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Wen X, Brothers T, Ward KE, Kogut S. Reducing the risks of prenatal opioid exposure in children. BMJ 2024; 385:q803. [PMID: 38658037 DOI: 10.1136/bmj.q803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Affiliation(s)
- Xuerong Wen
- Pharmacy Practice and Clinical Research, College of Pharmacy, University of Rhode Island, Kingston, RI, USA
| | - Todd Brothers
- Pharmacy Practice and Clinical Research, College of Pharmacy, University of Rhode Island, Kingston, RI, USA
| | - Kristina E Ward
- Pharmacy Practice and Clinical Research, College of Pharmacy, University of Rhode Island, Kingston, RI, USA
| | - Stephen Kogut
- Pharmacy Practice and Clinical Research, College of Pharmacy, University of Rhode Island, Kingston, RI, USA
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Taha SA, Westra JR, Tacker DH, Raji MA, Kuo YF. Trends in co-prescribed opioids and benzodiazepines, non-prescribed opioids and benzodiazepines, and schedule-I drugs in the United States, 2013 to 2019. Prev Med Rep 2024; 38:102584. [PMID: 38292029 PMCID: PMC10827545 DOI: 10.1016/j.pmedr.2023.102584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 08/22/2023] [Accepted: 12/27/2023] [Indexed: 02/01/2024] Open
Abstract
Concurrent opioid and benzodiazepine users are at increased risk of overdose death, compared to opioid-only users. The objective of this study was to understand recent time trends in opioid and benzodiazepine concurrent use, misuse, and schedule-I drug use, and how these differ by age, sex and geographic region. Commercial, United States medical insurance claims data and urine drug test results from 2013 to 2019 were used to study the outcomes of concurrent use (n = 756,258), schedule-I drug use (n = 746,672) and prescription misuse (n = 452,523). Drug use outcomes were studied at quarterly time points for each year. Data analysis included joinpoint regression models to estimate quarterly drug use rates, determined by positive urine tests for corresponding drug categories, and was conducted from November 2021 through January 2022. Concurrent use decreased from 19.3% to 9.8%, misuse generally decreased from 75.6% to 55.1%, and schedule-I use increased from 8.9% to 13.8%, from 2013 to 2019. Concurrent use decreased at greater rates after 2016, after the Centers for Disease Control and Food and Drug Administration guidelines against concurrent use were released, while schedule-I use increased, notably after the 2014 hydrocodone reschedule. This indicates a potential shift from prescription use to non-prescribed drug use, where most affected groups included males, younger individuals, and those residing in Northeastern regions. Study results support public health initiatives focused on policy that increases access to multimodal pain management and substance use disorder management programs-critical steps in preventing patients from seeking non-prescribed drugs for self- medicating due to pain or addiction.
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Affiliation(s)
- Shaden A. Taha
- Center for Metabolic Health, University of Texas Medical Branch, Galveston, TX, USA
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, TX, USA
| | - Jordan R. Westra
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, TX, USA
- Office of Biostatistics, University of Texas Medical Branch, Galveston, TX, USA
| | - Danyel H. Tacker
- Department of Pathology, Anatomy, and Laboratory Medicine, West Virginia University, WV, USA
| | - Mukaila A. Raji
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX, USA
| | - Yong-Fang Kuo
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, TX, USA
- Office of Biostatistics, University of Texas Medical Branch, Galveston, TX, USA
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX, USA
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Yan CH, Hubbard CC, Lee TA, Sharp LK, Evans CT, Calip GS, Rowan SA, McGregor JC, Gellad WF, Suda KJ. Impact of Hydrocodone Rescheduling on Dental Prescribing of Opioids. JDR Clin Trans Res 2023; 8:402-412. [PMID: 35708454 DOI: 10.1177/23800844221102830] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION In the United States, dentists frequently prescribe hydrocodone. In October 2014, the US Drug Enforcement Administration rescheduled hydrocodone from controlled substance schedule III to II, introducing more restricted prescribing and dispensing regulations, which may have changed dental prescribing of opioids. OBJECTIVE The study aim was to evaluate the impact of the hydrocodone rescheduling on dental prescribing of opioids in the United States. METHODS This was a cross-sectional study of opioids prescribed by dentists between October 2012 and October 2016, using the IQVIA Longitudinal Prescription Dataset. Monthly dentist-based opioid prescribing rate (opioid prescription [Rx]/1,000 dentists) and monthly average opioid dosages per prescription (mean morphine milligram equivalent per day [MME/d]) were measured in the 24 mo before and after hydrocodone rescheduling in October 2014 (index or interruption). An interrupted time-series analysis was conducted using segmented ordinary least square regression models, with Newey-West standard errors to handle autocorrelation. RESULTS Dentists prescribed 50,412,942 opioid prescriptions across the 49 mo. Hydrocodone was the most commonly prescribed opioid pre- and postindex (74.9% and 63.8%, respectively), followed by codeine (13.8% and 21.6%), oxycodone (8.1% and 9.5%), and tramadol (2.9% and 4.8%). At index, hydrocodone prescribing immediately decreased by -834.8 Rx/1,000 dentists (95% confidence interval [CI], -1,040.2 to -629.4), with increased prescribing of codeine (421.9; 95% CI, 369.7-474.0), oxycodone (85.3; 95% CI, 45.4-125.2), and tramadol (111.8; 95% CI, 101.4-122.3). The mean MME increased at index for all opioids except for hydrocodone, and dosages subsequently decreased during the postindex period. CONCLUSION Following the rescheduling, dentist prescribing of hydrocodone declined while prescribing of nonhydrocodone opioids increased. Understanding the impact of this regulation informs strategies to ensure appropriate prescribing of opioids for dental pain. KNOWLEDGE TRANSFER STATEMENT The study findings can be used by policy makers to make informed decisions in developing future risk mitigation strategies aimed to regulate opioid prescribing behaviors. Furthermore, dentist-specific resources and guidelines are needed subsequent to these policies in order to meet the dental population needs.
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Affiliation(s)
- C H Yan
- Department of Pharmacy Systems, Outcomes, and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - C C Hubbard
- Department of Pharmacy Systems, Outcomes, and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - T A Lee
- Department of Pharmacy Systems, Outcomes, and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - L K Sharp
- Department of Pharmacy Systems, Outcomes, and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - C T Evans
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, IL, USA
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - G S Calip
- Department of Pharmacy Systems, Outcomes, and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - S A Rowan
- College of Dentistry, University of Illinois at Chicago, Chicago, IL, USA
| | - J C McGregor
- College of Pharmacy, Oregon State University, Portland, OR, USA
| | - W F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - K J Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Lawal OD, Meador KJ, Hume AL, Wen X. Utilization of Antiseizure Medications in Women of Childbearing Age With Epilepsy and Nonepilepsy Indications: A Retrospective Cohort Study. Neurology 2023; 101:e1083-e1096. [PMID: 37407266 PMCID: PMC10491435 DOI: 10.1212/wnl.0000000000207580] [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] [Received: 08/02/2022] [Accepted: 05/10/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Antiseizure medications (ASMs) are among the most commonly prescribed teratogenic drugs in women of childbearing age. Limited data exist on utilization patterns across different indications for therapy and for the newer-generation ASMs in this population. Thus, we assessed the pattern of ASM use in women of childbearing age with epilepsy and nonepilepsy indications (pain and psychiatric disorders). METHODS We conducted a retrospective analysis of deidentified administrative data submitted to the Optum Clinformatics database. Eligible participants included women aged 12-50 years who filled ASMs between year 2011 and 2017. Participants were followed from date of index prescription filled to study end or insurance disenrollment, whichever came first. For the overall cohort and potential therapy indications, we assessed the type and frequency of ASMs filled; proportion of participants on monotherapy, polytherapy, or treatment switching; and duration of continuous use. Trends were characterized using annual percent change from study start to study end. RESULTS Our analysis included 465,131 participants who filled 603,916 distinct ASM prescriptions. At baseline, most of the participants had chronic pain (51.0%) and psychiatric disorders (32.7%), with epilepsy the least common (0.9%). The most frequently dispensed were diazepam (24.3%), lorazepam (20.1%), gabapentin (17.4%), clonazepam (12.7%), topiramate (11.3%), and lamotrigine (4.6%). Significant linear increase in trends were observed with gabapentin (annual percent change [95% CI]: 8.4 [7.3-9.4]; p < 0.001) and levetiracetam (3.4 [0.7-6.2]; p = 0.022) and decreasing trends for diazepam (-3.5 [-2.4 to 4.5]; p < 0.001) and clonazepam (-3.4 [-2.3 to 4.5]; p = 0.001). No significant change in trend was observed with valproate (-0.4 [-2.7 to 1.9]; p = 0.651), while nonlinear changes in trends were observed with lorazepam, topiramate, lamotrigine, and pregabalin. DISCUSSION Decreasing trends were observed with older ASMs in the overall cohort and across the potential indications for therapy. Conversely, increasing trends were seen with the newer ASMs. Considering the risk of teratogenicity associated with the newer medications largely unknown, counseling and education in addition to a careful consideration of the benefits vs potential risks should remain pivotal when prescribing ASMs for women of childbearing age.
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Affiliation(s)
- Oluwadolapo D Lawal
- From the Department of Pharmacy Practice (O.D.L., A.L.H., X.W.), College of Pharmacy, University of Rhode Island, Kingstown; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University School of Medicine, CA
| | - Kimford J Meador
- From the Department of Pharmacy Practice (O.D.L., A.L.H., X.W.), College of Pharmacy, University of Rhode Island, Kingstown; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University School of Medicine, CA
| | - Anne L Hume
- From the Department of Pharmacy Practice (O.D.L., A.L.H., X.W.), College of Pharmacy, University of Rhode Island, Kingstown; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University School of Medicine, CA
| | - Xuerong Wen
- From the Department of Pharmacy Practice (O.D.L., A.L.H., X.W.), College of Pharmacy, University of Rhode Island, Kingstown; and Department of Neurology & Neurological Sciences (K.J.M.), Stanford University School of Medicine, CA.
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Covvey JR, Blakely ML, Singh R, Peckham AM, Evoy KE. Pharmacist, prescriber, and drug policy expert opinions on gabapentinoid misuse. Res Social Adm Pharm 2023; 19:599-609. [PMID: 36503683 DOI: 10.1016/j.sapharm.2022.12.001] [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: 08/23/2022] [Revised: 11/28/2022] [Accepted: 12/03/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gabapentinoids (gabapentin and pregabalin) are widely used in clinical practice, but recent evidence indicates that they carry an increased risk of misuse. As healthcare professionals (HCPs) and policymakers plan different strategies to promote harm reduction, it is important to understand different interested party viewpoints. OBJECTIVE To explore prescriber, pharmacist, and drug policy expert (DPE) awareness, opinions, and experiences regarding gabapentinoid misuse. METHODS A qualitative description study using individual semi-structured virtual interviews was conducted between February and April 2021. Participants included prescribers (physicians, physician assistants [PA], or nurse practitioners [NP]) and pharmacists practicing in outpatient, ambulatory, or community-based healthcare settings; individuals with relevant drug policy expertise were also included. Qualtrics (Provo, Utah) and Zoom (San Jose, California) were used to facilitate quantitative (for initial screening and participant characteristics) and qualitative (interview) data collection. Data were coded and organized into themes in NVivo (QSR International; Burlington, Massachusetts) using thematic analysis steps. RESULTS A total of 43 individuals participated in this study, including 16 (37.2%) pharmacists, 13 (30.2%) physicians, seven (16.3%) NPs, four (9.3%) DPEs, two (4.7%) pharmacist/DPEs, and one (2.3%) PA. Results were organized along four themes: (1) challenges/opportunities in gabapentinoid use; (2) gabapentinoid misuse awareness; (3) solutions to gabapentinoid misuse and (4) contributing barriers in pain management. Participants invoked different opinions in their consideration of gabapentinoid misuse, including the desire for harm reduction, the limitations of the current healthcare and insurance system, the lack of options for pain and substance use disorder treatment, and the influence of patient expectations. CONCLUSIONS Gabapentinoid misuse was commonly framed in comparative fashion to ongoing concerns with opioids, and proposed solutions often focused less on regulatory control and more toward patient and HCP education and an overhaul of the health system approach to substance use and healthcare overall.
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Affiliation(s)
- Jordan R Covvey
- Duquesne University School of Pharmacy, 600 Forbes Ave, Pittsburgh, PA, 15282, USA.
| | - Michelle L Blakely
- University of Wyoming School of Pharmacy, 1000 E University Ave, Laramie, WY, 82071, USA.
| | - Reshmi Singh
- University of Wyoming School of Pharmacy, 1000 E University Ave, Laramie, WY, 82071, USA.
| | - Alyssa M Peckham
- Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02115, USA.
| | - Kirk E Evoy
- The University of Texas at Austin College of Pharmacy, USA; UT Health San Antonio School of Medicine, 7703 Floyd Curl Drive - MC 6220; San Antonio, TX, 78229, USA.
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Stulberg JJ, Vu L, Huang R, Balbale SN, Yoo P, Tra P, Metcalfe LN. How Reclassification of Hydrocodone Combination Products Affects Dispensing. Hosp Pharm 2023. [DOI: 10.1177/00185787231155839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Affiliation(s)
- Jonah J. Stulberg
- University of Texas McGovern Medical School, Houston, TX, USA
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Department of Surgery & Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Lan Vu
- Health Care Service Corporation, Richardson, TX, USA
| | - Reiping Huang
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Department of Surgery & Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Salva N. Balbale
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Department of Surgery & Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL & Center of Innovation for Complex Chronic Healthcare, Health Services Research & Development, Edward Hines, Jr. VA Hospital, Hines, IL 60141, USA
| | - Phillip Yoo
- Health Care Service Corporation, Richardson, TX, USA
| | - Phiyen Tra
- Health Care Service Corporation, Richardson, TX, USA
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Olfson M, Waidmann T, King M, Pancini V, Schoenbaum M. Population-Based Opioid Prescribing and Overdose Deaths in the USA: an Observational Study. J Gen Intern Med 2023; 38:390-398. [PMID: 35657466 PMCID: PMC9905341 DOI: 10.1007/s11606-022-07686-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 05/20/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Rising opioid-related death rates have prompted reductions of opioid prescribing, yet limited data exist on population-level associations between opioid prescribing and opioid-related deaths. OBJECTIVE To evaluate population-level associations between five opioid prescribing measures and opioid-related deaths. DESIGN An ecological panel analysis was performed using linear regression models with year and commuting zone fixed effects. PARTICIPANTS People ≥10 years aggregated into 886 commuting zones, which are geographic regions collectively comprising the entire USA. MAIN MEASURES Annual opioid prescriptions were measured with IQVIA Real World Longitudinal Prescription Data including 76.5% (2009) to 90.0% (2017) of US prescriptions. Prescription measures included opioid prescriptions per capita, percent of population with ≥1 opioid prescription, percent with high-dose prescription, percent with long-term prescription, and percent with opioid prescriptions from ≥3 prescribers. Outcomes were age- and sex-standardized associations of change in opioid prescriptions with change in deaths involving any opioids, synthetics other than methadone, heroin but not synthetics or methadone, and prescription opioids, but not other opioids. KEY RESULTS Change in total regional opioid-related deaths was positively correlated with change in regional opioid prescriptions per capita (β=.110, p<.001), percent with ≥1 opioid prescription (β=.100, p=.001), and percent with high-dose prescription (β=.081, p<.001). Change in total regional deaths involving prescription opioids was positively correlated with change in all five opioid prescribing measures. Conversely, change in total regional deaths involving synthetic opioids was negatively correlated with change in percent with long-term opioid prescriptions and percent with ≥3 prescribers, but not for persons ≥45 years. Change in total regional deaths in heroin was not associated with change in any prescription measure. CONCLUSIONS Regional decreases in opioid prescriptions were associated with declines in overdose deaths involving prescription opioids, but were also associated with increases in deaths involving synthetic opioids (primarily fentanyl). Individual-level inferences are limited by the ecological nature of the analysis.
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Affiliation(s)
- Mark Olfson
- New York State Psychiatric Institute/Department of Psychiatry, Columbia University Vagelos College of Physicians & Surgeons, 1051 Riverside Drive, New York, NY, USA.
- Columbia University Mailman School of Public Health, New York, NY, USA.
| | | | - Marissa King
- School of Management, Yale University, New Haven, CT, USA
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Chiu K, Thow AM, Bero L. Understanding the Dynamics of More Restrictive Medicines Policy: A Case Study of Codeine Up-Scheduling in Australia. Int J Health Policy Manag 2022; 12:6872. [PMID: 37579455 PMCID: PMC10125097 DOI: 10.34172/ijhpm.2022.6872] [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: 10/19/2021] [Accepted: 11/19/2022] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND There has been increasing concern over opioid-related harms across the world. In Australia in 2018, codeine-containing products were up-scheduled from over-the-counter access at pharmacies, to requiring a prescription. The drug regulator's decision to up-schedule was contentious and widely debated, due to the potentially large impact on consumers and healthcare professionals. This study aimed to analyse influences on the codeine up-scheduling policy. METHODS This retrospective policy analysis used the Advocacy Coalition Framework (ACF) to understand how policy actors with shared beliefs formed adversarial coalitions to shape policy. Data were drawn from documents (regulator policy documents, public submissions, news reports, organisational media releases and position statements) and semi-structured interviews with 15 key policy actors. Codes were generated relating to policy processes and actor beliefs; broad themes included the role of health professionals, perceptions of opioids, impact on consumers, and the role of government in healthcare. RESULTS Two coalitions in this policy subsystem were identified: (1) supportive [with respect to the up-scheduling], and (2) opposing. The key evident beliefs of the supportive coalition were that the harms of codeine outweighed the benefits, and that government regulation was the best pathway for protecting consumers. The opposing coalition believed that the benefits of codeine accessible through pharmacists outweighed any harms, and consumers should manage their health without any more intervention than necessary. The policy decision reflected the influence of the supportive coalition, and this analysis highlighted the importance of their public health framing of the issue, the acceptability of their experts and supporting evidence, and the perceived legitimacy of the up-scheduling process. CONCLUSION Understanding these coalitions, their beliefs, and how they are translated through existing policy processes and institutions provides insight for those interested in influencing future health policy. Specific lessons include the importance of strategic frames and advocacy, and engagement with formal policy processes.
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Affiliation(s)
- Kellia Chiu
- School of Pharmacy, Faculty of Medicine and Health & Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - Anne Marie Thow
- Menzies Centre for Health Policy, School of Public Health, Faculty of Medicine and Health & Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - Lisa Bero
- Center for Bioethics and Humanities, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Johansson MS, Pottegård A, Søndergaard J, Englund M, Grønne DT, Skou ST, Roos EM, Thorlund JB. Chronic opioid use before and after exercise therapy and patient education among patients with knee or hip osteoarthritis. Osteoarthritis Cartilage 2022; 30:1536-1544. [PMID: 35988705 DOI: 10.1016/j.joca.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 07/10/2022] [Accepted: 08/01/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To investigate changes in opioid use after supervised exercise therapy and patient education among knee or hip osteoarthritis patients with chronic opioid use. METHOD In this cohort study, we linked data from the Good Life with osteoArthritis in Denmark register (GLA:D®; standardised treatment program for osteoarthritis; January 2013 to November 2018) with national health registries. Among 35,549 patients, 1,262 were classified as chronic opioid users based on amount and temporal distribution of dispensed opioids the year before the intervention. We investigated changes in opioid use, measured as mg oral morphine equivalents (OMEQs), from the year before the intervention to the year after using generalized estimating equations. RESULTS We found a 10% decrease in mg OMEQs from the year before to the year after the intervention (incidence rate ratio [IRR]: 0.90, 95% confidence interval [CI]: 0.86, 0.94). Additional analyses suggested this decrease to be mainly attributable to regulatory actions targeting opioid prescribing during the study period (IRR among patients participating in the intervention before: 0.98 [95% CI: 0.89, 1.07] vs after: 0.83 [0.74, 0.93] regulatory actions). In a random general population sample of matched chronic opioid users, a similar opioid use pattern was observed over time, further supporting the impact of regulatory actions on the opioid use in the study population. CONCLUSION Among patients with knee or hip osteoarthritis and chronic opioid use, a standardised treatment program did not change opioid use when regulatory changes in opioid prescribing were taken into account.
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Affiliation(s)
- M S Johansson
- Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark; Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark.
| | - A Pottegård
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark.
| | - J Søndergaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark.
| | - M Englund
- Clinical Epidemiology Unit, Orthopaedics, Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden.
| | - D T Grønne
- Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.
| | - S T Skou
- Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark; The Research Unit PROgrez, Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Slagelse, Denmark.
| | - E M Roos
- Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.
| | - J B Thorlund
- Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark; Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark.
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Smith JR, Salven S, Beÿ CK, Thihalolipavan S, Lev R, Koenig KL. Opioid-Prescribing Trends in San Diego County, 2008-2019. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2022; 28:264-271. [PMID: 34939599 DOI: 10.1097/phh.0000000000001456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
CONTEXT In 2019, drug overdoses accounted for 70 630 deaths in the United States, 70.6% of which involved an opioid. Approximately 28% of these deaths involved prescription medications, representing a significant number nationally. Local, state, and national efforts continue to address the impact of prescription medications within the ongoing opioid epidemic. OBJECTIVE This study examines trends in opioid prescription patterns from 2008 to 2019 in San Diego County, California, a major metropolitan area and the fifth most populous county in the United States. A timeline of events highlighting local, state, and national milestones is included to better contextualize distinct trends. DESIGN Collection and analysis of annual Prescription Drug Monitoring Program (PDMP) data for San Diego County. SETTING San Diego County, California. PARTICIPANTS Prescribing physicians using the Controlled Substance Utilization Review and Evaluation System (CURES 2.0), California's PDMP. MAIN OUTCOME MEASURES Prescribing data for all opioids were aggregated by formulation and strength and then converted into morphine milligram equivalents (MME) per person using CDC (Centers for Disease Control and Prevention) conversion guidelines and local population estimates. Additional outcomes analyzed include the number of prescriptions dispensed, number of pills per prescription, pill strength, and specific drug. RESULTS Total opioids prescribed increased by 29.7% from 2008 (399 MME per person) to 2012 (517 MME per person) and subsequently decreased by 54.4% from 2012 to 2019 (235 MME per person). The annual decrease in total MME from 2012 to 2019 averaged 5.9%. However, the 2-year decrease in MME from 2017 to 2019 was 35.1%, indicating an accelerated reduction in recent years. CONCLUSIONS Opioid-prescribing trends in San Diego County from 2008 to 2019 are defined by 2 distinct periods. These trends may serve as an example of how local, state, and national efforts focusing on prescriber outreach, patient education, and regulatory oversight can address the impact of prescription opioids on the ongoing opioid epidemic.
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Affiliation(s)
- Joshua R Smith
- Emergency Medical Services (Drs Smith and Koenig and Mr Beÿ) and Public Health Services (Dr Thihalolipavan), Health & Human Services Agency, County of San Diego, San Diego, California; San Diego State University, San Diego, California (Ms Salven); Emergency Department, Scripps Mercy Hospital, San Diego, California (Dr Lev)
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McCoy J, Nielsen S, Bruno R. A prospective cohort study evaluating the impact of upscheduling codeine in Australia among frequent users of codeine. Addiction 2022; 117:677-686. [PMID: 34490926 DOI: 10.1111/add.15683] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 08/18/2021] [Indexed: 12/11/2022]
Abstract
AIM To evaluate and document the impacts of re-scheduling codeine to a prescription-only medication in Australia in February 2018. DESIGN Prospective cohort study. Participants completed an on-line survey with a range of outcome measures at four time-points, once before codeine was re-scheduled (November 2017) and three times after the event: 1 month after (February 2018), 4 months after (June 2018) and 12 months after (February 2019). SETTING Australia. PARTICIPANTS Participants were 260 Australians aged 18 years and above who reported regular over-the-counter (OTC) codeine use and, at the time of the study, were not engaged in treatment for codeine dependence. MEASUREMENTS Survey measures included estimates of daily average codeine use (mg) and overall daily average opioid use [calculated using an oral morphine equivalent daily dose (OMEDD, mg)], opioid use disorder with regard to codeine use (using a modified Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV), pain and pain self-efficacy, anxiety and depression and health service use. FINDINGS A reduction in total daily codeine use (mg) from 64.3 mg [95% confidence interval (CI) = 46.7-81.9] in November 2017 (baseline) to 27.6 mg (95% CI = 19.2-36.0) in February 2019 (final time-point) was observed. A decline in the proportion of participants who met criteria for an opioid use disorder was also evident, with 51.2% (n = 133) at baseline relative to 33.3% (n = 58) at the 12-month follow-up. This study had an overall participant retention rate of 67% at the final time-point. CONCLUSION Re-scheduling codeine in Australia has been accompanied by significant reductions in codeine use and prevalence rates of opioid use disorder in a cohort of individuals who regularly use the medication, without apparent adverse impacts on pain or measures of anxiety and depression.
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Affiliation(s)
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Australia, 3199, Australia
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12
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Polychronopoulou E, Kuo YF, Wilkes D, Raji MA. Prescribing of Gabapentinoids with or without opioids after burn injury in the US, 2012-2018. Burns 2022; 48:293-302. [PMID: 34991930 PMCID: PMC9007844 DOI: 10.1016/j.burns.2021.12.006] [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: 06/01/2021] [Revised: 12/14/2021] [Accepted: 12/17/2021] [Indexed: 12/14/2022]
Abstract
Burn injury pain manifests as a combination of inflammatory, nociceptive, and neuropathic features. While opioids are the mainstay of burn pain management, non-opioid medications, such as gabapentinoids, have also been considered as they target the central nervous system. Increased opioid adverse events and overdose deaths in the United States led to the 2014 and 2016 guidelines to reduce opioid prescribing and consider alternatives, such as gabapentinoids. In the context of burn, the rate of gabapentinoid prescribing at the national level is unknown and it is unclear whether any shift has occurred in prescribing practices over time. We conducted a population level cohort study of adult burn patients from 2012 to 2018 to evaluate the rates and determinants of gabapentinoid prescribing, with and without opioids. Of 98,001 patients with burn, 22,521 (22.98%) received opioids and/or gabapentinoids (GABA). GABA represented 2.4% of prescriptions in 2012, but increased to 7.2% by 2018, while GABA-opioid co-prescriptions increased from 2.3% to 5.1%. The rate of increase in GABA prescriptions was higher for those aged 50-65 years or residing in the South. After adjustment, GABA was 44% more likely to be prescribed in 2017 and 2018 compared to 2012 and 2013, opioids were 38% less likely, while co-prescribing did not show a statistically significant change. Our study showed a modest increase in gabapentinoids' outpatient prescribing for burn patients after the 2014 and 2016 guidelines, indicating more opportunities for prescribers to expand non-opioid pain management in this population.
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Affiliation(s)
- Efstathia Polychronopoulou
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch,Division of Rehabilitation Sciences, University of Texas Medical Branch
| | - Yong-Fang Kuo
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch,Department of Internal Medicine, Division of Geriatrics and Palliative Medicine, University of Texas Medical Branch,Sealy Center on Aging, University of Texas Medical Branch,Institute for Translational Sciences, University of Texas Medical Branch
| | - Denise Wilkes
- Department of Anesthesiology, The University of Texas Medical Branch
| | - Mukaila A. Raji
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch,Department of Internal Medicine, Division of Geriatrics and Palliative Medicine, University of Texas Medical Branch,Sealy Center on Aging, University of Texas Medical Branch
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13
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Chen Y, Spillane S, Shiels MS, Young L, Quach D, Berrington de González A, Freedman ND. Trends in Opioid Use Among Cancer Patients in the United States: 2013-2018. JNCI Cancer Spectr 2022; 6:pkab095. [PMID: 35098020 PMCID: PMC8793171 DOI: 10.1093/jncics/pkab095] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/20/2021] [Accepted: 10/27/2021] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND In response to the US opioid epidemic, the Centers for Disease Control and Prevention updated their guideline on prescription opioids for chronic pain management in March 2016. The aim of this study was to provide detailed analysis of trends in opioid claims among cancer patients in the United States during 2013-2018. METHODS We analyzed pharmaceutical dispensing data from Symphony Health's Integrated Dataverse database, which covers approximately 80% of the US population. We examined annual trends in dispensed opioids in cancer patients during 2013-2018. We examined quarterly trends of the prevalence, mean number of days, and dose (stated as morphine milligram equivalents) of opioid dispensing in cancer patients. RESULTS Dispensing records of an average of over 3.7 million cancer patients contributed to the study annually in 2013-2018. The annual prevalence of opioid dispensing claims declined from 40.2% in 2013 to 34.5% in 2018. Annual declines occurred across cancer sites, and particularly among patients with metastatic cancer (decline of 19.8%), breast cancer (18.2%), and lung cancer (13.8%). By quarter, the prevalence of opioid claims declined statistically significantly from 26.6% in Q1 2013 to 21.2% in Q4 2018; this decline was more pronounced after Q3 2016 (2-sided P = .004). Both quarterly trends in mean days and morphine milligram equivalents of opioids supplied showed a gradual decline from 2013 to 2018, with a slightly larger decline after 2016. CONCLUSIONS We observed a decline in opioid use among cancer patients, particularly after 2016, coinciding with the publication of the Centers for Disease Control and Prevention's guideline on prescription opioids for chronic pain management.
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Affiliation(s)
- Yingxi Chen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Susan Spillane
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Meredith S Shiels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | | | | | | | - Neal D Freedman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
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14
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Duan WR, Hand DJ. Association between opioid overdose death rates and educational attainment - United States, 2010-2019. Prev Med 2021; 153:106785. [PMID: 34506817 DOI: 10.1016/j.ypmed.2021.106785] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 07/30/2021] [Accepted: 09/04/2021] [Indexed: 10/20/2022]
Abstract
Educational attainment may be an indicator of disparities in the ongoing opioid-overdose crisis. To understand the association between educational attainment and fatal opioid overdose, death records in the mortality files published by the Centers for Disease Control and Prevention (CDC) from 2010 to 2019 were analyzed. Proportionate mortality due to opioid overdose, PMOD, was used, as age-adjusted death rates suffer dual data-source errors caused by differences in educational data reported in death records and in population surveys. From 2013 to 2019, PMOD increased by 120% for the "less-than-high-school-diploma" (<HS) education group, whereas the increase was 60% and 30% for groups with bachelor's and graduate-level educations, respectively. Educational gradient was observed for both males and females, with PMOD for males higher than females. From 2013 to 2019, males and females with <HS education experienced 142% and 85% increases in PMOD, respectively, compared with the 94% and 26% increases for males and females, respectively, with BS education. The PMOD increase was primarily driven by synthetic opioids (ICD-10 code T40.4). From 2013 to 2019, for males with <HS education, PMOD related to T40.4 opioids increased by 19-fold, whereas the increase was more than 100-fold for adult Black males with <HS education. These results suggest that the impact of lower educational attainment may be getting worse and furthering inequities in health. Responses to the opioid-overdose epidemic should consider the large educational gradient. Extra attention to the most vulnerable groups is necessary.
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Affiliation(s)
- William R Duan
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States of America.
| | - Dennis J Hand
- Department of Obstetrics & Gynecology, Thomas Jefferson University, Philadelphia, PA, United States of America; Department of Psychiatry & Human Behavior, Thomas Jefferson University; Philadelphia, PA, United States of America
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15
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Polychronopoulou E, Raji MA, Wolf SE, Kuo YF. US national trends in prescription opioid use after burn injury, 2007 to 2017. Surgery 2021; 170:952-961. [PMID: 33472746 PMCID: PMC8285464 DOI: 10.1016/j.surg.2020.12.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/30/2020] [Accepted: 12/09/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Opioid misuse and overdose in the United States remain a public health emergency. Overprescribing has been recognized as a significant contributor to the epidemic. Opioids are the mainstay for pain management after burn; however, to date, no large-scale nationally representative study has evaluated outpatient opioid prescribing practices in this population. METHODS A retrospective study was conducted of patients up to 65 years old with burn injuries between 2007 and 2017 using national commercial insurance data. The primary outcome was initial opioid prescribing after burn injury. Secondary outcomes were total days' supply, oral daily morphine milligram equivalents, and number of refills. RESULTS Of the 140,753 patients with burns, 34,685 (24.6%) received an opioid prescription. The odds of prescription opioid use were lower in 2015, 2016, and 2017 compared with 2007. Interactions with age, severity (P < .0001), and region (P = .003) showed significant variation in rates of decline from 2007 to 2017, with the steepest decline in those aged <20 and in residents of Northeast United States. Prescribing rates remained stable over time among those with more severe burn injuries. The significant decline in daily opioid morphine milligram equivalents after 2013 was paralleled by an increase in days of supply (P values <.005). The odds of refill declined in 2016 and 2017. CONCLUSION While opioid prescribing after burn has declined in the past decade, significant variation remains among regions and age groups, suggesting a need to develop uniform guidelines to improve the quality of opioid prescribing and pain management protocols in burn patients.
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Affiliation(s)
- Efstathia Polychronopoulou
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, TX; Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX
| | - Mukaila A Raji
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, TX; Department of Internal Medicine, Division of Geriatrics and Palliative Medicine, University of Texas Medical Branch, Galveston, TX; Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX
| | - Steven E Wolf
- Division of Burn and Trauma Surgery, Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Yong-Fang Kuo
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, TX; Department of Internal Medicine, Division of Geriatrics and Palliative Medicine, University of Texas Medical Branch, Galveston, TX; Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX; Institute for Translational Sciences, University of Texas Medical Branch, Galveston, TX.
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16
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Lowe H, Toyang N, Steele B, Bryant J, Ngwa W. The Endocannabinoid System: A Potential Target for the Treatment of Various Diseases. Int J Mol Sci 2021; 22:9472. [PMID: 34502379 PMCID: PMC8430969 DOI: 10.3390/ijms22179472] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/23/2021] [Accepted: 08/26/2021] [Indexed: 02/06/2023] Open
Abstract
The Endocannabinoid System (ECS) is primarily responsible for maintaining homeostasis, a balance in internal environment (temperature, mood, and immune system) and energy input and output in living, biological systems. In addition to regulating physiological processes, the ECS directly influences anxiety, feeding behaviour/appetite, emotional behaviour, depression, nervous functions, neurogenesis, neuroprotection, reward, cognition, learning, memory, pain sensation, fertility, pregnancy, and pre-and post-natal development. The ECS is also involved in several pathophysiological diseases such as cancer, cardiovascular diseases, and neurodegenerative diseases. In recent years, genetic and pharmacological manipulation of the ECS has gained significant interest in medicine, research, and drug discovery and development. The distribution of the components of the ECS system throughout the body, and the physiological/pathophysiological role of the ECS-signalling pathways in many diseases, all offer promising opportunities for the development of novel cannabinergic, cannabimimetic, and cannabinoid-based therapeutic drugs that genetically or pharmacologically modulate the ECS via inhibition of metabolic pathways and/or agonism or antagonism of the receptors of the ECS. This modulation results in the differential expression/activity of the components of the ECS that may be beneficial in the treatment of a number of diseases. This manuscript in-depth review will investigate the potential of the ECS in the treatment of various diseases, and to put forth the suggestion that many of these secondary metabolites of Cannabis sativa L. (hereafter referred to as "C. sativa L." or "medical cannabis"), may also have potential as lead compounds in the development of cannabinoid-based pharmaceuticals for a variety of diseases.
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Affiliation(s)
- Henry Lowe
- Biotech R & D Institute, University of the West Indies, Mona 99999, Jamaica; (H.L.); (J.B.)
- Vilotos Pharmaceuticals Inc., Baltimore, MD 21202, USA;
- Flavocure Biotech Inc., Baltimore, MD 21202, USA
- Department of Medicine, University of Maryland Medical School, Baltimore, MD 21202, USA
| | - Ngeh Toyang
- Vilotos Pharmaceuticals Inc., Baltimore, MD 21202, USA;
- Flavocure Biotech Inc., Baltimore, MD 21202, USA
| | - Blair Steele
- Biotech R & D Institute, University of the West Indies, Mona 99999, Jamaica; (H.L.); (J.B.)
| | - Joseph Bryant
- Biotech R & D Institute, University of the West Indies, Mona 99999, Jamaica; (H.L.); (J.B.)
| | - Wilfred Ngwa
- Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02215, USA;
- Johns Hopkins University School of Medicine, Baltimore, MD 21218, USA
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17
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Evoy KE, Peckham AM, Covvey JR, Tidgewell KJ. Gabapentinoid Pharmacology in the Context of Emerging Misuse Liability. J Clin Pharmacol 2021; 61 Suppl 2:S89-S99. [PMID: 34396549 DOI: 10.1002/jcph.1833] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 02/13/2021] [Indexed: 12/15/2022]
Abstract
This article will review the epidemiology and pharmacology of gabapentinoids (gabapentin and pregabalin) relevant to their emerging misuse potential and provide guidance for clinical and regulatory management. Gabapentinoids are γ-aminobutyric acid analogues that produce their therapeutic effects by inhibiting voltage-gated calcium channels and decreasing neurotransmitter release. Recently gabapentinoid prescribing and use have increased tremendously. Although traditionally thought to possess a favorable safety profile, gabapentinoid misuse has also risen significantly. Gabapentinoid misuse generally occurs in combination with other substances, most notably opioids, and may be for purposes of eliciting euphoric effects, enhancing the effects of other substances, or self-treating conditions such as withdrawal, pain, anxiety, or insomnia. Given its faster onset, increased bioavailability and potency, and nonsaturable absorption, pregabalin's pharmacokinetics theoretically enhance its misuse liability versus gabapentin. However, gabapentin can produce similar euphoric effects, and epidemiologic studies have identified higher rates of gabapentin misuse in the United States, likely because of greater availability and less regulated prescribing. Although adverse events of gabapentinoid-only ingestion are relatively benign, a growing body of evidence indicates that gabapentinoids significantly increase opioid-related morbidity and mortality when used concomitantly. In addition, significant withdrawal effects may occur on abrupt discontinuation. As a result of these trends, several US states have begun to further regulate gabapentinoid prescribing, reclassifying it as a controlled substance or mandating reporting to local prescription drug-monitoring programs. Although increased regulation of gabapentin prescribing may be warranted, harm reduction efforts and increased patient and provider education are necessary to mitigate this concerning gabapentinoid misuse trend.
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Affiliation(s)
- Kirk E Evoy
- The University of Texas at Austin College of Pharmacy, Austin, Texas, USA.,University Health System, San Antonio, Texas, USA
| | - Alyssa M Peckham
- School of Pharmacy, Northeastern University, Boston, Massachusetts, USA.,Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jordan R Covvey
- Duquesne University School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Kevin J Tidgewell
- Duquesne University School of Pharmacy, Pittsburgh, Pennsylvania, USA
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Mehta HB, Kuo YF, Raji MA, Westra J, Boyd C, Alexander GC, Goodwin JS. State Variation in Chronic Opioid Use in Long-Term Care Nursing Home Residents. J Am Med Dir Assoc 2021; 22:2593-2599.e4. [PMID: 34022153 DOI: 10.1016/j.jamda.2021.04.016] [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: 12/10/2020] [Revised: 04/07/2021] [Accepted: 04/13/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Policies and regulations on opioid use have evolved from being primarily state-to federally based. We examined the trends and variation in chronic opioid use among states and nursing homes. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS We used the nursing home Minimum Data Set and Medicare claims from 2014 to 2018 and included long-term care nursing home residents from each year who had at least 120 days of consecutive stay. MEASUREMENTS Chronic opioid use was defined as use for ≥90 days. Three-level hierarchical logistic regression models (resident, nursing home, state) were constructed to estimate intraclass correlation coefficient (ICC) at the state level and at the nursing home level. The ICC shows the proportion of variation in chronic opioid use that is attributable to states or nursing homes. All models were constructed separately for each calendar year and controlled for resident, nursing home, and state characteristics. RESULTS We included 3,245,714 nursing home stays from 2014 to 2018, representing 1,502,131 unique residents. The stays ranged from 676,413 in 2014 to 594,874 in 2018, with residents contributing a maximum of 1 stay per year. Chronic opioid use among nursing home residents declined from 14.1% in 2014 to 11.4% in 2018. The variation (ICC) in chronic opioid use among states declined from 2.5% in 2014 to 1.7% in 2018. In contrast, the variation (ICC) among nursing homes increased from 5.6% in 2014 to 6.5% in 2018. CONCLUSIONS AND IMPLICATIONS Variation in chronic opioid use declined by one-third at the state level but not at the nursing home level. National guidelines on opioid use and federal policies on opioid use may have contributed to reducing state-level variation in chronic opioid use.
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Affiliation(s)
- Hemalkumar B Mehta
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Yong-Fang Kuo
- Office of Biostatistics, Department of Preventive Medicine and Population Health, University of Texas Medical Branch at Galveston, TX, USA
| | - Mukaila A Raji
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Jordan Westra
- Office of Biostatistics, Department of Preventive Medicine and Population Health, University of Texas Medical Branch at Galveston, TX, USA
| | - Cynthia Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - G Caleb Alexander
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - James S Goodwin
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
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Tucker J, Salas J, Zhang Z, Grucza R, Scherrer JF. Provider specialty and odds of a new codeine, hydrocodone, oxycodone and tramadol prescription before and after the CDC opioid prescribing guideline publication. Prev Med 2021; 146:106466. [PMID: 33636196 DOI: 10.1016/j.ypmed.2021.106466] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 02/15/2021] [Accepted: 02/20/2021] [Indexed: 11/19/2022]
Abstract
The CDC Guideline for Prescribing Opioids for Chronic Pain cautioned against high dose prescribing but did not provide guidance on type of opioid for new pain episodes. We determined if new prescriptions for Schedule II opioids vs. tramadol decreased in the 18 months after vs. before the CDC guideline and if this decrease was associated with physician specialty. New opioid prescriptions, provider type and covariates were measured using a nationally distributed, Optum® de-identified Electronic Health Record (EHR) data base. Eligible patients were free of cancer and HIV and started a new prescription for Schedule II opioids (i.e. codeine, hydrocodone, oxycodone) or Schedule IV (tramadol) in the 18 months before (n = 141,219) or 18 months after (n = 138,216) guideline publication. Fully adjusted multilevel multinomial models estimated the association between provider type (anesthesiology/pain medicine, surgical specialty, emergency, hospital, primary care, other specialty and unknown) before and after adjusting for covariates. New oxycodone prescriptions were most common among surgical and anesthesia/pain management, and new tramadol prescriptions were most common in primary care. The greatest decreases in odds of a Schedule II opioid vs. tramadol were observed in emergency care (oxycodone vs. tramadol OR = 0.82; 95%CI:0.76-0.88) and primary care (hydrocodone vs. tramadol OR = 0.85; 95%CI:0.81-0.89). Surgical specialists were least likely to start opioid therapy with tramadol. In the 18 months after vs. before the CDC guideline, emergency care and primary care providers increased tramadol prescribing. Guidelines tailored to specialists that frequently begin opioid therapy with oxycodone may enhance safe opioid prescribing.
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Affiliation(s)
- Jane Tucker
- Department of Family and Community Medicine, Saint Louis University School of Medicine, 1402 South Grand Blvd, St. Louis, MO 63104, United States of America
| | - Joanne Salas
- Department of Family and Community Medicine, Saint Louis University School of Medicine, 1402 South Grand Blvd, St. Louis, MO 63104, United States of America; AHEAD Institute, Saint Louis University School of Medicine, Salus Center, 4th Floor, 3545, Lafayette Ave., St. Louis, MO 63104, United States of America
| | - Zidong Zhang
- AHEAD Institute, Saint Louis University School of Medicine, Salus Center, 4th Floor, 3545, Lafayette Ave., St. Louis, MO 63104, United States of America
| | - Richard Grucza
- Department of Family and Community Medicine, Saint Louis University School of Medicine, 1402 South Grand Blvd, St. Louis, MO 63104, United States of America; AHEAD Institute, Saint Louis University School of Medicine, Salus Center, 4th Floor, 3545, Lafayette Ave., St. Louis, MO 63104, United States of America
| | - Jeffrey F Scherrer
- Department of Family and Community Medicine, Saint Louis University School of Medicine, 1402 South Grand Blvd, St. Louis, MO 63104, United States of America; AHEAD Institute, Saint Louis University School of Medicine, Salus Center, 4th Floor, 3545, Lafayette Ave., St. Louis, MO 63104, United States of America.
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20
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Wu A, Phan C, Nguyen KC, Quindoy M, Lewis J, Apollonio DE. Trends in hydrocodone combination product exposures reported to California Poison Control System (CPCS) following DEA rescheduling. Clin Toxicol (Phila) 2021; 59:313-319. [PMID: 32840386 PMCID: PMC7996450 DOI: 10.1080/15563650.2020.1803350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/22/2020] [Accepted: 07/23/2020] [Indexed: 10/23/2022]
Abstract
CONTEXT On October 6, 2014, the United States Drug Enforcement Administration (DEA) implemented a regulatory change for hydrocodone combination products (HCPs), moving them from Schedule III to II, in an effort to decrease drug overdoses. Existing research suggests this regulatory action reduced HCP prescribing and dispensing; however, there is limited research assessing its possible effects on overdoses and accidental exposures. OBJECTIVE To analyze the changes in opioid exposures reported to the California Poison Control System (CPCS) before and after DEA rescheduling of HCPs. METHODS We collected monthly exposure data reported to CPCS from 2012 to 2019 and conducted interrupted time series analyses to assess changes in exposures after rescheduling for HCPs, tramadol, oxycodone, morphine, codeine, fentanyl, and heroin. Additional analyses were done to assess any changes in exposures resulting in severe outcomes (moderate or major health effects). For HCPs, we also conducted logistic regressions to identify characteristics of exposures resulting in severe outcomes before and after rescheduling. RESULTS Overall monthly opioid exposures reported to CPCS decreased after DEA rescheduling of HCPs. These decreases were significant for HCP, tramadol, and morphine (p < 0.001). Exposures significantly increased for heroin and fentanyl (p < 0.001). There were no significant changes in the share of severe outcomes attributed to HCP exposures after rescheduling. DISCUSSION The DEA rescheduling of HCPs was associated with a significant decrease in HCP exposures and prescription opioid exposures overall, but was associated with increased fentanyl and heroin exposures. While other initiatives may have contributed to this decrease, our findings suggest that rescheduling may be a useful regulatory strategy to reduce drug exposures. CONCLUSION DEA rescheduling of HCPs was associated with a significant reduction in prescription opioid exposures, suggesting that rescheduling high-risk drugs may be an effective strategy to improve public health.
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Affiliation(s)
- Alice Wu
- Clinical Pharmacy, University of California, San Francisco, San Francisco, CA, USA
| | - Christine Phan
- Clinical Pharmacy, University of California, San Francisco, San Francisco, CA, USA
| | - Kim Chi Nguyen
- Clinical Pharmacy, University of California, San Francisco, San Francisco, CA, USA
| | - Melvin Quindoy
- Clinical Pharmacy, University of California, San Francisco, San Francisco, CA, USA
| | - Justin Lewis
- California Poison Control System - Sacramento Division, University of California Davis Medical Center, Sacramento, CA, USA
| | - Dorie E. Apollonio
- Clinical Pharmacy, University of California, San Francisco, San Francisco, CA, USA
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21
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Outcomes associated with scheduling or up-scheduling controlled substances. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 91:103110. [PMID: 33476862 DOI: 10.1016/j.drugpo.2021.103110] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/30/2020] [Accepted: 12/31/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Many nations place drugs into various "schedules" according to their risk of abuse and/or recognized medical value that vary in terms of their restrictions. To mitigate diversion or abuse, drugs sometimes get rescheduled or are scheduled for the first time. Until now, there have not been efforts to integrate lessons from across the range of such past events. METHODS AND DATA We searched for peer-reviewed evaluations of instances of (re-)scheduling drugs in the United States after 1969 and a comparably large set of instances from other countries. Those 109 articles were supplemented by 30 others found in other ways but not meeting those search criteria (e.g., because the information on rescheduling was a minor part of a more general article). FINDINGS Findings are reported for many outcomes and with diverse measures over different timelines, making standardization of outcomes difficult. For more than half of the events for which quantitative outcomes were reported, there were declines in use-related measures by at least 40 percent. It is common for there to be reports of increases in indicators pertaining to other substances, sometimes more dangerous but sometimes less dangerous; overall, substitution appears to occur, but be partial. CONCLUSION Scheduling and up-scheduling can - though does not always - have substantial effects on a range of outcomes. Substitution to other substances is a possibility and so should be anticipated.
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Gibson DC, Raji MA, Baillargeon JG, Kuo YF. Regional and temporal variation in receipt of long-term opioid therapy among older breast, colorectal, lung, and prostate cancer survivors in the United States. Cancer Med 2021; 10:1550-1561. [PMID: 33423372 PMCID: PMC7940244 DOI: 10.1002/cam4.3709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 11/04/2020] [Accepted: 12/18/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Older cancer survivors have high rates of long-term opioid therapy (≥90 days/year). However, the geographical and temporal variation in long-term opioid therapy rates for older cancer survivors is not known. METHODS A retrospective cohort study was conducted using SEER-Medicare data. Persons aged ≥66 years, diagnosed with breast, colorectal, lung, or prostate cancer from 1991 to 2011, and alive ≥5 years after diagnosis were included. Persons were followed from 1/1/2008 until 12/31/2016. Persons were assigned to a census region in their state of residence each year. Individuals who were covered by an opioid prescription for at least 90 days in a calendar year were classified as having received long-term opioid therapy. Multivariable analysis was conducted using generalized estimating equations. RESULTS Temporal trends significantly varied by region (p < 0.0001) and opioid-naïve status (p < 0.0001). Compared to 2013, opioid-naïve cancer survivors in the south and non-naïve survivors in the south and west experienced significant declines in long-term opioid therapy in 2015 and 2016. Significant declines were observed in 2016 for opioid-naïve and non-naïve cancer survivors residing in the northeast and among opioid-naïve cancer survivors living in the Midwest. CONCLUSION The annual trends in the receipt of long-term opioid therapy significantly varied by region among older cancer survivors. Variation in a clinical practice suggests the need for more research and interventions to improve efficiency, process, cost, and quality of care.
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Affiliation(s)
- Derrick C Gibson
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch - Galveston, Galveston, TX, USA
| | - Mukaila A Raji
- Division of Geriatrics and Palliative Medicine, Department of Internal Medicine, University of Texas Medical Branch - Galveston, Galveston, TX, USA
| | - Jacques G Baillargeon
- Department of Preventive Medicine and Population Health, Office of Biostatistics, University of Texas Medical Branch - Galveston, Galveston, TX, USA
| | - Yong-Fang Kuo
- Department of Preventive Medicine and Population Health, Office of Biostatistics, University of Texas Medical Branch - Galveston, Galveston, TX, USA
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Mueller SR, Glanz JM, Nguyen AP, Stowell M, Koester S, Rinehart DJ, Binswanger IA. Restrictive opioid prescribing policies and evolving risk environments: A qualitative study of the perspectives of patients who experienced an accidental opioid overdose. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 92:103077. [PMID: 33423916 DOI: 10.1016/j.drugpo.2020.103077] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/23/2020] [Accepted: 12/04/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Despite policy efforts to prevent overdose, accidental overdoses among individuals prescribed opioids continue to occur. Guided by Rhodes' Risk Environment Framework, we examined the unintended consequences of restrictive policies by identifying macro policy and micro-level contextual factors that patients prescribed opioids for pain identified as contributing to overdose events. METHODS Semi-structured interviews were conducted with 31 patients prescribed opioids who experienced an accidental opioid overdose between April 2017 and June 2019 in two health systems. RESULTS We identified three interrelated factors that emerged within an evolving risk environment and may have increased patients' vulnerability for an accidental opioid overdose: desperation from persistent pain and comorbidities; limited knowledge about opioid medication safety and effectiveness; and restrictive opioid prescribing policies that exacerbated stigma, fear and mistrust and prevented open patient-clinician communication. When experiencing persistent pain, patients took matters into their own hands by taking more medications or in different intervals than prescribed, mixing them with other substances, or using illicitly obtained opioids. CONCLUSION For some patients, macro-level policies and guidelines designed to reduce opioid overdoses by restricting opioid supply may have paradoxically created a micro-level risk environment that contributed to overdose events in a subset of patients.
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Affiliation(s)
- Shane R Mueller
- Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO 80237, USA.
| | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO 80237, USA; Department of Epidemiology, Colorado School of Public Health, 13001 E 17th Place, Mail Stop B-119, Aurora CO 80045, United States
| | - Anh P Nguyen
- Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO 80237, USA
| | - Melanie Stowell
- Center for Health Systems Research, Office of Research, Denver Health and Hospital Authority, 777 Bannock St, MC 6551 Denver, Colorado 80204, United States
| | - Stephen Koester
- Anthropology, Health & Behavioral Sciences, University of Colorado Denver, 777 Lawrence St, Denver, CO 80204, United States
| | - Deborah J Rinehart
- Center for Health Systems Research, Office of Research, Denver Health and Hospital Authority, 777 Bannock St, MC 6551 Denver, Colorado 80204, United States; Division of General Internal Medicine, University of Colorado School of Medicine, 13001 E 17th Place, Aurora CO 80045, United States
| | - Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO 80237, USA; Division of General Internal Medicine, University of Colorado School of Medicine, 13001 E 17th Place, Aurora CO 80045, United States; Colorado Permanente Medical Group, 10350 E. Dakota Ave, Denver CO 80247, United States
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Abstract
OBJECTIVE Opioid-related deaths are a leading cause of accidental deaths in the United States (U.S.). This study aims to examine the national trends in opioid exposures reported to U.S. poison centers (PCs). METHODS The National Poison Data System (NPDS) was queried for opioid exposures between 2011 and 2018. We descriptively assessed the demographic and clinical characteristics. Trends in opioid frequencies and rates were analyzed using Poisson regression. Independent predictors of serious adverse events in opioid exposures were studied. RESULTS There were a total of 604,183 opioid exposure calls made to the PCs during the study period. The frequency of opioid exposures decreased by 28.9% (95% CI: -29.6%, -28.1%; p < 0.001), and the rate of opioid exposures decreased by 21.2% (95% CI: -24.7%, -16.9%; p < 0.001). Multiple substance exposures accounted for 48.9% cases. The most frequent age group was 20-29 years (19.3%). Suspected suicides accounted for 34.9% cases. There were 7,246 deaths in our study sample, with 6.8% of cases demonstrating major effects. Hydrocodone was the most frequently observed opioid causing a toxic exposure and naloxone was used in 20.6% cases. Important predictors of a serious adverse event were age, gender, multi-substance exposures, and reasons for exposure. CONCLUSIONS Analysis of calls to PCs indicated a decreasing trend of opioid exposures. However, the proportion of SAEs due to such exposures increased. There was a high proportion of intentional exposures and occurred in older age groups. PCs are a vital component of real-time public health surveillance of overdoses in the current opioid crisis.
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Affiliation(s)
- Saumitra V Rege
- Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Moira Smith
- Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Heather A Borek
- Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Christopher P Holstege
- Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
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Usmani SA, Hollmann J, Goodin A, Hincapie-Castillo JM, Adkins LE, Ourhaan N, Oueini R, Bhagwandass H, Easey T, Vouri SM. Effects of hydrocodone rescheduling on opioid use outcomes: A systematic review. J Am Pharm Assoc (2003) 2020; 61:e20-e44. [PMID: 33127312 DOI: 10.1016/j.japh.2020.09.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/21/2020] [Accepted: 09/22/2020] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To evaluate opioid prescribing, dispensing, and use in relation to hydrocodone-containing product (HCP) rescheduling. METHODS Seven biomedical databases and grey literature sources were searched with keywords and database-specific controlled vocabulary relevant to HCP rescheduling for items published between January 2014 and July 2019. We included English-language quasi-experimental studies that assessed changes in HCP and other opioid prescribing, dispensing, utilization, and opioid-related health outcomes before and after HCP rescheduling. A data extraction sheet was created for this review. Two authors evaluated risk of bias for each included study. Two of 4 authors each independently extracted patient demographics and opioid-related outcomes from the included studies. Conflicts were resolved by a third author. RESULTS All studies identified (n = 44) were quasi-experimental in design with 10 using an interrupted time series approach. A total of 24 studies reported a decrease in HCP prescribing by 3.1%-66.0%. Six studies reported a decrease in HCP days' supply or doses by 14.0%-80.8%. There was increased prescribing of oxycodone-containing products by 4.5%-13.9% in 5 studies, tramadol by 2.7%-53.0% in 9 studies, codeine-containing products by 0.8%-1352.9% in 8 studies). Five studies reported a decrease in morphine equivalents by at least 10%, whereas 2 studies reported an increase in morphine equivalents. Differences in populations, sample sizes, and approaches did not allow for a meta-analysis. Details regarding approach and findings were limited in published conference abstracts (n = 16). CONCLUSIONS Hydrocodone rescheduling was associated with reductions in prescribing and use of HCPs but was also associated with increased prescribing and use of other opioids, both schedule II and nonschedule II.
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Sørensen AMS, Rasmussen L, Ernst MT, Mogensen SH, Laursen MV, Jimenez-Solem E, Pottegård A. Use of tramadol and other analgesics following media attention and risk minimization actions from regulators: a Danish nationwide drug utilization study. Eur J Clin Pharmacol 2020; 77:617-624. [PMID: 33112987 PMCID: PMC7935826 DOI: 10.1007/s00228-020-03016-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 10/07/2020] [Indexed: 12/23/2022]
Abstract
Purpose To describe the use of tramadol and other analgesics in Denmark focusing on the impact of media attention (June and December 2017) and regulatory actions (September 2017 and January 2018) on the use of tramadol. Methods Using nationwide registries, we identified all adults who filled a prescription for tramadol and other analgesics from 2014 to 2019. We described incidence rates, prevalence proportions, and total use of tramadol and other analgesics over time. We also described switching between analgesics, treatment duration, skewness in drug use, and doctor-shopping. Results From early 2017 until the end of 2019, total tramadol use decreased markedly while the use of morphine and oxycodone decreased slightly. The quarterly prevalence of tramadol use decreased from 32/1000 individuals in 2014 to 18/1000 at the end of 2019, dropping mainly at the time of media attention. Concomitantly, the quarterly prevalence increased for oxycodone (from 5.1 to 8.2) and morphine (from 8.5 to 9.8), mainly due to more short-term and sporadic users, and decreased for codeine (14 to 9.6). From 2014 to mid-2017, the incidence of tramadol use was stable (around 2.2/1000 person-months) but dropped in June 2017 to 1.7/1000, coinciding with the media attention. The incidence of tramadol use continued to decrease (to 1.1/1000 at the end of 2019). Conclusion We identified a decline in tramadol use coinciding with the media attention in 2017 and continuing during regulatory actions. There was generally no evidence of unintended effects on the utilization of opioids related to the media attention and regulatory actions. Electronic supplementary material The online version of this article (10.1007/s00228-020-03016-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Lotte Rasmussen
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, JB Winsløwsvej 19, 2, DK-5000, Odense, Denmark
| | - Martin Thomsen Ernst
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, JB Winsløwsvej 19, 2, DK-5000, Odense, Denmark
| | | | | | - Espen Jimenez-Solem
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark.,Copenhagen Phase IV unit (Phase4CPH), Department of Clinical Pharmacology and Center of Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark.,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Anton Pottegård
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, JB Winsløwsvej 19, 2, DK-5000, Odense, Denmark.
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Schuler MS, Heins SE, Smart R, Griffin BA, Powell D, Stuart EA, Pardo B, Smucker S, Patrick SW, Pacula RL, Stein BD. The state of the science in opioid policy research. Drug Alcohol Depend 2020; 214:108137. [PMID: 32652376 PMCID: PMC7423757 DOI: 10.1016/j.drugalcdep.2020.108137] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 06/09/2020] [Accepted: 06/18/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Characterize the state of the science in opioid policy research based on a literature review of opioid policy studies. METHODS We conducted a scoping review of studies evaluating the impact of U.S. state-level and federal-level policies on opioid-related outcomes published in 2005-2018. We characterized: 1) state and federal policies evaluated, 2) opioid-related outcomes examined, and 3) study design and analytic methods (summarized overall and by policy category). RESULTS In total, 145 studies were reviewed (79 % state-level policies, 21 % federal-level policies) and classified with respect to 8 distinct policy categories and 7 outcome categories. The majority of studies evaluated policies related to prescription opioids (prescription drug monitoring programs (PDMPs), opioid prescribing policies, federal regulation of prescription opioids, pain clinic laws) and considered policy impacts with respect to proximal outcomes (e.g., opioid prescribing behaviors). In total, only 29 (20 % of studies) met each of three key criteria for rigorous design: analysis of longitudinal data with a comparison group design, adjustment for difference between policy-enacting and comparison states, and adjustment for potentially confounding co-occurring policies. These more rigorous studies were predominately published in 2017-2018 and primarily evaluated PDMPs, marijuana laws, treatment-related policies, and overdose prevention policies. CONCLUSIONS Our results indicated that study design rigor varied notably across policy categories, highlighting the need for broader adoption of rigorous methods in the opioid policy field. More evaluation studies are needed regarding overdose prevention policies and policies related to treatment access. Greater examination of distal outcomes and potential unintended consequences are also warranted.
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Affiliation(s)
- Megan S Schuler
- RAND Corporation, 20 Park Plaza #920, Boston, MA, 02216, USA.
| | - Sara E Heins
- RAND Corporation, 4570 Fifth Ave #600, Pittsburgh, PA, 15213, USA
| | - Rosanna Smart
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401, USA
| | - Beth Ann Griffin
- RAND Corporation, 1200 S Hayes Street, Arlington, VA, 22202, USA
| | - David Powell
- RAND Corporation, 4570 Fifth Ave #600, Pittsburgh, PA, 15213, USA
| | - Elizabeth A Stuart
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
| | - Bryce Pardo
- RAND Corporation, 1200 S Hayes Street, Arlington, VA, 22202, USA
| | - Sierra Smucker
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401, USA
| | - Stephen W Patrick
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center 2200 Children's Way, 11111 Doctors' Office Tower, Nashville, TN, 37232, USA
| | - Rosalie Liccardo Pacula
- Schaeffer Center for Health Policy and Economics, University of Southern California, 635 Downey Way, Verna and Peter Dauterive Hall, Los Angeles, CA, 90089, USA
| | - Bradley D Stein
- RAND Corporation, 4570 Fifth Ave #600, Pittsburgh, PA, 15213, USA; Department of Psychiatry, University of Pittsburgh School of Medicine, 3811 O'Hara Street, Pittsburgh, PA, 15213, USA
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Liu Y, Baker O, Schuur JD, Weiner SG. Effects of Rescheduling Hydrocodone on Opioid Prescribing in Ohio. PAIN MEDICINE 2020; 21:1863-1870. [PMID: 31502638 DOI: 10.1093/pm/pnz210] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND We quantified opioid prescribing after the 2014 rescheduling of hydrocodone from schedule III to II in the United States using a state-wide prescription database and studied trends three years before and after the policy change, focusing on certain specialties. METHODS We used Ohio's state prescription drug monitoring program database, which includes all filled schedule II and III prescriptions regardless of payer or pharmacy, to conduct an interrupted time series analysis of the nine most prescribed opioids: hydrocodone, oxycodone, tramadol, codeine, and others. We analyzed hydrocodone prescribing trends for the physician specialties of internal medicine, anesthesiology, and emergency medicine. We evaluated trends 37 months before and after the rescheduling change. RESULTS Rescheduling was associated with a hydrocodone level change of -26,358 (95% confidence interval [CI] = -36,700 to -16,016) prescriptions (-5.8%) and an additional decrease in prescriptions of -1,568 (95% CI = -2,296 to -839) per month (-0.8%). Codeine prescribing temporarily increased, at a level change of 6,304 (95% CI = 3,003 to 9,606) prescriptions (18.5%), indicating a substitution effect. Hydrocodone prescriptions by specialty were associated with a level change of -805 (95% CI = -1,280 to -330) prescriptions (-8.5%) for anesthesiologists and a level change of -14,619 (95% CI = -23,710 to -5,528) prescriptions (-10.2%) for internists. There was no effect on prescriptions by emergency physicians. CONCLUSIONS The 2014 federal rescheduling of hydrocodone was associated with declines in hydrocodone prescriptions in Ohio beyond what had already been occurring, and hydrocodone may have been briefly substituted with codeine. These results indicate that rescheduling did have a lasting effect but affected prescribing specialties variably.
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Affiliation(s)
- Yingna Liu
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Olesya Baker
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jeremiah D Schuur
- Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
| | - Scott G Weiner
- Brigham and Women's Hospital, Boston, Massachusetts, USA
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Drug Enforcement Agency 2014 Hydrocodone Rescheduling Rule and Opioid Dispensing after Surgery. Anesthesiology 2020; 132:1151-1164. [PMID: 32101973 DOI: 10.1097/aln.0000000000003188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND In 2014, the U.S. Drug Enforcement Agency reclassified hydrocodone from Schedule III to Schedule II of the Controlled Substances Act, resulting in new restrictions on refills. The authors hypothesized that hydrocodone rescheduling led to decreases in total opioid dispensing within 30 days of surgery and reduced new long-term opioid dispensing among surgical patients. METHODS The authors studied privately insured, opioid-naïve adults undergoing 10 general or orthopedic surgeries between 2011 and 2015. The authors conducted a differences-in-differences analysis that compared overall opioid dispensing before versus after the rescheduling rule for patients treated by surgeons who frequently prescribed hydrocodone before rescheduling (i.e., patients who were functionally exposed to rescheduling's impact) while adjusting for secular trends via a comparison group of patients treated by surgeons who rarely prescribed hydrocodone (i.e., unexposed patients). The primary outcome was any filled opioid prescription between 90 and 180 days after surgery; secondary outcomes included the 30-day refill rate and the amount of opioids dispensed initially and at 30 days postoperatively. RESULTS The sample included 65,136 patients. The percentage of patients filling a prescription beyond 90 days was similar after versus before rescheduling (absolute risk difference, -1.1%; 95% CI, -2.3% to 0.1%; P = 0.084). The authors estimated the rescheduling rule to be associated with a 45.4-mg oral morphine equivalent increase (difference-in-differences estimate; 95% CI, 34.2-56.7 mg; P < 0.001) in initial opioid dispensing, a 4.1% absolute decrease (95% CI, -5.5% to -2.7%; P < 0.001) in refills within 30 days, and a 37.7-mg oral morphine equivalent increase (95% CI, 20.6-54.8 mg; P = 0.008) in opioids dispensed within 30 days. CONCLUSIONS Among patients treated by surgeons who frequently prescribed hydrocodone before the Drug Enforcement Agency 2014 hydrocodone rescheduling rule, rescheduling did not impact long-term opioid receipt, although it was associated with an increase in opioid dispensing within 30 days of surgery.
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Time Trends in Opioid Use by Dementia Severity in Long-Term Care Nursing Home Residents. J Am Med Dir Assoc 2020; 22:124-131.e1. [PMID: 32605815 DOI: 10.1016/j.jamda.2020.04.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 04/17/2020] [Accepted: 04/27/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Current information on opioid use in nursing home residents, particularly those with dementia, is unknown. We examined the temporal trends in opioid use by dementia severity and the association of dementia severity with opioid use in long-term care nursing home residents. DESIGN Repeated measures cross-sectional study. SETTING Long-term care nursing homes. PARTICIPANTS Using 20% Minimum Data Set (MDS) and Medicare claims from 2011-2017, we included long-term care residents (n = 734,739) from each year who had 120 days of consecutive stay. In a secondary analysis, we included residents who had an emergency department visit for a fracture (n = 12,927). MEASUREMENTS Dementia was classified as no, mild, moderate, and severe based on the first MDS assessment each year. In the 120 days of nursing home stay, opioid use was measured as any, prolonged (>90 days), and high-dose (≥90 morphine milligram equivalent dose/day). For residents with a fracture, opioid use was measured within 7 days after emergency department discharge. Association of dementia severity with opioid use was evaluated using logistic regression. RESULTS Overall, any opioid use declined by 8.5% (35.2% to 32.2%, P < .001), prolonged use by 5.0% (14.1% to 13.4%, P < .001), and high-dose by 21.4% (1.4% to 1.1%, P < .001) from 2011 to 2017. Opioid use declined across 4 dementia severity groups. Among residents with fracture, opioid use declined by 9% in mild, 9.5% in moderate, and 12.3% in severe dementia. The odds of receiving any, prolonged, and high-dose opioids decreased with increasing severity of dementia. For example, severe dementia reduced the odds of any [23.5% vs 47.6%; odds ratio (OR) 0.56, 95% confidence interval (CI) 0.55-0.57], prolonged (9.8% vs 20.7%; OR 0.69, 95% CI 0.67-0.71), and high-dose (1.0% vs 2.3%; OR 0.69, 95% CI 0.63-0.74) opioids. CONCLUSIONS AND IMPLICATIONS Use of opioids declined in nursing home residents from 2011 to 2017, and the use was lower in residents with dementia, possibly reflecting suboptimal pain management in this population.
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Miller CS, Ke C, Witty JT, Nagarajan R. Prescribing patterns of opioid analgesics in a dental setting: 2013-2018. Oral Surg Oral Med Oral Pathol Oral Radiol 2020; 130:402-410. [PMID: 32660860 DOI: 10.1016/j.oooo.2020.06.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/11/2020] [Accepted: 06/14/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Analgesic prescribing patterns are influenced by internal and external factors. Understanding these factors could help improve prescribing practices. STUDY DESIGN We conducted a retrospective analysis of electronic health records with regard to analgesic prescriptions written from 2013 through 2018 at the University of Kentucky College of Dentistry. Deidentified information (age, gender, dental procedures, analgesic drug, quantity, and refills) were recorded and studied with respect to national guidelines and recent state legislation using the χ2 test, analysis of variance, logistic regression, and multiple linear regression. RESULTS Opioids comprised 74.9% of the 17,099 analgesic prescriptions written. Extractions were most commonly associated with opioid prescriptions. Multivariate analysis showed that (1) older patients were more likely to receive an opioid prescription (P < .01) but with fewer pills (P < .01); (2) surgical extractions were associated with a lower opioid prescription rate (P < .01) but more opioid pills per prescription compared with nonsurgical extractions (P < .01); and (3) the odds of receiving an opioid prescription and the number of opioid pills prescribed decreased over year after release of the national guideline (P < .01) and after enactment of state legislation (P < .01). CONCLUSIONS Regulations and guidelines were associated with reduction in opioid prescriptions.
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Affiliation(s)
- Craig S Miller
- Division of Oral Diagnosis, Oral Medicine and Oral Radiology, University of Kentucky, College of Dentistry, Lexington, KY, USA.
| | - Chenlu Ke
- Department of Statistical Sciences and Operations Research, College of Humanities and Sciences, Virginia Commonwealth University, Richmond, Virginia
| | - Jeffrey T Witty
- Information Technology, University of Kentucky, College of Dentistry, Lexington, KY, USA
| | - Radha Nagarajan
- Center for Oral and Systemic Health, Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, WI, USA
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Fulton-Kehoe D, Lofy KH, Le V, Sterling R, Sears JM, Franklin G. Opioid-Prescribing Metrics in Washington State: Trends and Challenges. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2020; 26:214-221. [DOI: 10.1097/phh.0000000000001149] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Coyle DT, Woodworth TS, Moeny D, Staffa J, Meyer T, Woods C, Welch EC, Haynes K, Toh S, Maro JC. Concomitant Filled Prescriptions of Oxymorphone or Oxycodone with CYP3A Inhibitors and Inducers. J Manag Care Spec Pharm 2020; 26:668-672. [PMID: 32347183 PMCID: PMC10391052 DOI: 10.18553/jmcp.2020.26.5.668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Oxymorphone's metabolism does not involve the hepatic cytochrome P450 (CYP) system. The effect of this pharmacokinetic feature of oxymorphone on opioid prescribing is unknown. OBJECTIVE To assess the relative frequency with which oxymorphone and oxycodone (a CYP3A-metabolized opioid analgesic) were each prescribed to patients concomitantly receiving CYP3A-modifying drugs (i.e., inducers and inhibitors) to characterize opioid-prescribing patterns in patients at risk for CYP3A-related drug interactions. METHODS We analyzed the Sentinel Distributed Database from January 1, 2013, to December 31, 2016, to identify the proportion of patients with concomitant dispensing of selected CYP3A modifiers among initiators of oxymorphone. We then repeated the analysis using oxycodone instead of oxymorphone. We conducted sensitivity analyses that varied the washout periods for each opioid to account for potential opioid switching. RESULTS In the primary analysis, the proportion of patients with concomitant incident dispensings of oxymorphone and selected CYP3A modifiers was 3.26% (95% CI = 3.09%-3.43%), and the proportion of patients with incident dispensings of oxycodone and selected CYP3A modifiers was 2.82% (95% CI = 2.79%-2.85%). The difference between proportions was 0.43% (95% CI = 0.26%-0.60%). Sensitivity analyses that varied the washout periods for each opioid with respect to the other opioid to account for switching yielded similar results. CONCLUSIONS We observed similar proportions of patients using selected CYP3A modifiers concomitantly with both oxymorphone and oxycodone. While the CIs of the point estimates did not overlap, the absolute differences between the proportions were small. DISCLOSURES This project was supported by Task Order HHSF22301001T under Master Agreement HHSF223201400030I from the U.S. Food and Drug Administration (FDA). The FDA approved the study protocol, including the statistical analysis plan, and reviewed and approved the manuscript. Coauthors from the FDA participated in the results interpretation and in the preparation and decision to submit the manuscript for publication. Coyle, Money, Staffa, Meyer, and Woods are employed by the FDA. The other authors have no financial conflicts of interest to report. The views expressed are those of the authors and not necessarily those of the U.S. Department of Health and Human Services, U.S. Food and Drug Administration.
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Affiliation(s)
- D. Tyler Coyle
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Tiffany S. Woodworth
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - David Moeny
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Judy Staffa
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Tamra Meyer
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Corinne Woods
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Emily C. Welch
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | - Sengwee Toh
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Judith C. Maro
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
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Liaw V, Kuo YF, Raji MA, Baillargeon J. Opioid Prescribing Among Adults With Disabilities in the United States After the 2014 Federal Hydrocodone Rescheduling Regulation. Public Health Rep 2020; 135:114-123. [PMID: 31835012 DOI: 10.1177/0033354919892638] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Deaths from prescription opioid overdoses have reached an epidemic level in the United States, particularly among persons with disabilities. The 2014 federal rescheduling regulation is associated with reduced opioid prescribing in the general US population; however, to date, no data have been published on this regulation's effect on persons with disabilities. We examined whether the 2014 hydrocodone rescheduling change was associated with reduced opioid prescribing among adult Medicare beneficiaries with disabilities. METHODS We identified 680 876 Medicare beneficiaries with disabilities aged 21-64 in 2013 and 657 687 in 2015 from a 20% national sample. We examined changes in the monthly opioid-prescribing rates from January 1, 2013, through December 31, 2015. We also compared opioid-prescribing rates in 2013 with rates in 2015. RESULTS In 2014, the percentage of Medicare beneficiaries with disabilities who received hydrocodone prescriptions decreased by 0.154% per month (95% confidence interval [CI], -0.186 to -0.121, P < .001). The percentage of Medicare beneficiaries with disabilities who received hydrocodone prescriptions decreased from 32.2% in 2013 to 27.7% in 2015, whereas rates of any opioid prescribing, prolonged prescribing (≥90-day supply), and high-dose prescribing (≥100 morphine milligram equivalents per day for >30 days) decreased only modestly, from 50.2% to 49.0%, from 27.4% to 26.5%, and from 7.5% to 7.0%, respectively. CONCLUSIONS The 2014 federal rescheduling of hydrocodone was associated with only minor changes in overall and potentially high-risk opioid-prescribing rates. Neither state variation in long-term prescribing nor beneficiary characteristics explained the changes in persistently high opioid-prescribing rates among adults with disabilities after the 2014 regulation. Future studies should examine patient and provider characteristics underlying the persistent high-risk prescribing patterns in this population.
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Affiliation(s)
- Victor Liaw
- College of Natural Sciences, University of Texas at Austin, Austin, TX, USA
| | - Yong-Fang Kuo
- Department of Internal Medicine and Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX, USA.,Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX, USA.,Institute for Translational Science, University of Texas Medical Branch, Galveston, TX, USA.,Office of Biostatistics, University of Texas Medical Branch, Galveston, TX, USA
| | - Mukaila A Raji
- Department of Internal Medicine and Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX, USA.,Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX, USA
| | - Jacques Baillargeon
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX, USA.,Institute for Translational Science, University of Texas Medical Branch, Galveston, TX, USA.,Office of Biostatistics, University of Texas Medical Branch, Galveston, TX, USA
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Gibson DC, Chou LN, Raji MA, Baillargeon JG, Kuo YF. Opioid Prescribing Trends in Women Following Mastectomy or Breast-Conserving Surgery Before and After the 2014 Federal Reclassification of Hydrocodone. Oncologist 2020; 25:281-289. [PMID: 32297437 DOI: 10.1634/theoncologist.2019-0758] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 10/31/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Given concerns about suboptimal pain management for actively treated cancer patients following the 2014 federal reclassification of hydrocodone, we examined changes in patterns of opioid prescribing among surgical breast cancer patients. MATERIALS AND METHODS Data from a large nationally representative commercial health insurance program from 2009 to 2017 were used to identify women aged 18 years and older who were diagnosed with carcinoma in-situ or malignant breast cancer and received breast-conserving surgery or mastectomy from 2010 to 2016. Generalized linear mixed models were used to estimate the adjusted odds ratio (aOR) for receipt of ≥1-day, >30-day, or ≥ 90-day supply of opioids in the 12 months following surgery adjusting for demographics, cancer treatment-related characteristics, and preoperative opioid use. RESULTS A total of 60,080 patients were included in the study. Surgically treated breast cancer patients in 2015 (aOR = 0.90, 0.84-0.97) and 2016 (aOR = 0.80, 0.74-0.86) were less likely to receive ≥1-day supply of opioid prescriptions when compared with patients in 2013. Patients who had surgery in 2015 (aOR = 0.89, 0.81-0.98) and 2016 (aOR = 0.80, 0.73-0.87) were also less likely to receive >30-day supply of prescription opioids in the 12 months following surgery. However, only surgical breast cancer patients in 2016 were less likely to receive ≥90-day supply (aOR = 0.86, 0.76-0.98). CONCLUSION Surgically treated breast cancer patients are less likely to receive short- and long-term opioid prescriptions following the implementation of hydrocodone rescheduling. Further studies on the potential impact of federal policy on cancer patient pain management are needed. IMPLICATIONS FOR PRACTICE Clinicians and researchers with diverse perspectives should be included as stakeholders during policy development for restricting opioid prescriptions. Stakeholders can identify potential unintended consequences early and help identify methods to mitigate concerns, specifically as it relates to policy that influences how providers manage pain for actively treated cancer patients. This work shows how federal policy may have led to declines in opioid prescribing for breast cancer patients who underwent mastectomy or breast-conserving surgery.
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Affiliation(s)
- Derrick C Gibson
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch - Galveston, Galveston, Texas, USA
| | - Lin-Na Chou
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch - Galveston, Galveston, Texas, USA
- Office of Biostatistics, University of Texas Medical Branch - Galveston, Galveston, Texas, USA
| | - Mukaila A Raji
- Department of Internal Medicine, Division of Geriatrics, University of Texas Medical Branch - Galveston, Galveston, Texas, USA
| | - Jacques G Baillargeon
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch - Galveston, Galveston, Texas, USA
- Office of Biostatistics, University of Texas Medical Branch - Galveston, Galveston, Texas, USA
| | - Yong-Fang Kuo
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch - Galveston, Galveston, Texas, USA
- Office of Biostatistics, University of Texas Medical Branch - Galveston, Galveston, Texas, USA
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Cairns R, Schaffer AL, Brown JA, Pearson SA, Buckley NA. Codeine use and harms in Australia: evaluating the effects of re-scheduling. Addiction 2020; 115:451-459. [PMID: 31577369 DOI: 10.1111/add.14798] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 08/16/2019] [Accepted: 08/26/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Globally, codeine is the most-used opioid. In December 2016, Australia announced that low-strength codeine (≤ 15 mg) would be re-scheduled and no longer available for purchase over-the-counter; this was implemented in February 2018. We aimed to evaluate the effect of this scheduling change on codeine misuse and use and misuse of other opioids. DESIGN AND SETTING Interrupted time-series analysis of monthly opioid exposure calls to New South Wales Poisons Information Centre (NSWPIC, captures 50% of Australia's poisoning calls), January 2015- January 2019 and monthly national codeine sales, March 2015-March 2019. We incorporated a washout period (January 2017 - January 2018) between the announcement and implementation, when prescriber/consumer behaviour may have been influenced. PARTICIPANTS Intentional opioid overdoses resulting in a call to NSWPIC. MEASUREMENTS We used linear segmented regression to identify abrupt changes in level and slope of fitted lines. Codeine poisonings and sales were stratified into high strength (> 15 mg per dose unit) and low strength (≤ 15 mg). Only low-strength formulations were re-scheduled. FINDINGS We observed an abrupt -50.8 percentage [95% confidence interval (CI) = -79.0 to -22.6%] level change in monthly codeine-related poisonings and no change in slope in the 12 months after February 2018. There was no increase in calls to the NSWPIC for high-strength products, level change: -37.2% (95% CI = -82.3 to 8%) or non-codeine opioids, level change: -4.4% (95% CI = -33.3 to 24.4%). Overall, the re-scheduling resulted in a level change in opioid calls of -35.8% calls/month (95% CI = -51.2 to -20.4%). Low-strength codeine sales decreased by 87.3% (95% CI = -88.5 to -85.9%), with no increase in high-strength codeine sales in the 14 months following re-scheduling, -4.0% (95% CI = -19.6 to 14.6%). CONCLUSIONS Codeine re-scheduling in Australia appears to have reduced codeine misuse and sales.
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Affiliation(s)
- Rose Cairns
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, Australia.,NSW Poisons Information Centre, The Children's Hospital at Westmead, Sydney, Australia
| | - Andrea L Schaffer
- Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia
| | - Jared A Brown
- NSW Poisons Information Centre, The Children's Hospital at Westmead, Sydney, Australia.,Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia
| | - Sallie-Anne Pearson
- Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia
| | - Nicholas A Buckley
- NSW Poisons Information Centre, The Children's Hospital at Westmead, Sydney, Australia.,School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
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Lee WC, Hutchison RW, Lin S, Kuo YF. Patient Education on Opioid Storage, Security, and Disposal of Opioids: Should the Approach Differ in Rural and Urban Settings? TEXAS JOURNAL OF HEALTH-SYSTEM PHARMACY 2020; 19:46-51. [PMID: 33117995 PMCID: PMC7591146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PURPOSE The opioid crisis is devastating rural America, but findings of opioid utilization vary among previous studies. Previous studies were focused on misuse behaviors or overdose issues. This study will focus on the number of pills and prescriptions that rural and urban adults received. METHODS Using the adult data of the 2011-2016 Medical Expenditure Panel Survey, we compared rural-urban differences in likelihood of using opioids and actual utilization. Multivariate models were further adjusted for predisposing, enabling and need factors. RESULTS During 2011-2016, opioid utilization decreased in both urban and rural areas. However, rural adults were still more likely to have a prescription, and among users, rural adult prescription pill count was higher than urban counterparts. The rural-urban difference was not significant after adjusting for covariates, indicating that personal and contextual characteristics account for more variations in utilization than rurality. CONCLUSIONS Strategies to improve pain management without causing opioid addiction and overdose deaths are imperative. The findings of unadjusted analyses suggest: (1) providing counseling to teach rural adults to store opioids in a locked container, not share medication with others and safely dispose of unused pills; (2) reinforcing the mail-back program or giving patients a specially-designed package to neutralize the drugs; and (3) if a community-based drug-disposal program is not available, educating to remove labeling from the bottle, mix the drugs with an unpleasant substance, and place the drugs and unpleasant substance in the garbage separate from the bottle. The findings of adjusted analyses indicate that another study will be helpful to explore the associations between personal characteristics and opioid utilization in depth.
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Affiliation(s)
- Wei-Chen Lee
- Office of Health Policy and Legislative Affairs, The University of Texas Medical Branch, Galveston, Texas
| | - Robert W Hutchison
- Department of Pharmacy Practice, Texas A&M University, Irma Lerma Rangel College of Pharmacy, Round Rock, Texas
| | - Sherry Lin
- Department of Health Policy & Management, Texas A&M University, School of Public Health, College Station, Texas
| | - Yong-Fang Kuo
- Department of Preventive Medicine & Population Health, Office of Biostatistics, The University of Texas Medical Branch, Galveston, Texas
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Ighodaro EO, McCall KL, Chung DY, Nichols SD, Piper BJ. Dynamic changes in prescription opioids from 2006 to 2017 in Texas. PeerJ 2019; 7:e8108. [PMID: 31824762 PMCID: PMC6901007 DOI: 10.7717/peerj.8108] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 10/28/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The US is experiencing an epidemic of opioid overdoses which may be at least partially due to an over-reliance on opioid analgesics in the treatment of chronic non-cancer pain and subsequent escalation to heroin or illicit fentanyl. As Texas was reported to be among the lowest in the US for opioid use and misuse, further examination of this state is warranted. MATERIALS AND METHODS This study was conducted to quantify prescription opioid use in Texas. Data was obtained from the publicly available US Drug Enforcement Administration's Automation of Reports and Consolidated Orders System (ARCOS) which monitors controlled substances transactions from manufacture to commercial distribution. Data for 2006-2017 from Texas for ten prescription opioids including eight primarily used to relieve pain (codeine, fentanyl, hydrocodone, hydromorphone, meperidine, morphine, oxycodone, oxymorphone) and two (buprenorphine and methadone) for the treatment of an Opioid Use Disorder (OUD) were examined. RESULTS The change in morphine mg equivalent (MME) of all opioids (+23.3%) was only slightly greater than the state's population gains (21.1%). Opioids used to treat an OUD showed pronounced gains (+90.8%) which were four-fold faster than population growth. Analysis of individual agents revealed pronounced elevations in codeine (+387.5%), hydromorphone (+106.7%), and oxycodone (+43.6%) and a reduction in meperidine (-80.3%) in 2017 relative to 2006. Methadone in 2017 accounted for a greater portion (39.5%) of the total MME than hydrocodone, oxycodone, morphine, hydromorphone, oxymorphone, and meperidine, combined. There were differences between urban and rural areas in the changes in hydrocodone and buprenorphine. CONCLUSIONS Collectively, these findings indicate that continued vigilance is needed in Texas to appropriately treat pain and an OUD while minimizing the potential for prescription opioid diversion and misuse. Texas may lead the US in a return to pre-opioid epidemic prescription levels.
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Affiliation(s)
- Ebuwa O. Ighodaro
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA, United States of America
| | - Kenneth L. McCall
- Department of Pharmacy Practice, University of New England, Portland, ME, United States of America
| | - Daniel Y. Chung
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA, United States of America
| | - Stephanie D. Nichols
- Department of Pharmacy Practice, University of New England, Portland, ME, United States of America
- Department of Psychiatry, Tufts University, Medford, MA, United States of America
| | - Brian J. Piper
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA, United States of America
- Center for Pharmacy Innovation and Outcomes, Forty Fort, PA, United States of America
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V Subramaniam A, Salem Yehya AH, Oon CE. Molecular Basis of Cancer Pain Management: An Updated Review. MEDICINA (KAUNAS, LITHUANIA) 2019; 55:E584. [PMID: 31547335 PMCID: PMC6780247 DOI: 10.3390/medicina55090584] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 09/05/2019] [Accepted: 09/09/2019] [Indexed: 02/02/2023]
Abstract
Pain can have a significantly negative impact on the quality of life of patients. Therefore, patients may resort to analgesics to relieve the pain. The struggle to manage pain in cancer patients effectively and safely has long been an issue in medicine. Analgesics are the mainstay treatment for pain management as they act through various methods on the peripheral and central pain pathways. However, the variability in the patient genotypes may influence a drug response and adverse drug effects that follow through. This review summarizes the observed effects of analgesics on UDP-glucuronosyl (UGT) 2B7 isoenzyme, cytochrome P450 (CYP) 2D6, μ-opioid receptor μ 1 (OPRM1), efflux transporter P-glycoprotein (P-gp) and ATP-binding cassette B1 ABCB1/multiple drug resistance 1 (MDR1) polymorphisms on the mechanism of action of these drugs in managing pain in cancer. Furthermore, this review article also discusses the responses and adverse effects caused by analgesic drugs in cancer pain management, due to the inter-individual variability in their genomes.
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Affiliation(s)
- Ayappa V Subramaniam
- Institute for Research in Molecular Medicine (INFORMM), Universiti Sains Malaysia (USM), Pulau Pinang 11800, Malaysia.
| | - Ashwaq Hamid Salem Yehya
- Institute for Research in Molecular Medicine (INFORMM), Universiti Sains Malaysia (USM), Pulau Pinang 11800, Malaysia.
| | - Chern Ein Oon
- Institute for Research in Molecular Medicine (INFORMM), Universiti Sains Malaysia (USM), Pulau Pinang 11800, Malaysia.
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Cicero TJ. Is a Reduction in Access to Prescription Opioids the Cure for the Current Opioid Crisis? Am J Public Health 2019; 108:1322-1323. [PMID: 30207773 DOI: 10.2105/ajph.2018.304648] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Theodore J Cicero
- Theodore J. Cicero is with the Department of Psychiatry, Washington University, St. Louis, MO
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Impact of Schedule IV controlled substance classification on carisoprodol utilization in the United States: An interrupted time series analysis. Drug Alcohol Depend 2019; 202:172-177. [PMID: 31352307 DOI: 10.1016/j.drugalcdep.2019.05.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 05/15/2019] [Accepted: 05/19/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND In January 2012, the Drug Enforcement Agency (DEA) classified carisoprodol as a Schedule IV controlled substance at the US federal level. We aimed to examine the effect of this policy on the use of carisoprodol in a commercially-insured population. METHODS This interrupted time series study included individuals with musculoskeletal disorders in the IBM MarketScan Commercial Database between December 2009 and February 2014. We used comparative segmented linear regression to assess changes in the proportions of patients who filled/newly filled carisoprodol each month. RESULTS A total of 13.3 million patients were included. 29 states with no scheduling prior to the DEA classification had lower baseline prevalence of carisoprodol use compared to 17 states that had scheduled carisoprodol individually before 2010 (11.0 vs. 21.1 patients with fills per 1000 patients). The federal scheduling was associated with an immediate decline (-1.12 per 1000 patients, p < 0.01) and decreasing trend in prevalence (-0.07 per 1000 patients per month, p = 0.02). This effect was not modified by existing state-level scheduling status. During the first, second, third, and fourth 6-month periods after federal scheduling, the relative difference between observed and predicted prevalence was 7.8%, 10.5%, 13.4%, and 19.8%. Similar patterns were observed for carisoprodol initiation. Overall, declining use was more pronounced among younger age groups and patients with injury. CONCLUSIONS Schedule IV controlled substance classification at the federal level was associated with a moderate reduction in the dispensing of carisoprodol regardless of whether scheduling was already present at the state level.
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The opioid crisis is more than overdoses. JAAPA 2019; 32:11-12. [DOI: 10.1097/01.jaa.0000553623.91538.95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Shah R, Chou LN, Kuo YF, Raji MA. Long-Term Opioid Therapy in Older Cancer Survivors: A Retrospective Cohort Study. J Am Geriatr Soc 2019; 67:945-952. [PMID: 31026356 DOI: 10.1111/jgs.15945] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 03/29/2019] [Accepted: 04/01/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To examine the rates and predictors of long-term opioid therapy in older cancer survivors. DESIGN Retrospective cohort study. SETTING Texas, United States. PARTICIPANTS Cancer survivors (5 years or more postcancer diagnosis) diagnosed from 1995 to 2008 and who were also Medicare Parts A, B, and D beneficiaries. MEASUREMENTS We used Medicare Part D event data to calculate the proportion of cancer survivors with a prolonged opioid prescription (90-day or more supply of opioids/year). Adjusted odds ratios were calculated to identify predictors of prolonged opioid prescribing. All analyses were repeated with a subcohort of opioid-naïve cancer survivors. RESULTS The rate of prolonged opioid therapy for cancer patients diagnosed in 2008 was 7.1% prior to cancer diagnosis; it rose to 9.8% within a year of cancer treatments, and to 13.3% at 5 years postdiagnosis. The rate at the sixth year varied by cancer sites: 19.4% in lung cancer and 9.6% in prostate cancer. Among opioid-naïve survivors, the rate increased from 1.4% to 7.1%, from 5 to 18 years postcancer diagnosis. Cancer survivors diagnosed in 2004 to 2008 had higher rates of opioid prescribing compared to those diagnosed in 1995 to 1998 and 1999 to 2003. Years since diagnosis, a later year of diagnosis, female sex, urban location, lung cancer diagnosis, disability as reason for Medicare entitlement, Medicaid eligibility, one or more comorbidity, and history of depression or drug abuse were predictors of prolonged opioid therapy. Among opioid-naïve cancer survivors, diagnosis in 2004 to 2008 was the strongest predictor, while a history of drug abuse was the strongest predictor for all the survivors. CONCLUSION The rates of prolonged opioid prescribing for older cancer survivors remained high at 5 or more years after cancer diagnosis. Our findings have potential to inform the development of clinical guidelines and public policy to ensure safer and more effective pain treatment in older cancer survivors. J Am Geriatr Soc 67:945-952, 2019.
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Affiliation(s)
- Rahul Shah
- School of Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Lin-Na Chou
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas
| | - Yong-Fang Kuo
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas.,Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas.,Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas.,Institute for Translational Sciences, University of Texas Medical Branch, Galveston, Texas
| | - Mukaila A Raji
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas.,Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas.,Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas
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Geographic Variation in the Initiation of Commonly Used Opioids and Dosage Strength in United States Nursing Homes. Med Care 2019; 56:847-854. [PMID: 30113423 DOI: 10.1097/mlr.0000000000000972] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To examine and quantify geographic variation in the initiation of commonly used opioids and prescribed dosage strength among older US nursing home residents. METHODS We merged 2011 Minimum Data Set 3.0 to Medicare claims and facility characteristics data to conduct a cross-sectional study among long-stay nursing home residents who initiated short-acting opioids commonly used in nursing homes (oxycodone, hydrocodone, or tramadol). We examined geographic variation in specific opioids initiated and potentially inappropriate doses (≥50 mg oral morphine equivalent/d) across hospital referral regions (HRRs). Multilevel logistic models quantified the proportional change in between-HRR variation and associations between commonly initiated opioids and inappropriate doses after adjusting for resident characteristics, facility characteristics, and state. RESULTS Oxycodone (9.4%) was initiated less frequently than hydrocodone (56.2%) or tramadol (34.5%) but varied dramatically between HRRs (range, 0%-74.5%). In total, resident/facility characteristics and state of residence, respectively explained 84.1%, 58.2%, 59.1%, and 46.6% of the between-HRR variation for initiating oxycodone, hydrocodone, tramadol, and inappropriate doses. In all cases, state explained the largest proportion of between-HRR variation. Relative to hydrocodone, residents initiating oxycodone were more likely (adjusted odds ratio, 5.00; 95% confidence interval, 4.57-5.47) and those initiating tramadol were less likely (adjusted odds ratio, 0.28; 95% confidence interval, 0.25-0.31) to be prescribed potentially inappropriately high doses. CONCLUSIONS We documented extensive geographic variation in the opioid and dose initiated for nursing home residents, with state explaining the largest proportion of the observed variation. Further work is needed to understand potential drivers of opioid prescribing patterns at the state level.
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Steckler TJ, Mosher HJ, Desloover-Koch Y, Lund BC. Impact of hydrocodone reclassification on analgesic prescribing in the Veterans Health Administration. Am J Health Syst Pharm 2019; 76:S61-S67. [DOI: 10.1093/ajhp/zxy090] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 12/28/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Taylor J Steckler
- Department of Pharmacy Services, Iowa City VA Healthcare System, Iowa City, IA
| | - Hilary J Mosher
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Healthcare System, Iowa City, IA, and Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | | | - Brian C Lund
- Department of Pharmacy Services, Iowa City VA Healthcare System, Iowa City, IA, and Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Healthcare System, Iowa City, IA
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Murray BP, Carpenter JE, Dunkley CA, Moran TP, Alfaifi M, Alsukaiti WS, Kazzi Z. Seizures in tramadol overdoses reported in the ToxIC registry: predisposing factors and the role of naloxone. Clin Toxicol (Phila) 2019; 57:692-696. [DOI: 10.1080/15563650.2018.1547826] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Brian Patrick Murray
- Georgia Poison Center, Grady Hospital, Atlanta, GA, USA
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
- US Air Force, Air Force Institute of Technology, Wright Patterson AFB, Dayton, OH, USA
| | - Joseph E. Carpenter
- Georgia Poison Center, Grady Hospital, Atlanta, GA, USA
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Camille A. Dunkley
- Georgia Poison Center, Grady Hospital, Atlanta, GA, USA
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Tim P. Moran
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Musa Alfaifi
- Georgia Poison Center, Grady Hospital, Atlanta, GA, USA
| | | | - Ziad Kazzi
- Georgia Poison Center, Grady Hospital, Atlanta, GA, USA
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
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Peckham AM, Ananickal MJ, Sclar DA. Gabapentin use, abuse, and the US opioid epidemic: the case for reclassification as a controlled substance and the need for pharmacovigilance. Risk Manag Healthc Policy 2018; 11:109-116. [PMID: 30154674 PMCID: PMC6103607 DOI: 10.2147/rmhp.s168504] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The abuse potential of gabapentin is well documented; with gabapentin having been noted as an agent highly sought after for use in potentiating opioids. When combined with opioids, the risk of respiratory depression and opioid-related mortality increases significantly. In the US, gabapentin was approved by the Food and Drug Administration as a non-controlled substance. To date, and in spite of empirical evidence suggestive of diversion and abuse with opioids, gabapentin remains a non-controlled substance at the federal level. This has forced individual US states and jurisdictions – often significantly impacted by the opioid epidemic – to forge ahead with legislative initiatives designed to reclassify and/or monitor the use of gabapentin. Since August 1, 2016, 14 of 51 US states and jurisdictions have either implemented legislative mandates requiring pharmacovigilance programs, amended rules and regulations, are in the throes of crafting policy, or are in the midst of gathering additional data for decision making. This fragmented geographic approach yields only a modest benefit in combating the abuse of gabapentin and/or the national opioid epidemic. Herein, we report state-by-state efforts to enhance pharmacovigilance and call for a re-evaluation of the schedule status of gabapentin at the federal level, and design and implementation of a national pharmacovigilance program.
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Affiliation(s)
- Alyssa M Peckham
- Department of Pharmacy Practice, Midwestern University College of Pharmacy-Glendale, Glendale, AZ, USA,
| | - Maria J Ananickal
- Department of Pharmacy Practice, Midwestern University College of Pharmacy-Glendale, Glendale, AZ, USA,
| | - David A Sclar
- Department of Pharmacy Practice, Midwestern University College of Pharmacy-Glendale, Glendale, AZ, USA,
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Martin J, Cunliffe J, Décary-Hétu D, Aldridge J. Effect of restricting the legal supply of prescription opioids on buying through online illicit marketplaces: interrupted time series analysis. BMJ 2018; 361:k2270. [PMID: 29899119 PMCID: PMC5998052 DOI: 10.1136/bmj.k2270] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To examine the effect on the trade in opioids through online illicit markets ("cryptomarkets") of the US Drug Enforcement Administration's ruling in 2014 to reschedule hydrocodone combination products. DESIGN Interrupted time series analysis. SETTING 31 of the world's largest cryptomarkets operating from October 2013 to July 2016. MAIN OUTCOME MEASURES The proportion of total transactions, advertised and active listings for prescription opioids, prescription sedatives, prescription steroids, prescription stimulants, and illicit opioids, and the composition of the prescription opioid market between the US and elsewhere. RESULTS The sale of prescription opioids through US cryptomarkets increased after the schedule change, with no statistically significant changes in sales of prescription sedatives, prescription steroids, prescription stimulants, or illicit opioids. In July 2016 sales of opioids through US cryptomarkets represented 13.7% of all drug sales (95% confidence interval 11.5% to 16.0%) compared with a modelled estimate of 6.7% of all sales (3.7% to 9.6%) had the new schedule not been introduced. This corresponds to a 4 percentage point yearly increase in the amount of trade that prescription opioids represent in the US market, set against no corresponding changes for comparable products or for prescription opioids sold outside the US. This change was first observed for sales, and later observed for product availability. There was also a change in the composition of the prescription opioid market: fentanyl was the least purchased product during July to September 2014, then the second most frequently purchased by July 2016. CONCLUSIONS The scheduling change in hydrocodone combination products coincided with a statistically significant, sustained increase in illicit trading of opioids through online US cryptomarkets. These changes were not observed for other drug groups or in other countries. A subsequent move was observed towards the purchase of more potent forms of prescription opioids, particularly oxycodone and fentanyl.
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Affiliation(s)
- James Martin
- Department of Social Sciences, Swinburne University, Melbourne, Australia
| | - Jack Cunliffe
- School of Social Policy, Sociology and Social Research, University of Kent, Canterbury, Kent CT2 7NF, UK
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Kuo YF, Raji MA, Liaw V, Baillargeon J, Goodwin JS. Opioid Prescriptions in Older Medicare Beneficiaries After the 2014 Federal Rescheduling of Hydrocodone Products. J Am Geriatr Soc 2018; 66:945-953. [PMID: 29656382 PMCID: PMC5992099 DOI: 10.1111/jgs.15332] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 01/25/2018] [Accepted: 01/27/2018] [Indexed: 01/27/2023]
Abstract
OBJECTIVES To examine how an October 2014 Drug Enforcement Administration policy reclassified hydrocodone product from schedule III to II has affected older adults, who are among the largest consumers of prescription opioids in the United States. DESIGN Retrospective cohort study. SETTING United States. PARTICIPANTS A 20% sample of Medicare Part D beneficiaries aged 65 and older from 2013 through 2015 (> 2,500,000 beneficiaries each year) MEASUREMENTS: From January 2013 to December 2015, we calculated the monthly prevalence of opioid prescriptions and the prevalence of individuals who received prescriptions for a 90-day supply or longer (prolonged), as well as hospitalizations related to opioid toxicity in 2013 and 2015. RESULTS From 2013 to 2015, the proportion of Medicare Part D enrollees who received a hydrocodone prescription in a year decreased from 21.9% to 18.3%. Monthly rates for hydrocodone prescriptions declined significantly in 2014. The risk of receiving prolonged opioid prescriptions decreased by approximately 7% in the multivariable analyses comparing 2015 to 2013 (prevalence ratio=0.93, 95% confidence interval (CI)=0.93-0.94). Medicare enrollees with an original entitlement because of disability or with Medicaid eligibility had smaller decreases in prolonged prescriptions and, unexpectedly, small increases in high-dose prescriptions. Opioid-related hospitalizations did not change significantly, but opioid-related hospitalizations without a documented opioid prescription increased (odds ratio=1.24, 95% CI=1.03-1.50). CONCLUSION The 2014 change in hydrocodone from schedule III to schedule II was associated with modest decreases in rates of opioid use in the elderly. The unexpected increase in opioid-related hospitalizations without documented opioid prescriptions may represent an increase in illegal use.
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Affiliation(s)
- Yong-Fang Kuo
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas
- Institute for Translational Science, University of Texas Medical Branch, Galveston, Texas
| | - Mukaila A. Raji
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas
| | - Victor Liaw
- College of Natural Sciences, University of Texas at Austin, Austin, Texas
| | - Jacques Baillargeon
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas
- Institute for Translational Science, University of Texas Medical Branch, Galveston, Texas
| | - James S. Goodwin
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas
- Institute for Translational Science, University of Texas Medical Branch, Galveston, Texas
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