Characterizations of long-term oxycodone/acetaminophen prescriptions in veteran patients

Dosing profiles of concurrent opioid and benzodiazepine use associated with overdose risk among US Medicare beneficiaries: group-based multi-trajectory models

BACKGROUND AND AIMS

One-third of opioid (OPI) overdose deaths involve concurrent benzodiazepine (BZD) use. Little is known about concurrent opioid and benzodiazepine use (OPI-BZD) most associated with overdose risk. We aimed to examine associations between OPI-BZD dose and duration trajectories, and subsequent OPI or BZD overdose in US Medicare.

DESIGN

Retrospective cohort study.

SETTING

US Medicare.

PARTICIPANTS

Using a 5% national Medicare data sample (2013-16) of fee-for-service beneficiaries without cancer initiating OPI prescriptions, we identified 37 879 beneficiaries (age ≥ 65 = 59.3%, female = 71.9%, white = 87.6%, having OPI overdose = 0.3%).

MEASUREMENTS

During the 6 months following OPI initiation (i.e. trajectory period), we identified OPI-BZD dose and duration patterns using group-based multi-trajectory models, based on average daily morphine milligram equivalents (MME) for OPIs and diazepam milligram equivalents (DME) for BZDs. To label dose levels in each trajectory, we defined OPI use as very low (< 25 MME), low (25-50 MME), moderate (51-90 MME), high (91-150 MME) and very high (>150 MME) dose. Similarly, we defined BZD use as very low (< 10 DME), low (10-20 DME), moderate (21-40 DME), high (41-60 DME) and very high (> 60 DME) dose. Our primary analysis was to estimate the risk of time to first hospital or emergency department visit for OPI overdose within 6 months following the trajectory period using inverse probability of treatment-weighted Cox proportional hazards models.

FINDINGS

We identified nine distinct OPI-BZD trajectories: group A: very low OPI (early discontinuation)-very low declining BZD (n = 10 598; 28.0% of the cohort); B: very low OPI (early discontinuation)-very low stable BZD (n = 4923; 13.0%); C: very low OPI (early discontinuation)-medium BZD (n = 4997; 13.2%); D: low OPI-low BZD (n = 5083; 13.4%); E: low OPI-high BZD (n = 3906; 10.3%); F: medium OPI-low BZD (n = 3948; 10.4%); G: very high OPI-high BZD (n = 1371; 3.6%); H: very high OPI-very high BZD (n = 957; 2.5%); and I: very high OPI-low BZD (n = 2096; 5.5%). Compared with group A, five trajectories (32.3% of the study cohort) were associated with increased 6-month OPI overdose risks: E: low OPI-high BZD [hazard ratio (HR) = 3.27, 95% confidence interval (CI) = 1.61-6.63]; F: medium OPI-low BZD (HR = 4.04, 95% CI = 2.06-7.95); G: very high OPI-high BZD (HR = 6.98, 95% CI = 3.11-15.64); H: very high OPI-very high BZD (HR = 4.41, 95% CI = 1.51-12.85); and I: very high OPI-low BZD (HR = 6.50, 95% CI = 3.15-13.42).

CONCLUSIONS

Patterns of concurrent opioid and benzodiazepine use most associated with overdose risk among fee-for-service US Medicare beneficiaries initiating opioid prescriptions include very high-dose opioid use (MME > 150), high-dose benzodiazepine use (DME > 40) or medium-dose opioid with low-dose benzodiazepine use.

Opioid Prescribing and Use Among Cancer Survivors: A Mapping Review of Observational and Intervention Studies

CONTEXT

Recent years show a sharp increase in research on opioid use among cancer survivors, but evidence syntheses are lacking, leaving knowledge gaps. Corresponding research needs are unclear.

OBJECTIVES

To provide an evidence synthesis.

METHODS

We searched PubMed and Embase, identifying articles related to cancer, and opioid prescribing/use published through September 2020. We screened resulting titles/abstracts. Relevant studies underwent full-text review. Inclusion criteria were quantitative examination of and primary focus on opioid prescribing or use, and explicit inclusion of cancer survivors. Exclusion criteria included end-of-life opioid use and opioid use as a secondary or downstream outcome (for intervention studies). We extracted information on the opioid-related outcome(s) examined (including definitions and terminology used), study design, and methods.

RESULTS

Research returned 16,591 articles; 296 were included. Only 22 of 296 studies evaluated an intervention. There were 105 studies evaluating outcomes indicative of potentially high-risk, nonrecommended, or avoidable opioid use, e.g., continuous use-described as chronic use, prolonged use, and persistent use (n = 17); use after completion of curative-intent treatment-described as chronic opioid use, long-term opioid use, persistent opioid use, prolonged opioid use, continued opioid use, late opioid use, post-treatment opioid use (n = 27); use of opioids concurrent with other potentially high-risk medications (n = 13), and opioid misuse (n = 14).

CONCLUSIONS

We found lack of consistency in the measurement of and terms used to describe similar opioid use outcomes, and a lack of interventional research targeting well-documented patterns of potentially nonrecommended, potentially avoidable, or potentially high-risk opioid prescribing or use.

Relationship between concomitant benzodiazepine-opioid use and adverse outcomes among US veterans

Benzodiazepines and opioids are commonly used among veterans suffering from mental health disorders and pain conditions. The objective of this study is to determine whether concomitant benzodiazepine-opioid use increases the incidence of adverse outcomes above the baseline risk of nonacute opioid-only use. The dataset contained all veterans who filled at least 1 opioid prescription during the years 2008 to 2012. Nonacute opioid use was defined as having opioid prescriptions greater than or equal to 20 days within a 60-day period. Concomitant use was defined as having opioid and benzodiazepine prescriptions that overlapped for at least 7 days. Nonacute opioid-only users were matched to concomitant opioid-benzodiazepine users based on propensity scores. A 365-day observation period was used to identify adverse outcomes. The primary outcome examines the existence of one or more of the following outcomes: opioid-related accidents and overdoses, alcohol- and nonopioid drug-related accidents and overdoses, self-inflicted injuries, violence-related injuries, wounds/injuries overall, and death. A logistic propensity score adjusted regression controlling for propensity toward concomitant use was used to determine the association of concomitant use with adverse outcomes. The final matched sample consisted of 396,141 nonacute opioid-only using veterans and 48,971 concomitant benzodiazepine-opioid users. Receiving opioids and benzodiazepines concomitantly increased the risk of experiencing an adverse outcome with an odds ratio of 1.359 (95% confidence interval: 1.320-1.400; P < 0.0001). Among veterans receiving opioids, concomitant benzodiazepine use is associated with an increased risk of adverse outcomes when compared to the baseline risk of opioid-only using veterans.

Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis

Objectives To identify trends in concurrent use of a benzodiazepine and an opioid and to identify the impact of these trends on admissions to hospital and emergency room visits for opioid overdose.Design Retrospective analysis of claims data, 2001-13.Setting Administrative health claims database.Participants 315 428 privately insured people aged 18-64 who were continuously enrolled in a health plan with medical and pharmacy benefits during the study period and who also filled at least one prescription for an opioid.Interventions Concurrent benzodiazepine/opioid use, defined as an overlap of at least one day in the time periods covered by prescriptions for each drug. Main outcome measures Annual percentage of opioid users with concurrent benzodiazepine use; annual incidence of visits to emergency room and inpatient admissions for opioid overdose.Results 9% of opioid users also used a benzodiazepine in 2001, increasing to 17% in 2013 (80% relative increase). This increase was driven mainly by increases among intermittent, as opposed to chronic, opioid users. Compared with opioid users who did not use benzodiazepines, concurrent use of both drugs was associated with an increased risk of an emergency room visit or inpatient admission for opioid overdose (adjusted odds ratio 2.14, 95% confidence interval 2.05 to 2.24; P<0.001) among all opioid users. The adjusted odds ratio for an emergency room visit or inpatient admission for opioid overdose was 1.42 (1.33 to 1.51; P<0.001) for intermittent opioid users and 1.81 (1.67 to 1.96; P<0.001) chronic opioid users. If this association is causal, elimination of concurrent benzodiazepine/opioid use could reduce the risk of emergency room visits related to opioid use and inpatient admissions for opioid overdose by an estimated 15% (95% confidence interval 14 to 16).Conclusions From 2001 to 2013, concurrent benzodiazepine/opioid use sharply increased in a large sample of privately insured patients in the US and significantly contributed to the overall population risk of opioid overdose.

Benzodiazepine use in patients with chronic pain in an interdisciplinary pain rehabilitation program

Objectives

In the context of widespread opioid use, increased emphasis has been placed on the potentially deleterious effects of concurrent benzodiazepine (BZD) and opioid use. Although use of opioids in chronic pain has been a major focus, BZD use is equally concerning. Thus, the primary aim of this study was to determine the associations between BZD and opioid use in adults with chronic pain upon admission to an outpatient interdisciplinary pain rehabilitation (IPR) program.

Methods

The study cohort involved 847 consecutive patients admitted to a 3-week outpatient IPR program from January 2013 through December 2014. Study variables included baseline demographic and clinical characteristics, Center for Epidemiologic Studies-Depression Scale, Pain Catastrophizing Scale, and the pain severity subscale of the Multidimensional Pain Inventory.

Results

Upon admission, 248 (29%) patients were taking BZDs. Patients using BZDs were significantly more likely to use opioids and to be female. Additionally, patients using BZDs had significantly greater depression, pain catastrophizing, and pain severity scores. In univariable logistic regression analysis, opioid use, female sex, and greater scores of depression, pain catastrophizing, and pain severity were significantly associated with BZD use. In multivariable logistic regression analysis adjusted for age, sex, pain duration, opioid use, depression, pain catastrophizing, and pain severity, only female sex and greater depression scores were significantly associated with BZD use.

Discussion

Among patients participating in an outpatient IPR program, female sex and greater depression scores were associated with BZD use. Results identify a high prevalence of BZD use in patients with chronic pain and reinforce the need to weigh the risks versus benefits when prescribing in this patient population.

The association between benzodiazepine prescription and aberrant drug-related behaviors in primary care patients receiving opioids for chronic pain

BACKGROUND

Benzodiazepine use has been associated with addiction-related risks, but little is known about its association with aberrant drug-related behaviors in patients receiving opioids for chronic pain. The authors examined the association between receipt of a benzodiazepine prescription and 2 aberrant drug-related behaviors, early opioid refills and illicit drug (cocaine) use in patients receiving opioids for noncancer chronic pain.

METHODS

This was a retrospective cohort study of 847 patients with ≥1 visit to either a hospital-based primary care clinic or one of two community health centers between September 1, 2011, and August 31, 2012. All patients received ≥3 opioid prescriptions written at least 21 days apart within 6 months, and ≥1 urine drug screen during the study period. A Cox proportional hazards model estimated the hazard of a second early opioid refill, defined as an opioid prescription written 7-25 days after the previous prescription for the same drug, as a function of time-varying benzodiazepine prescription. A logistic regression model examined the relationship between benzodiazepine prescription and a positive urine test for cocaine. Models were adjusted for demographics and mental/substance use disorder diagnoses.

RESULTS

Twenty-three percent (n = 196) of patients received ≥1 benzodiazepine prescription during the study period. Twenty-two percent (n = 183) of patients had ≥2 early opioid refills, and 11% (n = 93) had ≥1 positive urine drug tests for cocaine. Receipt of benzodiazepine prescription was associated with an increased hazard of having a second early opioid refill, adjusted hazard ratio = 1.54 (95% confidence interval [CI]: 1.09-2.18), but not associated with a positive cocaine test, adjusted odds ratio = 1.07 (95% CI: 0.55-2.23).

CONCLUSIONS

Among primary care patients receiving chronic opioid therapy, benzodiazepine prescription was associated with early opioid refills but not with cocaine use. Further research should better elucidate the risks and benefits of prescribing benzodiazepines to patients receiving opioids for chronic pain.

Pain management strategies and lessons from the military: A narrative review

BACKGROUND

Wounded soldiers often experience substantial pain, which must be addressed before returning to active duty or civilian life. The United States (US) military has instituted several guidelines and initiatives aimed at improving pain management by providing rapid access to medical care, and developing interdisciplinary multimodal pain management strategies based on outcomes observed both in combat and hospital settings.

OBJECTIVE

To provide a narrative review regarding US military pain management guidelines and initiatives, which may guide improvements in pain management, particularly chronic pain management and prevention, for the general population.

METHODS

A literature review of US military pain management guidelines and initiatives was conducted, with a particular focus on the potential of these guidelines to address shortcomings in chronic pain management in the general population.

DISCUSSION

The application of US military pain management guidelines has been shown to improve pain monitoring, education and relief. In addition, the US military has instituted the development of programs and guidelines to ensure proper use and discourage aberrant behaviours with regard to opioid use, because opioids are regarded as a critical part of acute and chronic pain management schemes. Inadequate pain management, particularly inadequate chronic pain management, remains a major problem for the general population in the US. Application of military strategies for pain management to the general US population may lead to more effective pain management and improved long-term patient outcomes.

Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study

OBJECTIVE

To study the association between benzodiazepine prescribing patterns including dose, type, and dosing schedule and the risk of death from drug overdose among US veterans receiving opioid analgesics.

DESIGN

Case-cohort study.

SETTING

Veterans Health Administration (VHA), 2004-09.

PARTICIPANTS

US veterans, primarily male, who received opioid analgesics in 2004-09. All veterans who died from a drug overdose (n=2400) while receiving opioid analgesics and a random sample of veterans (n=420,386) who received VHA medical services and opioid analgesics.

MAIN OUTCOME MEASURE

Death from drug overdose, defined as any intentional, unintentional, or indeterminate death from poisoning caused by any drug, determined by information on cause of death from the National Death Index.

RESULTS

During the study period 27% (n=112,069) of veterans who received opioid analgesics also received benzodiazepines. About half of the deaths from drug overdose (n=1185) occurred when veterans were concurrently prescribed benzodiazepines and opioids. Risk of death from drug overdose increased with history of benzodiazepine prescription: adjusted hazard ratios were 2.33 (95% confidence interval 2.05 to 2.64) for former prescriptions versus no prescription and 3.86 (3.49 to 4.26) for current prescriptions versus no prescription. Risk of death from drug overdose increased as daily benzodiazepine dose increased. Compared with clonazepam, temazepam was associated with a decreased risk of death from drug overdose (0.63, 0.48 to 0.82). Benzodiazepine dosing schedule was not associated with risk of death from drug overdose.

CONCLUSIONS

Among veterans receiving opioid analgesics, receipt of benzodiazepines was associated with an increased risk of death from drug overdose in a dose-response fashion.

Comparison of the risks of shopping behavior and opioid abuse between tapentadol and oxycodone and association of shopping behavior and opioid abuse

OBJECTIVES

This study compared the risks of opioid shopping behavior and opioid abuse between tapentadol immediate release and oxycodone immediate release and, to validate the definition of shopping, examined the association between opioid shopping and opioid abuse further.

MATERIALS AND METHODS

This retrospective cohort study using linked dispensing and diagnosis databases followed opioid-naive patients for development of shopping behavior and/or opioid abuse during 1 year after initial exposure to tapentadol or oxycodone. Shopping was defined by having overlapping opioid prescriptions from >1 prescriber filled at ≥3 pharmacies; abuse by having International Classification of Diseases, 9th revision diagnoses reflecting opioid abuse, addiction, or dependence. To determine their association, we cross-tabulated shopping and opioid abuse and calculated odds ratios. Risks of developing each outcome were estimated using logistic regression.

RESULTS

Among 277,401 participants initiating opioid use with tapentadol (39,524) or oxycodone (237,877), 0.6% developed shopping behavior, 0.75% developed abuse. Higher proportions of patients in the oxycodone group developed shopping behavior and abuse than in the tapentadol group (shopping: adjusted odds ratio [95% confidence interval], 0.45 [0.36-0.55]; abuse: 0.44 [0.37-0.54]). Shopping behavior and abuse were associated; of those with shopping behavior, 6.5% had abuse. Age (18 to 64 y), sex (male), prior benzodiazepine use, paying cash, and history (mood disorders, abuse of nonopioid medications, and back pain) were risk factors for developing either outcome.

DISCUSSION

Shopping behavior and abuse measure complementary, but associated, constructs, which further validates the current definition of shopping. The risk of developing either is lower among patients who initiate opioid use with tapentadol than those who initiate opioid use with oxycodone.

Risk of adverse health outcomes with increasing duration and regularity of opioid therapy

PURPOSE

The purpose of this study was to examine trends in frequency and daily dosage of opioid use and related adverse health outcomes in a commercially insured population.

METHODS

We examined medical claims from the Truven Health MarketScan commercial claims database for 789,457 continuously enrolled patients ages 18 to 64 years to whom opioids were dispensed during the first half of 2008. We tracked them every 6 months until either opioid use was discontinued or the end of 2010. We compared outcomes among all opioid users with those for patients who used opioids with only limited interruptions during the index period, referred to as "daily users." We contrasted the experience of daily users, other users, and nonusers for various outcomes.

RESULTS

Of all claimants, 10.7% had at least one opioid prescription during the first 6 months of 2008. Of these, 39.9% continued through a second 6-month period, and 18.0% continued through the end of 2010. Only 9.0% of all users qualified as daily users, but 87.1% of them continued some use of opioids through the end of 2010. Only 43.8% of all users who continued use through 2010 initially qualified as daily users. Among all users who continued use through 2010, days of use and daily dosage increased with duration of use. Among daily users, only dosage increased, rising from 101 to 114 morphine milligram equivalents/day over the 3 years. The prevalence of benzodiazepine use was greater for daily than all users, exceeding 40% among daily users who continued opioid use for 3 years. Drug abuse and overdose rates increased with longer use. Daily users accounted for 25.0%, other users for 43.6%, and nonusers for 31.4% of opioid analgesic overdoses.

CONCLUSIONS

Adverse health outcomes can increase with accumulating opioid use and increasing dosage. Existing guidelines developed by specialty societies for managing patients using opioids daily or nearly daily do not address the larger number of patients who use opioids intermittently over periods of years. Practitioners should consider applying such guidelines to patients who use opioids less frequently.

Chronic pain and pain medication use in chronic obstructive pulmonary disease. A cross-sectional study

RATIONALE

Pain is a common problem for patients with chronic obstructive pulmonary disease (COPD). However, pain is minimally discussed in COPD management guidelines.

OBJECTIVES

The objective of this study was to describe chronic pain prevalence among patients with COPD compared with similar patients with other chronic diseases in a managed care population in the southwestern United States (age ≥ 40 yr).

METHODS

Using data for the period January 1, 2006 through December 31, 2010, patients with COPD were matched to two control subjects without COPD but with another chronic illness based on age, sex, insurance, and healthcare encounter type. Odds ratios (OR) for evidence of chronic pain were estimated using conditional logistic regression. Pulmonary function data for 200 randomly selected patients with COPD were abstracted.

MEASUREMENTS AND MAIN RESULTS

Retrospectively analyzed recurrent pain-related utilization (diagnoses and treatment) was considered evidence of chronic pain. The study sample comprised 7,952 patients with COPD (mean age, 69 yr; 42% male) and 15,904 patients with other chronic diseases (non-COPD). Patients with COPD compared with non-COPD patients had a higher percentage of chronic pain (59.8 vs. 51.7%; P < 0.001), chronic use of pain-related medications (41.2 vs. 31.5%; P < 0.001), and chronic use of short-acting (24.2 vs. 15.1%; P < 0.001) and long-acting opioids (4.4 vs. 1.9%; P < 0.001) compared with non-COPD patients. In conditional logistic regression models, adjusting for age, sex, Hispanic ethnicity, and comorbidities, patients with COPD had higher odds of chronic pain (OR, 1.56; 95% confidence interval [CI], 1.43-1.71), chronic use of pain-related medications (OR, 1.60; 95% CI, 1.46-1.74), and chronic use of short-acting or long-acting opioids (OR, 1.74; 95% CI, 1.57-1.92).

CONCLUSIONS

Chronic pain and opioid use are prevalent among adults with COPD. This finding was not explained by the burden of comorbidity.

Tamper-resistant opioid formulations in the treatment of acute pain

INTRODUCTION

Pain-including acute or persistent acute pain-is a common condition that is increasingly being treated with opioids in the United States. The acute pain treatment setting may represent a key target for addressing the growing epidemic of prescription drug abuse occurring hand in hand with the rise in opioid prescribing. Balancing the needs of pain treatment with abuse prevention can be challenging for clinicians.

METHODS

This article identified efforts to balance opioid abuse risks with opioid availability through the extensive experience of the author in this field. In addition, PubMed literature searches using terms such as "prescription opioid abuse", "abuse-deterrent opioids", and "tamper-resistant opioids"; and inspection of the bibliographies of relevant articles were used to identify relevant sources.

RESULTS

These multifaceted efforts have included: improving assessment of patient risk for drug misuse, abuse, or diversion; funding of and encouraging referral to addiction treatment programs; access to and widespread use of prescription monitoring programs (PMPs); public knowledge of prescription opioid abuse; proper storage of opioid medications; and development of new formulations designed to resist tampering and deter abuse. This review discusses the problem of prescription opioid abuse and strategies to minimize risk within the context of acute pain treatment, and explores the potential role of tamper-resistant opioid formulations and other abuse deterrence strategies in the area of acute or persistent acute pain management.

CONCLUSION

In order to stem the tide of prescription opioid abuse and preserve the availability of opioids as a much needed analgesic option, a multifaceted approach that includes tamper-resistant opioid formulations-for chronic or acute pain-along with strategies such as improved patient risk assessment, funding for and referral to addiction treatment programs, greater use of PMPs, and raised awareness of prescription opioid abuse is needed.

Risks, management, and monitoring of combination opioid, benzodiazepines, and/or alcohol use

The concurrent use of opioids, benzodiazepines (BZDs), and/or alcohol poses a formidable challenge for clinicians who manage chronic pain. While the escalating use of opioid analgesics for the treatment of chronic pain and the concomitant rise in opioid-related abuse and misuse are widely recognized trends, the contribution of combination use of BZDs, alcohol, and/or other sedative agents to opioid-related morbidity and mortality is underappreciated, even when these agents are used appropriately. Patients with chronic pain who use opioid analgesics along with BZDs and/or alcohol are at higher risk for fatal/nonfatal overdose and have more aberrant behaviors. Few practice guidelines for BZD treatment are readily available, especially when they are combined clinically with opioid analgesics and other central nervous system-depressant agents. However, coadministration of these agents produces a defined increase in rates of adverse events, overdose, and death, warranting close monitoring and consideration when treating patients with pain. To improve patient outcomes, ongoing screening for aberrant behavior, monitoring of treatment compliance, documentation of medical necessity, and the adjustment of treatment to clinical changes are essential. In this article, we review the prevalence and pharmacologic consequences of BZDs and/or alcohol use among patients with pain on chronic opioid therapy, as well as the importance of urine drug testing, an indispensable tool for therapeutic drug monitoring, which helps to ensure the continued safety of patients. Regardless of risk or known aberrant drug-related behaviors, patients on chronic opioid therapy should periodically undergo urine drug testing to confirm adherence to the treatment plan.

Prescription opioids for back pain and use of medications for erectile dysfunction

STUDY DESIGN

Cross-sectional analysis of electronic medical and pharmacy records.

OBJECTIVE

To examine associations between use of medication for erectile dysfunction or testosterone replacement and use of opioid therapy, patient age, depression, and smoking status.

SUMMARY OF BACKGROUND DATA

Males with chronic pain may experience erectile dysfunction related to depression, smoking, age, or opioid-related hypogonadism. The prevalence of this problem in back pain populations and the relative importance of several risk factors are unknown.

METHODS

We examined electronic pharmacy and medical records for males with back pain in a large group model health maintenance organization during 2004. Relevant prescriptions were considered for 6 months before and after the index visit.

RESULTS

There were 11,327 males with a diagnosis of back pain. Males who received medications for erectile dysfunction or testosterone replacement (n = 909) were significantly older than those who did not and had greater comorbidity, depression, smoking, and use of sedative-hypnotics. In logistic regressions, the long-term use of opioids was associated with greater use of medications for erectile dysfunction or testosterone replacement compared with no opioid use (odds ratio, 1.45; 95% confidence interval, 1.12-1.87, P < 0.01). Age, comorbidity, depression, and use of sedative-hypnotics were also independently associated with the use of medications for erectile dysfunction or testosterone replacement. Patients prescribed daily opioid doses of 120 mg of morphine-equivalents or more had greater use of medication for erectile dysfunction or testosterone replacement than patients without opioid use (odds ratio, 1.58; 95% confidence interval, 1.03-2.43), even with adjustment for the duration of opioid therapy.

CONCLUSION

Dose and duration of opioid use, as well as age, comorbidity, depression, and use of sedative-hypnotics, were associated with evidence of erectile dysfunction. These findings may be important in the process of decision making for the long-term use of opioids.

LEVEL OF EVIDENCE

4.

Comparison of opioid doctor shopping for tapentadol and oxycodone: a cohort study

Obtaining opioids from multiple prescribers, known as doctor shopping, is 1 example of opioid abuse and diversion. The dual mechanism of action of tapentadol could make tapentadol less likely to be abused than other opioids. The aim of this retrospective cohort study was to compare the risk of shopping behavior between tapentadol immediate release (IR) and oxycodone IR. Subjects exposed to tapentadol or oxycodone with no recent opioid use were included and followed for 1 year. The primary outcome was the proportion of subjects who developed shopping behavior defined as subjects who had opioid prescriptions written by >1 prescriber with ≥1 day of overlap filled at ≥3 pharmacies. The opioids involved in the shopping episodes were assessed. A total of 112,821 subjects were exposed to oxycodone and 42,940 to tapentadol. Shopping behavior was seen in .8% of the subjects in the oxycodone group and in .2% of the subjects in the tapentadol group, for an adjusted odds ratio of 3.5 (95% confidence interval, 2.8 to 4.4). In the oxycodone group, 28.0% of the shopping events involved exclusively oxycodone, whereas in the tapentadol group, .6% of the shopping events involved exclusively tapentadol. Results suggest that the risk of shopping behavior is substantially lower with tapentadol than with oxycodone.

PERSPECTIVE

The risk of opioid doctor shopping, ie, obtaining opioid prescriptions from multiple prescribers, is lower with tapentadol than with oxycodone.

Separate and combined psychopharmacological effects of alprazolam and oxycodone in healthy volunteers

BACKGROUND

There are epidemiological data indicating that medical and/or nonmedical use of prescription opioids oftentimes involves concurrent use of other substances. One of those substances is benzodiazepines. It would be of relevance to characterize the effects of an opioid and a benzodiazepine when taken together to determine if measures related to abuse liability-related effects and psychomotor performance impairment are increased compared to when the drugs are taken alone.

METHODS

Twenty volunteers participated in a crossover, randomized, double-blind study in which they received placebo, 0.5mg alprazolam, 10mg oxycodone, and 0.5mg alprazolam combined with 10 mg oxycodone, all p.o. Subjective, psychomotor, and physiological measures were assessed during each of the four sessions.

RESULTS

Oxycodone by itself increased drug liking and "take again" ratings relative to placebo, but these ratings were not increased when oxycodone was taken with alprazolam, which by itself did not increase either of these ratings. The two drugs in combination produced stronger effects (larger in magnitude or longer lasting) than when either was taken alone on a number of measures, including psychomotor performance impairment.

CONCLUSIONS

In healthy volunteers, abuse liability-related subjective effects of oxycodone were not enhanced by alprazolam. There was enhanced behavioral toxicity when the drugs were taken together, and thus, this is of significant concern from a public safety standpoint.

Dynamic risk factors in the misuse of opioid analgesics

OBJECTIVE

Identify the risk factors for prescription opioid misuse among patients taking prescription opioids to deal with chronic pain.

METHODS

We examined the literature for a variety of dynamic risk factors associated with opioid misuse among the chronic pain population in order to present a narrative review. Considered were: taking single or multiple opioids, pain intensity, mental health disorders, including a history of preadolescent sexual abuse, personal and familial history of substance abuse, a history of legal problems, being a crime victim, drug-seeking behaviors, drug craving, and age.

RESULTS

A variety of risk factors have been studied in the literature. Risk factors in chronic opioid therapy patients are dynamic in that they can change with disease progression, tolerance, changes in pain quality, mental health, comorbidities, other drug therapies or drug interactions, and changes in the patient's lifestyle.

CONCLUSION

Opioid analgesic therapy must be tailored to carefully monitor all patients in order to minimize misuse and abuse, since the risk is constant and dynamic and therefore every patient is at some degree of risk for opioid misuse.

Prescription long-term opioid use in HIV-infected patients

OBJECTIVES

To examine changes the in use of prescription opioids for the management of chronic noncancer pain in human immunodeficiency virus (HIV)-infected patients and to identify patient characteristics associated with long-term use.

METHODS

Long-term prescription opioid use (ie, 120+ days supply or 10+ prescriptions during a year) was assessed between 1997 and 2005 among 6939 HIV-infected Kaiser Permanente members and HIV-uninfected persons in the general health plan memberships.

RESULTS

In 2005, 8% of HIV individuals had prevalent long-term opioid use, more than double the prevalence among HIV-uninfected individuals. However, the large increases in use from 1997 to 2005 in the general population were not observed for HIV-infected individuals. The strongest associations with prevalent use among HIV-infected individuals were female sex with a prevalence ratio (PR) of 1.8 (95% CI=1.3, 2.5); Charlson comorbidity score of 2 or more (compared with a score of 0) with a PR of 1.9 (95% CI=1.4, 2.8); injection drug use history with a PR of 1.8 (95% CI=1.3, 2.6); and substance use disorders with a PR of 1.8 (95% CI=1.3, 2.5). CD4, HIV viral load, and acquired immunodeficiency syndrome diagnoses were associated with prevalent opioid use early in the antiretroviral therapy era (1997), but not in 2005.

CONCLUSIONS

Long-term opioid use for chronic pain has remained stable over time for HIV patients, whereas its use increased in the general population. The prevalence of prescribed opioids in HIV patients was highest for certain subgroups, including women, and those with a comorbidity and substance abuse history.

Prescription opioid abuse, pain and addiction: clinical issues and implications

ISSUES

Prescription opioid misuse in the USA has increased over threefold since 1990 to epidemic proportions, with substantial increases in prescription opioid use also reported in other countries, such as Australia and New Zealand. The broad availability of prescription pain medications, coupled with public misconceptions about their safety and addictive potential, have contributed to the recent surge in non-medical use of prescription opioids and corresponding increases in treatment admissions for problems related to opioid misuse. Given competing pressures faced by physicians to both diagnose and treat pain syndromes and identify individuals at risk for addictive disorders, the use of opioids in the treatment of pain poses a significant clinical challenge.

APPROACH

This paper reviews the interaction between pain and opioid addiction with a focus on clinical management issues, including risk factors for opioid dependence in patients with chronic pain and the use of assessment tools to identify and monitor at-risk individuals. Treatment options for opioid dependence and pain are reviewed, including the use of the partial µ agonist buprenorphine in the management of concurrent pain and opioid addiction.

IMPLICATIONS

Physicians should strive to find a reasonable balance between minimising potential adverse effects of opioid medications without diminishing legitimate access to opioids for analgesia.

CONCLUSIONS

The article discusses the need to identify methods for minimising risks and negative consequences associated with opioid analgesics and poses research directions, including the development of abuse-deterrent opioid formulations, genetic risk factors for opioid dependence and opioid-induced hyperalgesia as a potential target for medication therapy.

Opioids for back pain patients: primary care prescribing patterns and use of services

BACKGROUND

Opioid prescribing for noncancer pain has increased dramatically. We examined whether the prevalence of unhealthy lifestyles, psychologic distress, health care utilization, and co-prescribing of sedative-hypnotics increased with increasing duration of prescription opioid use.

METHODS

We analyzed electronic data for 6 months before and after an index visit for back pain in a managed care plan. Use of opioids was characterized as "none," "acute" (≤90 days), "episodic," or "long term." Associations with lifestyle factors, psychologic distress, and utilization were adjusted for demographics and comorbidity.

RESULTS

There were 26,014 eligible patients. Of these, 61% received a course of opioids, and 19% were long-term users. Psychologic distress, unhealthy lifestyles, and utilization were associated incrementally with duration of opioid prescription, not just with chronic use. Among long-term opioid users, 59% received only short-acting drugs; 39% received both long- and short-acting drugs; and 44% received a sedative-hypnotic. Of those with any opioid use, 36% had an emergency visit.

CONCLUSIONS

Prescription of opioids was common among patients with back pain. The prevalence of psychologic distress, unhealthy lifestyles, and health care utilization increased incrementally with duration of use. Coprescribing sedative-hypnotics was common. These data may help in predicting long-term opioid use and improving the safety of opioid prescribing.

Adherence and long-term effect of oxycodone/paracetamol in chronic noncancer pain: a retrospective study

INTRODUCTION

Long-term administration of opiates in patients with chronic noncancer pain (CNCP) is subject to debate due to insufficient clinical evidence to support efficacy and tolerability.

METHODS

This retrospective analysis used hospital records to investigate the effects of low doses of the combination of oxycodone/paracetamol on CNCP in an outpatient clinic setting to verify adherence to therapy and long-term efficacy. All patients receiving therapy for CNCP were examined between May and September 2010 and information was collected on medication, duration of therapy, and static and dynamic pain measured using numeric rating scales (NRS) from relevant charts.

RESULTS

Two hundred and thirty-one patients (157 men, 68%) with a mean (± SD) age of 66.4±15.5 years were analyzed. Pain indexes at baseline revealed a mean (± SD) static NRS (sNRS) of 3.5±1.77 and a mean dynamic NRS (dNRS) of 7.24±1.33. At last follow-up, mean (± SD) pain reductions versus baseline were 1.58±1.42 for sNRS and 3.04±1.43 for dNRS (P<0.0001 for both). Regarding the duration of therapy, 54 patients (23.4%) were treated for <4 months, and 177 patients (76.6%) for 4 months up to 23 months. Pain reduction was significant in all groups (P<0.0001) but was greatest in patients who had been receiving therapy for ≥4 months. Improvements in pain relief were not associated with an increase in daily dose, which remained stable or decreased slightly over time.

DISCUSSION

The results of this study support the hypothesis that an opiate-based combination at low doses improves tolerability and adherence and results in patients obtaining long-term efficacy. Larger studies of the use of opiates in this setting and clinical monitoring on the regional and national level may convince clinicians to view opiates as efficacious analgesics and not as dangerous substances of abuse.

Efficacy of oxycodone/paracetamol for patients with bone-cancer pain: a multicenter, randomized, double-blinded, placebo-controlled trial

WHAT IS KNOWN AND OBJECTIVE

Bone-cancer pain is a common and refractory cancer pain. Opioids, on their own, do not control this type of pain well enough, and co-analgesics are necessary.

METHODS

Patients with bone metastasis-related pain at Numeric Rating Scale ≥4 were enrolled to this randomized placebo-controlled trial. They had also received morphine or transdermal fentanyl patches for at least 1 week. During the 3-day efficacy phase, patients received placebo or 1-3 tablets of oxycodone/paracetamol (5/325 mg), four times daily for 3 days. All patients kept a daily pain diary. The primary endpoint was the Pain Intensity Difference (PID). Secondary endpoints were cases of breakthrough pain and rescue morphine consumption. Additional analyses included the Short Form-6 Dimensions (SF-6D) quality-of-life scale and a general impression (GI) of patient satisfaction with treatment at the end of the phase.

RESULTS AND DISCUSSION

Of the 246 patients in the intent-to-treat set, 89·4% completed the 3-day efficacy phase. PIDs were 0·9 and 0·3 in the oxycodone/paracetamol and placebo groups respectively, on day 1 (P < 0·001), and 1·5 and 0·3 respectively on day 3 (P < 0·001). Thirty-eight patients in the treatment group, and 58 in the placebo group, suffered breakthrough pain on day 3 (P < 0·001). The SF-6D score decreased to 21·2 ± 2·5 in the oxycodone/paracetamol group at the end of the phase (P = 0·001). In the oxycodone/paracetamol group, 67% rated GI as good, very good, or excellent.

WHAT IS NEW AND CONCLUSION

Patients with bone-cancer pain, already on opioids, obtain clinically important, additional pain-control, with regular oxycodone/paracetamol dosing.

Characteristics of older adults receiving opioids in primary care: treatment duration and outcomes

OBJECTIVE

To describe characteristics of older adults who received opioids for chronic non-cancer pain (CP), ascertain types of opioid treatments received, and examine associations between patient characteristics and treatment outcomes.

DESIGN

Retrospective cohort study.

SETTING

Primary care practice in New York City.

PATIENTS

Eligible patients were >or=65 and newly started on an opioid for CP.

OUTCOME MEASURES

Patient characteristics and provider treatments, as well as duration of opioid therapy, proportion discontinuing therapy, and evidence of pain reduction and continued use of opioid for more than 1 year. Other outcomes included the presence and type(s) of side effects, abuse/misuse behaviors, and adverse events.

RESULTS

Participants (N = 133) had a mean age of 82 (range = 65-105), were mostly female (84%), and white (74%). Common indications for opioid treatment included back pain (37%) and osteoarthritis (35%). Mean duration of opioid use was 388 days (range = 0-1,880). Short-acting analgesics were most commonly prescribed. Physicians recorded side effects in 40% of cases. Opioids were discontinued in 48% of cases, mostly due to side effects/lack of efficacy. Pain reduction was documented in 66% of patient records, while 32% reported less pain and continued treatment for >or=1 year. Three percent displayed abuse/misuse behaviors, and 5% were hospitalized due to opioid-related adverse events.

CONCLUSIONS

Over 50% of older patients with CP tolerated treatment. Treatment was discontinued in 48% of cases, mostly due to side effects and lack of analgesic efficacy. Efforts are needed to establish the long-term safety and efficacy of opioid treatment for CP in diverse older patient populations.

Oxycodone combinations for pain relief

No single analgesic drug provides the perfect therapeutic/adverse effect profile for every pain condition. In addition to convenience and possibly improved compliance, a combination of analgesic drugs offers the potential, requiring verification, of providing greater pain relief and/or reduced adverse effects than the constituent drugs when used individually. We review here analgesic combinations containing oxycodone. We found surprisingly little preclinical information about the analgesic or adverse effect profiles of the combinations (with acetaminophen, paracetamol, nonsteroidal anti-inflammatory drugs, morphine, gabapentin or pregabalin). Clinical experience and studies suggest that the combinations are safe and effective and may offer certain advantages. As with all combinations, the profile of adverse effects must also be determined in order to provide the clinician with the overall benefit/risk assessment.

Long-term opioid management for chronic noncancer pain

BACKGROUND

Opioid therapy for chronic noncancer pain (CNCP) is controversial due to concerns regarding long-term effectiveness and safety, particularly the risk of tolerance, dependence, or abuse.

OBJECTIVES

To assess safety, efficacy, and effectiveness of opioids taken long-term for CNCP.

SEARCH STRATEGY

We searched 10 bibliographic databases up to May 2009.

SELECTION CRITERIA

We searched for studies that: collected efficacy data on participants after at least 6 months of treatment; were full-text articles; did not include redundant data; were prospective; enrolled at least 10 participants; reported data of participants who had CNCP. Randomized controlled trials (RCTs) and pre-post case-series studies were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted safety and effectiveness data and settled discrepancies by consensus. We used random-effects meta-analysis' to summarize data where appropriate, used the I(2) statistic to quantify heterogeneity, and, where appropriate, explored heterogeneity using meta-regression. Several sensitivity analyses were performed to test the robustness of the results.

MAIN RESULTS

We reviewed 26 studies with 27 treatment groups that enrolled a total of 4893 participants. Twenty five of the studies were case series or uncontrolled long-term trial continuations, the other was an RCT comparing two opioids. Opioids were administered orally (number of study treatments groups [abbreviated as "k"] = 12, n = 3040), transdermally (k = 5, n = 1628), or intrathecally (k = 10, n = 231). Many participants discontinued due to adverse effects (oral: 22.9% [95% confidence interval (CI): 15.3% to 32.8%]; transdermal: 12.1% [95% CI: 4.9% to 27.0%]; intrathecal: 8.9% [95% CI: 4.0% to 26.1%]); or insufficient pain relief (oral: 10.3% [95% CI: 7.6% to 13.9%]; intrathecal: 7.6% [95% CI: 3.7% to 14.8%]; transdermal: 5.8% [95% CI: 4.2% to 7.9%]). Signs of opioid addiction were reported in 0.27% of participants in the studies that reported that outcome. All three modes of administration were associated with clinically significant reductions in pain, but the amount of pain relief varied among studies. Findings regarding quality of life and functional status were inconclusive due to an insufficient quantity of evidence for oral administration studies and inconclusive statistical findings for transdermal and intrathecal administration studies.

AUTHORS' CONCLUSIONS

Many patients discontinue long-term opioid therapy (especially oral opioids) due to adverse events or insufficient pain relief; however, weak evidence suggests that patients who are able to continue opioids long-term experience clinically significant pain relief. Whether quality of life or functioning improves is inconclusive. Many minor adverse events (like nausea and headache) occurred, but serious adverse events, including iatrogenic opioid addiction, were rare.

Differences in Prevalence of Prescription Opiate Misuse Among Rural and Urban Probationers

We compared the prevalence of prescription opiate misuse among 2 cohorts of felony probationers (N = 1525). Multiple logistic regression was utilized to determine the independent correlates of prescription opiate misuse among rural (n = 782) and urban (n = 743) probationers participating in an HIV-intervention study. After adjustment for differences in demographic and drug use characteristics, rural participants were almost five times more likely than their urban counterparts to have misused prescription opiates. The prevalence of prescription opiate misuse was significantly higher among the rural probationers; however, given the paucity of illicit opiates and relatively recent emergence of prescription opiates in rural areas, rural substance abuse treatment may be ill-prepared to treat prescription opiate misuse.

Opiate prescription medication dependence and pain perceptions

Our study showed that the perception of pain lessens with detoxification from chronic prescription opiate medications. Thus, removal of opiates resulted in less pain, and chronic administration of opiates actually increased pain perceptions. The underlying pathophysiology of increased pain sensitivity from chronic administration is not well understood. However, the enhanced pain from the development of tolerance and dependence is a common phenomenon. Clinicians are advised to limit their prescribing of opiate drugs to patients on a chronic basis. Further, unresolved pain complaints, and continued complaints of pain despite escalating doses of opiate medications suggest addiction and its adverse consequences. Identification of addiction and detoxification is the proper approach to pain management in chronic opiate administration.

Do users of regularly prescribed opioids have higher rates of substance use problems than nonusers?

OBJECTIVE

To determine whether individuals who use prescribed opioids for chronic noncancer pain have higher rates of any opioid misuse, any problem opioid misuse, nonopioid illicit drug use, nonopioid problem drug use, or any problem alcohol use, compared with those who do not use prescribed opioids.

METHODS

Respondents were from a nationally representative survey (N = 9,279), which contained measures of regular use of prescribed opioids, substance use problems, mental health disorders, physical health, pain, and sociodemographics.

RESULTS

In unadjusted models, compared with nonusers of prescription opioids, users of prescription opioids had significantly higher rates of any opioid misuse (odds ratio [OR] = 5.48, P < 0.001), problem opioid misuse (OR = 14.76, P < 0.001), nonopioid illicit drug use (OR = 1.73, P < 0.01), nonopioid problem drug use (OR = 4.48, P < 0.001), and problem alcohol use (OR = 1.89, P = 0.04). In adjusted models, users of prescribed opioids had significantly higher rates of any opioid misuse (OR = 3.07, P < 0.001) and problem opioid misuse (OR = 6.11, P < 0.001) but did not have significantly higher rates of the other outcomes.

CONCLUSIONS

Users of prescribed opioids had higher rates of opioid and nonopioid abuse problems compared with nonusers of prescribed opioids, but these higher rates appear to be partially mediated by depressive and anxiety disorders. It is not possible to assign causal priority based on our cross-sectional data, but our findings are more compatible with mental disorders leading to substance abuse among prescription opioid users than prescription opioids themselves prompting substance abuse iatrogenically. In patients receiving prescribed opioids, clinicians need to be alert to drug abuse problems and potentially mediating mental health disorders.

Adverse drug interactions involving common prescription and over-the-counter analgesic agents

BACKGROUND

Eight analgesic preparations with approved indications for acute pain were among the top 200 drugs prescribed in the United States in 2006. In addition, an estimated 36 million Americans use over-the-counter (OTC) analgesics daily. Given this volume of use, it is not surprising that a number of drug interactions involving analgesic drugs have been reported.

OBJECTIVES

This article examines the pharmacologic factors that enhance the clinical relevance of potential drug interactions and reviews the literature on drug interactions involving the most commonly used analgesic preparations in the United States.

METHODS

A PubMed search was conducted for English-language articles published between January 1967 and July 2007. Among the search terms were drug interactions, acetaminophen, aspirin, ibuprofen, naproxen, celecoxib, NSAIDs, hydrocodone, oxycodone, codeine, tramadol, OTC analgesics, alcohol, ethanol, antihypertensive drugs, methotrexate, warfarin, SSRIs, paroxetine, fluoxetine, sertraline, citalopram, serotonin syndrome, MAOIs, and overdose. Controlled clinical trials, case-control studies, and case reports were included in the review.

RESULTS

A number of case reports and well-controlled clinical trials were identified that provided evidence of the relatively well known drug-drug interactions between prescription/OTC NSAIDs and alcohol, antihypertensive drugs, high-dose methotrexate, and lithium, as well as between frequently prescribed narcotics and other central nervous system depressants. In contrast, the ability of recent alcohol ingestion to exacerbate the hepatotoxic potential of therapeutic doses of acetaminophen is not supported by either case reports or clinical research. Use of ibuprofen according to OTC guidelines in patients taking cardioprotective doses of aspirin does not appear to interfere with aspirin's antiplatelet activity, whereas chronic prescription use of ibuprofen and other NSAIDs may interfere. Low-dose aspirin intake appears to abolish the gastroprotective effects of cyclooxygenase-2-selective inhibitors, including celecoxib. There is evidence of other less well known and potentially clinically significant drug-drug interactions, including the ability of selective serotonin reuptake inhibitors to inhibit the analgesic activity of tramadol and codeine through inhibition of their metabolic activation, to induce serotonin syndrome when used chronically in the presence of high doses of tramadol through synergistic serotonergic action, and to increase the potential for gastrointestinal bleeding associated with NSAID therapy through additive or supra-additive antiplatelet activity.

CONCLUSIONS

Considering the widespread use of analgesic agents, the overall incidence of serious drug-drug interactions involving these agents has been relatively low. The most serious interactions usually involved other interacting drugs with low therapeutic indices or chronic and/or high-dose use of an analgesic and the interacting drug.

Long-term opioid therapy for chronic noncancer pain: a systematic review and meta-analysis of efficacy and safety

Opioid therapy for chronic noncancer pain (CNCP) is controversial due to concerns regarding long-term efficacy and adverse events (including addiction). We systematically reviewed the clinical evidence on patients treated with opioids for CNCP for at least six months. Of 115 studies identified by our search of eleven databases (through April 7, 2007), 17 studies (patients [n]=3,079) met inclusion criteria. Studies evaluated oral (studies [k]=7; n=1,504), transdermal (k=3; n=1, 993), and/or intrathecal (k=8; n=177) opioids. Many patients withdrew from the clinical trials due to adverse effects (oral: 32.5% [95% confidence interval (CI), 26.1%-39.6%]; intrathecal: 6.3% [95% CI, 2.9%-13.1%]; transdermal: 17.5% [95% CI, 6.5%-39.0%]), or due to insufficient pain relief (oral: 11.9% [95% CI, 7.8%-17.7%]; intrathecal: 10.5% [95% CI, 3.5%-27.4%]; transdermal: 5.8% [95% CI, 4.2%-7.3%]). Signs of opioid addiction were reported in only 0.05% (1/2,042) of patients and abuse in only 0.43% (3/685). There was an insufficient amount of data on transdermal opioids to quantify pain relief. For patients able to remain on oral or intrathecal opioids for at least six months, pain scores were reduced long-term (oral: standardized mean difference [SMD] 1.99, 95% CI, 1.17-2.80; intrathecal: SMD 1.33, 95% CI, 0.97-1.69). We conclude that many patients discontinue long-term opioid therapy due to adverse events or insufficient pain relief; however, weak evidence suggests that oral and intrathecal opioids reduce pain long-term in the relatively small proportion of individuals with CNCP who continue treatment.

The association between statins and cancer incidence in a veterans population

BACKGROUND

Meta-analyses of trials of 3-hydroxy-3-methyl-glutaryl-CoA reductase inhibitors or statins for cardiovascular disease prevention have failed to show any statistically significant benefit of statins for cancer prevention. However, these trials included relatively young participants, who develop few cancers, and their follow-up periods may have been too short to detect an association between statin use and cancer incidence. We investigated this association in a population of veterans.

METHODS

We identified patients using antihypertensive medications but no cholesterol-lowering medications (n = 25,594) and patients using statins (n = 37,248) who were enrolled in the Veterans Affairs New England Healthcare System between January 1, 1997, and December 31, 2005. Age- and multivariable-adjusted Cox proportional hazards models were used to calculate the hazard ratio (HR) and its 95% confidence interval (CI) for cancer incidence, excluding nonmelanoma skin cancer, among patients taking statins compared with patients taking antihypertensive medications and among patients grouped by statin dose (as equivalent simvastatin dose). All statistical tests were two-sided.

RESULTS

The absolute incidence of total cancers was 9.4% among statin users and 13.2% among nonusers (difference = 3.8%, 95% CI = 3.3% to 4.3%, P(difference) < .001). Statin users had a statistically significant lower risk for total cancer than nonusers after adjustment for age (HR = 0.76, 95% CI = 0.73 to 0.80) and multiple potential confounders (HR = 0.74, 95% CI = 0.70 to 0.78). After multivariable adjustment, a statistically significantly decreased risk of all cancers was also associated with increasing statin use (P(trend) < .001).

CONCLUSIONS

Patients using statins may be at lower risk for developing cancer. Additional observational studies and randomized trials of statins for cancer prevention are warranted.

Long-term, high-dose benzodiazepine prescriptions in veteran patients with PTSD: influence of preexisting alcoholism and drug-abuse diagnoses

Databases from the New England Veterans Integrated Service Network were analyzed to determine factors associated with long-term, high-dose anxiolytic benzodiazepine prescriptions dispensed to patients with posttraumatic stress disorder (PTSD) and existing alcoholism and/or drug abuse diagnoses. Among 2,183 PTSD patients, 234 received the highest 10% average daily doses for alprazolam, clonazepam, diazepam, or lorazepam, doses above those typically recommended. Highest doses were more commonly prescribed to patients with existing drug abuse diagnoses. Among patients with PTSD and alcoholism, younger age, drug abuse, and concurrent prescriptions for another benzodiazepine and oxycodone/acetaminophen independently predicted high doses. Results indicate that for veteran patients with PTSD, alcoholism alone is not associated with high-dose benzodiazepines, but existing drug abuse diagnoses do increase that risk.

Failure of enforcement controlled substance laws in health policy for prescribing opiate medications: a painful assessment of morbidity and mortality

Controlled substances can be used for legitimate medical purposes to relieve pain and suffering, and allow management of medical and surgical conditions, whether acute or chronic in duration. However, because these are attractive, addicting drugs, diversion from sources such as physicians and pharmacists can lead to serious health problems. Of importance is that addiction to opiate medications can interfere with treatment of the original pain condition, and can lead to life threatening states because of poor judgment and depressed mood in the users. Consequently, the public has a vested interest in protecting the medical uses of these medications on the one hand, although reducing the morbidity and mortality from their diversion and addictive use. The controlled substance laws contain 3 sources of policy framework that governs the medical use and diversion of controlled substances: (1) international treaties, (2) federal laws and regulations, and (3) state laws and regulations. These laws are aimed at balancing the need to controlling use with adverse consequences against the therapeutic benefits opiate medications provide the public.

Effects of opioid prescription medication dependence and detoxification on pain perceptions and self-reports

The purpose of this work is to document whether prescription opioid medications used for pain enhanced or worsened pain syndromes from medical conditions in patients who received a diagnosis of prescription opioid dependence as determined by a diagnosis by Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV criteria. Further, whether detoxification improved or worsened pain perceptions and self-reports in patients who chronically administered prescription opioid medications. Our study consisted of a retrospective sample of patients taken from the Addiction Treatment Unit at St Lawrence Hospital in Lansing, MI. Patients were selected from those who voluntarily sought detoxification from opioid medications in an inpatient setting. Selection criteria for the study consisted of a DSM-IV diagnosis of opioid prescription medication dependence, willingness to undergo medical detoxification, cooperation with self-report scales, and abstinence from opioid medications. Study patients were randomly selected from discharges in patient census for the years 2001 to 2003. The significant findings were that self-reported pain scores improved during the detoxification from admission to discharge, from a mean of 5.5 at admission to mean of 3.4 at discharge (0 is no pain and 10 is the most pain). The detoxification period extended to an average of 5 days. Whereas oxycodone CR (OxyContin) produced higher levels of self-reported pain at admission than at discharge, and these patients experienced significant levels of pain reduction with decremental opioid doses as with other opioid medications. Patients with a DSM-IV diagnosis of prescription opioid dependence reported (self) less pain with detoxification and abstinence from the opioid medications.

Prescription opioid use among older adults with arthritis or low back pain

OBJECTIVE

To examine patterns of chronic opioid use in selected groups with arthritis and low back pain and compare them with patterns among persons with ischemic heart disease.

METHODS

The study database consisted of Medicare beneficiaries who were enrolled in a drug benefit program for low-to-moderate income Pennsylvania residents. We identified selected patients who had a diagnosis of rheumatoid arthritis, osteoarthritis, chronic low back pain, or ischemic heart disease since 1995. Chronic opioid use, defined as at least six 30-day prescriptions in a year, was the endpoint of interest. We examined the proportion of patients meeting this definition during the period 1996-2001 and determined predictors based on multivariable Cox proportional hazards models.

RESULTS

Four percent of subjects with rheumatoid arthritis used opioids chronically in 2001, compared with <1% in each of the other groups. There was no increase in the chronic use of opioids over the 6-year study period. Low-potency opioids were the most commonly prescribed preparations for chronic users from all patient groups. The prior use of medicines for psychiatric illness, including benzodiazepines or barbiturates, was associated with chronic prescription opioid use across all diagnoses. However, subjects with a prior diagnosis of psychiatric illness were less likely to receive chronic opioids.

CONCLUSION

Chronic opioid use is relatively uncommon, even among older individuals with arthritis or low back pain. The proportion of these individuals receiving such medicines has not increased in the late 1990s. There seems to be a complex relationship between psychiatric medication use, psychiatric diagnoses, and the use of chronic opioids among these individuals.

Endogenous opiates and behavior: 2004

This paper is the 27th consecutive installment of the annual review of research concerning the endogenous opioid system, now spanning over 30 years of research. It summarizes papers published during 2004 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia; stress and social status; tolerance and dependence; learning and memory; eating and drinking; alcohol and drugs of abuse; sexual activity and hormones, pregnancy, development and endocrinology; mental illness and mood; seizures and neurologic disorders; electrical-related activity and neurophysiology; general activity and locomotion; gastrointestinal, renal and hepatic functions; cardiovascular responses; respiration and thermoregulation; and immunological responses.

Characterizations of long-term anxiolytic benzodiazepine prescriptions in veteran patients

To characterize long-term prescriptions for commonly prescribed anxiolytic benzodiazepines to veteran patients and to identify factors associated with high daily doses, we analyzed the linked pharmacy and administrative databases from New England Veterans Healthcare System (VISN 1). We analyzed treatment episodes of 3 months or longer with the 4 most commonly prescribed agents: alprazolam, clonazepam, diazepam, and lorazepam. Descriptive statistics and univariate and multivariate analyses described the sample and tested associations of pharmacological and clinical variables for patients prescribed the top 5% of average daily doses ("high-dose" prescriptions). From 16,630 full or partial treatment episodes for all 4 agents analyzed within a 42-month window, average daily doses were predominantly moderate, age-sensitive, and stable; refill lag intervals were short. Patients on "high-dose" prescriptions for the 4 agents combined, compared with "middle quartile" dose prescriptions, in adjusted analyses, were younger, more likely to have posttraumatic stress disorder (odds ratio [OR], 2.6; 95% confidence interval [CI], 2.17-3.13), substance abuse (OR, 1.50; 95% CI, 1.25-1.80), and anxiety (OR, 1.33; 95% CI, 1.11-1.60) and were more likely to be receiving concurrent oxycodone/acetaminophen (OR, 2.05; 95% CI, 1.64-2.56), anxiolytic benzodiazepine (OR, 1.51; 95% CI, 1.12-2.03), antidepressant (OR, 2.15; 95% CI, 1.80-2.58), and neuroleptic (OR, 2.03; 95% CI, 1.69-2.44) prescriptions. These results indicate that veteran patients prescribed anxiolytic benzodiazepines typically receive modest, nonincreasing doses over long-term treatment episodes. However, those on the highest average daily doses, typically more than recommended guidelines, are more likely to have clinical diagnoses and concurrent prescriptions for psychoactive medications indicative of more complex and, perhaps, problematic management.

Regular use of prescribed opioids: association with common psychiatric disorders

Use of opioids for chronic non-cancer pain is increasing, but the clinical epidemiology and standards of care for this practice are poorly defined. Psychiatric disorders are associated with increased physical symptoms and may be associated with opioid use. We performed a secondary analysis of cross-sectional data from the Health Care for Communities (HCC) survey conducted in 1997-1998 (N=9279) to determine the association of psychiatric disorders and self-reported regular use of prescribed opioids within the past year. Regular prescription opioid use was reported by 282 (3%) respondents. In unadjusted logistic regression models, respondents with common mental disorders in the past year (major depression, dysthymia, generalized anxiety disorder, or panic disorder) were more likely to report regular prescription opioid use than those without any of these disorders (OR=6.15, 95% CI=4.13, 9.14, P< 0.001). Respondents reporting problem drug use (OR=4.75, 95% CI=2.52, 8.94, P<0.001), or problem alcohol use (OR=1.89, 95% CI=1.03, 3.40, P=.041) reported higher rates of prescribed opioid use than those without problem use. In multivariate logistic regression models controlling for demographic and clinical variables, the presence of a common mental disorder remained a significant predictor of prescription opioid use (OR=3.15, 95% CI=1.69, 5.88, P<0.001), among individuals reporting low pain interference (N=8307); but not (OR=1.27, n.s.) among those reporting high pain interference (N=972). Depressive, anxiety and drug abuse disorders are associated with increased use of regular opioids in the general population. Depressive and anxiety disorders are more common and more strongly associated with prescribed opioid use than drug abuse disorders.