Benzodiazepine-opioid co-prescribing in a national probability sample of ED encounters

Opioid and Benzodiazepine Co-Prescribing Trends from the Emergency Department from 2012 to 2019: A National Analysis

BACKGROUND

In 2016, the U.S. Food and Drug Administration (FDA) issued its strongest safety warning ("Black Box Warning") for concomitant use of prescription opioids and benzodiazepines due to overdose deaths.

OBJECTIVE

Our objective was to look at trends of opioid and benzodiazepine co-prescribing in the emergency department (ED) using national data, because recent data are sparse.

METHODS

This is a retrospective review of data collected by the National Hospital Ambulatory Medical Care Survey between 2012 and 2019. Our primary outcome was to determine whether there was a trend in ED visits when opioids and benzodiazepines were co-prescribed at discharge. We also compared the rate of visits when co-prescribing occurred before (2012-2015) and after (2017-2019) the 2016 FDA warning. We identified commonly co-prescribed benzodiazepines and opioids, and the rate of naloxone co-prescribing. We used descriptive statistics and bivariate tests to describe data.

RESULTS

Between 2012 and 2019, there were 4,489,613 ED visits (0.41% of ED visits) when benzodiazepines and opioids were co-prescribed. There was no trend in the rate of co-prescribing overall, but a decrease in visits after the 2016 FDA Black Box Warning (2012-2015: mean 0.49%; 2017-2019: mean 0.29%; p < 0.0001). There were 7980 ED visits (0.18%) when naloxone was co-prescribed for these visits within this time frame and an increase over time (p < 0.001).

CONCLUSIONS

Our study found that between 2012 and 2019, there was no overall reduction in co-prescribing of opioids and benzodiazepines across EDs nationwide, but a decrease after the 2016 Black Box Warning.

Opioid and benzodiazepine utilization patterns in metropolitan and rural Texas

INTRODUCTION

Although many drugs are implicated in the crisis, opioids and concomitant sedatives are associated with increased overdose risk in both rural and urban communities. Individuals in rural areas are up to 5-fold more likely to experience adverse outcomes related to opioids. The primary objective of this study was to evaluate concomitant use of opioid and benzodiazepine prescriptions in Texas, compare metropolitan and rural differences, and use these data to inform clinicians and to help develop harm reduction strategies.

METHODS

Prescribing data were extracted from the Texas Prescription Drug Monitoring Program (PDMP) public use data file, the statewide monitoring program administered by the Texas State Board of Pharmacy. An overlapping drug combination prescription day was defined as any day in which a patient had at least one of the overlapping drug types-eg, opioid + benzodiazepine, opioid + benzodiazepine + carisoprodol.

RESULTS

In Texas, 47.4 percent of the counties with the highest number of overlapping days (per patient) bordered other states. Providers who practice in rural areas prescribe opioid and benzodiazepine medications with 8.2 more overlapping days per quarter.

DISCUSSION

Taking both opioid and benzodiazepine prescriptions is associated with increased overdose risk. Opioid prescription data provide a distinct view into the opioid epidemic that allows all states and counties to view the trends of opioid utilization. There are only a few studies using PDMP data to compare urban and rural trends.

CONCLUSIONS

Rural patients had more benzodiazepine and opioid days overlap than urban patients. The prevalence is higher among older adults and providers who practice in rural areas (average 8.2 more days per quarter). Our findings in Texas indicate a trend downward in overlap for both rural and urban areas over the last year of measurement. However, rural areas are still significantly higher.

Anhedonia modulates benzodiazepine and opioid demand among persons in treatment for opioid use disorder

Background

Benzodiazepine (BZD) misuse is a significant public health problem, particularly in conjunction with opioid use, due to increased risks of overdose and death. One putative mechanism underlying BZD misuse is affective dysregulation, via exaggerated negative affect (e.g., anxiety, depression, stress-reactivity) and/or impaired positive affect (anhedonia). Similar to other misused substances, BZD consumption is sensitive to price and individual differences. Although purchase tasks and demand curve analysis can shed light on determinants of substance use, few studies have examined BZD demand, nor factors related to demand.

Methods

This ongoing study is examining simulated economic demand for alprazolam (among BZD lifetime misusers based on self-report and DSM-5 diagnosis; n = 23 total; 14 male, 9 female) and each participant's preferred-opioid/route using hypothetical purchase tasks among patients with opioid use disorder (n = 59 total; 38 male, 21 female) who are not clinically stable, i.e., defined as being early in treatment or in treatment longer but with recent substance use. Aims are to determine whether: (1) BZD misusers differ from never-misusers on preferred-opioid economic demand, affective dysregulation (using questionnaire and performance measures), insomnia/behavioral alertness, psychiatric diagnoses or medications, or urinalysis results; and (2) alprazolam demand among BZD misusers is related to affective dysregulation or other measures.

Results

Lifetime BZD misuse is significantly (p < 0.05) related to current major depressive disorder diagnosis, opioid-negative and methadone-negative urinalysis, higher trait anxiety, greater self-reported affective dysregulation, and younger age, but not preferred-opioid demand or insomnia/behavioral alertness. Alprazolam and opioid demand are each significantly positively related to higher anhedonia and, to a lesser extent, depression symptoms but no other measures of negative-affective dysregulation, psychiatric conditions or medications (including opioid agonist therapy or inpatient/outpatient treatment modality), or sleep-related problems.

Conclusion

Anhedonia (positive-affective deficit) robustly predicted increased BZD and opioid demand; these factors could modulate treatment response. Routine assessment and effective treatment of anhedonia in populations with concurrent opioid and sedative use disorder may improve treatment outcomes.

Clinical trial registration

https://clinicaltrials.gov/ct2/show/NCT03696017, identifier NCT03696017.

Five-year incidence of substance use and mental health diagnoses following exposure to opioids or opioids with benzodiazepines during an emergency department encounter for traumatic injury

BACKGROUND

Benzodiazepines and opioids are used alone or in conjunction in certain care settings, but each have the potential for misuse.

OBJECTIVE

This longitudinal observational study evaluated substance use and mental health outcomes associated with providing opioids with or without benzodiazepine to treat traumatic injury in the emergency department (ED) setting.

METHODS

We analyzed a limited dataset obtained through the IBM Watson Health Explorys. Matched cohorts were defined for: 1) patients treated with opioids during the ED encounter (ED-Opioid) vs. neither opioid or benzodiazepine treatment (No medication) (n = 5372); 2) patients treated with opioids and benzodiazepines during the ED encounter (ED-Opioid+Benzodiazepines) vs. No Medication (n = 2454); and 3) ED-Opioid+Benzodiazepines vs. ED-Opioid (n = 2454). Patients consisted of adults with an emergency department encounter in the MetroHealth System (Cleveland, Ohio) with a chief complaint of traumatic injury and medical records for five years following the encounter. Control patients for each cohort were matched to the exposure patients on demographics, body mass index, and residential zip code median income. Outcomes were five-year incidence rates for alcohol, substance use, depression, and anxiety-related diagnoses.

RESULTS

Our results indicate that, although receiving opioids during the ED visit predicted a relatively lower likelihood of subsequent substance use and mental health diagnoses, the brief co-use of benzodiazepines was strongly associated with poorer outcomes.

CONCLUSIONS

Even brief exposure to co-prescribed opioids and benzodiazepines during emergency traumatic injury care may be associated with negative substance use and mental health consequences in the years following the event.

Receipt of Concurrent VA and Non-VA Opioid and Sedative-Hypnotic Prescriptions Among Post-9/11 Veterans With Traumatic Brain Injury

OBJECTIVE

Receipt of concurrent psychotropic prescription medications from both US Department of Veterans Affairs (VA) and non-VA healthcare providers may increase risk of adverse opioid-related outcomes among veterans with traumatic brain injury (TBI). Little is known about patterns of dual-system opioid or sedative-hypnotic prescription receipt in this population. We estimated the prevalence and patterns of, and risk factors for, VA/non-VA prescription overlap among post-9/11 veterans with TBI receiving opioids from VA providers in Oregon.

SETTING

Oregon VA and non-VA outpatient care.

PARTICIPANTS

Post-9/11 veterans in Oregon with TBI who received an opioid prescription from VA providers between the years of 2014 and 2019.

DESIGN

Historical cohort study.

MAIN MEASURES

Prescription overlap of VA opioids and non-VA opioids or sedative-hypnotics; proportions of veterans who received VA or non-VA opioid, benzodiazepine, and nonbenzodiazepine sedative-hypnotic prescriptions were also examined by year and by veteran characteristics.

RESULTS

Among 1036 veterans with TBI receiving opioids from the VA, 210 (20.3%) received an overlapping opioid prescription from a non-VA provider; 5.3% received overlapping benzodiazepines; and none received overlapping nonbenzodiazepine sedative-hypnotics. Proportions of veterans with prescription overlap tended to decrease over time. Veterans with other than urban versus urban addresses (OR = 1.4; 95% CI, 1.0-1.8), high versus medium average annual VA visits (OR = 1.7; 95% CI, 1.1-2.6), and VA service connection of 50% or more versus none/0% to 40% (OR = 4.3; 95% CI, 1.3-14.0) were more likely to have concurrent VA/non-VA prescriptions in bivariable analyses; other than urban remained associated with overlap in multivariable models. Similarly, veterans with comorbid posttraumatic stress disorder diagnoses were more likely to have concurrent VA/non-VA prescriptions in both bivariable and multivariable (OR = 2.1; 95% CI, 1.0-4.1) models.

CONCLUSION

Among post-9/11 veterans with TBI receiving VA opioids, a considerable proportion had overlapping non-VA prescription medications. Providers and healthcare systems should consider all sources of psychotropic prescriptions, and risk factors for overlapping medications, to help mitigate potentially unsafe medication use among veterans with TBI.

A Prospective Observational Study of Emergency Department-Initiated Physical Therapy for Acute Low Back Pain

OBJECTIVE

Low back pain accounts for nearly 4 million emergency department (ED) visits annually and is a significant source of disability. Physical therapy has been suggested as a potentially effective nonopioid treatment for low back pain; however, no studies to our knowledge have yet evaluated the emerging resource of ED-initiated physical therapy. The study objective was to compare patient-reported outcomes in patients receiving ED-initiated physical therapy and patients receiving usual care for acute low back pain.

METHODS

This was a prospective observational study of ED patients receiving either physical therapy or usual care for acute low back pain from May 1, 2018, to May 24, 2019, at a single academic ED (>91,000 annual visits). The primary outcome was pain-related functioning, assessed with Oswestry Disability Index (ODI) and Patient-Reported Outcomes Measurement Information System pain interference (PROMIS-PI) scores. The secondary outcome was use of high-risk medications (opioids, benzodiazepines, and skeletal muscle relaxants). Outcomes were compared over 3 months using adjusted linear mixed and generalized estimating equation models.

RESULTS

For 101 participants (43 receiving ED-initiated physical therapy and 58 receiving usual care), the median age was 40.5 years and 59% were women. Baseline outcome scores in the ED-initiated physical therapy group were higher than those in the usual care group (ODI = 51.1 vs 36.0; PROMIS-PI = 67.6 vs 62.7). Patients receiving ED-initiated physical therapy had greater improvements in both ODI and PROMIS-PI scores at the 3-month follow-up (ODI = -14.4 [95% CI = -23.0 to -5.7]; PROMIS-PI = -5.1 [95% CI = -9.9 to -0.4]) and lower use of high-risk medications (odds ratio = 0.05 [95% CI = 0.01 to 0.58]).

CONCLUSION

In this single-center observational study, ED-initiated physical therapy for acute low back pain was associated with improvements in functioning and lower use of high-risk medications compared with usual care; the causality of these relationships remains to be explored.

IMPACT

ED-initiated physical therapy is a promising therapy for acute low back pain that may reduce reliance on high-risk medications while improving patient-reported outcomes.

LAY SUMMARY

Emergency department-initiated physical therapy for low back pain was associated with greater improvement in functioning and lower use of high-risk medications over 3 months.

Methocinnamox (MCAM) antagonizes the behavioral suppressant effects of morphine without impairing delayed matching-to-sample accuracy in rhesus monkeys

RATIONALE

Opioid abuse remains a serious public health problem. The pseudoirreversible mu opioid receptor antagonist methocinnamox (MCAM) might be useful for treating opioid abuse and overdose. Because endogenous opioid systems can modulate cognition and decision-making, it is important to evaluate whether long-term blockade of mu opioid receptors by MCAM adversely impacts complex operant behavior involving memory.

OBJECTIVE

This study tested the effects of MCAM in rhesus monkeys responding under a delayed matching-to-sample task, with correct responses reinforced by sucrose pellets. Because MCAM did not alter performance, antagonism of the rate-decreasing effects of morphine was used to confirm that an effective dose of MCAM was administered. Moreover, the muscarinic receptor antagonist scopolamine and the N-methyl-D-aspartate antagonist phencyclidine were studied as positive controls to demonstrate sensitivity of this procedure to memory disruption.

RESULTS

Neither MCAM (0.32 mg/kg) nor morphine (1-5.6 mg/kg) impaired delayed matching-to-sample accuracy. Morphine dose-dependently decreased the number of trials completed before MCAM administration, and a single injection of MCAM blocked the behavioral suppressant effects of morphine for at least 7 days. Scopolamine (0.01-0.056 mg/kg) and phencyclidine (0.1-0.56 mg/kg) dose-dependently decreased delayed matching-to-sample accuracy and the number of trials completed.

CONCLUSIONS

MCAM did not impair memory (as measured by accuracy in a delayed matching-to-sample task) and did not decrease responding for or consumption of sucrose pellets. This dose of MCAM attenuates self-administration of opioids and reverses as well as prevents opioid-induced respiratory depression. These results provide further support for a favorable adverse effect profile for MCAM.

US national treatment admissions with opioids and benzodiazepines

INTRODUCTION AND AIMS

Opioids and benzodiazepines (O/BZD) are increasingly involved in drug overdose deaths in the USA. Expanding treatment capacity may reduce these deaths. Knowledge about co-occurring O/BZD admissions compared to opioid admissions (opioid) is needed to plan this expansion.

DESIGN AND METHODS

US treatment admissions to specialty facilities for 2011-2017 were analysed for trends and 2017 for group differences. Due to 1.9 million admissions in 2017, comparisons between O/BZD and opioid admissions were summarised as effect sizes. Additional analysis compared the administratively pre-coded category 'other opiates and synthetics' to other opiates and synthetics/benzodiazepines admissions to control for possible similarity in drug source. Differences within O/BZD admissions by primary drug were explored.

RESULTS

Although opioid admissions showed a steady increase over time (25.9% to 38.2%), O/BZD admissions showed increases until decline in 2017 (3.2% to 4.0%). In 2017 no factor reached moderate effect size (≥0.2) in group comparisons or within the O/BZD admissions. Heroin was self-reported in 70% of both O/BZD and opioid admissions.

DISCUSSION AND CONCLUSIONS

No meaningful US national differences on data routinely collected were found for O/BZD compared to opioid admissions including the subgroup with other opiates and synthetics only. Efforts to expand existing opioid treatment in specialty treatments may help reduce opioid and O/BZD deaths. However, the analysis could not address whether changes in treatment would improve outcomes.

Coprescribing of Benzodiazepines and Opioids in Older Adults: Rates, Correlates, and National Trends

BACKGROUND

To estimate prescribing trends of and correlates independently associated with coprescribing of benzodiazepines and opioids among adults aged 65 years or older in office-based outpatient visits.

METHODS

I examined a nationally representative sample of office-based physician visits by older adults between 2006 and 2015 (n = 109,149 unweighted) using data from the National Ambulatory Medical Care Surveys (NAMCS). National rates and prescribing trends were estimated. Then, I used multivariable logistic regression analyses to identify demographic and clinical factors associated with coprescriptions of benzodiazepines and opioids.

RESULTS

From 2006 to 2015, 15,954 (14.6%) out of 109,149 visits, representative of 39.3 million visits nationally, listed benzodiazepine, opioid, or both medications prescribed. The rate of prescription benzodiazepines only increased monotonically from 4.8% in 2006-2007 to 6.2% in 2014-2015 (p < .001), and the rate of prescription opioids only increased monotonically from 5.9% in 2006-2007 to 10.0% in 2014-2015 (p < .001). The coprescribing rate of benzodiazepines and opioids increased over time from 1.1% in 2006-2007 to 2.7% in 2014-2015 (p < .001). Correlates independently associated with a higher likelihood of both benzodiazepine and opioid prescriptions included: female sex, a visit for chronic care, receipt of six or more concomitantly prescribed medications, and clinical diagnoses of anxiety and pain (p < .01 for all).

CONCLUSION

The coprescribing rate of benzodiazepines and opioids increased monotonically over time in outpatient care settings. Because couse of benzodiazepines and opioids is associated with medication burdens and potential harms, future research is needed to address medication safety in these vulnerable populations.

Prescribing Analgesics to Older People: A Challenge for GPs

Background: Due to population aging, there is an increase in the prevalence of chronic diseases, and in particular musculoskeletal diseases. These trends are associated with an increased demand for prescription analgesics and an increased risk of polypharmacy and adverse medication reactions, which constitutes a challenge, especially for general practitioners (GPs), as the providers who are most responsible for the prescription policy. Objectives: To identify patterns of analgesics prescription for older people in the study area and explore associations between a long-term analgesic prescription and comorbidity patterns, as well as the prescription of psychotropic and other common medications in a continuous use. Methods: A retrospective study was conducted in 2015 in eastern Croatia. Patients were GP attenders ≥40 years old (N = 675), who were recruited during their appointments (consecutive patients). They were divided into two groups: those who have been continuously prescribed analgesics (N = 432) and those who have not (N = 243). Data from electronic health records were used to provide information about diagnoses of musculoskeletal and other chronic diseases, as well as prescription rates for analgesics and other medications. Exploratory methods and logistic regression models were used to analyse the data. Results: Analgesics have been continuously prescribed to 64% of the patients, mostly to those in the older age groups (50–79 years) and females, and they were indicated mainly for dorsalgia symptoms and arthrosis. Non-opioid analgesics were most common, with an increasing tendency to prescribe opioid analgesics to older patient groups aged 60–79 years. The study results indicate that there is a high rate of simultaneous prescription of analgesics and psychotropic medications, despite the intention of GPs to avoid prescribing psychotropic medications to patients who use any option with opioid analgesics. In general, receiving prescription analgesics does not exceed the prescription for chronic diseases over the rates that can be found in patients who do not receive prescription analgesics. Conclusion: Based on the analysis of comorbidities and parallel prescribing, the results of this study can improve GPs’ prescription and treatment strategies for musculoskeletal diseases and chronic pain conditions.

Effects of oxycodone and diazepam alone and in combination on operant nociception

Developing effective analgesics with fewer unwanted side effects is a pressing concern. Due to a lack of effective nonopioid options currently available, an alternative approach termed opioid-sparing evaluates the ability of a coadministered drug to reduce the amount of opioid needed to produce an antinociceptive effect. Opioids and benzodiazepines are often coprescribed. Although this approach is theoretically rational given the prevalent comorbidity of chronic pain and anxiety, it also has inherent risks of respiratory depression, which is likely responsible for the substantial percentage of fatal opioid overdoses that have involved benzodiazepines. Moreover, there have been no clinical trials to support the effectiveness of this drug combination nor has there been corroborative preclinical evidence using traditional animal models of nociception. The present studies examined the prescription µ-opioid analgesic oxycodone (0.003-0.1 mg/kg) and the prototypical benzodiazepine anxiolytic diazepam (0.03-1.0 mg/kg), alone and in combination, using an animal model of pain that examines the restoration of conflict-related operant behavior as evidence of analgesia. Results documented significant dose-related increases in thermal threshold following oxycodone treatment. Diazepam treatment alone did not produce significant antinociception. In combination, diazepam pretreatment shifted oxycodone functions upward in a dose-dependent manner, but the additive effects were limited to a narrow dose range. In addition, combinations of diazepam and oxycodone at higher doses abolished responding. Taken together, though intriguing, these findings do not provide sufficient evidence that coadministration of an anxiolytic will result in clinically relevant opioid-sparing for pain management, especially when considering the inherent risks of this drug class combination.

Patterns of Polysubstance Use among Adults with Tranquilizer Misuse

Background: The misuse of benzodiazepine tranquilizers is prevalent and is associated with increased risk of overdose when combined with other substances. Yet, little is known about other substance use among those who misuse tranquilizers. Objectives: This study characterized subgroups of individuals with tranquilizer misuse, based on patterns of polysubstance use. Methods: Data were extracted from the 2015-2017 National Survey on Drug Use and Health; adults with past-month tranquilizer misuse were included (N = 1253). We utilized latent class analysis to identify patterns of polysubstance use in the previous month. Results: We identified three distinct latent classes, including the: (1) limited polysubstance use class (approximately 54.6% of the sample), (2) binge alcohol and cannabis use class (28.5% of the sample), and (3) opioid use class (16.9% of the sample). The binge alcohol and cannabis use class and the opioid use class were characterized by high probabilities of other substance misuse, including cocaine and prescription stimulants. Those in the binge alcohol and cannabis use class and the opioid use class reported more motives for tranquilizer misuse and higher rates of sexually transmitted infection, criminal involvement, and suicidal ideation. Those in the opioid use class also had greater psychological distress and higher rates of injection drug use. Conclusions: Nearly half of those with tranquilizer misuse in a general population sample were categorized into one of two high polysubstance use classes, and these two classes were associated with poorer functioning. Findings from these analyses underscore the need to reduce polysubstance use among those who misuse tranquilizers.

Retrospective descriptive observational study of patients who presented to an Australian hospital emergency department with neck soft tissue injury

OBJECTIVE

To describe clinical presentation and management of neck soft tissue injury in an Australian ED.

METHODS

This is a retrospective cohort study conducted in a tertiary hospital ED in Queensland, Australia. This study included all patients aged 18-65 years presenting with neck sprain/strain in 2016. Main outcome measures are patient demographics, comorbidities, presentation, acute management and follow up.

RESULTS

Of 339 patients, 176 (52%) had cervical computed tomography (CT) scans and 3% plain radiographs. Two had fractures (CT yield of 2/176; 1.1%) and three were admitted with neurological symptoms, leaving 334 patients. Of 264 patients receiving medications in the ED, simple analgesia + oral opioid (146, 55.3%) was most frequently used, followed by simple analgesia (89, 33.7%) and opioid + benzodiazepine +/- simple analgesia (16, 6%). Opioids were prescribed for 169 (64%) (including i.v. opioids for 34 [12.9%] and for 85/97 (88%) with pain scores ≤4), and benzodiazepines for 22 (8.3%). Ten (3%) were referred for physiotherapy management in ED and eight (2.4%) for outpatient physiotherapy follow up. Of 113/334 (33.8%) receiving discharge prescription, 60 (53.1%) were prescribed oral opioid + simple analgesia, 37 (32.7%) oral opioids and seven (6.2%) opioids + benzodiazepines; 205 (61%) were discharged without a recorded follow-up plan.

CONCLUSIONS

There is large practice variation in management of neck soft tissue injury in ED. Over half of the patients received CT scans with modest yield. Opioids were commonly used both in ED and on discharge. There is need for a standard management plan to be developed for patients presenting with acute neck soft tissue injury.

Potentially Inappropriate Medication Prescriptions for Older Adults with Painful Conditions and Association with Return Emergency Department Visits

OBJECTIVES

To describe the frequency and risk of return visit to the emergency department (ED) by older adults after prescription of any of four potentially inappropriate medication (PIM) classes included in the 2015 Beers Criteria commonly used for the relief of acute pain in the ED.

DESIGN

Retrospective cohort study.

SETTING

Large urban academic ED from January 1, 2013, to December 31, 2015.

PARTICIPANTS

Patients age 65 and older discharged from the ED with an initial pain score of 1 or higher (11 822 visits).

MEASUREMENTS

Prescriptions for PIM classes were collected from the medical record: nonsteroidal anti-inflammatory drugs (NSAIDs), benzodiazepines, skeletal muscle relaxants, and opioids. The proportion of patients with ED returns within 9 days were compared by medication class and pain severity (mild, moderate, or severe). Multivariable logistic regression was performed for each pain category to determine adjusted odds ratios (aORs) of ED return.

RESULTS

Of 11 822 included patients, PIMs were prescribed in 3392 (28.7%): 2550 (21.6%) opioids, 826 (7.0%) NSAIDs, 277 (2.3%) benzodiazepines, and 68 (0.6%) nonbenzodiazepine skeletal muscle relaxants. Total 9-day ED returns were 1125 (9.5%): mild 7.0%, moderate 8.3%, and severe pain 11.7%. Opioids were not associated with more frequent ED returns for mild or moderate pain, and they were associated with less frequent ED returns for severe pain (9.2% vs 12.7%; p < .001; aOR 0.69; 95% confidence interval [CI] = 0.54-0.87). Benzodiazepines were associated with more frequent ED returns for patients with moderate pain (15.5% vs 8.2%; p < .01; aOR = 2.01; 95%CI = 1.10-3.70).

CONCLUSIONS

These results are consistent with recommendations to limit benzodiazepine prescriptions for older adults and that among older adults with severe pain, opioid prescribing is associated with less frequent ED visits within 9 days of discharge. However, this study was not designed to evaluate safety, adverse events, or other important patient-centered outcomes. J Am Geriatr Soc 67:719-725, 2019.

The association of tobacco use with prescription of muscle relaxants, benzodiazepines, and opioid analgesics for non-cancer pain

BACKGROUND AND OBJECTIVES

Tobacco use and co-prescription of sedative hypnotics are risk factors for misuse of prescribed opioids among patients with non-cancer pain. However, the association between tobacco use and these co-prescriptions has not been clarified. We aimed to assess differences in the prescription and co-prescription rates of opioid analgesics with muscle relaxants and/or benzodiazepines between tobacco users and non-users.

METHODS

Visit data were obtained from the 2006 to 2009 National Ambulatory Medical Care Survey, an annual cross-sectional survey of visits to office-based physicians in outpatient settings in the United States. Our sample patients were aged ≥18 years and diagnosed with non-cancer back and neck pain. The χ² test and multiple logistic regression analysis were used to assess bivariate and multivariate associations between prescription or co-prescription rates and tobacco use status.

RESULTS

We analyzed a total of 114,199,536 weighted visits (unweighted number: 3,521). Significant odds ratios (ORs) of tobacco users (vs non-users) for medical prescriptions were as follows: opioid analgesics, OR 2.14, 95% confidence interval (CI) 1.64-2.80; muscle relaxants and opioid analgesics, OR 2.57, 95%CI 1.76-3.74; benzodiazepines and opioid analgesics, OR 3.66, 95%CI 2.11-6.35, and muscle relaxants, benzodiazepines, and opioid analgesics, OR 7.02, 95%CI 2.98-16.57.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Tobacco users were more likely to receive prescriptions for opioid analgesics with muscle relaxants and/or benzodiazepines than non-users. Healthcare professionals need to limit co-prescription of opioid analgesics with muscle relaxants and/or benzodiazepines among tobacco users and provide a comprehensive approach to pain management. (Am J Addict 2019;XX:1-8).

A comparison of analgesic prescribing among ED back and neck pain visits receiving physical therapy versus usual care

OBJECTIVE

Physical therapy (PT) is commonly cited as a non-opioid pain strategy, and previous studies indicate PT reduces opioid utilization in outpatients with back pain. No study has yet examined whether PT is associated with lower analgesic prescribing in the ED setting.

METHODS

This was a retrospective cohort study of discharged ED visits with a primary ICD-10 diagnosis relating to back or neck pain from 10/1/15 to 2/21/17 at an urban academic ED. Visits receiving a PT evaluation were matched with same-date visits receiving usual care. We compared the primary outcomes of opioid and benzodiazepine prescribing between the two cohorts using chi-squared test and multivariable logistic regression.

RESULTS

74 ED visits received PT during the study period; these visits were matched with 390 same-date visits receiving usual care. Opioid prescribing among ED-PT visits was not significantly higher compared to usual care visits on both unadjusted analysis (50% vs 42%, p = 0.19) and adjusted analysis (adjOR 1.05, 95% CI 0.48-2.28). However, benzodiazepine prescribing among ED-PT visits was significantly higher than usual care visits on both unadjusted (45% vs 23%, p < 0.001) and adjusted analysis (adjOR 3.65, 95% CI 1.50-8.83).

CONCLUSIONS

In this single center study, ED back and neck pain visits receiving PT were no less likely to receive an opioid prescription and were more likely to receive a benzodiazepine than visits receiving usual care. Although prior studies demonstrate that PT may reduce opioid utilization in the subsequent year, these results indicate that analgesic prescribing is not reduced at the initial ED encounter.

Benzodiazepine Use: The Underbelly of the Opioid Epidemic

In the United States, benzodiazepine medication use is the secondary epidemic to opioid drug use and carries serious consequences as well, even though its use is enabled by well-intended clinicians. Benzodiazepine drugs are intended for short-term use, not to exceed 2 to 4 weeks; yet, it is common for clients to be taking benzodiazepine medications for up to 10 years. In addition to dependence or addiction, adverse effects include depression, emotional blunting, ataxia, aggression, irritability, nervousness, and cognitive impairment. These medications also contribute to increased risk for falls, suicide, overdose fatality, and vehicle crashes. The current article describes the epidemiology of benzodiazepine medication use, patient and prescriber factors that contribute to overuse and misuse, and recommendations for prescribing and deprescribing. [Journal of Psychosocial Nursing and Mental Health Services, 56(6), 11-15.].

Concomitant use of buprenorphine for medication-assisted treatment of opioid use disorder and benzodiazepines: Using the prescription behavior surveillance system

BACKGROUND

Despite clinical guidelines discouraging the practice, it is well-documented that the concomitant use of benzodiazepines and opioid analgesics occurs regularly. Information on concomitant use of buprenorphine for medication-assisted treatment (MAT) of opioid use disorder (OUD) and benzodiazepines, however, is limited. Thus, we aimed to describe real-world drug dispensing patterns for the concomitant use of buprenorphine products approved for MAT and benzodiazepines.

METHODS

We examined concomitant use of buprenorphine for MAT and benzodiazepines using the 2013 Prescription Behavior Surveillance System data from eight states. For prescription-level analysis, we estimated the proportion of concomitant buprenorphine and benzodiazepine prescriptions and the proportions of concomitant prescriptions prescribed by the same provider (co-prescribing) and dispensed by the same pharmacy (co-dispensing) for each state. For patient-level analysis, we calculated the proportion of patients with ≥1 buprenorphine therapy episode overlapping with a benzodiazepine episode, i.e., concomitant users, and the proportion of concomitant users who experienced co-prescribing or co-dispensing.

RESULTS

In 2013, 1,925,072 prescriptions of buprenorphine products for MAT were dispensed to 190,907 patients in eight states. Approximately 1 in 8 buprenorphine prescriptions was used concomitantly with ≥1 benzodiazepine prescription(s). Co-prescribing proportions ranged from 22.2 to 64.6% across states, while co-dispensing proportions ranged from 54.7 to 91.0%. Approximately 17.7% of patients had >1 buprenorphine episode overlapping a benzodiazepine episode for ≥7 cumulative days' supply. Among these patients, 33.1-65.2% experienced co-prescribing, and 65.1-93.3% experienced co-dispensing.

CONCLUSIONS

The concomitant use of buprenorphine for MAT and benzodiazepines occurs frequently, with variations by state in co-prescribing and co-dispensing.

Gender Differences in Pain Experience and Treatment after Motor Vehicle Collisions: A Secondary Analysis of the CRASH Injury Study

PURPOSE

Little is known about gender differences in the treatment of pain after motor vehicle collisions (MVCs) in an emergency department (ED). We aimed to describe gender differences in pain experiences and treatment, specifically the use of opioids and benzodiazepines after ED discharge, for MVC-related pain.

METHODS

This was a secondary analysis of previously collected data from the CRASH Injury studies. We included patients who were seen and discharged from an ED after an MVC and who were enrolled in 1 of 2 multicenter longitudinal prospective cohort studies (1 black/non-Hispanic and 1 white/non-Hispanic). First, we compared the experience of pain as defined by self-reported moderate-to-severe axial pain, widespread pain, number of somatic symptoms, pain catastrophizing, and peritraumatic distress between women and men using bivariate analyses. We then determined whether there were gender differences in the receipt of prescription medications for post-MVC pain symptoms (opioids and benzodiazepines) using multivariate logistic regression adjusting for demographic characteristics, pain, and collision characteristics.

FINDINGS

In total, 1878 patients were included: 61.4% were women. More women reported severe symptoms on the pain catastrophizing scale (36.8% vs 31.0%; P = 0.032) and peritraumatic distress following the MVC (59.7% vs 42.5%; P < 0.001), and women reported more somatic symptoms than men (median, 3.9; interquartile range, 3.7-4.0 vs median, 3.3; interquartile range, 3.1-3.5; P < 0.001). Unadjusted, similar proportions of women and men were given opioids (29.2% vs 29.7%; P = 0.84). After adjusting for covariates, women and men remained equally likely to receive a prescription for opioids (relative risk = 0.83; 95% confidence interval, 0.58-1.19). Women were less likely than men to receive a benzodiazepine at discharge from an ED (relative risk = 0.53; 95% confidence interval, 0.32-0.88).

IMPLICATIONS

In a large, multicenter study of ED patients treated for MVC, there were gender differences in the acute psychological response to MVC with women reporting more psychological and somatic symptoms. Women and men were equally likely to receive opioid prescriptions at discharge. Future research should investigate potential gender-specific interventions to reduce both posttraumatic distress and the risk of developing negative long-term outcomes like chronic pain.

Emergency Department Provider Perspectives on Benzodiazepine-Opioid Coprescribing: A Qualitative Study

OBJECTIVE

Benzodiazepines and opioids are prescribed simultaneously (i.e., "coprescribed") in many clinical settings, despite guidelines advising against this practice and mounting evidence that concomitant use of both medications increases overdose risk. This study sought to characterize the contexts in which benzodiazepine-opioid coprescribing occurs and providers' reasons for coprescribing.

METHODS

We conducted focus groups with emergency department (ED) providers (resident and attending physicians, advanced practice providers, and pharmacists) from three hospitals using semistructured interviews to elicit perspectives on benzodiazepine-opioid coprescribing. Discussions were audio-recorded and transcribed. We performed qualitative content analysis of the resulting transcripts using a consensual qualitative research approach, aiming to identify priority categories that describe the phenomenon of benzodiazepine-opioid coprescribing.

RESULTS

Participants acknowledged coprescribing rarely and reluctantly and often provided specific discharge instructions when coprescribing. The decision to coprescribe is multifactorial, often isolated to specific clinical and situational contexts (e.g., low back pain, failed solitary opioid therapy) and strongly influenced by a provider's beliefs about the efficacy of combination therapy. The decision to coprescribe is further influenced by a self-imposed pressure to escalate care or avoid hospital admission. When considering potential interventions to reduce the incidence of coprescribing, participants opposed computerized alerts but were supportive of a pharmacist-assisted intervention. Many providers found the process of participating in peer discussions on prescribing habits to be beneficial.

CONCLUSIONS

In this qualitative study of ED providers, we found that benzodiazepine-opioid coprescribing occurs in specific clinical and situational contexts, such as the treatment of low back pain or failed solitary opioid therapy. The decision to coprescribe is strongly influenced by a provider's beliefs and by self-imposed pressure to escalate care or avoid admission.