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Lee-Easton MJ, Magura S, Abu-Obaid R, Reed P, Allgaier B, Fish E, Maletta A, Amaratunga P, Lorenz-Lemberg B, Levitas M, Achtyes E. Direct-To-Definitive Urine and Oral Fluid Test Results for Unscreened and Rarely Screened Drugs in Individuals Applying for Methadone Treatment in 7 U.S. States. J Psychoactive Drugs 2024:1-12. [PMID: 38329134 DOI: 10.1080/02791072.2024.2314220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/22/2023] [Indexed: 02/09/2024]
Abstract
The standard protocol in addiction treatment/pain management is to conduct immunoassay screens for major drugs subject to misuse, followed by confirmatory testing of positive results. However, this may miss unscreened or rarely screened drugs that could pose risks, especially to polydrug users. We sought to determine the prevalences of unscreened/rarely screened drugs in a sample of individuals misusing drugs in 7 U.S. states, and to compare the results of urine vs. oral testing for these drugs by direct-to-definitive liquid chromatography/tandem mass spectrometry (LC-MS-MS). The five drugs with the highest prevalences were: gabapentin (16.8%), quetiapine (6.2%), chlorpheniramine (5.3%), hydroxyzine (4.9%), and ephedrine (3.5%). All have clinical significance as indicated by severity of possible side effects, interactions with other drugs, and/or misuse potential. Drugs were generally detected more frequently in oral fluid than urine, but gabapentin was more frequently detected in urine. The prevalences of the included drugs seem high enough, and their clinical significance important enough, to warrant consideration of expanding clinical drug test panels, either by direct-to-definitive testing or the addition of selected immunoassay screens when available. Oral fluid was usually more suitable than urine as the test matrix, given the higher rates of detection in oral fluid for most substances included in this study.
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Affiliation(s)
- Miranda J Lee-Easton
- Evaluation Center, The Evaluation Center at Western Michigan University, Kalamazoo, MI, United States
| | - Stephen Magura
- Evaluation Center, The Evaluation Center at Western Michigan University, Kalamazoo, MI, United States
| | - Ruqayyah Abu-Obaid
- Evaluation Center, The Evaluation Center at Western Michigan University, Kalamazoo, MI, United States
| | - Pete Reed
- Forensic Fluids Laboratories, Kalamazoo, MI, United States
| | | | - Emily Fish
- Forensic Fluids Laboratories, Kalamazoo, MI, United States
| | | | | | | | | | - EricD Achtyes
- School of Medicine, Western Michigan University, Kalamazoo, MI, United States
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Eide D, McDonald R, Hamina A, Clausen T, Odsbu I, Skurtveit S. Prescription high-risk polysubstance use among opioid maintenance treatment patients. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023:104196. [PMID: 37741700 DOI: 10.1016/j.drugpo.2023.104196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 08/01/2023] [Accepted: 09/13/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND Among individuals receiving buprenorphine or methadone as opioid maintenance treatment (OMT), concomitant use of other central nervous system depressants, including prescription drugs, can increase risk of overdose. We aimed to 1) determine the prevalence of use of high-risk prescription drugs (opioid analgesics, benzodiazepines, benzodiazepine-related drugs, and gabapentinoids) among OMT patients, 2) calculate its associations with different mental health and pain-related diagnoses, and 3) compare prevalence of concomitant use with the general population. METHODS A national sample comprising all individuals filling at least one prescription of OMT drugs in Norway in 2019 was formed. Healthcare registry data were linked to investigate high-risk prescription drug use and different diagnoses. We calculated one-year prevalence of use, amount dispensed in defined daily doses (DDDs), and the number of prescribers for the different high-risk prescription drugs. Logistic regression was used to determine associations (adjusted odds ratios; aOR, 95% confidence intervals (CIs)) between diagnoses and use. Prevalence of use was calculated both in the OMT patient sample and the general population. RESULTS Among the OMT patient sample (n=7,299), 47.6% (n=3,476) filled prescriptions for benzodiazepines. For each high-risk prescription drug group, there was a median of 1-2 prescribers. Musculoskeletal diagnoses were the strongest factor for concomitant high-risk prescription drug use for both males (aOR 3.23, CI: 2.72-3.85) and females (aOR 3.07, CI: 2.42- 3.90). The 1-year prevalence of benzodiazepine use was 11.4 times higher for males and 7.1 times higher for females in OMT than the general population. The amount in DDDs was higher for every drug for OMT patients than the general population, particularly for benzodiazepines. CONCLUSIONS OMT patients frequently filled prescriptions for high-risk drugs, and in higher dosages than the general population. However, we found little evidence of 'doctor shopping.' Given that these prescription drugs carry overdose risk, particularly when combined with OMT drugs, our findings emphasize the continued need for education and caution to both prescribers and patients on their concomitant use with OMT.
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Affiliation(s)
- Desiree Eide
- Norwegian Centre for Addiction Research University of Oslo, 166 Kirkeveien 0450 Oslo, Norway.
| | - Rebecca McDonald
- Norwegian Centre for Addiction Research University of Oslo, 166 Kirkeveien 0450 Oslo, Norway
| | - Aleksi Hamina
- Norwegian Centre for Addiction Research University of Oslo, 166 Kirkeveien 0450 Oslo, Norway
| | - Thomas Clausen
- Norwegian Centre for Addiction Research University of Oslo, 166 Kirkeveien 0450 Oslo, Norway
| | - Ingvild Odsbu
- Department of Chronic Diseases Norwegian Institute of Public Health, PO Box 222 Skøyen 0213 Oslo, Norway
| | - Svetlana Skurtveit
- Norwegian Centre for Addiction Research University of Oslo, 166 Kirkeveien 0450 Oslo, Norway; Department of Chronic Diseases Norwegian Institute of Public Health, PO Box 222 Skøyen 0213 Oslo, Norway
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Powell D, Shetty KD, Peet ED. Trends in overdose deaths involving gabapentinoids and Z-drugs in the United States. Drug Alcohol Depend 2023; 249:109952. [PMID: 37301069 DOI: 10.1016/j.drugalcdep.2023.109952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/10/2023] [Accepted: 05/27/2023] [Indexed: 06/12/2023]
Abstract
INTRODUCTION As policies have been implemented to limit access to prescription opioids, other drugs have been prescribed off-label, sometimes concurrently with opioids, to manage pain. There are concerns about the use of gabapentinoids and "Z-drugs" with opioids. As the opioid crisis transitions to illicit opioids and polysubstance use, little work quantifies the concurrent involvement of non-opioid prescription drugs and illicit opioids in overdose deaths. METHODS Data from the census of deaths in the United States for 1999-2020 were used to understand trends in deaths involving gabapentinoids/Z-drugs and opioid co-involvement. These trends were studied overall and by sex, race, age, and education. RESULTS Per capita overdose deaths involving gabapentinoids/Z-drugs increased almost continuously since 1999, averaging 15.8% annual growth. This rate increased to 32% in 2020, primarily due to overdoses involving synthetic opioids. Women typically had higher rates of overdose deaths involving both opioids and gabapentinoids/Z-drugs, though this disparity disappeared in 2020. White Americans and American Indians/Alaskan Natives historically had higher rates than other racial groups; however, Black Americans experienced over 60% annual growth in recent years. Low education groups have been disproportionately impacted. The age incidence tends to be older than overdoses involving opioids more generally. CONCLUSION Overdose deaths involving opioids and gabapentinoids/Z-drugs have tended to disproportionately affect women and older age groups compared to all opioid-involved overdoses. As deaths involving synthetic opioids likely reflect use of illicitly-obtained opioids, there may be less of a role for policies targeting the concurrent prescribing of gabapentinoids/Z-drugs with opioids to reduce these deaths.
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Affiliation(s)
- David Powell
- RAND, 1200 S. Hayes St, Arlington, VA22202, United States.
| | | | - Evan D Peet
- RAND, 4570 Fifth Ave, Pittsburgh, PA15213, United States
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Flynn S, France CP. Effects of Gabapentinoids on Heroin-Induced Ventilatory Depression and Reversal by Naloxone. ACS Pharmacol Transl Sci 2023; 6:519-525. [PMID: 37082751 PMCID: PMC10111619 DOI: 10.1021/acsptsci.2c00230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Indexed: 03/08/2023]
Abstract
Despite an increasing prevalence of gabapentinoids (gabapentin and pregabalin) in opioid overdose deaths, little research has evaluated potentially harmful interactions between gabapentinoids and opioids. This study sought to determine the effects of gabapentinoids on the ventilatory depressive effects of heroin and their reversal by naloxone. Rats were given gabapentin, pregabalin, or saline prior to receiving increasing doses of heroin while ventilation was monitored using whole-body plethysmography. In some sessions naloxone was administered following the largest dose of heroin. The primary outcomes of this study were minute volume and Pause. Heroin dose-dependently reduced minute volume and increased Pause. Administration of naloxone dose-dependently reversed the effects of heroin on ventilation. Gabapentinoids did not alter the ventilatory depressive effects of heroin alone but reduced the potency of naloxone to reverse heroin-induced ventilatory depression. These preliminary findings emphasize the need for further research evaluating interactions between gabapentinoids and opioids related to substance misuse and overdose.
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Affiliation(s)
- Shawn
M. Flynn
- Department
of Pharmacology, University of Texas Health
Science Center at San Antonio, 7703 Floyd Curl Drive, Mail Code 7764, San
Antonio, Texas 78229, United States
- Addiction
Research, Treatment and Training (ARTT) Center of Excellence, University of Texas Health Science Center at San Antonio, San Antonio, Texas 78229, United States
| | - Charles P. France
- Department
of Pharmacology, University of Texas Health
Science Center at San Antonio, 7703 Floyd Curl Drive, Mail Code 7764, San
Antonio, Texas 78229, United States
- Addiction
Research, Treatment and Training (ARTT) Center of Excellence, University of Texas Health Science Center at San Antonio, San Antonio, Texas 78229, United States
- Department
of Psychiatry, University of Texas Health
Science Center at San Antonio, San Antonio, Texas 78229, United States
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Oh GY, Moga DC, Abner EL. Gabapentin utilization among older adults with different cognitive statuses enrolled in the National Alzheimer's Coordinating Center (2006-2019). Br J Clin Pharmacol 2023; 89:410-415. [PMID: 36097795 PMCID: PMC9772139 DOI: 10.1111/bcp.15532] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 08/14/2022] [Accepted: 08/29/2022] [Indexed: 12/24/2022] Open
Abstract
This study aimed to examine gabapentin utilization trends among older adults with different cognitive statuses and investigate concurrent medication use of potentially inappropriate medications. Data were extracted from the National Alzheimer's Coordinating Center Uniform Data Set (2006-2019). We estimated the yearly prevalence of gabapentin use, both overall and within subgroups defined by cognitive status (normal, mild cognitive impairment and dementia) and demographics (age and sex) for participants aged 65+. Additionally, we assessed the prevalence of concurrent use of gabapentin with opioids, combined opioids and benzodiazepine, antidepressant and antipsychotic. From 35 205 eligible older adults (mean age [SD]: 75.7 [7.0]; male: 43.1%), gabapentin use increased from 2006 to 2019 in both overall and every participant subgroup. About 10%-30% of gabapentin users reported to concurrently use opioids, and the concurrent use of gabapentin, opioid and benzodiazepine was up to 7.5% throughout the study period. The frequency of concurrent use with antipsychotics or antidepressants was higher in participants with dementia than those with normal cognition or those who were mildly cognitively impaired. Given increasing use among older adults, rigorous studies are needed to examine the safety of gabapentin in this population.
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Affiliation(s)
- GYeon Oh
- Sanders-Brown Center on Aging, University of Kentucky, Lexington, KY, USA
| | - Daniela C. Moga
- Sanders-Brown Center on Aging, University of Kentucky, Lexington, KY, USA
- Department of Epidemiology, University of Kentucky, Lexington, KY, USA
- Department of Pharmacy Practice and Science, University of Kentucky, Lexington, KY, USA
| | - Erin L. Abner
- Sanders-Brown Center on Aging, University of Kentucky, Lexington, KY, USA
- Department of Epidemiology, University of Kentucky, Lexington, KY, USA
- Department of Biostatistics, University of Kentucky, Lexington, KY, USA
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Ellis MS, Qureshi R, Buttram ME. Understanding motivations and use typologies of gabapentin with opioid agonist medications. Drug Alcohol Depend 2023; 242:109713. [PMID: 36462231 DOI: 10.1016/j.drugalcdep.2022.109713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Prior research suggests a potential relationship between the nonmedical use of gabapentin and use of opioid agonist medications (OAMs), buprenorphine and methadone. However, this research has been limited in scope and understanding despite increases in gabapentin prescribing in opioid use disorder (OUD) treatment settings and increased detection in opioid overdose fatalities. METHODS Data were analyzed for 346 participants of a follow-up program to an ongoing national opioid surveillance program of new entrants to treatment for opioid use disorder. Data were sourced from a cross-sectional online survey distributed in July/August 2021. RESULTS Lifetime exposure to gabapentin was reported by 60.0 % of the sample, while lifetime history of nonmedical use was reported by 43.2 %. Of those nonmedically using gabapentin, 50.0 % did so while also on a dosage of either buprenorphine or methadone, with 28.4 % engaged in concurrent nonmedical use of both gabapentin and OATs. Motivations for concurrent nonmedical use included high-seeking (38.6 %), self-management of pain/physical symptoms (33.3 %), and self-management of OUD (22.2 %). CONCLUSIONS Gabapentin exposure in treatment-seeking persons with OUD appears to be quite common, and use, both medically and nonmedically, frequently occurs alongside OAMs. Motivations for concurrent nonmedical use of gabapentin and OATs mirrors motivations for off-label prescribing by healthcare providers, but may also serve as a form of self-management of OUD when OAM regimens are interrupted, insufficiently prescribed or prescribed at insufficient dosages. Further research should seek to understand the risks versus benefits of gabapentin in OAM treatment settings.
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Affiliation(s)
- Matthew S Ellis
- Washington University in St. Louis, School of Medicine, Department of Psychiatry. St. Louis, MO, USA.
| | - Rida Qureshi
- Washington University in St. Louis, St. Louis, MO, USA
| | - Mance E Buttram
- University of Arkansas, Department of Health, Human Performance & Recreation, Fayetteville, AR, USA
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Sacarny A, Avilova T, Powell D, Williamson I, Merrick W, Jacobson M. A Randomized Trial Of Letters To Encourage Prescription Monitoring Program Use And Safe Opioid Prescribing. Health Aff (Millwood) 2023; 42:140-149. [PMID: 36623221 DOI: 10.1377/hlthaff.2022.00859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
To facilitate safer prescribing of opioids and other drugs, nearly all states operate prescription monitoring programs (PMPs), which collect and share data on controlled substance dispensing. Policy makers have sought to raise clinicians' engagement with these programs but lack evidence on effective interventions. Working with the Minnesota Prescription Monitoring Program, we conducted a randomized trial to assess whether letters to clinicians increased program use and decreased risky coprescribing of opioids with benzodiazepines or gabapentinoids. In March 2021 we randomly assigned 12,000 coprescribers to either a control arm or one of three study arms sent differing letters. The respective letters highlighted a new mandate to check the PMP before prescribing, provided information about coprescribing risks with a list of coprescribed patients, or contained both messages combined. Letters highlighting the mandate alone or along with coprescribing information increased PMP search rates by 4.5 and 4.0 percentage points, respectively, with no significant effect on coprescribing. These letters also increased PMP account-holding rates among clinicians. Effects persisted for at least eight months. The letter with only coprescribing information had no detected effects on key outcomes. Our results support the use of simple letter interventions as evidence-based tools to increase PMP engagement and potentially facilitate better-informed prescribing.
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Affiliation(s)
- Adam Sacarny
- Adam Sacarny , Columbia University, New York, New York
| | | | - David Powell
- David Powell, RAND Corporation, Arlington, Virginia
| | - Ian Williamson
- Ian Williamson, Minnesota Management and Budget Agency, Saint Paul, Minnesota
| | | | - Mireille Jacobson
- Mireille Jacobson, University of Southern California, Los Angeles, California
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Kim TW, Samet JH, Lodi S, Kimmel SD, Forman LS, Lira MC, Liebschutz JM, Williams EC, Walley AY. Functional Impairment and Cognitive Symptoms Among People with HIV Infection on Chronic Opioid Therapy for Pain: The Impact of Gabapentin and Other Sedating Medications. AIDS Behav 2022; 26:3889-3896. [PMID: 35737281 PMCID: PMC11055610 DOI: 10.1007/s10461-022-03716-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2022] [Indexed: 11/01/2022]
Abstract
Gabapentin is associated with dizziness, falls, and somnolence yet commonly prescribed to people with HIV (PWH) treated with chronic opioid therapy (COT). Physical function and cognition are understudied when prescribed together. Among PWH on COT, we evaluated whether co-prescribed gabapentin is associated with (a) functional impairment; (b) trouble thinking clearly; and (c) difficulty controlling drowsiness using logistic regression models adjusted for prescribed opioid dose, other (non-gabapentin) sedating medication, substance use disorder, and mental/physical health indicators in a cross-sectional study. Among 166 participants, 40% were prescribed gabapentin, 41% reported functional impairment, 41% trouble thinking clearly, and 38% difficulty controlling drowsiness. Gabapentin co-prescribed with COT was significantly associated with trouble thinking clearly but not with functional impairment or difficulty controlling drowsiness. Clinicians should be cognizant of potential problems with thinking clearly when co-prescribing gabapentin and opioid medication.
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Affiliation(s)
- Theresa W Kim
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.
| | - Jeffrey H Samet
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA
| | - Sara Lodi
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Simeon D Kimmel
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Leah S Forman
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, USA
| | - Marlene C Lira
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Jane M Liebschutz
- Division of General Internal Medicine, Department of Medicine, Center for Research on Health Care, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Emily C Williams
- Department of Health Services, University of Washington, Seattle, WA, USA
- Veterans Health Administration Health Services Research and Development, Center of Innovation for Veteran-Centered Value-Drive Care, Seattle, WA, USA
| | - Alexander Y Walley
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
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Oh GY, Moga DC, Fardo DW, Abner EL. The association of gabapentin initiation and neurocognitive changes in older adults with normal cognition. Front Pharmacol 2022; 13:910719. [PMID: 36506564 PMCID: PMC9732650 DOI: 10.3389/fphar.2022.910719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 11/08/2022] [Indexed: 11/26/2022] Open
Abstract
Background: Gabapentin is increasingly prescribed to older adults, which raises concerns about its potential to cause neurocognitive changes. Therefore, we aimed to examine the association of gabapentin use with neurocognitive changes (i.e., cognitive decline, functional status decline, and motor function change) in older adults. Methods: We conducted a retrospective cohort study using the National Alzheimer's Coordinating Center Uniform Data Set (UDS; September 2005-March 2021 data freeze). From the eligible sample (≥age 65 years), we identified cognitively normal new-users of gabapentin and the visit they initiated gabapentin (i.e., index visit). Initiators were matched to randomly selected nonusers on year of UDS enrollment and visit number from enrollment to index. Cognitive decline was defined as any increase in the Clinical Dementia Rating global score (CDRGLOB) and as a 1-point increase in CDR sum of boxes (CDR-SB). Functional status decline was defined as a 3-point increase in the sum of the Functional Activities Questionnaire (FAQ) and as 0.3-point increase in mean FAQ. Decline in motor function was defined as new clinician reports of gait disorder, falls, and slowness. To mitigate confounding and selection bias, we used joint stabilized inverse probability of treatment weights and stabilized inverse probability of censoring weights. All analyses were conducted comparing index to index+1 and index+2 visits. Results: From the eligible UDS participants (N = 23,059), we included 480 initiators (mean age [SD]: 78.7 [6.9]; male 34.4%); 4,320 nonusers (78.3 [7.0]; 34.4%). Gabapentin initiation was significantly associated with cognitive/functional status decline: worsening CDRGLOB at index+1 visit (odds ratio [95% confidence interval]: 1.55 [1.07, 2.25]); CDR-SB at index+1 visit (1.94 [1.22, 3.09]); and mean of FAQ at index+2 visit (1.78 [1.12, 2.83]). After excluding initiators with extant motor dysfunction (n = 21), we identified 459 initiators (78.7 [6.9]; 34.0%) and 4,131 nonusers (78.2 [6.9]; 34.7%); in this sample, gabapentin initiation was associated with increased falls at the index+2 visit (2.51 [1.19, 5.31]). Conclusion: Gabapentin initiation was significantly associated with deleterious neurocognitive changes among older adults with initially normal cognition. Further studies are needed to examine the risk/benefit of prescribing gabapentin in older adults.
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Affiliation(s)
- GYeon Oh
- Sanders-Brown Center on Aging, University of Kentucky, Lexington, KY, United States,*Correspondence: GYeon Oh,
| | - Daniela C. Moga
- Sanders-Brown Center on Aging, University of Kentucky, Lexington, KY, United States,Department of Epidemiology and Environmental Health, University of Kentucky, Lexington, KY, United States,Department of Pharmacy Practice and Science, University of Kentucky, Lexington, KY, United States,Institute for Pharmaceutical Outcomes and Policy, University of Kentucky, Lexington, KY, United States
| | - David W. Fardo
- Sanders-Brown Center on Aging, University of Kentucky, Lexington, KY, United States,Department of Biostatistics, University of Kentucky, Lexington, KY, United States
| | - Erin L. Abner
- Sanders-Brown Center on Aging, University of Kentucky, Lexington, KY, United States,Department of Epidemiology and Environmental Health, University of Kentucky, Lexington, KY, United States,Department of Biostatistics, University of Kentucky, Lexington, KY, United States
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Hahn J, Jo Y, Yoo SH, Shin J, Yu YM, Ah YM. Risk of major adverse events associated with gabapentinoid and opioid combination therapy: A systematic review and meta-analysis. Front Pharmacol 2022; 13:1009950. [PMID: 36304170 PMCID: PMC9593000 DOI: 10.3389/fphar.2022.1009950] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 09/12/2022] [Indexed: 07/29/2023] Open
Abstract
Background: The use of opioid-gabapentinoid combinations has increased, raising several safety concerns. However, meta-analysis studies focusing on this issue are limited. Objective: To evaluate the risk of central nervous system (CNS) depression, gastrointestinal (GI) adverse events, and mortality of combination therapy compared with those of opioid therapy and to explore the differences in the results according to study design and indications. Methods: Relevant studies were selected (published before 30 January 2022) by searching the MEDLINE, Embase, and CENTRAL databases. The pooled odds ratios (OR) with 95% confidence intervals (CI) of the outcomes were estimated using the Mantel-Haenszel method. Subgroup and meta-regression analyses were performed according to study characteristics. Quality assessment was conducted using the Risk of Bias 2 tool for randomized controlled trials (RCTs) and Cochrane Collaboration's Risk of Bias in non-RCTs tool for non-randomized trials. Results: Adverse events were reported in 26 RCTs and 7 non-RCTs, and mortality was reported in 10 non-RCTs. Compared to opioid therapy, dizziness, cognitive dysfunction, and respiratory depression in combination therapy significantly increased in non-RCTs (OR 3.26, 95% CI 1.82-5.85; OR 3.13, 95% CI 1.51-6.50; OR 1.71, 95% CI 1.31-2.24, respectively), and a similar trend for dizziness and cognitive dysfunction was also identified in the RCT analysis, although the difference was not significant. Combination therapy for cancer pain was associated with the highest risk of sedation in subgroup analysis. Combination therapy significantly decreased the risk of GI adverse events, including nausea, vomiting, and constipation. The mortality risk associated with combination therapy was higher than that associated with opioid therapy (OR 2.76, 95% CI 1.26-6.05). Conclusion: Opioid-gabapentinoid combination therapy could be associated with an increased risk of CNS depression and mortality, despite tolerable GI adverse events. These data suggest that combination therapy requires close monitoring of CNS depression, especially in cancer patients. Caution is needed in interpreting the clinical meanings owing to the lack of risk difference in respiratory depression in the RCT-only analysis and the absence of RCT or prospective studies investigating mortality.
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Affiliation(s)
- Jongsung Hahn
- School of Pharmacy, Jeonbuk National University, Jeonju, Jeonbuk, South Korea
- KIURI Research Center, Ajou University, Suwon, South Korea
| | - Youngkwon Jo
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon, South Korea
| | - So Hee Yoo
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon, South Korea
| | - Jaekyu Shin
- Department of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco, San Francisco, CA, United States
| | - Yun Mi Yu
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon, South Korea
- Department of Pharmaceutical Medicine and Regulatory Sciences, Colleges of Medicine and Pharmacy, Yonsei University, Incheon, South Korea
| | - Young-Mi Ah
- College of Pharmacy, Yeungnam University, Gyeongsan, Gyeongsangbuk-do, South Korea
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11
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Olopoenia A, Camelo-Castillo W, Qato DM, Adekoya A, Palumbo F, Sera L, Simoni-Wastila L. Adverse outcomes associated with concurrent gabapentin, opioid, and benzodiazepine utilization: A nested case-control study. LANCET REGIONAL HEALTH. AMERICAS 2022; 13:100302. [PMID: 36777316 PMCID: PMC9904085 DOI: 10.1016/j.lana.2022.100302] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Gabapentin, opioids, and/or benzodiazepines are commonly prescribed for a variety of pain and psychiatric conditions. Despite the high likelihood of co-prescription of these medications, little is known about co-utilization of gabapentin (GABA), opioids (OP), and benzodiazepines (BZD) and associated public health outcomes. Methods Using Medicare CCW Data, 2013-2016, we conducted a nested case-control study to examine the association between concurrent utilization of GABA, OP, and BZD and respiratory depression, opioid, and substance-related overdose among Medicare disabled beneficiaries. Cases and controls were Fee-for-service disabled beneficiaries who had a diagnosis of acute pain (AP), chronic pain (CP) or mental health conditions (MH) and received GABA, OP or BZD. Cases with respiratory depression, opioid or substance-related overdose were matched with up to 4 controls on socio-demographics, year of cohort entry and disease risk score. Primary exposure was concurrent medication utilization defined as an overlap of at least one day in prescriptions for GABA, OP and BZD. Findings Across all cohorts, the majority of cases and controls were under 65, female, dually eligible and had prior histories of pain and mental health conditions. GABA+OP+BZD use was associated with increased odds of respiratory depression [AOR(95%CI)-AP: 1.35 (1.19-1.52), CP:1.24 (1.11-1.38) and MH: 1.16 (1.02-1.32) vs. OP only], opioid-related overdose [AP: 1.43 (1.04-1.98), CP: 1.47 (1.07-2.00) and MH: 1.44 (1.04-2.00) vs. OP only], and substance-related overdose [AP: 1.77 (1.26-2.50), CP: 1.70 (1.24-2.34) and MH: 1.92 (1.31-2.82) vs. GABA only]. While there were cohort differences in the association between GABA+OP and both respiratory depression and opioid-related overdose, GABA+OP and GABA+BZD use were associated with significantly higher odds of substance-related overdose across all clinical cohorts. Interpretation Among Medicare disabled beneficiaries, concurrent utilization of gabapentin, opioids, and benzodiazepines is associated with multiple adverse outcomes. Given this, it is imperative that the benefits and risks of co-prescribing these medications be comprehensively examined. Funding None.
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Affiliation(s)
- Abisola Olopoenia
- Department of Pharmaceutical Health Services Research, University of Maryland Baltimore, Baltimore, MD, USA,Corresponding author at: 2671 Avenir Pl, Vienna, VA, 22180.
| | - Wendy Camelo-Castillo
- Department of Pharmaceutical Health Services Research, University of Maryland Baltimore, Baltimore, MD, USA
| | - Danya M. Qato
- Department of Pharmaceutical Health Services Research, University of Maryland Baltimore, Baltimore, MD, USA,School of Medicine, University of Maryland Baltimore, Baltimore, MD, USA
| | - Adepeju Adekoya
- Johns Hopkins Medicine, Department of Anesthesiology & Critical Care Medicine, Division of Chronic Pain Medicine, Baltimore, MD, USA
| | - Frank Palumbo
- Department of Pharmaceutical Health Services Research, University of Maryland Baltimore, Baltimore, MD, USA
| | - Leah Sera
- Department of Pharmacy Practice and Science, University of Maryland Baltimore, Baltimore, MD, USA
| | - Linda Simoni-Wastila
- Department of Pharmaceutical Health Services Research, University of Maryland Baltimore, Baltimore, MD, USA,Peter Lamy Center on Drug Therapy and Aging, University of Maryland Baltimore, Baltimore, MD, USA
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12
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Ellis MS, Buttram ME, Kasper ZA. Nonmedical use of gabapentin and opioid agonist medications in treatment-seeking individuals with opioid use disorder. Drug Alcohol Depend 2022; 234:109400. [PMID: 35290917 DOI: 10.1016/j.drugalcdep.2022.109400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 03/07/2022] [Accepted: 03/07/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND As prescriptions for gabapentin have increased in recent years, nonmedical use and risk of adverse outcomes (e.g., hospitalizations and overdose) have been identified, particularly in association with opioids, including opioid agonist medications (OAMs) buprenorphine and methadone. However, there is a lack of systematic, nationwide data assessing the relationship between the nonmedical use of gabapentin and OAMs. METHODS Data were sourced from two nationwide opioid surveillance programs of treatment-seeking individuals with opioid use disorder (OUD). Both programs utilized an identical serial, cross sectional survey of 12,792 new entrants to one of 163 substance use treatment programs for OUD in 46 states and the District of Columbia from January 2019 to December 2020. RESULTS Past month nonmedical use of gabapentin was endorsed by 9.3% of the sample. Of those using gabapentin nonmedically, 64.1% also endorsed nonmedical use of an OAM, including concomitant use of methadone (35.3%), and buprenorphine (49.0%). Concomitant nonmedical use of gabapentin and OAMs was more prevalent (versus nonmedical use of gabapentin alone) in the Southern region, among those living in a street dwelling, those with chronic pain and healthcare professionals. CONCLUSIONS Nonmedical use of gabapentin in people with OUD appears to frequently coincide with nonmedical use of OAMs. As prescriptions and off-label use of gabapentin increase, provider education should include the risks of concomitant gabapentin and OAM use, particularly amongst buprenorphine prescribers. Future research should investigate motivations (e.g., OUD self-management) for nonmedical use of gabapentin and OAMs within the context of OUD treatment access and retention.
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Affiliation(s)
- Matthew S Ellis
- Washington University in St. Louis, School of Medicine. Department of Psychiatry, St. Louis, MO, USA.
| | - Mance E Buttram
- University of Arkansas, Department of Health, Human Performance & Recreation, Fayetteville, AR, USA
| | - Zachary A Kasper
- Washington University in St. Louis, School of Medicine. Department of Psychiatry, St. Louis, MO, USA
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13
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Kalk NJ, Chiu CT, Sadoughi R, Baho H, Williams BD, Taylor D, Copeland CS. Fatalities associated with gabapentinoids in England (2004-2020). Br J Clin Pharmacol 2022; 88:3911-3917. [PMID: 35435281 PMCID: PMC9543893 DOI: 10.1111/bcp.15352] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/06/2022] [Accepted: 04/08/2022] [Indexed: 11/29/2022] Open
Abstract
The gabapentinoids were reclassified as Schedule II medications and Class C drugs in the UK in 2019 due to their potential misuse. In this study we examined deaths following gabapentinoid use in England reported to the National Programme on Substance Abuse Deaths. A total of 3051 deaths were reported (gabapentin: 913 cases; pregabalin: 2322 cases [both detected in 184 cases]). Prescribed and illicitly obtained gabapentinoids accounted for similar proportions of deaths (gabapentin illicit 38.0%, prescribed 37.1%; pregabalin illicit 41.0%, prescribed 34.6%). Opioids were co‐detected in most cases (92.0%), and co‐prescribed in a quarter (25.3%). Postmortem blood gabapentinoid concentrations were commonly (sub)therapeutic (65.0% of gabapentin cases; 50.8% of pregabalin cases). In only two cases was gabapentinoid toxicity alone attributed in causing death. Gabapentinoids alone rarely cause death. Clinically relevant doses can, however, prove fatal, possibly by reducing tolerance to opioids. Doctors and patients should be aware of this interaction. Gabapentinoid–opioid co‐prescribing needs urgent revision.
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Affiliation(s)
- Nicola J Kalk
- Department of Addictions, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,South London and Maudsley NHS Foundation Trust, KCH Alcohol Care Team, London, UK
| | - Ching-Ting Chiu
- Centre for Pharmaceutical Medicine Research, Institute of Pharmaceutical. Science, King's College London, London, UK
| | - Rasa Sadoughi
- Population Health Research Institute, St George's, University of London, London, UK
| | - Heli Baho
- Population Health Research Institute, St George's, University of London, London, UK
| | | | - David Taylor
- South London and Maudsley NHS Foundation Trust, KCH Alcohol Care Team, London, UK.,Centre for Pharmaceutical Medicine Research, Institute of Pharmaceutical. Science, King's College London, London, UK
| | - Caroline S Copeland
- Centre for Pharmaceutical Medicine Research, Institute of Pharmaceutical. Science, King's College London, London, UK.,Population Health Research Institute, St George's, University of London, London, UK
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14
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Olopoenia A, Camelo-Castillo W, Qato DM, Adekoya A, Palumbo F, Sera L, Simoni-Wastila L. Patterns of opioid and benzodiazepine use with gabapentin among disabled Medicare beneficiaries - A retrospective cohort study. Drug Alcohol Depend 2022; 230:109180. [PMID: 34847506 DOI: 10.1016/j.drugalcdep.2021.109180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 10/18/2021] [Accepted: 10/29/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Our goal was to describe specific patterns associated with co-prescriptions of gabapentin, opioids, and benzodiazepines among disabled Medicare beneficiaries. METHODS Using 2013-2015 Medicare data, we conducted a retrospective cohort study among fee-for-service disabled beneficiaries continuously enrolled in Medicare Parts A, B, and D. The index date was defined as the earliest fill date for a gabapentin, opioid, or benzodiazepine prescription. Monotherapy, dual therapy, and tri-therapy were defined as utilization of one, two, and three medication classes, respectively. Augmentation was defined as a prescription for a different medication class in addition to prescription for initial medication; switching referred to a change in prescription for a different medication class with no subsequent fills of initial medication. We used descriptive statistics, Kaplan Meier analyses and Cox proportional hazards to examine the association between initial therapy and monotherapy, dual therapy, tri-therapy, switching and augmentation. RESULTS Among 151,552 disabled beneficiaries, gabapentin initiators were more likely to augment therapy (50.1%) when compared to opioid (28.7%) and benzodiazepine (38.7%) users. When compared to opioid initiators, the risk of augmentation (HR[95%CI]: 1.85[1.82-1.89]) and switching (1.62 [1.51-1.73]) was significantly higher among gabapentin initiators. Risk of augmentation was also significantly higher among beneficiaries with co-morbid pain and mental health conditions (p < 0.01). Overall, the majority of beneficiaries augmented and switched within 2-months and 4-months after initiating therapy, respectively. CONCLUSIONS Given safety concerns associated with gabapentin, opioids, and benzodiazepines, it is imperative that the benefits and risks of co-prescribing these medications be examined comprehensively, especially for those in vulnerable sub-groups.
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Affiliation(s)
- Abisola Olopoenia
- University of Maryland, Baltimore, Department of Pharmaceutical Health Services Research, 220N. Arch St., Baltimore, MD 21201, United States.
| | - Wendy Camelo-Castillo
- University of Maryland, Baltimore, Department of Pharmaceutical Health Services Research, 220N. Arch St., Baltimore, MD 21201, United States.
| | - Danya M Qato
- University of Maryland, Baltimore, Department of Pharmaceutical Health Services Research, 220N. Arch St., Baltimore, MD 21201, United States; University of Maryland, Baltimore, School of Medicine, 655W. Baltimore St, Baltimore, MD 21201, United States.
| | - Adepeju Adekoya
- Johns Hopkins Medicine, Department of Anesthesiology & Critical Care Medicine, Division of Chronic Pain Medicine, United States.
| | - Frank Palumbo
- University of Maryland, Baltimore, Department of Pharmaceutical Health Services Research, 220N. Arch St., Baltimore, MD 21201, United States.
| | - Leah Sera
- University of Maryland, Baltimore, Department of Pharmacy Practice and Science, United States.
| | - Linda Simoni-Wastila
- University of Maryland, Baltimore, Department of Pharmaceutical Health Services Research, 220N. Arch St., Baltimore, MD 21201, United States; Peter Lamy Center on Drug Therapy and Aging, University of Maryland Baltimore, Baltimore, United States.
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15
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Karavolis ZA, Su AB, Peckham AM. State-level response to gabapentin misuse in the United States: Implications and future direction. Am J Health Syst Pharm 2021; 79:e143-e148. [PMID: 34951456 DOI: 10.1093/ajhp/zxab486] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE Gabapentin misuse is on the rise and has forced many US states to mobilize policies to address this public health concern. The purpose of this manuscript is to update state-level gabapentin misuse-related policies in the US through September 1, 2021, discuss the benefits and risks of current measures, and highlight gaps in national response. METHODS Identification of state and federal district policy changes and deliberations related to gabapentin were searched via internet for all 50 states and 1 federal district (n = 51). Only results from state regulatory bodies, such as the board of pharmacy, or state legislative bodies, such as the senate, were considered for inclusion. RESULTS Results showed that 22 states and federal districts (43.1%) tightened regulation, while another 2 (3.9%) are considering doing so. Of the 22 states and federal districts with policy changes, 15 (68.2%) enrolled gabapentin into their prescription drug monitoring program, while 7 (31.8%) reclassified gabapentin as a Schedule V controlled substance (C-V). CONCLUSION Absent of federal guidance surrounding gabapentin misuse, the onus has fallen on individual states; thus, approaches have ranged from no intervention to reclassification as a C-V. These measures aim to reduce medication supply but fall short of addressing patient outcomes and reducing harm. Therefore, harm reduction-informed public health policies must be implemented to positively impact patient outcomes and enhance safety.
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Affiliation(s)
- Zoe A Karavolis
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, and School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Andrew B Su
- School of Pharmacy, Northeastern University, Boston, MA, USA
| | - Alyssa M Peckham
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
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16
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Aindow S, Crossin R, Toop L, Hudson B. Managing the misuse potential and risk of psychological harm from gabapentinoids in primary care in New Zealand. J Prim Health Care 2021; 13:302-307. [PMID: 34937640 DOI: 10.1071/hc21011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 12/01/2021] [Indexed: 11/23/2022] Open
Abstract
Gabapentinoid prescribing is increasing in New Zealand. International evidence suggests that this prescribing trend is followed by increasing harms, including misuse, dependence, overdose, and psychological harms including suicidal thoughts or behaviours. However, there is limited guidance for prescribers on how to manage these potential harms. Here, we summarise the current international literature and identify three main risk factors that can be used for screening purposes when considering prescribing a gabapentinoid, to identify patients that may be at greater risk of harm. Based on current knowledge of harms, we provide guidance to prescribers on monitoring patients taking gabapentinoids. Finally, we summarise the evidence regarding tapering, and highlight key knowledge gaps including other interventions, referral, and data from primary care populations.
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Affiliation(s)
- Shaun Aindow
- University of Otago Medical School, Christchurch, New Zealand
| | - Rose Crossin
- Department of Population Health, University of Otago Medical School, 34 Gloucester St, Christchurch, New Zealand; and Corresponding author.
| | - Les Toop
- Department of General Practice, University of Otago Medical School, Christchurch, New Zealand
| | - Ben Hudson
- Department of General Practice, University of Otago Medical School, Christchurch, New Zealand
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17
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Riley SB, Garbutt K, Crow C, Isbell TS, Scalzo AJ. Gabapentin prevalence: clinical and forensic experience in St. Louis, Missouri, USA. Forensic Sci Res 2021; 6:218-223. [PMID: 34868714 PMCID: PMC8635626 DOI: 10.1080/20961790.2021.1991075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Gabapentin (Neurontin) is an anti-epileptic drug that has had wide off-label prescription use since market release due to presumed negligible abuse potential. However, trends in drug misuse have demonstrated that gabapentin misuse is occurring, particularly in those with a history of opioid misuse. This is concerning, because although gabapentin has no direct ligand activity at opioid receptors, it does potentiate the analgesic effect of opioids, and concurrent use of gabapentin and opioids may increase the risk of respiratory depressive effects of opioids. This study investigates the incidence of gabapentin detected in urine samples collected for clinical drug screening purposes in a local hospital emergency department and in postmortem samples submitted by medical examiners in the St. Louis metropolitan area. The prevalence of gabapentin and co-detected drugs in both populations is contrasted, compared, and discussed. This study found that 30% of urine samples collected from patients with suspected drug intoxication presenting to SSM Health Saint Louis University Hospital, a quaternary care medical center, were positive for gabapentin, and nearly two thirds of those were also positive for oxycodone. Over a 6-month period, the incidence of gabapentin positive postmortem cases increased from 18% to 20%. Nearly all gabapentin positive postmortem cases were also positive for an opioid, the most significant being fentanyl, suggesting that gabapentin misuse may be due to its potentiating effect of opioid drug action. This study also highlights the limited utility of immunoassay-based urine drug screens.
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Affiliation(s)
- Sarah B Riley
- School of Medicine Department of Pathology, Saint Louis University, St. Louis, Missouri, USA.,School of Medicine Department of Pediatrics, Saint Louis University, St. Louis, Missouri, USA
| | - Kelsie Garbutt
- Department of Sociology and Anthropology, Forensic Sciences Program, Saint Louis University, St. Louis, Missouri, USA
| | - Chelsea Crow
- School of Medicine Department of Pathology, Saint Louis University, St. Louis, Missouri, USA
| | - T Scott Isbell
- School of Medicine Department of Pathology, Saint Louis University, St. Louis, Missouri, USA.,School of Medicine Department of Pediatrics, Saint Louis University, St. Louis, Missouri, USA
| | - Anthony J Scalzo
- Department of Sociology and Anthropology, Forensic Sciences Program, Saint Louis University, St. Louis, Missouri, USA
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18
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Sun X, Keywanlu M, Tayebee R. Experimental and molecular dynamics simulation study on the delivery of some common drugs by ZIF‐67, ZIF‐90, and ZIF‐8 zeolitic imidazolate frameworks. Appl Organomet Chem 2021. [DOI: 10.1002/aoc.6377] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Xiaodong Sun
- Department of Hepatobiliary Surgery The Third Hospital of Jinan Jinan China
| | - Maryam Keywanlu
- Department of Chemistry, School of Sciences Hakim Sabzevari University Sabzevar Iran
| | - Reza Tayebee
- Department of Chemistry, School of Sciences Hakim Sabzevari University Sabzevar Iran
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19
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Duhart Clarke SE, Kral AH, Zibbell JE. Consuming illicit opioids during a drug overdose epidemic: Illicit fentanyls, drug discernment, and the radical transformation of the illicit opioid market. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 99:103467. [PMID: 34662847 DOI: 10.1016/j.drugpo.2021.103467] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 09/09/2021] [Accepted: 09/11/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND North America continues to face an opioid overdose epidemic, driven by persistent increases in illicit fentanyls and fluctuations in potency leading to uncertainty for consumers. This qualitative study was conducted to better understand how people who inject drugs (PWID) came to recognize fentanyl as a growing adulterant of heroin and the subsequent sensory discernment strategies they employed to continue injecting. Our main objective was to investigate how observations and knowledge are combined as homegrown techniques for detecting fentanyl and minimizing risk. Secondary objectives were to examine the impact of growing fentanyl adulteration on individual drug use behavior. METHODS Between April and May 2019, 28 PWID (18 men, 10 women; average age = 38.43 years, SD = 9.26) were purposely recruited from a needle services program in Greensboro, North Carolina. Study participants were interviewed in-person using a qualitative, semi-structured instrument. Interviews were analyzed with a general inductive approach using NVivo12. RESULTS Participants described methods for detecting fentanyl in illicit opioids. Sudden increases in the potency of the 'rush' and sharp decreases in the length of the 'high' were chief indicators along with changes in drug color and texture. Heavy sedation was associated with fentanyl use and histamine-releasing effects characterized as 'pins and needles' were ascribed to injecting fentanyl as a component of the rush. Fentanyl's short high helped explain higher injection frequency and heavy sedation was the leading reason for co-using fentanyl with cocaine/crack or methamphetamine. CONCLUSION PWID have the capacity to recognize changes to the illicit opioid supply. Study participants navigated unpredictable fluctuations in the illicit opioid market by employing homegrown discernment techniques, modifying drug use behavior, and co-using non-opioid drugs. Researchers and policymakers should involve PWID as subject matter experts to help modernize harm reduction for the fentanyl age with practical strategies to boost resiliency and save lives.
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Affiliation(s)
| | - Alex H Kral
- RTI International, Durham, NC, United states
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20
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Lavin RA, Liu C, Yuspeh L, Kalia N, Leung N, Tsourmas NF, Williams L, Hunt DL, Bernacki EJ, Tao XG. Trends in the Utilization and Dose of Gabapentinoids in Combination With Opioids in an Injured Worker Population Between 2008 and 2018. J Occup Environ Med 2021; 63:e694-e700. [PMID: 34354021 DOI: 10.1097/jom.0000000000002344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine long term (11 year) trends in gabapentin and pregabalin prescribing among workers' compensation claimants at various opioid dose combinations (low, medium, high, and very high) in Louisiana. METHOD A longitudinal study of 18,737 claimants who filled any prescriptions between 2008 and 2018. RESULTS The proportion of claimants prescribed opioids alone at all dose levels decreased dramatically. The proportion claimants prescribed the combination of low dose opioids and low dose gabapentinoids increased (7.7% to 10.9%). Prescribing higher daily doses of gabapentinoids was associated with higher daily doses of opioids. Gabapentinoid prescribing was associated with continued prescribing of medium and high dose opioids as claims matured. CONCLUSIONS Overall opioid prescribing decreased over time, while prescribing low dose opioids with gabapentinoids, increased.
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Affiliation(s)
- Robert A Lavin
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland (Dr Lavin); Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland (Dr Lavin, Mr Yuspeh, Dr Kalia, Dr Leung, Dr Tsourmas, Dr Bernacki, and Dr Tao); Occupational and Environmental Medicine Residency Program, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Dr Liu); Strategy, Enterprise Risk, and Research, Louisiana Workers' Compensation Corporation, Baton Rouge, Louisiana (Mr Yuspeh); The General Electric Company, Cincinnati, Ohio (Dr Kalia); Texas Mutual: Workers' Compensation Insurance, Austin, Texas (Dr Leung, Dr Tsourmas, and Dr Williams); Corporate Administration Office, AF Group, Lansing, Michigan (Dr Hunt)
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21
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Abstract
This review summarizes current evidence on the abuse and misuse of the gabapentinoids pregabalin and gabapentin. Pharmacovigilance studies, register-based studies, surveys, clinical toxicology studies, and forensic toxicology studies were identified and scrutinized with the goal to define the problem, identify risk factors, and discuss possible methods to reduce the potential for abuse and misuse. Studies found that gabapentinoids are abused and misused and that individuals with a history of psychiatric disorders or substance use disorder seem to be at high risk. Moreover, some evidence supports the notion that patients with opioid use disorders may be at an increased risk of abusing gabapentinoids. Available evidence also suggests that abuse and misuse are more frequent in users of pregabalin compared with users of gabapentin. Health professionals and prescribers should be aware of the risk for misuse of pregabalin and gabapentin, which eventually could lead to abuse, substance dependence, and intoxications. Prescribing to patients belonging to risk populations such as those with psychiatric disorders or substance use disorder should be avoided if possible and, if prescribed, signs of misuse and abuse should be monitored.
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Affiliation(s)
- Staffan Hägg
- Futurum, Jönköping, Region Jönköping County and Department of Biomedicine and Clinical Sciences, Faculty of Medicine and Health Sciences, Linköping University, Futurum, Hus B4, Ryhov Hospital, S-551 85, Jönköping, Sweden.
| | - Anna K Jönsson
- Division of Drug Research, Department of Biomedicine and Clinical Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
- Department of Forensic Genetics and Forensic Chemistry, National Board of Forensic Medicine, Linköping, Sweden
| | - Johan Ahlner
- Division of Drug Research, Department of Biomedicine and Clinical Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
- Department of Forensic Genetics and Forensic Chemistry, National Board of Forensic Medicine, Linköping, Sweden
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22
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Darke S, Duflou J, Peacock A, Farrell M, Lappin J. Characteristics of fatal gabapentinoid-related poisoning in Australia, 2000-2020. Clin Toxicol (Phila) 2021; 60:304-310. [PMID: 34402696 DOI: 10.1080/15563650.2021.1965159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Gabapentinoids are centrally active GABA agonists whose use has increased substantially in the past decade. The current study aimed to provide a comprehensive clinical profile of a national case series of fatal poisonings related to gabapentinoids. METHODS Retrospective study of all deaths due to drug toxicity in Australia in which gabapentinoids were a contributory mechanism, retrieved from the National Coronial Information System (2000-2020). Information was collected on case characteristics, toxicology and major organ pathology. RESULTS A total of 887 cases were identified, with a mean age of 45.7 years and 55.2% being male. Death was due to accidental toxicity in 81.3% of cases and intentional in 18.7%. Pre-existing disease was co-contributory to drug toxicity in 19.5%. Pregabalin was present in 92.9% of cases, with a median blood concentration of 7.6 mg/L (range 0.1-850.0 mg/L). Gabapentin was present in 7.2%, with a median blood concentration of 9.5 mg/L (range 0.5-1940.0 mg/L). Both pregabalin and gabapentin were present in five cases. No other gabapentinoids were detected. Drugs other than gabapentinoids were present in 99.8%, most frequently opioids (90.1%), hypnosedatives (76.9%) and antidepressants (60.5%). A body mass index in the obese range was seen in 45.4%. Clinically significant pre-existing disease was common, notably cardiomegaly (24.9%), emphysema (20.2%), nephrosclerosis (18.7%) and severe hepatic steatosis (11.7%). CONCLUSIONS The concomitant use of other drugs was close to universal, with CNS depressants predominating. Mental health problems, chronic pain and substance misuse were prominent.
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Affiliation(s)
- Shane Darke
- National Drug & Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Johan Duflou
- National Drug & Alcohol Research Centre, University of New South Wales, Sydney, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia
| | - Amy Peacock
- National Drug & Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Michael Farrell
- National Drug & Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Julia Lappin
- National Drug & Alcohol Research Centre, University of New South Wales, Sydney, Australia.,School of Psychiatry, University of New South Wales, Sydney, Australia
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23
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Oldfield BJ, Li Y, Vickers-Smith R, Becker WC, Barry DT, Crystal S, Gordon KS, Kerns RD, Rentsch CT, Marshall BDL, Edelman EJ. Sociodemographic and clinical correlates of gabapentin receipt with and without opioids among a national cohort of patients with HIV. AIDS Care 2021; 34:1053-1063. [PMID: 34114904 PMCID: PMC8664891 DOI: 10.1080/09540121.2021.1939851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Benjamin J Oldfield
- Yale School of Medicine, New Haven, CT, USA.,Fair Haven Community Health Care, New Haven, CT, USA
| | - Yu Li
- Brown University School of Public Health, Providence, RI, USA
| | - Rachel Vickers-Smith
- Center on Drug and Alcohol Research, Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, KY, USA.,University of Kentucky College of Public Health, Lexington, KY, USA
| | - William C Becker
- Yale School of Medicine, New Haven, CT, USA.,VA Connecticut Healthcare System, West Haven, CT, USA
| | | | - Stephen Crystal
- Center for Health Services Research, Institute for Health, Rutgers University, Rutgers, NJ, USA
| | - Kirsha S Gordon
- Yale School of Medicine, New Haven, CT, USA.,VA Connecticut Healthcare System, West Haven, CT, USA
| | - Robert D Kerns
- Yale School of Medicine, New Haven, CT, USA.,VA Connecticut Healthcare System, West Haven, CT, USA
| | - Christopher T Rentsch
- VA Connecticut Healthcare System, West Haven, CT, USA.,London School of Hygiene and Tropical Medicine, London, UK
| | | | - E Jennifer Edelman
- Yale School of Medicine, New Haven, CT, USA.,Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA
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Zhang Y, Castracane AR, Winstanley EL. Assessment of gabapentin misuse using prescription drug monitoring program data. Subst Abus 2021; 42:454-459. [PMID: 33689673 DOI: 10.1080/08897077.2021.1891602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Gabapentin is an anticonvulsant medication with potential misuse reported in case reports and population studies, highlighting the need to reexamine its abuse liability. The purpose of this study was to describe gabapentin dispensing patterns and assess potential misuse. Methods: We used data from Ohio's Prescription Drug Monitoring Program (PDMP) from December 1, 2016 to March 31, 2017 and restricted the population to adults who filled at least one gabapentin prescription (N = 379,372). Gabapentin dispensing patterns are described and multiple strategies were used to assess potential misuse, including Lorenz-1 curve analysis. Supratherapeutic dosing, number of prescribers and number of pharmacies used were compared for individuals who were co-dispensed medications for opioid use disorder (MOUD) and those who were not. Results: More than one million gabapentin prescriptions were dispensed during the 4-month period, with a mean dose of 1103.8 mg. While few individuals received supratherapeutic dosing, exceptionally high doses were observed. Half of the individuals (50.9%) were co-dispensed gabapentin and opioids. The Lorenz-1 value for gabapentin (5.5%) did not exceed the threshold for misuse potential. Individuals co-dispensed MOUD were more likely to have supratherapeutic dosing; however, they had a lower Lorenz-1 value compared to individuals not co-dispensed MOUD. Conclusions: Among Ohio residents dispensed gabapentin, there was no evidence of misuse using PDMP data based on the Lorenz-1 value, yet supratherapeutic dosing of gabapentin was observed and was associated with OUD. New strategies may be needed to identify the non-medical use of gabapentin.
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Affiliation(s)
- Yifan Zhang
- School of Pharmacy, West Virginia University, Morgantown, West Virginia, USA
| | | | - Erin L Winstanley
- Department of Behavioral Medicine and Psychiatry, School of Medicine and Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA.,Department of Neuroscience, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
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25
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Campbell LS, Coomer TN, Jacob GK, Lenz RJ. Gabapentin controlled substance status. J Am Pharm Assoc (2003) 2021; 61:e218-e224. [PMID: 33674205 DOI: 10.1016/j.japh.2021.01.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/13/2021] [Accepted: 01/17/2021] [Indexed: 11/29/2022]
Abstract
Gabapentin is approved to treat postherpetic neuralgia and epilepsy with partial-onset seizures. The large majority of gabapentin prescribing is off label. Gabapentin may be abused for euphoria, potentiating the high from opiates, reduction of alcohol cravings, a cocaine-like high, as well as sedation or sleep. Individuals at the highest risk for abusing gabapentin include those with opioid abuse, mental illness, or previous history of prescription drug abuse. States are now taking action to track gabapentin use through prescription monitoring programs, and some states have reclassified it as a Schedule V controlled substance. This commentary summarizes gabapentin's abuse potential, identifies state-level actions regarding gabapentin monitoring, and discusses possible clinical implications and ways to enhance patient safety when prescribing gabapentin.
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Wishik G, Gaeta JM, Racine MW, O'Connell JJ, Baggett TP. Substance consumption and intoxication patterns in a medically supervised overdose prevention program for people experiencing homelessness. Subst Abus 2021; 42:851-857. [PMID: 33617749 DOI: 10.1080/08897077.2021.1876201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background: Opioid overdose is a leading cause of death among homeless individuals. Combining psychoactive substances with opioids increases overdose risk. This study aimed to describe intoxication patterns at a drop-in space offering medical monitoring and harm reduction services to individuals who arrive intoxicated and at risk of overdose. Methods: We examined data from visits to the Supportive Place for Observation and Treatment at Boston Health Care for the Homeless Program between January 1, 2017 and December 31, 2017. We used k-means cluster analysis to characterize intoxication patterns based on clinically assessed sedation levels and vital sign parameters. Multinomial logistic regression analysis assessed demographic and substance consumption predictors of cluster membership. Linear and logistic regression models examined associations between cluster membership and care outcomes. Results: Across 305 care episodes involving 156 unique patients, cluster analysis revealed 3 distinct intoxication patterns. Cluster A (26.6%) had mild sedation and normal vital signs. Cluster B (44.5%) featured greater sedation with bradycardia and/or hypotension. Cluster C (28.9%) was comparable to cluster B but with the addition of hypoxia. Self-reported consumption of non-opioid sedatives prior to arrival was common (63.3% of episodes) and predicted membership in cluster B (aOR 2.75, 95% CI 1.40, 5.40) and cluster C (aOR 3.38, 95% CI 1.48, 7.70). In comparison to cluster A episodes, cluster C episodes were longer (mean 4.8 vs. 2.3 hours, p < 0.001) and more likely to require supplemental oxygen (27.3% vs. 2.5%, p < 0.001). Few episodes required hospital transfer (4.7%) or naloxone (1.0%). No deaths occurred. Conclusions: In a medically supervised overdose monitoring program, reported use of non-opioid sedatives strongly predicted more complex clinical courses and should be factored into overdose prevention efforts. Low-threshold medical monitoring in an ambulatory setting was sufficient for most episodes, suggesting a role for such programs in reducing harm and averting costly emergency services.
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Affiliation(s)
- Gabriel Wishik
- Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, Massachusetts, USA
| | - Jessie M Gaeta
- Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, Massachusetts, USA.,Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Melanie W Racine
- Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, Massachusetts, USA
| | - James J O'Connell
- Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, Massachusetts, USA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Travis P Baggett
- Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, Massachusetts, USA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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27
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Ibiloye EA, Barner JC, Lawson KA, Rascati KL, Evoy KE, Peckham AM. Prevalence of and Factors Associated with Gabapentinoid Use and Misuse Among Texas Medicaid Recipients. Clin Drug Investig 2021; 41:245-253. [PMID: 33580482 DOI: 10.1007/s40261-021-01009-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Gabapentin and pregabalin have been considered relatively safe opioid-sparing adjuncts for pain management. However, rising prescribing trends, presence of gabapentinoids in opioid-related overdoses, and the growing body of evidence regarding gabapentinoid misuse and abuse, have caused gabapentinoids to emerge as a drug class of public health concern. This study aimed to assess the prevalence of, and factors associated with gabapentinoid use and misuse. METHODS This retrospective study of Texas Medicaid data from 1/1/2012 to 30/8/2016 included patients aged 18-63 years at index date, with ≥ 1 gabapentinoid prescription, and continuously enrolled 6 months pre-index and 12 months post-index. Gabapentinoid misuse was defined as ≥ 3 claims exceeding daily doses of 3600 mg for gabapentin and 600 mg for pregabalin. Age, gender, concurrent opioid use, neuropathic pain diagnoses and gabapentinoid type were independent variables. Descriptive and inferential statistics were used. RESULTS Of included subjects (N = 39,000), 0.2% (N = 81) met study criteria for gabapentinoid misuse. Overall, the majority (76.4%) of gabapentinoid users were aged 41-63 years with a mean ± SD age of 48.2 ± 10.7 years. Those patients meeting the study criteria for gabapentinoid misuse were significantly younger (45.1 ± 11.0 vs 48.2 ± 10.7, p = 0.0084). Majority of the study sample was female (68.1%). However, a significantly higher proportion of males met the study criteria for gabapentinoid misuse compared to females (0.3% vs 0.2%, p = 0.0079). Approximately one-half (51.9%) of the study sample had neuropathic pain, and gabapentinoid misuse was significantly higher in neuropathic pain patients compared to those without neuropathic pain (0.3% vs 0.1%, p = 0.0078). Over three-quarters (77.4%) of patients were using gabapentin; however, gabapentinoid misuse was significantly higher among pregabalin users (0.4% vs 0.2%, p = 0.0003). Approximately 20% (17.3%) of gabapentinoid users had ≥ 90 days of concurrent opioid use. However, there was no significant difference in gabapentinoid misuse among patients with concurrent opioid use compared to patients without (0.3% vs 0.2%, p = 0.1440). Factors significantly associated with misuse included: male sex (odds ratio [OR] 0.486; 95% confidence interval [CI] 0.313-0.756; p = 0.0013); neuropathic pain (OR 2.065; 95% CI 1.289-3.308; p = 0.0026); and pregabalin versus gabapentin use (OR 2.337, 95% CI 1.492-3.661; p = 0.0002). Concurrent opioid use was not significantly associated with gabapentinoid misuse (OR 1.542, 95% CI 0.920-2.586; p = 0.1006). CONCLUSION Prevalence of gabapentinoid misuse was low (0.2%) among Texas Medicaid recipients. Younger age, male gender, neuropathic pain diagnosis and pregabalin use were significantly associated with higher levels of gabapentinoid misuse.
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Affiliation(s)
- Elizabeth A Ibiloye
- Division of Health Outcomes, College of Pharmacy, University of Texas at Austin, Austin, Texas, USA.
| | - Jamie C Barner
- Division of Health Outcomes, College of Pharmacy, University of Texas at Austin, Austin, Texas, USA
| | - Kenneth A Lawson
- Division of Health Outcomes, College of Pharmacy, University of Texas at Austin, Austin, Texas, USA
| | - Karen L Rascati
- Division of Health Outcomes, College of Pharmacy, University of Texas at Austin, Austin, Texas, USA
| | - Kirk E Evoy
- Pharmacotherapy Division, College of Pharmacy, University of Texas at Austin, San Antonio, Texas, USA
- University Health System, San Antonio, Texas, USA
| | - Alyssa M Peckham
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston, Massachusetts, USA
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
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Evoy KE, Covvey JR, Peckham AM, Reveles KR. Gabapentinoid misuse, abuse and non-prescribed obtainment in a United States general population sample. Int J Clin Pharm 2021; 43:1055-1064. [PMID: 33387188 DOI: 10.1007/s11096-020-01217-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 12/08/2020] [Indexed: 11/24/2022]
Abstract
Background Reports of gabapentinoid (gabapentin and pregabalin) misuse are on the rise, but few studies have assessed this within the general US population. Objective Describe lifetime misuse/abuse/non-prescribed obtainment of gabapentinoids and descriptive characteristics associated with such actions in a US general population sample. Setting This cross-sectional questionnaire was administered online by Qualtrics® research panel aggregator via quota-based sampling. Methods Data were collected from a sample of respondents that mirrored the general US population aged 18-59 years with regards to age, geographic region, ethnicity, income, and education level, based on most recent census data. Misuse/abuse/non-prescribed obtainment was collectively defined as use of a gabapentinoid for reasons other than a diagnosed medical condition, using with the intention of altering one's state of consciousness, or obtaining without a prescription. A multivariable logistic regression model was created to predict misuse/abuse/non-prescribed obtainment of gabapentinoids, incorporating relevant covariates. Main outcome measure Proportion of sample indicating lifetime misuse/abuse/non-prescribed obtainment of gabapentinoids. Results Among 1,843 respondents, 121 (6.6%) reported gabapentinoid misuse/abuse/non-prescribed obtainment. Specifically, 2.1% (n = 39) and 1.5% (n = 27) of respondents for gabapentin and pregabalin, respectively, met study criteria for abuse. Opioids were the most common medication co-administered with gabapentinoids (among 50-70% of respondents) for misuse/abuse. Previous treatment for addiction (OR: 2.61, 95% CI: 1.32-5.14, p = 0.005) and the total attitudinal risk score (OR: 1.14, 95% CI: 1.09-1.19, p < 0.001) were associated with gabapentinoid misuse/abuse/non-prescribed obtainment. Conclusion Among those surveyed, 6.6% reported previous gabapentinoid misuse/abuse/non-prescribed obtainment, providing one of the first estimates within a nationally distributed, US general population sample.
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Affiliation(s)
- Kirk E Evoy
- The University of Texas At Austin College of Pharmacy, 7703 Floyd Curl Dr. - MC 6220, San Antonio, TX, 78229, USA. .,University Health System, San Antonio, TX, USA. .,The University of Texas Health San Antonio School of Medicine, 7703 Floyd Curl Dr. MC - 6220, San Antonio, TX, 78229, USA.
| | - Jordan R Covvey
- Duquesne University School of Pharmacy, 600 Forbes Avenue, 418 Mellon Hall, Pittsburgh, PA, 15282, USA
| | - Alyssa M Peckham
- School of Pharmacy, Northeastern University, Bouvé College of Health Sciences, 360 Huntington Ave, Boston, MA, R218 TF02115, USA.,Department of Pharmacy, Massachusetts General Hospital, 360 Huntington Ave, Boston, MA, R218 TF02115, USA
| | - Kelly R Reveles
- The University of Texas At Austin College of Pharmacy, 7703 Floyd Curl Dr. - MC 6220, San Antonio, TX, 78229, USA.,The University of Texas Health San Antonio School of Medicine, 7703 Floyd Curl Dr. MC - 6220, San Antonio, TX, 78229, USA
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Ameline A, Farrugia A, Raul JS, Kintz P. Toxicological investigations, including hair testing, in a death involving gabapentin. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2020. [DOI: 10.1016/j.toxac.2020.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
BACKGROUND A 2017 systematic review (SR) identified 59 studies examining gabapentinoid (pregabalin and gabapentin) misuse/abuse. Evidence of gabapentinoid misuse/abuse has since grown substantially. OBJECTIVE Update previous SR and describe new insights regarding gabapentinoid abuse. METHODS A SR of PubMed was conducted to identify studies published from 7/29/2016-8/31/2020. Four searches were performed using the following terms: "gabapentin [MeSH] OR pregabalin [MeSH] OR gabapentinoid" AND one of the following substance misuse/abuse-related terms: "substance-related disorders [MeSH]", "overdose", "abuse", or "misuse". Clinicaltrials.gov and the Cochrane Library database were searched to identify ongoing studies or similar SRs. Reference lists of included studies were reviewed to identify additional literature. All studies with novel data related to pregabalin and/or gabapentin abuse, misuse, or overdose conducted during the study period were included. Articles not written in English, review articles, and animal studies were excluded. RESULTS Fifty-five studies were included (29 [52.7%] from North America, 17 [30.9%] Europe, 6 [10.9%] Asia, and 3 [5.5%] Australia). Forty-six observational studies and 10 case reports/series were included (one manuscript included both). Twenty (36.4%) studied gabapentin only, 18 (32.7%) pregabalin only, and 17 (30.9%) both pregabalin/gabapentin. These studies corroborate findings from the previous SR that gabapentinoids are increasingly abused or misused to self-medicate, that gabapentinoids can produce desirable effects alone but are often used concomitantly with other drugs, and that opioid use disorder is the greatest risk factor for gabapentinoid abuse. While the original SR identified the largest studies having been published in Europe, this review identified several more generalisable US studies that have subsequently been conducted. The most concerning finding was increased evidence of associated patient harm, including increased hospital utilisation and opioid-related overdose mortality risk. CONCLUSION Evidence suggests that gabapentinoid misuse/abuse represents a growing trend that is causing significant patient harm. Prescribers should exercise appropriate caution with use in high-risk populations and monitor for signs of misuse or abuse.
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Havens JR, Knudsen HK, Young AM, Lofwall MR, Walsh SL. Longitudinal trends in nonmedical prescription opioid use in a cohort of rural Appalachian people who use drugs. Prev Med 2020; 140:106194. [PMID: 32652132 PMCID: PMC7680378 DOI: 10.1016/j.ypmed.2020.106194] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 06/13/2020] [Accepted: 07/05/2020] [Indexed: 01/22/2023]
Abstract
Rural Appalachia remains an epicenter of the prescription opioid epidemic. In 2008, a cohort study was undertaken to examine longitudinal trends in nonmedical prescription opioid use (NMPOU). Eight waves of data (2008-2020) from the Social Networks among Appalachian People (SNAP) cohort were utilized for the current analysis. Only those who reported recent (past 6-month) NMPOU at baseline are included (n = 498, 99%). Mixed-effects logistic regression was used to model factors associated with NMPOU over time. Recent NMPOU declined significantly over the past decade (p < .001). However, 54.1% of participants still engaged in NMPOU at their most recent follow-up. Receipt of benefits for a physical or mental disability (adjusted odds ratio [aOR]: 3.11, 95% Confidence Interval [CI]: 1.98, 4.90) and self-described poor health status (aOR: 3.67, 95% CI: 1.61, 8.37) were both associated with NMPOU. All treatment modalities (methadone maintenance, residential, outpatient counseling) tested in the model, with the notable exception of detoxification, were associated with significantly lower odds of NMPOU. Although significant declines in prescription opioid misuse were observed in the cohort, more than half of all participants were engaged in NMPOU more than a decade after entering the study. Substance use disorder (SUD) treatment (excluding detoxification) was shown associated with reduced odds of continued NMPOU; therefore, increasing access to evidence-based treatments should be a priority in rural areas affected by the ongoing opioid epidemic.
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Affiliation(s)
- Jennifer R Havens
- Center on Drug and Alcohol Use, University of Kentucky College of Medicine, United States of America; Department of Behavioral Science, University of Kentucky College of Medicine, United States of America.
| | - Hannah K Knudsen
- Center on Drug and Alcohol Use, University of Kentucky College of Medicine, United States of America; Department of Behavioral Science, University of Kentucky College of Medicine, United States of America
| | - April M Young
- Center on Drug and Alcohol Use, University of Kentucky College of Medicine, United States of America; Department of Epidemiology, University of Kentucky College of Public Health, United States of America
| | - Michelle R Lofwall
- Center on Drug and Alcohol Use, University of Kentucky College of Medicine, United States of America; Department of Behavioral Science, University of Kentucky College of Medicine, United States of America
| | - Sharon L Walsh
- Center on Drug and Alcohol Use, University of Kentucky College of Medicine, United States of America; Department of Behavioral Science, University of Kentucky College of Medicine, United States of America
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Pauly NJ, Delcher C, Slavova S, Lindahl E, Talbert J, Freeman PR. Trends in Gabapentin Prescribing in a Commercially Insured U.S. Adult Population, 2009-2016. J Manag Care Spec Pharm 2020; 26:246-252. [PMID: 32105169 PMCID: PMC7155217 DOI: 10.18553/jmcp.2020.26.3.246] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Gabapentin is prescribed for a variety of conditions and is often used off label. It is important to understand the prevalence of gabapentin prescribing and the characteristics of individuals who are prescribed gabapentin, given increasing concern regarding its potential for misuse. OBJECTIVES To (a) examine state- and region-level prevalence and trends in gabapentin prescribing from 2009 to 2016 and (b) characterize demographic and clinical characteristics of individuals prescribed gabapentin in a nationwide population of commercially insured adults. METHODS This retrospective, longitudinal study examined trends in gabapentin prescribing from 2009 to 2016. The study population included individuals aged 18-64 years who were enrolled in a commercial insurance plan at any point from 2009 to 2016. Individuals who were prescribed gabapentin were defined as beneficiaries with at least 1 gabapentin prescription claim in a calendar year (CY). A cross-sectional descriptive analysis was performed to examine differences in demographic and clinical characteristics of individuals prescribed or not prescribed gabapentin in CY 2016. RESULTS The prevalence of gabapentin prescribing nearly doubled from 2009 to 2016. During this time, gabapentin prescribing increased in every state (range: 44%-179%). State-specific prevalence rates in 2016 varied from 12.7 to 43.9 per 1,000 beneficiaries. Overall, 2.7% of beneficiaries filled ≥ 1 gabapentin prescription in 2016. Individuals prescribed gabapentin were more likely to fill opioid prescriptions (60.8% vs. 16.5%, P < 0.01); reside in the South (53.7% vs. 47%, P < 0.01); be female (62.5% vs. 52.3%, P < 0.01); and be aged 55-64 years (41.7% vs. 21.2%, P < 0.01) compared with the comparator. Individuals who were prescribed gabapentin also had significantly higher rates of seizure disorders, neuropathic pain, mental health disorders, substance use disorders, and diabetes. CONCLUSIONS The prevalence of gabapentin prescribing among a U.S. privately insured population has increased steadily in recent years. Additional research should examine coprescribing of gabapentin in the context of the opioid epidemic. DISCLOSURES The project described in this study was supported by the NIH National Center for Advancing Translational Sciences through grant number UL1TR001998. This study was also partially supported by grant number 2017-PM-BX-K026 (Data-Driven Responses to Prescription Drug Misuse in Kentucky) awarded by the Bureau of Justice Assistance. Viewpoints or opinions in this document are those of the authors and do not necessarily represent the official position or policies of the U.S. Department of Justice or the official views of the NIH. The authors do not have any conflicts of interest to report. Portions of this study have been previously presented in poster presentations at the 2019 Academy Health Annual Research Meeting; June 2-4, 2019; Washington, DC, and the 2019 University of Kentucky Substance Use Research Day; March 3, 2019; Lexington, KY.
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Affiliation(s)
- Nathan J. Pauly
- Department of Health Policy, Management, and Leadership, West Virginia University School of Public Health, Morgantown
| | - Chris Delcher
- Institute for Pharmaceutical Outcomes and Policy, University of Kentucky College of Pharmacy, Lexington
| | - Svetla Slavova
- Department of Biostatistics, University of Kentucky College of Public Health, Lexington
| | - Eric Lindahl
- Institute for Pharmaceutical Outcomes and Policy, University of Kentucky College of Pharmacy, Lexington
| | - Jeff Talbert
- Institute for Pharmaceutical Outcomes and Policy, University of Kentucky College of Pharmacy, Lexington
| | - Patricia R. Freeman
- Institute for Pharmaceutical Outcomes and Policy, University of Kentucky College of Pharmacy, Lexington
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Stein MD, Kenney SR, Anderson BJ, Conti MT, Bailey GL. Prescribed and non-prescribed gabapentin use among persons seeking inpatient opioid detoxification. J Subst Abuse Treat 2019; 110:37-41. [PMID: 31952626 DOI: 10.1016/j.jsat.2019.12.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 11/11/2019] [Accepted: 12/12/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Persons with opioid use disorder (OUD) are at increased risk for gabapentin misuse. Rising rates of concomitant gabapentin-opioid use in the U.S. are concerning given heightened risk of fatal overdose. OBJECTIVE To examine predictors of ever using gabapentin among persons seeking treatment for opioid use and to assess if reasons for gabapentin use differed by gender and how gabapentin was procured (prescribed, non-prescribed, or both). METHOD Persons with OUD were recruited from a managed withdrawal program. t-Tests and Pearson χ2 tests of independence were used to compare reasons for gabapentin use by gender and source of acquisition. RESULTS Among participants (n = 401; 69.1% male, 84.5% White, 86.8% sought treatment for heroin use, 90.0% insured), female gender, higher educational attainment, injection drug use (IDU), history of overdose, and chronic pain were associated with gabapentin use. Overall, reasons for use were similar across genders among those reporting a history of gabapentin use (65.8%), although males were more likely to use to get high than females. About half (47.0%) reported only using gabapentin that was not prescribed, 20.5% had only used prescribed gabapentin, and 32.5% reported prescribed and non-prescribed use. Persons prescribed gabapentin were most likely to use it to control pain (81.5%); for those using diverted gabapentin only and those reporting both prescribed and non-prescribed gabapentin use, the most common reasons for intake were to: get high, increase effects of heroin, substitute for opioids, and help with opioid withdrawal. CONCLUSIONS In this sample of people with OUD entering inpatient detoxification program, a majority reported a history of gabapentin use, with most using diverted gabapentin. The range of reasons for gabapentin use point to the need to better understand why co-use is common.
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Affiliation(s)
- Michael D Stein
- Behavioral Medicine Department, Butler Hospital, Providence, RI 02906, United States of America; Boston University School of Public Health, Boston, MA 02118, United States of America
| | - Shannon R Kenney
- Behavioral Medicine Department, Butler Hospital, Providence, RI 02906, United States of America; Warren Alpert Medical School of Brown University, Providence, RI 02912, United States of America.
| | - Bradley J Anderson
- Behavioral Medicine Department, Butler Hospital, Providence, RI 02906, United States of America
| | - Micah T Conti
- Stanley Street Treatment and Resources, Inc., Fall River, MA 02720, United States of America
| | - Genie L Bailey
- Warren Alpert Medical School of Brown University, Providence, RI 02912, United States of America; Stanley Street Treatment and Resources, Inc., Fall River, MA 02720, United States of America
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Reynolds K, Kaufman R, Korenoski A, Fennimore L, Shulman J, Lynch M. Trends in gabapentin and baclofen exposures reported to U.S. poison centers. Clin Toxicol (Phila) 2019; 58:763-772. [DOI: 10.1080/15563650.2019.1687902] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
| | - Robert Kaufman
- University of Pittsburgh, School of Nursing, Pittsburgh, PA, USA
| | | | - Laura Fennimore
- University of Pittsburgh, School of Nursing, Pittsburgh, PA, USA
| | - Joshua Shulman
- Division of Medical Toxicology, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael Lynch
- Pittsburgh Poison Center, Pittsburgh, PA, USA
- Division of Medical Toxicology, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Wei YJJ, Chen C, Fillingim R, Schmidt SO, Winterstein AG. Trends in prescription opioid use and dose trajectories before opioid use disorder or overdose in US adults from 2006 to 2016: A cross-sectional study. PLoS Med 2019; 16:e1002941. [PMID: 31689302 PMCID: PMC6830744 DOI: 10.1371/journal.pmed.1002941] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 09/13/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND With governments' increasing efforts to curb opioid prescription use and limit dose below the Centers for Disease Control and Prevention (CDC)-recommended threshold of 90 morphine milligram equivalents per day, little is known about prescription opioid patterns preceding opioid use disorder (OUD) or overdose. This study aimed to determine prescribed opioid fills and dose trajectories in the year before an incident OUD or overdose diagnosis using a 2005-2016 commercial healthcare database. METHODS AND FINDINGS This cross-sectional study identified individuals aged 18 to 64 years with incident OUD or overdose in the United States. We measured the prevalence of opioid prescription fills and trajectories of opioid morphine equivalent dose (MED) prescribed during the 12-month period before the diagnosis. Of 227,038 adults with incident OUD or overdose, 33.1% were aged 18 to 30 years, 52.9% were males, and 85.0% were metropolitan residents. Half (50.5%) of the patients had a diagnosis of chronic pain, 32.7% had depression, and 20.3% had anxiety. Overall, 79,747 (35.1%) patients filled no opioid prescription in the 12 months before OUD or overdose diagnosis, with the proportion significantly increasing between 2006 and 2016 (adjusted prevalence ratio, 1.86; 95% CI 1.79-1.93; P < 0.001). Patients without (versus with) prescribed opioids tended to be younger males and metropolitan and Northeast US residents. Of 145,609 patients who filled opioid prescriptions, 5 distinct prescribed daily dose trajectories preceding diagnosis emerged: consistent low dose (<3 mg MED, 34.6%), consistent moderate dose (20 mg MED, 27.3%), consistent high dose (150 mg MED, 15.0%), escalating dose (from <3 to 20 mg MED, 13.7%), and de-escalating dose (from 20 to <3mg MED, 9.4%). Overall, over two-thirds of patients with OUD or overdose with prescription opioids were prescribed a mean daily dose below 90 mg MED before diagnosis. Major limitations include the limited generalizability of the study findings and lack of information on out-of-pocket drug spending, race/ethnicity, and socioeconomic status of participants, which prevents analyses addressing these characteristics. CONCLUSIONS In this study, we found that absence of opioid prescription fills in the year before incident OUD or overdose diagnosis was prevalent, and the majority of the patients received prescription opioid doses below the risk threshold of 90 mg MED. An increasing proportion of high-risk patients could be missed by current programs solely based on opioid prescribing and dispensing information in this new era of limited access to prescription opioids.
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Affiliation(s)
- Yu-Jung Jenny Wei
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, United States of America
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida, United States of America
- * E-mail:
| | - Cheng Chen
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, United States of America
| | - Roger Fillingim
- College of Dentistry, University of Florida, Gainesville, Florida, United States of America
- Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, Florida, United States of America
| | - Siegfried O. Schmidt
- Department of Community Health and Family Medicine, College of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Almut G. Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, United States of America
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida, United States of America
- Department of Epidemiology, College of Medicine and College of Public Health & Health Professions, University of Florida, Gainesville, Florida, United States of America
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Jenny Wei YJ, Chen C, Schmidt SO, LoCiganic WH, Winterstein AG. Trends in prior receipt of prescription opioid or adjuvant analgesics among patients with incident opioid use disorder or opioid-related overdose from 2006 to 2016. Drug Alcohol Depend 2019; 204:107600. [PMID: 31586806 PMCID: PMC6927577 DOI: 10.1016/j.drugalcdep.2019.107600] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 06/22/2019] [Accepted: 07/21/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND With increasing efforts to scrutinize and reduce opioid prescribing, limited data exist on the recent trend in receipt of prescription pain medications before diagnosis of opioid use disorder (OUD) or opioid-related overdose (OD). METHODS Using 2005-2016 Truven MarketScan Commercial Claims databases, we assessed trends in annual 1) incidence of OUD or OD and 2) prevalence of receipt of prescription opioids or four commonly-prescribed adjuvant analgesics among patients newly diagnosed with OUD/OD. Trends were examined in the overall sample and by 3 age groups, including youths (≤18 years), adults (19-64 years), and older adults (≥65 years). RESULTS The incidence of diagnosed OUD or OD increased more than 3-fold from 4.99 to 23.81 per 10,000 persons from 2006 to 2016, with the highest increase (14.18-fold) seen in older adults, followed by adults (3.53-fold), and youths (0.16-fold). Between 2006 and 2016, the proportion of patients with incident OUD/OD who received anticonvulsant adjuvant analgesics in the year before diagnosis increased (from 23.4% to 34.3% [P-trend = .005]) whereas the proportion receiving high-dose prescriptions opioids decreased (from 45.5% to 34.8% [P-trend =< .001]). A decreasing trend was observed in general for tricyclic antidepressants and serotonin and norepinephrine reuptake inhibitors. DISCUSSION In US commercially insured patients newly diagnosed with OUD/OD, receipt of high-dose opioid prescriptions preceding the diagnosis decreased over time, paralleled by increased use of anticonvulsants commonly prescribed for pain conditions. Further investigations are warranted to understand how prescribed and anticonvulsants contribute to the development of OUD/OD.
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Affiliation(s)
- Yu-Jung Jenny Wei
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, 1225 Center Drive, Gainesville, Florida 32610, USA,Center for Drug Evaluation and Safety, College of Pharmacy, 1225 Center Drive, Gainesville, Florida 32610, USA
| | - Cheng Chen
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, 1225 Center Drive, Gainesville, Florida 32610, USA
| | - Siegfried O. Schmidt
- Department of Community Health and Family Medicine, University of Florida College of Medicine, 1600 SW Archer Road, Gainesville, Florida 32610, USA
| | - Wei-Hsuan LoCiganic
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, 1225 Center Drive, Gainesville, Florida 32610, USA
| | - Almut G. Winterstein
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, 1225 Center Drive, Gainesville, Florida 32610, USA,Department of Epidemiology, University of Florida Colleges of Medicine and Public Health and Health Professions, 2004 Mowry Road, Gainesville, Florida 32610, USA,Center for Drug Evaluation and Safety, College of Pharmacy, 1225 Center Drive, Gainesville, Florida 32610, USA
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Chatterjee A, Lopez D, Ramkellawan S, Brown R, Smith K, Gaeta JM, Baggett TP. “That’s what we call the cocktail”: Non-Opioid medication and supplement misuse among opioid users. Subst Abus 2019; 42:175-182. [DOI: 10.1080/08897077.2019.1671943] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Avik Chatterjee
- Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, Massachusetts, USA
- Division of Global Health Equity, Department of Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Diego Lopez
- Harvard Medical School, Boston, Massachusetts, USA
| | | | - Rory Brown
- Harvard College, Cambridge, Massachusetts, USA
| | - Kamala Smith
- Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, Massachusetts, USA
| | - Jessie M. Gaeta
- Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, Massachusetts, USA
- Division of General Internal Medicine, Department of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Travis P. Baggett
- Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, Massachusetts, USA
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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De La Vega H, Fox K, Pardi J, Santiago-Tirado W, Cooper G. Validation of a High-throughput Screening and Quantification Method for the Determination of Gabapentinoids in Blood Using a Combination of LC-TOF-MS and LC-MS-MS. J Anal Toxicol 2019; 43:696-702. [PMID: 31436295 DOI: 10.1093/jat/bkz070] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 06/03/2019] [Accepted: 06/06/2019] [Indexed: 01/19/2023] Open
Abstract
Gabapentinoids such as gabapentin (GP) and pregabalin (PGL) have been used to treat a wide range of neurological and psychiatric disorders. In recent years, there has been an increasing awareness of GP and PGL misuse among individuals with a history of polysubstance use. Both GP and PGL are understood to potentiate the effects of opioids, with fatalities involving GP and PGL being reported with increasing frequency. An efficient procedure was developed to screen and quantitate GP and PGL in blood samples using a combination of liquid chromatography time-of-flight mass spectrometry (LC-TOF-MS) and liquid chromatography tandem mass spectrometry (LC-MS-MS). The developed LC-MS-MS method was linear from 0.5-50 mg/L, with a limit of detection (LOD) of 0.1 mg/L for GP and PGL. An LOD of 0.5 mg/L was determined for both analytes on the LC-TOF-MS screen. A total of 1,091 blood specimens were subjected to a protein crash with methanol, in the presence of deuterated internal standards, PGL-d6 and GP-d10, to minimize the effects of varying matrix conditions. Specimens tested included both post-mortem blood and preserved blood specimens collected for the purposes of investigating drug-impaired driving and suspected drug-facilitated crimes. Of the total of specimens tested, 101 (9.3%) screened positive using the developed LC-TOF-MS method for GP while only 13 (1.2%) blood specimens screened positive for PGL. All (100%) of the cases that screened positive for GP and PGL were confirmed positive by LC-MS-MS. Blood concentrations of GP and PGL ranged from <0.5 to 215 mg/L and from <0.5 to 32 mg/L, respectively. Of the blood specimens that had previously screened negative by LC-TOF-MS, 10% (N = 100) were randomly selected and tested by LC-MS-MS with 100% confirmed negative for GP and PGL. The developed methods provide a fast and reliable high-throughput screening and confirmation testing strategy for the detection of GP and PGL in blood specimens.
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Affiliation(s)
- Hilda De La Vega
- Department of Forensic Toxicology, New York City Office of Chief Medical Examiner, New York City, NY 10016 USA
| | - Kim Fox
- Department of Forensic Toxicology, New York City Office of Chief Medical Examiner, New York City, NY 10016 USA
| | - Justine Pardi
- Department of Forensic Toxicology, New York City Office of Chief Medical Examiner, New York City, NY 10016 USA
| | - Wendy Santiago-Tirado
- Department of Forensic Toxicology, New York City Office of Chief Medical Examiner, New York City, NY 10016 USA
| | - Gail Cooper
- Department of Forensic Toxicology, New York City Office of Chief Medical Examiner, New York City, NY 10016 USA
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Gibson CJ, Li Y, Huang AJ, Rife T, Seal KH. Menopausal Symptoms and Higher Risk Opioid Prescribing in a National Sample of Women Veterans with Chronic Pain. J Gen Intern Med 2019; 34:2159-2166. [PMID: 31414358 PMCID: PMC6816610 DOI: 10.1007/s11606-019-05242-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 05/15/2019] [Accepted: 07/09/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND The greatest increases in long-term opioid use and opioid-related overdose mortality in recent years have been among women in midlife. Common menopausal symptoms broadly affect health and health care utilization in midlife, but their contribution to chronic pain management during this period is unknown. OBJECTIVE To examine relationships between menopausal symptoms and long-term opioid prescription patterns among midlife women with chronic pain. DESIGN Cross-sectional analysis of national Veterans Health Administration medical and pharmacy records (2014-2015). PARTICIPANTS Women Veterans aged 45-64 with ≥ 1 outpatient visit and chronic pain diagnoses spanning ≥ 90 days. MAIN MEASURES Long-term opioids (prescribed oral opioids for ≥ 90 days), high-dose long-term opioids (> 50 mg average morphine equivalent daily dose), and long-term opioids co-prescribed with central nervous system depressants (benzodiazepine and non-benzodiazepine sedative-hypnotics, gabapentin/pregabalin, muscle relaxants). Multivariable logistic regression models were used to examine associations between outcomes and menopausal symptoms (menopausal symptom-related diagnoses (i.e., "symptomatic menopausal states") on ≥ 2 encounters and/or menopausal hormone therapy, adjusting for race, age, body mass index, and mental health and substance use disorder diagnoses. KEY RESULTS In this national sample of 104,984 midlife women Veterans with chronic pain (mean age 54.5, SD 5.4 years), 17% had evidence of menopausal symptoms, 51% were prescribed long-term opioids, 13% were prescribed high-dose long-term opioids, and 35% were co-prescribed long-term opioids and central nervous system depressants. In multivariable analyses, women with menopausal symptoms had increased odds of long-term opioids (OR 1.21, 95% CI 1.18-1.26), high-dose long-term opioids (OR 1.08, 95% CI 1.02-1.13), and long-term opioids co-prescribed with central nervous system depressants (sedative-hypnotics OR 1.25, 95% CI 1.22-1.30; gabapentin/pregabalin OR 1.23, 95% CI 1.20-1.27; muscle relaxants OR 1.24, 95% CI 1.20-1.28). CONCLUSIONS Among midlife women Veterans with chronic pain, evidence of menopausal symptoms was associated with potentially risky long-term opioid prescription patterns, independent of known risk factors.
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Affiliation(s)
- Carolyn J Gibson
- San Francisco VA Health Care System, San Francisco, USA.
- University of California, San Francisco, San Francisco, USA.
| | - Yongmei Li
- San Francisco VA Health Care System, San Francisco, USA
| | - Alison J Huang
- University of California, San Francisco, San Francisco, USA
| | - Tessa Rife
- San Francisco VA Health Care System, San Francisco, USA
- University of California, San Francisco, San Francisco, USA
| | - Karen H Seal
- San Francisco VA Health Care System, San Francisco, USA
- University of California, San Francisco, San Francisco, USA
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Reinert JP, Dunn RL. Management of overdoses of loperamide, gabapentin, and modafinil: a literature review. Expert Rev Clin Pharmacol 2019; 12:901-908. [DOI: 10.1080/17512433.2019.1657830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Justin P. Reinert
- Fisch College of Pharmacy, The University of Texas at Tyler, Tyler, TX, USA
| | - Rebecca L. Dunn
- Fisch College of Pharmacy, The University of Texas at Tyler, Tyler, TX, USA
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Nahar LK, Murphy KG, Paterson S. Misuse and Mortality Related to Gabapentin and Pregabalin are Being Under-Estimated: A Two-Year Post-Mortem Population Study. J Anal Toxicol 2019; 43:564-570. [DOI: 10.1093/jat/bkz036] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 02/28/2019] [Accepted: 04/15/2019] [Indexed: 12/19/2022] Open
Abstract
Abstract
Due to the rise in their misuse and associated mortality, the UK government is reclassifying gabapentin (GBP) and pregabalin (PGL) to Class C controlled drugs from April 2019. However, it is impossible to gauge the extent of their use with current post-mortem toxicological screening, where GBP and PGL are only screened for if they are mentioned in the case documents. This study determines the prevalence of GBP and PGL, the potential extent of their under-reporting and poly-drug use in a post-mortem population. Between 1 January 2016 and 31 December 2017, 3,750 deceased from Coroners’ cases in London and South East England underwent a routine drugs screen and a specific screen for GBP and PGL. The prevalence of both drugs was determined in the cohort and the subcategories of heroin users and non-heroin-users. The prevalence of both drugs was compared to tramadol (Class C drug). Case documents were reviewed to investigate the under-reporting of GBP and PGL and poly-drug use. Of 3,750 samples analyzed, 118 (3.1%) were positive for GBP, 229 (6.1%) for PGL and 120 (3.2%) were positive for tramadol. If routine analysis without additional screening of GBP and PGL had been performed in this cohort, GBP would have been under-reported by 57.6% (P < 0.0001) and PGL by 53.7% (P < 0.0001) in deaths. The most common drug group observed with GBP and PGL was non-heroin-related opioids at 60.2% and 64.6%, respectively. In total 354 deceased (9.4%) were heroin users. GBP was positive in 23 (6.5%) of these cases and PGL was positive in 69 (19.5%). The prevalence of PGL in heroin users (19.5%) was 4.1 times greater than in non-heroin users (4.7%) (P < 0.0001). GBP and PGL are being significantly under reported in fatalities. Both drugs are extensively used with opioids. The prevalence of PGL in heroin users is highly significant.
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Affiliation(s)
- Limon Khatun Nahar
- Toxicology Unit, Imperial College London, Charing Cross Campus, St. Dunstan’s Road, London W6 8RP, UK
| | - Kevin G Murphy
- Department of Endocrinology & Metabolism, Imperial College London, London W12 0NN, UK
| | - Sue Paterson
- Toxicology Unit, Imperial College London, Charing Cross Campus, St. Dunstan’s Road, London W6 8RP, UK
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Slavova S, Delcher C, Buchanich JM, Bunn TL, Goldberger BA, Costich JF. Methodological Complexities in Quantifying Rates of Fatal Opioid-Related Overdose. CURR EPIDEMIOL REP 2019; 6:263-274. [PMID: 31259141 PMCID: PMC6559129 DOI: 10.1007/s40471-019-00201-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW Effective responses to the US opioid overdose epidemic rely on accurate and timely drug overdose mortality data, which are generated from medicolegal death investigations (MDI) and certifications of overdose deaths. We identify nuances of MDI and certification of overdose deaths that can influence drug overdose mortality surveillance, as well as recent research, recommendations, and epidemiological tools for improved identification and quantification of specific drug involvement in overdose mortality. RECENT FINDINGS Death certificates are the foundation of drug overdose mortality surveillance. Accordingly, counts and rates of specific drug involvement in overdose deaths are only as accurate as the drug listed on death certificates. Variation in systematic approaches or jurisdictional office policy in drug overdose death certification can lead to bias in mortality rate calculations. Recent research has examined statistical adjustments to improve underreported opioid involvement in overdose deaths. New cause-of-death natural language text analysis tools improve quantification of specific opioid overdose mortality rates. Enhanced opioid overdose surveillance, which combines death certificate data with other MDI-generated data, has the potential to improve understanding of factors and circumstances of opioid overdose mortality. SUMMARY The opioid overdose crisis has brought into focus some of the limitations of US MDI systems for drug overdose surveillance and has given rise to a sense of urgency regarding the pressing need for improvements in our MDI data for public health action and research. Epidemiologists can stimulate positive changes in MDI data quality by demonstrating the critical role of data in guiding public health and safety decisions and addressing the challenges of accurate and timely overdose mortality measures with stakeholders. Education, training, and resources specific to drug overdose surveillance and analysis will be essential as the nation's overdose crisis continues to evolve.
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Affiliation(s)
- Svetla Slavova
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, KY USA
- Kentucky Injury Prevention and Research Center, University of Kentucky, 333 Waller Ave, Suite 242, Lexington, KY 40504 USA
| | - Chris Delcher
- Department of Pharmacy Practice and Science, Institute for Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Kentucky, Lexington, KY USA
| | - Jeannine M. Buchanich
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA USA
| | - Terry L. Bunn
- Kentucky Injury Prevention and Research Center, University of Kentucky, 333 Waller Ave, Suite 242, Lexington, KY 40504 USA
- Department of Preventive Medicine and Environmental Health, College of Public Health, University of Kentucky, Lexington, KY USA
| | - Bruce A. Goldberger
- Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Julia F. Costich
- Kentucky Injury Prevention and Research Center, University of Kentucky, 333 Waller Ave, Suite 242, Lexington, KY 40504 USA
- Department of Health Management and Policy, College of Public Health, University of Kentucky, Lexington, KY USA
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Yuan B, Wu W, Zhang H, Gu H, Guo D, Jiang J, Wang X. Adenomatous polyposis coli as a predictor of environmental chemical-induced transgenerational effects related to male infertility. J Biochem Mol Toxicol 2019; 33:e22331. [PMID: 30934153 DOI: 10.1002/jbt.22331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 02/25/2019] [Accepted: 03/15/2019] [Indexed: 11/10/2022]
Abstract
Exposure to toxic environmental chemicals during pregnancy is a ubiquitous threat to health with potentially transgenerational consequences. However, the underlying mechanism of how transgenerational effects occur as part of environmental chemical exposure are not well understood. We investigated the potential molecular changes associated with dibutyl phthalate exposure that induced transgenerational effects, using a rat model. Through the analysis of the Gene Expression Omnibus database, we found some similar studies of environmental exposure induced transgenerational effects. Then, we analyzed one of the studies and our results to identify the adenomatous polyposis coli (APC) gene. This gene participated the most of the pathways and was upregulated in both studies. We used the miRWALK data set to predict the microRNAs which targeted the APC gene. We confirmed the miR-30 family were significantly downregulated in F3 testis tissues and targeted the APC gene. In conclusion, the miR-30 family/APC interaction is a potential mechanism for the transgenerational effects induced by the environmental chemical.
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Affiliation(s)
- Beilei Yuan
- College of Safety Science and Engineering, Nanjing Tech University, Nanjing, Jiangsu, China.,School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Wei Wu
- School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Huazhong Zhang
- Department of Emergency Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Hao Gu
- School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Dan Guo
- School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Juncheng Jiang
- College of Safety Science and Engineering, Nanjing Tech University, Nanjing, Jiangsu, China
| | - Xinru Wang
- School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China
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Blackmer J, Lindahl E, Strahl A, Schadler A, Freeman PR. Regulating gabapentin as a drug of abuse: A survey study of Kentucky community pharmacists. J Am Pharm Assoc (2003) 2019; 59:379-382. [PMID: 30786971 DOI: 10.1016/j.japh.2018.12.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 12/07/2018] [Accepted: 12/20/2018] [Indexed: 01/17/2023]
Abstract
OBJECTIVES As the number of gabapentin prescriptions has increased, so have reports of its misuse and diversion. This trend has led some states to closer monitoring of gabapentin dispensing through prescription drug monitoring programs (PDMPs). The objective of this study was to collect and analyze Kentucky community pharmacists' perceptions of gabapentin misuse and diversion, and their support or opposition to regulatory efforts to reclassify the drug as a controlled substance (CS). METHODS Responses were collected using an online survey sent by e-mail to all pharmacists practicing in Kentucky in August 2016. The survey collected basic demographic characteristics and pharmacists' experience with gabapentin dispensing. Descriptive statistics were calculated using question response frequencies. Pearson's chi-squared statistics were calculated to examine the distribution of support for gabapentin as a CS in Kentucky across each of the categories of the individual variables. Logistic regression was used to estimate the effects of pharmacist demographic characteristics and experiences with gabapentin on their support of gabapentin reclassification as a CS. RESULTS One thousand seven hundred sixty-nine surveys were collected (response rate = 34.2%). Responding community pharmacists (n = 1084) believe that the abuse and diversion of gabapentin are a problem in their communities, with 9 in 10 (89.6%) indicating that they agree or strongly agree. More than three-fourths (87.5%) indicated support for reclassifying gabapentin as a CS. Common reasons for opposition to gabapentin regulatory changes were that they would not reduce or eliminate abuse (45.8%) and that they would be an inconvenience to patients (17.0%). Pharmacists practicing in independent pharmacies and pharmacists in practice greater than 20 years were less likely to indicate support for gabapentin reclassification. CONCLUSION Kentucky community pharmacists express considerable concern over the possible misuse and diversion of gabapentin and widely support regulatory changes reclassifying gabapentin as a CS.
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