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Thirukumaran CP, Fiscella KA, Rosenthal MB, Doshi JA, Schloemann DT, Ricciardi BF. Association of race and ethnicity with opioid prescribing for Medicare beneficiaries following total joint replacements. J Am Geriatr Soc 2024; 72:102-112. [PMID: 37772461 PMCID: PMC10841259 DOI: 10.1111/jgs.18605] [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: 03/02/2023] [Revised: 06/29/2023] [Accepted: 08/24/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND Profound racial and ethnic disparities exist in the use and outcomes of total hip/knee replacements (total joint replacements [TJR]). Whether similar disparities extend to post-TJR pain management remains unknown. Our objective is to examine the association of race and ethnicity with opioid fills following elective TJRs for White, Black, and Hispanic Medicare beneficiaries. METHODS We used the 2019 national Medicare data to identify beneficiaries who underwent total hip/knee replacements. Primary outcomes were at least one opioid fill in the period from discharge to 30 days post-discharge, and 31-90 days following discharge. Secondary outcomes were morphine milligram equivalent per day and number of opioid fills. Key independent variable was patient race-ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic). We estimated multivariable hierarchical logistic regressions and two-part models with state-level clustering. RESULTS Among 67,550 patients, 93.36% were White, 3.69% were Black, and 2.95% were Hispanic. Compared to White patients, more Black patients and fewer Hispanic patients filled an opioid script (84.10% [Black] and 80.11% [Hispanic] vs. 80.33% [White], p < 0.001) in the 30-day period. On multivariable analysis, Black patients had 18% higher odds of filling an opioid script in the 30-day period (odds ratio [OR]: 1.18, 95% confidence interval [CI]: 1.05-1.33, p = 0.004), and 39% higher odds in the 31-90-day period (OR: 1.39, 95% CI: 1.26-1.54, p < 0.001). There were no significant differences in the endpoints between Hispanic and White patients in the 30-day period. However, Hispanic patients had 20% higher odds of filling an opioid script in the 31- to 90-day period (OR: 1.20, 95% CI: 1.07-1.34, p = 0.002). CONCLUSIONS Important race- and ethnicity-based differences exist in post-TJR pain management with opioids. The mechanisms leading to the higher use of opioids by racial/ethnic minority patients need to be carefully examined.
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Affiliation(s)
- Caroline P. Thirukumaran
- Department of Orthopaedics – University of Rochester, NY
- Department of Public Health Sciences – University of Rochester, NY
- Center for Musculoskeletal Research – University of Rochester, NY
| | - Kevin A. Fiscella
- Department of Public Health Sciences – University of Rochester, NY
- Department of Family Medicine – University of Rochester, NY
| | - Meredith B. Rosenthal
- Department of Health Policy and Management – Harvard T. H. Chan School of Public Health, MA
| | - Jalpa A. Doshi
- Division of General Internal Medicine – University of Pennsylvania Perelman School of Medicine, PA
| | - Derek T. Schloemann
- Department of Orthopaedics – University of Rochester, NY
- Center for Musculoskeletal Research – University of Rochester, NY
| | - Benjamin F. Ricciardi
- Department of Orthopaedics – University of Rochester, NY
- Center for Musculoskeletal Research – University of Rochester, NY
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Seymour RB, Wally MK, Hsu JR. Impact of clinical decision support on controlled substance prescribing. BMC Med Inform Decis Mak 2023; 23:234. [PMID: 37864226 PMCID: PMC10588193 DOI: 10.1186/s12911-023-02314-0] [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: 09/30/2022] [Accepted: 09/29/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND Prescription drug overdose and misuse has reached alarming numbers. A persistent problem in clinical care is lack of easy, immediate access to all relevant information at the actionable time. Prescribers must digest an overwhelming amount of information from each patient's record as well as remain up-to-date with current evidence to provide optimal care. This study aimed to describe prescriber response to a prospective clinical decision support intervention designed to identify patients at risk of adverse events associated with misuse of prescription opioids/benzodiazepines and promote adherence to clinical practice guidelines. METHODS This study was conducted at a large multi-center healthcare system, using data from the electronic health record. A prospective observational study was performed as clinical decision support (CDS) interventions were sequentially launched (January 2016-July 2019). All data were captured from the medical record prospectively via the CDS tools implemented. A consecutive series of all patient encounters including an opioid/benzodiazepine prescription were included in this study (n = 61,124,172 encounters; n = 674,785 patients). Physician response to the CDS interventions was the primary outcome, and it was assessed over time using control charts. RESULTS An alert was triggered in 23.5% of encounters with a prescription (n = 555,626). The prescriber decision was influenced in 18.1% of these encounters (n = 100,301). As the number of risk factors increased, the rate of decision being influenced also increased (p = 0.0001). The effect of the alert differed by drug, risk factor, specialty, and facility. CONCLUSION The delivery of evidence-based, patient-specific information had an influence on the final prescription in nearly 1 in 5 encounters. Our intervention was sustained with minimal prescriber fatigue over many years in a large and diverse health system.
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Affiliation(s)
- Rachel B Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, 1000 Blythe Boulevard, Charlotte, NC, 28203, USA.
- Atrium Health Musculoskeletal Institute, 2001 Vail Avenue, 6th floor, Charlotte, NC, 28207, USA.
| | - Meghan K Wally
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, 1000 Blythe Boulevard, Charlotte, NC, 28203, USA
| | - Joseph R Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, 1000 Blythe Boulevard, Charlotte, NC, 28203, USA
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Kendler KS, Lönn SL, Ektor-Andersen J, Sundquist J, Sundquist K. Risk factors for the development of opioid use disorder after first opioid prescription: a Swedish national study. Psychol Med 2023; 53:6223-6231. [PMID: 36415073 PMCID: PMC10520598 DOI: 10.1017/s003329172200349x] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 10/13/2022] [Accepted: 10/18/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND We need to better understand the frequency and predictors of opioid use disorder (OUD) after first opioid prescription (OP). METHODS We followed 1 516 392 individuals from the Swedish population born 1980-2000, from 1 July 2007, until 31 Dec 2017. We examined putative risk predictors with univariable and multivariable Cox Models and the potential causal effects of predictors by propensity score and co-sibling analyses. RESULT Of the individuals in our cohort, 24.8% (375 404) received a first OP, of whom 3034 (0.90%) developed a subsequent first OUD. The hazard ratio (HR) (± 95% CIs) for OUD after OP equaled 7.10 (6.75-7.46), with a mean time to onset of 3.41 (2.39) years. The strongest putative risk factors for development of OUD after OP were prior psychiatric and substance use disorders, criminal behavior, parental divorce/death, poor school performance, current community deprivation, divorce, and male sex. Few predictors differed across sexes. OP renewal was associated with a HR of 3.66 (3.41-3.93) for OUD. Co-sibling and propensity score analyses suggested that at least a moderate proportion of the risk factor-OUD association was likely causal. A risk score to predict OUD after OP had an AUC of 0.85, where nearly 60% of cases scoring in the top decile. CONCLUSIONS In a general population sample, an OP represents a substantial risk factor for subsequent OUD. Many of the risk factors for OUD after OP can be readily assessed at the time of potential OP, permitting clinicians to evaluate the risk of iatrogenic OUD.
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Affiliation(s)
- Kenneth S. Kendler
- Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University, Richmond, VA, USA
- Department of Psychiatry, Virginia Commonwealth University, Richmond, VA, USA
| | - Sara L. Lönn
- Center for Primary Health Care Research, Lund University, Malmö, Sweden
| | - John Ektor-Andersen
- Department of Family Medicine and Community Health, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Jan Sundquist
- Center for Primary Health Care Research, Lund University, Malmö, Sweden
- Department of Clinical Sciences Lund, Psychiatry, Faculty of Medicine, Lund University, Lund, Sweden and Addiction Center Malmö, Division of Psychiatry, Malmö, Sweden
| | - Kristina Sundquist
- Center for Primary Health Care Research, Lund University, Malmö, Sweden
- Department of Clinical Sciences Lund, Psychiatry, Faculty of Medicine, Lund University, Lund, Sweden and Addiction Center Malmö, Division of Psychiatry, Malmö, Sweden
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Parker DJ, Geist H, Yazdanyar A, Rosentel J, McCambridge M, Chestnut V, Matthews A, Liptak ME, Lebby EB, Beauchamp GA. Surgical Opioid Stewardship for Orthopedic Surgery: A Quality Improvement Initiative. Orthopedics 2023; 46:e230-e236. [PMID: 36779731 DOI: 10.3928/01477447-20230207-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
The aim of this quality improvement initiative was to reduce unnecessary opioid prescribing by sharing data with prescribers on opioid use by patients. In our study, transition of care clinicians performed follow-up phone calls to select postoperative orthopedic patients to determine opioid use. We implemented a standardized postoperative 7-day opioid wean and designed a dashboard to track the information gathered. We calculated descriptive statistics for continuous and categorical variables. In the initial assessment of opioid use by orthopedic patients, the study consisted of 296 patients with a mean age of 64.8±11.4 years, 147 females (49.7%) and 149 males (50.3%), 59.1% joint replacements (hip, knee, shoulder), and 40.9% spine surgeries (lumbar decompression, cervical fusion, hemilaminectomy). Among those prescribed an opioid, 50% received a prescription for 30 pills or less and 52.4% reported taking more than 80% of the opioid pills, while 35.1% reported taking less than 60%. In the prescribing quality improvement assessment, there were a total of 1547 hospitalizations for joint replacement surgeries from June 2018 to June 2020: 774 (50.0%) hips and 773 (50.0%) knees. There was a significant difference in morphine milligram equivalents per day and quantity prescribed when comparing the preintervention period with the postintervention period without significant increases in opioid refill requests or return visit rates. In our study, sharing data around patient opioid use and provider-facing prescribing metrics reduced postoperative opioid prescribing without significantly increasing opioid refill or emergency department return visit rates. [Orthopedics. 2023;46(4):e230-e236.].
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MOHANTI BIDHUKALYAN. Opioid: Plenitude versus pittance. THE NATIONAL MEDICAL JOURNAL OF INDIA 2023; 35:303-307. [PMID: 37167507 DOI: 10.25259/nmji_539_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
The opioid crisis in the USA and in other developed countries can potentially affect low- and middle-income countries (LMICs). The licit medical use of opioids has two sides. The USA and high-income countries maintain abundant supply for medical prescription. Between 1990 and 2010, the use of opioids for cancer pain relief was overtaken by a dramatic rise in the opioid prescriptions for non-cancer acute or chronic pain. The surge led to the opioid epidemic, recognized as social catastrophe in the USA, Canada and in some countries in Europe. From 2016, the medical community, health policy regulators and law-makers have taken actions to tackle this opioid crisis. On the other side, formulary deficiency and low opioid availability exists for three-fourths of the global population living in LMICs. Physicians and nurses in Asia and Africa engaged in cancer pain relief and palliative care face a constant paucity of opioids. Millions of patients in LMICs, suffering from life-modifying cancer pain, do not have access to morphine and other essential opioids, due to restrictive opioid policies. Attention will be needed to improve opioid availability in large parts of the world, even though the opioid crisis has led to control the licit medical use in the USA.
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Olfson M, Waidmann T, King M, Pancini V, Schoenbaum M. Population-Based Opioid Prescribing and Overdose Deaths in the USA: an Observational Study. J Gen Intern Med 2023; 38:390-398. [PMID: 35657466 PMCID: PMC9905341 DOI: 10.1007/s11606-022-07686-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 05/20/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Rising opioid-related death rates have prompted reductions of opioid prescribing, yet limited data exist on population-level associations between opioid prescribing and opioid-related deaths. OBJECTIVE To evaluate population-level associations between five opioid prescribing measures and opioid-related deaths. DESIGN An ecological panel analysis was performed using linear regression models with year and commuting zone fixed effects. PARTICIPANTS People ≥10 years aggregated into 886 commuting zones, which are geographic regions collectively comprising the entire USA. MAIN MEASURES Annual opioid prescriptions were measured with IQVIA Real World Longitudinal Prescription Data including 76.5% (2009) to 90.0% (2017) of US prescriptions. Prescription measures included opioid prescriptions per capita, percent of population with ≥1 opioid prescription, percent with high-dose prescription, percent with long-term prescription, and percent with opioid prescriptions from ≥3 prescribers. Outcomes were age- and sex-standardized associations of change in opioid prescriptions with change in deaths involving any opioids, synthetics other than methadone, heroin but not synthetics or methadone, and prescription opioids, but not other opioids. KEY RESULTS Change in total regional opioid-related deaths was positively correlated with change in regional opioid prescriptions per capita (β=.110, p<.001), percent with ≥1 opioid prescription (β=.100, p=.001), and percent with high-dose prescription (β=.081, p<.001). Change in total regional deaths involving prescription opioids was positively correlated with change in all five opioid prescribing measures. Conversely, change in total regional deaths involving synthetic opioids was negatively correlated with change in percent with long-term opioid prescriptions and percent with ≥3 prescribers, but not for persons ≥45 years. Change in total regional deaths in heroin was not associated with change in any prescription measure. CONCLUSIONS Regional decreases in opioid prescriptions were associated with declines in overdose deaths involving prescription opioids, but were also associated with increases in deaths involving synthetic opioids (primarily fentanyl). Individual-level inferences are limited by the ecological nature of the analysis.
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Affiliation(s)
- Mark Olfson
- New York State Psychiatric Institute/Department of Psychiatry, Columbia University Vagelos College of Physicians & Surgeons, 1051 Riverside Drive, New York, NY, USA.
- Columbia University Mailman School of Public Health, New York, NY, USA.
| | | | - Marissa King
- School of Management, Yale University, New Haven, CT, USA
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7
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Punches BE, Stolz U, Freiermuth CE, Ancona RM, McLean SA, House SL, Beaudoin FL, An X, Stevens JS, Zeng D, Neylan TC, Clifford GD, Jovanovic T, Linnstaedt SD, Germine LT, Bollen KA, Rauch SL, Haran JP, Storrow AB, Lewandowski C, Musey PI, Hendry PL, Sheikh S, Jones CW, Kurz MC, Gentile NT, McGrath ME, Hudak LA, Pascual JL, Seamon MJ, Harris E, Chang AM, Pearson C, Peak DA, Merchant RC, Domeier RM, Rathlev NK, O’Neil BJ, Sanchez LD, Bruce SE, Pietrzak RH, Joormann J, Barch DM, Pizzagalli DA, Smoller JW, Luna B, Harte SE, Elliott JM, Kessler RC, Ressler KJ, Koenen KC, Lyons MS. Predicting at-risk opioid use three months after ed visit for trauma: Results from the AURORA study. PLoS One 2022; 17:e0273378. [PMID: 36149896 PMCID: PMC9506640 DOI: 10.1371/journal.pone.0273378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 08/07/2022] [Indexed: 11/18/2022] Open
Abstract
Objective Whether short-term, low-potency opioid prescriptions for acute pain lead to future at-risk opioid use remains controversial and inadequately characterized. Our objective was to measure the association between emergency department (ED) opioid analgesic exposure after a physical, trauma-related event and subsequent opioid use. We hypothesized ED opioid analgesic exposure is associated with subsequent at-risk opioid use. Methods Participants were enrolled in AURORA, a prospective cohort study of adult patients in 29 U.S., urban EDs receiving care for a traumatic event. Exclusion criteria were hospital admission, persons reporting any non-medical opioid use (e.g., opioids without prescription or taking more than prescribed for euphoria) in the 30 days before enrollment, and missing or incomplete data regarding opioid exposure or pain. We used multivariable logistic regression to assess the relationship between ED opioid exposure and at-risk opioid use, defined as any self-reported non-medical opioid use after initial ED encounter or prescription opioid use at 3-months. Results Of 1441 subjects completing 3-month follow-up, 872 participants were included for analysis. At-risk opioid use occurred within 3 months in 33/620 (5.3%, CI: 3.7,7.4) participants without ED opioid analgesic exposure; 4/16 (25.0%, CI: 8.3, 52.6) with ED opioid prescription only; 17/146 (11.6%, CI: 7.1, 18.3) with ED opioid administration only; 12/90 (13.3%, CI: 7.4, 22.5) with both. Controlling for clinical factors, adjusted odds ratios (aORs) for at-risk opioid use after ED opioid exposure were: ED prescription only: 4.9 (95% CI 1.4, 17.4); ED administration for analgesia only: 2.0 (CI 1.0, 3.8); both: 2.8 (CI 1.2, 6.5). Conclusions ED opioids were associated with subsequent at-risk opioid use within three months in a geographically diverse cohort of adult trauma patients. This supports need for prospective studies focused on the long-term consequences of ED opioid analgesic exposure to estimate individual risk and guide therapeutic decision-making.
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Affiliation(s)
- Brittany E. Punches
- College of Nursing, The Ohio State University, Columbus, OH, United States of America
- Department of Emergency Medicine College of Medicine, The Ohio State University, Columbus, OH, United States of America
- * E-mail:
| | - Uwe Stolz
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, United States of America
| | - Caroline E. Freiermuth
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, United States of America
- Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
| | - Rachel M. Ancona
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Samuel A. McLean
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
- Department of Anesthesiology, Institute for Trauma Recovery, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Stacey L. House
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Francesca L. Beaudoin
- Department of Emergency Medicine & Department of Health Services, Policy, and Practice, The Alpert Medical School of Brown University, Rhode Island Hospital and The Miriam Hospital, Providence, RI, United States of America
| | - Xinming An
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Jennifer S. Stevens
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Donglin Zeng
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, United States of America
| | - Thomas C. Neylan
- Departments of Psychiatry and Neurology, University of California San Francisco, San Francisco, CA, United States of America
| | - Gari D. Clifford
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, GA, United States of America
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, United States of America
| | - Tanja Jovanovic
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University, Detroit, MA, United States of America
| | - Sarah D. Linnstaedt
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Laura T. Germine
- Institute for Technology in Psychiatry, McLean Hospital, Belmont, MA, United States of America
- The Many Brains Project, Belmont, MA, United States of America
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States of America
| | - Kenneth A. Bollen
- Department of Psychology and Neuroscience & Department of Sociology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Scott L. Rauch
- Institute for Technology in Psychiatry, McLean Hospital, Belmont, MA, United States of America
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States of America
- Department of Psychiatry, McLean Hospital, Belmont, MA, United States of America
| | - John P. Haran
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA, United States of America
| | - Alan B. Storrow
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Christopher Lewandowski
- Department of Emergency Medicine, Henry Ford Health System, Detroit, MI, United States of America
| | - Paul I. Musey
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Phyllis L. Hendry
- Department of Emergency Medicine, University of Florida College of Medicine -Jacksonville, Jacksonville, FL, United States of America
| | - Sophia Sheikh
- Department of Emergency Medicine, University of Florida College of Medicine -Jacksonville, Jacksonville, FL, United States of America
| | - Christopher W. Jones
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - Michael C. Kurz
- Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham, AL, United States of America
- Department of Surgery, Division of Acute Care Surgery, University of Alabama School of Medicine, Birmingham, AL, United States of America
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Nina T. Gentile
- Department of Emergency Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States of America
| | - Meghan E. McGrath
- Department of Emergency Medicine, Boston Medical Center, Boston, MA, United States of America
| | - Lauren A. Hudak
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Jose L. Pascual
- Department of Surgery, Department of Neurosurgery, University of Pennsylvania, Pennsylvania, PA, United States of America
- Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA, United States of America
| | - Mark J. Seamon
- Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA, United States of America
- Department of Surgery, Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Pennsylvania, PA, United States of America
| | - Erica Harris
- Department of Emergency Medicine, Einstein Healthcare Network, Pennsylvania, PA, United States of America
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Pennsylvania, PA, United States of America
| | - Anna M. Chang
- Department of Emergency Medicine, Jefferson University Hospitals, Pennsylvania, PA, United States of America
| | - Claire Pearson
- Department of Emergency Medicine, Wayne State University, Detroit, MA, United States of America
| | - David A. Peak
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Roland C. Merchant
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Robert M. Domeier
- Department of Emergency Medicine, Saint Joseph Mercy Hospital, Ypsilanti, MI, United States of America
| | - Niels K. Rathlev
- Department of Emergency Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA, United States of America
| | - Brian J. O’Neil
- Department of Emergency Medicine, Wayne State University, Detroit, MA, United States of America
| | - Leon D. Sanchez
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
- Department of Emergency Medicine, Harvard Medical School, Boston, MA, United States of America
| | - Steven E. Bruce
- Department of Psychological Sciences, University of Missouri—St. Louis, St. Louis, MO, United States of America
| | - Robert H. Pietrzak
- National Center for PTSD, Clinical Neurosciences Division, VA Connecticut Healthcare System, West Haven, CT, United States of America
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America
| | - Jutta Joormann
- Department of Psychology, Yale School of Medicine, New Haven, CT, United States of America
| | - Deanna M. Barch
- Department of Psychological & Brain Sciences, Washington University in St. Louis, MO, United States of America
| | - Diego A. Pizzagalli
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States of America
- Division of Depression and Anxiety, McLean Hospital, Belmont, MA, United States of America
| | - Jordan W. Smoller
- Department of Psychiatry, Psychiatric and Neurodevelopmental Genetics Unit, Massachusetts General Hospital, Boston, MA, United States of America
- Stanley Center for Psychiatric Research, Broad Institute, Cambridge, MA, United States of America
| | - Beatriz Luna
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Steven E. Harte
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, United States of America
- Department of Internal Medicine-Rheumatology, University of Michigan Medical School, Ann Arbor, MI, United States of America
| | - James M. Elliott
- Kolling Institute, University of Sydney, St Leonards, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Northern Sydney Local Health District, New South Wales, Australia
- Physical Therapy & Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States of America
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, MA, United States of America
| | - Kerry J. Ressler
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States of America
- Division of Depression and Anxiety, McLean Hospital, Belmont, MA, United States of America
| | - Karestan C. Koenen
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, United States of America
| | - Michael S. Lyons
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, United States of America
- Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
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Broder JS, Oliveira J E Silva L, Bellolio F, Freiermuth CE, Griffey RT, Hooker E, Jang TB, Meltzer AC, Mills AM, Pepper JD, Prakken SD, Repplinger MD, Upadhye S, Carpenter CR. Guidelines for Reasonable and Appropriate Care in the Emergency Department 2 (GRACE-2): Low-risk, recurrent abdominal pain in the emergency department. Acad Emerg Med 2022; 29:526-560. [PMID: 35543712 DOI: 10.1111/acem.14495] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 03/18/2022] [Accepted: 03/19/2022] [Indexed: 02/07/2023]
Abstract
This second Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-2) from the Society for Academic Emergency Medicine is on the topic "low-risk, recurrent abdominal pain in the emergency department." The multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding four priority questions for adult emergency department patients with low-risk, recurrent, undifferentiated abdominal pain. The intended population includes adults with multiple similar presentations of abdominal signs and symptoms recurring over a period of months or years. The panel reached the following recommendations: (1) if a prior negative computed tomography of the abdomen and pelvis (CTAP) has been performed within 12 months, there is insufficient evidence to accurately identify populations in whom repeat CTAP imaging can be safely avoided or routinely recommended; (2) if CTAP with IV contrast is negative, we suggest against ultrasound unless there is concern for pelvic or biliary pathology; (3) we suggest that screening for depression and/or anxiety may be performed during the ED evaluation; and (4) we suggest an opioid-minimizing strategy for pain control. EXECUTIVE SUMMARY: The GRACE-2 writing group developed clinically relevant questions to address the care of adult patients with low-risk, recurrent, previously undifferentiated abdominal pain in the emergency department (ED). Four patient-intervention-comparison-outcome-time (PICOT) questions were developed by consensus of the writing group, who performed a systematic review of the literature and then synthesized direct and indirect evidence to formulate recommendations, following GRADE methodology. The writing group found that despite the commonality and relevance of these questions in emergency care, the quantity and quality of evidence were very limited, and even fundamental definitions of the population and outcomes of interest are lacking. Future research opportunities include developing precise and clinically relevant definitions of low-risk, recurrent, undifferentiated abdominal pain and determining the scope of the existing populations in terms of annual national ED visits for this complaint, costs of care, and patient and provider preferences.
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Affiliation(s)
- Joshua S Broder
- Department of Surgery, Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Caroline E Freiermuth
- Department of Emergency Medicine, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - Richard T Griffey
- Department of Emergency Medicine and Emergency Care Research Core, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Edmond Hooker
- Department of Health Services Administration, Xavier University, Cincinnati, Ohio, USA
| | - Timothy B Jang
- Department of Emergency Medicine, University of California Los Angeles, UCLA Santa Monica Medical Center, Torrance, California, USA
| | - Andrew C Meltzer
- Department of Emergency Medicine, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Angela M Mills
- Department of Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA.,Society for Academic Emergency Medicine, Des Plaines, Illinois, USA
| | | | | | - Michael D Repplinger
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Suneel Upadhye
- Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Christopher R Carpenter
- Department of Emergency Medicine and Emergency Care Research Core, Washington University School of Medicine, St. Louis, Missouri, USA.,Society for Academic Emergency Medicine, Des Plaines, Illinois, USA
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9
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Kendler KS, Lönn SL, Sundquist J, Sundquist K. Predicting the Onset of Opioid Use Disorder in the Swedish General Population. J Stud Alcohol Drugs 2022; 83:332-341. [PMID: 35590173 PMCID: PMC9134993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023] Open
Abstract
OBJECTIVE Given the public health importance of opioid use disorder (OUD), we sought to understand better its risk predictors in the Swedish general population. METHOD We examined the Swedish population, born 1950-1970 (n = 2,092,359), and followed through 2018. Using Cox, logistic, and co-sibling models, we explored associations between a wide range of putative risk factors and a first onset of OUD--assessed through medical, criminal, and pharmacy registers--in the entire cohort and in the cohort wherein prior cases of drug use disorder (DUD) were censored. RESULTS OUD was predicted by the following four risk factor domains: (a) externalizing syndromes, especially prior non-opioid DUD; (b) psychopathology; (c) psychosocial factors, including social class and immigrant and marital status; and (d) serious injuries and pain diagnoses. When predicting OUD as the first form of DUD, the importance of pain diagnoses as a predictor increased. Co-sibling analyses suggested that the association of some of these risk factors with OUD onset was likely largely causal, whereas others were a mixture of causal effects and familial confounding. An aggregate risk score from these individual risk factors had reasonable receiver operating characteristic (ROC) curve performance. CONCLUSIONS OUD is a multifactorial syndrome for which risk can be meaningfully predicted by prior externalizing syndromes, internalizing and psychotic psychopathology, indicators of psychosocial status, and predictors of pain diagnoses. Some important differences were seen in the prediction of any OUD onset versus OUD onset as the first form of DUD. Much of the effect of these predictors appear, in co-sibling analyses, to likely reflect causal influences.
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Affiliation(s)
- Kenneth S. Kendler
- Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University, Richmond, Virginia
- Department of Psychiatry, Virginia Commonwealth University, Richmond, Virginia
- Correspondence may be sent to Kenneth S. Kendler at the Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University, Box 980126, Richmond, VA 23298-0126, or via e-mail at:
| | - Sara L. Lönn
- Center for Primary Health Care Research, Lund University, Malmö, Sweden
| | - Jan Sundquist
- Center for Primary Health Care Research, Lund University, Malmö, Sweden
- Department of Family Medicine and Community Health, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
- Center for Community-based Healthcare Research and Education (CoHRE), Department of Functional Pathology, School of Medicine, Shimane University, Japan
| | - Kristina Sundquist
- Center for Primary Health Care Research, Lund University, Malmö, Sweden
- Department of Family Medicine and Community Health, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
- Center for Community-based Healthcare Research and Education (CoHRE), Department of Functional Pathology, School of Medicine, Shimane University, Japan
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10
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Tollinche LE, Seier KP, Yang G, Tan KS, Tayban YD, Pastores SM, Yeoh CB, Karamchandani K. Discharge prescribing of enteral opioids in opioid naïve patients following non-surgical intensive care: A retrospective cohort study. J Crit Care 2021; 68:16-21. [PMID: 34856489 DOI: 10.1016/j.jcrc.2021.10.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 10/13/2021] [Accepted: 10/23/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE To estimate the incidence of new prescription of enteral opioids on hospital discharge in opioid naïve, non-surgical, critically ill patients and evaluate the risk factors associated with such occurrence. METHODS Using hospital-wide and ICU databases, we retrospectively identified all patients (≥ 18 years old) who were admitted to the 20-bed adult ICU of Memorial Sloan Kettering Cancer Center (MSKCC) between July 1, 2015 and April 20, 2020. Patients' electronic medical records (EMR) were retrieved and patient demographics, peri-ICU admission data were captured and analyzed. RESULTS During the study period, a total of 3755 opioid naïve patients were admitted to the ICU and 848 patients met the inclusion criteria. Among these, 346 (40.8%) patients were discharged with a new opioid prescription. Age at ICU admission, preadmission use of benzodiazepine, and antidepressants, a diagnosis of sepsis, and use of mechanical ventilation, antidepressants or, opioid infusion for greater than 4 h during the ICU stay, hospital length of stay (LOS), and days between ICU discharge and hospital discharge were independently associated with increased odds of a new opioid prescription. CONCLUSIONS A significant proportion of opioid naïve non-surgical ICU survivors receive a new opioid prescription on hospital discharge.
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Affiliation(s)
| | - Kenneth P Seier
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, USA.
| | - Gloria Yang
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, USA.
| | - Kay See Tan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, USA.
| | - Yekaterina D Tayban
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, USA.
| | - Stephen M Pastores
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, USA.
| | - Cindy B Yeoh
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, USA.
| | - Kunal Karamchandani
- Department of Anesthesiology and Pain Medicine, UT Southwestern Medical Center, USA.
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11
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Balbale SN, Cao L, Trivedi I, Stulberg JJ, Suda KJ, Gellad WF, Evans CT, Lambert BL, Jordan N, Keefer LA. High-Dose Opioid Use Among Veterans with Unexplained Gastrointestinal Symptoms Versus Structural Gastrointestinal Diagnoses. Dig Dis Sci 2021; 66:3938-3950. [PMID: 33385263 PMCID: PMC8245587 DOI: 10.1007/s10620-020-06742-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 11/20/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND In a cohort of Veterans dually enrolled in the Department of Veterans Affairs (VA) and Medicare Part D, we sought to describe high-dose daily opioid use among Veterans with unexplained gastrointestinal (GI) symptoms and structural GI diagnoses and examine factors associated with high-dose use. METHODS We used linked national patient-level data from the VA and Centers for Medicare and Medicaid Services (CMS). We grouped patients into 3 subsets: those with unexplained GI symptoms (e.g., chronic abdominal pain); structural GI diagnoses (e.g., chronic pancreatitis); and those with a concurrent unexplained GI symptom and structural GI diagnosis. High-dose daily opioid use levels were examined as a binary variable [≥ 100 morphine milligram equivalents (MME)/day] and as an ordinal variable (50-99 MME/day, 100-119 MME/day, or ≥ 120 MME/day). RESULTS We identified 141,805 chronic GI patients dually enrolled in VA and Part D. High-dose opioid use was present in 11% of Veterans with unexplained GI symptoms, 10% of Veterans with structural GI diagnoses, and 15% of Veterans in the concurrent GI group. Compared to Veterans with only an unexplained GI symptom or structural diagnosis, concurrent GI patients were more likely to have higher daily opioid doses, more opioid days ≥ 100 MME, and higher risk of chronic use. Factors associated with high-dose use included opioid receipt from both VA and Part D, younger age, and benzodiazepine use. CONCLUSIONS A significant subset of chronic GI patients in the VA are high-dose opioid users. Efforts are needed to reduce high-dose use among Veterans with concurrent GI symptoms and diagnoses.
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Affiliation(s)
- Salva N Balbale
- Center for Health Services & Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
- Center of Innovation for Complex Chronic Healthcare, Health Services Research and Development, Edward Hines, Jr. VA Hospital, Hines, IL, USA.
| | - Lishan Cao
- Center of Innovation for Complex Chronic Healthcare, Health Services Research and Development, Edward Hines, Jr. VA Hospital, Hines, IL, USA
| | - Itishree Trivedi
- Division of Gastroenterology and Hepatology, University of Illinois At Chicago, Chicago, IL, USA
| | - Jonah J Stulberg
- Center for Health Services & Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Surgical Outcomes and Quality Improvement Center (SOQIC), Division of Gastrointestinal Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Katie J Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Charlesnika T Evans
- Center for Health Services & Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Center of Innovation for Complex Chronic Healthcare, Health Services Research and Development, Edward Hines, Jr. VA Hospital, Hines, IL, USA
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Bruce L Lambert
- Center for Communication and Health, Northwestern University School of Communication, Chicago, IL, USA
| | - Neil Jordan
- Center for Health Services & Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Center of Innovation for Complex Chronic Healthcare, Health Services Research and Development, Edward Hines, Jr. VA Hospital, Hines, IL, USA
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Laurie A Keefer
- Division of Gastroenterology, Icahn School of Medicine At Mount Sinai, New York, NY, USA
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12
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Abstract
Efforts to minimize the impact of prescribed opioids on future adverse outcomes are reliant on emergency care providers' ability to screen and detect opioid use disorder (OUD). Many prescriptions are initiated in the emergency department (ED) for acute pain; thus, validated measures are especially needed. Our systematic review describes the available opioid-related screening measures identified through search of the available literature. Measures were categorized by intent and applied clinical setting. We found 44 articles, identifying 15 screening measures. Of these, nine were developed to screen for current opioid misuse and five to screen for risk of future opioid misuse. None were created for use outside of a chronic pain setting. Many measures were applied differently from intended purpose. Although several measures are available, screening for adverse opioid outcomes in the ED is hampered by lack of validated instruments. Development of clarified conceptual models and ED-specific research is necessary to limit OUD.
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13
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Makhinson M, Seshia SS, Young GB, Smith PA, Stobart K, Guha IN. The iatrogenic opioid crisis: An example of 'institutional corruption of pharmaceuticals'? J Eval Clin Pract 2021; 27:1033-1043. [PMID: 33760335 DOI: 10.1111/jep.13566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 03/09/2021] [Accepted: 03/12/2021] [Indexed: 11/28/2022]
Abstract
RATIONALE Prescribed opioids are major contributors to the international public health opioid crisis. Such widespread iatrogenic harms usually result from collective decision failures of healthcare organizations rather than solely of individual organizations or professionals. Findings from a system-wide safety analysis of the iatrogenic opioid crisis that includes roles of pertinent healthcare organizations may help avoid or mitigate similar future iatrogenic consequences. In this retrospective exploratory study, we report such an analysis. METHODS The study population encompassed the entire age spectrum and included those in whom opioids prescribed for chronic pain (unrelated to malignancy) were associated with death or morbidity. Root cause analysis, incorporating recent suggestions for improvement, was used to identify possible contributory factors from the literature. Based on their mandated roles and potential influences to prevent or mitigate the iatrogenic crisis, relevant organizations were grouped and stratified from most to least influential. RESULTS The analysis identified a chain of multiple interrelated causal factors within and between organizations. The most influential organizations were pharmaceutical, political, and drug regulatory; next: experts and their related societies, and publications. Less influential: accreditation, professional licensing and regulatory, academic and healthcare funding bodies. Collectively, their views and decisions influenced prescribing practices of frontline healthcare professionals and advocacy groups. Financial associations between pharmaceutical and most other organizations/groups were common. Ultimately, patients were adversely affected. There was a complex association with psychosocial variables. LIMITATIONS The analysis suggests associations not causality. CONCLUSION The iatrogenic crisis has multiple intricately linked roots. The major catalyst: pervasive pharma-linked financial conflicts of interest (CoIs) involving most other healthcare organizations. These extensive financial CoIs were likely triggers for a cascade of erroneous decisions and actions that adversely affected patients. The actions and decisions of pharma ranged from unethical to illegal. The iatrogenic opioid crisis may exemplify 'institutional corruption of pharmaceuticals'.
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Affiliation(s)
- Michael Makhinson
- Department of Psychiatry and Biobehavioral Science, David Geffen School of Medicine at the University of California, Los Angeles, California, USA.,Department of Psychiatry, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Shashi S Seshia
- Department of Pediatrics, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Gordon Bryan Young
- Clinical Neurological Sciences and Medicine (Critical Care), Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada.,Grey Bruce Health Services, Owen Sound, Ontario, Canada
| | - Preston A Smith
- College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Kent Stobart
- College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Indra Neil Guha
- NIHR Nottingham BRC, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
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14
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Videau M, Aussedat M, Leboucher G, Lebel D, Bussières JF. [Consumption of narcotics, substances assimilated to narcotics and psychotropic drugs in health establishments: Profile of a hospital from France and a hospital from Quebec]. ANNALES PHARMACEUTIQUES FRANÇAISES 2021; 80:312-326. [PMID: 34425078 DOI: 10.1016/j.pharma.2021.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 03/24/2021] [Accepted: 08/17/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVES The objective was to describe the trends in the consumption of narcotic drugs, substances related to narcotic drugs (SAS) and psychotropic drugs between a French hospital and a Quebec hospital between 2013 and 2017. METHODS This is a retrospective descriptive study. The consumption data was obtained from the pharmacy management software and was extracted by financial year (January 1st, 2013 to December 31st, 2017 for the French hospital and April 1st, 2013 to March 31st, 2018 for the Quebec hospital). For each drug considered to be narcotics, SAS and psychotropic drugs in France or subject to the legislation on designated substances in Quebec, we identified the quantities consumed from 2013 to 2017. The data werepresented according to the following therapeutic classes: opioids (N02A), other analgesics (N02B), anxiolytics (N05B), hypnotics and sedatives (N05C), general anesthetics (N01A), psychostimulants (N06B), androgens (G03B) and antagonists peripheral opioid receptors (A06A). The data were expressed as a defined daily dose (DDJ) for 1000 patient-days (PDs). RESULTS In the French hospital, the consumption of narcotics, SAS and psychotropic drugs varied from 676 to 560 DDJ per 1000 PDs between 2013 and 2017. While it varied from 1019 to 756 DDJ per 1000 PDs between 2013 and 2017 in the Quebec hospital. In 2017, the most widely used therapeutic classes in French hospitals were, in decreasing order, anxiolytics (211 DDJ per 1000 PDs) (i.e. alprazolam), opioids (205 DDJ per 1000 PDs) (i.e. tramadol, morphine injectable) and hypnotics and sedatives (64 DDJ per 1000 PDs) (i.e. midazolam injectable). In Quebec hospitals, the three therapeutic classes the most used in 2017 were, in decreasing order, opioids (314 DDJ per 1000 PDs) (i.e. hydromorphone injectable, morphine injectable), anxiolytics (221 DDJ per 1000 PDs) (i.e. clobazam) and hypnotics and sedatives (108 DDJ per 1000 PDs) (i.e. midazolam injectable). CONCLUSION This study notes a decrease in the consumption of opioids and other substances in both the French and Quebec establishments between 2013-2017. More work is needed to better describe the differences observed between the profile of each establishment. This is why monitoring consumption trends, therapeutic indications and preventive measures are essential.
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Affiliation(s)
- M Videau
- Unité de recherche en pratique pharmaceutique, département de pharmacie, CHU Sainte-Justine, 3175, chemin de la Côte Sainte-Catherine, H3T 1C5 Montréal, QC, Canada
| | - M Aussedat
- Hospices civils de Lyon, 3, quai des Célestins, 69002 Lyon, France
| | - G Leboucher
- Hospices civils de Lyon, 3, quai des Célestins, 69002 Lyon, France
| | - D Lebel
- Unité de recherche en pratique pharmaceutique, département de pharmacie, CHU Sainte-Justine, 3175, chemin de la Côte Sainte-Catherine, H3T 1C5 Montréal, QC, Canada
| | - J-F Bussières
- Unité de recherche en pratique pharmaceutique, département de pharmacie, CHU Sainte-Justine, 3175, chemin de la Côte Sainte-Catherine, H3T 1C5 Montréal, QC, Canada; Faculté de pharmacie, université de Montréal, 2940, chemin de Polytechnique, H3T 1J4, Montréal, QC, Canada.
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15
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Simpson SA, Goans C, Loh R, Ryall K, Middleton MCA, Dalton A. Suicidal ideation is insensitive to suicide risk after emergency department discharge: Performance characteristics of the Columbia-Suicide Severity Rating Scale Screener. Acad Emerg Med 2021; 28:621-629. [PMID: 33346922 DOI: 10.1111/acem.14198] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/19/2020] [Accepted: 10/21/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVES We describe the Columbia-Suicide Severity Rating Scale (C-SSRS)-Clinical Practice Screener's ability to predict suicide and emergency department (ED) visits for self-harm in the year following an ED encounter. METHODS Screening data from adult patients' first ED encounter during a 27-month study period were analyzed. Patients were excluded if they died during the encounter or left without being identified. The outcomes were suicide as reported by the state health department and a recurrent ED visit for suicide attempt or self-harm reported by the state hospital association. Multivariable regression examined the screener's correlation with these outcomes. RESULTS Among 92,643 patients analyzed, eleven (0.01%) patients died by suicide within a month after ED visit. The screener's sensitivity and specificity for suicide by 30 days were 0.18 (95% confidence interval [CI] = 0.00 to 0.41) and 0.99 (95% CI = 0.99 to 0.99). Sensitivity and specificity were better for predicting self-harm by 30 days: 0.53 (95% CI = 0.42 to 0.64) and 0.97 (95% CI = 0.97 to 0.97), respectively. Multivariable regression demonstrated that screening risk remained associated with both suicide and self-harm outcomes in the presence of covariates. Suicide risk was not mitigated by hospitalization or psychiatric intervention in the ED. CONCLUSIONS The C-SSRS screener is insensitive to suicide risk after ED discharge. Most patients who died by suicide screened negative and did not receive psychiatric services in the ED. Moreover, most patients with suicidal ideation died by causes other than suicide. The screener was more sensitive for predicting nonfatal self-harm and may inform a comprehensive risk assessment. These results compel us to reimagine the provision of emergency psychiatric services.
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Affiliation(s)
| | | | - Ryan Loh
- Denver Health and Hospital Authority Denver Colorado USA
| | - Karen Ryall
- Denver Health and Hospital Authority Denver Colorado USA
| | | | - Alicia Dalton
- Denver Health and Hospital Authority Denver Colorado USA
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16
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Punches BE, Ancona RM, Freiermuth CE, Brown JL, Lyons MS. Incidence of opioid use disorder in the year after discharge from an emergency department encounter. J Am Coll Emerg Physicians Open 2021; 2:e12476. [PMID: 34189517 PMCID: PMC8219283 DOI: 10.1002/emp2.12476] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 05/07/2021] [Accepted: 05/19/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Therapeutic opioid exposure is associated with long-term use. How much later use is due to opioid use disorder (OUD) and the incidence of OUD without preceding therapeutic exposure are unknown. We preliminarily explored the association between emergency department opioid prescriptions and subsequent OUD. METHODS This retrospective cohort study queried electronic health records for discharged adult patients in the year before (2014) and after (2016) their first encounter in 2015 at either of 2 EDs in a Midwestern healthcare system. OUD was defined by diagnosis codes and prescription history. Patients with OUD history before the index encounter were excluded. We report OUD incidence within 1 year, with time to first indicator of OUD among those with a repeat health system encounter post index using a Cox proportional hazards model. Secondary outcomes were sources of therapeutic opioid exposure and frequency of risk factors associated with OUD among those who developed OUD. RESULTS Of the 49,904 unique, adult ED patients without history of OUD, 669 (1.3%; 95% CI, 1.2-1.4) had health records indicating OUD within 12 months. The proportion of ED patients with OUD at 12 months was 1.5% (95% CI, 1.2-1.9) if prescribed an opioid at index and 1.3% (95% CI, 1.2-1.4) if not. Of the 669 who developed OUD, 80 (12.0%) were prescribed an opioid at the index ED visit, 54 (8%) received an opioid prescription at a subsequent ED visit, and median time to OUD was 4.5 months (interquartile range 1.6-7.6, range 0.0-11.9). When controlling for demographics, mental health, and prior opioid prescriptions, there was no difference in OUD incidence between patients who did or did not receive an initial ED opioid prescription (HR, 1.1; 95% CI, 0.9-1.4). CONCLUSIONS A small but meaningful proportion of the ED population will develop OUD within 1 year even without ED opioid prescription. Though we found no association between ED opioid prescription and later OUD, further study is warranted given the complexity factors influencing OUD incidence, ongoing ED opioid exposure, and limitations inherent to this study design.
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Affiliation(s)
- Brittany E. Punches
- University of Cincinnati College of NursingCincinnatiOhioUSA
- University of Cincinnati College of Medicine Department of Emergency MedicineCincinnatiOhioUSA
- Center for Addiction ResearchUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Rachel M. Ancona
- University of Cincinnati College of Medicine Department of Emergency MedicineCincinnatiOhioUSA
| | - Caroline E. Freiermuth
- University of Cincinnati College of Medicine Department of Emergency MedicineCincinnatiOhioUSA
- Center for Addiction ResearchUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Jennifer L. Brown
- Center for Addiction ResearchUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
- Department of Psychiatry and Behavioral NeuroscienceUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Michael S. Lyons
- University of Cincinnati College of Medicine Department of Emergency MedicineCincinnatiOhioUSA
- Center for Addiction ResearchUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
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17
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Larach DB, Sahara MJ, As-Sanie S, Moser SE, Urquhart AG, Lin J, Hassett AL, Wakeford JA, Clauw DJ, Waljee JF, Brummett CM. Patient Factors Associated With Opioid Consumption in the Month Following Major Surgery. Ann Surg 2021; 273:507-515. [PMID: 31389832 PMCID: PMC7068729 DOI: 10.1097/sla.0000000000003509] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The aim of this study was to determine preoperative patient characteristics associated with postoperative outpatient opioid use and assess the frequency of postoperative opioid overprescribing. SUMMARY BACKGROUND DATA Although characteristics associated with inpatient opioid use have been described, data regarding patient factors associated with opioid use after discharge are lacking. This hampers the development of individualized approaches to postoperative prescribing. METHODS We included opioid-naïve patients undergoing hysterectomy, thoracic surgery, and total knee and hip arthroplasty in a single-center prospective observational cohort study. Preoperative phenotyping included self-report measures to assess pain severity, fibromyalgia survey criteria score, pain catastrophizing, depression, anxiety, functional status, fatigue, and sleep disturbance. Our primary outcome measure was self-reported total opioid use in oral morphine equivalents. We constructed multivariable linear-regression models predicting opioids consumed in the first month following surgery. RESULTS We enrolled 1181 patients; 1001 had complete primary outcome data and 913 had complete phenotype data. Younger age, non-white race, lack of a college degree, higher anxiety, greater sleep disturbance, heavy alcohol use, current tobacco use, and larger initial opioid prescription size were significantly associated with increased opioid consumption. Median total oral morphine equivalents prescribed was 600 mg (equivalent to one hundred twenty 5-mg hydrocodone pills), whereas median opioid consumption was 188 mg (38 pills). CONCLUSIONS In this prospective cohort of opioid-naïve patients undergoing major surgery, we found a number of characteristics associated with greater opioid use in the first month after surgery. Future studies should address the use of non-opioid medications and behavioral therapies in the perioperative period for these higher risk patients.
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Affiliation(s)
- Daniel B. Larach
- Department of Anesthesiology, Weill Cornell Medical College, New York, NY
| | | | - Sawsan As-Sanie
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | | | - Andrew G. Urquhart
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI
| | - Jules Lin
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Afton L. Hassett
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | | | - Daniel J. Clauw
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | | | - Chad M. Brummett
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
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18
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van Amsterdam J, Pierce M, van den Brink W. Is Europe Facing an Emerging Opioid Crisis Comparable to the U.S.? Ther Drug Monit 2021; 43:42-51. [PMID: 32649487 DOI: 10.1097/ftd.0000000000000789] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 06/13/2020] [Indexed: 01/09/2023]
Abstract
ABSTRACT In the U.S., an opioid overdose crisis has emerged, attributable to over-prescription of opioid analgesics, driven by aggressive marketing by pharmaceutical companies, followed by surging heroin overdose deaths, and more recently, by the high mortality rates predominately because of illicitly manufactured fentanyl and analogs of fentanyl. In Europe, the use of prescription opioids for pain management has also increased in the last 2 decades, although it is debatable as to whether this could lead to a similar opioid overdose crisis. To address this issue, recent trends in opioid prescription rates, prevalence rates of fatal and nonfatal incidents, and addiction care treatment were used as proxies of opioid-related harm. The current overview, comparing opioid use and its negative consequences in Germany, France, the U.K., and the Netherlands, using the same indicators as in the U.S., demonstrates that there is no evidence of a current or emerging opioid crisis in these European countries. Scotland, however, is an alarming exception, with high rates of opioid-related harms. Considering that the use of prescription opioids has been declining rather than increasing in Europe, an opioid crisis is not anticipated there yet. Authorities should, however, remain vigilant.
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Affiliation(s)
- Jan van Amsterdam
- Department of Psychiatry, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
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19
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Quinn PD, Fine KL, Rickert ME, Sujan AC, Boersma K, Chang Z, Franck J, Lichtenstein P, Larsson H, D’Onofrio BM. Association of Opioid Prescription Initiation During Adolescence and Young Adulthood With Subsequent Substance-Related Morbidity. JAMA Pediatr 2020; 174:1048-1055. [PMID: 32797146 PMCID: PMC7418042 DOI: 10.1001/jamapediatrics.2020.2539] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
IMPORTANCE Concerns about adverse outcomes associated with opioid analgesic prescription have led to major guideline and policy changes. Substantial uncertainty remains, however, regarding the association between opioid prescription initiation and increased risk of subsequent substance-related morbidity. OBJECTIVE To examine the association of opioid initiation among adolescents and young adults with subsequent broadly defined substance-related morbidity. DESIGN, SETTING, AND PARTICIPANTS This cohort study analyzed population-register data from January 1, 2007, to December 31, 2013, on Swedish individuals aged 13 to 29 years by January 1, 2013, who were naive to opioid prescription. To account for confounding, the analysis compared opioid prescription recipients with recipients of nonsteroidal anti-inflammatory drugs as an active comparator, compared opioid-recipient twins and other multiple birth individuals with their nonrecipient co-multiple birth offspring (co-twin control), examined dental prescription as a specific indication, and included individual, parental, and socioeconomic covariates. Data were analyzed from March 30, 2019, to January 22, 2020. EXPOSURES Opioid prescription initiation, defined as first dispensed opioid analgesic prescription. MAIN OUTCOMES AND MEASURES Substance-related morbidity, assessed as clinically diagnosed substance use disorder or overdose identified from inpatient or outpatient specialist records, substance use disorder or overdose cause of death, dispensed pharmacotherapy for alcohol use disorder, or conviction for substance-related crime. RESULTS Among the included cohort (n = 1 541 862; 793 933 male [51.5%]), 193 922 individuals initiated opioid therapy by December 31, 2013 (median age at initiation, 20.9 years [interquartile range, 18.2-23.6 years]). The active comparator design included 77 143 opioid recipients without preexisting substance-related morbidity and 229 461 nonsteroidal anti-inflammatory drug recipients. The adjusted cumulative incidence of substance-related morbidity within 5 years was 6.2% (95% CI, 5.9%-6.5%) for opioid recipients and 4.9% (95% CI, 4.8%-5.1%) for nonsteroidal anti-inflammatory drug recipients (hazard ratio, 1.29; 95% CI, 1.23-1.35). The co-twin control design produced comparable results (3013 opioid recipients and 3107 nonrecipients; adjusted hazard ratio, 1.43; 95% CI, 1.02-2.01), as did restriction to analgesics prescribed for dental indications and additional sensitivity analyses. CONCLUSIONS AND RELEVANCE Among adolescents and young adults analyzed in this study, initial opioid prescription receipt was associated with an approximately 30% to 40% relative increase in risk of subsequent substance-related morbidity in multiple designs that adjusted for confounding. These findings suggest that this increase may be smaller than previously estimated in some other studies.
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Affiliation(s)
- Patrick D. Quinn
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington
| | - Kimberly L. Fine
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington
| | - Martin E. Rickert
- Department of Psychological and Brain Sciences, Indiana University, Bloomington
| | - Ayesha C. Sujan
- Department of Psychological and Brain Sciences, Indiana University, Bloomington
| | - Katja Boersma
- Center for Health and Medical Psychology, School of Law, Psychology and Social Work, Örebro University, Örebro, Sweden
| | - Zheng Chang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Johan Franck
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Paul Lichtenstein
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Larsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden,School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Brian M. D’Onofrio
- Department of Psychological and Brain Sciences, Indiana University, Bloomington,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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20
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Beauchamp GA, Nelson LS, Perrone J, Lyons MS. A theoretical framework and nomenclature to characterize the iatrogenic contribution of therapeutic opioid exposure to opioid induced hyperalgesia, physical dependence, and opioid use disorder. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2020; 46:671-683. [PMID: 32897113 DOI: 10.1080/00952990.2020.1778713] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Opioid use, misuse, and risky use contribute to a critically important and complex crisis in current healthcare. Consequences of long-term opioid use, including opioid induced hyperalgesia, physical dependence, and opioid use disorder, can be considered iatrogenic, or partially iatrogenic, in cases where therapeutic opioid exposures were contributory. Research investigation and presumptive clinical action are needed to attenuate the iatrogenic component of the opioid crisis; treatment of individuals already suffering from opioid use disorder will not prevent incident cases. This work will be challenged by a remarkably high degree of complexity involving myriad and highly variable factors along the continuum from initial opioid exposure to long-term opioid use. An organized view of this complex problem should accelerate the pace of innovation and facilitate clinical implementation of research findings. Herein, we propose a theoretical framework and modern nomenclature for characterizing therapeutic opioid exposure and the degree to which it contributes iatrogenically to adverse outcomes. In doing so, we separate the role of exposure from other factors contributing to long-term opioid use, clarify the relationship between opioid exposure and outcomes, emphasize that exposure source is an important consideration for health services research and practice in the areas of pain treatment and opioid prevention, and recommend terminology necessary to quantify therapeutic opioid exposure separately from nonmedical exposure.
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Affiliation(s)
- Gillian A Beauchamp
- Lehigh Valley Health Network Department of Emergency and Hospital Medicine, Divsion of Medical Toxicology/USF Morsani College of Medicine , Allentown, PA, USA
| | - Lewis S Nelson
- Department of Emergency Medicine, Division of Medical Toxicology, Rutgers New Jersey Medical School , Newark, NJ, USA
| | - Jeanmarie Perrone
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania , Philadelphia, PA, USA
| | - Michael S Lyons
- Department of Emergency Medicine, University of Cincinnati College of Medicine , Cincinnati, OH, USA
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21
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[How long does a long-term therapy last?]. Schmerz 2020; 34:438-442. [PMID: 32880757 PMCID: PMC7471546 DOI: 10.1007/s00482-020-00493-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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22
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Wunsch H, Hill AD, Fu L, Fowler RA, Wang HT, Gomes T, Fan E, Juurlink DN, Pinto R, Wijeysundera DN, Scales DC. New Opioid Use after Invasive Mechanical Ventilation and Hospital Discharge. Am J Respir Crit Care Med 2020; 202:568-575. [PMID: 32348694 PMCID: PMC7427379 DOI: 10.1164/rccm.201912-2503oc] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 04/27/2020] [Indexed: 01/21/2023] Open
Abstract
Rationale: Patients who receive invasive mechanical ventilation (IMV) are usually exposed to opioids as part of their sedation regimen. The rates of posthospital prescribing of opioids are unknown.Objectives: To determine the frequency of persistent posthospital opioid use among patients who received IMV.Methods: We assessed opioid-naive adults who were admitted to an ICU, received IMV, and survived at least 7 days after hospital discharge in Ontario, Canada over a 26-month period (February, 2013 through March, 2015). The primary outcome was new, persistent opioid use during the year after discharge. We assessed factors associated with persistent use by multivariable logistic regression. Patients receiving IMV were also compared with matched hospitalized patients who did not receive intensive care (non-ICU).Measurements and Main Results: Among 25,085 opioid-naive patients on IMV, 5,007 (20.0%; 95% confidence interval [CI], 19.5-20.5) filled a prescription for opioids in the 7 days after hospital discharge. During the next year, 648 (2.6%; 95% CI, 2.4-2.8) of the IMV cohort met criteria for new, persistent opioid use. The patient characteristic most strongly associated with persistent use in the IMV cohort was being a surgical (vs. medical) patient (adjusted odds ratio, 3.29; 95% CI, 2.72-3.97). The rate of persistent use was slightly higher than for matched non-ICU patients (2.6% vs. 1.5%; adjusted odds ratio, 1.37 [95% CI, 1.19-1.58]).Conclusions: A total of 20% of IMV patients received a prescription for opioids after hospital discharge, and 2.6% met criteria for persistent use, an average of 300 new persistent users per year in a population of 14 million. Receipt of surgery was the factor most strongly associated with persistent use.
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Affiliation(s)
- Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine
- Department of Anesthesia
| | - Andrea D. Hill
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | | | - Rob A. Fowler
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine
- Department of Medicine, and
| | - Han Ting Wang
- Critical Care Division, Department of Medicine, Maisonneuve-Rosemont Hospital affiliated with the University of Montreal, Montreal, Quebec, Canada; and
| | - Tara Gomes
- ICES, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute and
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine
- Department of Medicine, and
| | - David N. Juurlink
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Medicine, and
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Duminda N. Wijeysundera
- ICES, Toronto, Ontario, Canada
- Department of Anesthesia
- Li Ka Shing Knowledge Institute and
- Department of Anesthesia, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Damon C. Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine
- Department of Medicine, and
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23
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Dennis JA, Zhang Y, Curtis S, Brismée JM, Sizer PS. Conventional and Complementary Health Care Approaches Used by American Adults Reporting Joint Pain: Patterns from the National Health Interview Survey 2012. J Altern Complement Med 2020; 26:1080-1083. [PMID: 32757943 DOI: 10.1089/acm.2020.0237] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: To describe patterns of conventional health care (CH) and complementary and alternative medicine (CAM) use among U.S. adults reporting recent joint symptoms in a nationally representative sample. Design: This study uses the adult alternative medicine supplement from the 2012 National Health Interview Survey (NHIS). Location: United States. Subjects: Nationally representative cross-sectional sample of non-institutionalized U.S. residents. Of 34,525 respondents who answered the alternative medicine supplement, approximately 30% (n = 10,964) reported recent pain symptoms (pain, aching, stiffness). Outcome measures: Among adults reporting joint symptoms, we examine reported use of CH, CAM, both CH and CAM, or neither specifically for joint symptoms or joint condition. Results: Among adults reporting joint symptoms in the past 30 days, 64% reported using only CH for their joint pain, whereas ∼10% reported using CAM. Among those using CAM for their joint symptoms, 83% also sought help from a CH practitioner. CAM-only users comprised only 1.6% of the sample of joint pain sufferers. Those who reported using both CH and CAM for joint pain were more likely to report a diagnosis of a joint condition compared with CAM-only users, but also reported higher comorbidities and worse self-reported health. Conclusion: Most U.S. adults reporting recent joint pain seek care only from a CH practitioner, although among the 10% who report CAM use for joint conditions, a strong majority also report seeking care from a CH practitioner. CH and CAM providers should consistently inquire about other forms of treatment their patients are using for specific symptoms to provide effective integrative health care management.
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Affiliation(s)
- Jeff A Dennis
- Department of Public Health, Graduate School of Biomedical Sciences, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Yan Zhang
- Harris College of Nursing and Health Sciences, Texas Christian University, Fort Worth, TX, USA
| | - Samantha Curtis
- Department of Public Health, Graduate School of Biomedical Sciences, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Jean-Michel Brismée
- Department of Rehabilitation Sciences, School of Health Professions, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Phillip S Sizer
- Department of Rehabilitation Sciences, School of Health Professions, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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24
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Holmgren AJ, Botelho A, Brandt AM. A History of Prescription Drug Monitoring Programs in the United States: Political Appeal and Public Health Efficacy. Am J Public Health 2020; 110:1191-1197. [PMID: 32552023 PMCID: PMC7349461 DOI: 10.2105/ajph.2020.305696] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2020] [Indexed: 11/04/2022]
Abstract
Prescription drug monitoring programs (PDMPs) have become a widely embraced policy to address the US opioid crisis. Despite mixed scientific evidence on their effectiveness at improving health and reducing overdose deaths, 49 states and Washington, DC have adopted PDMPs, and they have received strong bipartisan legislative support. This article explores the history of PDMPs, tracking their evolution from paper-based administrative databases in the early 1900s to modern-day electronic systems that intervene at the point of care. We focus on two questions: how did PDMPs become so widely adopted in the United States, and how did they gain popularity as an intervention in the contemporary opioid crisis? Through this historical approach, we evaluate what PDMPs reflect about national drug policy and broader cultural understandings of substance use disorder in the United States today. (Am J Public Health. 2020;110:1191-1197. 10.2105/AJPH.2020.305696).
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Affiliation(s)
- A Jay Holmgren
- A. Jay Holmgren is with the Harvard Business School, Harvard University, Boston, MA. Alyssa Botelho is with the Medical Scientist Training Program, Harvard Medical School, Boston, MA, and the Department of the History of Science, Harvard University, Cambridge, MA. Allan M. Brandt is with the Department of Global Health and Social Medicine, Harvard Medical School, Boston, and the Department of the History of Science, Harvard University, Cambridge
| | - Alyssa Botelho
- A. Jay Holmgren is with the Harvard Business School, Harvard University, Boston, MA. Alyssa Botelho is with the Medical Scientist Training Program, Harvard Medical School, Boston, MA, and the Department of the History of Science, Harvard University, Cambridge, MA. Allan M. Brandt is with the Department of Global Health and Social Medicine, Harvard Medical School, Boston, and the Department of the History of Science, Harvard University, Cambridge
| | - Allan M Brandt
- A. Jay Holmgren is with the Harvard Business School, Harvard University, Boston, MA. Alyssa Botelho is with the Medical Scientist Training Program, Harvard Medical School, Boston, MA, and the Department of the History of Science, Harvard University, Cambridge, MA. Allan M. Brandt is with the Department of Global Health and Social Medicine, Harvard Medical School, Boston, and the Department of the History of Science, Harvard University, Cambridge
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25
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Dennis JA, Gittner LS, George AK, Queen CM. Opioid Use Disorder Terminologies and the Role of Public Health in Addressing Stigma. ALCOHOLISM TREATMENT QUARTERLY 2020. [DOI: 10.1080/07347324.2020.1787118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Jeff A. Dennis
- Department of Public Health, Graduate School of Biomedical Sciences, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Lisaann S. Gittner
- Department of Public Health, Graduate School of Biomedical Sciences, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Asher K. George
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Courtney M. Queen
- Department of Public Health, Graduate School of Biomedical Sciences, Texas Tech University Health Sciences Center, Abilene, Texas, USA
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26
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Beauchamp GA, Rosentel J, Yazdanyar A, Farber E, Levi J, Laubach LT, Esposito SB, Iqbal S, MacKenzie RS, Richardson DM. Implementation of an emergency department discharge opioid taper protocol. Am J Emerg Med 2020; 41:247-250. [PMID: 32534875 DOI: 10.1016/j.ajem.2020.05.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/14/2020] [Accepted: 05/28/2020] [Indexed: 11/18/2022] Open
Affiliation(s)
- Gillian A Beauchamp
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network, Cedar Crest Blvd & I-78, Allentown 18103, PA, USA; University of South Florida (USF), Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, USA 18103.
| | - Joshua Rosentel
- Department of Quality Assessment, Lehigh Valley Health Network, Cedar Crest Blvd & I-78, Allentown 18103, PA, USA
| | - Ali Yazdanyar
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network, Cedar Crest Blvd & I-78, Allentown 18103, PA, USA; University of South Florida (USF), Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, USA 18103
| | - Erin Farber
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network, Cedar Crest Blvd & I-78, Allentown 18103, PA, USA; University of South Florida (USF), Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, USA 18103
| | - Joseph Levi
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network, Cedar Crest Blvd & I-78, Allentown 18103, PA, USA; University of South Florida (USF), Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, USA 18103
| | - Lexis T Laubach
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network, Cedar Crest Blvd & I-78, Allentown 18103, PA, USA; University of South Florida (USF), Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, USA 18103
| | - Samantha B Esposito
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network, Cedar Crest Blvd & I-78, Allentown 18103, PA, USA; University of South Florida (USF), Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, USA 18103
| | - Sarah Iqbal
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network, Cedar Crest Blvd & I-78, Allentown 18103, PA, USA; University of South Florida (USF), Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, USA 18103
| | - Richard S MacKenzie
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network, Cedar Crest Blvd & I-78, Allentown 18103, PA, USA; University of South Florida (USF), Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, USA 18103
| | - David M Richardson
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network, Cedar Crest Blvd & I-78, Allentown 18103, PA, USA; University of South Florida (USF), Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, USA 18103
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27
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Abstract
OBJECTIVE To determine the proportion of initial opioid prescriptions for opioid-naive patients prescribed by surgeons, dentists, and emergency physicians. We hypothesized that the percentage of such prescriptions grew as scrutiny of primary care and pain medicine opioid prescribing increased and guidelines were developed. SUMMARY OF BACKGROUND DATA Data regarding the types of care for which opioid-naive patients are provided initial opioid prescriptions are limited. METHODS A retrospective cross-sectional study using a nationwide insurance claims dataset to study US adults aged 18 to 64 years. Our primary outcome was a change in opioid prescription share for opioid-naive patients undergoing surgical, emergency, and dental care from 2010 to 2016; we also examined the type and amounts of opioid filled. RESULTS From 87,941,718 analyzed lives, we identified 16,292,018 opioid prescriptions filled by opioid-naive patients. The proportion of prescriptions for patients receiving surgery, emergency, and dental care increased by 15.8% from 2010 to 2016 (P < 0.001), with the greatest increases related to surgical (18.1%) and dental (67.8%) prescribing. In 2016, surgery patients filled 22.0% of initial prescriptions, emergency medicine patients 13.0%, and dental patients 4.2%. Surgical patients' mean total oral morphine equivalents per prescription increased from 240 mg (SD 509) in 2010 to 403 mg (SD 1369) in 2016 (P < 0.001). Over the study period, surgical patients received the highest proportion of potent opioids (90.2% received hydrocodone or oxycodone). CONCLUSIONS Initial opioid prescribing attributable to surgical and dental care is increasing relative to primary and chronic pain care. Evidence-based guideline development for surgical and dental prescribing is warranted in order to curb iatrogenic opioid morbidity and mortality.
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Alexandridis AA, Dasgupta N, Ringwalt CL, Rosamond WD, Chelminski PR, Marshall SW. Association between opioid analgesic therapy and initiation of buprenorphine management: An analysis of prescription drug monitoring program data. PLoS One 2020; 15:e0227350. [PMID: 31923197 PMCID: PMC6953786 DOI: 10.1371/journal.pone.0227350] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 12/02/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In the US, medication assisted treatment, particularly with office-based buprenorphine, has been an important component of opioid dependence treatment among patients with iatrogenic addiction to opioid analgesics. The predictors of initiating buprenorphine for addiction among opioid analgesic patients have not been well-described. METHODS We conducted a time-to-event analysis using data from the North Carolina (NC) Prescription Drug Monitoring Program (PDMP). Our outcome of interest was time-to-initiation of sublingual buprenorphine. Our study population was a prospective cohort of all state residents receiving a full-agonist opioid analgesic between 2011 and 2015. Predictors of initiation of sublingual buprenorphine examined included: age, gender, cumulative pharmacies and prescribers utilized, cumulative opioid intensity (defined as cumulative opioid exposure divided by duration of opioid exposure), and benzodiazepine dispensing. FINDINGS Of 4.3 million patients receiving opioid analgesics in NC between 2011 and 2015 (accumulated 8.30 million person-years of follow-up), and a total of 28,904 patients initiated buprenorphine formulations intended for addiction treatment (overall rate 3.48 per 1,000 person-years). In adjusted multivariate models, the utilization of 3 or more pharmacies (HR: 2.93; 95% CI: 2.82, 3.05) or 6 or more controlled substance prescribers (HR: 12.09; 95% CI: 10.76, 13.57) was associated with buprenorphine initiation. A dose-response relationship was observed for cumulative opioid intensity (HR in highest decile relative to lowest decile: 5.05; 95% CI: 4.70, 5.42). Benzodiazepine dispensing was negatively associated with buprenorphine initiation (HR: 0.63; 95% CI: 0.61, 0.65). CONCLUSIONS Opioid analgesic patients utilizing multiple prescribers or pharmacies are more likely to initiate sublingual buprenorphine. This finding suggests that patients with multiple healthcare interactions are more likely to be treated for high-risk opioid use, or may be more likely to be identified and treated for addiction. Future research should utilize prescription monitoring program data linked to electronic health records to include diagnosis information in analytic models.
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Affiliation(s)
- Apostolos A. Alexandridis
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Nabarun Dasgupta
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Christopher L. Ringwalt
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Wayne D. Rosamond
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Paul R. Chelminski
- Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Stephen W. Marshall
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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Engster SA, Molina BSG, Bogen DL. Adolescent and Parent Knowledge, Attitudes, and Perceptions of Harm of Household Controlled Medications. Subst Use Misuse 2020; 55:734-742. [PMID: 31847677 DOI: 10.1080/10826084.2019.1701034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Introduction: Adolescents learn knowledge, attitudes, and behaviors from their parents, yet little is known about how these attributes are associated with management of household controlled prescription medications. We aimed to assess adolescent and parent: 1) knowledge and attitudes regarding household controlled medications, including previous healthcare counseling; 2) perceptions of harm of medication misuse and diversion; and 3) potential associations of these attributes with household management. Methods: This was a cross-sectional study with paired data using brief, online, confidential surveys of adolescents and parents via an adolescent medicine clinic associated with a large academic center. Eligible adolescents were aged 12-18 years old with at least one controlled prescription medication in the home. Data collection and analysis occured in 2017-2018. Results: Of the 243 adolescent-parent dyads, many adolescents and parents had: low knowledge (15%; 6%), risky attitudes (31%; 32%), received healthcare counseling on safe management of controlled medications (30%; 96%), and low perceived harm of adolescent diversion (39%; 49%). Parents practicing unsafe household management were 2.4 (95% CI = 1.3, 4.3) times as likely to have risky attitudes. Adolescents with families practicing unsafe medication management were 3.7 (95% CI = 1.1, 10.4) times as likely to have low perceptions of harm from diversion. Conclusions: Many adolescents and parents have low knowledge, risky attitudes, and low perceptions of harm of adolescent diversion, some of which are associated with unsafe household medication management. Providers should aim to utilize interventions to improve these attributes for adolescents and parents to enhance safe household medication management.
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Affiliation(s)
- Stacey A Engster
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA.,Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA
| | - Brooke S G Molina
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA.,Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA.,Department of Psychology, University of Pittsburgh, School of Medicine, Pittsburgh, PA
| | - Debra L Bogen
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA.,Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA.,Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
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30
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Garcia J, Ohanisian L, Sidley A, Ferris A, Luck G, Basich G, Garcia A. Resident Knowledge and Perception of Pain Management. Cureus 2019; 11:e6107. [PMID: 31886047 PMCID: PMC6901364 DOI: 10.7759/cureus.6107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Chronic pain involves a complex mechanism that afflicts 50 million adults in the United States and incurs societal costs upwards of $560 billion annually. The consequences of this epidemic have resulted in an epidemic of its own, with the opioid crisis becoming a top priority in healthcare. Historically, the sub-optimal practices of overprescribing opioids and inadequate monitoring of iatrogenic addiction have contributed to this problem. If progress is to be made in this area, it is imperative that we examine how future physicians are being trained to manage pain. We examined internal medicine resident knowledge regarding pain as well as their satisfaction with medical school preparation in this regard using two surveys: The Knowledge and Attitudes Survey Regarding Pain (KASRP) and The Medical School Pain Curriculum Survey (MSPCS). Residents scored an overall 60.7% on the knowledge assessment survey, and less than 50% of respondents agreed that their medical school curriculum had prepared them sufficiently. This suggests that improvements can be made in medical school curricula regarding pain management education to better train physicians on how to manage pain, particularly in an era that demands expertise in this area.
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Affiliation(s)
- Jose Garcia
- Internal Medicine, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
| | - Levonti Ohanisian
- Orthopaedic Surgery, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
| | - Angel Sidley
- Biomedical Science, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
| | - Allison Ferris
- Integrated Medical Science, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
| | - George Luck
- Integrated Medical Science, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
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Menchine M, Lam CN, Arora S. Prescription Opioid Use in General and Pediatric Emergency Departments. Pediatrics 2019; 144:peds.2019-0302. [PMID: 31619511 DOI: 10.1542/peds.2019-0302] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/21/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Recent evidence reveals that exposure to emergency department (ED) opioids is associated with a higher risk of misuse. Pediatric EDs are generally thought to provide the highest-quality care for young persons, but most children are treated in general EDs. We sought to determine if ED opioid administration and prescribing vary between pediatric and general EDs. METHODS We analyzed the National Hospital Ambulatory Medical Care Survey (2006-2015), a representative survey of ED visits, by using multivariate logistic regressions. Outcomes of interest were the proportion of patients ≤25 years of age who (1) were administered an opioid in the ED, (2) were given a prescription for an opioid, or (3) were given a prescription for a nonopioid analgesic. The key predictor variable was ED type. A secondary analysis was conducted on the subpopulation of patients with a diagnosis of fracture or dislocation. RESULTS Of patients ≤25 years of age, 91.1% were treated in general EDs. The odds of being administered an opioid in the ED were similar in pediatric versus general EDs (adjusted odds ratio [OR] 0.88; 95% confidence interval [CI] 0.61-1.27; P = .49). Patients seen in pediatric EDs were less likely to receive an outpatient prescription for opioids (adjusted OR 0.38; 95% CI 0.27-0.52; P < .01) than similar patients in general EDs. This was true for the fracture subset as well (adjusted OR 0.27; 95% CI 0.13-0.54; P < .01). CONCLUSIONS Although children, adolescents, and young adults had similar odds of being administered opioids while in the ED, they were much less likely to receive an opioid prescription from a pediatric ED compared with a general ED.
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Affiliation(s)
- Michael Menchine
- Keck School of Medicine, University of Southern California and LAC + USC Medical Center, Los Angeles, California
| | - Chun Nok Lam
- Keck School of Medicine, University of Southern California and LAC + USC Medical Center, Los Angeles, California
| | - Sanjay Arora
- Keck School of Medicine, University of Southern California and LAC + USC Medical Center, Los Angeles, California
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Shigematsu-Locatelli M, Kawano T, Koyama T, Iwata H, Nishigaki A, Aoyama B, Tateiwa H, Kitaoka N, Yokoyama M. Therapeutic experience with tramadol for opioid dependence in a patient with chronic low back pain: a case report. JA Clin Rep 2019; 5:68. [PMID: 32026047 PMCID: PMC6967209 DOI: 10.1186/s40981-019-0289-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 10/01/2019] [Indexed: 11/10/2022] Open
Abstract
Background Long-term opioid treatment for chronic non-cancer pain has become controversial, given the increasing prevalence of opioid dependence. However, there is little information on therapeutic strategies for this condition in Japanese patients. Here, we present a case of successful management of iatrogenic opioid dependence with tramadol in a patient with chronic low back pain. Case presentation A 68-year-old male suffering from intractable low back pain was referred to our pain clinic. He was previously treated in another hospital with transdermal fentanyl patches 6 mg/day and fentanyl sublingual tablets (100 μg as required) for this condition. On the basis of medical examination, including a review of the patient’s medical history, physical examination, X-ray, and his family statement, we diagnosed him with iatrogenic opioid dependence due to inadequate fentanyl use. Then, we developed a treatment plan consisting in fentanyl detoxification with a weak opioid, tramadol. At first, the use of fentanyl sublingual tablets was interrupted after obtaining informed consent. Then, we reduced the dose of transdermal fentanyl 1 mg per 4–5 days replacing with oral sustained-release tramadol. The patient developed mild to moderate withdrawal symptoms during this period, which could be effectively managed by supportive treatments. The hospital psychiatry liaison team continuously provided the patient and his wife with information, counseling, and education regarding the treatment of opioid dependence. Throughout the detoxification process, his reported pain did not exacerbate, even slightly improved over time. The final prescription was sustained-release tramadol 300 mg/day without fentanyl, and his activities of daily living drastically improved. However, unfortunately, he died due to an aortic dissection of stent-graft edge 65 days after surgery. Conclusions Our case highlighted that sustained-release tramadol could be effectively applied as a detoxification agent for iatrogenic opioid dependence in patients with chronic non-cancer pain.
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Affiliation(s)
- Marie Shigematsu-Locatelli
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan
| | - Takashi Kawano
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan.
| | - Tsuyoshi Koyama
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan
| | - Hideki Iwata
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan
| | - Atsushi Nishigaki
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan
| | - Bun Aoyama
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan
| | - Hiroki Tateiwa
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan
| | - Noriko Kitaoka
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan
| | - Masataka Yokoyama
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan
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Trends in use and misuse of opioids in the Netherlands: a retrospective, multi-source database study. LANCET PUBLIC HEALTH 2019; 4:e498-e505. [DOI: 10.1016/s2468-2667(19)30128-8] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 06/18/2019] [Accepted: 07/05/2019] [Indexed: 01/13/2023]
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Campbell E. Faculty Perspectives of Teaching Pain Management to Nursing Students. Pain Manag Nurs 2019; 21:179-186. [PMID: 31492600 DOI: 10.1016/j.pmn.2019.07.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 06/13/2019] [Accepted: 07/23/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Pain management education is threaded through prelicensure nursing education. However, the perspectives of faculty teaching pain assessment and management within the context of the opioid crisis are not addressed in the literature. Pain assessment and management is a complex process requiring critical thinking and clinical reasoning. The current opioid crisis has brought new challenges to health care professionals who provide pain management, and this is a concern for nurses. AIMS The purpose of the study was to discover the perspectives of nursing faculty on teaching pain management content in prelicensure nursing programs. DESIGN Following a systematic review to determine gaps in knowledge, a qualitative study was conducted using nursing faculty as participants. PARTICIPANTS The sample consisted of 17 faculty members from 15 nursing programs on the East Coast. METHODS The qualitative descriptive approach allowed for a rich, detailed exploration of faculty perspectives. Qualitative content analysis of the participant narratives indicated the need to approach pain management education from a perspective of relieving suffering and preventing harm to patients rather than focusing on the opioid crisis. RESULTS Participants perceived the opioid crisis as distinct from the legitimate use of pain medication. The findings indicate that nursing curricula includes only the basics of pain management. CONCLUSIONS Participants' teaching practice was based on experiential learning rather than formal education and often was heavily influenced by a seminal event in their own nursing practice. The findings support the need to improve the education of undergraduate nursing students about pain management in the context of the current opioid crisis.
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Affiliation(s)
- Eileen Campbell
- Department of Nursing, Western Connecticut State University, Danbury, Connecticut.
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Bojaxhi E, Lumermann LA, Mazer LS, Howe BL, Ortiguera CJ, Clendenen SR. Interscalene brachial plexus catheter versus single-shot interscalene block with periarticular local infiltration analgesia for shoulder arthroplasty. Minerva Anestesiol 2019; 85:840-845. [DOI: 10.23736/s0375-9393.19.13387-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Basilico M, Bhashyam AR, Harris MB, Heng M. Prescription Opioid Type and the Likelihood of Prolonged Opioid Use After Orthopaedic Surgery. J Am Acad Orthop Surg 2019; 27:e423-e429. [PMID: 30289795 PMCID: PMC6590520 DOI: 10.5435/jaaos-d-17-00663] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION A common belief is that some narcotic medications have a higher association with prolonged use. We assessed whether the initial opiate type prescribed to postoperative, opiate-naive orthopaedic trauma patients was associated with prolonged opioid use. METHODS We studied 17,961 adult, opiate-naive patients treated for a surgical musculoskeletal injury. Discharge prescription in morphine milligram equivalents (MMEs, a standardized dosing unit that allows for comparison across opioid types) was calculated. Opioid prescribing beyond 90 days after injury was defined as prolonged use. RESULTS Initial analysis demonstrated a higher likelihood of prolonged use for patients discharged on hydromorphone or morphine versus hydrocodone. However, when we adjusted for discharge MME, only opioid quantity was predictive of prolonged use (P < 0.001). In addition, discharge MME was associated with opioid type (P < 0.01). DISCUSSION Persistent opiate use was associated with discharge opioid quantity, not the opioid type. These results highlight the importance of calculating equivalence doses when selecting opioid types and considering amount of narcotics prescribed. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Matthew Basilico
- Department of Economics, Harvard University and Harvard Medical School
| | | | - Mitchel B. Harris
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Orthopaedic Trauma Initiative, Harvard Medical School
| | - Marilyn Heng
- Department of Orthopaedics, Massachusetts General Hospital, Harvard Orthopaedic Trauma Initiative, Harvard Medical School
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Freiermuth CE, Lavonas EJ, Anderson VE, Kleinschmidt KC, Sharma K, Rapp-Olsson M, Gerardo C. Antivenom Treatment Is Associated with Fewer Patients using Opioids after Copperhead Envenomation. West J Emerg Med 2019; 20:497-505. [PMID: 31123552 PMCID: PMC6526891 DOI: 10.5811/westjem.2019.3.42693] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 03/29/2019] [Accepted: 03/20/2019] [Indexed: 11/11/2022] Open
Abstract
Introduction Copperhead envenomation causes local tissue destruction, leading people to seek treatment for the pain and swelling. First-line treatment for the pain is opioid medications. There is rising concern that an initial opioid prescription from the emergency department (ED) can lead to long-term addiction. This analysis sought to determine whether use of Fab antivenom (FabAV) for copperhead envenomation affected opioid use. Methods We performed a secondary analysis using data from a randomized clinical trial designed to determine the effect of FabAV on limb injury recovery following mild to moderate copperhead envenomation. Opioid use was a defined secondary outcome in the parent trial. Patients were contacted after discharge, and data were obtained regarding medications used for pain and the patients’ functional status. This analysis describes the proportion of patients in each treatment group reporting opioid use at each time point. It also assesses the interaction between functional status and use of opioids. Results We enrolled 74 patients in the parent trial (45 received FabAV, 29 placebo), of whom 72 were included in this secondary analysis. Thirty-five reported use of any opioids after hospital discharge. A smaller proportion of patients treated with FabAV reported opioid use: 40.9% vs 60.7% of those in the placebo group. The proportion of patients using opioids remained smaller in the FabAV group at each follow-up time point. Controlling for confounders and interactions between variables, the model estimated that the odds ratio of using opioids after hospital discharge among those who received placebo was 5.67 times that of those who received FabAV. Patients who reported higher baseline pain, those with moderate as opposed to mild envenomation, and females were more likely to report opioid use at follow-up. Patients with ongoing limitations to functional status had an increased probability of opioid use, with a stronger association over time. Opioid use corresponded with the trial’s predefined criteria for full recovery, with only two patients reporting opioid use in the 24 hours prior to achieving full limb recovery and no patients in either group reporting opioid use after full limb recovery. Conclusion In this study population, the proportion of patients using opioids for pain related to envenomation was smaller in the FabAV treatment group at all follow-up time points.
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Affiliation(s)
| | - Eric J Lavonas
- Denver Health and Hospital Authority, Rocky Mountain Poison and Drug Center, Denver, Colorado
| | - Victoria E Anderson
- Denver Health and Hospital Authority, Rocky Mountain Poison and Drug Center, Denver, Colorado
| | - Kurt C Kleinschmidt
- University of Texas Southwestern Medical Center, Department of Emergency Medicine, Dallas, Texas
| | - Kapil Sharma
- University of Texas Southwestern Medical Center, Department of Emergency Medicine, Dallas, Texas
| | - Malin Rapp-Olsson
- Denver Health and Hospital Authority, Rocky Mountain Poison and Drug Center, Denver, Colorado
| | - Charles Gerardo
- Duke University, Division of Emergency Medicine, Durham, North Carolina
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Abstract
The treatment of patients with acute and chronic pain not attributed to cancer or end-of-life conditions is a challenge for many clinicians. Although CDC guidelines that focus on the primary care setting have provided critical recommendations, evidence-based guidance is lacking on optimal duration of opioid treatment for postoperative and acute care in specialty settings. Over the last 2 decades, the liberal use of opioids has resulted in many unintended consequences, including dependence and abuse, illicit distribution of legally and illegally prescribed opioid medication, progression to IV heroin and an epidemic of overdoses, and most recently an increase in the incidence of HIV among patients sharing syringes, frequently in communities with historically low HIV rates. This article analyzes these complex issues and proposes strategies to help clinicians improve patient care through education and responsible prescribing.
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Using Historical Variation in Opioid Prescribing Immediately After Fracture Surgery to Guide Maximum Initial Prescriptions. J Orthop Trauma 2019; 33:e131-e136. [PMID: 30570619 PMCID: PMC6599458 DOI: 10.1097/bot.0000000000001392] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Recent studies have advocated for prescription opioid maximums (based on percentage reductions from historical amounts) to reduce excess prescribing. Implementing this in orthopaedic trauma has been difficult, given the injury variety and limited historical data on postoperative prescribing. We report on the initial opioid prescriptions for a large cohort of postoperative, opiate-naive fracture patients and hypothesize that prescribing was associated with fracture location and morphology. DESIGN Retrospective cohort analysis. SETTING Two American College of Surgeons Level I trauma centers. PATIENTS Six thousand eight hundred seventy-nine orthopaedic trauma patients treated between 2002 and 2015. Only patients who had a single operatively treated injury and were opiate naive (had not received an opioid prescription in the 6 months before presentation) were included. INTERVENTION Postoperative opioid discharge prescription. OUTCOMES We analyzed the quantity of initial opioids prescribed in morphine milligram equivalents (MMEs, a standardized unit of opioid dosage used for comparison across opioid types). Fracture location and morphology were classified using the OTA/AO classification. RESULTS Fracture location was an independent predictor of the MME prescribed (P < 0.001). All other fracture locations were prescribed significantly higher MME than distal radius fractures (control group, 150 MME, P < 0.01). There was no difference in MMEs prescribed by articular involvement or degree of comminution. CONCLUSIONS We demonstrate significant variation in initial postoperative opioid prescribing to opiate-naive orthopaedic trauma patients by fracture location, but not by fracture morphology. We use these data to propose a guideline based on the OTA/AO fracture classification for the maximum initial prescription of opioids. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Bhashyam AR, Young J, Qudsi RA, Parisien RL, Dyer GSM. Opioid Prescribing Patterns of Orthopedic Surgery Residents After Open Reduction Internal Fixation of Distal Radius Fractures. J Hand Surg Am 2019; 44:201-207.e2. [PMID: 30635200 DOI: 10.1016/j.jhsa.2018.11.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 09/27/2018] [Accepted: 11/08/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE In many academic medical centers, resident physicians typically write initial opioid prescriptions, but little is known about their prescribing practices. We hypothesized that lower resident postgraduate year, residency-training program, and noncompletion of an opioid prescribing training would be factors associated with increased opioid prescribing by orthopedic residents after open reduction and internal fixation of distal radius fractures. METHODS A survey was administered to all 135 residents from 4 orthopedic residency programs in a state located in the northeastern United States between August 2017 and November 2017. Respondents were asked to indicate the initial analgesia (quantity and duration) they would prescribe for a younger and older, otherwise healthy, opiate-naïve female patient after open reduction and internal fixation of a distal radius fracture. We analyzed the quantity of initial opioids prescribed in morphine milligram equivalents (MME) and number of days supplied. Three different measures of overprescribing were assessed: prescribing over 150 MME, 225 MME, or 7 days of opioids. RESULTS The response rate was 63% (85 of 135 residents). Of all respondents, 36.5% of residents reported completion of an opioid training in the past. In terms of overprescribing by duration, 19% of residents prescribed more than 7 days of opioids. For overprescribing by quantity, 36% to 59% (depending on patient age) of residents prescribed more than 20 tablets of 5 mg oxycodone (150 MME) and 16% to 25% (depending on patient age) prescribed more than 30 tablets of 5 mg oxycodone (225 MME). In comparison with junior residents, senior residents were more likely to prescribe over 225 MME. CONCLUSIONS After open reduction and internal fixation of distal radius fractures, 19% of orthopedic surgery residents would prescribe more than 7 days of prescription opioids, which is beyond the state law maximum. In addition, we found that less than half of residents had participated in an opioid training program. Our results highlight the need for continued resident guidance when prescribing. Enrollment in opioid prescribing training programs that have been shown to decrease prescribed opioid quantities while still effectively managing patient pain is probably important. CLINICAL RELEVANCE This study describes the opioid prescribing practices and prior training of orthopedic residents. It highlights an opportunity for increased involvement in educational programs on opioid prescribing that better align with published recommendations/guidelines.
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Affiliation(s)
- Abhiram R Bhashyam
- Department of Orthopaedic Surgery, Harvard Combined Orthopaedics Residency Program, Boston, MA.
| | - Jason Young
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA
| | - Rameez A Qudsi
- Department of Orthopaedic Surgery, Harvard Combined Orthopaedics Residency Program, Boston, MA
| | - Robert L Parisien
- Department of Orthopaedic Surgery, Boston University Orthopaedic Surgery Residency Program, Boston, MA
| | - George S M Dyer
- Department of Orthopaedic Surgery, Harvard Combined Orthopaedics Residency Program, Boston, MA
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Associations between initial opioid exposure and the likelihood for long-term use. J Am Pharm Assoc (2003) 2019; 59:17-22. [DOI: 10.1016/j.japh.2018.09.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 07/24/2018] [Accepted: 09/08/2018] [Indexed: 01/22/2023]
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Van Winkle PJ, Ghobadi A, Chen Q, Menchine M, Sharp AL. Association of age and opioid use for adolescents and young adults in community emergency departments. Am J Emerg Med 2018; 37:1397-1403. [PMID: 30343960 DOI: 10.1016/j.ajem.2018.10.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 10/08/2018] [Accepted: 10/15/2018] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES Adolescents and young adults are at high risk for opioid misuse and abuse. The emergency department (ED) plays a key role in treatment of acute and chronic pain and is a primary place that this patient population is exposed to prescription opioids. We evaluate the effect of patient age on use of opioids for adolescents and young adults in community EDs. METHODS Retrospective cohort study of adolescent and young adult encounters in 14 community EDs from 2013 to 2014. We evaluate the percent of ED encounters with parenteral and/or oral opioids administered, morphine milligram equivalents per ED patient encounter, and percent of patient encounters discharged with an opioid prescription. Age was the main exposure. The association between outcomes and age was examined using bivariate and multivariate logistic regression adjusting for measurable confounders. RESULTS There were 259,632 adolescent and young adult encounters in our sample, average age 17.6 years, with 15.8% given opioids. Increasing patient age was associated with a significant increase in the percent of encounters with opioids given (AOR, 1.11; 95% CI 1.10-1.11), morphine milligram equivalents administered (β 0.38; 95% CI 0.33-0.43 for parenteral and β 0.26; 95% CI 0.23-0.28 for oral), and percent of patients receiving outpatient prescriptions (AOR, 1.14; 95% CI 1.13-1.14). Significant variability also existed between medical centers (AOR, 2.02; 95% CI 1.86-2.20). CONCLUSION For adolescent and young adult patients in the ED, there is a significant association between opioid prescribing and increasing age. This describes an opportunity to reduce opioid use in older adolescents and young adults.
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Affiliation(s)
- Patrick J Van Winkle
- Kaiser Permanente, Orange County, 3440 La Palma Ave, Anaheim, CA 92806, United States of America.
| | - Ali Ghobadi
- Kaiser Permanente, Orange County, 3440 La Palma Ave, Anaheim, CA 92806, United States of America.
| | - Qiaoling Chen
- Southern California Permanente Medical Group, 100 South Los Robles Ave, Pasadena, CA 91101, United States of America.
| | - Michael Menchine
- University of Southern California, 1975 Zonal Ave, Los Angeles, CA 90033, United States of America
| | - Adam L Sharp
- Kaiser Permanente, Los Angeles, 4867 Sunset Blvd, Los Angeles, CA 90027, United States of America.
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Pitt AL, Humphreys K, Brandeau ML. Modeling Health Benefits and Harms of Public Policy Responses to the US Opioid Epidemic. Am J Public Health 2018; 108:1394-1400. [PMID: 30138057 PMCID: PMC6137764 DOI: 10.2105/ajph.2018.304590] [Citation(s) in RCA: 161] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To estimate health outcomes of policies to mitigate the opioid epidemic. METHODS We used dynamic compartmental modeling of US adults, in various pain, opioid use, and opioid addiction health states, to project addiction-related deaths, life years, and quality-adjusted life years from 2016 to 2025 for 11 policy responses to the opioid epidemic. RESULTS Over 5 years, increasing naloxone availability, promoting needle exchange, expanding medication-assisted addiction treatment, and increasing psychosocial treatment increased life years and quality-adjusted life years and reduced deaths. Other policies reduced opioid prescription supply and related deaths but led some addicted prescription users to switch to heroin use, which increased heroin-related deaths. Over a longer horizon, some such policies may avert enough new addiction to outweigh the harms. No single policy is likely to substantially reduce deaths over 5 to 10 years. CONCLUSIONS Policies focused on services for addicted people improve population health without harming any groups. Policies that reduce the prescription opioid supply may increase heroin use and reduce quality of life in the short term, but in the long term could generate positive health benefits. A portfolio of interventions will be needed for eventual mitigation.
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Affiliation(s)
- Allison L Pitt
- Allison L. Pitt and Margaret L. Brandeau are with the Department of Management Science and Engineering, Stanford University, Stanford, CA. Keith Humphreys is with the Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, and the Department of Psychiatry and Behavioral Sciences, Stanford University
| | - Keith Humphreys
- Allison L. Pitt and Margaret L. Brandeau are with the Department of Management Science and Engineering, Stanford University, Stanford, CA. Keith Humphreys is with the Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, and the Department of Psychiatry and Behavioral Sciences, Stanford University
| | - Margaret L Brandeau
- Allison L. Pitt and Margaret L. Brandeau are with the Department of Management Science and Engineering, Stanford University, Stanford, CA. Keith Humphreys is with the Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, and the Department of Psychiatry and Behavioral Sciences, Stanford University
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Reid L. Scientism in Medical Education and the Improvement of Medical Care: Opioids, Competencies, and Social Accountability. HEALTH CARE ANALYSIS 2018; 26:155-170. [PMID: 28986710 DOI: 10.1007/s10728-017-0351-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Scientism in medical education distracts educators from focusing on the content of learning; it focuses attention instead on individual achievement and validity in its measurement. I analyze the specific form that scientism takes in medicine and in medical education. The competencies movement attempts to challenge old "scientistic" views of the role of physicians, but in the end it has invited medical educators to focus on validity in the measurement of individual performance for attitudes and skills that medicine resists conceptualizing as objective. Academic medicine should focus its efforts instead on quality and relevance of care. The social accountability movement proposes to shift the focus of academic medicine to the goal of high quality and relevant care in the context of community service and partnership with the institutions that together with medicine create and cope with health and with health deficits. I make the case for this agenda through a discussion of the linked histories of the opioid prescribing crisis and the professionalism movement.
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Affiliation(s)
- Lynette Reid
- Department of Bioethics, Dalhousie University, PO Box 15000, Halifax, NS, B3H 4R2, Canada.
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Cicero TJ, Ellis MS. The prescription opioid epidemic: a review of qualitative studies on the progression from initial use to abuse. DIALOGUES IN CLINICAL NEUROSCIENCE 2018. [PMID: 29302223 PMCID: PMC5741109 DOI: 10.31887/dcns.2017.19.3/tcicero] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Most research designed to answer the “why” of the prescription opioid epidemic has relied on structured interviews, which rigidly attempt to capture the complex reasons people use opioids. In contrast this systematic literature review focuses on peer-reviewed studies that have used a qualitative approach to examine the development of an opioid-use disorder from the point of initial exposure. Rather than simply providing a “high,” opioids reportedly relieve psychological/emotional problems or provide an escape from life stressors. As use continues, avoidance of withdrawal sickness becomes an overriding concern, with all other benefits playing minor roles in persistent use. These studies indicate that terms used in structured interviews, such as “nontherapeutic use” or variations thereof, poorly capture the complex range of needs opioids satisfy. Both quantitative/structured studies and more qualitative ones, as well as more focused studies, have an important role in better informing prevention and treatment efforts.
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Affiliation(s)
- Theodore J Cicero
- Washington University Department of Psychiatry, St Louis, Missouri, USA
| | - Matthew S Ellis
- Washington University Department of Psychiatry, St Louis, Missouri, USA
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Voon P, Greer AM, Amlani A, Newman C, Burmeister C, Buxton JA. Pain as a risk factor for substance use: a qualitative study of people who use drugs in British Columbia, Canada. Harm Reduct J 2018; 15:35. [PMID: 29976203 PMCID: PMC6034304 DOI: 10.1186/s12954-018-0241-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 06/27/2018] [Indexed: 12/18/2022] Open
Abstract
Background People who use drugs have a significantly higher prevalence of chronic non-cancer pain compared to the general population, yet little is known about how various policy, economic, physical, and social environments may serve as risk or protective factors in the context of concurrent pain and substance use. Therefore, this study sought to explore perspectives, risks, and harms associated with pain among people who use drugs. Methods Thirteen focus group interviews were held across British Columbia, Canada, from July to September 2015. In total, 83 people who had lived experience with substance use participated in the study. Using an interpretive description approach, themes were conceptualized according to the Rhodes’ Risk Environment and patient-centered care frameworks. Results Participants described how their experiences with inadequately managed pain in various policy, economic, physical, and social environments reinforced marginalization, such as restrictive policies, economic vulnerability, lack of access to socio-physical support systems, stigma from health professionals, and denial of pain medication leading to risky self-medication. Principles of patient-centered care were often not upheld, from a lack of recognition of patients as experts in understanding their unique pain needs and experiences, to an absence of shared power and decision-making, which often resulted in distrust of the patient-provider relationship. Conclusions Various risk environments and non-patient-centered interactions may contribute to an array of health and social harms in the context of inadequately managed pain among people who use drugs.
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Affiliation(s)
- Pauline Voon
- British Columbia Centre on Substance Use, 400 - 1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.,School of Population and Public Health, Faculty of Medicine, University of British Columbia, 2206 East Mall, Vancouver, BC, V6Z 1Z3, Canada
| | - Alissa M Greer
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, 2206 East Mall, Vancouver, BC, V6Z 1Z3, Canada.,British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Ashraf Amlani
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Cheri Newman
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Charlene Burmeister
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Jane A Buxton
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, 2206 East Mall, Vancouver, BC, V6Z 1Z3, Canada. .,British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada.
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Becker NV, Gibbins KJ, Perrone J, Maughan BC. Geographic variation in postpartum prescription opioid use: Opportunities to improve maternal safety. Drug Alcohol Depend 2018; 188:288-294. [PMID: 29807216 DOI: 10.1016/j.drugalcdep.2018.04.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 04/11/2018] [Accepted: 04/13/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Obstetric delivery is among the most common in-hospital procedures experienced by reproductive-age women, yet there is little literature on patterns of postpartum opioid prescriptions after such episodes. METHODS We used claims data from 871,195 vaginal deliveries to 768,455 privately-insured women with an in-hospital delivery between June 2001 and July 2013 to examine the state- and census division-level proportions of women who filled an opioid prescription within four days of hospital discharge after vaginal delivery. Our primary outcome examined the proportion of women who filled an opioid prescription after uncomplicated vaginal delivery (e.g., without forceps extraction, vacuum extraction, or 3rd/4th degree perineal laceration). Secondary outcomes examined state- and census division-level variation in opioid prescription duration (proportion of prescriptions exceeding five days) and dose (proportion of prescriptions exceeding 280 morphine milligram equivalents). We also displayed national temporal trends in opioid prescribing rate and dose for uncomplicated vaginal delivery in comparison to complicated vaginal delivery. RESULTS Across states, we found a 7-fold variation in postpartum opioid prescription rates (7.6-53.4%), a 5-fold variation in opioid prescriptions for greater than five days' duration (5.1-25.7%), and a 19% absolute difference in opioid prescriptions for greater than 280 morphine milligram equivalents (0-19.3%) following uncomplicated vaginal delivery. CONCLUSIONS These wide variations in postpartum opioid prescription practices suggest opportunities to develop guidelines on postpartum opioid use, to improve prescription safety, and to reduce opioid-related harms among women in the postpartum period.
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Affiliation(s)
- Nora V Becker
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19104, United States; Department of Health Care Management, Wharton School of Business, 204 Colonial Penn Center, 3641 Locust Walk, Philadelphia, PA, 19104-6218, United States; Department of Internal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, United States.
| | - Karen J Gibbins
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Utah Health, 50 N Medical Dr, Salt Lake City, UT, 84112, United States.
| | - Jeanmarie Perrone
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19104, United States.
| | - Brandon C Maughan
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19104, United States; Department of Health Care Management, Wharton School of Business, 204 Colonial Penn Center, 3641 Locust Walk, Philadelphia, PA, 19104-6218, United States; Robert Wood Johnson Foundation Clinical Scholars Program, University of Pennsylvania, 13th Floor Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104, United States; Department of Emergency Medicine, Crescenz Veterans Affairs Medical Center, 3900 Woodland Ave, Philadelphia, PA, 19104, United States.
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Polysubstance use and misuse or abuse of prescription opioid analgesics: a multi-level analysis of international data. Pain 2018; 158:1138-1144. [PMID: 28267061 DOI: 10.1097/j.pain.0000000000000892] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Increasing mortality and morbidity associated with opioid analgesics has led to concerns about their misuse and abuse, even when obtained through a prescription. These concerns have been most pronounced in the United States, but limited data make it difficult to determine whether it is a problem in other countries. We investigated opioid analgesic misuse and abuse in participants from the Global Drug Survey 2015 resident in the United States (N = 1334), United Kingdom (N = 1199), France (N = 1258), Germany (N = 866), and Australia (N = 1013) who had used at least 1 prescription opioid analgesic medication in the past year. We also investigated the relationship with polysubstance use, one of the most consistent predictors of problematic opioid analgesic use. Data included misuse and abuse of codeine, hydrocodone, oxycodone, and tramadol; ability to obtain a prescription; different sources for obtaining drugs; and past-year use of benzodiazepines and illicit drugs. In multilevel models, country of residence accounted for less than 3% of the variance in opioid analgesic misuse or abuse. Adjusting for country of residence and sociodemographic factors, use of illicit drugs and benzodiazepines was associated with 4-fold greater odds of misuse (odds ratio 4.36, 95% confidence interval 3.29-5.93) and 6-fold greater odds of abuse compared with not using either drug (odds ratio 6.49, 95% confidence interval 4.0-10.48), although the strength of the association with abuse varied by country. Misuse and abuse by those prescribed opioid analgesics seem to be a problem that is not limited to the United States and warrant attention on an international scale.
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Hirschtritt ME, Delucchi KL, Olfson M. Outpatient, combined use of opioid and benzodiazepine medications in the United States, 1993-2014. Prev Med Rep 2017; 9:49-54. [PMID: 29340270 PMCID: PMC5766756 DOI: 10.1016/j.pmedr.2017.12.010] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 12/12/2017] [Accepted: 12/18/2017] [Indexed: 01/22/2023] Open
Abstract
The combined use of opioid and benzodiazepine medications increases the risk of hazardous effects, such as respiratory depression. Although recent increases in outpatient use of opioid prescriptions have been documented, there are limited data regarding rates and correlates of combined opioid and benzodiazepines among adults in outpatient settings. Our objective was to examine annual trends in outpatient visits including opioids, benzodiazepines, and their combination among adults as well as clinical and demographic correlates. We used data from the 1993–2014 National Ambulatory Medical Care Survey (NAMCS) among non-elderly (i.e., ages 18–64 years) adults to examine the probability of a visit including an opioid, benzodiazepine, or their combination, in addition to clinical and demographic correlates. From 1993 to 2014, benzodiazepines-with-opioids visits increased from 9.8 to 62.5 (OR = 9.23, 95% CI = 5.45–15.65) per 10,000 visits. Highest-represented groups among benzodiazepines-with-opioids visits were older (50–64 years) (49.1%), white (88.8%), commercially insured (58.0%) patients during their first visit (87.6%) to a primary-care physician (41.9%). We identified a significant increase in the outpatient co-prescription of opioids and benzodiazepines, notably among adults aged 50–64 years during primary-care visits. Educational and policy changes to provide alternatives to benzodiazepine-with-opioid co-prescription and limiting opioid prescription to pain specialists may reduce rates of this potentially hazardous combination. Current guidelines for prescribing opioids recommend against co-administration with benzodiazepines Concurrent use of opioids and benzodiazepines increases the risk of overdose, respiratory depression, and death. We examined 22 years of outpatient prescribing patterns of opioids and benzodiazepines using a survey of US physicians. Over this period, visits with both opioids and benzodiazepines increased from roughly 9.8 to 62.5 per 10,000 visits. These visits were more likely among older (50–64 years), white, privately insured patients with a low-back pain diagnosis.
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Affiliation(s)
- Matthew E Hirschtritt
- Department of Psychiatry, University of California, San Francisco, 401 Parnassus Ave, Box 0984-RTP, San Francisco, CA 94143, United States
| | - Kevin L Delucchi
- Department of Psychiatry, University of California, San Francisco, 401 Parnassus Ave, Box 0984, San Francisco, CA 94143, United States
| | - Mark Olfson
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University and New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, United States
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Song Z. Mortality Quadrupled Among Opioid-Driven Hospitalizations, Notably Within Lower-Income And Disabled White Populations. Health Aff (Millwood) 2017; 36:2054-2061. [PMID: 29200349 PMCID: PMC5814297 DOI: 10.1377/hlthaff.2017.0689] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Hospitals play an important role in caring for patients in the current opioid crisis, but data on the outcomes and composition of opioid-driven hospitalizations in the United States have been lacking. Nationally representative all-payer data for the period 1993-2014 from the National Inpatient Sample were used to compare the mortality rates and composition of hospitalizations with opioid-related primary diagnoses and those of hospitalizations for other drugs and for all other causes. Mortality among opioid-driven hospitalizations increased from 0.43 percent before 2000 to 2.02 percent in 2014, an average increase of 0.12 percentage points per year relative to the mortality of hospitalizations due to other drugs-which was unchanged. While the total volume of opioid-driven hospitalizations remained relatively stable, it shifted from diagnoses mostly involving opioid dependence or abuse to those centered on opioid or heroin poisoning (the latter have higher case fatality rates). After 2000, hospitalizations for opioid/heroin poisoning grew by 0.01 per 1,000 people per year, while hospitalizations for opioid dependence or abuse declined by 0.01 per 1,000 people per year. Patients admitted for opioid/heroin poisoning were more likely to be white, ages 50-64, Medicare beneficiaries with disabilities, and residents of lower-income areas. As the United States combats the opioid epidemic, efforts to help hospitals respond to the increasing severity of opioid intoxication are needed, especially in vulnerable populations.
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Affiliation(s)
- Zirui Song
- Zirui Song ( ) is an assistant professor of health care policy at Harvard Medical School and an internal medicine physician at Massachusetts General Hospital, both in Boston, Massachusetts
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