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

Might chronic opioid use impact sleep-disordered breathing and vice versa?

Orr JE, Wallace MS, Malhotra A. Might chronic opioid use impact sleep-disordered breathing and vice versa? J Clin Sleep Med . 2020;16(6):843–845.

Association between psychotropic drug use and prescription opioid use among older adults

This study investigated the association between psychotropic drug use and prescription opioid use/high dosage opioid use among older adults. A sample of 203,750 older adults enrolled in Pennsylvania's Pharmaceutical Assistance Contract for the Elderly (PACE) program during 2017 was evaluated for prescription opioid and psychotropic drug usage. High dosage opioid use was defined as using >90 morphine milligram equivalents (MME)/day for ≥90 consecutive days. Overall, 20.7% of enrollees filled opioid prescriptions, of which 1.4% used them at high dosages. Multivariate logistic regression indicated that the odds of prescription opioid use increased with anxiolytic/sedative/hypnotic use and antidepressant use. Moreover, high dosage opioid use was significantly associated with anxiolytic/sedative/hypnotic use, antidepressant use and other factors including being younger, male, white, and married but living separately, and having multiple opioid prescribers. Clinicians should carefully evaluate opioid use among older patients using anxiolytics or antidepressants to minimize risks for adverse consequences of opioids.

An Observational Study of Retail Pharmacy Naloxone Prescriptions: Differences Across Provider Specialties and Patient Populations

BACKGROUND

Despite exponential growth in pharmacy-dispensed naloxone, little information is available regarding variation in naloxone prescribing pattern across specialty groups, regions, and patient populations.

OBJECTIVE

Explore variation in pharmacy-dispensed naloxone by prescriber specialty and patient characteristics.

DESIGN

Cross-sectional analysis of the 2016 national retail pharmacy naloxone prescription claims from the IQVIA Real Longitudinal Prescriptions database.

PARTICIPANTS

Naloxone prescribers and individuals filling naloxone prescriptions.

MAIN MEASURES

Descriptive statistics assess differences across prescriber specialty groups in number of naloxone prescribers, patient and prescription characteristics, and geographic variation in naloxone dispensation and naloxone market share across prescriber specialty groups or formulation.

KEY RESULTS

In 2016, 100,958 naloxone prescriptions written by 14,026 prescribers were filled by 88,735 patients. Primary care physicians accounted for the largest share of naloxone prescribers (45.9%); pain and anesthesia physicians and non-physicians prescribed to significantly greater numbers of patients (means of 10 and 8, respectively). While responsible for a relatively small share of naloxone dispensed (6.1%), psychiatrists and addiction specialists disproportionately served younger individuals, accounting for 49.5% of all prescriptions for individuals aged 35 and younger. Naloxone fill rates differed greatly across geographic regions, with the highest per capita rates in New England and the most concentrated prescribing in the West South Central and South Atlantic regions, where naloxone prescribers had the highest average numbers of patients (9.7 and 7.9, respectively). The South Atlantic and West South Central also had naloxone markets dominated by the Evzio® auto-injector, responsible for 50.3% and 43.8% of all naloxone dispensed in the regions; in contrast, New England's naloxone market was predominantly comprised of generic formulations (48.8%) and Narcan® nasal spray (45.4%).

CONCLUSIONS

Our findings reflect a need to better understand barriers to uptake of naloxone prescribing behavior among physicians and other prescribers to ensure individuals have adequate opportunity to receive naloxone from their treating clinicians.

Safe Opioid Storage and Disposal: A Survey of Patient Beliefs and Practices

Objective

To evaluate knowledge, practices, and beliefs of US patients receiving prescription opioids regarding opioid storage, disposal, and diversion.

Design

Internet-based, cross-sectional survey conducted between September and October 2018. Fisher’s exact tests and Kendall’s Tau-c were used to assess associations with storage and disposal outcomes.

Participants

Patients aged ≥18 years with acute (n=250) or chronic noncancer (n=250) pain were prescribed an oral opioid within 90 days of the survey.

Results

Mean (SD) patient age was 48 (14.7) years, 57.2% were female, 82.6% lived with ≥1 person in the home, and 28.0% had remaining/unused pills. One-third of all patients received safe opioid storage (35.2%) and/or disposal (31.4%) counseling from a healthcare provider, while 50.0% received neither storage nor disposal information. Only 27.4% of all patients stored their opioids in a locked location, and 17.9% of those with remaining/unused pills disposed of their medication. Patients who received any opioid counseling were more likely to keep their medication in a locked location compared with those who did not (42.4% vs 12.4%, respectively; P<0.0001), as were those who perceived any risk of opioid diversion in the home compared with those who perceived no risk or were unsure (53.7% vs 24.2%, respectively; P<0.0001). Disposal rates did not differ based on counseling received (20.8% counseled vs 16.1% not counseled; P=0.5011) or perceived diversion risk (27.8% perceived any risk vs 16.4% perceived no risk or unsure; P=0.3166).

Conclusion

The proportion of patients receiving prescription opioids who receive safe storage/disposal counseling from a healthcare provider appears suboptimal. Further research is warranted to develop effective ways to improve patient opioid storage/disposal education and practices.

Impact of workplace injury on opioid dependence, abuse, illicit use and overdose: a 36-month retrospective study of insurance claims

OBJECTIVES

To examine the impact of workplace injury on opioid dependence, abuse and overdose (opioid-related morbidity) and if severity of injury increases the hazard of these health effects.

METHODS

We used MarketScan databases to follow injured and propensity score matched non-injured workers, both without prior opioid-related diagnoses. Using a Cox proportional hazard model, we examined the impact of workplace injury on opioid-related morbidity.

RESULTS

The hazard of opioid-related morbidity for injured workers was 1.79 times than that of matched non-injured workers (95% CI 1.89 to 3.60). For medical-only and lost-time injured workers, it was respectively 1.54 (95% CI 1.02 to 2.32) and 2.91 (95% CI 1.75 to 4.84) times that of non-injured workers.

CONCLUSIONS

Reducing workplace injury or severity of workplace injury, as well as efforts to ensure appropriate opioid prescribing for injured workers, may help to reduce the societal costs of opioid use.

Trends in opioid prescribing in Estonia (2011-2017)

Our objective was to examine the trends and variation in opioid prescribing in Estonia from 2011 to 2017. This retrospective cross-sectional study is based on a nationwide prescription medicines database. We stratified the analysis by treatment indication (cancer vs noncancer pain). Between 2011 and 2017, annual opioid prescribing rates increased by 67% (from 82.9 to 138.6 prescriptions per 1000 population). The annual number of prescriptions per patient did not change substantially (from 2.94 in 2011 to 2.87 in 2017), and was higher among cancer patients (5.07 vs 2.67 annual prescriptions per cancer and noncancer patients, respectively, in 2017). The use of the most potent opioids (morphine, fentanyl) was higher in noncancer than in cancer patients. The use of prescription opioids is low, and raises concern about the potential undertreatment of cancer pain, in parallel with misuse of opioids for either noncancer pain or diversion.

Association of Formulary Exclusions and Restrictions for Opioid Alternatives With Opioid Prescribing Among Medicare Beneficiaries

IMPORTANCE

Although there are many pharmacologic alternatives to opioids, it is unclear whether the structure of Medicare Part D formularies discourages use of the alternatives.

OBJECTIVES

To quantify the coverage of opioid alternatives and prevalence of prior authorization, step therapy, quantity limits, and tier placement for these drugs, and test whether these formulary exclusions and restrictions are associated with increased opioid prescribing to older adults at the county level.

DESIGN, SETTING, AND PARTICIPANTS

County fixed-effect models were estimated using a panel of counties across the 50 US states and the District of Columbia over calendar years 2015 and 2016. Data analysis was conducted from July 1 to September 23, 2019. The sample included 2721 counties in 2015 and 2671 counties in 2016 with sufficient data on Medicare Part D formulary design and opioid prescribing.

MAIN OUTCOMES AND MEASURES

County-level opioid prescribing rate (number of opioid claims divided by the number of overall claims) and counts of excluded opioid alternatives and opioid alternatives with prior authorization, step therapy, quantity limits, and high-tier placements.

RESULTS

A total of 30 nonopioid analgesics were examined across 28 997 Medicare plans in 2015 and 30 390 plans in 2016. Medicare plans did not cover a mean of 7% of these drugs (interquartile range, 10%; lower to upper limit, 0%-23%). Among covered nonopioids, prior authorization and step therapy were uncommon, with fewer than 5% affected by prior authorization and 0% by step therapy. However, 13% of covered nonopioids had quantity limits (interquartile range, 10%; lower to upper limit, 0%-31%) and 22% were in high-cost tiers (interquartile range, 38%; lower to upper limit, 0%-50%). Increases in the number of nonopioids excluded on Medicare plans in a county were associated with increased opioid prescribing (effect size relative to mean, 2.2%-3.7%; P = .004). Conversely, increases in the number of opioids not covered on Medicare plans in a county was found to be associated with decreased opioid prescribing (effect size relative to mean, 0.8%-1.5%; P = .02). None of the utilization management strategies (prior authorization, step therapy, and quantity limits) examined or high-cost tier placements of nonopioids were associated with increased opioid prescribing.

CONCLUSIONS AND RELEVANCE

Lack of Medicare coverage for pharmacologic alternatives to opioids may be associated with increased opioid prescribing.

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.

Experiences of people taking opioid medication for chronic non-malignant pain: a qualitative evidence synthesis using meta-ethnography

OBJECTIVE

To review qualitative studies on the experience of taking opioid medication for chronic non-malignant pain (CNMP) or coming off them.

DESIGN

This is a qualitative evidence synthesis using a seven-step approach from the methods of meta-ethnography.

DATA SOURCES AND ELIGIBILITY CRITERIA

We searched selected databases-Medline, Embase, AMED, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Web of Science and Scopus (Science Citation Index and Social Science Citation Index)-for qualitative studies which provide patients' views of taking opioid medication for CNMP or of coming off them (June 2017, updated September 2018).

DATA EXTRACTION AND SYNTHESIS

Papers were quality appraised using the Critical Appraisal Skills Programme tool, and the GRADE-CERQual (Grading of Recommendations Assessment, Development and Evaluation working group - Confidence in Evidence from Reviews of Qualitative research) guidelines were applied. We identified concepts and iteratively abstracted these concepts into a line of argument.

RESULTS

We screened 2994 unique citations and checked 153 full texts, and 31 met our review criteria. We identified five themes: (1) reluctant users with little choice; (2) understanding opioids: the good and the bad; (3) a therapeutic alliance: not always on the same page; (4) stigma: feeling scared and secretive but needing support; and (5) the challenge of tapering or withdrawal. A new overarching theme of 'constantly balancing' emerged from the data.

CONCLUSIONS

People taking opioids were constantly balancing tensions, not always wanting to take opioids, and weighing the pros and cons of opioids but feeling they had no choice because of the pain. They frequently felt stigmatised, were not always 'on the same page' as their healthcare professional and felt changes in opioid use were often challenging.

TRIAL REGISTRATION NUMBER

49470934; Pre-results.

The opioid mortality epidemic in North America: do we understand the supply side dynamics of this unprecedented crisis?

While there has been extensive attention to the 'demand side' - or use and adverse consequences, including mortality - of the 'opioid crisis' presently unfolding across North America, few considerations have focused on the supply side. This paper examines the supply side dynamics of this unprecedented public health phenomenon. We provide evidence for several interrelated supply-side elements that have contributed to the present public health crisis. We observe that initially, persistently high levels of prescription opioid availability and use exposed large proportions of the North American population to opioids, resulting in correspondingly high levels of medical and non-medical use (e.g., involving diversion). While various intervention measures to control prescription opioid availability and use have been implemented in recent years, leading to eventual reductions in opioid dispensing levels, these occurred late in the crisis's evolution. Moreover, these supply reductions have not been met by corresponding reductions in opioid use or demand levels. These growing discrepancies between opioid demand and prescription-based sources have left major gaps in opioid supplies. In response to such supply gaps, highly potent and toxic illicit opioid products have rapidly proliferated across North America, and become a core driver of the dramatic spikes in opioid overdose fatality levels in recent years. These supply-related interrelations are corroborated by a corresponding increase in illicit opioid-related fatalities, which arose just as medical opioid supplies began to decrease in many jurisdictions. Improved analyses and understanding of the supply-side dynamics of the opioid crisis are urgently needed in order to inform future intervention and policy development. Meanwhile, the high mortality toll related to illicit, highly toxic opioid exposure requires sustained solutions, including supply-oriented measures (e.g., safer opioid distribution for at-risk users) towards improved public health protection.

Clinical Effectiveness of Decision Support for Prescribing Opioids for Chronic Noncancer Pain: A Prospective Cohort Study

OBJECTIVES

This prospective cohort study examines the clinical effectiveness of electronic medical record clinical decision support (EMR CDS) for opioid prescribing.

METHODS

Data analysis included primary care patients with chronic opioid therapy for noncancer pain seen within an integrated health delivery system in Louisiana between January 2017 and October 2018. EMR CDS incorporated an opioid health maintenance tool to display the status of risk mitigation, and the medication order embedded the morphine equivalent daily dose (MEDD) calculator and a hyperlink to the Louisiana pharmacy drug monitoring program. Outcome measures included change in the average MEDD and rates of opioid risk mitigation, hospitalization, and emergency department use.

RESULTS

Among 14 221 patients, 9% had prescriptions with an average MEDD ≥90 mg. There were no significant changes in MEDD after EMR CDS implementation. Increasing age, Charlson Comorbidity Index score, female sex, black non-Hispanic race, non-opioid pain medication co-prescriptions, and specialty referrals were associated with a lower odds of MEDD ≥90 (high-dose threshold). Medicare or self-pay, substance abuse history, and pain agreements were associated with increased odds of prescribing above this high-dose threshold. After incorporation of EMR CDS, patients had higher rates of urine drug screens (17% vs 7%) and naloxone prescriptions (3% vs 1%, all P < .001). In addition, specialty referrals to physical or occupational therapy, orthopedics, neurology, and psychiatry or psychology increased in the postintervention period. Although emergency department use decreased (rate ratio 0.92; 95% confidence interval 0.89-0.95), hospitalization rates did not change.

CONCLUSIONS

EMR CDS improved adherence to opioid risk mitigation strategies. Further research examining which practice redesign interventions effectively reduce high-dose opioid prescribing is needed.

Opioid prescribing patterns among medical providers in the United States, 2003-17: retrospective, observational study

OBJECTIVE

To examine the distribution and patterns of opioid prescribing in the United States.

DESIGN

Retrospective, observational study.

SETTING

National private insurer covering all 50 US states and Washington DC.

PARTICIPANTS

An annual average of 669 495 providers prescribing 8.9 million opioid prescriptions to 3.9 million patients from 2003 through 2017.

MAIN OUTCOME MEASURES

Standardized doses of opioids in morphine milligram equivalents (MMEs) and number of opioid prescriptions.

RESULTS

In 2017, the top 1% of providers accounted for 49% of all opioid doses and 27% of all opioid prescriptions. In absolute terms, the top 1% of providers prescribed an average of 748 000 MMEs-nearly 1000 times more than the middle 1%. At least half of all providers in the top 1% in one year were also in the top 1% in adjacent years. More than two fifths of all prescriptions written by the top 1% of providers were for more than 50 MMEs a day and over four fifths were for longer than seven days. In contrast, prescriptions written by the bottom 99% of providers were below these thresholds, with 86% of prescriptions for less than 50 MMEs a day and 71% for fewer than seven days. Providers prescribing high amounts of opioids and patients receiving high amounts of opioids persisted over time, with over half of both appearing in adjacent years.

CONCLUSIONS

Most prescriptions written by the majority of providers are under the recommended thresholds, suggesting that most US providers are careful in their prescribing. Interventions focusing on this group of providers are unlikely to effect beneficial change and could induce unnecessary burden. A large proportion of providers have established relationships with their patients over multiple years. Interventions to reduce inappropriate opioid prescribing should be focused on improving patient care, management of patients with complex pain, and reducing comorbidities rather than seeking to enforce a threshold for prescribing.

Gender differences in diversion among non-medical users of prescription opioids and sedatives

BACKGROUND

Non-medical use of prescription drugs is a major public health concern in the United States. Prescription opioids and sedatives are among the most widely abused drugs and their combined use can be lethal. Increasingly rigid prescribing guidelines may contribute to the changing context of opioid use and increase drug diversion.

OBJECTIVE

To examine gender differences in diversion of prescription opioids and sedatives among non-medical prescription opioid and sedative polysubstance users. We hypothesize that men will be more likely than women to engage in incoming diversion.

METHODS

Data from the Prescription Drug Abuse, Misuse, and Dependence Study, a cross-sectional study focused on prescription drug users, were analyzed. Non-medical use was defined as use of a drug that was not prescribed or use in a way other than prescribed. Individuals who reported past 12-month non-medical opioid and sedative use were included; diversion was defined as incoming (obtaining drugs from a source other than a health professional) and outgoing (giving away/selling/trading prescription drugs).

RESULTS

Among the 198 polysubstance users, 41.4% were female. Men were 2.85 times as likely as women to report incoming diversion (95% CI: 1.21-6.72). Women were more likely to obtain opioids from a healthcare professional; men were more likely to obtain sedatives from a roommate, coworker, or friend. Over half of men and women reported outgoing diversion opioids or sedatives.

CONCLUSION

Drug diversion highlights an important point of intervention. Current prevention efforts that target prescribers should be expanded to include users and diversion activities; these interventions should be gender-specific.

Patient Education on Opioid Storage, Security, and Disposal of Opioids: Should the Approach Differ in Rural and Urban Settings?

PURPOSE

The opioid crisis is devastating rural America, but findings of opioid utilization vary among previous studies. Previous studies were focused on misuse behaviors or overdose issues. This study will focus on the number of pills and prescriptions that rural and urban adults received.

METHODS

Using the adult data of the 2011-2016 Medical Expenditure Panel Survey, we compared rural-urban differences in likelihood of using opioids and actual utilization. Multivariate models were further adjusted for predisposing, enabling and need factors.

RESULTS

During 2011-2016, opioid utilization decreased in both urban and rural areas. However, rural adults were still more likely to have a prescription, and among users, rural adult prescription pill count was higher than urban counterparts. The rural-urban difference was not significant after adjusting for covariates, indicating that personal and contextual characteristics account for more variations in utilization than rurality.

CONCLUSIONS

Strategies to improve pain management without causing opioid addiction and overdose deaths are imperative. The findings of unadjusted analyses suggest: (1) providing counseling to teach rural adults to store opioids in a locked container, not share medication with others and safely dispose of unused pills; (2) reinforcing the mail-back program or giving patients a specially-designed package to neutralize the drugs; and (3) if a community-based drug-disposal program is not available, educating to remove labeling from the bottle, mix the drugs with an unpleasant substance, and place the drugs and unpleasant substance in the garbage separate from the bottle. The findings of adjusted analyses indicate that another study will be helpful to explore the associations between personal characteristics and opioid utilization in depth.

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.

Analysis of 207,543 children with acute opioid poisonings from the United States National Poison Data System

Introduction: Previous studies using administrative data have demonstrated that the United States opioid epidemic is harming both adults and children, and is straining health care systems. Our objective is to describe the outcomes and trends in resource use among children with acute opioid ingestions using patient-level case report data.Materials and Methods: This study was a retrospective analysis of prospectively collected data from the 55 poison control centers in the United States which comprise the National Poison Data System (NPDS). Children under 19 years of age with a primary opioid ingestion between 1 January 2005 and 31 December 2018 were included in the analysis. Trends over three eras (2005-2009, 2010-2014, 2015-2018) were assessed using a Cochran-Armitage Trend Test. Yearly trends in the proportion of cases were calculated using generalized linear models. Multi-variable logistic regression analysis was used to calculate the adjusted odds of variables associated with having at least one Pediatric Intensive Care Unit (PICU) level intervention.Results: Children were involved in 207,543 (27.54%) of a total of 1,002,947 primary exposure-related opioid poisoning cases reported to US poison centers. The percentage of patients admitted to a critical care unit from these exposures increased in each era (6.6%, 8.5%, 9.6%). Suicidal intent increased in each era (14.0%, 15.3%, 21.2%), and was associated with increased adjusted odds of receiving a PICU procedure (OR 9.68, CI 7.97-11.76). Fentanyl (OR 12, CI 9.2-15.7), heroin (OR 11.1, CI 9.4-13.1), and methadone (OR 15, CI 13-17.3) were the opioids most associated with having a PICU procedure.Discussion and Conclusions: The severity of admissions for acute opioid ingestions, especially following attempted suicide, has increased over the studied time frame. Efforts focused on reducing access, especially to synthetic and illicit opioids, and addressing adolescent suicidality are needed to reduce these serious consequences of the opioid epidemic on children in the United States.

Postoperative opioid cessation rates based on preoperative opioid use

Aims

The aim of this study was to characterize the relationship between pre- and postoperative opioid use among patients undergoing common elective orthopaedic procedures

Patients and Methods

Pre- and postoperative opioid use were studied among patients from a national insurance database undergoing seven common orthopaedic procedures using univariate log-rank tests and multivariate Cox proportional hazards analyses.

Results

A total of 98 769 patients were included; 35 701 patients were opioid-naïve, 11 621 used opioids continuously for six months before surgery, and 4558 used opioids continuously for at least six months but did not obtain any prescriptions in the three months before surgery. Among opioid-naïve patients, between 0.76% and 4.53% used opioids chronically postoperatively. Among chronic preoperative users, between 42% and 62% ceased chronic opioids postoperatively. A three-month opioid-free period preoperatively led to a rate of cessation of chronic opioid use between 82% and 93%, as compared with between 31% and 50% with continuous preoperative use (p < 0.001 for significant changes in opioid use before and after surgery in each procedure). Between 5.6 and 20.0 preoperative chronic users ceased chronic use for every new chronic opioid user. Risk factors for chronic postoperative use included chronic preoperative opioid use (odds ratio (OR) 4.84 to 39.75; p < 0.0001) and depression (OR 1.14 to 1.55; p < 0.05 except total hip arthroplasty). With a three-month opioid-free period before surgery, chronic preoperative opioids elevated the risk of chronic opioid use only mildly, if at all (OR 0.47 to 1.75; p < 0.05 for total shoulder arthroplasty, rotator cuff repair, and carpal tunnel release).

Conclusion

Chronic preoperative opioid use increases the risk of chronic postoperative use, but an opioid-free period before surgery decreases this risk compared with continuous preoperative use Cite this article: Bone Joint J 2019;101-B:1570–1577

Opioid prescription rates and risk for substantiated child abuse and neglect: A Bayesian spatiotemporal analysis

OBJECTIVES

To determine the association between opioid prescribing rates and substantiated abuse and neglect across Tennessee counties during an 11-year period.

METHODS

We adopted a Bayesian spatiotemporal approach to determine the association between opioid prescribing and rates of substantiated child abuse and neglect over and above environmental and population-level covariates. Annual county-level data for Tennessee (2006-2016) included rates of substantiated child abuse and neglect, rates of drug and non-drug crime incidents, racial and Hispanic composition, per capita income, child poverty and teen birth rates, and vacant housing.

RESULTS

Higher opioid prescribing rates were associated with greater risk for substantiated child abuse and neglect across Tennessee counties. Risk for substantiated child abuse and neglect was positively associated with vacant housing, child poverty, teen birth rates, and rates of both drug and non-drug criminal incidents - including stimulant arrests. Risk for substantiated child abuse and neglect was negatively associated with percentages of African Americans.

CONCLUSIONS

Results underscore the importance of opioid prescribing and crime rates as independent determinants of spatial and temporal variation in risk for substantiated child abuse and neglect. Policies that regulate and reduce opioid prescribing have the potential to reduce risk for child abuse and neglect.

Long-term use of hydrocodone vs. oxycodone in primary care

BACKGROUND

Hydrocodone and oxycodone are the Schedule II opioids most often prescribed in primary care. Notwithstanding the dangers of prescription opioid use, the likelihood of long-term use with either drug is presently unknown.

METHODS

Using a retrospective cohort design and data from a commerical healthcare claims repository, we compared the likelihood of long-term use of hydrocodone and oxycodone in primary care patients presenting with acute back pain. Treatment was categorized as long-term if the prescription dates spanned ≥90 days from initial prescription to the run-out date of the last prescription, and included ≥120 days' supply or ≥10 fills. Instrumental variable methods and probit regression were used to model the effect of drug choice on long-term use, estimate the average treatment effect, and correct for confounding by indication.

RESULTS

A total of 3,983 patients who were prescribed only hydrocodone or only oxycodone were followed for 270 days in 2016. Long-term opioid use was observed in 320 patients (8%). Controlling for potential confounders including morphine milligram equivalents and dosage, an estimated 12% (95 CI, 10%-14%) treated with hydrocodone transitioned to long-term use vs. 2% (95 CI, 1%-3%) on oxycodone. Among patients who received more than one prescription (n = 1,866), an estimated 23% (95 CI, 19%-26%) treated with hydrocodone transitioned to long-term use vs. 5% (95 CI, 3%-7%) on oxycodone. The difference between drugs was supported in sensitivity and subgroup analyses. Sample selection bias was not detected.

CONCLUSIONS

Long-term use was substantially greater for patients treated with hydrocodone than oxycodone, despite equianalgesia.

Opioid-Related Diagnoses and Concurrent Claims for HIV, HBV, or HCV among Medicare Beneficiaries, United States, 2015

Unsterile opioid injection increases risk for infection transmission, including HIV, hepatitis B virus (HBV), or hepatitis C virus (HCV). We assess prevalence of and risk factors associated with opioid overdose and infections with HIV, HBV, or HCV among Medicare beneficiaries with opioid-related fee-for-service claims during 2015. We conducted a cross-sectional analysis to estimate claims for opioid use and overdose and HIV, HBV, or HCV infections, using data from US Medicare fee-for-service claims. Beneficiaries with opioid-related claims had increased odds for HIV (2.3; 95% confidence interval (CI), 2.3–2.4), acute HBV (6.7; 95% CI, 6.3–7.1), chronic HBV (5.0; 95% CI, 4.7–5.4), acute HCV (9.6; 95% CI, 9.2–10.0), and chronic HCV (8.9; 95% CI, 8.7–9.1). Beneficiaries with opioid-related claims and for HIV, HBV, or HCV infection, respectively, had a 1.1–1.9-fold odds for having a claim for opioid overdose. Independent risk factors for opioid overdose and each selected infection outcome included age, sex, race/ethnicity, region, and residence in a high-vulnerability county. Having opioid-related claims and selected demographic attributes were independent, significant risk factors for having HIV, HBV, or HCV claims among US Medicare beneficiaries. These results might help guide interventions intended to reduce incidences of HIV, HCV, and HBV infections among beneficiaries with opioid-related claims.

Characteristics and Health Care Utilization of Different Segments of a Multiethnic Asian Population in Singapore

IMPORTANCE

Descriptive population-level health data are critical components of the evidence base for population health policy. Human populations often display marked heterogeneity in their health status among subgroups of the population. The recent widespread adoption of electronic health records provides opportunities to use routine real-world health care data to examine population health.

OBJECTIVE

To report population sociodemographic characteristics, health conditions, health care utilization, and health care costs for different population segments of a multiethnic Asian population divided according to a modified British Columbia Population Segmentation Framework.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cross-sectional study used 2016 data from the Singapore Eastern Regional Health System, the largest Regional Health System in Singapore. Data were obtained from deidentified national-level electronic health records at the Ministry of Health Singapore. Participants included all residents in the Singapore Eastern Regional Health System catchment area in 2016. The descriptive analysis was conducted in August 2018.

MAIN OUTCOMES AND MEASURES

Socioeconomic profiles, disease prevalence, health care utilization, and cost patterns of population segments.

RESULTS

The total size of the study population in 2016 was 1 181 024 residents (576 663 [48.83%] male; median [interquartile range] age, 40 [22-57] years). The population was divided into 8 segments: healthy with no outpatient utilization (493 483 residents), healthy with outpatient utilization (259 909 residents), healthy with inpatient admissions (49 588 residents), low complex (215 134 residents), medium complex (79 350 residents), high complex (44 445 residents), cancer (34 217 residents), and end of life (4898 residents). Overall, the 3 most prevalent conditions were chronic kidney disease (31.89%), hypertension (18.52%), and lipid disorders (18.33%). Distributions of chronic conditions differed across the segments. Different segments had varying health care utilization patterns: the high-complex segment had the highest number of primary care clinic visits (mean [SD], 4.25 [5.46] visits), the cancer segment had the highest number of specialist outpatient clinic visits (mean [SD], 5.55 [8.49] visits), and the end-of-life segment had the highest numbers of accident and emergency department visits (mean [SD], 1.80 [1.88] visits) and inpatient admissions (mean [SD], 1.99 [1.89] admissions) during 2016. For health care costs, specialist outpatient clinic and inpatient care together made up more than 85% of the total cost of nearly 2 billion Singapore dollars. The end-of-life segment contributed approximately 50% of the health care cost per capita of 60 000 Singapore dollars.

CONCLUSIONS AND RELEVANCE

Different population segments displayed heterogeneity in sociodemographic characteristics, health conditions, health care utilization, and health care cost patterns. This critical health information can be used as baseline data to inform regional and national health priorities for health services research and policy.

The Effect of Bupivacaine on the Efficacy of Antibiotic Coating on Penile Implants in Preventing Infection

Background

In an effort to reduce dependence on opioids following inflatable penile prosthesis placement, intra-operative soaking of the implant in Bupivacaine (BUP) has been proposed as part of a multimodal approach to pain control. However, no study has shown if the addition of BUP affects the antimicrobial properties of InhibiZone on AMS700 (Boston Scientific, Marlborough, MA) and/or of antibiotic soaked Titan Coloplast (Coloplast Corporation, Minneapolis, MN).

Aim

To determine if BUP alters the zone of inhibition (ZOI) against Staphylococcus epidermidis (S epidermidis) and Escherichia coli (E coli), common gram-positive and gram-negative bacterial causes of infection, respectively, created by InhibiZone coated AMS and/or by antibiotic-soaked Coloplast implant.

Methods

S epidermidis and E coli were spread on agar plates. After a 30-minute incubation, four AMS with InhibiZone strips treated with sterile saline or BUP (1.25 mg/mL) were placed on a plate. 4 Coloplast strips were dipped in varying routinely used concentrations of Rifampin (0–10 mg/mL) plus Gentamicin (0–1 mg/mL; rifampin and gentamicin (R+G)) solution with or without BUP. The ZOI for AMS with InhibiZone and Coloplast dipped in antibiotic solution was measured using ImageJ software. Normalized ZOI was calculated as (ZOI area/plate area) × 100. Unpaired t-test compared the mean ± SD ZOI between BUP and no BUP groups (n = 4/group).

Outcomes

The primary outcome of the study was the ZOI against E coli and S epidermidis at 24 and 48 hours.

Results

Growth of both S epidermidis and E coli at 24 and 48 hours of incubation was inhibited in both implants and the addition of BUP did not alter the ZOI. Coloplast strips dipped in R+G produced a ZOI in a dose-dependent manner. Interestingly, the ZOI against S epidermidis compared to that of E coli was much wider for both implants.

Clinical Implications

This suggests that the use of BUP does not affect the protective effects of antibiotic dips and can potentially be used during penile prosthesis surgery pending clinical trials.

Strengths and Limitations

This is the first study to evaluate the effect of BUP on anti-bacterial dips. As with all in vitro analysis, further research must be done to see if these findings hold true in the clinical setting.

Conclusions

The addition of BUP does not impede the in vitro antibacterial activity of InhibiZone-coated AMS or R+G-soaked Coloplast. Whether these in vitro findings translate to surgical outcomes needs to be evaluated in future preclinical trials.

Lokeshwar SD, Horodyski L, Lahorewala SS, et al. The Effect of Bupivacaine on the Efficacy of Antibiotic Coating on Penile Implants in Preventing Infection. J Sex Med 2019;7:337−344.