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Hayes CJ, Raciborski RA, Nowak M, Acharya M, Nunes EV, Winhusen TJ. Medications for opioid use disorder: Predictors of early discontinuation and reduction of overdose risk in US military veterans by medication type. Addiction 2024. [PMID: 39243190 DOI: 10.1111/add.16659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 07/30/2024] [Indexed: 09/09/2024]
Abstract
AIM This study: (1) estimated the effect of early discontinuation of medication for opioid use disorder (MOUD) on overdose probability and (2) measured the relationship between patient characteristics and early discontinuation probability for each MOUD type. DESIGN, SETTING AND PARTICIPANTS This was a retrospective cohort using electronic health record data from the US Veterans Healthcare Administration. Participants were veterans initiating MOUD with buprenorphine (BUP), methadone (MET) or extended-release naltrexone (XR-NTX) from fiscal years 2012-19. A total of 39 284 veterans met eligibility with 22 721 (57.8%) initiating BUP, 12 652 (32.2%) initiating MET and 3911 (10.0%) initiating XR-NTX. MEASUREMENTS Measurements (1) determined whether the veteran experienced an overdose in the 365 days after MOUD initiation (primary) and (2) early discontinuation of MOUD, defined as discontinuation before 180 days (secondary). We assumed that unobserved patient characteristics would jointly influence the probability of discontinuation and overdose. and estimated the joint distribution with a bivariate probit model. FINDINGS We found that 9.0% of BUP initiators who experienced an overdose above the predicted 3.9% had no veteran-discontinued BUP early; findings for XR-NTX were similar, with 12.2% of initiators overdosing above the predicted 4.5%, but this was statistically inconclusive. We found no relationship between early discontinuation and overdose for MET initiators, probably due to the high risk of both events. The patient characteristics included in our post-estimation exploratory analysis of early discontinuation varied by MOUD type, with between 14 (XR-NTX) and 25 (BUP) tested. The only characteristics with at least one level showing a statistically significant change in probability of early discontinuation for all three MOUD types were geography and prior-year exposure to psychotherapy, although direction and magnitude varied. CONCLUSION Early discontinuation of buprenorphine, and probably extended-release naltrexone, appears to be associated with a greater probability of experiencing a fatal or non-fatal overdose among US veterans receiving medication for opioid use disorder (MOUD); methadone does not show the same association. There is no consistent set of characteristics among early discontinuers by MOUD type.
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Affiliation(s)
- Corey J Hayes
- Department of Biomedical Informatics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Institute for Digital Health and Innovation, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
| | - Rebecca A Raciborski
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
- Behavioral Health Quality Enhancement Research Initiative, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
- Evidence, Policy, and Implementation Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
| | - Matthew Nowak
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Mahip Acharya
- Institute for Digital Health and Innovation, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Obstetrics and Gynecology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Edward V Nunes
- Division of Substance Use Disorders, Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA
| | - T John Winhusen
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Dong H, Stringfellow EJ, Russell A, Jalali MS. State Mandates On Naloxone Coprescribing Associated With Short-Term Increase In Naloxone Codispensing. Health Aff (Millwood) 2024; 43:1319-1328. [PMID: 39226505 DOI: 10.1377/hlthaff.2023.01667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2024]
Abstract
In the midst of the opioid crisis in the US, efforts to mitigate overdose risks have become paramount, leading some states to introduce mandates for coprescribing the life-saving overdose reversal drug naloxone. These mandates were designed to specifically address people receiving opioid analgesics who had an elevated risk for overdose. This included people receiving high opioid dosages, those concurrently using benzodiazepines, or those with a history of substance use disorder or overdose. Using a nationally representative, multipayer cohort of patients receiving prescription opioids, we investigated how naloxone codispensing rates changed at the state level from 2016 to 2021 among patients with an elevated risk for overdose. Then we used controlled interrupted time series analyses to assess mandates' longitudinal impact on naloxone codispensing in ten states that implemented mandates. We observed an immediate and significant increase in the naloxone codispensing rates in eight states after the implementation of mandates. Nevertheless, in five of these states, the codispensing rates exhibited a subsequent downward trend after the initial increase. State mandates show potential for improving naloxone codispensing; however, mandates alone might not be adequate for sustained change. Further research is needed to identify strategies complementing and enhancing the impact of mandates in combating the overdose crisis.
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Affiliation(s)
- Huiru Dong
- Huiru Dong, Harvard University, Boston, Massachusetts
| | | | - Alton Russell
- Alton Russell, McGill University, Montreal, Québec, Canada
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Weiner SG, Little K, Yoo J, Flores DP, Hildebran C, Wright DA, Ritter GA, El Ibrahimi S. Opioid Overdose After Medication for Opioid Use Disorder Initiation Following Hospitalization or ED Visit. JAMA Netw Open 2024; 7:e2423954. [PMID: 39037812 PMCID: PMC11265135 DOI: 10.1001/jamanetworkopen.2024.23954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 05/28/2024] [Indexed: 07/24/2024] Open
Abstract
Importance Hospitalizations related to opioid use disorder (OUD) represent an opportunity to initiate medication for OUD (MOUD). Objective To assess whether starting MOUD after a hospitalization or emergency department (ED) visit is associated with the odds of fatal and nonfatal opioid overdose at 6 and 12 months. Design, Setting, and Participants This population-based cohort study used data from the Oregon Comprehensive Opioid Risk Registry, which links all payer claims data to other administrative health datasets, for individuals aged 18 years or older who had diagnosis codes related to OUD recorded at an index ED visit or hospitalization from January 2017 to December 2019. Data were analyzed between May 2023 and January 2024. Exposures Receipt of MOUD within the 7 days after an OUD-related hospital visit. Main Outcomes and Measures The primary outcome was fatal or nonfatal overdose at 6 and 12 months after discharge. Sample characteristics, including age, sex, insurance plan, number of comorbidities, and opioid-related overdose events, were stratified by receipt or nonreceipt of MOUD within 7 days after an OUD-related hospital visit. A logistic regression model was used to investigate the association between receipt of MOUD and having an opioid overdose event. Results The study included 22 235 patients (53.1% female; 25.0% aged 25-39 years) who had an OUD-related hospital visit during the study period. Overall, 1184 patients (5.3%) received MOUD within 7 days of their ED visit or hospitalization. Of these patients, 683 (57.7%) received buprenorphine, 463 (39.1%) received methadone, and 46 (3.9%) received long-acting injectable naltrexone. Patients who received MOUD within 7 days after discharge had lower adjusted odds of fatal or nonfatal overdose at 6 months compared with those who did not (adjusted odds ratio [AOR], 0.63; 95% CI, 0.41-0.97). At 12 months, there was no difference in adjusted odds of fatal or nonfatal overdose between these groups (AOR, 0.79; 95% CI, 0.58-1.08). Patients had a lower risk of fatal or nonfatal overdose at 6 months associated with buprenorphine use (AOR, 0.50; 95% CI, 0.27-0.95) but not with methadone use (AOR, 0.57; 95% CI, 0.28-1.17). Conclusions and Relevance In this cohort study of individuals with an OUD-related hospital visit, initiation of MOUD was associated with reduced odds of opioid-related overdose at 6 months. Hospitals should consider implementing programs and protocols to offer initiation of MOUD to patients with OUD who present for care.
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Affiliation(s)
- Scott G. Weiner
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | | | - Jiah Yoo
- Comagine Health, Portland, Oregon
| | | | | | | | | | - Sanae El Ibrahimi
- Comagine Health, Portland, Oregon
- School of Public Health, University of Nevada, Las Vegas
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Hayes CJ, Bin Noor N, Raciborski RA, Martin B, Gordon A, Hoggatt K, Hudson T, Cucciare M. Development and validation of machine-learning algorithms predicting retention, overdoses, and all-cause mortality among US military veterans treated with buprenorphine for opioid use disorder. J Addict Dis 2024:1-18. [PMID: 38946144 DOI: 10.1080/10550887.2024.2363035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
BACKGROUND Buprenorphine for opioid use disorder (B-MOUD) is essential to improving patient outcomes; however, retention is essential. OBJECTIVE To develop and validate machine-learning algorithms predicting retention, overdoses, and all-cause mortality among US military veterans initiating B-MOUD. METHODS Veterans initiating B-MOUD from fiscal years 2006-2020 were identified. Veterans' B-MOUD episodes were randomly divided into training (80%;n = 45,238) and testing samples (20%;n = 11,309). Candidate algorithms [multiple logistic regression, least absolute shrinkage and selection operator regression, random forest (RF), gradient boosting machine (GBM), and deep neural network (DNN)] were used to build and validate classification models to predict six binary outcomes: 1) B-MOUD retention, 2) any overdose, 3) opioid-related overdose, 4) overdose death, 5) opioid overdose death, and 6) all-cause mortality. Model performance was assessed using standard classification statistics [e.g., area under the receiver operating characteristic curve (AUC-ROC)]. RESULTS Episodes in the training sample were 93.0% male, 78.0% White, 72.3% unemployed, and 48.3% had a concurrent drug use disorder. The GBM model slightly outperformed others in predicting B-MOUD retention (AUC-ROC = 0.72). RF models outperformed others in predicting any overdose (AUC-ROC = 0.77) and opioid overdose (AUC-ROC = 0.77). RF and GBM outperformed other models for overdose death (AUC-ROC = 0.74 for both), and RF and DNN outperformed other models for opioid overdose death (RF AUC-ROC = 0.79; DNN AUC-ROC = 0.78). RF and GBM also outperformed other models for all-cause mortality (AUC-ROC = 0.76 for both). No single predictor accounted for >3% of the model's variance. CONCLUSIONS Machine-learning algorithms can accurately predict OUD-related outcomes with moderate predictive performance; however, prediction of these outcomes is driven by many characteristics.
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Affiliation(s)
- Corey J Hayes
- Department of Biomedical Informatics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Institute for Digital Health and Innovation, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
| | - Nahiyan Bin Noor
- Institute for Digital Health and Innovation, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Rebecca A Raciborski
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
- Behavioral Health Quality Enhancement Research Initiative, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
- Evidence, Policy, and Implementation Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
| | - Bradley Martin
- Division of Pharmaceutical Evaluation and Policy, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Adam Gordon
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Medicine, School of Medicine, University of Utah, Salt Lake City, UT, USA
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Healthcare System, Salt Lake City, UT, USA
| | - Katherine Hoggatt
- San Francisco VA Medical Center, San Francisco, CA, USA
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Teresa Hudson
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
- Center for Health Services Research, Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Emergency Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Michael Cucciare
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
- Center for Health Services Research, Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Veterans Affairs South Central Mental Illness Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
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Alessio-Bilowus D, Chua KP, Peahl A, Brummett CM, Gunaseelan V, Bicket MC, Waljee JF. Epidemiology of Opioid Prescribing After Discharge From Surgical Procedures Among Adults. JAMA Netw Open 2024; 7:e2417651. [PMID: 38922619 PMCID: PMC11208979 DOI: 10.1001/jamanetworkopen.2024.17651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 04/18/2024] [Indexed: 06/27/2024] Open
Abstract
Importance Opioid medications are commonly prescribed for the management of acute postoperative pain. In light of increasing awareness of the potential risks of opioid prescribing, data are needed to define the procedures and populations for which most opioid prescribing occurs. Objective To identify the surgical procedures accounting for the highest proportion of opioids dispensed to adults after surgery in the United States. Design, Setting, and Participants This cross-sectional analysis of the 2020-2021 Merative MarketScan Commercial and Multi-State Databases, which capture medical and pharmacy claims for 23 million and 14 million annual privately insured patients and Medicaid beneficiaries, respectively, included surgical procedures for individuals aged 18 to 64 years with a discharge date between December 1, 2020, and November 30, 2021. Procedures were identified using a novel crosswalk between 3664 Current Procedural Terminology codes and 1082 procedure types. Data analysis was conducted from November to December 2023. Main Outcomes and Measures The total amount of opioids dispensed within 3 days of discharge from surgery across all procedures in the sample, as measured in morphine milligram equivalents (MMEs), was calculated. The primary outcome was the proportion of total MMEs attributable to each procedure type, calculated separately among procedures for individuals aged 18 to 44 years and those aged 45 to 64 years. Results Among 1 040 934 surgical procedures performed (mean [SD] age of patients, 45.5 [13.3] years; 663 609 [63.7%] female patients), 457 016 (43.9%) occurred among individuals aged 18 to 44 years and 583 918 (56.1%) among individuals aged 45 to 64 years. Opioid prescriptions were dispensed for 503 058 procedures (48.3%). Among individuals aged 18 to 44 years, cesarean delivery accounted for the highest proportion of total MMEs dispensed after surgery (19.4% [11 418 658 of 58 825 364 MMEs]). Among individuals aged 45 to 64 years, 4 of the top 5 procedures were common orthopedic procedures (eg, arthroplasty of knee, 9.7% of total MMEs [5 885 305 of 60 591 564 MMEs]; arthroscopy of knee, 6.5% [3 912 616 MMEs]). Conclusions and Relevance In this cross-sectional study of the distribution of postoperative opioid prescribing in the United States, a small number of common procedures accounted for a large proportion of MMEs dispensed after surgery. These findings suggest that the optimal design and targeting of surgical opioid stewardship initiatives in adults undergoing surgery should focus on the procedures that account for the most opioid dispensed following surgery over the life span, such as childbirth and orthopedic procedures. Going forward, systems that provide periodic surveillance of opioid prescribing and associated harms can direct quality improvement initiatives to reduce opioid-related morbidity and mortality.
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Affiliation(s)
- Dominic Alessio-Bilowus
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor
- Overdose Prevention Engagement Network, Ann Arbor, Michigan
| | - Kao-Ping Chua
- Department of Pediatrics, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan
| | - Alex Peahl
- Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan
- Department of Obstetrics and Gynecology, Michigan Medicine, Ann Arbor
| | - Chad M. Brummett
- Overdose Prevention Engagement Network, Ann Arbor, Michigan
- Division of Pain Research, Department of Anesthesiology, Michigan Medicine, Ann Arbor
| | - Vidhya Gunaseelan
- Overdose Prevention Engagement Network, Ann Arbor, Michigan
- Division of Pain Research, Department of Anesthesiology, Michigan Medicine, Ann Arbor
| | - Mark C. Bicket
- Overdose Prevention Engagement Network, Ann Arbor, Michigan
- Division of Pain Research, Department of Anesthesiology, Michigan Medicine, Ann Arbor
| | - Jennifer F. Waljee
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor
- Overdose Prevention Engagement Network, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan
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Hansgen JP, Robertson ML, Verzino EM, Manning LM. Increasing Naloxone Access and Prescribing for Patients on High-Dose Opioids From a Managed Care Pharmacy Health Plan Perspective. J Pharm Pract 2024:8971900241247598. [PMID: 38685768 DOI: 10.1177/08971900241247598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
Background: Opioid overdoses decrease when communities have access to naloxone. Clinicians play a key role in offering naloxone to high-risk chronic opioid patients. Managed care pharmacists within our health plan noted disproportionate processing for claims of opioid utilizers compared to claims of naloxone prescriptions. Objective: To increase naloxone access and prescribing to members who classify at a dosage with a higher risk for opioid overdose, defined as over 90 morphine milligram equivalents (MME). Methods: Multiple system-wide initiatives were implemented to improve naloxone access. A claims file was pulled monthly to identify members on opioids meeting MME criteria >90 MME per day excluding members with cancer, sickle cell disease, or on hospice. A separate report was then matched to naloxone claims and prescribing percentages calculated. Results: 12 444 utilizing members on opioids were identified from June 2019 prescription claims data. Of these, 131 were on opioids exceeding 90 MME per day, or 1.05% of utilizers, and the percentage of members exceeding 90 MME per day prescribed naloxone was 6.87%. By May 2023, the percentage of opioid utilizers exceeding 90 MME per day decreased to 0.58%. Naloxone prescribing increased to 41.18%. Conclusion: A multi-pronged approach to improve access to naloxone and continued educational efforts by our health plan increased naloxone prescribing in members on opioids exceeding 90 MME per day.
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Affiliation(s)
- Jodi P Hansgen
- Pharmacy Services, Baylor Scott & White Health Plan, Temple, TX, USA
| | - Megan L Robertson
- Pharmacy Services, Baylor Scott & White Health Plan, Temple, TX, USA
| | - Ellen M Verzino
- Pharmacy Services, Baylor Scott & White Health Plan, Temple, TX, USA
| | - Lindsay M Manning
- Pharmacy Services, Baylor Scott & White Health Plan, Temple, TX, USA
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Attisso E, Guenette L, Dionne CE, Kröger E, Dialahy I, Tessier S, Jean S. New opioid prescription claims and their clinical indications: results from health administrative data in Quebec, Canada, over 14 years. BMJ Open 2024; 14:e077664. [PMID: 38589264 PMCID: PMC11015182 DOI: 10.1136/bmjopen-2023-077664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 03/27/2024] [Indexed: 04/10/2024] Open
Abstract
OBJECTIVES Describe new opioid prescription claims, their clinical indications and annual trends among opioid naïve adults covered by the Quebec's public drug insurance plan (QPDIP) for the fiscal years 2006/2007-2019/2020. DESIGN AND SETTING A retrospective observational study was conducted using data collected between 2006/2007 and 2019/2020 within the Quebec Integrated Chronic Disease Surveillance System, a linkage administrative data. PARTICIPANTS A cohort of opioid naïve adults and new opioid users was created for each study year (median number=2 263 380 and 168 183, respectively, over study period). INTERVENTION No. MAIN OUTCOME MEASURE AND ANALYSES A new opioid prescription was defined as the first opioid prescription claimed by an opioid naïve adult during a given fiscal year. The annual incidence proportion for each year was then calculated and standardised for age. A hierarchical algorithm was built to identify the most likely clinical indication for this prescription. Descriptive and trend analyses were performed. RESULTS There was a 1.7% decrease of age-standardised annual incidence proportion during the study period, from 7.5% in 2006/2007 to 5.8% in 2019/2020. The decrease was highest after 2016/2017, reaching 5.5% annual percentage change. Median daily dose and days' supply decreased from 27 to 25 morphine milligram equivalent/day and from 5 to 4 days between 2006/2007 and 2019/2020, respectively. Between 2006/2007 and 2019/2020, these prescriptions' most likely clinical indications increased for cancer pain from 34% to 48%, for surgical pain from 31% to 36% and for dental pain from 9% to 11%. Inversely, the musculoskeletal pain decreased from 13% to 2%. There was good consistency between the clinical indications identified by the algorithm and prescriber's specialty or user's characteristics. CONCLUSIONS New opioid prescription claims (incidence, dose and days' supply) decreased slightly over the last 14 years among QPDIP enrollees, especially after 2016/2017. Non-surgical and non-cancer pain became less common as their clinical indication.
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Affiliation(s)
- Eugene Attisso
- Quebec National Institute of Public Health, Quebec, Quebec, Canada
| | - Line Guenette
- Faculty of Pharmacy, Laval University, Quebec, Quebec, Canada
- Centre de recherche du CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - Clermont E Dionne
- Centre de recherche du CHU de Québec-Université Laval, Quebec, Quebec, Canada
- Faculty of Medicine, Laval University, Quebec, Quebec, Canada
| | - Edeltraut Kröger
- Faculty of Pharmacy, Laval University, Quebec, Quebec, Canada
- Sustainable Health Research Centre, VITAM, Quebec, Quebec, Canada
| | - Isaora Dialahy
- Quebec National Institute of Public Health, Quebec, Quebec, Canada
| | | | - Sonia Jean
- Quebec National Institute of Public Health, Quebec, Quebec, Canada
- Faculty of Medicine, Laval University, Quebec, Quebec, Canada
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Bromley MI, Gain EP, Ajoku M, Ray MA, Mzayek F, Kedia SK, Yu X. Burden of Chronic and Heavy Opioid Use Among Elderly Community Dwellers in the U.S. AJPM FOCUS 2024; 3:100175. [PMID: 38298247 PMCID: PMC10828592 DOI: 10.1016/j.focus.2023.100175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
Introduction Opioid overprescribing may fuel the opioid epidemic and increase the risk of complications of opioid misuse. This study examined trends and determinants of chronic and heavy opioid use among elderly community dwellers in the U.S. Methods Medicare Current Beneficiary Surveys data from 2006 to 2019 were used. Common opioid medications were identified in the prescription medication files (n=47,264). Patients with Chronic users were defined as those receiving 6 or more opioid prescriptions within a year or on medication for 3 or more months, and heavy users were those having an average daily dose of 90 or more morphine milligram equivalents or 3,780 morphine milligram equivalents or more per continuous treatment episode. Results One in 6 elderly community dwellers ever used opioids during the study period. Chronic users were more likely to be women than men (68.9% vs 31.1%, p<0.001). Of all survey participants, 4.3% were chronic users, and 2.8% were heavy users. Among ever users, 27.7% were chronic users, and 18.1% were heavy users. The rate of opioid use rose from 12.1% in 2006, peaked at 22.8% in 2013, and decreased to 11.7% in 2019. Chronic use was 5.1%, 10.7%, and 7.6%, respectively. Heavy use was 5.5%, 10.7%, and 7.6%, respectively. However, for chronic and heavy users, there was no significant difference in the median opioid dosage and opioid duration between males and females. Conclusions Among elderly Medicare beneficiaries, opioid prescriptions have been decreasing since 2013. However, a substantial number of elderly people were chronic and heavy users, calling for better opioid management among them.
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Affiliation(s)
- Morgan I. Bromley
- Epidemiology, Biostatistics, and Environmental Health Division, School of Public Health, The University of Memphis, Memphis, Tennessee
| | - Easter P. Gain
- Epidemiology, Biostatistics, and Environmental Health Division, School of Public Health, The University of Memphis, Memphis, Tennessee
| | - Mark'Quest Ajoku
- Epidemiology, Biostatistics, and Environmental Health Division, School of Public Health, The University of Memphis, Memphis, Tennessee
| | - Meredith A. Ray
- Epidemiology, Biostatistics, and Environmental Health Division, School of Public Health, The University of Memphis, Memphis, Tennessee
| | - Fawaz Mzayek
- Epidemiology, Biostatistics, and Environmental Health Division, School of Public Health, The University of Memphis, Memphis, Tennessee
| | - Satish K. Kedia
- Epidemiology, Biostatistics, and Environmental Health Division, School of Public Health, The University of Memphis, Memphis, Tennessee
| | - Xinhua Yu
- Epidemiology, Biostatistics, and Environmental Health Division, School of Public Health, The University of Memphis, Memphis, Tennessee
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Sharif L, Zubieta CS, Arora A, Gunaseelan V, Waljee J, Bicket MC, Englesbe M, Brummett CM. Medicaid Insurance Predicts Increased Postoperative Care Encounters Among Patients on Long-Term Opioid Therapy. Ann Surg 2024:00000658-990000000-00811. [PMID: 38482682 PMCID: PMC11399323 DOI: 10.1097/sla.0000000000006262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
OBJECTIVE This study examined the association between insurance type and postoperative unplanned care encounters among patients on long-term opioid therapy prior to surgery. SUMMARY BACKGROUND DATA Preoperative long-term opioid therapy is associated with unique risks and poorer outcomes following surgery. To date, the extent to which insurance coverage influences postoperative outcomes in this population remains unclear. METHODS Among individuals receiving a supply of greater than 120 total days or at least 10 opioid prescriptions in the year prior to surgery, we examined patients with Medicaid or private insurance who underwent abdominopelvic surgery from 2017 to 2021 across 70 hospitals in the state of Michigan. The primary outcome was unplanned care encounters, defined as an emergency department visit or unplanned readmission within 30 days of discharge from surgery. Multivariable logistic regression was used to assess the likelihood of acute care events with insurance type as the primary covariate of interest. RESULTS Among 1212 patients on long-term opioid therapy prior to surgery, 45.6% (n = 553) had Medicaid insurance. Overall, one in eight (n=151) patients met criteria for a postoperative unplanned care encounter within 30 days. The probability of an unplanned encounter was 4.5 percentage points higher among patients with Medicaid insurance compared to private insurance (95% CI: 0.5%, 8.4%). CONCLUSIONS Among patients on preoperative long-term opioid therapy, unplanned care encounters were higher among patients with Medicaid when compared to private insurance. While this is likely multifactorial, differences by insurance status may point to disparities in underlying social determinants of health and suggest the need for postoperative care pathways that address these gaps.
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Affiliation(s)
- Limi Sharif
- University of Michigan Medical School
- Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
| | | | | | - Vidhya Gunaseelan
- Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
| | - Jennifer Waljee
- Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
| | - Mark C Bicket
- Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
- Institute for Healthcare Innovation and Policy, Ann Arbor, MI
- School of Public Health, University of Michigan, Ann Arbor, MI
| | - Michael Englesbe
- Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Michigan Surgical Quality Collaborative, Ann Arbor, MI
| | - Chad M Brummett
- Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
- Opioid Research Institute, University of Michigan, Ann Arbor, MI
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Durrance CP, Austin AE, Runyan CW, Runyan DK, Martin SL, Mercer J, Shanahan ME. Affordable housing through the Low-Income Housing Tax Credit program and opioid overdose emergency department visits. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 158:209249. [PMID: 38081542 DOI: 10.1016/j.josat.2023.209249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 09/13/2023] [Accepted: 12/04/2023] [Indexed: 03/18/2024]
Abstract
INTRODUCTION The United States continues to experience an opioid overdose crisis. As a key social determinant of health, housing insecurity may contribute to initiation of substance use and can threaten outcomes for those with substance use disorders by increasing stress, risky substance use, discontinuity of treatment, and return to use, all of which may increase the risk of overdose. The Low-Income Housing Tax Credit (LIHTC) program supports access to rental housing for low-income populations. By facilitating access to affordable housing, this program may improve housing security, thereby reducing overdose risk. METHODS We used data from LIHTC Property Data and the State Emergency Department Database (SEDD) to identify the number of LIHTC units available and opioid overdoses discharged from the emergency department (ED) in 13 states between 2005 and 2014. RESULTS Between 2005 and 2014, mean opioid overdose ED visits were higher in states with fewer LIHTC units (<28 LIHTC units per 100,000 population) at 26.5 per 100,000 population as compared to states with higher LIHTC units (≥28 LIHTC units per 100,000 population) at 21.1 per 100,000. We find that greater availability of LIHTC units was associated with decreased rates of opioid overdose ED visits (RR 0.94; CI 0.90, 1.00). CONCLUSIONS Given the importance of housing as a key social determinant of health, the provision of affordable housing may mitigate substance misuse and prevent nonfatal opioid overdose.
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Affiliation(s)
| | - Anna E Austin
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, United States of America; Injury Prevention Research Center, University of North Carolina at Chapel Hill, United States of America
| | - Carol W Runyan
- Department of Epidemiology, Colorado School of Public Health, United States of America; Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, United States of America
| | - Desmond K Runyan
- Department of Pediatrics and Kempe Center, University of Colorado School of Medicine, United States of America
| | - Sandra L Martin
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, United States of America
| | - Jeremy Mercer
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, United States of America
| | - Meghan E Shanahan
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, United States of America; Injury Prevention Research Center, University of North Carolina at Chapel Hill, United States of America
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11
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Hawk KF, Weiner SG, Rothenberg C, Bernstein E, D'Onofrio G, Herring A, Hoppe J, Ketcham E, LaPietra A, Nelson L, Perrone J, Ranney M, Samuels EA, Strayer R, Sharma D, Goyal P, Schuur J, Venkatesh AK. Leveraging a Learning Collaborative Model to Develop and Pilot Quality Measures to Improve Opioid Prescribing in the Emergency Department. Ann Emerg Med 2024; 83:225-234. [PMID: 37831040 DOI: 10.1016/j.annemergmed.2023.08.490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 10/14/2023]
Abstract
The American College of Emergency Physicians (ACEP) Emergency Medicine Quality Network (E-QUAL) Opioid Initiative was launched in 2018 to advance the dissemination of evidence-based resources to promote the care of emergency department (ED) patients with opioid use disorder. This virtual platform-based national learning collaborative includes a low-burden, structured quality improvement project, data benchmarking, tailored educational content, and resources designed to support a nationwide network of EDs with limited administrative and research infrastructure. As a part of this collaboration, we convened a group of experts to identify and design a set of measures to improve opioid prescribing practices to provide safe analgesia while reducing opioid-related harms. We present those measures here, alongside initial performance data on those measures from a sample of 370 nationwide community EDs participating in the 2019 E-QUAL collaborative. Measures include proportion of opioid administration in the ED, proportion of alternatives to opioids as first-line treatment, proportion of opioid prescription, opioid pill count per prescription, and patient medication safety education among ED visits for atraumatic back pain, dental pain, or headache. The proportion of benzodiazepine and opioid coprescribing for ED visits for atraumatic back pain was also evaluated. This project developed and effectively implemented a collection of 6 potential measures to evaluate opioid analgesic prescribing across a national sample of community EDs, representing the first feasibility assessment of opioid prescribing-related measures from rural and community EDs.
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Affiliation(s)
- Kathryn F Hawk
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT.
| | | | - Craig Rothenberg
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Edward Bernstein
- Boston Medical Center Department of Emergency Medicine, Boston, MA
| | - Gail D'Onofrio
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Andrew Herring
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, University of California, San Francisco
| | - Jason Hoppe
- Department of Emergency Medicine, University of Colorado School of Medicine, Denver
| | - Eric Ketcham
- Presbyterian Healthcare, Espanola & Santa Fe, NM
| | - Alexis LaPietra
- Division of Emergency Medicine, RWJBarnabus Health, West Orange, NJ
| | - Lewis Nelson
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark
| | - Jeanmarie Perrone
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Megan Ranney
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT
| | | | - Reuben Strayer
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY
| | - Dhruv Sharma
- American College of Emergency Physicians, Dallas, TX
| | - Pawan Goyal
- American College of Emergency Physicians, Dallas, TX
| | - Jeremiah Schuur
- Department of Emergency Medicine, Brown School of Medicine, Providence, RI
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
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12
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Romano IG, Core SB, Lee NR, Mowry C, Van Rompay KKA, Huang Y, Chackerian B, Frietze KM. A bacteriophage virus-like particle vaccine against oxycodone elicits high-titer and long-lasting antibodies that sequester drug in the blood. Vaccine 2024; 42:471-480. [PMID: 38160131 PMCID: PMC10872394 DOI: 10.1016/j.vaccine.2023.12.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/21/2023] [Accepted: 12/23/2023] [Indexed: 01/03/2024]
Abstract
Opioid use disorder (OUD) and opioid overdoses are public health emergencies. In 2021, 80,000 opioid overdose associated deaths were reported in the United States. Despite the availability of treatment strategies, including medications for opioid use disorder (MOUD) and naloxone, opioid overdoses continue to increase at an alarming rate. Opioid vaccines are a novel approach to combat the growing crisis with several candidates recently entering human clinical trials. In this study, we investigated Qβ bacteriophage virus-like particles (VLPs) as a vaccine platform for immunogenic display of oxycodone. A derivative of oxycodone was conjugated to pre-formed Qβ VLPs using a sulfhydryl-amine reactive heterobifunctional crosslinker with high loading of oxycodone. In mice, intramuscular immunization with Qβ-oxycodone elicited high-titer, high-avidity and long-lasting antibody responses. Qβ-oxycodone was also immunogenic after storage at ambient room temperature for over two weeks, demonstrating that the vaccine is highly thermostable. In mice, immunization with Qβ-oxycodone elicited antibodies that sequester oxycodone in the serum, an important mechanism for preventing the adverse effects of opioid activity. Finally, Qβ-oxycodone is immunogenic in nonhuman primates, eliciting serum oxycodone antibodies after intramuscular immunization of rhesus macaques. These data establish Qβ-oxycodone as a promising opioid vaccine candidate.
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Affiliation(s)
- Isabella G Romano
- Department of Molecular Genetics and Microbiology, School of Medicine, University of New Mexico, MSC 08-4660, 1 University of New Mexico, Albuquerque, NM 87131, USA
| | - Susan B Core
- Department of Molecular Genetics and Microbiology, School of Medicine, University of New Mexico, MSC 08-4660, 1 University of New Mexico, Albuquerque, NM 87131, USA
| | - Naomi R Lee
- Department of Chemistry and Biochemistry, Northern Arizona University, 700 S. Osborne Drive, P.O. Box 5698, Flagstaff, AZ 86011, USA
| | - Curtis Mowry
- Department of Chemistry and Chemical Biology, University of New Mexico, MSC 03-2060, 1 University of New Mexico, Albuquerque, NM 87131, USA
| | - Koen K A Van Rompay
- California National Primate Research Center, University of California - Davis, One Shields Avenue, Davis, CA 95616, USA
| | - Yumei Huang
- CellMosaic, Inc, 10A Roessler Road, Woburn, MA 01801, USA
| | - Bryce Chackerian
- Department of Molecular Genetics and Microbiology, School of Medicine, University of New Mexico, MSC 08-4660, 1 University of New Mexico, Albuquerque, NM 87131, USA
| | - Kathryn M Frietze
- Department of Molecular Genetics and Microbiology, School of Medicine, University of New Mexico, MSC 08-4660, 1 University of New Mexico, Albuquerque, NM 87131, USA.
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13
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Weiner SG, Hoppe JA. Contextualising opioid-related risk factors before an initial opioid prescription. BMJ Qual Saf 2023; 33:1-3. [PMID: 37500564 PMCID: PMC10817995 DOI: 10.1136/bmjqs-2023-016336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2023] [Indexed: 07/29/2023]
Affiliation(s)
- Scott G Weiner
- Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jason A Hoppe
- Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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14
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García-Sempere A, Hurtado I, Robles C, Llopis-Cardona F, Sánchez-Saez F, Rodriguez-Bernal C, Peiró-Moreno S, Sanfélix-Gimeno G. Initial opioid prescription characteristics and risk of opioid misuse, poisoning and dependence: retrospective cohort study. BMJ Qual Saf 2023; 33:13-23. [PMID: 37414557 PMCID: PMC10804034 DOI: 10.1136/bmjqs-2022-015833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 06/09/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE To identify individual and initial prescription-related factors associated with an increased risk for opioid-related misuse, poisoning and dependence (MPD) in patients with non-cancer pain. METHODS Cohort study linking several databases covering 5 million inhabitants of the region of Valencia, Spain, including all adults initiating prescription opioids in the period 2012-2018. To ascertain the association between the characteristics of the initial prescription choice and the risk of opioid MPD, we used shared frailty Cox regression models. We additionally considered death as a competing risk in sensitivity analyses. RESULTS 958 019 patients initiated opioid prescription from 2012 to 2018, of which 0.13% experienced MPD. Most patients were prescribed tramadol as initial opioid (76.7%) followed by codeine (16.3%), long-acting opioids (6.7%), short-acting opioids (0.2%) and ultrafast opioids (0.1%). Initiation with ultrafast (HR 7.2; 95% CI 4.1 to 12.6), short-acting (HR 4.8; 95% CI 2.3 to 10.2) and long-acting opioids (HR 1.5; 95% CI 1.2 to 1.9) were associated with a higher risk of MPD when compared with tramadol. Initial prescriptions covering 4-7 days (HR 1.3; 95% CI 1.0 to 1.8), 8-14 days (HR 1.4; 95% CI 1.0 to 1.9), 15-30 days (HR 1.7; 95% CI 1.2 to 2.3) and more than one a month (HR 1.8; 95% CI 1.3 to 2.5) were associated with more MPD risk than initial prescriptions for 1-3 days. Treatments with >120 daily morphine milligram equivalents (MME) increased MPD risk (vs <50 MME, HR 1.6; 95% CI 1.1 to 2.2). Main individual factors associated with increased risk of MPD risk were male sex (HR 2.4; 95% CI 2.1 to 2.7), younger age (when compared with patients aged 18-44 years, patients aged 45-64 years, HR 0.4; 95% CI 0.4 to 0.5; patients aged 65-74 years, HR 0.4; 95% CI 0.3 to 0.5 and patients aged 75 years old and over, HR 0.7; 95% CI 0.6 to 0.8), lack of economic resources (2.1; 95% CI 1.8 to 2.5) and registered misuse of alcohol (2.9; 95% CI 2.4 to 3.5). Sensitivity analyses yielded overall comparable results. CONCLUSIONS Our study identifies riskier patterns of opioid prescription initiation for non-cancer indications, as well as patient subgroups with higher risk of misuse, poisoning and dependence.
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Affiliation(s)
- Aníbal García-Sempere
- Health Services Research Unit, Fundacio per al Foment de la Investigacio Sanitaria i Biomedica, Valencia, Spain
- Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud - RICAPPS, Barcelona, Spain
| | - Isabel Hurtado
- Health Services Research Unit, Fundacio per al Foment de la Investigacio Sanitaria i Biomedica, Valencia, Spain
- Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud - RICAPPS, Barcelona, Spain
| | - Celia Robles
- Health Services Research Unit, Fundacio per al Foment de la Investigacio Sanitaria i Biomedica, Valencia, Spain
- Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud - RICAPPS, Barcelona, Spain
| | - Fran Llopis-Cardona
- Health Services Research Unit, Fundacio per al Foment de la Investigacio Sanitaria i Biomedica, Valencia, Spain
- Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud - RICAPPS, Barcelona, Spain
| | - Francisco Sánchez-Saez
- Health Services Research Unit, Fundacio per al Foment de la Investigacio Sanitaria i Biomedica, Valencia, Spain
- Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud - RICAPPS, Barcelona, Spain
| | - Clara Rodriguez-Bernal
- Health Services Research Unit, Fundacio per al Foment de la Investigacio Sanitaria i Biomedica, Valencia, Spain
- Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud - RICAPPS, Barcelona, Spain
| | - Salvador Peiró-Moreno
- Health Services Research Unit, Fundacio per al Foment de la Investigacio Sanitaria i Biomedica, Valencia, Spain
- Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud - RICAPPS, Barcelona, Spain
| | - Gabriel Sanfélix-Gimeno
- Health Services Research Unit, Fundacio per al Foment de la Investigacio Sanitaria i Biomedica, Valencia, Spain
- Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud - RICAPPS, Barcelona, Spain
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15
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El Ibrahimi S, Hendricks MA, Little K, Ritter GA, Flores D, Loy B, Wright D, Weiner SG. The association between community social vulnerability and prescription opioid availability with individual opioid overdose. Drug Alcohol Depend 2023; 252:110991. [PMID: 37862877 PMCID: PMC10754350 DOI: 10.1016/j.drugalcdep.2023.110991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 10/05/2023] [Accepted: 10/10/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND This study aims to assess the association of community social vulnerability and community prescription opioid availability with individual non-fatal or fatal opioid overdose. METHODS We identified patients 12 years of age or older from the Oregon All Payer Claims database (APCD) linked to other public health datasets. Community-level characteristics were captured in an exposure period (EP) (1/1/2018-12/31/2018) and included: census tract-level social vulnerability domains (socio-economic status, household composition, racial and ethnic minority status, and housing type and transportation), census tract-level prescriptions and community-level opioid use disorder (OUD) diagnoses per 100 capita binned into quartiles or quintiles. We employed Cox models to estimate the risk of fatal and non-fatal opioid overdoses events in the 12 months following the EP. MAIN FINDINGS We identified 1,548,252 individuals. Patients were mostly female (54%), White (61%), commercially insured (54%), and lived in metropolitan areas (81%). Of the total sample, 2485 (0.2%) experienced a non-fatal opioid overdose and 297 died of opioid overdose. There was higher hazard for non-fatal overdose in communities with greater OUD per 100 capita. We also found higher non-fatal and fatal hazards for opioid overdose among patients in communities with higher housing type and transportation-related vulnerability compared to the lowest quintile. Conversely, patients were at less risk of opioid overdose when living in communities with greater prevalence of the young or the elderly, the disabled, single parent families or low English proficiency. CONCLUSION These findings underscore the importance of the environmental context when considering public health policies to reduce opioid harms.
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Affiliation(s)
- Sanae El Ibrahimi
- Division of Research and Evaluation, Comagine Health, Portland, OR, United States; School of Public Health, Department of Epidemiology and Biostatistics, University of Nevada, Las Vegas, United States.
| | - Michelle A Hendricks
- General Medical Sciences division, Washington University School of Medicine, St. Luis, MO, United States
| | - Kacey Little
- Division of Research and Evaluation, Comagine Health, Portland, OR, United States
| | - Grant A Ritter
- Schneider Institutes for Health Policy, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, United States
| | - Diana Flores
- Division of Research and Evaluation, Comagine Health, Portland, OR, United States
| | - Bryan Loy
- Injury and Violence Prevention Program - Public Health Division - Oregon Health Authority, Portland, OR, United States
| | - Dagan Wright
- Injury and Violence Prevention Program - Public Health Division - Oregon Health Authority, Portland, OR, United States
| | - Scott G Weiner
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, United States
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16
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Wang L, Hong PJ, Jiang W, Rehman Y, Hong BY, Couban RJ, Wang C, Hayes CJ, Juurlink DN, Busse JW. Predictors of fatal and nonfatal overdose after prescription of opioids for chronic pain: a systematic review and meta-analysis of observational studies. CMAJ 2023; 195:E1399-E1411. [PMID: 37871953 PMCID: PMC10593195 DOI: 10.1503/cmaj.230459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND Higher doses of opioids, mental health comorbidities, co-prescription of sedatives, lower socioeconomic status and a history of opioid overdose have been reported as risk factors for opioid overdose; however, the magnitude of these associations and their credibility are unclear. We sought to identify predictors of fatal and nonfatal overdose from prescription opioids. METHODS We systematically searched MEDLINE, Embase, CINAHL, PsycINFO and Web of Science up to Oct. 30, 2022, for observational studies that explored predictors of opioid overdose after their prescription for chronic pain. We performed random-effects meta-analyses for all predictors reported by 2 or more studies using odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS Twenty-eight studies (23 963 716 patients) reported the association of 103 predictors with fatal or nonfatal opioid overdose. Moderate- to high-certainty evidence supported large relative associations with history of overdose (OR 5.85, 95% CI 3.78-9.04), higher opioid dose (OR 2.57, 95% CI 2.08-3.18 per 90-mg increment), 3 or more prescribers (OR 4.68, 95% CI 3.57-6.12), 4 or more dispensing pharmacies (OR 4.92, 95% CI 4.35-5.57), prescription of fentanyl (OR 2.80, 95% CI 2.30-3.41), current substance use disorder (OR 2.62, 95% CI 2.09-3.27), any mental health diagnosis (OR 2.12, 95% CI 1.73-2.61), depression (OR 2.22, 95% CI 1.57-3.14), bipolar disorder (OR 2.07, 95% CI 1.77-2.41) or pancreatitis (OR 2.00, 95% CI 1.52-2.64), with absolute risks among patients with the predictor ranging from 2-6 per 1000 for fatal overdose and 4-12 per 1000 for nonfatal overdose. INTERPRETATION We identified 10 predictors that were strongly associated with opioid overdose. Awareness of these predictors may facilitate shared decision-making regarding prescribing opioids for chronic pain and inform harm-reduction strategies SYSTEMATIC REVIEW REGISTRATION: Open Science Framework (https://osf.io/vznxj/).
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Affiliation(s)
- Li Wang
- Department of Anesthesia (L. Wang, Busse); The Michael G. DeGroote Institute for Pain Research and Care (L. Wang, Rehman, Couban, Busse); Department of Health Research Methods, Evidence & Impact (L. Wang, Rehman, Busse), McMaster University, Hamilton, Ont.; Department of Anesthesiology and Pain Medicine (P.J. Hong), University of Toronto, Toronto, Ont.; Faculty of Health Science (Jiang), McMaster University, Hamilton, Ont.; Division of Plastic Surgery, Department of Surgery (B.Y. Hong), University of Toronto, Toronto, Ont.; Guangdong Science and Technology Library (C. Wang), Institute of Information, Guangdong Academy of Sciences, Guangzhou, China; Department of Biomedical Informatics (Hayes), College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Ark.; Center for Mental Healthcare and Outcomes Research (Hayes), Central Arkansas Veterans Healthcare System, North Little Rock, Ark.; Sunnybrook Health Sciences Centre (Juurlink); Institute for Clinical Evaluative Sciences (Juurlink); Institute of Health Policy, Management, and Evaluation (Juurlink), University of Toronto, Toronto, Ont.
| | - Patrick J Hong
- Department of Anesthesia (L. Wang, Busse); The Michael G. DeGroote Institute for Pain Research and Care (L. Wang, Rehman, Couban, Busse); Department of Health Research Methods, Evidence & Impact (L. Wang, Rehman, Busse), McMaster University, Hamilton, Ont.; Department of Anesthesiology and Pain Medicine (P.J. Hong), University of Toronto, Toronto, Ont.; Faculty of Health Science (Jiang), McMaster University, Hamilton, Ont.; Division of Plastic Surgery, Department of Surgery (B.Y. Hong), University of Toronto, Toronto, Ont.; Guangdong Science and Technology Library (C. Wang), Institute of Information, Guangdong Academy of Sciences, Guangzhou, China; Department of Biomedical Informatics (Hayes), College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Ark.; Center for Mental Healthcare and Outcomes Research (Hayes), Central Arkansas Veterans Healthcare System, North Little Rock, Ark.; Sunnybrook Health Sciences Centre (Juurlink); Institute for Clinical Evaluative Sciences (Juurlink); Institute of Health Policy, Management, and Evaluation (Juurlink), University of Toronto, Toronto, Ont
| | - Wenjun Jiang
- Department of Anesthesia (L. Wang, Busse); The Michael G. DeGroote Institute for Pain Research and Care (L. Wang, Rehman, Couban, Busse); Department of Health Research Methods, Evidence & Impact (L. Wang, Rehman, Busse), McMaster University, Hamilton, Ont.; Department of Anesthesiology and Pain Medicine (P.J. Hong), University of Toronto, Toronto, Ont.; Faculty of Health Science (Jiang), McMaster University, Hamilton, Ont.; Division of Plastic Surgery, Department of Surgery (B.Y. Hong), University of Toronto, Toronto, Ont.; Guangdong Science and Technology Library (C. Wang), Institute of Information, Guangdong Academy of Sciences, Guangzhou, China; Department of Biomedical Informatics (Hayes), College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Ark.; Center for Mental Healthcare and Outcomes Research (Hayes), Central Arkansas Veterans Healthcare System, North Little Rock, Ark.; Sunnybrook Health Sciences Centre (Juurlink); Institute for Clinical Evaluative Sciences (Juurlink); Institute of Health Policy, Management, and Evaluation (Juurlink), University of Toronto, Toronto, Ont
| | - Yasir Rehman
- Department of Anesthesia (L. Wang, Busse); The Michael G. DeGroote Institute for Pain Research and Care (L. Wang, Rehman, Couban, Busse); Department of Health Research Methods, Evidence & Impact (L. Wang, Rehman, Busse), McMaster University, Hamilton, Ont.; Department of Anesthesiology and Pain Medicine (P.J. Hong), University of Toronto, Toronto, Ont.; Faculty of Health Science (Jiang), McMaster University, Hamilton, Ont.; Division of Plastic Surgery, Department of Surgery (B.Y. Hong), University of Toronto, Toronto, Ont.; Guangdong Science and Technology Library (C. Wang), Institute of Information, Guangdong Academy of Sciences, Guangzhou, China; Department of Biomedical Informatics (Hayes), College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Ark.; Center for Mental Healthcare and Outcomes Research (Hayes), Central Arkansas Veterans Healthcare System, North Little Rock, Ark.; Sunnybrook Health Sciences Centre (Juurlink); Institute for Clinical Evaluative Sciences (Juurlink); Institute of Health Policy, Management, and Evaluation (Juurlink), University of Toronto, Toronto, Ont
| | - Brian Y Hong
- Department of Anesthesia (L. Wang, Busse); The Michael G. DeGroote Institute for Pain Research and Care (L. Wang, Rehman, Couban, Busse); Department of Health Research Methods, Evidence & Impact (L. Wang, Rehman, Busse), McMaster University, Hamilton, Ont.; Department of Anesthesiology and Pain Medicine (P.J. Hong), University of Toronto, Toronto, Ont.; Faculty of Health Science (Jiang), McMaster University, Hamilton, Ont.; Division of Plastic Surgery, Department of Surgery (B.Y. Hong), University of Toronto, Toronto, Ont.; Guangdong Science and Technology Library (C. Wang), Institute of Information, Guangdong Academy of Sciences, Guangzhou, China; Department of Biomedical Informatics (Hayes), College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Ark.; Center for Mental Healthcare and Outcomes Research (Hayes), Central Arkansas Veterans Healthcare System, North Little Rock, Ark.; Sunnybrook Health Sciences Centre (Juurlink); Institute for Clinical Evaluative Sciences (Juurlink); Institute of Health Policy, Management, and Evaluation (Juurlink), University of Toronto, Toronto, Ont
| | - Rachel J Couban
- Department of Anesthesia (L. Wang, Busse); The Michael G. DeGroote Institute for Pain Research and Care (L. Wang, Rehman, Couban, Busse); Department of Health Research Methods, Evidence & Impact (L. Wang, Rehman, Busse), McMaster University, Hamilton, Ont.; Department of Anesthesiology and Pain Medicine (P.J. Hong), University of Toronto, Toronto, Ont.; Faculty of Health Science (Jiang), McMaster University, Hamilton, Ont.; Division of Plastic Surgery, Department of Surgery (B.Y. Hong), University of Toronto, Toronto, Ont.; Guangdong Science and Technology Library (C. Wang), Institute of Information, Guangdong Academy of Sciences, Guangzhou, China; Department of Biomedical Informatics (Hayes), College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Ark.; Center for Mental Healthcare and Outcomes Research (Hayes), Central Arkansas Veterans Healthcare System, North Little Rock, Ark.; Sunnybrook Health Sciences Centre (Juurlink); Institute for Clinical Evaluative Sciences (Juurlink); Institute of Health Policy, Management, and Evaluation (Juurlink), University of Toronto, Toronto, Ont
| | - Chunming Wang
- Department of Anesthesia (L. Wang, Busse); The Michael G. DeGroote Institute for Pain Research and Care (L. Wang, Rehman, Couban, Busse); Department of Health Research Methods, Evidence & Impact (L. Wang, Rehman, Busse), McMaster University, Hamilton, Ont.; Department of Anesthesiology and Pain Medicine (P.J. Hong), University of Toronto, Toronto, Ont.; Faculty of Health Science (Jiang), McMaster University, Hamilton, Ont.; Division of Plastic Surgery, Department of Surgery (B.Y. Hong), University of Toronto, Toronto, Ont.; Guangdong Science and Technology Library (C. Wang), Institute of Information, Guangdong Academy of Sciences, Guangzhou, China; Department of Biomedical Informatics (Hayes), College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Ark.; Center for Mental Healthcare and Outcomes Research (Hayes), Central Arkansas Veterans Healthcare System, North Little Rock, Ark.; Sunnybrook Health Sciences Centre (Juurlink); Institute for Clinical Evaluative Sciences (Juurlink); Institute of Health Policy, Management, and Evaluation (Juurlink), University of Toronto, Toronto, Ont
| | - Corey J Hayes
- Department of Anesthesia (L. Wang, Busse); The Michael G. DeGroote Institute for Pain Research and Care (L. Wang, Rehman, Couban, Busse); Department of Health Research Methods, Evidence & Impact (L. Wang, Rehman, Busse), McMaster University, Hamilton, Ont.; Department of Anesthesiology and Pain Medicine (P.J. Hong), University of Toronto, Toronto, Ont.; Faculty of Health Science (Jiang), McMaster University, Hamilton, Ont.; Division of Plastic Surgery, Department of Surgery (B.Y. Hong), University of Toronto, Toronto, Ont.; Guangdong Science and Technology Library (C. Wang), Institute of Information, Guangdong Academy of Sciences, Guangzhou, China; Department of Biomedical Informatics (Hayes), College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Ark.; Center for Mental Healthcare and Outcomes Research (Hayes), Central Arkansas Veterans Healthcare System, North Little Rock, Ark.; Sunnybrook Health Sciences Centre (Juurlink); Institute for Clinical Evaluative Sciences (Juurlink); Institute of Health Policy, Management, and Evaluation (Juurlink), University of Toronto, Toronto, Ont
| | - David N Juurlink
- Department of Anesthesia (L. Wang, Busse); The Michael G. DeGroote Institute for Pain Research and Care (L. Wang, Rehman, Couban, Busse); Department of Health Research Methods, Evidence & Impact (L. Wang, Rehman, Busse), McMaster University, Hamilton, Ont.; Department of Anesthesiology and Pain Medicine (P.J. Hong), University of Toronto, Toronto, Ont.; Faculty of Health Science (Jiang), McMaster University, Hamilton, Ont.; Division of Plastic Surgery, Department of Surgery (B.Y. Hong), University of Toronto, Toronto, Ont.; Guangdong Science and Technology Library (C. Wang), Institute of Information, Guangdong Academy of Sciences, Guangzhou, China; Department of Biomedical Informatics (Hayes), College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Ark.; Center for Mental Healthcare and Outcomes Research (Hayes), Central Arkansas Veterans Healthcare System, North Little Rock, Ark.; Sunnybrook Health Sciences Centre (Juurlink); Institute for Clinical Evaluative Sciences (Juurlink); Institute of Health Policy, Management, and Evaluation (Juurlink), University of Toronto, Toronto, Ont
| | - Jason W Busse
- Department of Anesthesia (L. Wang, Busse); The Michael G. DeGroote Institute for Pain Research and Care (L. Wang, Rehman, Couban, Busse); Department of Health Research Methods, Evidence & Impact (L. Wang, Rehman, Busse), McMaster University, Hamilton, Ont.; Department of Anesthesiology and Pain Medicine (P.J. Hong), University of Toronto, Toronto, Ont.; Faculty of Health Science (Jiang), McMaster University, Hamilton, Ont.; Division of Plastic Surgery, Department of Surgery (B.Y. Hong), University of Toronto, Toronto, Ont.; Guangdong Science and Technology Library (C. Wang), Institute of Information, Guangdong Academy of Sciences, Guangzhou, China; Department of Biomedical Informatics (Hayes), College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Ark.; Center for Mental Healthcare and Outcomes Research (Hayes), Central Arkansas Veterans Healthcare System, North Little Rock, Ark.; Sunnybrook Health Sciences Centre (Juurlink); Institute for Clinical Evaluative Sciences (Juurlink); Institute of Health Policy, Management, and Evaluation (Juurlink), University of Toronto, Toronto, Ont
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17
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Beyene K, Fahmy H, Chan AHY, Tomlin A, Cheung G. Predictors of persistent opioid use in non-cancer older adults: a retrospective cohort study. Age Ageing 2023; 52:afad167. [PMID: 37659093 DOI: 10.1093/ageing/afad167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/19/2023] [Indexed: 09/04/2023] Open
Abstract
BACKGROUND Long-term opioid use and associated adverse outcomes have increased dramatically in recent years. Limited research is available on long-term opioid use in older adults. OBJECTIVE We aimed to determine the incidence and predictors of long-term or persistent opioid use (POU) amongst opioid-naïve older adults without a cancer diagnosis. METHODS This was a retrospective cohort study using five national administrative healthcare databases in New Zealand. We included all opioid-naïve older adults (≥65 years) who were initiated on opioid therapy between January 2013 and June 2018. The outcome of interest was POU, defined as having continuously filled ≥1 opioid prescription within 91-180 days after the index opioid prescription. Multivariable logistic regression was used to examine the predictors of POU. RESULTS The final sample included 268,857 opioid-naïve older adults; of these, 5,849(2.2%) developed POU. Several predictors of POU were identified. The use of fentanyl (adjusted odds ratio (AOR) = 3.61; 95% confidence interval (CI) 2.63-4.95), slow-release opioids (AOR = 3.02; 95%CI 2.78-3.29), strong opioids (AOR = 2.03; 95%CI 1.55-2.65), Charlson Comorbidity Score ≥ 3 (AOR = 2.09; 95% CI 1.78-2.46), history of substance abuse (AOR = 1.52; 95%CI 1.35-1.72), living in most socioeconomically deprived areas (AOR = 1.40; 95%CI 1.27-1.54), and anti-epileptics (AOR = 2.07; 95%CI 1.89-2.26), non-opioid analgesics (AOR = 2.05; 95%CI 1.89-2.21), antipsychotics (AOR = 1.96; 95%CI 1.78-2.17) or antidepressants (AOR = 1.50; 95%CI 1.41-1.59) medication use were the strongest predictors of POU. CONCLUSION A significant proportion of patients developed POU, and several factors were associated with POU. The findings will enable healthcare providers and policymakers to target early interventions to prevent POU and related adverse events.
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Affiliation(s)
- Kebede Beyene
- Department of Pharmaceutical and Administrative Sciences, University of Health Sciences and Pharmacy, St. Louis, MO, USA
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Hoda Fahmy
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Amy Hai Yan Chan
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Andrew Tomlin
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Gary Cheung
- Department of Psychological Medicine, School of Medicine, The University of Auckland, Auckland, New Zealand
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18
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Lindner SR, Hart K, Manibusan B, McCarty D, McConnell KJ. State- and County-Level Geographic Variation in Opioid Use Disorder, Medication Treatment, and Opioid-Related Overdose Among Medicaid Enrollees. JAMA HEALTH FORUM 2023; 4:e231574. [PMID: 37351873 PMCID: PMC10290243 DOI: 10.1001/jamahealthforum.2023.1574] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 04/20/2023] [Indexed: 06/24/2023] Open
Abstract
Importance The opioid crisis disproportionately affects Medicaid enrollees, yet little systematic evidence exists regarding how prevalence of and health care utilization for opioid use disorder (OUD) vary across geographical areas. Objectives To characterize state- and county-level variation in claims-based prevalence of OUD and rates of medication treatment for OUD and OUD-related nonfatal overdose among Medicaid enrollees. Design, Setting, and Participants This cross-sectional study used data from the Transformed Medicaid Statistical Information System Analytic Files from January 1, 2016, to December 31, 2018. Participants were Medicaid enrollees with or without OUD in 46 states; Washington, DC; and Puerto Rico who were aged 18 to 64 years and not dually enrolled in Medicare. The analysis was conducted between September 2022 and April 2023. Exposure Calendar-year OUD prevalence. Main Outcomes and Measures The main outcomes were claims-based measures of OUD prevalence and rates of medication treatment for OUD and opioid-related nonfatal overdose. Individual records were aggregated at the state and county level, and variation was assessed within and across states. Results Of the 76 390 817 Medicaid enrollee-year observations included in our study (mean [SD] enrollee age, 36.5 [1.6] years; 59.0% female), 2 280 272 (3.0%) had a claims-based OUD (mean [SD] age, 38.9 [3.6] years; 51.4% female). Of enrollees with OUD, 41.2% were eligible due to Medicaid expansion, 46.4% had other substance use disorders, 55.8% had mental health conditions, 55.2% had claims indicating some form of OUD medication, and 5.8% had claims indicating an overdose during a calendar year. Claims-based outcomes exhibited substantial variation across states: OUD prevalence ranged from 0.6% in Arkansas and Puerto Rico to 9.7% in Maryland, rates of OUD medication treatment ranged from 17.7% in Kansas to 82.8% in Maine, and rates of overdose ranged from 0.3% in Mississippi to 10.5% in Illinois. Pronounced variation was also found within states (eg, OUD prevalence in Maryland ranged from 2.2% in Prince George's County to 21.6% in Cecil County). Conclusions and Relevance In this cross-sectional study of Medicaid enrollees from 2016 to 2018, claims-based prevalence of OUD and rates of OUD medication treatment and opioid-related overdose varied substantially across and within states. Further research appears to be needed to identify important factors influencing this variation.
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Affiliation(s)
- Stephan R. Lindner
- Center for Health Systems Effectiveness, Oregon Health & Science University (OHSU), Portland
- OHSU–Portland State University School of Public Health, Portland
| | - Kyle Hart
- Center for Health Systems Effectiveness, Oregon Health & Science University (OHSU), Portland
| | - Brynna Manibusan
- Center for Health Systems Effectiveness, Oregon Health & Science University (OHSU), Portland
| | - Dennis McCarty
- OHSU–Portland State University School of Public Health, Portland
- Division of General and Internal Medicine, School of Medicine, OHSU, Portland
| | - K. John McConnell
- Center for Health Systems Effectiveness, Oregon Health & Science University (OHSU), Portland
- OHSU–Portland State University School of Public Health, Portland
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19
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Waljee JF, Gunaseelan V, Bicket MC, Brummett CM, Chua KP. Safety and Distribution of Opioid Prescribing by U.S. Surgeons. Ann Surg 2023; 277:944-951. [PMID: 36727966 PMCID: PMC10354205 DOI: 10.1097/sla.0000000000005802] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To estimate high-risk prescribing patterns among opioid prescriptions from U.S. surgeons; to characterize the distribution of high-risk prescribing among surgeons. BACKGROUND National data on the prevalence of opioid prescribing and high-risk opioid prescribing by U.S. surgeons are lacking. METHODS Using the IQVIA Prescription Database, which reports dispensing from 92% of U.S. pharmacies, we identified opioid prescriptions from surgeons dispensed in 2019 to patients ages ≥12 years. "High-risk" prescriptions were characterized by: days supplied >7, daily dosage ≥50 oral morphine equivalents (OMEs), opioid-benzodiazepine overlap, and extended-release/long-acting opioid. We determined the proportion of opioid prescriptions, total OMEs, and high-risk prescriptions accounted for by "high-volume surgeons" (those in the ≥95th percentile for prescription counts). We used linear regression to identify characteristics associated with being a high-volume surgeon. RESULTS Among 15,493,018 opioid prescriptions included, 7,036,481 (45.4%) were high-risk. Among 114,610 surgeons, 5753 were in the 95th percentile or above for prescription count, with ≥520 prescriptions dispensed in 2019. High-volume surgeons accounted for 33.5% of opioid prescriptions, 52.8% of total OMEs, and 44.2% of high-risk prescriptions. Among high-volume surgeons, 73.9% were orthopedic surgeons and 60.6% practiced in the South. Older age, male sex, specialty, region, and lack of affiliation with academic institutions or health systems were correlated with high-risk prescribing. CONCLUSIONS The top 5% of surgeons account for 33.5% of opioid prescriptions and 45.4% of high-risk prescriptions. Quality improvement initiatives targeting these surgeons may have the greatest yield given their outsized role in high-risk prescribing.
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Affiliation(s)
- Jennifer F Waljee
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
- Michigan Opioid Prescribing Engagement Network, Institute for Health Care Policy and Innovation, University of Michigan Medical School, Ann Arbor
| | - Vidhya Gunaseelan
- Michigan Opioid Prescribing Engagement Network, Institute for Health Care Policy and Innovation, University of Michigan Medical School, Ann Arbor
| | - Mark C Bicket
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
- Division of Pain Medicine, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
| | - Chad M Brummett
- Division of Pain Medicine, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Kao-Ping Chua
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, Ann Arbor
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
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20
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Stalter N, Ma S, Simon G, Pruinelli L. Psychosocial problems and high amount of opioid administration are associated with opioid dependence and abuse after first exposure for chronic pain patients. Addict Behav 2023; 141:107657. [PMID: 36796176 DOI: 10.1016/j.addbeh.2023.107657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 12/29/2022] [Accepted: 02/06/2023] [Indexed: 02/11/2023]
Abstract
Controversy surrounding the use of opioids for the treatment and the unique characteristics of chronic pain heighten the risks for abuse and dependence; however, it's unclear if higher doses of opioids and first exposure are associated with dependence and abuse. This study aimed to identify patients who developed dependence or opioid abuse after exposed to opioids for the first time and what were the risks factors associated with the outcome. A retrospective observational cohort study analyzed 2,411 patients between 2011 and 2017 who had a diagnosis of chronic pain and received opioids for the first time. A logistic regression model was used to estimate the likelihood of opioid dependence/abuse after the first exposure based on their mental health conditions, prior substance abuse disorders, demographics, and the amount of MME per day patients received. From 2,411 patients, 5.5 % of the patients had a diagnosis of dependence or abuse after the first exposure. Patients who were depressed (OR = 2.09), previous non-opioid substance dependence or abuse (OR = 1.59) or received greater than 50 MME per day (OR = 1.03) showed statistically significant relationship with developing opioid dependence or abuse, while age (OR = -1.03) showed to be a protective factor. Further studies should stratify chronic pain patients into groups who is in higher risk in developing opioid dependence or abuse and develop alternative strategies for pain management and treatments beyond opioids. This study reinforces the psychosocial problems as determinants of opioid dependence or abuse and risk factors, and the need for safer opioid prescribing practices.
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Affiliation(s)
- Nicholas Stalter
- Department of Computer Sciences and Engineering, University of Minnesota, Minneapolis, MN, United States
| | - Sisi Ma
- School of Medicine and Institute for Health Informatics, University of Minnesota, Minneapolis, MN, United States
| | - Gyorgy Simon
- School of Medicine and Institute for Health Informatics, University of Minnesota, Minneapolis, MN, United States
| | - Lisiane Pruinelli
- College of Nursing, University of Florida, Gainesville, FL, United States.
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21
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Dickerson DM, Mariano ER, Szokol JW, Harned M, Clark RM, Mueller JT, Shilling AM, Udoji MA, Mukkamala SB, Doan L, Wyatt KEK, Schwalb JM, Elkassabany NM, Eloy JD, Beck SL, Wiechmann L, Chiao F, Halle SG, Krishnan DG, Cramer JD, Ali Sakr Esa W, Muse IO, Baratta J, Rosenquist R, Gulur P, Shah S, Kohan L, Robles J, Schwenk ES, Allen BFS, Yang S, Hadeed JG, Schwartz G, Englesbe MJ, Sprintz M, Urish KL, Walton A, Keith L, Buvanendran A. Multiorganizational consensus to define guiding principles for perioperative pain management in patients with chronic pain, preoperative opioid tolerance, or substance use disorder. Reg Anesth Pain Med 2023:rapm-2023-104435. [PMID: 37185214 DOI: 10.1136/rapm-2023-104435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/12/2023] [Indexed: 05/17/2023]
Abstract
Significant knowledge gaps exist in the perioperative pain management of patients with a history of chronic pain, substance use disorder, and/or opioid tolerance as highlighted in the US Health and Human Services Pain Management Best Practices Inter-Agency Task Force 2019 report. The report emphasized the challenges of caring for these populations and the need for multidisciplinary care and a comprehensive approach. Such care requires stakeholder alignment across multiple specialties and care settings. With the intention of codifying this alignment into a reliable and efficient processes, a consortium of 15 professional healthcare societies was convened in a year-long modified Delphi consensus process and summit. This process produced seven guiding principles for the perioperative care of patients with chronic pain, substance use disorder, and/or preoperative opioid tolerance. These principles provide a framework and direction for future improvement in the optimization and care of 'complex' patients as they undergo surgical procedures.
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Affiliation(s)
- David M Dickerson
- Department of Anesthesiology, Critical Care and Pain Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
- Department of Anesthesia & Critical Care, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Edward R Mariano
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Joseph W Szokol
- Department of Anesthesiology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Michael Harned
- Department of Anesthesiology, Division of Pain Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Randall M Clark
- American Society of Anesthesiologists, Park Ridge, Illinois, USA
| | - Jeffrey T Mueller
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Ashley M Shilling
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Mercy A Udoji
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA
- Atlanta VA Health Care System, Decatur, Georgia, USA
| | | | - Lisa Doan
- Department of Anesthesiology, PerioperativeCare and Pain Medicine, New York University School of Medicine, New York, New York, USA
| | - Karla E K Wyatt
- Department of Anesthesiology, Perioperativeand Pain Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Jason M Schwalb
- Department of Neurosurgery, Henry Ford Medical Group, Detroit, Michigan, USA
| | - Nabil M Elkassabany
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jean D Eloy
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Stacy L Beck
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Maternal Fetal Medicine, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Lisa Wiechmann
- Department of Surgery, NewYork-Presbyterian/Columbia University Medical Center, New York, New York, USA
| | - Franklin Chiao
- Department of Anesthesiology, Westchester Medical Center, Valhalla, New York, USA
| | - Steven G Halle
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Deepak G Krishnan
- Department of Oral & Maxillofacial Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
- Department of Oral & Maxillofacial Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - John D Cramer
- Department of Otolaryngology - Head and Neck Surgery, Wayne State University, Detroit, Michigan, USA
| | - Wael Ali Sakr Esa
- Department of Pain Management, Cleveland Clinic, Cleveland, Ohio, USA
| | - Iyabo O Muse
- Department of Anesthesiology, Montefiore Medical Center, Bronx, New York, USA
- Department of Anesthesiology, Westchester Medical Center Health Network, Valhalla, New York, USA
| | - Jaime Baratta
- Department of Anesthesiology and Perioperative Medicine, Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | | | - Padma Gulur
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Shalini Shah
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Orange, California, USA
| | - Lynn Kohan
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, USA
| | - Jennifer Robles
- Department of Urology Division of Endourology and Stone Disease, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Surgical Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Eric S Schwenk
- Department of Anesthesiology and Perioperative Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brian F S Allen
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stephen Yang
- Department of Surgery, Division of Thoracic Surgery, Johns Hopkins Medical Institutions Campus, Baltimore, Maryland, USA
| | | | - Gary Schwartz
- AABP Integrative Pain Care, Melville, New York, USA
- Maimonides Medical Center, Brooklyn, New York, USA
| | | | - Michael Sprintz
- Sprintz Center for Pain and Recovery, Shenandoah, Texas, USA
| | - Kenneth L Urish
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ashley Walton
- American Society of Anesthesiologists, Washington, District of Columbia, USA
| | - Lauren Keith
- American Society of Anesthesiologists, Park Ridge, Illinois, USA
| | - Asokumar Buvanendran
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
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22
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van Brug HE, Nelissen RGHH, Rosendaal FR, van Steenbergen LN, van Dorp ELA, Bouvy ML, Dahan A, Gademan MGJ. Out-of-hospital opioid prescriptions after knee and hip arthroplasty: prescribers and the first prescribed opioid. Br J Anaesth 2023; 130:459-467. [PMID: 36858887 DOI: 10.1016/j.bja.2022.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 12/14/2022] [Accepted: 12/28/2022] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND We determined the first prescribed opioid and the prescribers of opioids after knee and hip arthroplasty (KA/HA) between 2013 and 2018 in the Netherlands. We also evaluated whether the first prescribed opioid dose was associated with the total dispensed dose and long-term opioid use in the first postoperative year. METHODS The Dutch Foundation for Pharmaceutical Statistics was linked to the Dutch Arthroplasty Register. Stratified for KA/HA, the first out-of-hospital opioid within 30 days of operation was quantified as median morphine milligram equivalent (MME). Opioid prescribers were orthopaedic surgeons, general practitioners, rheumatologists, anaesthesiologists, and other physicians. Long-term use was defined as ≥1 opioid prescription for >90 postoperative days. We used linear and logistic regression analyses adjusted for confounders. RESULTS Seventy percent of 46 106 KAs and 51% of the 42 893 HAs were prescribed ≥1 opioid. Oxycodone increased as first prescribed opioid (from 44% to 85%) whereas tramadol decreased (64-11%), but their dosage remained stable (stronger opioids were preferred by prescribers). An increase in the first prescription of 1% MME resulted in a 0.43%/0.37% increase in total MME (KA/HA, respectively). A 100 MME increase in dose of the first dispensed opioid had a small effect on long-term use (prevalence: 25% KA, 20% HA) (odds ratio=1.02/1.01 for KA/HA, respectively). Orthopaedic surgeons increasingly prescribed the first prescription between 2013 and 2018 (44-69%). General practitioners mostly prescribed consecutive prescriptions (>50%). CONCLUSION Oxycodone increased as first out-of-hospital prescription between 2013 and 2018. The dose of the first prescribed opioid was associated with the total dose and a small increased risk of prolonged use. First prescriptions were mostly written by orthopaedic surgeons and consecutive prescriptions by general practitioners.
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Affiliation(s)
- Heather E van Brug
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands.
| | - Rob G H H Nelissen
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands; Dutch Arthroplasty Register (LROI), s-Hertogenbosch, the Netherlands
| | - Frits R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Eveline L A van Dorp
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Marcel L Bouvy
- Utrecht Institute for Pharmaceutical Sciences (UIPS), Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, the Netherlands
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Maaike G J Gademan
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
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23
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Fishbein DH, Sloboda Z. A National Strategy for Preventing Substance and Opioid Use Disorders Through Evidence-Based Prevention Programming that Fosters Healthy Outcomes in Our Youth. Clin Child Fam Psychol Rev 2023; 26:1-16. [PMID: 36542196 PMCID: PMC9768412 DOI: 10.1007/s10567-022-00420-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2022] [Indexed: 12/24/2022]
Abstract
The recently released National Drug Control Strategy (2022) from the White House Office of National Drug Control Policy (ONDCP) lays out a comprehensive plan to, not only enhance access to treatment and increase harm reduction strategies, but also increase implementation of evidence-based prevention programming at the community level. Furthermore, the Strategy provides a framework for enhancing our national data systems to inform policy and to evaluate all components of the plan. However, not only are there several missing components to the Strategy that would assure its success, but there is a lack of structure to support a national comprehensive service delivery system that is informed by epidemiological data, and trains and credentials those delivering evidence-based prevention, treatment, and harm reduction/public health interventions within community settings. This paper provides recommendations for the establishment of such a structure with an emphasis on prevention. Systematically addressing conditions known to increase liability for behavioral problems among vulnerable populations and building supportive environments are strategies consistently found to avert trajectories away from substance use in general and substance use disorders (SUD) in particular. Investments in this approach are expected to result in significantly lower rates of SUD in current and subsequent generations of youth and, therefore, will reduce the burden on our communities in terms of lowered social and health systems involvement, treatment needs, and productivity. A national strategy, based on strong scientific evidence, is presented to implement public health policies and prevention services. These strategies work by improving child development, supporting families, enhancing school experiences, and cultivating positive environmental conditions.
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Affiliation(s)
- Diana H Fishbein
- Frank Porter Graham Child Development Institute, University of North Carolina-Chapel Hill, 105 Smith Level Road, Chapel Hill, NC, 27599, USA.
- The Pennsylvania State University, State College, PA, USA.
- National Prevention Science Coalition to Improve Lives, Oakland, CA, USA.
| | - Zili Sloboda
- National Prevention Science Coalition to Improve Lives, Oakland, CA, USA
- Applied Prevention Science International, Ontario, OH, USA
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24
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Hendricks MA, El Ibrahimi S, Ritter GA, Flores D, Fischer MA, Weiss RD, Wright DA, Weiner SG. Association of Household Opioid Availability With Opioid Overdose. JAMA Netw Open 2023; 6:e233385. [PMID: 36930154 PMCID: PMC10024199 DOI: 10.1001/jamanetworkopen.2023.3385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
IMPORTANCE Previous studies that examined the role of household opioid prescriptions in opioid overdose risk were limited to commercial claims, did not include fatal overdoses, and had limited inclusion of household prescription characteristics. Broader research is needed to expand understanding of the risk of overdose. OBJECTIVE To assess the role of household opioid availability and other household prescription factors associated with individuals' odds of fatal or nonfatal opioid overdose. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study assessing patient outcomes from January 1, 2015, through December 31, 2018, was conducted on adults in the Oregon Comprehensive Opioid Risk Registry database in households of at least 2 members. Data analysis was performed between October 16, 2020, and January 26, 2023. EXPOSURES Household opioid prescription availability and household prescription characteristics. MAIN OUTCOMES AND MEASURES Opioid overdoses were captured from insurance claims, death records, and hospital discharge data. Household opioid prescription availability and prescription characteristics for individuals and households were modeled as 6-month cumulative time-dependent measures, updated monthly. To assess the association between household prescription availability, household prescription characteristics, and overdose, multilevel logistic regression models were developed, adjusting for demographic, clinical, household, and prescription characteristics. RESULTS The sample included 1 691 856 individuals in 1 187 140 households, of which most were women (53.2%), White race (70.7%), living in metropolitan areas (75.8%), and having commercial insurance (51.8%), no Elixhauser comorbidities (69.5%), and no opioid prescription fills in the study period (57.0%). A total of 28 747 opioid overdose events were observed during the study period (0.0526 per 100 person-months). Relative to individuals without personal or household opioid fills, the odds of opioid-related overdose increased by 60% when another household member had an opioid fill in the past 6 months (adjusted odds ratio [aOR], 1.60; 95% CI, 1.54-1.66) and were highest when both the individual and another household member had opioid fills in the preceding 6 months (aOR, 6.25; 95% CI, 6.09-6.40). CONCLUSIONS AND RELEVANCE In this cohort study of adult Oregon residents in households of at least 2 members, the findings suggest that household prescription availability is associated with increased odds of opioid overdose for others in the household, even if they do not have their own opioid prescription. These findings underscore the importance of educating patients about proper opioid disposal and the risks of household opioids.
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Affiliation(s)
| | - Sanae El Ibrahimi
- Division of Research and Evaluation, Comagine Health, Portland, Oregon
- School of Public Health, Department of Epidemiology and Biostatistics, University of Nevada, Las Vegas
| | - Grant A. Ritter
- Schneider Institutes for Health Policy, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Diana Flores
- Division of Research and Evaluation, Comagine Health, Portland, Oregon
| | - Michael A. Fischer
- Section of General Internal Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Roger D. Weiss
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
- Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, Massachusetts
| | - Dagan A. Wright
- Injury and Violence Prevention Program–Public Health Division–Oregon Health Authority, Portland
| | - Scott G. Weiner
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Real-World Observational Evaluation of Common Interventions to Reduce Emergency Department Prescribing of Opioid Medications. Jt Comm J Qual Patient Saf 2023; 49:239-246. [PMID: 36914528 DOI: 10.1016/j.jcjq.2023.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Prior work on opioid prescribing has examined dosing defaults, interruptive alerts, or "harder" stops such as electronic prescribing of controlled substances (EPCS), which has become increasingly required by state policy. Given that real-world opioid stewardship policies are concurrent and overlapping, the authors examined the effect of such policies on emergency department (ED) opioid prescriptions. METHODS The researchers performed observational analysis of all ED visits discharged between December 17, 2016, and December 31, 2019, across seven EDs of a hospital system. Four interventions were examined in chronological order, with each successive intervention added on top of all previous interventions: 12-pill prescription default, EPCS, electronic health record (EHR) pop-up alert, and 8-pill prescription default. The primary outcome was opioid prescribing, which was described as number of opioid prescriptions per 100 discharged ED visits and modeled as a binary outcome for each visit. Secondary outcomes included prescription morphine milligram equivalents (MME) and non-opioid analgesia prescriptions. RESULTS A total of 775,692 ED visits were included in the study. Compared to the preintervention period, cumulative reductions in opioid prescribing were seen with incremental interventions, including after adding a 12-pill default (odds ratio [OR] 0.88, 95% confidence interval [CI] 0.82-0.94), after adding EPCS (OR 0.7, 95% CI 0.63-0.77), after adding pop-up alerts (OR 0.67, 95% CI 0.63-0.71), and after adding an 8-pill default (OR 0.61, 95% CI 0.58-0.65). CONCLUSION EHR-implemented solutions such as EPCS, pop-up alerts, and pill defaults had varying but significant effects on reducing ED opioid prescribing. Policy makers and quality improvement leaders might achieve sustainable improvements in opioid stewardship while balancing clinician alert fatigue through policy efforts promoting implementation of EPCS and default dispense quantities.
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Melucci AD, Dave YA, Lynch OF, Hsu S, Erlick MR, Linehan DC, Moalem J. Predictors of opioid-free discharge after laparoscopic cholecystectomy. Am J Surg 2023; 225:206-211. [PMID: 35948514 DOI: 10.1016/j.amjsurg.2022.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 07/25/2022] [Accepted: 07/28/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Post-discharge opioid requirement after laparoscopic cholecystectomy (LC) is minimal, yet postoperative opioid prescriptions vary and opioid-free discharges are rare. STUDY DESIGN Adult patients who underwent LC from 01/2019-12/2019 were reviewed. Univariate and multivariable logistic regression analyses were performed to identify predictors of opioid-free discharge. RESULTS Of 393 included patients, 330 were discharged with opioids (median 12 oxycodone 5 mg pills) and 63 were discharged without opioids. One opioid-free discharge patient called for a prescription. Older age (OR = 1.02, 95% CI = 1.002-1.041) and non-elective procedure (OR = 0.35, 95% CI = 0.2291-0.8521) were independent predictors of opioid-free discharge. CONCLUSION Significant opportunities for opioid reduction or elimination after discharge from LC exist. Non-elective procedure and older age are predictors of opioid-free discharge, and should be considered when individualizing prescription quantities as surgeons strive to reduce or eliminate opioid overprescription.
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Affiliation(s)
- Alexa D Melucci
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA. https://twitter.com/AlexaMelucci
| | - Yatee A Dave
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Olivia F Lynch
- School of Medicine and Dentistry, University of Rochester, Rochester, NY, 14642, USA
| | - Shawn Hsu
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Mariah R Erlick
- School of Medicine and Dentistry, University of Rochester, Rochester, NY, 14642, USA
| | - David C Linehan
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Jacob Moalem
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
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Keyhani S, Leonard S, Byers AL, Zaman T, Krebs E, Austin PC, Moss-Vazquez T, Austin C, Sandbrink F, Bravata DM. Association of a Positive Drug Screening for Cannabis With Mortality and Hospital Visits Among Veterans Affairs Enrollees Prescribed Opioids. JAMA Netw Open 2022; 5:e2247201. [PMID: 36525274 PMCID: PMC9856228 DOI: 10.1001/jamanetworkopen.2022.47201] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE Cannabis has been proposed as a therapeutic with potential opioid-sparing properties in chronic pain, and its use could theoretically be associated with decreased amounts of opioids used and decreased risk of mortality among individuals prescribed opioids. OBJECTIVE To examine the risks associated with cannabis use among adults prescribed opioid analgesic medications. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted among individuals aged 18 years and older who had urine drug screening in 2014 to 2019 and received any prescription opioid in the prior 90 days or long-term opioid therapy (LTOT), defined as more than 84 days of the prior 90 days, through the Veterans Affairs health system. Data were analyzed from November 2020 through March 2022. EXPOSURES Biologically verified cannabis use from a urine drug screen. MAIN OUTCOMES AND MEASURES The main outcomes were 90-day and 180-day all-cause mortality. A composite outcome of all-cause emergency department (ED) visits, all-cause hospitalization, or all-cause mortality was a secondary outcome. Weights based on the propensity score were used to reduce confounding, and hazard ratios [HRs] were estimated using Cox proportional hazards regression models. Analyses were conducted among the overall sample of patients who received any prescription opioid in the prior 90 days and were repeated among those who received LTOT. Analyses were repeated among adults aged 65 years and older. RESULTS Among 297 620 adults treated with opioids, 30 514 individuals used cannabis (mean [SE] age, 57.8 [10.5] years; 28 784 [94.3%] men) and 267 106 adults did not (mean [SE] age, 62.3 [12.3] years; P < .001; 247 684 [92.7%] men; P < .001). Among all patients, cannabis use was not associated with increased all-cause mortality at 90 days (HR, 1.07; 95% CI, 0.92-1.22) or 180 days (HR, 1.00; 95% CI, 0.90-1.10) but was associated with an increased hazard of the composite outcome at 90 days (HR, 1.05; 95% CI, 1.01-1.07) and 180 days (HR, 1.04; 95% CI, 1.01-1.06). Among 181 096 adults receiving LTOT, cannabis use was not associated with increased risk of all-cause mortality at 90 or 180 days but was associated with an increased hazard of the composite outcome at 90 days (HR, 1.05; 95% CI, 1.02-1.09) and 180 days (HR, 1.05; 95% CI, 1.02-1.09). Among 77 791 adults aged 65 years and older receiving LTOT, cannabis use was associated with increased 90-day mortality (HR, 1.55; 95% CI, 1.17-2.04). CONCLUSIONS AND RELEVANCE This study found that cannabis use among adults receiving opioid analgesic medications was not associated with any change in mortality risk but was associated with a small increased risk of adverse outcomes and that short-term risks were higher among older adults receiving LTOT.
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Affiliation(s)
- Salomeh Keyhani
- Department of Medicine, University of California, San Francisco
- San Francisco VA Medical Center, San Francisco, California
| | - Samuel Leonard
- Northern California Institute for Research and Education, San Francisco
| | - Amy L. Byers
- Department of Medicine, University of California, San Francisco
- San Francisco VA Medical Center, San Francisco, California
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
| | - Tauheed Zaman
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
- Addiction Recovery and Treatments Services, San Francisco VA Health Care System, San Francisco, California
| | - Erin Krebs
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota Medical School, Minneapolis
| | - Peter C. Austin
- Institute of Health Policy, Management and Evaluation, University of Toronto
| | | | - Charles Austin
- Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
| | - Friedhelm Sandbrink
- National Pain Management, Opioid Safety and Prescription Drug Monitoring Program, Veterans Health Administration, Washington, District of Columbia
- Department of Neurology, George Washington University, Washington District of Columbia
| | - Dawn M. Bravata
- Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Departments of Medicine and Neurology, Indiana University School of Medicine, Indianapolis
- Regenstreif Institute, Indianapolis Indiana
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Lee M, Joehanes R, McCartney DL, Kho M, Hüls A, Wyss AB, Liu C, Walker RM, R Kardia SL, Wingo TS, Burkholder A, Ma J, Campbell A, Wingo AP, Huan T, Sikdar S, Keshawarz A, Bennett DA, Smith JA, Evans KL, Levy D, London SJ. Opioid medication use and blood DNA methylation: epigenome-wide association meta-analysis. Epigenomics 2022; 14:1479-1492. [PMID: 36700736 PMCID: PMC9979153 DOI: 10.2217/epi-2022-0353] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 01/13/2023] [Indexed: 01/27/2023] Open
Abstract
Aim: To identify differential methylation related to prescribed opioid use. Methods: This study examined whether blood DNA methylation, measured using Illumina arrays, differs by recent opioid medication use in four population-based cohorts. We meta-analyzed results (282 users; 10,560 nonusers) using inverse-variance weighting. Results: Differential methylation (false discovery rate <0.05) was observed at six CpGs annotated to the following genes: KIAA0226, CPLX2, TDRP, RNF38, TTC23 and GPR179. Integrative epigenomic analyses linked implicated loci to regulatory elements in blood and/or brain. Additionally, 74 CpGs were differentially methylated in males or females. Methylation at significant CpGs correlated with gene expression in blood and/or brain. Conclusion: This study identified DNA methylation related to opioid medication use in general populations. The results could inform the development of blood methylation biomarkers of opioid use.
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Affiliation(s)
- Mikyeong Lee
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC 27709, USA
| | - Roby Joehanes
- Department of Health and Human Services, Framingham Heart Study, National Heart, Lung, and Blood Institute, National Institutes of Health, Framingham, MA 01702, USA
| | - Daniel L McCartney
- Centre for Genomic & Experimental Medicine, Institute of Genetics & Cancer, University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh, UK
| | - Minjung Kho
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA
| | - Anke Hüls
- Department of Epidemiology & Gangarosa, Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA
| | - Annah B Wyss
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC 27709, USA
| | - Chunyu Liu
- Department of Biostatistics, School of Public Health, Boston University, Boston, MA 02215, USA
- Framingham Heart Study, Boston University, Framingham, MA 01702, USA
| | - Rosie M Walker
- Centre for Clinical Brain Science, Chancellor's Building, 49 Little France Crescent, Edinburgh Bioquarter, Edinburgh, UK
- School of Psychology, University of Exeter, Exeter, UK
| | - Sharon L R Kardia
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA
| | - Thomas S Wingo
- Department of Neurology & Human Genetics, Emory University, Atlanta, GA 30322, USA
| | - Adam Burkholder
- Office of Environmental Science Cyberinfrastructure, National Institute of Environmental Health Sciences, Research Triangle Park, NC 27709, USA
| | - Jiantao Ma
- Department of Health and Human Services, Framingham Heart Study, National Heart, Lung, and Blood Institute, National Institutes of Health, Framingham, MA 01702, USA
| | - Archie Campbell
- Centre for Genomic & Experimental Medicine, Institute of Genetics & Cancer, University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh, UK
| | - Aliza P Wingo
- Department of Psychiatry & Behavioral Sciences, Emory University, Atlanta, GA 30322, USA
| | - Tianxiao Huan
- Department of Health and Human Services, Framingham Heart Study, National Heart, Lung, and Blood Institute, National Institutes of Health, Framingham, MA 01702, USA
- Department of Ophthalmology, University of Massachusetts Medical School, Worcester, MA 01655, USA
| | - Sinjini Sikdar
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC 27709, USA
- Department of Mathematics & Statistics, Old Dominion University, Norfolk, VA 23529, USA
| | - Amena Keshawarz
- Framingham Heart Study, Framingham, MA 01702, USA
- Population Sciences Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - David A Bennett
- Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, IL 60612, USA
| | - Jennifer A Smith
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA
| | - Kathryn L Evans
- Centre for Genomic & Experimental Medicine, Institute of Genetics & Cancer, University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh, UK
| | - Daniel Levy
- Department of Health and Human Services, Framingham Heart Study, National Heart, Lung, and Blood Institute, National Institutes of Health, Framingham, MA 01702, USA
| | - Stephanie J London
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC 27709, USA
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Hurtado I, Robles C, Peiró S, García-Sempere A, Llopis-Cardona F, Sánchez-Sáez F, Rodríguez-Bernal C, Sanfélix-Gimeno G. Real-world patterns of opioid therapy initiation in Spain, 2012-2018: A population-based, retrospective cohort study with 957,080 patients and 1,509,488 initiations. Front Pharmacol 2022; 13:1025340. [PMID: 36467078 PMCID: PMC9709437 DOI: 10.3389/fphar.2022.1025340] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 11/01/2022] [Indexed: 07/29/2023] Open
Abstract
Introduction: Europe has seen a steady increase in the use of prescription opioids, especially in non-cancer indications. Epidemiological data on the patterns of use of opioids is required to optimize prescription. We aim to describe the patterns of opioid therapy initiation for non-cancer pain and characteristics of patients treated in a region with five million inhabitants in the period 2012 to 2018. Methods: Population-based retrospective cohort study of all adult patients initiating opioid therapy for non-cancer pain in the region of Valencia. We described patient characteristics at baseline and the characteristics of baseline and subsequent treatment initiation. We used multinominal regression models to identify individual factors associated with initiation. Results: A total of 957,080 patients initiated 1,509,488 opioid treatments (957,080 baseline initiations, 552,408 subsequent initiations). For baseline initiations, 738,749 were with tramadol (77.19%), 157,098 with codeine (16.41%) 58,436 (6.11%) with long-acting opioids, 1,518 (0.16%) with short-acting opioids and 1,279 (0.13%) with ultrafast drugs. When compared to tramadol, patients initiating with short-acting, long-acting and ultrafast opioids were more likely to be older and had more comorbidities, whereas initiators with codeine were more prone to be healthier and younger. Treatments lasting less than 7 days accounted for 41.82% of initiations, and 11.89% lasted more than 30 days. 19.55% of initiators with ultrafast fentanyl received more than 120 daily Morphine Milligram Equivalents (MME), and 16.12% of patients initiating with long-acting opioids were prescribed more than 90 daily MME (p < 0.001). Musculoskeletal indications accounted for 65.05% of opioid use. Overlap with benzodiazepines was observed in 24.73% of initiations, overlap with gabapentinoids was present in 11.04% of initiations with long-acting opioids and 28.39% of initiators with short-acting opioids used antipsychotics concomitantly. In subsequent initiations, 55.48% of treatments included three or more prescriptions (vs. 17.60% in baseline initiations) and risk of overlap was also increased. Conclusion: Opioids are initiated for a vast array of non-oncological indications, and, despite clinical guidelines, short-acting opioids are used marginally, and a significant number of patients is exposed to potentially high-risk patterns of initiation, such as treatments lasting more than 14 days, treatments surpassing 50 daily MMEs, initiating with long-acting opioids, or hazardous overlapping with other therapies.
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Affiliation(s)
- Isabel Hurtado
- Health Services Research Unit, Foundation for the Promotion of Health and Biomedical Research of Valencia Region, Valencia, Fisabio
- Network for Research on Chronicity Primary Care and Health Promotion (RICAPPS), Valencia, Fisabio
| | - Celia Robles
- Health Services Research Unit, Foundation for the Promotion of Health and Biomedical Research of Valencia Region, Valencia, Fisabio
- Network for Research on Chronicity Primary Care and Health Promotion (RICAPPS), Valencia, Fisabio
| | - Salvador Peiró
- Health Services Research Unit, Foundation for the Promotion of Health and Biomedical Research of Valencia Region, Valencia, Fisabio
- Network for Research on Chronicity Primary Care and Health Promotion (RICAPPS), Valencia, Fisabio
| | - Aníbal García-Sempere
- Health Services Research Unit, Foundation for the Promotion of Health and Biomedical Research of Valencia Region, Valencia, Fisabio
- Network for Research on Chronicity Primary Care and Health Promotion (RICAPPS), Valencia, Fisabio
| | - Fran Llopis-Cardona
- Health Services Research Unit, Foundation for the Promotion of Health and Biomedical Research of Valencia Region, Valencia, Fisabio
- Network for Research on Chronicity Primary Care and Health Promotion (RICAPPS), Valencia, Fisabio
| | - Francisco Sánchez-Sáez
- Health Services Research Unit, Foundation for the Promotion of Health and Biomedical Research of Valencia Region, Valencia, Fisabio
- Network for Research on Chronicity Primary Care and Health Promotion (RICAPPS), Valencia, Fisabio
| | - Clara Rodríguez-Bernal
- Health Services Research Unit, Foundation for the Promotion of Health and Biomedical Research of Valencia Region, Valencia, Fisabio
- Network for Research on Chronicity Primary Care and Health Promotion (RICAPPS), Valencia, Fisabio
| | - Gabriel Sanfélix-Gimeno
- Health Services Research Unit, Foundation for the Promotion of Health and Biomedical Research of Valencia Region, Valencia, Fisabio
- Network for Research on Chronicity Primary Care and Health Promotion (RICAPPS), Valencia, Fisabio
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Kavanagh K, Tallian K, Sepulveda JA, Rojas S, Martin S, Sikand H. Do buprenorphine doses and ratios matter in medication assisted treatment adherence? Ment Health Clin 2022; 12:241-246. [PMID: 36071736 PMCID: PMC9405633 DOI: 10.9740/mhc.2022.08.241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Buprenorphine (BUP), generally prescribed as buprenorphine/naloxone, is a key component of medication-assisted treatment (MAT) to manage opioid use disorder. Studies suggest higher doses of BUP increase treatment adherence. Routine urine drug screens (UDS) assist in monitoring MAT adherence via measurement of excreted BUP and its metabolite, norbuprenorphine (NBP). The clinical significance between BUP/NBP concentrations and their ratios for assessing adherence and substance use is not well-described. Methods We conducted a single-center, retrospective chart review of 195 clients age ≥18 years enrolled in a local MAT program from August 2017 to February 2021. Demographics, BUP doses, prescription history, and UDS results were collected. Participants were divided based on MAT adherence (<80% vs ≥80%) and median total daily dose (TDD) of BUP (≥16 mg vs <16 mg) in addition to pre- and post-COVID-19 cohorts. Results Median BUP/NBP urinary concentrations were significantly correlated with MAT adherence (P < .0001 for each) and a reduced percentage of positive UDS for opioids (P = .0004 and P < .0001, respectively) but not their ratios. Median TDD of BUP ≥16 mg (n = 126) vs <16 mg (n = 68) was not correlated with MAT adherence (P = .107) or incidence of nonprescription use (P = .117). A significantly higher incidence of UDS positive for opiates (P = .049) and alcohol (P = .035) was observed post-COVID-19. Discussion Clients appearing adherent to MAT who had higher concentrations of urinary BUP/NBP demonstrated a reduced incidence of opioid-positive UDS independent of the BUP dose prescribed. An increase in opioid- and alcohol-positive UDSs were observed during the COVID-19 pandemic.
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Affiliation(s)
- Kevin Kavanagh
- 1 Clinical Psychiatric Pharmacist, Health and human Services Agency Pharmacy, San Diego County Psychiatry Hospital, San Diego, California
| | | | - Joe A. Sepulveda
- 3 Chief of Psychiatry and Medical Director, Substance Use Disorder Services, Family Health Centers of San Diego, San Diego, California
| | - Sarah Rojas
- 4 Family Medicine Specialist, Family Health Centers of San Diego, San Diego, California
| | - Shedrick Martin
- 5 Clinical Pharmacist Specialist, Department of Pharmacy, Santa Rosa Memorial Hospital, Santa Rosa, California
| | - Harminder Sikand
- 6 Director of Clinical Services and Residency Programs, Department of Pharmacy, Scripps Mercy Hospital, San Diego, California
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Evans EA, Delorme E, Cyr KD, Geissler KH. The Massachusetts public health data warehouse and the opioid epidemic: A qualitative study of perceived strengths and limitations for advancing research. Prev Med Rep 2022; 28:101847. [PMID: 35669857 PMCID: PMC9166413 DOI: 10.1016/j.pmedr.2022.101847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 05/24/2022] [Accepted: 05/28/2022] [Indexed: 12/17/2022] Open
Abstract
The Massachusetts Public Health Data Warehouse is a public health innovation. We assessed the utility of this big data resource for research on the opioid epidemic. Big data have many advantages and limitations for opioid epidemic research. Findings can help to maximize the advantages of big data and avoid inappropriate use. Lessons learned can aid other states to establish big data for public health.
Due to the opioid overdose epidemic, Massachusetts created a Public Health Data Warehouse, encompassing individually-linked administrative data on most of the population as provided by more than 20 systems. As others seek to assemble and mine big data on opioid use, there is a need to consider its research utility. To identify perceived strengths and limitations of administrative big data, we collected qualitative data in 2019 from 39 stakeholders with knowledge of the Massachusetts Public Health Data Warehouse. Perceived strengths included the ability to: (1) detect new and clinically significant relationships; (2) observe treatments and services across institutional boundaries, broadening understanding of risk and protective factors, treatment outcomes, and intervention effectiveness; (3) use geographic-specific lenses for community-level health; (4) conduct rigorous “real-world” research; and (5) generate impactful findings that legitimize the scope and impacts of the opioid epidemic and answer urgent questions. Limitations included: (1) oversimplified information and imprecise measures; (2) data access and analysis challenges; (3) static records and substantial lag times; and (4) blind spots that bias or confound results, mask upstream or root causes, and contribute to incomplete understanding. Using administrative big data to conduct research on the opioid epidemic offers advantages but also has limitations which, if unrecognized, may undermine its utility. Findings can help researchers to capitalize on the advantages of big data, and avoid inappropriate uses, and aid states that are assembling big data to guide public health practice and policy.
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Affiliation(s)
- Elizabeth A Evans
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, MA, USA
| | - Elizabeth Delorme
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, MA, USA
| | - Karl D Cyr
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, MA, USA
| | - Kimberley H Geissler
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, MA, USA
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Coyne KS, Schnoll SH, Butler SF, Barsdorf AI, Currie BM, Mazière JY, Pierson RF, Porter LN, Franks CMJ, Farrar JT. Clinical scoring algorithm for the prescription opioid misuse and abuse questionnaire (POMAQ). Curr Med Res Opin 2022; 38:971-980. [PMID: 35437075 DOI: 10.1080/03007995.2022.2065139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE The Prescription Opioid Misuse and Abuse Questionnaire (POMAQ) was developed to identify prescription opioid misuse and abuse among patients with chronic pain. A clinical scoring algorithm was developed and refined to align with the patient experience. METHODS This study utilized data from the POMAQ validation study (3033-4, NCT02660606) conducted on a sample of patients with chronic pain living in the United States. The study was carried out in two phases. Two purposefully enriched patient samples, one for each phase, were created based on patient responses to select POMAQ items and the availability of urine and hair samples. Two clinical experts (SHS, SFB) reviewed patient data to classify prescription opioid use behavior. Classification differences were adjudicated by a third clinical expert (JTF). Comparisons were made between the final clinical classification determined by the experts and the proposed classification based on the POMAQ algorithm. RESULTS Sixty patients were included in Phase I (only POMAQ data) and 52 in Phase II (including POMAQ and ancillary sources [e.g. electronic medical records, urine toxicity screen]). Refinements were made to the POMAQ scoring algorithm following discussions with clinical experts to ensure it was clinically relevant. For both phases, classifications were reviewed and discussed to achieve maximal concordance of classifications across experts. The proposed scoring algorithm was then modified to maximize agreement with the expert interpretation of clinically relevant patient experiences. CONCLUSION The clinical scoring algorithm for the POMAQ was developed and refined to reflect clinically relevant patient behaviors identified by expert review. Future testing is needed to determine the sensitivity and specificity of this measure.
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Affiliation(s)
- Karin S Coyne
- Patient-Centered Research, Evidera, Bethesda, MD, USA
| | - Sidney H Schnoll
- Pharmaceutical Risk Management, Pinney Associates Inc, Bethesda, MD, USA
| | | | | | | | | | - Renee F Pierson
- Janssen Pharmaceutical Companies of Johnson and Johnson, Global Patient-reported Outcomes, Janssen Inc, Raritan, NJ, USA
| | - Leslie N Porter
- Real World Clinical Research, Health ResearchTx, Trevose, PA, USA
| | | | - John T Farrar
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
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Weiner SG, Hendricks MA, El Ibrahimi S, Ritter GA, Hallvik SE, Hildebran C, Weiss RD, Boyer EW, Flores DP, Nelson LS, Kreiner PW, Fischer MA. Opioid-related overdose and chronic use following an initial prescription of hydrocodone versus oxycodone. PLoS One 2022; 17:e0266561. [PMID: 35381052 PMCID: PMC8982846 DOI: 10.1371/journal.pone.0266561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 03/22/2022] [Indexed: 11/18/2022] Open
Abstract
Background
Hydrocodone and oxycodone are prescribed commonly to treat pain. However, differences in risk of opioid-related adverse outcomes after an initial prescription are unknown.
This study aims to determine the risk of opioid-related adverse events, defined as either chronic use or opioid overdose, following a first prescription of hydrocodone or oxycodone to opioid naïve patients.
Methods
A retrospective analysis of multiple linked public health datasets in the state of Oregon. Adult patients ages 18 and older who a) received an initial prescription for oxycodone or hydrocodone between 2015–2017 and b) had no opioid prescriptions or opioid-related hospitalizations or emergency department visits in the year preceding the prescription were followed through the end of 2018. First-year chronic opioid use was defined as ≥6 opioid prescriptions (including index) and average ≤30 days uncovered between prescriptions. Fatal or non-fatal opioid overdose was indicated from insurance claims, hospital discharge data or vital records.
Results
After index prescription, 2.8% (n = 14,458) of individuals developed chronic use and 0.3% (n = 1,480) experienced overdose. After adjustment for patient and index prescription characteristics, patients receiving oxycodone had lower odds of developing chronic use relative to patients receiving hydrocodone (adjusted odds ratio = 0.95, 95% confidence interval (CI) 0.91–1.00) but a higher risk of overdose (adjusted hazard ratio (aHR) = 1.65, 95% CI 1.45–1.87). Oxycodone monotherapy appears to greatly increase the hazard of opioid overdose (aHR 2.18, 95% CI 1.86–2.57) compared with hydrocodone with acetaminophen. Oxycodone combined with acetaminophen also shows a significant increase (aHR 1.26, 95% CI 1.06–1.50), but not to the same extent.
Conclusions
Among previously opioid-naïve patients, the risk of developing chronic use was slightly higher with hydrocodone, whereas the risk of overdose was higher after oxycodone, in combination with acetaminophen or monotherapy. With a goal of reducing overdose-related deaths, hydrocodone may be the favorable agent.
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Affiliation(s)
- Scott G. Weiner
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - Michelle A. Hendricks
- Division of Research and Evaluation, Comagine Health, Portland, Oregon, United States of America
| | - Sanae El Ibrahimi
- Division of Research and Evaluation, Comagine Health, Portland, Oregon, United States of America
- Department of Epidemiology and Biostatistics, School of Public Health, University of Nevada, Las Vegas, Las Vegas, Nevada, United States of America
| | - Grant A. Ritter
- Brandeis University, Waltham, Massachusetts, United States of America
| | - Sara E. Hallvik
- Division of Research and Evaluation, Comagine Health, Portland, Oregon, United States of America
| | - Christi Hildebran
- Division of Research and Evaluation, Comagine Health, Portland, Oregon, United States of America
| | - Roger D. Weiss
- Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Psychiatry, McLean Hospital, Belmont, Massachusetts, United States of America
| | - Edward W. Boyer
- Department of Emergency Medicine, Ohio State University, Columbus, Ohio, United States of America
| | - Diana P. Flores
- Division of Research and Evaluation, Comagine Health, Portland, Oregon, United States of America
| | - Lewis S. Nelson
- Department of Emergency Medicine Rutgers New Jersey Medical School, Newark, New Jersey, United States of America
| | - Peter W. Kreiner
- Brandeis University, Waltham, Massachusetts, United States of America
| | - Michael A. Fischer
- Section of General Internal Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, United States of America
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