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Xuan Z, Walley AY, Yan S, Chatterjee A, Green TG, Pollini RA. Pharmacy Naloxone Standing Order and Community Opioid Fatality Rates Over Time. JAMA Netw Open 2024; 7:e2427236. [PMID: 39207758 PMCID: PMC11362859 DOI: 10.1001/jamanetworkopen.2024.27236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 06/13/2024] [Indexed: 09/04/2024] Open
Abstract
Importance Despite the proliferation of pharmacy standing-order naloxone dispensing across many US states before the change to over-the-counter status, few policy analyses have evaluated the implementation of pharmacy naloxone standing orders in addressing opioid overdose fatality among communities. Objective To determine whether the implementation of pharmacy standing-order naloxone was associated with lower opioid fatality rates compared with communities without pharmacies with standing-order naloxone. Design, Setting, and Participants This retrospective multisite study was conducted with an interrupted time series analysis across 351 municipalities in Massachusetts over 24 quarters (from January 1, 2013, through December 31, 2018). Standing-order naloxone dispensing data were collected from 2 sources for all major chain pharmacies and many independent pharmacies, covering 70% of retail pharmacies in Massachusetts. Municipalities had various standing-order naloxone implementation inceptions during the study period. Data were analyzed from December 2021 to November 2023. Exposure The main exposure was measured by the first quarter with standing-order naloxone dispensation as the actual implementation inception. Main Outcomes and Measures The primary study outcome was municipal opioid fatality rate per 100 000 population obtained from the Massachusetts Registry of Vital Records and Statistics. Results The median (IQR) population size across 351 municipalities was 10 314 (3635 to 21 781) people, with mean (SD) proportion of female individuals was 51.1% (2.8 percentage points). Pharmacies from 214 municipalities (60.9%) reported dispensing standing-order naloxone over the study period. At the baseline of the first quarter of 2013, municipalities that eventually had standing-order naloxone had greater quarterly opioid fatality rates compared with those that never implemented standing-order naloxone (3.51 vs 1.03 deaths per 100 000 population; P < .001). After adjusting for municipal-level sociodemographic and opioid prevention factors, there was significant slope decrease of opioid fatality rates (annualized rate ratio, 0.84; 95% CI, 0.78-0.91; P < .001) following standing-order naloxone dispensing, compared with the municipalities that did not implement standing-order naloxone. There were no significant level changes of opioid fatality rates in the adjusted models. Sensitivity analyses yielded similar and significant findings. Conclusions and Relevance These findings suggest that community pharmacy dispensing of naloxone with standing orders was associated with a relative, gradual, and significant decrease in opioid fatality rates compared with communities that did not implement the standing-order naloxone program. These findings support the expansion of naloxone access, including over-the-counter naloxone as part of a multifaceted approach to address opioid overdose.
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Affiliation(s)
- Ziming Xuan
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
| | - Alexander Y. Walley
- Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
| | - Shapei Yan
- Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
| | - Avik Chatterjee
- Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
| | - Traci G. Green
- Institute for Behavioral Health, The Heller School for Social Policy and Management at Brandeis University, Waltham, Massachusetts
| | - Robin A. Pollini
- Department of Behavioral Medicine and Psychiatry, West Virginia University School of Medicine, Morgantown
- Department of Epidemiology and Biostatistics, West Virginia University School of Public Health, Morgantown
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Sidlak A, Dibble B, Dhaliwal M, Bottone P, Marino R, Henry L, Howell J. Analysis of rising cases of adolescent opioid use presentations to the emergency department and their management. Drug Alcohol Depend 2024; 258:111136. [PMID: 38518662 DOI: 10.1016/j.drugalcdep.2024.111136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 02/13/2024] [Accepted: 02/17/2024] [Indexed: 03/24/2024]
Abstract
OBJECTIVE We sought to answer the question of how adolescents (ages 12-17 years old) with opioid-related presentations are currently managed in the ED. The two main outcomes were the proportion of visits where naloxone and buprenorphine were both used and prescribed, and the rate of revisits to the emergency department in the six months following ED presentation. METHODS This was a multi-center retrospective cross-sectional study. We studied patients presenting to the ED who were 12-17 years old with an opioid-related presentation. RESULTS Two-hundred and thirty-one patients were identified out of 571 encounters screened. Of these presentations, 77/231 (33%) were girls and 154/231 (67%) were boys. The majority of patients were Latino (64%; n=147); 26% were white (n=59), 6% were middle eastern or Arab (14), and 4% were black (10). Incidence of opioid use disorder per 100,000 presentations increased by 2800% from 2014 to 2022 (21/100,000 +/- 10 [2014] to 600/100,000 +/- 50 [2022]). A plurality of cases was related to opioid withdrawal (42%; 97). On discharge from the ED, 29% of patients received naloxone. For patients in withdrawal, 4% received a prescription for buprenorphine. Twenty-nine percent of patients had a return to the ED in the six months following initial visit. CONCLUSIONS Adolescent opioid-related presentations to the ED are rapidly increasing. Increasing ED presentations, compounded by a high 6-month revisit rate, pose a management challenge amid limited outpatient resources for this population. Opioid agonist therapy and naloxone are not routinely provided. Increasing the use of both are two ways to improve the quality of care for this population.
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Affiliation(s)
- Alexander Sidlak
- Inova Fairfax Hospital, Emergency Department, Falls Church, VA, United States.
| | - Brent Dibble
- Inova Fairfax Hospital, Emergency Department, Falls Church, VA, United States
| | - Mannet Dhaliwal
- University of Virginia Medical School, Charlottesville, VA, United States
| | - Paul Bottone
- Children's Hospital of Pennsylvania, Division of Adolescent Medicine, Philadelphia, PA, United States
| | - Ryan Marino
- University Hospitals, Division of Toxicology and Addiction Medicine, Cleveland, OH, United States
| | - Linda Henry
- Inova Fairfax Hospital, Medicine Service Line, Falls Church, VA, United States
| | - John Howell
- Inova Fairfax Hospital, Emergency Department, Falls Church, VA, United States
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Wally MK, Thompson ME, Odum S, Kazemi DM, Hsu JR, Seymour RB. Opioid Prescribing for Chronic Musculoskeletal Conditions: Trends over Time and Implementation of Safe Opioid-Prescribing Practices. Appl Clin Inform 2023; 14:961-972. [PMID: 38057261 PMCID: PMC10700149 DOI: 10.1055/s-0043-1776879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 10/09/2023] [Indexed: 12/08/2023] Open
Abstract
OBJECTIVES This study aimed (1) to determine the impact of a clinical decision support (CDS) tool on rate of opioid prescribing and opioid dose for patients with chronic musculoskeletal conditions and (2) to identify prescriber and facility characteristics associated with adherence to the Centers for Disease Control and Prevention guideline for prescribing opioids for chronic pain in this population.We conducted an interrupted time series analysis to assess trends in percentage of patients from 2016 to 2020, receiving an opioid and the average opioid dose, as well as the change associated with implementation of the CDS toolkit. We conducted a retrospective cohort study to assess the association between prescriber and facility characteristics and safe opioid-prescribing practices. METHODS We assessed the impact of the CDS intervention on percent of patients receiving an opioid and average opioid dose (morphine milligram equivalents). We operationalized safe opioid prescribing as a composite score of several behaviors (i.e., prescribing naloxone, initiating a pain agreement, prescribing <90 MME, avoiding extended-release prescriptions for opioid-naïve patients, and avoiding coprescribing opioids and benzodiazepines) and used a hierarchical linear regression model to assess associations between prescriber and facility characteristics and safe opioid prescribing. RESULTS This CDS intervention had a modest but statistically significant 1.6% reduction on the percent of patients (n = 1,290,746) receiving an opioid (mean: 15% preintervention; 10% postintervention). The average dose of opioid prescriptions did not significantly change. Advanced practice providers and prescribers with higher percentages of patients aged 18 to 64 exhibited safer opioid prescribing, while prescribers with higher percentages of white patients and larger numbers of patients on opioids exhibited less safe opioid prescribing. CONCLUSION A CDS intervention was associated with a small improvement in percent of patients receiving an opioid, but not on average dose. Clinicians are not prescribing opioids for chronic musculoskeletal conditions frequently, when they do, they are generally adhering to guidelines.
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Affiliation(s)
- Meghan K. Wally
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, United States
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina, United States
| | - Michael E. Thompson
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina, United States
| | - Susan Odum
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, United States
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina, United States
| | - Donna M. Kazemi
- School of Nursing, College of Health and Human Services, University of North Carolina at Charlotte, Charlotte, North Carolina, United States
| | - Joseph R. Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, United States
| | - Rachel B. Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, United States
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Galindo RJ, Inselman SA, Umpierrez GE, Moazzami B, Munoz Mendoza J, Ali MK, Tuttle KR, McCoy RG. National Trends in Glucagon Prescriptions Among U.S. Adults With Diabetes and End-Stage Kidney Disease Treated by Dialysis: 2013-2017. Diabetes Care 2023; 46:e130-e132. [PMID: 37167455 PMCID: PMC10300513 DOI: 10.2337/dc23-0554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 03/30/2023] [Indexed: 05/13/2023]
Affiliation(s)
- Rodolfo J. Galindo
- Division of Endocrinology, University of Miami Miller School of Medicine, Miami, FL
| | - Shealeigh A. Inselman
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | | | - Bobak Moazzami
- Division of Endocrinology, Emory University School of Medicine, Atlanta, GA
| | - Jair Munoz Mendoza
- Katz Family Division of Nephrology and Hypertension, University of Miami Miller School of Medicine, Miami, FL
| | - Mohammed K. Ali
- Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, GA
| | - Katherine R. Tuttle
- Division of Nephrology, Kidney Research Institute, and Institute of Translational Health Sciences, University of Washington, Seattle, WA
- Providence Medical Research Center, Providence Inland Northwest Health, Spokane, WA
| | - Rozalina G. McCoy
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, MN
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Jennings LK, Ward R, Pekar E, Szwast E, Sox L, Hying J, Mccauley J, Obeid JS, Lenert LA. The effectiveness of a noninterruptive alert to increase prescription of take-home naloxone in emergency departments. J Am Med Inform Assoc 2023; 30:683-691. [PMID: 36718091 PMCID: PMC10018256 DOI: 10.1093/jamia/ocac257] [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] [Received: 10/10/2022] [Revised: 12/21/2022] [Accepted: 12/31/2022] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE Opioid-related overdose (OD) deaths continue to increase. Take-home naloxone (THN), after treatment for an OD in an emergency department (ED), is a recommended but under-utilized practice. To promote THN prescription, we developed a noninterruptive decision support intervention that combined a detailed OD documentation template with a reminder to use the template that is automatically inserted into a provider's note by decision rules. We studied the impact of the combined intervention on THN prescribing in a longitudinal observational study. METHODS ED encounters involving an OD were reviewed before and after implementation of the reminder embedded in the physicians' note to use an advanced OD documentation template for changes in: (1) use of the template and (2) prescription of THN. Chi square tests and interrupted time series analyses were used to assess the impact. Usability and satisfaction were measured using the System Usability Scale (SUS) and the Net Promoter Score. RESULTS In 736 OD cases defined by International Classification of Disease version 10 diagnosis codes (247 prereminder and 489 postreminder), the documentation template was used in 0.0% and 21.3%, respectively (P < .0001). The sensitivity and specificity of the reminder for OD cases were 95.9% and 99.8%, respectively. Use of the documentation template led to twice the rate of prescribing of THN (25.7% vs 50.0%, P < .001). Of 19 providers responding to the survey, 74% of SUS responses were in the good-to-excellent range and 53% of providers were Net Promoters. CONCLUSIONS A noninterruptive decision support intervention was associated with higher THN prescribing in a pre-post study across a multiinstitution health system.
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Affiliation(s)
- Lindsey K Jennings
- Department of Emergency Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ralph Ward
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ekaterina Pekar
- Biomedical Informatics Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Elizabeth Szwast
- Biomedical Informatics Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Luke Sox
- Biomedical Informatics Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Joseph Hying
- Biomedical Informatics Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jenna Mccauley
- Department of Psychiatry and Behavioral Science, Addiction Sciences Division, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jihad S Obeid
- Biomedical Informatics Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Leslie A Lenert
- Corresponding Author: Leslie A. Lenert, MD, Biomedical Informatics Center, Medical University of South Carolina, 22 West Edge Suite 13, Charleston, SC 29425, USA;
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