Mandatory Provider Review And Pain Clinic Laws Reduce The Amounts Of Opioids Prescribed And Overdose Death Rates

Effect of State Policy Changes in Florida on Opioid-Related Overdoses

INTRODUCTION

With a rapid increase in prescription opioid overdose deaths and a proliferation of pain clinics in the mid-2000s, Florida emerged as an epicenter of the opioid overdose epidemic. In response, Florida implemented pain clinic laws and operationalized its Prescription Drug Monitoring Program. This study examines the effect of these policies on rates of inpatient stays and emergency department visits for opioid-related overdoses.

METHODS

Using data from the 2008-2015 State Emergency Department Databases and State Inpatient Databases, quarterly rates of inpatient stays and emergency department visits for prescription opioid-related overdoses and heroin-related overdoses were computed. A comparative interrupted time series analysis examined the effect of these policies on opioid overdose rates. North Carolina served as a control state because it did not implement similar policies during the study period. The data were analyzed in 2019.

RESULTS

Compared with North Carolina, Florida's polices were associated with reductions in the rates of prescription opioid-related overdose inpatient stays and emergency department visits, a level reduction of 2.31 per 100,000 and a reduction in the trend of 0.16 per 100,000 population each quarter. The policies were associated with a reduction of 13,532 inpatient stays and emergency department visits for prescription opioid-related overdoses during the study period. No statistically significant association was found between the policies and heroin-related overdose inpatient stays and emergency department visits.

CONCLUSIONS

To address the opioid overdose epidemic, states have implemented policies such as Prescription Drug Monitoring Programs and pain clinic laws designed to reduce inappropriate opioid prescribing. Such laws may be effective in reducing prescription opioid-related overdoses.

Effect of a Law Requiring Prescription Drug Monitoring Program Use on Emergency Department Opioid Prescribing: A Single-Center Analysis

OBJECTIVE

To compare opioid prescribing behavior of emergency medicine providers following the enactment of Connecticut Public Act (PA) 15-198 at a large academic tertiary medical center.

METHODS

This study is a single-center pre and postlaw retrospective cohort of ED patients discharged with opioid prescriptions. Patients discharged from January 1, 2015, to June 30, 2015, were analyzed as the prelaw cohort, and patients discharged from January 1, 2016, to June 30, 2016, were analyzed as the postlaw cohort. The primary outcome was the cumulative dose of solid dosage forms of opioids per prescription, calculated in morphine milligram equivalents (MME).

RESULTS

A total of 10,307 prescriptions included in the final analysis. A statistically significant decrease in the primary outcome was seen in the postlaw cohort compared with the prelaw cohort, respectively (75 MME [interquartile range, IQR: 60-100) vs 80 MME [IQR: 75-150]; P < .001). The postlaw cohort also saw 1289 (22.2%) fewer opioid prescriptions, primarily driven by a reduction in the number of schedule II opioids prescribed. In a posthoc analysis, the primary outcome remained statistically significant even when opioid prescriptions were only included if their prebuilt settings were unchanged between pre and postlaw cohorts, respectively (85.1%; 95.6 MME (±56.0); n = 5041 vs 86.7 MME (±39.6); n = 3713; P < .001).

CONCLUSIONS

The passage of PA 15-198 was associated with a decrease in the cumulative dose of opioids per prescription of solid dosage form products. This drop was precipitated by a transition from using opioids in schedule II to opioids in schedule IV and a modest decrease in prescribed opioid quantity.

Prescription Drug Monitoring Programs and Prescription Opioid-Related Outcomes in the United States

Prescription drug monitoring programs (PDMPs) are a crucial component of federal and state governments' response to the opioid epidemic. Evidence about the effectiveness of PDMPs in reducing prescription opioid-related adverse outcomes is mixed. We conducted a systematic review to examine whether PDMP implementation within the United States is associated with changes in 4 prescription opioid-related outcome domains: opioid prescribing behaviors, opioid diversion and supply, opioid-related morbidity and substance-use disorders, and opioid-related deaths. We searched for eligible publications in Embase, Google Scholar, MEDLINE, and Web of Science. A total of 29 studies, published between 2009 and 2019, met the inclusion criteria. Of the 16 studies examining PDMPs and prescribing behaviors, 11 found that implementing PDMPs reduced prescribing behaviors. All 3 studies on opioid diversion and supply reported reductions in the examined outcomes. In the opioid-related morbidity and substance-use disorders domain, 7 of 8 studies found associations with prescription opioid-related outcomes. Four of 8 studies in the opioid-related deaths domain reported reduced mortality rates. Despite the mixed findings, emerging evidence supports that the implementation of state PDMPs reduces opioid prescriptions, opioid diversion and supply, and opioid-related morbidity and substance-use disorder outcomes. When PDMP characteristics were examined, mandatory access provisions were associated with reductions in prescribing behaviors, diversion outcomes, hospital admissions, substance-use disorders, and mortality rates. Inconsistencies in the evidence base across outcome domains are due to analytical approaches across studies and, to some extent, heterogeneities in PDMP policies implemented across states and over time.

Trends in opioid use disorder and overdose among opioid-naive individuals receiving an opioid prescription in Massachusetts from 2011 to 2014

AIMS

To examine how the risks of incident opioid use disorder (OUD), non-fatal and fatal overdose have changed over time among opioid-naive individuals receiving an initial opioid prescription.

DESIGN

Retrospective, longitudinal study using the Massachusetts Chapter 55 data set, which linked multiple administrative data sets to study the opioid epidemic. We identified the cumulative incidence of OUD, non-fatal and fatal overdose among the opioid-naive initiating opioid treatment in Massachusetts from 2011 to 2014 and estimated rates of these outcomes at 6 months and at 1, 2, 3 and 4 years to 2015. We used Cox regression to examine the association between characteristics of the initial prescription and risk of these outcomes.

SETTING

Massachusetts, USA.

PARTICIPANTS

Massachusetts residents aged ≥ 11 years in 2011-15 who were opioid-naive (no opioid prescriptions or evidence of OUD in the 6 months prior to the index prescription) (n = 2 154 426). The mean age was 49.1 years, 55.3% were female and 47.3% had commercial insurance.

MEASUREMENTS

Opioid prescriptions were identified in the Prescription Monitoring Program (PMP) database, as were the characteristics of the initial prescription database. The outcomes of OUD and non-fatal overdose were identified from claims in the All Payer Claims Database (APCD) and hospital encounters in the acute hospital case mix files. Fatal overdoses were identified using Registry of Vital Records and Statistics (RVRS) death certificates and the Office of the Chief Medical Examiner (OCME) circumstances of death and toxicology reports.

FINDINGS

Among opioid-naive individuals receiving an initial opioid prescription, the risk of incident OUD appears to have declined between 2011 and 2014, while rates of overdose were largely unchanged. For example, the 1-year OUD rate was 1.18% in 2011, 1.11% in 2012, 1.26% in 2013 and 0.94% in 2014. Longer therapy duration was associated with higher risk of OUD [hazard ratio (HR) = 2.24, 95% confidence interval (CI) = 2.19-2.29 for duration of 3 or more months], non-fatal (HR = 1.67, 95% CI = 1.53-1.82) and fatal opioid overdose (HR = 2.24, 95% CI = 1.91-2.61). Concurrent benzodiazepine treatment was also associated with higher risk of OUD (HR = 1.14, 95% CI = 1.12-1.17), non-fatal (HR = 1.20, 95% CI = 1.10-1.30) and fatal overdose (HR = 1.86, 95% CI = 1.61-2.16).

CONCLUSIONS

Among opioid-naive individuals in Massachusetts receiving an initial opioid prescription, the risk of incident opioid use disorder appears to have declined between 2011 and 2014, while rates of overdose were largely unchanged. Longer therapy duration and concurrent benzodiazepines were associated with higher rates of opioid use disorder and opioid overdose.

The Association of State Opioid Misuse Prevention Policies With Patient- and Provider-Related Outcomes: A Scoping Review

Policy Points This scoping review reveals a growing literature on the effects of certain state opioid misuse prevention policies, but persistent gaps in evidence on other prevalent state policies remain. Policymakers interested in reducing the volume and dosage of opioids prescribed and dispensed can consider adopting robust prescription drug monitoring programs with mandatory access provisions and drug supply management policies, such as prior authorization policies for high-risk prescription opioids. Further research should concentrate on potential unintended consequences of opioid misuse prevention policies, differential policy effects across populations, interventions that have not received sufficient evaluation (eg, Good Samaritan laws, naloxone access laws), and patient-related outcomes.

CONTEXT

In the midst of an opioid crisis in the United States, an influx of state opioid misuse prevention policies has provided new opportunities to generate evidence of policy effectiveness that can inform policy decisions. We conducted a scoping review to synthesize the available evidence on the effectiveness of US state interventions to improve patient and provider outcomes related to opioid misuse and addiction.

METHODS

We searched six online databases to identify evaluations of state opioid policies. Eligible studies examined legislative and administrative policy interventions that evaluated (a) prescribing and dispensing, (b) patient behavior, or (c) patient health.

FINDINGS

Seventy-one articles met our inclusion criteria, including 41 studies published between 2016 and 2018. These articles evaluated nine types of state policies targeting opioid misuse. While prescription drug monitoring programs (PDMPs) have received considerable attention in the literature, far fewer studies addressed other types of state policy. Overall, evidence quality is very low for the majority of policies due to a small number of evaluations. Of interventions that have been the subject of considerable research, promising means of reducing the volume and dosages of opioids prescribed and dispensed include drug supply management policies and robust PDMPs. Due to low study number and quality, evidence is insufficient to draw conclusions regarding interventions targeting patient behavior and health outcomes, including naloxone access laws and Good Samaritan laws.

CONCLUSIONS

Recent research has improved the evidence base on several state interventions targeting opioid misuse. Specifically, moderate evidence suggests that drug supply management policies and robust PDMPs reduce opioid prescribing. Despite the increase in rigorous evaluations, evidence remains limited for the majority of policies, particularly those targeting patient health-related outcomes.

Strengths and weaknesses of existing data sources to support research to address the opioids crisis

Better opioid prescribing practices, promoting effective opioid use disorder treatment, improving naloxone access, and enhancing public health surveillance are strategies central to reducing opioid-related morbidity and mortality. Successfully advancing and evaluating these strategies requires leveraging and linking existing secondary data sources. We conducted a scoping study in Fall 2017 at RAND, including a literature search (updated in December 2018) complemented by semi-structured interviews with policymakers and researchers, to identify data sources and linking strategies commonly used in opioid studies, describe data source strengths and limitations, and highlight opportunities to use data to address high-priority public health research questions. We identified 306 articles, published between 2005 and 2018, that conducted secondary analyses of existing data to examine one or more public health strategies. Multiple secondary data sources, available at national, state, and local levels, support such research, with substantial breadth in data availability, data contents, and the data's ability to support multi-level analyses over time. Interviewees identified opportunities to expand existing capabilities through systematic enhancements, including greater support to states for creating and facilitating data use, as well as key data challenges, such as data availability lags and difficulties matching individual-level data over time or across datasets. Multiple secondary data sources exist that can be used to examine the impact of public health approaches to addressing the opioid crisis. Greater data access, improved usability for research purposes, and data element standardization can enhance their value, as can improved data availability timeliness and better data comparability across jurisdictions.

The effects of medicare advantage on opioid use

Despite a vast literature on the determinants of prescription opioid use, the role of health insurance plans has received little attention. We study how the form of Medicare beneficiaries' drug coverage affects the volume of opioids they consume. We find that enrollment in Medicare Advantage, which integrates drug coverage with other medical benefits, significantly reduces beneficiaries' likelihood of filling an opioid prescription, as compared to enrollment in a stand-alone drug plan. Approximately half of this effect was due to fewer fills from prescribers who write a very large number of opioid prescriptions.

Impact of Iowa's Prescription Monitoring Program on Opioid Pain Reliever Prescribing Patterns: An Interrupted Time Series Study 2003-2014

OBJECTIVE

To evaluate the impact of Iowa's prescription monitoring program (PMP), implemented in 2009, on opioid pain reliever (OPR) prescribing patterns.

METHODS

We conducted interrupted time series analyses using 2003-2014 health insurance claims from a private health insurer in Iowa. OPR prescriptions for all beneficiaries were included. Another data set included only OPR prescription for new opioid users required to have six months of insurance coverage. We evaluate four OPR prescribing patterns: 1) average daily dosage in morphine milligrams equivalents (MME), 2) MME per prescription, 3) average days' supply per prescription, and 4) prescription rate per 1,000 insured person-years. We examined confounding and effect measure modification of the relationship between PMP and prescribing patterns by age and sex.

RESULTS

During the 12 years of follow-up, 1,512,388 insured Iowans contributed 6,169,634.92 person-years of follow-up. Of these, 505,274 patients filled 2,401,818 OPR prescriptions and 360,688 new OPR users filled as many first OPR prescriptions. The increasing trend of OPR prescription rates from 2003 to 2009 declined post-PMP. Similarly, there was a large decline in MME per day and MME per prescription. The OPR days' supply kept increasing post-PMP implementation, albeit at a slightly slower rate than pre-PMP implementation. There was no confounding by age and sex; however, we observed heterogeneity by age and sex; patients aged ≥50 years and females received higher doses and more prescriptions pre-PMP and experienced the greatest declines post-PMP.

CONCLUSIONS

Our study suggests that Iowa PMP implementation may have resulted in declines in OPR prescribing, and this impact varies by patient age and sex.

National U.S. time-trends in opioid use disorder hospitalizations and associated healthcare utilization and mortality

Background

The opioid epidemic is a major public health crisis in the U.S. Contemporary data on opioid use disorder (OUD) related hospitalizations are needed. Our objective was to assess whether OUD hospitalizations and associated mortality are increasing over time and examine the factors associated healthcare utilization and mortality.

Methods and findings

We examined the rates of OUD hospitalizations and associated mortality using the U.S. National Inpatient Sample (NIS) data from 1998–2016. Multivariable-adjusted logistic regression assessed the association of demographic, clinical and hospital characteristics with inpatient mortality and healthcare utilization (total hospital charges, discharge to a rehabilitation facility, length of hospital stay) during the index hospitalization for opioid use disorder. We calculated the odds ratio (OR) and 95% confidence intervals (CI). We estimated 781,767 OUD hospitalizations. The rate of OUD hospitalization and associated mortality (/100,000 overall NIS hospitalizations) increased from 59.8 and 1.2 in 1998–2000 to 190.7 and 5.9 in 2015–16, respectively. In the multivariable-adjusted analysis, the following factors were associated with worse outcomes; compared to age <34 years, older age was associated with higher risk of hospital charges above the median and length of stay >3 days, slightly higher risk of discharge to a rehabilitation facility. Higher Deyo-Charlson score was associated with higher hospital charges, length of hospital stay, and inpatient mortality. Women had lower odds of inpatient mortality than men and blacks had lower odds of mortality than whites.

Conclusions

Rising OUD hospitalizations from 1998 to 2016 and increasing associated inpatient mortality are concerning. Certain groups are at higher risk of poor utilization outcomes and inpatient mortality. Resources and healthcare policies need to focus on the high-risk group to reduce mortality and associated utilization.

Prescription drug monitoring programs and drug overdose deaths involving benzodiazepines and prescription opioids

BACKGROUND AND AIMS

In the US, benzodiazepine overdose deaths increased at an alarming rate in the past two decades. Benzodiazepines were also the most common drugs involved in prescription opioid overdose deaths. Benzodiazepine prescribing has been monitored by Prescription Drug Monitoring Programs (PDMPs), but little was known about whether PDMPs reduced drug overdose deaths involving benzodiazepines.

DESIGN AND METHODS

This study used a difference-in-difference design with state-quarter aggregate data on drug overdose deaths. The primary data source was Mortality Multiple Cause Files in 1999-2016. Three age-adjusted rates of drug overdose deaths were examined, including those involving benzodiazepines, those involving prescription opioids, and those involving both benzodiazepines and prescription opioids. The policy variables included PDMP data access for benzodiazepines and mandatory use of PDMP data for benzodiazepines. Linear multivariable regressions were used to assess the associations of PDMP policies specific to benzodiazepines with drug overdose death rates, controlling for other state-level policy and socioeconomic factors, state and time fixed effects, and state-specific time trends.

RESULTS

No significant associations were found between PDMP data access for benzodiazepines and changes in drug overdose death rates involving benzodiazepines and/or prescription opioids. Similarly, no significant associations were found between mandatory use of PDMP data for benzodiazepines and changes in drug overdose death outcomes.

DISCUSSION AND CONCLUSIONS

This study suggested no evidence that PDMP policies specific to benzodiazepines were associated with reduction in benzodiazepine overdose death rates. Future research is warranted to examine detailed features of PDMPs and continuously monitor the impacts of PDMP policies on benzodiazepine-related consequences.

Opioid Prescribing Behaviors - Prescription Behavior Surveillance System, 11 States, 2010-2016

Problem/Condition

In 2017, a total of 70,237 persons in the United States died from a drug overdose, and 67.8% of these deaths involved an opioid. Historically, the opioid overdose epidemic in the United States has been closely associated with a parallel increase in opioid prescribing and with widespread misuse of these medications. National and state policy makers have introduced multiple measures to attempt to assess and control the opioid overdose epidemic since 2010, including improvements in surveillance systems.

Period Covered

2010–2016

Description of System

The Prescription Behavior Surveillance System (PBSS) was created in 2011. Its goal was to track rates of prescribing of controlled substances and possible misuse of such drugs using data from selected state prescription drug monitoring programs (PDMP). PBSS data measure prescribing behaviors for prescription opioids using multiple measures calculated from PDMP data including 1) opioid prescribing, 2) average daily opioid dosage, 3) proportion of patients with daily opioid dosages ≥90 morphine milligram equivalents, 4) overlapping opioid prescriptions, 5) overlapping opioid and benzodiazepine prescriptions, and 6) multiple-provider episodes. For this analysis, PBSS data were available for 2010–2016 from 11 states representing approximately 38.0% of the U.S. population. Average quarterly percent changes (AQPC) in the rates of opioid prescribing and possible opioid misuse measures were calculated for each state.

Results and Interpretation

Opioid prescribing rates declined in all 11 states during 2010–2016 (range: 14.9% to 33.0%). Daily dosage declined least (AQPC: -0.4%) in Idaho and Maine, and most (AQPC: -1.6%) in Florida. The percentage of patients with high daily dosage had AQPCs ranging from -0.4% in Idaho to -2.3% in Louisiana. Multiple-provider episode rates declined by at least 62% in the seven states with available data. Variations in trends across the 11 states might reflect differences in state policies and possible differential effects of similar policies.

Public Health Actions

Use of PDMP data from individual states enables a more detailed examination of trends in opioid prescribing behaviors and indicators of possible misuse than is feasible with national commercially available prescription data. Comparison of opioid prescribing trends among states can be used to monitor the temporal association of national or state policy interventions and might help public health policymakers recognize changes in the use or possible misuse of controlled prescription drugs over time and allow for prompt intervention through amended or new opioid-related policies.

Prescriber responses to a pain clinic law: Cease or modify?

BACKGROUND

Pain clinic laws are designed to cease or modify high-risk prescribing behavior. However, prior evaluations have not differentiated between these types of prescriber responses in their analysis, even though they may have different implications for patients. The purpose of this analysis is to investigate the effect of a 2016 Tennessee pain clinic law on the two types of prescriber responses.

METHODS

We used data on opioid prescriptions from the Tennessee Controlled Substances Monitoring Database (CSMD) between July 1^st, 2015 and July 1^st, 2017. Prescribers were assigned to the cessation or modification group based on the date of their last opioid prescription during the time period July 1^st, 2015 to July 1^st, 2018 and its relationship to the change in law. A risk score was developed based on five indicators to capture two categories of risky prescriber behavior: increased risk for diversion or increased patient's risk of overdose. Within-prescriber differences were used to assess the effect of the law on several outcomes that capture the quantity and content of opioid prescriptions.

RESULTS

There was a significant decline in the number of prescriptions (cessation mean = -45.18 pval<0.001; continuation mean = -24.41 pval<0.001) and patients (cessation mean = -16.68pval<0.001; continuation mean = -10.92 pval<0.001) in both prescriber response groups, but the magnitude of decline was much larger in the cessation group. High-risk prescribers were more likely to cease prescribing than modify.

CONCLUSIONS

Prescribers who ceased prescribing in response to the pain clinic law disproportionately contributed to overall declines in opioid prescriptions.

Academic Advocacy: Opportunities to Influence Health and Science Policy Under U.S. Lobbying Law

Medical school faculty and their colleagues in schools of nursing, public health, social work, and elsewhere often research issues of critical importance to health and science policy. When academics engage with government policymakers to advocate for change based on their research, however, they may find themselves engaged in "lobbying," thereby entering a complex environment of legal requirements and institutional policies that they may not fully understand. To promote academic advocacy, this article explains what is and is not legally permitted when it comes to engaging with policymakers and encourages academic institutions to facilitate permissible advocacy activities.U.S. law permits academic researchers to conduct certain types of policy-focused advocacy without running afoul of legal restrictions on lobbying. Academics acting in their personal capacities and with their own resources may freely engage with policymakers in any branch of government to provide their expertise and advocate for desired outcomes. When acting in their professional capacities, academics are free to engage in most advocacy activities directed to the executive and judicial branches, and they also may advocate to influence legislation and legislators within certain limits that are particularly relevant to academic work. In all cases, academics must take care to not use restricted funds for lobbying.Academic researchers have an important role to play in advancing evidence-based health and science policy. They should familiarize themselves with legal restrictions and opportunities to influence policy based on their research, and their institutions should actively support them in doing so.

Chronic opioid use following anterior cervical discectomy and fusion surgery for degenerative cervical pathology

BACKGROUND CONTEXT

Although prescribing opioid medication on a limited basis for postoperative pain control is common practice, few studies have focused on chronic opioid use following anterior cervical discectomy and fusion (ACDF).

PURPOSE

To determine the prevalence of and risk factors for chronic opioid use following one and two-level ACDF for degenerative cervical pathology.

DESIGN

Retrospective cohort.

PATIENT SAMPLE

Using an insurance claims database, we identified patients aged 18-64 who underwent one or two-level primary ACDF from 2010 to 2015 for degenerative cervical pathology.

OUTCOME MEASURES

Opioid prescription strength at various timepoints pre- and postoperatively and development of chronic postoperative opioid use.

METHODS

Prescription opioid use was examined during the following periods: 90 days before 7 days preceding surgery (preoperative), 6 days preceding surgery to 90 days following surgery (perioperative) and from 91 to 365 days following surgery (postoperative). The primary outcome was chronic postoperative opioid use, defined as ≥120 days' supply of opioid prescriptions filled or ≥10 opioid prescriptions between 3 and 12 months postoperatively. Secondary outcomes were high-dose (>90 morphine milligram equivalents [MME]/day) and very high-dose (>200 MME/day) opioid prescriptions. A multivariate logistic model (area under the ROC curve 0.75, p<.001) was built to predict long-term opioid use.

RESULTS

Among 28,813 patients who underwent ACDF, most were female (55%) and underwent single-level ACDF (68%), with mean age of 50±8.0 years. Fifty-two percent of patients filled an opioid prescription in the preoperative period, 95% of patients filled a prescription in the perioperative period, and 39% of patients filled a prescription in the postoperative period. High-dose and very high-dose opioid prescriptions in the perioperative period were identified in 45% and 24% of patients, respectively, whereas 17% met criteria for chronic postoperative opioid use. The odds of chronic opioid use were highest in the Western US (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.3, 1.6). Duration of opioids prescribed was also highest in the Western US (median 111 days, interquartile range 11-336), p<.001. Factors associated with the highest risk for chronic opioid use were preoperative opioid use (OR 5.7, 95% CI 5.3, 56.2), drug abuse (OR 3.5, 95% CI 2.6, 4.5), depression (OR 1.7, 95% CI 1.6, 1.9), anxiety (OR 1.5, 95% CI 1.4, 1.6), and surgery in the western region of the United States (OR 1.5, 95% CI 1.3, 1.6).

CONCLUSIONS

Patients undergoing ACDF commonly receive high-dose opioid prescriptions after surgery, and certain patient factors increase risk for chronic opioid use following ACDF. Intervention focusing on patients with these factors is essential to reduce long-term use of prescription opioids and postoperative care.

The association between pain clinic laws and prescription opioid exposures: New evidence from multi-state comparisons

OBJECTIVES

States in the US are controlling opioid prescribing to combat the opioid epidemic. Prescription Drug Monitoring Programs (PDMPs) were widely adopted, whereas less attention was given to pain clinic laws. This study examined the associations of mandatory use of PDMPs and pain clinic laws with prescription opioid exposures.

METHODS

State-level quarterly prescription opioid exposures reported to the National Poison Data System during 2010-2017 were analyzed. The primary outcome was age-adjusted rates of prescription opioid exposures per 1,000,000 population. The primary policy variables included the implementation of mandatory use of PDMPs alone, the implementation of pain clinic laws alone, and the implementation of both mandatory use of PDMPs and pain clinic laws. Linear regressions were used to examine the associations, controlling for other opioid policies, marijuana policies, socioeconomic factors, state fixed effects, time fixed effects, and state-specific time trends.

RESULTS

Requiring mandatory use of PDMPs alone was not associated with significant changes in prescription opioid exposures. The implementation of pain clinic laws with or without concurrent mandatory use of PDMPs was associated with 5 fewer prescription opioid exposures per 1,000,000 population or a 9 % reduction compared to the pre-policy period (p < 0.01). Further analysis revealed that the reduction associated with pain clinic laws was pronounced in exposures reported by healthcare facilities.

CONCLUSIONS

This multi-state study provided new evidence that the implementation of pain clinic laws was associated with a significant reduction in prescription opioid exposures. Pain clinic laws may deserve further evaluation and consideration.

Do prescription drug monitoring programs encourage prescription - or illicit - opioid abuse?

BACKGROUND

Prescription drug monitoring programs (PDMPs) are tools that states can use to fight prescription opioid misuse within their jurisdiction. However, because PDMPs make prescription opioids more difficult to access, these programs may have the unintended consequence of increasing deaths related to illicit opioids. Methods: This study uses fixed effects models to estimate how PDMP regulatory strength is associated with both prescription opioid- and heroin-related deaths between 1999 and 2016. PDMP regulatory strength is measured by creating a score using multiple correspondence analysis (MCA). Additional models replace the MCA score with a binary indicator for the presence of one particular regulation requiring physicians to access the system before writing opioid prescriptions. Results: Results show that continuous measures of PDMP strength are not generally associated with prescription opioid- or heroin-related death rates. Yet, one model does show that PDMP scores are positively associated with the heroin-related death rate. The models using the binary mandatory access variable show a strong positive association with both prescription opioid and heroin deaths. Conclusions: This study supports the theory that more stringent state PDMPs are associated with higher rates of heroin-related deaths, potentially due to decreases in prescription opioid availability.

Prescription drug monitoring programs operational characteristics and fatal heroin poisoning

BACKGROUND

Prescription drug monitoring programs (PDMP), by reducing access to prescribed opioids (POs), may contribute to a policy environment in which some people with opioid dependence are at increased risk for transitioning from POs to heroin/other illegal opioids. This study examines how PDMP adoption and changes in the characteristics of PDMPs over time contribute to changes in fatal heroin poisoning in counties within states from 2002 to 2016.

METHODS

Latent transition analysis to classify PDMPs into latent classes (Cooperative, Proactive, and Weak) for each state and year, across three intervals (1999-2004, 2005-2009, 2010-2016). We examined the association between probability of PDMP latent class membership and the rate of county-level heroin poisoning death.

RESULTS

After adjustment for potential county-level confounders and co-occurring policy changes, adoption of a PDMP was significantly associated with increased heroin poisoning rates (22% increase by third year post-adoption). Findings varied by PDMP type. From 2010-2016, states with Cooperative PDMPs (those more likely to share data with other states, to require more frequent reporting, and include more drug schedules) had 19% higher heroin poisoning rates than states with Weak PDMPs (adjusted rate ratio [ARR] = 1.19; 95% CI = 1.14, 1.25). States with Proactive PDMPs (those more likely to report outlying prescribing and dispensing and provide broader access to law enforcement) had 6% lower heroin poisoning rates than states with No/Weak PDMPs (ARR = 0.94; 95% CI = 0.90, 0.98).

CONCLUSION

There is a consistent, positive association between state PDMP adoption and heroin poisoning mortality. However, this varies by PDMP type, with Proactive PDMPs associated with a small reduction in heroin poisoning deaths. This raises questions about the potential for PDMPs to support efforts to decrease heroin overdose risk, particularly by using proactive alerts to identify patients in need of treatment for opioid use disorder. Future research on mechanisms explaining the reduction in heroin poisonings after enactment of Proactive PDMPs is merited.

Erector Spinae Plane Block Decreases Pain and Opioid Consumption in Breast Surgery: Systematic Review

Adequate control of acute postoperative pain is crucial in breast surgeries, as it is a significant factor in the development of persistent chronic pain. Inadequate postoperative pain control increases length of hospital stays and risk of severe complications. Erector spinae plane block (ESPB) is a novel regional block that has the ability to sufficiently block unilateral multidermatomal sensation from T1 to L3. By reviewing the literature on ESPB, this paper aimed to elucidate its efficacy in breast surgery analgesia and its role in addressing the opioid crisis in North America.

Mandatory use of prescription drug monitoring program and benzodiazepine prescribing among U.S. Medicaid enrollees

BACKGROUND

In the past two decades, the U.S. saw an alarmingly increasing trend of benzodiazepine prescribing. Mandatory use of Prescription Drug Monitoring Programs (PDMPs) was suggested to have the potential to reduce opioid prescribing, but little is known about its impacts on benzodiazepines. This study examined whether PDMP data use mandates were associated with changes in benzodiazepine prescribing in the U.S. Methods: Aggregate state quarterly prescription drug records of benzodiazepines for Medicaid enrollees during 2010-2017 were obtained from the U.S. Medicaid State Drug Utilization Data. Three population-adjusted outcome variables were evaluated, including quantity, dosage, and Medicaid spending of benzodiazepine prescriptions per quarter per 100 Medicaid enrollees. The primary policy variable was the state-wide implementation of PDMP data use mandates for benzodiazepines. To account for between-state variations in mandates, an additional policy variable was considered to indicate strong mandates on PDMP data use, which required all prescribers to query a patient's PDMP records for first prescribing and subsequent prescribing at least every 12 months. Linear regressions with difference-in-difference approach were used to assess the associations between PDMP data use mandates and benzodiazepine prescribing, controlling for state-level time-varying policy and socioeconomic covariates. Results: The state-wide implementation of PDMP data use mandates for benzodiazepines was not associated with quantity, dosage, or Medicaid spending of benzodiazepine prescriptions. Strong mandates on PDMP data use were not associated with any benzodiazepine prescribing outcomes, either. Conclusions: There was no evidence for the associations between PDMP data use mandates for benzodiazepines and changes in benzodiazepine prescribing among Medicaid enrollees. Future research is warranted to replicate the study in other populations using individual patient records and continuously monitor the trends in benzodiazepine prescribing in association with PDMPs.

Evidence for state, community and systems-level prevention strategies to address the opioid crisis

BACKGROUND

Practitioners and policy makers need evidence to facilitate the selection of effective prevention interventions that can address the ongoing opioid overdose epidemic in the United States.

METHODS

We conducted a systematic review of publications reporting on rigorous evaluations of systems-level interventions to address provider and patient/public behavior and prevent prescription and illicit opioid overdose. A total of 251 studies were reviewed. Interventions studied included 1) state legislation and regulation, 2) prescription drug monitoring programs (PDMPs), 3) insurance strategies, 4) clinical guideline implementation, 5) provider education, 6) health system interventions, 7) naloxone education and distribution, 8) safe storage and disposal, 9) public education, 10) community coalitions, and 11) interventions employing public safety and public health collaborations.

RESULTS

The quality of evidence supporting selected interventions was low to moderate. Interventions with the strongest evidence include PDMP and pain clinic legislation, insurance strategies, motivational interviewing in clinical settings, feedback to providers on opioid prescribing behavior, intensive school and family-based programs, and patient education in the clinical setting.

CONCLUSIONS

Although evidence is growing, further high-quality research is needed. Investigators should aim to identify strategies that can prevent overdose, as well as influence public, patient, and provider behavior. Identifying which strategies are most effective at addressing prescription compared to illicit opioid misuse and overdose could be fruitful, as well as investigating synergistic effects and unintended consequences.

Evidence for state, community and systems-level prevention strategies to address the opioid crisis

BACKGROUND

Practitioners and policy makers need evidence to facilitate the selection of effective prevention interventions that can address the ongoing opioid overdose epidemic in the United States.

METHODS

We conducted a systematic review of publications reporting on rigorous evaluations of systems-level interventions to address provider and patient/public behavior and prevent prescription and illicit opioid overdose. A total of 251 studies were reviewed. Interventions studied included 1) state legislation and regulation, 2) prescription drug monitoring programs (PDMPs), 3) insurance strategies, 4) clinical guideline implementation, 5) provider education, 6) health system interventions, 7) naloxone education and distribution, 8) safe storage and disposal, 9) public education, 10) community coalitions, and 11) interventions employing public safety and public health collaborations.

RESULTS

The quality of evidence supporting selected interventions was low to moderate. Interventions with the strongest evidence include PDMP and pain clinic legislation, insurance strategies, motivational interviewing in clinical settings, feedback to providers on opioid prescribing behavior, intensive school and family-based programs, and patient education in the clinical setting.

CONCLUSIONS

Although evidence is growing, further high-quality research is needed. Investigators should aim to identify strategies that can prevent overdose, as well as influence public, patient, and provider behavior. Identifying which strategies are most effective at addressing prescription compared to illicit opioid misuse and overdose could be fruitful, as well as investigating synergistic effects and unintended consequences.

Past-year use of prescription opioids and/or benzodiazepines among adults in the United States: Estimating medical and nonmedical use in 2015-2016

BACKGROUND

The growing use of prescription opioids and benzodiazepines has become a major health threat in the United States, so it is important to document their use among adults to inform health policies or interventions.

METHODS

This study included 81,186 adults ages 18 and older from 2015 and 2016 National Survey on Drug Use and Health. Participants' self-reported medical and nonmedical use of prescription opioids and/or benzodiazepines in the past year was assessed along with their demographic characteristics.

RESULTS

In 2015-2016, 41.13% of adults reported using prescription opioids and/or benzodiazepines in the past year; 8.24% reported both, 28.59% reported prescription opioids only, and 4.30% reported benzodiazepines only. The majority of adults used the drugs for medical purposes, including 71.35% of participants who reported both drugs in the past year, 90.36% of those who reported prescription opioids only, and 86.24% of those who reported benzodiazepines only. Younger adults ages 18-34 were more likely to use prescription opioids and/or benzodiazepines for nonmedical purposes compared to adults ages 35 and over.

CONCLUSIONS

In the United States, the proportion of adults who used prescription opioids and/or benzodiazepines in the past year was high; most of them reported using these drugs for medical purposes. Special attention is needed to prevent potentially unnecessary medical co-prescribing of these drugs, particularly among younger adults, who were more likely report nonmedical use of both drugs than older adults.

An Examination of Concurrent Opioid and Benzodiazepine Prescribing in 9 States, 2015

INTRODUCTION

Concurrent prescribing of opioids and benzodiazepines is discouraged by evidence-based clinical guidelines because of the known risks of taking these medications in combination.

METHODS

This study analyzed concurrent opioid and benzodiazepine prescribing in 9 states using the 2015 Prescription Behavior Surveillance System, a multistate database of de-identified prescription drug monitoring program data. Concurrent prescribing rates were examined among individuals with both an opioid and a benzodiazepine prescription. Among patients with concurrent prescribing, total days of opioid supply, daily dosage of opioids, and total days of concurrent prescriptions were examined. Analyses were stratified by whether concurrent prescribing was from a single prescriber or multiple prescribers. Opioid prescribing and concurrent opioid and benzodiazepine prescribing rates were examined by age and sex. Analyses were conducted in 2018.

RESULTS

Among 19,977,642 patients that were prescribed an opioid, 21.6% (4,324,092) were also prescribed a benzodiazepine, of which 54.9% (2,375,219) had concurrent prescriptions. More than half of patients with concurrent opioids and benzodiazepines received prescriptions from 2 or more distinct prescribers. Mean total opioid days, daily opioid dosage, and days of concurrent prescribing were higher among patients when multiple prescribers were involved compared with concurrent prescriptions from the same prescriber. Concurrent prescribing was more common among adults aged ≥50 years and female patients.

CONCLUSIONS

Public health interventions are needed to reduce concurrent prescribing of opioids and benzodiazepines. Evidence-based guidelines can help reduce concurrent prescribing when one prescriber is involved, and utilization of prescription drug monitoring programs and improved care coordination could help address concurrent prescribing when multiple prescribers are involved.

Trends in prescription opioid use and dose trajectories before opioid use disorder or overdose in US adults from 2006 to 2016: A cross-sectional study

BACKGROUND

With governments' increasing efforts to curb opioid prescription use and limit dose below the Centers for Disease Control and Prevention (CDC)-recommended threshold of 90 morphine milligram equivalents per day, little is known about prescription opioid patterns preceding opioid use disorder (OUD) or overdose. This study aimed to determine prescribed opioid fills and dose trajectories in the year before an incident OUD or overdose diagnosis using a 2005-2016 commercial healthcare database.

METHODS AND FINDINGS

This cross-sectional study identified individuals aged 18 to 64 years with incident OUD or overdose in the United States. We measured the prevalence of opioid prescription fills and trajectories of opioid morphine equivalent dose (MED) prescribed during the 12-month period before the diagnosis. Of 227,038 adults with incident OUD or overdose, 33.1% were aged 18 to 30 years, 52.9% were males, and 85.0% were metropolitan residents. Half (50.5%) of the patients had a diagnosis of chronic pain, 32.7% had depression, and 20.3% had anxiety. Overall, 79,747 (35.1%) patients filled no opioid prescription in the 12 months before OUD or overdose diagnosis, with the proportion significantly increasing between 2006 and 2016 (adjusted prevalence ratio, 1.86; 95% CI 1.79-1.93; P < 0.001). Patients without (versus with) prescribed opioids tended to be younger males and metropolitan and Northeast US residents. Of 145,609 patients who filled opioid prescriptions, 5 distinct prescribed daily dose trajectories preceding diagnosis emerged: consistent low dose (<3 mg MED, 34.6%), consistent moderate dose (20 mg MED, 27.3%), consistent high dose (150 mg MED, 15.0%), escalating dose (from <3 to 20 mg MED, 13.7%), and de-escalating dose (from 20 to <3mg MED, 9.4%). Overall, over two-thirds of patients with OUD or overdose with prescription opioids were prescribed a mean daily dose below 90 mg MED before diagnosis. Major limitations include the limited generalizability of the study findings and lack of information on out-of-pocket drug spending, race/ethnicity, and socioeconomic status of participants, which prevents analyses addressing these characteristics.

CONCLUSIONS

In this study, we found that absence of opioid prescription fills in the year before incident OUD or overdose diagnosis was prevalent, and the majority of the patients received prescription opioid doses below the risk threshold of 90 mg MED. An increasing proportion of high-risk patients could be missed by current programs solely based on opioid prescribing and dispensing information in this new era of limited access to prescription opioids.

Global patterns of opioid use and dependence: harms to populations, interventions, and future action

We summarise the evidence for medicinal uses of opioids, harms related to the extramedical use of, and dependence on, these drugs, and a wide range of interventions used to address these harms. The Global Burden of Diseases, Injuries, and Risk Factors Study estimated that in 2017, 40·5 million people were dependent on opioids (95% uncertainty interval 34·3-47·9 million) and 109 500 people (105 800-113 600) died from opioid overdose. Opioid agonist treatment (OAT) can be highly effective in reducing illicit opioid use and improving multiple health and social outcomes-eg, by reducing overall mortality and key causes of death, including overdose, suicide, HIV, hepatitis C virus, and other injuries. Mathematical modelling suggests that scaling up the use of OAT and retaining people in treatment, including in prison, could avert a median of 7·7% of deaths in Kentucky, 10·7% in Kiev, and 25·9% in Tehran over 20 years (compared with no OAT), with the greater effects in Tehran and Kiev being due to reductions in HIV mortality, given the higher prevalence of HIV among people who inject drugs in those settings. Other interventions have varied evidence for effectiveness and patient acceptability, and typically affect a narrower set of outcomes than OAT does. Other effective interventions focus on preventing harm related to opioids. Despite strong evidence for the effectiveness of a range of interventions to improve the health and wellbeing of people who are dependent on opioids, coverage is low, even in high-income countries. Treatment quality might be less than desirable, and considerable harm might be caused to individuals, society, and the economy by the criminalisation of extramedical opioid use and dependence. Alternative policy frameworks are recommended that adopt an approach based on human rights and public health, do not make drug use a criminal behaviour, and seek to reduce drug-related harm at the population level.

Tracking Opioid Prescribing Metrics in Washington State (2012-2017): Differences by County-Level Urban-Rural and Economic Distress Classifications

PURPOSE

High-risk opioid prescribing is a critical driver of prescription opioid-related morbidity and mortality. This study explored opioid prescribing patterns across urban-rural and economic distress classifications. Secondarily, this study explored the urban-rural distribution of relevant health services, economic factors, and population characteristics.

METHODS

County-level opioid prescribing metrics were based on quarterly Washington State Prescription Monitoring Program data (2012-2017). Counties were classified using the 2013 National Center for Health Statistics Urban-Rural Classification Scheme for Counties, and Washington State unemployment-based distressed areas. County-level measures from Area Health Resources Files were used to describe the urban-rural continuum.

FINDINGS

Persistent economic distress was associated with higher-risk opioid prescribing. The large central metropolitan category had lower-risk opioid prescribing metrics than the other 5 urban-rural categories, which were similar to each other and not ordered by degree of rurality. High-risk prescribing declined over time, without notable trend divergence by either urban-rural or economic distress classifications.

CONCLUSIONS

The most striking urban-rural differences in opioid prescribing metrics were between large central metropolitan and all other categories; thus, we recommend caution when collapsing urban-rural categories for analysis. Further research is needed regarding geographic and economic patterning of opioid prescribing practices, as well as the dissemination of guidelines and best practices across the urban-rural continuum. Finally, the multiple intertwined burdens faced by rural communities-higher-risk prescribing practices, higher opioid morbidity and mortality rates, and fewer resources for primary care, mental health care, alternative pain treatment, and opioid use disorder treatment-must be addressed as an urgent public health priority.

Opioid Overdose Hospitalization Trajectories in States With and Without Opioid-Dosing Guidelines

OBJECTIVES

High-risk opioid-prescribing practices contribute to a national epidemic of opioid-related morbidity and mortality. The objective of this study was to determine whether the adoption of state-level opioid-prescribing guidelines that specify a high-dose threshold is associated with trends in rates of opioid overdose hospitalizations, for prescription opioids, for heroin, and for all opioids.

METHODS

We identified 3 guideline states (Colorado, Utah, Washington) and 5 comparator states (Arizona, California, Michigan, New Jersey, South Carolina). We used state-level opioid overdose hospitalization data from 2001-2014 for these 8 states. Data were based on the State Inpatient Databases and provided by the Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality, via HCUPnet. We used negative binomial panel regression to model trends in annual rates of opioid overdose hospitalizations. We used a multiple-baseline difference-in-differences study design to compare postguideline trends with concurrent trends for comparator states.

RESULTS

For each guideline state, postguideline trends in rates of prescription opioid and all opioid overdose hospitalizations decreased compared with trends in the comparator states. The mean annual relative percentage decrease ranged from 3.2%-7.5% for trends in rates of prescription opioid overdose hospitalizations and from 5.4%-8.5% for trends in rates of all opioid overdose hospitalizations.

CONCLUSIONS

These findings provide preliminary evidence that opioid-dosing guidelines may be an effective strategy for combating this public health crisis. Further research is needed to identify the individual effects of opioid-related interventions that occurred during the study period.

Screening tools for detecting problematic opioid use and potential application to community pharmacy practice: a review

Problematic opioid use, constituted by a myriad of conditions ranging from misuse to use disorders, has continued to receive an increasing amount of attention in recent years resulting from the high use of opioids in the United States coinciding with morbidity and mortality. Deaths from drug overdoses increased by over 11% between 2014 and 2015, which supports the need for identification of problematic opioid use in additional health care settings. One of these settings is community pharmacy. The community pharmacy is a unique health service setting to identify and potentially intervene with patients at risk of or exhibit problematic opioid use. Problematic opioid use can be identified using one of the various screening tools in conjunction with evaluating prescription drug monitoring systems. A total of 12 tools were identified that could be employed in community pharmacy settings for identifying problematic opioid use. This review highlights these tools and strategies for use that can be utilized in the community pharmacy, which should be adapted to individual pharmacy settings and local needs. Future research should assess pharmacy personnel's knowledge and perceptions of problematic opioid use and associated screening tools and interventions, which tools can be most effectively used in a community pharmacy, workflow needs to implement problematic opioid use screenings, and the impact of pharmacist engagement in problematic opioid use screening on patient clinical outcomes.

Assessing The Impact Of State Policies For Prescription Drug Monitoring Programs On High-Risk Opioid Prescriptions

Policies and practices have proliferated to optimize prescribers' use of their states' prescription drug monitoring programs, which are statewide databases of controlled substances dispensed at retail pharmacies. Our study assessed the effectiveness of three such policies: comprehensive legislative mandates to use the program, laws that allow prescribers to delegate its use to office staff, and state participation in interstate data sharing. Our analysis of information from a large commercial insurance database indicated that comprehensive use mandates implemented during 2011-15 were associated with a 6-9 percent reduction in opioid prescriptions with high risk for misuse and overdose. We also found delegate laws to be associated with reductions of a similar magnitude for selected outcomes. In general, the effects of all three policies strengthened over time, especially beginning in the second year after implementation. Our findings support comprehensive use mandates and delegate laws to optimize prescribers' use of drug monitoring programs, but the results will need updates in the context of evolving state opioid policies-including the increasing integration of drug monitoring data with electronic health records.

Evaluating the implementation and effectiveness of a multi-component intervention to reduce post-surgical opioid prescribing: study protocol of a mixed-methods design

INTRODUCTION

Opioids prescribed after surgery accounted for 5% of the 191 million opioid prescriptions filled in 2017. Approximately 80% of the opioid pills prescribed by surgical care providers remain unused, leaving a substantial number of opioids available for non-medical use. We developed a multi-component intervention to address surgical providers' role in the overprescribing of opioids. Our study will determine effective strategies for reducing post-surgical prescribing while ensuring adequate post-surgery patient-reported pain-related outcomes, and will assess implementation of the strategies.

METHODS AND ANALYSIS

The Minimising Opioid Prescribing in Surgery study will implement a multi-component intervention, in an Illinois network of six hospitals (one academical, two large community and three small community hospitals), to decrease opioid analgesics prescribed after surgery. The multi-component intervention involves four domains: (1) patient expectation setting, (2) baseline assessment of opioid use, (3) perioperative pain control optimisation and (4) post-surgical opioid minimisation. Four surgical specialities (general, orthopaedics, urology and gynaecology) at the six hospitals will implement the intervention. A mixed-methods approach will be used to assess the implementation and effectiveness of the intervention. Data from the network's enterprise data warehouse will be used to evaluate the intervention's effect on post-surgical prescriptions and a survey will collect pain-related patient-reported outcomes. Intervention effectiveness will be determined using a triangulation design, mixed-methods approach with staggered speciality-specific implementation for contemporaneous control of opioid prescribing changes over time. The Consolidated Framework for Implementation Research will be used to evaluate the site-specific contextual factors and adaptations to achieve implementation at each site.

ETHICS AND DISSEMINATION

The study aims to identify the most effective hospital-type and speciality-specific intervention bundles for rapid dissemination into our 56-hospital learning collaborative and in hospitals throughout the USA. All study activities have been approved by the Northwestern University Institutional Review Board (ID STU00205053).

Effects of mandatory prescription drug monitoring program (PDMP) use laws on prescriber registration and use and on risky prescribing

BACKGROUND

Comprehensive mandatory use laws for prescription drug monitoring programs (PDMPs) have been implemented in a number of states to help address the opioid overdose epidemic. These laws may reduce opioid-related overdose deaths by increasing prescribers' use of PDMPs and reducing high-risk prescribing behaviors.

METHODS

We used state PDMP data to examine the effect of these mandates on prescriber registration, use of the PDMP, and on prescription-based measures of patient risk in three states-Kentucky, Ohio, and West Virginia-that implemented mandates between 2010 and 2015. We conducted comparative interrupted time series analyses to examine changes in outcome measures after the implementation of mandates in the mandate states compared to control states.

RESULTS

Mandatory use laws increased prescriber registration and utilization of the PDMP in the mandate states compared to controls. The multiple provider episode rate, rate of opioid prescribing, rate of overlapping opioid prescriptions, and rate of overlapping opioid/benzodiazepine prescriptions decreased in Kentucky and Ohio. Nevertheless, the magnitude of changes in these measures varied among mandates states.

CONCLUSIONS

These findings indicate that PDMP mandates have the potential to reduce risky opioid prescribing practices. Variation in the laws may explain why the effectiveness varied between states.

Trends in and correlates of tranquilizer misuse among adults who misuse opioids in the United States, 2002-2014

PURPOSE

Almost a third of opioid overdose deaths also involve benzodiazepines, but few representative studies have examined misuse of benzodiazepines and other tranquilizers by adults who misuse opioids. This study estimated the prevalence and frequency of tranquilizer misuse among adults who misuse opioids and examined characteristics associated with tranquilizer misuse.

METHODS

A sample of adults who misused opioids in the past year (n = 36,043) were identified in the National Surveys on Drug Use and Health 2002-2014. Tranquilizer misuse prevalence was estimated for each year from 2002 to 2014. Data were then pooled for all years. Multiple logistic and Poisson regression was used to identify characteristics independently associated with the prevalence and frequency tranquilizer misuse respectively.

RESULTS

Twenty-eight percent of adults who misused illicit opioids in the past year also reported tranquilizer misuse. This prevalence did not change notably over the 13-year period examined. Among those who misused opioids, meeting criteria for opioid abuse or dependence was associated with a 134% increase in the odds of misusing tranquilizers during the same year. Other characteristics associated with increased odds of tranquilizer misuse included being aged 18-25 years, non-Hispanic white, uninsured, unemployed, and having used heroin.

CONCLUSIONS

Tranquilizer misuse is common among adults who misuse opioids and has not changed substantially over the past decade. Meeting criteria for abuse or dependence of opioids is associated with more than double the odds of tranquilizer misuse among adults who misuse opioids.

Government Legislation in Response to the Opioid Epidemic

PURPOSE OF REVIEW

Opioid misuse and abuse in the USA has evolved into an epidemic of tragic pain and suffering, resulting in the estimated death of over 64,000 people in 2016. Governmental regulation has escalated alongside growing awareness of the epidemic's severity, both on the state and federal levels.

RECENT FINDINGS

This article reviews the timeline of government interventions from the late 1990s to today, including the declaration of the opioid crisis as a national public health emergency and the resultant changes in funding and policy across myriad agencies. Aspects of the cultural climate that fuel the epidemic, and foundational change that may promote sustained success against it, are detailed within as well. As a consequence of misuse and abuse of opioids, governmental regulation has attempted to safeguard society, and clinicians should appreciate changes and expectations of prescribers.

Health insurance and opioid deaths: Evidence from the Affordable Care Act young adult provision

The concurrence of health insurance expansion under the Affordable Care Act (ACA) and increasing opioid-related mortality has led to debate whether insurance increases or decreases opioid deaths. I use the introduction of the ACA young adult (YA) provision as a quasi-experiment and utilize the resulting policy-induced variation across states over time in YA access to insurance to study the effect of coverage on opioid-related mortality. I rely on the share of state populations which stood to gain insurance before the ACA to perform a dose-response analysis, and find that the YA provision reduced opioid-related mortality. The analysis suggests that 1 percentage point more coverage reduced opioid mortality among YA by 2.5/100,000 or 19.8%.

Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury

PURPOSE

We aimed to produce comprehensive guidelines and recommendations that can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury.

METHODS

A panel of 15 members with expertise in orthopaedic trauma, pain management, or both was convened to review the literature and develop recommendations on acute musculoskeletal pain management. The methods described by the Grading of Recommendations Assessment, Development, and Evaluation Working Group were applied to each recommendation. The guideline was submitted to the Orthopaedic Trauma Association (OTA) for review and was approved on October 16, 2018.

RESULTS

We present evidence-based best practice recommendations and pain medication recommendations with the hope that they can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury. Recommendations are presented regarding pain management, cognitive strategies, physical strategies, strategies for patients on long term opioids at presentation, and system implementation strategies. We recommend the use of multimodal analgesia, prescribing the lowest effective immediate-release opioid for the shortest period possible, and considering regional anesthesia. We also recommend connecting patients to psychosocial interventions as indicated and considering anxiety reduction strategies such as aromatherapy. Finally, we also recommend physical strategies including ice, elevation, and transcutaneous electrical stimulation. Prescribing for patients on long term opioids at presentation should be limited to one prescriber. Both pain and sedation should be assessed regularly for inpatients with short, validated tools. Finally, the group supports querying the relevant regional and state prescription drug monitoring program, development of clinical decision support, opioid education efforts for prescribers and patients, and implementing a department or organization pain medication prescribing strategy or policy.

CONCLUSIONS

Balancing comfort and patient safety following acute musculoskeletal injury is possible when utilizing a true multimodal approach including cognitive, physical, and pharmaceutical strategies. In this guideline, we attempt to provide practical, evidence-based guidance for clinicians in both the operative and non-operative settings to address acute pain from musculoskeletal injury. We also organized and graded the evidence to both support recommendations and identify gap areas for future research.

Good Samaritan harm reduction policy and drug overdose deaths

OBJECTIVE

To examine the effects of a harm reduction policy, specifically Good Samaritan (GS) policy, on overdose deaths.

DATA SOURCES/STUDY SETTING

Secondary data from multiple cause of death, mortality records paired with state harm reduction and substance use prevention policy.

STUDY DESIGN

We estimate fixed effects Poisson count models to model the effect of GS policy on overdose deaths for all, prescription, and illicit drugs, controlled substances, and opioids, while controlling for other harm reduction and substance use prevention policies.

DATA COLLECTION/EXTRACTION METHODS

We merge secondary data sources by state and year between 1999 and 2016.

PRINCIPAL FINDINGS

We fail to identify a statistically significant effect of GS policy in reducing overdose deaths broadly.

CONCLUSIONS

While we are unable to identify an effect of GS policy on overdose deaths, GS policy may have important effects on first-stage outcomes not investigated in this paper. Given recent state policy changes and rapid increase in many categories of overdose deaths, additional research should continue to examine the implementation and effects of harm reduction policy specifically and substance use prevention policy broadly.

Pain And Opioid Systems, Implications In The Opioid Epidemic

Pain has a useful protective role; through avoidance learning, it helps to decrease the probability of engaging in tissue-damaging, or otherwise dangerous experiences. In our modern society, the experience of acute post-surgical pain and the development of chronic pain states represent an unnecessary negative outcome. This has become an important health issue as more than 30% of the US population reports experiencing "unnecessary" pain at any given time. Opioid therapies are often efficacious treatments for severe and acute pain; however, in addition to their powerful analgesic properties, opioids produce potent reinforcing properties and their inappropriate use has led to the current opioid overdose epidemic in North America. Dissecting the allostatic changes occurring in nociceptors and neuronal pathways in response to pain are the first and most important steps in understanding the physiologic changes underlying the opioid epidemic. Full characterization of these adaptations will provide novel targets for the development of safer pharmacotherapies. In this review, we highlight the current efforts toward safer opioid treatments and describe our current knowledge of the interaction between pain and opioid systems.

Minimizing Opioid Prescribing in Surgery (MOPiS) Initiative: An Analysis of Implementation Barriers

BACKGROUND

The United States is in the midst of an opioid epidemic. In response, our institution developed the Minimizing Opioid Prescribing in Surgery (MOPiS) initiative. MOPiS is a multicomponent intervention including: (1) patient education on opioid safety and pain management expectations; (2) clinician education on safe opioid prescribing; (3) prescribing data feedback; (4) patient risk screening to assess for addictive behavior; and (5) optimizations to the electronic health record (EHR). We conducted a preintervention formative evaluation to identify barriers and facilitators to implementation.

MATERIALS AND METHODS

We conducted 22 semistructured interviews with key stakeholders (surgeons, nurses, pharmacists, and administrators) at six hospitals within a single health care system. Interviewees were asked about perceived barriers and facilitators to the components of the intervention. Responses were analyzed to identify common themes using the Consolidated Framework for Implementation Research.

RESULTS

We identified common themes of potential implementation barriers and classified them under 12 Consolidated Framework for Implementation Research domains and three intervention domains. Time and resource constraints (needs and resources), the modality of educational material (design quality and packaging), and prescribers' concern for patient satisfaction scores (external policy and incentives) were identified as the most significant structural barriers. Resident physicians, pharmacists, and pain specialists were identified as potential key facilitating actors to the intervention.

CONCLUSIONS

We identified specific barriers to successful implementation of an opioid reduction initiative in a surgical setting. In our MOPiS initiative, a preintervention formative evaluation enabled the design of strategies that will overcome implementation barriers specific to the components of our initiative.

A Public Health Strategy for the Opioid Crisis

Drug overdose is now the leading cause of injury death in the United States. Most overdose fatalities involve opioids, which include prescription medication, heroin, and illicit fentanyl. Current data reveal that the overdose crisis affects all demographic groups and that overdose rates are now rising most rapidly among African Americans. We provide a public health perspective that can be used to mobilize a comprehensive local, state, and national response to the opioid crisis. We argue that framing the crisis from a public health perspective requires considering the interaction of multiple determinants, including structural factors (eg, poverty and racism), the inadequate management of pain, and poor access to addiction treatment and harm-reduction services (eg, syringe services). We propose a novel ecological framework for harmful opioid use that provides multiple recommendations to improve public health and clinical practice, including improved data collection to guide resource allocation, steps to increase safer prescribing, stigma-reduction campaigns, increased spending on harm reduction and treatment, criminal justice policy reform, and regulatory changes related to controlled substances. Focusing on these opportunities provides the greatest chance of making a measured and sustained impact on overdose and related harms.

Drivers of the fatal drug epidemic

This study examines the contributions of the medium-run evolution of local economies and of changes in the "drug environment' in explaining county-level changes in drug and related mortality rates from 1999 to 2015. A primary finding is that drug mortality rates did increase more in counties experiencing relative economic decline than in those with more robust growth, but that the relationship is weak and mostly accounted for by confounding factors. In the preferred estimates, less than one-tenth of the rise in drug and opioid-involved fatality rates is explained and the contribution is even smaller, quite possibly zero, when allowing for plausible selection on unobservables. Conversely, the risk of drug deaths varies systematically over time across population subgroups in ways that are consistent with an important role for the public health environment related to the availability and cost of drugs. In particular, the relative risk and share of drug mortality increased rapidly for males and younger adults, compared to their counterparts, when the primary driver of the fatal drug epidemic transitioned from prescription to illicit opioids. These results suggest that efforts to improve local economies, while desirable for other reasons, are not likely to yield significant reductions in overdose mortality, but with greater potential for interventions directly addressing the drug environment.

Trends and Patterns of Geographic Variation in Opioid Prescribing Practices by State, United States, 2006-2017

IMPORTANCE

Risk of opioid use disorder, overdose, and death from prescription opioids increases as dosage, duration, and use of extended-release and long-acting formulations increase. States are well suited to respond to the opioid crisis through legislation, regulations, enforcement, surveillance, and other interventions.

OBJECTIVE

To estimate temporal trends and geographic variations in 6 key opioid prescribing measures in 50 US states and the District of Columbia.

DESIGN, SETTING, AND PARTICIPANTS

Population-based cross-sectional analysis of opioid prescriptions filled nationwide at US retail pharmacies between January 1, 2006, and December 31, 2017. Data were obtained from the IQVIA Xponent database. All US residents who had an opioid prescription filled at a US retail pharmacy were included.

MAIN OUTCOMES AND MEASURES

Primary outcomes were annual amount of opioids prescribed in morphine milligram equivalents (MME) per person; mean duration per prescription in days; and 4 separate prescribing rates-for prescriptions 3 or fewer days, those 30 days or longer, those with a high daily dosage (≥90 MME), and those with extended-release and long-acting formulations.

RESULTS

Between 2006 and 2017, an estimated 233.7 million opioid prescriptions were filled in retail pharmacies in the United States each year. For all states combined, 4 measures decreased: (1) mean (SD) amount of opioids prescribed (mean [SD] decrease, 12.8% [12.6%]) from 628.4 (178.0) to 543.4 (158.6) MME per person, a statistically significant decrease in 23 states; (2) high daily dosage (mean [SD] decrease, 53.1% [13.6%]) from 12.3 (3.4) to 5.6 (1.7) per 100 persons, a statistically significant decrease in 49 states; (3) short-term (≤3 days) duration (mean [SD] decrease, 43.1% [9.4%]) from 18.0 (5.4) to 10.0 (2.5) per 100 persons, a statistically significant decrease in 48 states; and (4) extended-release and long-acting formulations (mean [SD] decrease, 14.7% [13.7%]) from 7.2 (1.9) to 6.0 (1.7) per 100 persons, a statistically significant decrease in 27 states. Two measures increased, each associated with the duration of prescription dispensed: (1) mean (SD) prescription duration (mean [SD] increase, 37.6% [6.9%]) from 13.0 (1.2) to 17.9 (1.4) days, a statistically significant increase in every state; and (2) prescriptions for a term of 30 days or longer (mean [SD] increase, 37.7% [28.9%]) from 18.3 (7.7) to 24.9 (10.7) per 100 persons, a statistically significant increase in 39 states. Two- to 3-fold geographic differences were observed across states, measured by comparing the ratio of each state's 90th to 10th percentile for each measure.

CONCLUSIONS AND RELEVANCE

In this study, across 12 years, the mean duration and prescribing rate for long-term prescriptions of opioids increased, whereas the amount of opioids prescribed per person and prescribing rate for high-dosage prescriptions, short-term prescriptions, and extended-release and long-acting formulations decreased. Some decreases were significant, but results were still high. Two- to 3-fold state variation in 5 measures occurred in most states. This information may help when state-specific intervention programs are being designed.

Prescription Drug Monitoring Programs and Opioid Overdoses: Exploring Sources of Heterogeneity

BACKGROUND

Prescription drug monitoring program are designed to reduce harms from prescription opioids; however, little is known about what populations benefit the most from these programs. We investigated how the relation between implementation of online prescription drug monitoring programs and rates of hospitalizations related to prescription opioids and heroin overdose changed over time, and varied across county levels of poverty and unemployment, and levels of medical access to opioids.

METHODS

Ecologic county-level, spatiotemporal study, including 990 counties within 16 states, in 2001-2014. We modeled overdose counts using Bayesian hierarchical Poisson models. We defined medical access to opioids as the county-level rate of hospital discharges for noncancer pain conditions.

RESULTS

In 2010-2014, online prescription drug monitoring programs were associated with lower rates of prescription opioid-related hospitalizations (rate ratio 2014 = 0.74; 95% credible interval = 0.69, 0.80). The association between online prescription drug monitoring programs and heroin-related hospitalization was also negative but tended to increase in later years. Counties with lower rates of noncancer pain conditions experienced a lower decrease in prescription opioid overdose and a faster increase in heroin overdoses. No differences were observed across different county levels of poverty and unemployment.

CONCLUSIONS

Areas with lower levels of noncancer pain conditions experienced the smallest decrease in prescription opioid overdose and the faster increase in heroin overdose following implementation of online prescription drug monitoring programs. Our results are consistent with the hypothesis that prescription drug monitoring programs are most effective in areas where people are likely to access opioids through medical providers.

Opioid Prescribing Practices of Orthopaedic Surgeons: Results of a National Survey

INTRODUCTION

Opioids are widely used after orthopaedic procedures. Nonmedical opioid use is a growing public health issue.

METHODS

An anonymous online survey was distributed by e-mail to the orthopaedic societies of all 50 states and several large private practices to assess practicing orthopaedic surgeons' opioid prescribing practices.

RESULTS

A total of 555 orthopaedic surgeons practicing in 37 states responded. The most commonly prescribed opioid for both teenagers and adults was hydrocodone/acetaminophen. Of note, 42.3% reported that a patient they have prescribed opioids for developed an opioid dependency, whereas 35.3% do not believe that opioid use is a problem in their practice. Of note, 30.3% reported prescribing refills, and factors significantly associated with increased prescribing of refills included a greater number of years in practice (P < 0.001) and practicing in a suburban rather than an urban or rural environment (P = 0.03).

CONCLUSION

Orthopaedic surgeons rarely prescribe any refills, tend to prescribe less opioids to teenagers than adults, and prescribe fairly uniformly for patients who are treated nonsurgically or undergo minor or arthroscopic surgery. They exhibit considerable variation in prescribing for fractures and major procedures.

Health Care Utilization of Opioid Overdose Decedents with No Opioid Analgesic Prescription History

Opioid overprescribing is a major driver of the current opioid overdose epidemic. However, annual opioid prescribing in the USA dropped from 782 to 640 morphine milligram equivalents per capita between 2010 and 2015, while opioid overdose deaths increased by 63%. To better understand the role of prescription opioids and health care utilization prior to opioid-related overdose, we analyzed the death records of decedents who died of an opioid overdose in Illinois in 2016 and linked to any existing controlled substance monitoring program (CSMP) and emergency department (ED) or hospital discharge records. We found that of the 1893 opioid-related overdoses, 573 (30.2%) decedents had not filled an opioid analgesic prescription within the 6 years prior to death. Decedents without an opioid prescription were more likely to be black (33.3% vs 20.2%, p < .001), Hispanic (16.3% vs 8.8%, p < .001), and Chicago residents (46.8% vs 25.6%, p < .001) than decedents with at least one filled opioid prescription. Decedents who did not fill an opioid prescription were less likely to die of an overdose involving prescribed opioids (7.3% vs 19.5%, p < .001) and more likely to fatally overdose on heroin (63% vs 50.4%, p < .001) or fentanyl/fentanyl analogues (50.3% vs 41.8%, p = .001). Between 2012 and the time of death, decedents without an opioid prescription had fewer emergency department admissions (2.5 ± 4.2 vs 10.6 ± 15.8, p < .001), were less likely to receive an opioid use disorder diagnosis (41.3% vs 47.5%, p = .052), and were less likely to be prescribed buprenorphine for opioid use disorder treatment (3.3% vs 8.6%, p < .001). Public health interventions have often focused on opioid prescribing and the use of CSMPs as the core preventive measures to address the opioid crisis. We identified a subset of individuals in Illinois who may not be impacted by such interventions. Additional research is needed to understand what strategies may be successful among high-risk populations that have limited opioid analgesic prescription history and low health care utilization.

A typology of prescription drug monitoring programs: a latent transition analysis of the evolution of programs from 1999 to 2016

BACKGROUND AND AIMS

Prescription drug monitoring programs (PDMP), defined as state-level databases used in the United States that collect prescribing information when controlled substances are dispensed, have varied substantially between states and over time. Little is known about the combinations of PDMP features that, collectively, may produce the greatest impact on prescribing and overdose. We aimed to (1) identify the types of PDMP models that have developed from 1999 to 2016, (2) estimate whether states have transitioned across PDMP models over time and (3) examine whether states have adopted different types of PDMP models in response to the burden of opioid overdose.

METHODS

A latent transition analysis of PDMP models based on an adaptation of nine PDMP characteristics classified by prescription opioid policy experts as potentially important determinants of prescribing practices and prescription opioid overdose events.

RESULTS

We divided the time-period into three intervals (1999-2004, 2005-09, 2010-16), and found three distinct PDMP classes in each interval. The classes in the first and second interval can be characterized as 'no/weak', 'proactive' and 'reactive' types of PDMPs, and in the third interval as 'weak', 'cooperative' and 'proactive'. The meaning of these classes changed over time: until 2009, states in the 'no/weak' class had no active PDMP, whereas states in the 'proactive' class were more likely to proactively provide unsolicited information to PDMP users, provide open access to law enforcement, and require more frequent data reporting than states in the 'reactive' class. In 2010-16, the 'weak' class resembled the 'reactive' class in previous intervals. States in the 'cooperative' class in 2010-16 were less likely than states in the 'proactive' class to provide unsolicited reports proactively or to provide open access to law enforcement; however, they were more likely than those in the 'proactive' class to share PDMP data with other states and to report more federal drug schedules.

CONCLUSIONS

Since 1999, US states have tended to transition to more robust classes of prescription drug monitoring programs. Opioid overdose deaths in prior years predicted the state's prescription drug monitoring program class but did not predict transitions between prescription drug monitoring program classes over time.

New Mexico Nurse-Midwives' Controlled Substance Prescribing and Monitoring Practices

INTRODUCTION

New Mexico, a state with a high incidence of opioid overdose deaths, requires certified nurse-midwives (CNMs) who prescribe controlled substances to use the statewide Prescription Monitoring Program (PMP). This study examined how frequently CNMs who practice in New Mexico and prescribe controlled substances use the PMP and the purposes for which they use it.

METHODS

All CNMs licensed in New Mexico (N = 210) were sent a link to an anonymous online survey. CNM demographics, practice characteristics, and controlled substance prescribing practices were examined.

RESULTS

Approximately 40% of CNMs licensed in New Mexico completed the survey (N = 83), 77% of whom (64/83) were providing direct clinical care services. Nearly all who were engaged in clinical care had a US Drug Enforcement Administration registration number and were registered in the PMP (97%; 62/64). Approximately 90% of those respondents (56/62) reported prescribing controlled substances. Approximately 10% (6/62) never logged into the PMP, 40% (25/62) never ran a self-report, and nearly 30% (18/62) reported never checking the PMP for patient alerts. Among those who reported prescribing controlled substances, the percentages who never logged in, never ran a self-report, and never checked for patient alerts were 7% (4/56), 37% (21/56), and 27% (15/56), respectively. Nearly half of those prescribing controlled substances (26/56) did so monthly or more often, but with respect to their own prescribing, approximately one-third of them (9/26) checked the PMP less frequently than every 6 months.

DISCUSSION

Most CNMs in New Mexico are authorized to prescribe controlled substances, but the frequency of prescribing varies, and some CNMs may not be making optimal use of the state PMP for self-reports, for patient alerts, or prior to prescribing a controlled substance. Additional education pertaining to the PMP is needed, as are best practice recommendations for monitoring CNMs' controlled substance prescribing.