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Teng C, Lu W, Che J, Wu Y, Meng D, Shan Y. Association of Pro-Inflammatory Diet, Smoking, and Alcohol Consumption with Bladder Cancer: Evidence from Case-Control and NHANES Studies from 1999 to 2020. Nutrients 2024; 16:1793. [PMID: 38892724 PMCID: PMC11174752 DOI: 10.3390/nu16111793] [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] [Received: 04/16/2024] [Revised: 05/30/2024] [Accepted: 06/03/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND AND PURPOSE Diet might be a modifiable factor in preventing cancer by modulating inflammation. This study aims to explore the association between the dietary inflammatory index (DII) score and the risk of bladder cancer (BC). METHODS A total of 112 BC patients and 292 control subjects were enrolled in a case-control trial. Additionally, we tracked a total of 109 BC patients and 319 controls, whose propensity scores were obtained from the Nutrition Examination Survey (NHANES) database spanning from 1999 to 2020. The baseline index and dietary intake data were assessed using a food frequency questionnaire (FFQ). DII scores were calculated based on the dietary intake of 20 nutrients obtained from participants and categorized into four groups. The association between the inflammatory potential of the diet and BC risk was investigated using multivariate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS High DII scores were associated with a pro-inflammatory diet and a higher risk of BC, with higher DII scores positively associated with a higher risk of BC (quartiles 4 vs. 1, ORs 4.89, 95% CIs 2.09-11.25 p < 0.001). Specifically, this might promote BC development by inducing oxidative stress and affecting DNA repair mechanisms. This result was consistent with the NHANES findings (quartiles 4 vs. 1, ORs 2.69, 95% CIs 1.25-5.77, p = 0.006) and further supported the association of pro-inflammatory diet and lifestyle factors with the risk of BC. CONCLUSIONS Diets with the highest pro-inflammatory potential were associated with an increased risk of BC. By adjusting lifestyle factors, individuals might effectively lower their DII, thereby reducing the risk of developing BC. The results are consistent with the NHANES cohort.
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Affiliation(s)
- Chunying Teng
- Department of Food Science and Engineering, School of Chemistry and Chemical Engineering, Harbin Institute of Technology, Harbin 150001, China;
| | - Weihong Lu
- Department of Food Science and Engineering, School of Chemistry and Chemical Engineering, Harbin Institute of Technology, Harbin 150001, China;
| | - Jiawen Che
- School of Public Health, Wenzhou Medical University, Wenzhou 325000, China; (J.C.); (Y.W.); (D.M.)
| | - Yanhong Wu
- School of Public Health, Wenzhou Medical University, Wenzhou 325000, China; (J.C.); (Y.W.); (D.M.)
| | - Danqun Meng
- School of Public Health, Wenzhou Medical University, Wenzhou 325000, China; (J.C.); (Y.W.); (D.M.)
| | - Yujuan Shan
- School of Public Health, Wenzhou Medical University, Wenzhou 325000, China; (J.C.); (Y.W.); (D.M.)
- Southern Zhejiang Institute of Radiation Medicine and Nuclear Technology, Wenzhou Medical University, Wenzhou 325035, China
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Bello JK, Xu KY, Salas J, Bedrick BS, Grucza RA. Pregnancy Rates Among Women Treated with Medication for Opioid Use Disorder. J Gen Intern Med 2024; 39:1342-1348. [PMID: 38424347 PMCID: PMC11169215 DOI: 10.1007/s11606-024-08689-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 02/16/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Treatment-seeking people with opioid use disorder (OUD) who are capable of pregnancy need accurate information about the potential impact of medication to treat OUD (MOUD) on fertility to make informed choices about treatment that are consistent with their reproductive wishes. There is a dearth of research on fertility associated with MOUD receipt in birthing people with OUD. OBJECTIVE To estimate the association between treatment with MOUD and odds of conception among birthing people using national administrative claims. DESIGN Retrospective case-crossover study using multi-state US administrative data (2006-2016). Dates of conception were estimated from delivery dates and served as "case" days for which MOUD exposures were compared to those on all other ("control") days of insurance enrollment. PARTICIPANTS Treatment-seeking people with OUD with a delivery during the observation period. MAIN MEASURES Odds ratios for conception from within-person fixed effects models were modeled as a function of exposure to MOUD (buprenorphine, methadone, extended-release depot naltrexone, or oral naltrexone) using conditional logistic regression. KEY RESULTS A total of 21,928 births among 19,133 people with OUD were identified. In the sample, 5873 people received buprenorphine, 1825 methadone, 486 extended-release naltrexone, and 714 oral naltrexone. Participants could receive more than one type of MOUD. Mean age was 28.2 years (SD = 2.2; range = 16-45), with 76.2% having Medicaid. vs. commercial insurance. Compared to no MOUD, periods of methadone (aOR = 0.55 [95% CI = 0.48-0.63]) or buprenorphine receipt (aOR = 0.84 [0.77-0.91]) were associated with fewer conceptions. Treatment periods with extended-release depot naltrexone compared to no medication were associated with higher odds of conception (aOR = 1.75 [1.22-2.50]) and there was no significant difference in conception with oral naltrexone (aOR = 1.02 [0.67-1.54]). CONCLUSIONS The association between MOUD and odds of conception among birthing people varied by type of MOUD, with extended-release naltrexone associated with higher odds of conceiving compared to no treatment. Clinical studies are urgently needed to investigate these findings further.
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Affiliation(s)
- Jennifer K Bello
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA.
| | - Kevin Y Xu
- Health and Behavior Research Center, Division of Addiction Science, Prevention and Treatment, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Joanne Salas
- Advanced Health Data Institute, Department of Health and Outcomes Research, Saint Louis University, St. Louis, MO, USA
| | - Bronwyn S Bedrick
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard A Grucza
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA
- Advanced Health Data Institute, Department of Health and Outcomes Research, Saint Louis University, St. Louis, MO, USA
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Walsh SL, Comer SD, Zdovc JA, Sarr C, Björnsson M, Strandgården K, Hjelmström P, Tiberg F. Pharmacokinetic-pharmacodynamic analysis of drug liking blockade by buprenorphine subcutaneous depot (CAM2038) in participants with opioid use disorder. Neuropsychopharmacology 2024; 49:1050-1057. [PMID: 38200140 PMCID: PMC11039630 DOI: 10.1038/s41386-023-01793-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/14/2023] [Accepted: 12/19/2023] [Indexed: 01/12/2024]
Abstract
Buprenorphine is used to treat opioid use disorder (OUD). Weekly and monthly subcutaneous long-acting buprenorphine injections (CAM2038) provide more stable buprenorphine plasma levels and reduce the treatment burden, misuse, and diversion associated with sublingual transmucosal buprenorphine formulations. To characterize the pharmacokinetic/pharmacodynamic (PK/PD) relationship, a maximum inhibition (Imax) model was developed relating CAM2038 buprenorphine plasma concentration to drug liking maximum effect (Emax) visual analog scale (VAS; bipolar) score after intramuscular hydromorphone administration. Data included time-matched observations of buprenorphine plasma concentration and drug liking Emax VAS score after hydromorphone 18 mg administration in 47 non-treatment-seeking adults with moderate to severe OUD in a phase 2 study. Analysis used non-linear mixed-effects modeling (NONMEM®). The final Imax model adequately described the PK/PD relationship between buprenorphine plasma concentration and drug liking Emax VAS score. Simulations showed drug liking was effectively blocked at low buprenorphine plasma concentrations (0.4 ng/mL) where the upper 95% confidence interval of the drug liking Emax VAS score was below the pre-defined 11-point complete blockade threshold. The buprenorphine plasma concentration required to achieve 90% of the maximal effect (IC90) of drug liking was 0.675 ng/mL. Interindividual variability in responses to buprenorphine was observed; some participants experienced fluctuating responses, and a few did not achieve drug liking blockade even with higher buprenorphine plasma concentrations. This affirms the need to individualize treatment and titrate doses for optimal treatment outcomes. PK/PD models were also developed for desire to use VAS and Clinical Opiate Withdrawal Scale (COWS) scores, with results aligned to those for drug liking.
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Affiliation(s)
- Sharon L Walsh
- Behavioral Science, Pharmacology, Psychiatry and Pharmaceutical Sciences Departments, University of Kentucky College of Medicine and Pharmacy, Kentucky, KY, USA
| | - Sandra D Comer
- Department of Psychiatry, Columbia University, New York, NY, USA
| | | | | | | | | | - Peter Hjelmström
- Camurus AB, Lund, Sweden
- Uppsala Monitoring Centre, Uppsala, Sweden
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Xu KY, Gertner AK, Greenfield SF, Williams AR, Grucza RA. Treatment setting and buprenorphine discontinuation: an analysis of multi-state insurance claims. Addict Sci Clin Pract 2024; 19:17. [PMID: 38493109 PMCID: PMC10943881 DOI: 10.1186/s13722-024-00450-0] [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: 09/09/2023] [Accepted: 03/07/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Potential differences in buprenorphine treatment outcomes across various treatment settings are poorly characterized in multi-state administrative data. We thus evaluated the association of opioid use disorder (OUD) treatment setting and insurance type with risk of buprenorphine discontinuation among commercial insurance and Medicaid enrollees initiated on buprenorphine. METHODS In this observational, retrospective cohort study using the Merative MarketScan databases (2006-2016), we analyzed buprenorphine retention in 58,200 US adults with OUD. Predictor variables included insurance status (Medicaid vs commercial) and treatment setting, operationalized as substance use disorder (SUD) specialty treatment facility versus outpatient primary care physicians (PCPs) versus outpatient psychiatry, ascertained by linking physician visit codes to buprenorphine prescriptions. Treatment setting was inferred based on timing of prescriber visit claims preceding prescription fills. We estimated time to buprenorphine discontinuation using multivariable cox regression. RESULTS Among enrollees with OUD receiving buprenorphine, 26,168 (45.0%) had prescriptions from SUD facilities without outpatient buprenorphine treatment, with the remaining treated by outpatient PCPs (n = 23,899, 41.1%) and psychiatrists (n = 8133, 13.9%). Overall, 50.6% and 73.3% discontinued treatment at 180 and 365 days respectively. Buprenorphine discontinuation was higher among enrollees receiving prescriptions from SUD facilities (aHR = 1.03[1.01-1.06]) and PCPs (aHR = 1.07[1.05-1.10]). Medicaid enrollees had lower buprenorphine retention than those with commercial insurance, particularly those receiving buprenorphine from SUD facilities and PCPs (aHR = 1.24[1.20-1.29] and aHR = 1.39[1.34-1.45] respectively, relative to comparator group of commercial insurance enrollees receiving buprenorphine from outpatient psychiatry). CONCLUSION Buprenorphine discontinuation is high across outpatient PCP, psychiatry, and SUD treatment facility settings, with potentially lower treatment retention among Medicaid enrollees receiving care from SUD facilities and PCPs.
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Affiliation(s)
- Kevin Y Xu
- Department of Psychiatry, Health and Behavior Research Center, Washington University School of Medicine, Renard Hospital 3007A, 4940 Children's Place, Saint Louis, MO, 63110, USA.
| | - Alex K Gertner
- University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Shelly F Greenfield
- Division of Women's Mental Health and Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Arthur Robin Williams
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Division of Substance Use Disorders, New York State Psychiatric Institute, New York, NY, USA
| | - Richard A Grucza
- Advanced Health Data Institute, Department of Health and Outcomes Research, Department of Family/Community Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA
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Xu KY, Huang V, Williams AR, Martin CE, Bazazi AR, Grucza RA. Co-occurring psychiatric disorders and disparities in buprenorphine utilization in opioid use disorder: An analysis of insurance claims. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 9:100195. [PMID: 38023343 PMCID: PMC10630609 DOI: 10.1016/j.dadr.2023.100195] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/18/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023]
Abstract
Background As the overdose crisis continues in the U.S. and Canada, opioid use disorder (OUD) treatment outcomes for people with co-occurring psychiatric disorders are not well characterized. Our objective was to examine the influence of co-occurring psychiatric disorders on buprenorphine initiation and discontinuation. Methods This retrospective cohort study used multi-state administrative claims data in the U.S. to evaluate rates of buprenorphine initiation (relative to psychosocial treatment without medication) in a cohort of 236,198 people with OUD entering treatment, both with and without co-occurring psychiatric disorders, grouping by psychiatric disorder subtype (mood, psychotic, and anxiety-and-related disorders). Among people initiating buprenorphine, we assessed the influence of co-occurring psychiatric disorders on buprenorphine retention. We used multivariable Poisson regression to estimate buprenorphine initiation and Cox regression to estimate time to discontinuation, adjusting for all 3 classes of co-occurring disorders simultaneously and adjusting for baseline demographic and clinical characteristics. Results Buprenorphine initiation occurred in 29.3 % of those with co-occurring anxiety-and-related disorders, compared to 25.9 % and 17.5 % in people with mood and psychotic disorders. Mood (adjusted-risk-ratio[aRR] = 0.82[95 % CI = 0.82-0.83]) and psychotic disorders (aRR = 0.95[0.94-0.96]) were associated with decreased initiation (versus psychosocial treatment), in contrast to greater initiation in the anxiety disorders cohort (aRR = 1.06[1.05-1.06]). We observed an increase in buprenorphine discontinuation associated with mood (adjusted-hazard-ratio[aHR] = 1.20[1.17-1.24]) and anxiety disorders (aHR = 1.12[1.09-1.14]), in contrast to no association between psychotic disorders and buprenorphine discontinuation. Conclusions We observed underutilization of buprenorphine among people with co-occurring mood and psychotic disorders, as well as high buprenorphine discontinuation across anxiety, mood, and psychotic disorders.
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Affiliation(s)
- Kevin Y Xu
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Vivien Huang
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Arthur Robin Williams
- Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York, New York, USA
- Division of Substance Use Disorders, New York State Psychiatric Institute, New York, New York, USA
| | - Caitlin E Martin
- Department of Obstetrics and Gynecology and the VCU Institute for Drug and Alcohol Studies, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Alexander R. Bazazi
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Richard A. Grucza
- Department of Family and Community Medicine, St. Louis University, St. Louis, Missouri, USA
- Department of Health and Clinical Outcomes Research, St. Louis University, St Louis, Missouri, USA
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6
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Ellis MS, Xu KY, Tardelli VS, Fidalgo TM, Buttram ME, Grucza RA. Gabapentin Use Among Individuals Initiating Buprenorphine Treatment for Opioid Use Disorder. JAMA Psychiatry 2023; 80:1269-1276. [PMID: 37672238 PMCID: PMC10483381 DOI: 10.1001/jamapsychiatry.2023.3145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 07/05/2023] [Indexed: 09/07/2023]
Abstract
Importance Gabapentin prescriptions have drastically increased in the US due to off-label prescribing in settings such as opioid use disorder (OUD) treatment to manage a range of comorbid conditions and withdrawal symptoms, despite a lack of evidence. Objective To assess the purpose and associated risks of off-label gabapentin use in OUD treatment. Design, Setting, and Participants This retrospective recurrent-event case-control study with a crossover design used administrative claims data from MarketScan Commercial and Multi-State Medicaid databases from January 1, 2006, to December 31, 2016. Individuals aged 12 to 64 years with an OUD diagnosis and filling buprenorphine prescriptions were included in the primary analysis conducted from July 1, 2022, through June 1, 2023. Unit of observation was the person-day. Exposures Days covered by filled gabapentin prescriptions. Main Outcomes and Measures Primary outcomes were receipt of gabapentin in the 90 days after initiation of buprenorphine treatment and drug-related poisoning. Drug-related poisonings were defined using codes from International Classification of Diseases, Ninth Revision, and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. Results A total of 109 407 patients were included in the analysis (mean [SD] age, 34.0 [11.2] years; 60 112 [54.9%] male). Among the 29 967 patients with Medicaid coverage, 299 (1.0%) were Hispanic, 1330 (4.4%) were non-Hispanic Black, 23 112 (77.1%) were non-Hispanic White, and 3399 (11.3%) were other. Gabapentin was significantly less likely to be prescribed to Black or Hispanic patients, and more likely to be prescribed to female patients, those with co-occurring substance use or mood disorders, and those with comorbid physical conditions such as neuropathic pain. Nearly one-third of persons who received gabapentin (4336 [31.1%]) had at least 1 drug-related poisoning after initiating buprenorphine treatment, compared with 13 856 (14.5%) among persons who did not receive gabapentin. Adjusted analyses showed that days of gabapentin use were not associated with hospitalization for drug-related poisoning (odds ratio, 0.98 [95% CI, 0.85-1.13]). Drug-related poisoning risks did not vary based on dosage. Conclusions and Relevance Gabapentin is prescribed in the context of a myriad of comorbid conditions. Even though persons receiving gabapentin are more likely to have admissions for drug-related poisoning, these data suggest that gabapentin is not associated with an increased risk of drug-related poisoning alongside buprenorphine in adjusted analyses. More data on the safety profile of gabapentin in OUD settings are needed.
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Affiliation(s)
- Matthew S. Ellis
- Department of Psychiatry, Washington University in St Louis, School of Medicine, St Louis, Missouri
| | - Kevin Y. Xu
- Department of Psychiatry, Washington University in St Louis, School of Medicine, St Louis, Missouri
| | - Vitor S. Tardelli
- Department of Psychiatry, Universidade Federal de São Paulo, São Paulo, Brazil
- Translational Addictions Research Laboratory, Centre for Addictions and Mental Health, University of Toronto, Toronto, Ontario, Canada
| | - Thiago M. Fidalgo
- Department of Psychiatry, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Mance E. Buttram
- Department of Health, Human Performance and Recreation, University of Arkansas, Fayetteville
| | - Richard A. Grucza
- Department of Family and Community Medicine, St Louis University, St Louis, Missouri
- Department of Health and Outcomes Research, St Louis University, St Louis, Missouri
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Xu KY, Schiff DM, Jones HE, Martin CE, Kelly JC, Bierut LJ, Carter EB, Grucza RA. Racial and Ethnic Inequities in Buprenorphine and Methadone Utilization Among Reproductive-Age Women with Opioid Use Disorder: an Analysis of Multi-state Medicaid Claims in the USA. J Gen Intern Med 2023; 38:3499-3508. [PMID: 37436568 PMCID: PMC10713957 DOI: 10.1007/s11606-023-08306-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 06/27/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND Associations between race/ethnicity and medications to treat OUD (MOUD), buprenorphine and methadone, in reproductive-age women have not been thoroughly studied in multi-state samples. OBJECTIVE To evaluate racial/ethnic variation in buprenorphine and methadone receipt and retention in a multi-state U.S. sample of Medicaid-enrolled, reproductive-age women with opioid use disorder (OUD) at the beginning of OUD treatment. DESIGN Retrospective cohort study. SUBJECTS Reproductive-age (18-45 years) women with OUD, in the Merative™ MarketScan® Multi-State Medicaid Database (2011-2016). MAIN MEASURES Differences by race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, "other" race/ethnicity) in the likelihood of receiving buprenorphine and methadone during the start of OUD treatment (yes/no) were estimated using multivariable logistic regression. Differences in time to medication discontinuation (days) by race/ethnicity were evaluated using multivariable Cox regression. RESULTS Of 66,550 reproductive-age Medicaid enrollees with OUD (84.1% non-Hispanic White, 5.9% non-Hispanic Black, 1.0% Hispanic, 5.3% "other"), 15,313 (23.0%) received buprenorphine and 6290 (9.5%) methadone. Non-Hispanic Black enrollees were less likely to receive buprenorphine (adjusted odds ratio, aOR = 0.76 [0.68-0.84]) and more likely to be referred to methadone clinics (aOR = 1.78 [1.60-2.00]) compared to non-Hispanic White participants. Across both buprenorphine and methadone in unadjusted analyses, the median discontinuation time for non-Hispanic Black enrollees was 123 days compared to 132 days and 141 days for non-Hispanic White and Hispanic enrollees respectively (χ2 = 10.6; P = .01). In adjusted analyses, non-Hispanic Black enrollees experienced greater discontinuation for buprenorphine and methadone (adjusted hazard ratio, aHR = 1.16 [1.08-1.24] and aHR = 1.16 [1.07-1.30] respectively) compared to non-Hispanic White peers. We did not observe differences in buprenorphine or methadone receipt or retention for Hispanic enrollees compared to the non-Hispanic White enrollees. CONCLUSIONS Our data illustrate inequities between non-Hispanic Black and non-Hispanic White Medicaid enrollees with regard to buprenorphine and methadone utilization in the USA, consistent with literature on the racialized origins of methadone and buprenorphine treatment.
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Affiliation(s)
- Kevin Y Xu
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA.
| | - Davida M Schiff
- Division of General Academic Pediatrics, Mass General Hospital for Children, Boston, MA, USA
| | - Hendrée E Jones
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Caitlin E Martin
- Department of Obstetrics and Gynecology and VCU Institute for Drug and Alcohol Studies, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Jeannie C Kelly
- Division of Maternal-Fetal Medicine and the Division of Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, USA
| | - Laura J Bierut
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
- Alvin J Siteman Cancer Center, Barnes Jewish Hospital, St. Louis, MO, USA
| | - Ebony B Carter
- Division of Maternal-Fetal Medicine and the Division of Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, USA
| | - Richard A Grucza
- Departments of Family and Community Medicine and Health and Outcomes Research, St. Louis University, St. Louis, MO, USA
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Domzaridou E, Carr MJ, Millar T, Webb RT, Ashcroft DM. Non-fatal overdose risk associated with prescribing opioid agonists concurrently with other medication: Cohort study conducted using linked primary care, secondary care and mortality records. Addiction 2023; 118:2374-2383. [PMID: 37536685 DOI: 10.1111/add.16306] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 06/25/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND AND AIMS An apparently protective effect of opioid agonist treatment (OAT) on all-cause and cause-specific mortality risk has been widely reported. Non-fatal overdose (NFO) often precedes subsequent drug-poisoning deaths. We hypothesized that benzodiazepines, gabapentinoids, antipsychotics, antidepressants, Z-drugs or opioids increase the NFO risk when co-prescribed with OAT. DESIGN We conducted a cohort study using the Clinical Practice Research Datalink GOLD and Aurum databases. The cohort was linked to Hospital Episode Statistics admitted patient care data (HES-APC), neighbourhood- and practice-level Index of Multiple Deprivation quintiles and mortality records from the Office for National Statistics. SETTING Primary care in England. PARTICIPANTS We studied patients with opioid use disorder, aged 18-64 years, who were prescribed OAT (15155 methadone and 5743 buprenorphine recipients) between Jan 1, 1998, and Dec 31, 2017. MEASUREMENTS The main outcome examined was NFO risk during co-prescription of OAT with benzodiazepines, antipsychotics, gabapentinoids, antidepressants, Z-drugs or opioids. Overdose was defined according to International Classification of Diseases codes from the HES-APC data set. Negative binomial regression models were used to estimate weighted rate ratios (wRR) for NFO during co-prescription of OAT and benzodiazepines, antipsychotics, gabapentinoids, antidepressants, Z-drugs or opioids with periods of exclusive OAT usage. FINDINGS Among 20 898 patients observed over 83 856 person-years, we found an elevated overdose risk that resulted in hospital admission during co-prescription of OAT with benzodiazepines [wRR: 1.45; 95% confidence interval (CI) = 1.26-1.67], gabapentinoids (wRR = 2.22; 95% CI = 1.77-2.79), Z-drugs (wRR = 1.60; 95% CI = 1.31-1.96), antipsychotics (wRR = 1.85; 95% CI = 1.53-2.25) and opioids (wRR = 1.28; 95% CI = 1.02-1.60). The risk ratio for antidepressant co-prescriptions was below unity (wRR = 0.90; 95% CI = 0.79-1.02) but this result was not statistically significant. CONCLUSION Elevated risk of non-fatal overdose among opioid agonist treatment recipients is associated with concurrent use of medication prescribed for other reasons.
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Affiliation(s)
- Eleni Domzaridou
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Matthew J Carr
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Tim Millar
- Centre for Mental Health and Safety, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Roger T Webb
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Centre for Mental Health and Safety, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Darren M Ashcroft
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Huang HC, Li WC, Tadrous M, Schumock GT, Touchette D, Awadalla S, Lee TA. Evaluating the use of methods to mitigate bias from non-transient medications in the case-crossover design: A systematic review. Pharmacoepidemiol Drug Saf 2023; 32:939-950. [PMID: 37283212 DOI: 10.1002/pds.5649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/30/2023] [Accepted: 06/02/2023] [Indexed: 06/08/2023]
Abstract
PURPOSE The case-crossover design is a self-controlled study design used to compare exposure immediately preceding an event occurrence with exposure in earlier control periods. The design is most suitable for transient exposures in order to avoid biases that can be problematic when using the case-crossover design for non-transient (i.e., chronic) exposures. Our goal was to conduct a systematic review of case-crossover studies and its variants (case-time-control and case-case-time-control) in order to compare design and analysis choices by medication type. METHODS We conducted a systematic search to identify recent case-crossover, case-time-control, and case-case-time-control studies focused on medication exposures. Articles indexed in MEDLINE and EMBASE using these study designs that were published between January 2015 and December 2021 in the English language were identified. Reviews, methodological studies, commentaries, articles without medications as the exposure of interest, and articles with no available full text were excluded. Study characteristics including study design, outcome, risk window, control window, reporting of discordant pairs, and inclusion of sensitivity analyses were summarized overall and by medication type. We further evaluated the implementation of recommended methods to account for biases introduced by non-transient exposures among articles that used the case-crossover design on a non-transient exposure. RESULTS Of the 2036 articles initially identified, 114 articles were included. The case-crossover was the most common study design (88%), followed by the case-time-control (17%), and case-case-time-control (3%). Fifty-three percent of the articles included only transient medications, 35% included only non-transient medications, and 12% included both. Across years, the proportion of case-crossover articles evaluating a non-transient medication ranged from 30% in 2018 to 69% in 2017. We found that 41% of the articles that evaluated a non-transient medication did not apply any of the recommended methods to account for biases and more than half of which were conducted by authors with no previous publication history of case-crossover studies. CONCLUSION Using the case-crossover design to evaluate a non-transient medication remains common in pharmacoepidemiology. Researchers should apply appropriate design and analysis choices when opting to use a case-crossover design with non-transient medication exposures.
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Affiliation(s)
- Hsiao-Ching Huang
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois Chicago, Chicago, Illinois, USA
| | - Wen-Chin Li
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois Chicago, Chicago, Illinois, USA
| | - Mina Tadrous
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Glen T Schumock
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois Chicago, Chicago, Illinois, USA
| | - Daniel Touchette
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois Chicago, Chicago, Illinois, USA
| | - Saria Awadalla
- Department of Epidemiology and Biostatistics, School of Public Health, University of Illinois Chicago, Chicago, Illinois, USA
| | - Todd A Lee
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois Chicago, Chicago, Illinois, USA
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10
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Martin CE, Patel H, Dzierewski JM, Moeller FG, Bierut LJ, Grucza RA, Xu KY. Benzodiazepine, Z-drug, and sleep medication prescriptions in male and female people with opioid use disorder on buprenorphine and comorbid insomnia: an analysis of multistate insurance claims. Sleep 2023; 46:zsad083. [PMID: 36970994 PMCID: PMC10262036 DOI: 10.1093/sleep/zsad083] [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] [Received: 12/02/2022] [Revised: 03/19/2023] [Indexed: 03/29/2023] Open
Abstract
STUDY OBJECTIVES In adult populations, women are more likely than men to be prescribed benzodiazepines. However, such disparities have not been investigated in people with opioid use disorder (OUD) and insomnia receiving buprenorphine, a population with particularly high sedative/hypnotic receipt. This retrospective cohort study used administrative claims data from Merative MarketScan Commercial and MultiState Medicaid Databases (2006-2016) to investigate sex differences in the receipt of insomnia medication prescriptions among patients in OUD treatment with buprenorphine. METHODS We included people aged 12-64 years with diagnoses of insomnia and OUD-initiating buprenorphine during the study timeframe. The predictor variable was sex (female versus male). The primary outcome was receipt of insomnia medication prescription within 60 days of buprenorphine start, encompassing benzodiazepines, Z-drugs, or non-sedative/hypnotic insomnia medications (e.g. hydroxyzine, trazodone, and mirtazapine). Associations between sex and benzodiazepine, Z-drug, and other insomnia medication prescription receipt were estimated using Poisson regression models. RESULTS Our sample included 9510 individuals (female n = 4637; male n = 4873) initiating buprenorphine for OUD who also had insomnia, of whom 6569 (69.1%) received benzodiazepines, 3891 (40.9%) Z-drugs, and 8441 (88.8%) non-sedative/hypnotic medications. Poisson regression models, adjusting for sex differences in psychiatric comorbidities, found female sex to be associated with a slightly increased likelihood of prescription receipt: benzodiazepines (risk ratio [RR], RR = 1.17 [1.11-1.23]), Z-drugs (RR = 1.26 [1.18-1.34]), and non-sedative/hypnotic insomnia medication (RR = 1.07, [1.02-1.12]). CONCLUSIONS Sleep medications are commonly being prescribed to individuals with insomnia in OUD treatment with buprenorphine, with sex-based disparities indicating a higher prescribing impact among female than male OUD treatment patients.
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Affiliation(s)
- Caitlin E Martin
- Department of Obstetrics and Gynecology and VCU Institute for Drug and Alcohol Studies, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Hetal Patel
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | | | - F. Gerard Moeller
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, USA
| | - Laura J Bierut
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
- Alvin J Siteman Cancer Center, Barnes Jewish Hospital, St. Louis, MO, USA
| | - Richard A Grucza
- Departments of Family and Community Medicine and Health and Outcomes Research, St. Louis University, St. Louis, MO, USA
| | - Kevin Y Xu
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
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11
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Maust DT, Bohnert ASB, Strominger J, Goldstick JE. Prescription characteristics associated with drug overdose risk among adults prescribed benzodiazepines: a cohort study. BMC Pharmacol Toxicol 2023; 24:34. [PMID: 37208726 PMCID: PMC10199543 DOI: 10.1186/s40360-023-00674-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 05/09/2023] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND Drug overdose (OD) deaths in the U.S. continue to rise. After opioids, benzodiazepines (BZD) are the medication most commonly involved in prescription overdoses, yet OD risk factors among those prescribed BZD are not well understood. Our objective was to examine characteristics of BZD, opioid, and other psychotropic prescriptions associated with increased drug OD risk following a BZD prescription. METHODS We completed a retrospective cohort study using a 20% sample of Medicare beneficiaries with prescription drug coverage. We identified patients with a BZD prescription ("index") claim between 1 April 2016 and 31 December 2017. In the 6 months pre-index, those without and with BZD claims comprised incident and continuing cohorts, which were split by age (incident < 65 [n = 105,737], 65 + [n = 385,951]; continuing < 65 [n = 240,358], 65 + [n = 508,230]). Exposures of interest were: average daily dose and days prescribed of the index BZD; baseline BZD medication possession ratio (MPR) for the continuing cohort; co-prescribed opioids and psychotropics. Our primary outcome was a treated drug OD event (including accidental, intentional, undetermined, or adverse effect) within 30 days of the index BZD, examined using Cox proportional hazards. RESULTS Among incident and continuing BZD cohorts, 0.78% and 0.56% experienced an OD event. Compared to 14-30 days, a < 14-day fill corresponded to higher OD risk in incident (< 65 adjusted hazard ratio [aHR] 1.16 [95% CI 1.03-1.31]; 65 + : aHR 1.21 [CI 1.13-1.30]) and continuing (< 65: aHR 1.33 [CI 1.15-1.53]; 65 + : aHR 1.43 [CI 1.30-1.57]) cohorts. Among continuing users, lower baseline exposure (i.e., MPR < 0.5) was associated with increased OD risk for those < 65 (aHR 1.20 [CI 1.06-1.36]); 65 + (aHR 1.12 [CI 1.01-1.24]). Along with opioids, concurrent antipsychotic use and antiepileptic use were associated with elevated risk of OD in all 4 cohorts (e.g., aHRs for the continuing 65 + cohort: opioid, 1.73 [CI 1.58-1.90]; antipsychotic, 1.33 [CI 1.18-1.50]; antiepileptic, 1.18 [1.08-1.30]). CONCLUSIONS In both the incident and continuing cohorts, patients dispensed fewer days' supply were at increased OD risk; those in the continuing cohort with more limited baseline BZD exposure were also at elevated risk. Concurrent medication exposures including opioids, antipsychotics, and antiepileptics were associated with short-term elevated OD risk.
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Affiliation(s)
- Donovan T Maust
- Injury Prevention Center, University of Michigan, Ann Arbor, MI, 48109, USA.
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA.
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
| | - Amy S B Bohnert
- Injury Prevention Center, University of Michigan, Ann Arbor, MI, 48109, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Julie Strominger
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Jason E Goldstick
- Injury Prevention Center, University of Michigan, Ann Arbor, MI, 48109, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
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12
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Borrelli EP, Bratberg J, Hallowell BD, Kogut SJ. Benzodiazepine Dose Intensity among Patients Concurrently Prescribed Buprenorphine in Rhode Island. Subst Use Misuse 2023; 58:1038-1045. [PMID: 37129006 DOI: 10.1080/10826084.2023.2205492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Background: The concomitant use of buprenorphine and benzodiazepines has been linked to patient fatalities, with greater risk occurring with higher doses of benzodiazepines. We assessed benzodiazepine dose intensity among patients who were concurrently prescribed buprenorphine, as compared with patients prescribed benzodiazepines who were not receiving buprenorphine. Methods: We conducted a cross-sectional analysis of adult patients who received at least a 30-day supply of benzodiazepines during 2018, using data from the Rhode Island (RI) Prescription Drug Monitoring Program. Mean daily diazepam milligram equivalents (DME) were calculated overall and according to patient sex, age group, payment type, and RI county. Multivariable logistic regression analyses were conducted to assess the odds of higher-dose benzodiazepine utilization among patients with concurrent use of buprenorphine, as compared with patients not prescribed buprenorphine, adjusting for patient demographics. Results: Compared to patients prescribed benzodiazepines who were not receiving buprenorphine, those with concurrent buprenorphine utilization had a significantly higher mean DME/day (19.22, 95% CI: 18.70-19.74; vs 10.94, 95% CI: 10.93-10.95; p < 0.001). Patients who were prescribed benzodiazepines with concurrent utilization of buprenorphine also had a comparatively higher odds of a DME/day ≥15 (aOR: 2.86, 95% CI: 2.63-3.10), ≥20 DME/day (aOR: 2.98, 95% CI: 2.75-3.24), and ≥25 DME/day (aOR: 2.99, 95% CI: 2.65-3.18). Conclusion: Compared to patients prescribed benzodiazepines for at least 30 days who were not receiving buprenorphine, patients concurrently utilizing benzodiazepines and buprenorphine had more than twice the odds of higher dose benzodiazepine utilization. Future studies are needed to assess the relationship between benzodiazepine dose intensity, overdose outcomes, and treatment retention among patients receiving buprenorphine.
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Affiliation(s)
- Eric P Borrelli
- University of Rhode Island College of Pharmacy, Kingston, Rhode Island, USA
| | - Jeffrey Bratberg
- University of Rhode Island College of Pharmacy, Kingston, Rhode Island, USA
| | | | - Stephen J Kogut
- University of Rhode Island College of Pharmacy, Kingston, Rhode Island, USA
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13
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Xu KY, Jones HE, Schiff DM, Martin CE, Kelly JC, Carter EB, Bierut LJ, Grucza RA. Initiation and Treatment Discontinuation of Medications for Opioid Use Disorder in Pregnant People Compared With Nonpregnant People. Obstet Gynecol 2023; 141:845-853. [PMID: 36897142 PMCID: PMC10201921 DOI: 10.1097/aog.0000000000005117] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/12/2023] [Indexed: 03/11/2023]
Abstract
OBJECTIVE To examine the association between pregnancy and medications for opioid use disorder (MOUD) initiation and discontinuation among reproductive-aged people receiving treatment for opioid use disorder (OUD) in the United States. METHODS We conducted a retrospective cohort study of people with gender recorded as female, aged 18-45 years, in the Merative TM MarketScan ® Commercial and Multi-State Medicaid Databases (2006-2016). Opioid use disorder and pregnancy status were identified based on inpatient or outpatient claims for established International Classification of Diseases, Ninth and Tenth Revision diagnosis and procedure codes. The main outcomes were buprenorphine and methadone initiation and discontinuation, determined by using pharmacy and outpatient procedure claims. Analyses were conducted at the treatment episode level. Adjusting for insurance status, age, and co-occurring psychiatric and substance use disorders, we used logistic regression to estimate MOUD initiation and used Cox regression to estimate MOUD discontinuation. RESULTS Our sample included 101,772 reproductive-aged people with OUD, encompassing 155,771 treatment episodes (mean age 30.8 years, 64.4% Medicaid insurance, 84.1% White), of whom 2,687 (3.2%, encompassing 3,325 episodes) were pregnant. In the pregnant group, 51.2% of treatment episodes (1,703/3,325) involved psychosocial treatment without MOUD, in comparison with 61.1% (93,156/152,446) in the nonpregnant comparator group. In adjusted analyses assessing likelihood of initiation for individual MOUD, pregnancy status was associated with an increase in buprenorphine (adjusted odds ratio [aOR] 1.57, 95% CI 1.44-1.70) and methadone initiation (aOR 2.04, 95% CI 1.82-2.27). Discontinuation rates of MOUD at 270 days were high for both buprenorphine (72.4% for nonpregnant episodes vs 59.9% for pregnant episodes) and methadone (65.7% for nonpregnant episodes vs 54.1% for pregnant episodes). Pregnancy was associated with a decreased likelihood of discontinuation at 270 days for both buprenorphine (adjusted hazard ratio [aHR] 0.71, 95% CI 0.67-0.76) and methadone (aHR 0.68, 95% CI 0.61-0.75), in comparison with nonpregnant status. CONCLUSION Although a minority of reproductive-aged people with OUD in the United States are initiated on MOUD, pregnancy is associated with a significant increase in treatment initiation and a reduced risk of medication discontinuation.
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Affiliation(s)
- Kevin Y Xu
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Hendrée E Jones
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Davida M Schiff
- Division of General Academic Pediatrics, Mass General Hospital for Children, Boston, MA, USA
| | - Caitlin E Martin
- Department of Obstetrics and Gynecology and VCU Institute for Drug and Alcohol Studies, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Jeannie C Kelly
- Division of Maternal-Fetal Medicine and the Division of Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, USA
| | - Ebony B Carter
- Division of Maternal-Fetal Medicine and the Division of Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, USA
| | - Laura J Bierut
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
- Alvin J Siteman Cancer Center, Barnes Jewish Hospital, St. Louis, MO, USA
| | - Richard A Grucza
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
- Departments of Family and Community Medicine and Health and Outcomes Research, St. Louis University, St. Louis, MO, USA
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14
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McHugh RK, Votaw VR, Trapani EW, McCarthy MD. Prevalence and correlates of the misuse of z-drugs and benzodiazepines in the National Survey on Drug Use and Health. Front Psychiatry 2023; 14:1129447. [PMID: 36970272 PMCID: PMC10033696 DOI: 10.3389/fpsyt.2023.1129447] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 02/23/2023] [Indexed: 03/11/2023] Open
Abstract
BackgroundBenzodiazepines and non-benzodiazepine hypnotics (z-drugs) are commonly prescribed for their anxiolytic and hypnotic properties, though they can also be misused. In studies examining the epidemiology of prescription drug misuse, these medication classes are commonly combined, rendering inadequate knowledge of their patterns of misuse. The objective of this study was to characterize the population prevalence, conditional dependence, and sociodemographic and clinical correlates of the misuse of benzodiazepines and z-drugs.MethodsData from the National Survey on Drug Use and Health from 2015 to 2019 were used to estimate population-level prevalence and characteristics of benzodiazepine and z-drug misuse. Groups were derived based on past-year misuse of benzodiazepines alone, z-drugs alone, or both drug types. Unadjusted regression analyses were used to compare groups on characteristics of interest.ResultsExposure to benzodiazepines and/or z-drugs via prescription or misuse was common; however, only 2% of the population was estimated to have misused a benzodiazepine in the past year, and less than 0.5% misused z-drugs. People who misused only z-drugs were generally older, more likely to have health insurance, more educated, and had less severe psychiatric symptoms. This group was also more likely to report misuse to cope with sleep difficulty. Although concurrent substance use was highly prevalent in all groups, people who misused z-drugs alone generally reported less concurrent substance use than the other groups.ConclusionThe misuse of z-drugs is less common than benzodiazepines, and people who misuse only z-drugs appear to generally have lower clinical severity. Nonetheless, a substantial subgroup of people exposed to z-drugs report concurrent, past-year use of other substances. Further research on z-drug misuse, including consideration of whether it should be grouped with other anxiolytic/hypnotic drugs, is needed.
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Affiliation(s)
- R. Kathryn McHugh
- Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA, United States
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
- *Correspondence: R. Kathryn McHugh,
| | - Victoria R. Votaw
- Department of Psychology, University of New Mexico, Albuquerque, NM, United States
- Center on Alcohol, Substance Use, and Addictions, University of New Mexico, Albuquerque, NM, United States
| | - Emma W. Trapani
- Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA, United States
| | - Megan D. McCarthy
- Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA, United States
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15
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Lape EC, Powers JM, Hooker JE, Edwards RR, Ditre JW. Benzodiazepine Use and Dependence in Relation to Chronic Pain Intensity and Pain Catastrophizing. THE JOURNAL OF PAIN 2023; 24:345-355. [PMID: 36243316 PMCID: PMC9898110 DOI: 10.1016/j.jpain.2022.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 09/21/2022] [Accepted: 09/27/2022] [Indexed: 11/07/2022]
Abstract
Benzodiazepines (BZDs), a class of sedative-hypnotic medications, generated concern as their popularity grew, with particular alarm regarding elevated rates of BZD use among chronic pain populations. Consistent with negative reinforcement/motivational models of substance use, desire for pain alleviation may motivate BZD use. Yet, little is known about relations between pain and addiction-relevant BZD use processes. This cross-sectional survey study aimed to: a) test associations between pain intensity and clinically relevant BZD use patterns, and b) examine the role of pain catastrophizing in hypothesized pain-BZD relations. Participants included 306 adults with chronic musculoskeletal pain and a current BZD prescription who completed an online survey study (Mage = 38.7, 38.9% female). Results indicated that pain intensity was positively associated with past-month BZD use frequency, BZD dependence severity, and likelihood of endorsing BZD misuse behaviors (ps < .05). Pain catastrophizing was positively associated with BZD dependence/likelihood of BZD misuse, covarying for pain intensity (P < .05). These findings build upon an emerging literature by highlighting positive covariation of pain intensity and pain catastrophizing with addiction-relevant BZD use behaviors. Results underscore the need to further investigate high-risk BZD use among individuals with chronic pain, with and without concurrent opioid use, to inform prevention/intervention efforts. PERSPECTIVE: This article presents findings on cross-sectional associations of pain intensity and pain catastrophizing with clinically relevant benzodiazepine (BZD) use outcomes, including dependence and misuse, among individuals with chronic pain. Findings help elucidate the higher burden of BZD misuse/dependence in chronic pain populations and suggest that pain relief may be a common, yet under recognized, self-reported motivation for taking BZDs.
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Affiliation(s)
- Emma C Lape
- Department of Psychology, Syracuse University, Syracuse, New York
| | - Jessica M Powers
- Department of Psychology, Syracuse University, Syracuse, New York
| | - Julia E Hooker
- Department of Psychology, Syracuse University, Syracuse, New York
| | - Robert R Edwards
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women's Hospital, Boston, Massachusetts
| | - Joseph W Ditre
- Department of Psychology, Syracuse University, Syracuse, New York.
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16
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Hallowell BD, Chambers LC, Samuels EA, Bratberg J, McDonald J, Nitenson A, Onyejekwe C, Beaudoin FL. Sociodemographic and prescribing characteristics that impact long-term retention in buprenorphine treatment for opioid use disorder among a statewide population. Drug Alcohol Depend 2022; 241:109680. [PMID: 36335834 PMCID: PMC10193454 DOI: 10.1016/j.drugalcdep.2022.109680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 10/24/2022] [Accepted: 10/24/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND AIMS Partial opioid agonist medications for opioid use disorder reduce mortality and morbidity, however long-term retention in treatment is challenging. The objective of this study was to identify patient and prescription characteristics associated with long-term buprenorphine treatment retention. METHODS We used data from the Rhode Island prescription drug monitoring program to identify residents who initiated buprenorphine treatment and determine if they were retained in long-term buprenorphine treatment 12-months after treatment initiation. Multivariable logistic regression models were used to identify sociodemographic and prescription characteristics associated with long-term buprenorphine retention. FINDINGS During the study period 4898 unique Rhode Island residents initiated buprenorphine treatment, of whom 37.8 % were retained in treatment at 12-months. Demographic factors associated with a higher odds of long-term buprenorphine retention included older age, female sex, Medicaid insurance (vs private), and living closer to the pharmacy where the prescription was filled. Individuals who were prescribed the tablet formulation (aOR: 0.82 [95 % CI 0.72, 0.93]) or received a non-buprenorphine opioid during the follow-up window (aOR: 0.37 [95 % CI 0.31, 0.44]) had lower odds of long-term treatment at 12-months. Individuals who received at least one day of overlapping benzodiazepine and buprenorphine prescriptions (aOR: 2.00 [95 % CI 1.70, 2.34]) and those given a longer days supply (aOR: 1.26 [95 % CI 1.01, 1.56]) had higher odds of long-term treatment at 12-months. Findings were similar for treatment retention at 6-months in sensitivity analyses. CONCLUSIONS These findings highlight several modifiable prescribing practices associated with long-term buprenorphine retention, suggesting that clinicians and public health practitioners can help remove barriers to long-term retention.
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Affiliation(s)
- Benjamin D Hallowell
- Substance Use Epidemiology Program, Rhode Island Department of Health, Providence, RI, USA.
| | - Laura C Chambers
- Substance Use Epidemiology Program, Rhode Island Department of Health, Providence, RI, USA; Division of Infectious Diseases, The Miriam Hospital, Providence, RI, USA; Department of Epidemiology, Brown University, Providence, RI, USA
| | - Elizabeth A Samuels
- Department of Epidemiology, Brown University, Providence, RI, USA; Department of Emergency Medicine, Brown University, Providence, RI, USA; Drug Overdose Prevention Program, Rhode Island Department of Health, Providence, RI, USA
| | - Jeffrey Bratberg
- Department of Pharmacy Practice, University of Rhode Island College of Pharmacy, Kingston, RI, USA
| | - James McDonald
- Prescription Drug Monitoring Program, Rhode Island Department of Health, Providence, RI, USA
| | - Adam Nitenson
- Prescription Drug Monitoring Program, Rhode Island Department of Health, Providence, RI, USA
| | - Collette Onyejekwe
- Prescription Drug Monitoring Program, Rhode Island Department of Health, Providence, RI, USA
| | - Francesca L Beaudoin
- Department of Epidemiology, Brown University, Providence, RI, USA; Department of Emergency Medicine, Brown University, Providence, RI, USA
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17
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Coffin PO, Martinez RS, Wylie B, Ryder B. Primary care management of Long-Term opioid therapy. Ann Med 2022; 54:2451-2469. [PMID: 36111417 PMCID: PMC9487960 DOI: 10.1080/07853890.2022.2121417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 08/17/2022] [Accepted: 08/31/2022] [Indexed: 11/01/2022] Open
Abstract
The United States underwent massive expansion in opioid prescribing from 1990-2010, followed by opioid stewardship initiatives and reduced prescribing. Opioids are no longer considered first-line therapy for most chronic pain conditions and clinicians should first seek alternatives in most circumstances. Patients who have been treated with opioids long-term should be managed differently, sometimes even continued on opioids due to physiologic changes wrought by long-term opioid therapy and documented risks of discontinuation. When providing long-term opioid therapy, clinicians should document opioid stewardship measures, including assessments, consents, medication reconciliation, and offering naloxone, along with the rationale to continue opioid therapy. Clinicians should screen regularly for opioid use disorder and arrange for or directly provide treatment. In particular, buprenorphine can be highly useful for co-morbid pain and opioid use disorder. Addressing other substance use disorders, as well as preventive health related to substance use, should be a priority in patients with opioid use disorder. Patient-centered practices, such as shared decision-making and attending to related facets of a patient's life that influence health outcomes, should be implemented at all points of care.Key messagesAlthough opioids are no longer considered first-line therapy for most chronic pain, management of patients already taking long-term opioid therapy must be individualised.Documentation of opioid stewardship measures can help to organise opioid prescribing and protect clinicians from regulatory scrutiny.Management of resultant opioid use disorder should include provision of medications, most often buprenorphine, and several additional screening and preventive measures.
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Affiliation(s)
- Phillip O. Coffin
- San Francisco Department of Public Health, Center on Substance Use and Health, San Francisco, CA, USA
| | - Rebecca S. Martinez
- San Francisco Department of Public Health, Center on Substance Use and Health, San Francisco, CA, USA
| | - Brian Wylie
- San Francisco Department of Public Health, Center on Substance Use and Health, San Francisco, CA, USA
| | - Bunny Ryder
- San Francisco Department of Public Health, Center on Substance Use and Health, San Francisco, CA, USA
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18
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Baumann SL, Samuels WE. Comorbidities in older adults with opioid use disorders. J Am Assoc Nurse Pract 2022; 34:1280-1288. [PMID: 36354181 DOI: 10.1097/jxx.0000000000000801] [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: 03/30/2022] [Accepted: 09/28/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND There is a growing number of opioid use disorders (OUDs) and overdose deaths in older adults. In addition, older adults with OUD routinely receive lower-quality preventive and chronic care that result in poorer overall health. PURPOSE The purpose of this study was to identify older patients with OUD at the study site and determine the prevalence of medical and psychiatric comorbidities. METHODOLOGY This retrospective study used a computer algorithm employed by a network of Federally Qualified Health Center primary care clinics in lower New York state. With the approval from institutional review board, the IT department of the organization captured data about older adults with an OUD diagnosis. The IT department identified 664 patients and provided anonymized demographic and medical history data of these patients for analysis. RESULTS Patients with OUD had 2-3 times more medical and psychiatric co-occurring conditions than national sample of older adults with no OUD of similar age and income. The most frequent co-occurring medical conditions in the patients were heart or circulatory disorders, movement disorders, respiratory disorders, pain disorders, nutritional disorders, and metabolic disorders. The most common co-occurring psychiatric conditions were anxiety disorders, major depressive disorder, post-traumatic stress disorder (PTSD), and bipolar disorder. CONCLUSIONS Older adults with OUD often have complex health care needs that often include one or more chronic medical and psychiatric conditions. IMPLICATIONS Providers should be aware of the multiple needs of older adults with OUD so that appropriate and comprehensive care can be offered to the patients.
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Affiliation(s)
- Steven L Baumann
- Hunter College of the City University of New York, New York, New York
- Sun River Health, Inwood Clinic, Bronx, New York
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19
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Xu KY, Mintz CM, Presnall N, Bierut LJ, Grucza RA. Association of Bupropion, Naltrexone, and Opioid Agonist Treatment With Stimulant-Related Admissions Among People With Opioid Use Disorder: A Case-Crossover Analysis. J Clin Psychiatry 2022; 83:21m14112. [PMID: 35759785 PMCID: PMC9939241 DOI: 10.4088/jcp.21m14112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Background: Stimulant use has substantially increased among people with opioid use disorder (OUD) and is associated with worse treatment outcomes. This study's objective was to compare risk of stimulant-related emergency department (ED) and hospital admissions associated with exposure to bupropion, OUD medication (buprenorphine, naltrexone, and methadone), and selective serotonin reuptake inhibitors (SSRIs; active comparator) relative to days without active prescriptions for medication. Methods: This recurrent-event, case-crossover study used insurance claims from 51,084 individuals with OUD enrolled in the IBM MarketScan (2006-2016) Databases who had at least 1 stimulant-related ED or hospital admission. Conditional logistic regression models estimated the risk of admissions between days without active prescriptions and days with prescriptions for bupropion, OUD medication, and SSRIs. Secondary analyses were conducted by stimulant subtype (cocaine; amphetamine) and event subtype (falls, injuries, or poisonings; psychotic events). Results: Compared to days without active prescriptions, days with bupropion treatment were associated with decreased odds of stimulant-related ED or hospital admissions (odds ratio [OR] = 0.77; 95% confidence interval [CI], 0.72-0.82) Among OUD medications, we observed strong protective associations with decreased admissions for buprenorphine (OR = 0.67; 95% CI, 0.64-0.71), naltrexone (OR = 0.65; 95% CI, 0.60-0.70), and methadone (OR = 0.59; 95% CI, 0.51-0.67). The SSRI active comparator group was associated with a small protective association with decreased admissions (OR = 0.90; 95% CI, 0.86-0.93). These effects were sustained in secondary analyses stratifying by stimulant and event subtype. Conclusions: Bupropion and OUD medication, including both naltrexone and opioid agonists, are associated with fewer stimulant-related ED or hospital admissions in patients with OUD. Bupropion may show promise as adjunctive therapy targeting stimulant-specific poisoning risk.
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Affiliation(s)
- Kevin Y Xu
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St Louis, Missouri.,Corresponding author: Kevin Y. Xu, MD, MPH, Department of Psychiatry, Washington University School of Medicine, 420 South Euclid Ave, Campus Box 8134, St Louis, MO 63110
| | - Carrie M Mintz
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
| | - Ned Presnall
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
| | - Laura J Bierut
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO,Alvin J Siteman Cancer Center, Barnes Jewish Hospital and Washington University School of Medicine, St. Louis, MO
| | - Richard A Grucza
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO,Departments of Family and Community Medicine and Health and Outcomes Research, St. Louis University, St. Louis, MO
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20
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Mintz CM, Xu KY, Presnall NJ, Hartz SM, Levin FR, Scherrer JF, Bierut LJ, Grucza RA. Analysis of Stimulant Prescriptions and Drug-Related Poisoning Risk Among Persons Receiving Buprenorphine Treatment for Opioid Use Disorder. JAMA Netw Open 2022; 5:e2211634. [PMID: 35544135 PMCID: PMC9096599 DOI: 10.1001/jamanetworkopen.2022.11634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE Stimulant medication use is common among individuals receiving buprenorphine for opioid use disorder (OUD). Associations between prescription stimulant use and treatment outcomes in this population have been understudied. OBJECTIVES To investigate whether use of prescription stimulants was associated with (1) drug-related poisoning and (2) buprenorphine treatment retention. DESIGN, SETTING, AND PARTICIPANTS This retrospective, recurrent-event cohort study with a case-crossover design used a secondary analysis of administrative claims data from IBM MarketScan Commercial and Multi-State Medicaid databases from January 1, 2006, to December 31, 2016. Primary analyses were conducted from March 1 through August 31, 2021. Individuals aged 12 to 64 years with an OUD diagnosis and prescribed buprenorphine who experienced at least 1 drug-related poisoning were included in the analysis. Unit of observation was the person-day. EXPOSURES Days of active stimulant prescriptions. MAIN OUTCOMES AND MEASURES Primary outcomes were drug-related poisoning and buprenorphine treatment retention. Drug-related poisonings were defined using International Classification of Diseases, Ninth Revision, and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, codes; treatment retention was defined by continuous treatment claims until a 45-day gap was observed. RESULTS There were 13 778 567 person-days of observation time among 22 946 individuals (mean [SD] age, 32.8 [11.8] years; 50.3% men) who experienced a drug-related poisoning. Stimulant treatment days were associated with 19% increased odds of drug-related poisoning (odds ratio [OR], 1.19 [95% CI, 1.06-1.34]) compared with nontreatment days; buprenorphine treatment days were associated with 38% decreased odds of poisoning (OR, 0.62 [95% CI, 0.59-0.65]). There were no significant interaction effects between use of stimulants and buprenorphine. Stimulant treatment days were associated with decreased odds of attrition from buprenorphine treatment (OR, 0.64 [95% CI, 0.59-0.70]), indicating that stimulants were associated with 36% longer mean exposure to buprenorphine and its concomitant protection. CONCLUSIONS AND RELEVANCE Among persons with OUD, use of prescription stimulants was associated with a modest increase in per-day risk of drug-related poisoning, but this risk was offset by the association between stimulant use and improved retention to buprenorphine treatment, which is associated with protection against overdose.
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Affiliation(s)
- Carrie M. Mintz
- Department of Psychiatry, Washington University School of Medicine, St Louis, Missouri
| | - Kevin Y. Xu
- Department of Psychiatry, Washington University School of Medicine, St Louis, Missouri
| | - Ned J. Presnall
- Department of Social Work, Washington University in St Louis, St Louis, Missouri
| | - Sarah M. Hartz
- Department of Social Work, Washington University in St Louis, St Louis, Missouri
| | - Frances R. Levin
- Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York, New York
- Division of Substance Use Disorders, New York State Psychiatric Institute, New York, New York
| | - Jeffrey F. Scherrer
- Department of Family and Community Medicine, St Louis University, St. Louis, Missouri
- Department of Health and Outcomes Research, St. Louis University, St Louis, Missouri
| | - Laura J. Bierut
- Department of Psychiatry, Washington University School of Medicine, St Louis, Missouri
| | - Richard A. Grucza
- Department of Family and Community Medicine, St Louis University, St. Louis, Missouri
- Department of Health and Outcomes Research, St. Louis University, St Louis, Missouri
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21
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Xu KY, Mintz CM, Presnall N, Bierut LJ, Grucza RA. Comparative Effectiveness Associated With Buprenorphine and Naltrexone in Opioid Use Disorder and Cooccurring Polysubstance Use. JAMA Netw Open 2022; 5:e2211363. [PMID: 35536575 PMCID: PMC9092203 DOI: 10.1001/jamanetworkopen.2022.11363] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
IMPORTANCE Despite prevalent polysubstance use, treatment patterns and outcomes for individuals with opioid use disorder (OUD) and cooccurring substance use disorders (SUD) are understudied. OBJECTIVE To evaluate the distribution of buprenorphine and naltrexone initiation among individuals with OUD with vs without cooccurring SUD and to assess the comparative effectiveness associated with buprenorphine and naltrexone against drug-related poisonings. DESIGN, SETTING, AND PARTICIPANTS This observational comparative effectiveness study used insurance claims from 2011 to 2016 from the US IBM MarketScan databases to study initiation of medications for OUD (MOUD) among treatment-seeking individuals aged 12 to 64 years with a primary diagnosis of OUD. Cooccurring SUD was defined as SUD diagnosed concurrent with or in the 6 months prior to OUD treatment initiation. Treatment was codified as psychosocial treatment without MOUD or initiation or buprenorphine or naltrexone (including extended-release or oral). Methadone recipients were excluded from analysis. Data were analyzed from February 3, 2021, through February 26, 2022. EXPOSURES MOUD. MAIN OUTCOMES AND MEASURES Associations between cooccurring SUD diagnoses with treatment type were assessed with multivariable regression. The association of drug-related poisoning admissions with days covered with buprenorphine or naltrexone prescriptions vs days without prescriptions was assessed among MOUD initiators. Odds ratios from within-person fixed effects models were estimated as a function of MOUD and stratified by cooccurring SUDs. RESULTS Among 179 280 individuals with OUD (mean [SD] age, 33.2 [11.0] years; 90 196 [50.5%] men), 102 930 (57.4%) received psychosocial treatment without MOUD. Across 47 488 individuals with cooccurring SUDs, 33 449 (70.4%) did not receive MOUD, whereas across 131 792 individuals without cooccurring SUDs, 69 481 (52.7%) did not receive MOUD. Cooccurring SUD was associated with decreased odds of initiating buprenorphine (risk ratio [RR], 0.55 [95% CI, 0.54-0.56]) but increased odds of initiating naltrexone (extended release: RR, 1.12 [95% CI, 1.05-1.20]; oral: RR, 1.95 [95% CI, 1.86-2.03]). Among 12 485 individuals initiating MOUD who experienced at least 1 drug-related poisoning during insurance enrollment, buprenorphine treatment days were associated with decreased poisonings compared with days without MOUD for individuals with cooccurring SUD (odds ratio [OR], 0.56 [95% CI, 0.48-0.65]) and individuals without cooccurring SUD (OR, 0.57 [95% CI, 0.53-0.63]), with comparable associations observed for extended-release naltrexone. No protective association was observed for oral naltrexone. CONCLUSIONS AND RELEVANCE These findings suggest that individuals with OUD and polysubstance use were less likely to initiate buprenorphine and naltrexone than individuals without polysubstance use. Among individuals initiating MOUD, polysubstance use was associated with decreased buprenorphine and increased naltrexone initiation, despite buprenorphine's protective associations against drug-related poisoning.
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Affiliation(s)
- Kevin Y Xu
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri
| | - Carrie M Mintz
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri
| | - Ned Presnall
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri
| | - Laura J Bierut
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri
- Alvin J. Siteman Cancer Center, Barnes Jewish Hospital and Washington University School of Medicine, St. Louis, Missouri
| | - Richard A Grucza
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri
- Departments of Family and Community Medicine and Health and Outcomes Research, St. Louis University, St. Louis, Missouri
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22
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Abstract
Benzodiazepine and related sedative use has been increasing. There has been a growing number of unregulated novel psychoactive substances, including designer benzodiazepines. Benzodiazepines have neurobiological and pharmacologic properties that result in a high potential for misuse and physical dependence. Options for discontinuing long-term benzodiazepine use include an outpatient benzodiazepine taper or inpatient withdrawal management at a hospital or detoxification facility. The quality of evidence on medications for benzodiazepine discontinuation is overall low, whereas cognitive behavioral therapy has shown the most benefit in terms of behavioral treatments. Benzodiazepines may also have significant adverse effects, increasing the risk of overdose and death.
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Affiliation(s)
- Linda Peng
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Addiction Medicine Section, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code L475, Portland, Oregon 97239, USA.
| | - Kenneth L Morford
- Department of Internal Medicine, Section of General Internal Medicine, Program in Addiction Medicine, Yale School of Medicine, 367 Cedar Street, ES Harkness A, Room 417A, New Haven, Connecticut 06510, USA
| | - Ximena A Levander
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Addiction Medicine Section, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code L475, Portland, Oregon 97239, USA. https://twitter.com/XimenaLevander
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23
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Bishop-Freeman SC, Friederich LW, Feaster MS, Hudson JS. Buprenorphine-Related Deaths in North Carolina from 2010-2018. J Anal Toxicol 2021; 45:780-791. [PMID: 34145443 DOI: 10.1093/jat/bkab073] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/11/2021] [Accepted: 06/18/2021] [Indexed: 12/16/2022] Open
Abstract
Buprenorphine is a commonly prescribed medication for the treatment of opioid-use disorder. As prescriptions increase in North Carolina, buprenorphine is more frequently encountered statewide in routine postmortem casework. Between 2010 and 2018, there were 131 select cases investigated by the Office of the Chief Medical Examiner where buprenorphine was detected in peripheral blood and considered a primary cause of death, with no other opioids present and no other non-opioid substances found in the lethal range. The decedents ranged in age from 14 to 64 years, with 67% male. The mean/median peripheral blood concentrations were 4.1/2.1 ng/mL for buprenorphine and 7.8/3.4 ng/mL for the metabolite, norbuprenorphine. These postmortem blood concentrations overlap antemortem therapeutic concentrations in plasma reported in the literature for opioid-dependent subjects receiving sublingual maintenance therapy. The pathologist considered scene findings, prescription history, autopsy findings, toxicological analysis, and decedent behavior prior to death to conclude a drug-related cause of death. Many of the deaths were complicated by the presence of other central nervous system depressants along with contributory underlying cardiovascular and respiratory disease. The three most prevalent additive substances were alprazolam, ethanol, and gabapentin, found in 67, 36, and 32 cases out of 131, respectively. Interpreting buprenorphine involvement in a death is complex, and instances may be under-estimated in epidemiological data because of the lack of a defined toxic or lethal range in postmortem blood along with its good safety profile. As expansion to access of opioid-use disorder treatment becomes a priority, awareness of the challenges of postmortem interpretation is needed as increased use and diversion of buprenorphine are inevitable.
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Affiliation(s)
- Sandra C Bishop-Freeman
- Office of the Chief Medical Examiner, Raleigh, NC, USA.,UNC Department of Pathology and Laboratory Medicine, Chapel Hill, NC, USA
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