Implementation Of Prescription Drug Monitoring Programs Associated With Reductions In Opioid-Related Death Rates

Trends in Opioid and Nonsteroidal Anti-Inflammatory Drug Use for Patients with Kidney Stones in United States Emergency Departments from 2015 to 2021

Introduction: Renal colic is frequently treated with opioids; however, narcotic analgesic use can lead to dependence and abuse. We evaluated use trends of opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management of kidney stones in United States emergency departments (EDs) from 2015 to 2021. Methods: Kidney stone encounters were identified using National Hospital Ambulatory Medical Care Survey data. We applied a multistage survey weighting procedure to account for selection probability, nonresponse, and population weights. Medication use trends were estimated through logistic regressions on the timing of the encounter, adjusted for selected demographic and clinical characteristics. Results: Between 2015 and 2021, there were an estimated 9,433,291 kidney stone encounters in United States EDs. Opioid use decreased significantly (annual odds ratio [OR]: 0.87, p = 0.003), and there was no significant trend in NSAID use. At discharge, male patients were more likely than females (OR: 1.93, p = 0.001) to receive opioids, and Black patients were less likely than White patients (OR: 0.34, p = 0.010) to receive opioids. Regional variation was also observed, with higher odds of discharge prescriptions in the West (OR: 3.15, p = 0.003) and Midwest (OR: 2.49, p = 0.010), compared with the Northeast. Thirty-five percent of patients received opioids that were stronger than morphine. Conclusion: These results suggest improved opioid stewardship from ED physicians in response to the national opioid epidemic. However, regional variation as well as disparities in discharge prescriptions for Black and female patients underscore opportunities for continued efforts.

Risk of Death at 1 Year Following Postpartum Opioid Exposure

OBJECTIVE

 Opioids are commonly prescribed to women for acute pain following childbirth. Postpartum prescription opioid exposure is associated with adverse opioid-related morbidities but the association with all-cause mortality is not well studied. This study aimed to examine the association between postpartum opioid prescription fills and the 1-year risk of all-cause mortality among women with live births.

METHODS

 In a retrospective cohort study of live births among women enrolled in Tennessee Medicaid (TennCare) between 2007 and 2015, we compared women who filled two or more postpartum outpatient opioid prescriptions (up to 41 days of postdelivery discharge) to women who filled one or fewer opioid prescription. Women were followed from day 42 postdelivery discharge through 365 days of follow-up or date of death. Deaths were identified using linked death certificates (2007-2016). We used Cox's proportional hazard regression and inverse probability of treatment weights to compare time to death between exposure groups while adjusting for relevant confounders. We also examined effect modification by delivery route, race, opioid use disorder, use of benzodiazepines, and mental health condition diagnosis.

RESULTS

 Among 264,135 eligible births, 216,762 (82.1%) had one or fewer maternal postpartum opioid fills and 47,373 (17.9%) had two or more fills. There were 182 deaths during follow-up. The mortality rate was higher in women with two or more fills (120.5 per 100,000 person-years) than in those with one or fewer (57.7 per 100,000 person-years). The risk of maternal death remained higher in participants exposed to two or more opioid fills after accounting for relevant covariates using inverse probability of treatment weighting (adjusted hazard ratio: 1.46 [95% confidence interval: 1.01, 2.09]). Findings from stratified analyses were consistent with main findings.

CONCLUSION

 Filling two or more opioid prescriptions during the postpartum period was associated with a significant increase in 1-year risk of death among new mothers.

KEY POINTS

· Opioid prescribing in the postpartum period is common.. · Prior studies show that >1 postnatal opioid fill is associated with adverse opioid-related events.. · > 1 opioid fill within 42 days of delivery was associated with an increase in 1-year risk of death..

Government Direct-to-Consumer Education to Reduce Prescription Opioid Use: A Cluster Randomized Clinical Trial

Importance

Direct-to-consumer education reduces chronic sedative use. The effectiveness of this approach for prescription opioids among patients with chronic noncancer pain remains untested.

Objectives

To evaluate the effectiveness of a government-led educational information brochure mailed to community-dwelling, long-term opioid consumers to reduce prescription opioid use compared with usual care.

Design, Setting, and Participants

This cluster randomized clinical trial was conducted from July 2018 to January 2019 in Manitoba, Canada. All adults with long-term opioid prescriptions were enrolled (n = 4225). Participants were identified via the Manitoba Drug Program Information Network. Individuals receiving palliative care or with a diagnosis of cancer or dementia were excluded. Data were analyzed from July 2019 to March 2020.

Intervention

Participants were clustered according to their primary care clinic and randomized to the intervention (a codesigned direct-to-consumer educational brochure sent by mail) or usual care (comparator group).

Main Outcomes and Measures

The main outcome was discontinuation of opioid prescriptions at the participant level after 6 months, ascertained by pharmacy drug claims. Secondary outcomes included dose reduction (in morphine milligram equivalents [MME]) and/or therapeutic switch. Reduction in opioid use was assessed using generalized estimating equations to account for clustering, with prespecified subgroup analyses by age and sex. Analysis was intention to treat.

Results

Of 4206 participants, 2409 (57.3%) were male; mean (SD) age was 60.0 (14.4) years. Mean (SD) baseline opioid use was comparable between groups (intervention, 157.7 [179.7] MME/d; control, 153.4 [181.8] MME/d). After 6 months, 235 of 2136 participants (11.0%) in 127 clusters in the intervention group no longer filled opioid prescriptions compared with 228 of 2070 (11.0%) in 124 clusters in the comparator group (difference, 0.0%; 95% CI, -1.9% to 1.9%). More participants in the intervention group than in the control group reduced their dose (1410 [66.0%] vs 1307 [63.1%]; difference, 2.8% [95% CI, 0.0%-5.7%]). Receipt of the brochure led to greater dose reductions for participants who were male (difference, 3.9%; 95% CI, 0.1%-7.7%), aged 18 to 64 years (difference, 3.7%; 95% CI, 0.2%-7.2%), or living in urban areas (difference, 5.9%; 95% CI, 1.9%-9.9%) compared with usual care.

Conclusions and Relevance

In this cluster randomized clinical trial, no significant difference in the prevalence of opioid cessation was observed after 6 months between the intervention and usual care groups; however, the intervention resulted in more adults reducing their opioid dose compared with usual care.

Trial Registration

ClinicalTrials.gov Identifier: NCT03400384.

Polysubstance mortality trends in White and Black Americans during the opioid epidemic, 1999-2018

BACKGROUND

Psychoactive drug combinations are increasingly contributing to overdose deaths among White and Black Americans. To understand the evolving nature of overdose crisis, inform policies, and develop tailored and equitable interventions, this study provides a comprehensive assessment of polysubstance mortality trends by race and sex during the opioid epidemic.

METHODS

We used serial cross-sectional US mortality data for White and Black populations from 1999 through 2018 to calculate annual age-adjusted death rates (AADR) involving any opioid, opioid subtypes, benzodiazepines, cocaine, psychostimulants, or combinations of these drugs, stratified by race and sex. Trend changes in AADR were analyzed using joinpoint regression models and expressed as average annual percent change (AAPC) during each period of the three waves of the opioid epidemic: 1999-2010 (wave 1), 2010-2013 (wave 2), and 2013-2018 (wave 3). Prevalence measures assessed the percent co-involvement of an investigated drug in the overall death from another drug.

RESULTS

Polysubstance mortality has shifted from a modest rise in death rates due to benzodiazepine-opioid overdoses among White persons (wave 1) to a substantial increase in death rates due to illicit drug combinations impacting both White and Black populations (wave 3). Concurrent cocaine-opioid use had the highest polysubstance mortality rates in 2018 among Black (5.28 per 100,000) and White (3.53 per 100,000) persons. The steepest increase in death rates during wave 3 was observed across all psychoactive drugs when combined with synthetic opioids in both racial groups. Since 2013, Black persons have died faster from cocaine-opioid and psychostimulant-opioid overdoses. Between 2013 and 2018, opioids were highly prevalent in cocaine-related deaths, increasing by 33% in White persons compared to 135% in Blacks. By 2018, opioids contributed to approximately half of psychostimulant and 85% of benzodiazepine fatal overdoses in both groups. The magnitude and type of drug combinations with the highest death rates differed by race and sex, with Black men exhibiting the highest overdose burden beginning in 2013.

CONCLUSIONS

The current drug crisis should be considered in the context of polysubstance use. Effective measures and policies are needed to curb synthetic opioid-involved deaths and address disparate mortality rates in Black communities.

Drug-Related Problems in Elderly Patients Attended to by Emergency Services

The progressive aging and comorbidities of the population have led to an increase in the number of patients with polypharmacy attended to in the emergency department. Drug-related problems (DRPs) have become a major cause of admission to these units, as well as a high rate of short-term readmissions. Anticoagulants, antibiotics, antidiabetics, and opioids have been shown to be the most common drugs involved in this issue. Inappropriate polypharmacy has been pointed out as one of the major causes of these emergency visits. Different ways of conducting chronic medication reviews at discharge, primary care coordination, and phone contact with patients at discharge have been shown to reduce new hospitalizations and new emergency room visits due to DRPs, and they are key elements for improving the quality of care provided by emergency services.

Opioid prescription rates associated with surgery among adolescents in the United States from 2015 to 2020

INTRODUCTION

The United States currently faces an epidemic of opioid misuse which extends to adolescent surgical populations. Opioid prescriptions after surgery are associated with persistent opioid use and serve as a reservoir for diversion. However, it is unclear what proportion of opioid prescriptions are surgical, and little is known about trends in opioid prescription rates associated with surgery in adolescents in the United States. This study aims to describe national trends in postsurgical opioid prescription rates over time among adolescents in the United States.

METHODS

We conducted a population-based cross-sectional analysis of data captured in the Medical Expenditure Panel Survey (MEPS) from 2015 to 2020. MEPS classified adolescents 10-19 years of age (n = 26 909) as having a surgical procedure if they had any inpatient, outpatient, or emergency department visit during which a surgical procedure was performed.

RESULTS

Mean age (SD) of the sample was 14.4 (0.01) years. Sociodemographic characteristics were representative of the USA adolescent population. In total, 4.7% of adolescents underwent a surgical procedure. The surgery rate remained stable between 2015 (4.3%): and 2020 (4.4%) and was lower among minority populations. The combined rate of opioid prescribing for surgical and nonsurgical indications significantly decreased from 4.1% in 2015 to 1.4% in 2020 among all adolescents, an estimated difference of 2.7% (95% confidence interval (CI): 1.7%-3.7%, p < .0001). However, opioid prescribing for surgery remained relatively stable (1% in 2015 vs. 0.8% in 2020).

DISCUSSION

Opioid prescription rates associated with surgery remained stable between 2015 and 2020 in the United States, despite significant decreases in prescribing among nonsurgical populations. Surgery is now a leading source of medical prescribed opioids among adolescents. Secondary findings included a stable trend in surgery utilization between 2015 and 2020, as well as continued racial disparities, both in terms of surgery utilization and opioid prescribing.

CONCLUSION

The large number of adolescents being prescribed opioids for surgery in the USA each year, suggests there is a need for national guidelines aimed at adolescent opioid use, similar to the recent CDC guidelines aimed at adult opioid use.

Association of State Drug Laws with Nonmedical Use of Prescription Medications in Adolescents

OBJECTIVE

The aim of the study is to examine the associations between mandatory access prescription drug monitoring programs (PDMPs), pain management clinic (PMC) laws, and doctor shopping (DS) laws with adolescent nonmedical use of prescription medications (NUPM).

METHODS

We linked 2011-2015 Youth Risk Behavior Survey data on 364,103 adolescents across 40 states with PDMP, PMC laws, and DS laws. We conducted a 2-way fixed effects logistic regression model to examine the associations between state drug laws and adolescent self-reported NUPM.

RESULTS

We found some evidence that implementation of a mandatory access PDMP was associated with a decrease in nonmedical use of prescription drugs at the P = 0.079 level (average marginal effect: -0.017, 95% confidence interval = -0.036 to 0.002), while there were no associations with the implementation of PMC and DS laws.

CONCLUSIONS

Our findings suggest that current state drug laws to combat NUPM are inadequate for adolescents.

Association between prescription drug monitoring programs use mandates and prescription stimulants received by Medicaid enrollees

INTRODUCTION

Prescription drug monitoring program (PDMP) use mandates are an important policy tool to curb nonmedical opioid use. However, data are scarce about their efficacy on other commonly used prescription drugs such as stimulants.

METHODS

We used 2010-2020 state-level secondary data from Medicaid State Drug Utilisation Data and quasi-experimental difference-in-differences research design to estimate the association between PDMP use mandates and population-adjusted stimulants (amphetamines and methylphenidate) prescribing outcomes: (i) number of prescriptions filled; and (ii) total amount reimbursed in US dollars. To account for heterogeneity in mandates across US states, two policy variables were considered: limited and expansive. Limited PDMP use mandates require prescribers or dispensers to check the PDMP only when prescribing/dispensing opioids or benzodiazepines, while expansive PDMP use mandates are non-specific to opioids/benzodiazepines and require prescribers or dispensers to check the PDMP when prescribing/dispensing targeted controlled substances in Drug Enforcement Agency Schedule II-V. The sample included 49 US states and the District of Columbia. Nevada was excluded since it implemented the PDMP mandate before the period of analysis.

RESULTS

The state-wide implementation of the PDMP use mandate, either limited or expansive, was not associated with the number of prescriptions filled or the total amount reimbursed in US dollars for stimulants among Medicaid enrollees.

DISCUSSION AND CONCLUSION

There was no evidence for the associations between PDMP use mandates and stimulant prescribing among Medicaid enrollees. Future works are encouraged to replicate the study in other populations and with longer post-period analysis when the impact of the mandates might be more successfully materialised.

Prescription drug monitoring programs use mandates and prescription stimulant and depressant quantities

BACKGROUND

While the mandate to check patients' prescription history in Prescription Drug Monitoring Program (PDMP) database before prescribing/dispensing controlled drugs has been shown to be an important tool to curb opioid abuse, less is known about whether the mandate can reduce the misuse of other commonly abused prescription drugs. We examined whether PDMP use mandates were associated with changes in prescription stimulant and depressant quantities.

METHODS

Using data from Automated Reports and Consolidate Ordering System (ARCOS), we employed difference-in-differences design to estimate the association between PDMP use mandates and prescription stimulant and depressant quantities in 50 U.S. states and the District of Columbia from 2006 to 2020. Limited PDMP use mandate was specific only to opioids or benzodiazepines. Expansive PDMP use mandate was non-specific to opioid or benzodiazepine and required prescribers/dispensers to check PDMP when prescribing/dispensing targeted controlled substances in Schedule II-V. The main outcomes were population-adjusted prescription stimulant (amphetamine, methylphenidate, lisdexamfetamine) and depressant (amobarbital, butalbital, pentobarbital, secobarbital) quantities in grams.

RESULTS

There was no evidence that limited PDMP use mandate was associated with a reduction in the prescription stimulant and depressant quantities. However, expansive PDMP use mandate that was non-specific to opioid or benzodiazepine and required prescribers/dispensers to check PDMP when prescribing/dispensing targeted controlled substances in Schedule II-V was associated with 6.2% (95% CI: -10.06%, -2.08%) decline in prescription amphetamine quantity.

CONCLUSION

Expansive PDMP use mandate was associated with a decline in prescription amphetamine quantity. Limited PDMP use mandate did not appear to change prescription stimulant and depressant quantities.

Estimated Reductions in Opioid Overdose Deaths With Sustainment of Public Health Interventions in 4 US States

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.

Annual Prevalence of Opioid Receipt by South Carolina Medicaid-Enrolled Children and Adolescents: 2000-2020

Understanding patterns of opioid receipt by children and adolescents over time and understanding differences between age groups can help identify opportunities for future opioid stewardship. We conducted a retrospective cohort study, using South Carolina Medicaid data for children and adolescents 0-18 years old between 2000-2020, calculating the annual prevalence of opioid receipt for medical diagnoses in ambulatory settings. We examined differences in prevalence by calendar year, race/ethnicity, and by age group. The annual prevalence of opioid receipt for medical diagnoses changed significantly over the years studied, from 187.5 per 1000 in 2000 to 41.9 per 1000 in 2020 (Cochran-Armitage test for trend, p < 0.0001). In all calendar years, older ages were associated with greater prevalence of opioid receipt. Adjusted analyses (logistic regression) assessed calendar year differences in opioid receipt, controlling for age group, sex, and race/ethnicity. In the adjusted analyses, calendar year was inversely associated with opioid receipt (aOR 0.927, 95% CI 0.926-0.927). Males and older ages were more likely to receive opioids, while persons of Black race and Hispanic ethnicity had lower odds of receiving opioids. While opioid receipt declined among all age groups during 2000-2020, adolescents 12-18 had persistently higher annual prevalence of opioid receipt when compared to younger age groups.

Association of Prescription Drug Monitoring Programs With Opioid Prescribing and Overdose in Adolescents and Young Adults

STUDY OBJECTIVE

Prescription opioid use is associated with substance-related adverse outcomes among adolescents and young adults through a pathway of prescribing, diversion and misuse, and addiction and overdose. Assessing the effect of current prescription drug monitoring programs (PDMPs) on opioid prescribing and overdoses will further inform strategies to reduce opioid-related harms.

METHODS

We performed interrupted time series analyses to measure the association between state-level implementation of PDMPs with annual opioid prescribing and opioid-related overdoses in adolescents (13 to 18 years) and young adults (19 to 25 years) between 2008 and 2019. We focused on PDMPs that included mandatory reviews by providers. Data were obtained from a commercial insurance company.

RESULTS

Among 9,344,504 adolescents and young adults, 1,405,382 (15.0%) had a dispensed opioid prescription, and 6,262 (0.1%) received treatment for an opioid-related overdose. Mandated PDMP review was associated with a 4.2% (95% CI, 1.9% to 6.4%) reduction in annual opioid dispensations among adolescents and a 7.8% (95% CI, 4.7% to 10.9%) annual reduction among young adults. For opioid-related overdoses, mandated PDMP review was associated with a 16.1% (95% CI, 3.8 to 26.7) and 15.9% (95% CI, 7.6 to 23.4) reduction in annual opioid overdoses for adolescents and young adults, respectively.

CONCLUSION

PDMPs were associated with sustained reductions in opioid prescribing and overdoses in adolescents and young adults. Although these findings support the value of mandated PDMPs as part of ongoing strategies to reduce opioid overdoses, further studies with prospective study designs are needed to characterize the effect of these programs fully.

The Impact of the Florida Law HB21 on Opioid Prescribing Patterns After Spine Surgery

Background

The opioid epidemic represents a major public health issue in the United States and has led to significant morbidity and mortality. On July 1 2018, Florida implemented state-law House Bill 21 (HB21), limiting opioid prescriptions to a 3-day supply for acute pain or 7 days if an exception is documented. The purpose of this study is to evaluate the effects of HB21 on opioid prescribing patterns after spine surgery.

Methods

Patients 18 years and older who underwent spine surgery between January 2017 and January 2021 were eligible for inclusion. Information including demographics, pills, days, and morphine milligram equivalents (MMEs) was obtained via retrospective chart review using the Florida Prescription Drug Monitoring Program and Epic Chart Review. Student's t tests and Fisher's exact tests were used for comparison of continuous variables. Multiple logistic regression was utilized to determine which variables were associated with postoperative opioid prescriptions. p<.05 was considered significant.

Results

We reviewed 114 patients who underwent spine surgery from January 2017 to July 2018 and 264 patients from July 2018 to January 21. There were no significant differences between the groups in age, sex, ethnicity, body mass index, number of levels fused, or preoperative opioid use. The average number of MMEs, pills prescribed and days in the first postoperative prescription decreased significantly after HB21. Multiple logistic regression revealed that the variable most predictive of MMEs and number of pills in the first postoperative prescription was postlaw status (p=.002, p=.50).

Conclusions

Florida law HB21 was successful in decreasing postoperative opioid prescriptions after spine surgery, however, the need for additional progress remains. Legislation should be combined with multimodal pain regimens, as well as patient and provider education in order to further decrease postoperative opioid requirements. Future studies should include a larger number of patients treated by multiple spine surgeons across multiple institutions in order to further evaluate the effects of HB21 on postoperative opioid prescriptions.

Medical Marijuana Legalization and Opioid- and Pain-Related Outcomes Among Patients Newly Diagnosed With Cancer Receiving Anticancer Treatment

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.

Barriers to Increasing Prescription Drug Monitoring Program Use: A Multidisciplinary Perspective

Prescription drug monitoring programs are implemented through individual state policies and are one solution to curb the opioid crisis. The objectives of this study are to: (1) describe the multidisciplinary experiences using this program in practice; (2) identify limitations of the program and the desired features for improvement; and (3) characterize expectations for improved access when prescription drug monitoring programs are embedded in the electronic health record. A qualitative descriptive study design used semistructured interviews of 15 multidisciplinary healthcare providers. Textual data were analyzed using content analysis. Results showed the prescription drug monitoring program was helpful to decision-making processes related to opioid prescribing and referral to treatment; there were barriers limiting healthcare providers' use of the prescription drug monitoring program; preferences were delineated for integrating prescription drug monitoring program into electronic health record; and recommendations were provided to improve the program and increase use. In conclusion, the prescription drug monitoring program was viewed as useful in making strides to reduce the impact of inappropriate opioid prescribing in our country. By engaging a multidisciplinary group of healthcare providers, solutions were offered to improve the interface and function of the prescription drug monitoring program to assist in increasing use.

Social, psychological, and substance use characteristics of U.S. adults who use kratom: Initial findings from an online, crowdsourced study

Kratom, a plant that produces opioid-like effects, has gained popularity in the U.S. for self-treating symptoms of chronic pain, mood disorders, and substance-use disorders (SUDs). Most data on kratom are from surveys into which current kratom-using adults could self-select; such surveys may underrepresent people who have used kratom and chosen to stop. Available data also do not adequately assess important psychosocial factors surrounding kratom use. In this study, U.S. adults who reported past 6-month alcohol, opioid, and/or stimulant use (N = 1,670) were recruited via Amazon Mechanical Turk between September and December 2020. Of the 1,510 evaluable respondents, 202 (13.4%) reported lifetime kratom use. Kratom-using adults, relative to others, were typically younger, male, unpartnered, without children, and had lower income. They had higher rates of chronic pain (31.7% vs. 21.9%, p = .003), childhood adversity, anxiety, and depression (p < .001), and lower perceived social rank (d = .19, .02-.22) and socioeconomic status (d = .37 .16-.26). They also reported higher use rates for most substances (except alcohol); this included medically supervised and unsupervised use of prescription opioids and diverted opioid agonist therapy (OAT) medications. Most (83.2%) met diagnostic criteria for any past-year SUD. Those reporting kratom use were less likely to reside in an urban/suburban area. The strongest predictors of kratom use were use of other drugs: cannabidiol (OR = 3.73), psychedelics (OR = 3.39), and nonmedical prescription opioids (OR = 1.72). Another strong predictor was lifetime OAT utilization (OR = 2.31). Despite seemingly poorer psychosocial functioning and health among respondents reporting lifetime kratom use, use of other substances may be the strongest indicators of kratom use. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

"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

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.

Harm Reduction: Not Dirty Words Any More

Although many of the tenets of harm reduction have been around for centuries and more traditional harm reduction services such as syringe services programs have been in existence for decades, there has been a recent increase in interest and acceptance of harm reduction as an essential component of a public health approach to substance use. This article provides an overview of harm reduction and its application to alcohol, tobacco, and drug use. It discusses the importance of integrating harm reduction principles and services with traditional psychiatric, medical, and addiction treatment programs.

American College of Preventive Medicine: Addressing the Opioid Epidemic Through a Prevention Framework

The opioid epidemic has resulted in significant morbidity and mortality in the U.S. Health systems, policymakers, payers, and public health have enacted numerous strategies to reduce the harms of opioids, including opioid use disorder (OUD). Much of this implementation has occurred before the development of OUD‒related comparative effectiveness evidence, which would enable an understanding of the benefits and harms of different approaches. This article from the American College of Preventive Medicine (ACPM) uses a prevention framework to identify the current approaches and make recommendations for addressing the opioid epidemic, encompassing strategies across a primordial, primary, secondary, and tertiary prevention approach. Key primordial prevention strategies include addressing social determinants of health and reducing adverse childhood events. Key primary prevention strategies include supporting the implementation of evidence-based prescribing guidelines, expanding school-based prevention programs, and improving access to behavioral health supports. Key secondary prevention strategies include expanding access to evidence-based medications for opioid use disorder, especially for high-risk populations, including pregnant women, hospitalized patients, and people transitioning out of carceral settings. Key tertiary prevention strategies include the expansion of harm reduction services, including expanding naloxone availability and syringe exchange programs. The ACPM Opioid Workgroup also identifies opportunities for de-implementation, in which historical and current practices may be ineffective or causing harm. De-implementation strategies include reducing inappropriate opioid prescribing; avoiding mandatory one-size-fits-all policies; eliminating barriers to medications for OUD, debunking the myth of detoxification as a primary solo treatment for opioid use disorder; and destigmatizing care practices and policies to better treat people with OUD.

A Scoping Review of Data Sources for the Conduct of Policy-Relevant Substance Use Research

OBJECTIVE

Existing administrative and survey data are critical for understanding the effects of exigent policies on population health outcomes related to opioid, cannabis, and other substance use disorders (SUDs). The objective of this study was to determine the state of the data available for evaluating SUD-related health outcomes.

METHODS

We performed a scoping review of national and state government data sources to measure and evaluate the effects of state policy changes on substance use and SUD-related health outcomes and health care use. We used Massachusetts as a case study for availability of relevant state-level data as well as national datasets with state-level indicators available to measure outcomes. We compared key features of each dataset to assess their usefulness for research and policy evaluation. We conducted our review during November 2018-March 2019, and we updated data availability as of March 2019 for all data sources.

RESULTS

We identified 11 survey datasets, 12 national administrative datasets, and 10 state administrative datasets as being suitable for policy-relevant research and practice purposes. These datasets varied substantially in their usefulness for evaluation and research. Despite substantial data limitations, including prohibitive regulatory and monetary costs to obtain the data and limited availability, these data can be mined to examine a diversity of policy-relevant questions.

CONCLUSIONS

Findings provide a comprehensive resource for using survey and administrative data to evaluate the health effects of SUD-related policies and interventions. The construction of state-level public health data warehouses or record linkage projects connecting individual-level information in state data sources is valuable for analyzing the effects of policy changes. Understanding strengths and limitations of available data sources is important for ongoing research and evaluation.

Impact evaluation of a brief online training module on physician use of the Maryland, USA, Prescription Drug Monitoring Program

Background

Prescription Drug Monitoring Programs (PDMPs) are electronic databases that track controlled substance prescriptions in a state. They are underused tools in preventing opioid abuse. Most PDMP education research measures changes in knowledge or confidence rather than behavior.

Objective

To evaluate the impact of online case-based training on healthcare provider use of the Maryland (USA) PDMP.

Methods

We used e-mail distribution lists to recruit providers to complete a brief educational module. Using a pre-training and post-training survey in the module, we measured self-reported PDMP use patterns and perceived PDMP value in specific clinical situations and compared pre- and post-training responses. Within the module, we presented three fictional pain cases and asked participants how they would manage each, both before, and then after presenting prescription drug history simulating a PDMP report. We measured changes in the fictional case treatment plans before and after seeing prescription history. Finally, we measured and compared how often each participant accessed the Maryland PDMP database before and after completing the educational module. We used multivariate logistic regression to measure the effect of the intervention on actual PDMP use frequency.

Results

One hundred and fifty participants enrolled and completed the training module, and we successfully retrieved real-world PDMP use data of 137 of them. Participants’ decisions to prescribe opioids changed significantly after reviewing PDMP data in each of the fictional cases provided in the module. In the months following the training, the rate of PDMP use increased by a median of four use-cases per month among providers in practice for less than 20 years (p = 0.039) and two use-cases per month among infrequent opioid prescribers (p = 0.014).

Conclusion

A brief online case-based educational intervention was associated with a significant increase in the rate of PDMP use among infrequent opioid prescribers and those in practice less than 20 years.

Opioid prescribing patterns in a commercially insured population

BACKGROUND

Claims data evaluations have advanced our understanding about patient risk factors and predictors for opioid misuse and aid in patient identification. However, less evidence is available to guide the identification of prescribers with at-risk prescribing practices. Thus, an algorithm was developed to identify prescribers with outlying patterns of opioid prescriptions in a managed care organization.

METHODS

A retrospective analysis used enrollment, prescription, and medical claims data from September-December 2019 to identify prescribers of schedule II, III or IV opioid analgesic medications. Criteria were used to characterize these prescribers as frequent, continuous, and/or high-dose prescribers of opioids.

RESULTS

For prescribers with > 25 patients with any prescriptions, the algorithm identified 5136 prescribers who had prescribed at least one opioid. This group of prescribers accounted for 53.9% of the total opioids prescribed and wrote an average of 6.5 opioid prescriptions per prescriber during a 3-month period. There were 629 prescribers (12.2%) that had prescribed an opioid to ≥ 50% of their population (frequent prescribers); 493 prescribers (9.6%) that had prescribed >185 day-supply of opioids within 6 months to 10% or more of their population (continuous prescribers); 147 prescribers (2.9%) that had prescribed an average daily MME > 90 mg to ≥ 10% of their population in the most recent 90 days (high-dose prescribers); and 47 prescribers (0.9%) that met all three criteria.

CONCLUSIONS

The algorithm identified a targeted prescriber group to employ resources to mitigate opioid misuse and abuse. Flexible criteria for frequent, continuous, and/or high-dose prescribing allows tailoring to the needs of different managed care organizations.

Attention deficit/hyperactivity disorder in adults: A case study

Attention-Deficit/Hyperactivity Disorder (ADHD) is often misdiagnosed or mistreated in adults because it is often thought of as a childhood problem. If a child is diagnosed and treated for the disorder, it often persists into adulthood. In adult ADHD, the symptoms may be comorbid or mimic other conditions making diagnosis and treatment difficult. Adults with ADHD require an in-depth assessment for proper diagnosis and treatment. The presentation and treatment of adults with ADHD can be complex and often requires interdisciplinary care. Mental health and non-mental health providers often overlook the disorder or feel uncomfortable treating adults with ADHD. The purpose of this manuscript is to discuss the diagnosis and management of adults with ADHD.

Leveraging the Prescription Drug Monitoring Program to Curb Opioid Prescribing in Arkansas

Effective means of accurately identifying problematic opioid prescribing are needed. Using an iterative approach with the Arkansas State Medical Board Pain Subcommittee, we modified existing opioid prescriber criteria to create seven metrics to be deployed in Arkansas. These included metrics of dose and days' supply, concomitant use of opioid and benzodiazepines, solid dosage units, and numbers of opioid patients and certain opioid prescriptions. Two of these metrics (average MME daily dose per prescription and total oxycodone 30 mg or hydromorphone prescriptions) were weighted by 2, creating a maximum score of 9 of which each prescriber could receive. Twenty prescribers with a score of 7 or greater were identified and referred to the Arkansas State Medical Board Pain Subcommittee for review and subsequent investigation if deemed necessary. Of those 20 prescribers, four were previously investigated and under disciplinary action, and three were under current investigation for misconduct related to prescribing practices. Five prescribers had new investigations opened due to the findings from the metrics, and disciplinary action was taken. Therefore, 12 of the 20 prescribers referred to the Arkansas State Medical Board were deemed worthy of investigation and disciplinary action. The Arkansas opioid prescriber metrics are able to accurately identify prescribers with potentially problematic opioid prescribing.

Quality Improvement Project to Reduce Opioid Use in Patients Undergoing Cesarean Birth

After observing the effectiveness of Enhanced Recovery After Surgery (ERAS) protocols for gynecological surgery patients, an interdisciplinary team initiated a quality improvement project with an ERAS protocol to minimize opioid use of patients undergoing elective cesarean birth. Secondary outcomes during the three-month project included decreasing the patient's length of stay and inpatient care costs. We used the Lean Six Sigma methodology and measured aggregated patient outcomes of opioid use, length of hospital stay, and total cost. In addition, we incorporated the ERAS protocol into the electronic health record. Results showed a reduction use of morphine milligram equivalents of opioids, a slight decrease in length of hospital stay, and no change in the inpatient costs. The team recognized that implementation of an ERAS protocol is a best practice to reduce opioid use in patients undergoing a cesarean birth and decided to permanently include it in patient care processes.

"The DEA would come in and destroy you": a qualitative study of fear and unintended consequences among opioid prescribers in WV

Background

West Virginia has one of the highest rates of opioid overdose related deaths and is known as the epicenter of the opioid crisis in the United States. In an effort to reduce opioid-related harms, SB 273 was signed in 2018, and aimed to restrict opioid prescribing in West Virginia. SB 273 was enacted during a time when physician arrests and convictions had been increasing for years and were becoming more prevalent and more publicized. This study aims to better understand the impact of the legislation on patients and providers.

Methods

Twenty semi-structured interviews were conducted with opioid-prescribing primary care physicians and specialists practicing throughout West Virginia.

Results

Four themes emerged, 1. Fear of disciplinary action, 2. Exacerbation of opioid prescribing fear due to restrictive legislation, 3. Care shifts and treatment gaps, and 4. Conversion to illicit substances. The clinicians recognized the harms of inappropriate prescribing and how this could affect their patients. Decreases in opioid prescribing were already occurring prior to the law implementation. Disciplinary actions against opioid prescribers resulted in prescriber fear, which was then exacerbated by SB 273 and contributed to shifts in care that led to forced tapering and opioid under-prescribing. Providers felt that taking on patients who legitimately required opioids could jeopardize their career.

Conclusion

A holistic and patient-centered approach should be taken by legislative and disciplinary bodies to ensure patients are not abandoned when disciplinary actions are taken against prescribers or new legislation is passed.

The effect of state policies on rates of high-risk prescribing of an initial opioid analgesic

BACKGROUND

Multiple state policies, such as prescription drug monitoring programs (PDMPs) and duration limits, have been implemented to decrease high-risk opioid prescribing. Studies demonstrate that many policies decrease certain opioid prescribing behaviors, but few examine their intended effects on the targeted high-risk prescribing practices, nor disentangle the effects of concurrent state or federal policies likely to influence those practices.

METHODS

Forty-one million initial prescriptions for new opioid episodes from 2007 to 2018 were identified using national pharmacy claims. We identified high-risk initial prescriptions, defined as >7 days' supply, average daily MME >90, or concurrent with benzodiazepines and estimated three multivariable logistic regression models to assess the association between policies and outcomes controlling for patient, prescriber, and county characteristics.

RESULTS

Initial prescriptions for >7 days declined from 23.8% in 2007 to 14.9% in 2018, associated with mandatory and interoperable PDMPs and prescription duration limits but not other policies examined. Initial prescriptions with daily MME > 90 declined from 13.2% to 1.9%, associated with pain management clinic laws but not consistently with other policies. Initial prescriptions concurrent with benzodiazepines declined only modestly from 6.9% to 6.5%, associated with pain management clinic laws but not other policies examined.

CONCLUSIONS

The opioid policy environment has changed rapidly with a range of different policies being implemented addressing high-risk prescribing. PDMP laws mandating prescriber use and pain clinic laws both appear efficacious but decrease different types of high-risk opioid prescribing. New policies should be considered in light of the prevalence of the problem being addressed.

Mapping the research addressing prescription drug monitoring programs: A scoping review

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.

The Impact of a PDMP-EHR Data Integration Combined With Clinical Decision Support on Opioid and Benzodiazepine Prescribing Across Clinicians in a Metropolitan Area

INTRODUCTION

Despite inconclusive evidence that prescription drug monitoring programs (PDMP) reduce opioid-related mortality, guidelines recommend PDMP review with opioid prescribing. Some reported barriers to use include time-consuming processes to obtain data and workflow disruptions.

METHODS

We provided access to a PMDP-electronic health record (EHR) integrated program to 123 clinicians in one healthcare system. Remaining clinicians within the healthcare system and metropolitan area did not receive PDMP-EHR integration program access. We identified changes in opioid prescribing by linking prescription data available in the state PMDP database to individual clinicians. The primary outcome was change in receipt of high dose opioid prescriptions (>90 mg morphine equivalents) by Colorado residents before and after program integration. Secondary outcomes included changes in long-acting opioid receipt and overlapping opioid and benzodiazepine prescription days. Next, we surveyed clinicians to assess their perspectives on PDMP data acquisition before and after PDMP-EHR integration program access.

RESULTS

High-dose opioid receipt decreased significantly across all 3 clinician groups [PDMP-EHR integration program access (27.6%, to 6.9%, P < 0.001); no program access in the same healthcare system (4.8% to 2.9%, P < 0.001), and no program access across the metropolitan area (13.5% to 6.1%, P < 0.001)]. Clinicians reported improved access to PDMP data using the PDMP-EHR integrated program compared to the state PDMP website (98.6%).

CONCLUSIONS

Further study of PDMP-EHR integration programs on patient and clinician outcomes may illuminate the role of this technology in public health and in clinical practice.

Ensemble learning to predict opioid-related overdose using statewide prescription drug monitoring program and hospital discharge data in the state of Tennessee

Objective

To develop and validate algorithms for predicting 30-day fatal and nonfatal opioid-related overdose using statewide data sources including prescription drug monitoring program data, Hospital Discharge Data System data, and Tennessee (TN) vital records. Current overdose prevention efforts in TN rely on descriptive and retrospective analyses without prognostication.

Materials and Methods

Study data included 3 041 668 TN patients with 71 479 191 controlled substance prescriptions from 2012 to 2017. Statewide data and socioeconomic indicators were used to train, ensemble, and calibrate 10 nonparametric “weak learner” models. Validation was performed using area under the receiver operating curve (AUROC), area under the precision recall curve, risk concentration, and Spiegelhalter z-test statistic.

Results

Within 30 days, 2574 fatal overdoses occurred after 4912 prescriptions (0.0069%) and 8455 nonfatal overdoses occurred after 19 460 prescriptions (0.027%). Discrimination and calibration improved after ensembling (AUROC: 0.79–0.83; Spiegelhalter P value: 0–.12). Risk concentration captured 47–52% of cases in the top quantiles of predicted probabilities.

Discussion

Partitioning and ensembling enabled all study data to be used given computational limits and helped mediate case imbalance. Predicting risk at the prescription level can aggregate risk to the patient, provider, pharmacy, county, and regional levels. Implementing these models into Tennessee Department of Health systems might enable more granular risk quantification. Prospective validation with more recent data is needed.

Conclusion

Predicting opioid-related overdose risk at statewide scales remains difficult and models like these, which required a partnership between an academic institution and state health agency to develop, may complement traditional epidemiological methods of risk identification and inform public health decisions.

Pain Management and Risks Associated With Substance Use: Practice Recommendations

Assessing and managing pain while evaluating risks associated with substance use and substance use disorders continues to be a challenge faced by health care clinicians. The American Society for Pain Management Nursing and the International Nurses Society on Addictions uphold the principle that all persons with co-occurring pain and substance use or substance use disorders have the right to be treated with dignity and respect, and receive evidence-based, high quality assessment, and management for both conditions. The American Society for Pain Management Nursing and International Nurses Society on Addictions have updated their 2012 position statement on this topic supporting an integrated, holistic, multidimensional approach, which includes nonopioid and nonpharmacological modalities. Opioid use disorder is used as an exemplar for substance use disorders and clinical recommendations are included with expanded attention to risk assessment and mitigation with interventions targeted to minimize the risk for relapse or escalation of substance use. Opioids should not be excluded for anyone when indicated for pain management. A team-based approach is critical, promotes the active involvement of the person with pain and their support systems, and includes pain and addiction specialists whenever possible. Health care systems should establish policies and procedures that facilitate and support the principles and recommendations put forth in this article.

Longitudinal Study on Deterrent Effect of Drug-Induced Homicide Law on Opioid-Related Mortality Across 92 Counties and the District of Columbia in the U.S

In response to the opioid epidemic in the United States, the federal and state governments have initiated various public health responses to mitigate the problem. Among others, Drug-Induced Homicide Laws (DIHL) have been introduced to disrupt opioid supply by imposing unconventionally punitive sanctions against sales and distribution. The purpose of this study was to examine whether DIHL had an impact on opioid-related deaths, while controlling for other laws and socioeconomic indices. A dynamic panel model was used with cases from 92 counties across 10 states and the District of Columbia between 2013 and 2018. The findings suggest that DIHL implementation has curtailed the rate of opioid mortality. Supply-interruption approaches may have merits and should be further evaluated.

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

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.

Validation and threshold identification of a prescription drug monitoring program clinical opioid risk metric with the WHO alcohol, smoking, and substance involvement screening test

BACKGROUND

Prescription drug monitoring programs (PDMPs) are critical for pharmacists to identify risky opioid medication use. We performed an independent evaluation of the PDMP-based Narcotic Score (NS) metric.

METHODS

This study was a one-time, cross-sectional health assessment within 19 pharmacies from a national chain among adults picking-up opioid medications. The NS metric is a 3-digit composite indicator. The WHO Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) was the gold-standard to which the NS metric was compared. Machine learning determined optimal risk thresholds; Receiver Operating Characteristic curves and Spearman (P) and Kappa (K) coefficients analyzed concurrent validity. Regression analyses evaluated participant characteristics associated with misclassification.

RESULTS

The NS metric showed fair concurrent validity (area under the curve≥0.70; K=0.35; P = 0.37, p < 0.001). The ASSIST and NS metric categorized 37% of participants as low-risk (i.e., not needing screening/intervention) and 32.3% as moderate/high-risk (i.e., needing screening/intervention). Further, 17.2% were categorized as low ASSIST risk but moderate/high NS metric risk, termed false positives. These reported disability (OR=3.12), poor general health (OR=0.66), and/or greater pain severity/interference (OR=1.12/1.09; all p < 0.05; i.e., needing unmanaged-pain screening/intervention). A total of 13.4% were categorized as moderate/high ASSIST risk but low NS metric risk, termed false negatives. These reported greater overdose history (OR=1.24) and/or substance use (OR=1.81-12.66; all p < 0.05).

CONCLUSIONS

The NS metric could serve as a useful initial universal prescription opioid-risk screener given its: 1) low-burden (i.e., no direct assessment); 2) high accuracy (86.5%) of actionable data identifying low-risk patients and those needing opioid use/unmanaged pain screening/intervention; and 3) broad availability.

Preoperative Opioid Education has No Effect on Opioid Use in Patients Undergoing Arthroscopic Rotator Cuff Repair: A Prospective, Randomized Clinical Trial

OBJECTIVES

The purpose of this study was to determine whether a preoperative video-based opioid education reduced narcotics consumption after arthroscopic rotator cuff repair in opioid-naive patients.

METHODS

This was a single-center randomized controlled trial. Preoperatively, the control group received our institution's standard of care for pain management education, whereas the experimental group watched an educational video on the use of opioids. Patients were discharged with 30 × 5 mg/325 mg oxycodone-acetaminophen prescribed: 1 to 2 tablets every 4 to 6 hours. They were contacted daily and asked to report opioid use and visual analog scale pain. A chart review at 3 months post-op was used to analyze for opioid refills.

RESULTS

A total of 130 patients completed the study (65 control and 65 experimental). No statistically significant differences were noted in patient demographics between groups (P > 0.05). Patients in the education group did not use a statistically significant different number of narcotics than the control group throughout the first postoperative week (14.0 pills experimental versus 13.7 pills control, P = 0.60). No statistically significant differences were noted between groups at follow-regarding the rate of prescription refills (P > 0.05).

CONCLUSION

This study suggests that preoperative video-based opioid education may have no effect on reducing the number of narcotic pills consumed after arthroscopic rotator cuff repair.

CLINICAL RELEVANCE

Data exist to suggest that preoperative video-based opioid education has an effect on postoperative consumption; however, the effect of this education in the setting of already-limited opioid-prescribing is not known.

CLINICALTRIALSGOV IDENTIFIER

NCT04018768.

The complementarity of drug monitoring programs and health IT for reducing opioid-related mortality and morbidity

In response to the opioid crisis, each US state has implemented a prescription drug monitoring program (PDMP) to collect data on controlled substances prescribed and dispensed in the state. I study whether health information technology (HIT) complements patient prescription data in PDMPs to reduce opioid-related mortality and morbidity. A novel dataset is constructed that records state policies that integrate PDMP with HIT and facilitate interstate data sharing. Using difference-in-differences models, I find that PDMP-HIT integration policies reduce opioid-related inpatient morbidity. The reductions are substantial in states that established integration without ever mandating the use of a PDMP. A mechanism test suggests that PDMP integration works mainly through the hospital system while a mandate affects legal opioids prescription. The impacts from integration are strongest for the vulnerable groups-middle-aged, low-to middle-income patients, and those with public insurance. There is suggestive evidence that interstate data sharing further complements integration despite not having a significant impact independently. The results are robust to a set of tests using alternative specifications and measures. The total benefits from integration far exceed the associated costs.

Nonprofit Hospital Community Benefits: Collaboration With Local Health Departments to Address the Drug Epidemic

BACKGROUND

Nonprofit hospitals (NFPs) are required to provide community benefits, which have been historically focused on provision of medical care, to keep their tax exemption status. To increase hospital investment in community health, the Patient Protection and Affordable Care Act required NFPs to conduct community health needs assessments and address identified needs. Some states have leveraged this provision to encourage collaboration between NFPs and local health departments (LHDs) in local health planning.

OBJECTIVE

The objective of this study was to examine the association of NFP-LHD collaboration in local health planning targeting drug use, with drug-induced mortality.

RESEARCH DESIGN

We conducted difference-in-differences analyses using drug-induced mortality data from 2009 to 2016, encompassing the first 3 years after NFP-LHD collaboration in local health planning specific to drug use. We evaluated drug-induced mortality in 22 counties in which collaboration was required in comparison with that in 198 control counties. We used data collected from implementation strategy reports by NFPs and combined it with data on hospital characteristics, as well as state-level and county-level factors associated with drug-induced mortality.

MEASURES

The primary outcome was county-level drug-induced mortality per 100,000 population.

RESULTS

Counties, in which NFP-LHD collaboration in local health planning was required and in which NFPs and LHDs jointly prioritized drug use, experienced a deceleration in drug-induced mortality of ~8 deaths per 100,000 population compared with the mortality rate they would have experienced without collaboration.

CONCLUSIONS

Collaboration between NFPs and LHDs to address drug use was associated with a deceleration in drug-induced mortality. Policymakers can leverage community benefit regulation to encourage NFP-LHD collaboration in local health planning.

Can electronic prescribing mandates reduce opioid-related overdoses?

As the opioid crisis has escalated, states have enacted numerous policies targeting opioid access and monitoring possible misuse. Recently, the majority of states have passed electronic prescribing mandates for controlled substances. These mandates require that controlled substances be prescribed electronically directly to the pharmacy. The electronic system maintains a rich patient history that prescribers will observe when issuing a prescription while also reducing opportunities for fraud. The first enforced mandate was implemented in New York in March 2016; thus empirical evidence about the effects of such mandates is limited. We study how adoption of the New York e-prescribing mandate affected opioid supply and opioid-related overdoses. We estimate that the mandate reduced the rate of overdoses involving natural and semi-synthetic opioids by 22 %. We find little evidence of any corresponding changes in overdose rates involving illicit opioids.

The change in postoperative opioid prescribing after lumbar decompression surgery following state-level opioid prescribing reform

OBJECTIVE

On August 31, 2017, the state of Ohio implemented legislation limiting the dosage and duration of opioid prescriptions. Despite the widespread adoption of such restrictions, few studies have investigated the effects of these reforms on opioid prescribing and patient outcomes. In the present study, the authors aimed to evaluate the effect of recent state-level reform on opioid prescribing, patient-reported outcomes (PROs), and postoperative emergency department (ED) visits and hospital readmissions after elective lumbar decompression surgery.

METHODS

This study was a retrospective cohort study of patients who underwent elective lumbar laminectomy for degenerative disease at one of 5 hospitals within a single health system in the years prior to and after the implementation of the statewide reform (September 1, 2016-August 31, 2018). Patients were classified according to the timing of their surgery relative to implementation of the prescribing reform: before reform (September 1, 2016-August 31, 2017) or after reform (September 1, 2017- August 31, 2018). The outcomes of interest included total outpatient opioids prescribed in the 90 days following discharge from surgery as measured in morphine-equivalent doses (MEDs), total number of opioid refill prescriptions written, patient-reported pain at the first postoperative outpatient visit as measured by the Numeric Pain Rating Scale, improvement in patient-reported health-related quality of life as measured by the Patient-Reported Outcomes Measurement Information System-Global Health (PROMIS-GH) questionnaire, and ED visits or hospital readmissions within 90 days of surgery.

RESULTS

A total of 1031 patients met the inclusion criteria for the study, with 469 and 562 in the before- and after-reform groups, respectively. After-reform patients received 26% (95% CI 19%-32%) fewer MEDs in the 90 days following discharge compared with the before-reform patients. No significant differences were observed in the overall number of opioid prescriptions written, PROs, or postoperative ED or hospital readmissions within 90 days in the year after the implementation of the prescribing reform.

CONCLUSIONS

Patients undergoing surgery in the year after the implementation of a state-level opioid prescribing reform received significantly fewer MEDs while reporting no change in the total number of opioid prescriptions, PROs, or postoperative ED visits or hospital readmissions. These results demonstrate that state-level reforms placing reasonable limits on opioid prescriptions written for acute pain may decrease patient opioid exposure without negatively impacting patient outcomes after lumbar decompression surgery.

Inappropriate Opioid Prescribing in Oregon's Coordinated Care Organizations

OBJECTIVES

The objective of this study is to identify demographic and clinical characteristics of patients with a pain diagnosis who fill potentially inappropriate opioid prescriptions within the Oregon Medicaid population.

METHODS

Using de-identified Oregon Medicaid claims data (2010-2014), a series of logistic regression models was estimated to identify factors associated with receipt of potential inappropriate opioid prescriptions among patients with acute or chronic pain. Analyses included a total of 204,364 records, representing 118,671 unique patients.

RESULTS

The percentage of patients with a pain diagnosis filling at least 1 inappropriate opioid prescription decreased over the study period, falling from 32.5% in 2010 to 22.3% in 2014. Multivariate logistic regression results indicated that white and older enrollees were more likely to fill an inappropriate prescription over the study period. The odds of filling an inappropriate opioid prescription were also greater for patients with chronic health conditions, psychiatric disorders, and substance use disorder. Results were similar for patients diagnosed with either acute or chronic pain, chronic pain only, or acute pain only.

CONCLUSIONS

Inappropriate opioid prescribing for patients with pain diagnoses decreased over the study period, which stands in stark contrast to other state Medicaid programs. However, in 2014, almost 23% of patients in the Oregon Medicaid program filled at least 1 inappropriate opioid prescription, suggesting additional strategies are needed to further reduce potential inappropriate prescribing. Medicaid programs may consider adopting enhanced prescription drug monitoring program features, enacting pain clinic legislation, and implementing additional prior authorization policies to reduce inappropriate prescribing of opioids.

Impact of prescription drug monitoring program mandate on postoperative opioid prescriptions in children

PURPOSE

Prescription drug monitoring programs (PDMPs) have been established to combat the opioid epidemic, but there is no data on their efficacy in children. We hypothesized that a statewide PDMP mandate would be associated with fewer opioid prescriptions in pediatric surgical patients.

METHODS

Patients < 18 undergoing inguinal hernia repair, orchiopexy, orchiectomy, appendectomy, or cholecystectomy at a tertiary children's hospital were included. The primary outcome, discharge opioid prescription, was compared for 10 months pre-PDMP (n = 158) to 10 months post-PDMP (n = 228). Interrupted time series analysis was performed to determine the effect of the PDMP on opioid prescribing.

RESULTS

Over the 20-month study period, there was an overall decrease in the rate of opioid prescriptions per month (- 3.6% change, p < 0.001). On interrupted time series analysis, PDMP implementation was not associated with a significant decrease in the monthly rate of opioid prescriptions (1.27% change post-PDMP, p = 0.4). However, PDMP implementation was associated with a reduction in opioid prescriptions of greater than 5 days' supply (- 2.7% per month, p = 0.03).

CONCLUSION

Opioid prescriptions declined in pediatric surgical patients over the study time period. State-wide PDMP implementation was associated with a reduction in postoperative opioid prescriptions of more than 5 days' duration.

New and Emerging Opioid Overdose Risk Factors

Purpose of Review

The purpose of this review is to provide a review of the current literature surrounding opioid overdose risk factors, focusing on relatively new factors in the opioid crisis.

Recent Findings

Both a market supply driving force and a subpopulation of people who use opioids actively seeking out fentanyl are contributing to its recent proliferation in the opioid market. Harm reduction techniques such as fentanyl testing strips, naloxone education and distribution, drug sampling behaviors, and supervised injection facilities are all seeing expanded use with increasing amounts of research being published regarding their effectiveness. Availability and use of interventions such as medication for opioid use disorder and peer recovery coaching programs are also on the rise to prevent opioid overdose.

Summary

The opioid epidemic is an evolving crisis, necessitating continuing research to identify novel overdose risk factors and the development of new interventions targeting at-risk populations.

Impact of a Mandatory Prescription Drug Monitoring Program Check on Emergency Department Opioid Prescribing Rates

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.

Assessing the impact of Indiana legislation on opioid-based doctor shopping among Medicaid-enrolled pregnant women: a regression analysis

Background

States have passed various legislative acts in an attempt to reduce opioid prescribing and corresponding doctor shopping, including prescription drug monitoring programs. This study seeks to determine the association between two state-based interventions enacted in Indiana and the level of doctor shopping among Medicaid-enrolled pregnant women.

Methods

Indiana Medicaid claims data over the period of January 2014 to March 2019 were used in a regression model to determine the longitudinal change in percentage of pregnant women engaged in doctor shopping based on passage of Indiana Administrative Code Title 884 in 2014 and Public Law 194 in 2018. The primary reasons for prescribing were also identified.

Results

There were 37,451 women that had both pregnancy and prescription opioid claims over the time horizon. Of these, 2130 women met the criteria for doctor shopping. Doctor shopping continued to increase over the time between the passage of the two interventions but decreased after passage of Public Law 194.

Conclusion

The decrease in doctor shopping among Medicaid-enrolled pregnant women after passage of Public Law 194 points to the importance of addressing this issue across a broad set of healthcare professionals including nurse practitioners and physician assistants. It is also possible that the potential punitive component in the Law for non-compliance played a role.

State-led opioid overdose prevention efforts: Challenges, solutions and lessons learned from the CDC Prevention for States Program (PfS)

Background: The Centers for Disease Control and Prevention's Prevention for States (PfS) program funded 29 state health departments to prevent opioid overdose by implementing evidence-based prevention strategies. The objectives of this analysis were to describe the scope of activities implemented across the four PfS strategies and identify implementation challenges. Methods: PfS recipients submitted annual progress reports (APRs) to state support staff at CDC from 2015 to 2017. APR data were used to calculate the number of required and optional activities implemented under each PfS strategy. APR data were qualitatively analyzed using a systematic content analysis approach to identify key implementation challenges. Results: From 2015 to 2017, PfS recipients implemented 177 activities across four strategies from 2015 to 2017. Cross-cutting implementation challenges were (1) multi-sector collaboration, (2) lack of knowledge and misperceptions about opioid used disorder (OUD) among some partners and local communities and; (3) management and access to opioid data among PfS recipients. Conclusions: PfS recipients implemented an array of prevention interventions to address the opioid overdose crisis and encountered several cross-cutting implementation challenges. Challenges and state driven solutions over the course of implementing PfS led to several lessons learned and actions that CDC enacted to continue to support and expand overdose prevention.

The importance of data source in prescription drug monitoring program research

OBJECTIVE

To develop a legal research protocol for identifying various measures of prescription drug monitoring program (PDMP) start dates, apply the protocol to create a useable PDMP database, and test whether the different legal databases that are meant to contain the same information produce divergent results when used in an illustrative empirical exercise.

DATA SOURCES

Original research from state statutes, regulations, policy statements, and interviews; alternative PDMP data from the National Alliance for Model State Drug Laws and Prescription Drug Abuse Policy System; claims from a 40 percent random sample of Medicare beneficiaries, 2006-2014.

STUDY DESIGN

Collaborative research effort among a group of lawyers to develop protocol. Legal research to produce an original database of dates state PDMP laws: (a) were enacted, (b) became operational, and (c) required query before prescribing controlled substances. Descriptive analyses characterize differences in dates of enactment, operation, and must query requirements. Regression analyses estimating, for each beneficiary annually any opioid prescription received in a calendar year, among other measures. Estimates conducted on under age 65 and full Medicare population.

DATA COLLECTION/EXTRACTION METHODS

PDMP legal databases were linked to annual Medicare claims.

PRINCIPAL FINDINGS

An original database differs from commonly used, publicly available data. Outcomes tested depend on the measure of PDMP date used and differ by data source. Must-query laws show the largest effects among all the laws tested.

CONCLUSIONS

Data choices likely have had large consequences for study results and may explain contradictory outcomes in prior research. Researchers must understand and report protocol for dates used in PDMP research to ensure that results are internally consistent and verifiable.