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Jawed AI, Papakyrikos C, Stewart R, Villagran K, Zwirlein C, Zaim N, Casella JF. Lost and found, safe and sound: a case report surrounding the stabilization of a medically complex young adult patient with opioid use disorder through an acute wrapround care approach. J Addict Dis 2023; 41:341-349. [PMID: 35946477 DOI: 10.1080/10550887.2022.2109377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Background: Hospitalization can be a critical time to stabilize chronically ill patients across levels that transcend medical and social determinants of health. The use of the biopsychosocial model can be instrumental in understanding both medically and psychosocially complex patient cases. An acute inpatient hospitalization provides an opportunity to mediate both intrinsic and extrinsic risk factors for both substance use disorder and suicide risk in the context of achieving medical stabilization and crisis mobilization. Case Presentation: Inpatient care of a 22-year-old African American female patient who was chronically ill involved tapping into existing resources within the larger academic hospital inclusive of both adult and pediatric expertise. This patient's care and treatment was multidisciplinary and involved a range of consults that further expanded both the depth and breadth of care and optimized stability from both medical and psychosocial standpoints. In fact, this patient's hospitalization presented a window of opportunity to facilitate a time of transition in chronic disease management and mobilize resources as part of securing wraparound care for her within a one-week timespan. Her care involved the integration of pediatrics (hematology, adolescent medicine), adult medicine (hematology, addiction medicine), and psychiatry. In addition to treating acute symptomology, underlying sources of pain stemming from her opioid use disorder were also alleviated. Furthermore, her care embodied the interface of chronic illness with opioid use, as her reported pain crises were determined to be motivated by intrinsic factors (e.g. poor coping skills from cumulative stressors) supporting her opioid use disorder. Conclusions: The biopsychosocial treatment approach taken for this patient also clearly delineated that physiological and mental health domains are interrelated aspects of chronic pain in chronic illness. Furthermore, this case also emphasized that chronically ill patients are at elevated risk of developing substance use disorders. This case study lends itself nicely to elucidating parity in physiological and mental health domains as crucial elements in promoting health and safety in patient care.
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Affiliation(s)
- Aysha I Jawed
- Department of Pediatric and OB/GYN Social Work, Charlotte R. Bloomberg Children's Center at the Johns Hopkins Hospital, Baltimore, MD, USA
| | - Cole Papakyrikos
- Department of Pediatrics, Charlotte R. Bloomberg Children's Center at the Johns Hopkins Hospital, Baltimore, MD, USA
| | - Rosalyn Stewart
- Department of Pediatrics, Division of Pediatric Hospital Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kyle Villagran
- Department of Pediatric Nursing, Charlotte R. Bloomberg Children's Center at the Johns Hopkins Hospital, Baltimore, MD, USA
| | - Christina Zwirlein
- Department of Pediatric Nursing, Charlotte R. Bloomberg Children's Center at the Johns Hopkins Hospital, Baltimore, MD, USA
| | - Nadia Zaim
- Division of Child and Adolescent Psychiatry, Charlotte R. Bloomberg Children's Center at the Johns Hopkins Hospital, Baltimore, MD, USA
| | - James F Casella
- Pediatric Hematology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Ahmed W, Billing W, Stump TE, Strobel T, Sagi S, Fischer M, Bohm M. Opioid Legislation in Patients With Inflammatory Bowel Disease: A State-wide Retrospective Cohort Study. Inflamm Bowel Dis 2023; 29:1355-1361. [PMID: 36271877 DOI: 10.1093/ibd/izac218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Indiana State opioid prescription legislation has been shown to decrease overall opioid prescriptions. However, this effect has not been studied in specific diseases associated with chronic pain such as inflammatory bowel disease (IBD). We aimed to determine the effect of state opioid prescription legislation on opioid prescribing patterns in IBD. METHODS A retrospective cohort analysis using an interrupted time-series from December 15, 2010 to July 1, 2018, with 2 time periods separated by Title 844 of the Indiana Administrative Code, in a statewide health care system capturing the majority of the state's population including all adult patients with IBD. The primary outcome was opioid prescription rate per person-year. RESULTS In total, 9436 patients met inclusion criteria. After legislation, the total number of opioid orders per patient-year continued to increase (0.543, 95% CI, 0.528-0.558, to 0.663, 95% CI, 0.654-0.672), with fewer scripts from the emergency department (0.113, 95% CI, 0.106-0.120, to 0.092, 95% CI, 0.088-0.095) and more from outpatient providers (0.303, 95% CI, 0.292-0.314 to 0.432, 95% CI, 0.424-0.439). There were increases in biologic (0.206, 95% CI, 0.197-0.215 to 0.517, 95% CI, 0.509-0.525) and steroid (0.182, 95% CI, 0.173-0.190 to 0.237, 95% CI, 0.232-0.243) prescriptions per person-year following legislation. Factors associated with heavy opioid use included chronic steroids (odds ratio, 5.030; 95% CI, 4.176-6.054), history of IBD-related surgery (odds ratio, 2.807; 95% CI, 2.367-3.323) and current smoking (odds ratio, 2.650; 95% CI, 2.223-3.158). CONCLUSIONS Despite legislation and the increased use of disease-modifying drugs, statewide opioid prescriptions continued to increase. The increase in opiate use, high steroid use, and significant health care utilization suggests poor underlying disease control.
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Affiliation(s)
- Waseem Ahmed
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Wade Billing
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Timothy E Stump
- Indiana University School of Medicine, Department of Biostatistics, Indianapolis, Indiana, USA
| | - Thomas Strobel
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sashidhar Sagi
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Monika Fischer
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mathew Bohm
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Fu Y, Kurin M, Landsman M, Fass R, Song G. Irritable Bowel Syndrome Is an Independent Risk Factor for Developing Opioid Use Disorder in Patients with Inflammatory Bowel Disease. J Pers Med 2023; 13:917. [PMID: 37373905 DOI: 10.3390/jpm13060917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/19/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Symptoms of IBS can fluctuate even when IBD is in clinical remission. Patients with IBD are at an increased risk of developing opioid addiction. The aim of the study was to determine whether IBS is an independent risk factor for developing opioid addiction and related gastrointestinal symptoms in patients with IBD. METHODS We identified patients with Crohn's disease (CD)+IBS and ulcerative colitis (UC) + IBS using TriNetX. The control groups consisted of patients with CD or UC alone without IBS. The main outcome was to compare the risks of receiving oral opioids and developing opioid addiction. A subgroup analysis was performed by selecting patients who were prescribed oral opioids and to compare with those not prescribed opioids. Gastrointestinal symptoms and mortality rates were compared in the cohorts. RESULTS Patients with concomitant IBD and IBS were more likely to be prescribed oral opioids (24.6% vs. 17.2% for CD; 20.2% vs. 12.3% for UC, p < 0.0001) and develop opioid dependence or abuse (p < 0.05). The subset of patients who were prescribed opioids are more likely to develop gastroesophageal reflux disease, ileus, constipation, nausea, and vomiting (p < 0.05). CONCLUSIONS IBS is an independent risk factor for IBD patients to receive opioids and develop opioid addiction.
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Affiliation(s)
- Yuhan Fu
- Department of Internal Medicine, Metrohealth Medical Center/Case Western Reserve University, Cleveland, OH 44109, USA
| | - Michael Kurin
- Department of Gastroenterology, Metrohealth Medical Center/Case Western Reserve University, Cleveland, OH 44109, USA
| | - Marc Landsman
- Department of Gastroenterology, Metrohealth Medical Center/Case Western Reserve University, Cleveland, OH 44109, USA
| | - Ronnie Fass
- Department of Gastroenterology, Metrohealth Medical Center/Case Western Reserve University, Cleveland, OH 44109, USA
| | - Gengqing Song
- Department of Gastroenterology, Metrohealth Medical Center/Case Western Reserve University, Cleveland, OH 44109, USA
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Patton EA, Cunningham P, Noneman M, Helms HP, Martinez-Muniz G, Sumal AS, Dhameja MK, Unger CA, Alahdami AK, Enos RT, Chatzistamou I, Velázquez KT. Acute Administration of Ojeok-san Ameliorates Pain-like Behaviors in Pre-Clinical Models of Inflammatory Bowel Diseases. Nutrients 2023; 15:nu15071559. [PMID: 37049400 PMCID: PMC10096710 DOI: 10.3390/nu15071559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/20/2023] [Accepted: 03/21/2023] [Indexed: 04/14/2023] Open
Abstract
(1) Background: Gastrointestinal pain and fatigue are the most reported concerns of patients with inflammatory bowel disease (IBD). Commonly prescribed drugs focus on decreasing excessive inflammation. However, up to 20% of IBD patients in an "inactive" state experience abdominal pain. The medicinal herb Ojeok-san (OJS) has shown promise in the amelioration of visceral pain. However, no research on OJS has been conducted in preclinical models of IBD. The mechanism by which OJS promotes analgesia is still elusive, and it is unclear if OJS possesses addictive properties. (2) Aims: In this study, we examined the potential of OJS to promote analgesic effects and rewarding behavior. Additionally, we investigated if tumor necrosis factor alpha (TNFα) from macrophages is a primary culprit of IBD-induced nociception. (3) Methods: Multiple animal models of IBD were used to determine if OJS can reduce visceral nociception. TNFα-macrophage deficient mice were used to investigate the mechanism of action by which OJS reduces nociceptive behavior. Mechanical sensitivity and operant conditioning tests were used to determine the analgesic and rewarding effects of OJS. Body weight, colon length/weight, blood in stool, colonic inflammation, and complete blood count were assessed to determine disease progression. (4) Results: OJS reduced the evoked mechanical nociception in the dextran sulphate sodium model of colitis and IL-10 knockout (KO) mice and delayed aversion to colorectal distension in C57BL/6 mice. No rewarding behavior was observed in OJS-treated IL-10 KO and mdr1a KO mice. The analgesic effects of OJS are independent of macrophage TNFα levels and IBD progression. (5) Conclusions: OJS ameliorated elicited mechanical and visceral nociception without producing rewarding effects. The analgesic effects of OJS are not mediated by macrophage TNFα.
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Affiliation(s)
- Emma A Patton
- Department of Pathology, Microbiology and Immunology, University of South Carolina School of Medicine, Columbia, SC 29209, USA
| | - Patrice Cunningham
- Department of Pathology, Microbiology and Immunology, University of South Carolina School of Medicine, Columbia, SC 29209, USA
| | - Matthew Noneman
- Department of Pathology, Microbiology and Immunology, University of South Carolina School of Medicine, Columbia, SC 29209, USA
| | - Henry P Helms
- Department of Pathology, Microbiology and Immunology, University of South Carolina School of Medicine, Columbia, SC 29209, USA
| | - Gustavo Martinez-Muniz
- Department of Pathology, Microbiology and Immunology, University of South Carolina School of Medicine, Columbia, SC 29209, USA
| | - Aman S Sumal
- Department of Pathology, Microbiology and Immunology, University of South Carolina School of Medicine, Columbia, SC 29209, USA
| | - Milan K Dhameja
- Department of Pathology, Microbiology and Immunology, University of South Carolina School of Medicine, Columbia, SC 29209, USA
| | - Christian A Unger
- Department of Pathology, Microbiology and Immunology, University of South Carolina School of Medicine, Columbia, SC 29209, USA
| | - Ahmed K Alahdami
- Department of Pathology, Microbiology and Immunology, University of South Carolina School of Medicine, Columbia, SC 29209, USA
| | - Reilly T Enos
- Department of Pathology, Microbiology and Immunology, University of South Carolina School of Medicine, Columbia, SC 29209, USA
| | - Ioulia Chatzistamou
- Department of Pathology, Microbiology and Immunology, University of South Carolina School of Medicine, Columbia, SC 29209, USA
| | - Kandy T Velázquez
- Department of Pathology, Microbiology and Immunology, University of South Carolina School of Medicine, Columbia, SC 29209, USA
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Sheehan JL, Jacob J, Berinstein EM, Greene-Higgs L, Steiner CA, Berry SK, Shannon C, Cohen-Mekelburg SA, Higgins PDR, Berinstein JA. The Relationship Between Opioid Use and Healthcare Utilization in Patients With Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis. Inflamm Bowel Dis 2022; 28:1904-1914. [PMID: 35230420 PMCID: PMC9924039 DOI: 10.1093/ibd/izac021] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pain is commonly experienced by patients with inflammatory bowel disease (IBD). Unfortunately, pain management is a challenge in IBD care, as currently available analgesics are associated with adverse events. Our understanding of the impact of opioid use on healthcare utilization among IBD patients remains limited. METHODS A systematic search was completed using PubMed, Embase, the Cochrane Library, and Scopus through May of 2020. The exposure of interest was any opioid medication prescribed by a healthcare provider. Outcomes included readmissions rate, hospitalization, hospital length of stay, healthcare costs, emergency department visits, outpatient visits, IBD-related surgeries, and IBD-related medication utilization. Meta-analysis was conducted on study outcomes reported in at least 4 studies using random-effects models to estimate pooled relative risk (RR) and 95% confidence interval (CI). RESULTS We identified 1969 articles, of which 30 met inclusion criteria. Meta-analysis showed an association between opioid use and longer length of stay (mean difference, 2.25 days; 95% CI, 1.29-3.22), higher likelihood of prior IBD-related surgery (RR, 1.72; 95% CI, 1.32-2.25), and higher rates of biologic use (RR, 1.38; 95% CI, 1.13-1.68) but no difference in 30-day readmissions (RR, 1.17; 95% CI, 0.86-1.61), immunomodulator use (RR, 1.13; 95% CI, 0.89-1.44), or corticosteroid use (RR, 1.36; 95% CI, 0.88-2.10) in patients with IBD. On systematic review, opioid use was associated with increased hospitalizations, healthcare costs, emergency department visits, outpatient visits, and polypharmacy. DISCUSSION Opioids use among patients with IBD is associated with increased healthcare utilization. Nonopioid alternatives are needed to reduce burden on the healthcare system and improve patient outcomes.
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Affiliation(s)
- Jessica L Sheehan
- Address correspondence to: Jessica L. Sheehan, MD, MS, 1500 E. Medical Center Drive, Ann Arbor, MI 48109, USA ()
| | - Janson Jacob
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Elliot M Berinstein
- Department of Medicine, St. Joseph Mercy Ann Arbor Hospital, Ypsilanti, MI, USA
| | | | - Calen A Steiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Colorado, Aurora, Colorado, USA
| | - Sameer K Berry
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Carol Shannon
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, Michigan, USA
| | - Shirley A Cohen-Mekelburg
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA,VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI, USA,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
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Niccum B, Moninuola O, Miller K, Khalili H. Opioid Use Among Patients With Inflammatory Bowel Disease: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2021; 19:895-907.e4. [PMID: 32835841 DOI: 10.1016/j.cgh.2020.08.041] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 08/04/2020] [Accepted: 08/14/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Despite reported adverse effects of opioids in patients with inflammatory bowel disease (IBD), the burden of opioid use in this population appears to be high. We performed a systematic review and meta-analysis of prior studies to determine the prevalence of opioid use among patients with IBD as well as risk factors and outcomes associated with opioid use in this population. METHODS We conducted a systematic search of MEDLINE, Embase, Web of Science, and the Cochrane Library through November of 2019. Primary outcomes included the prevalence of opioid use and demographic and clinical variables associated with opioid use in patients with IBD. Quality was assessed using the Newcastle-Ottawa scale. We used random-effect meta-analysis to estimate pooled relative risks (RRs) and 95% CIs. RESULTS Of 780 citations identified, 31 were included in our study. The prevalence of opioid use was 21% (95% CI, 13%-30%) in the outpatient setting. Likewise, 62% (95% CI, 25%-92%) of patients received opioids while hospitalized for IBD. Opioid use was associated with female sex (RR 1.20; 95% CI 1.03-1.40), depression (1.99; 95% CI 1.80-2.19), substance abuse (4.67; 95% CI 2.87-7.60), prior gastrointestinal surgery (2.33; 95% CI 1.66-3.26), biologic use (1.36; 95% CI 1.06-1.74), and steroid use (1.41; 95% CI 1.04-1.91). Based on the systematic review, opioid use also appeared to be associated with increased IBD activity, healthcare use, infection, and mortality. CONCLUSION In a systematic review and meta-analysis, we found that 21% of outpatients with IBD (and 62% of hospitalized patients) are opioid users; use is associated with more severe IBD and increased healthcare use. Further studies are required to determine whether opioids are the cause or an effect of these associations. Nonetheless, urgent interventions are needed to reduce opioid use, improve disease-related outcomes and reduce healthcare costs.
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Affiliation(s)
- Blake Niccum
- Department of Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Oluwatoba Moninuola
- Department of Internal Medicine, Saint Peter's University Hospital, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Kaia Miller
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hamed Khalili
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts; Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden.
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Szigethy EM, Murphy SM, Ehrlich OG, Heller CA, Engel-Nitz NM, Meadows P, Allen JI. Opioid Use Associated With Higher Costs Among Patients With Inflammatory Bowel Disease. Crohns Colitis 360 2021; 3:otab021. [PMID: 36778940 PMCID: PMC9802349 DOI: 10.1093/crocol/otab021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Indexed: 11/12/2022] Open
Abstract
Background Opioid use by patients with inflammatory bowel disease (IBD) has been associated with poorer health outcomes. This study describes socioeconomic characteristics; health utilization trends; and costs of patients with IBD and either no opioid prescriptions, or in 1 of 3 opioid duration categories based on Center for Disease Control guidelines: acute (0-30 days), moderate (31-90 days), or chronic (>90 days). We utilized the Cost of IBD Care Optum research database results for this study. Methods The Optum Research Database from years 2007 to 2016 including IBD patients with commercial or Medicare Advantage insurance in the United States was used. Additional inclusion criteria included continuous enrollment with medical and pharmacy benefit coverage for at least 24 months (12 months before and 12 months after the index date of IBD diagnosis). The association between costs and patient characteristics were assessed across a no opioid use group during this period and the 3 opioid duration groups. Results Among 51,178 IBD patients, 33,229 (64.93%) were part of the no opioid use group, while 13,635 (26.64%) were in acute, 1698 (3.32%) were in moderate, and 2616 (5.11%) were in chronic use groups, as determined by pharmacy claims data. Patients in the chronic group were more likely to be white (75.38%) compared to all the other groups (no opioid use, acute, and moderate), have attained less education (only high school diploma), have had lower incomes, and have had Medicare instead of commercial insurance. Patients across all opioid prescription groups were more likely to have had diagnoses associated with pain in the prior year, with rates increasing by the length of opioid prescription (63.68%, 80.17%, and 86.11% for acute, moderate, and chronic groups). Compared to the no-use group, the acute group had more ambulatory (outpatient) visits, while the chronic group had fewer. Emergency department visits and inpatient hospitalizations were higher in all 3 opioid groups compared to the no opioid use group. Ambulatory, emergency department, inpatient, and total (medical + pharmacy) costs were higher in all 3 opioid groups, compared to the no opioid use group, even after adjusting for demographic and clinical patient characteristics. Conclusions Among patients with IBD, increasing opioid use was associated with higher healthcare resource utilization and, concomitantly, higher healthcare costs during this period.
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Affiliation(s)
- Eva M Szigethy
- Department of Psychiatry and Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA,Address correspondence to: Eva M. Szigethy, MD, PhD, Department of Psychiatry and Medicine, University of Pittsburgh Medical Center, 3708 Fifth Avenue, Suite 401, Pittsburgh, Pennsylvania 15213, USA ()
| | - Sean M Murphy
- Department of Population Health Sciences, Weill Cornell Medical College, New York, New York, USA
| | - Orna G Ehrlich
- Research Department, Crohn’s & Colitis Foundation, New York, New York, USA
| | - Caren A Heller
- Research Department, Crohn’s & Colitis Foundation, New York, New York, USA
| | - Nicole M Engel-Nitz
- Health Economics and Outcomes Research Department, Optum, Eden Prairie, Minnesota, USA
| | - Perry Meadows
- Department of Government Programs, Medical Director, Government Programs, Geisinger Health Plan, Danville, Pennsylvania, USA
| | - John I Allen
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
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