularly in opioid-naive patients in the first 30 days postoperatively. Preoperative opioid tolerance is correlated with significantly higher MME dosing postoperatively after shoulder arthroplasty.

Opioid prescribing practices in academic otolaryngology: A single institutional survey

OBJECTIVES

Opioids are highly addictive medications and otolaryngologists have a responsibility to practice opioid stewardship. We investigated postoperative opioid prescribing patterns among resident and attending physicians as an educational platform to underscore the importance of conscientious opioid prescribing.

METHODS

This quality improvement study was designed as a cross-sectional electronic survey. Residents and attending clinical faculty members at a single academic institution were queried from February through April 2020. An electronic survey was distributed to capture postoperative opioid prescribing patterns after common procedures. At the conclusion of the study, results were sent to all faculty and residents.

RESULTS

A total of 29 attending otolaryngologists and 22 residents completed the survey. Resident physicians prescribed on average fewer postoperative opioid pills than attendings. Among attendings, the largest number of opioids were prescribed following tonsillectomy (dose varied by patient age), neck dissection (12.6 pills), brow lift (13.3 pills), facelift (13.3 pills), and open reduction of facial trauma (10.7 pills). For residents, surgeries with the most postoperatively prescribed opioids were for tonsillectomy (varied by patient age), neck dissection (13.4 pills), open reduction of facial trauma (10.5 pills), parotidectomy (10.0 pills), and thyroid/parathyroidectomy (9.0 pills). The largest volume of postoperative opioids for both groups was prescribed following tonsillectomy. Attendings prescribed significantly more opioids after facelift and brow lift than did residents (p = 0.01 and p = 0.003, respectively).

CONCLUSION

There was good concordance between resident and attending prescribers. Improvement in opioid prescribing and pain management should be an essential component of otolaryngology residency education and attending continuing medical education.

LEVEL OF EVIDENCE

4.

Implications of county-level variation in U.S. opioid distribution

BACKGROUND

Prescription opioids accounted for the majority of opioid-related deaths in the United States prior to 2010, and continue to contribute to opioid misuse and mortality. We used a novel dataset to investigate the distributional patterns of prescription opioids, whether opioid pill volume was associated with opioid-related mortality, and whether early state Medicaid expansions were associated with either pill volume or opioid-related mortality.

METHODS

Data on opioid shipments to retail pharmacies for 2006-2013 were obtained from the U.S. Drug Enforcement Administration, and opioid-related deaths (ORDs) were obtained from the Centers for Disease Control and Prevention. We first compared characteristics of counties in the highest and lowest quartiles for per capita pill volume (PCPV). We used adjusted difference-in-differences regression models to identify factors associated with PCPV or ORDs, and whether early state Medicaid expansions were associated with either outcome. All models were estimated as linear regressions with standard errors clustered by county, and weighted by county population.

RESULTS

We found large geographic variations in opioid distribution, and this variation appears to be driven by differences in demographics, healthcare access, and healthcare supply. In adjusted models, a one-pill increase in PCPV was associated with a 0.20 increase in ORDs per 100,000 population (95 % CI 0.11-0.30). Early Medicaid expansions were associated with lower PCPV (-2.20, 95 % CI -2.97 to -1.43).

CONCLUSIONS

Our findings validate the relationship between PCPV and ORDs, identify important environmental drivers of the opioid epidemic, and suggest early state Medicaid expansions were beneficial in reducing opioid pill volume.

Medical Marijuana and Opioids (MEMO) Study: protocol of a longitudinal cohort study to examine if medical cannabis reduces opioid use among adults with chronic pain

INTRODUCTION

In the USA, opioid analgesic use and overdoses have increased dramatically. One rapidly expanding strategy to manage chronic pain in the context of this epidemic is medical cannabis. Cannabis has analgesic effects, but it also has potential adverse effects. Further, its impact on opioid analgesic use is not well studied. Managing pain in people living with HIV is particularly challenging, given the high prevalence of opioid analgesic and cannabis use. This study's overarching goal is to understand how medical cannabis use affects opioid analgesic use, with attention to Δ9-tetrahydrocannabinol and cannabidiol content, HIV outcomes and adverse events.

METHODS AND ANALYSES

We are conducting a cohort study of 250 adults with and without HIV infection with (a) severe or chronic pain, (b) current opioid use and (c) who are newly certified for medical cannabis in New York. Over 18 months, we collect data via in-person visits every 3 months and web-based questionnaires every 2 weeks. Data sources include: questionnaires; medical, pharmacy and Prescription Monitoring Program records; urine and blood samples; and physical function tests. Using marginal structural models and comparisons within participants' 2-week time periods (unit of analysis), we will examine how medical cannabis use (primary exposure) affects (1) opioid analgesic use (primary outcome), (2) HIV outcomes (HIV viral load, CD4 count, antiretroviral adherence, HIV risk behaviours) and (3) adverse events (cannabis use disorder, illicit drug use, diversion, overdose/deaths, accidents/injuries, acute care utilisation).

ETHICS AND DISSEMINATION

This study is approved by the Montefiore Medical Center/Albert Einstein College of Medicine institutional review board. Findings will be disseminated through conferences, peer-reviewed publications and meetings with medical cannabis stakeholders.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03268551); Pre-results.

Recent changes in trends of opioid overdose deaths in North America

Background

As several regulatory and environmental changes have occurred in North America, trends in overdose deaths were examined in the United States (US), Ontario and British Columbia (BC), including changes in consumption levels of prescription opioids (PO) and overdose deaths, changes in correlations between consumption levels of PO and overdose deaths and modeled differences between observed and predicted overdose deaths if no changes had occurred.

Methods

Consumption levels of PO included defined daily doses for statistical purposes per million inhabitants per day for the US and Canada (2001–2015). Overdose deaths included opioid overdose deaths for the US (2001–2017) and Ontario (2003–2017) and illicit drug overdose deaths for BC (2001–2017). The analytic techniques included structural break point analyses, Pearson product-moment correlations and multivariate Gaussian state space modeling.

Results

Consumption levels of PO changed in the US in 2010 and in Canada in 2012. Overdose deaths changed in the US in 2014 and in Ontario and BC in 2015. Prior to the observed changes in consumption levels of PO, there were positive correlations between consumption levels of PO and overdose deaths in the US (r = 0.99, p < 0.001) and Ontario (r = 0.92, p = 0.003). After the observed changes in consumption levels of PO, there was a negative correlation between consumption levels of PO and overdose deaths in the US (r = − 0.99, p = 0.002). Observed overdose deaths exceeded predicted overdose deaths by 5.7 (95% Confidence Interval [CI]: 4.8–6.6), 3.5 (95% CI: 3.2–3.8) and 21.8 (95% CI: 18.6–24.9) deaths per 100,000 people in the US, Ontario and BC, respectively in 2017. These excess deaths corresponded to 37.7% (95% CI: 31.9–43.6), 39.2% (95% CI: 36.3–42.1) and 72.2% (95% CI: 61.8–82.6) of observed overdose deaths in the US, Ontario and BC, respectively in 2017.

Conclusions

The opioid crisis has evolved in North America, as a sizeable proportion of overdose deaths are now attributable to the several regulatory and environmental changes. These findings necessitate substance use policies to be conceptualized more broadly as well as the continued expansion of harm reduction services and types of pharmacotherapy interventions.

Health Information Technology and Doctor Shopping: A Systematic Review

Doctor shopping is the practice of visiting multiple physicians to obtain multiple prescriptions. Health information technology (HIT) allows healthcare providers and patients to leverage records or shared information to improve effective care. Our research objective was to determine how HIT is being leveraged to control for doctor shopping. We analyzed articles that covered a 10-year time period from four databases and reported using preferred reporting items for systematic reviews and meta-analysis (PRISMA). We compared intervention, study design, and bias, in addition to showing intervention interactions with facilitators, barriers, and medical outcomes. From 42 articles published from six countries, we identified seven interventions, five facilitator themes with two individual observations, three barrier themes with six individual observations, and two medical outcome themes with four individual observations. Multiple HIT mechanisms exist to control for doctor shopping. Some are associated with a decrease in overdose mortality, but access is not universal or compulsory, and data sharing is sporadic. Because shoppers travel hundreds of miles in pursuit of prescription drugs, data sharing should be an imperative. Research supports leveraging HIT to control doctor shopping, yet without robust data sharing agreements, the efforts of the system are limited to the efforts of the entity with the least number of barriers to their goal. Shoppers will seek out and exploit that organization that does not require participation or checking of prescription drug monitoring programs (PDMP), and the research shows that they will drive great distances to exploit this weakest link.

Examining correlations between opioid dispensing and opioid-related hospitalizations in Canada, 2007-2016

BACKGROUND

High levels of opioid-related mortality, as well as morbidity, contribute to the excessive opioid-related disease burden in North America, induced by high availability of opioids. While correlations between opioid dispensing levels and mortality outcomes are well-established, fewer evidence exists on correlations with morbidity (e.g., hospitalizations).

METHODS

We examined possible overtime correlations between medical opioid dispensing and opioid-related hospitalizations in Canada, by province, 2007-2016. For dispensing, we examined annual volumes of medical opioid dispensing derived from a representative, stratified sample of retail pharmacies across Canada. Raw dispensing information for 'strong opioids' was converted into Defined Daily Doses per 1000 population per day (DDD/1000/day). Opioid-related hospitalization rates referred to opioid poisoning-related admissions by province, for fiscal years 2007-08 to 2016-17, drawn from the national Hospital Morbidity Database. We assessed possible correlations between opioid dispensing and hospitalizations by province using the Pearson product moment correlation; correlation values (r) and confidence intervals were reported.

RESULTS

Significant correlations for overtime correlations between population-levels of opioid dispensing and opioid-related hospitalizations were observed for three provinces: Quebec (r = 0.87, CI: 0.49-0.97; p = 0.002); New Brunswick (r = 0.85;CI: 0.43-0.97; p = 0.004) and Nova Scotia (r = 0.78; CI:0.25-0.95; p = 0.012), with an additional province, Saskatchewan, (r = 0.073; CI:-0.07-0.91;p = 0.073) featuring borderline significance.

CONCLUSIONS

The correlations observed further add to evidence on opioid dispensing levels as a systemic driver of population-level harms. Notably, correlations were not identified principally in provinces with reported high contribution levels (> 50%) of illicit opioids to mortality, which are not captured by dispensing data and so may have distorted or concealed potential correlation effects due to contamination.

Changes in associations of prescription opioid use disorder and illegal behaviors among adults in the United States from 2002 to 20

BACKGROUND AND AIMS

In the United States, the availability of prescription opioids has decreased in recent years. Whether there have been corresponding changes in the likelihood of people with prescription opioid use disorder (POUD) to engage in illegal behaviors related to drug use remains unknown. We examined changes in prevalence of illegal behaviors between people with and without POUD over time, and how transactions for obtaining opioids have changed among people with POUD over time.

DESIGN

Temporal trend analysis of repeated cross-sectional data.

SETTING

United States household dwelling population from all 50 states and District of Columbia.

PARTICIPANTS

Adult subsamples from the 2002-14 National Survey of Drug Use and Health (n = 5393 people with POUD; n = 486 768 people without POUD).

MEASUREMENTS

Outcome variables were selected illegal behaviors and sources of opioids used non-medically. POUD was defined using the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, criteria. Time was treated as a continuous variable. The variable of interest for each illegal behavior analysis was the interaction between POUD diagnosis and time. Covariates included age, sex and race/ethnicity.

FINDINGS

During the 13-year period examined, the adjusted interaction odds ratio (AIOR) describing the change in association between POUD and selling illicit drugs increased by a factor of 2.41 [95% confidence interval (CI) = 1.56-3.71, P < 0.001]. Similar trends were noted for stealing (AIOR = 2.12, 95% CI = 1.31-3.44, P = 0.002) and for life-time history of arrest (AIOR = 1.53, 95% CI = 1.06-2.19, P = 0.021). People with POUD became less likely to receive opioids for free from friends and family [adjusted odds ratio (AOR) = 0.42, 95% CI = 0.25-0.71, P = 0.001] and more likely to buy them from friends and family (AOR = 3.29, 95% CI = 1.76-6.13, P < 0.001) from 2005 to 2014.

CONCLUSIONS

In the United States, against a backdrop of a decreasing prescription opioid supply, rates of some crimes potentially related to drug use increased among people with prescription opioid use disorder compared with those without prescription opioid use disorder from 2002 to 2014.

Factors associated with potentially problematic opioid prescriptions among individuals with private insurance and medicaid

If opioid analgesics are prescribed and used inappropriately, they can lead to addiction and other adverse effects. In this study, we (1) examine factors associated with potentially problematic opioid prescriptions and (2) quantify the link between potentially problematic prescriptions and the development of opioid use disorder. We found that older age; female sex; having back pain, arthritis, or migraine; hydrocodone prescription; previous pharmacotherapy for opioid use disorder; and frequent emergency department use were associated with problematic prescriptions among individuals with Medicaid and private insurance. Patients with commercial insurance and Medicaid who had potentially problematic opioid prescriptions were eight and three times more likely, respectively, to develop an opioid use disorder than patients without potentially problematic opioid prescriptions. Our findings help identify factors associated with problematic prescriptions and underscore the importance of targeted public health interventions.

Investigating the Social Ecological Contexts of Opioid Use Disorder and Poisoning Hospitalizations in Pennsylvania

OBJECTIVE

Opioid use disorder (OUD) and overdose rates have been sharply on the rise in the United States. Although systematic patterns of geographic variation in OUD and opioid overdose have been identified, the factors that explain why opioid-related hospitalizations increase in certain areas are not well understood.

METHOD

We examined Pennsylvania Health Care Cost Containment Council (PHC4) hospital inpatient discharge data at the ZIP code level to measure the geographic growth and spread of OUD as measured by 44 quarters of inpatient hospitalization data (from 2004 through 2014) for the entire state of Pennsylvania (n = 16,275 ZIP codes). We assessed the relative contribution of specific attributes of areas (e.g., population density) to patterns of OUD, heroin poisonings, and non-heroin opioid poisonings. Unit misalignment and spatial autocorrelation were corrected for using Bayesian space-time conditional autoregressive models.

RESULTS

The associations between a greater density of manual labor establishments and all opioid-related hospitalizations were well supported and positive. A dose-response relationship between population density and opioid-related hospitalizations existed, with a stronger association for heroin poisonings (relative rate, densest quintile vs. least dense: 3.40 [95% credible interval 2.68, 4.39]).

CONCLUSIONS

Posterior distributions from these models enabled the identification of locations most vulnerable to problems related to the opioid epidemic in Pennsylvania. Understanding spatial patterns of OUD and poisonings can enhance the development and implementation of effective prevention programs.

Prescription Opioids Are Associated With Population Mortality in US Deep South Middle-Age Non-hispanic Whites: An Ecological Time Series Study

Objective: The US Burden of Disease Collaborators reported that between 1990 and 2016, the top 10 states with increasing probability of death between the ages of 20 and 55 years were all in the South. A recent study of annual surveillance data found that increasing all-cause mortality rates were occurring in middle-age non-Hispanic whites. The vast proportion of all-cause mortality consists of medical causes, not external causes (i.e., overdose, mental illness, suicide, homicide, or motor vehicle crashes). It has been hypothesized by researchers that the ongoing opioid epidemic has an etiologic role in the trend of increasing medical death, but ecological studies looking for an association have not been published. The objective of this study was to test the hypothesis that hydrocodone and oxycodone sales are temporally associated and correlated with annual NHW45-54 medical-cause mortality rates in the Deep South region comprised of Alabama, Arkansas, Louisiana, Mississippi, Oklahoma, and South Carolina.

Methods: Mortality and opioid sales data were obtained from the Centers for Disease Control and Prevention Wonder Detailed Mortality and University of Wisconsin State Health Access Data Assistance Center databases, respectively. Annual, state and regional NHW45-54 medical-cause mortality and opioid sales data were analyzed using Spearman rank correlation (rs) testing, after first and second differencing, in order to achieve stationarity and control for trend similarities.

Results: Sales of prescription opioids follow very similar temporal patterns across these six states, with simultaneous increases in 2007 and 2013. With few exceptions, annual opioids sales trends were correlated state-to-state. Two prominent spikes are evident in the aggregated opioid sales trends of the six states, with both sales spikes preceding same-directional fluctuations in medical-cause mortality by ~1 year. After a 1 year adjustment of second-differenced data, population hydrocodone exposure was correlated with female NHW45-54 population medical-cause mortality [rs₍₁₃₎ = 0.540; P = 0.038]; and oxycodone exposure correlated with male NHW45-54 population medical-cause mortality [rs₍₁₃₎ = 0.607; P = 0.016].

Conclusions: State sales of prescription hydrocodone and oxycodone in the six states studied follow non-random, systematic trajectories. A strong correlation and temporal association exists between prescription opioid sales and medical-cause mortality in this Deep South NHW45-54 population.

Assessing Spatial Relationships between Prescription Drugs, Race, and Overdose in New York State from 2013 to 2015

Over the last decade, New York State has experienced one of the greatest increases in opioid overdose deaths in the United States, particularly from heroin and synthetic opioids. This study investigated spatial patterns in the distribution of county-level rates of overdose deaths in New York State and associations between prescriptions for opioid pain relievers, race, and overdose deaths from 2013-2015. Global and local Moran's I tests for spatial autocorrelation examined Bayesian smoothed rates of overdose for clusters of counties with high and low rates of overdose mortality. Getis Ord* analyses identified local hotspots of high and low clusters of overdose. Model performance indicators selected the best-fitting spatial regression model to examine associations between prescriptions for opioid pain relievers, race/ethnicity (non-Hispanic White, Black, and Hispanic) after adjusting for spatial dependence in the data. Socio-demographic characteristics of clusters were examined. Findings suggest rates of opioid overdose deaths are clustered in New York. Rates of prescription opioids were associated with rates of overdose from any opioid, prescription pain relievers, and synthetic opioids. Greater populations of African Americans were associated with greater rates of heroin overdose death rates. Findings from this study inform public health opioid overdose prevention interventions and policies.

The opioid and related drug epidemics in rural Appalachia: A systematic review of populations affected, risk factors, and infectious diseases

Background/aims: To examine trends in rural Appalachian opioid and related drug epidemics during the past 10 years, including at-risk populations, substance use shifts and correlates, and associated infections. Methods: We conducted this review in accordance with the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. Seven databases were searched for quantitative studies, published between January 2006 and December 2017, of drug use, drug-related mortality, or associated infections in rural Appalachia. Results: Drug-related deaths increased in study states, and a high incidence of polydrug toxicity was noted. Rural substance use was most common among young, white males, with low education levels. A history of depression/anxiety was common among study populations. Prescription opioids were most commonly used, often in conjunction with sedatives. Women emerged as a distinct user subpopulation, with different routes of drug use initiation and drug sources. Injection drug use was accompanied by risky injection behaviors and was associated with hepatitis C. Conclusions: This review can help to inform substance use intervention development and implementation in rural Appalachian populations. Those at highest risk are young, white males who often engage in polysubstance use and have a history of mental health issues. Differences in risk factors among other groups and characteristics of drug use in rural Appalachian populations that are conducive to human immunodeficiency virus (HIV) spread also warrant consideration.

Detection of Spatiotemporal Prescription Opioid Hot Spots With Network Scan Statistics: Multistate Analysis

Background

Overuse and misuse of prescription opioids have become significant public health burdens in the United States. About 11.5 million people are estimated to have misused prescription opioids for nonmedical purposes in 2016. This has led to a significant number of drug overdose deaths in the United States. Previous studies have examined spatiotemporal clusters of opioid misuse, but they have been restricted to circular shaped regions.

Objective

The goal of this study was to identify spatiotemporal hot spots of opioid users and opioid prescription claims using Medicare data.

Methods

We examined spatiotemporal clusters with significantly higher number of beneficiaries and rate of prescriptions for opioids using Medicare payment data from the Centers for Medicare & Medicaid Services. We used network scan statistics to detect significant clusters with arbitrary shapes, the Kulldorff scan statistic to examine the significant clusters for each year (2013, 2014, and 2015) and an expectation-based version to examine the significant clusters relative to past years. Regression analysis was used to characterize the demographics of the counties that are a part of any significant cluster, and data mining techniques were used to discover the specialties of the anomalous providers.

Results

We examined anomalous spatial clusters with respect to opioid prescription claims and beneficiary counts and found some common patterns across states: the counties in the most anomalous clusters were fairly stable in 2014 and 2015, but they have shrunk from 2013. In Virginia, a higher percentage of African Americans in a county lower the odds of the county being anomalous in terms of opioid beneficiary counts to about 0.96 in 2015. For opioid prescription claim counts, the odds were 0.92. This pattern was consistent across the 3 states and across the 3 years. A higher number of people in the county with access to Medicaid increased the odds of the county being in the anomalous cluster to 1.16 in both types of counts in Virginia. A higher number of people with access to direct purchase of insurance plans decreased the odds of a county being in an anomalous cluster to 0.85. The expectation-based scan statistic, which captures change over time, revealed different clusters than the Kulldorff statistic. Providers with an unusually high number of opioid beneficiaries and opioid claims include specialties such as physician’s assistant, nurse practitioner, and family practice.

Conclusions

Our analysis of the Medicare claims data provides characteristics of the counties and provider specialties that have higher odds of being anomalous. The empirical analysis identifies highly refined spatial hot spots that are likely to encounter prescription opioid misuse and overdose. The methodology is generic and can be applied to monitor providers and their prescription behaviors in regions that are at a high risk of abuse.

The prescription opioid crisis: role of the anaesthesiologist in reducing opioid use and misuse

Reports of strategies to prevent and treat the opioid epidemic are growing. Significant attention has been paid to the benefits of opioid addiction research, clinical prescribing, and public policy initiatives in curbing the epidemic. However, the role of the anaesthesiologist in minimising opioid use and misuse remains underexplored. For many patients with an opioid use disorder, the perioperative period represents the source of initial exposure. As perioperative physicians, anaesthesiologists are in the unique position to manage pain effectively while simultaneously decreasing opioid consumption. Multiple opportunities exist for anaesthesiologists to minimise opioid exposure and prevent subsequent persistent opioid use. We present a global strategy for decreasing perioperative opioid use and misuse among surgical patients. A historical perspective of the opioid epidemic is presented, together with an analysis of opioid supply and demand forces. We then present specific temporal strategies for opioid use reduction in the perioperative period. We emphasise the importance of preoperative identification of patients at risk for long-term opioid use and misuse, review the evidence supporting the opioid sparing capacity of individual multimodal analgesic agents, and discuss the benefits of regional anaesthesia for minimising opioid consumption. We describe postoperative and post-discharge tools, including effective multimodal analgesia and the role of a transitional pain service. Finally, we offer general institutional strategies that can be led by anaesthesiologists, identify gaps in knowledge, and offer directions for future research.

Physician Dispensing of Oxycodone and Other Commonly Used Opioids, 2000-2015, United States

Objective

An average of 91 people in the United States die every day from an opioid-related overdose (including prescription opioids and heroin). The direct dispensing of opioids from health care practitioner offices has been linked to opioid-related harms. The objective of this study is to describe the changing nature of the volume of this type of prescribing at the state level.

Methods

This descriptive study examines the distribution of opioids by practitioners using 1999-2015 Automation of Reports and Consolidated Orders System data. Analyses were restricted to opioids distributed to practitioners. Amount distributed (morphine milligram equivalents [MMEs]) and number of practitioners are presented.

Results

Patterns of distribution to practitioners and the number of practitioners varied markedly by state and changed dramatically over time. Comparing 1999 with 2015, the MME distributed to dispensing practitioners decreased in 16 states and increased in 35. Most notable was the change in Florida, which saw a peak of 8.94 MMEs per 100,000 persons in 2010 (the highest distribution in all states in all years) and a low of 0.08 in 2013.

Discussion

This study presents the first state estimates of office-based dispensing of opioids. Increases in direct dispensing in recent years may indicate a need to monitor this practice and consider whether changes are needed. Using controlled substances data to identify high prescribers and dispensers of opioids, as well as examining overall state trends, is a foundational activity to informing the response to potentially high-risk clinical practices.

Understanding Differences in Types of Opioid Prescriptions Across Time and Space: A Community-Level Analysis

For the better part of the 21st century, opioid abuse and related consequences have beleaguered the United States. Effectively fighting the crisis may require a better understanding of potential differences among the types of opioids available as treating them as one homogeneous group may mask emerging trends and conflate more benign ones with those more troubling. The purpose of our study is to investigate changes in prescribing patterns of four groups of opioids (hydrocodone, oxycodone, fentanyl, and other) and how community-level factors explain their variation over time. We use a census tract–level data set with population, concentrated disadvantage, and prescription drug monitoring payment variables to address our goals. Findings show disparate prescribing patterns among the four types of opioids and considerable differences in the community factors that predict their change. Implications for future research and interventions follow.

Correlations between population-levels of prescription opioid dispensing and related deaths in Ontario (Canada), 2005-2016

Canada is experiencing an ongoing opioid-related public health crisis, including persistently rising opioid (e.g., poisoning) mortality. Previous research has documented marked correlations between population-levels of opioid dispensing and deaths. We examined possible correlations between annual population-level dispensing of specific opioid formulations and related poisoning deaths in Ontario (Canada), for the period 2005-2016. Annual coroner statistics-based numbers of poisoning deaths associated with six main opioid formulations (codeine, fentanyl, hydromorphone, methadone, morphine, and oxycodone) for Ontario were converted into annual death rates (per 100,000 population). Annual dispensing data for the opioid formulations under study were based on commercial retail-sales data from a representative, stratified sample of community pharmacies (IMSQuintiles/IQVIA CompuScript), converted into Defined Daily Doses (DDD/1,000 population/day). Possible relationships between the annual death and dispensing rates were assessed by Pearson's correlation coefficient analyses. Death rates increased for almost all, while dispensing rates increased for half of the opioid categories. A significant positive correlation between death and dispensing rates was found for hydromorphone (r = 0.97, 95% CI: 0.88-0.99) and oxycodone (r = 0.90, 95% CI: 0.68-0.97) formulations; a significant negative correlation was found for codeine (r = -0.78, 95% CI: -0.93 to -0.37). No significant correlations were detected for fentanyl, methadone, and morphine related deaths. Strong correlations between levels of dispensing and deaths for select opioid formulations were found. For select others, extrinsic factors - e.g., increasing involvement of non-medical opioid products (e.g., fentanyl) in overdose deaths - likely confounded underlying correlation effects. Opioid dispensing levels continue to influence population-level mortality levels, and need to be addressed by prevention strategies.

Opioid prescribing and dispensing: Experiences and perspectives from a survey of community pharmacists practising in the province of Quebec

Background

Canada leads in opioid prescription and consumption rates, and this has resulted in high levels of opioid-related morbidity and mortality. Pharmacists' input could contribute significantly to understanding the disadvantages of opioid prescribing and dispensing and improving the service. This study aimed to examine the experiences of community pharmacists in relation to opioid prescribing and dispensing, with a focus on optimizing collaboration and communication.

Methods

An online survey was performed among pharmacists from the province of Quebec, Canada, in 2016. Pharmacists were eligible if registered and working in community pharmacies.

Results

In all, 542 questionnaires were analyzed (participation rate of 8.1%). Pharmacotherapy-related problems were reported in at least 50% of opioid prescriptions: additional drug(s) required (reported by 30% of pharmacists), interaction(s) between opioid(s) and other drug(s) (16%), physician did not meet the general issuing standards for opioid prescriptions (26%) and patient had mild to moderate pain that was easily managed by a nonopioid analgesic (20%). Half of the patients were reported as requesting anticipated refills, possibly indicating abuse or poor pain control. Most pharmacists (89.6%) reported needing to contact physicians in 1 to 3 out of 10 opioid prescriptions, but many pharmacists (71.8%, often or very often) reported difficulties communicating with physicians.

Conclusions

Pharmacists' observations of pharmacotherapy-related problems and patients' unusual behaviours reveal a significant number of issues related to opioid prescribing and dispensing in an outpatient setting. Improved collaboration between physicians and pharmacists appears mandatory to address the issues reported in this study.

Cannabis Use is Associated with Lower Odds of Prescription Opioid Analgesic Use Among HIV-Infected Individuals with Chronic Pain

BACKGROUND

Chronic pain is common in the United States and prescribed opioid analgesics use for noncancer pain has increased dramatically in the past two decades, possibly accounting for the current opioid addiction epidemic. Co-morbid drug use in those prescribed opioid analgesics is common, but there are few data on polysubstance use patterns.

OBJECTIVE

We explored patterns of use of cigarette, alcohol, and illicit drugs in HIV-infected people with chronic pain who were prescribed opioid analgesics.

METHODS

We conducted a secondary data analysis of screening interviews conducted as part of a parent randomized trial of financial incentives to improve HIV outcomes among drug users. In a convenience sample of people with HIV and chronic pain, we collected self-report data on demographic characteristics; pain; patterns of opioid analgesic use (both prescribed and illicit); cigarette, alcohol, and illicit drug use (including cannabis, heroin, and cocaine) within the past 30 days; and current treatment for drug use and HIV.

RESULTS

Almost half of the sample of people with HIV and chronic pain reported current prescribed opioid analgesic use (N = 372, 47.1%). Illicit drug use was common (N = 505, 63.9%), and cannabis was the most commonly used illicit substance (N = 311, 39.4%). In multivariate analyses, only cannabis use was significantly associated with lower odds of prescribed opioid analgesic use (adjusted odds ratio = 0.57; 95% confidence interval: 0.38-0.87). Conclusions/Importance: Our data suggest that new medical cannabis legislation might reduce the need for opioid analgesics for pain management, which could help to address adverse events associated with opioid analgesic use.

The Opioid Crisis in Black Communities

While much of the social and political attention surrounding the nationwide opioid epidemic has focused on the dramatic increase in overdose deaths among white, middle-class, suburban and rural users, the impact of the epidemic in Black communities has largely been unrecognized. Though rates of opioid use at the national scale are higher for whites than they are for Blacks, rates of increase in opioid deaths have been rising more steeply among Blacks (43%) than whites (22%) over the last five years. Moreover, the rate of opioid overdose deaths among Blacks already exceeds that of whites in several states. The lack of discussion of Black overdose deaths in the national opioid discourse further marginalizes Black people, and is highly consistent with a history of framing the addictions of people of color as deserving of criminal punishment, rather than worthy of medical treatment. This article argues that, because racial inequalities are embedded in American popular and political cultures as well as in medicine, the federal and state governments should develop more culturally targeted programs to benefit Black communities in the opioid crisis. Such programs include the use of faith-based organizations to deliver substance use prevention and treatment services, the inclusion of racial impact assessments in the implementation of drug policy proposals, and the formal consideration of Black people's interaction with the criminal justice system in designing treatment options.

Trends in Medical Use of Opioids in the U.S., 2006-2016

INTRODUCTION

The U.S. is experiencing an opioid epidemic which is at least partially iatrogenic and fueled by both prescription and illicit misuse. This study provides a nationwide examination of opioid distribution patterns during the last decade.

METHODS

Data were obtained from the U.S. Drug Enforcement Administration's Automation of Reports and Consolidated Orders System for 2006-2016. Analyses include quantities of ten opioids legally dispensed nationwide by weight and converted to Morphine Milligram Equivalents. Geospatial and state-level analyses were also completed in 2017.

RESULTS

The total for ten opioids peaked in 2011 (389.5 metric tons Morphine Milligram Equivalents) relative to both 2006 (286.1) and 2016 (364.6). Changes in the volume of opioids by weight over the decade were agent specific. Since 2011, there were decreases in hydrocodone (-28.4%); oxymorphone (-28.0%); fentanyl (-21.4%); morphine (-18.9%); oxycodone (-13.8%); and meperidine (-58.0%) and an increase in buprenorphine (75.2%) in 2016. There were substantial inter-state variations in rates with a fivefold difference between the highest Morphine Milligram Equivalents in 2016 (Rhode Island=2,623.7 mg/person) relative to the lowest (North Dakota=484.7 mg/person). An association was identified between state median age and per capita Morphine Milligram Equivalents (r =0.49, p<0.0005).

CONCLUSIONS

With the exception of buprenorphine, used to treat an opioid use disorder, prescription opioid use has been decreasing over the past 5 years in the U.S. Further efforts are needed to continue to optimize the balance between appropriate opioid access for acute pain while minimizing diversion and treating opioid addiction.

Relationship between high-risk patients receiving prescription opioids and high-volume opioid prescribers

AIMS

(1) To characterize the amount of prescription opioids prescribed for high-risk patients by low-volume prescribers; (2) to quantify how high- and low-volume prescribers differ systematically in their prescribing patterns.

DESIGN

Cross-sectional study using 2015 longitudinal, all-payer QuintilesIMS pharmacy claims. We conducted an aggregated analysis for the first aim and an individual-level analysis for the second aim.

SETTING

California, Florida, Georgia, Maryland, and Washington, USA.

PARTICIPANTS

Among 4 046 275 patients, we identified 375 848 concomitant users (filling more than 30-days of concomitant opioids and benzodiazepines), 150 814 chronic users (using 100+ morphine milligram equivalents (MMEs) per day for more than 90 days), and 3190 patients prescribed opioids by > 3 prescribers and filling opioids at > 3 pharmacies during any 90-day period. Among 192 126 prescribers, we identified 8023 high-volume prescribers, who comprised the highest fifth percentile of opioid volume during four calendar quarters.

MEASUREMENTS

(1) MME dose per transaction, (2) days supplied per transaction, (3) total opioid volume per patient and (4) number of prescriptions per patient. We also examined differences in opioid dispensing between high- and low-volume prescribers among patients receiving opioids from both.

FINDINGS

Low-volume prescribers accounted for 15-29% of opioid volume and 18-56% of opioid prescriptions for high-risk patients, compared with 28-37% and 53-58% for low-risk patients. After accounting for state of residence, comorbid burden, prescriber specialty and care sequence, patients were more likely to receive higher doses (60.9 versus 53.2 MMEs per day, P < 0.01), longer supplies (22.1 versus 15.6 days, P < 0.01), more prescriptions (4.0 versus 2.6 prescriptions, P < 0.01) and greater opioid volume (5.6 versus 1.9 g, P < 0.01) from high- than low-volume prescribers.

CONCLUSIONS

In the United States, high-risk patients obtain a substantial proportion of prescription opioids from low-volume prescribers. The differences in prescribing patterns between high- and low-volume prescribers suggest the importance of interventions targeting prescriber behaviors.

Risks associated with the environmental release of pharmaceuticals on the U.S. Food and Drug Administration "flush list"

A select few prescription drugs can be especially harmful and, in some cases, fatal with just one dose when not used as prescribed. Therefore, the U. S. Food and Drug Administration (FDA) recommends that expired, unwanted, or otherwise unused portions of most of these drugs be disposed of quickly through a take-back program. If such an option is not readily available, FDA recommends that they be flushed down the sink or toilet. The goal of the current investigation was to evaluate the ecological and human-health risks associated with the environmental release of the 15 active pharmaceutical ingredients (APIs) currently on the FDA "flush list". The evaluation suggests that even when highly conservative assumptions are used-including that the entire API mass supplied for clinical use is flushed, all relevant sources in addition to clinical use of the API are considered, and no metabolic loss, environmental degradation, or dilution of wastewater effluents are used in estimating environmental concentrations-most of these APIs present a negligible eco-toxicological risk, both as individual compounds and as a mixture. For a few of these APIs, additional eco-toxicological data will need to be developed. Using similar conservative assumptions for human-health risks, all 15 APIs present negligible risk through ingestion of water and fish.

Impact of prescription drug monitoring programs (PDMPs) on opioid utilization among Medicare beneficiaries in 10 US States

BACKGROUND AND AIMS

Prescription Drug Monitoring Programs (PDMPs) are a principal strategy used in the United States to address prescription drug abuse. We (1) compared opioid use pre- and post-PDMP implementation and (2) estimated differences of PDMP impact by reason for Medicare eligibility and plan type.

DESIGN

Analysis of opioid prescription claims in US states that implemented PDMPs relative to non-PDMP states during 2007-12.

SETTING

Florida, Louisiana, Nebraska, New Jersey, Vermont, Georgia, Wisconsin, Maryland, New Hampshire and Arkansas, USA.

PARTICIPANTS

A total of 310 105 disabled and older adult Medicare enrolees.

MEASUREMENTS

Primary outcomes were monthly total opioid volume, mean daily morphine milligram equivalent (MME) dose per prescription and number of opioid prescriptions dispensed. The key predictors were PDMP status and time. Tests for moderation examined PDMP impact by Medicare eligibility (disability versus age) and drug plan [privately provided Medicare Advantage (MAPD) versus fee-for-service (PDP)].

FINDINGS

Overall, PDMP implementation was associated with reduced opioid volume [-2.36 kg/month, 95% confidence interval (CI) = -3.44, -1.28] and no changes in mean MMEs or opioid prescriptions 12 months after implementation compared with non-PDMP states. We found evidence of strong moderation effects. In PDMP states, estimated monthly opioid volumes decreased 1.67 kg (95% CI = -2.38, -0.96) and 0.75 kg (95% CI = -1.32, -0.18) among disabled and older adults, respectively, and 1.2 kg, regardless of plan type. MME reductions were 3.73 mg/prescription (95% CI = -6.22, -1.24) in disabled and 3.02 mg/prescription (95% CI = -3.86, -2.18) in MAPD beneficiaries, but there were no changes in older adults and PDP beneficiaries. Dispensed prescriptions increased 259/month (95% CI = 39, 479) among the disabled and decreased 610/month (95% CI = -953, -257) among MAPD beneficiaries.

CONCLUSIONS

Prescription drug monitoring programs (PDMPs) are associated with reductions in opioid use, measured by volume, among disabled and older adult Medicare beneficiaries in the United States compared with states that do not have PDMPs. PDMP impact on daily doses and daily prescriptions varied by reason for eligibility and plan type. These findings cannot be generalized beyond the 10 US states studied.

Naloxone for heroin, prescription opioid, and illicitly made fentanyl overdoses: Challenges and innovations responding to a dynamic epidemic

Community-based overdose prevention programs first emerged in the 1990's and are now the leading public health intervention for overdose. Key elements of these programs are overdose education and naloxone distribution to people who use opioids and their social networks. We review the evolution of naloxone programming through the heroin overdose era of the 1990's, the prescription opioid era of the 2000's, and the current overdose crisis stemming from the synthetic opioid era of illicitly manufactured fentanyl and its analogues in the 2010's. We present current challenges arising in this new era of synthetic opioids, including variable potency of illicit drugs due to erratic adulteration of the drug supply with synthetic opioids, potentially changing efficacy of standard naloxone formulations for overdose rescue, potentially shorter overdose response time, and reports of fentanyl exposure among people who use drugs but are opioid naïve. Future directions for adapting naloxone programming to the dynamic opioid epidemic are proposed, including scale-up to new venues and social networks, new standards for post-overdose care, expansion of supervised drug consumption services, and integration of novel technologies to detect overdose and deliver naloxone.

The Evolution of BioSense: Lessons Learned and Future Directions

The BioSense program was launched in 2003 with the aim of establishing a nationwide integrated public health surveillance system for early detection and assessment of potential bioterrorism-related illness. The program has matured over the years from an initial Centers for Disease Control and Prevention-centric program to one focused on building syndromic surveillance capacity at the state and local level. The uses of syndromic surveillance have also evolved from an early focus on alerts for bioterrorism-related illness to situational awareness and response, to various hazardous events and disease outbreaks. Future development of BioSense (now the National Syndromic Surveillance Program) includes, in the short term, a focus on data quality with an emphasis on stability, consistency, and reliability and, in the long term, increased capacity and innovation, new data sources and system functionality, and exploration of emerging technologies and analytics.

Epidemiology of overdose episodes from the period prior to hospitalization for drug poisoning until discharge in Japan: An exploratory descriptive study using a nationwide claims database

Background

Little is known about the nationwide epidemiology of the annual rate, causative substance, and clinical course of overdose-related admission. We aimed to describe the epidemiology of overdose episodes from the period prior to hospitalization for drug poisoning until discharge to home.

Methods

We assessed all cases of admission due to overdose (21,663 episodes) in Japan from October 2012 through September 2013 using the National Database of Health Insurance Claims and Specific Health Checkups of Japan.

Results

The annual rate of overdose admission was 17.0 per 100,000 population. Women exhibited two peaks in admission rates at 19–34 years (40.9 per 100,000) and ≥75 years (27.8 per 100,000). Men exhibited one peak in the admission rate at ≥75 years (23.7 per 100,000). Within 90 days prior to overdose, ≥60% and ≥9% of patients aged 19–49 years received a prescription for benzodiazepines and barbiturates, respectively. In addition, 59% of patients aged ≥75 years received a prescription for benzodiazepines prior to overdose, 47% had a history of congestive heart failure, and 24% had a diagnosis of poisoning by cardiovascular drugs. The proportion of patients with recent psychiatric treatments decreased with age (65.1% in those aged 35–49 years and 13.9% in those aged ≥75 years).

Conclusions

The findings emphasize the need for overdose prevention programs that focus on psychiatric patients aged 19–49 years who are prescribed benzodiazepines or barbiturates and on non-psychiatric patients aged ≥75 years who are prescribed benzodiazepines or digitalis.

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Benzodiazepines were prescribed to ≥59% of overdose patients aged ≥19 years.

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Cardiovascular drugs were frequently ingested among overdose patients aged ≥75 years.

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The proportions of patients with recent psychiatric treatments decreased with age.

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Overdose prevention should be optimized according to the age-related differences.

Cohort Study of the Impact of High-Dose Opioid Analgesics on Overdose Mortality

OBJECTIVE

Previous studies examining opioid dose and overdose risk provide limited granularity by milligram strength and instead rely on thresholds. We quantify dose-dependent overdose mortality over a large spectrum of clinically common doses. We also examine the contributions of benzodiazepines and extended release opioid formulations to mortality.

DESIGN

Prospective observational cohort with one year follow-up.

SETTING

One year in one state (NC) using a controlled substances prescription monitoring program, with name-linked mortality data.

SUBJECTS

Residential population of North Carolina (n = 9,560,234), with 2,182,374 opioid analgesic patients.

METHODS

Exposure was dispensed prescriptions of solid oral and transdermal opioid analgesics; person-years calculated using intent-to-treat principles. Outcome was overdose deaths involving opioid analgesics in a primary or additive role. Poisson models were created, implemented using generalized estimating equations.

RESULTS

Opioid analgesics were dispensed to 22.8% of residents. Among licensed clinicians, 89.6% prescribed opioid analgesics, and 40.0% prescribed ER formulations. There were 629 overdose deaths, half of which had an opioid analgesic prescription active on the day of death. Of 2,182,374 patients prescribed opioids, 478 overdose deaths were reported (0.022% per year). Mortality rates increased gradually across the range of average daily milligrams of morphine equivalents. 80.0% of opioid analgesic patients also received benzodiazepines. Rates of overdose death among those co-dispensed benzodiazepines and opioid analgesics were ten times higher (7.0 per 10,000 person-years, 95 percent CI: 6.3, 7.8) than opioid analgesics alone (0.7 per 10,000 person years, 95 percent CI: 0.6, 0.9).

CONCLUSIONS

Dose-dependent opioid overdose risk among patients increased gradually and did not show evidence of a distinct risk threshold. There is urgent need for guidance about combined classes of medicines to facilitate a better balance between pain relief and overdose risk.

Prescribe to Prevent: Overdose Prevention and Naloxone Rescue Kits for Prescribers and Pharmacists

In March of 2015, the United States Department of Health and Human Services identified 3 priority areas to reduce opioid use disorders and overdose, which are as follows: opioid-prescribing practices; expanded use and distribution of naloxone; and expansion of medication-assisted treatment. In this narrative review of overdose prevention and the role of prescribers and pharmacists in distributing naloxone, we address these priority areas and present a clinical scenario within the review involving a pharmacist, a patient with chronic pain and anxiety, and a primary care physician. We also discuss current laws related to naloxone prescribing and dispensing. This review was adapted from the Prescribe to Prevent online continuing medical education module created for prescribers and pharmacists (http://www.opioidprescribing.com/naloxone_module_1-landing).