Investigation of the First Seven Reported Cases of Candida auris, a Globally Emerging Invasive, Multidrug-Resistant Fungus-United States, May 2013-August 2016

November 11, 2016/65(44);1234-1237. What is already known about this topic? Candida auris is an emerging pathogenic fungus that has been reported from at least a dozen countries on four continents during 2009-2015. The organism is difficult to identify using traditional biochemical methods, some isolates have been found to be resistant to all three major classes of antifungal medications, and C. auris has caused health care-associated outbreaks. What is added by this report? This is the first description of C. auris cases in the United States. C. auris appears to have emerged in the United States only in the last few years, and U.S. isolates are related to isolates from South America and South Asia. Evidence from U.S. case investigations suggests likely transmission of the organism occurred in health care settings. What are the implications for public health practice? It is important that U.S. laboratories accurately identify C. auris and for health care facilities to implement recommended infection control practices to prevent the spread of C. auris. Local and state health departments and CDC should be notified of possible cases of C. auris and of isolates of C. haemulonii and Candida spp. that cannot be identified after routine testing.

Fibromyalgia Outcomes Over Time: Results from a Prospective Observational Study in the United States

Background:

Longitudinal research on outcomes of patients with fibromyalgia is limited.

Objective:

To assess clinician and patient-reported outcomes over time among fibromyalgia patients.

Methods:

At enrollment (Baseline) and follow-up (approximately 2 years later), consented patients were screened for chronic widespread pain (CWP), attended a physician site visit to determine fibromyalgia status, and completed an online questionnaire assessing pain, sleep, function, health status, productivity, medications, and healthcare resource use.

Results:

Seventy-six fibromyalgia patients participated at both time points (at Baseline: 86.8% white, 89.5% female, mean age 50.9 years, and mean duration of fibromyalgia 4.1 years). Mean number of tender points at each physician visit was 14.1 and 13.5, respectively; 11 patients no longer screened positive for CWP at follow-up. A majority reported medication use for pain (59.2% at Baseline, 62.0% at Follow-up). The most common medication classes were opioids (32.4%), SSRIs (16.9%), and tramadol (14.1%) at Follow-up. Significant mean changes over time were observed for fibromyalgia symptoms (modified American College of Rheumatology 2010 criteria: 18.4 to 16.9; P=0.004), pain interference with function (Brief Pain Inventory-Short Form: 5.9 to 5.3; P=0.013), and sleep (Medical Outcomes Study-Sleep Scale: 58.3 to 52.7; P=0.004). Patients achieving ≥2 point improvement in pain (14.5%) experienced greater changes in pain interference with function (6.8 to 3.4; P=0.001) and sleep (62.4 to 51.0; P=0.061).

Conclusion:

Fibromyalgia patients reported high levels of burden at both time points, with few significant changes observed over time. Outcomes were variable among patients over time and were better among those with greater pain improvement.

Progression of fibromyalgia: results from a 2-year observational fibromyalgia and chronic pain study in the US

Background

A previous fibromyalgia (FM) research reports that 20%–47% of diagnosed patients may not meet the study definition of FM 1–2 years after diagnosis. The aim of this study was to gain a better understanding of the progression of FM in a geographically diverse cohort over a 2-year time period.

Methods

This cohort study followed 226 subjects recruited online to assess FM and chronic widespread pain (CWP) diagnosis stability over time. At enrollment (baseline), subjects provided informed consent, completed an online questionnaire consisting of the London Fibromyalgia Epidemiology Study Screening Questionnaire to screen for CWP (bilateral pain above/below waist lasting ≥1 week in the past 3 months), visited a site for physician evaluation for FM, and completed a questionnaire with validated patient-reported outcome instruments. Subjects were classified into mutually exclusive groups: FM+CWP+ (screened positive for CWP and received physician diagnosis of FM), FM−CWP+ (screened positive for CWP but did not receive physician diagnosis of FM), and FM−CWP− (screened negative for CWP). Approximately 2 years later (follow-up), subjects were reassessed at the same study site and completed a questionnaire with the same patient-reported outcomes.

Results

Seventy-six FM+CWP+ subjects completed assessments at both time points; 56 (73.7%) met the FM study definition at follow-up. Twenty subjects no longer met the FM study definition (eleven became FM−CWP− and nine became FM−CWP+). Ten subjects (two from FM−CWP− and eight from FM−CWP+) transitioned into the FM+CWP+ group at follow-up; they reported more tender points and pain interference with sleep and worse physical function at baseline compared with subjects who did not transition to FM+CWP+. Most (76.7%) of the subjects who transitioned into/out of FM+CWP+ experienced changes in CWP, number of positive tender points, or both.

Conclusion

The results suggest that some FM+CWP+ patients experience fluctuation in symptoms over time, which may reflect the waxing and waning nature of FM and affect diagnosis and treatment.

The Comparative Burden of Chronic Widespread Pain and Fibromyalgia in the United States

BACKGROUND/PURPOSE

Little information exists on the comparative patient and economic burden of chronic widespread pain (CWP) and fibromyalgia (FM) in the United States.

METHODS

This multistage, observational study included an online screening survey of a large geographically diverse US sample to assess CWP status, a physician/site visit to determine FM diagnosis, and an online subject questionnaire to capture clinical characteristics, pain, health status, functioning, sleep, healthcare resource use (HRU), productivity, and costs. Based on the screener and physician evaluation, mutually exclusive groups of subjects without CWP (CWP-), with CWP but without FM (CWP+), and with confirmed FM were identified.

RESULTS

Disease burden was examined in 472 subjects (125 CWP-, 176 CWP+, 171 FM). Age, race, and ethnicity were similar across groups. Mean body mass index and number of comorbidities increased from CWP- to CWP+ to FM (P = 0.0044, P < 0.0001, respectively). From CWP- to CWP+ to FM, there were reductions in health status (EQ-5D, SF-12) and sleep outcomes (MOS-SS, SSQ) (all P < 0.05). Pain severity, interference with function (BPI-SF), and overall work impairment (WPAI:SHP) increased from CWP- to CWP+ to FM (all P < 0.0001). Higher proportions of CWP+ (52.8%) and FM subjects (62.6%) were taking pain-related prescription medications relative to CWP- subjects (32.8%; P < 0.0001). Significant differences in total direct and indirect costs across the three groups (both P < 0.0001) were observed, with highest costs among FM subjects.

CONCLUSION

Fibromyalgia subjects were characterized by the greatest disease burden with more comorbidities and pain-related medications, poorer health status, function, sleep, lower productivity, and higher costs.

Abuse liability measures for use in analgesic clinical trials in patients with pain: IMMPACT recommendations

Assessing and mitigating the abuse liability (AL) of analgesics is an urgent clinical and societal problem. Analgesics have traditionally been assessed in randomized clinical trials (RCTs) designed to demonstrate analgesic efficacy relative to placebo or an active comparator. In these trials, rigorous, prospectively designed assessment for AL is generally not performed. The Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) convened a consensus meeting to review the available evidence and discuss methods for improving the assessment of the AL of analgesics in clinical trials in patients with pain. Recommendations for improved assessment include: (1) performing trials that include individuals with diverse risks of abuse; (2) improving the assessment of AL in clinical trials (eg, training study personnel in the principles of abuse and addiction behaviors, designing the trial to assess AL outcomes as primary or secondary outcome measures depending on the trial objectives); (3) performing standardized assessment of outcomes, including targeted observations by study personnel and using structured adverse events query forms that ask all subjects specifically for certain symptoms (such as euphoria and craving); and (4) collecting detailed information about events of potential concern (eg, unexpected urine drug testing results, loss of study medication, and dropping out of the trial). The authors also propose a research agenda for improving the assessment of AL in future trials.

Classification and definition of misuse, abuse, and related events in clinical trials: ACTTION systematic review and recommendations

As the nontherapeutic use of prescription medications escalates, serious associated consequences have also increased. This makes it essential to estimate misuse, abuse, and related events (MAREs) in the development and postmarketing adverse event surveillance and monitoring of prescription drugs accurately. However, classifications and definitions to describe prescription drug MAREs differ depending on the purpose of the classification system, may apply to single events or ongoing patterns of inappropriate use, and are not standardized or systematically employed, thereby complicating the ability to assess MARE occurrence adequately. In a systematic review of existing prescription drug MARE terminology and definitions from consensus efforts, review articles, and major institutions and agencies, MARE terms were often defined inconsistently or idiosyncratically, or had definitions that overlapped with other MARE terms. The Analgesic, Anesthetic, and Addiction Clinical Trials, Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership convened an expert panel to develop mutually exclusive and exhaustive consensus classifications and definitions of MAREs occurring in clinical trials of analgesic medications to increase accuracy and consistency in characterizing their occurrence and prevalence in clinical trials. The proposed ACTTION classifications and definitions are designed as a first step in a system to adjudicate MAREs that occur in analgesic clinical trials and postmarketing adverse event surveillance and monitoring, which can be used in conjunction with other methods of assessing a treatment's abuse potential.

Assessment of the abuse of tapentadol immediate release: the first 24 months

OBJECTIVE

Prescription opioid analgesics play an important role in the management of moderate to severe pain. An unintended consequence of prescribing opioid analgesics is the abuse and diversion of these medications. The authors estimated abuse and diversion rates for tapentadol immediate release (IR) compared with oxycodone, hydrocodone, and tramadol during the first 24 months of tapentadol IR availability.

METHODS

The Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS®) System measures rates of prescription opioid abuse and diversion throughout the United States. Quarterly data from the Poison Center, Drug Diversion, Opioid Treatment, and Survey of Key Informants' Patients (SKIP) programs were plotted to visually compare the rates of tapentadol IR abuse and diversion with those of other opioid analgesics from July 2009 through June 2011 using both cases per 100,000 population and per 1,000 unique recipients of dispensed drug (URDD) as denominators. Trends in abuse and diversion rates over time were determined using a linear regression model of rate versus time.

RESULTS

During the 24 months following its introduction, tapentadol IR had very low population-based rates of abuse and diversion that were similar to rates for tramadol and lower than rates for oxycodone and hydrocodone. Rates of tapentadol IR abuse and diversion based on URDD were variable by program due to changes in market share and had not stabilized as of June 2011.

CONCLUSIONS

Rates of tapentadol IR abuse and diversion have been low during the first 24 months after its launch. Continued monitoring of trends in these data is warranted.

Core outcome measures for opioid abuse liability laboratory assessment studies in humans: IMMPACT recommendations

A critical component in development of opioid analgesics is assessment of their abuse liability (AL). Standardization of approaches and measures used in assessing AL have the potential to facilitate comparisons across studies, research laboratories, and drugs. The goal of this report is to provide consensus recommendations regarding core outcome measures for assessing the abuse potential of opioid medications in humans in a controlled laboratory setting. Although many of the recommended measures are appropriate for assessing the AL of medications from other drug classes, the focus here is on opioid medications because they present unique risks from both physiological (e.g., respiratory depression, physical dependence) and public health (e.g., individuals in pain) perspectives. A brief historical perspective on AL testing is provided, and those measures that can be considered primary and secondary outcomes and possible additional outcomes in AL assessment are then discussed. These outcome measures include the following: subjective effects (some of which comprise the primary outcome measures, including drug liking; physiological responses; drug self-administration behavior; and cognitive and psychomotor performance. Before presenting recommendations for standardized approaches and measures to be used in AL assessments, the appropriateness of using these measures in clinical trials with patients in pain is discussed.

Research design considerations for clinical studies of abuse-deterrent opioid analgesics: IMMPACT recommendations

Opioids are essential to the management of pain in many patients, but they also are associated with potential risks for abuse, overdose, and diversion. A number of efforts have been devoted to the development of abuse-deterrent formulations of opioids to reduce these risks. This article summarizes a consensus meeting that was organized to propose recommendations for the types of clinical studies that can be used to assess the abuse deterrence of different opioid formulations. Because of the many types of individuals who may be exposed to opioids, an opioid formulation will need to be studied in several populations using various study designs to determine its abuse-deterrent capabilities. It is recommended that the research conducted to evaluate abuse deterrence should include studies assessing: (1) abuse liability, (2) the likelihood that opioid abusers will find methods to circumvent the deterrent properties of the formulation, (3) measures of misuse and abuse in randomized clinical trials involving pain patients with both low risk and high risk of abuse, and (4) postmarketing epidemiological studies.

Adverse reactions to over-the-counter cough and cold products among children: the cases managed out of hospitals

BACKGROUND AND OBJECTIVE

Prompted by continuing concerns about the safety of over-the-counter (OTC) cough and cold medications, we examined the frequency and severity of pediatric adverse drug reactions (ADRs) to OTC cough and cold products reported to a major poison control center. The goal was to focus on cases that are usually managed out of hospitals and may not be recognized by the traditional adverse events surveillance and reporting programs.

METHODS

We conducted a retrospective review of electronic records on ADRs reported to the New Jersey Poison Information and Education System (NJPIES) through the National Poison Data System. Analyses included ADRs involving a single OTC cough and cold product. The number and proportion of reported ADRs to OTC cough and cold medicines were examined and compared by severity level between children <2 years of age, and children from 2 through 11 years of age.

RESULTS

A total of 91 pediatric ADRs to OTC cough and cold products were reported to the NJPIES from 2000 through 2007. Of these, 61 cases (67%) were of minor severity. A larger proportion of the children 2-11 years of age (21.2%), compared with children <2 years of age (8.0%), experienced a reaction of moderate to major severity.

CONCLUSIONS

While we found fewer ADR cases of moderate to major severity in younger children, our results call for a further review of the safety of OTC cough and cold medicines in children 2 years of age and older.

Evaluation of adverse drug reactions reported to a poison control center between 2000 and 2007

PURPOSE

The likelihood of hospitalization caused by adverse drug reactions (ADRs) from commonly implicated therapeutic groups is discussed.

METHODS

A retrospective analysis of the computerized records of exposure cases involving pharmaceutical substances reported to the New Jersey Poison Information and Education System (NJPIES) was conducted from 2000 through 2007. The cases in the National Poisoning Data System that were categorized as an ADR were included in the study set. Only reports involving a single drug were selected for inclusion in the analyses. Characteristics of the ADRs, such as the sex and age of the patient, the therapeutic group involved, and the medical outcome of the exposure, were examined. Reports of ADRs with the most frequently implicated therapeutic groups were analyzed based on whether the patients were managed onsite, referred to a health care facility, or managed at a health care facility. The Adverse Drug Reaction Hospitalization (ADRH) index was calculated for all therapeutic groups, but the focus of the analyses was on the groups that were implicated in 5% or more of all ADRs.

RESULTS

A total of 454,520 cases of human poisoning exposure were reported to NJPIES from 2000 through 2007. Of these cases, 162,105 were exposures implicating a single drug, of which 5,461 (3.4%) were classified as an ADR. Of the 5,461 cases, 385 patients were admitted into a health care facility. Antidepressants had the highest ADRH index (20.4%) among the therapeutic groups implicated, and antimicrobials had the lowest (2.2%).

CONCLUSION

The analyses revealed a substantial variation in the likelihood of hospitalization associated with ADRs within different therapeutic groups. Among the groups that were most frequently implicated in ADRs, antidepressants showed the highest probability for an ADR-related hospitalization, followed by dietary supplements, herbals, and homeopathics and then by sedatives, hypnotics, and antipsychotics.

Challenges in the development of prescription opioid abuse-deterrent formulations

Opioid analgesics remain the cornerstone of effective management for moderate-to-severe pain. In the face of persistent lack of access to opioids by patients with legitimate pain problems, the rate of prescription opioid abuse in the United States has escalated over the past 15 years. Abuse-deterrent opioid products can play a central role in optimizing the risk-benefit ratio of opioid analgesics--if these products can be developed cost-effectively without compromising efficacy or creating new safety issues for the target treatment population. The development of scientific methods for assessing prescription opioid abuse potential remains a critical and challenging step in determining whether a claim of abuse deterrence for a new opioid product is indeed valid and will thus be accepted by the medical, regulatory, and reimbursement communities. To explore this and other potential impediments to the development of prescription opioid abuse-deterrent formulations, a panel of experts on opioid abuse and diversion from academia, industry, and governmental agencies participated in a Tufts Health Care Institute-supported symposium held on October 27 and 28, 2005, in Boston, MA. This manuscript captures the main consensus opinions of those experts, and also information gleaned from a review of the relevant published literature, to identify major impediments to the development of opioid abuse-deterrent formulations and offer strategies that may accelerate their commercialization.

Foundations of opioid risk management

Increased abuse and diversion of prescription opioids has been a consequence of the increased availability of opioids to address the widespread problem of undertreated pain. Opioid risk management refers to the effort to minimize harms associated with opioid therapy while maintaining appropriate access to therapy. Management of these linked public health issues requires a coordinated and balanced effort among a disparate group of stakeholders at the federal, state, industry, practitioner, and patient levels. This paper reviews the principles of opioid risk management by examining the epidemiology of prescription opioid abuse in the United States; identifying key stakeholders involved in opioid risk management and their responsibilities for managing or monitoring opioid abuse and diversion; and summarizing the mechanisms currently used to monitor and address prescription opioid abuse. Limitations of current approaches, and emerging directions in opioid risk management, are also presented.

A Study of AVINZA�(Morphine Sulfate Extended-Release Capsules) for Chronic Moderate-to-Severe Noncancer Pain Conducted Under Real-World Treatment Conditions?The ACCPT Study

This study evaluated the clinical effects and pattern of use of AVINZA((r)), morphine sulfate extended-release tablets, under real-world treatment conditions. Opioid-naive subjects or subjects who have failed other opioids were eligible if they had chronic moderate-to-severe noncancer pain with an average pain score > or =4 (0-10 scale) in the preceding month. Subjects answered in-depth monthly questionnaires in three months. For the 491 evaluable subjects enrolled, the median AVINZA dose was 30 mg at baseline, titrated to 60 mg by month 1, and remained at 60 mg through month 3. Adherence was high, with almost 90% of the subjects reporting never having forgotten to take AVINZA. Mean daily pain scores (scale 0-10) significantly improved from 7.83 at enrollment to 5.77 at month 1 (P < 0.01) and then remained at this level through month 3. Significant improvements were seen in all sleep measures, and the mean Composite Sleep Score, a global measure of sleep quality (scale 0-10), significantly improved from 5.73 at baseline to 4.96 at month 3 (P < 0.01). Physical functioning was improved for activities requiring a moderate effort (P = 0.053), such as climbing one flight of stairs (P = 0.008). Two hospitalizations for nausea and vomiting were the only reported drug-related serious adverse events. This study showed that once-daily AVINZA significantly reduced pain scores, and resulted in improved sleep and physical functioning in patients with chronic moderate-to-severe pain. These results were achieved with a stable daily morphine dose over the three-month study period.

The Diversion of Ultram®, Ultracet®, and Generic Tramadol HCl

Ultram (tramadol HCL) was approved by the Food and Drug Administration in 1994 as a non-scheduled drug under the Controlled Substance Act. The non-scheduled status was contingent on the development and implementation of a comprehensive post-marketing surveillance program by an Independent Steering Committee external to Ortho-McNeil Pharmaceutical charged with monitoring abuse and recommending scheduling if unexpectedly high abuse occurred. The program developed by this committee was composed of a variety of studies, and the results of the first three years of the surveillance efforts revealed that the rate of Ultram abuse was low. At a meeting of the FDA in 1998 to reexamine the scheduling status of Ultram, it was recommended that the scope of the postmarketing surveillance program be broadened to include data on diversion. After a 1-year pilot study, by January 2002, a nationwide diversion survey was fully operational. This brief communication describes the experiences of this diversion study, and compares the findings on the diversion of Ultram and other tramadol HCL products with that of more widely abused drugs. Survey data suggest that the diversion of Ultram and other tramadol products is low, and overall, diversion investigators did not consider tramadol to be a problem in their respective jurisdictions.

A comparison of the abuse liability of tramadol, NSAIDs, and hydrocodone in patients with chronic pain

Concern about abuse/dependence in chronic pain patients taking opioid analgesics may lead to undertreatment of pain, yet little is known about the prevalence of abuse/dependence in these patients and how it differs among analgesic agents. The objective of this study was to assess the prevalence of tramadol abuse compared to nonsteroidal anti-inflammatory drugs (NSAIDs) and hydrocodone-containing analgesics in patients with chronic noncancer pain (CNP). The study had three arms. The first arm consisted of subjects prescribed tramadol alone; the second of subjects randomized to either NSAIDs or tramadol; and the third of subjects randomized to hydrocodone or tramadol. Each investigator received two boxes of prescriptions randomized so that one in every four prescriptions was for tramadol. Upon deciding on the therapeutically appropriate arm, the physician selected the appropriate box, opened the next envelope and completed the enclosed prescription. After the initial randomization, physicians could prescribe whatever medication was therapeutically appropriate. A total of 11,352 subjects were enrolled. Up to nine interviews using a structured questionnaire were conducted over a 12-month period. An algorithm called the "Abuse Index" was developed to identify subjects who were abusing the drug. The primary components of the index were increasing dose without physician approval, use for purposes other than intended, inability to stop its use, and withdrawal. The percent of subjects who scored positive for abuse at least once during the 12-month follow-up were 2.5% for NSAIDs, 2.7% for tramadol, and 4.9% for hydrocodone. When more than one hit on the algorithm was used as a measure of persistence, abuse rates were 0.5% for NSAIDs, 0.7% for tramadol, and 1.2% for hydrocodone. Thus, the results of this study suggest that the prevalence of abuse/dependence over a 12-month period in a CNP population that was primarily female was equivalent for tramadol and NSAIDs, with both significantly less than the rate for hydrocodone.

Rates of abuse of tramadol remain unchanged with the introduction of new branded and generic products: results of an abuse monitoring system, 1994-2004

PURPOSE

The analgesic Tramadol HCl (Ultram) was approved in 1994 as a non-scheduled drug under the CSA provided that a novel risk-management program would be developed by an Independent Steering Committee (ISC). The risk-management program began in 1995 with the launch of Ultram, and has been modified over the past decade to accommodate Ultracet (Ultram and acetaminophen) in 2001 and generic tramadol in 2002. This provided a unique opportunity to study the potential changes in abuse as the generic and combination products became available.

METHODS

To proactively detect cases of abuse and diversion, the ISC developed a comprehensive questionnaire which was completed quarterly by an extensive network of drug abuse experts (n = 309) and police agencies (n = 100) who were asked to indicate how many diversion cases involving Ultram, Ultracet, and generic tramadol were identified during the preceding 3 months and what were the ten most commonly diverted drugs in their catchment area during that period.

RESULTS AND CONCLUSIONS

The data generated demonstrate that the abuse of tramadol remained very low despite new branded and generic formulations. Contrary to the hypothesis that cheaper generic drugs would lead to higher rates of abuse, we found no increase in abuse with the introduction of generic tramadol. Ultracet abuse rates, unlike those found with other widely used hydrocodone and oxycodone combination products, have been even lower than that observed for tramadol. Since the FDA has now mandated that proactive risk-management plans be implemented for new drugs, the tramadol risk-management plan may be useful as a prototypic model which can be modified to accommodate other drugs with abuse potential.

A prospective study of off-label use of, abuse of, and dependence on nicotine inhaler

OBJECTIVE

To determine the incidence of off-label use of, abuse of, and dependence on prescription nicotine inhaler.

DESIGN

Prospective telephone and internet interviews for six months.

PARTICIPANTS

535 new inhaler users.

MAIN OUTCOME

Structured interview about off-label use (that is, use of inhaler for non-cessation reasons or concurrent use of inhaler and cigarettes) and Diagnostic and statistical manual, fourth edition (DSM-IV) and International classification of diseases, 10th edition (ICD-10) criteria for abuse and dependence

RESULTS

Although many used inhaler and cigarettes concurrently at some time (43-55%), few used inhaler for non-cessation reasons (4-9%) and few persisted in off label use (8-16%; 95% confidence interval (CI) 5% to 19%). No participant met ICD-10 criteria for harmful use/abuse (95% CI 0% to 3.3%). Eight subjects (1.4%) appeared to meet DSM-IV or ICD-10 criteria for dependence on inhaler, but none were found dependent in a clinical expert interview (95% CI 0% to 3.3%).

CONCLUSIONS

Although transient concurrent use of inhaler and cigarettes often occurs, use for non-cessation reasons, abuse and dependence are rare.

An independent assessment of MEDWatch reporting for abuse/dependence and withdrawal from Ultram (tramadol hydrochloride)

OBJECTIVE

Assess the validity of medical products reporting program (MEDWatch) reports of abuse/dependence and withdrawal associated with Ultram (tramadol).

METHODS

Reports of possible abuse/dependence or withdrawal associated with Ultram during 13 quarters following launch were spontaneously reported to the manufacturer Ortho-McNeil Pharmaceutical (OMP) and also solicited from 255 NIDA grantees and addiction treatment professionals by an Independent Steering Committee (ISC). Reports were classified by the ISC using DSM-IV criteria, by the Drug Safety and Surveillance (DSS) units of Robert Wood Johnson Pharmaceutical Research Institute (PRI) using World Health Organization Adverse Reaction Terms (WHOART) terms, and reported to the food and drug administration (FDA) via MEDWatch. Rates of abuse/dependence and withdrawal per 100000 persons exposed were calculated separately for classifications made by the PRI and the ISC, and confidence intervals calculated to determine the degree to which they agreed.

RESULTS

For 681 reports submitted to PRI, confidence intervals of ISC ratings contained PRI ratings 12 of 13 times for abuse/dependence, and 12 of 13 times for withdrawal. For 242 reports submitted to the ISC, confidence intervals of ISC ratings contained PRI ratings 10 of 13 times for abuse/dependence, and 12 of 13 times for withdrawal. Proactive surveillance increased the total number of cases of abuse/dependence but not withdrawal. Many cases of withdrawal without signs or symptoms of abuse/dependence were identified.

CONCLUSIONS

There was good/excellent concordance between MEDWatch and ISC classifications. Proactive surveillance increased cases of abuse/dependence but not withdrawal. Withdrawal with no signs or symptoms of dependence was common. More use of proactive surveillance is likely to improve assessments of public health risks associated with adverse events.

Physical dependence on Ultram (tramadol hydrochloride): both opioid-like and atypical withdrawal symptoms occur

In 1994, the Drug Abuse Advisory Committee (DAAC) of the Food and Drug Administration (FDA) concluded that Ultram (tramadol hydrochloride) could be marketed as an analgesic drug without scheduling under the Controlled Substances Act based upon extensive pre-clinical, clinical and European epidemiological data. However, to guard against unexpectedly high levels of abuse in the United States, the DAAC recommended that an independent steering committee (ISC) be appointed to proactively monitor abuse/dependence. In the event that high rates of abuse were found, this ISC was given the authority to immediately recommend to the FDA that Ultram be scheduled. In the course of the surveillance project, the ISC received reports of withdrawal following abrupt discontinuation of Ultram and in some instances, following dose reductions. In most cases, the withdrawal symptoms consisted of classical opioid withdrawal, but in some cases were accompanied by withdrawal symptoms not normally observed in opiate withdrawal, such as hallucinations, paranoia, extreme anxiety, panic attacks, confusion and unusual sensory experiences such as numbness and tingling in one or more extremities. Withdrawal symptoms of either type were one of the more prevalent adverse events associated with chronic Ultram use, comprising nearly 40% of all adverse events reported with Ultram. Most of these consisted of typical opiate withdrawal symptoms, but 1 in 8 cases presented as atypical. These results indicate that physicians and other healthcare professionals need to be aware of the potential of Ultram to induce withdrawal of the classical opioid type, and that atypical withdrawal may also occur.

A postmarketing surveillance program to monitor Ultram (tramadol hydrochloride) abuse in the United States

Tramadol HCl, marketed as Ultram in the USA, was introduced as a non-scheduled drug in April 1995 based on the assumption that the risk of abuse was sufficiently low to warrant a non-scheduled status. However, approval was contingent upon the development of an innovative proactive surveillance program, to be overseen by an independent steering committee, which would detect unexpectedly high levels of abuse. The postmarketing surveillance program consisted of systematic collection and scientific evaluation of reports of suspected abuse in high-risk populations surveyed through an extensive key informant network of drug abuse specialists and all spontaneous reports of abuse received through the FDA MedWatch system. Methods to estimate the number of patients prescribed tramadol were also developed. Monthly rates of abuse were calculated as an index of the risk-benefit ratio (i.e., abuse cases per 100,000 patients prescribed the drug). The data for the 3 years since the drug was introduced show that the reported rate of abuse has been low. Although a period of experimentation seemed to occur in the first 18 months after its introduction--which reached a peak rate of approximately two cases per 100,000 patients exposed--during the 2 year period prior to June 1998, the reported rate of abuse has significantly (P = 0.011) declined, reaching levels of less than one case per 100,000 patients in the last 18 months. The overwhelming majority of abuse cases (97%) have been found to occur among individuals with a history of substance abuse and the abuse has been confined to isolated pockets around the country-notably none of which have significant populations of street drug abusers. Thus, the data support the decision not to schedule tramadol and, furthermore, suggest that a proactive post-marketing surveillance program can be successfully developed to effectively monitor abuse of new medications.

Patient satisfaction and experience with health services and quality of care

This article discusses the use of patient satisfaction and personal health care experiences as a measure of health care quality. It also presents a field-proven patient experience and satisfaction assessment methodology known as the Patient Experience Survey (PES) that has been employed throughout the country for the last decade. Finally, it offers recommendations and comments on the use of patient satisfaction data in quality assessment and improvement.

Patient satisfaction surveys and multicollinearity

The measurement of patient satisfaction is now an integral part of hospital market research. Just as consumer satisfaction is a function of the extent to which providers do things right, the value of consumer-oriented market research is directly related to whether the research itself is done right. The use of poorly designed consumer research instruments, no matter how well executed, can cause multicollinearity among the independent variables, which, in turn, can result in misleading conclusions.

The consistency of estimates obtained through central-location sampling: analysis of the Partnership for a Drug-Free America Attitude Tracking Study

To evaluate the reliability and validity of estimates of drug use obtained through multiple-site central-location sampling, data from the Partnership Attitude Tracking Study (PATS), collected annually beginning in 1987, are tracked longitudinally and compared with data collected through traditional household interviews. Comparisons with demographic estimates from Current Population Surveys indicate that central-location sampling can provide a broadly representative sample of the adult population. However, there is some coverage bias in central-location sampling, most notably in the underrepresentation of adults who do not have high school diplomas. Sample estimates obtained from central-location sampling are consistent over time. Basic demographic characteristics of the samples--education, income, marital status, and area of residence--vary by less than 5% across the four waves of the tracking study. Prevalence estimates of self-reported drug use demonstrate an even higher degree of consistency over time. Comparisons of PATS and National Household Survey of Drug Abuse data and the Monitoring the Future data indicate a higher level of drug use and a lower level of perceived risk of occasional use among PATS respondents. While the trends in use and perceived risk reported in all studies are similar, we suggest that perceived threats to confidentiality and anonymity often result in significant underreporting of drug use, particularly in household surveys. Sample estimate differences are attributed to sampling and measurement error. Some discrepancy in prevalence estimates is associated with the fact that the PATS sample is not a true probability sample; as a result, the sampling error of the overall study cannot be estimated precisely. It is also likely that the difference in estimates between the studies is a product of the decreased measurement error of PATS methodology. In central-location sampling, respondents are completely anonymous and may feel more comfortable in providing honest answers about illicit activities such as drug use. The potential applications of this methodology are discussed.

Sociodemographic and attitudinal correlates of alcohol and other drug use among children and adolescents: analysis of a large-scale attitude tracking study

Data from the Partnership Attitude Tracking Study are analyzed to provide a greater understanding of the contributing factors to alcohol and other drug use among children and adolescents. The data were collected from children (ages 9 to 12) and teenagers (ages 13 to 17) in central locations (usually shopping malls) located in 100 primary sampling units across the United States. The analysis, which primarily employed stepwise multiple regression for model estimation, reinforced the importance of friends use, perceived risk, and tobacco and alcohol use in predicting marijuana use. An exposure model, which included antidrug advertisements, was a particularly powerful model. Implications of the findings are discussed.

Drug abuse discharges from non-federal short-stay hospitals

An analysis of inpatient drug abuse cases was done using the National Hospital Discharge Survey (NHDS). An estimated two million discharges with a drug abuse diagnosis occurred in non-federal short-stay hospitals during 1979-85, a figure which is believed to be an underestimate. Compared to other hospital inpatients, drug abuse inpatients are more likely to be male, ages 15-44, and other than White race. Increases in hospital use for drug abuse treatment were found to have occurred between 1979 and 1985, with discharge rates per 10,000 population increasing from 3.1 to 6.0 for drug dependence and from 3.8 to 7.7 for nondependent drug abuse. Concurrent increases in availability of hospital-based inpatient drug and alcohol treatment programs and insurance coverage for drug abuse treatment were found to have occurred during the same period.

Trends in prevalence and consequences of cocaine use

A variety of data sources and research studies are used to examine changes in the prevalence of cocaine use and assess the population at risk. The issues of progression to more intensified use of cocaine and the use of other drugs in combination with cocaine are investigated. Consequences of cocaine use are discussed, as is the potential impact of changing routes of administration on both the frequency and severity of those consequences.

Epidemiology of drug abuse: an overview

Issues regarding the use of epidemiology in drug abuse research are discussed and systems for monitoring national trends and identifying risk factors are described. Data indicate a general decline in marijuana use among youth, a cohort aging effect among heroin and marijuana users, and increased prevalence and health consequences associated with cocaine use.