1
|
Bongiovanni T, Gan S, Finlayson E, Ross JS, Harrison JD, Boscardin WJ, Steinman MA. Association of Race and Ethnicity With Postoperative Gabapentinoid and Opioid Prescribing Trends for Older Adults. J Surg Res 2024; 298:47-52. [PMID: 38554545 DOI: 10.1016/j.jss.2024.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 02/01/2024] [Accepted: 02/22/2024] [Indexed: 04/01/2024]
Abstract
BACKGROUND Disparities in opioid prescribing by race/ethnicity have been described in many healthcare settings, with White patients being more likely to receive an opioid prescription than other races studied. As surgeons increase prescribing of nonopioid medications in response to the opioid epidemic, it is unknown whether postoperative prescribing disparities also exist for these medications, specifically gabapentinoids. METHODS We conducted a retrospective cohort study using a 20% Medicare sample for 2013-2018. We included patients ≥66 years without prior gabapentinoid use who underwent one of 14 common surgical procedures. The primary outcome was the proportion of patients prescribed gabapentinoids at discharge among racial and ethnic groups. Secondary outcomes were days' supply of gabapentinoids, opioid prescribing at discharge, and oral morphine equivalent (OME) of opioid prescriptions. Trends over time were constructed by analyzing proportion of postoperative prescribing of gabapentinoids and opioids for each year. For trends by year by racial/ethnic groups, we ran a multivariable logistic regression with an interaction term of procedure year and racial/ethnic group. RESULTS Of the 494,922 patients in the cohort (54% female, 86% White, 5% Black, 5% Hispanic, mean age 73.7 years), 3.7% received a new gabapentinoid prescription. Gabapentinoid prescribing increased over time for all groups and did not differ significantly among groups (P = 0.13). Opioid prescribing also increased, with higher proportion of prescribing to White patients than to Black and Hispanic patients in every year except 2014. CONCLUSIONS We found no significant prescribing variation of gabapentinoids in the postoperative period between racial/ethnic groups. Importantly, we found that despite national attention to disparities in opioid prescribing, variation continues to persist in postoperative opioid prescribing, with a higher proportion of White patients being prescribed opioids, a difference that persisted over time.
Collapse
Affiliation(s)
- Tasce Bongiovanni
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, California.
| | - Siqi Gan
- Division of Geriatrics, University of California San Francisco School of Medicine, San Francisco, California; Northern California Institute for Research and Education, San Francisco, California
| | - Emily Finlayson
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, California
| | - Joseph S Ross
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut; Section of General Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; Department of Health Policy and Management, Yale University School of Public Health, New Haven, Connecticut
| | - James D Harrison
- Division of Hospital Medicine, University of California San Francisco School of Medicine, San Francisco, California
| | - W John Boscardin
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, California; Department of Epidemiology & Biostatistics, University of California San Francisco School of Medicine, San Francisco, California
| | - Michael A Steinman
- Division of Geriatrics, University of California San Francisco School of Medicine, San Francisco, California; San Francisco VA Medical Center, San Francisco, California
| |
Collapse
|
2
|
Berman RB, Villanueva J, Margolin EJ, Balasubramanian A, Lee J, Shah O. Trends in Opioid and Nonsteroidal Anti-Inflammatory Drug Use for Patients with Kidney Stones in United States Emergency Departments from 2015 to 2021. J Endourol 2024; 38:458-465. [PMID: 38308477 DOI: 10.1089/end.2023.0636] [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: 02/04/2024] Open
Abstract
Introduction: Renal colic is frequently treated with opioids; however, narcotic analgesic use can lead to dependence and abuse. We evaluated use trends of opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management of kidney stones in United States emergency departments (EDs) from 2015 to 2021. Methods: Kidney stone encounters were identified using National Hospital Ambulatory Medical Care Survey data. We applied a multistage survey weighting procedure to account for selection probability, nonresponse, and population weights. Medication use trends were estimated through logistic regressions on the timing of the encounter, adjusted for selected demographic and clinical characteristics. Results: Between 2015 and 2021, there were an estimated 9,433,291 kidney stone encounters in United States EDs. Opioid use decreased significantly (annual odds ratio [OR]: 0.87, p = 0.003), and there was no significant trend in NSAID use. At discharge, male patients were more likely than females (OR: 1.93, p = 0.001) to receive opioids, and Black patients were less likely than White patients (OR: 0.34, p = 0.010) to receive opioids. Regional variation was also observed, with higher odds of discharge prescriptions in the West (OR: 3.15, p = 0.003) and Midwest (OR: 2.49, p = 0.010), compared with the Northeast. Thirty-five percent of patients received opioids that were stronger than morphine. Conclusion: These results suggest improved opioid stewardship from ED physicians in response to the national opioid epidemic. However, regional variation as well as disparities in discharge prescriptions for Black and female patients underscore opportunities for continued efforts.
Collapse
Affiliation(s)
- Richard B Berman
- Department of Urology, Columbia University Irving Medical Center, New York, New York, USA
| | - Juliana Villanueva
- Department of Urology, Columbia University Irving Medical Center, New York, New York, USA
| | - Ezra J Margolin
- Department of Urology, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Justin Lee
- Department of Urology, Columbia University Irving Medical Center, New York, New York, USA
| | - Ojas Shah
- Department of Urology, Columbia University Irving Medical Center, New York, New York, USA
| |
Collapse
|
3
|
Acharya M, Hayes CJ, Li C, Painter JT, Dayer L, Martin BC. Opioid therapy trajectories of patients with chronic non-cancer pain over 1 year of follow-up after initiation of short-acting opioid formulations. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:173-186. [PMID: 38243702 PMCID: PMC10906713 DOI: 10.1093/pm/pnad169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/09/2023] [Indexed: 01/21/2024]
Abstract
OBJECTIVE This study compared opioid utilization trajectories of persons initiating tramadol, short-acting hydrocodone, or short-acting oxycodone, and it characterized opioid dose trajectories and type of opioid in persistent opioid therapy subsamples. METHODS A retrospective cohort study of adults with chronic non-cancer pain who were initiating opioid therapy was conducted with the IQVIA PharMetrics® Plus for Academics data (2008-2018). Continuous enrollment was required for 6 months before ("baseline") and 12 months after ("follow-up") the first opioid prescription ("index date"). Opioid therapy measures were assessed every 7 days over follow-up. Group-based trajectory modeling (GBTM) was used to identify trajectories for any opioid and total morphine milligram equivalent measures, and longitudinal latent class analysis was used for opioid therapy type. RESULTS A total of 40 276 tramadol, 141 023 hydrocodone, and 45 221 oxycodone initiators were included. GBTM on any opioid therapy identified 3 latent trajectories: early discontinuers (tramadol 39.0%, hydrocodone 54.1%, oxycodone 61.4%), late discontinuers (tramadol 37.9%, hydrocodone 39.4%, oxycodone 33.3%), and persistent therapy (tramadol 6.7%, hydrocodone 6.5%, oxycodone 5.3%). An additional fourth trajectory, intermittent therapy (tramadol 16.4%), was identified for tramadol initiators. Of those on persistent therapy, 2687 individuals were on persistent therapy with tramadol, 9169 with hydrocodone, and 2377 with oxycodone. GBTM on opioid dose resulted in 6 similar trajectory groups in each persistent therapy group. Longitudinal latent class analysis on opioid therapy type identified 6 latent classes for tramadol and oxycodone and 7 classes for hydrocodone. CONCLUSION Opioid therapy patterns meaningfully differed by the initial opioid prescribed, notably the presence of intermittent therapy among tramadol initiators and higher morphine milligram equivalents and prescribing of long-acting opioids among oxycodone initiators.
Collapse
Affiliation(s)
- Mahip Acharya
- Division of Pharmaceutical Evaluation and Policy, Department of Pharmacy Practice, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Corey J Hayes
- Department of Biomedical Informatics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare Systems, North Little Rock, AR 72211, United States
| | - Chenghui Li
- Division of Pharmaceutical Evaluation and Policy, Department of Pharmacy Practice, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Jacob T Painter
- Division of Pharmaceutical Evaluation and Policy, Department of Pharmacy Practice, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare Systems, North Little Rock, AR 72211, United States
| | - Lindsey Dayer
- College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Bradley C Martin
- Division of Pharmaceutical Evaluation and Policy, Department of Pharmacy Practice, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| |
Collapse
|
4
|
Hawk KF, Weiner SG, Rothenberg C, Bernstein E, D'Onofrio G, Herring A, Hoppe J, Ketcham E, LaPietra A, Nelson L, Perrone J, Ranney M, Samuels EA, Strayer R, Sharma D, Goyal P, Schuur J, Venkatesh AK. Leveraging a Learning Collaborative Model to Develop and Pilot Quality Measures to Improve Opioid Prescribing in the Emergency Department. Ann Emerg Med 2024; 83:225-234. [PMID: 37831040 DOI: 10.1016/j.annemergmed.2023.08.490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 10/14/2023]
Abstract
The American College of Emergency Physicians (ACEP) Emergency Medicine Quality Network (E-QUAL) Opioid Initiative was launched in 2018 to advance the dissemination of evidence-based resources to promote the care of emergency department (ED) patients with opioid use disorder. This virtual platform-based national learning collaborative includes a low-burden, structured quality improvement project, data benchmarking, tailored educational content, and resources designed to support a nationwide network of EDs with limited administrative and research infrastructure. As a part of this collaboration, we convened a group of experts to identify and design a set of measures to improve opioid prescribing practices to provide safe analgesia while reducing opioid-related harms. We present those measures here, alongside initial performance data on those measures from a sample of 370 nationwide community EDs participating in the 2019 E-QUAL collaborative. Measures include proportion of opioid administration in the ED, proportion of alternatives to opioids as first-line treatment, proportion of opioid prescription, opioid pill count per prescription, and patient medication safety education among ED visits for atraumatic back pain, dental pain, or headache. The proportion of benzodiazepine and opioid coprescribing for ED visits for atraumatic back pain was also evaluated. This project developed and effectively implemented a collection of 6 potential measures to evaluate opioid analgesic prescribing across a national sample of community EDs, representing the first feasibility assessment of opioid prescribing-related measures from rural and community EDs.
Collapse
Affiliation(s)
- Kathryn F Hawk
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT.
| | | | - Craig Rothenberg
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Edward Bernstein
- Boston Medical Center Department of Emergency Medicine, Boston, MA
| | - Gail D'Onofrio
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Andrew Herring
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, University of California, San Francisco
| | - Jason Hoppe
- Department of Emergency Medicine, University of Colorado School of Medicine, Denver
| | - Eric Ketcham
- Presbyterian Healthcare, Espanola & Santa Fe, NM
| | - Alexis LaPietra
- Division of Emergency Medicine, RWJBarnabus Health, West Orange, NJ
| | - Lewis Nelson
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark
| | - Jeanmarie Perrone
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Megan Ranney
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT
| | | | - Reuben Strayer
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY
| | - Dhruv Sharma
- American College of Emergency Physicians, Dallas, TX
| | - Pawan Goyal
- American College of Emergency Physicians, Dallas, TX
| | - Jeremiah Schuur
- Department of Emergency Medicine, Brown School of Medicine, Providence, RI
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| |
Collapse
|
5
|
Agarwal AK, Xiong R, Ebert J, Shofer F, Spencer E, Lee D, Ali Z, Delgado MK. Identifying Patient Characteristics Associated With Opioid Use to Inform Surgical Pain Management. ANNALS OF SURGERY OPEN 2023; 4:e355. [PMID: 38144506 PMCID: PMC10735081 DOI: 10.1097/as9.0000000000000355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 09/28/2023] [Indexed: 12/26/2023] Open
Abstract
Objective Balancing surgical pain management and opioid stewardship is complex. Identifying patient-level variables associated with low or no use can inform tailored prescribing. Methods A prospective, observational study investigating surgical procedures, prescription data, and patient-reported outcomes at an academic health system in Pennsylvania. Surgical patients were consented following surgery, and prospective data were captured using automated text messaging (May 1, 2021-February 29, 2022). The primary outcome was opioid use. Results Three thousand six hundred three (30.2%) patients consented. Variation in patient reported used included 28.1% of men reported zero use versus 24.3% of women, 20.5% of Black patients reported zero use versus 27.2% of white patients. Opioid-naïve patients reported more zero use as compared with chronic use (29.7% vs 9.8%). Patients reporting higher use had more telephone calls and office visits within 30 days but no change in emergency department utilization or admissions. Higher discharge pain score was associated with higher use. In the adjusted analysis, opioid use relative to the guideline, higher use was associated with age, male sex, obesity, discharge pain score, and history of mental health disorder. In the adjusted model, younger age and being opioid-naïve to be associated with low to zero use across procedures. Conclusions Younger age, being opioid-naïve, and lower discharge pain score are associated with low or no postoperative opioid use. These characteristics can be used by clinicians to help tailor opioid prescribing to specific patients to reduce the risk of prolonged exposure and unused `ts in the community.
Collapse
Affiliation(s)
- Anish K. Agarwal
- From the Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA
| | - Ruiying Xiong
- From the Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Jeffrey Ebert
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Fran Shofer
- From the Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA
| | - Evan Spencer
- From the Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Daniel Lee
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Surgery, Division of Urology, University of Pennsylvania, Philadelphia, PA
| | - Zarina Ali
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA
| | - M. Kit Delgado
- From the Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
6
|
Chen Q, Maher CG, Han CS, Abdel Shaheed C, Lin CWC, Rogan EM, Machado GC. Continued Opioid Use and Adverse Events Following Provision of Opioids for Musculoskeletal Pain in the Emergency Department: A Systematic Review and Meta-Analysis. Drugs 2023; 83:1523-1535. [PMID: 37768540 PMCID: PMC10624756 DOI: 10.1007/s40265-023-01941-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND The prevalence of continued opioid use or serious adverse events (SAEs) following opioid therapy in the emergency department (ED) for musculoskeletal pain is unclear. The aim of this review was to examine the prevalence of continued opioid use and serious adverse events (SAEs) following the provision of opioids for musculoskeletal pain in the emergency department (ED) or at discharge. METHODS Records were searched from MEDLINE, EMBASE and CINAHL from inception to 7 October 2022. We included randomised controlled trials and observational studies enrolling adult patients with musculoskeletal pain who were administered and/or prescribed opioids in the ED. Continued opioid use and opioid misuse data after day 4 since ED discharge were extracted. Adverse events were coded using the Common Terminology Criteria for Adverse Events (CTCAE), and those rated as grades 3-4 (severe or life-threatening) and grade 5 (death) were considered SAEs. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool. RESULTS Seventy-two studies were included. Among opioid-naïve patients who received an opioid prescription, 6.8-7.0% reported recent opioid use at 3-12 months after discharge, 4.4% filled ≥ 5 opioid prescriptions and 3.1% filled > 90-day supply of opioids within 6 months. The prevalence of SAEs was 0.02% [95% confidence interval (CI) 0, 0.2%] in the ED and 0.1% (95% CI 0, 1.5%) within 2 days. One study observed 42.9% of patients misused opioids within 30 days after discharge. CONCLUSIONS Around 7% of opioid-naïve patients with musculoskeletal pain receiving opioid therapy continue opioid use at 3-12 months after ED discharge. SAEs following ED administration of an opioid were uncommon; however, studies only monitored patients for 2 days. PROTOCOL REGISTRATION 10.31219/osf.io/w4z3u.
Collapse
Affiliation(s)
- Qiuzhe Chen
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia.
| | - Chris G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia
| | - Christopher S Han
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia
| | - Christina Abdel Shaheed
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia
| | - Chung-Wei Christine Lin
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia
| | - Eileen M Rogan
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia
- Emergency Department, Canterbury Hospital, Campsie, NSW, Australia
| | - Gustavo C Machado
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, NSW, Australia
| |
Collapse
|
7
|
Crowley AP, Sun C, Yan XS, Navathe A, Liao JM, Patel MS, Pagnotti D, Shen Z, Delgado MK. Disparities in emergency department and urgent care opioid prescribing before and after randomized clinician feedback interventions. Acad Emerg Med 2023; 30:809-818. [PMID: 36876410 DOI: 10.1111/acem.14717] [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: 10/08/2022] [Revised: 02/25/2023] [Accepted: 02/27/2023] [Indexed: 03/07/2023]
Abstract
OBJECTIVES Racial and ethnic minorities receive opioid prescriptions at lower rates and dosages than White patients. Though opioid stewardship interventions can improve or exacerbate these disparities, there is little evidence about these effects. We conducted a secondary analysis of a cluster-randomized controlled trial conducted among 438 clinicians from 21 emergency departments and 27 urgent care clinics. Our objective was to determine whether randomly allocated opioid stewardship clinician feedback interventions that were designed to reduce opioid prescriptions had unintended effects on disparities in prescribing by patient race and ethnicity. METHODS The primary outcome was likelihood of receiving a low-pill prescription (low ≤10 pills, medium 11-19 pills, high ≥20 pills). Generalized mixed-effects models were used to determine patient characteristics associated with low-pill prescriptions during the baseline period. These models were then used to determine whether receipt of a low-pill prescription varied by patient race or ethnicity during the intervention period between usual care and three opioid stewardship interventions: (1) individual audit feedback, (2) peer comparison feedback, and (3) combined (individual audit + peer comparison) feedback. RESULTS Compared with White patients, Black patients were more likely to receive a low-pill prescription during the baseline (adjusted odds ratio [OR] 1.18, 95% confidence interval [CI] 1.06-1.31, p = 0.002) and intervention (adjusted OR 1.43, 95% CI 1.07-1.91, p = 0.015). While combined feedback was associated with an overall increase in low-pill prescriptions as intended (adjusted OR 1.89, 95% CI 1.28-2.78, p = 0.001), there were no significant differences in treatment effects of any of the interventions by patient race and ethnicity. CONCLUSIONS Combined individual audit and peer comparison feedback was associated with fewer opioid pills per prescription equally by patient race and ethnicity. However, the intervention did not significantly close the baseline disparity in prescribing by race.
Collapse
Affiliation(s)
- Aidan P Crowley
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Chuxuan Sun
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Xiaowei Sherry Yan
- Center for Health Systems Research, Sutter Health, Walnut Creek, California, USA
| | - Amol Navathe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Joshua M Liao
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | | | - David Pagnotti
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Zijun Shen
- Center for Health Systems Research, Sutter Health, Walnut Creek, California, USA
| | - M Kit Delgado
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Emergency Medicine and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
8
|
Howard R, Brown CS, Lai YL, Gunaseelan V, Brummett CM, Englesbe M, Waljee J, Bicket MC. Postoperative Opioid Prescribing and New Persistent Opioid Use: The Risk of Excessive Prescribing. Ann Surg 2023; 277:e1225-e1231. [PMID: 35129474 PMCID: PMC10537242 DOI: 10.1097/sla.0000000000005392] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Evaluate the association between postoperative opioid prescribing and new persistent opioid use. SUMMARY BACKGROUND DATA Opioid-nave patients who develop new persistent opioid use after surgery are at increased risk of opioid-related morbidity and mortality. However, the extent to which postoperative opioid prescribing is associated with persistent postoperative opioid use is unclear. METHODS Retrospective study of opioid-naïve adults undergoing surgery in Michigan from 1/1/2017 to 10/31/2019. Postoperative opioid prescriptions were identified using a statewide clinical registry and prescription fills were identified using Michigan's prescription drug monitoring program. The primary outcome was new persistent opioid use, defined as filling at least 1 opioid prescription between post-discharge days 4 to 90 and filling at least 1 opioid prescription between post-discharge days 91 to 180. RESULTS A total of 37,654 patients underwent surgery with a mean age of 52.2 (16.7) years and 20,923 (55.6%) female patients. A total of 31,920 (84.8%) patients were prescribed opioids at discharge. Six hundred twenty-two (1.7%) patients developed new persistent opioid use after surgery. Being prescribed an opioid at discharge was not associated with new persistent opioid use [adjusted odds ratio (aOR) 0.88 (95% confidence interval (CI) 0.71-1.09)]. However, among patients prescribed an opioid, patients prescribed the second largest [12 (interquartile range (IQR) 3) pills] and largest [20 (IQR 7) pills] quartiles of prescription size had higher odds of new persistent opioid use compared to patients prescribed the smallest quartile [7 (IQR 1) pills] of prescription size [aOR 1.39 (95% CI 1.04-1.86) andaOR 1.97 (95% CI 1.442.70), respectively]. CONCLUSIONS In a cohort of opioid-naïve patients undergoing common surgical procedures, the risk of new persistent opioid use increased with the size of the prescription. This suggests that while opioid prescriptions in and of themselves may not place patients at risk of long-term opioid use, excessive prescribing does. Consequently, these findings support ongoing efforts to mitigate excessive opioid prescribing after surgery to reduce opioid-related harms.
Collapse
Affiliation(s)
- Ryan Howard
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, MI
| | - Craig S Brown
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, MI
| | - Yen-Ling Lai
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and innovation, Ann Arbor, MI
| | - Vidhya Gunaseelan
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and innovation, Ann Arbor, MI
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
| | - Chad M Brummett
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and innovation, Ann Arbor, MI
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
| | - Michael Englesbe
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and innovation, Ann Arbor, MI
| | - Jennifer Waljee
- Department of Surgery, Michigan Medicine, Ann Arbor, MI
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and innovation, Ann Arbor, MI
| | - Mark C Bicket
- Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and innovation, Ann Arbor, MI
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
| |
Collapse
|
9
|
Larson MJ, Bauer MR, Moresco N, Huntington N, Ritter G, Paul-Kagiri R, Hyppolite R, Richard P. Variation in prescribing of opioids for emergency department encounters: A cohort study in the Military Health System. J Eval Clin Pract 2022; 28:1157-1167. [PMID: 35666601 DOI: 10.1111/jep.13702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/29/2022] [Accepted: 05/04/2022] [Indexed: 11/30/2022]
Abstract
UNLABELLED RATIONALE, AIMS AND OBJECTIVES: Emergency department (ED) clinicians account for approximately 13% of all opioid prescriptions to opioid-naïve patients and variability in the rates of prescribing have been noted among individual clinicians and different EDs. This study elucidates the amount of variability within a unified health system (the U.S. Military Health System [MHS]) with the expectation that understanding the sources of variability will enable health system leaders to improve the quality of decision making. METHODS The design was a retrospective cohort study examining variation in opioid prescribing within EDs of the US MHS. Participants were Army soldiers who returned from a deployment and received care between October 2009 and September 2016. The exposure was ED encounters at a military treatment facility. Key measures were the proportion of ED encounters with an opioid prescription fill; total opioid dose of the fill (morphine milligram equivalent, MME); and total opioid days-supply of the fill. RESULTS The mean proportion of ED encounters with an opioid fill across providers was 19.7% (SD 8.8%), median proportion was 18.6%, and the distribution was close to symmetric with the 75th percentile provider prescribing opioids in 24.6% of their ED encounters and the 25th percentile provider prescribing in 13.4% of their encounters. The provider-level mean opioid dose per encounter was 113.1 MME (SD 56.0) with the 75th percentile (130.1) 50% higher than the 25th percentile (87.4). The mean opioid supply per encounter was 6.8 days (SD 3.9) with more than a twofold ratio between the 75th percentile (8.3) and the 25th (4.1). Using a series of multilevel regression models to examine opioid fills associated with ED encounters and their dose levels, the variation among providers within facilities was much larger in magnitude than the variation among facilities. CONCLUSION Among ED encounters of Army soldiers at military treatment facilities, there was substantial variation among providers in prescribing opioid prescriptions that were not explained by patient case-mix. These results suggest that programmes and protocols to address less than optimal prescribing in the ED should be initiated to improve the quality of care.
Collapse
Affiliation(s)
- Mary J Larson
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, USA
| | - Mark R Bauer
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, USA
| | - Natalie Moresco
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, USA
| | - Nick Huntington
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, USA
| | - Grant Ritter
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, USA
| | - Rachelle Paul-Kagiri
- School of Medicine, Uniformed Services of the Health Sciences, Bethesda, Maryland, USA
| | - Regine Hyppolite
- School of Medicine, Uniformed Services of the Health Sciences, Bethesda, Maryland, USA
| | - Patrick Richard
- School of Medicine, Uniformed Services of the Health Sciences, Bethesda, Maryland, USA
| |
Collapse
|
10
|
Prescription quantity and duration predict progression from acute to chronic opioid use in opioid-naïve Medicaid patients. PLOS DIGITAL HEALTH 2022; 1:e0000075. [PMID: 36203857 PMCID: PMC9534483 DOI: 10.1371/journal.pdig.0000075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Opiates used for acute pain are an established risk factor for chronic opioid use (COU). Patient characteristics contribute to progression from acute opioid use to COU, but most are not clinically modifiable. To develop and validate machine-learning algorithms that use claims data to predict progression from acute to COU in the Medicaid population, Adult opioid naïve Medicaid patients from 6 anonymized states who received an opioid prescription between 2015 and 2019 were included. Five machine learning (ML) Models were developed, and model performance assessed by area under the receiver operating characteristic curve (auROC), precision and recall. In the study, 29.9% (53820/180000) of patients transitioned from acute opioid use to COU. Initial opioid prescriptions in COU patients had increased morphine milligram equivalents (MME) (33.2 vs. 23.2), tablets per prescription (45.6 vs. 36.54), longer prescriptions (26.63 vs 24.69 days), and higher proportions of tramadol (16.06% vs. 13.44%) and long acting oxycodone (0.24% vs 0.04%) compared to non- COU patients. The top performing model was XGBoost that achieved average precision of 0.87 and auROC of 0.63 in testing and 0.55 and 0.69 in validation, respectively. Top-ranking prescription-related features in the model included quantity of tablets per prescription, prescription length, and emergency department claims. In this study, the Medicaid population, opioid prescriptions with increased tablet quantity and days supply predict increased risk of progression from acute to COU in opioid-naïve patients. Future research should evaluate the effects of modifying these risk factors on COU incidence.
Collapse
|
11
|
Khouja T, Zhou J, Gellad WF, Mitsantisuk K, Hubbard CC, Yan CH, Sharp LK, Calip GS, Evans CT, Suda KJ. Serious opioid-related adverse outcomes associated with opioids prescribed by dentists. Pain 2022; 163:1571-1580. [PMID: 35838648 PMCID: PMC9803557 DOI: 10.1097/j.pain.0000000000002545] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/18/2021] [Indexed: 01/03/2023]
Abstract
ABSTRACT Although nonsteroidal anti inflammatory drugs are superior to opioids in dental pain management, opioids are still prescribed for dental pain in the United States. Little is known about the serious adverse outcomes of short-acting opioids within the context of dental prescribing. The objective of this study was to evaluate adverse outcomes and persistent opioid use (POU) after opioid prescriptions by dentists, based on whether opioids were overprescribed or within recommendations. A cross-sectional analysis of adults with a dental visit and corresponding opioid prescription (index) from 2011 to 2018 within a nationwide commercial claims database was conducted. Opioid overprescribing was defined as >120 morphine milligram equivalents per Centers for Disease Control and Prevention guidelines. Generalized estimating equation models were used to assess adverse outcomes (emergency department visits, hospitalizations, newly diagnosed substance use disorder, naloxone administration, or death within 30 days from index) and POU (≥1 prescription 4-90 days postindex). Predicted probabilities are reported. Of 633,387 visits, 2.6% experienced an adverse outcome and 16.6% had POU. Adverse outcome risk was not different whether opioids were overprescribed or within recommendations (predicted probability 9.0%, confidence interval [CI]: 8.0%-10.2% vs 9.1%, CI: 8.1-10.3), but POU was higher when opioids were overprescribed (predicted probability 27.4%, CI: 26.1%-28.8% vs 25.2%, CI: 24.0%-26.5%). Visits associated with mild pain and those with substance use disorders had the highest risk of both outcomes. Findings from this study demonstrate that dental prescribing of opioids was associated with adverse outcomes and POU, even when prescriptions were concordant with guidelines. Additional efforts are required to improve analgesic prescribing in dentistry, especially in groups at high risk of opioid-related adverse outcomes.
Collapse
Affiliation(s)
- Tumader Khouja
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jifang Zhou
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
| | - Walid F. Gellad
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kannop Mitsantisuk
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Colin C. Hubbard
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL, USA
| | - Connie H. Yan
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL, USA
| | - Lisa K. Sharp
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL, USA
| | - Gregory S. Calip
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL, USA
| | | | - Katie J. Suda
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| |
Collapse
|
12
|
Lurie T, Bonnin N, Rea J, Tuteja G, Dezman Z, Wilkerson RG, Buganu A, Chasm R, Haase DJ, Tran QK. Patterns of opioid prescribing in emergency departments during the early phase of the COVID-19 pandemic. Am J Emerg Med 2022; 56:63-70. [PMID: 35367681 PMCID: PMC8956353 DOI: 10.1016/j.ajem.2022.03.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/09/2022] [Accepted: 03/20/2022] [Indexed: 02/06/2023] Open
Abstract
Introduction The COVID-19 pandemic was superimposed upon an ongoing epidemic of opioid use disorder and overdose deaths. Although the trend of opioid prescription patterns (OPP) had decreased in response to public health efforts before the pandemic, little is known about the OPP from emergency department (ED) clinicians during the COVID-19 pandemic. Methods We conducted a pre-post study of adult patients who were discharged from 13 EDs and one urgent care within our academic medical system between 01/01/2019 and 09/30/2020 using an interrupted time series (ITS) approach. Patient characteristics and prescription data were extracted from the single unified electronic medical record across all study sites. Prescriptions of opioids were converted into morphine equivalent dose (MED). We compared the “Covid-19 Pandemic” period (C19, 03/29/2020–9/30/2020) and the “Pre-Pandemic” period (PP, 1/19/2020–03/28/2020). We used a multivariate logistic regression to assess clinical factors associated with opioid prescriptions. Results We analyzed 361,794 ED visits by adult patients, including 259,242 (72%) PP and 102,552 (28%) C19 visits. Demographic information and percentages of patients receiving opioid prescriptions were similar in both groups. The median [IQR] MED per prescription was higher for C19 patients (70 [56–90]) than for PP patients (60 [60–90], P < 0.001). ITS demonstrated a significant trend toward higher MED prescription per ED visit during the pandemic (coefficient 0.11, 95% CI 0.05–0.16, P = 0.002). A few factors, that were associated with lower likelihood of opioid prescriptions before the pandemic, became non-significant during the pandemic. Conclusion Our study demonstrated that emergency clinicians increased the prescribed amount of opioids per prescription during the COVID-19 pandemic compared to the pre-pandemic period. Etiologies for this finding could include lack of access to primary care and other specialties during the pandemic, or lower volumes allowing for emergency clinicians to identify who is safe to be prescribed opioids.
Collapse
|
13
|
Broder JS, Oliveira J E Silva L, Bellolio F, Freiermuth CE, Griffey RT, Hooker E, Jang TB, Meltzer AC, Mills AM, Pepper JD, Prakken SD, Repplinger MD, Upadhye S, Carpenter CR. Guidelines for Reasonable and Appropriate Care in the Emergency Department 2 (GRACE-2): Low-risk, recurrent abdominal pain in the emergency department. Acad Emerg Med 2022; 29:526-560. [PMID: 35543712 DOI: 10.1111/acem.14495] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 03/18/2022] [Accepted: 03/19/2022] [Indexed: 02/07/2023]
Abstract
This second Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-2) from the Society for Academic Emergency Medicine is on the topic "low-risk, recurrent abdominal pain in the emergency department." The multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding four priority questions for adult emergency department patients with low-risk, recurrent, undifferentiated abdominal pain. The intended population includes adults with multiple similar presentations of abdominal signs and symptoms recurring over a period of months or years. The panel reached the following recommendations: (1) if a prior negative computed tomography of the abdomen and pelvis (CTAP) has been performed within 12 months, there is insufficient evidence to accurately identify populations in whom repeat CTAP imaging can be safely avoided or routinely recommended; (2) if CTAP with IV contrast is negative, we suggest against ultrasound unless there is concern for pelvic or biliary pathology; (3) we suggest that screening for depression and/or anxiety may be performed during the ED evaluation; and (4) we suggest an opioid-minimizing strategy for pain control. EXECUTIVE SUMMARY: The GRACE-2 writing group developed clinically relevant questions to address the care of adult patients with low-risk, recurrent, previously undifferentiated abdominal pain in the emergency department (ED). Four patient-intervention-comparison-outcome-time (PICOT) questions were developed by consensus of the writing group, who performed a systematic review of the literature and then synthesized direct and indirect evidence to formulate recommendations, following GRADE methodology. The writing group found that despite the commonality and relevance of these questions in emergency care, the quantity and quality of evidence were very limited, and even fundamental definitions of the population and outcomes of interest are lacking. Future research opportunities include developing precise and clinically relevant definitions of low-risk, recurrent, undifferentiated abdominal pain and determining the scope of the existing populations in terms of annual national ED visits for this complaint, costs of care, and patient and provider preferences.
Collapse
Affiliation(s)
- Joshua S Broder
- Department of Surgery, Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Caroline E Freiermuth
- Department of Emergency Medicine, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - Richard T Griffey
- Department of Emergency Medicine and Emergency Care Research Core, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Edmond Hooker
- Department of Health Services Administration, Xavier University, Cincinnati, Ohio, USA
| | - Timothy B Jang
- Department of Emergency Medicine, University of California Los Angeles, UCLA Santa Monica Medical Center, Torrance, California, USA
| | - Andrew C Meltzer
- Department of Emergency Medicine, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Angela M Mills
- Department of Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA.,Society for Academic Emergency Medicine, Des Plaines, Illinois, USA
| | | | | | - Michael D Repplinger
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Suneel Upadhye
- Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Christopher R Carpenter
- Department of Emergency Medicine and Emergency Care Research Core, Washington University School of Medicine, St. Louis, Missouri, USA.,Society for Academic Emergency Medicine, Des Plaines, Illinois, USA
| |
Collapse
|
14
|
Opioid prescribing in out-of-hours primary care in Flanders and the Netherlands: A retrospective cross-sectional study. PLoS One 2022; 17:e0265283. [PMID: 35390027 PMCID: PMC8989290 DOI: 10.1371/journal.pone.0265283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 02/27/2022] [Indexed: 11/19/2022] Open
Abstract
Background
Increased opioid prescribing has raised concern, as the benefits of pain relief not always outweigh the risks. Acute and chronic pain is often treated in a primary care out-of-hours (OOH) setting. This setting may be a driver of opioid use but the extent to which opioids are prescribed OOH is unknown. We aimed to investigate weak and strong opioid prescribing at OOH primary care services (PCS) in Flanders (Northern, Dutch-speaking part of Belgium) and the Netherlands between 2015 and 2019.
Methods
We performed a retrospective cross sectional study using data from routine electronic health records of OOH-PCSs in Flanders and the Netherlands (2015–2019). Our primary outcome was the opioid prescribing rate per 1000 OOH-contacts per year, in total and for strong (morphine, hydromorphone, oxycodone, oxycodone and naloxone, fentanyl, tapentadol, and buprenorphine and weak opioids (codeine combinations and tramadol and combinations) and type of opioids separately.
Results
Opioids were prescriped in approximately 2.5% of OOH-contacts in both Flanders and the Netherlands. In Flanders, OOH opioid prescribing went from 2.4% in 2015 to 2.1% in 2017 and then increased to 2.3% in 2019. In the Netherlands, opioid prescribing increased from 1.9% of OOH-contacts in 2015 to 2.4% in 2017 and slightly decreased thereafter to 2.1% of OOH-contacts. In 2019, in Flanders, strong opioids were prescribed in 8% of the OOH-contacts with an opioid prescription. In the Netherlands a strong opioid was prescribed in 57% of these OOH-contacts. Two thirds of strong opioids prescriptions in Flanders OOH were issued for patients over 75, in the Netherlands one third was prescribed to this age group.
Conclusion
We observed large differences in strong opioid prescribing at OOH-PCSs between Flanders and the Netherlands that are likely to be caused by differences in accessibility of secondary care, and possibly existing opioid prescribing habits. Measures to ensure judicious and evidence-based opioid prescribing need to be tailored to the organisation of the healthcare system.
Collapse
|
15
|
Navathe AS, Liao JM, Yan XS, Delgado MK, Isenberg WM, Landa HM, Bond BL, Small DS, Rareshide CAL, Shen Z, Pepe RS, Refai F, Lei VJ, Volpp KG, Patel MS. The Effect Of Clinician Feedback Interventions On Opioid Prescribing. Health Aff (Millwood) 2022; 41:424-433. [PMID: 35254932 DOI: 10.1377/hlthaff.2021.01407] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
An initial opioid prescription with a greater number of pills is associated with a greater risk for future long-term opioid use, yet few interventions have reliably influenced individual clinicians' prescribing. Our objective was to evaluate the effect of feedback interventions for clinicians in reducing opioid prescribing. The interventions included feedback on a clinician's outlier prescribing (individual audit feedback), peer comparison, and both interventions combined. We conducted a four-arm factorial pragmatic cluster randomized trial at forty-eight emergency department (ED) and urgent care (UC) sites in the western US, including 263 ED and 175 UC clinicians with 294,962 patient encounters. Relative to usual care, there was a significant decrease in pills per prescription both for peer comparison feedback (-0.8) and for the combination of peer comparison and individual audit feedback (-1.2). This decrease was sustained during follow-up. There were no significant changes for individual audit feedback alone, and no interventions changed the proportion of encounters with an opioid prescription.
Collapse
Affiliation(s)
- Amol S Navathe
- Amol S. Navathe , Corporal Michael J. Cresencz Veterans Affairs Medical Center and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua M Liao
- Joshua M. Liao, University of Washington, Seattle, Washington, and University of Pennsylvania
| | - Xiaowei S Yan
- Xiaowei S. Yan, Sutter Health, Walnut Creek, California
| | | | | | | | - Barbara L Bond
- Barbara L. Bond, Sutter Health, Castro Valley, California
| | | | | | - Zijun Shen
- Zijun Shen, Sutter Health, San Francisco
| | | | | | | | | | - Mitesh S Patel
- Mitesh S. Patel, Corporal Michael J. Cresencz Veterans Affairs Medical Center and University of Pennsylvania
| |
Collapse
|
16
|
Meisel ZF, Shofer F, Dolan A, Goldberg EB, Rhodes KV, Hess EP, Bellamkonda VR, Perrone J, Cannuscio CC, Becker L, Rodgers MA, Zyla MM, Bell JJ, McCollum S, Engel-Rebitzer E, Tiako MJN, Ridgeway G, Schapira MM. A Multicentered Randomized Controlled Trial Comparing the Effectiveness of Pain Treatment Communication Tools in Emergency Department Patients With Back or Kidney Stone Pain. Am J Public Health 2022; 112:S45-S55. [PMID: 35143273 PMCID: PMC8842217 DOI: 10.2105/ajph.2021.306511] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2021] [Indexed: 11/04/2022]
Abstract
Objectives. To compare the effectiveness of 3 approaches for communicating opioid risk during an emergency department visit for a common painful condition. Methods. This parallel, multicenter randomized controlled trial was conducted at 6 geographically disparate emergency department sites in the United States. Participants included adult patients between 18 and 70 years of age presenting with kidney stone or musculoskeletal back pain. Participants were randomly assigned to 1 of 3 risk communication strategies: (1) a personalized probabilistic risk visual aid, (2) a visual aid and a video narrative, or 3) general risk information. The primary outcomes were accuracy of risk recall, reported opioid use, and treatment preference at time of discharge. Results. A total of 1301 participants were enrolled between June 2017 and August 2019. There was no difference in risk recall at 14 days between the narrative and probabilistic groups (43.7% vs 38.8%; absolute risk reduction = 4.9%; 95% confidence interval [CI] = -2.98, 12.75). The narrative group had lower rates of preference for opioids at discharge than the general risk information group (25.9% vs 33.0%; difference = 7.1%; 95% CI = 0.64, 0.97). There were no differences in reported opioid use at 14 days between the narrative, probabilistic, and general risk groups (10.5%, 10.3%, and 13.3%, respectively; P = .44). Conclusions. An emergency medicine communication tool incorporating probabilistic risk and patient narratives was more effective than general information in mitigating preferences for opioids in the treatment of pain but was not more effective with respect to opioid use or risk recall. Trial Registration. Clinical Trials.gov identifier: NCT03134092. (Am J Public Health. 2022;112(S1):S45-S55. https://doi.org/10.2105/AJPH.2021.306511).
Collapse
Affiliation(s)
- Zachary F Meisel
- Zachary F. Meisel, Frances Shofer, Abby Dolan, Erica B. Goldberg, Melissa A. Rodgers, Michael M. Zyla, Jeffrey J. Bell, Sharon McCollum, Eden Engel-Rebitzer, and Max Jordan Nguemeni Tiako are with the Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Karin V. Rhodes is with the Agency for Healthcare Research and Quality, Bethesda, MD. Erik P. Hess is with the Vanderbilt University School of Medicine, Department of Emergency Medicine, Nashville, TN. Venkatesh R. Bellamkonda is with the Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Rochester, MN. Jeanmarie Perrone is with the Center for Addiction Medicine and Policy, University of Pennsylvania. Lance Becker is with the Department of Emergency Medicine, Zucker School of Medicine at Hofstra/Northwell, New York, NY. Carolyn C. Cannuscio is with the Center for Public Health Initiatives, University of Pennsylvania. Greg Ridgeway is with the Department of Criminology, University of Pennsylvania. Marilyn M. Schapira is with the Center for Health Equity and Research Promotion, Philadelphia VA Medical Center
| | - Frances Shofer
- Zachary F. Meisel, Frances Shofer, Abby Dolan, Erica B. Goldberg, Melissa A. Rodgers, Michael M. Zyla, Jeffrey J. Bell, Sharon McCollum, Eden Engel-Rebitzer, and Max Jordan Nguemeni Tiako are with the Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Karin V. Rhodes is with the Agency for Healthcare Research and Quality, Bethesda, MD. Erik P. Hess is with the Vanderbilt University School of Medicine, Department of Emergency Medicine, Nashville, TN. Venkatesh R. Bellamkonda is with the Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Rochester, MN. Jeanmarie Perrone is with the Center for Addiction Medicine and Policy, University of Pennsylvania. Lance Becker is with the Department of Emergency Medicine, Zucker School of Medicine at Hofstra/Northwell, New York, NY. Carolyn C. Cannuscio is with the Center for Public Health Initiatives, University of Pennsylvania. Greg Ridgeway is with the Department of Criminology, University of Pennsylvania. Marilyn M. Schapira is with the Center for Health Equity and Research Promotion, Philadelphia VA Medical Center
| | - Abby Dolan
- Zachary F. Meisel, Frances Shofer, Abby Dolan, Erica B. Goldberg, Melissa A. Rodgers, Michael M. Zyla, Jeffrey J. Bell, Sharon McCollum, Eden Engel-Rebitzer, and Max Jordan Nguemeni Tiako are with the Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Karin V. Rhodes is with the Agency for Healthcare Research and Quality, Bethesda, MD. Erik P. Hess is with the Vanderbilt University School of Medicine, Department of Emergency Medicine, Nashville, TN. Venkatesh R. Bellamkonda is with the Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Rochester, MN. Jeanmarie Perrone is with the Center for Addiction Medicine and Policy, University of Pennsylvania. Lance Becker is with the Department of Emergency Medicine, Zucker School of Medicine at Hofstra/Northwell, New York, NY. Carolyn C. Cannuscio is with the Center for Public Health Initiatives, University of Pennsylvania. Greg Ridgeway is with the Department of Criminology, University of Pennsylvania. Marilyn M. Schapira is with the Center for Health Equity and Research Promotion, Philadelphia VA Medical Center
| | - Erica B Goldberg
- Zachary F. Meisel, Frances Shofer, Abby Dolan, Erica B. Goldberg, Melissa A. Rodgers, Michael M. Zyla, Jeffrey J. Bell, Sharon McCollum, Eden Engel-Rebitzer, and Max Jordan Nguemeni Tiako are with the Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Karin V. Rhodes is with the Agency for Healthcare Research and Quality, Bethesda, MD. Erik P. Hess is with the Vanderbilt University School of Medicine, Department of Emergency Medicine, Nashville, TN. Venkatesh R. Bellamkonda is with the Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Rochester, MN. Jeanmarie Perrone is with the Center for Addiction Medicine and Policy, University of Pennsylvania. Lance Becker is with the Department of Emergency Medicine, Zucker School of Medicine at Hofstra/Northwell, New York, NY. Carolyn C. Cannuscio is with the Center for Public Health Initiatives, University of Pennsylvania. Greg Ridgeway is with the Department of Criminology, University of Pennsylvania. Marilyn M. Schapira is with the Center for Health Equity and Research Promotion, Philadelphia VA Medical Center
| | - Karin V Rhodes
- Zachary F. Meisel, Frances Shofer, Abby Dolan, Erica B. Goldberg, Melissa A. Rodgers, Michael M. Zyla, Jeffrey J. Bell, Sharon McCollum, Eden Engel-Rebitzer, and Max Jordan Nguemeni Tiako are with the Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Karin V. Rhodes is with the Agency for Healthcare Research and Quality, Bethesda, MD. Erik P. Hess is with the Vanderbilt University School of Medicine, Department of Emergency Medicine, Nashville, TN. Venkatesh R. Bellamkonda is with the Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Rochester, MN. Jeanmarie Perrone is with the Center for Addiction Medicine and Policy, University of Pennsylvania. Lance Becker is with the Department of Emergency Medicine, Zucker School of Medicine at Hofstra/Northwell, New York, NY. Carolyn C. Cannuscio is with the Center for Public Health Initiatives, University of Pennsylvania. Greg Ridgeway is with the Department of Criminology, University of Pennsylvania. Marilyn M. Schapira is with the Center for Health Equity and Research Promotion, Philadelphia VA Medical Center
| | - Erik P Hess
- Zachary F. Meisel, Frances Shofer, Abby Dolan, Erica B. Goldberg, Melissa A. Rodgers, Michael M. Zyla, Jeffrey J. Bell, Sharon McCollum, Eden Engel-Rebitzer, and Max Jordan Nguemeni Tiako are with the Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Karin V. Rhodes is with the Agency for Healthcare Research and Quality, Bethesda, MD. Erik P. Hess is with the Vanderbilt University School of Medicine, Department of Emergency Medicine, Nashville, TN. Venkatesh R. Bellamkonda is with the Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Rochester, MN. Jeanmarie Perrone is with the Center for Addiction Medicine and Policy, University of Pennsylvania. Lance Becker is with the Department of Emergency Medicine, Zucker School of Medicine at Hofstra/Northwell, New York, NY. Carolyn C. Cannuscio is with the Center for Public Health Initiatives, University of Pennsylvania. Greg Ridgeway is with the Department of Criminology, University of Pennsylvania. Marilyn M. Schapira is with the Center for Health Equity and Research Promotion, Philadelphia VA Medical Center
| | - Venkatesh R Bellamkonda
- Zachary F. Meisel, Frances Shofer, Abby Dolan, Erica B. Goldberg, Melissa A. Rodgers, Michael M. Zyla, Jeffrey J. Bell, Sharon McCollum, Eden Engel-Rebitzer, and Max Jordan Nguemeni Tiako are with the Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Karin V. Rhodes is with the Agency for Healthcare Research and Quality, Bethesda, MD. Erik P. Hess is with the Vanderbilt University School of Medicine, Department of Emergency Medicine, Nashville, TN. Venkatesh R. Bellamkonda is with the Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Rochester, MN. Jeanmarie Perrone is with the Center for Addiction Medicine and Policy, University of Pennsylvania. Lance Becker is with the Department of Emergency Medicine, Zucker School of Medicine at Hofstra/Northwell, New York, NY. Carolyn C. Cannuscio is with the Center for Public Health Initiatives, University of Pennsylvania. Greg Ridgeway is with the Department of Criminology, University of Pennsylvania. Marilyn M. Schapira is with the Center for Health Equity and Research Promotion, Philadelphia VA Medical Center
| | - Jeanmarie Perrone
- Zachary F. Meisel, Frances Shofer, Abby Dolan, Erica B. Goldberg, Melissa A. Rodgers, Michael M. Zyla, Jeffrey J. Bell, Sharon McCollum, Eden Engel-Rebitzer, and Max Jordan Nguemeni Tiako are with the Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Karin V. Rhodes is with the Agency for Healthcare Research and Quality, Bethesda, MD. Erik P. Hess is with the Vanderbilt University School of Medicine, Department of Emergency Medicine, Nashville, TN. Venkatesh R. Bellamkonda is with the Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Rochester, MN. Jeanmarie Perrone is with the Center for Addiction Medicine and Policy, University of Pennsylvania. Lance Becker is with the Department of Emergency Medicine, Zucker School of Medicine at Hofstra/Northwell, New York, NY. Carolyn C. Cannuscio is with the Center for Public Health Initiatives, University of Pennsylvania. Greg Ridgeway is with the Department of Criminology, University of Pennsylvania. Marilyn M. Schapira is with the Center for Health Equity and Research Promotion, Philadelphia VA Medical Center
| | - Carolyn C Cannuscio
- Zachary F. Meisel, Frances Shofer, Abby Dolan, Erica B. Goldberg, Melissa A. Rodgers, Michael M. Zyla, Jeffrey J. Bell, Sharon McCollum, Eden Engel-Rebitzer, and Max Jordan Nguemeni Tiako are with the Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Karin V. Rhodes is with the Agency for Healthcare Research and Quality, Bethesda, MD. Erik P. Hess is with the Vanderbilt University School of Medicine, Department of Emergency Medicine, Nashville, TN. Venkatesh R. Bellamkonda is with the Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Rochester, MN. Jeanmarie Perrone is with the Center for Addiction Medicine and Policy, University of Pennsylvania. Lance Becker is with the Department of Emergency Medicine, Zucker School of Medicine at Hofstra/Northwell, New York, NY. Carolyn C. Cannuscio is with the Center for Public Health Initiatives, University of Pennsylvania. Greg Ridgeway is with the Department of Criminology, University of Pennsylvania. Marilyn M. Schapira is with the Center for Health Equity and Research Promotion, Philadelphia VA Medical Center
| | - Lance Becker
- Zachary F. Meisel, Frances Shofer, Abby Dolan, Erica B. Goldberg, Melissa A. Rodgers, Michael M. Zyla, Jeffrey J. Bell, Sharon McCollum, Eden Engel-Rebitzer, and Max Jordan Nguemeni Tiako are with the Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Karin V. Rhodes is with the Agency for Healthcare Research and Quality, Bethesda, MD. Erik P. Hess is with the Vanderbilt University School of Medicine, Department of Emergency Medicine, Nashville, TN. Venkatesh R. Bellamkonda is with the Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Rochester, MN. Jeanmarie Perrone is with the Center for Addiction Medicine and Policy, University of Pennsylvania. Lance Becker is with the Department of Emergency Medicine, Zucker School of Medicine at Hofstra/Northwell, New York, NY. Carolyn C. Cannuscio is with the Center for Public Health Initiatives, University of Pennsylvania. Greg Ridgeway is with the Department of Criminology, University of Pennsylvania. Marilyn M. Schapira is with the Center for Health Equity and Research Promotion, Philadelphia VA Medical Center
| | - Melissa A Rodgers
- Zachary F. Meisel, Frances Shofer, Abby Dolan, Erica B. Goldberg, Melissa A. Rodgers, Michael M. Zyla, Jeffrey J. Bell, Sharon McCollum, Eden Engel-Rebitzer, and Max Jordan Nguemeni Tiako are with the Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Karin V. Rhodes is with the Agency for Healthcare Research and Quality, Bethesda, MD. Erik P. Hess is with the Vanderbilt University School of Medicine, Department of Emergency Medicine, Nashville, TN. Venkatesh R. Bellamkonda is with the Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Rochester, MN. Jeanmarie Perrone is with the Center for Addiction Medicine and Policy, University of Pennsylvania. Lance Becker is with the Department of Emergency Medicine, Zucker School of Medicine at Hofstra/Northwell, New York, NY. Carolyn C. Cannuscio is with the Center for Public Health Initiatives, University of Pennsylvania. Greg Ridgeway is with the Department of Criminology, University of Pennsylvania. Marilyn M. Schapira is with the Center for Health Equity and Research Promotion, Philadelphia VA Medical Center
| | - Michael M Zyla
- Zachary F. Meisel, Frances Shofer, Abby Dolan, Erica B. Goldberg, Melissa A. Rodgers, Michael M. Zyla, Jeffrey J. Bell, Sharon McCollum, Eden Engel-Rebitzer, and Max Jordan Nguemeni Tiako are with the Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Karin V. Rhodes is with the Agency for Healthcare Research and Quality, Bethesda, MD. Erik P. Hess is with the Vanderbilt University School of Medicine, Department of Emergency Medicine, Nashville, TN. Venkatesh R. Bellamkonda is with the Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Rochester, MN. Jeanmarie Perrone is with the Center for Addiction Medicine and Policy, University of Pennsylvania. Lance Becker is with the Department of Emergency Medicine, Zucker School of Medicine at Hofstra/Northwell, New York, NY. Carolyn C. Cannuscio is with the Center for Public Health Initiatives, University of Pennsylvania. Greg Ridgeway is with the Department of Criminology, University of Pennsylvania. Marilyn M. Schapira is with the Center for Health Equity and Research Promotion, Philadelphia VA Medical Center
| | - Jeffrey J Bell
- Zachary F. Meisel, Frances Shofer, Abby Dolan, Erica B. Goldberg, Melissa A. Rodgers, Michael M. Zyla, Jeffrey J. Bell, Sharon McCollum, Eden Engel-Rebitzer, and Max Jordan Nguemeni Tiako are with the Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Karin V. Rhodes is with the Agency for Healthcare Research and Quality, Bethesda, MD. Erik P. Hess is with the Vanderbilt University School of Medicine, Department of Emergency Medicine, Nashville, TN. Venkatesh R. Bellamkonda is with the Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Rochester, MN. Jeanmarie Perrone is with the Center for Addiction Medicine and Policy, University of Pennsylvania. Lance Becker is with the Department of Emergency Medicine, Zucker School of Medicine at Hofstra/Northwell, New York, NY. Carolyn C. Cannuscio is with the Center for Public Health Initiatives, University of Pennsylvania. Greg Ridgeway is with the Department of Criminology, University of Pennsylvania. Marilyn M. Schapira is with the Center for Health Equity and Research Promotion, Philadelphia VA Medical Center
| | - Sharon McCollum
- Zachary F. Meisel, Frances Shofer, Abby Dolan, Erica B. Goldberg, Melissa A. Rodgers, Michael M. Zyla, Jeffrey J. Bell, Sharon McCollum, Eden Engel-Rebitzer, and Max Jordan Nguemeni Tiako are with the Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Karin V. Rhodes is with the Agency for Healthcare Research and Quality, Bethesda, MD. Erik P. Hess is with the Vanderbilt University School of Medicine, Department of Emergency Medicine, Nashville, TN. Venkatesh R. Bellamkonda is with the Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Rochester, MN. Jeanmarie Perrone is with the Center for Addiction Medicine and Policy, University of Pennsylvania. Lance Becker is with the Department of Emergency Medicine, Zucker School of Medicine at Hofstra/Northwell, New York, NY. Carolyn C. Cannuscio is with the Center for Public Health Initiatives, University of Pennsylvania. Greg Ridgeway is with the Department of Criminology, University of Pennsylvania. Marilyn M. Schapira is with the Center for Health Equity and Research Promotion, Philadelphia VA Medical Center
| | - Eden Engel-Rebitzer
- Zachary F. Meisel, Frances Shofer, Abby Dolan, Erica B. Goldberg, Melissa A. Rodgers, Michael M. Zyla, Jeffrey J. Bell, Sharon McCollum, Eden Engel-Rebitzer, and Max Jordan Nguemeni Tiako are with the Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Karin V. Rhodes is with the Agency for Healthcare Research and Quality, Bethesda, MD. Erik P. Hess is with the Vanderbilt University School of Medicine, Department of Emergency Medicine, Nashville, TN. Venkatesh R. Bellamkonda is with the Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Rochester, MN. Jeanmarie Perrone is with the Center for Addiction Medicine and Policy, University of Pennsylvania. Lance Becker is with the Department of Emergency Medicine, Zucker School of Medicine at Hofstra/Northwell, New York, NY. Carolyn C. Cannuscio is with the Center for Public Health Initiatives, University of Pennsylvania. Greg Ridgeway is with the Department of Criminology, University of Pennsylvania. Marilyn M. Schapira is with the Center for Health Equity and Research Promotion, Philadelphia VA Medical Center
| | - Max Jordan Nguemeni Tiako
- Zachary F. Meisel, Frances Shofer, Abby Dolan, Erica B. Goldberg, Melissa A. Rodgers, Michael M. Zyla, Jeffrey J. Bell, Sharon McCollum, Eden Engel-Rebitzer, and Max Jordan Nguemeni Tiako are with the Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Karin V. Rhodes is with the Agency for Healthcare Research and Quality, Bethesda, MD. Erik P. Hess is with the Vanderbilt University School of Medicine, Department of Emergency Medicine, Nashville, TN. Venkatesh R. Bellamkonda is with the Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Rochester, MN. Jeanmarie Perrone is with the Center for Addiction Medicine and Policy, University of Pennsylvania. Lance Becker is with the Department of Emergency Medicine, Zucker School of Medicine at Hofstra/Northwell, New York, NY. Carolyn C. Cannuscio is with the Center for Public Health Initiatives, University of Pennsylvania. Greg Ridgeway is with the Department of Criminology, University of Pennsylvania. Marilyn M. Schapira is with the Center for Health Equity and Research Promotion, Philadelphia VA Medical Center
| | - Greg Ridgeway
- Zachary F. Meisel, Frances Shofer, Abby Dolan, Erica B. Goldberg, Melissa A. Rodgers, Michael M. Zyla, Jeffrey J. Bell, Sharon McCollum, Eden Engel-Rebitzer, and Max Jordan Nguemeni Tiako are with the Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Karin V. Rhodes is with the Agency for Healthcare Research and Quality, Bethesda, MD. Erik P. Hess is with the Vanderbilt University School of Medicine, Department of Emergency Medicine, Nashville, TN. Venkatesh R. Bellamkonda is with the Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Rochester, MN. Jeanmarie Perrone is with the Center for Addiction Medicine and Policy, University of Pennsylvania. Lance Becker is with the Department of Emergency Medicine, Zucker School of Medicine at Hofstra/Northwell, New York, NY. Carolyn C. Cannuscio is with the Center for Public Health Initiatives, University of Pennsylvania. Greg Ridgeway is with the Department of Criminology, University of Pennsylvania. Marilyn M. Schapira is with the Center for Health Equity and Research Promotion, Philadelphia VA Medical Center
| | - Marilyn M Schapira
- Zachary F. Meisel, Frances Shofer, Abby Dolan, Erica B. Goldberg, Melissa A. Rodgers, Michael M. Zyla, Jeffrey J. Bell, Sharon McCollum, Eden Engel-Rebitzer, and Max Jordan Nguemeni Tiako are with the Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Karin V. Rhodes is with the Agency for Healthcare Research and Quality, Bethesda, MD. Erik P. Hess is with the Vanderbilt University School of Medicine, Department of Emergency Medicine, Nashville, TN. Venkatesh R. Bellamkonda is with the Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Rochester, MN. Jeanmarie Perrone is with the Center for Addiction Medicine and Policy, University of Pennsylvania. Lance Becker is with the Department of Emergency Medicine, Zucker School of Medicine at Hofstra/Northwell, New York, NY. Carolyn C. Cannuscio is with the Center for Public Health Initiatives, University of Pennsylvania. Greg Ridgeway is with the Department of Criminology, University of Pennsylvania. Marilyn M. Schapira is with the Center for Health Equity and Research Promotion, Philadelphia VA Medical Center
| |
Collapse
|
17
|
Keefe FJ. Managing Acute Pain With Opioids in the Emergency Department: A Teachable Moment? Am J Public Health 2022; 112:S9-S11. [PMID: 35143264 PMCID: PMC8842220 DOI: 10.2105/ajph.2022.306748] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Francis J. Keefe
- Francis J. Keefe is with the Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Chapel Hill, NC
| |
Collapse
|
18
|
Kilaru AS, Lowenstein M, Agarwal AK. Optimizing Opioid Prescriptions for Patients in the Emergency Department-How Much Is Almost Never? JAMA Netw Open 2022; 5:e2143433. [PMID: 35024839 DOI: 10.1001/jamanetworkopen.2021.43433] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Austin S Kilaru
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute for Health Economics, Wharton School, University of Pennsylvania, Philadelphia
| | - Margaret Lowenstein
- Leonard Davis Institute for Health Economics, Wharton School, University of Pennsylvania, Philadelphia
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Anish K Agarwal
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute for Health Economics, Wharton School, University of Pennsylvania, Philadelphia
| |
Collapse
|
19
|
New persistent opioid use after surgery in patients with a history of remote opioid use. Surgery 2021; 171:1635-1641. [PMID: 34895768 DOI: 10.1016/j.surg.2021.11.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 10/21/2021] [Accepted: 11/08/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Postoperative pain management is particularly challenging in patients using opioids preoperatively, but previous studies have not stratified patients not using opioids at the time of surgery according to history of opioid use. This study was designed to test the hypothesis that history of opioid use among patients not reporting opioid use at the time of surgery was independently associated with new persistent opioid use after surgery. METHODS Using prospective perioperative data from the Analgesic Outcomes Study, we assessed outcomes of patients 18 years of age or older who underwent elective surgery between December 2015 and January 2019 and were not using opioids at the time of surgery. Patient self-reported outcome measures were collected on the day of surgery and at 2 weeks, 1 month, and 3 months postoperatively. The primary outcome was new persistent opioid use, defined as continued opioid use 3 months after surgery. The primary explanatory variable was history of opioid use, which was categorized as no history of opioid use, history of non-continuous opioid use, or history of continuous opioid use (defined as daily or almost every day for 3 months or longer). Other covariates included demographics, validated measures (pain, mood), surgery type and approach, comorbidities, and use of tobacco, alcohol, cannabis, and benzodiazepines. Backward stepwise logistic regression models were used to determine patient factors associated with new persistent opioid use and refill after surgery. RESULTS A total of 1,249 patients not taking opioids preoperatively were included in the study cohort for new persistent opioid use. A total of 54 (4.3%) patients had continued use 3 months after surgery. New persistent opioid use after surgery was independently associated with non-continuous opioid use history (adjusted odds ratio 2.9, [95% confidence interval, 1.21 to 6.94]), continuous opioid use history (adjusted odds ratio 5.0, [95% confidence interval, 1.48 to 16.76]), and moderate to high alcohol use (adjusted odds ratio 2.5, [95% confidence interval, 1.24 to 4.93]). Similarly, opioid prescription refill at 1 month after surgery was independently associated with history of non-continuous opioid use (adjusted odds ratio 1.6, [95% confidence interval, 1.12 to 2.24]), history of continuous opioid use (adjusted odds ratio 2.2, [95% confidence interval, 1.15 to 4.06]), and moderate to high alcohol use (adjusted odds ratio 1.7, [95% confidence interval, 1.18 to 2.48]). CONCLUSION Among patients not using opioids preoperatively, a history of opioid use was independently associated with new persistent opioid use after surgery, especially those with a history of continuous opioid use.
Collapse
|
20
|
Enns B, Krebs E, Thomson T, Dale LM, Min JE, Nosyk B. Opioid analgesic prescribing for opioid-naïve individuals prior to identification of opioid use disorder in British Columbia, Canada. Addiction 2021; 116:3422-3432. [PMID: 33861882 DOI: 10.1111/add.15515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/08/2020] [Accepted: 03/31/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND AIMS Prescription opioid analgesics have contributed to the development of opioid use disorder (OUD) in many individuals. We aimed to characterize non-cancer opioid prescribing for opioid-naive individuals prior to OUD identification. DESIGN Population-based retrospective cohort study using six linked health administrative databases. SETTING British Columbia (BC), Canada. PARTICIPANTS People with OUD between 1 January 2001 and 30 September 2018 who initiated opioid analgesic therapy for non-cancer pain prior to OUD identification. MEASUREMENTS Dose (morphine milligram equivalent per day), days prescribed and clinical guideline non-concordance for initial opioid prescriptions (dose ≥ 90 morphine milligram equivalent per day; ≥ 7 days prescribed; concomitant sedative prescription). We estimated the probability of non-concordant initial prescriptions by source (inpatient post-discharge, non-inpatient acute, non-acute) using logistic regression, adjusting for individual characteristics and comorbidities. FINDINGS Among 66 372 individuals identified with OUD from 2001 to 2018, 21 331 (32.1%) received opioid analgesics prior to OUD identification. This proportion increased from 3.0% in 2001 to 41.0% in 2011, before decreasing to 34.2% in 2017. Roughly half of opioid prescriptions were attributed to non-acute care visits, peaking at 56.8% in 2007, while the proportion from inpatient visits increased from 19.7% in 2001 to 28.5% in 2017. The predicted probability of receiving non-guideline concordant prescriptions declined over time-periods across all three measures for inpatient and non-inpatient acute care, while remaining stable for non-acute care. In particular, the predicted probability of receiving ≥ 7-day prescriptions following inpatient visits decreased from 53.3% [95% confidence interval (CI) = 50.9, 55.8%] in 2001-06 to 37.2% (95% CI = 33.9, 40.5%) in 2013-18. CONCLUSIONS Among the 66 372 individuals in British Columbia, Canada diagnosed with opioid use disorder between 2001 and 2018, more than 32% were earlier prescribed non-cancer opioid analgesics. The proportion who had received an opioid analgesic prescription prior to OUD identification peaked at more than 40% in 2011, before stabilizing between 2011 and 2016 and declining thereafter. Guideline concordance improved over time for high-dose and concomitant sedative prescribing.
Collapse
Affiliation(s)
- Benjamin Enns
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Emanuel Krebs
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Trevor Thomson
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Laura M Dale
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Jeong Eun Min
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Bohdan Nosyk
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| |
Collapse
|
21
|
Using Prescription Drug Monitoring Program Data to Assess Likelihood of Incident Long-Term Opioid Use: a Statewide Cohort Study. J Gen Intern Med 2021; 36:3672-3679. [PMID: 33742304 PMCID: PMC8642457 DOI: 10.1007/s11606-020-06555-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 12/22/2020] [Indexed: 10/21/2022]
Abstract
BACKGROUND Limiting the incidence of opioid-naïve patients who transition to long-term opioid use (i.e., continual use for > 90 days) is a key strategy for reducing opioid-related harms. OBJECTIVE To identify variables constructed from data routinely collected by prescription drug monitoring programs that are associated with opioid-naïve patients' likelihood of transitioning to long-term use after an initial opioid prescription. DESIGN Statewide cohort study using prescription drug monitoring program data PARTICIPANTS: All opioid-naïve patients in California (no opioid prescriptions within the prior 2 years) age ≥ 12 years prescribed an initial oral opioid analgesic from 2010 to 2017. METHODS AND MAIN MEASURES Multiple logistic regression models using variables constructed from prescription drug monitoring program data through the day of each patient's initial opioid prescription, and, alternatively, data available up to 30 and 60 days after the initial prescription were constructed to identify probability of transition to long-term use. Model fit was determined by the area under the receiver operating characteristic curve (C-statistic). KEY RESULTS Among 30,569,125 episodes of patients receiving new opioid prescriptions, 1,809,750 (5.9%) resulted in long-term use. Variables with the highest adjusted odds ratios included concurrent benzodiazepine use, ≥ 2 unique prescribers, and receipt of non-pill, non-liquid formulations. C-statistics for the day 0, day 30, and day 60 models were 0.81, 0.88, and 0.94, respectively. Models assessing opioid dose using the number of pills prescribed had greater discriminative capacity than those using milligram morphine equivalents. CONCLUSIONS Data routinely collected by prescription drug monitoring programs can be used to identify patients who are likely to develop long-term use. Guidelines for new opioid prescriptions based on pill counts may be simpler and more clinically useful than guidelines based on days' supply or milligram morphine equivalents.
Collapse
|
22
|
Tseregounis IE, Tancredi DJ, Stewart SL, Shev AB, Crawford A, Gasper JJ, Wintemute G, Marshall BDL, Cerdá M, Henry SG. A Risk Prediction Model for Long-term Prescription Opioid Use. Med Care 2021; 59:1051-1058. [PMID: 34629423 PMCID: PMC8595680 DOI: 10.1097/mlr.0000000000001651] [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] [Indexed: 11/26/2022]
Abstract
BACKGROUND Tools are needed to aid clinicians in estimating their patients' risk of transitioning to long-term opioid use and to inform prescribing decisions. OBJECTIVE The objective of this study was to develop and validate a model that predicts previously opioid-naive patients' risk of transitioning to long-term use. RESEARCH DESIGN This was a statewide population-based prognostic study. SUBJECTS Opioid-naive (no prescriptions in previous 2 y) patients aged 12 years old and above who received a pill-form opioid analgesic in 2016-2018 and whose prescriptions were registered in the California Prescription Drug Monitoring Program (PDMP). MEASURES A multiple logistic regression approach was used to construct a prediction model with long-term (ie, >90 d) opioid use as the outcome. Models were developed using 2016-2017 data and validated using 2018 data. Discrimination (c-statistic), calibration (calibration slope, intercept, and visual inspection of calibration plots), and clinical utility (decision curve analysis) were evaluated to assess performance. RESULTS Development and validation cohorts included 7,175,885 and 2,788,837 opioid-naive patients with outcome rates of 5.0% and 4.7%, respectively. The model showed high discrimination (c-statistic: 0.904 for development, 0.913 for validation), was well-calibrated after intercept adjustment (intercept, -0.006; 95% confidence interval, -0.016 to 0.004; slope, 1.049; 95% confidence interval, 1.045-1.053), and had a net benefit over a wide range of probability thresholds. CONCLUSIONS A model for the transition from opioid-naive status to long-term use had high discrimination and was well-calibrated. Given its high predictive performance, this model shows promise for future integration into PDMPs to aid clinicians in formulating opioid prescribing decisions at the point of care.
Collapse
Affiliation(s)
| | - Daniel J Tancredi
- Center for Healthcare Policy and Research
- Department of Pediatrics, University of California, Davis, Sacramento
| | - Susan L Stewart
- Department of Public Health Sciences, University of California, Davis, Davis
| | - Aaron B Shev
- Violence Prevention Research Program, Department of Emergency Medicine, University of California, Davis, Sacramento
| | - Andrew Crawford
- Violence Prevention Research Program, Department of Emergency Medicine, University of California, Davis, Sacramento
| | - James J Gasper
- Department of Family and Community Medicine, National Clinician Consultation Center, University of California, San Francisco, San Francisco, CA
| | - Garen Wintemute
- Violence Prevention Research Program, Department of Emergency Medicine, University of California, Davis, Sacramento
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, Providence, RI
| | - Magdalena Cerdá
- Department of Population Health, Center for Opioid Epidemiology and Policy, New York University Langone Health, New York, NY
| | - Stephen G Henry
- Center for Healthcare Policy and Research
- Department of Internal Medicine, University of California, Davis, Sacramento, CA
| |
Collapse
|
23
|
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
|
24
|
Khouja T, Tadrous M, Matusiak L, Suda K. Opioid Prescribing in United States Health Systems, 2015 to 2019. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:1279-1284. [PMID: 34452707 DOI: 10.1016/j.jval.2021.04.1274] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/23/2021] [Accepted: 04/26/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Health systems (nonfederal hospitals and clinics) are the second major source for drug expenditure in the United States. Opioids prescribed in these healthcare settings are commonly short-acting opioids that can lead to persistent opioid use. Nevertheless, there are no national data that describe trends in opioid use and the associated expenditure in health systems. Therefore, the objective of this article was to describe opioid use and expenditures in US health systems from 2015 to 2019. METHODS We used data from IQVIA National Sales Perspectives to describe prescription opioid expenditure and use in health systems (nonfederal hospitals and clinics). RESULTS Over the 5-year study period, health systems dispensed a total of 6.55 billion units of opioids (26.88% decrease) with an associated expenditure of $3.33 billion (26.78% decrease). Relative to all opioid formulations in our study, oxycodone, hydrocodone, and fentanyl were the opioids with the highest use in US health systems. All opioid prescriptions decreased except fentanyl use, which increased by 29.80% in clinics. The use of abuse-deterrent formulations of opioids decreased by 51.00% over the study period, although the decrease seems to be driven mainly by long-acting oxycodone (brand name Oxycontin). CONCLUSIONS Opioid use and expenditures in health systems have been decreasing following national trends from retail pharmacies. Nevertheless, fentanyl use increased in clinics and was prescribed at higher proportions in nonfederal hospitals than other opioids, which warrants further investigation.
Collapse
Affiliation(s)
- Tumader Khouja
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mina Tadrous
- Leslie Dan Faculty of Pharmacy, University of Toronto, Institute for Clinical Evaluative Sciences, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | | | - Katie Suda
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
| |
Collapse
|
25
|
Naavaal S, Kelekar U, Shah S. Opioid and Nonopioid Analgesic Prescriptions for Dental Visits in the Emergency Department, 2015-2017 National Hospital Ambulatory Medical Care Survey. Prev Chronic Dis 2021; 18:E58. [PMID: 34114544 PMCID: PMC8220966 DOI: 10.5888/pcd18.200571] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Prescription and nonprescription opioid misuse and the rising number of dental visits in emergency departments (EDs) are growing public health concerns in the US. Our study objective was to examine the relationship between prescription analgesics (opioids and nonopioids) and the type of ED visits (dental and nondental) at the national level. METHODS We used data from the 2015-2017 National Hospital Ambulatory Medical Care Survey to examine the association between opioid, nonopioid, and combination of opioid and nonopioid analgesic prescriptions and dental and nondental visits in the ED. Covariates included socioeconomic variables, time of visit, provider type, triage level, hospital location (urban vs rural), and pain level. We conducted descriptive, bivariate, and multivariable analyses using weighted estimates. RESULTS The final study sample included 57,098 ED visits from approximately 6 million dental and 414 million nondental visits to EDs during 2015-2017 nationally. Among dental visits, 20.8% received nonopioid analgesics (vs 23.4% among nondental visits), 36.6% received opioid analgesics (vs 14.0% among nondental visits), and 17.7% received both opioids and nonopioid analgesics (vs 8.7% among nondental visits). Adjusted multinomial logistic regression model indicated that, compared with nondental visits, dental visits had 4.8, 1.9, and 3.4 times higher likelihood of receipt of an opioid, nonopioid, or both opioid and nonopioid analgesic prescription, respectively, in the ED than no analgesic prescriptions. CONCLUSION Dental visits resulted in receipt of a significantly higher proportion of opioid prescriptions compared with nondental visits during 2015-2017. The study findings highlight the need for developing interventions to reduce opioid prescriptions in the ED, especially for dental visits.
Collapse
Affiliation(s)
- Shillpa Naavaal
- Department of Dental Public Health and Policy, School of Dentistry, Virginia Commonwealth University, Richmond, Virginia.,Oral Health Equity Core, Institute for Inclusion, Inquiry and Innovation, Virginia Commonwealth University, Richmond, Virginia.,1101 E Leigh St, Richmond, Virginia 23298.
| | - Uma Kelekar
- School of Business, College of Business, Innovation, Leadership and Technology, Marymount University, Arlington, Virginia
| | - Shital Shah
- Department of Health Systems Management, Rush University, Chicago, Illinois.,Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
| |
Collapse
|
26
|
Lau T, Hayward J, Vatanpour S, Innes G. Sex-related differences in opioid administration in the emergency department: a population-based study. Emerg Med J 2021; 38:467-473. [PMID: 33853938 DOI: 10.1136/emermed-2020-210215] [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: 06/12/2020] [Revised: 02/16/2021] [Accepted: 03/24/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Sex differences in pain experience and expression may influence ED pain management. Our objective was to evaluate the effect of sex on ED opioid administration. METHODS We conducted a multicentre population-based observational cohort study using administrative data from Calgary's four EDs between 2017 and 2018. Eligible patients had a presenting complaint belonging to one of nine pain categories or an arrival pain score >3. We performed multivariable analyses to identify predictors of opioid administration and stratified analyses by age, pain severity and pain category. RESULTS We studied 119 510 patients (mean age 47.4 years; 55.4% female). Opioid administration rates were similar for men and women. After adjusting for age, hospital site, pain category, ED length of stay and pain severity, male sex was not a predictor of opioid treatment (adjusted OR (aOR)=0.93; 95% CI 0.85 to 1.02). However, men were more likely to receive opioids in the categories of trauma (aOR=1.58, 95% CI 1.40 to 1.78), flank pain (aOR=1.24, 95% CI 1.11 to 1.38), headache (aOR=1.18, 95% CI 1.03 to 1.34) and abdominal pain (aOR=1.11, 95% CI 1.08 to 1.18). Pain category appears to be a strong determinant of opioid administration, especially back pain (aOR=6.56, 95% CI 5.99 to 7.19) and flank pain (aOR=6.04, 95% CI 5.48 to 6.65). There was significant variability in opioid provision by ED site (aOR 0.76 to 1.24). CONCLUSIONS This population-based study demonstrated high variability in opioid use across different settings. Overall, men and women had similar likelihood of receiving opioids; however men with trauma, flank pain, headache and abdominal pain were much more likely to receive opioids. ED physicians should self-examine their analgesic practices with respect to possible sex biases, and departments should introduce evidence-based, indication-specific analgesic protocols to reduce practice variability and optimise opioid analgesia.
Collapse
Affiliation(s)
- Torey Lau
- Family Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Jake Hayward
- Emergency Medicine, University of Alberta Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada
| | - Shabnam Vatanpour
- Emergency Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Grant Innes
- Emergency Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| |
Collapse
|
27
|
Impact of a Mandatory Prescription Drug Monitoring Program Check on Emergency Department Opioid Prescribing Rates. J Med Toxicol 2021; 17:265-270. [PMID: 33821434 DOI: 10.1007/s13181-021-00837-4] [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: 10/26/2020] [Revised: 02/22/2021] [Accepted: 03/04/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Prescription drug monitoring programs (PDMPs) exist in 49 states to guide opioid prescribing. In 40 states, clinicians must check the PDMP prior to prescribing an opioid. Data on mandated PDMP checks show mixed results on opioid prescribing. OBJECTIVES This study sought to examine the impact of the Massachusetts mandatory PDMP check on opioid prescribing for discharges from an urban tertiary emergency department (ED). METHODS This was a retrospective cohort study of discharges from one ED from 7/1/2010-10/15/2018. The primary outcome was the monthly percentage of patients discharged from the ED with an opioid prescription. The intervention was Massachusetts mandating a PDMP check for all opioid prescriptions. Prescribing was compared pre- and post-mandate. Interrupted time series (ITS) analysis accounted for known declining trends in opioid prescribing. RESULTS Of 273,512 ED discharges, 35,050 (12.8%) received opioid prescriptions. Mean monthly opioid prescribing decreased post-intervention from 15.1% (SD ± 3.5%) to 5.1% (SD ± 0.9%; p < 0.001). ITS showed equal pre and post-intervention slopes (-0.002, p = 0.819). A small immediate decrease occurred in prescribing around the mandated check: a 3-month level effect decrease of 0.018 (p = 0.039), 6-month level effect 0.019 (p = 0.023), and a 12-month level effect of 0.020 (p = 0.019). The 24-month level effect was not decreased. CONCLUSION Prior to the mandated PDMP check, ED opioid prescribing was declining. The mandate did not change the rate of decline but was associated with a non-sustained drop in opioid prescribing immediately following enactment.
Collapse
|
28
|
Risk and protective factors for cannabis, cocaine, and opioid use disorders: An umbrella review of meta-analyses of observational studies. Neurosci Biobehav Rev 2021; 126:243-251. [PMID: 33737104 DOI: 10.1016/j.neubiorev.2021.03.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 03/11/2021] [Accepted: 03/11/2021] [Indexed: 11/21/2022]
Abstract
Several meta-analyses of observational studies have addressed the association between risk and protective factors and cannabis/cocaine/opioid use disorders, but results are conflicting. No umbrella review has ever graded the credibility of this evidence (not significant/weak/suggestive/highly suggestive/convincing). We searched Pubmed-MEDLINE/PsycInfo, last search September 21, 2020. We assessed the quality of meta-analyses with the AMSTAR-2 tool. Out of 3,072 initial references, five were included, providing 19 associations between 12 putative risk/protective factors and cannabis/cocaine/opioid use disorders (cases: 4539; N = 1,118,872,721). While 84 % of the associations were statistically significant, none was convincing. One risk factor (smoking) had highly suggestive evidence for association with nonmedical use of prescription opioid medicines (OR = 3.07, 95 %CI:2.27 to 4.14). Convincing evidence emerged in sensitivity analyses on antisocial behavior and cannabis use disoder (OR 3.34, 95 %CI 2.53-4.41). Remaining associations had weak evidence. The quality of meta-analyses was rated as moderate in two (40 %), low in one (20 %), and critically low in two (40 %). Future research is needed to better profile risk/protective factors for cannabis/cocaine/opioid use disorders disorders informing preventive approaches.
Collapse
|
29
|
de Oliveira Costa J, Bruno C, Baranwal N, Gisev N, Dobbins TA, Degenhardt L, Pearson SA. Variations in Long-term Opioid Therapy Definitions: A Systematic Review of Observational Studies Using Routinely Collected Data (2000-2019). Br J Clin Pharmacol 2021; 87:3706-3720. [PMID: 33629352 DOI: 10.1111/bcp.14798] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/21/2020] [Accepted: 02/17/2021] [Indexed: 12/27/2022] Open
Abstract
Routinely collected data have been increasingly used to assess long-term opioid therapy (LTOT) patterns, with very little guidance on how to measure LTOT from these data sources. We conducted a systematic review of studies published between January 2000 and July 2019 to catalogue LTOT definitions, the rationale for definitions and LTOT rates in observational research using routinely collected data in nonsurgical settings. We screened 4056 abstracts, 210 full-text manuscripts and included 128 studies, mostly from the United States (81%) and published between 2015 and 2019 (69%). We identified 78 definitions of LTOT, commonly operationalised as 90 days of use within a year (23%). Studies often used multiple criteria to derive definitions (60%), mostly based on measures of duration, such as supply days/days of use (66%), episode length (21%) or prescription fills within specified time periods (12%). Definitions were based on previous publications (63%), clinical judgment (16%) or empirical data (3%); 10% of studies applied more than one definition. LTOT definition was not provided with enough details for replication in 14 studies and 38 studies did not specify the opioids evaluated. Rates of LTOT within study populations ranged from 0.2% to 57% according to study design and definition used. We observed a substantial rise in the last 5 years in studies evaluating LTOT with large variability in the definitions used and poor reporting of the rationale and implementation of definitions. This variation impacts on research reproducibility, comparability of findings and the development of strategies aiming to curb therapy that is not guideline-recommended.
Collapse
Affiliation(s)
| | - Claudia Bruno
- Centre for Big Data Research in Health, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
| | - Navya Baranwal
- Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Natasa Gisev
- National Drug and Alcohol Research Centre, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
| | - Timothy A Dobbins
- National Drug and Alcohol Research Centre, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
| | - Sallie-Anne Pearson
- Centre for Big Data Research in Health, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia.,Menzies Centre for Health Policy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| |
Collapse
|
30
|
Probst C, Elton-Marshall T, Imtiaz S, Patte KA, Rehm J, Sornpaisarn B, Leatherdale ST. A supportive school environment may reduce the risk of non-medical prescription opioid use due to impaired mental health among students. Eur Child Adolesc Psychiatry 2021; 30:293-301. [PMID: 32215733 DOI: 10.1007/s00787-020-01518-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 03/16/2020] [Indexed: 02/08/2023]
Abstract
Canada is in the midst of an ongoing, escalating opioid crisis, with significant impacts on adolescents and young adults. Accordingly, mental health impairment was examined as a risk factor for non-medical prescription opioid use (NMPOU) among high school students. In addition, the moderating effects of the school environment, in terms of the availability of mental health services and substance use policies, were characterized. Self-reported, cross-sectional data were obtained from the COMPASS study, including 61,239 students (grades 9-12) in 121 secondary schools across Canada. Current and lifetime NMPOU were ascertained. Categorical indicators of mental health impairment and school environment were derived. The main analytical strategy encompassed hierarchal multilevel logistic regression, including the addition of interaction terms to characterize the moderation effects. Current and lifetime NMPOU were reported by 5.8% and 7.2% of the students, respectively. After adjusting for confounders, students in the highest quintile of mental health impairment had odds ratios (OR) of 2.60 (95% confidence interval [CI] 2.29-2.95) and 2.96 (95% CI 2.64-3.33) for current and lifetime NMPOU, respectively when compared to students in the lowest quintile of mental health impairment. A significant interaction between mental health impairment and school environment indicated relatively lower risks of NMPOU in students from schools that provide more mental health services and have stricter substance use policies. Mental health impairment increased the risk of NMPOU, but the associations were moderated by the school environment. These findings underscore the importance of mental health services and substance use regulations in schools.
Collapse
Affiliation(s)
- Charlotte Probst
- Centre for Addiction and Mental Health (CAMH), Institute for Mental Health Policy Research, Toronto, ON, M5S 2S1, Canada. .,Heidelberg Institute of Global Health, Universitätsklinikum Heidelberg, 69120, Heidelberg, Germany.
| | - Tara Elton-Marshall
- Centre for Addiction and Mental Health (CAMH), Institute for Mental Health Policy Research, Toronto, ON, M5S 2S1, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, M5T 3M7, Canada
| | - Sameer Imtiaz
- Centre for Addiction and Mental Health (CAMH), Institute for Mental Health Policy Research, Toronto, ON, M5S 2S1, Canada
| | - Karen A Patte
- Department of Health Sciences, Brock University, St. Catharines, ON, L2S 3A1, Canada
| | - Jürgen Rehm
- Centre for Addiction and Mental Health (CAMH), Institute for Mental Health Policy Research, Toronto, ON, M5S 2S1, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, M5T 3M7, Canada.,Campbell Family Mental Health Research Institute, CAMH, Toronto, ON, M5T 1R8, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, M5T 1R8, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, M5S 1A8, Canada.,Institute of Clinical Psychology and Psychotherapy & Center for Clinical Epidemiology and Longitudinal Studies, Technische Universität Dresden, 01187, Dresden, Germany.,Department of International Health Projects, Institute for Leadership and Health Management, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation, 119992
| | - Bundit Sornpaisarn
- Centre for Addiction and Mental Health (CAMH), Institute for Mental Health Policy Research, Toronto, ON, M5S 2S1, Canada
| | - Scott T Leatherdale
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, N2L 3G1, Canada
| |
Collapse
|
31
|
Ancker JS, Gossey JT, Nosal S, Xu C, Banerjee S, Wang Y, Veras Y, Mitchell H, Bao Y. Effect of an Electronic Health Record "Nudge" on Opioid Prescribing and Electronic Health Record Keystrokes in Ambulatory Care. J Gen Intern Med 2021; 36:430-437. [PMID: 33105005 PMCID: PMC7878599 DOI: 10.1007/s11606-020-06276-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 09/28/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Multiple policy initiatives encourage more cautious prescribing of opioids in light of their risks. Electronic health record (EHR) redesign can influence prescriber choices, but some redesigns add to workload. OBJECTIVE To estimate the effect of an EHR prescribing redesign on both opioid prescribing choices and keystrokes. DESIGN Quality improvement quasi-experiment, analyzed as interrupted time series. PARTICIPANTS Adult patients of an academic multispecialty practice and a federally qualified health center (FQHC) who received new prescriptions for short-acting opioids, and their providers. INTERVENTION In the redesign, new prescriptions of short-acting opioids defaulted to the CDC-recommended minimum for opioid-naïve patients, with no alerts or hard stops, such that 9 keystrokes were required for a guideline-concordant prescription and 24 for a non-concordant prescription. MAIN MEASURES Proportion of guideline-concordant prescriptions, defined as new prescriptions with a 3-day supply or less, calculated per 2-week period. Number of mouse clicks and keystrokes needed to place prescriptions. KEY RESULTS Across the 2 sites, 22,113 patients received a new short-acting opioid prescription from 821 providers. Before the intervention, both settings showed secular trends toward smaller-quantity prescriptions. At the academic practice, the intervention was associated with an immediate increase in guideline-concordant prescriptions from an average of 12% to 31% of all prescriptions. At the FQHC, about 44% of prescriptions were concordant at the time of the intervention, which was not associated with an additional significant increase. However, total keystrokes needed to place the concordant prescriptions decreased 62.7% from 3552 in the 6 months before the intervention to 1323 in the 6 months afterwards. CONCLUSIONS Autocompleting prescription forms with guideline-recommended values was associated with a large increase in guideline concordance in an organization where baseline concordance was low, but not in an organization where it was already high. The redesign markedly reduced the number of keystrokes needed to place orders, with important implications for EHR-related stress. TRIAL REGISTRATION www.ClinicalTrials.gov protocol 1710018646.
Collapse
Affiliation(s)
- Jessica S Ancker
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA.
| | - J Travis Gossey
- Physician Organization Information Services, Weill Cornell Medicine, New York, NY, USA.,Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Sarah Nosal
- Institute for Family Health, New York, NY, USA
| | - Chenghuiyun Xu
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Samprit Banerjee
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Yuming Wang
- Physician Organization Information Services, Weill Cornell Medicine, New York, NY, USA
| | - Yulia Veras
- Institute for Family Health, New York, NY, USA
| | - Hannah Mitchell
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Yuhua Bao
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| |
Collapse
|
32
|
Meltzer AC, Wolfson AB, Mufarrij P, MacPherson C, Montano N, Kirkali Z, Burrows PK, Jackman SV. Analgesic and Opioid Use for Patients Discharged from the Emergency Department with Ureteral Stones. J Endourol 2021; 35:1067-1071. [PMID: 33213185 DOI: 10.1089/end.2020.0835] [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: 11/13/2022] Open
Abstract
Objective: The aim of this study was to describe and characterize the analgesic and opioid use for patients discharged from the emergency department (ED) with renal colic due to ureteral stone. Methods: This is a secondary analysis of a multicenter prospective trial of ED patients diagnosed by CT scan as having a symptomatic ureteral stone <9 mm in diameter. Participants were contacted after randomization on days 2, 7, 15, 20, and 29 and reported opioid and nonopioid analgesic use and stone passage. CT scan was repeated on day 29 to 36 to confirm passage. Results: Of 403 participants, 314 (77.9%) took an analgesic after discharge and 199 (49.4%) took opioids. Opioids were more commonly used by younger patients (p = 0.04) and those with a family history of stones (p = 0.003). Stone size and tamsulosin use were not associated with analgesic utilization. Shorter time to passage and more distal stone location were associated with less analgesic and opioid use. For those who did not expel a stone, 55.0% took opioids at any time, and for those who did expel a stone, 31.9% took opioids before the stone was expelled and 15.7% took opioids at any time after the stone was expelled. Conclusions: Factors associated with increased use of analgesics in patients discharged from the ED include a longer time to stone passage, no spontaneous passage, and proximal position of the stone in the ureter. Some patients continued to use analgesics after the stone had passed, but most stopped using analgesics by day 29. The study has been registered at https://clinicaltrials.gov (NCT00382265).
Collapse
Affiliation(s)
- Andrew C Meltzer
- Department of Emergency Medicine, George Washington University School of Medicine & Health Sciences, Washington, District of Columbia, USA
| | - Allan B Wolfson
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Patrick Mufarrij
- Department of Urology, George Washington University School of Medicine & Health Sciences, Washington, District of Columbia, USA
| | - Cora MacPherson
- The George Washington University Biostatistics Center, Rockville, Maryland, USA
| | - Nataly Montano
- Department of Emergency Medicine, George Washington University School of Medicine & Health Sciences, Washington, District of Columbia, USA
| | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | | | - Stephen V Jackman
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
33
|
Yanuck J, Lee JB, Saadat S, Rouhi J, Ghanem G, Chakravarthy B, Shah S. Opioid Prescription Patterns for Discharged Patients from the Emergency Department. Pain Res Manag 2021; 2021:4980170. [PMID: 33532010 PMCID: PMC7837768 DOI: 10.1155/2021/4980170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/20/2020] [Accepted: 01/06/2021] [Indexed: 11/28/2022]
Abstract
Objectives It is important to analyze the types of etiologies and provider demographics that drive opioid prescription in our emergency departments. Our study aimed to determine which patients in the ED are receiving opioid prescriptions, as well as their strength and quantity. Secondary outcomes included identifying difference in prescribing between provider classes. Methods We conducted a retrospective study at a tertiary care university-based, level-one trauma ED from November 2017 to October 2018. We identified and analyzed data from 2,259 patients who were sent home with an opioid prescription. We retrieved patient and provider demographics, diagnosis, etiologies, and prescription information. Results The mean age of a patient receiving an opioid prescription was 45, and 72.7% of patients were white. The most common diagnosis groups associated with an opioid prescription were abdominal pain (18.5%), nonfracture extremity pain (18.4%), and back/neck pain (12.5%). Hydrocodone-acetaminophen 5-325 mg was the most commonly prescribed (67.4%). The median total prescribed milligram morphine equivalent (MME) was highest for extremity fracture (75.0; IQR 54.0-100.0). The median total prescribed amount of pills was highest for patients with extremity fractures (15.0; IQR 12.0-20.0). Conclusions Our study elucidates the prescribing patterns of an academic level 1 trauma center and should pave the way for future studies looking to maximize effectiveness at ways to curb ED opioid prescription.
Collapse
Affiliation(s)
- Justin Yanuck
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston 02114, Massachusetts, USA
- Department of Emergency Medicine, University of California, Irvine, California, USA
| | - Jonathan B. Lee
- Department of Emergency Medicine, University of California, Irvine, California, USA
| | - Soheil Saadat
- Department of Emergency Medicine, University of California, Irvine, California, USA
| | - Jila Rouhi
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, California, USA
| | - Ghadi Ghanem
- Department of Emergency Medicine, University of California, Irvine, California, USA
| | - Bharath Chakravarthy
- Department of Emergency Medicine, University of California, Irvine, California, USA
| | - Shalini Shah
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, California, USA
| |
Collapse
|
34
|
Use of Tramadol or Other Analgesics in Patients Treated in the Emergency Department as a Risk Factor for Opioid Use. Pain Res Manag 2020; 2020:8847777. [PMID: 33273995 PMCID: PMC7700031 DOI: 10.1155/2020/8847777] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 10/09/2020] [Accepted: 10/31/2020] [Indexed: 12/30/2022]
Abstract
The objective of this cohort study was to determine the association between the use of tramadol in emergency departments and the later consumption of opioids at the outpatient level in a group of patients from Colombia. Based on a medication dispensation database, patients over 18 years of age treated in different clinics in Colombia who for the first time received tramadol, dipyrone, or a nonsteroidal anti-inflammatory drug (NSAID) in the emergency room between January and December 2018 were identified. Three mutually exclusive cohorts were created, and each patient was followed up for 12 months after the administration of the analgesic to identify new formulations of any opioid. A Cox proportional-hazards regression model was constructed to identify variables associated with receiving a new opioid. A total of 12,783 patients were identified: 6020 treated with dipyrone, 5309 treated with NSAIDs, and 1454 treated with tramadol. The mean age was 47.1 ± 20.4 years, and 61.6% were women. A total of 17.3% (n = 2207) of all patients received an opioid during follow-up. Those treated with tramadol received a new opioid with a higher frequency (n = 346, 23.8%) than the other cohorts (14.7% NSAIDs and 17.9% dipyrone, both p < 0.001). In the tramadol group, using more than 10 mg of morphine equivalents was associated with a greater use of new opioids (HR:1.47, 95%CI:1.12-1.93). Patients treated with tramadol in emergency departments have a higher risk of opioid use at the one-year follow-up than those treated with NSAIDs or dipyrone.
Collapse
|
35
|
Schlesinger N, Brunetti L. Treatment of Acute Gout Flares in the Emergency Department: Comment on the Article by Dalal et al. Arthritis Care Res (Hoboken) 2020; 72:1663. [DOI: 10.1002/acr.24166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 02/04/2020] [Indexed: 11/08/2022]
Affiliation(s)
- Naomi Schlesinger
- Robert Wood Johnson Medical School Rutgers University New Brunswick NJ
| | - Luigi Brunetti
- Ernest Mario School of Pharmacy Rutgers University Piscataway NJ
| |
Collapse
|
36
|
Shen Y, Bhagwandass H, Branchcomb T, Galvez SA, Grande I, Lessing J, Mollanazar M, Ourhaan N, Oueini R, Sasser M, Valdes IL, Jadubans A, Hollmann J, Maguire M, Usmani S, Vouri SM, Hincapie-Castillo JM, Adkins LE, Goodin AJ. Chronic Opioid Therapy: A Scoping Literature Review on Evolving Clinical and Scientific Definitions. THE JOURNAL OF PAIN 2020; 22:246-262. [PMID: 33031943 DOI: 10.1016/j.jpain.2020.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/21/2020] [Accepted: 09/22/2020] [Indexed: 01/24/2023]
Abstract
The management of chronic noncancer pain (CNCP) with chronic opioid therapy (COT) is controversial. There is a lack of consensus on how COT is defined resulting in unclear clinical guidance. This scoping review identifies and evaluates evolving COT definitions throughout the published clinical and scientific literature. Databases searched included PubMed, Embase, and Web of Science. A total of 227 studies were identified from 8,866 studies published between January 2000 and July 2019. COT definitions were classified by pain population of application and specific dosage/duration definition parameters, with results reported according to PRISMA-ScR. Approximately half of studies defined COT as "days' supply duration >90 days" and 9.3% defined as ">120 days' supply," with other days' supply cut-off points (>30, >60, or >70) each appearing in <5% of total studies. COT was defined by number of prescriptions in 63 studies, with 16.3% and 11.0% using number of initiations or refills, respectively. Few studies explicitly distinguished acute treatment and COT. Episode duration/dosage criteria was used in 90 studies, with 7.5% by Morphine Milligram Equivalents + days' supply and 32.2% by other "episode" combination definitions. COT definitions were applied in musculoskeletal CNCP (60.8%) most often, and typically in adults aged 18 to 64 (69.6%). The usage of ">90 days' supply" COT definitions increased from 3.2 publications/year before 2016 to 20.7 publications/year after 2016. An increasing proportion of studies define COT as ">90 days' supply." The most recent literature trends toward shorter duration criteria, suggesting that contemporary COT definitions are increasingly conservative. PERSPECTIVE: This study summarized the most common, current definition criteria for chronic opioid therapy (COT) and recommends adoption of consistent definition criteria to be utilized in practice and research. The most recent literature trends toward shorter duration criteria overall, suggesting that COT definition criteria are increasingly stringent.
Collapse
Affiliation(s)
- Yun Shen
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida
| | - Hemita Bhagwandass
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Tychell Branchcomb
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Sophia A Galvez
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Ivanna Grande
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Julia Lessing
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Mikela Mollanazar
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Natalie Ourhaan
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Razanne Oueini
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Michael Sasser
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Ivelisse L Valdes
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Ashmita Jadubans
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Josef Hollmann
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Michael Maguire
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Silken Usmani
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida
| | - Scott M Vouri
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida
| | - Juan M Hincapie-Castillo
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida; Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, Florida
| | - Lauren E Adkins
- University of Florida Health Science Center Libraries, Gainesville, Florida
| | - Amie J Goodin
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, Florida; Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida.
| |
Collapse
|
37
|
Clinical Policy: Critical Issues Related to Opioids in Adult Patients Presenting to the Emergency Department. Ann Emerg Med 2020; 76:e13-e39. [DOI: 10.1016/j.annemergmed.2020.06.049] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
|
38
|
Delcher C, Pauly N, Moyo P. Advances in prescription drug monitoring program research: a literature synthesis (June 2018 to December 2019). Curr Opin Psychiatry 2020; 33:326-333. [PMID: 32250984 PMCID: PMC7409839 DOI: 10.1097/yco.0000000000000608] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Nearly every U.S. state operates a prescription drug monitoring program (PDMP) to monitor dispensing of controlled substances. These programs are often considered key policy levers in the ongoing polydrug epidemic. Recent years have seen rapid growth of peer-reviewed literature examining PDMP consultation and the impacts of these programs on diverse patient populations and health outcomes. This literature synthesis presents a review of studies published from June 2018 to December 2019 and provides relevant updates from the perspective of three researchers in this field. RECENT FINDINGS The analyzed studies were primarily distributed across three overarching research focus areas: outcome evaluations (n = 29 studies), user surveys (n = 23), and surveillance (n = 22). Identified themes included growing awareness of the unintended consequences of PDMPs on access to opioids, effects on benzodiazepines and stimulant prescribing, challenges with workflow integration across multiple specialties, and new opportunities for applied data science. SUMMARY There is a critical gap in existing PDMP literature assessing how these programs have impacted psychiatrists, their prescribing behaviors, and their patients. Although PDMPs have improved population-level monitoring of controlled substances from medical sources, their role in responding to a drug epidemic shifting to illicitly manufactured drugs is under scrutiny.
Collapse
Affiliation(s)
- Chris Delcher
- Institute for Pharmaceutical Outcomes and Policy, University of Kentucky College of Pharmacy, Lexington, Kentucky
| | - Nathan Pauly
- Department of Health Policy Management and Leadership, West Virginia University School of Public Health, Morgantown, West Virginia
| | - Patience Moyo
- Department of Health Services, Policy, and Practice, Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| |
Collapse
|
39
|
Opioid prescriptions in emergency departments: Findings from the 2016 National Hospital Ambulatory Medical Care Survey. Prev Med 2020; 136:106035. [PMID: 32112795 DOI: 10.1016/j.ypmed.2020.106035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 02/12/2020] [Accepted: 02/21/2020] [Indexed: 11/24/2022]
Abstract
In the past decade, there has been a rising trend in the emergency department (ED) visits in the US and these visits carry a significant burden of prescription opioids. This study utilized the latest available data from the 2016 National Hospital Ambulatory Medical Care Survey (NHAMCS) and examined the factors associated with opioid prescriptions in the ED. The outcome variable was receipt of opioid prescription, and the primary variable of interest was the type of visit (dental/non-dental). Other variables included age, gender, race/ethnicity, region, payer, day of the visit, and pain level. Descriptive and multivariate analyses were conducted and predicted marginal probabilities were determined. P ≤ 0.05 was considered statistically significant. In 2016, 22.5% of visits in ER received opioid prescriptions. In the unadjusted analysis, opioid prescriptions were associated with all correlates except day of the visit. In the adjusted model, odds of receiving opioid prescription were 3.5 times more among dental visits compared to non-dental visits (95% Confidence Interval [CI] = 2.4-5.1) and 9.4 times more among visits with severe pain compared to visits with mild pain (95% CI = 7.7-11.4). Opioid prescriptions among 45-64 years old were 7.1 times (95% CI = 5.5-9.1] more likely compared to those among under 18 age-group. Opioid prescriptions in ED differed significantly by the type of visit and pain level. Given the higher likelihood of opioid prescriptions among dental visits, it is imperative to develop better prescription guidelines for dental visits in ED.
Collapse
|
40
|
Pouryahya P, Birkett W, McR Meyer AD, Louey S, Belhadfa M, Ferdousi S, Imperial K, Nguyen P, Wang A. Oxycodone prescribing in the emergency department during the opioid crisis. Emerg Med Australas 2020; 32:996-1000. [PMID: 32537895 DOI: 10.1111/1742-6723.13545] [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: 07/10/2019] [Revised: 04/01/2020] [Accepted: 04/29/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Misuse of prescription opioids is a significant public health issue in Australia. There has been a rapid rise in prescription opioid use, with an associated increase in overdose and death. The over-prescribing of oral opioids, especially oxycodone, in the ED has been identified as a contributor to this problem overseas. It is unclear if similar practice occurs in the Australian ED. The primary aim of our study was to identify the incidence of oral oxycodone administration to patients within the ED. The secondary outcome was to identify the incidence of oxycodone prescribed to patients on discharge from the ED into the community. METHODS Our study was designed as an observational, retrospective data analysis of the incidence of oxycodone prescribed within the three EDs of a large Australian public health service. All immediate-release (IR) and slow-release (SR) oral oxycodone prescribed over a 4-year period (2015-2018) was included. RESULTS There were 890 557 presentations to the three EDs during the period, which resulted in 288 242 episodes of oxycodone administration within department, equivalent to 324 administrations per 1000 presentations. There were 39 381 prescriptions for oxycodone provided on discharge, resulting in an incidence of 44 prescriptions per 1000 discharged. The most frequently prescribed opioid medication in the ED was oxycodone IR 5 mg, 78.6% of discharge prescriptions generated provided a maximum quantity (20 for IR formulation or 28 for SR) of tablets allowable under the pharmaceutical benefits scheme. CONCLUSIONS There is a higher incidence of oxycodone prescribing in the Australian ED than previously recognised. An overuse of oxycodone may be contributing to adverse patient outcomes and a public health crisis. Hospitals should consider appropriate steps to reduce the incidence of opioid prescribing and the supply of these medications into the community.
Collapse
Affiliation(s)
- Pourya Pouryahya
- Emergency Department, Program of Emergency Medicine, Casey Hospital, Monash Health, Melbourne, Victoria, Australia.,Monash Emergency Research Collaborative, Program of Emergency Medicine, Monash Health, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - William Birkett
- Emergency Department, Program of Emergency Medicine, Casey Hospital, Monash Health, Melbourne, Victoria, Australia
| | - Alastair D McR Meyer
- Emergency Department, Program of Emergency Medicine, Casey Hospital, Monash Health, Melbourne, Victoria, Australia.,Monash Emergency Research Collaborative, Program of Emergency Medicine, Monash Health, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Stephen Louey
- Pharmacy Department, Casey Hospital, Monash Health, Melbourne, Victoria, Australia
| | - Miriam Belhadfa
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Sapphire Ferdousi
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Kimberly Imperial
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Phi Nguyen
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Amber Wang
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
41
|
Friedman BW, Gallagher EJ. In reply:. Ann Emerg Med 2020; 75:676-677. [DOI: 10.1016/j.annemergmed.2020.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Indexed: 10/24/2022]
|