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Hebard S, Weaver G, Hansen WB, Ruppert S. Evaluation of a Pilot Program to Prevent the Misuse of Prescribed Opioids Among Health Care Workers: Repeated Measures Survey Study. JMIR Form Res 2024; 8:e53665. [PMID: 38607664 PMCID: PMC11053396 DOI: 10.2196/53665] [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: 10/25/2023] [Revised: 02/13/2024] [Accepted: 03/13/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND Overprescription of opioids has led to increased misuse of opioids, resulting in higher rates of overdose. The workplace can play a vital role in an individual's intentions to misuse prescription opioids with injured workers being prescribed opioids, at a rate 3 times the national average. For example, health care workers are at risk for injuries, opioid dispensing, and diversion. Intervening within a context that may contribute to risks for opioid misuse while targeting individual psychosocial factors may be a useful complement to interventions at policy and prescribing levels. OBJECTIVE This pilot study assessed the effects of a mobile-friendly opioid misuse intervention prototype tailored for health care workers using the preparation phase of a multiphase optimization strategy design. METHODS A total of 33 health care practitioners participated in the pilot intervention, which included 10 brief web-based lessons aimed at impacting psychosocial measures that underlie opioid misuse. The lesson topics included: addiction beliefs, addiction control, Centers for Disease Control and Prevention guidelines and recommendations, beliefs about patient-provider relationships and communication, control in communicating with providers, beliefs about self-monitoring pain and side effects, control in self-monitoring pain and side effects, diversion and disposal beliefs, diversion and disposal control, and a conclusion lesson. Using a treatment-only design, pretest and posttest surveys were collected. A general linear repeated measures ANOVA was used to assess mean differences from pretest to posttest. Descriptive statistics were used to assess participant feedback about the intervention. RESULTS After completing the intervention, participants showed significant mean changes with increases in knowledge of opioids (+0.459; P<.001), less favorable attitudes toward opioids (-1.081; P=.001), more positive beliefs about communication with providers (+0.205; P=.01), more positive beliefs about pain management control (+0.969; P<.001), and increased intentions to avoid opioid use (+0.212; P=.03). Of the 33 practitioners who completed the program, most felt positive about the information presented, and almost 70% (23/33) agreed or strongly agreed that other workers in the industry should complete a program like this. CONCLUSIONS While attempts to address the opioid crisis have been made through public health policies and prescribing initiatives, opioid misuse continues to rise. Certain industries place workers at greater risk for injury and opioid dispensing, making interventions that target workers in these industries of particular importance. Results from this pilot study show positive impacts on knowledge, attitudes, and beliefs about communicating with providers and pain management control, as well as intentions to avoid opioid misuse. However, the dropout rate and small sample size are severe limitations, and the results lack generalizability. Results will be used to inform program revisions and future optimization trials, with the intention of providing insight for future intervention development and evaluation of mobile-friendly eHealth interventions for employees.
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Affiliation(s)
| | - GracieLee Weaver
- Department of Public Health Education, University of North Carolina Greensboro, Greensboro, NC, United States
| | | | - Scarlett Ruppert
- Department of Public Health Education, University of North Carolina Greensboro, Greensboro, NC, United States
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Villa NAE, Shum K, Atkinson A, Ong A, Muller A, Espiridion E. Opioid Use in Pelvic Fractures: The Impact of Opioid Prescribing Laws in Pennsylvania. Am Surg 2024:31348241241644. [PMID: 38516756 DOI: 10.1177/00031348241241644] [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: 03/23/2024]
Abstract
Pennsylvania's Prescription Drug Monitoring Program (PDMP) was established in 2016, but its impact on opioid use for pelvic fractures is understudied. We compared opioid use in 277 pelvic fracture cases between two periods: 2015-2017 (T1) and 2018-2020 (T2). Outcomes included daily inpatient morphine milligram equivalents (MME), long-term opioid use (LOU) 60-90 days post-discharge, and intermediate-term opioid use (IOU) 30-60 days post-discharge. T1 and T2 had comparable baseline characteristics. T2 was associated with a decrease in average daily inpatient MME (58.6 vs 78.5, P = .02), particularly in younger patients. Regression analyses showed age and Injury Severity Score (ISS) were significant predictors for daily inpatient MME, while time period was not. Geriatric patients in T2 had significantly decreased IOU (30% vs 9%, P = .05). Pelvic fracture type and daily MME predicted IOU, while pelvic fracture type predicted LOU. This study suggests a modest impact of these laws, but further study is needed.
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Affiliation(s)
- Nicole Ann E Villa
- Drexel University College of Medicine at Tower Health, Wyomissing, PA, USA
| | - Kristina Shum
- Drexel University College of Medicine at Tower Health, Wyomissing, PA, USA
| | - Allison Atkinson
- Drexel University College of Medicine at Tower Health, Wyomissing, PA, USA
| | - Adrian Ong
- Department of Surgery, Tower Health Systems, Reading Hospital, West Reading, PA, USA
| | - Alison Muller
- Department of Surgery, Tower Health Systems, Reading Hospital, West Reading, PA, USA
| | - Eduardo Espiridion
- Drexel University College of Medicine at Tower Health, Wyomissing, PA, USA
- Department of Psychiatry, Tower Health Systems, Reading Hospital, West Reading, PA, USA
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Calabrese MJ, Shaya FT, Palumbo F, McPherson ML, Villalonga-Olives E, Zafari Z, Mutter R. State-level policies and receipt of CDC-informed opioid thresholds among commercially insured new chronic opioid users. J Opioid Manag 2024; 20:149-168. [PMID: 38700395 DOI: 10.5055/jom.0824] [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: 05/05/2024]
Abstract
OBJECTIVES To evaluate the association of state-level policies on receipt of opioid regimens informed by Centers for Disease Control and Prevention (CDC) morphine milligram equivalent (MME)/day recommendations. DESIGN A retrospective cohort study of new chronic opioid users (NCOUs). SETTING Commercially insured plans across the United States using IQVIA PharMetrics® Plus for Academics database with new chronic use between January 2014 and March 2015. PARTICIPANTS NCOUs with ≥60-day coverage of opioids within a 90-day period with ≥30-day opioid-free period prior to the date of the first qualifying opioid prescription. INTERVENTIONS State-level policies including Prescription Drug Monitoring Program (PDMP) robustness and cannabis policies involving the presence of medical dispensaries and state-wide decriminalization. MAIN OUTCOME MEASURES NCOUs were placed in three-tiered risk-based average MME/day thresholds: low (>0 to <50), medium (≥50 to <90), and high (≥90). Multinomial logistic regression was used to estimate the association of state-level policies with the thresholds while adjusting for relevant patient-specific factors. RESULTS NCOUs in states with medium or high PDMP robustness had lower odds of receiving medium (adjusted odds ratio [AOR] 0.74; 95 percent confidence interval [CI]: 0.62-0.69) and high (AOR 0.74; 95 percent CI: 0.59-0.92) thresholds. With respect to cannabis policies, NCOUs in states with medical cannabis dispensaries had lower odds of receiving high (AOR 0.75; 95 percent CI: 0.60-0.93) thresholds, while cannabis decriminalization had higher odds of receiving high (AOR 1.24; 95 percent CI: 1.04-1.49) thresholds. CONCLUSION States with highly robust PDMPs and medical cannabis dispensaries had lower odds of receiving higher opioid thresholds, while cannabis decriminalization correlated with higher odds of receiving high opioid thresholds.
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Affiliation(s)
- Martin J Calabrese
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland Baltimore School of Pharmacy; Center for Medicare, Centers for Medicare & Medicaid Services, Baltimore, Maryland. ORCID: https://orcid.org/0000-0003-4304-396X
| | - Fadia T Shaya
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland Baltimore School of Pharmacy, Baltimore, Maryland
| | - Francis Palumbo
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland Baltimore School of Pharmacy, Baltimore, Maryland
| | - Mary Lynn McPherson
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland Baltimore School of Pharmacy, Baltimore, Maryland
| | - Ester Villalonga-Olives
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland Baltimore School of Pharmacy, Baltimore, Maryland
| | - Zafar Zafari
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland Baltimore School of Pharmacy, Baltimore, Maryland
| | - Ryan Mutter
- Congressional Budget Office, Health Analysis Division, Washington, DC
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Joyce G, Zhou B, Kaestner R. Why higher copayments for opioids did not reduce use among Medicare beneficiaries. HEALTH ECONOMICS 2024; 33:466-481. [PMID: 37985466 PMCID: PMC10872383 DOI: 10.1002/hec.4779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 09/21/2023] [Accepted: 10/30/2023] [Indexed: 11/22/2023]
Abstract
To examine whether higher cost-sharing deterred prescription opioid use. Medicare Part D claims from 2007 to 2016 for a 20% random sample of Medicare enrollees. We obtain estimates of the effect of cost-sharing on prescription opioid use using ordinary least squares and instrumental variables methods. In both, we exploit the variation (change) in cost-sharing within plans over time for a sample of beneficiaries who remain in the same plan. Focusing on changes in cost-sharing within a plan for a constant sample of beneficiaries mitigates potential bias from plan selection and using a constant set of weights derived from use in year (t) eliminates changes in the cost-sharing indexes due to (endogenous) consumer choice in year (t+1). Part D plans adopted benefit changes designed to reduce opioid use, including moving opioids to higher cost-sharing tiers. Increasing plan copayments for hydrocodone or oxycodone was associated with reductions in plan-paid claims and offsetting increases in cash claims. Widespread availability of low-cost generics combined with the anti-clawback provision in Part D mediated the effect of higher cost sharing to curb opioid use. As plans moved generic opioids to higher cost-sharing tiers, beneficiaries simply paid cash prices and aggregate use remained largely unchanged. The anti-clawback provision in Part D, intended to protect beneficiaries from price gouging, limited plans' ability to constrain opioid use through typical demand-side measures such as increased cost-sharing.
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Affiliation(s)
- Geoffrey Joyce
- University of Southern California Schaeffer Center for Health Policy and Economics
- USC School of Pharmacy
| | - Bo Zhou
- University of Southern California Schaeffer Center for Health Policy and Economics
- USC School of Pharmacy
| | - Robert Kaestner
- University of Southern California Schaeffer Center for Health Policy and Economics
- Harris School of Public Policy, University of Chicago and NBER
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5
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Hoppe JA, Ledbetter C, Tolle H, Heard K. Implementation of Electronic Health Record Integration and Clinical Decision Support to Improve Emergency Department Prescription Drug Monitoring Program Use. Ann Emerg Med 2024; 83:3-13. [PMID: 37632496 DOI: 10.1016/j.annemergmed.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 06/30/2023] [Accepted: 07/06/2023] [Indexed: 08/28/2023]
Abstract
STUDY OBJECTIVE(S) To evaluate the implementation of 3 electronic health record (EHR)-based interventions to increase prescription drug monitoring program (PDMP) use in the emergency department (ED): EHR-PDMP integration, addition of a PDMP risk score, and addition of EHR-based clinical decision support alert to review the PDMP when prescribing an opioid. METHODS Three intervention stages were implemented using a prospective stepped-wedge design at 5 university-affiliated EDs split into 3 practice groups. The PDMP use and prescribing rates during the 3 stages were compared with baseline before EHR integration and a sustainability stage where the clinical decision support alert was removed, but EHR integration and risk score remained. Generalized linear mixed model with logit link function and a random intercept for clinicians was analyzed. RESULTS The ED provider PDMP review before opioid prescribing was low in all stages. The highest review rate occurred during interruptive clinical decision support alerts, 23.8% (interquartile range 10.6 to 37.5). Overall, opioid prescribing declined, and PDMP review was not associated with a decrease in opioid prescribing. PDMP review was associated with a reduction in the probability of prescribing an opioid as the number of prior opioid prescriptions increased (odds ratio: 0.92 [95% confidence interval: 0.91 to 0.94] for every additional prescription). CONCLUSION The EHR-PDMP integration did not increase PDMP use in the ED, but a PDMP risk score and a clinical decision support alert were associated with modest increases in the probability of PDMP review. When the PDMP is reviewed, ED clinicians are less likely to prescribe opioids to patients with a high number of prior opioid prescriptions.
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Affiliation(s)
- Jason A Hoppe
- Department of Emergency Medicine, University of Colorado, Aurora, CO.
| | - Caroline Ledbetter
- Center for Innovative Design and Analysis, the Colorado School of Public Health, Aurora, CO
| | - Heather Tolle
- Department of Emergency Medicine, University of Colorado, Aurora, CO
| | - Kennon Heard
- Department of Emergency Medicine, University of Colorado, Aurora, CO
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Olsen AA, Dannenbaum JH, Horan T, Niu R, Talmo CT. Correlation of Patient-Reported Preoperative Narcotic Use and Postoperative Requirements in Total Joint Arthroplasty. Orthopedics 2024; 47:34-39. [PMID: 37216566 DOI: 10.3928/01477447-20230517-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Preoperative narcotic use is associated with diminished outcomes and increased complications in patients undergoing primary total joint arthroplasty (TJA). The goal of this study was to compare self-reported and state database identified preoperative narcotic use and correlate it with perioperative narcotic requirements in patients undergoing primary arthroplasty. A total of 788 patients undergoing unilateral TJA from a single institution were examined using self-reported preoperative narcotic use questionnaires and were verified using the Massachusetts Prescriber Awareness Tool (MassPAT). Demographic data, perioperative morphine milligram equivalents, and postdischarge refills were recorded and analyzed. Of the total population, 16.4% of patients undergoing TJA had verified MassPAT narcotics prescriptions preoperatively. Of these patients, 55% accurately reported use to their surgeon. Patients with verified MassPAT narcotic prescriptions required more morphine milligram equivalents than patients without MassPAT prescriptions, regardless of their preoperative self-report at all time points in the study. Patients who accurately reported use required more narcotics than those who did not. Patients with MassPAT prescriptions required more postdischarge refills than patients without MassPAT prescriptions. These data suggest that state-run narcotics databases may be more useful than self-reports for identifying which patients may require more opioids both immediately postoperatively and after hospital discharge. [Orthopedics. 2024;47(1):34-39.].
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Judd D, King CR, Galke C. The Opioid Epidemic: A Review of the Contributing Factors, Negative Consequences, and Best Practices. Cureus 2023; 15:e41621. [PMID: 37565101 PMCID: PMC10410480 DOI: 10.7759/cureus.41621] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2023] [Indexed: 08/12/2023] Open
Abstract
The opioid epidemic is a significant public health crisis that has caused extensive harm and devastation in the United States. This literature review aimed to identify the contributing factors and negative consequences of the epidemic, as well as best practices for healthcare providers in managing the epidemic. Overprescribing opiates and opioids, lack of education and opportunity, and being unmarried or divorced were some of the identified contributing factors to dependence on opioids. The epidemic's negative consequences are substantial, leading to increased access to opioids for vulnerable populations, which consequently cause accidental death among men and the degradation of rural community health services. As part of the literature review, we also analyzed the best practices for healthcare providers, including implementing prescription drug monitoring programs (PDMPs). However, we found that while PDMPs resulted in a decrease in opioid overprescription and an increase in provider confidence when prescribing medication, the evidence for their effectiveness in improving rural community health services or reducing opioid overdoses and opioid-related deaths was inconclusive. Our review highlights that the greatest challenge to overcome is a lack of legal mandates and proper education for healthcare providers on best practices for addressing the epidemic. To regulate and control opioids effectively, tracking and standardizing prescription models by federal agencies and medical institutions is necessary but not enough. Legal action is vital for the successful containment of the opioid crisis.
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Affiliation(s)
- Dallin Judd
- Medicine, Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth, USA
| | - Connor R King
- Marriott School of Business, Brigham Young University, Provo, USA
| | - Curtis Galke
- Family Medicine and OMM, Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth, USA
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Lu H, Zheng J, Wang Y. Geospatial Analysis of Opioid Dispensing Patterns in California: A 2021 Real-World Study. Healthcare (Basel) 2023; 11:1732. [PMID: 37372850 DOI: 10.3390/healthcare11121732] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/04/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023] Open
Abstract
The misuse and abuse of opioids has become a serious public health threat in the United States. The state of California has been hit particularly hard by the opioid epidemic, with a noticeable increase in opioid-related fatalities and hospitalizations. This brief report paper aims to contribute to the growing literature by conducting a geospatial analysis of opioid dispensing patterns in California in 2021. The primary objective was to identify areas characterized by high-risk opioid dispending patterns and explore possible contributing factors. This retrospective study analyzed data from over 7 million records of opioid and benzodiazepine prescriptions dispensed by outpatient pharmacies in California in 2021. A series of generalized linear regression models was employed to assess the impact of neighborhood characteristics on opioid recipients and high-risk opioid dispensing. The study defined high-risk opioid dispensing behavior as: (1) multiple provider episodes, (2) overlapping opioid prescriptions for seven or more days, (3) overlapping opioid and benzodiazepine prescriptions for seven or more days, and (4) a high standardized dosage of opioid prescriptions per month. The study identified variables associated with high-risk opioid dispensing behaviors, including age, population density, income, and housing-related variables, as well as marital status and family-related variables. The study uncovered that there are noticeable disparities in opioid dispensing among different racial and ethnic groups within California. The findings indicated a correlation of high-risk dispensing indicators with certain demographic and socioeconomic factors. There was a substantial regional variation in opioid dispensing practices, with certain rural areas having higher rates of opioid prescriptions than urban areas.
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Affiliation(s)
- Hongxia Lu
- Department of Pharmaceutical Economics and Policy, School of Pharmacy, Chapman University, Irvine, CA 92618, USA
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Jianwei Zheng
- Department of Pharmaceutical Economics and Policy, School of Pharmacy, Chapman University, Irvine, CA 92618, USA
| | - Yun Wang
- Department of Pharmaceutical Economics and Policy, School of Pharmacy, Chapman University, Irvine, CA 92618, USA
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Chhatwal J, Mueller PP, Chen Q, Kulkarni N, Adee M, Zarkin G, LaRochelle MR, Knudsen AB, Barbosa C. Estimated Reductions in Opioid Overdose Deaths With Sustainment of Public Health Interventions in 4 US States. JAMA Netw Open 2023; 6:e2314925. [PMID: 37294571 PMCID: PMC10257094 DOI: 10.1001/jamanetworkopen.2023.14925] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 04/08/2023] [Indexed: 06/10/2023] Open
Abstract
Importance In 2021, more than 80 000 US residents died from an opioid overdose. Public health intervention initiatives, such as the Helping to End Addiction Long-term (HEALing) Communities Study (HCS), are being launched with the goal of reducing opioid-related overdose deaths (OODs). Objective To estimate the change in the projected number of OODs under different scenarios of the duration of sustainment of interventions, compared with the status quo. Design, Setting, and Participants This decision analytical model simulated the opioid epidemic in the 4 states participating in the HCS (ie, Kentucky, Massachusetts, New York, and Ohio) from 2020 to 2026. Participants were a simulated population transitioning from opioid misuse to opioid use disorder (OUD), overdose, treatment, and relapse. The model was calibrated using 2015 to 2020 data from the National Survey on Drug Use and Health, the US Centers for Disease Control and Prevention, and other sources for each state. The model accounts for reduced initiation of medications for OUD (MOUDs) and increased OODs during the COVID-19 pandemic. Exposure Increasing MOUD initiation by 2- or 5-fold, improving MOUD retention to the rates achieved in clinical trial settings, increasing naloxone distribution efforts, and furthering safe opioid prescribing. An initial 2-year duration of interventions was simulated, with potential sustainment for up to 3 additional years. Main Outcomes and Measures Projected reduction in number of OODs under different combinations and durations of sustainment of interventions. Results Compared with the status quo, the estimated annual reduction in OODs at the end of the second year of interventions was 13% to 17% in Kentucky, 17% to 27% in Massachusetts, 15% to 22% in New York, and 15% to 22% in Ohio. Sustaining all interventions for an additional 3 years was estimated to reduce the annual number of OODs at the end of the fifth year by 18% to 27% in Kentucky, 28% to 46% in Massachusetts, 22% to 34% in New York, and 25% to 41% in Ohio. The longer the interventions were sustained, the better the outcomes; however, these positive gains would be washed out if interventions were not sustained. Conclusions and Relevance In this decision analytical model study of the opioid epidemic in 4 US states, sustained implementation of interventions, including increased delivery of MOUDs and naloxone supply, was found to be needed to reduce OODs and prevent deaths from increasing again.
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Affiliation(s)
- Jagpreet Chhatwal
- Institute for Technology Assessment, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Peter P. Mueller
- Institute for Technology Assessment, Massachusetts General Hospital, Boston
| | - Qiushi Chen
- Institute for Technology Assessment, Massachusetts General Hospital, Boston
- Harold and Inge Marcus Department of Industrial and Manufacturing Engineering, The Pennsylvania State University, University Park
| | - Neeti Kulkarni
- Institute for Technology Assessment, Massachusetts General Hospital, Boston
| | - Madeline Adee
- Institute for Technology Assessment, Massachusetts General Hospital, Boston
| | - Gary Zarkin
- RTI International, Research Triangle Park, North Carolina
| | - Marc R. LaRochelle
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
- Boston Medical Center, Boston, Massachusetts
| | - Amy B. Knudsen
- Institute for Technology Assessment, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
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Sahebi-Fakhrabad A, Sadeghi AH, Handfield R. Evaluating State-Level Prescription Drug Monitoring Program (PDMP) and Pill Mill Effects on Opioid Consumption in Pharmaceutical Supply Chain. Healthcare (Basel) 2023; 11:healthcare11030437. [PMID: 36767012 PMCID: PMC9914561 DOI: 10.3390/healthcare11030437] [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: 12/23/2022] [Revised: 01/29/2023] [Accepted: 02/01/2023] [Indexed: 02/09/2023] Open
Abstract
The opioid crisis in the United States has had devastating effects on communities across the country, leading many states to pass legislation that limits the prescription of opioid medications in an effort to reduce the number of overdose deaths. This study evaluates the impact of two categories of PDMP and Pill Mill regulations on the supply of opioid prescriptions at the level of dispensers and distributors (excluding manufacturers) using ARCOS data. The study uses a difference-in-difference method with a two-way fixed design to analyze the data. The study finds that both of the regulations are associated with reductions in the volume of opioid distribution. However, the study reveals that these regulations may have unintended consequences, such as shifting the distribution of controlled substances to neighboring states. For example, in Tennessee, the implementation of Operational PDMP regulations reduces the in-state distribution of opioid drugs by 3.36% (95% CI, 2.37 to 4.3), while the out-of-state distribution to Georgia, which did not have effective PDMP regulations in place, increases by 16.93% (95% CI, 16.42 to 17.44). Our studies emphasize that policymakers should consider the potential for unintended distribution shifts of opioid drugs to neighboring states with laxer regulations as well as varying impacts on different dispenser types.
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Affiliation(s)
- Amirreza Sahebi-Fakhrabad
- Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, NC 27606, USA
- Department of Business Management, Poole College of Management, North Carolina State University, 2806-A Hillsborough St. Building 217, Raleigh, NC 27695, USA
| | - Amir Hossein Sadeghi
- Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, NC 27606, USA
| | - Robert Handfield
- Department of Business Management, Poole College of Management, North Carolina State University, 2806-A Hillsborough St. Building 217, Raleigh, NC 27695, USA
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Bao Y, Zhang H, Bruera E, Portenoy R, Rosa WE, Reid MC, Wen H. Medical Marijuana Legalization and Opioid- and Pain-Related Outcomes Among Patients Newly Diagnosed With Cancer Receiving Anticancer Treatment. JAMA Oncol 2023; 9:206-214. [PMID: 36454553 PMCID: PMC9716439 DOI: 10.1001/jamaoncol.2022.5623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 09/12/2022] [Indexed: 12/03/2022]
Abstract
Importance The past decade saw rapid declines in opioids dispensed to patients with active cancer, with a concurrent increase in marijuana use among cancer survivors possibly associated with state medical marijuana legalization. Objective To assess the associations between medical marijuana legalization and opioid-related and pain-related outcomes for adult patients receiving cancer treatment. Design, Setting, and Participants This cross-sectional study used 2012 to 2017 national commercial claims data and a difference-in-differences design to estimate the associations of interest for patients residing in 34 states without medical marijuana legalization by January 1, 2012. Secondary analysis differentiated between medical marijuana legalization with and without legal allowances for retail dispensaries. Data analysis was conducted between December 2021 and August 2022. Study samples included privately insured patients aged 18 to 64 years who received anticancer treatment during the 6 months after a new breast (in women), colorectal, or lung cancer diagnosis. Exposures State medical marijuana legalization that took effect between 2012 and 2017. Main Outcomes and Measures Having 1 or more days of opioids, 1 or more days of long-acting opioids, total morphine milligram equivalents of any opioid dispensed to patients with 1 or more opioid days, and 1 or more pain-related emergency department visits or hospitalizations (hereafter, hospital events) during the 6 months after a new cancer diagnosis. Interaction terms were included between each policy indicator and an indicator of recent opioids, defined as having 1 or more opioid prescriptions during the 12 months before the new cancer diagnosis. Logistic models were estimated for dichotomous outcomes, and generalized linear models were estimated for morphine milligram equivalents. Results The analysis included 38 189 patients newly diagnosed with breast cancer (38 189 women [100%]), 12 816 with colorectal cancer (7100 men [55.4%]), and 7190 with lung cancer (3674 women [51.1%]). Medical marijuana legalization was associated with a reduction in the rate of 1 or more opioid days from 90.1% to 84.4% (difference, 5.6 [95% CI, 2.2-9.0] percentage points; P = .001) among patients with breast cancer with recent opioids, from 89.4% to 84.4% (difference, 4.9 [95% CI, 0.5-9.4] percentage points; P = .03) among patients with colorectal cancer with recent opioids, and from 33.8% to 27.2% (difference, 6.5 [95% CI, 1.2-11.9] percentage points; P = .02) among patients with lung cancer without recent opioids. Medical marijuana legalization was associated with a reduction in the rate of 1 or more pain-related hospital events from 19.3% to 13.0% (difference, 6.3 [95% CI, 0.7-12.0] percentage points; P = .03) among patients with lung cancer with recent opioids. Conclusions and Relevance Findings of this cross-sectional study suggest that medical marijuana legalization implemented from 2012 to 2017 was associated with a lower rate of opioid dispensing and pain-related hospital events among some adults receiving treatment for newly diagnosed cancer. The nature of these associations and their implications for patient safety and quality of life need to be further investigated.
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Affiliation(s)
- Yuhua Bao
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
- Department of Psychiatry, Weill Cornell Medicine, New York, New York
| | - Hao Zhang
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Russell Portenoy
- MJHS Institute for Innovation in Palliative Care, New York, New York
- Saul R. Korey Department of Neurology, Albert Einstein College of Medicine, New York, New York
- Department of Family and Social Medicine, Albert Einstein College of Medicine, New York, New York
| | - William E. Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Hefei Wen
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
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Margraf AM, Davoodi NM, Chen K, Shield RR, McAuliffe LM, Collins CM, Zullo AR. Provider beliefs about the ideal design of an opioid deprescribing and substitution intervention for older adults. Am J Health Syst Pharm 2023; 80:53-60. [PMID: 36205419 DOI: 10.1093/ajhp/zxac282] [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: 10/01/2022] [Indexed: 01/19/2023] Open
Abstract
PURPOSE Opportunities exist to meaningfully reduce suboptimal prescription opioid use among older adults. Deprescribing is one possible approach to reducing suboptimal use. Appropriate interventions should outline how to carefully taper opioids, closely monitor adverse events, substitute viable alternative and affordable nonopioid pain treatments, and initiate medications for opioid use disorder to properly manage use disorders, as needed. We sought to document and understand provider perceptions to begin developing effective and safe opioid deprescribing interventions. METHODS We conducted 3 semistructured focus groups that covered topics such as participant perspectives on opioid deprescribing in older adults, how to design an ideal intervention, and how to identify potential barriers or facilitators in implementing an intervention. Focus group transcripts were double coded and qualitatively analyzed to identify overarching themes. RESULTS Healthcare providers (n = 17), including physicians, pharmacists, nurses, social workers, and administrative staff, participated in 3 focus groups. We identified 4 key themes: (1) involve pharmacists in deprescribing and empower them as leaders of an opioid deprescribing service; (2) ensure tight integration and close collaboration throughout the deprescribing process from the inpatient to outpatient settings; (3) more expansive inclusion criteria than age alone; and (4) provision of access to alternative pharmacological and nonpharmacological pain management modalities to patients. CONCLUSION Our findings, which highlight various healthcare provider beliefs about opioid deprescribing interventions, are expected to serve as a framework for other organizations to develop and implement interventions. Future studies should incorporate patients' and family caregivers' perspectives.
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Affiliation(s)
- Alissa M Margraf
- Department of Pharmacy, Rhode Island Hospital and Lifespan Corporation, Providence, RI, USA
| | | | - Kevin Chen
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Renee R Shield
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Laura M McAuliffe
- Department of Pharmacy, Rhode Island Hospital and Lifespan Corporation, Providence, RI, USA
| | - Christine M Collins
- Department of Pharmacy, Rhode Island Hospital and Lifespan Corporation, Providence, RI, USA
| | - Andrew R Zullo
- Department of Pharmacy, Rhode Island Hospital, Providence, RI.,Departments of Epidemiology, Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
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Hijji FY, Sanda T, Huff SD, Froehle AW, Henningsen JD, Schneider AD, Lyons JG, Mian HM, Jerele J, Venkatarayappa I. Accuracy of self-reported opioid use in orthopaedic trauma patients. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:185-190. [PMID: 34981218 DOI: 10.1007/s00590-021-03178-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 11/27/2021] [Indexed: 01/07/2023]
Abstract
PURPOSE Opioids have long been a mainstay of treatment for pain in patients with orthopaedic injuries, but little is known about the accuracy of self-reported narcotic usage in orthopaedic trauma. The purpose of this study is to evaluate the accuracy of self-reported opioid usage in orthopaedic trauma patients. METHODS A retrospective review of all new patients presenting to the orthopaedic trauma clinic of a level 1 trauma centre with a chief complaint of recent orthopaedic-related injury over a 2-year time frame was conducted. Participants were administered a survey inquiring about narcotic usage within the prior 3 months. Responses were cross-referenced against a query of a statewide prescription drug monitoring program system. RESULTS The study comprised 241 participants; 206 (85.5%) were accurate reporters, while 35 (14.5%) were inaccurate reporters. Significantly increased accuracy was associated with hospital admission prior to clinic visit (β = - 1.33; χ2 = 10.68, P < 0.01; OR: 0.07, 95% CI 0.01-0.62). Decreased accuracy was associated with higher pre-visit total morphine equivalent dose (MED) (β = 0.002; χ2 = 11.30, P < 0.01), with accurate reporters having significantly lower pre-index visit MED levels compared to underreporters (89.2 ± 208.7 mg vs. 249.6 ± 509.3 mg; P = 0.04). An Emergency Department (ED) visit prior to the index visit significantly predicted underreporting (β = 0.424; χ2 = 4.28, P = 0.04; OR: 2.34, 95% CI 1.01-5.38). CONCLUSION This study suggests that most new patients presenting to an orthopaedic trauma clinic with acute injury will accurately report their narcotic usage within the preceding 3 months. Prior hospital admissions increased the likelihood of accurate reporting while higher MEDs or an ED visit prior to the initial visit increased the likelihood of underreporting.
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Affiliation(s)
- Fady Y Hijji
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
| | - Tyler Sanda
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
| | - Scott D Huff
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
| | - Andrew W Froehle
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
| | - Joseph D Henningsen
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
| | - Andrew D Schneider
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
| | - Joseph G Lyons
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, USA.
| | - Humza M Mian
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
| | - Jennifer Jerele
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
| | - Indresh Venkatarayappa
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
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The Geography of Pain in the United States and Canada. THE JOURNAL OF PAIN 2022; 23:2155-2166. [PMID: 36057388 PMCID: PMC9927593 DOI: 10.1016/j.jpain.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 08/07/2022] [Accepted: 08/12/2022] [Indexed: 01/04/2023]
Abstract
Pain epidemiologists have, thus far, devoted scant attention to geospatial analyses of pain. Both cross-national and, especially, subnational variation in pain have been understudied, even though geographic comparisons could shed light on social factors that increase or mitigate pain. This study presents the first comparative analysis of pain in the U.S. and Canada, comparing the countries in aggregate, while also analyzing variation across states and provinces. Analyses are based on cross-sectional data collected in 2020 from U.S. and Canadian adults 18 years and older (N = 4,113). The focal pain measure is a product of pain frequency and pain interference. We use decomposition and regression analyses to link socioeconomic characteristics and pain, and inverse-distance weighting spatial interpolation to map pain levels. We find significantly and substantially higher pain in the U.S. than in Canada. The difference is partly linked to Americans' worse economic conditions. Additionally, we find significant pain variability within the U.S. and Canada. U.S. states in the Deep South, Appalachia, and parts of the West stand out as pain 'hotspots' with particularly high pain levels. Overall, our findings identify areas with a high need for pain prevention and management; they also urge further scholarship on geographic factors as important covariates in population pain. PERSPECTIVE: This study documents the high pain burden in the U.S. versus Canada, and points to states in the Deep South, Appalachia, and parts of the West as having particularly high pain burden. The findings identify geographic areas with a high need for pain prevention and management.
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15
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Shah KN, Reid DBC, Ruddell JH, Shapiro BH, James P, Gil JA, Daniels AH, Akelman E. Is Opioid-Limiting Legislation Effective for Hand Surgery Patients? Hand (N Y) 2022; 17:1139-1146. [PMID: 33530762 PMCID: PMC9608291 DOI: 10.1177/1558944720988132] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The Rhode Island State Legislature passed the Uniform Controlled Substances Act in 2016 to limit opioid prescriptions. We aimed to objectively evaluate its effect on opioid prescribing for hand surgery patients and also identify risk factors for prolonged opioid use. METHODS A 6-month period (January-June 2016) prior to passage of the law was compared with a period following its implementation (July-December 2017). Thumb carpometacarpal arthroplasty and distal radius fracture fixation were classified as "major surgery" and carpal tunnel and trigger finger release as "minor surgery." Prescription Drug Monitoring Database was used to review controlled substances filled during the study periods. RESULTS A total of 1380 patients met our inclusion criteria, with 644 prelaw and 736 postlaw patients. Patients undergoing "major surgery" saw a significant decrease in the number of pills issued in the first postoperative prescription (41.1 vs 21.0) and a corresponding decrease in morphine milligram equivalents (MMEs) (318.6 vs 159.2 MMEs) after implementation. A 30% decrease in MMEs was also seen in those undergoing "major surgery" in the first 30 days postoperatively (544.7 vs 381.7 MMEs). Risk factors for prolonged opioid use included male sex and preoperative opioid use. CONCLUSIONS In Rhode Island, opioid-limiting legislation resulted in a significant decrease in the number of pills and MMEs of the initial prescription and a 30% decrease in total MMEs in the 30-day postoperative period after "major hand surgery." Additional research is needed to explore the association between legislation and clinical outcomes.
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Dahlem CH, Schepis TS, McCabe SE, Rank AL, Teter CJ, Kcomt L, McCabe VV, Voepel-Lewis T. Prescription Opioid Misuse in Older Adult Surgical Patients: Epidemiology, Prevention, and Clinical Implications. J Addict Nurs 2022; 33:218-232. [PMID: 37140410 PMCID: PMC10162467 DOI: 10.1097/jan.0000000000000488] [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] [Indexed: 05/05/2023]
Abstract
ABSTRACT The United States and many other developed nations are in the midst of an opioid crisis, with consequent pressure on prescribers to limit opioid prescribing and reduce prescription opioid misuse. This review addresses prescription opioid misuse for older adult surgical populations. We outline the epidemiology and risk factors for persistent opioid use and misuse in older adults undergoing surgery. We also address screening tools and prescription opioid misuse prevention among vulnerable older adult surgical patients (e.g., older adults with a history of an opioid use disorder), followed by clinical management and patient education recommendations. A significant plurality of older adults engaged in prescription opioid misuse obtain opioid medication for misuse from health providers. Thus, nurses can play a critical role in identifying those older adults at a higher risk for misuse and deliver quality care while balancing the need for adequate pain management against the risk for prescription opioid misuse.
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Affiliation(s)
- Chin Hwa Dahlem
- Center for the Study of Drugs, Alcohol, Smoking and Health, Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
| | - Ty S. Schepis
- Center for the Study of Drugs, Alcohol, Smoking and Health, Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
- Department of Psychology, Texas State University, San Marcos, Texas, USA
| | - Sean Esteban McCabe
- Center for the Study of Drugs, Alcohol, Smoking and Health, Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Social Research, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Research on Women and Gender, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Aaron L. Rank
- Department of Anesthesiology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Regional One Physicians, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Christian J. Teter
- Center for the Study of Drugs, Alcohol, Smoking and Health, Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
- Department of Pharmacy, Research Pharmacy Core, McLean Hospital, Belmont, Massachusetts, USA
- Marblehead NeuroPsychiatric Rx, LLC, Marblehead, Massachusetts, USA
| | - Luisa Kcomt
- Center for the Study of Drugs, Alcohol, Smoking and Health, Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
| | - Vita V. McCabe
- Center for the Study of Drugs, Alcohol, Smoking and Health, Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Terri Voepel-Lewis
- Center for the Study of Drugs, Alcohol, Smoking and Health, Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
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Zavodnick J, Wickersham A, Petok A, Worster B, Leader A. "1,000 conversations I'd rather have than that one:" A qualitative study of prescriber experiences with opioids and the impact of a prescription drug monitoring program. J Addict Dis 2022; 40:527-537. [PMID: 35133217 PMCID: PMC9357854 DOI: 10.1080/10550887.2022.2035168] [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] [Indexed: 10/19/2022]
Abstract
BACKGROUND Prescription Drug Monitoring Programs (PDMPs) have shown impacts on a number of opioid-related outcomes but their role in clinician emotional experience of opioid prescribing has not been studied. OBJECTIVES This study explores the impact of PDMPs on clinician attitudes toward and comfort with opioid prescribing, their satisfaction with patient interactions involving discussion of opioid prescriptions, and their recognition of opioid use disorder (OUD) and ability to refer patients to treatment. METHODS Researchers conducted semi-structured interviews with five physicians and two nurse practitioners from a variety of specialties and practice environments. RESULTS Many participants reported negative emotions surrounding opioid-related patient encounters, with decreased anxiety related to PDMP availability. These effects were less pronounced with clinicians who had greater opioid prescribing experience (either longer careers or higher-volume pain practices). Many participants felt uncomfortable around opioid prescribing. Data from the PDMP often changed prescribing practices, sometimes leading to greater comfort writing a prescription that might have felt riskier without PDMP data. Clinicians easily recognized patient behaviors, symptoms, and prescription requests suggesting that opioid-related adverse events were accumulating, but did not usually apply a label of OUD to these situations. PDMP findings occasionally contributed to a diagnosis and treatment referral for OUD. CONCLUSIONS PDMP data is part of a nuanced approach to prescribing opioids. The objectivity of the data may be helpful in mitigating clinician negative emotions that are common around opioid therapy.
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Affiliation(s)
- Jillian Zavodnick
- Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University
| | - Alexis Wickersham
- Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University
| | - Alison Petok
- Division of Infectious Diseases, Massachusetts General Hospital
| | - Brooke Worster
- Department of Medical Oncology, Sidney Kimmel Medical College at Thomas Jefferson University
| | - Amy Leader
- Department of Medical Oncology, Sidney Kimmel Medical College at Thomas Jefferson University
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18
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Giordano NA, Seilern Und Aspang J, Baker J, Medline A, Rice CW, Barrell B, Kirk L, Ortega E, Wallace M, Steck A, Schenker ML. Integration of Life Care Specialists Into Orthopaedic Trauma Care to Improve Postoperative Outcomes: A Pilot Study. Pain Manag Nurs 2022; 23:608-615. [PMID: 35477669 DOI: 10.1016/j.pmn.2022.03.010] [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: 10/25/2021] [Revised: 03/08/2022] [Accepted: 03/23/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND AIM: This pilot study assessed the feasibility and impact of integrating a Life Care Specialist (LCS) into orthopaedic trauma care. DESIGN This was a prospective feasibility single group pilot study at a level 1 trauma center. METHOD The LCS is a paraprofessional behavior-based "pain coach" and delivered patient-centered opioid safety education, trained participants on nonpharmacologic pain management approaches, conducted opioid risk assessments, and coordinated care. Numeric Rating Scale pain scores were assessed on admission, at discharge, and at 2-week follow-up. Daily morphine milligram equivalents (MME) during hospitalization, opioid medication use at 2-weeks, and patient satisfaction were recorded. T test compared mean morphine milligram equivalents (MME) to historical orthopaedic trauma patient population's mean dosage at discharge from the study site. Generalized linear models assessed pain scores over time. RESULTS Twenty-two percent of 121 total participants met criteria for moderate to severe risk of opioid misuse at initial hospitalization. On average, 2.8 LCS pain management interventions were utilized, most frequently progressive muscle relaxation (80%) and sound therapy (48%). Mean inpatient MME/day was 40.5, which was significantly lower than mean historical MME/day of 49.7 (p < .001). Pain scores improved over time from admission to 2-weeks postoperatively (p < .001). Nearly all participants agreed that the LCS was helpful in managing pain (99%). CONCLUSIONS The findings indicate feasibility to integrate LCS into orthopaedic trauma care, evident by participant engagement and satisfaction, and that LCS serve as valuable resources to assist with pain management and opioid education.
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Affiliation(s)
| | | | - J'Lynn Baker
- Emory University Orthopaedic Surgery, Grady Memorial Hospital, Atlanta, Georgia
| | - Alexandra Medline
- Emory University Orthopaedic Surgery, Grady Memorial Hospital, Atlanta, Georgia
| | | | | | | | - Erika Ortega
- Emory University Orthopaedic Surgery, Grady Memorial Hospital, Atlanta, Georgia
| | | | - Alaina Steck
- Emory University Department of Emergency Medicine, Grady Memorial Hospital, Atlanta, Georgia
| | - Mara L Schenker
- Emory University Orthopaedic Surgery, Grady Memorial Hospital, Atlanta, Georgia; Grady Memorial Hospital, Atlanta, Georgia.
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Ellyson AM, Grooms J, Ortega A. Flipping the script: The effects of opioid prescription monitoring on specialty-specific provider behavior. HEALTH ECONOMICS 2022; 31:297-341. [PMID: 34773311 DOI: 10.1002/hec.4446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 08/20/2021] [Accepted: 10/05/2021] [Indexed: 06/13/2023]
Abstract
Mandatory access Prescription Drug Monitoring Programs (MA-PDMPs) aim to curb the epidemic at a common point of initiation of use, the prescription. However, there is recent concern about whether opioid policies have been too restrictive and reduced appropriate access to patients with the most need for opioid pharmaceuticals. We assess MA-PDMP's effect on specialty-specific opioid prescribing behavior of Medicare providers. Our findings suggest that requiring providers to query a PDMP differentially affects opioid prescribing across provider specialties. We find a three to four percent decrease in prescribing for Primary Care and Internal Medicine providers. This result is driven by healthcare providers at the lower end of the prescribing distribution. There is also suggestive evidence of an increase in opioid use disorder treatment drugs prescribed by these same providers. We also find no evidence for the hypothesis that MA-PDMPs restrict prescribing by providers who treat patients with potentially high levels of pain, few drug substitutes, or urgency for pain treatment (e.g., Oncology/Palliative care). This result is not dependent on whether a state provides exemptions for these providers. Our results indicate that MA-PDMPs may help close provider-patient informational gaps while retaining a provider's ability to supply these drugs to patients with a need for opioids.
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Affiliation(s)
- Alice M Ellyson
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, Washington, USA
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Jevay Grooms
- Department of Economics, Howard University, Washington, District of Columbia, USA
| | - Alberto Ortega
- O'Neill School of Public and Environmental Affairs, Indiana University, Bloomington, Indiana, USA
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Hoppe D, Karimi L, Khalil H. Mapping the research addressing prescription drug monitoring programs: A scoping review. Drug Alcohol Rev 2022; 41:803-817. [PMID: 35106867 DOI: 10.1111/dar.13431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 10/19/2021] [Accepted: 12/08/2021] [Indexed: 12/29/2022]
Abstract
ISSUES Prescription drug monitoring programs are a harm minimisation intervention and clinical decision support tool that address the public health concern surrounding prescription drug misuse. Given the large number of studies published to date and the ongoing implementation of these programs, it is important to map the literature and identify areas for further research to improve practice. APPROACH A scoping review was undertaken to identify the research on prescription drug monitoring programs published between January 2015 and April 2021. KEY FINDINGS A total of 153 citations were included in this scoping review. The majority of the studies originated from the USA and were quantitative. Results on program effectiveness are mixed and mainly examine their association with opioid-related outcomes. Unintended consequences are revealed in the literature and this review also highlights barriers to program use. IMPLICATIONS Overall, findings are mixed despite the large number of studies published to date. Mapping the literature identifies priority areas for further research that can advise policymakers and clinicians on practice improvement. CONCLUSION Results on prescription drug monitoring program effectiveness are mixed and mainly examine their association with opioid-related outcomes. This review highlights barriers to prescription drug monitoring program effectiveness related to program use and system integration. Further research is needed in these areas to improve prescription drug monitoring program use and patient outcomes.
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Affiliation(s)
- Dimi Hoppe
- School of Psychology and Public Health, La Trobe University, Melbourne, Australia
| | - Leila Karimi
- School of Psychology and Public Health, La Trobe University, Melbourne, Australia
| | - Hanan Khalil
- School of Psychology and Public Health, La Trobe University, Melbourne, Australia
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21
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Zhao S, Browning J, Cui Y, Wang J. Using machine learning to classify patients on opioid use. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2022; 12:502-508. [PMID: 35003334 DOI: 10.1093/jphsr/rmab055] [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: 02/05/2021] [Accepted: 10/04/2021] [Indexed: 11/12/2022]
Abstract
Objectives High-frequent opioid use tends to increase an individual's risk of opioid use disorder, overdose and death. Thus, it is important to predict an individuals' opioid use frequency to improve opioid prescription utilization outcomes. Methods Individuals receiving at least one opioid prescription from 2016 to 2018 in the national representative data, Medical Expenditure Panel Survey, were included. This study applied five machine learning (ML) techniques, including support vector machine, random forest, neural network, gradient boosting and XGBoost (extreme gradient boosting), to predict opioid use frequency. This study compared the performance of these ML models with penalized logistic regression. The study outcome was whether an individual lied in the upper 10% of the opioid prescription distribution. Predictors were selected based on Gelberg-Andersen's Behavioral Model of Health Services Utilization. The prediction performance was assessed using the area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC) in the test data. Patient characteristics as predictors for high-frequency use of opioids were ranked by the relative importance in prediction in the test data. Key findings Random forest and gradient boosting achieved the top values of both AUROC and AUPRC, outperforming logistic regression and three other ML methods. In the best performing model, the random forest, the following characteristics had high predictive power in the frequency of opioid use: age, number of chronic conditions, public insurance and self-perceived health status. Conclusions The results of this study demonstrate that ML techniques can be a promising and powerful technique in predicting the frequency of opioid use and health outcomes.
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Affiliation(s)
- Shirong Zhao
- Department of Investment, School of Finance, Dongbei University of Finance and Economics, Dalian, Liaoning, China
| | - Jamie Browning
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Memphis, TN, USA
| | - Yan Cui
- Department of Genetics, Genomics & Informatics, University of Tennessee Health Science Center, Memphis, TNUSA
| | - Junling Wang
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Memphis, TN, USA
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22
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Giordano NA, Seilern Und Aspang J, Baker J, Rice CW, Barrell B, Kirk L, Ortega E, Wallace M, Steck A, Schenker ML. The effect of a Life Care Specialist on pain management and opioid-related outcomes among patients with orthopedic trauma: study protocol for a randomized controlled trial. Trials 2021; 22:858. [PMID: 34838101 PMCID: PMC8626911 DOI: 10.1186/s13063-021-05841-1] [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] [Received: 06/25/2021] [Accepted: 11/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Orthopedic trauma patients face complex pain management needs and are frequently prescribed opioids, leaving them at-risk for prolonged opioid use. To date, post-trauma pain management research has placed little emphasis on individualized risk assessments for misuse and systematically implementing non-pharmacologic pain management strategies. Therefore, a community-academic partnership was formed to design a novel position in the healthcare field (Life Care Specialist (LCS)), who will educate patients on the risks of opioids, tapering usage, safe disposal practices, and harm reduction strategies. In addition, the LCS teaches patients behavior-based strategies for pain management, utilizing well-described techniques for coping and resilience. This study aims to determine the effects of LCS intervention on opioid utilization, pain control, and patient satisfaction in the aftermath of orthopedic trauma. METHODS In total, 200 orthopedic trauma patients will be randomized to receive an intervention (LCS) or a standard-of-care control at an urban level 1 trauma center. All patients will be assessed with comprehensive social determinants of health and substance use surveys immediately after surgery (baseline). Follow-up assessments will be performed at 2, 6, and 12 weeks postoperatively, and will include pain medication utilization (morphine milligram equivalents), pain scores, and other substance use. In addition, overall patient wellness will be evaluated with objective actigraphy measures and patient-reported outcomes. Finally, a survey of patient understanding of risks of opioid use and misuse will be collected, to assess the influence of LCS opioid education. DISCUSSION There is limited data on the role of individualized, multimodal, non-pharmacologic, behavioral-based pain management intervention in opioid-related risk-mitigation in high-risk populations, including the orthopedic trauma patients. The findings from this randomized controlled trial will provide scientific and clinical evidence on the efficacy and feasibility of the LCS intervention. Moreover, the final aim will provide early evidence into which patients benefit most from LCS intervention. TRIAL REGISTRATION ClinicalTrials.gov NCT04154384 . Registered on 11/6/2019 (last updated on 6/10/2021).
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Affiliation(s)
- Nicholas A Giordano
- Emory University, Nell Hodgson Woodruff School of Nursing, 1520 Clifton Road, Atlanta, GA, 30322, USA
| | - Jesse Seilern Und Aspang
- Emory University Orthopaedic Surgery, Grady Memorial Hospital, 80 Jesse Hill Jr Drive SE, Atlanta, GA, 30303, USA
| | - J'Lynn Baker
- Emory University Orthopaedic Surgery, Grady Memorial Hospital, 80 Jesse Hill Jr Drive SE, Atlanta, GA, 30303, USA
| | | | | | | | - Erika Ortega
- Emory University Orthopaedic Surgery, Grady Memorial Hospital, 80 Jesse Hill Jr Drive SE, Atlanta, GA, 30303, USA
| | | | - Alaina Steck
- Emory University Department of Emergency Medicine, Grady Memorial Hospital, 80 Jesse Hill Jr Drive SE, Atlanta, GA, 30303, USA
| | - Mara L Schenker
- Emory University Orthopaedic Surgery, Grady Memorial Hospital, 80 Jesse Hill Jr Drive SE, Atlanta, GA, 30303, USA. .,Grady Memorial Hospital, Atlanta, GA, USA.
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Martins SS, Bruzelius E, Stingone JA, Wheeler-Martin K, Akbarnejad H, Mauro CM, Marziali ME, Samples H, Crystal S, S. Davis C, Rudolph KE, Keyes KM, Hasin DS, Cerdá M. Prescription Opioid Laws and Opioid Dispensing in US Counties: Identifying Salient Law Provisions With Machine Learning. Epidemiology 2021; 32:868-876. [PMID: 34310445 PMCID: PMC8556655 DOI: 10.1097/ede.0000000000001404] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hundreds of laws aimed at reducing inappropriate prescription opioid dispensing have been implemented in the United States, yet heterogeneity in provisions and their simultaneous implementation have complicated evaluation of impacts. We apply a hypothesis-generating, multistage, machine-learning approach to identify salient law provisions and combinations associated with dispensing rates to test in future research. METHODS Using 162 prescription opioid law provisions capturing prescription drug monitoring program (PDMP) access, reporting and administration features, pain management clinic provisions, and prescription opioid limits, we used regularization approaches and random forest models to identify laws most predictive of county-level and high-dose dispensing. We stratified analyses by overdose epidemic phases-the prescription opioid phase (2006-2009), heroin phase (2010-2012), and fentanyl phase (2013-2016)-to further explore pattern shifts over time. RESULTS PDMP patient data access provisions most consistently predicted high-dispensing and high-dose dispensing counties. Pain management clinic-related provisions did not generally predict dispensing measures in the prescription opioid phase but became more discriminant of high dispensing and high-dose dispensing counties over time, especially in the fentanyl period. Predictive performance across models was poor, suggesting prescription opioid laws alone do not strongly predict dispensing. CONCLUSIONS Our systematic analysis of 162 law provisions identified patient data access and several pain management clinic provisions as predictive of county prescription opioid dispensing patterns. Future research employing other types of study designs is needed to test these provisions' causal relationships with inappropriate dispensing and to examine potential interactions between PDMP access and pain management clinic provisions. See video abstract at, http://links.lww.com/EDE/B861.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Stephen Crystal
- Rutgers University, Center for Health Services Research, Institute for Health, and School of Social Work
| | | | | | | | - Deborah S. Hasin
- Columbia University Department of Epidemiology
- Columbia University Department of Psychiatry
| | - Magdalena Cerdá
- NYU Grossman School of Medicine Department of Population Health
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Callegari M, Jella T, Mahran A, Alfahmy A, Muncey W, Patel A, Loeb A, Thirumavalavan N. Opioid prescription patterns among urologists as compiled from within Medicare. Can Urol Assoc J 2021; 15:E574-E581. [PMID: 33999804 PMCID: PMC8641906 DOI: 10.5489/cuaj.7086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION We aimed to evaluate opioid prescribing patterns of urologists across the United States (U.S.) and the District of Columbia (D.C.) using publicly available data from Medicare Part D. Our secondary analysis was to identify any loco-regional trends that may exist within the U.S. METHODS We queried publicly reported information from the Part D prescriber database, which is compiled from beneficiaries enrolled within the Medicare Part D prescription drug program. Only providers with the specialty description of urologist were included in this study. RESULTS Between 2013 and 2017, a five-year average of 452 901 opioid claims by 9640 urologists - amounting to $5 357 114 USD and comprising 3.78% of all claims made - were identified. The state of Maine featured the highest percentage of opioid claims in relation to all claims (5.81%). West Virginia had the greatest average total opioid claims per provider (90), while Michigan featured the highest average proportion of opioid claims per provider (10.63%). The fewest opioid claims were processed within the Mid-Atlantic and New England regions. CONCLUSIONS A multitude of factors likely contributes to variability between states. Urologists should be increasingly aware of their individual prescription tendencies and use available drug monitoring programs to reduce unnecessary prescriptions, all while providing more targeted and appropriate pain management.
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Affiliation(s)
- Michael Callegari
- Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Tarun Jella
- Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Amr Mahran
- Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Anood Alfahmy
- Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Wade Muncey
- Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Anish Patel
- Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Aram Loeb
- Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Nannan Thirumavalavan
- Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
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Vadiei N, Eldridge LA, Meyerson BE, Agley J. "The gatekeepers in prevention": Community pharmacist perceptions of their role in the opioid epidemic. Subst Abus 2021; 43:319-327. [PMID: 34214407 DOI: 10.1080/08897077.2021.1941516] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Community pharmacists are at the frontline of patient care, yet their role in the opioid epidemic remains unclear. This qualitative study examines the perception of community pharmacists about their role in the opioid epidemic and challenges to fulfilling this role. Methods: A secondary analysis of cross-sectional survey data from an Indiana census of community managing pharmacists was conducted. Qualitative data were coded using a priori and emergent themes. A priori categories included the perceived role of pharmacists in the opioid epidemic and perception of practice barriers. Results: A total of 215 Indiana community managing pharmacists participated in this study. Pharmacists understood themselves as gatekeepers in preventing opioid misuse and overdose. Reported pharmacy practices included providing patient education and communicating with prescribers. Challenges to fulfilling this role included pharmacy structure and operation, lack of patient and provider clarity about pharmacist scope of practice, and pharmacist perception that that there is no available discretionary time to support additional services. Conclusion: Pharmacists believe they have a vital role in combatting opioid misuse and overdose but are hampered by structural aspects of pharmacy practice and lack of recognition of their role. Pharmacy associations and policy partners are encouraged to identify opportunities to address these barriers.
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Affiliation(s)
- Nina Vadiei
- Department of Pharmacy Practice and Science, The University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - Lori Ann Eldridge
- Department of Applied Health Science, Indiana University School of Public Health - Bloomington, Bloomington, IN, USA.,Prevention Insights, Institute for Research on Addictive Behavior, Indiana University School of Public Health - Bloomington, Bloomington, IN, USA
| | - Beth E Meyerson
- Southwest Institute for Research on Women, College of Social & Behavioral Sciences, The University of Arizona, Tucson, AZ, USA.,Family & Community Medicine, College of Medicine, The University of Arizona, Tucson, AZ, USA
| | - Jon Agley
- Department of Applied Health Science, Indiana University School of Public Health - Bloomington, Bloomington, IN, USA.,Prevention Insights, Institute for Research on Addictive Behavior, Indiana University School of Public Health - Bloomington, Bloomington, IN, USA
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Abstract
Despite technological advancements in health care documentation and the proliferation of electronic health records, health information and health data remain disparate. Patients and health care teams benefit from access to comprehensive patient records to make informed health care decisions. Significant governmental policy and investments have been made to promote interoperability of systems that connect health information with the ultimate intent of developing a longitudinal patient record. In this article, we discuss how health data, interoperability, and related systems are influenced by federal policy. The intent is to expand occupational therapy practitioners' understanding of the promise of interoperability and the role the occupational therapy profession can play in advancing the infrastructure needed to optimize health care delivery.
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Affiliation(s)
- Joy Doll
- Joy Doll, OTD, OTR/L, FNAP, is Vice President, Community and Academic Programs, CyncHealth, Omaha, NE
| | - Julie Malloy
- Julie Malloy, MOT, OTR/L, PMP, CPHQ, is Director of Quality, Practice Improvement, American Occupational Therapy Association, North Bethesda, MD;
| | - Jaime Bland
- Jaime Bland, DNP, MBA, RN, is President and Chief Executive Officer, CyncHealth, Nebraska Health Information Initiative, Omaha
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Query mandates in prescription drug monitoring programs reduce opioid use among commercially insured patients with cancer. J Am Pharm Assoc (2003) 2021; 62:363-369. [PMID: 34246576 DOI: 10.1016/j.japh.2021.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/29/2021] [Accepted: 06/09/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Prescription drug monitoring programs (PDMPs) have been shown to reduce opioid use in the general and noncancer populations. However, evidence of PDMP impacts on patients with cancer remains limited. OBJECTIVE The aim of the study was to examine the impact of PDMP mandates on individual-level opioid use among patients with cancer. METHODS This is a retrospective cohort study of patients with newly diagnosed cancer aged 18-65 years in the IQVIA PharMetrics Plus database (IQVIA Inc; nationally representative data of the U.S. commercially insured population in 49 states) between 2013 and 2015. The primary exposure was PDMP rigor (ranked from highest to lowest rigor): provider query + registration, query only, registration only, and unexposed. The study outcomes included (1) prevalent use among all individuals; and among opioid users (2) total days supplied, (3) daily morphine equivalent dose (MED), and (4) cumulative MED. RESULTS Of the eligible cohort (n=28,353), 37.5% (10,656) received opioids after a cancer diagnosis. The individuals exposed to these mandates were as follows: query + registration: 3899 (13.8%); query only: 3459 (12.2%); registration only: 2764 (9.7%); and no mandates: 18,231 (64.3%). The PDMP mandates had no effect on prevalent opioid use. Compared with unexposed patients, those subject to query mandates-alone or with registration mandates-experienced 12 fewer opioid days supplied and a lower mean cumulative MED (-662 mg and -702 mg, respectively), P < 0.01. Registration-only mandates were associated with 21 days more (P < 0.01) total days supplied and lower daily MED (1.1 mg; P < 0.05) but had no statistically significant effect on cumulative MED (-46 mg, P > 0.05). CONCLUSION Query mandates are a stronger PDMP tool than registration mandates in reducing opioid days supplied and cumulative MED. Initiatives should target PDMP mandates toward intended patient groups to reduce high-risk opioid use without compromising adequate pain treatment.
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Sabesan VJ, Echeverry N, Dalton C, Grunhut J, Lavin A, Chatha K. The impact of state-mandated opioid prescribing restrictions on prescribing patterns surrounding reverse total shoulder arthroplasty. JSES Int 2021; 5:663-666. [PMID: 34223412 PMCID: PMC8245979 DOI: 10.1016/j.jseint.2021.04.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background Orthopedic surgeons are the third-highest prescribers of opioid medications, and the recent opioid crisis has placed more scrutiny on physicians and their prescribing habits. House Bill 21, a new law limiting the prescription of opioid medications, was signed in Florida on July 1, 2018 and similar laws have been passed in a number of other states as well. The purpose of this study was to understand the effect of new legal mandates on opioid prescribing patterns and dependence rates for patients undergoing reverse shoulder arthroplasty. Methods A retrospective review of 143 patients who underwent primary reverse shoulder arthroplasty from 2017 to 2019 was performed. There were 87 patients in the pre-legislation group (group 1), compared to 56 in the post-legislation group (group 2). Demographics data and opioid prescriptions provided 90 days before and after surgery were obtained using the physician drug monitoring database. Descriptive statistics and Student's t-tests were used to examine differences. Results Preoperatively, both groups received similar numbers of pills and total morphine equivalents (TMEs; group 1: 47.3 pills and 59.9 TMEs, group 2: 30.9 pills and 24.8 TMEs) (P = .292, P = .081). Group 1 had 88.5% of patients fill an opioid prescription postoperatively, compared to 50.9% of group 2 (P < .001). Postoperatively, initial opioid prescriptions were higher in average pills for group 1 (26 pills with an average of 375.6 TMEs) compared to group 2 (18 pills with an average of 199.6 TMEs) (P < .001, P = .122). For the entire postoperative course, patients in group 1 filled prescriptions for an average of 1740.7 TMEs and 84 pills, compared to 461.9 TMEs and 32 pills in group 2 (P = .035, P < .001). In the cohort, 17.8% of group 2 had multiple recorded opioid prescriptions, compared to 70.1% of group 1. There were also significant differences observed in postoperative dependence rates, with 23.0% in group 1 compared to 12.5% in group 2 (P = .043). Conclusions State-mandated opioid prescribing restrictions have been successful in decreasing opioid prescribing and dependence rates for orthopedic shoulder patients. Further efforts are required to reduce preoperative prescriptions involving chronic shoulder pathology as current legislature has not had an impact on this. Legislative changes may be an effective way to help reduce abuse and opioid dependence in shoulder arthroplasty patients; however, further research is needed.
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Affiliation(s)
- Vani J Sabesan
- Levitetz Department of Orthopedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Nikolas Echeverry
- Charles E Schmidt School of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Conner Dalton
- Charles E Schmidt School of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Joel Grunhut
- Charles E Schmidt School of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Alessia Lavin
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - Kiran Chatha
- Levitetz Department of Orthopedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
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Impact of a Mandatory Prescription Drug Monitoring Program Check on Emergency Department Opioid Prescribing Rates. J Med Toxicol 2021; 17:265-270. [PMID: 33821434 DOI: 10.1007/s13181-021-00837-4] [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] [Received: 10/26/2020] [Revised: 02/22/2021] [Accepted: 03/04/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Prescription drug monitoring programs (PDMPs) exist in 49 states to guide opioid prescribing. In 40 states, clinicians must check the PDMP prior to prescribing an opioid. Data on mandated PDMP checks show mixed results on opioid prescribing. OBJECTIVES This study sought to examine the impact of the Massachusetts mandatory PDMP check on opioid prescribing for discharges from an urban tertiary emergency department (ED). METHODS This was a retrospective cohort study of discharges from one ED from 7/1/2010-10/15/2018. The primary outcome was the monthly percentage of patients discharged from the ED with an opioid prescription. The intervention was Massachusetts mandating a PDMP check for all opioid prescriptions. Prescribing was compared pre- and post-mandate. Interrupted time series (ITS) analysis accounted for known declining trends in opioid prescribing. RESULTS Of 273,512 ED discharges, 35,050 (12.8%) received opioid prescriptions. Mean monthly opioid prescribing decreased post-intervention from 15.1% (SD ± 3.5%) to 5.1% (SD ± 0.9%; p < 0.001). ITS showed equal pre and post-intervention slopes (-0.002, p = 0.819). A small immediate decrease occurred in prescribing around the mandated check: a 3-month level effect decrease of 0.018 (p = 0.039), 6-month level effect 0.019 (p = 0.023), and a 12-month level effect of 0.020 (p = 0.019). The 24-month level effect was not decreased. CONCLUSION Prior to the mandated PDMP check, ED opioid prescribing was declining. The mandate did not change the rate of decline but was associated with a non-sustained drop in opioid prescribing immediately following enactment.
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Campbell NL, Holden RJ, Tang Q, Boustani MA, Teal E, Hillstrom J, Tu W, Clark DO, Callahan CM. Multicomponent behavioral intervention to reduce exposure to anticholinergics in primary care older adults. J Am Geriatr Soc 2021; 69:1490-1499. [PMID: 33772749 DOI: 10.1111/jgs.17121] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 02/10/2021] [Accepted: 02/13/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To test the impact of a multicomponent behavioral intervention to reduce the use of high-risk anticholinergic medications in primary care older adults. DESIGN Cluster-randomized controlled trial. SETTING AND PARTICIPANTS Ten primary care clinics within Eskenazi Health in Indianapolis. INTERVENTION The multicomponent intervention included provider- and patient-focused components. The provider-focused component was computerized decision support alerting of the presence of a high-risk anticholinergic and offering dose- and indication-specific alternatives. The patient-focused component was a story-based video providing education and modeling an interaction with a healthcare provider resulting in a medication change. Alerts within the medical record triggered staff to play the video for a patient. Our design intended for parallel, independent priming of both providers and patients immediately before an outpatient face-to-face interaction. MEASUREMENT Medication orders were extracted from the electronic medical record system to evaluate the prescribing behavior and population prevalence of anticholinergic users. The intervention was introduced April 1, 2019, through March 31, 2020, and a preintervention observational period of April 1, 2018, through March 31, 2019, facilitated difference in difference comparisons. RESULTS A total of 552 older adults had visits at primary care sites during the study period, with mean age of 72.1 (SD 6.4) years and 45.3% African American. Of the 259 provider-focused alerts, only three (1.2%) led to a medication change. Of the 276 staff alerts, 4.7% were confirmed to activate the patient-focused intervention. The intervention resulted in no significant differences in either the number of discontinue orders for anticholinergics (intervention: two additional orders; control: five fewer orders, p = 0.7334) or proportion of the population using anticholinergics following the intervention (preintervention: 6.2% and postintervention: 5.1%, p = 0.6326). CONCLUSION This multicomponent intervention did not reduce the use of high-risk anticholinergics in older adults receiving primary care. Improving nudges or a policy-focused component may be necessary to reduce use of high-risk medications.
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Affiliation(s)
- Noll L Campbell
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, Indiana, USA.,Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA.,Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, Indiana, USA.,Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Center for Health Innovation and Implementation Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Richard J Holden
- Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA.,Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, Indiana, USA.,Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Center for Health Innovation and Implementation Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Qing Tang
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Malaz A Boustani
- Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA.,Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, Indiana, USA.,Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Center for Health Innovation and Implementation Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Evgenia Teal
- Data Core, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Jennifer Hillstrom
- Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, Indiana, USA
| | - Wanzhu Tu
- Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA.,Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Daniel O Clark
- Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA.,Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, Indiana, USA.,Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Christopher M Callahan
- Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA.,Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, Indiana, USA.,Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Carlson A, Nelson ME, Patel H. Longitudinal impact of a pre-populated default quantity on emergency department opioid prescriptions. J Am Coll Emerg Physicians Open 2021; 2:e12337. [PMID: 33521788 PMCID: PMC7819264 DOI: 10.1002/emp2.12337] [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] [Received: 09/21/2020] [Revised: 11/13/2020] [Accepted: 11/24/2020] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Previously published studies indicate that a pre-populated default quantity may decrease opioid amounts on discharge prescriptions from the emergency department (ED). However, the longitudinal effect of defaulted quantities has not been described in the literature. METHODS A retrospective review of electronic health record data from visits to 4 hospital EDs in a community health system examined opioid prescription dispense quantities 3.5 years pre- and 6.5 years post-implementation of a defaulted dispense quantity of seventeen. The primary purpose was to determine the percentage of ED discharge opioid prescriptions containing the prepopulated default dispense quantity after implementation. The longitudinal effect of a default quantity implementation on the average quantity prescribed (normalized per 1000 visits) was examined by comparing the pre-implementation period (January 1, 2009-July 31, 2012) to the post-implementation period (August 1, 2012-June 30, 2018). RESULTS After implementation in 2012, the acceptance rate of the default dispense quantity increased each year, up to 48% in 2016 and maintained through 2018. A significant decrease in prescribed opioid quantities post-default quantity implementation was sustained, with the average quantity prescribed from 2015-2018 maintained at 17 or lower. CONCLUSION A pre-populated default quantity impacts discharge opioid prescribing as evidenced by a high sustained rate of prescriber utilization over years and reduction in the per prescription average pill quantity. The acceptance of a pre-populated default quantity may allow for selection of even a lower quantity to influence prescribing patterns of opioid analgesics.
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Affiliation(s)
| | - Michael E. Nelson
- NorthShore University Health SystemEvanstonILUSA
- John H. Stroger Jr. Hospital of Cook CountyCook County HealthChicagoILUSA
| | - Hina Patel
- NorthShore University Health SystemEvanstonILUSA
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Arfken CL, Tutag Lehr V. Commercial and public payer opioid analgesic prescribing policies: a case study. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2021; 16:4. [PMID: 33407646 PMCID: PMC7789815 DOI: 10.1186/s13011-020-00340-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 12/21/2020] [Indexed: 12/03/2022]
Abstract
Background One strategy to address the high number of U.S. opioid-related deaths is to restrict high-risk or inappropriate opioid analgesic prescribing and dispensing. Federal and state laws and regulations have implemented restrictions but less is known about commercial and public payers’ policies aside from clinician anecdotal reports that these policies are increasing. To assess the number and types of policies with temporal trends, we examined commercial and public (Medicaid) payer policies in one state, Michigan, that has high opioid-related deaths and implemented opioid analgesic prescribing laws. Methods Policies for seven large commercial payers and the public payer for 2012–2018 were reviewed and categorized by actions. Joinpoint regression was used to summarize temporal trends on number of policies for all payers and subgroups. Results Across the 7 years, there were 529 action policies (75.57 (95% confidence intervals (CI) 35.93, 115.22) actions per year) with a range of 36 to 103 actions by payer. Limitations on number of days for initial prescriptions and prior authorizations were the most frequently implemented policy. The temporal trend showed a decline in new policies from 2012 to 2013 but a steady increase from 2014 to 2018 (average annual percent change or AAPC=29.6% (95% confidence intervals 13.2, 48.5%)). The public payer (n=47 policies) showed no increase in number of policies over time (AAPC=2.9% (95% CI -41.6, 61.6%). Conclusions The eight commercial and public payers implemented many new policies to restrict opioid analgesic prescribing with a steady increase in the number of such policies implemented from 2014 to 2018. This case study documented that at least in one state with high opioid-related deaths and multiple commercial payers, new and different policies were increasingly implemented creating barriers to patient care. The impact of these policies is understudied, complicating recommendation of best practices.
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Affiliation(s)
- Cynthia L Arfken
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, 3901 Chrysler Drive, Suite 1B, Detroit, MI, 48201, USA
| | - Victoria Tutag Lehr
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Avenue, Room 4144, Detroit, MI, 48201, USA.
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Lyle Cooper R, Thompson J, Edgerton R, Watson J, MacMaster SA, Kalliny M, Huffman MM, Juarez P, Mathews-Juarez P, Tabatabai M, Singh KP. Modeling dynamics of fatal opioid overdose by state and across time. Prev Med Rep 2020; 20:101184. [PMID: 32995141 PMCID: PMC7516293 DOI: 10.1016/j.pmedr.2020.101184] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 08/12/2020] [Accepted: 08/14/2020] [Indexed: 11/29/2022] Open
Abstract
Opioid overdose fatalities include deaths from natural opioids (morphine and codeine), semi-synthetic opioids (oxycodone, hydrocodone), synthetic opioids (prescription and illicit fentanyl, tramadol), methadone, and heroin. From 1999 to 2017, there were 702,568 drug overdose deaths in the U.S., with 399,230 attributed to opioids. This study aimed to assess the dynamics of opioid related fatalities throughout the U.S. from 2006-2016. This study is a secondary analysis of data obtained through the Kaiser Family Foundation's analysis of Centers for Disease Control and Prevention data, 1999-2016. The data obtained were from all 50 states and the District of Columbia. A total of 272,130 individuals were included in the analysis. This represents the number of opioid overdose deaths in the United States from 2006-2016. Descriptive analysis of overall rates was conducted and mapped for visualization. Novel predictive models of increase for each drug overdose category were developed and used to calculate rate changes. Finally, the elasticity of change in rate for each drug category was calculated annually for the past 11 years. The highest rate of opioid overdose-related death occurred in West Virginia (40.03 per 100,000). In our secondary analysis, we explored the change in the rate of opioid-related deaths from 2015 to 2016. The changing dynamics of fatal opioid overdose at the state level is critical to guiding policy makers in addressing this crisis. Rates of fatal opioid overdose vary across the states, but we identify some trends. Regional differences are identified in states with the highest overdose rates from all opioids combined.
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Affiliation(s)
- R. Lyle Cooper
- Department of Family and Community Medicine, Meharry Medical College, 1005 Dr. D.B. Todd Jr. Blvd Nashville, TN 37208, United States
| | - Janese Thompson
- Meharry Medical College, Meharry Medical College, 1005 Dr. D.B. Todd Jr. Blvd, Nashville, TN 37208, United States
| | - Ryan Edgerton
- Department of Family and Community Medicine, Meharry Medical College, 1005 Dr. D.B. Todd Jr. Blvd Nashville, TN 37208, United States
| | - Julia Watson
- Department of Family and Community Medicine, Meharry Medical College, 1005 Dr. D.B. Todd Jr. Blvd Nashville, TN 37208, United States
| | - Samuel A. MacMaster
- Department of Family and Community Medicine at Baylor College of Medicine in Houston, Texas, United States
| | - Medhat Kalliny
- Meharry Medical College, 1005 Dr. D.B. Todd Jr. Blvd Nashville, TN 37208, United States
| | - Miranda M. Huffman
- Meharry Medical College, Meharry Medical College, 1005 Dr. D.B. Todd Jr. Blvd, Nashville, TN 37208, United States
| | - Paul Juarez
- Department of Family and Community Medicine, Meharry Medical College, 1005 Dr. D.B. Todd Jr. Blvd Nashville, TN 37208, United States
| | - Patricia Mathews-Juarez
- Department of Family and Community Medicine, Meharry Medical College, 1005 Dr. D.B. Todd Jr. Blvd Nashville, TN 37208, United States
| | - Mohammad Tabatabai
- School of Graduate Studies and Research, Meharry Medical College 1005 Dr. D.B. Todd Jr. Blvd Nashville, TN 37208, United States
| | - Karan P. Singh
- Department of Epidemiology and Biostatistics, School of Community and Rural Health, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, United States
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Ung C, Ung R, Yonekawa Y. Opioid Prescribing Patterns among Retina Specialists in the United States. Ophthalmol Retina 2020; 5:696-701. [PMID: 33130002 DOI: 10.1016/j.oret.2020.10.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 10/22/2020] [Accepted: 10/23/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE To determine the opioid prescribing patterns among retina specialists and to assess predictors for high-volume prescribing. DESIGN Retrospective cohort study. PARTICIPANTS American Society of Retina Specialists (ASRS) members in the 2013 through 2016 Medicare Part D Prescriber database. METHODS American Society of Retina Specialists members within the United States were profiled from the ASRS member directory as of April 2019. The Centers for Medicare and Medicaid Services Medicare Part D Prescriber Public Use Files for 2013, 2014, 2015, and 2016 were accessed. Data were collected and analyzed regarding the prescribing patterns for opioid drugs for all participating ASRS members. MAIN OUTCOME MEASURES Mean number of opioid prescriptions written annually by retina specialists, prescriber rates compared with all prescriptions written, and geographic distribution of opioid prescriptions written by retina specialists. RESULTS The authors identified 1518 ASRS members in the Medicare database in 2016. Members had written a total of 14 127 prescriptions in 2016, with 66% of members writing at least 1 opioid prescription. On average, members wrote 11 opioid prescriptions per year. Almost one fifth (21%) wrote more than 10 prescriptions annually. A minority (6%) wrote more than 50 prescriptions. Among those writing more than 10 prescriptions annually, approximately 35 opioid prescriptions were written annually with a mean supply of 4 days. Using multivariate analysis, the factors associated with increased number of opioid prescriptions were male gender (β = 2.80; P < 0.001), a practice location in the South (β = 5.61; P < 0.001), and larger patient panel size (β = 0.029; P < 0.001). The total number of opioid prescriptions, including refills, written by members also decreased by 18% from 2013 to 2016 (P < 0.001). CONCLUSIONS American Society of Retina Specialists members prescribed opioids at a rate (1.5%) lower than the national mean of all prescribers across all medical specialties (6.8%). Male gender and a practice location in the South were correlated to number of prescriptions. Further research is needed to elucidate the appropriate indications for the prescription of opioids among retina specialists.
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Affiliation(s)
- Cindy Ung
- South Coast Retina Center, Long Beach, California
| | - Rich Ung
- School of Information, University of California, Berkeley, Berkeley, California
| | - Yoshihiro Yonekawa
- Wills Eye Hospital, Mid Atlantic Retina, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania.
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35
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Rao PN, Jotwani R, Joshi J, Gulati A, Mehta N. Reevaluating chronic opioid monitoring during and after the COVID-19 pandemic. Pain Manag 2020; 10:353-358. [PMID: 32945238 PMCID: PMC7505054 DOI: 10.2217/pmt-2020-0063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 08/19/2020] [Indexed: 11/21/2022] Open
Affiliation(s)
- Prashant N Rao
- Department of Anesthesiology, NewYork-Presbyterian/Weill Cornell Medical Center, NY 10065, USA
| | - Rohan Jotwani
- Department of Anesthesiology, NewYork-Presbyterian/Weill Cornell Medical Center, NY 10065, USA
| | - Jatin Joshi
- Department of Anesthesiology, NewYork-Presbyterian/Weill Cornell Medical Center, NY 10065, USA
| | - Amitabh Gulati
- Department of Anesthesiology & Critical Care, Memorial Sloan Kettering Cancer Center, NY 10065, USA
| | - Neel Mehta
- Department of Anesthesiology, NewYork-Presbyterian/Weill Cornell Medical Center, NY 10065, USA
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36
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Boloori A, Arnetz BB, Viens F, Maiti T, Arnetz JE. Misalignment of Stakeholder Incentives in the Opioid Crisis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E7535. [PMID: 33081276 PMCID: PMC7589670 DOI: 10.3390/ijerph17207535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/03/2020] [Accepted: 10/04/2020] [Indexed: 12/14/2022]
Abstract
The current opioid epidemic has killed more than 446,000 Americans over the past two decades. Despite the magnitude of the crisis, little is known to what degree the misalignment of incentives among stakeholders due to competing interests has contributed to the current situation. In this study, we explore evidence in the literature for the working hypothesis that misalignment rooted in the cost, quality, or access to care can be a significant contributor to the opioid epidemic. The review identified several problems that can contribute to incentive misalignment by compromising the triple aims (cost, quality, and access) in this epidemic. Some of these issues include the inefficacy of conventional payment mechanisms in providing incentives for providers, practice guidelines in pain management that are not easily implementable across different medical specialties, barriers in adopting multi-modal pain management strategies, low capacity of providers/treatments to address opioid/substance use disorders, the complexity of addressing the co-occurrence of chronic pain and opioid use disorders, and patients' non-adherence to opioid substitution treatments. In discussing these issues, we also shed light on factors that can facilitate the alignment of incentives among stakeholders to effectively address the current crisis.
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Affiliation(s)
- Alireza Boloori
- Department of Statistics and Probability, Michigan State University, East Lansing, MI 48824, USA; (F.V.); (T.M.)
- Department of Family Medicine, Michigan State University, Grand Rapids, MI 49503, USA; (B.B.A.); (J.E.A.)
| | - Bengt B. Arnetz
- Department of Family Medicine, Michigan State University, Grand Rapids, MI 49503, USA; (B.B.A.); (J.E.A.)
| | - Frederi Viens
- Department of Statistics and Probability, Michigan State University, East Lansing, MI 48824, USA; (F.V.); (T.M.)
| | - Taps Maiti
- Department of Statistics and Probability, Michigan State University, East Lansing, MI 48824, USA; (F.V.); (T.M.)
| | - Judith E. Arnetz
- Department of Family Medicine, Michigan State University, Grand Rapids, MI 49503, USA; (B.B.A.); (J.E.A.)
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Ansari B, Tote KM, Rosenberg ES, Martin EG. A Rapid Review of the Impact of Systems-Level Policies and Interventions on Population-Level Outcomes Related to the Opioid Epidemic, United States and Canada, 2014-2018. Public Health Rep 2020; 135:100S-127S. [PMID: 32735190 DOI: 10.1177/0033354920922975] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES In the United States, rising rates of overdose deaths and recent outbreaks of hepatitis C virus and HIV infection are associated with injection drug use. We updated a 2014 review of systems-level opioid policy interventions by focusing on evidence published during 2014-2018 and new and expanded opioid policies. METHODS We searched the MEDLINE database, consistent with the 2014 review. We included articles that provided original empirical evidence on the effects of systems-level interventions on opioid use, overdose, or death; were from the United States or Canada; had a clear comparison group; and were published from January 1, 2014, through July 19, 2018. Two raters screened articles and extracted full-text data for qualitative synthesis of consistent or contradictory findings across studies. Given the rapidly evolving field, the review was supplemented with a search of additional articles through November 17, 2019, to assess consistency of more recent findings. RESULTS The keyword search yielded 535 studies, 66 of which met inclusion criteria. The most studied interventions were prescription drug monitoring programs (PDMPs) (59.1%), and the least studied interventions were clinical guideline changes (7.6%). The most common outcome was opioid use (77.3%). Few articles evaluated combination interventions (18.2%). Study findings included the following: PDMP effectiveness depends on policy design, with robust PDMPs needed for impact; health insurer and pharmacy benefit management strategies, pill-mill laws, pain clinic regulations, and patient/health care provider educational interventions reduced inappropriate prescribing; and marijuana laws led to a decrease in adverse opioid-related outcomes. Naloxone distribution programs were understudied, and evidence of their effectiveness was mixed. In the evidence published after our search's 4-year window, findings on opioid guidelines and education were consistent and findings for other policies differed. CONCLUSIONS Although robust PDMPs and marijuana laws are promising, they do not target all outcomes, and multipronged interventions are needed. Future research should address marijuana laws, harm-reduction interventions, health insurer policies, patient/health care provider education, and the effects of simultaneous interventions on opioid-related outcomes.
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Affiliation(s)
- Bahareh Ansari
- 1084 Department of Information Science, University at Albany-State University of New York, Albany, NY, USA
| | - Katherine M Tote
- 43360 Department of Epidemiology and Biostatistics, University at Albany-State University of New York, Albany, NY, USA.,Center for Collaborative HIV Research in Practice and Policy, Albany, NY, USA
| | - Eli S Rosenberg
- 43360 Department of Epidemiology and Biostatistics, University at Albany-State University of New York, Albany, NY, USA.,Center for Collaborative HIV Research in Practice and Policy, Albany, NY, USA
| | - Erika G Martin
- Center for Collaborative HIV Research in Practice and Policy, Albany, NY, USA.,43360 Department of Public Administration and Policy, University at Albany-State University of New York, Albany, NY, USA
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38
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Barbosa C, Dowd WN, Zarkin G. Economic Evaluation of Interventions to Address Opioid Misuse: A Systematic Review of Methods Used in Simulation Modeling Studies. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:1096-1108. [PMID: 32828223 DOI: 10.1016/j.jval.2020.03.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 02/28/2020] [Accepted: 03/15/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Several evidence-based interventions exist for people who misuse opioids, but there is limited guidance on optimal intervention selection. Economic evaluations using simulation modeling can guide the allocation of resources and help tackle the opioid crisis. This study reviews methods employed by economic evaluations using computer simulations to investigate the health and economic effects of interventions meant to address opioid misuse. METHODS We conducted a systematic mapping review of studies that used simulation modeling to support the economic evaluation of interventions targeting prevention, treatment, or management of opioid misuse or its direct consequences (ie, overdose). We searched 6 databases and extracted information on study population, interventions, costs, outcomes, and economic analysis and modeling approaches. RESULTS Eighteen studies met the inclusion criteria. All of the studies considered only one segment of the continuum of care. Of the studies, 13 evaluated medications for opioid use disorder, and 5 evaluated naloxone distribution programs to reduce overdose deaths. Most studies estimated incremental cost per quality-adjusted life-years and used health system and/or societal perspectives. Models were decision trees (n = 4), Markov (n = 10) or semi-Markov models (n = 3), and microsimulations (n = 1). All of the studies assessed parameter uncertainty though deterministic and/or probabilistic sensitivity analysis, 4 conducted formal calibration, only 2 assessed structural uncertainty, and only 1 conducted expected value of information analyses. Only 10 studies conducted validation. CONCLUSIONS Future economic evaluations should consider synergies between interventions and examine combinations of interventions to inform optimal policy response. They should also more consistently conduct model validation and assess the value of further research.
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Affiliation(s)
- Carolina Barbosa
- Behavioral Health Research Division, RTI International, Chicago, IL, USA.
| | - William N Dowd
- Behavioral Health Research Division, RTI International, Research Triangle Park, NC, USA
| | - Gary Zarkin
- Behavioral Health Research Division, RTI International, Research Triangle Park, NC, USA
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A Time-Series Analysis of the Association Between Occupational Health Policies and Opioid Prescription Patterns in United States Active Duty Military Service Members From 2006 to 2018. J Occup Environ Med 2020; 62:e295-e301. [PMID: 32730032 DOI: 10.1097/jom.0000000000001872] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The Department of Defense (DoD) implemented numerous occupational health policies to guide opioid prescribing to active duty military service members (ADSM). This retrospective time series analysis evaluated the impact of DoD policies on opioid prescribing trends in ADSM from 2006 to 2018. METHODS Bayesian structural time-series models with a Markov chain Monte Carlo algorithm for posterior inference and a semi-local linear trend were constructed to estimate the impact of polices. RESULTS Results indicate annual opioid proportions significantly decreased after the introduction of occupational health policies introduced in 2011 to 2012. Collectively, occupational policies were associated with a significant reduction (6.6%) in annual opioid rates to ADSM following 2012. This observed effect was associated with approximately 121,000 less opioid prescriptions dispensed in 2018 alone. CONCLUSIONS Occupational health policy interventions were associated with reductions in opioid prescribing within the DoD.
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Liaw V, Kuo YF, Raji MA, Baillargeon J. Opioid Prescribing Among Adults With Disabilities in the United States After the 2014 Federal Hydrocodone Rescheduling Regulation. Public Health Rep 2020; 135:114-123. [PMID: 31835012 DOI: 10.1177/0033354919892638] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Deaths from prescription opioid overdoses have reached an epidemic level in the United States, particularly among persons with disabilities. The 2014 federal rescheduling regulation is associated with reduced opioid prescribing in the general US population; however, to date, no data have been published on this regulation's effect on persons with disabilities. We examined whether the 2014 hydrocodone rescheduling change was associated with reduced opioid prescribing among adult Medicare beneficiaries with disabilities. METHODS We identified 680 876 Medicare beneficiaries with disabilities aged 21-64 in 2013 and 657 687 in 2015 from a 20% national sample. We examined changes in the monthly opioid-prescribing rates from January 1, 2013, through December 31, 2015. We also compared opioid-prescribing rates in 2013 with rates in 2015. RESULTS In 2014, the percentage of Medicare beneficiaries with disabilities who received hydrocodone prescriptions decreased by 0.154% per month (95% confidence interval [CI], -0.186 to -0.121, P < .001). The percentage of Medicare beneficiaries with disabilities who received hydrocodone prescriptions decreased from 32.2% in 2013 to 27.7% in 2015, whereas rates of any opioid prescribing, prolonged prescribing (≥90-day supply), and high-dose prescribing (≥100 morphine milligram equivalents per day for >30 days) decreased only modestly, from 50.2% to 49.0%, from 27.4% to 26.5%, and from 7.5% to 7.0%, respectively. CONCLUSIONS The 2014 federal rescheduling of hydrocodone was associated with only minor changes in overall and potentially high-risk opioid-prescribing rates. Neither state variation in long-term prescribing nor beneficiary characteristics explained the changes in persistently high opioid-prescribing rates among adults with disabilities after the 2014 regulation. Future studies should examine patient and provider characteristics underlying the persistent high-risk prescribing patterns in this population.
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Affiliation(s)
- Victor Liaw
- College of Natural Sciences, University of Texas at Austin, Austin, TX, USA
| | - Yong-Fang Kuo
- Department of Internal Medicine and Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX, USA.,Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX, USA.,Institute for Translational Science, University of Texas Medical Branch, Galveston, TX, USA.,Office of Biostatistics, University of Texas Medical Branch, Galveston, TX, USA
| | - Mukaila A Raji
- Department of Internal Medicine and Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX, USA.,Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX, USA
| | - Jacques Baillargeon
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX, USA.,Institute for Translational Science, University of Texas Medical Branch, Galveston, TX, USA.,Office of Biostatistics, University of Texas Medical Branch, Galveston, TX, USA
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41
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Puac-Polanco V, Chihuri S, Fink DS, Cerdá M, Keyes KM, Li G. Prescription Drug Monitoring Programs and Prescription Opioid-Related Outcomes in the United States. Epidemiol Rev 2020; 42:134-153. [PMID: 32242239 DOI: 10.1093/epirev/mxaa002] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 03/24/2020] [Accepted: 03/25/2020] [Indexed: 11/14/2022] Open
Abstract
Prescription drug monitoring programs (PDMPs) are a crucial component of federal and state governments' response to the opioid epidemic. Evidence about the effectiveness of PDMPs in reducing prescription opioid-related adverse outcomes is mixed. We conducted a systematic review to examine whether PDMP implementation within the United States is associated with changes in 4 prescription opioid-related outcome domains: opioid prescribing behaviors, opioid diversion and supply, opioid-related morbidity and substance-use disorders, and opioid-related deaths. We searched for eligible publications in Embase, Google Scholar, MEDLINE, and Web of Science. A total of 29 studies, published between 2009 and 2019, met the inclusion criteria. Of the 16 studies examining PDMPs and prescribing behaviors, 11 found that implementing PDMPs reduced prescribing behaviors. All 3 studies on opioid diversion and supply reported reductions in the examined outcomes. In the opioid-related morbidity and substance-use disorders domain, 7 of 8 studies found associations with prescription opioid-related outcomes. Four of 8 studies in the opioid-related deaths domain reported reduced mortality rates. Despite the mixed findings, emerging evidence supports that the implementation of state PDMPs reduces opioid prescriptions, opioid diversion and supply, and opioid-related morbidity and substance-use disorder outcomes. When PDMP characteristics were examined, mandatory access provisions were associated with reductions in prescribing behaviors, diversion outcomes, hospital admissions, substance-use disorders, and mortality rates. Inconsistencies in the evidence base across outcome domains are due to analytical approaches across studies and, to some extent, heterogeneities in PDMP policies implemented across states and over time.
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Affiliation(s)
- Victor Puac-Polanco
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Stanford Chihuri
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York.,Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - David S Fink
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Magdalena Cerdá
- Department of Population Health, New York University Grossman School of Medicine, New York, New York
| | - Katherine M Keyes
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Guohua Li
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York.,Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
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MAURI AMANDAI, TOWNSEND TARLISEN, HAFFAJEE REBECCAL. The Association of State Opioid Misuse Prevention Policies With Patient- and Provider-Related Outcomes: A Scoping Review. Milbank Q 2020; 98:57-105. [PMID: 31800142 PMCID: PMC7077777 DOI: 10.1111/1468-0009.12436] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Policy Points This scoping review reveals a growing literature on the effects of certain state opioid misuse prevention policies, but persistent gaps in evidence on other prevalent state policies remain. Policymakers interested in reducing the volume and dosage of opioids prescribed and dispensed can consider adopting robust prescription drug monitoring programs with mandatory access provisions and drug supply management policies, such as prior authorization policies for high-risk prescription opioids. Further research should concentrate on potential unintended consequences of opioid misuse prevention policies, differential policy effects across populations, interventions that have not received sufficient evaluation (eg, Good Samaritan laws, naloxone access laws), and patient-related outcomes. CONTEXT In the midst of an opioid crisis in the United States, an influx of state opioid misuse prevention policies has provided new opportunities to generate evidence of policy effectiveness that can inform policy decisions. We conducted a scoping review to synthesize the available evidence on the effectiveness of US state interventions to improve patient and provider outcomes related to opioid misuse and addiction. METHODS We searched six online databases to identify evaluations of state opioid policies. Eligible studies examined legislative and administrative policy interventions that evaluated (a) prescribing and dispensing, (b) patient behavior, or (c) patient health. FINDINGS Seventy-one articles met our inclusion criteria, including 41 studies published between 2016 and 2018. These articles evaluated nine types of state policies targeting opioid misuse. While prescription drug monitoring programs (PDMPs) have received considerable attention in the literature, far fewer studies addressed other types of state policy. Overall, evidence quality is very low for the majority of policies due to a small number of evaluations. Of interventions that have been the subject of considerable research, promising means of reducing the volume and dosages of opioids prescribed and dispensed include drug supply management policies and robust PDMPs. Due to low study number and quality, evidence is insufficient to draw conclusions regarding interventions targeting patient behavior and health outcomes, including naloxone access laws and Good Samaritan laws. CONCLUSIONS Recent research has improved the evidence base on several state interventions targeting opioid misuse. Specifically, moderate evidence suggests that drug supply management policies and robust PDMPs reduce opioid prescribing. Despite the increase in rigorous evaluations, evidence remains limited for the majority of policies, particularly those targeting patient health-related outcomes.
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Affiliation(s)
- AMANDA I. MAURI
- University of Michigan School of Public Health
- Injury Prevention CenterUniversity of Michigan Medical School
| | - TARLISE N. TOWNSEND
- University of Michigan School of Public Health
- Injury Prevention CenterUniversity of Michigan Medical School
- University of Michigan Department of Sociology
| | - REBECCA L. HAFFAJEE
- University of Michigan School of Public Health
- Injury Prevention CenterUniversity of Michigan Medical School
- RAND Corporation
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Smart R, Kase CA, Taylor EA, Lumsden S, Smith SR, Stein BD. Strengths and weaknesses of existing data sources to support research to address the opioids crisis. Prev Med Rep 2020; 17:101015. [PMID: 31993300 PMCID: PMC6971390 DOI: 10.1016/j.pmedr.2019.101015] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 10/22/2019] [Accepted: 11/02/2019] [Indexed: 12/18/2022] Open
Abstract
Better opioid prescribing practices, promoting effective opioid use disorder treatment, improving naloxone access, and enhancing public health surveillance are strategies central to reducing opioid-related morbidity and mortality. Successfully advancing and evaluating these strategies requires leveraging and linking existing secondary data sources. We conducted a scoping study in Fall 2017 at RAND, including a literature search (updated in December 2018) complemented by semi-structured interviews with policymakers and researchers, to identify data sources and linking strategies commonly used in opioid studies, describe data source strengths and limitations, and highlight opportunities to use data to address high-priority public health research questions. We identified 306 articles, published between 2005 and 2018, that conducted secondary analyses of existing data to examine one or more public health strategies. Multiple secondary data sources, available at national, state, and local levels, support such research, with substantial breadth in data availability, data contents, and the data's ability to support multi-level analyses over time. Interviewees identified opportunities to expand existing capabilities through systematic enhancements, including greater support to states for creating and facilitating data use, as well as key data challenges, such as data availability lags and difficulties matching individual-level data over time or across datasets. Multiple secondary data sources exist that can be used to examine the impact of public health approaches to addressing the opioid crisis. Greater data access, improved usability for research purposes, and data element standardization can enhance their value, as can improved data availability timeliness and better data comparability across jurisdictions.
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Affiliation(s)
| | | | | | - Susan Lumsden
- Office of Health Policy, Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, United States
| | - Scott R. Smith
- Office of Health Policy, Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, United States
| | - Bradley D. Stein
- RAND Corporation, Pittsburgh, PA, United States
- University of Pittsburgh School of Medicine, Pittsburgh PA, United States
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Shah KN, Ruddell JH, Reid DBC, Shapiro BH, Akelman E, Fadale PD, Daniels AH. Opioid-Limiting Regulation: Effect on Patients Undergoing Knee and Shoulder Arthroscopy. Arthroscopy 2020; 36:824-831. [PMID: 31866279 DOI: 10.1016/j.arthro.2019.09.045] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 09/24/2019] [Accepted: 09/26/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the effect prescription-limiting legislation passed in Rhode Island has had on opioids prescribed following arthroscopic knee and shoulder surgery at various time points, up to 90 days postoperatively. METHODS All patients undergoing the 3 most common arthroscopic procedures at our institution (anterior cruciate ligament reconstruction, partial meniscectomy, and rotator cuff repair) were included. Patients were selected from 2 6-month study periods (prepassage and postimplementation of the law). The state's Prescription Drug Monitoring Program database was queried for controlled substances filled in the perioperative period (from 30 days preoperatively to 90 days postoperatively). Multiple logistic regressions were used to identify predictors of chronic (>30 days) opioid use. RESULTS The morphine milligram equivalents (MMEs) prescribed in the initial postoperative script decreased from 319.04 (∼43 5-mg oxycodone tablets) in the prepassage to 152.45 MMEs (∼20 5-mg oxycodone tablets) in the postimplementation group (P < .001). The total MMEs filled in the first 30 days decreased from 520.93 to 299.94 MMEs (∼70 to ∼40 5-mg oxycodone tablets) (P < .001). MMEs filled between 30 and 90 days fell by 22.5% for all patients in this study; however, this change was not statistically significant (P = .263). Preoperative opioid use (odds ratio, 10.85; P < .001) and preoperative benzodiazepine use (odds ratio, 2.13; P = .005) predicted chronic opioid use postoperatively. CONCLUSIONS State opioid-limiting legislation reduced cumulative MMEs following arthroscopic knee and shoulder surgery in the first 30 days. Further research assessing the impact of this legislation on postoperative pain control, patient satisfaction, and functional outcomes following surgery is warranted. LEVEL OF EVIDENCE Level III, case-control study.
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Affiliation(s)
- Kalpit N Shah
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island, U.S.A..
| | - Jack H Ruddell
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island, U.S.A
| | - Daniel B C Reid
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island, U.S.A
| | - Benjamin H Shapiro
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island, U.S.A
| | - Edward Akelman
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island, U.S.A
| | - Paul D Fadale
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island, U.S.A
| | - Alan H Daniels
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island, U.S.A
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Liang D, Shi Y. Prescription drug monitoring programs and drug overdose deaths involving benzodiazepines and prescription opioids. Drug Alcohol Rev 2020; 38:494-502. [PMID: 31317593 DOI: 10.1111/dar.12959] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 05/10/2019] [Accepted: 05/18/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND AIMS In the US, benzodiazepine overdose deaths increased at an alarming rate in the past two decades. Benzodiazepines were also the most common drugs involved in prescription opioid overdose deaths. Benzodiazepine prescribing has been monitored by Prescription Drug Monitoring Programs (PDMPs), but little was known about whether PDMPs reduced drug overdose deaths involving benzodiazepines. DESIGN AND METHODS This study used a difference-in-difference design with state-quarter aggregate data on drug overdose deaths. The primary data source was Mortality Multiple Cause Files in 1999-2016. Three age-adjusted rates of drug overdose deaths were examined, including those involving benzodiazepines, those involving prescription opioids, and those involving both benzodiazepines and prescription opioids. The policy variables included PDMP data access for benzodiazepines and mandatory use of PDMP data for benzodiazepines. Linear multivariable regressions were used to assess the associations of PDMP policies specific to benzodiazepines with drug overdose death rates, controlling for other state-level policy and socioeconomic factors, state and time fixed effects, and state-specific time trends. RESULTS No significant associations were found between PDMP data access for benzodiazepines and changes in drug overdose death rates involving benzodiazepines and/or prescription opioids. Similarly, no significant associations were found between mandatory use of PDMP data for benzodiazepines and changes in drug overdose death outcomes. DISCUSSION AND CONCLUSIONS This study suggested no evidence that PDMP policies specific to benzodiazepines were associated with reduction in benzodiazepine overdose death rates. Future research is warranted to examine detailed features of PDMPs and continuously monitor the impacts of PDMP policies on benzodiazepine-related consequences.
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Affiliation(s)
- Di Liang
- Department of Family Medicine and Public Health, University of California San Diego, La Jolla, USA
| | - Yuyan Shi
- Department of Family Medicine and Public Health, University of California San Diego, La Jolla, USA
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Editor's Spotlight/Take 5: Has Prescription-limiting Legislation in Rhode Island Helped to Reduce Opioid Use After Total Joint Arthroplasty? Clin Orthop Relat Res 2020; 478:200-204. [PMID: 31899743 PMCID: PMC7438152 DOI: 10.1097/corr.0000000000001109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Abstract
Opioid use disorder (OUD) is a chronic relapsing disorder that, whilst initially driven by activation of brain reward neurocircuits, increasingly engages anti-reward neurocircuits that drive adverse emotional states and relapse. However, successful recovery is possible with appropriate treatment, although with a persisting propensity to relapse. The individual and public health burdens of OUD are immense; 26.8 million people were estimated to be living with OUD globally in 2016, with >100,000 opioid overdose deaths annually, including >47,000 in the USA in 2017. Well-conducted trials have demonstrated that long-term opioid agonist therapy with methadone and buprenorphine have great efficacy for OUD treatment and can save lives. New forms of the opioid receptor antagonist naltrexone are also being studied. Some frequently used approaches have less scientifically robust evidence but are nevertheless considered important, including community preventive strategies, harm reduction interventions to reduce adverse sequelae from ongoing use and mutual aid groups. Other commonly used approaches, such as detoxification alone, lack scientific evidence. Delivery of effective prevention and treatment responses is often complicated by coexisting comorbidities and inadequate support, as well as by conflicting public and political opinions. Science has a crucial role to play in informing public attitudes and developing fuller evidence to understand OUD and its associated harms, as well as in obtaining the evidence today that will improve the prevention and treatment interventions of tomorrow.
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Pain management and prescribing practices in otolaryngology residency programs. Am J Otolaryngol 2020; 41:102265. [PMID: 31387767 DOI: 10.1016/j.amjoto.2019.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 07/15/2019] [Indexed: 11/20/2022]
Abstract
PURPOSE To understand the knowledge, competency and influencing factors regarding postoperative opioid prescribing practices among Otolaryngology Residents. To understand the educational background and resources regarding pain management and opioid prescribing among Otolaryngology Residency Programs. MATERIALS AND METHODS An anonymous electronic survey was distributed to Otolaryngology residents in the greater New York City area. Subjects reported their preferred pain management prescription for eight common otolaryngology surgeries. Questions addressed opioid and non-opioid prescribing influences, use/knowledge of pain management resources, and prior opioid prescribing education (OPE). An anonymous survey was distributed to US Otolaryngology Program Directors addressing resident prescribing influences and OPE in residency training programs. RESULTS Thirty-Five residents and fifteen PDs participated. Resident opioid prescribing was widely variable with averages ranging from 3.8 to 21.1 narcotic pills among eight standard otolaryngology surgeries. Attending/senior preference was believed to largely influence resident prescribing habits among residents (3.66, ±6.68), and PDs (4.73, ±0.46). Only 20% of programs had formal OPE in place, consistent with the 65.71% of residents who reported no prior OPE. CONCLUSIONS AND RELEVANCE A large inconsistency in Otolaryngology resident postoperative pain management exists, despite their responsibility to provide analgesic therapy. The lack of formal OPE programs in US Otolaryngology residency programs may lead to outside factors unrelated to surgery influencing these prescribing practices. This brings light to the need of Otolaryngology Resident OPE to assist in standardizing prescribing practices, provide meaningful patient education on opioid use and disposal and educate residents on the risk assessment tools offered to provide the most appropriate and safe analgesic therapy to patients.
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Cicero TJ, Ellis MS, Kasper ZA. Polysubstance Use: A Broader Understanding of Substance Use During the Opioid Crisis. Am J Public Health 2019; 110:244-250. [PMID: 31855487 DOI: 10.2105/ajph.2019.305412] [Citation(s) in RCA: 167] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Objectives. To understand important changes in co-occurring opioid and nonopioid drug use (i.e., polysubstance use) within the opioid epidemic in the United States.Methods. We analyzed survey data on the past month co-use of prescription and illicit opioids and 12 nonopioid psychoactive drug classes from a national sample of 15 741 persons entering treatment of opioid use disorder.Results. Past-month illicit opioid use increased from 44.8% in 2011 to 70.1% in 2018, while the use of prescription opioids alone dropped from 55.2% to 29.9%, yet overall remained high (94.5% to 85.2%). Past-month use of at least 1 nonopioid drug occurred in nearly all participants (> 90%), with significant increases in methamphetamine (+85%) and decreases across nonopioid prescription drug classes (range: -40% to -68%).Conclusions. Viewing opioid trends in a "silo" ignores the fact not only that polysubstance use is ubiquitous among those with opioid use disorder but also that significant changes in polysubstance use should be monitored alongside opioid trends.Public Health Implications. Treatment, prevention, and policymaking must address not only the supply and demand of a singular drug class but also the global nature of substance use overall.
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Affiliation(s)
- Theodore J Cicero
- All of the authors are with Washington University in St Louis, St Louis, MO
| | - Matthew S Ellis
- All of the authors are with Washington University in St Louis, St Louis, MO
| | - Zachary A Kasper
- All of the authors are with Washington University in St Louis, St Louis, MO
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Obadan-Udoh E, Lupulescu-Mann N, Charlesworth CJ, Muench U, Jura M, Kim H, Schwarz E, Mertz E, Sun BC. Opioid prescribing patterns after dental visits among beneficiaries of Medicaid in Washington state in 2014 and 2015. J Am Dent Assoc 2019; 150:259-268.e1. [PMID: 30922457 DOI: 10.1016/j.adaj.2018.12.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 12/21/2018] [Accepted: 12/25/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND Dentists contribute to the prevailing opioid epidemic in the United States. Concerning the population enrolled in Medicaid, little is known about dentists' opioid prescribing. METHODS The authors performed a retrospective cohort study of beneficiaries of Medicaid in Washington state with dental claims in 2014 and 2015. The primary outcome was the proportion of dental visits associated with an opioid prescription. The authors categorized visits as invasive or noninvasive by using procedure codes and each beneficiary as being at low or high risk by using his or her prescription history from the prescription drug monitoring program. RESULTS A total of 126,660 (10.3%) of all dental visits, most of which were invasive (66.9%), among the population enrolled in Medicaid in Washington state was associated with opioid prescriptions. However, noninvasive dental visits and visits for beneficiaries who had prior high-risk prescription use were associated with significantly higher mean days' supply and mean quantity of opioids prescribed. Results from the multivariate logistic regression showed that the probability of having an opioid-associated visit increased by 35.6 percentage points when the procedures were invasive and by 11.1 percentage points when the beneficiary had prior high-risk prescription use. CONCLUSIONS This baseline of opioid prescribing patterns after dental visits among the population enrolled in Medicaid in Washington state in 2014 and 2015 can inform future studies in which the investigators examine the effect of policies on opioid prescribing patterns and reasons for the variability in the dosage and duration of opioid prescriptions associated with noninvasive visits. PRACTICAL IMPLICATIONS Dentists must exercise caution when prescribing opioids during invasive visits and to patients with prior high-risk prescription use.
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