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Olopoenia A, Camelo-Castillo W, Qato DM, Adekoya A, Palumbo F, Sera L, Simoni-Wastila L. Adverse outcomes associated with concurrent gabapentin, opioid, and benzodiazepine utilization: A nested case-control study. LANCET REGIONAL HEALTH. AMERICAS 2022; 13:100302. [PMID: 36777316 PMCID: PMC9904085 DOI: 10.1016/j.lana.2022.100302] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Gabapentin, opioids, and/or benzodiazepines are commonly prescribed for a variety of pain and psychiatric conditions. Despite the high likelihood of co-prescription of these medications, little is known about co-utilization of gabapentin (GABA), opioids (OP), and benzodiazepines (BZD) and associated public health outcomes. Methods Using Medicare CCW Data, 2013-2016, we conducted a nested case-control study to examine the association between concurrent utilization of GABA, OP, and BZD and respiratory depression, opioid, and substance-related overdose among Medicare disabled beneficiaries. Cases and controls were Fee-for-service disabled beneficiaries who had a diagnosis of acute pain (AP), chronic pain (CP) or mental health conditions (MH) and received GABA, OP or BZD. Cases with respiratory depression, opioid or substance-related overdose were matched with up to 4 controls on socio-demographics, year of cohort entry and disease risk score. Primary exposure was concurrent medication utilization defined as an overlap of at least one day in prescriptions for GABA, OP and BZD. Findings Across all cohorts, the majority of cases and controls were under 65, female, dually eligible and had prior histories of pain and mental health conditions. GABA+OP+BZD use was associated with increased odds of respiratory depression [AOR(95%CI)-AP: 1.35 (1.19-1.52), CP:1.24 (1.11-1.38) and MH: 1.16 (1.02-1.32) vs. OP only], opioid-related overdose [AP: 1.43 (1.04-1.98), CP: 1.47 (1.07-2.00) and MH: 1.44 (1.04-2.00) vs. OP only], and substance-related overdose [AP: 1.77 (1.26-2.50), CP: 1.70 (1.24-2.34) and MH: 1.92 (1.31-2.82) vs. GABA only]. While there were cohort differences in the association between GABA+OP and both respiratory depression and opioid-related overdose, GABA+OP and GABA+BZD use were associated with significantly higher odds of substance-related overdose across all clinical cohorts. Interpretation Among Medicare disabled beneficiaries, concurrent utilization of gabapentin, opioids, and benzodiazepines is associated with multiple adverse outcomes. Given this, it is imperative that the benefits and risks of co-prescribing these medications be comprehensively examined. Funding None.
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Affiliation(s)
- Abisola Olopoenia
- Department of Pharmaceutical Health Services Research, University of Maryland Baltimore, Baltimore, MD, USA,Corresponding author at: 2671 Avenir Pl, Vienna, VA, 22180.
| | - Wendy Camelo-Castillo
- Department of Pharmaceutical Health Services Research, University of Maryland Baltimore, Baltimore, MD, USA
| | - Danya M. Qato
- Department of Pharmaceutical Health Services Research, University of Maryland Baltimore, Baltimore, MD, USA,School of Medicine, University of Maryland Baltimore, Baltimore, MD, USA
| | - Adepeju Adekoya
- Johns Hopkins Medicine, Department of Anesthesiology & Critical Care Medicine, Division of Chronic Pain Medicine, Baltimore, MD, USA
| | - Frank Palumbo
- Department of Pharmaceutical Health Services Research, University of Maryland Baltimore, Baltimore, MD, USA
| | - Leah Sera
- Department of Pharmacy Practice and Science, University of Maryland Baltimore, Baltimore, MD, USA
| | - Linda Simoni-Wastila
- Department of Pharmaceutical Health Services Research, University of Maryland Baltimore, Baltimore, MD, USA,Peter Lamy Center on Drug Therapy and Aging, University of Maryland Baltimore, Baltimore, MD, USA
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Olopoenia A, Camelo-Castillo W, Qato DM, Adekoya A, Palumbo F, Sera L, Simoni-Wastila L. Patterns of opioid and benzodiazepine use with gabapentin among disabled Medicare beneficiaries - A retrospective cohort study. Drug Alcohol Depend 2022; 230:109180. [PMID: 34847506 DOI: 10.1016/j.drugalcdep.2021.109180] [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: 06/05/2021] [Revised: 10/18/2021] [Accepted: 10/29/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Our goal was to describe specific patterns associated with co-prescriptions of gabapentin, opioids, and benzodiazepines among disabled Medicare beneficiaries. METHODS Using 2013-2015 Medicare data, we conducted a retrospective cohort study among fee-for-service disabled beneficiaries continuously enrolled in Medicare Parts A, B, and D. The index date was defined as the earliest fill date for a gabapentin, opioid, or benzodiazepine prescription. Monotherapy, dual therapy, and tri-therapy were defined as utilization of one, two, and three medication classes, respectively. Augmentation was defined as a prescription for a different medication class in addition to prescription for initial medication; switching referred to a change in prescription for a different medication class with no subsequent fills of initial medication. We used descriptive statistics, Kaplan Meier analyses and Cox proportional hazards to examine the association between initial therapy and monotherapy, dual therapy, tri-therapy, switching and augmentation. RESULTS Among 151,552 disabled beneficiaries, gabapentin initiators were more likely to augment therapy (50.1%) when compared to opioid (28.7%) and benzodiazepine (38.7%) users. When compared to opioid initiators, the risk of augmentation (HR[95%CI]: 1.85[1.82-1.89]) and switching (1.62 [1.51-1.73]) was significantly higher among gabapentin initiators. Risk of augmentation was also significantly higher among beneficiaries with co-morbid pain and mental health conditions (p < 0.01). Overall, the majority of beneficiaries augmented and switched within 2-months and 4-months after initiating therapy, respectively. CONCLUSIONS Given safety concerns associated with gabapentin, opioids, and benzodiazepines, it is imperative that the benefits and risks of co-prescribing these medications be examined comprehensively, especially for those in vulnerable sub-groups.
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Affiliation(s)
- Abisola Olopoenia
- University of Maryland, Baltimore, Department of Pharmaceutical Health Services Research, 220N. Arch St., Baltimore, MD 21201, United States.
| | - Wendy Camelo-Castillo
- University of Maryland, Baltimore, Department of Pharmaceutical Health Services Research, 220N. Arch St., Baltimore, MD 21201, United States.
| | - Danya M Qato
- University of Maryland, Baltimore, Department of Pharmaceutical Health Services Research, 220N. Arch St., Baltimore, MD 21201, United States; University of Maryland, Baltimore, School of Medicine, 655W. Baltimore St, Baltimore, MD 21201, United States.
| | - Adepeju Adekoya
- Johns Hopkins Medicine, Department of Anesthesiology & Critical Care Medicine, Division of Chronic Pain Medicine, United States.
| | - Frank Palumbo
- University of Maryland, Baltimore, Department of Pharmaceutical Health Services Research, 220N. Arch St., Baltimore, MD 21201, United States.
| | - Leah Sera
- University of Maryland, Baltimore, Department of Pharmacy Practice and Science, United States.
| | - Linda Simoni-Wastila
- University of Maryland, Baltimore, Department of Pharmaceutical Health Services Research, 220N. Arch St., Baltimore, MD 21201, United States; Peter Lamy Center on Drug Therapy and Aging, University of Maryland Baltimore, Baltimore, United States.
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Carlson KA, Potter CE. Empowering Nurses: Communicating Potential Medication Misuse. J Am Psychiatr Nurses Assoc 2022; 28:68-75. [PMID: 34196243 DOI: 10.1177/10783903211028635] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND In nursing education and practice, we prepare nurses on topics such as patient care, pathophysiology, pharmacology, nursing leadership, and nursing competencies. Unfortunately, we may be missing the mark when it comes to integrating these topics and applying them to situations that arise in health care such as medication misuse. Nurses work intimately with patients and can recognize potential medication misuse by reviewing medication regimens and assessing necessity of PRN patient requests. In cases where nurses suspect misuse, they may or may not feel comfortable addressing these concerns with other members of the health care team. AIMS Study aims were to assess the baseline of whether nurses are comfortable with their level of skill to recognize potential patient medication misuse and to assess nurses' comfortability with communicating these concerns with other nurses, providers, and patients. METHODS This survey study was designed to obtain practical information about nurses understanding of misused and diverted prescription medications and level of comfort with expressing concerns about the use of central nervous system depressants to inform education, practice, and research. Three-hundred and fifty nurses at one hospital were invited to participate in an anonymous REDCap survey. RESULTS Thirty-five percent of the surveyed nurses returned the survey. Responding nurses were more comfortable sharing their own knowledge and the need for more education on the topic than they were discussing interdisciplinary communication. CONCLUSIONS Empowering nurses to communicate this knowledge with others on the health care team has major public health implications to reduce the negative outcomes of misused medications.
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Affiliation(s)
- Kelly A Carlson
- Kelly A. Carlson, PhD, PMHNP-BC, CNE, McLean Hospital, Belmont, MA, USA; Regis College, Weston, MA, USA
| | - Corey E Potter
- Corey E. Potter, MA, BSN, LMHC, RN, McLean Hospital, Belmont, MA, USA; Northeastern University, Boston, MA, USA
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Young JC, Dasgupta N, Chidgey BA, Stürmer T, Pate V, Hudgens M, Funk MJ. Day-of-Surgery Gabapentinoids and Prolonged Opioid Use: A Retrospective Cohort Study of Medicare Patients Using Electronic Health Records. Anesth Analg 2021; 133:1119-1128. [PMID: 34260433 PMCID: PMC8542643 DOI: 10.1213/ane.0000000000005656] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND While preoperative gabapentinoids are commonly used in surgical multimodal analgesia protocols, little is known regarding the effects this therapy has on prolonged postsurgical opioid use. In this observational study, we used data from a large integrated health care system to estimate the association between preoperative day-of-surgery gabapentinoids and the risk of prolonged postsurgical opioid use. METHODS We identified adults age ≥65 years undergoing major therapeutic surgical procedures from a large integrated health care system from 2016 to 2019. Exposure to preoperative gabapentinoids on the day of surgery was measured using inpatient medication administration records, and the outcome of prolonged opioid use was measured using outpatient medication orders. We used stabilized inverse probability of treatment-weighted log-binomial regression to estimate risk ratios and 95% confidence intervals (CIs) of prolonged opioid use, comparing patients who received preoperative gabapentinoids to those who did not and adjusting for relevant clinical factors. The main analysis was conducted in the overall surgical population, and a secondary analysis was conducted among procedures where at least 30% of all patients received a preoperative gabapentinoid. RESULTS Overall, 13,958 surgical patients met inclusion criteria, of whom 21.0% received preoperative gabapentinoids. The observed 90-day risk of prolonged opioid use following surgery was 0.91% (95% CI, 0.77-1.08). Preoperative gabapentinoid administration was not associated with a reduced risk of prolonged opioid use in the main analysis conducted in a broad surgical population (adjusted risk ratio [adjRR], 1.19 [95% CI, 0.67-2.12]) or in the secondary analysis conducted in patients undergoing colorectal resection, hip arthroplasty, knee arthroplasty, or hysterectomy (adjRR, 1.01 [95% CI, 0.30-3.33]). CONCLUSIONS In a large integrated health system, we did not find evidence that preoperative gabapentinoids were associated with reduced risk of prolonged opioid use in patients undergoing a broad range of surgeries.
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Affiliation(s)
- Jessica C. Young
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599-7400, U.S.A
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Martin Luther King Jr. Blvd, Chapel Hill, NC 27599
| | - Nabarun Dasgupta
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, 725 Martin Luther King Jr. Blvd., Chapel Hill, NC 27599
| | - Brooke A. Chidgey
- Department of Anesthesiology and Pain Management, University of North Carolina School of Medicine, Chapel Hill, NC 27599
| | - Til Stürmer
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599-7400, U.S.A
| | - Virginia Pate
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599-7400, U.S.A
| | - Michael Hudgens
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599-7400, U.S.A
| | - Michele Jonsson Funk
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599-7400, U.S.A
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Pentylenetetrazol-like stimulus is not produced following naloxone-precipitated mitragynine withdrawal in rats. Psychopharmacology (Berl) 2021; 238:3183-3191. [PMID: 34333672 DOI: 10.1007/s00213-021-05934-4] [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: 04/11/2021] [Accepted: 07/08/2021] [Indexed: 01/22/2023]
Abstract
RATIONALE Kratom (Mitragyna speciosa Korth), a native medicinal plant of Southeast Asia, is proposed to exhibit potential therapeutic value as an opioid substitute. However, studies of its negative emotional states resulting from withdrawal particularly of its main psychoactive compound, mitragynine (MG), are limited. OBJECTIVES Using the pentylenetetrazol (PTZ) discrimination assay, this study aims to investigate the effects of MG in responding to the PTZ stimulus and to assess the generalisation effects of withdrawal from MG to the PTZ stimulus. METHODS Rats (n = 20) were trained on a tandem (FR-10, VI-15) schedule of food reinforcement to press one lever after administration of the anxiogenic compound PTZ (16 mg/kg, i.p.) and an alternate lever after vehicle. Following acute tests, training was suspended, and rats were chronically treated with MG or morphine at 8-h intervals for 9 days and withdrawal was precipitated on the tenth day using naloxone (1 mg/kg, i.p.). The rats were tested for generalisation to PTZ at 2, 8 and 24 h after the last dose of MG or morphine administration. RESULTS Unlike morphine that produced dose-related PTZ-like stimulus, MG at 3, 10, 30 and 45 mg/kg doses showed no substitution to the PTZ discriminative stimulus. In contrast to morphine which produced a time-dependent generalisation to the PTZ stimulus, naloxone did not precipitate withdrawal effects in MG-treated rats as they selected the vehicle lever at three withdrawal time points. CONCLUSION These results demonstrate that MG produces a very different response to morphine withdrawal that is not associated with anxiogenic-like subjective symptoms. These characteristics of MG may provide further support for use as a novel pharmacotherapeutic intervention for managing opioid use disorder.
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Graves JM, Dilley JA, Terpak L, Brooks-Russell A, Whitehill JM, Klein TA, Liebelt E. Kratom exposures among older adults reported to U.S. poison centers, 2014-2019. J Am Geriatr Soc 2021; 69:2176-2184. [PMID: 34143890 DOI: 10.1111/jgs.17326] [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: 12/09/2020] [Revised: 04/06/2021] [Accepted: 04/13/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND In recent years, use of the herbal supplement kratom has increased in the United States. The reasons for use include pain relief, particularly as a substitute for opioids. OBJECTIVES To describe epidemiologic trends in kratom-related exposures among older adults reported to U.S. poison centers. DESIGN Retrospective analysis of American Association of Poison Control Center's National Poison Data System (NPDS). SETTING Data from all U.S. poison centers from 2014 to 2019 were examined. PARTICIPANTS Kratom exposure cases involving adults aged 18 and older. Kratom cases were identified by product and NPDS generic codes. Non-human and information-only calls were excluded. Data were examined for all calls for exposures among adults, with a focus on older adults aged 60-69 years and above 70 years. MEASUREMENTS Descriptive analyses were used to characterize individual demographic, exposure information, clinical effects, and medical outcomes associated with kratom exposures among older adults. Comparisons across age groups (18-59, 60-69, and 70+ years) were made using Fisher's exact tests. RESULTS Among 3484 kratom-related exposures reported between 2014 and 2019, 4.6% (n = 162) were among adults over 60 years. The number of kratom-related exposures increased over time. Most cases originated with calls from healthcare facilities (81.1%) and involved kratom as a single ingestant (63.0%). The reason for most ingestions was intentional (74.5%). One in five exposures among adults aged 70 and older involved an adverse reaction (e.g., drug interaction; 21.9%), compared with 12.3% among ages 60-69 and 9.6% among ages 18-59 years. Neurological and cardiovascular clinical effects were observed. Twenty-three deaths were observed among older adults. CONCLUSION Healthcare providers and older adult patients should be aware of the potential risks of kratom use, including medication interactions and falls. When reviewing medication lists, providers should query this population for all medications and substances being used, especially in people being treated for pain.
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Affiliation(s)
- Janessa M Graves
- College of Nursing, Washington State University, Spokane, Washington, USA
| | - Julia A Dilley
- Multnomah County Health Department and Oregon Public Health Division, Program Design and Evaluation Services, Portland, Oregon, USA
| | - Lucia Terpak
- Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Ashley Brooks-Russell
- Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jennifer M Whitehill
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, Massachusetts, USA
| | - Tracy A Klein
- College of Nursing, Washington State University, Vancouver, Washington, USA
| | - Erica Liebelt
- Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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Van Cleave JH, Booker SQ, Powell-Roach K, Liang E, Kawi J. A Scoping Review of Nursing's Contribution to the Management of Patients with Pain and Opioid Misuse. Pain Manag Nurs 2021; 22:58-68. [PMID: 33414010 DOI: 10.1016/j.pmn.2020.11.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 11/08/2020] [Accepted: 11/16/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Nursing brings a unique lens to care of patients with pain and opioid misuse. AIMS This scoping review describes nursing's contribution to the literature on the management of patients with pain and opioid misuse, generating evidence to guide clinical care. DESIGN The scoping review was conducted according to Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews guideline. DATA SOURCES Using combined key terms ("opioid misuse," "pain," "nursing") in systematic searches in PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) electronic databases, snowball technique, and personal knowledge resulted in 108 relevant articles, reports, and websites. ANALYSIS METHOD Summative approach to content analysis was used to quantify and describe nursing's contribution to the literature. RESULTS Contributions of nurses emerged in the areas of research, clinical practice, policy, and education. The highest number of publications addressed research (50%, 54 of 108), whereas the fewest number of publications involved education (7%, 8 of 108). CONCLUSION Results provide a picture of the breadth of expertise and crucial leadership that nurses contribute to influence management of patients with pain and opioid misuse. IMPLICATIONS FOR NURSING This scoping review indicates the importance of continued support from key stakeholders, including training and interprofessional collaboration opportunities supported by the National Institutes of Health, to sustain nursing's contribution to quality care of patients with pain and opioid misuse. Ultimately, all health care professionals must collaborate to conduct rigorous research and construct evidence-based guidelines to inform policy initiatives and education strategies to solve the complex co-occurring epidemics of pain and opioid misuse.
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Affiliation(s)
| | - Staja Q Booker
- University of Florida, College of Nursing, Gainesville, Florida
| | | | - Eva Liang
- NYU Rory Meyers College of Nursing, New York, New York
| | - Jennifer Kawi
- University of Nevada, Las Vegas, School of Nursing, Las Vegas, Nevada
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Abstract
The management of pain, particularly chronic pain, is still an area of medical need. In this context, opioids remain a gold standard for the treatment of pain. However, significant side effects, mainly of central origin, limit their clinical use. Here, we review recent progress to improve the therapeutic and safety profiles of opioids for pain management. Characterization of peripheral opioid-mediated pain mechanisms have been a key component of this process. Several studies identified peripheral µ, δ, and κ opioid receptors (MOR, DOR, and KOR, respectively) and nociceptin/orphanin FQ (NOP) receptors as significant players of opioid-mediated antinociception, able to achieve clinically significant effects independently of any central action. Following this, particularly from a medicinal chemistry point of view, main efforts have been directed towards the peripheralization of opioid receptor agonists with the objective of optimizing receptor activity and minimizing central exposure and the associated undesired effects. These activities have allowed the characterization of a great variety of compounds and investigational drugs that show low central nervous system (CNS) penetration (and therefore a reduced side effect profile) yet maintaining the desired opioid-related peripheral antinociceptive activity. These include highly hydrophilic/amphiphilic and massive molecules unable to easily cross lipid membranes, substrates of glycoprotein P (a extrusion pump that avoids CNS penetration), nanocarriers that release the analgesic agent at the site of inflammation and pain, and pH-sensitive opioid agonists that selectively activate at those sites (and represent a new pharmacodynamic paradigm). Hopefully, patients with pain will benefit soon from the incorporation of these new entities.
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Reynolds K, Kaufman R, Korenoski A, Fennimore L, Shulman J, Lynch M. Trends in gabapentin and baclofen exposures reported to U.S. poison centers. Clin Toxicol (Phila) 2019; 58:763-772. [DOI: 10.1080/15563650.2019.1687902] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
| | - Robert Kaufman
- University of Pittsburgh, School of Nursing, Pittsburgh, PA, USA
| | | | - Laura Fennimore
- University of Pittsburgh, School of Nursing, Pittsburgh, PA, USA
| | - Joshua Shulman
- Division of Medical Toxicology, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael Lynch
- Pittsburgh Poison Center, Pittsburgh, PA, USA
- Division of Medical Toxicology, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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