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Heneedak HM, Abdelshakour MA, Darwish KM, Mostafa SM, Elgawish MS. Green innovation in analytical chemistry: A sustainable densitometric HPTLC approach for the distinctive separation and quantification of structurally related abused drugs - tramadol, tapentadol, and venlafaxine - in seized pharmaceutical dosage forms. J Pharm Biomed Anal 2024; 243:116109. [PMID: 38518458 DOI: 10.1016/j.jpba.2024.116109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 03/04/2024] [Accepted: 03/14/2024] [Indexed: 03/24/2024]
Abstract
An innovative ecofriendly high-performance thin layer chromatographic (HPTLC) method with spectrophotometric detection for simultaneous determination of Tramadol (TMD), Tapentadol (TAP), and Venlafaxine (VEN) in seized dosage forms was presented. Our method was conducted to achieve separation following the optimal conditions: pre-coated silica gel plates using a green mobile phase (heptane: acetone: ammonia, 7:3:0.5 v/v), with absorbance scanning at 272 nm. The validation of the method was done following International Conference on Harmonization (ICH) guidelines, demonstrates linearity, accuracy, precision, selectivity, robustness, and system suitability. Separation was achieved with a detection limit of 0.34, 0.16, and 0.084 (ug/band) for TMD, TAP, and VEN, respectively, the method successfully analyzes seized samples. Trueness is confirmed through a high degree of similarity between HPTLC and gas chromatography results. The study's ecofriendly approach, simplicity, and selectivity position it as a promising method for efficient, on-site monitoring of seized samples.
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Affiliation(s)
- Hala M Heneedak
- Medicinal Chemistry Department, Faculty of Pharmacy, Suez Canal University, Ismailia 41522, Egypt; Forensic Chemistry Department, Forensic Medicine Authority, Ministry of Justice, Cairo 11617, Egypt
| | - Mohamed A Abdelshakour
- Pharmaceutical Analytical Chemistry Department, Faculty of pharmacy, Sohag University, Sohag 82524, Egypt
| | - Khaled M Darwish
- Medicinal Chemistry Department, Faculty of Pharmacy, Suez Canal University, Ismailia 41522, Egypt
| | - Samia M Mostafa
- Medicinal Chemistry Department, Faculty of Pharmacy, Suez Canal University, Ismailia 41522, Egypt
| | - Mohamed Saleh Elgawish
- Medicinal Chemistry Department, Faculty of Pharmacy, Suez Canal University, Ismailia 41522, Egypt; Chemistry Department, Korea University, Seoul 02841, Republic of Korea.
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2
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Keshwani S, Smith SM, Brown J, Lo-Ciganic WH, Yang S, Smolinski NE, Hincapie-Castillo JM. Trends in Prescribing of Non-steroidal Anti-inflammatory Medications in the US Ambulatory Care Setting From 2006 to 2016. THE JOURNAL OF PAIN 2023; 24:1994-2002. [PMID: 37330160 DOI: 10.1016/j.jpain.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 05/25/2023] [Accepted: 06/07/2023] [Indexed: 06/19/2023]
Abstract
While opioid prescribing has significantly decreased from a peak in 2012, less is known about the national utilization of non-opioid analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen (APAP) in the context of the opioid crisis. The objective of this study is to characterize the prescribing trends of NSAIDs and APAP in the US ambulatory care setting. We conducted repeated cross-sectional analyses using the 2006-2016 National Ambulatory Medical Care Survey. NSAID-involved visits were defined as patient visits among adults in which NSAIDs were ordered, supplied, administered, or continued. We used similarly-defined APAP visits as a referent group for context. After excluding aspirin and other NSAID/APAP combination products containing opioids, we calculated the annual proportion of NSAID-involved visits among all ambulatory visits. We conducted trend analyses using multivariable logistic regression adjusted for years, patient, and prescriber characteristics. From 2006 to 2016, there were 775.7 million NSAID-involved visits and 204.3 million APAP-involved visits. Most NSAIDs-involved visits were from patients aged 46-64 years (39.6%), female (60.4%), White (83.2%), and having commercial insurance (49.0%). There were significant increasing trends for the proportion of NSAID-involved visits (8.1-9.6%) and APAP-involved visits (1.7-2.9%) (both P < .0001). We observed an overall increase in NSAID and APAP-involved visits in US ambulatory care settings from 2006 to 2016. This trend may be attributed to decreasing opioid prescribing and raises safety concerns related to acute or chronic NSAID and APAP use. PERSPECTIVE: This study shows an overall increasing trend in NSAID use reported in nationally representative ambulatory care visits in the United States. This increase coincides with previously reported significant decreases in opioid analgesic use, particularly after 2012. Given the safety concerns related to chronic or acute NSAID use, there is a need to continue monitoring the use trends of this class of medication.
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Affiliation(s)
- Shailina Keshwani
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Steven M Smith
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida
| | - Joshua Brown
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Seonkyeong Yang
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Nicole E Smolinski
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Juan M Hincapie-Castillo
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
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Kennedy J, Wood EG, Wu CH. Factors associated with frequent or daily use of prescription opioids among adults with chronic pain in the United States. J Int Med Res 2023; 51:3000605221149289. [PMID: 36708204 PMCID: PMC9893079 DOI: 10.1177/03000605221149289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVES We aimed to estimate utilization rates of prescription opioids among adults with chronic pain in the United States (US) and identify factors associated with the frequent or daily use of prescription opioids. METHODS This was a case-control analysis of the 2019 National Health Interview Survey of adults. RESULTS Over 50.2 million adults in the US reported chronic pain in the past 3 months, but only 10.5% of this group said they used prescription opioids frequently or daily to manage their pain. Adults with chronic pain were significantly more likely to use opioids if they had incomes below the federal poverty level (15.7%), relied on public health insurance (14.8%), had been hospitalized in the past year (17.8%), or rated their health as fair or poor (18.4%). The highest rates of opioid use were reported among adults with severe (24.4%) or moderate disability (18.9%). CONCLUSIONS Approximately 5.3 million adults use prescription opioids frequently or daily to manage chronic pain. These individuals should receive regular clinical assistance to manage their pain, including medication management and, when appropriate, referral to evidence-based treatment programs for opioid use disorder.
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Affiliation(s)
- Jae Kennedy
- Department of Community and Behavioral Health, Washington State University College of Medicine, Spokane, WA, USA,Jae Kennedy, Elson S Floyd College of Medicine, Washington State University, Health Education and Research Building, Room 430, 665 N Riverpoint Blvd, Spokane, WA 99202-1495, USA.
| | - Elizabeth Geneva Wood
- Department of Community and Behavioral Health, Washington State University College of Medicine, Spokane, WA, USA
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Federico CA, Heagerty PJ, Lantos J, O'Rourke P, Rahimzadeh V, Sugarman J, Weinfurt K, Wendler D, Wilfond BS, Magnus D. Ethical and epistemic issues in the design and conduct of pragmatic stepped-wedge cluster randomized clinical trials. Contemp Clin Trials 2022; 115:106703. [PMID: 35176501 PMCID: PMC9272561 DOI: 10.1016/j.cct.2022.106703] [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: 10/01/2021] [Revised: 01/27/2022] [Accepted: 02/02/2022] [Indexed: 11/27/2022]
Abstract
Stepped-wedge cluster randomized trial (SW-CRT) designs are increasingly employed in pragmatic research; they differ from traditional parallel cluster randomized trials in which an intervention is delivered to a subset of clusters, but not to all. In a SW-CRT, all clusters receive the intervention under investigation by the end of the study. This approach is thought to avoid ethical concerns about the denial of a desired intervention to participants in control groups. Such concerns have been cited in the literature as a primary motivation for choosing SW-CRT design, however SW-CRTs raise additional ethical concerns related to the delayed implementation of an intervention and consent. Yet, PCT investigators may choose SW-CRT designs simply because they are concerned that other study designs are infeasible. In this paper, we examine justifications for the use of SW-CRT study design, over other designs, by drawing on the experience of the National Institutes of Health's Health Care Systems Research Collaboratory (NIH Collaboratory) with five pragmatic SW-CRTs. We found that decisions to use SW-CRT design were justified by practical and epistemic reasons rather than ethical ones. These include concerns about feasibility, the heterogeneity of cluster characteristics, and the desire for simultaneous clinical evaluation and implementation. In this paper we compare the potential benefits of SW-CRTs against the ethical and epistemic challenges brought forth by the design and suggest that the choice of SW-CRT design must balance epistemic, feasibility and ethical justifications. Moreover, given their complexity, such studies need rigorous and informed ethical oversight.
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Affiliation(s)
- Carole A Federico
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA 94305, USA
| | - Patrick J Heagerty
- Department of Biostatistics, University of Washington, Seattle, WA 98185, USA
| | - John Lantos
- Children's Mercy Hospital Bioethics Center, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | | | - Vasiliki Rahimzadeh
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA 94305, USA
| | - Jeremy Sugarman
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Kevin Weinfurt
- Center for Health Measurement, Duke University, Durham, NC 27701, USA
| | - David Wendler
- Department of Bioethics, NIH Clinical Center, Bethesda, MD 20892, USA
| | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA 98185, USA
| | - David Magnus
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA 94305, USA.
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Serdarevic M, Osborne V, Striley CW, Cottler LB. Prescription Opioid Use Among a Community Sample of Older and Younger Women. J Womens Health (Larchmt) 2022; 31:270-278. [PMID: 33826866 PMCID: PMC8864428 DOI: 10.1089/jwh.2020.8610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Background: Women bear a heavier burden of the consequences related to prescription opioid use compared to their male counterparts; however, there has been little attention in the literature regarding prescription opioid use among women. We aimed to examine risk factors for prescription opioid use among women. Methods: Demographics, health status, and substance use data, including prescription opioid use, were collected through a community engagement program, HealthStreet, during a health needs assessment. Women older than 18 years were classified by opioid use: past 30-day, lifetime, but not past 30-day, or no lifetime prescription opioid use. Descriptive statistics and chi-square tests were calculated, and multinomial logistic regression was used to calculate adjusted odds ratios (aORs; confidence interval [CI]). Results: Among 5,549 women assessed, 15% reported past 30-day use and 41% reported lifetime use of prescription opioids. While prescription sedative use was the strongest risk factor for past 30-day use among younger women (aOR = 4.84; 95% CI, 3.59-6.51), past 6-month doctor visits was the strongest risk factor for past 30-day use among older women (aOR = 4.15; 95% CI, 2.62-6.60). Conclusions: We found higher rates of prescription opioid use in this community sample of women compared to national rates. Risk factors for recent prescription opioid use (past 30-day use) differed among older and younger women. Clinicians should be more vigilant about prescribing opioids as the medical profile for women may change through age, especially the co-prescribing of opioids and sedatives.
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Affiliation(s)
- Mirsada Serdarevic
- Center for Outcomes Research, JPS Health Network, Fort Worth, Texas, USA.,Department of Medical Education, TCU and UNTHSC School of Medicine, Fort Worth, Texas, USA.,Department of Epidemiology, University of Florida, Gainesville, Florida, USA.,Address correspondence to: Mirsada Serdarevic, PhD, Center for Outcomes Research, JPS Health Network, 1500 S. Main Street, Fort Worth, TX 76104, USA
| | - Vicki Osborne
- Drug Safety Research Unit, Southampton, United Kingdom
| | | | - Linda B. Cottler
- Department of Epidemiology, University of Florida, Gainesville, Florida, USA
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Zhao S, Browning J, Cui Y, Wang J. Using machine learning to classify patients on opioid use. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2022; 12:502-508. [PMID: 35003334 DOI: 10.1093/jphsr/rmab055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 10/04/2021] [Indexed: 11/12/2022]
Abstract
Objectives High-frequent opioid use tends to increase an individual's risk of opioid use disorder, overdose and death. Thus, it is important to predict an individuals' opioid use frequency to improve opioid prescription utilization outcomes. Methods Individuals receiving at least one opioid prescription from 2016 to 2018 in the national representative data, Medical Expenditure Panel Survey, were included. This study applied five machine learning (ML) techniques, including support vector machine, random forest, neural network, gradient boosting and XGBoost (extreme gradient boosting), to predict opioid use frequency. This study compared the performance of these ML models with penalized logistic regression. The study outcome was whether an individual lied in the upper 10% of the opioid prescription distribution. Predictors were selected based on Gelberg-Andersen's Behavioral Model of Health Services Utilization. The prediction performance was assessed using the area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC) in the test data. Patient characteristics as predictors for high-frequency use of opioids were ranked by the relative importance in prediction in the test data. Key findings Random forest and gradient boosting achieved the top values of both AUROC and AUPRC, outperforming logistic regression and three other ML methods. In the best performing model, the random forest, the following characteristics had high predictive power in the frequency of opioid use: age, number of chronic conditions, public insurance and self-perceived health status. Conclusions The results of this study demonstrate that ML techniques can be a promising and powerful technique in predicting the frequency of opioid use and health outcomes.
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Affiliation(s)
- Shirong Zhao
- Department of Investment, School of Finance, Dongbei University of Finance and Economics, Dalian, Liaoning, China
| | - Jamie Browning
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Memphis, TN, USA
| | - Yan Cui
- Department of Genetics, Genomics & Informatics, University of Tennessee Health Science Center, Memphis, TNUSA
| | - Junling Wang
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Memphis, TN, USA
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Dasgupta N, Brown JR, Nocera M, Lazard A, Slavova S, Freeman PR. Abuse-Deterrent Opioids: A Survey of Physician Beliefs, Behaviors, and Psychology. Pain Ther 2021; 11:133-151. [PMID: 34870790 PMCID: PMC8861217 DOI: 10.1007/s40122-021-00343-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/18/2021] [Indexed: 11/18/2022] Open
Abstract
Objective Evaluate beliefs and behaviors pertaining to abuse-deterrent opioids (ADFs). Design Survey in 2019 by invitation to all licensed physicians. Setting Commonwealth of Kentucky. Participants 374 physicians. Methods Descriptive statistics, and hypothesis test that early adopter prescribers would have greater endorsement of opioid risk management. Results Of all prescribers, 55% believed all opioid analgesics should have ADF requirements (15% were unsure); 74% supported mandating insurance coverage. Only one-third considered whether an opioid was ADF when prescribing, motivated by patient family diversion (94%) and societal supply reduction (88%). About half believed ADFs were equally effective in preventing abuse by intact swallowing, injection, chewing, snorting, smoking routes. Only 4% of OxyContin prescribers chose it primarily because of ADF properties. Instead, the most common reason (33%) was being started by another prescriber. A quarter of physicians chose not to prescribe ADFs because of heroin switching potential. Early adopters strongly believed ADFs were effective in reducing abuse (PR 3.2; 95% CI 1.5, 6.6) compared to mainstream physicians. Early-adopter risk-management practices more often included tools increasing agency and measurement: urine drug screens (PR 2.0; 1.3, 3.1), risk screening (PR 1.3; 0.94, 1.9). While nearly all respondents (96%) felt that opioid abuse was a problem in the community, only 57% believed it was a problem among patients in their practice. Attribution theory revealed an externalization of opioid abuse problems that deflected blame from patients on to family members. Conclusions The primary motivator for prescribing ADFs was preventing diversion by family members, not patient-level abuse concerns. Supplementary Information The online version contains supplementary material available at 10.1007/s40122-021-00343-z.
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Affiliation(s)
- Nabarun Dasgupta
- UNC CB 7505, 725 Martin Luther King Jr. Blvd., Chapel Hill, NC, 27599, USA.
| | - John R Brown
- UNC CB 7505, 725 Martin Luther King Jr. Blvd., Chapel Hill, NC, 27599, USA
| | - Maryalice Nocera
- UNC CB 7505, 725 Martin Luther King Jr. Blvd., Chapel Hill, NC, 27599, USA
| | - Allison Lazard
- UNC CB 7505, 725 Martin Luther King Jr. Blvd., Chapel Hill, NC, 27599, USA
| | - Svetla Slavova
- UNC CB 7505, 725 Martin Luther King Jr. Blvd., Chapel Hill, NC, 27599, USA
| | - Patricia R Freeman
- UNC CB 7505, 725 Martin Luther King Jr. Blvd., Chapel Hill, NC, 27599, USA
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Marchetti Calônego MA, Sikandar S, Ferris FD, Moreira de Barros GA. Spread the Word: There Are Two Opioid Crises! Drugs 2021; 80:1147-1154. [PMID: 32533500 DOI: 10.1007/s40265-020-01342-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Pain is associated with emotional and physical suffering that severely impacts quality of life. Many guidelines for the treatment of moderate to severe cancer pain indicate the use of opioids. For a small proportion of the global population, opioids are readily accessible, but are consequently also subject to risk of overuse and misuse. On the other hand, many regions provide limited access to licensed opioid therapeutics and patients struggle for better pain management. The use of prescription opioids for treatment of severe cancer and acute pain is well established, but opioid use in chronic non-cancer pain is controversial and not supported by the literature. The opioid crisis and the increasing overdose fatalities in some countries have resulted in a resurgence of opiophobia in these countries, but even worse, amplified opiophobia in countries with lower opioid consumption. In this narrative review, we highlight how the opioid crisis of overuse in some countries can negatively impact appropriate access to opioids elsewhere. The availability of opioids for clinical and recreational use differs between countries worldwide-this is an important factor in determining the occurrence of a 'crisis of recreational use of opioids' or a 'crisis of under-prescription of opioids' for pain management.
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Affiliation(s)
| | - Shafaq Sikandar
- William Harvey Research Institute, Barts, The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Frank D Ferris
- Palliative Medicine, Research and Education, OhioHealth, Columbus, OH, USA
| | - Guilherme Antonio Moreira de Barros
- Anesthesiology Department, Medical School, Sao Paulo State University (UNESP), Av. Prof. Mario Rubens Guimaraes Montenegro, s/n, Botucatu, São Paulo, 18618687, Brazil.
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Ruiz-López D, Alonso-Babarro A. [Questionnaire made to understand the opioid analgesics prescription habits in the community of Madrid (Spain)]. Aten Primaria 2021; 53:102040. [PMID: 33857704 PMCID: PMC8065263 DOI: 10.1016/j.aprim.2021.102040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 12/29/2020] [Accepted: 01/21/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Pain is the fearest and disabling symptom for cancer patients. The cornerstone of treatment is opioid analgesics. The objective of this research was to relate the opioid consumption existing in the Community of Madrid (CM) with the prescription habits expressed by the Primary Care (PrC) and Palliative Care (PalC) physicians. DESIGN An opioid prescription habits questionnaire was designed. Sampling was consecutive non-probability. SITE: PrC and specific PalC resources in the CM. PARTICIPANTS The study population included all the family doctors who worked in PrC in the Madrid Public Health Service and all the physicians who worked in some specific PalC resources, both home-based teams and supportive hospital teams in the CM of the public and private/concerted health network services. MAIN MEASUREMENTS We asked about the strong and weak opioids most used in moderate-severe oncological and non-oncological pain, the preferred administration route, the safety in the use of opioids in the treatment of pain and the preferred clinical practice guidelines. RESULTS The questionnaire was answered by 840 PrC physicians (20%) and 56 PalC physicians (45%). For the treatment of moderate-severe cancer pain in both groups of professionals, the first choice was morphine; however, in non-cancer pain for PrC it was fentanyl and morphine for PalC professionals. Regarding the route of administration, 70% of family doctors and 87% of PalC physicians stated that the oral route was the first choice, compared to 27% in PrC and 5% in PalC who preferred the transdermal route. The PrC physicians rated their ability to use opioids as average (4-7/10), while the palliativists considered it as high (8-10/10). In PrC, they declared that they knew, above all, the European Association for Palliative Care (EAPC) and National Institute for Health and Care Excellence (NICE) guidelines, although the largest number answered that they trusted their experience. PalC physicians preferred to use the EAPC guide. CONCLUSIONS There is a clear disagreement between the actual consumption of opioids and the prescribing habits manifested by family doctors, as well as a false certainty in prescribing these drugs.
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Affiliation(s)
- Diego Ruiz-López
- Equipo de Soporte Paliativo Domiciliario (ESAPD), Centro de Salud Legazpi, Dirección Asistencial Noroeste de Atención Primaria, Servicio Madrileño de Salud, Madrid, España.
| | - Alberto Alonso-Babarro
- Unidad de Cuidados Paliativos, Hospital Universitario de La Paz, Servicio Madrileño de Salud, Madrid, España
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Leonard C, Ayele R, Ladebue A, McCreight M, Nolan C, Sandbrink F, Frank JW. Barriers to and Facilitators of Multimodal Chronic Pain Care for Veterans: A National Qualitative Study. PAIN MEDICINE 2021; 22:1167-1173. [PMID: 32974662 DOI: 10.1093/pm/pnaa312] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Chronic pain is more common among veterans than among the general population. Expert guidelines recommend multimodal chronic pain care. However, there is substantial variation in the availability and utilization of treatment modalities in the Veterans Health Administration. We explored health care providers' and administrators' perspectives on the barriers to and facilitators of multimodal chronic pain care in the Veterans Health Administration to understand variation in the use of multimodal pain treatment modalities. METHODS We conducted semi-structured qualitative interviews with health care providers and administrators at a national sample of Veterans Health Administration facilities that were classified as either early or late adopters of multimodal chronic pain care according to their utilization of nine pain-related treatments. Interviews were conducted by telephone, recorded, and transcribed verbatim. Transcripts were coded and analyzed through the use of team-based inductive and deductive content analysis. RESULTS We interviewed 49 participants from 25 facilities from April through September of 2017. We identified three themes. First, the Veterans Health Administration's integrated health care system is both an asset and a challenge for multimodal chronic pain care. Second, participants discussed a temporal shift from managing chronic pain with opioids to multimodal treatment. Third, primary care teams face competing pressures from expert guidelines, facility leadership, and patients. Early- and late-adopting sites differed in perceived resource availability. CONCLUSIONS Health care providers often perceive inadequate support and resources to provide multimodal chronic pain management. Efforts to improve chronic pain management should address both organizational and patient-level challenges, including primary care provider panel sizes, accessibility of training for primary care teams, leadership support for multimodal pain care, and availability of multidisciplinary pain management resources.
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Affiliation(s)
- Chelsea Leonard
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado
| | - Roman Ayele
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado.,Colorado School of Public Health, University of Colorado-Anschutz Medical Campus, Aurora, Colorado
| | - Amy Ladebue
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado
| | - Marina McCreight
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado
| | - Charlotte Nolan
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado
| | - Friedhelm Sandbrink
- Department of Neurology, Washington DC VA Medical Center, Washington, DC.,Department of Neurology, George Washington University, Washington, DC
| | - Joseph W Frank
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado.,Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado
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11
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Doan LV, Padjen K, Ok D, Gover A, Rashid J, Osmani B, Avraham S, Wang J, Kendale S. Relation between preoperative benzodiazepines and opioids on outcomes after total joint arthroplasty. Sci Rep 2021; 11:10528. [PMID: 34006976 PMCID: PMC8131602 DOI: 10.1038/s41598-021-90083-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 05/06/2021] [Indexed: 11/09/2022] Open
Abstract
To examine the association of preoperative opioids and/or benzodiazepines on postoperative outcomes in total knee and hip arthroplasty, we retrospectively compared postoperative outcomes in those prescribed preoperative opioids and/or benzodiazepines versus those who were not who underwent elective total knee and hip arthroplasty at a single urban academic institution. Multivariable logistic regression was performed for readmission rate, respiratory failure, infection, and adverse cardiac events. Multivariable zero-truncated negative binomial regression was used for length of stay. After exclusions, there were 4307 adult patients in the study population, 2009 of whom underwent total knee arthroplasty and 2298 of whom underwent total hip arthroplasty. After adjusting for potential confounders, preoperative benzodiazepine use was associated with increased odds of readmission (p < 0.01). Preoperative benzodiazepines were not associated with increased odds of respiratory failure nor increased length of stay. Preoperative opioids were not associated with increased odds of the examined outcomes. There were insufficient numbers of infection and cardiac events for analysis. In this study population, preoperative benzodiazepines were associated with increased odds of readmission. Preoperative opioids were not associated with increased odds of the examined outcomes. Studies are needed to further examine risks associated with preoperative benzodiazepine use.
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Affiliation(s)
- Lisa V Doan
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, 550 1st Ave., New York, NY, 10016, USA.
| | - Kristoffer Padjen
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, 550 1st Ave., New York, NY, 10016, USA
| | - Deborah Ok
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, 550 1st Ave., New York, NY, 10016, USA
| | - Adam Gover
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, 550 1st Ave., New York, NY, 10016, USA
| | - Jawad Rashid
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, 550 1st Ave., New York, NY, 10016, USA
| | - Bijan Osmani
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, 550 1st Ave., New York, NY, 10016, USA
| | - Shirley Avraham
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, 550 1st Ave., New York, NY, 10016, USA
| | - Jing Wang
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, 550 1st Ave., New York, NY, 10016, USA.,Department of Neuroscience and Physiology, New York University Grossman School of Medicine, New York, NY, USA
| | - Samir Kendale
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, 550 1st Ave., New York, NY, 10016, USA
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12
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Summers AD, Ailes EC, Bohm MK, Tran EL, Broussard CS, Frey MT, Gilboa SM, Ko JY, Lind JN, Honein MA. Opioid prescription claims among women aged 15-44 years-United States, 2013-2017. J Opioid Manag 2021; 17:125-133. [PMID: 33890276 DOI: 10.5055/jom.2021.0623] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To estimate the annual percentage of women of reproductive age with private insurance or Medicaid who had opioid prescription claims during 2013-2017 and describe trends over time. DESIGN A secondary analysis of insurance claims data from IBM MarketScan® Commercial and Multi-State Medicaid Databases to assess outpatient pharmacy claims for prescription opioids among women aged 15-44 years during 2013-2017. PARTICIPANTS Annual cohorts of 3.5-3.8 million women aged 15-44 years with private insurance and 0.9-2.1 million women enrolled in Medicaid. MAIN OUTCOME MEASURE The percentage of women aged 15-44 years with outpatient pharmacy claims for opioid prescriptions. RESULTS During 2013-2017, the proportion of women aged 15-44 years with private insurance who had claims for opioid prescriptions decreased by 22.1 percent, and among women enrolled in Medicaid, the proportion decreased by 31.5 -percent. CONCLUSIONS Opioid prescription claims decreased from 2013 to 2017 among insured women of reproductive age. However, opioid prescription claims remained common and were more common among women enrolled in Medicaid than those with private insurance; additional strategies to improve awareness of the risks associated with opioid prescribing may be needed.
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Affiliation(s)
- April D Summers
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, CDC, Chamblee, Georgia
| | - Elizabeth C Ailes
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, CDC, Chamblee, Georgia
| | - Michele K Bohm
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC, Chamblee, Georgia
| | - Emmy L Tran
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, CDC, Chamblee, Georgia; Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee
| | - Cheryl S Broussard
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, CDC, Chamblee, Georgia
| | - Meghan T Frey
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, CDC, Chamblee, Georgia
| | - Suzanne M Gilboa
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, CDC, Chamblee, Georgia
| | - Jean Y Ko
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC, Chamblee, Georgia; United States Public Health Service, Commissioned Corps
| | - Jennifer N Lind
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, CDC, Chamblee, Georgia; United States Public Health Service, Commissioned Corps
| | - Margaret A Honein
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, CDC, Chamblee, Georgia
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13
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Bryl AW, Demartinis N, Etkin M, Hollenbach KA, Huang J, Shah S. Reducing Opioid Doses Prescribed From a Pediatric Emergency Department. Pediatrics 2021; 147:peds.2020-1180. [PMID: 33674462 DOI: 10.1542/peds.2020-1180] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Opioid overdose and abuse have reached epidemic rates in the United States. Medical prescriptions are a large source of opioid misuse. Our quality improvement initiative aimed to reduce opioid exposure from the pediatric emergency department (ED). Objective was to reduce opioid doses prescribed weekly from our ED by 50% within 4 months. METHODS Three categories of interventions were implemented in Plan-Do-Study-Act cycles: guidelines and education, electronic medical record optimization, and provider-specific feedback. Primary measures were opioid doses prescribed weekly from the ED and opioid doses per 100 ED visits. Process measures were opioid prescriptions, opioid doses per prescription, and opioid prescriptions for unspecified abdominal pain, headache, and viral upper respiratory infection. Balancing measures were phone calls and return visits for poor pain control in patients prescribed opioids and reports of poor pain control in call backs to orthopedic reduction patients. We used statistical process control to examine changes in measures over time. RESULTS Opioid doses decreased from 153 to 14 per week and from 8 to 0.7 doses per 100 ED visits in 10 months, sustained for 9 months. Opioid prescriptions, opioid doses per prescription, and prescriptions for unspecified abdominal pain, headache, and viral upper respiratory infection decreased. Phone calls and return visits in patients prescribed opioids did not increase. There were 2 reports of poor pain control among 152 orthopedic reduction patients called back. CONCLUSIONS We decreased opioid doses prescribed weekly from the pediatric ED by 91% while minimizing return visits and reports of poor pain control.
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Affiliation(s)
- Amy W Bryl
- Department of Pediatrics, School of Medicine and .,Emergency Care Center, Rady Children's Hospital San Diego, San Diego, California
| | - Nicole Demartinis
- Department of Pediatrics, School of Medicine and.,Emergency Care Center, Rady Children's Hospital San Diego, San Diego, California
| | - Marc Etkin
- Department of Pediatrics, School of Medicine and.,Emergency Care Center, Rady Children's Hospital San Diego, San Diego, California
| | - Kathryn A Hollenbach
- Emergency Care Center, Rady Children's Hospital San Diego, San Diego, California.,Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California; and
| | | | - Seema Shah
- Department of Pediatrics, School of Medicine and.,Emergency Care Center, Rady Children's Hospital San Diego, San Diego, California
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14
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Dzierzanowski T, Kozlowski M. Opioid prescribing attitudes of palliative care physicians versus other specialists: a questionnaire-based survey. Postgrad Med J 2021; 98:119-123. [PMID: 33414178 DOI: 10.1136/postgradmedj-2020-139152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/02/2020] [Accepted: 11/09/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE OF THE STUDY While opioid overuse is a public health crisis in the USA, opioid analgesics are used suboptimally in Central and Eastern Europe, causing many pain cases to remain untreated or undertreated. STUDY DESIGN This questionnaire study aimed to identify the prevalent prescribing patterns and attitudes and the possible internal impediments to optimal opioid use among palliative care physicians and other specialists in Poland. RESULTS Tramadol was the most commonly preferred opioid. While palliative care physicians (n=81) used various strong opioids, other physicians (n=87) prescribed mostly buprenorphine, accessible with standard prescription forms. Neither internal prejudices and beliefs nor administrative regulations impede prescribing opioids by palliative care physicians, unlike specialists other than palliative medicine. Special prescription forms for psychoactive medications, fear of drug addiction of their patients and penalties for possible errors on prescriptions affect the latter's optimal prescribing. They also revealed significant gaps in the knowledge of prescribing opioids and would take part in additional training. Palliative care physicians appeared optimally prepared for cancer pain management and report fewer internal barriers than other specialists. CONCLUSIONS Continuous medical education on cancer pain treatment should be provided to all specialists to ensure optimal opioid pharmacotherapy and avoid overprescribing or underprescribing opioids. Administrative restrictions are the main barrier to optimal pain treatment.
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Affiliation(s)
- Tomasz Dzierzanowski
- Laboratory of Palliative Medicine, Department of Social Medicine and Public Health, Medical University of Warsaw, Warszawa, Poland
| | - Michael Kozlowski
- Clinic of Pain Treatment and Palliative Care, Chair of Internal Medicine and Geriatrics, Jagiellonian University Medical College, Krakow, Poland
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15
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Sasidharan S, Dhillon H. The lingering agony of chronic pain. JOURNAL OF ORTHOPEDICS, TRAUMATOLOGY AND REHABILITATION 2021. [DOI: 10.4103/jotr.jotr_74_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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16
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Sasidharan S, Dhillon H. The psychobiology and management of chronic pain. HAMDAN MEDICAL JOURNAL 2021. [DOI: 10.4103/hmj.hmj_50_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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17
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Morasco BJ, Smith N, Dobscha SK, Deyo RA, Hyde S, Yarborough BJ. Prospective Investigation of Factors Associated with Prescription Opioid Dose Escalation among Patients in Integrated Health Systems. J Gen Intern Med 2020; 35:895-902. [PMID: 33145684 PMCID: PMC7728960 DOI: 10.1007/s11606-020-06250-x] [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] [Received: 01/16/2020] [Accepted: 09/17/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Prior research has identified factors associated with prescription opioid initiation, but little is known about the prevalence or predictors of dose escalation among patients already prescribed long-term opioid therapy (LTOT). OBJECTIVE This was a 2-year prospective cohort study to examine patient and clinician factors associated with opioid dose escalation. DESIGN A prospective cohort study. Participants were seen at baseline and every 6 months for a total of 2 years. PARTICIPANTS Patients prescribed a stable dose of LTOT for musculoskeletal pain were recruited from two integrated health systems (Kaiser Permanente and the Department of Veterans Affairs, respectively). MAIN MEASURES The prescription opioid dose was based on pharmacy records and self-report. Administrative data were gathered on characteristics of the opioid-prescribing clinician and healthcare utilization. Participants completed measures of pain, functioning, and quality of life. KEY RESULTS Of enrolled participants (n = 517), 19.5% had an opioid dose increase. In multivariate analyses, patient variables associated with dose escalation were lower opioid dose (hazard ratio [HR] = 0.86, 95% confidence interval [CI] = 0.79-0.94, for every 10-mg increase in baseline dose) and greater pain catastrophizing (HR = 1.03, 95% CI = 1.01-1.05). Other variables associated with dose escalation were as follows: receiving medications from a nurse practitioner primary care provider (HR = 2.10, 95% CI = 1.12-3.96) or specialty physician (HR = 3.18, 95% CI = 1.22-8.34), relative to a physician primary care provider, and having undergone surgery within the past 6 months (HR = 1.80, 95% CI = 1.10-2.94). Other variables, including pain intensity, pain disability, or depression, were not associated with dose escalation. CONCLUSIONS In this 2-year prospective cohort study, variables associated with opioid dose escalation were lower opioid dose, higher pain catastrophizing, receiving opioids from a medical specialist (rather than primary care clinician) or nurse practitioner, and having recently undergone surgery. Study findings highlight intervention points that may be helpful for reducing the likelihood of future prescription opioid dose escalation.
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Affiliation(s)
- Benjamin J Morasco
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System (R&D99), Portland, OR, USA. .,Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA.
| | - Ning Smith
- Kaiser Permanente Northwest Center for Health Research, Portland, OR, USA
| | - Steven K Dobscha
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System (R&D99), Portland, OR, USA.,Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA
| | - Richard A Deyo
- Kaiser Permanente Northwest Center for Health Research, Portland, OR, USA.,Department of Family Medicine, Oregon Health & Sciences University, Portland, OR, USA.,Department of Internal Medicine, Oregon Health & Sciences University, Portland, OR, USA.,Oregon Institute for Occupational Health Sciences, Oregon Health & Sciences University, Portland, OR, USA.,School of Public Health, Oregon Health & Sciences University, Portland, OR, USA
| | - Stephanie Hyde
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System (R&D99), Portland, OR, USA.,Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA
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18
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Grucza RA, Bello-Kottenstette JK, Mintz CM, Borodovsky JT. The changing landscape of alcohol use disorder and problem drinking in the USA: implications for primary care. Fam Pract 2020; 37:870-872. [PMID: 32634209 PMCID: PMC7699309 DOI: 10.1093/fampra/cmaa066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Richard A Grucza
- Department of Family and Community Medicine, St. Louis, MO, USA.,Center for Health Outcomes Research, Saint Louis University, St. Louis, MO, USA
| | | | - Carrie M Mintz
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Jacob T Borodovsky
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
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19
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Community pharmacists' preparedness to intervene with concerns around prescription opioids: findings from a nationally representative survey. Int J Clin Pharm 2020; 43:411-419. [PMID: 32951182 DOI: 10.1007/s11096-020-01152-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 09/11/2020] [Indexed: 02/03/2023]
Abstract
Background Prescription opioid use and related harms have dramatically increased in many countries. Objective To investigate pharmacists' preparedness and confidence to intervene when concerned about supplying prescription opioids and strategies used when concerned about supplying these opioids. Setting Online survey among a representative sample of Australian community pharmacists. Method Pharmacists completed an online survey about their concerns, comfort and strategies used when supplying prescription opioids. Correlates of comfort to intervene and active intervention strategies were explored using multivariable ordered logistic regression and adjusted odd ratios (aOR) and 95% confidence intervals were reported. Main outcome measures Comfort to intervene when concerned about supplying prescription opioids and pharmacists' discussing these concerns with the patient, and the prescriber. Results Most pharmacists were concerned about supplying prescription opioids to patients in the past week. Being female [adjusted odds ratio (aOR) 0.63; 95% confidence interval (CI) 0.47-0.85] was associated with reduced comfort, while practicing within a large chain pharmacy (aOR 1.52, 95% CI 1.08-2.15) was associated with greater comfort to intervene when concerned about prescription opioid supply. Pharmacists practicing in rural areas were significantly less likely than those in capital cities to discuss concerns with patients (aOR 0.66, 95% CI 0.45-0.97). Post-graduate education about substance use disorders was associated with increased likelihood of discussing concerns with patients (aOR 1.54, 95% CI 1.12-2.13). Pharmacists that indicated greater comfort in intervening when concerned about prescription opioids were more likely to discuss concerns with both patients and prescribers. Females were significantly more likely to discuss concerns with prescribers (aOR 1.67, 95% CI 1.22-2.29), whereas years of practice reduced the odds of discussing concerns with prescribers (aOR 0.98, 95% CI 0.97-0.99). Conclusion Considering specific factors such as gender and years of practice to help target pharmacist training may lead to increased comfort in discussing concerns related to prescription opioids, which in turn may improve communication with prescribers and patients.
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20
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Thombs RP, Thombs DL, Jorgenson AK, Harris Braswell T. What Is Driving the Drug Overdose Epidemic in the United States? JOURNAL OF HEALTH AND SOCIAL BEHAVIOR 2020; 61:275-289. [PMID: 32674692 DOI: 10.1177/0022146520939514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
The demand-side perspective argues that the drug overdose epidemic is a consequence of changes in the economy that leave behind working-class people who lack a college education. In contrast, the supply-side perspective maintains that the epidemic is primarily due to changes in the licit and illicit drug environment, whereas a third, distinct perspective argues that income inequality is likely a key driver of the epidemic. To evaluate these competing perspectives, we use a two-level random intercept model and U.S. state-level data from 2006 to 2017. Contrary to the demand-side approach, we find that educational attainment is not associated with drug-related mortality. In support of the supply-side approach, we provide evidence indicating that opioid prescription rates are positively associated with drug-related mortality. We also find that income inequality is a key driver of the epidemic, particularly the lack of resources going to the bottom 20% of earners. We conclude by arguing that considerations of income inequality are an important way to link the arguments made by the demand-side and the supply-side perspectives.
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21
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Jarvik JG, Meier EN, James KT, Gold LS, Tan KW, Kessler LG, Suri P, Kallmes DF, Cherkin DC, Deyo RA, Sherman KJ, Halabi SS, Comstock BA, Luetmer PH, Avins AL, Rundell SD, Griffith B, Friedly JL, Lavallee DC, Stephens KA, Turner JA, Bresnahan BW, Heagerty PJ. The Effect of Including Benchmark Prevalence Data of Common Imaging Findings in Spine Image Reports on Health Care Utilization Among Adults Undergoing Spine Imaging: A Stepped-Wedge Randomized Clinical Trial. JAMA Netw Open 2020; 3:e2015713. [PMID: 32886121 PMCID: PMC7489827 DOI: 10.1001/jamanetworkopen.2020.15713] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Lumbar spine imaging frequently reveals findings that may seem alarming but are likely unrelated to pain. Prior work has suggested that inserting data on the prevalence of imaging findings among asymptomatic individuals into spine imaging reports may reduce unnecessary subsequent interventions. OBJECTIVE To evaluate the impact of including benchmark prevalence data in routine spinal imaging reports on subsequent spine-related health care utilization and opioid prescriptions. DESIGN, SETTING, AND PARTICIPANTS This stepped-wedge, pragmatic randomized clinical trial included 250 401 adult participants receiving care from 98 primary care clinics at 4 large health systems in the United States. Participants had imaging of their backs between October 2013 and September 2016 without having had spine imaging in the prior year. Data analysis was conducted from November 2018 to October 2019. INTERVENTIONS Either standard lumbar spine imaging reports (control group) or reports containing age-appropriate prevalence data for common imaging findings in individuals without back pain (intervention group). MAIN OUTCOMES AND MEASURES Health care utilization was measured in spine-related relative value units (RVUs) within 365 days of index imaging. The number of subsequent opioid prescriptions written by a primary care clinician was a secondary outcome, and prespecified subgroup analyses examined results by imaging modality. RESULTS We enrolled 250 401 participants (of whom 238 886 [95.4%] met eligibility for this analysis, with 137 373 [57.5%] women and 105 497 [44.2%] aged >60 years) from 3278 primary care clinicians. A total of 117 455 patients (49.2%) were randomized to the control group, and 121 431 patients (50.8%) were randomized to the intervention group. There was no significant difference in cumulative spine-related RVUs comparing intervention and control conditions through 365 days. The adjusted median (interquartile range) RVU for the control group was 3.56 (2.71-5.12) compared with 3.53 (2.68-5.08) for the intervention group (difference, -0.7%; 95% CI, -2.9% to 1.5%; P = .54). Rates of subsequent RVUs did not differ between groups by specific clinical findings in the report but did differ by type of index imaging (eg, computed tomography: difference, -29.3%; 95% CI, -42.1% to -13.5%; magnetic resonance imaging: difference, -3.4%; 95% CI, -8.3% to 1.8%). We observed a small but significant decrease in the likelihood of opioid prescribing from a study clinician within 1 year of the intervention (odds ratio, 0.95; 95% CI, 0.91 to 1.00; P = .04). CONCLUSIONS AND RELEVANCE In this study, inserting benchmark prevalence information in lumbar spine imaging reports did not decrease subsequent spine-related RVUs but did reduce subsequent opioid prescriptions. The intervention text is simple, inexpensive, and easily implemented. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02015455.
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Affiliation(s)
- Jeffrey G. Jarvik
- Department of Radiology, University of Washington, Seattle
- Department of Neurological Surgery, University of Washington, Seattle
- Department of Health Services, University of Washington, Seattle
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle
| | - Eric N. Meier
- Department of Biostatistics, University of Washington, Seattle
- Center for Biomedical Statistics, University of Washington, Seattle
| | - Kathryn T. James
- Department of Radiology, University of Washington, Seattle
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle
| | - Laura S. Gold
- Department of Radiology, University of Washington, Seattle
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle
| | - Katherine W. Tan
- Department of Biostatistics, University of Washington, Seattle
- Center for Biomedical Statistics, University of Washington, Seattle
- Flatiron Health, New York, New York
| | - Larry G. Kessler
- Department of Health Services, University of Washington, Seattle
| | - Pradeep Suri
- Rehabilitation Care Services, VA Puget Sound Health Care System, Seattle, Washington
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | | | | | - Richard A. Deyo
- Departments of Family Medicine and Internal Medicine, Oregon Health and Science University, Portland
| | | | - Safwan S. Halabi
- Department of Radiology, Henry Ford Hospital, Detroit, Michigan
- Department of Radiology, Stanford University School of Medicine, Palo Alto, California
| | - Bryan A. Comstock
- Department of Biostatistics, University of Washington, Seattle
- Center for Biomedical Statistics, University of Washington, Seattle
| | | | - Andrew L. Avins
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Sean D. Rundell
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | - Brent Griffith
- Department of Radiology, Henry Ford Hospital, Detroit, Michigan
| | - Janna L. Friedly
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | | | - Kari A. Stephens
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
| | - Judith A. Turner
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle
- Department of Rehabilitation Medicine, University of Washington, Seattle
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
| | - Brian W. Bresnahan
- Department of Radiology, University of Washington, Seattle
- Comparative Effectiveness, Cost, and Outcomes Research Center, University of Washington, Seattle
| | - Patrick J. Heagerty
- Department of Biostatistics, University of Washington, Seattle
- Center for Biomedical Statistics, University of Washington, Seattle
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22
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Buonora M, Perez HR, Heo M, Cunningham CO, Starrels JL. Race and Gender Are Associated with Opioid Dose Reduction Among Patients on Chronic Opioid Therapy. PAIN MEDICINE 2020; 20:1519-1527. [PMID: 30032197 DOI: 10.1093/pm/pny137] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Among patients with chronic pain, risk of opioid use is elevated with high opioid dose or concurrent benzodiazepine use. This study examined whether these clinical factors, or sociodemographic factors of race and gender, are associated with opioid dose reduction. DESIGN AND SETTING A retrospective cohort study of outpatients prescribed chronic opioid therapy between 2007 and 2012 within a large, academic health care system in Bronx, New York, using electronic medical record data. Included patients were prescribed a stable dose of chronic opioid therapy over a one-year "baseline period" and did not have cancer. METHODS The primary outcome was opioid dose reduction (≥30% reduction from baseline) within two years. Multivariable logistic regression tested the associations of two clinical variables (baseline daily opioid dose and concurrent benzodiazepine prescription) and two sociodemographic variables (race/ethnicity and gender) with opioid dose reduction. RESULTS Of 1,097 patients, 463 (42.2%) had opioid dose reduction. High opioid dose (≥100 morphine-milligram equivalents [MME]) was associated with lower odds of opioid dose reduction compared with an opioid dose <100 MME (adjusted odds ratio [AOR] = 0.69, 95% confidence interval [CI] = 0.54-0.89). Concurrent benzodiazepine prescription was not associated with opioid dose reduction. Black (vs white) race and female (vs male) gender were associated with greater odds of opioid dose reduction (AOR = 1.82, 95% CI = 1.22-2.70; and AOR = 1.43, 95% CI = 1.11-1.83, respectively). CONCLUSIONS Black race and female gender were associated with greater odds of opioid dose reduction, whereas clinical factors of high opioid dose and concurrent benzodiazepine prescription were not. Efforts to reduce opioid dose should target patients based on clinical factors and address potential biases in clinical decision-making.
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Affiliation(s)
| | - Hector R Perez
- Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
| | - Moonseong Heo
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Chinazo O Cunningham
- Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
| | - Joanna L Starrels
- Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
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23
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Shaw WS, Roelofs C, Punnett L. Work Environment Factors and Prevention of Opioid-Related Deaths. Am J Public Health 2020; 110:1235-1241. [PMID: 32552015 DOI: 10.2105/ajph.2020.305716] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Opioid use disorder (OUD) and opioid overdose deaths (OODs) are prevalent among US workers, but work-related factors have not received adequate attention as either risk factors or opportunities for OOD prevention. Higher prevalence of OOD in those with heavy physical jobs, more precarious work, and limited health care benefits suggest work environment and organizational factors may predispose workers to the development of OUD.Organizational policies that reduce ergonomic risk factors, respond effectively to employee health and safety concerns, provide access to nonpharmacologic pain management, and encourage early substance use treatment are important opportunities to improve outcomes. Organizational barriers can limit disclosure of pain and help-seeking behavior, and opioid education is not effectively integrated with workplace safety training and health promotion programs.Policy development at the employer, government, and association levels could improve the workplace response to workers with OUD and reduce occupational risks that may be contributing factors.
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Affiliation(s)
- William S Shaw
- William S. Shaw is with the Division of Occupational and Environmental Medicine, Department of Medicine, University of Connecticut School of Medicine, Farmington. Cora Roelofs and Laura Punnett are with the Department of Biomedical Engineering, Francis College of Engineering, University of Massachusetts Lowell
| | - Cora Roelofs
- William S. Shaw is with the Division of Occupational and Environmental Medicine, Department of Medicine, University of Connecticut School of Medicine, Farmington. Cora Roelofs and Laura Punnett are with the Department of Biomedical Engineering, Francis College of Engineering, University of Massachusetts Lowell
| | - Laura Punnett
- William S. Shaw is with the Division of Occupational and Environmental Medicine, Department of Medicine, University of Connecticut School of Medicine, Farmington. Cora Roelofs and Laura Punnett are with the Department of Biomedical Engineering, Francis College of Engineering, University of Massachusetts Lowell
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24
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Homer J, Wakeland W. A dynamic model of the opioid drug epidemic with implications for policy. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2020; 47:5-15. [PMID: 32515234 DOI: 10.1080/00952990.2020.1755677] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Background: The U.S. opioid epidemic has caused substantial harm for over 20 years. Policy interventions have had limited impact and sometimes backfired. Experts recommend a systems modeling approach to address the complexities of opioid policymaking.Objectives: Develop a system dynamics simulation model that reflects the complexities and can anticipate intended and unintended intervention effects.Methods: The model was developed from literature review and data gathering. Its outputs, starting in 1990, were compared against 12 historical time series. Four illustrative interventions were simulated for 2020-2030: reducing prescription dosage by 20%, cutting diversion by 30%, increasing addiction treatment from 45% to 65%, and increasing lay naloxone use from 4% to 20%. Sensitivity testing was performed to determine effects of uncertainties. No human subjects were studied.Results: The model fits historical data well with error percentage averaging 9% across 201 data points. Interventions to reduce dosage and diversion reduce the number of persons with opioid use disorder (PWOUD) by 11% and 16%, respectively, but each of these interventions reduces overdoses by only 1%. Boosting treatment reduces overdoses by 3% but increases PWOUD by 1%. Expanding naloxone reduces overdose deaths by 12% but increases PWOUD by 2% and overdoses by 3%. Combining all four interventions reduces PWOUD by 24%, overdoses by 4%, and deaths by 18%. Uncertainties may affect these numerical results, but policy findings are unchanged.Conclusion: No single intervention significantly reduces both PWOUD and overdose deaths, but a combination strategy can do so. Entering the 2020s, only protective measures like naloxone expansion could significantly reduce overdose deaths.
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Affiliation(s)
- Jack Homer
- Homer Consulting, Barrytown, New York, USA
| | - Wayne Wakeland
- Systems Science Graduate Program, Portland State University, Portland, Oregon, USA
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Maher E, Nielsen S, Summers R, Wood P. Core competencies for Australian pharmacists when supplying prescribed opioids: a modified Delphi study. Int J Clin Pharm 2020; 43:430-438. [PMID: 32447518 DOI: 10.1007/s11096-020-01060-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 05/12/2020] [Indexed: 11/30/2022]
Abstract
Background In the past decade, there has been an increase in prescription opioid related harms. These include dependence, non-fatal and fatal overdose. Pharmacists play a an important role in safe opioid supply. As most opioids are supplied through pharmacies, pharmacists are in a prime position to reduce harms associated with opioid use. Development of specific core competencies for pharmacists may facilitate consistent and safer opioid supply. Objective To reach consensus on which competency items identified by the Association of Faculties of Pharmacy of Canada's Opioid Working Group are considered core competencies for Australian pharmacists in opioid supply and assess expert pharmacists' perceptions of how well these competencies are currently met by practicing pharmacists. Setting Expert pharmacists in the area of opioid supply from across Australia. Method A series of questionnaires were presented to Australian opioid expert pharmacists via a modified Delphi study, with the aim to reach consensus on which items should be considered competencies for opioid supply by Australian pharmacists. Items were rated on a 6-point Likert scale and analysed using Statistical Package for the Social Sciences® (SPSS). Participants were also asked to rate how well they perceived that currently practicing pharmacists met each of these competency items. Main outcome measure Consensus on competency items for pharmacists when supplying prescribed opioids. Results All competency items presented to participants reached immediate agreement. When rating whether participants perceived currently practicing pharmacists met these competencies, results were variable. The competencies that participants rated practicing pharmacist met to a higher degree reflected knowledge and skills items that can be applied to all medications and were not opioid specific. The lower rated competencies appeared to be related to newer or more complex or specialised areas of opioid supply. Conclusion There was strong agreement by participants on what should be considered core competencies for Australian pharmacists in opioid supply. Given the large number of items identified, further research may help determine priorities for training and education.
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Affiliation(s)
- Ella Maher
- Department of Pharmacy and Biomedical Science, College of Science, Health and Engineering, La Trobe University, PO Box 199, Bendigo, VIC, 3552, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Monash University, Peninsula Campus, 47-49 Moorooduc Hwy, Frankston, VIC, 3199, Australia
| | - Richard Summers
- Department of Pharmacy and Biomedical Science, College of Science, Health and Engineering, La Trobe University, PO Box 199, Bendigo, VIC, 3552, Australia
| | - Pene Wood
- Department of Pharmacy and Biomedical Science, College of Science, Health and Engineering, La Trobe University, PO Box 199, Bendigo, VIC, 3552, Australia.
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Gleber R, Vilke GM, Castillo EM, Brennan J, Oyama L, Coyne CJ. Trends in emergency physician opioid prescribing practices during the United States opioid crisis. Am J Emerg Med 2020; 38:735-740. [DOI: 10.1016/j.ajem.2019.06.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 06/04/2019] [Accepted: 06/04/2019] [Indexed: 11/30/2022] Open
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Burke LG, Zhou X, Boyle KL, Orav EJ, Bernson D, Hood ME, Land T, Bharel M, Frakt AB. Trends in opioid use disorder and overdose among opioid-naive individuals receiving an opioid prescription in Massachusetts from 2011 to 2014. Addiction 2020; 115:493-504. [PMID: 31691390 DOI: 10.1111/add.14867] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/19/2019] [Accepted: 10/14/2019] [Indexed: 02/03/2023]
Abstract
AIMS To examine how the risks of incident opioid use disorder (OUD), non-fatal and fatal overdose have changed over time among opioid-naive individuals receiving an initial opioid prescription. DESIGN Retrospective, longitudinal study using the Massachusetts Chapter 55 data set, which linked multiple administrative data sets to study the opioid epidemic. We identified the cumulative incidence of OUD, non-fatal and fatal overdose among the opioid-naive initiating opioid treatment in Massachusetts from 2011 to 2014 and estimated rates of these outcomes at 6 months and at 1, 2, 3 and 4 years to 2015. We used Cox regression to examine the association between characteristics of the initial prescription and risk of these outcomes. SETTING Massachusetts, USA. PARTICIPANTS Massachusetts residents aged ≥ 11 years in 2011-15 who were opioid-naive (no opioid prescriptions or evidence of OUD in the 6 months prior to the index prescription) (n = 2 154 426). The mean age was 49.1 years, 55.3% were female and 47.3% had commercial insurance. MEASUREMENTS Opioid prescriptions were identified in the Prescription Monitoring Program (PMP) database, as were the characteristics of the initial prescription database. The outcomes of OUD and non-fatal overdose were identified from claims in the All Payer Claims Database (APCD) and hospital encounters in the acute hospital case mix files. Fatal overdoses were identified using Registry of Vital Records and Statistics (RVRS) death certificates and the Office of the Chief Medical Examiner (OCME) circumstances of death and toxicology reports. FINDINGS Among opioid-naive individuals receiving an initial opioid prescription, the risk of incident OUD appears to have declined between 2011 and 2014, while rates of overdose were largely unchanged. For example, the 1-year OUD rate was 1.18% in 2011, 1.11% in 2012, 1.26% in 2013 and 0.94% in 2014. Longer therapy duration was associated with higher risk of OUD [hazard ratio (HR) = 2.24, 95% confidence interval (CI) = 2.19-2.29 for duration of 3 or more months], non-fatal (HR = 1.67, 95% CI = 1.53-1.82) and fatal opioid overdose (HR = 2.24, 95% CI = 1.91-2.61). Concurrent benzodiazepine treatment was also associated with higher risk of OUD (HR = 1.14, 95% CI = 1.12-1.17), non-fatal (HR = 1.20, 95% CI = 1.10-1.30) and fatal overdose (HR = 1.86, 95% CI = 1.61-2.16). CONCLUSIONS Among opioid-naive individuals in Massachusetts receiving an initial opioid prescription, the risk of incident opioid use disorder appears to have declined between 2011 and 2014, while rates of overdose were largely unchanged. Longer therapy duration and concurrent benzodiazepines were associated with higher rates of opioid use disorder and opioid overdose.
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Affiliation(s)
- Laura G Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Xiner Zhou
- Department of Biostatistics, University of California, Davis, CA, USA
| | - Katherine L Boyle
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - E John Orav
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Dana Bernson
- The Massachusetts Department of Public Health, Boston, MA, USA
| | | | - Thomas Land
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Monica Bharel
- The Massachusetts Department of Public Health, Boston, MA, USA
| | - Austin B Frakt
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Partnered Evidence-based Policy Resource Center, VA Boston System, Boston, MA, USA.,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
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Starr JB, Gold LS, McCormick Z, Suri P, Friedly J. Repeat procedures and prescription opioid use after lumbar medial branch nerve radiofrequency ablation in commercially insured patients. Spine J 2020; 20:344-351. [PMID: 31654808 PMCID: PMC7060813 DOI: 10.1016/j.spinee.2019.10.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 10/07/2019] [Accepted: 10/15/2019] [Indexed: 02/03/2023]
Abstract
PURPOSE Although the effectiveness of medial branch nerve radiofrequency ablation (RFA) for lumbosacral facet pain has been described, little is known regarding patterns of repeat RFA utilization and prescription opioid use afterward. DESIGN Retrospective cohort analysis. PATIENT SAMPLE Patients undergoing lumbosacral RFA in MarketScan from 2007 to 2016. METHODS The time until and number of staged RFAs (<180 days after initial RFA) and repeat RFAs (≥180 days after initial RFA), as well as opioid use at 90 and 180 days after RFA were assessed. Survival analyses were employed to estimate subsequent RFA rates, whereas subsequent RFA frequencies were estimated with inverse probability weighting. Repeated measures testing was performed comparing opioid use pre- and post-RFA. RESULTS Initial RFAs were identified in 44,936 patients. Staged RFAs were performed in 33.1% of patients. Repeat RFAs through 1, 3, and 7 years were performed for 14.6%, 33.5%, and 45.7% of patients, respectively. Within 3 years, 12.2% of patients underwent one repeat RFA, whereas 13.2% of patients underwent two or more. Post-RFA opioid use was examined in 128,310 patients, 32.2% of whom used opioids pre-RFA. By 180 days post-RFA, 8.1% of patients discontinued opioids and 6.7% started opioids (p<.001). Exclusively examining pre-RFA opioid users, 24.9% stopped filling opioid prescriptions 180 days after RFA. CONCLUSIONS This study delineates utilization rates of repeat RFA in the commerciall y insured population, with one-third undergoing repeat RFA within 3 years. Additionally, the present data indicate that lumbosacral RFA is associated with reduced filling of opioid prescriptions through 180 days.
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Affiliation(s)
- Jordan B. Starr
- Department of Anesthesiology and Pain Medicine, University of Washington
| | | | - Zachary McCormick
- Division of Physical Medicine and Rehabilitation, University of Utah
| | - Pradeep Suri
- Department of Rehabilitation Medicine, University of Washington,Rehabilitation Care Services, VA Puget Sound Health Care System
| | - Janna Friedly
- Department of Rehabilitation Medicine, University of Washington
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Abstract
The opioid epidemic underscores the need for safer and more effective treatments for pain. Combining opioid receptor agonists with drugs that relieve pain through nonopioid mechanisms could be a useful strategy for reducing the dose of opioid needed to treat pain, thereby reducing risks associated with opioids alone. Opioid/cannabinoid mixtures might be useful in this context; individually, opioids and cannabinoids have modest effects on cognition, and it is important to determine whether those effects occur with mixtures. Delay discounting and delayed matching-to-sample tasks were used to examine effects of the mu-opioid receptor agonist morphine (0.32-5.6 mg/kg), the cannabinoid CB1/CB2 receptor agonist CP55940 (0.0032-0.1 mg/kg), and morphine/CP55940 mixtures on impulsivity (n = 3) and memory (n = 4) in rhesus monkeys. Alone, each drug decreased rate of responding without modifying choice in the delay-discounting task, and morphine/CP55940 mixtures reduced choice of one pellet in a delay dependent manner, with monkeys instead choosing delayed delivery of the larger number of pellets. With the exception of one dose in one monkey, accuracy in the delayed matching-to-sample task was not altered by either drug alone. Morphine/CP55940 mixtures decreased accuracy in two monkeys, but the doses in the mixture were equal to or greater than doses that decreased accuracy or response rate with either drug alone. Rate-decreasing effects of morphine/CP55940 mixtures were additive. These data support the notion that opioid/cannabinoid mixtures that might be effective for treating pain do not have greater, and might have less, adverse effects compared with larger doses of each drug alone.
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Xia W, MacFater WS, Barazanchi AWH, Sammour T, Hill AG. Risk factors associated with unplanned readmission following excisional haemorrhoidectomy. Colorectal Dis 2020; 22:187-194. [PMID: 31491051 DOI: 10.1111/codi.14852] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 08/09/2019] [Indexed: 02/08/2023]
Abstract
AIM Excisional haemorrhoidectomy is the gold standard for management of advanced symptomatic haemorrhoids. Although an effective treatment, it is associated with significant postoperative morbidity with pain, bleeding and a high readmission rate. This study seeks to investigate potential risk factors that may predict unplanned 30-day readmissions following excisional haemorrhoidectomy. METHOD A retrospective cohort review of all haemorrhoidectomies performed at Counties Manukau District Health Board, Auckland, New Zealand, between January 2012 and December 2017 was performed. Baseline demographic data, readmission data and potential variables for readmission were recorded. Univariate and multivariate logistic regression analyses were performed to determine significant variables for readmission within 30 days. RESULTS In total, 485 cases of excisional haemorrhoidectomy were included in the final analysis with 62 (12.8%) unplanned readmissions. The demographics between the no readmission and unplanned readmission groups were similar. Multivariate logistic regression analysis demonstrated that male gender (P = 0.018) and the use of non-diathermy devices (P = 0.017) were significant risk factors for readmission. Initial dispensing of opioid analgesia did not decrease the risk of readmission. CONCLUSION This study suggests that male gender and surgical technique are associated with increased risk of readmission.
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Affiliation(s)
- W Xia
- Department of Surgery, South Auckland Clinical Campus, Middlemore Hospital, University of Auckland, Auckland, New Zealand
| | - W S MacFater
- Department of Surgery, South Auckland Clinical Campus, Middlemore Hospital, University of Auckland, Auckland, New Zealand
| | - A W H Barazanchi
- Department of Surgery, South Auckland Clinical Campus, Middlemore Hospital, University of Auckland, Auckland, New Zealand
| | - T Sammour
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - A G Hill
- Department of Surgery, South Auckland Clinical Campus, Middlemore Hospital, University of Auckland, Auckland, New Zealand
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Poole R, Bailey J, Robinson CA. The opioid crisis and British prisons. CRIMINAL BEHAVIOUR AND MENTAL HEALTH : CBMH 2020; 30:1-5. [PMID: 31837040 DOI: 10.1002/cbm.2136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 11/18/2019] [Indexed: 06/10/2023]
Affiliation(s)
- Rob Poole
- Centre for Mental Health and Society, Bangor University, Wrexham Technology Park, Wrexham, Wales
| | - John Bailey
- Centre for Mental Health and Society, Bangor University, Bangor, Wales
| | - Catherine A Robinson
- Social Care and Society, School of Health Sciences, Manchester University, Manchester, England
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Osborne V, Serdarevic M, Striley CW, Nixon SJ, Winterstein AG, Cottler LB. Age of First Use of Prescription Opioids and Prescription Opioid Non-Medical Use among Older Adolescents. Subst Use Misuse 2020; 55:2420-2427. [PMID: 33059498 DOI: 10.1080/10826084.2020.1823420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Non-medical use (NMU) of prescription opioids is of concern due to the opioid epidemic in the United States. Objective: We examined sex differences in the effect of age of first use of prescription opioids on prescription opioid NMU among 17- and 18-year olds. Methods: The National Monitoring of Adolescent Prescription Stimulants Study (N-MAPSS) recruited youth 10-18 years from 10 United States cities between 2008 and 2011 (n = 11,048). The cross-sectional survey included questions on past 30 day prescription opioid use (10,965 provided responses; 278 age 17 to 18 years who used opioids in past 30 days), with NMU defined as non-oral use and/or use of someone else's opioids. Nonparametric survival analysis with lifetable estimates was used to examine age at first use. Binomial logistic regression was conducted predicting any NMU, adjusted for covariates. Results: Among 278 youth 17 to 18 years, a significant difference in age of first use between those with MU only and any NMU (p < .0001) was observed. Each one year increase in age resulted in a 33% decrease in the odds of any prescription opioid NMU compared to MU only, after controlling for covariates (Odds Ratio = 0.67, 95% Confidence Interval: 0.47,0.96). Sex differences in age at first use were not observed. Conclusions: Risk of past 30 day prescription opioid NMU decreased by a third for each one year increase in age of first use, after adjustment for other covariates. Use of prescription opioids in young adolescents may need to be limited where possible and researched further.
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Affiliation(s)
- Vicki Osborne
- Department of Epidemiology, University of Florida, Gainesville, Florida, USA.,Drug Safety Research Unit, Southampton, UK
| | - Mirsada Serdarevic
- Center for Outcomes Research, JPS Health Network, Fort Worth, Texas, USA.,Department of Medical Education, TCU and UNTHSC School of Medicine, Fort Worth, Texas, USA
| | - Catherine W Striley
- Department of Epidemiology, University of Florida, Gainesville, Florida, USA
| | - Sara J Nixon
- Department of Psychiatry, University of Florida, Gainesville, Florida, USA
| | - Almut G Winterstein
- Department of Epidemiology, University of Florida, Gainesville, Florida, USA.,Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA
| | - Linda B Cottler
- Department of Epidemiology, University of Florida, Gainesville, Florida, USA
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Perez HR, Buonora M, Cunningham CO, Heo M, Starrels JL. Opioid Taper Is Associated with Subsequent Termination of Care: a Retrospective Cohort Study. J Gen Intern Med 2020; 35:36-42. [PMID: 31428983 PMCID: PMC6957663 DOI: 10.1007/s11606-019-05227-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 04/03/2019] [Accepted: 06/18/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Opioid tapering is increasingly utilized by providers to decrease risks of chronic opioid therapy, but it is unknown whether tapering is associated with termination of care. OBJECTIVE To determine whether patients taking chronic opioid therapy who experienced opioid tapers were at greater risk of subsequently terminating their care compared with those who were continued on their doses. DESIGN Retrospective cohort study of patients in a large, urban health system between 2008 and 2012 with 2 years of follow-up. PARTICIPANTS Adult patients prescribed a stable baseline dose of chronic opioid therapy of at least 25 morphine milligram equivalents per day during a baseline year. MAIN MEASURES An opioid taper during an exposure year, defined as a reduction in the average daily dose of at least 30% from the baseline dose in both of the two 6-month periods in the year following the baseline year. Opioid dose continuation was defined as any increase in dose, no change in dose, or any decrease up to 30% compared with baseline dose in the exposure year. The primary outcome was termination of care, defined as no outpatient encounters in the health system, in the year following the exposure year. KEY RESULTS Of 1624 patients on chronic opioid therapy, 207 (15.5%) experienced an opioid taper and 78 (4.8%) experienced termination of care. Compared with opioid dose continuation, opioid taper was significantly associated with termination of care (AOR 4.3 [95% CI 2.2-8.5]). CONCLUSIONS Opioid taper is associated with subsequent termination of care. These findings invite caution and demonstrate the need to fully understand the risks and benefits of opioid tapers.
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Affiliation(s)
- Hector R Perez
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Michele Buonora
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Moonseong Heo
- Department of Public Health Sciences, College of Behavioral, Social and Health Sciences, Clemson University, Clemson, SC, USA
| | - Joanna L Starrels
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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Obadan-Udoh E, Lupulescu-Mann N, Charlesworth CJ, Muench U, Jura M, Kim H, Schwarz E, Mertz E, Sun BC. Opioid prescribing patterns after dental visits among beneficiaries of Medicaid in Washington state in 2014 and 2015. J Am Dent Assoc 2019; 150:259-268.e1. [PMID: 30922457 DOI: 10.1016/j.adaj.2018.12.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 12/21/2018] [Accepted: 12/25/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND Dentists contribute to the prevailing opioid epidemic in the United States. Concerning the population enrolled in Medicaid, little is known about dentists' opioid prescribing. METHODS The authors performed a retrospective cohort study of beneficiaries of Medicaid in Washington state with dental claims in 2014 and 2015. The primary outcome was the proportion of dental visits associated with an opioid prescription. The authors categorized visits as invasive or noninvasive by using procedure codes and each beneficiary as being at low or high risk by using his or her prescription history from the prescription drug monitoring program. RESULTS A total of 126,660 (10.3%) of all dental visits, most of which were invasive (66.9%), among the population enrolled in Medicaid in Washington state was associated with opioid prescriptions. However, noninvasive dental visits and visits for beneficiaries who had prior high-risk prescription use were associated with significantly higher mean days' supply and mean quantity of opioids prescribed. Results from the multivariate logistic regression showed that the probability of having an opioid-associated visit increased by 35.6 percentage points when the procedures were invasive and by 11.1 percentage points when the beneficiary had prior high-risk prescription use. CONCLUSIONS This baseline of opioid prescribing patterns after dental visits among the population enrolled in Medicaid in Washington state in 2014 and 2015 can inform future studies in which the investigators examine the effect of policies on opioid prescribing patterns and reasons for the variability in the dosage and duration of opioid prescriptions associated with noninvasive visits. PRACTICAL IMPLICATIONS Dentists must exercise caution when prescribing opioids during invasive visits and to patients with prior high-risk prescription use.
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Letter to the Editor: Prescription Opioid Type and the Likelihood of Prolonged Opioid Use After Orthopaedic Surgery. J Am Acad Orthop Surg 2019; 27:895-896. [PMID: 31008875 DOI: 10.5435/jaaos-d-19-00054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Rock AN, Akakpo K, Cheresnick C, Zmistowksi BM, Essig GF, Chio E, Nogan S. Postoperative Prescriptions and Corresponding Opioid Consumption After Septoplasty or Rhinoplasty. EAR, NOSE & THROAT JOURNAL 2019; 100:462S-466S. [PMID: 31610698 DOI: 10.1177/0145561319866824] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The objective of our study was to assess the relationship between postoperative opioid prescribing patterns and opioid consumption among patients who underwent septoplasty or rhinoplasty. A chart review of patients who underwent either septoplasty or rhinoplasty by 3 surgeons between July 2016 and June 2017 was performed, and pertinent clinical data were collected including the amount of narcotic pain medications prescribed. A telephone interview was then conducted to assess opioid usage and pain control regimen postoperatively. The number of opioid tablets prescribed and the number consumed were converted to total morphine milligram equivalent (MME) for uniform comparison. A total of 75 patients met the inclusion criteria, and 64 completed the telephone survey. Among these 64 patients, the mean (standard deviation [SD]) prescribed MME was 289.7 (101.3), and the mean (SD) consumed MME was 100.6 (109). Similarly, the mean (SD) number of opioid tablets prescribed was 42.4 (9.7), and the mean number of tablets consumed was 14.7 (16.3). Gender, procedure performed (septoplasty or rhinoplasty), use of Doyle splints, and surgeon were not associated with the amount of opioids prescribed or used. Subjective pain control was the only factor associated with an increase in opioid use (P = .0288). There was an overabundance of opioid pain medications prescribed compared to the amount consumed for pain control after septoplasty or rhinoplasty. Abuse of prescription opioids represents an important component of the nation's opioid crisis. Surgeons must be cognizant of the problem and adjust prescribing practices accordingly.
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Affiliation(s)
- Alexander N Rock
- Department of Otolaryngology-Head and Neck Surgery, 12306The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Kenneth Akakpo
- Department of Otolaryngology and Communication Sciences, 5506Medical College of Wisconsin, Milwaukee, WI, USA
| | - Corey Cheresnick
- Department of Otolaryngology-Head and Neck Surgery, 12306The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Garth F Essig
- Department of Otolaryngology-Head and Neck Surgery, 12306The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Eugene Chio
- Department of Otolaryngology-Head and Neck Surgery, 12306The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Stephen Nogan
- Department of Otolaryngology-Head and Neck Surgery, 12306The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Abstract
OBJECTIVE In the context of the current opioid epidemic, there has been a renewed interest in the use of ketamine as an analgesic agent. METHODS We reviewed ketamine analgesia. RESULTS Ketamine is well-known as an antagonist for N-methyl-D-aspartate receptors. In addition, it can regulate the function of opioid receptors and sodium channels. Ketamine also increases signaling through α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptors. These myriad of molecular and cellular mechanisms are responsible for a number of pharmacological functions including pain relief and mood regulation. Clinically, a number of studies have investigated the role of ketamine in the setting of acute and chronic pain, and there is evidence that ketamine can provide analgesia in a variety of pain syndromes. DISCUSSION In this review, we examined basic mechanisms of ketamine and its current clinical use and potential novel use in pain management.
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Griesler PC, Hu MC, Wall MM, Kandel DB. Medical Use and Misuse of Prescription Opioids in the US Adult Population: 2016-2017. Am J Public Health 2019; 109:1258-1265. [PMID: 31318593 DOI: 10.2105/ajph.2019.305162] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Objectives. To characterize prescription opioid medical users and misusers among US adults.Methods. We used the 2016-2017 National Surveys on Drug Use and Health to compare medical prescription opioid users with misusers without prescriptions, misusers of own prescriptions, and misusers with both types of misuse. Multinomial logistic regressions identified substance use characteristics and mental and physical health characteristics that distinguished the groups.Results. Among prescription opioid users, 12% were misusers; 58% of misusers misused their own prescriptions. Misusers had higher rates of substance use than did medical users. Compared with with-prescription-only misusers, without-and-with-prescription misusers and without-prescription-only misusers had higher rates of marijuana use and benzodiazepine misuse; without-and-with-prescription misusers had higher rates of heroin use. Compared with without-prescription-only misusers, without-and-with-prescription and with-prescription-only misusers had higher rates of prescription opioid use disorder. Most misusers, especially with-prescription-only misusers, used prescription opioids to relieve pain. Misusers were more likely to be depressed than medical users.Conclusions. Prescription opioid misusers who misused both their own prescriptions and prescription opioid drugs not prescribed to them may be most at risk for overdose. Prescription opioid misuse is a polysubstance use problem.
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Affiliation(s)
- Pamela C Griesler
- Pamela C. Griesler, Mei-Chen Hu, Melanie M. Wall, and Denise B. Kandel are with the Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, NY. Pamela C. Griesler, Melanie M. Wall, and Denise B. Kandel are also with the New York State Psychiatric Institute, New York
| | - Mei-Chen Hu
- Pamela C. Griesler, Mei-Chen Hu, Melanie M. Wall, and Denise B. Kandel are with the Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, NY. Pamela C. Griesler, Melanie M. Wall, and Denise B. Kandel are also with the New York State Psychiatric Institute, New York
| | - Melanie M Wall
- Pamela C. Griesler, Mei-Chen Hu, Melanie M. Wall, and Denise B. Kandel are with the Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, NY. Pamela C. Griesler, Melanie M. Wall, and Denise B. Kandel are also with the New York State Psychiatric Institute, New York
| | - Denise B Kandel
- Pamela C. Griesler, Mei-Chen Hu, Melanie M. Wall, and Denise B. Kandel are with the Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, NY. Pamela C. Griesler, Melanie M. Wall, and Denise B. Kandel are also with the New York State Psychiatric Institute, New York
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Abstract
BACKGROUND AND OBJECTIVES The opioid crisis in America affects both adults and children. However, knowledge about the epidemiology of the opioid crisis, opioid prescribing patterns, and the link between opioid prescribing and problematic opioid behaviors remain limited. Thus, children are often excluded from health care policies and guidelines aimed at curbing the opioid crises. The primary aim of this topical review is to provide a brief overview of the opioid crises affecting children, followed by a synopsis of recent research on opioid prescribing patterns and data on the links between legitimate opioid use and risk for problematic opioid use behaviors. METHODS This is a narrative review. RESULTS Opioid misuse is a public health crisis facing children and adolescents in the United States and serves as a key antecedent for other problematic opioid behaviors, including opioid use disorder, heroin use, and opioid overdose. Furthermore, the United States experienced a significant increase in opioid prescribing to children and adolescents as compared with prescribing rates before the year 2000. Yet, data on the associations between opioid prescribing patterns and risk for problematic opioid use remains limited. DISCUSSION There exist an urgent need to identify adolescents at increased risk for problematic opioid use behaviors following a receipt of medically prescribed opioids. The article closes with some general guidelines that providers may follow to reduce the risk of opioids in pediatric patients.
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Affiliation(s)
- Cornelius B Groenewald
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA
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Adogwa O, Davison MA, Lilly DT, Vuong VD, Desai SA, Moreno J, Cheng J, Bagley C. A 2-Year Cost Analysis of Maximum Nonoperative Treatments in Patients With Symptomatic Lumbar Stenosis or Spondylolisthesis That Ultimately Required Surgery. Global Spine J 2019; 9:424-433. [PMID: 31218202 PMCID: PMC6562213 DOI: 10.1177/2192568218824956] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES The purpose of this study is to characterize the utilization and costs of maximal nonoperative therapies (MNTs) within 2 years prior to spinal fusion surgery in patients with symptomatic lumbar stenosis or spondylolisthesis. METHODS A large insurance database was queried for patients with symptomatic lumbar stenosis or spondylolisthesis undergoing index 1-, 2-, or 3-level lumbar decompression and fusion procedures between 2007 and 2016. This database consists of 20.9 million covered lives and includes private/commercially insured and Medicare Advantage beneficiaries. The utilization of MNTs within 2 years prior to index surgery was assessed by cost billed to the patient, prescriptions written, and number of units billed. RESULTS A total of 27 877 out of 3 423 114 (0.8%) eligible patients underwent posterior lumbar instrumented fusion. Patient MNT utilization was as follows: 11 383 (40.8%) used nonsteroidal anti-inflammatory drugs (NSAIDs), 19 770 (70.9%) used opioids, 12 414 (44.5%) used muscle relaxants, 14 422 (51.7%) received lumbar epidural steroid injection (LESI), 11 156 (40.0%) attended physical therapy/occupational therapy, 4005 (14.4%) presented to the emergency department, and 4042 (14.5%) received chiropractor treatments. The total direct cost associated with all MNTs prior to index spinal fusion was $28 241 320 ($1013.07 per/patient). LESI comprised the largest portion of the total cost of MNT ($15 296 941, 54.2%), followed by opioids ($3 702 463, 13.1%) and NSAIDs ($3 058 335, 10.8%). CONCLUSIONS Opioids are the most frequently prescribed and most used therapy in the preoperative period. Assuming minimal improvement in pain and functional disability after maximum nonoperative therapies, the incremental cost effectiveness ratio for MNT could be highly unfavorable.
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Affiliation(s)
- Owoicho Adogwa
- Rush University Medical Center, Chicago, IL, USA,Owoicho Adogwa, Department of Neurosurgery, Rush
University Medical Center, 1725 W Harrison, Suite 855, Chicago, IL 60612, USA.
| | | | | | | | | | - Jessica Moreno
- University of Texas South Western Medical Center, Dallas, TX, USA
| | - Joseph Cheng
- University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Carlos Bagley
- University of Texas South Western Medical Center, Dallas, TX, USA
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Modeling the Prescription Opioid Epidemic. Bull Math Biol 2019; 81:2258-2289. [DOI: 10.1007/s11538-019-00605-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 04/09/2019] [Indexed: 10/27/2022]
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43
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Li G, Chihuri S. Prescription opioids, alcohol and fatal motor vehicle crashes: a population-based case-control study. Inj Epidemiol 2019; 6:11. [PMID: 31245260 PMCID: PMC6582661 DOI: 10.1186/s40621-019-0187-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 02/19/2019] [Indexed: 11/28/2022] Open
Abstract
Background The prevalence of prescription opioid use among drivers has increased markedly in the past two decades. The purpose of this study is to assess the associations of prescription opioid use and alcohol use with the risk of fatal crash involvement in US drivers. Methods We performed a population-based case-control study using toxicological testing data from two national data systems. Cases (n = 3606) were drivers involved in fatal motor vehicle crashes selected from the Fatality Analysis Reporting System and controls (n = 15,600) were drivers participating in the 2007 and 2013 National Roadside Surveys of Alcohol and Drug Use by Drivers. Multivariable logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs) of fatal crash involvement associated with prescription opioid use with and without the presence of alcohol. Results Overall, cases were significantly more likely than controls to test positive for prescription opioids (5.0% vs. 3.7%, p < 0.001), alcohol (56.2% vs. 7.1%, p < 0.0001), and both substances (2.2% vs. 0.2%, p < 0.001). Relative to drivers testing negative for prescription opioids and alcohol, the adjusted ORs of fatal crash involvement were 1.72 (95% CI: 1.37, 2.17) for those testing positive for prescription opioids and negative for alcohol, 17.92 (95% CI: 16.19, 19.84) for those testing positive for alcohol and negative for prescription opioids, and 21.89 (95% CI: 14.38, 33.32) for those testing positive for both substances. The interaction effect on fatal crash risk of prescription opioid use and alcohol use was not statistically significant on either additive or multiplicative scale. Conclusions Prescription opioid use is associated with a significantly increased risk of fatal crash involvement independently of alcohol use. Concurrent use of prescription opioids and alcohol is associated with a 21-fold increased risk of fatal crash involvement.
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Affiliation(s)
- Guohua Li
- 1Center for Injury Epidemiology and Prevention, Columbia University Irving Medical Center, 622 West 168th St, PH5-505, New York, NY 10032 USA.,2Department of Anesthesiology, Columbia University College of Physicians and Surgeons, 622 West 168th St, PH5-505, New York, NY 10032 USA.,3Department of Epidemiology, Columbia University Mailman School of Public Health, 622 West 168th St, PH5-505, New York, NY 10032 USA
| | - Stanford Chihuri
- 1Center for Injury Epidemiology and Prevention, Columbia University Irving Medical Center, 622 West 168th St, PH5-505, New York, NY 10032 USA.,2Department of Anesthesiology, Columbia University College of Physicians and Surgeons, 622 West 168th St, PH5-505, New York, NY 10032 USA
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Simon J, Gehret J, Stolzenberg D, Beredjiklian PK, Teng J, Paskey T, Raju R. Concomitant Use of Opioids and Benzodiazepines in the Outpatient Setting. PM R 2019; 11:337-343. [PMID: 30884142 DOI: 10.1016/j.pmrj.2018.09.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 08/26/2018] [Accepted: 09/06/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Benzodiazepines have been identified as a concurrent factor in opioid-related deaths. Although the dangers of concomitant administration of opioids and benzodiazepines are well documented, implementation of this knowledge into practice may be lagging behind. OBJECTIVE To examine the concomitant use of opioids and benzodiazepines in the outpatient setting. DESIGN Retrospective study. SETTING Academic outpatient multispecialty practice. PARTICIPANTS Over 2000 outpatient clinic visits from January 2018 to April 2018 among four physiatrists were analyzed. METHODS All patients were reviewed in the Prescription Drug Monitoring Program (PDMP) website to identify whether they have filled either opioid or benzodiazepine prescription(s) in the last 12 months. MAIN OUTCOME MEASUREMENTS Number of opioid and benzodiazepine prescriptions, discrepancies in reporting of medications, providers prescribing medications, and cigarette/alcohol use. RESULTS A total of 353 patients were identified to have filled either opioid or benzodiazepine prescription(s) in last 12 months. 49.4% of patients prescribed opioids were found to be taking benzodiazepines concurrently. Reporting discrepancies were noted between the outpatient electronic medical record and PDMP in 17.2% of patients. Among patients taking both opioids and benzodiazepines, 38.9% had multiple providers prescribing these medications, 41.9% were over 65 years old, and 11.9% were daily cigarette/alcohol users. Patients taking both types of drugs (opioids and benzodiazepines) were significantly more likely to use different providers (38.9%) compared to patients taking one type of drug (9.8%, P < .001). The former group was also noted to fill significantly more prescriptions than the latter group (P < .001). CONCLUSION The study results emphasize that clinicians may not be aware that some of their patients are concurrently taking opioids and benzodiazepines. These results highlight the importance of routinely checking the PDMP and using that information to make fully informed decisions to minimize risks in use of these controlled substances. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Jeremy Simon
- Department of Physical Medicine and Rehabilitation, Rothman Institute/Thomas Jefferson University Hospital, Philadelphia, PA
| | - Jeffrey Gehret
- Department of Physical Medicine and Rehabilitation, Rothman Institute/Thomas Jefferson University Hospital, Philadelphia, PA
| | - David Stolzenberg
- Department of Physical Medicine and Rehabilitation, Rothman Institute/Thomas Jefferson University Hospital, Philadelphia, PA
| | - Pedro K Beredjiklian
- Department of Hand and Wrist Surgery, Rothman Institute/Thomas Jefferson University Hospital, Philadelphia, PA
| | - Jonathon Teng
- Department of Physical Medicine and Rehabilitation, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Taylor Paskey
- Department of Physical Medicine and Rehabilitation, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Robin Raju
- Department of Physical Medicine and Rehabilitation, Rothman Institute/Thomas Jefferson University Hospital, 925 Chestnut Street, Philadelphia, PA 19107
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45
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Zhu W, Chernew ME, Sherry TB, Maestas N. Initial Opioid Prescriptions among U.S. Commercially Insured Patients, 2012-2017. N Engl J Med 2019; 380:1043-1052. [PMID: 30865798 PMCID: PMC6487883 DOI: 10.1056/nejmsa1807069] [Citation(s) in RCA: 113] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND The United States is undergoing a crippling opioid epidemic, spurred in part by overuse of prescription opioids by adults 25 to 64 years of age. Of concern are long-duration and high-dose initial prescriptions, which place the patients and their friends and relatives at heightened risk for long-term opioid use, misuse, overdose, and death. METHODS We estimated the incidence of initial opioid prescriptions in each month between July 2012 and December 2017 using administrative-claims data from across the United States (accessed through Blue Cross-Blue Shield [BCBS] Axis); monthly incidence was estimated as the percentage of enrollees who received an initial opioid prescription among those who had not used opioids (i.e., no opioid prescription or a diagnosis of opioid use disorder in the 6 months before a given month). We then estimated the percentage of enrollees initiating opioid therapy who received a long-duration or high-dose initial opioid prescription in each month during this period. We also calculated the number of providers who initiated opioid therapy in any patient who had not used opioids in each month and examined monthly trends in the duration and dose of initial opioid prescriptions in prescriber and patient subgroups. Our study sample included 63,817,512 enrollees who had not used opioids (mean, 15,897,673 per month). RESULTS The monthly incidence of initial opioid prescriptions among enrollees who had not used opioids declined by 54%, from 1.63% in July 2012 to 0.75% in December 2017. This decline was accompanied by a decreasing number of providers (from 114,043 in July 2012 to 80,462 in December 2017) who initiated opioid therapy in any patient who had not used opioids. Nonetheless, among the shrinking subgroup of physicians who initiated opioid therapy in such patients, high-risk prescribing (i.e., prescriptions for more than a 3-day supply or for a dose of 50 morphine milligram equivalents per day or higher) persisted at a monthly rate of 115,378 prescriptions per 15,897,673 enrollees who had not used opioids. CONCLUSIONS As the opioid crisis progressed between July 2012 and December 2017, many providers stopped initiating opioid therapy. Although the number of initial opioid prescriptions declined, a subgroup of providers continued to write high-risk initial opioid prescriptions. (Funded by the National Institute on Aging and a gift from Owen and Linda Robinson.).
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Affiliation(s)
- Wenjia Zhu
- From the Department of Health Care Policy, Harvard Medical School (W.Z., M.E.C., N.M.), RAND (T.B.S.), and the Department of Medicine, Brigham and Women's Hospital (T.B.S.) - all in Boston
| | - Michael E Chernew
- From the Department of Health Care Policy, Harvard Medical School (W.Z., M.E.C., N.M.), RAND (T.B.S.), and the Department of Medicine, Brigham and Women's Hospital (T.B.S.) - all in Boston
| | - Tisamarie B Sherry
- From the Department of Health Care Policy, Harvard Medical School (W.Z., M.E.C., N.M.), RAND (T.B.S.), and the Department of Medicine, Brigham and Women's Hospital (T.B.S.) - all in Boston
| | - Nicole Maestas
- From the Department of Health Care Policy, Harvard Medical School (W.Z., M.E.C., N.M.), RAND (T.B.S.), and the Department of Medicine, Brigham and Women's Hospital (T.B.S.) - all in Boston
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Ruhm CJ. Drivers of the fatal drug epidemic. JOURNAL OF HEALTH ECONOMICS 2019; 64:25-42. [PMID: 30784811 DOI: 10.1016/j.jhealeco.2019.01.001] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 12/23/2018] [Accepted: 01/09/2019] [Indexed: 05/06/2023]
Abstract
This study examines the contributions of the medium-run evolution of local economies and of changes in the "drug environment' in explaining county-level changes in drug and related mortality rates from 1999 to 2015. A primary finding is that drug mortality rates did increase more in counties experiencing relative economic decline than in those with more robust growth, but that the relationship is weak and mostly accounted for by confounding factors. In the preferred estimates, less than one-tenth of the rise in drug and opioid-involved fatality rates is explained and the contribution is even smaller, quite possibly zero, when allowing for plausible selection on unobservables. Conversely, the risk of drug deaths varies systematically over time across population subgroups in ways that are consistent with an important role for the public health environment related to the availability and cost of drugs. In particular, the relative risk and share of drug mortality increased rapidly for males and younger adults, compared to their counterparts, when the primary driver of the fatal drug epidemic transitioned from prescription to illicit opioids. These results suggest that efforts to improve local economies, while desirable for other reasons, are not likely to yield significant reductions in overdose mortality, but with greater potential for interventions directly addressing the drug environment.
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Affiliation(s)
- Christopher J Ruhm
- Frank Batten School of Leadership & Public Policy, University of Virginia, 235 McCormick Road, P.O. Box 400893, Charlottesville, VA, 22904-4893, United States.
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Changes in pain intensity after discontinuation of long-term opioid therapy for chronic noncancer pain. Pain 2019; 159:2097-2104. [PMID: 29905648 DOI: 10.1097/j.pain.0000000000001315] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Little is known about changes in pain intensity that may occur after discontinuation of long-term opioid therapy (LTOT). The objective of this study was to characterize pain intensity after opioid discontinuation over 12 months. This retrospective U.S. Department of Veterans Affairs (VA) administrative data study identified N = 551 patients nationally who discontinued LTOT. Data over 24 months (12 months before and after discontinuation) were abstracted from VA administrative records. Random-effects regression analyses examined changes in 0 to 10 pain numeric rating scale scores over time, whereas growth mixture models delineated pain trajectory subgroups. Mean estimated pain at the time of opioid discontinuation was 4.9. Changes in pain after discontinuation were characterized by slight but statistically nonsignificant declines in pain intensity over 12 months after discontinuation (B = -0.20, P = 0.14). Follow-up growth mixture models identified 4 pain trajectory classes characterized by the following postdiscontinuation pain levels: no pain (average pain at discontinuation = 0.37), mild clinically significant pain (average pain = 3.90), moderate clinically significant pain (average pain = 6.33), and severe clinically significant pain (average pain = 8.23). Similar to the overall sample, pain trajectories in each of the 4 classes were characterized by slight reductions in pain over time, with patients in the mild and moderate pain trajectory categories experiencing the greatest pain reductions after discontinuation (B = -0.11, P = 0.05 and B = -0.11, P = 0.04, respectively). Pain intensity after discontinuation of LTOT does not, on average, worsen for patients and may slightly improve, particularly for patients with mild-to-moderate pain at the time of discontinuation. Clinicians should consider these findings when discussing risks of opioid therapy and potential benefits of opioid taper with patients.
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Osborne V, Striley CW, Nixon SJ, Winterstein AG, Cottler LB. Sex differences in patterns of prescription opioid non-medical use among 10-18 year olds in the US. Addict Behav 2019; 89:163-171. [PMID: 30316142 DOI: 10.1016/j.addbeh.2018.10.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 09/10/2018] [Accepted: 10/07/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Non-medical use (NMU) of prescription opioids is a public health concern and sex differences in prevalence of NMU have been observed previously. Little is known about how youth are obtaining and using these drugs. While any regular use could be problematic, NMU is particularly concerning. More information is needed on NMU patterns among youth and how these patterns might differ by sex. METHODS The National Monitoring of Adolescent Prescription Stimulants Study (N-MAPSS) recruited youth 10-18 years of age from 10 US metropolitan areas from 2008 to 2011 with a final sample of 11,048 youth. The cross-sectional survey included questions on past 30 day use of prescription opioids (10,965 provided responses), with NMU defined as non-oral use and/or use of someone else's opioids. NMU through use of a patient's own prescription orally for a reason other than prescribed could not be identified, though this is usually contained within the standard definition of NMU. RESULTS Among the 10,965 youth, past 30 day prevalence of NMU of prescription opioids was 3.1% (n = 345) with 59.7% (n = 206) using someone else's opioids only, 5.2% (n = 18) having non-oral use only and 35.1% (n = 121) having both. In total, seven sources and three routes of administration were assessed. The most common source among males was someone from school (n = 111, 60.0%), with no highly prevalent second source. Among females, there were two prevalent sources of prescription opioids; a parent (n = 59,41.6%) and someone from school (n = 53,37.3%). For non-oral use, snorting prescription opioids was more frequent among males compared to females (n = 85, 31.8% and n = 44, 17.1%; p < .01). CONCLUSIONS Based on these findings, to combat the current opioid crisis, implementation of strategies to prevent youth from sharing opioids, especially with friends from school, should be considered and tested.
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Rubenstein E, Young JC, Croen LA, DiGuiseppi C, Dowling NF, Lee LC, Schieve L, Wiggins LD, Daniels J. Brief Report: Maternal Opioid Prescription from Preconception Through Pregnancy and the Odds of Autism Spectrum Disorder and Autism Features in Children. J Autism Dev Disord 2019; 49:376-382. [PMID: 30132098 PMCID: PMC6331251 DOI: 10.1007/s10803-018-3721-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Opioid use during pregnancy is associated with suboptimal pregnancy outcomes. Little is known about child neurodevelopmental outcomes. We examined associations between maternal opioid prescriptions preconception to delivery (peri-pregnancy) and child's risk of ASD, developmental delay/disorder (DD) with no ASD features, or ASD/DD with autism features in the Study to Explore Early Development, a case-control study of neurodevelopment. Preconception opioid prescription was associated with 2.43 times the odds of ASD [95% confidence interval (CI) 0.99, 6.02] and 2.64 times the odds of ASD/DD with autism features (95% CI 1.10, 6.31) compared to mothers without prescriptions. Odds for ASD and ASD/DD were non-significantly elevated for first trimester prescriptions. Work exploring mechanisms and timing between peri-pregnancy opioid use and child neurodevelopment is needed.
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Affiliation(s)
- Eric Rubenstein
- Waisman Center, University of Wisconsin-Madison, Rm 529, 1500 Highland Avenue, Madison, WI, 53705, USA.
| | - Jessica C Young
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27599, USA
| | - Lisa A Croen
- Kaiser Permanente Division of Research, 2000 Broadway, Oakland, CA, 94612, USA
| | - Carolyn DiGuiseppi
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus School of Public Health, 13001 E. 17th Place, Aurora, CO, 80045, USA
| | - Nicole F Dowling
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30329, USA
| | - Li-Ching Lee
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Laura Schieve
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30329, USA
| | - Lisa D Wiggins
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30329, USA
| | - Julie Daniels
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27599, USA
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National Trends and Factors Associated With Inpatient Mortality in Adult Patients With Opioid Overdose. Anesth Analg 2019; 128:152-160. [DOI: 10.1213/ane.0000000000003755] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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