1
|
Isoardi KZ, Isbister GK. Opioid poisoning in Newcastle over the last three decades: From heroin to prescription opioids. Emerg Med Australas 2023; 35:946-952. [PMID: 37415078 PMCID: PMC10947284 DOI: 10.1111/1742-6723.14272] [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: 04/03/2023] [Revised: 06/08/2023] [Accepted: 06/08/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE Opioid-related harm has risen in recent decades, but limited research describes the clinical burden of opioid poisoning to Australian EDs. We aimed to investigate hospital presentations with opioid poisoning over three decades. METHODS This is an observational series of prospectively collected data investigating presentations of opioid poisoning to an ED in Newcastle (1990-2021). Type of opioid, naloxone administration, intubation, intensive care unit (ICU) admission, length of stay and death were extracted from the unit's database. RESULTS There were 4492 presentations in 3574 patients (median age 36, 57.7% female), increasing from an average of 93 presentations annually in the first decade to 199 in the third decade. Deliberate self-poisonings accounted for 3694 presentations (82.2%). Heroin dominated the 1990s, peaking in 1999 before decreasing. Prescription opioids then rose, with codeine (usually in paracetamol combination) predominating until 2018, after which oxycodone presentations exceeded them. Methadone consistently increased from six presentations annually in the first decade to 16 in the last decade. Naloxone was administered in 990 (22.0%) presentations and 266 (5.9%) were intubated, most frequently following methadone and heroin exposures. ICU admissions increased from 5% in 1990 to 16% in 2021. Codeine exposures resulted in less severe effects, whereas methadone had more severe effects overall. The median length of stay was 17 h (interquartile range 9-27 h). There were 28 deaths (0.6%). CONCLUSION Opioid presentations increased in number and severity over three decades as the type of opioid changed. Oxycodone is currently the main opioid of concern. Methadone poisoning was the most severe.
Collapse
Affiliation(s)
- Katherine Z Isoardi
- Clinical Toxicology Research GroupThe University of NewcastleNewcastleNew South WalesAustralia
| | - Geoffrey K Isbister
- Clinical Toxicology Research GroupThe University of NewcastleNewcastleNew South WalesAustralia
- Department of Clinical ToxicologyCalvary Mater NewcastleNewcastleNew South WalesAustralia
| |
Collapse
|
2
|
Koulouris A, Baio G, Clark A, Alexandre L. Opioid burden in patients with inoperable pancreatic adenocarcinoma and the development of a multivariable risk prediction model for opioid use: A retrospective cohort study. Pancreatology 2023; 23:818-828. [PMID: 37741797 DOI: 10.1016/j.pan.2023.08.009] [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: 01/24/2023] [Revised: 06/26/2023] [Accepted: 08/26/2023] [Indexed: 09/25/2023]
Abstract
INTRODUCTION Risk prediction models to guide patient selection for early pre-emptive endoscopic ultrasound guided coeliac plexus neurolysis are lacking. This study aimed to determine in patients with inoperable pancreatic cancer: (1) opioid burden, (2) the relationship between opioid use and all-cause mortality, (3) risk factors for opioid use, and (4) develop and internally validate a risk prediction model for opioid use at three months. METHODS This was a single-centre retrospective cohort study of patients with confirmed pancreatic cancer. Cox proportional hazard regression estimated the association between opioid use at baseline and all-cause mortality. Logistic regression estimated the associations between clinical and radiological variables with opioid use by three months. Two risk prediction models were developed for opioid use (clinical and clinical-radiological). Model discrimination and calibration was assessed. RESULTS In total, 383 patients with inoperable pancreatic cancer were included. Prevalence of pain ranged between 37% and 47% at three monthly intervals in the first year of diagnosis. Opioid use at baseline was associated with poorer survival. Age, pain at presentation, performance status, tumour distance from the right ganglion, the anterior-posterior and the latero-lateral tumour dimensions were independent risk factors for the opioid use at three months. The Area Under Curve (AUC) for the clinical and clinical-radiological models was 0.81 and 0.84, respectively. Models were well calibrated. CONCLUSIONS Opioid use is prevalent in patients with pancreatic cancer, associated with poor prognosis, and can be predicted based on clinical and radiological variables. External validation of this predictive model is required.
Collapse
Affiliation(s)
- Andreas Koulouris
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk, NR4 7TJ, United Kingdom; Norfolk and Norwich University Hospital, Norwich, Colney Lane, NR4 7UY, United Kingdom.
| | - Gabriella Baio
- Norfolk and Norwich University Hospital, Norwich, Colney Lane, NR4 7UY, United Kingdom
| | - Allan Clark
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk, NR4 7TJ, United Kingdom
| | - Leo Alexandre
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk, NR4 7TJ, United Kingdom; Norfolk and Norwich University Hospital, Norwich, Colney Lane, NR4 7UY, United Kingdom
| |
Collapse
|
3
|
Goswami S, Ramachandran S, Sharma M, Barnard M. Gabapentin and Opioids Utilization in Patients With Diabetic Neuropathy Enrolled in Medicare (2012-2016): A Cohort Study. J Pharm Pract 2023; 36:1085-1094. [PMID: 35414302 DOI: 10.1177/08971900221087119] [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] [Indexed: 11/15/2022]
Abstract
This retrospective cohort study describes the utilization of opioids and gabapentin among patients with diabetic neuropathy who were gabapentin and opioid naïve, and assesses predictors of concomitant use of opioids and gabapentin. Using Medicare claims data (2012-2016), 22 037 patients were identified, of whom 23.42% (N = 5161) initiated opioids without concomitant gabapentin, 4.56% (N = 1004) initiated gabapentin without concomitant opioids, and 3.87% (N = 852) had concomitant use of gabapentin and opioids 12 months following their index date (date of earliest diagnosis). Concomitant gabapentin and opioid use were more common for lower doses of both drugs and for 15 days or more cumulatively. Compared to individuals aged 65-74, those aged 75-84 (OR: .759; 95% CI: 0.653-.882) or ≥ 85 years (OR: .586, 95% CI: 0.462-.743) had lower odds of concomitant use. People residing in the Northeast had lower odds of concomitant use, compared to those residing in the South (OR: .646 95% CI: 0.535-.779). Females compared to males (OR: 1.185, 95% CI: 1.027-1.367), people with higher Charlson's Comorbidity Index (CCI) scores (OR: 1.085, 95% CI: 1.037-1.135) or those having anxiety (OR: 1.462, 95% CI: 1.131-1.889) had higher odds of concomitant use. Concomitant prescriptions of opioids and gabapentin were more common for longer durations, indicating the need for interventions aimed at minimizing this prescribing practice.
Collapse
Affiliation(s)
- Swarnali Goswami
- Department of Pharmacy Administration, The University of Mississippi, University, MS, USA
| | - Sujith Ramachandran
- Department of Pharmacy Administration, The University of Mississippi, University, MS, USA
| | - Manvi Sharma
- Department of Pharmacy Administration, The University of Mississippi, University, MS, USA
| | - Marie Barnard
- Department of Pharmacy Administration, The University of Mississippi, University, MS, USA
| |
Collapse
|
4
|
Babatunde A, Rennert L, Walker KB, Furmanek DL, Blackhurst DW, Cancellaro VA, Litwin AH, Howard KA. Association between Initial Opioid Prescription and Patient Pain with Continued Opioid Use among Opioid-Naïve Patients Undergoing Elective Surgery in a Large American Health System. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20105766. [PMID: 37239497 DOI: 10.3390/ijerph20105766] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/02/2023] [Accepted: 05/06/2023] [Indexed: 05/28/2023]
Abstract
There is growing concern about the over-prescription of opioids and the risks of long-term use. This study examined the relationship between initial need (pre-operative, post-operative, and discharge pain) and dosage of opioids in the first prescription after surgery with continued opioid use through opioid refills over 12 months, while considering patient-level characteristics. A total of 9262 opioid-naïve patients underwent elective surgery, 7219 of whom were prescribed opioids following surgery. The results showed that 17% of patients received at least one opioid refill within one year post-surgery. Higher initial opioid doses, measured in morphine milligram equivalent (MME), were associated with a greater likelihood of continued use. Patients receiving a dose greater than 90 MME were 1.57 times more likely to receive a refill compared to those receiving less than 90 MME (95% confidence interval: 1.30-1.90, p < 0.001). Additionally, patients who experienced pain before or after surgery were more likely to receive opioid refills. Those experiencing moderate or severe pain were 1.66 times more likely to receive a refill (95% confidence interval: 1.45-1.91, p < 0.001). The findings highlight the need to consider surgery-related factors when prescribing opioids and the importance of developing strategies to balance the optimization of pain management with the risk of opioid-related harms.
Collapse
Affiliation(s)
- Abass Babatunde
- Department of Public Health Sciences, Clemson University, Clemson, SC 29634, USA
- Center for Public Health Modeling and Response, Clemson University, Clemson, SC 29634, USA
| | - Lior Rennert
- Department of Public Health Sciences, Clemson University, Clemson, SC 29634, USA
- Center for Public Health Modeling and Response, Clemson University, Clemson, SC 29634, USA
| | | | | | | | | | - Alain H Litwin
- Prisma Health, Greenville, SC 29605, USA
- School of Health Research, Clemson University, Clemson, SC 29634, USA
- School of Medicine Greenville, University of South Carolina, Greenville, SC 29605, USA
| | - Kerry A Howard
- Department of Public Health Sciences, Clemson University, Clemson, SC 29634, USA
- Center for Public Health Modeling and Response, Clemson University, Clemson, SC 29634, USA
| |
Collapse
|
5
|
Quinn PD, Chang Z, Pujol TA, Bair MJ, Gibbons RD, Kroenke K, D’Onofrio BM. Association between prescribed opioid dose and risk of motor vehicle crashes. Pain 2023; 164:e228-e236. [PMID: 36155384 PMCID: PMC11104685 DOI: 10.1097/j.pain.0000000000002790] [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: 11/23/2021] [Accepted: 09/12/2022] [Indexed: 11/26/2022]
Abstract
ABSTRACT Opioid-involved motor vehicle traffic fatalities have increased over the past 2 decades. However, the extent to which prescribed opioids increase the risk of motor vehicle crashes remains uncertain. This study used real-world healthcare claims data to examine the association between prescription opioid dose and motor vehicle crash risk. Using nationwide US commercial insurance claims data for 2010 to 2018, we identified 772,404 adults who received incident, noncancer opioid therapy. We examined associations between daily prescription opioid dose, calculated in morphine milligram equivalents (MME) from filled prescription claims, and risk of motor vehicle crashes, assessed as diagnoses of motor vehicle injuries in claims for emergency visits, inpatient hospitalizations, and ambulance transportation. We estimated associations using a within-individual design, which ruled out all time-stable confounding. We complemented the design with time-varying statistical adjustment for other pharmacotherapies and a negative control pain pharmacotherapy analysis (with incident cyclic antidepressant prescriptions). During 2,150,009 person-years of follow-up, there were 12,123 motor vehicle crashes (5.64 crashes per 1000 person-years). In within-individual comparisons, crash risk was greater during opioid prescription periods involving doses ≤60 MME/day (odds ratio [OR], 3.86; 95% confidence interval [CI], 3.54, 4.21), >60 to 120 MME/day (OR, 5.46; 95% CI, 4.44, 6.73), and >120 MME/day (OR, 3.45; 95% CI, 2.31, 5.15) than during off-treatment periods. The negative control analysis supported the specificity of the results to opioids rather than to other processes associated with pharmacologic pain management. These findings suggest that the receipt of prescription opioids, even at doses ≤60 MME/day, is associated with an increased risk of motor vehicle crashes.
Collapse
Affiliation(s)
- Patrick D. Quinn
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington, Indiana
| | - Zheng Chang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | | | - Matthew J. Bair
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
- Regenstrief Institute, Indianapolis, Indiana
| | - Robert D. Gibbons
- Center for Health Statistics, University of Chicago, Chicago, Illinois
- Department of Medicine, University of Chicago, Chicago, Illinois
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
| | - Kurt Kroenke
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
- Regenstrief Institute, Indianapolis, Indiana
| | - Brian M. D’Onofrio
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, Indiana
| |
Collapse
|
6
|
Ji X, Sun W, Lv C, Huang J, Zhang H. Meta-analysis of the efficacy and safety of thermal ablation for treating large benign thyroid nodules. Clin Endocrinol (Oxf) 2022; 97:654-663. [PMID: 35170792 DOI: 10.1111/cen.14695] [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: 07/13/2021] [Revised: 01/17/2022] [Accepted: 02/10/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Many large benign thyroid nodules have symptoms and cosmetic problems. This study consisted of a meta-analysis to accurately assess the effect of thermal ablation on these nodules. METHODS The PubMed, Embase, Web of Science, and Scopus databases were systematically searched for retrospective or prospective studies of thermal ablation since June 1, 2021. The weighted mean differences of the measures were analysed before and after treatment. RESULTS A total of 10 eligible studies were included. By comparing the initial nodule volume with the nodular volume after thermal ablation, we found that the volume reduction rate was increased significantly after 1 month (SMD = 0.453, 95% CI: 0.323-0.583, p < .001), 3 months (SMD = 0.655, 95% CI: 0.563-0.747, p < .001), 6 months (SMD = 0.691, 95% CI: 0.607-0.774, p < .001), and 12 months (SMD = 0.694, 95% CI: 0.583-0.803), p < .001). The nodular volume was also found to decrease significantly, after 1 month (SMD = 2.381, 95% CI: 1.278-3.485, p < .001), 3 months (SMD = 5.071, 95% CI: 2.386-7.756, p < .001), 6 months (SMD = 5.363, 95% CI: 2.765-7.962, p < .001), and 12 months (SMD = 8.194, 95% CI: 2.113-14.274), p < .001). Symptom score (SMD = 4.419, 95% CI: 2.573-6.265, p < .001)and cosmetic score (SMD = 4.245, 95% CI: 2.566-5.359, p < .001) were reduced after thermal ablation. CONCLUSIONS Thermal ablation could become an alternative to manage large benign thyroid nodules.
Collapse
Affiliation(s)
- Xiaoyu Ji
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, China
| | - Wei Sun
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, China
| | - Chengzhou Lv
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, China
| | - Jiapeng Huang
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, China
| | - Hao Zhang
- Department of Thyroid Surgery, The First Hospital of China Medical University, Shenyang, China
| |
Collapse
|
7
|
Reid S, Day C, White N, Harrison C, Haber P, Bayram C. Opioid prescribing in general practice: an Australian cross-sectional survey. BMC PRIMARY CARE 2022; 23:171. [PMID: 35804306 PMCID: PMC9264661 DOI: 10.1186/s12875-022-01783-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 06/20/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Prescribed opioid doses > 100 mg oral morphine equivalent (OME) and/or co-prescribing of sedating psychoactive medications increase the risk of unintentional fatal overdose. We describe general practice encounters where opioids are prescribed and examine high-risk opioid prescribing. METHODS The 2006-2016 BEACH study data, a rolling national cross-sectional survey of randomly selected GPs, was analysed. RESULTS Opioid prescribing increased 2006-2007 to 2015-2016, however, this plateaued across the latter half-decade. From 2012-2016 3,897 GPs recorded 389,700 encounters and at least one opioid was prescribed at 5.2%. Opioid encounters more likely involved males, those 45-64 years, concession card holders and the socioeconomically disadvantaged. GPs more likely to prescribe opioids were 55 years or older, male, Australian graduates, and in regional and remote areas. The most common problems managed with opioids involved chronic non-cancer pain. One-in-ten opioid prescribing episodes involved high-risk doses and 11% involved co-prescription of sedating psychoactive medications. Over one-third of GPs provided other (non-pharmacological) interventions at encounters with opioid prescriptions. CONCLUSIONS Only 5% of GP encounters involved an opioid prescription. Of concern, were: prescribing for chronic non-cancer pain, potentially high-risk opioid encounters where > 100 OME daily dose was prescribed, and/or there was co-prescription of sedating psychoactive medication. However, approximately one-in-three opioid prescribing encounters involved non-pharmacological interventions.
Collapse
Affiliation(s)
- Sharon Reid
- Speciality of Addiction Medicine, Central Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, 2006, Australia.
- Drug Health Services, Royal Prince Alfred Hospital, Sydney Local Health District, Camperdown, NSW, 2050, Australia.
- Edith Collins Centre (Translational Research in Alcohol Drugs and Toxicology), Sydney Local Health District, Camperdown, NSW, 2050, Australia.
| | - Carolyn Day
- Speciality of Addiction Medicine, Central Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, 2006, Australia
- Edith Collins Centre (Translational Research in Alcohol Drugs and Toxicology), Sydney Local Health District, Camperdown, NSW, 2050, Australia
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, NSW, 2006, Australia
| | - Natalie White
- Speciality of Addiction Medicine, Central Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, 2006, Australia
| | - Christopher Harrison
- Menzies Centre for Health Policy, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, NSW, 2006, Australia
| | - Paul Haber
- Speciality of Addiction Medicine, Central Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, 2006, Australia
- Drug Health Services, Royal Prince Alfred Hospital, Sydney Local Health District, Camperdown, NSW, 2050, Australia
- Edith Collins Centre (Translational Research in Alcohol Drugs and Toxicology), Sydney Local Health District, Camperdown, NSW, 2050, Australia
| | - Clare Bayram
- Menzies Centre for Health Policy, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, NSW, 2006, Australia
| |
Collapse
|
8
|
Zhang M, Fan Y, Nie L, Wang G, Sun K, Cheng Y. Clinical Outcomes of Immune Checkpoint Inhibitor Therapy in Patients With Advanced Non-small Cell Lung Cancer and Preexisting Interstitial Lung Diseases: A Systematic Review and Meta-analysis. Chest 2022; 161:1675-1686. [PMID: 35026298 DOI: 10.1016/j.chest.2021.12.656] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 11/19/2021] [Accepted: 12/20/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Patients with non-small cell lung cancer (NSCLC) and preexisting interstitial lung disease (ILD) are often excluded from clinical trials of immune checkpoint inhibitors (ICIs), leaving a gap in knowledge. RESEARCH QUESTION What are the clinical outcomes of ICIs in patients with NSCLC and preexisting ILD? STUDY DESIGN AND METHODS Systematic searches were conducted of PubMed, EMBASE, and Cochrane Library through April 2021 with no language or study design restrictions. Studies reporting the safety and efficacy data among patients with cancer and ILD receiving ICI therapy were collected. The primary end points were clinical efficacy to immunotherapy and the incidence of immune-related adverse events, especially for checkpoint inhibitor pneumonitis (CIP). RESULTS A total of 179 patients in 10 studies were included. The pooled overall response rate (ORR) and pooled disease control rate (DCR) were 34% (95% CI, 20-47) and 66% (95% CI, 56-75), respectively. The ORR in patients with preexisting ILD was significantly higher than that in patients without ILD (OR, 1.99; 95% CI, 1.31-3.00). The DCR and progression-free survival in patients with preexisting ILD were not inferior to those without ILD (pooled OR, 1.46; 95% CI, 0.94-2.25 for DCR). The pooled incidences of any grade and grade 3 or higher CIP were 27% (95% CI, 17-37) and 15% (95% CI, 9-22) in patients with preexisting ILD, and 10% (95% CI, 6-13) and 4% (95% CI, 2-6) in patients without ILD. Meta-analysis found a significantly higher incidence rate of any grade and grade 3 or higher CIP in patients with NSCLC and preexisting ILD than in those patients without ILD (OR, 3.23 [95% CI, 2.06-5.06]; OR, 2.91 [95% CI, 1.47-5.74]). INTERPRETATION Programmed cell death protein 1/programmed cell death ligand 1 inhibitors had favorable efficacy in NSCLC with preexisting ILD. CIP is frequent in patients with preexisting ILD who receive ICI therapy but is often mild and easily manageable. Clinicians should be cautious when using ICIs in patients with preexisting ILD.
Collapse
Affiliation(s)
- Meng Zhang
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Yong Fan
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Ligong Nie
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Guangfa Wang
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Kunyan Sun
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Yuan Cheng
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, Beijing, China.
| |
Collapse
|
9
|
Azmanov H, Bayatra A, Ilan Y. Digital Analgesic Comprising a Second-Generation Digital Health System: Increasing Effectiveness by Optimizing the Dosing and Minimizing Side Effects. J Pain Res 2022; 15:1051-1060. [PMID: 35444460 PMCID: PMC9013915 DOI: 10.2147/jpr.s356319] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 03/02/2022] [Indexed: 12/30/2022] Open
Abstract
Opioids remain an essential part of the treatment of chronic pain. However, their use and increasing rates of misuse are associated with high morbidity and mortality. The development of tolerance to opioids and analgesics further complicates dosing and the need to reduce side effects. First-generation digital systems were developed to improve analgesics but are not always capable of making clinically relevant associations and do not necessarily lead to better clinical efficacy. A lack of improved clinical outcomes makes these systems less applicable for adoption by clinicians and patients. There is a need to enhance the therapeutic regimens of opioids. In the present paper, we present the use of a digital analgesic that consists of an analgesic administered under the control of a second-generation artificial intelligence system. Second-generation systems focus on improved patient outcomes measured based on clinical response and reduced side effects in a single subject. The algorithm regulates the administration of analgesics in a personalized manner. The digital analgesic provides advantages for both users and providers. The system enables dose optimization, improving effectiveness, and minimizing side effects while increasing adherence to beneficial therapeutic regimens. The algorithm improves the clinicians’ experience and assists them in managing chronic pain. The system reduces the financial burden on healthcare providers by lowering opioid-related morbidity and provides a market disruptor for pharma companies.
Collapse
Affiliation(s)
- Henny Azmanov
- Hebrew University, Faculty of Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Areej Bayatra
- Hebrew University, Faculty of Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Yaron Ilan
- Hebrew University, Faculty of Medicine, Hadassah Medical Center, Jerusalem, Israel
| |
Collapse
|
10
|
Nielsen S, Scott N, Tidhar T, Quiroga MDM, Lenton S, Dietze P. The cost and impact of distributing naloxone to people who are prescribed opioids to prevent opioid-related deaths: findings from a modelling study. Addiction 2022; 117:1009-1019. [PMID: 34793616 DOI: 10.1111/add.15727] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 10/11/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND AIMS Although most opioid-related mortality in Australia involves prescription opioids, most research to understand the impact of naloxone supply on opioid-related mortality has focused upon people who inject heroin. We aimed to examine the cost and probable impact of up-scaling naloxone supply to people who are prescribed opioids. DESIGN Decision-tree model. Four scenarios were compared with a baseline scenario (the current status quo): naloxone scale-up between 2020 and 2030 to reach 30 or 90% coverage by 2030, among the subgroups of people prescribed either ≥ 50 or ≥ 100 mg of oral morphine equivalents (OME). SETTING Australia. PARTICIPANTS People who are prescribed opioids. MEASUREMENTS Possible deaths averted, costs (ambulance and naloxone distribution) and cost per life saved for different scenarios of naloxone scale-up. FINDINGS Maintaining the status quo, there would be an estimated 7478 [uncertainty interval (UI) = 6868-8275] prescription opioid overdose deaths between 2020 and 2030, resulting in Australian dollars (A$)51.9 million (49.4, 56.0) in ambulance costs. If naloxone were scaled-up to 90% of people prescribed > 50 mg OME, an estimated 657 (UI = 245, 1489) deaths could be averted between 2020 and 2030 (a 20% reduction in the final year of the model compared with the no naloxone scenario), with a cost of A$43 600 (20 800-110 500) per life saved. If naloxone were scaled-up to 30% of people prescribed > 50 mg OME an estimated 219 (82-496) deaths could be averted with the same cost per live saved. If naloxone were restricted to those prescribed > 100 mg OME, an estimated 130 (UI = 44-289) deaths would be averted if scaled-up to 30% or 390 (UI = 131-866) deaths averted if scaled-up to 90%, with the cost per life saved for both scenarios A$38 200 (UI = 12 400-97 400). CONCLUSION In Australia, scaling-up take-home naloxone by 2030 to reach 90% of people prescribed daily doses of ≥ 50 mg of oral morphine equivalents would be cost-effective and save more than 650 lives.
Collapse
Affiliation(s)
- Suzanne Nielsen
- Behaviours and Health Risks, Burnet Institute, Melbourne, VIC, Australia.,Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, VIC, Australia
| | - Nick Scott
- Behaviours and Health Risks, Burnet Institute, Melbourne, VIC, Australia
| | - Tom Tidhar
- Behaviours and Health Risks, Burnet Institute, Melbourne, VIC, Australia
| | - Maria Del Mar Quiroga
- Behaviours and Health Risks, Burnet Institute, Melbourne, VIC, Australia.,Melbourne Data Analytics Platform, University of Melbourne, Victoria, Australia
| | - Simon Lenton
- National Drug Research Institute, Curtin University, Bentley, WA, Australia
| | - Paul Dietze
- Behaviours and Health Risks, Burnet Institute, Melbourne, VIC, Australia.,Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, VIC, Australia.,National Drug Research Institute, Curtin University, Bentley, WA, Australia
| |
Collapse
|
11
|
Quinn PD, Chang Z, Bair MJ, Rickert ME, Gibbons RD, Kroenke K, D’Onofrio BM. Associations of opioid prescription dose and discontinuation with risk of substance-related morbidity in long-term opioid therapy. Pain 2022; 163:e588-e595. [PMID: 34326295 PMCID: PMC8795234 DOI: 10.1097/j.pain.0000000000002415] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/28/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Efforts to reduce opioid-related harms have decreased opioid prescription but have provoked concerns about unintended consequences, particularly for long-term opioid therapy (LtOT) recipients. Research is needed to address the knowledge gap regarding how risk of substance-related morbidity changes across LtOT and its discontinuation. This study used nationwide commercial insurance claims data and a within-individual design to examine associations of LtOT dose and discontinuation with substance-related morbidity. We identified 194,839 adolescents and adults who initiated opioid prescription in 2010 to 2018 and subsequently received LtOT. The cohort was followed for a median of 965 days (interquartile range, 525-1550), of which a median of 176 days (119-332) were covered by opioid prescription. During follow-up, there were 17,582 acute substance-related morbidity events, defined as claims for emergency visits, inpatient hospitalizations, and ambulance transportation with substance use disorder or overdose diagnoses. Relative to initial treatment, risk was greater within individual during subsequent periods of >60 to 120 (adjusted odds ratio [OR], 1.29; 95% CI, 1.12 to 1.49) and >120 (OR, 1.48; 95% CI, 1.24-1.76) daily morphine milligram equivalents. Risk was also greater during days 1 to 30 after discontinuations than during initial treatment (OR, 1.19; 95% CI, 1.05-1.35). However, it was no greater than during the 30 days before discontinuations, indicating that the risk may not be wholly attributable to discontinuation itself. Results were supported by a negative control pharmacotherapy analysis and additional sensitivity analyses. They suggest that LtOT recipients may experience increased substance-related morbidity risk during treatment subsequent to initial opioid prescription, particularly in periods involving higher doses.
Collapse
Affiliation(s)
- Patrick D. Quinn
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington, Indiana
| | - Zheng Chang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Matthew J. Bair
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
- Regenstrief Institute, Indianapolis, Indiana
| | - Martin E. Rickert
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, Indiana
| | - Robert D. Gibbons
- Center for Health Statistics, University of Chicago, Chicago, Illinois
- Department of Medicine, University of Chicago, Chicago, Illinois
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
| | - Kurt Kroenke
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
- Regenstrief Institute, Indianapolis, Indiana
| | - Brian M. D’Onofrio
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, Indiana
| |
Collapse
|
12
|
Fine KL, Rickert ME, O’Reilly LM, Sujan AC, Boersma K, Chang Z, Franck J, Lichtenstein P, Larsson H, D’Onofrio BM, Quinn PD. Initiation of Opioid Prescription and Risk of Suicidal Behavior Among Youth and Young Adults. Pediatrics 2022; 149:184742. [PMID: 35128560 PMCID: PMC9624202 DOI: 10.1542/peds.2020-049750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Opioids are involved in an increasing proportion of suicide deaths. This study examined the association between opioid analgesic prescription initiation and suicidal behavior among young people. METHODS We analyzed Swedish population-register data on 1 895 984 individuals ages 9 to 29 years without prior recorded opioid prescriptions. We identified prescriptions dispensed from January 2007 onward and diagnosed self-injurious behavior and death by suicide through December 2013. We first compared initiators with demographically matched noninitiators. To account for confounding, we applied an active comparator design, which examined suicidal behavior among opioid initiators relative to prescription nonsteroidal antiinflammatory drug (NSAID) initiators while inverse-probability-of-treatment weighting with individual and familial covariates. RESULTS Among the cohort, 201 433 individuals initiated opioid prescription. Relative to demographically matched noninitiators, initiators (N = 180 808) had more than doubled risk of incident suicidal behavior (hazard ratio = 2.64; 95% confidence interval [CI], 2.47-2.81). However, in the active comparator design, opioid initiators (N = 86 635) had only 19% relatively greater risk of suicidal behavior compared with NSAID initiators (N = 255 096; hazard ratio = 1.19; 95% CI,: 1.11-1.28), corresponding to a weighted 5-year cumulative incidence of 2.2% (95% CI, 2.1-2.4) for opioid and 1.9% (95% CI, 1.9-2.0) for NSAID initiators. Most sensitivity analyses produced comparable results. CONCLUSIONS Opioid initiation may make only a small contribution to the elevated risk of suicidal behavior among young people receiving pharmacologic pain management. In weighing benefits and harms of opioid initiation, our results suggest that increased risk of suicidal behavior may not be a major concern.
Collapse
Affiliation(s)
| | - Martin E. Rickert
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, Indiana
| | - Lauren M. O’Reilly
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, Indiana
| | - Ayesha C. Sujan
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, Indiana
| | - Katja Boersma
- Center for Health and Medical Psychology (CHAMP), School of Law, Psychology and Social Work
| | - Zheng Chang
- Departments of Medical Epidemiology and Biostatistics
| | - Johan Franck
- Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | | | - Henrik Larsson
- School of Medical Sciences, Örebro University, Örebro, Sweden,Departments of Medical Epidemiology and Biostatistics
| | - Brian M. D’Onofrio
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, Indiana,Departments of Medical Epidemiology and Biostatistics
| | - Patrick D. Quinn
- Department of Applied Health Science, School of Public Health,Address correspondence to Patrick D. Quinn, PhD, Department of Applied Health Science, School of Public Health, Indiana University, 1025 E. 7 St., Room 116, Bloomington, IN 47405. E-mail:
| |
Collapse
|
13
|
Association Between Benzodiazepine and Opioid Prescription and Mortality Among Patients in a Large Healthcare System. J Addict Med 2022; 16:65-71. [PMID: 35120065 PMCID: PMC8817063 DOI: 10.1097/adm.0000000000000828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Coprescription of opioids and benzodiazepines (BDZ) is associated with adverse outcomes, including greater healthcare utilization and overdose risk. This study aims to examine opioid and BDZ coprescription, dosing, and mortality among patients with and without opioid use disorder (OUD) in a large healthcare system. METHODS Using data from the California state Prescription Drug Monitoring Program during 2010 to 2014 linked with a large healthcare system electronic health record database and mortality records from the Centers for Disease Control National Death Index, this study examined 5202 patients (1978 with OUD, 3224 controls). Multiple logistic regression analyses were conducted to examine relationships between most recent BDZ and opioid prescription, and their interaction with respect to mortality. RESULTS About 10.5% of the sample died on or before December 31, 2014. About 17.7% were prescribed BDZ during the final month of observation. Individuals with OUD were prescribed higher average BDZ and opioid doses than those without OUD. After adjusting for covariates, increased prescribed doses of BDZ (odds ratio [OR]=1.34, 95%CI: 1.15-1.55 per 10 mg/d increment) and opioids (OR = 1.04, 95%CI: 1.02-1.05 per 10 mg/d increment) were positively associated with mortality. Non-OUD patients who received both BDZ and opioid prescriptions had a higher mortality than those who received only BDZ or opioids (The ratio of odds ratio (ROR) = 3.83, 95%CI: 1.78-8.21). CONCLUSIONS Study findings highlight significant mortality associated with the coprescription of opioids and BDZ in a general healthcare setting. Further research is needed to elucidate factors associated with mortality among non-OUD patients who are co-prescribed opioids and BDZ.
Collapse
|
14
|
Henschel AV, Flanagan JC, Augur IF, Jeffirs SM, Back SE. Motives for prescription opioid use: The role of alexithymia and distress tolerance. Am J Addict 2022; 31:55-60. [PMID: 34570408 PMCID: PMC8799478 DOI: 10.1111/ajad.13230] [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: 05/12/2021] [Revised: 09/10/2021] [Accepted: 09/12/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Prescription opioid (PO) use disorder is a national public health crisis. Distress tolerance and alexithymia are two separate but related components of emotion regulation that are known to impact substance use disorders. No studies to date, however, have examined the role of distress tolerance and alexithymia in PO use disorder. Thus, the current study examined the association between distress tolerance, alexithymia, and specific motivations for PO use. METHODS Participants were non-treatment-seeking individuals with current PO use disorder (N = 81; average age = 35.0). Assessments included the Distress Tolerance Scale, Toronto Alexithymia Scale, and the Inventory of Drug Taking Situations. RESULTS The findings indicate that distress tolerance mediated the association between alexithymia and PO use in negative situations. Specifically, distress tolerance mediated the association between alexithymia and unpleasant emotions, testing personal control, and conflict with others. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE The results provide novel information regarding emotional states that may contribute to PO use and are malleable intervention targets. Additionally, this study adds to existing literature exploring the relationship between distress tolerance and substance use and is the first to expand upon the connection between alexithymia and distress tolerance in an opioid-using population. Implications for clinical practice and future research are discussed.
Collapse
Affiliation(s)
- Aisling V. Henschel
- University of Missouri-Kansas City, Department of Psychology, Kansas City, MO
| | | | - Isabel F. Augur
- University of Arkansas, Department of Psychological Science, Fayetteville AR
| | | | - Sudie E. Back
- Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC 29401,Medical University of South Carolina, Department of Psychiatry and Behavioral Sciences, Charleston, SC 29425
| |
Collapse
|
15
|
Basco WT, McCauley JL, Zhang J, Marsden JE, Simpson KN, Heidari K, Mauldin PD, Ball SJ. High-risk opioid analgesic dispensing to adolescents 12-18 years old in South Carolina: 2010-2017. Pharmacoepidemiol Drug Saf 2021; 31:353-360. [PMID: 34859532 DOI: 10.1002/pds.5389] [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: 05/24/2021] [Revised: 11/23/2021] [Accepted: 11/29/2021] [Indexed: 11/09/2022]
Abstract
PURPOSE To evaluate "high-risk" opioid dispensing to adolescents, including daily morphine milligram equivalents (MME) above recommended amounts, the percentage of extended-release opioid prescriptions dispensed to opioid-naïve adolescents, and concurrent use of opioids and benzodiazepines, and to evaluate changes in those rates over time. METHODS Retrospective cohort study of one state's prescription drug monitoring program data (2010-2017), evaluating adolescents 12-18 years old dispensed opioid analgesic prescriptions. Outcomes of interest were the quarterly frequencies of the high-risk measures. We utilized generalized linear regression to determine whether the rate of the outcomes changed over time. RESULTS The quarterly percentage of adolescents ages 12-18 years old dispensed an opioid who received ≥90 daily MME declined from 4.1% in the first quarter (Q1) of 2010 to 3.4% in the final quarter (Q4) of 2017 (p < 0.0001). The frequency of adolescents dispensed ≥50 daily MME changed little over time. In 2010, the percentage of adolescents receiving an extended-release opioid who were opioid naïve was 60.7%, declining to 50.6% by Q4 of 2017 (p > 0.10 overall change 2010-2017). The percentage of adolescent opioid days overlapping with benzodiazepine days was 1.6% in Q1 of 2010, declining to 1.1% by Q4 of 2017 (p < 0.001). CONCLUSIONS Among persons 12-18 years old dispensed an opioid analgesic, receipt of ≥90 daily MME declined during the years 2010-2017, as did the percentage of adolescent opioid days that overlapped with benzodiazepines. More than half of the individuals who received extended-release opioid analgesics were identified as opioid naïve and, counter to guidelines, received products intended for opioid-tolerant individuals.
Collapse
Affiliation(s)
- William T Basco
- Department of Pediatrics, College of Medicine, The Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jenna L McCauley
- Department of Psychiatry and Behavioral Services, College of Medicine, The Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jingwen Zhang
- Department of Medicine, College of Medicine, The Medical University of South Carolina, Charleston, South Carolina, USA
| | - Justin E Marsden
- Department of Medicine, College of Medicine, The Medical University of South Carolina, Charleston, South Carolina, USA
| | - Kit N Simpson
- Department of Healthcare Leadership and Management, College of Health Professions, The Medical University of South Carolina, Charleston, South Carolina, USA
| | - Khosrow Heidari
- Blue Cross Blue Shield of South Carolina, Columbia, South Carolina, USA
| | - Patrick D Mauldin
- Department of Medicine, College of Medicine, The Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sarah J Ball
- Department of Medicine, College of Medicine, The Medical University of South Carolina, Charleston, South Carolina, USA
| |
Collapse
|
16
|
Cleary EM, Smid MC, Bokat C, Costantine MM, Rood KM. Indicated Opioids in Pregnancy: Guidance on Providing Comprehensive Care. Am J Perinatol 2021; 40:602-611. [PMID: 34768306 DOI: 10.1055/s-0041-1739427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
In modern obstetric practice, providers will encounter patients for whom opioid use in pregnancy is reasonable or even necessary. A "one-size-fits-all" approach to the counseling and management of such patients is misguided. Understanding indications for ongoing opioid use in pregnancy is essential to patient-centered care. Specifically, recognition of the nuanced differences between opioid dependence and opioid use disorder is crucial for appropriate diagnosis, screening for common concurrent conditions, adequately counseling about individualized maternal and perinatal risks, and accurate documentation of diagnoses and medical decision-making. In this paper, we explore the current typical scenarios in which opioid use in pregnancy may be encountered, ongoing opioid prescribing should be considered, and provide a guide for the obstetric provider to navigate the antepartum, intrapartum, and postpartum periods. KEY POINTS: · Opioid use in pregnant and postpartum individuals is not rare.. · Obstetric providers may elect to assume opioid prescribing.. · Obstetric providers are positioned to optimize outcomes for the mother-infant dyad..
Collapse
Affiliation(s)
- Erin M Cleary
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
| | - Marcela C Smid
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
| | - Christina Bokat
- Department of Anesthesia, University of Utah Health, Salt Lake City, Utah
| | - Maged M Costantine
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
| | - Kara M Rood
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
| |
Collapse
|
17
|
Bauer MR, Larson MJ, Moresco N, Huntington N, Walker R, Richard P. Association between 1-year patient outcomes and opioid-prescribing group of emergency department clinicians: A cohort study with Army active-duty soldiers. Acad Emerg Med 2021; 28:1251-1261. [PMID: 34245641 PMCID: PMC10393064 DOI: 10.1111/acem.14331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 06/07/2021] [Accepted: 06/23/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective was to examine the association between clinicians' opioid prescribing group and patients' outcomes among patients treated in the emergency department (ED). METHODS This was a retrospective cohort study. The setting was the EDs of the U.S. Military Health System (MHS). Patients were 181,557 Army active-duty opioid-naïve (no fill in past 180 days) patients with an index encounter to the ED between October 2010 and September 2016. Exposure was patients classified by opioid prescribing tier of the treating ED clinician: top, middle, or bottom third relative to the clinician's peers in the same ED. Follow-up measurement was from 31 to 365 days after the index encounter. The primary outcome was long-term opioid prescriptions (LTOPs) defined as 180 (or more) days' supply within the follow-up window. We also computed the total morphine milligram equivalents (MME) and total opioid days' supply. Secondary measures were any repeat ED encounter, any hospitalization, any sick leave, and any military-duty restriction. RESULTS We found a 2.5-fold variation in opioid prescribing rates among clinicians in the same MHS ED. Controlling for sample demographics, reason for encounter, and military background, in multivariate analyses the odds of receiving a 180-day opioid supply during follow-up were 1.19 (95% confidence interval [CI] = 1.01 to 1.40, p < 0.05) for the top opioid exposure group and 1.37 (95% CI = 1.19 to 1.57, p < 0.001) for the middle opioid exposure group compared to the bottom exposure group, and there were significant increases in total opioid days' supply and total MME. There were no differences in secondary outcome measures. CONCLUSION In a relatively healthy sample of Army soldiers, variation in opioid exposure defined by clinician's prescribing history was associated with increased odds of LTOP and increase in opioid volume, but not in functional outcomes.
Collapse
Affiliation(s)
- Mark R. Bauer
- Institute for Behavioral Health The Heller School for Social Policy and Management Brandeis University Waltham MA USA
| | - Mary Jo Larson
- Institute for Behavioral Health The Heller School for Social Policy and Management Brandeis University Waltham MA USA
| | - Natalie Moresco
- Institute for Behavioral Health The Heller School for Social Policy and Management Brandeis University Waltham MA USA
| | - Nick Huntington
- Institute for Behavioral Health The Heller School for Social Policy and Management Brandeis University Waltham MA USA
| | - Regine Walker
- Uniformed Services University of the Health Sciences Bethesda MD USA
| | - Patrick Richard
- Uniformed Services University of the Health Sciences Bethesda MD USA
| |
Collapse
|
18
|
Prescription Opioid Characteristics and Nonfatal Overdose Among Patients Discharged from Tennessee Emergency Departments. J Emerg Med 2021; 62:51-63. [PMID: 34535302 DOI: 10.1016/j.jemermed.2021.07.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/27/2021] [Accepted: 07/25/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Despite increasing trends of nonfatal opioid overdoses in emergency departments (EDs), population-based studies comparing prescription opioid dosing patterns before and after nonfatal opioid overdoses are limited. OBJECTIVES To evaluate characteristics of prescribing behaviors before and after nonfatal overdoses, with a focus on opioid dosage. METHODS Included were 5,395 adult residents of Tennessee discharged from hospital EDs after a first nonfatal opioid overdose (2016-2017). Patients were linked to eligible prescription records in the Tennessee Controlled Substance Monitoring Database. We estimated odds ratios (OR) and 95% confidence intervals (CI) to evaluate characteristics associated with filling opioid prescriptions 90 days before overdose and with high daily dose (≥ 90 morphine milligram equivalents) 90 days after overdose. RESULTS Among patients who filled a prescription both before and after an overdose, the percentage filling a low, medium, and high dose was 33.7%, 31.9%, and 34.4%, respectively, after an opioid overdose (n = 1,516). Most high-dose users before an overdose (>70%) remained high-dose users with the same prescriber after the overdose. Male gender, ages ≥ 35 years, and medium metro residence were associated with increased odds of high-dose filling after an opioid overdose. Patients filling overlapping opioid-benzodiazepine prescriptions and with > 7 days' supply had increased odds of filling high dose after an opioid overdose (OR 1.4, 95% CI 1.08-1.70 and OR 3.7, 95% CI 2.28-5.84, respectively). CONCLUSIONS In Tennessee, many patients treated in the ED for an overdose are still prescribed high-dose opioid analgesics after an overdose, highlighting a missed opportunity for intervention and coordination of care between ED and non-ED providers.
Collapse
|
19
|
Beneficial Effects of Opioid Rotation to Buprenorphine/Naloxone on Opioid Misuse, Craving, Mental Health, and Pain Control in Chronic Non-Cancer Pain Patients with Opioid Use Disorder. J Clin Med 2021; 10:jcm10163727. [PMID: 34442024 PMCID: PMC8396821 DOI: 10.3390/jcm10163727] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/17/2021] [Accepted: 08/18/2021] [Indexed: 12/12/2022] Open
Abstract
Patients with chronic non-cancer pain (CNCP) often use opioids for long periods of time. This may lead to opioid use disorder (OUD) and psychiatric symptoms: mainly depression and anxiety. The current study investigated the effect of buprenorphine/naloxone (BuNa) rotation on opioid misuse, craving, psychiatric symptoms and pain in patients with CNCP and OUD. Forty-three participants with CNCP and OUD were converted from a full mu-receptor agonist opioid (mean morphine equivalent dose: 328.3 mg) to BuNa, in an inpatient setting. Opioid misuse, craving, co-occurring psychiatric symptoms, and pain perception were determined at baseline and after a two-month follow-up, using the following self-report questionnaires: Current Opioid Misuse Measurement (COMM), Visual Analog Scale (VAS-craving and VAS-pain) and Depression, Anxiety and Stress Scale (DASS), respectively. VAS-craving and VAS-pain were also determined immediately after conversion. A total of 37 participants completed the protocol. The mean COMM decreased from 17.1 to 6.7 (F = 36.5; p < 0.000), the mean VAS-craving decreased from 39.3 to 5.3 (−86.6%; F = 26.5, p < 0.000), the mean DASS decreased from 12.1 to 6.6 (F = 56.3, p < 0.000), and the mean VAS-pain decreased from 51.3 to 37.2 (−27.4%, F = 3.3; p = 0.043). Rotation to BuNa in patients with CNCP and OUD was accompanied by reductions in (i) opioid misuse, (ii) opioid craving, (iii) the severity of co-occurring psychiatric symptoms, and (iv) self-reported pain. BuNa as opioid agonist treatment may therefore be a beneficial strategy in CNCP patients with OUD. The limited sample size and the observational nature of this study underline the need for the replication of the current findings in large-scale, controlled studies.
Collapse
|
20
|
Dunlop AJ, Lokuge B, Lintzeris N. Opioid prescribing in Australia: too much and not enough. Med J Aust 2021; 215:117-118. [PMID: 34272736 PMCID: PMC9292861 DOI: 10.5694/mja2.51180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/22/2021] [Accepted: 06/22/2021] [Indexed: 12/02/2022]
Affiliation(s)
- Adrian J Dunlop
- Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW.,University of Newcastle, Newcastle, NSW
| | - Buddhima Lokuge
- Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW.,University of Newcastle, Newcastle, NSW
| | - Nicholas Lintzeris
- University of Sydney, Sydney, NSW.,Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, NSW
| |
Collapse
|
21
|
Ball SJ, Simpson K, Zhang J, Marsden J, Heidari K, Moran WP, Mauldin PD, McCauley JL. High-Risk Opioid Prescribing Trends: Prescription Drug Monitoring Program Data From 2010 to 2018. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2021; 27:379-384. [PMID: 32956292 PMCID: PMC7940459 DOI: 10.1097/phh.0000000000001203] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Deaths due to opioids have continued to increase in South Carolina, with 816 opioid-involved overdose deaths reported in 2018, a 9% increase from the prior year. The objective of the current study is to examine longitudinal trends (quarter [Q] 1 2010 through Q4 2018) of opioid prescribing volume and high-risk opioid prescribing behaviors in South Carolina using comprehensive dispensing data available in the South Carolina Prescription Drug Monitoring Program (SC PDMP). DESIGN Retrospective analyses of SC PDMP data were performed using general linear models to assess quarterly time trends and change in rate of each outcome Q1 2010 through Q4 2018. PARTICIPANTS Opioid analgesic prescription fills from SC state residents between Q1 2010 and Q4 2018. MAIN OUTCOME MEASURES High-risk prescribing behaviors included (1) opioid prescribing rate; (2) percentage of patients receiving opioids dispensed 90 or more average morphine milligram equivalents daily; (3) percentage of opioid prescribed days with overlapping opioid and benzodiazepine prescriptions; (4) rate per 100 000 residents of multiple provider episodes; and (5) percentage of patients prescribed extended release opioids who were opioid naive. RESULTS A total of 33 027 461 opioid prescriptions were filled by SC state residents within the time period of Q1 2010 through Q4 2018. A 41% decrease in the quarterly prescribing rate of opioids occurred from Q1 2010 to Q4 2018. The decrease in overall opioid prescribing was mirrored by significant decreases in all 4 high-risk prescribing behaviors. CONCLUSION PDMPs may represent the most complete data regarding the dispensing of opioid prescriptions and as such be valuable tools to inform and monitor the supply of licit opioids. Our results indicate that public health policy, legislative action, and multiple clinical interventions aimed at reducing high rates of opioid prescribing across the health care ecosystem appear to be succeeding in the state of South Carolina.
Collapse
Affiliation(s)
- Sarah J. Ball
- Division of General Internal Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Kit Simpson
- Department of Health Administration and Policy, College of Health Professions, Medical University of South Carolina, Charleston, SC, USA
| | - Jingwen Zhang
- Division of General Internal Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Justin Marsden
- Division of General Internal Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | | | - William P. Moran
- Division of General Internal Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Patrick D. Mauldin
- Division of General Internal Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Jenna L. McCauley
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| |
Collapse
|
22
|
Abstract
OBJECTIVE Evaluate opioid prescribing patterns following tympanoplasty/mastoidectomy and assess factors associated to recurrent opioid use. STUDY DESIGN Retrospective cohort study. SETTING National pharmaceutical database recording opioid fulfillment (Truven Health Marketscan Commercial Claims/Encounters and Medicare Claims/Encounters database). PARTICIPANTS Patients who 1) underwent tympanoplasty and/or mastoidectomy, 2) filled postoperative opioid prescriptions between 2011 and 2016, and 3) had no opioid prescriptions filled 60 days before surgery. Cohort 1 filled only one prescription and cohort 2 filled more than one prescription in the 12 months following surgery. Univariate/multivariate analysis was performed to assess for associations with recurrent opioid use. MAIN OUTCOME MEASURE(S) Opioid prescription details and recurrent opioid use. RESULTS The study included 398 patients (cohort 1 = 233, cohort 2 [recurrent opioid user] = 165). Hydrocodone 5 mg was most frequently used. The average duration opioids were prescribed was 5.8 days with an average quantity of tablets of 36.51. Recurrent opioid use in cohort 2 was associated with total morphine milligram equivalents prescribed/d in the first postoperative week (odds ratio [OR] = 1.02, p < 0.001), post-op chronic pain disorder (OR = 2.00, p = 0.04), post-op substance abuse (OR = 2.12, p = 0.05), and post-op anxiety (OR = 1.96, p = 0.02). CONCLUSION Recurrent opioid use following tympanoplasty/mastoidectomy is associated with the amount prescribed per day but not opioid type or duration of treatment. Postoperative diagnoses such as chronic pain disorder, substance abuse, or anxiety could be predictive of or coexistent with recurrent opioid use. Limiting opioids prescribed per day and use of anti-inflammatory medications could decrease the risk of recurrent opioid use.
Collapse
|
23
|
Wilton J, Chong M, Abdia Y, Purssell R, MacInnes A, Gomes T, Dart RC, Balshaw RF, Otterstatter M, Wong S, Yu A, Alvarez M, Janjua NZ, Buxton JA. Cohort profile: development and characteristics of a retrospective cohort of individuals dispensed prescription opioids for non-cancer pain in British Columbia, Canada. BMJ Open 2021; 11:e043586. [PMID: 33849849 PMCID: PMC8051385 DOI: 10.1136/bmjopen-2020-043586] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Prescription opioids (POs) are widely prescribed for chronic non-cancer pain but are associated with several risks and limited long-term benefit. Large, linked data sources are needed to monitor their harmful effects. We developed and characterised a retrospective cohort of people dispensed POs. PARTICIPANTS We used a large linked administrative database to create the Opioid Prescribing Evaluation and Research Activities cohort of individuals dispensed POs for non-cancer pain in British Columbia (BC), Canada (1996-2015). We created definitions to categorise episodes of PO use based on a review of the literature (acute, episodic, chronic), developed an algorithm for inferring clinical indication and assessed patterns of PO use across a range of characteristics. FINDINGS TO DATE The current cohort includes 1.1 million individuals and 3.4 million PO episodes (estimated to capture 40%-50% of PO use in BC). The majority of episodes were acute (81%), with most prescribed for dental or surgical pain. Chronic use made up 3% of episodes but 88% of morphine equivalents (MEQ). Across the acute to episodic to chronic episode gradient, there was an increasing prevalence of higher potency POs (hydromorphone, oxycodone, fentanyl, morphine), long-acting formulations and chronic pain related indications (eg, back, neck, joint pain). Average daily dose (MEQ) was similar for acute/episodic but higher for chronic episodes. Approximately 7% of the cohort had a chronic episode and chronic pain was the characteristic most strongly associated with chronic PO use. Individuals initiating a chronic episode were also more likely to have higher social/material deprivation and previous experience with a mental health condition or a problem related to alcohol or opioid use. Overall, these findings suggest our episode definitions have face validity and also provide insight into characteristics of people initiating chronic PO therapy. FUTURE PLANS The cohort will be refreshed every 2 years. Future analyses will explore the association between POs and adverse outcomes.
Collapse
Affiliation(s)
- James Wilton
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Mei Chong
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Younathan Abdia
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
- School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Roy Purssell
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
- Department of Emergency Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Aaron MacInnes
- Pain Management Clinic, JPOCSC, Fraser Health Authority, Surrey, British Columbia, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Tara Gomes
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Richard C Dart
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, Colorado, USA
- Department of Emergency Medicine, University of Colorado Health Sciences Center, Denver, Colorado, USA
| | - Robert F Balshaw
- George and Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Michael Otterstatter
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
- School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Stanley Wong
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Amanda Yu
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Maria Alvarez
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Naveed Zafar Janjua
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
- School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Jane A Buxton
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
- School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
24
|
Derefinko KJ, Gong Z, Bursac Z, Hand SB, Johnson KC, Mihalko WM. Opioid Use Patterns After Primary Total Knee Replacement. Orthop Clin North Am 2021; 52:103-110. [PMID: 33752831 DOI: 10.1016/j.ocl.2020.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Orthopedic surgeries are associated with the prescription of more narcotics than any other surgical specialty, particularly for total knee replacement (TKR) surgery. The authors examined controlled substance prescriptions following TKR surgery in a sample of 560 TKR patients. Results indicated that of all the 5164 prescriptions documented on the controlled substance monitoring database, 64% were for opioid medications. More than half of the patients received controlled substances from both the surgery site provider and a nonsurgery site provider in the year following surgery. The authors recommend that providers consider the possibility of outside prescribing when prescribing opioid analgesic.
Collapse
Affiliation(s)
- Karen J Derefinko
- Department of Preventive Medicine, Department of Pharmacology, Addiction Science, and Toxicology, The University of Tennessee Health Science Center, 66 North Pauline Street, Room 649, Memphis, TN 38163-2181, USA.
| | - Zhenghua Gong
- Department of Biostatistics, Florida International University, 11200 Southwest 8th Street, Miami, FL 33199, USA
| | - Zoran Bursac
- Department of Biostatistics, Florida International University, 11200 Southwest 8th Street, Miami, FL 33199, USA
| | - Sarah B Hand
- Department of Preventive Medicine, University of Tennessee Health Science Center, 403 Doctor's Office Building, 66 North Pauline Street, Memphis, TN 38163, USA. https://twitter.com/SarahHand
| | - Karen C Johnson
- Department of Preventive Medicine, University of Tennessee Health Science Center, 659 Doctor's Office Building, 66 North Pauline Street, Memphis, TN 38163, USA
| | - William M Mihalko
- Department of Orthopaedic Surgery and Biomedical Engineering, Joint Graduate Program in Biomedical Engineering, Campbell Clinic, University of Tennessee Health Science Center, E226 Coleman Building, 956 Court Avenue, Memphis, TN 38163, USA
| |
Collapse
|
25
|
Jami M, Marrache M, Puvanesarajah V, Raad M, Prasad N, Jain A. Treatment of Neck Pain with Opioids in the Primary Care Setting: Trends and Geographic Variation. PAIN MEDICINE 2021; 22:740-745. [PMID: 33260217 DOI: 10.1093/pm/pnaa372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Neck pain is a leading cause of years lived with disability and is often managed with opioid medications in primary care settings, though this is contraindicated by national guidelines. The aim of this study was to determine the prevalence of opioid prescription for neck pain at a primary care visit and to analyze the geographic variation and trends in opioid prescriptions between 2011 and 2017. METHODS Using a prescription drug claims database, we identified 591,961 adult patients who presented for neck pain in primary care settings between 2011 and 2017. Patients who had outpatient specialty visits within 1 year before presentation, a concomitant diagnosis of a non-musculoskeletal cause of neck pain, or preexisting chronic opioid use were excluded. RESULTS The mean age of the patients was 45 ± 12 years, and 64% were female. Fifteen percent of patients were prescribed opioids within 30 days of their encounter. Eleven percent of patients were prescribed moderate- to high-dose opioids (>20 morphine milligram equivalents). From 2011-2017, the proportion of both overall opioid prescriptions and moderate- to high-dose prescriptions given to first time presenters to an outpatient clinic for neck pain was highest in Mississippi (20%) and lowest in New Mexico (6%) (P < 0.001). In 2017, the proportion of both overall opioid prescriptions and moderate- to high-dose prescriptions was highest in the Midwest (10.4%) and lowest in the Northeast (4.9%). The proportion of patients with filled opioid prescriptions declined between 2011 (19%) and 2017 (13%) (P < 0.001), and the proportion of patients with moderate- to high-dose prescriptions declined from 2011 (13%) to 2017 (8%) (P < 0.001). first-time presenters of neck pain to an outpatient clinic. CONCLUSIONS Opioid medication use for neck pain in the primary care setting is significant. Although opioid prescriptions are declining, there remains a need for further standardization in prescription practices.
Collapse
Affiliation(s)
- Meghana Jami
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Majd Marrache
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Varun Puvanesarajah
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Micheal Raad
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Niyathi Prasad
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Amit Jain
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
26
|
Bursua A, Mudreac A, Koppen L, Larson C, Park YS, Sreedhar R. Effect of Default Order Standardization on Opioid Prescribing Patterns. Jt Comm J Qual Patient Saf 2021; 47:431-437. [PMID: 33896745 DOI: 10.1016/j.jcjq.2021.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 01/31/2021] [Accepted: 03/08/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Opioid misuse, overprescribing, dependency, and overdose remains a significant concern in the United States. A quality improvement study was conducted at the University of Illinois Hospital & Health Sciences System to determine the effect of standardizing the default orders for hydrocodone-acetaminophen products implemented on June 22, 2016. METHODS Prior to the intervention, default orders had variable dose tablet numbers (1 or 2) and dosing frequencies (every 4 or 6 hours), and no default dispense quantity. Defaults were modified to 1 tablet every 6 hours as needed for pain and dispense quantities of 3 and 5 days' supply were added. Number of tablets per order, dosing frequency, and days' supply prescribed between January 1, 2016, and June 21, 2016, were compared to those placed between June 22, 2016, and December 31, 2016. Opioid doses were converted into morphine milligram equivalents (MME). Analyses were performed to determine the effect of the intervention on daily opioid dose and number of days' supply prescribed. RESULTS 22,052 orders were included in this study. Following the intervention, the number of tablets prescribed was reduced by an average of 19,832 tablets per month. Every 6 hours dosing (as opposed to every 4 hours) increased by 21.52 percentage points. Prescriptions with ≥ 50 MME/day dropped by 5.8 percentage points, and > 3 days' supply decreased by 2.54 percentage points. Linear regression demonstrated an increase in opioid prescriptions with daily < 50 MME (odds ratio [OR] = 1.72, p < 0.001) and ≤ 3 days' supply (OR = 1.27, p < 0.001). CONCLUSION Default electronic health record settings strongly influence prescribing patterns.
Collapse
|
27
|
Antoniou T, Pritlove C, Shearer D, Martins D, Tadrous M, Munro C, Gomes T. A qualitative study of a publicly funded pharmacy-dispensed naloxone program. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 92:103146. [PMID: 33568317 DOI: 10.1016/j.drugpo.2021.103146] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 01/26/2021] [Accepted: 01/28/2021] [Indexed: 12/28/2022]
Abstract
AIMS To characterize the experiences of individuals accessing pharmacy-based naloxone and relate these experiences to the risk environments and discourses in which they are embedded. METHODS We conducted a qualitative study using in-depth interviews of 37 adults aged 18 years and over who had accessed pharmacy-dispensed naloxone. Participants were recruited from across Ontario, Canada, and comprised individuals taking opioids for chronic pain, those taking opioids for reasons other than chronic pain, and individuals acquiring naloxone to act as bystanders in an opioid overdose setting. We drew upon risk environment theory to interpret participants' accounts. RESULTS Following analysis and interpretation, we generated five theoretically-informed themes characterizing the experiences of individuals accessing pharmacy-dispensed naloxone: 'intersection of naloxone narrative with pharmacy environment', 'individual risk environment and pharmacy-dispensed naloxone uptake', 'safe spaces: creating an enabling environment for pharmacy-dispensed naloxone', 'individuation: becoming a first responder' and 'beyond naloxone: the macro risk environment'. Specifically, participants described how judgement and stereotyping associated with the broader naloxone narrative can be amplified in the space of the pharmacy, leading to fears of reprisals and strategies to mitigate social risk. In addition, the social construction of naloxone as a drug for 'problematic' opioid use and a lack of pharmacist awareness regarding the risk environments in which opioid use occurs was perceived to limit opportunities for optimizing naloxone distribution and training. Finally, participants described approaches that could create enabling environments in the space of the pharmacy while remaining cognizant of the structural changes required in the macro risk environments of people who take opioids. CONCLUSIONS Despite increasing the availability of naloxone, participants characterized several social and environmental factors that could limit the accessibility of the drug from pharmacies. Strategies to address these factors could create enabling environments within pharmacies that optimize the reach and impact of pharmacy-dispensed naloxone.
Collapse
Affiliation(s)
- Tony Antoniou
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada; Department of Family and Community Medicine, Unity Health, Toronto, Ontario, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Ontario Drug Policy Research Network, Toronto, Ontario, Canada
| | - Cheryl Pritlove
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada; School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada
| | - Dana Shearer
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada; Ontario Drug Policy Research Network, Toronto, Ontario, Canada
| | - Diana Martins
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada; Ontario Drug Policy Research Network, Toronto, Ontario, Canada
| | - Mina Tadrous
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada; Ontario Drug Policy Research Network, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; Women's College Research Institute, Toronto, Ontario, Canada
| | - Charlotte Munro
- Ontario Drug Policy Research Network, Toronto, Ontario, Canada
| | - Tara Gomes
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada; Ontario Drug Policy Research Network, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
28
|
Quinn PD, Fine KL, Rickert ME, Sujan AC, Boersma K, Chang Z, Franck J, Lichtenstein P, Larsson H, D’Onofrio BM. Association of Opioid Prescription Initiation During Adolescence and Young Adulthood With Subsequent Substance-Related Morbidity. JAMA Pediatr 2020; 174:1048-1055. [PMID: 32797146 PMCID: PMC7418042 DOI: 10.1001/jamapediatrics.2020.2539] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
IMPORTANCE Concerns about adverse outcomes associated with opioid analgesic prescription have led to major guideline and policy changes. Substantial uncertainty remains, however, regarding the association between opioid prescription initiation and increased risk of subsequent substance-related morbidity. OBJECTIVE To examine the association of opioid initiation among adolescents and young adults with subsequent broadly defined substance-related morbidity. DESIGN, SETTING, AND PARTICIPANTS This cohort study analyzed population-register data from January 1, 2007, to December 31, 2013, on Swedish individuals aged 13 to 29 years by January 1, 2013, who were naive to opioid prescription. To account for confounding, the analysis compared opioid prescription recipients with recipients of nonsteroidal anti-inflammatory drugs as an active comparator, compared opioid-recipient twins and other multiple birth individuals with their nonrecipient co-multiple birth offspring (co-twin control), examined dental prescription as a specific indication, and included individual, parental, and socioeconomic covariates. Data were analyzed from March 30, 2019, to January 22, 2020. EXPOSURES Opioid prescription initiation, defined as first dispensed opioid analgesic prescription. MAIN OUTCOMES AND MEASURES Substance-related morbidity, assessed as clinically diagnosed substance use disorder or overdose identified from inpatient or outpatient specialist records, substance use disorder or overdose cause of death, dispensed pharmacotherapy for alcohol use disorder, or conviction for substance-related crime. RESULTS Among the included cohort (n = 1 541 862; 793 933 male [51.5%]), 193 922 individuals initiated opioid therapy by December 31, 2013 (median age at initiation, 20.9 years [interquartile range, 18.2-23.6 years]). The active comparator design included 77 143 opioid recipients without preexisting substance-related morbidity and 229 461 nonsteroidal anti-inflammatory drug recipients. The adjusted cumulative incidence of substance-related morbidity within 5 years was 6.2% (95% CI, 5.9%-6.5%) for opioid recipients and 4.9% (95% CI, 4.8%-5.1%) for nonsteroidal anti-inflammatory drug recipients (hazard ratio, 1.29; 95% CI, 1.23-1.35). The co-twin control design produced comparable results (3013 opioid recipients and 3107 nonrecipients; adjusted hazard ratio, 1.43; 95% CI, 1.02-2.01), as did restriction to analgesics prescribed for dental indications and additional sensitivity analyses. CONCLUSIONS AND RELEVANCE Among adolescents and young adults analyzed in this study, initial opioid prescription receipt was associated with an approximately 30% to 40% relative increase in risk of subsequent substance-related morbidity in multiple designs that adjusted for confounding. These findings suggest that this increase may be smaller than previously estimated in some other studies.
Collapse
Affiliation(s)
- Patrick D. Quinn
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington
| | - Kimberly L. Fine
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington
| | - Martin E. Rickert
- Department of Psychological and Brain Sciences, Indiana University, Bloomington
| | - Ayesha C. Sujan
- Department of Psychological and Brain Sciences, Indiana University, Bloomington
| | - Katja Boersma
- Center for Health and Medical Psychology, School of Law, Psychology and Social Work, Örebro University, Örebro, Sweden
| | - Zheng Chang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Johan Franck
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Paul Lichtenstein
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Larsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden,School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Brian M. D’Onofrio
- Department of Psychological and Brain Sciences, Indiana University, Bloomington,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
29
|
Adewumi AD, Maravilla JC, Alati R, Hollingworth SA, Hu X, Loveday B, Connor JP. Pharmaceutical opioids utilisation by dose, formulation, and socioeconomic status in Queensland, Australia: a population study over 22 years. Int J Clin Pharm 2020; 43:328-339. [PMID: 32964404 DOI: 10.1007/s11096-020-01155-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 09/14/2020] [Indexed: 12/11/2022]
Abstract
Background Prescription opioids are a central aspect of pain management and as the prevalence of pain is increasing so is the rate of use of prescription opioids. Increased opioid prescriptions increases the risk of deaths and morbidity. Objective To (a) describe the 22-year trend of prescription opioid dispensing in Queensland, (b) examine the effect of opioid dose, formulation and socioeconomic status on the number of prescriptions dispensed. Design/setting Retrospective analysis of data from the Monitoring of Drugs of Dependence system of the Monitored Medicines Unit of Queensland Health, Australia. Participants Queensland residents (3.3 million) from 18 years old dispensed 18.8 million opioid prescriptions from January 1997 to December 2018. Results Opioid prescriptions dispensed annually increased to over two million in 2018 from about 150,000 prescriptions in 1997. The number of prescriptions for modified-release formulations dispensed annually was three times higher compared to the immediate-release formulations. Oxycodone accounted for over 60% of prescriptions for pharmaceutical opioids since 2013. There was an increase in the number of prescriptions dispensed as socioeconomic status decreased and modified-release opioid formulations positively affects the pattern of dispensing. The highest increase in number of prescriptions dispensed (for all opioids) was observed among the high socioeconomic status (IRR = 1.25, 95% CI 1.25, 1.26). The disparities in the annual number of prescriptions across dose categories are wider in the modified-release than the immediate-release formulations. Conclusion The dispensing of opioids increased significantly in Queensland. There was a positive relationship between the increased dispensing of opioids and locations of lower socioeconomic status.
Collapse
Affiliation(s)
- Adeleke D Adewumi
- Maryborough Hospital Pharmacy, Wide Bay Hospital and Health Service, 185 Walker Street, Maryborough, QLD, 4650, Australia. .,Discipline of Psychiatry, The University of Queensland, Herston, QLD, 4029, Australia. .,School of Clinical Medicine - Rural Clinical School, The University of Queensland, 2-4 Medical Place, Urraween, QLD, 4655, Australia.
| | - Joemer C Maravilla
- Institute for Social Science Research, The University of Queensland, 80 Meiers Rd, Indooroopilly, QLD, 4068, Australia
| | - Rosa Alati
- School of Public Health, Curtin University, Kent Street, Bentley Campus, Perth, WA, 6845, Australia
| | - Samantha A Hollingworth
- School of Pharmacy, The University of Queensland, 20 Cornwall St, Woolloongabba, QLD, 4102, Australia
| | - Xuelei Hu
- School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, QLD, 4072, Australia
| | - Bill Loveday
- Monitored Medicines Unit, Chief Medical Officer & Healthcare Regulation Branch, Department of Health, Brisbane, QLD, 4000, Australia
| | - Jason P Connor
- Discipline of Psychiatry, The University of Queensland, Herston, QLD, 4029, Australia.,Centre for Youth Substance Abuse Research, The University of Queensland, 17 Upland Road, St. Lucia, QLD, 4067, Australia
| |
Collapse
|
30
|
Hirsh AT, Anastas TM, Miller MM, Quinn PD, Kroenke K. Patient race and opioid misuse history influence provider risk perceptions for future opioid-related problems. AMERICAN PSYCHOLOGIST 2020; 75:784-795. [PMID: 32915023 PMCID: PMC7490831 DOI: 10.1037/amp0000636] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In response to the dual public health crises of chronic pain and opioid use, providers have become more vigilant about assessing patients for risk of opioid-related problems. Little is known about how providers are making these risk assessments. Given previous studies indicating that Black patients are at increased risk for suboptimal pain care, which may be related to stereotypes about drug abuse, the current study examined how patient race and previous opioid misuse behaviors impact providers' risk assessments for future prescription opioid-related problems. Physician residents and fellows (N = 135) viewed videos and read vignettes about 8 virtual patients with chronic pain who varied by race (Black/White) and history of prescription opioid misuse (absent/present). Providers rated patients' risk for future prescription opioid-related adverse events, misuse/abuse, addiction, and diversion, and also completed measures of implicit racial attitudes and explicit beliefs about race differences in pain. Two significant interactions emerged indicating that Black patients were perceived to be at greater risk for future adverse events (when previous misuse was absent) and diversion (when previous misuse was present). Significant main effects indicated that Black patients and patients with previous misuse were perceived to be at greater risk for future misuse/abuse of prescription opioids, and that patients with previous misuse were perceived to be at greater risk of addiction. These findings suggest that racial minorities and patients with a history of prescription opioid misuse are particularly vulnerable to any unintended consequences of efforts to stem the dual public health crises of chronic pain and opioid use. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
Collapse
Affiliation(s)
- Adam T. Hirsh
- Department of Psychology, Indiana University – Purdue University Indianapolis
| | - Tracy M. Anastas
- Department of Psychology, Indiana University – Purdue University Indianapolis
| | - Megan M. Miller
- Department of Psychology, Indiana University – Purdue University Indianapolis
| | - Patrick D. Quinn
- Department of Applied Health Science, Indiana University, Bloomington
| | - Kurt Kroenke
- Department of Medicine, Indiana University School of Medicine
| |
Collapse
|
31
|
Adewumi AD, Maravilla JC, Alati R, Hollingworth SA, Hu X, Loveday B, Connor JP. Multiple opioid prescribers: A genuine quest for treatment rather than aberrant behaviour. A two-decade population-based study. Addict Behav 2020; 108:106458. [PMID: 32416363 DOI: 10.1016/j.addbeh.2020.106458] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/23/2020] [Accepted: 04/26/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Accessing multiple prescribers for opioid prescription, referred to as doctor-shopping, is associated with an increased risk of opioid overdose and fatalities. AIM The primary aim of this study was to assess the probability of accessing multiple prescribers among patients dispensed prescription opioids. METHOD A retrospective population-based study using the Monitoring of Drugs of Dependence system of the Medicines Monitoring Unit (MMU) of Queensland Health, Australia. We assessed the odds of accessing multiple prescribers across both -short-term (≤1 month, 2-3 months) and longer-term (4-6 months and ≥7 months). We examined the relationship between multiple doctor visits, the dispensed dose of opioid and patient's residential socioeconomic status (SES). RESULT Compared to those dispensed opioid prescriptions for ≥7-12 months, those dispensed opioids for ≤1 month were more likely to have visited ≥3 prescribers (adjusted odds ratio (aOR)) 4.06, 95% CI 4.01, 4.10, while for 2-3 months and 4-6 months the odds were aOR 2.36, 95% CI 2.33, 2.39 and aOR 1.79, 95% CI 1.74, 1.79 respectively. Patients dispensed opioid doses of ≥100 oral morphine milligram equivalent per day (MME/day) were more likely to obtain prescriptions from ≥3 prescribers compare to those receiving a dose of <20MME/day (aOR 1.90; 95% CI 1.87, 1.94). The probability of obtaining opioid prescriptions from multiple prescribers increased as the socioeconomic status decreased: aOR 1.41; 95% CI 1.38, 1.44 for lowest SES compared to the highest SES. CONCLUSION Patients were more than four time likely to be dispensed opioid prescriptions from multiple prescribers within the first 30 days of initiating opioid treatment, possibly as part of multidisciplinary referral post-hospital discharge. High dose opioid and low SES was associated with higher probability of accessing multiple prescribers.
Collapse
|
32
|
Quantifying the Crisis: Opioid-Related Adverse Events in Outpatient Ambulatory Plastic Surgery. Plast Reconstr Surg 2020; 145:687-695. [PMID: 32097308 DOI: 10.1097/prs.0000000000006570] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The United States is currently in the midst of an opioid epidemic precipitated, in part, by the excessive outpatient supply of opioid pain medications. Accordingly, this epidemic has necessitated evaluation of practice and prescription patterns among surgical specialties. The purpose of this study was to quantify opioid-related adverse events in ambulatory plastic surgery. METHODS A retrospective review of 43,074 patient profiles captured from 2001 to 2018 within an American Association for Accreditation of Ambulatory Surgery Facilities quality improvement database was conducted. Free-text search terms related to opioids and overdose were used to identify opioid-related adverse events. Extracted profiles included information submitted by accredited ambulatory surgery facilities and their respective surgeons. Descriptive statistics were used to quantify opioid-related adverse events. RESULTS Among our cohort, 28 plastic surgery patients were identified as having an opioid-related adverse event. Overall, there were three fatal and 12 nonfatal opioid-related overdoses, nine perioperative opioid-related adverse events, and four cases of opioid-related hypersensitivities or complications secondary to opioid tolerance. Of the nonfatal cases evaluated in the hospital (n = 17), 16 patients required admission, with an average 3.3 ± 1.7 days' hospital length of stay. CONCLUSIONS Opioid-related adverse events are notable occurrences in ambulatory plastic surgery. Several adverse events may have been prevented had different diligent medication prescription practices been performed. Currently, there is more advocacy supporting sparing opioid medications when possible through multimodal anesthetic techniques, education of patients on the risks and harms of opioid use and misuse, and the development of societal guidance regarding ambulatory surgery prescription practices.
Collapse
|
33
|
Abstract
OBJECTIVE To evaluate opioid prescribing patterns following cochlear implantation (CI) and assess factors associated with recurrent opioid use. STUDY DESIGN Retrospective cohort study. SETTING National pharmaceutical database recording opioid fulfillment (Truven Health Marketscan Commercial Claims and Encounters and Medicare Claims and Encounters database) PARTICIPANTS:: CI recipients who filled opioid prescriptions between January 2011 and December 2016. All patients had no previous opioid prescriptions filled 60 days before implantation and filled at least one opioid prescription within 1 week after surgery. Cohort 1 filled only one prescription and cohort 2 filled more than one prescription in the 12 months following CI. Univariate/multivariate analysis was performed to assess for associations with recurrent opioid use. MAIN OUTCOME MEASURE(S) Opioid prescription details and recurrent opioid use. RESULTS The study included 98 patients (cohort 1 = 57, cohort 2 (recurrent opioid use) = 41). Hydrocodone 5 mg was most frequently used. The average duration opioids were prescribed was 5.49 days with an average quantity of tablets of 36.1. Recurrent opioid use in cohort 2 was associated with both total morphine milligram equivalents (MME) prescribed/day in the first postoperative week (OR = 1.03, p = 0.01) and use of stronger MME opioids (OR = 7.20, p = 0.05). CONCLUSION Prescribing patterns following CI can influence recurrent opioid use in patients. Each additional tablet of hydrocodone 5 mg beyond 8 tablets/d or oxycodone 5 mg beyond 5.33 tablets/d, increases the likelihood of recurrent opioid use by 15 or 22.5%, respectively. Limiting opioids prescribed per day to no more than 40 MME could lower the likelihood of patients becoming recurrent opioid users postoperatively.
Collapse
|
34
|
Adewumi AD, Maravilla JC, Alati R, Hollingworth SA, Hu X, Loveday B, Connor JP. Duration of opioid use and association with socioeconomic status, daily dose and formulation: a two-decade population study in Queensland, Australia. Int J Clin Pharm 2020; 43:340-350. [PMID: 32556897 DOI: 10.1007/s11096-020-01079-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 06/04/2020] [Indexed: 01/25/2023]
Abstract
Background There is an association between the duration of prescription opioids use and an increased risk of serious harm, often unintentional. Objective (1) Describe the trends in duration of prescription opioids dispensing and, (2) determine the risk of long-term use (≥4 months) based on patients' socioeconomic status, daily dose in oral daily morphine milligram equivalent, and opioid formulation. Setting Residents of Queensland (2,827,727), Australia from the age 18 years and who were dispensed pharmaceutical opioids from 1 January 1997 to 31 December 2018. Method Retrospective, longitudinal population-based analysis using data obtained from the Monitoring of Drugs of Dependence system of the Monitored Medicines Unit of Queensland Health. Main outcome measure Contribution of socioeconomic status, and daily dose and opioid formulation (modified-release or immediate-release) to the risk of long-term opioid use. Results There was little difference between the number of patients dispensed opioids for ≥4 months and ≤3 months between 1997 and 2011. Thereafter, the number for those using opioids long-term increased. The highest risk of having opioids dispensed for ≥4 months were for patients in the lowest level of socioeconomic status (adjusted odds ratio 1.36; 95% CI, 1.34, 1.38), compared to people in the highest socioeconomic status areas, followed by the low-socioeconomic status areas, mid-socioeconomic status areas, and high-socioeconomic status areas respectively. The risk of being dispensed prescription opioids for ≥4 months significantly increased as the dose increased: adjusted odds ratio 1.73; 95% CI, 1.71, 1.75, adjusted odds ratio 1.89; 95% CI, 1.87, 1.92, and adjusted odds ratio 3.63; 95% CI, 3.58, 3.69 for the ≥20 to <50 oral daily morphine milligram equivalent, ≥50 to <100 oral daily morphine milligram equivalent and ≥100 oral daily morphine milligram equivalent dose categories, respectively. Conclusion Higher doses and living in a low socioeconomic status areas were associated with increased risk of long-term dispensing of opioid prescriptions.
Collapse
Affiliation(s)
- Adeleke D Adewumi
- Maryborough Hospital Pharmacy, Wide Bay Hospital and Health Service, 185 Walker Street Maryborough 4650, Herston, QLD, Australia. .,Discipline of Psychiatry, The University of Queensland, Herston, QLD, 4029, Australia. .,School of Clinical Medicine - Rural Clinical School, The University of Queensland, 2-4 Medical Place, Urraween, QLD, 4655, Australia.
| | - Joemer C Maravilla
- Institute for Social Science Research, The University of Queensland, 80 Meiers Rd, Indooroopilly, QLD, 4068, Australia
| | - Rosa Alati
- School of Public Health, Curtin University, Kent Street, Bentley Campus, Perth, WA, 6845, Australia
| | - Samantha A Hollingworth
- School of Pharmacy, The University of Queensland, 20 Cornwall St, Woolloongabba, QLD, 4102, Australia
| | - Xuelei Hu
- School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, QLD, 4072, Australia
| | - Bill Loveday
- Monitored Medicines Unit, Chief Medical Officer and Healthcare Regulation Branch, Department of Health, Brisbane, QLD, 4000, Australia
| | - Jason P Connor
- Discipline of Psychiatry, The University of Queensland, Herston, QLD, 4029, Australia.,Centre for Youth Substance Abuse Research, The University of Queensland, 17 Upland Road, St Lucia, QLD, 4067, Australia
| |
Collapse
|
35
|
Hayes CJ, Krebs EE, Hudson T, Brown J, Li C, Martin BC. Impact of opioid dose escalation on the development of substance use disorders, accidents, self-inflicted injuries, opioid overdoses and alcohol and non-opioid drug-related overdoses: a retrospective cohort study. Addiction 2020; 115:1098-1112. [PMID: 31944486 PMCID: PMC7263736 DOI: 10.1111/add.14940] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/10/2019] [Accepted: 12/06/2019] [Indexed: 12/11/2022]
Abstract
AIM To understand the potential harmful effects of dose escalation among patients with chronic, non-cancer pain (CNCP) on chronic opioid therapy. DESIGN Retrospective cohort study. SETTING United States Veterans Healthcare Administration. PARTICIPANTS Veterans with CNCP and on chronic opioid therapy were identified using data from fiscal years 2008-15. The Veteran sample was approximately 90% male and 70% white. MEASUREMENTS Dose escalators [increase of > 20% average morphine milligram equivalent (MME) daily dose] were compared with dose maintainers (change of ±20% average MME daily dose). A composite measure of subsequent substance use disorders (SUDs: opioid, non-opioid and alcohol use disorders) and opioid-related adverse outcomes (AOs: accidents resulting in wounds/injuries, opioid-related and alcohol and non-opioid medication-related accidents and overdoses, self-inflicted injuries) as well as the individual SUDs and AOs was examined. The primary analyses were conducted among a 1 : 1 matched sample of escalators and maintainers matched on propensity score and index date. Propensity scores were generated using demographic characteristics, medical comorbidities, medication and health-care utilization characteristics. Subgroup analyses were conducted by quartile of the propensity score. Sensitivity analyses were conducted using adjusted logistic regression, logistic regression using stabilized inverse probability of treatment weighting (SIPTW) and instrumental variable (IV) models using geographic variation in opioid dose escalation as the IV. FINDINGS There were 32 420 maintainers and 20 767 escalators resulting in 19 358 (93.2%) matched pairs. Composite AOs [odds ratio (OR) = 1.31, 95% confidence interval (CI) = 1.23, 1.40], composite SUDs (OR = 1.31, 95% CI = 1.22, 1.41) and individual SUD and AO subtypes were higher among dose escalators, except for opioid-related accidents and overdoses and violence-related injuries. Subgroup analyses within the propensity score quartiles found similar results. Sensitivity analyses with the adjusted and SIPTW logistic regressions found similar results to the primary analyses for all outcomes except for opioid-related accidents and overdoses, which were found to be significantly higher among escalators. Sensitivity analyses with IV models provided mixed results with SUDs and the individual types of AOs. CONCLUSION Escalating the opioid dose for those with chronic, non-cancer pain is associated with increased risks of substance use disorder and opioid-related adverse outcomes.
Collapse
Affiliation(s)
- Corey J. Hayes
- Division of Health Services Research, College of Medicine,
University of Arkansas for Medical Sciences, 4301 West Markham, Slot 755 Little
Rock, AR 72205
- Center for Mental Healthcare and Outcomes Research, Central
Arkansas Veterans Healthcare System, 4301 West Markham, Slot 755 Little Rock, AR
72205
| | - Erin E. Krebs
- Center for Care Delivery and Outcomes Research, Minneapolis
VA Healthcare System, 1 Veterans Dr, Minneapolis, MN 55417
- Department of Medicine, University of Minnesota Medical
School, 1 Veterans Dr, Minneapolis, MN 55417
| | - Teresa Hudson
- Division of Health Services Research, College of Medicine,
University of Arkansas for Medical Sciences, 4301 West Markham, Slot 755 Little
Rock, AR 72205
- Center for Mental Healthcare and Outcomes Research, Central
Arkansas Veterans Healthcare System, 4301 West Markham, Slot 755 Little Rock, AR
72205
| | - Joshua Brown
- Center for Drug Evaluation and Safety, Department of
Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, 1225
Center Drive HPNP #3334 Gainesville, FL 32610
| | - Chenghui Li
- Division of Pharmaceutical Evaluation and Policy, College
of Pharmacy, University of Arkansas for Medical Sciences, 4301 West Markham, Slot
522 Little Rock, AR 72205
| | - Bradley C. Martin
- Division of Pharmaceutical Evaluation and Policy, College
of Pharmacy, University of Arkansas for Medical Sciences, 4301 West Markham, Slot
522 Little Rock, AR 72205
| |
Collapse
|
36
|
Prescription opioid misuse among adolescents and emerging adults in the United States: A scoping review. Prev Med 2020; 132:105972. [PMID: 31904397 PMCID: PMC7024638 DOI: 10.1016/j.ypmed.2019.105972] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 12/06/2019] [Accepted: 12/27/2019] [Indexed: 02/06/2023]
Abstract
The U.S. opioid epidemic is a critical public health problem. As substance use and misuse typically begin in adolescence and emerging adulthood, there is a critical need for prevention efforts for this key developmental period to disrupt opioid misuse trajectories, reducing morbidity and mortality [e.g., overdose, development of opioid use disorders (OUD)]. This article describes the current state of research focusing on prescription opioid misuse (POM) among adolescents and emerging adults (A/EAs) in the U.S. Given the rapidly changing nature of the opioid epidemic, we applied PRISMA Scoping Review (PRISMA-ScR) guidelines to identify empirical articles published in the past 5 years (January 2013-September 2018) from nine databases examining POM among A/EAs (ages 10-25) in the U.S. Seventy-six articles met our inclusion criteria focusing on POM in the following areas: cross-sectional surveys (n = 60), longitudinal cohort studies (n = 5), objective, non-self-reported data sources (n = 9), and interventions (n = 2). Final charted data elements were organized by methodology and sample, with results tables describing design, sample, interventions (where applicable), outcomes, and limitations. Most studies focused on the epidemiology of POM and risk/protective factors, including demographic (e.g., sex, race), individual (e.g., substance use, mental health), and social (e.g., peer substance use) factors. Despite annual national surveys conducted, longitudinal studies examining markers of initiation and escalation of prescription opioid misuse (e.g., repeated overdoses, time to misuse) are lacking. Importantly, few evidence-based prevention or early intervention programs were identified. Future research should examine longitudinal trajectories of POM, as well as adaptation and implementation of promising prevention approaches.
Collapse
|
37
|
Patterns of Prescription Opioid Use in Women With Endometriosis: Evaluating Prolonged Use, Daily Dose, and Concomitant Use With Benzodiazepines. Obstet Gynecol 2020; 133:1120-1130. [PMID: 31135725 PMCID: PMC6553518 DOI: 10.1097/aog.0000000000003267] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To examine opioid use, opioid prescribing patterns, and timing of the first opioid prescription in endometriosis patients compared with matched women in the control group without endometriosis. METHODS We conducted a retrospective analysis of the Clinformatics Datamart database. Women diagnosed with endometriosis from January 2006 through December 2016 and aged 18-49 years were compared with women in the control group matched on age, region, race, insurance payer, and plan type. Key outcomes included: filled prescription for an opioid, multiple opioid prescriptions, number of days' supply, daily dose (morphine milligram equivalents), and concomitant opioid and benzodiazepine prescriptions. Cohorts were descriptively analyzed using t- and χ statistics and multivariable regression analyses yielded adjusted relative risk (RR) ratios and 95% CI. RESULTS The study sample included 53,847 endometriosis patients and 107,694 patients in the control group. The mean age was 38 years, 62.4% of patients were white, and 51.6% lived in the South. Women in the endometriosis case group, compared with women in the control group, were more likely to fill an opioid prescription (42,705 [79.3%] women in the case group vs 26,106 [24.2%] women in the control group; adjusted RR ratio 2.91; 2.87-2.94), had higher likelihood of filling prescriptions with a dose of 50 morphine milligram equivalents or more (24,544 [45.6%] vs 10,463 [9.7%]; adjusted RR ratio 4.07; 3.98-4.16) or 100 morphine milligram equivalents or more (8,013 [14.9%] vs 3,582 [3.3%]; adjusted RR ratio 3.56; 3.43-3.70). Women in the case group were more likely to have concomitant opioid and benzodiazepine prescriptions (5,453 [10.1%] vs 3,711 [3.5%]; adjusted RR ratio 1.95; 1.88-2.03) and to have used these drugs concurrently for at least 30 days (1,596 [3.0%] vs 1,265 [1.2%]; adjusted RR ratio 1.43; 1.34-1.52) or at least 90 days (875 [1.6%] vs 777 [0.7%]; adjusted RR ratio 1.27; 1.17-1.37). Similar results were obtained after excluding opioid prescriptions received during a 30-day postsurgery window. CONCLUSION Women with endometriosis had higher probabilities of prolonged use of opioids and concomitant use with benzodiazepines compared with women without this condition. FUNDING SOURCE This study was funded by AbbVie, Inc.
Collapse
|
38
|
Ulker E, Del Fabbro E. Best Practices in the Management of Nonmedical Opioid Use in Patients with Cancer-Related Pain. Oncologist 2019; 25:189-196. [PMID: 31872911 DOI: 10.1634/theoncologist.2019-0540] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 11/06/2019] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Nonmedical opioid use (NMOU) in patients with cancer is a term covering a spectrum of nonprescribed opioid use. The extent to which an individual uses opioids in a nonprescribed manner will influence propensity for adverse effects such as neurotoxicity, substance use disorder, overdose, and death. OBJECTIVES The objectives of this study were to (A) evaluate current literature regarding management of NMOU in patients with cancer-related pain; (B) provide best practice recommendations based on evidence; and (C) integrate practices derived from the management of noncancer pain, where clinically appropriate or when the oncology literature is limited. METHODS This study is a narrative review. IMPLICATIONS Although harm from NMOU was thought to be rare among oncology patients, about one in five patients with cancer is at risk of adverse outcomes including prolonged opioid use, high opioid doses, and increased health care utilization. The management of NMOU can be challenging because pain is a multidimensional experience encompassing physical, psychological, and spiritual domains. An interdisciplinary team approach is most effective, and management strategies may include (A) education of patients and families; (B) harm reduction, including opioid switching, decreasing the overall daily dose, avoiding concurrent sedative use, and using adjuvant medications for their opioid-sparing potential; (C) managing psychological and spiritual distress with an interdisciplinary team and techniques such as brief motivational interviewing; and (D) risk mitigation by pill counts, frequent clinic visits, and accessing statewide prescription drug monitoring plans. CONCLUSION Although many of the management strategies for NMOU in patients with cancer-related pain are modeled on those for chronic non-cancer-related pain, there is emerging evidence that education and harm-reduction initiatives specifically for cancer-related pain are effective. IMPLICATIONS FOR PRACTICE Nonmedical opioid use (NMOU) in patients with cancer is a term covering a broad spectrum of nonprescribed opioid use. The extent to which an individual uses opioids in a nonprescribed manner will influence propensity for adverse effects such as neurotoxicity, substance use disorder, overdose, and death. This review evaluates the evidence for best practices in oncology and addresses limitations in the literature with supplemental evidence from noncancer chronic pain. Management recommendations for NMOU are provided, based on a combination of literature-based evidence and best clinical practice. Effective management of NMOU in oncology has the potential to improve quality of life, decrease health utilization, and improve survival.
Collapse
Affiliation(s)
- Esad Ulker
- Virginia Commonwealth University, Richmond, Virginia, USA
| | | |
Collapse
|
39
|
Wei YJJ, Chen C, Fillingim R, Schmidt SO, Winterstein AG. Trends in prescription opioid use and dose trajectories before opioid use disorder or overdose in US adults from 2006 to 2016: A cross-sectional study. PLoS Med 2019; 16:e1002941. [PMID: 31689302 PMCID: PMC6830744 DOI: 10.1371/journal.pmed.1002941] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 09/13/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND With governments' increasing efforts to curb opioid prescription use and limit dose below the Centers for Disease Control and Prevention (CDC)-recommended threshold of 90 morphine milligram equivalents per day, little is known about prescription opioid patterns preceding opioid use disorder (OUD) or overdose. This study aimed to determine prescribed opioid fills and dose trajectories in the year before an incident OUD or overdose diagnosis using a 2005-2016 commercial healthcare database. METHODS AND FINDINGS This cross-sectional study identified individuals aged 18 to 64 years with incident OUD or overdose in the United States. We measured the prevalence of opioid prescription fills and trajectories of opioid morphine equivalent dose (MED) prescribed during the 12-month period before the diagnosis. Of 227,038 adults with incident OUD or overdose, 33.1% were aged 18 to 30 years, 52.9% were males, and 85.0% were metropolitan residents. Half (50.5%) of the patients had a diagnosis of chronic pain, 32.7% had depression, and 20.3% had anxiety. Overall, 79,747 (35.1%) patients filled no opioid prescription in the 12 months before OUD or overdose diagnosis, with the proportion significantly increasing between 2006 and 2016 (adjusted prevalence ratio, 1.86; 95% CI 1.79-1.93; P < 0.001). Patients without (versus with) prescribed opioids tended to be younger males and metropolitan and Northeast US residents. Of 145,609 patients who filled opioid prescriptions, 5 distinct prescribed daily dose trajectories preceding diagnosis emerged: consistent low dose (<3 mg MED, 34.6%), consistent moderate dose (20 mg MED, 27.3%), consistent high dose (150 mg MED, 15.0%), escalating dose (from <3 to 20 mg MED, 13.7%), and de-escalating dose (from 20 to <3mg MED, 9.4%). Overall, over two-thirds of patients with OUD or overdose with prescription opioids were prescribed a mean daily dose below 90 mg MED before diagnosis. Major limitations include the limited generalizability of the study findings and lack of information on out-of-pocket drug spending, race/ethnicity, and socioeconomic status of participants, which prevents analyses addressing these characteristics. CONCLUSIONS In this study, we found that absence of opioid prescription fills in the year before incident OUD or overdose diagnosis was prevalent, and the majority of the patients received prescription opioid doses below the risk threshold of 90 mg MED. An increasing proportion of high-risk patients could be missed by current programs solely based on opioid prescribing and dispensing information in this new era of limited access to prescription opioids.
Collapse
Affiliation(s)
- Yu-Jung Jenny Wei
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, United States of America
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida, United States of America
| | - Cheng Chen
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, United States of America
| | - Roger Fillingim
- College of Dentistry, University of Florida, Gainesville, Florida, United States of America
- Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, Florida, United States of America
| | - Siegfried O. Schmidt
- Department of Community Health and Family Medicine, College of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Almut G. Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, United States of America
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida, United States of America
- Department of Epidemiology, College of Medicine and College of Public Health & Health Professions, University of Florida, Gainesville, Florida, United States of America
| |
Collapse
|
40
|
Sears JM, Edmonds AT, Fulton-Kehoe D. Tracking Opioid Prescribing Metrics in Washington State (2012-2017): Differences by County-Level Urban-Rural and Economic Distress Classifications. J Rural Health 2019; 36:152-166. [PMID: 31583779 DOI: 10.1111/jrh.12400] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 07/04/2019] [Accepted: 08/19/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE High-risk opioid prescribing is a critical driver of prescription opioid-related morbidity and mortality. This study explored opioid prescribing patterns across urban-rural and economic distress classifications. Secondarily, this study explored the urban-rural distribution of relevant health services, economic factors, and population characteristics. METHODS County-level opioid prescribing metrics were based on quarterly Washington State Prescription Monitoring Program data (2012-2017). Counties were classified using the 2013 National Center for Health Statistics Urban-Rural Classification Scheme for Counties, and Washington State unemployment-based distressed areas. County-level measures from Area Health Resources Files were used to describe the urban-rural continuum. FINDINGS Persistent economic distress was associated with higher-risk opioid prescribing. The large central metropolitan category had lower-risk opioid prescribing metrics than the other 5 urban-rural categories, which were similar to each other and not ordered by degree of rurality. High-risk prescribing declined over time, without notable trend divergence by either urban-rural or economic distress classifications. CONCLUSIONS The most striking urban-rural differences in opioid prescribing metrics were between large central metropolitan and all other categories; thus, we recommend caution when collapsing urban-rural categories for analysis. Further research is needed regarding geographic and economic patterning of opioid prescribing practices, as well as the dissemination of guidelines and best practices across the urban-rural continuum. Finally, the multiple intertwined burdens faced by rural communities-higher-risk prescribing practices, higher opioid morbidity and mortality rates, and fewer resources for primary care, mental health care, alternative pain treatment, and opioid use disorder treatment-must be addressed as an urgent public health priority.
Collapse
Affiliation(s)
- Jeanne M Sears
- Department of Health Services, University of Washington, Seattle, Washington.,Department of Environmental & Occupational Health Sciences, University of Washington, Seattle, Washington.,Harborview Injury Prevention and Research Center, Seattle, Washington.,Institute for Work & Health, Toronto, Ontario, Canada
| | - Amy T Edmonds
- Department of Health Services, University of Washington, Seattle, Washington
| | - Deborah Fulton-Kehoe
- Department of Environmental & Occupational Health Sciences, University of Washington, Seattle, Washington
| |
Collapse
|
41
|
Raman SR, Bush C, Karmali RN, Greenblatt LH, Roberts AW, Skinner AC. Characteristics of New Opioid Use Among Medicare Beneficiaries: Identifying High-Risk Patterns. J Manag Care Spec Pharm 2019; 25:966-972. [PMID: 31456497 PMCID: PMC7121919 DOI: 10.18553/jmcp.2019.25.9.966] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Opioid prescription patterns, including long-term use, multiple prescribers, and high opioid doses, increase the risk for adverse outcomes; however, previous research in older adult populations has primarily described opioid dose patterns using average daily dose measures or using very high thresholds (i.e., > 100 morphine milligram equivalents [MME] per day). OBJECTIVE To describe prescription patterns by peak dose among older adults who have newly initiated opioid use in 2014 and describe long-term opioid use and the use of multiple pharmacies and prescribers among those with peak opioid doses over 50 and over 90 MME per day. METHODS This was a retrospective cohort study of Medicare Part D prescription claims data (5% sample) for beneficiaries aged 65 years and older who were prescribed ≥ 1 opioid prescription in 2014 and did not have an opioid prescription in the preceding 180 days. Within a 1-year period of follow-up, we used prescription claims to characterize individuals' opioid exposure, measuring long-term opioid use (≥ 90 days of continuous opioid supply), unique opioid prescribers, and unique opioid-dispensing pharmacies. Peak MME was defined as the maximum daily MME received across all overlapping opioid prescriptions in the observation period. RESULTS 144,127 beneficiaries without an opioid prescription in the previous 6 months filled ≥ 1 opioid prescription in 2014. During the 1-year follow-up period, 6.5% of beneficiaries transitioned to long-term opioid use; 39.5% received opioid prescriptions from > 1 prescriber; 18.1% filled opioid prescriptions from > 1 pharmacy; and 21.8% had a peak MME of 50-89. Among the 28.1% of beneficiaries exposed to a peak MME > 50, 8.6% developed long-term opioid use; 7.0% had 3 or more opioid dispensing pharmacies; and 28.0% had 3 or more opioid prescribers. Among the 6.2% of beneficiaries exposed to a peak MME ≥ 90, 18.5% developed long-term opioid use; 13.0% had 3 or more opioid dispensing pharmacies; and 39.6% had 3 or more opioid prescribers. CONCLUSIONS High doses of opioids were prescribed for about one quarter (28%) of Medicare beneficiaries with new opioid use in 2014. Having multiple opioid prescribers or multiple opioid dispensing pharmacies was common, especially among those prescribed higher doses. These prescription patterns can be particularly helpful to identify older adults with increased opioid-related risk. DISCLOSURES No funding supported this study. Raman reports research grants from GlaxoSmithKline not related to this study. Roberts was supported by a CTSA grant from NCATS awarded to the University of Kansas Medical Center for Frontiers: The Heartland Institute for Clinical and Translational Research (#KL2TR000119). The other authors have no potential conflicts to report.
Collapse
Affiliation(s)
- Sudha R. Raman
- Department of Population Health Sciences, Duke University School of Medicine, and Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Christopher Bush
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Ruchir N. Karmali
- Department of Population Health Sciences, Duke University School of Medicine and Duke Clinical Research Institute, Duke University, Durham, North Carolina, and Division of Research, Kaiser Permanente Northern California, Oakland
| | - Lawrence H. Greenblatt
- Department of Medicine and Department of Community and Family Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Andrew W. Roberts
- Department of Population Health and Department of Anesthesiology, University of Kansas Medical Center, Kansas City
| | - Asheley C. Skinner
- Department of Population Health Sciences, Duke University School of Medicine, and Duke Clinical Research Institute, Duke University, Durham, North Carolina
| |
Collapse
|
42
|
Zin CS, Alias NE, Taufek NH, Ahmad MM. Sex differences in high opioid dose escalation among Malaysian patients with long term opioid therapy. J Pain Res 2019; 12:1251-1257. [PMID: 31118748 PMCID: PMC6499483 DOI: 10.2147/jpr.s199243] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 03/26/2019] [Indexed: 01/16/2023] Open
Abstract
Purpose: This study evaluated the risk of opioid dose escalation as it relates to sex differences among patients receiving opioids for long-term therapy. Patients and methods: This retrospective cohort study was conducted in tertiary hospital settings in Malaysia using electronic prescription records. Opioid naïve patients, aged ≥18 years, who were undergoing long-term opioid therapy of ≥90 days, with at least one opioid prescription (buprenorphine, morphine, oxycodone, fentanyl, dihydrocodeine or tramadol) between 1st January 2011 and 31st December 2016, were included in the study. They were followed until (i) the end of the study period, (ii) death from any cause or (iii) discontinuation of therapy from their first opioid prescription without any intervals of ≥120 days between successive prescriptions. The risk of high opioid dose escalation to ≥100 mg/day and ≥200 mg/day relative to men and women was measured. Results: A total of 4688 patients (58.8% women, 41.3% men) on long-term opioid therapy were identified. Among these patients, 248 (5.29%) were escalated to high opioid doses of ≥100 mg/day and 69 (1.47%) were escalated to ≥200 mg/day. The escalation to high-dose opioid therapy was more likely to occur in men than in women, even after adjustment for age (dose ≥100 mg/day [adjusted hazard ratio 2.32; 95% confidence interval (CI), 1.79 to 3.00; p<0.0001] and ≥200 mg/day [adjusted hazard ratio 6.10; 95% CI, 3.39 to 10.98; p<0.0001]). Conclusion: The risk of opioid dose escalation differed between men and women, as men were at higher risk than women for high opioid dose escalation.
Collapse
Affiliation(s)
- Che Suraya Zin
- Kulliyah of Pharmacy, International Islamic University Malaysia, Kuantan Campus, 25200 Kuantan, Pahang, Malaysia
| | - Nor Elina Alias
- Kulliyah of Pharmacy, International Islamic University Malaysia, Kuantan Campus, 25200 Kuantan, Pahang, Malaysia
| | - Nor Hidayah Taufek
- Kulliyah of Pharmacy, International Islamic University Malaysia, Kuantan Campus, 25200 Kuantan, Pahang, Malaysia
| | - Mazlila Meor Ahmad
- Hospital Selayang, Lebuhraya Selayang-Kepong, 68100 Batu Caves, Selangor Darul Ehsan, Malaysia
| |
Collapse
|
43
|
Capsule Commentary on Katzman et al., Army and Navy ECHO Pain Telementoring Improves Clinician Opioid Prescribing for Military Patients: An Observational Cohort Study. J Gen Intern Med 2019; 34:445. [PMID: 30623380 PMCID: PMC6420593 DOI: 10.1007/s11606-018-4762-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
44
|
|