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Lim G, Xue L, Donohue JM, Junker S, Wilson JD, Suffoletto B, Lynch MJ, Pacella-LaBarbara ML, Chang CCH, Krans E, Jarlenski M. Associations between acute pain after vaginal delivery and postpartum opioid prescription fills: a retrospective case-controlled study. Br J Anaesth 2024; 132:978-981. [PMID: 38423825 DOI: 10.1016/j.bja.2024.01.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 01/16/2024] [Accepted: 01/22/2024] [Indexed: 03/02/2024] Open
Affiliation(s)
- Grace Lim
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Lingshu Xue
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - Julie M Donohue
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - Stefanie Junker
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - J Deanna Wilson
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Brian Suffoletto
- Department of Emergency Medicine, Stanford University, Palo Alto, CA, USA
| | - Michael J Lynch
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Chung-Chou H Chang
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Elizabeth Krans
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Magee-Women's Research Institute, Pittsburgh, PA, USA
| | - Marian Jarlenski
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
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2
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Kelley CJ, Niznik JD, Ferreri SP, Schlusser C, Armistead LT, Hughes TD, Henage CB, Busby-Whitehead J, Roberts E. Patient Perceptions of Opioids and Benzodiazepines and Attitudes Toward Deprescribing. Drugs Aging 2023; 40:1113-1122. [PMID: 37792262 PMCID: PMC10768261 DOI: 10.1007/s40266-023-01071-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Opioids and benzodiazepines (BZDs) pose a public health problem. Older adults are especially susceptible to adverse events from opioids and BZDs owing to an increased usage of opioids and BZDs, multiple comorbidities, and polypharmacy. Deprescribing is a possible, yet challenging, solution to reducing opioid and BZD use. OBJECTIVE We aimed to explore older adult patients' knowledge of opioids and BZDs, perceived facilitators and barriers to deprescribing opioids and BZDs, and attitudes toward alternative treatments for opioids and BZDs. METHODS We conducted 11 semi-structured interviews with patients aged 65+ years with long-term opioid and/or BZD prescriptions. The interview guide was developed by an interprofessional team and focused on patients' knowledge of opioids and BZDs, perceived ability to reduce opioid or BZD use, and attitudes towards alternative treatments. RESULTS Three patients had taken opioids, either currently or in the past, three had taken BZDs, and five had taken both opioids and BZDs. Generally, knowledge of opioids and BZDs was variable among patients; yet facilitators and barriers to deprescribing both opioids and BZDs were consistent. Facilitators of deprescribing included patient-provider trust and slow tapering of medications, while barriers included concerns about re-emergence of symptoms and a lack of motivation, particularly if medications and symptoms were stable. Patients were generally unenthusiastic about pursuing alternative pharmacologic and non-pharmacologic alternatives to opioids and BZDs for symptom management. CONCLUSIONS Our findings indicate that patients are open to deprescribing opioids and BZDs under certain circumstances, but overall remain hesitant with a lack of enthusiasm for alternative treatments. Future studies should focus on supportive approaches to alleviate older adults' deprescribing concerns.
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Affiliation(s)
- Casey J Kelley
- Division of Geriatric Medicine and Center for Aging and Health, School of Medicine, University of North Carolina at Chapel Hill, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA
| | - Joshua D Niznik
- Division of Geriatric Medicine and Center for Aging and Health, School of Medicine, University of North Carolina at Chapel Hill, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA.
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA.
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA.
| | - Stefanie P Ferreri
- Division of Practice Advancement and Clinical Education, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Courtney Schlusser
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lori T Armistead
- Division of Practice Advancement and Clinical Education, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Tamera D Hughes
- Division of Practice Advancement and Clinical Education, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Cristine B Henage
- Division of Geriatric Medicine and Center for Aging and Health, School of Medicine, University of North Carolina at Chapel Hill, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA
| | - Jan Busby-Whitehead
- Division of Geriatric Medicine and Center for Aging and Health, School of Medicine, University of North Carolina at Chapel Hill, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA
| | - Ellen Roberts
- Division of Geriatric Medicine and Center for Aging and Health, School of Medicine, University of North Carolina at Chapel Hill, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA
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Shabbir F, Bashir A. Moderating effects of stress coping: evaluating the relationships between personality and prescription drug misuse amongst Young adults. JOURNAL OF SUBSTANCE USE 2023. [DOI: 10.1080/14659891.2023.2183908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Affiliation(s)
- Farokh Shabbir
- Sardar Yasin Malik Professional Development Centre University of Karachi, Karachi, Pakistan
| | - Asma Bashir
- Department of Biosciences, Faculty of Life Sciences, Shaheed Zulfikar Ali Bhutto Institute of Science and Technology (SZABIST), Karachi, Pakistan
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Falise AM, Sharma V, Hoeflich CC, Lopez-Quintero C, Striley CW. Screening the "Invisible Population" of Older Adult Patients for Prescription Pain Reliever Non-Medical Use and Use Disorders. Subst Use Misuse 2022; 58:153-159. [PMID: 36519790 PMCID: PMC10104763 DOI: 10.1080/10826084.2022.2148483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background: In the United States, the number of older adults reporting non-medical use of prescription pain relievers (NMUPPR) between 2015 and 2019 has remained constant, while those meeting criteria for opioid use disorders (OUDs) between 2013 and 2018 increased three-fold. These rates are expected to increase due to increased life expectancy among this population coupled with higher rates of substance use. However, they have consistently lower screening rates for problematic prescription pain reliever use, compared to younger cohorts. Objectives: This commentary reviewed trends in older adult NMUPPR and OUDs and reviewed several available screening tools. We then considered reasons why providers may not be screening their patients, with a focus on older adults, for NMUPPR and OUDs. Finally, we provided recommendations to increase screenings in healthcare settings. Results: Low screening rates in older adult patients may be due to several contributing factors, such as providers' implicit biases and lack of training, time constraints, and comorbid conditions that mask NMUPPR and OUD-related symptoms. Recommendations include incorporating more addiction-related curricula in medical schools, encouraging participation in CME training focused on substance use, attending implicit bias training, and breaking down the silos between pharmacy and geriatric, addiction, and family medicine. Conclusions: There is a growing need for older adult drug screenings, and we have provided several recommendations for improvement. By increasing screenings among older populations, providers will assist in the identification and referral of patients to appropriate and timely substance use treatment and resources to ultimately ameliorate the health of older adult patients.
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Affiliation(s)
- Alyssa M. Falise
- Department of Epidemiology, College of Public Health & Health Professions and College of Medicine, University of Florida, Gainesville, FL, USA
| | - Vinita Sharma
- Department of Epidemiology, College of Public Health & Health Professions and College of Medicine, University of Florida, Gainesville, FL, USA
- School of Public and Population Health, Boise State University, Boise, ID, USA
| | - Carolin C. Hoeflich
- Department of Epidemiology, College of Public Health & Health Professions and College of Medicine, University of Florida, Gainesville, FL, USA
| | - Catalina Lopez-Quintero
- Department of Epidemiology, College of Public Health & Health Professions and College of Medicine, University of Florida, Gainesville, FL, USA
| | - Catherine W. Striley
- Department of Epidemiology, College of Public Health & Health Professions and College of Medicine, University of Florida, Gainesville, FL, USA
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5
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Chronic Pain. Hematol Oncol Clin North Am 2022; 36:1151-1165. [DOI: 10.1016/j.hoc.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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6
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Zhang S, Silverman A, Suen SC, Andrews C, Chen BK. Differential patterns of opioid misuse between younger and older adults - a retrospective observational study using data from South Carolina's prescription drug monitoring program. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2022; 48:618-628. [PMID: 36194086 DOI: 10.1080/00952990.2022.2124380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background: Most research on opioid misuse focuses on younger adults, yet opioid-related mortality has risen fastest among older Americans over age 55.Objectives: To assess whether there are differential patterns of opioid misuse over time between younger and older adults and whether South Carolina's mandatory Prescription Drug Monitoring Program (PDMP) affected opioid misuse differentially between the two groups.Methods: We used South Carolina's Reporting and Identification Prescription Tracking System from 2010 to 2018 to calculate an opioid misuse score for 193,073 patients (sex unknown) using days' supply, morphine milligram equivalents (MME), and the numbers of unique prescribers and dispensaries. Multivariable regression was used to assess differential opioid misuse patterns by age group over time and in response to implementation of South Carolina's mandatory PDMP in 2017.Results: We found that between 2011 and 2018, older adults received 57% (p < .01) more in total MME and 25.4 days more (p < .01) in supply, but received prescriptions from fewer doctors (-0.063 doctors, p < 01) and pharmacies (-0.11 pharmacies, p < 01) per year versus younger adults. However, older adults had lower odds of receiving a high misuse score (OR 0.88, p < .01). After the 2017 legislation, misuse scores fell among younger adults (OR 0.79, p < .01) relative to 2011, but not among older adults.Conclusion: Older adults may misuse opioids differently compared to younger adults. Assessment of policies to reduce opioid misuse should take into account subgroup differences that may be masked at the population level.
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Affiliation(s)
- Suyanpeng Zhang
- Daniel J. Epstein Department of Industrial & Systems Engineering, University of Southern California, Los Angeles, CA, USA
| | - Allie Silverman
- Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Sze-Chuan Suen
- Daniel J. Epstein Department of Industrial & Systems Engineering, University of Southern California, Los Angeles, CA, USA
| | - Christina Andrews
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Brian K Chen
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
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7
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Niznik JD, Collins BJ, Armistead LT, Larson CK, Kelley CJ, Hughes TD, Sanders KA, Carlson R, Ferreri SP. Pharmacist interventions to deprescribe opioids and benzodiazepines in older adults: A rapid review. Res Social Adm Pharm 2022; 18:2913-2921. [PMID: 34281786 PMCID: PMC8836277 DOI: 10.1016/j.sapharm.2021.07.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 07/13/2021] [Accepted: 07/14/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Many older adults are prescribed opioids and benzodiazepines (BZDs), despite increased susceptibility to adverse events. Challenges of deprescribing include fragmented care and lack of knowledge or time. Pharmacists are well-positioned to overcome these challenges and facilitate deprescribing of these medications. OBJECTIVES We sought to evaluate interventions utilizing pharmacists to deprescribe opioids and BZDs in older adults. METHODS We conducted a rapid review following a comprehensive literature search to identify interventions with pharmacist involvement for deprescribing opioids and BZDs in older adults. Studies were included based on: (1) inclusion of patients ≥ 65 years old receiving BZDs and/or opioids, (2) evaluation of feasibility or outcomes following deprescribing (3) pharmacists as part of the intervention. We included randomized, observational, cohort, and pilot studies. Studies that did not report specific results for BZD or opioids were excluded. RESULTS We screened 687 abstracts and included 17 studies. Most (n = 13) focused on BZD deprescribing. Few studies focused on opioids (n = 2) or co-prescribing of opioids and BZDs (n = 2). The most common intervention was educational brochures (n = 8), majority being the EMPOWER brochure for deprescribing BZDs. Other interventions included chart review with electronic notes (n = 4), pharmacist-led programs/services (n = 2), and multifactorial interventions (n = 3). Many studies were underpowered or lacked suitable control groups. Generally speaking, interventions utilizing educational materials and those in which pharmacists engaged with patients and providers were more effective. Interventions relying on electronic communication by pharmacists were less successful, due to low acceptance or acknowledgement. CONCLUSIONS We identified a number of feasible interventions to reduce BZD use, but fewer interventions to reduce opioid use in older adults. An optimal approach for deprescribing likely requires pharmacists to engage directly with patients and providers. Larger well-designed studies are needed to evaluate the effectiveness of deprescribing interventions beyond feasibility.
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Affiliation(s)
- Joshua D Niznik
- University of North Carolina School of Medicine, Division of Geriatric Medicine and Center for Aging and Health, Chapel Hill, NC, USA; University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA; VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA.
| | - Brendan J Collins
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Lori T Armistead
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Claire K Larson
- University of North Carolina School of Medicine, Division of Geriatric Medicine and Center for Aging and Health, Chapel Hill, NC, USA
| | - Casey J Kelley
- University of North Carolina School of Medicine, Division of Geriatric Medicine and Center for Aging and Health, Chapel Hill, NC, USA
| | - Tamera D Hughes
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Kimberly A Sanders
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Rebecca Carlson
- University of North Carolina, Health Sciences Library, Chapel Hill, NC, USA
| | - Stefanie P Ferreri
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
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Bauer MR, Larson MJ, Moresco N, Huntington N, Walker R, Richard P. Association between 1-year patient outcomes and opioid-prescribing group of emergency department clinicians: A cohort study with Army active-duty soldiers. Acad Emerg Med 2021; 28:1251-1261. [PMID: 34245641 PMCID: PMC10393064 DOI: 10.1111/acem.14331] [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: 03/09/2021] [Revised: 06/07/2021] [Accepted: 06/23/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective was to examine the association between clinicians' opioid prescribing group and patients' outcomes among patients treated in the emergency department (ED). METHODS This was a retrospective cohort study. The setting was the EDs of the U.S. Military Health System (MHS). Patients were 181,557 Army active-duty opioid-naïve (no fill in past 180 days) patients with an index encounter to the ED between October 2010 and September 2016. Exposure was patients classified by opioid prescribing tier of the treating ED clinician: top, middle, or bottom third relative to the clinician's peers in the same ED. Follow-up measurement was from 31 to 365 days after the index encounter. The primary outcome was long-term opioid prescriptions (LTOPs) defined as 180 (or more) days' supply within the follow-up window. We also computed the total morphine milligram equivalents (MME) and total opioid days' supply. Secondary measures were any repeat ED encounter, any hospitalization, any sick leave, and any military-duty restriction. RESULTS We found a 2.5-fold variation in opioid prescribing rates among clinicians in the same MHS ED. Controlling for sample demographics, reason for encounter, and military background, in multivariate analyses the odds of receiving a 180-day opioid supply during follow-up were 1.19 (95% confidence interval [CI] = 1.01 to 1.40, p < 0.05) for the top opioid exposure group and 1.37 (95% CI = 1.19 to 1.57, p < 0.001) for the middle opioid exposure group compared to the bottom exposure group, and there were significant increases in total opioid days' supply and total MME. There were no differences in secondary outcome measures. CONCLUSION In a relatively healthy sample of Army soldiers, variation in opioid exposure defined by clinician's prescribing history was associated with increased odds of LTOP and increase in opioid volume, but not in functional outcomes.
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Affiliation(s)
- Mark R. Bauer
- Institute for Behavioral Health The Heller School for Social Policy and Management Brandeis University Waltham MA USA
| | - Mary Jo Larson
- Institute for Behavioral Health The Heller School for Social Policy and Management Brandeis University Waltham MA USA
| | - Natalie Moresco
- Institute for Behavioral Health The Heller School for Social Policy and Management Brandeis University Waltham MA USA
| | - Nick Huntington
- Institute for Behavioral Health The Heller School for Social Policy and Management Brandeis University Waltham MA USA
| | - Regine Walker
- Uniformed Services University of the Health Sciences Bethesda MD USA
| | - Patrick Richard
- Uniformed Services University of the Health Sciences Bethesda MD USA
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9
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Axon DR, Slack M, Barraza L, Lee JK, Warholak T. Nationally Representative Health Care Expenditures of Community-Based Older Adults with Pain in the United States Prescribed Opioids vs Those Not Prescribed Opioids. PAIN MEDICINE 2021; 22:282-291. [PMID: 32358611 DOI: 10.1093/pm/pnaa114] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To compare health care expenditures between older US adults (≥50 years) with pain who were prescribed opioid medications and those who were not. DESIGN Cross-sectional. SETTING Community-based adults in the 2015 Medical Expenditure Panel Survey (MEPS). SUBJECTS Nationally representative sample of US adults alive for the calendar year, aged 50 years or older, who reported having pain in the past four weeks. METHODS Older US adults (≥50 years) with pain in the 2015 MEPS data were identified. The key independent variable was opioid prescription status (prescribed opioid vs not prescribed opioid). Hierarchical linear regression models assessed health care expenditures (inpatient, outpatient, office-based, emergency room, prescription medications, other, and total) in US dollars for opioid prescription status from a community-dwelling US population perspective, adjusting for covariates. RESULTS The 2015 study cohort provided a national estimate of 50,898,592 noninstitutionalized US adults aged ≥50 years with pain in the past four weeks (prescribed opioid N = 16,757,516 [32.9%], not prescribed opioid N = 34,141,076 [67.1%]). After adjusting for covariates, individuals prescribed an opioid had 61% greater outpatient (β = 0.477, P < 0.0001), 69% greater office-based (β = 0.524, P < 0.0001), 14% greater emergency room (β = 0.131, P = 0.0045), 63% greater prescription medication (β = 0.486, P < 0.0001), 29% greater other (β = 0.251, P = 0.0002), and 105% greater total (β = 0.718, P < 0.0001) health care expenditures. There was no difference in opioid prescription status for inpatient expenditures (P > 0.05). CONCLUSIONS This study raises awareness of the economic impact associated with opioid use among US older adults with pain. Future research should investigate these variables in greater depth, over longer time periods, and in additional populations.
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Affiliation(s)
- David R Axon
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona, USA
| | - Marion Slack
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona, USA
| | - Leila Barraza
- Community, Environment, and Policy Department, University of Arizona College of Public Health, Tucson, Arizona, USA
| | - Jeannie K Lee
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona, USA
| | - Terri Warholak
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona, USA
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Keller MS, Truong L, Mays AM, Needleman J, Heilemann MSV, Nuckols TK. How do contraindications to non-opioid analgesics and opioids affect the likelihood that patients with back pain diagnoses in the primary care setting receive an opioid prescription? An observational cross-sectional study. BMC FAMILY PRACTICE 2021; 22:41. [PMID: 33610181 PMCID: PMC7896404 DOI: 10.1186/s12875-021-01386-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 02/08/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND Given the risks of opioids, clinicians are under growing pressure to treat pain with non-opioid medications. Yet non-opioid analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) have their own risks: patients with kidney disease or gastrointestinal diseases can experience serious adverse events. We examined the likelihood that patients with back pain diagnoses and contraindications to NSAIDs and opioids received an opioid prescription in primary care. METHODS We identified office visits for back pain from 2012 to 2017 and sampled the first office visit per patient per year (N = 24,543 visits). We created indicators reflecting contraindications for NSAIDs (kidney, liver, cardiovascular/cerebrovascular, and gastrointestinal diseases; concurrent or chronic use of anticoagulants/antiplatelets, chronic corticosteroid use) and opioids (depression, anxiety, substance use (SUD) and bipolar disorders, and concurrent benzodiazepines) and estimated four logistic regression models, with the one model including all patient visits and models 2-4 stratifying for previous opioid use. We estimated the population attributable risk for each contraindication. RESULTS In our model with all patients-visits, patients received an opioid prescription at 4% of visits. The predicted probability (PP) of receiving an opioid was 4% without kidney disease vs. 7% with kidney disease; marginal effect (ME): 3%; 95%CI: 1-4%). For chronic or concurrent anticoagulant/antiplatelet prescriptions, the PPs were 4% vs. 6% (ME: 2%; 95%CI: 1-3%). For concurrent benzodiazepines, the PPs were 4% vs. 11% (ME: 7%, 95%CI: 5-9%) and for SUD, the PPs were 4% vs. 5% (ME: 1%, 95%CI: 0-3%). For the model including patients with previous long-term opioid use, the PPs for concurrent benzodiazepines were 25% vs. 24% (ME: -1%; 95%CI: - 18-16%). The population attributable risk (PAR) for NSAID and opioid contraindications was small. For kidney disease, the PAR was 0.16% (95%CI: 0.08-0.23%), 0.44% (95%CI: 0.30-0.58%) for anticoagulants and antiplatelets, 0.13% for substance use (95%CI: 0.03-0.22%) and 0.20% for concurrent benzodiazepine use (95%CI: 0.13-0.26%). CONCLUSIONS Patients with diagnoses of kidney disease and concurrent use of anticoagulants/antiplatelet medications had a higher probability of receiving an opioid prescription at a primary care visit for low back pain, but these conditions do not explain a large proportion of the opioid prescriptions.
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Affiliation(s)
- Michelle S Keller
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Los Angeles, CA, 90048, USA.
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA.
| | - Lyna Truong
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Allison M Mays
- Division of Geriatrics, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jack Needleman
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | | | - Teryl K Nuckols
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Los Angeles, CA, 90048, USA
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11
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Lobo CP, Cochran G, Chang CCH, Gellad WF, Gordon AJ, Jalal H, Lo-Ciganic WH, Karp JF, Kelley D, Donohue JM. Associations Between the Specialty of Opioid Prescribers and Opioid Addiction, Misuse, and Overdose Outcomes. PAIN MEDICINE 2020; 21:1871-1890. [PMID: 31626295 DOI: 10.1093/pm/pnz234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To examine associations between opioid prescriber specialty and patient likelihood of opioid use disorder (OUD), opioid misuse, and opioid overdose. DESIGN Longitudinal retrospective study using Pennsylvania Medicaid data (2007-2015). METHODS We constructed an incident cohort of 432,110 enrollees initiating prescription opioid use without a history of OUD or overdose six months before opioid initiation. We attributed patients to one of 10 specialties using the first opioid prescriber's specialty or, alternatively, the specialty of the dominant prescriber writing the majority of the patient's opioid prescriptions. We estimated adjusted rates for OUD, misuse, and overdose, adjusting for demographic variables and medical (including pain) and psychiatric comorbidities. RESULTS The unadjusted incidence rates of OUD, misuse, and overdose were 7.13, 4.73, and 0.69 per 100,000 person-days, respectively. Patients initiating a new episode of opioid treatment with Pain Medicine/Anesthesiology (6.7 events, 95% confidence interval [CI] = 5.5 to 8.2) or Physical Medicine and Rehabilitation (PM&R; 6.1 events, 95% CI = 5.1 to 7.2) had higher adjusted rates for OUD per 100,000 person-days compared with Primary Care practitioners (PCPs; 4.4 events, 95% CI = 4.1 to 4.7). Patients with index prescriptions from Pain Medicine/Anesthesiology (15.9 events, 95% CI = 13.2 to 19.3) or PM&R (15.8 events, 95% CI = 13.5 to 18.4) had higher adjusted rates for misuse per 100,000 person-days compared with PCPs (9.6 events, 95% CI = 8.8 to 10.6). Findings were largely similar when patients were attributed to specialty based on dominant prescriber. CONCLUSIONS Differences in opioid-related risks by specialty of opioid prescriber may arise from differences in patient risk factors, provider behavior, or both. Our findings inform targeting of opioid risk mitigation strategies to specific practitioner specialties.
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Affiliation(s)
- Carroline P Lobo
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Gerald Cochran
- Division of Epidemiology, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Chung-Chou H Chang
- Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Walid F Gellad
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Division of General Internal Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Adam J Gordon
- Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0) VA Salt Lake City Healthcare System.,Department of General Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Hawre Jalal
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, Florida
| | - Jordan F Karp
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David Kelley
- Office of Medical Assistance Programs, Pennsylvania Department of Human Services, Harrisburg, Pennsylvania, USA
| | - Julie M Donohue
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania.,Division of General Internal Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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12
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Do D. The impact of Medicare Part D on opioid use among U.S. older adults. Drug Alcohol Depend 2020; 212:108069. [PMID: 32474361 DOI: 10.1016/j.drugalcdep.2020.108069] [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: 02/13/2020] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND To assess the association between the implementation of Medicare Part D and the use of outpatient prescription opioids. METHODS Nationally representative data on community-dwelling adults aged 60-69 came from the 2000-2015 Medical Expenditure Panel Survey (MEPS) (N = 26,545). A difference-in-differences approach was used to compare opioid use between Medicare eligible (ages 66-69) and Medicare ineligible (ages 60-64) adults before and after the introduction of Part D in 2006, while controlling for socio-demographic characteristics, risk factors for opioid use, and secular trends. RESULTS Medicare Part D was associated with a small and statistically non-significant increase in the number of outpatient prescription opioids filled in a year (coefficient, 0.03; 95% CI, -0.08 to 0.13), in the amount of morphine milligrams equivalents (coefficient, 113.23; 95% CI, -25.47 to 251.93), and in the odds of using any prescription opioid (OR, 1.03; 95% CI, 0.85 to 1.26). There was no evidence for a heterogeneous effect of Part D across subgroups. The results were robust to the impacts of the 2007-2009 recession, the spillover effect of the Affordable Care Act, and the anticipation effect of Part D. DISCUSSION Although policymakers suggested that gaining access to medical care as a result of insurance expansion might have fueled the opioid epidemic, this paper found limited evidence to support this claim. While Part D took effect more than a decade ago, its long-term implication for opioid use is still relevant for the recent opioid epidemic and future health insurance expansions such as the proposed Medicare-for-all initiative.
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Affiliation(s)
- Duy Do
- Population Studies Center, The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany.
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13
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Anwar M, Khoury D, Aldridge AP, Parker SJ, Conway KP. Using Twitter to Surveil the Opioid Epidemic in North Carolina: An Exploratory Study. JMIR Public Health Surveill 2020; 6:e17574. [PMID: 32469322 PMCID: PMC7380977 DOI: 10.2196/17574] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 04/27/2020] [Accepted: 05/15/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Over the last two decades, deaths associated with opioids have escalated in number and geographic spread, impacting more and more individuals, families, and communities. Reflecting on the shifting nature of the opioid overdose crisis, Dasgupta, Beletsky, and Ciccarone offer a triphasic framework to explain that opioid overdose deaths (OODs) shifted from prescription opioids for pain (beginning in 2000), to heroin (2010 to 2015), and then to synthetic opioids (beginning in 2013). Given the rapidly shifting nature of OODs, timelier surveillance data are critical to inform strategies that combat the opioid crisis. Using easily accessible and near real-time social media data to improve public health surveillance efforts related to the opioid crisis is a promising area of research. OBJECTIVE This study explored the potential of using Twitter data to monitor the opioid epidemic. Specifically, this study investigated the extent to which the content of opioid-related tweets corresponds with the triphasic nature of the opioid crisis and correlates with OODs in North Carolina between 2009 and 2017. METHODS Opioid-related Twitter posts were obtained using Crimson Hexagon, and were classified as relating to prescription opioids, heroin, and synthetic opioids using natural language processing. This process resulted in a corpus of 100,777 posts consisting of tweets, retweets, mentions, and replies. Using a random sample of 10,000 posts from the corpus, we identified opioid-related terms by analyzing word frequency for each year. OODs were obtained from the Multiple Cause of Death database from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (CDC WONDER). Least squares regression and Granger tests compared patterns of opioid-related posts with OODs. RESULTS The pattern of tweets related to prescription opioids, heroin, and synthetic opioids resembled the triphasic nature of OODs. For prescription opioids, tweet counts and OODs were statistically unrelated. Tweets mentioning heroin and synthetic opioids were significantly associated with heroin OODs and synthetic OODs in the same year (P=.01 and P<.001, respectively), as well as in the following year (P=.03 and P=.01, respectively). Moreover, heroin tweets in a given year predicted heroin deaths better than lagged heroin OODs alone (P=.03). CONCLUSIONS Findings support using Twitter data as a timely indicator of opioid overdose mortality, especially for heroin.
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Affiliation(s)
- Mohd Anwar
- North Carolina A&T State University, Greensboro, NC, United States
| | - Dalia Khoury
- Research Triangle Institute International, Research Triangle Park, NC, United States
| | - Arnie P Aldridge
- Research Triangle Institute International, Research Triangle Park, NC, United States
| | - Stephanie J Parker
- Research Triangle Institute International, Research Triangle Park, NC, United States
| | - Kevin P Conway
- Research Triangle Institute International, Research Triangle Park, NC, United States
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14
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Abstract
Substance use disorder prevalence in older adults is increasing as the baby boom generation ages. Of the different substances with concern for misuse and use disorder, alcohol, prescription drugs, and illicit drugs are the leading causes. High-risk drinking and alcohol use disorder is the leading substance use disorder in older adults. Prescription drug misuse and use disorder in older adults are the second leading cause for substance use disorder and most commonly involves prescription opioids and benzodiazepines. Illicit drug use in older adults is also increasing. Substance use disorders are difficult to recognize in older adults due to medical comorbidity, neurocognitive impairment, and functional decline. Older adults are also more susceptible to drug effects due to decreased hepatic and renal clearance of the substances. Older adults should be screened and assessed for substance use disorders, and when diagnosed, non-pharmacologic as well as pharmacologic intervention should be performed.
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Affiliation(s)
- Lynsey Seim
- Division of Hospital Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Priyanka Vijapura
- Division of Hospital Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Sandeep Pagali
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - M Caroline Burton
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA
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15
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Henche Ruiz AI. [Transmucosal fentanyl and breakthrough pain: The other side of the coin]. Rev Esp Geriatr Gerontol 2020; 55:56-57. [PMID: 31307779 DOI: 10.1016/j.regg.2019.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 02/02/2019] [Accepted: 02/08/2019] [Indexed: 06/10/2023]
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16
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Opioid treatment for acute and chronic pain in patients with sickle cell disease. Neurosci Lett 2020; 714:134534. [DOI: 10.1016/j.neulet.2019.134534] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 09/13/2019] [Accepted: 10/01/2019] [Indexed: 12/24/2022]
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17
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Felix C, Sharfstein JM, Olsen Y. Help Is on the Way: Medicare Coverage of Opioid Treatment Programs. J Am Geriatr Soc 2019; 68:637-640. [PMID: 31825528 DOI: 10.1111/jgs.16281] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 11/08/2019] [Accepted: 11/08/2019] [Indexed: 11/29/2022]
Abstract
Opioid use disorder (OUD) among older adults has been increasing, yet evidence still remains scarce for age-specific treatment. We discuss the three US Food and Drug Administration-approved medications used to treat OUD (methadone, buprenorphine, and naltrexone) and consider evidence gaps in OUD treatment in older adults. Legislation passed in 2018 (the Substance Use Disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities Act [also known as the SUPPORT Act]) expanded Medicare coverage to include bundled payment for OUD treatment through opioid treatment programs, permitting coverage of methadone treatment for the first time. Since the policy change will take effect in January 2020, healthcare providers need to be aware of new opportunities for treatment when caring for older adult patients with OUD. J Am Geriatr Soc 68:637-640, 2020.
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Affiliation(s)
- Cynthia Felix
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Joshua M Sharfstein
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Yngvild Olsen
- Institutes for Behavior Resources/REACH Health Services, Baltimore, Maryland
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18
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Chang YP, Cassalia J, Warunek M, Scherer Y. Motivational interviewing training with standardized patient simulation for prescription opioid abuse among older adults. Perspect Psychiatr Care 2019; 55:681-689. [PMID: 31187888 DOI: 10.1111/ppc.12402] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 04/14/2019] [Accepted: 05/05/2019] [Indexed: 11/29/2022] Open
Abstract
PURPOSE This study aimed to examine the effect of motivational interviewing (MI) education on the doctorate of nursing practice (DNP) students' learning outcomes. DESIGN AND METHODS This study used a one-group with preposttest design. The sample consisted of 31 DNP students who received an MI training, including a didactic lecture, role-playing exercise, and standardized patient simulation. FINDINGS Findings indicated a significant increase in students' knowledge and confidence regarding MI at both posttests compared with baseline. PRACTICE IMPLICATIONS Findings suggested that MI training with standardized patient simulation demonstrated preliminary promising effects on DNP students' knowledge and confidence in MI techniques to manage prescription opioid abuse among older adults. This study showed the potential to enhance the care of older adults who abuse opioids to address this problem in practice.
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Affiliation(s)
- Yu-Ping Chang
- School of Nursing, The State University of New York, University at Buffalo, Buffalo, New York
| | - Jade Cassalia
- Newark-Wayne Community Hospital, Rochester, New York
| | - Molli Warunek
- School of Nursing, The State University of New York, University at Buffalo, Buffalo, New York
| | - Yvonne Scherer
- School of Nursing, The State University of New York, University at Buffalo, Buffalo, New York
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19
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Clinical indications associated with opioid initiation for pain management in Ontario, Canada: a population-based cohort study. Pain 2019; 159:1562-1568. [PMID: 29762260 PMCID: PMC6085129 DOI: 10.1097/j.pain.0000000000001242] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Concerns over prescription opioids contributing to high levels of opioid use disorder and overdose have led policymakers and clinicians to seek means to reduce inappropriate and high-dose initial prescriptions. To inform such efforts, we sought to describe the clinical indications associated with opioid initiation and the characteristics of the initial prescriptions and patients through a retrospective population-based cohort study. Our cohort included Ontarians initiating prescription opioids for pain management between April 1, 2015, and March 31, 2016. We identified the apparent clinical indication for opioid initiation by linking prescription drug claims to procedural and diagnostic information on health service records on the day of, and 5 days preceding prescription. Outcomes included initial opioid type, prescription duration, and daily dose (in milligram morphine equivalents), stratified either by indication or indication cluster. Among 653,993 individuals, we successfully classified 575,512 (88.0%) people initiating opioids into 23 clinical indications in 6 clusters: dental (23.2%); postsurgical (17.4%); musculoskeletal (12.0%); trauma (11.2%); cancer/palliative care (6.5%); and other less frequent indications (17.7%). Individuals with postsurgical pain received the highest daily doses (40.5% with greater than 50 milligram morphine equivalent), and those with musculoskeletal pain received more initial prescriptions with a duration exceeding 7 days (34.2%). Opioids are initiated for a wide range of indications with varying doses and durations; yet, those who initiated opioids for postsurgical and musculoskeletal pain received the greatest doses and durations of therapy, respectively. These findings may help tailor and prioritize efforts to promote more appropriate opioid prescribing.
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20
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Affiliation(s)
- Susan W Lehmann
- From the Johns Hopkins University School of Medicine, Baltimore
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21
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Chinneck A, Thompson K, Mahu IT, Davis-MacNevin P, Dobson K, Stewart SH. Personality and prescription drug use/misuse among first year undergraduates. Addict Behav 2018; 87:122-130. [PMID: 30005334 DOI: 10.1016/j.addbeh.2018.07.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 06/07/2018] [Accepted: 07/02/2018] [Indexed: 11/15/2022]
Abstract
Emerging adults (18-25 year olds) endorse the highest rates of prescription drug misuse. Attending college or university may confer additional risk. Previous research suggests that personality is an important predictor of many addictive behaviours. Four traits have been consistently implicated: anxiety sensitivity, hopelessness, sensation seeking, and impulsivity. Published studies on personality as a predictor of prescription drug abuse are limited, however, by a primary focus on overall prescription drug use, inconsistent operationalisation of misuse, and failure to control for alcohol use. Sample sizes have been small and non-specific. We sought to better understand how personality predicted the overall use, the medically-sanctioned use, and the misuse of prescription sedatives/tranquilizers, opioids, and stimulants. A large (N = 1755) sample of first year Canadian undergraduate students (mean age = 18.6 years; 68.9% female) was used. We predicted that: anxiety sensitivity would be related to sedatives/tranquilizers, hopelessness to opioids, sensation seeking to stimulants, and impulsivity to all three. Save for the impulsivity to opioid use path, predictions were fully supported in our "any use" model. For medically-sanctioned use: anxiety sensitivity predicted sedative/tranquilizers, hopelessness predicted opioids, and impulsivity predicted stimulants. For misuse: anxiety sensitivity (marginally) predicted sedatives/tranquilizers, sensation seeking predicted stimulants, and impulsivity predicted all three. Our models support using personality-matched interventions. Specifically, results suggest targeting anxiety sensitivity for sedative/tranquilizer misuse, sensation seeking for stimulant misuse, and impulsivity for unconstrained prescription drug misuse. Interventions with early coping skills that pertain to all four traits might be useful for preventing prescription drug uptake and later misuse.
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Affiliation(s)
- A Chinneck
- Department of Psychology and Neuroscience, Dalhousie University, 1355 Oxford Street, Halifax, NS B3H 4R2, Canada.
| | - K Thompson
- Department of Psychology, St. Francis Xavier University, 2323 Notre Dame Avenue, Antigonish, NS B3G 2W5, Canada.
| | - I T Mahu
- Department of Psychology and Neuroscience, Dalhousie University, 1355 Oxford Street, Halifax, NS B3H 4R2, Canada.
| | - P Davis-MacNevin
- Department of Psychology and Neuroscience, Dalhousie University, 1355 Oxford Street, Halifax, NS B3H 4R2, Canada.
| | - K Dobson
- Department of Psychology, University of Calgary, 2500 University Drive N.W., Calgary, AB T2N 1N4, Canada.
| | - S H Stewart
- Department of Psychology and Neuroscience, Dalhousie University, 1355 Oxford Street, Halifax, NS B3H 4R2, Canada; Department of Psychiatry, Dalhousie University, 5909 Veteran's Memorial Lane, Halifax, NS B3H 2E2, Canada.
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22
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Marra EM, Mazer-Amirshahi M, Mullins P, Pines JM. Opioid Administration and Prescribing in Older Adults in U.S. Emergency Departments (2005-2015). West J Emerg Med 2018; 19:678-688. [PMID: 30013704 PMCID: PMC6040900 DOI: 10.5811/westjem.2018.5.37853] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 05/04/2018] [Accepted: 05/03/2018] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION We assess trends in opioid administration and prescribing from 2005-2015 in older adults in United States (U.S.) emergency departments (ED). METHODS We analyzed data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) survey from 2005 to 2015. ED visits for painful conditions were selected and stratified by age (18-64, 65-74, 75-84, ≥ 85 years). We analyzed trends in opioid administration in the ED and prescribing at discharge to encounters ≥ 65 and assessed predictors of use using survey-weighted chi-square tests and logistic regression. Trends in the use of five commonly prescribed opioids were also explored. RESULTS Opioid administration in the ED and prescribing at discharge for encounters with patients ≥ 65 years fell overall, but not significantly. By contrast, opioid administration in the ED and prescribing at discharge significantly declined for adult encounters 18-64 by 20% and 32%, respectively. A similar proportion of adult encounters ≥ 65 were administered opioids in the ED as 18-64, but adult encounters ≥ 85 had the lowest rates of administration. A smaller proportion of adult encounters ≥ 65 years with painful conditions were prescribed opioids at discharge compared to <65. However, this age-related disparity in prescribing narrowed over the study period. There were shifts in the specific types of opioids administered and prescribed in adult encounters ≥ 65 years over the study period, with the most notable being a 76% increase in hydromorphone administration comparing 2005-06 to 2014-15. CONCLUSION From 2005-15, 1 in 4 to 1 in 10 ED patients with painful conditions were administered or prescribed an opioid in U.S. EDs. Opioids prescribing increased from 2005-11 and then declined from 2012-15, more so among visits in the 18-64 age group compared to ≥ 65 years. Opioid administrating demonstrated a gradual rise and decline in all adult age groups. Age consistently appears to be an important consideration, where opioid prescribing declines with advancing age. Given the nationwide opioid crisis, ED providers should remain vigilant in limiting opioids, particularly in older adults who are at higher risk for adverse effects.
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Affiliation(s)
- Erin M Marra
- Aventura Hospital and Medical Center, Department of Emergency Medicine, Aventura, Florida
| | - Maryann Mazer-Amirshahi
- MedStar Washington Hospital Center, Department of Emergency Medicine, Washington, District of Columbia
| | - Peter Mullins
- The George Washington University, School of Medicine and Health Sciences, Washington, District of Columbia
| | - Jesse M Pines
- The George Washington University, School of Medicine and Health Sciences, Washington, District of Columbia
- The George Washington University, Department of Emergency Medicine, Washington, District of Columbia
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23
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Varrassi G, Fusco M, Skaper SD, Battelli D, Zis P, Coaccioli S, Pace MC, Paladini A. A Pharmacological Rationale to Reduce the Incidence of Opioid Induced Tolerance and Hyperalgesia: A Review. Pain Ther 2018; 7:59-75. [PMID: 29594972 PMCID: PMC5993687 DOI: 10.1007/s40122-018-0094-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Indexed: 02/06/2023] Open
Abstract
Chronic pain is an important health and social problem. Misuse and abuse of opioids in chronic non-cancer pain management seem to be a huge problem, in some countries. This could probably affect the normal use of such analgesics in patients in need of them. Basic and clinical researches should find the solution to mitigate the potential damage. Dysregulation of mast cell and microglia activation plays an important role in the pathogenesis and management of chronic pain. Persistent mast cell activation sensitizes nociceptors and initiates central nervous system inflammatory processes, involving microglial cell activation and sensitization of spinal somatosensory neurons. Exposure of mast cells and microglia to opioids is well known to provoke activation of these non-neuronal immune cell populations, thereby contributing to an exacerbation of pro-inflammatory and pro-nociceptive processes and promoting, over the long-term, opioid-induced hyperalgesia and tolerance. This review is intended to provide the reader with an overview of the role for these non-neuronal cells in opioid-induced chronic pain and tolerance as a consequence of prolonged exposure to these drugs. In addition, we will examine a potential strategy with the aim to modulate opioid-induced over-activation of glia and mast cells, based on endogenous defense mechanisms and fatty acid amide signaling molecules.
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Affiliation(s)
- Giustino Varrassi
- Department of Anesthesia and Pain Medicine, University of L'Aquila, L'Aquila, Italy.
| | - Mariella Fusco
- Center for Medical Documentation and Information, Epitech, Padua, Italy
| | | | - Daniele Battelli
- Department of Anesthesia and Pain Medicine, San Marino Hospital, San Marino, San Marino
| | - Panagiotis Zis
- Academic Department of Neurosciences, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Stefano Coaccioli
- Department of Internal Medicine, University of Perugia, Terni, Italy
| | - Maria Caterina Pace
- Department of Anesthesia and Pain Medicine, University of Napoli, Naples, Italy
| | - Antonella Paladini
- Department of Anesthesia and Pain Medicine, University of L'Aquila, L'Aquila, Italy
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24
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Psychotropic Medication Prescribing in Iraq/Afghanistan Veterans and Vietnam Era Veterans With Posttraumatic Stress Disorder. J Nerv Ment Dis 2017; 205:848-854. [PMID: 28953506 DOI: 10.1097/nmd.0000000000000755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A new generation of veterans from Iraq/Afghanistan wars is seeking psychotropic pharmacotherapy for posttraumatic stress disorder (PTSD) from the Veterans Health Administration, but little is known about differences in prescribing practices between this group and Vietnam era veterans with the same diagnosis. The Veterans Health Administration administrative data for fiscal year 2012 were used to compare prescribing for 155,631 Iraq/Afghanistan veterans and for 327,634 Vietnam era veterans diagnosed with PTSD. The proportion of veterans who were prescribed psychotropic medications (altogether and within five of seven medication classes) were not substantially different between veteran groups. Iraq/Afghanistan veterans were more frequently prescribed prazosin (p < 0.0001, relative risk = 1.51). However, the number of prescriptions for anxiolytics/sedatives/hypnotics as well as prazosin and opiates filled by this younger group was lower by a small magnitude (Cohen's d < 0.2). Iraq/Afghanistan veterans have good access to psychopharmacological treatment for PTSD but fill somewhat fewer prescriptions than Vietnam era veterans.
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25
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Mojtabai R. National trends in long-term use of prescription opioids. Pharmacoepidemiol Drug Saf 2017; 27:526-534. [PMID: 28879660 DOI: 10.1002/pds.4278] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 07/03/2017] [Accepted: 07/05/2017] [Indexed: 12/21/2022]
Abstract
PURPOSE This study examined recent trends and correlates of prescription opioid use and long-term use in the United States. METHODS Data were from 47 356 adult participants of National Health and Nutrition Survey from 1999-2000 to 2013-2014. Participants were asked about prescription medications used in the past 30 days. Long-term use of prescription opioids was defined by use for 90 days or longer. RESULTS The prevalence of prescription opioid use increased from 4.1% of US adults in 1999-2000 to 6.8% in 2013-2014 (odds ratio [OR] = 1.38, 95% confidence interval [CI] = 1.10-1.75, P = .007). This trend was driven by a sharp increase in long-term use which increased from 1.8% to 5.4% (OR = 2.22, 95% CI = 1.65-3.00, P < .001). Of all opioid users in 2013-2014, 79.4% were long-term users compared with 45.1% in 1999-2000. Long-term use was associated with poorer physical health, concurrent benzodiazepine use, and history of heroin use. CONCLUSIONS The findings highlight the need for research on potential benefits and harms of long-term use of opioids and efforts to restrict long-term use to patients for whom the benefits outweigh the risks.
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Affiliation(s)
- Ramin Mojtabai
- Department of Mental Health, Bloomberg School of Public Health and Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD, USA
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26
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Abstract
Opioid use disorders (OUDs) have long been a global problem, but the prevalence rates have increased over 20 years to epidemic proportions in the US, with concomitant increases in morbidity and all-cause mortality, but especially opioid overdose. These increases are in part attributable to a several-fold expansion in the prescription of opioid pain medications over the same time period. Opioid detoxification and psychosocial treatments alone have each not yielded sufficient efficacy for OUD, but μ-opioid receptor agonist, partial agonist, and antagonist medications have demonstrated the greatest overall benefit in OUD treatment. Buprenorphine, a μ-opioid receptor partial agonist, has been used successfully on an international basis for several decades in sublingual tablet and film preparations for the treatment of OUD, but the nature of formulation, which is typically self-administered, renders it susceptible to nonadherence, diversion, and accidental exposure. This article reviews the clinical trial data for novel buprenorphine delivery systems in the form of subcutaneous depot injections, transdermal patches, and subdermal implants for the treatment of OUD and discusses both the clinical efficacy of longer-acting formulations through increasing consistent medication exposure and their potential utility in reducing diversion. These new delivery systems also offer new dosing opportunities for buprenorphine and strategies for dosing intervals in the treatment of OUD.
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Affiliation(s)
- Richard N Rosenthal
- Department of Psychiatry, Addiction Institute at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York
| | - Viral V Goradia
- Department of Psychiatry, Upstate Medical University, Syracuse, NY, USA
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27
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Chhatre S, Cook R, Mallik E, Jayadevappa R. Trends in substance use admissions among older adults. BMC Health Serv Res 2017; 17:584. [PMID: 28830504 PMCID: PMC5568321 DOI: 10.1186/s12913-017-2538-z] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 08/14/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Substance abuse is a growing, but mostly silent, epidemic among older adults. We sought to analyze the trends in admissions for substance abuse treatment among older adults (aged 55 and older). METHODS Treatment Episode Data Set - Admissions (TEDS-A) for period between 2000 and 2012 was used. The trends in admission for primary substances, demographic attributes, characteristics of substance abused and type of admission were analyzed. RESULTS While total number of substance abuse treatment admissions between 2000 and 2012 changed slightly, proportion attributable to older adults increased from 3.4% to 7.0%. Substantial changes in the demographic, substance use pattern, and treatment characteristics for the older adult admissions were noted. Majority of the admissions were for alcohol as the primary substance. However there was a decreasing trend in this proportion (77% to 64%). The proportion of admissions for following primary substances showed increase: cocaine/crack, marijuana/hashish, heroin, non-prescription methadone, and other opiates and synthetics. Also, admissions for older adults increased between 2000 and 2012 for African Americans (21% to 28%), females (20% to 24%), high school graduates (63% to 75%), homeless (15% to 19%), unemployed (77% to 84%), and those with psychiatric problems (17% to 32%).The proportion of admissions with prior history of substance abuse treatment increased from 39% to 46% and there was an increase in the admissions where more than one problem substance was reported. Ambulatory setting continued to be the most frequent treatment setting, and individual (including self-referral) was the most common referral source. The use of medication assisted therapy remained low over the years (7% - 9%). CONCLUSIONS The changing demographic and substance use pattern of older adults implies that a wide array of psychological, social, and physiological needs will arise. Integrated, multidisciplinary and tailored policies for prevention and treatment are necessary to address the growing epidemic of substance abuse in older adults.
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Affiliation(s)
- Sumedha Chhatre
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Suite 4051, Philadelphia, Pennsylvania, 19104, USA.
| | - Ratna Cook
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eshita Mallik
- Department of Biotechnology, School of Engineering and Applied Sciences, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ravishankar Jayadevappa
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, 19104, USA.,Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Cochran G, Rosen D, McCarthy RM, Engel RJ. Risk Factors for Symptoms of Prescription Opioid Misuse: Do Older Adults Differ from Younger Adult Patients? JOURNAL OF GERONTOLOGICAL SOCIAL WORK 2017; 60:443-457. [PMID: 28489491 DOI: 10.1080/01634372.2017.1327469] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Limited research is available regarding the health risks associated with opioid medication misuse among middle age (50-64 years) and older adults (65 and older). Understanding the misuse symptom risk profiles of these populations has potential to advance the national opioid epidemic response. A survey was conducted in four community pharmacies in southwestern Pennsylvania among adult, non-cancer patients filling opioid medications (N = 318) regarding opioid medication misuse symptoms and misuse risk factors. Descriptive and multivariate statistical analyses compared respondent characteristics, misuse symptoms, and misuse risks among those 65 and older, 50 to 64, and those less than 50 years old. Those 65 and older (Incidence Rate Ratio [IRR] = 2.4, 95% CI = 1.46-3.95) and those 50 to 64 years (IRR = 1.26, 95% CI = 1.03-1.54) who reported illicit drug use had increased rates of misuse symptoms. Those 50-64 with posttraumatic stress disorder also had an increased rate of misuse symptoms (IRR = 1.29, 95% CI = 1.08-1.54). Misuse behaviors of those 65 and older and 50-64 involved shortening time between dosages (≥65 = 11.4%, 50-64 = 27.6%), taking higher dosages than prescribed (≥65 = 11.4%, 50-64 = 13.6%), and early refills (≥11.8%, 50-64 = 12.7%). Gerontological social workers must continue to work to understand and identify individuals engaged in misuse in order to develop and provide age appropriate care.
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Affiliation(s)
- Gerald Cochran
- a School of Social Work, University of Pittsburgh , School of Medicine, Department of Psychiatry , Pittsburgh , Pennsylvania , USA
| | - Daniel Rosen
- b School of Social Work, University of Pittsburgh , Pittsburgh , Pennsylvania , USA
| | | | - Rafael J Engel
- b School of Social Work, University of Pittsburgh , Pittsburgh , Pennsylvania , USA
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Abstract
OBJECTIVE To estimate the prevalence of filled opioid prescriptions after vaginal delivery. METHODS We conducted a retrospective cohort study of 164,720 Medicaid-enrolled women in Pennsylvania who delivered a liveborn neonate vaginally from 2008 to 2013, excluding women who used opioids during pregnancy or who had an opioid use disorder. We assessed overall filled prescriptions as well as filled prescriptions in the presence or absence of the following pain-inducing conditions: bilateral tubal ligation, perineal laceration, or episiotomy. Outcomes included a binary measure of whether a woman had any opioid prescription fill 5 days or less after delivery and, among those women, a second opioid prescription fill 6-60 days after delivery. Among women with no coded pain-inducing conditions at delivery, we used multivariable logistic regression with standard errors clustered to account for within-hospital correlation to assess the association between patient characteristics and odds of a filled opioid prescription. RESULTS Twelve percent of women (n=18,131) filled an outpatient opioid prescription 5 days or less after vaginal delivery; among those women, 14% (n=2,592, or 1.6% of the total) filled a second opioid prescription 6-60 days after delivery. Of the former, 5,110 (28.2%) had one or more pain-inducing conditions. Predictors of filled opioid prescriptions with no observed pain-inducing condition at delivery included tobacco use (adjusted odds ratio [OR] 1.3, 95% confidence interval [CI] 1.2-1.4) and a mental health condition (adjusted OR 1.3, 95% CI 1.2-1.4). Having a diagnosis of substance use disorder other than opioid use disorder was not associated with filling an opioid prescription 5 days or less after delivery, but was associated with having a second opioid prescription 6-60 days after delivery (adjusted OR 1.4, 95% CI 1.2-1.6). CONCLUSION More than 1 in 10 Medicaid-enrolled women fill an outpatient opioid prescription after vaginal delivery. National opioid-prescribing recommendations for common obstetrics procedures such as vaginal delivery are warranted.
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Gerlach LB, Olfson M, Kales HC, Maust DT. Opioids and Other Central Nervous System-Active Polypharmacy in Older Adults in the United States. J Am Geriatr Soc 2017; 65:2052-2056. [PMID: 28467623 DOI: 10.1111/jgs.14930] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine patterns of and trends in contributions to central nervous system (CNS) polypharmacy, defined by the Beers Criteria as three or more CNS-active medications of each medication class, of adults aged 65 and older seen in U.S. outpatient medical practices. DESIGN National Ambulatory Medical Care Survey (2004-2013). SETTING U.S. outpatient medical care. PARTICIPANTS Visits by older adults to outpatient physicians (N = 97,910). MEASUREMENTS Visits including three or more CNS medications including antipsychotics, benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonist hypnotics (NBRAs), tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and opioids. The proportion of CNS polypharmacy that each medication class contributed during 2011 to 2013 was determined, and then logistic regression was used to determine trends from 2004 to 2013 in the contribution of individual medication classes to such polypharmacy. RESULTS Of recent CNS polypharmacy visits, 76.2% included an opioid, and 61.8% included a benzodiazepine; 66.0% of the polypharmacy visits with benzodiazepines included opioids, and 53.3% of the polypharmacy visits with opioids included benzodiazepines. Between 2011 and 2013, opioid and benzodiazepine co-prescribing occurred at approximately 1.50 million visits (95% confidence interval (CI) = 1.23-1.78 million) annually. From 2004 (reference) to 2013, the proportion of polypharmacy visits with opioids rose from 69.6% to 76.2% (adjusted odds ratio = 2.15, 95% CI = 1.19-3.91, P = .01), and the corresponding proportion that included benzodiazepines fell. Of the polypharmacy visits, the odds of SSRI, NBRA, and antipsychotic use were unchanged, and that of TCAs decreased. CONCLUSION In older adults, opioid use appears to be largely driving the recent national increase in CNS polypharmacy. Although concomitant use of opioids and benzodiazepines is associated with greater mortality, they are the most common contributors to CNS polypharmacy in older adults.
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Affiliation(s)
- Lauren B Gerlach
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
| | - Mark Olfson
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, New York.,New York State Psychiatric Institute, New York, New York
| | - Helen C Kales
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan.,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Donovan T Maust
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan.,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
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Maree RD, Marcum ZA, Saghafi E, Weiner DK, Karp JF. A Systematic Review of Opioid and Benzodiazepine Misuse in Older Adults. Am J Geriatr Psychiatry 2016; 24:949-963. [PMID: 27567185 PMCID: PMC5069126 DOI: 10.1016/j.jagp.2016.06.003] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 04/28/2016] [Accepted: 06/01/2016] [Indexed: 01/09/2023]
Abstract
OBJECTIVE The authors assessed the prevalence of opioid and benzodiazepine prescription drug misuse in older adults, the risk factors associated with misuse, and age-appropriate interventions. METHODS Following PRISMA guidelines, a literature search of PubMed, PsycINFO, and EMBASE for peer-reviewed journal articles in English through April 2014 with updates through November 2015 was conducted for reports on misuse of prescription benzodiazepines and opioids in older adults. Relevant publications were reviewed that included participants age ≥65 years. Reference lists were manually searched for key identified articles and geriatric journals through April 2016. Information on the study design, sample, intervention, comparators, outcome, time frame, and risk of bias were abstracted for each article. RESULTS Of 4,932 reviewed reports, 15 were included in this systematic review. Thirteen studies assessed the prevalence of prescription drug misuse and included studies related to opioid shopping behavior, assessment of morbidity and mortality associated with opioid and/or benzodiazepine use, frequency and characteristics of opioid prescribing, frequency of substance use disorders and nonprescription use of pain relievers, and health conditions and experiences of long-term benzodiazepine users. One study identified risk factors for misuse, and one study described the effects of provider education and an electronic support tool as an intervention. CONCLUSION There is a dearth of high quality research on prescription drug misuse in older adults. Existing studies are heterogeneous, making it difficult to draw broad conclusions. The need for further research specific to prescription drug misuse among older adults is discussed.
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Affiliation(s)
- RD Maree
- Department of Psychiatry, University of Pittsburgh School of Medicine
| | - ZA Marcum
- School of Pharmacy, University of Washington
| | - E Saghafi
- Department of Information Science, University of Pittsburgh School of Medicine
| | - DK Weiner
- Department of Psychiatry, University of Pittsburgh School of Medicine,Department of Anesthesiology, University of Pittsburgh School of Medicine,Department of Medicine, University of Pittsburgh School of Medicine,Geriatric Research, Education & Clinical Center, VA Pittsburgh Healthcare System
| | - JF Karp
- Department of Psychiatry, University of Pittsburgh School of Medicine,Department of Anesthesiology, University of Pittsburgh School of Medicine,Geriatric Research, Education & Clinical Center, VA Pittsburgh Healthcare System
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Fleming ML, Driver L, Sansgiry SS, Abughosh SM, Wanat M, Sawant RV, Ferries E, Reeve K, Todd KH. Physicians' intention to prescribe hydrocodone combination products after rescheduling: A theory of reasoned action approach. Res Social Adm Pharm 2016; 13:503-512. [PMID: 27567741 DOI: 10.1016/j.sapharm.2016.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 07/16/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND The U.S. Drug Enforcement Administration (DEA) rescheduled hydrocodone combination products (HCPs) in an attempt to mitigate the prescription opioid epidemic. Many in the medical and pharmacy community expressed concerns of unintended consequences as a result of rescheduling. OBJECTIVES This study examined physicians' intentions to prescribe HCPs after rescheduling using the framework of the theory of reasoned action (TRA). METHODS A cover letter containing a link to the online questionnaire was sent to physicians of the Texas Medical Association who were likely to prescribe opioids. The questionnaire assessed physicians' intentions to prescribe HCPs after rescheduling. Predictor variables included attitude toward rescheduling, subjective norm toward HCP prescribing, and past prescribing behavior of schedule II prescriptions. All variables were measured on a 7-point, Likert-type scale. Intention to prescribe as a dependent variable was regressed over TRA variables and respondent characteristics. RESULTS A total of 1176 usable responses were obtained, yielding a response rate of 13.3%. Mean (M) age was 53.07 ± 11 and most respondents were male (70%) and Caucasian (75%). Physicians held a moderately positive intention to prescribe HCPs (M = 4.36 ± 2.08), held a moderately negative attitude towards rescheduling, M = 4.68 ± 1.51 (reverse coded). Subjective norm was moderately low, M = 3.06 ± 1.78, and past prescribing behavior M = 2.43 ± 1.21. The linear regression analysis indicated that attitude (β = 0.10; P = 0.006), subjective norm (β = 0.35; P < 0.0001) and past prescribing behavior (β = 0.59; P < 0.0001) were significant predictors of intention to prescribe HCPs after rescheduling. CONCLUSIONS TRA was shown to be a predictive model of physicians' intentions to prescribe HCPs after rescheduling. Overall, physicians held a moderately positive intention to prescribe HCPs. Past behavior concerning schedule II prescribing was found to be the most significant predictor of intention. Understanding the impact of federal rule changes on pain management care and patient satisfaction is necessary to determine whether this change has produced the intended consequences without harming patients in need of HCPs.
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Affiliation(s)
- Marc L Fleming
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston, College of Pharmacy, Texas Medical Center Campus, 1441 Moursund St, Houston, TX 77030, USA.
| | - Larry Driver
- Department of Pain Medicine, Division of Anesthesiology and Critical Care, The University of Texas-MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Sujit S Sansgiry
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston, College of Pharmacy, Texas Medical Center Campus, 1441 Moursund St, Houston, TX 77030, USA
| | - Susan M Abughosh
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston, College of Pharmacy, Texas Medical Center Campus, 1441 Moursund St, Houston, TX 77030, USA
| | - Matthew Wanat
- Department of Pharmacy Practice and Translational Research, University of Houston, College of Pharmacy, Texas Medical Center Campus, 1441 Moursund St, Houston, TX 77030, USA
| | - Ruta V Sawant
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston, College of Pharmacy, Texas Medical Center Campus, 1441 Moursund St, Houston, TX 77030, USA
| | - Erin Ferries
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston, College of Pharmacy, Texas Medical Center Campus, 1441 Moursund St, Houston, TX 77030, USA
| | - Kathleen Reeve
- School of Nursing, University of Houston, 14000 University Blvd., Sugar Land, TX 77479, USA
| | - Knox H Todd
- The University of Texas-MD Anderson Cancer Center, Unit 1468, 1515 Holcombe Blvd., Houston, TX 77030, USA
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West NA, Dart RC. Prescription opioid exposures and adverse outcomes among older adults. Pharmacoepidemiol Drug Saf 2015; 25:539-44. [PMID: 26660909 DOI: 10.1002/pds.3934] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 10/29/2015] [Accepted: 11/16/2015] [Indexed: 11/08/2022]
Abstract
PURPOSE A high prevalence of chronic pain and high rates of polypharmacy among older adults suggest that this age group may be particularly susceptible to unintentional misuse of prescription opioids. We examined recent trends in misuse of prescription opioids and associated medical outcomes among older-aged adults (60+ years) and compared the patterns with trends among younger-aged adults (20-59 years). METHODS Linear regression trend analysis was used to analyze 57 681 misuse cases reported to participating US poison centers during 2006-2014. RESULTS Population rates of misuse of prescription opioids were higher for older adults than for younger adults, and this disparity increased over time. Rates among the older ages increased each year, although the rate of increase slowed over time (p < 0.0001 for negative quadratic trend). In contrast, among the younger adults, there was a significant negative quadratic trend in population rates (p < 0.0001) with a rise in rates during 2006-2010 followed by a decline during 2011-2014. Rates of serious medical outcomes among the older ages followed an increasing linear trend (p < 0.0001); in contrast, rates among younger adults rose and fell during the period, with recent rates trending downward (p < 0.0001 for quadratic trend). CONCLUSIONS Recent increases in rates of misuse of prescription opioids and associated unfavorable medical outcomes among older adults have important implications as the USA undergoes a rapid expansion of its elderly population. Copyright © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
- Nancy A West
- Research Department, Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, USA
| | - Richard C Dart
- Research Department, Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, USA.,Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Ashrafioun L, Bohnert ASB, Jannausch M, Ilgen MA. Evaluation of the current opioid misuse measure among substance use disorder treatment patients. J Subst Abuse Treat 2015; 55:15-20. [PMID: 25800105 PMCID: PMC4456230 DOI: 10.1016/j.jsat.2015.02.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 02/02/2015] [Accepted: 02/22/2015] [Indexed: 10/23/2022]
Abstract
The Current Opioid Misuse Measure (COMM) has demonstrated promising psychometric properties among pain clinic and primary care patients. Given the high prevalence of the nonmedical use of prescription opioids among substance use disorder patients, the COMM may also be useful in substance use disorder treatment settings. The purpose of this study was to assess the factor structure and validity of the COMM in a sample of substance use disorder patients. Participants (n = 351) were recruited from a large residential substance use disorder treatment center and completed the COMM and several questionnaires assessing various substance use and health functioning characteristics. Factor analyses yielded a two-factor solution; however, each of the items in the second factor cross-loaded onto the first factor and just one factor was retained. To provide support for this new 11-item COMM, we found that higher scores on this COMM were associated with greater drug use severity, greater endorsement of positive, negative, and pain relief outcome expectancies related to opioid use, increased pain intensity, and decreased physical and mental health functioning. These findings provide initial support for the psychometric properties of this version of the COMM adapted for substance use disorder treatment settings. Given its promising psychometric properties, the 11 items of the COMM to evaluate the nonmedical use of prescription opioids have potential utility among substance use disorder patients. The COMM could be used to examine nonmedical use over the course of treatment and to aid treatment planning. It could also be used in research as an outcome measure.
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Affiliation(s)
- Lisham Ashrafioun
- Bowling Green State University, Department of Psychology, 207 Psychology Building, Bowling Green, OH 43403; VA Ann Arbor Healthcare System, Mental Health Service, 2215 Fuller Rd., Ann Arbor, MI 48105.
| | - Amy S B Bohnert
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), Department of Veterans Affairs Healthcare System, Ann Arbor MI, North Campus Research Complex, 2800 Plymouth Rd Building 14, Ann Arbor, MI 48109; Department of Psychiatry, University of Michigan, Ann Arbor, MI, North Campus Research Complex, 2800 Plymouth Rd Building 10, Ann Arbor, MI 48109
| | - Mary Jannausch
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), Department of Veterans Affairs Healthcare System, Ann Arbor MI, North Campus Research Complex, 2800 Plymouth Rd Building 14, Ann Arbor, MI 48109; Department of Psychiatry, University of Michigan, Ann Arbor, MI, North Campus Research Complex, 2800 Plymouth Rd Building 10, Ann Arbor, MI 48109
| | - Mark A Ilgen
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), Department of Veterans Affairs Healthcare System, Ann Arbor MI, North Campus Research Complex, 2800 Plymouth Rd Building 14, Ann Arbor, MI 48109; Department of Psychiatry, University of Michigan, Ann Arbor, MI, North Campus Research Complex, 2800 Plymouth Rd Building 10, Ann Arbor, MI 48109
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Trends in prevalent and incident opioid receipt: an observational study in Veterans Health Administration 2004-2012. J Gen Intern Med 2015; 30:597-604. [PMID: 25519224 PMCID: PMC4395612 DOI: 10.1007/s11606-014-3143-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 10/10/2014] [Accepted: 11/24/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Improved understanding of temporal and regional trends may support safe and effective prescribing of opioids. OBJECTIVE We describe national, regional, and facility-level trends and variations in opioid receipt between fiscal years (FY) 2004 and 2012. DESIGN Observational cohort study using Veterans Health Administration (VHA) administrative databases. PARTICIPANTS All patients receiving primary care within 137 VHA healthcare systems during a given study year and receiving medications from VHA one year before and during a given study year. MAIN MEASURES Prevalent and incident opioid receipt during each year of the study period. KEY RESULTS The overall prevalence of opioid receipt increased from 18.9% of all veteran outpatients in FY2004 to 33.4% in FY2012, a 76.7% relative increase. In FY2012, women had higher rates of prevalent opioid receipt than men (42.4% vs. 32.9%), and the youngest veterans (18-34 years) had higher prevalent opioid receipt compared to the oldest veterans (≥ 80 years) (47.6% vs. 17.9%). All regions in the United States saw increased rates of prevalent opioid receipt during this time period. Prevalence rates varied widely by facility: in FY2012, the lowest-prescribing facility had a rate of 13.5%, and the highest of 50.8%. Annual incident opioid receipt increased from 8.8% in FY2004 to 10.2% in FY2011, with a decline to 9.8% in FY2012. Incident prescribing increased at some facilities and decreased at others. Facilities with high prevalent prescribing tended to have flat or decreasing incident prescribing rates during the study time frame. CONCLUSIONS Rates of opioid receipt increased throughout the study time frame, with wide variation in prevalent and incident rates across geographical region, sex, and age groups. Prevalence and incidence rates reflect distinct prescribing practices. Areas with the highest prevalence tended to have lower increases in incident opioid receipt over the study period. This likely reflects facility-level variations in prescribing practices as well as baseline rates of prevalent use. Future work assessing opioid prescribing should employ methodologies to account for and interpret both prevalent and incident opioid receipt.
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West NA, Severtson SG, Green JL, Dart RC. Trends in abuse and misuse of prescription opioids among older adults. Drug Alcohol Depend 2015; 149:117-21. [PMID: 25678441 DOI: 10.1016/j.drugalcdep.2015.01.027] [Citation(s) in RCA: 121] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 01/21/2015] [Accepted: 01/22/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Dramatic increases in the prescriptive use of opioid analgesics during the past two decades have been paralleled by alarming increases in rates of the abuse and intentional misuse of these drugs. We examined recent trends in the abuse and misuse and associated fatal outcomes among older adults (60+ years) and compared these to trends among younger adults (20-59 years). METHODS Trend analysis using linear regression models was used to analyze 184,136 cases and 1149 deaths associated with abuse and misuse of the prescription opioids oxycodone, fentanyl, hydrocodone, morphine, oxymorphone, hydromorphone, methadone, buprenorphine, tramadol, and tapentadol that were reported to participating U.S. Poison Centers of the Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS(®)) System between 2006-Q1 and 2013-Q4. RESULTS Rates of abuse and misuse of prescription opioids were lower for older adults than for younger adults; however, mortality rates among the older ages followed an increasing linear trend (P < 0.0001) and surpassed rates for younger adults in 2012 and 2013. In contrast, mortality rates among younger adults rose and fell during the period, with recent rates trending downward (P = 0.0003 for quadratic trend). Sub-analysis revealed an increasing linear trend among older adults specifically for suicidal intent (P < 0.0001), whereas these rates increased and then decreased among younger adults (P < 0.0001 for quadratic trend). CONCLUSION Recent linear increases in rates of death and use of prescription opioids with suicidal intent among older adults have important implications as the U.S. undergoes a rapid expansion of its elderly population.
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Affiliation(s)
- Nancy A West
- Research Department, Rocky Mountain Poison and Drug Center, 990 Bannock Street, M/C 0180, Denver Health and Hospital Authority, Denver, CO 80204, USA.
| | - Stevan G Severtson
- Research Department, Rocky Mountain Poison and Drug Center, 990 Bannock Street, M/C 0180, Denver Health and Hospital Authority, Denver, CO 80204, USA
| | - Jody L Green
- Research Department, Rocky Mountain Poison and Drug Center, 990 Bannock Street, M/C 0180, Denver Health and Hospital Authority, Denver, CO 80204, USA
| | - Richard C Dart
- Research Department, Rocky Mountain Poison and Drug Center, 990 Bannock Street, M/C 0180, Denver Health and Hospital Authority, Denver, CO 80204, USA; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
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Abstract
The co-occurrence of substance use disorders (SUDs) and anxiety disorders has been now well established. This association is frequent and can be explained by three models: the shared vulnerability factors model, the self-medication model, and the substance-induced model. General population epidemiological studies provide strong evidence of the frequency of the association for the most used substances: tobacco, alcohol, cannabis, and to a lesser extent sedatives, opiates, and cocaine. For substances that are less commonly used in the general population, the frequency of the co-occurrence can more precisely be studied in clinical samples. We provide the most recent literature results on the association of SUDs and anxiety, and evidence for one explicative model or the other when available. For substances with sedative properties (alcohol, benzodiazepines, cannabis, opioids), both evidence for a self-medication and for a toxic effect exist. For substances with psychostimulant properties (tobacco, cocaine, and amphetamines), the literature favors the toxic hypothesis to explain the association with anxiety disorders. We give practical steps for the recognition of these dual diagnoses and present therapeutic issues, although the strategies are rarely evidence based.
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McHugh RK, Nielsen S, Weiss RD. Prescription drug abuse: from epidemiology to public policy. J Subst Abuse Treat 2015; 48:1-7. [PMID: 25239857 PMCID: PMC4250400 DOI: 10.1016/j.jsat.2014.08.004] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 08/25/2014] [Indexed: 11/26/2022]
Abstract
Prescription drug abuse has reached an epidemic level in the United States. The prevalence of prescription drug abuse escalated rapidly beginning in the late 1990s, requiring a significant increase in research to better understand the nature and treatment of this problem. Since this time, a research literature has begun to develop and has provided important information about how prescription drug abuse is similar to, and different from the abuse of other substances. This introduction to a special issue of the Journal of Substance Abuse Treatment on prescription drug abuse provides an overview of the current status of the research literature in this area. The papers in this special issue include a sampling of the latest research on the epidemiology, clinical correlates, treatment, and public policy considerations of prescription drug abuse. Although much has been learned about prescription drug abuse in recent years, this research remains in early stages, particularly with respect to understanding effective treatments for this population. Future research priorities include studies on the interaction of prescription drugs with other licit and illicit substances, the impact of prescription drug abuse across the lifespan, the optimal treatment for prescription drug abuse and co-occurring conditions, and effective public policy initiatives for reducing prescription drug abuse.
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Affiliation(s)
- R Kathryn McHugh
- Division of Alcohol and Drug Abuse, McLean Hospital, 115 Mill Street, Belmont, MA 02478, USA; Department of Psychiatry, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
| | - Suzanne Nielsen
- University of New South Wales, National Drug and Alcohol Research Centre, New South Wales, Australia; Drug and Alcohol Services, South Eastern Sydney Local Health District, New South Wales, Australia
| | - Roger D Weiss
- Division of Alcohol and Drug Abuse, McLean Hospital, 115 Mill Street, Belmont, MA 02478, USA; Department of Psychiatry, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
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Torio CM, Encinosa W, Berdahl T, McCormick MC, Simpson LA. Annual report on health care for children and youth in the United States: national estimates of cost, utilization and expenditures for children with mental health conditions. Acad Pediatr 2015; 15:19-35. [PMID: 25444653 DOI: 10.1016/j.acap.2014.07.007] [Citation(s) in RCA: 134] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 07/24/2014] [Accepted: 07/31/2014] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To examine national trends in hospital utilization, costs, and expenditures for children with mental health conditions. METHODS The analyses of children aged 1 to 17 are based on AHRQ's 2006 and 2011 Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) and Nationwide Emergency Department Sample (NEDS) databases, and on AHRQ's pooled 2006 to 2011 Medical Expenditure Panel Survey (MEPS). All estimates are nationally representative, and standard errors account for the complex survey designs. RESULTS Although overall all-cause children's hospitalizations did not increase between 2006 and 2011, hospitalizations for all listed mental health conditions increased by nearly 50% among children aged 10 to 14 years, and by 21% for emergency department (ED) visits. Behavioral disorders experienced a shift in underlying patterns between 2006 and 2011: inpatient stays for alcohol-related disorders declined by 44%, but ED visits increased by 34% for substance-related disorders and by 71% for impulse control disorders. Inpatient visits for suicide, suicidal ideation, and self-injury increased by 104% for children ages 1 to 17 years, and by 151% for children ages 10 to 14 years during this period. A total of $11.6 billion was spent on hospital visits for mental health during this period. Medicaid covered half of the inpatient visits, but with 50% to 30% longer length of stays in 2006 and 2011, respectively, than private payers. Medicaid's overall share of the ED visits increased from 45% in 2006 to 53% in 2011. CONCLUSIONS These alarming trends highlight the renewed need for research on mental health care for children. This study also provides a baseline for evaluating the impact of the Affordable Care Act and the mental health parity legislation on mental health utilization and expenditures for children.
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Affiliation(s)
- Celeste Marie Torio
- Department of Health and Human Services, Agency for Healthcare Research and Quality, Rockville, Md.
| | - William Encinosa
- Department of Health and Human Services, Agency for Healthcare Research and Quality, Rockville, Md
| | - Terceira Berdahl
- Department of Health and Human Services, Agency for Healthcare Research and Quality, Rockville, Md
| | - Marie C McCormick
- Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, Mass
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Abstract
INTRODUCTION While delayed emptying is the defining criterion for gastroparesis, prokinetics often only have a limited impact on symptoms and have been associated with potentially serious adverse effects. The goal of this study was to determine how this information and regulatory changes affected gastroparesis management. METHODS The electronic medical records of patients seen between 2003 and 2012 in the outpatient clinic of a large tertiary center were retrieved based on the billing diagnosis of gastroparesis. Demographic, clinical, and survival data were abstracted. RESULTS A total of 709 patients were identified, with diabetes (21.2 %) and prior surgery (9.8 %) being the most common identifiable causes. The majority of patients (56 %) had idiopathic gastroparesis. The cohort was female predominant (79.5 %) with an average age of 45.4 ± 0.6 years. At the index encounter, 61.8 % received prokinetics. About one-third (37.7 %) used antiemetics at least intermittently. Between 2003 and 2012, prokinetic use dropped from 81 to 43 %, while the use of antiemetics increased from 14 to 41 %. Similarly, there was a significant increase in prescribed opioids and antidepressants. During the period of the study, 44 patients (6.2 %) died. Increasing age, a higher comorbidity burden, anxiety, and medication use were associated with higher mortality risks. CONCLUSION This large outpatient cohort suggests that treatment trends move away from prokinetics and focus on symptom-oriented therapy and/or confounding mood disorders.
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Steinman MA, Komaiko KDR, Fung KZ, Ritchie CS. Use of opioids and other analgesics by older adults in the United States, 1999-2010. PAIN MEDICINE 2014; 16:319-27. [PMID: 25352175 DOI: 10.1111/pme.12613] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND OBJECTIVE There has been concern over rising use of prescription opioids in young and middle-aged adults. Much less is known about opioid prescribing in older adults, for whom clinical recommendations and the balance of risks and benefits differ from younger adults. We evaluated changes in use of opioids and other analgesics in a national sample of clinic visits made by older adults between 1999 and 2010. DESIGN, SETTING, AND SUBJECTS Observational study of adults aged 65 and older from the 1999-2010 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, serial cross-sectional surveys of outpatient visits in the United States. METHODS Medication use was assessed at each study visit and included medications in use prior to the visit and medications newly prescribed at the visit. Results were adjusted for survey weights and design factors to provide nationally representative estimates. RESULTS Mean age was 75 ± 7 years, and 45% of visits occurred in primary care settings. Between 1999-2000 and 2009-2010, the percent of clinic visits at which an opioid was used rose from 4.1% to 9.0% (P < 0.001). Although use of all major opioid classes increased, the largest contributor to increased use was hydrocodone-containing combination opioids, which rose from 1.1% to 3.5% of visits over the study period (P < 0.001). Growth in opioid use was observed across a wide range of patient and clinic characteristics, including in visits for musculoskeletal problems (10.7% of visits in 1999-2000 to 17.0% in 2009-2010, P < 0.001) and in visits for other reasons (2.8% to 7.3%, P < 0.001). CONCLUSIONS Opioid use by older adults visiting clinics more than doubled between 1999 and 2010, and occurred across a wide range of patient characteristics and clinic settings.
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Affiliation(s)
- Michael A Steinman
- Division of Geriatrics, San Francisco VA Medical Center, University of California, San Francisco, California, USA
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Developing and Initiating Validation of a Model Opioid Patient-Prescriber Agreement as a Tool for Patient-Centered Pain Treatment. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2014; 8:349-58. [DOI: 10.1007/s40271-014-0094-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Abstract
IMPORTANCE Persistent pain is highly prevalent, costly, and frequently disabling in later life. OBJECTIVE To describe barriers to the management of persistent pain among older adults, summarize current management approaches, including pharmacologic and nonpharmacologic modalities; present rehabilitative approaches; and highlight aspects of the patient-physician relationship that can help to improve treatment outcomes. This review is relevant for physicians who seek an age-appropriate approach to delivering pain care for the older adult. EVIDENCE ACQUISITION Search of MEDLINE and the Cochrane database from January 1990 through May 2014, using the search terms older adults, senior, ages 65 and above, elderly, and aged along with non-cancer pain, chronic pain, persistent pain, pain management, intractable pain, and refractory pain to identify English-language peer-reviewed systematic reviews, meta-analyses, Cochrane reviews, consensus statements, and guidelines relevant to the management of persistent pain in older adults. FINDINGS Of the 92 identified studies, 35 evaluated pharmacologic interventions, whereas 57 examined nonpharmacologic modalities; the majority (n = 50) focused on older adults with osteoarthritis. This evidence base supports a stepwise approach with acetaminophen as first-line therapy. If treatment goals are not met, a trial of a topical nonsteroidal anti-inflammatory drug, tramadol, or both is recommended. Oral nonsteroidal anti-inflammatory drugs are not recommended for long-term use. Careful surveillance to monitor for toxicity and efficacy is critical, given that advancing age increases risk for adverse effects. A multimodal approach is strongly recommended-emphasizing a combination of both pharmacologic and nonpharmacologic treatments to include physical and occupational rehabilitation, as well as cognitive-behavioral and movement-based interventions. An integrated pain management approach is ideally achieved by cultivating a strong therapeutic alliance between the older patient and the physician. CONCLUSIONS AND RELEVANCE Treatment planning for persistent pain in later life requires a clear understanding of the patient's treatment goals and expectations, comorbidities, and cognitive and functional status, as well as coordinating community resources and family support when available. A combination of pharmacologic, nonpharmacologic, and rehabilitative approaches in addition to a strong therapeutic alliance between the patient and physician is essential in setting, adjusting, and achieving realistic goals of therapy.
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Affiliation(s)
- Una E Makris
- Department of Internal Medicine, Division of Rheumatic Diseases, UT Southwestern Medical Center, Dallas, Texas2Department of Medicine, Division of Rheumatology, Veterans Administration Medical Center, Dallas, Texas
| | - Robert C Abrams
- Department of Psychiatry, Weill Cornell Medical College, New York, New York4Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College, New York, New York
| | - Barry Gurland
- Stroud Center, Columbia University, New York, New York
| | - M Carrington Reid
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College, New York, New York
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Blanco C, Rafful C, Wall MM, Jin CJ, Kerridge B, Schwartz RP. The latent structure and predictors of non-medical prescription drug use and prescription drug use disorders: a national study. Drug Alcohol Depend 2013; 133:473-9. [PMID: 23962421 PMCID: PMC3818293 DOI: 10.1016/j.drugalcdep.2013.07.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 07/08/2013] [Accepted: 07/08/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Despite growing concerns about non-medical prescription drug use and prescription drug use disorders, whether vulnerability for these conditions is drug-specific or occurs through a shared liability and common risk factors is unknown. METHODS Exploratory and confirmatory factor analysis of Wave 1 of the National Epidemiologic Survey on Alcohol and Related Conditions were used to examine the latent structure of non-medical prescription drug use and prescription drug use disorders. Multiple Indicators Multiple Causes (MIMIC) analysis was used to examine whether the effect of sociodemographic and psychiatric covariates occurred through the latent factor, directly on each drug class or both. RESULTS A one-factor model described well the structure of both non-medical prescription drug use and prescription drug use disorders. Younger age, being White, having more intense pain or one of several psychiatric disorders increased the risk of non-medical prescription drug use through the latent factor. The same covariates, except for anxiety disorders also significantly increased the risk of prescription drug use disorders through the latent factor. Older age directly increased the risk of non-medical use of sedatives, and alcohol use disorders decreased the risk of non-medical tranquilizer use. No covariates had direct effects on the risk of any prescription drug use disorders beyond their effect through the latent factor. CONCLUSION The risk for non-medical prescription drug use and prescription drug use disorders occurs through a shared liability. Treatment, prevention and policy approaches directed at these drugs as a group maybe more effective than those focused on individual classes of drugs.
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Affiliation(s)
- Carlos Blanco
- Department of Psychiatry, New York State Psychiatric Institute/Columbia University, New York, NY 10032, United States.
| | - Claudia Rafful
- Department of Psychiatry, New York State Psychiatric Institute/Columbia University, New York, NY 10032
| | - Melanie M. Wall
- Department of Psychiatry, New York State Psychiatric Institute/Columbia University, New York, NY 10032
| | - Chelsea J. Jin
- Department of Psychiatry, New York State Psychiatric Institute/Columbia University, New York, NY 10032
| | - Bradley Kerridge
- Department of Epidemiology and Biostatistics, School of Public Health, University of Maryland, College Park
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