Mandatory review of a prescription drug monitoring program and impact on opioid and benzodiazepine dispensing

Comparing the effects of decreasing prescription opioid shipments and the release of an abuse deterrent OxyContin formulation on opioid overdose fatalities in WV: an interrupted time series study

INTRODUCTION

The 2010 release of an abuse deterrent formulation (ADF) of OxyContin, a brand name prescription opioid, has been cited as a major driver for the reduction in prescription drug misuse and the associated increasing illicit opioid use and overdose rates. However, studies of this topic often do not account for changes in supplies of other prescription opioids that were widely prescribed before and after the ADF OxyContin release, including generic oxycodone formulations and hydrocodone. We therefore sought to compare the impact of the ADF OxyContin release to that of decreasing prescription opioid supplies in West Virginia (WV).

METHODS

Opioid tablet shipment and overdose data were extracted from The Washington Post ARCOS (2006-2014) and the WV Forensic Drug Database (2005-2020), respectively. Locally estimated scatterplot smoothing (LOESS) was used to estimate the point when shipments of prescription opioids to WV began decreasing, measured via dosage units and morphine milligram equivalents (MMEs). Interrupted time series analysis (ITSA) was used to compare the impact LOESS-identified prescription supply changes and the ADF OxyContin release had on prescription (oxycodone and hydrocodone) and illicit (heroin, fentanyl, and fentanyl analogues) opioid overdose deaths in WV. Model fit was compared using Akaike Information Criteria (AIC).

RESULTS

The majority of opioid tablets shipped to WV from 2006 to 2014 were generic oxycodone or hydrocodone, not OxyContin. After accounting for a 6-month lag from ITSA models using the LOESS-identified change in prescription opioid shipments measured via dosage units (2011 Q3) resulted in the lowest AIC for both prescription (AIC = -188.6) and illicit opioid-involved overdoses (AIC = -189.4), indicating this intervention start date resulted in the preferred model. The second lowest AIC was for models using the ADF OxyContin release as an intervention start date.

DISCUSSION

We found that illicit opioid overdoses in WV began increasing closer to when prescription opioid shipments to the state began decreasing, not when the ADF OxyContin release occurred. Similarly, the majority of opioid tablets shipped to the state for 2006-2014 were generic oxycodone or hydrocodone. This may indicate that diminishing prescription supplies had a larger impact on opioid overdose patterns than the ADF OxyContin release in WV.

Tracking changes in opioid prescriptions dispensed following the enactment of a prescription drug monitoring program use mandate

BACKGROUND

Prescription drug monitoring programs (PDMPs) are state-based surveillance tools used to track controlled substances dispensed to patients and identify patients at-risk of misuse. Starting April 2017, Wisconsin required all prescribers access PDMP to review patient information before issuing a controlled substance prescription order for more than a 3-day supply. A primary goal of PDMP use mandates is to reduce avoidable prescribing and mitigate opioid related mortality and morbidity. Current literature has not evaluated the existence of a time point post-policy implementation, at which the trend in opioid dispensing changes, reflecting normalization/maintenance of opioid prescribing.

OBJECTIVE

We sought to evaluate the impact of the PDMP use mandate on trends in opioid prescriptions dispensed and test a hypothesis that a change or inflection in opioid prescriptions dispensed occurred post-mandate implementation.

METHODS

Interrupted Time Series Analysis (ITSA) design was used to examine whether the level (immediate impact) and trend in opioid prescribing changed significantly after the PDMP use mandate was implemented. We used a novel Change Point Analysis (CPA) approach to test the hypothesis i.e., identify if and when a change or inflection in opioid dispensing trend occurred after implementation of the PDMP use mandate.

RESULTS

ITSA model results showed a significant drop in opioid prescriptions dispensed (p < 0.05) immediately after the mandate implementation (i.e., April 2017). Results of the CPA identified a significant inflection in opioid prescriptions dispensed starting January 2019 (21-months post-policy implementation). An ITSA model using the inflection point as an interruption showed that the trend in opioid prescriptions dispensed became flatter after the inflection point, suggesting normalization.

CONCLUSION

Using a novel CPA approach, the findings showed an inflection in the trend in opioid prescriptions dispensed post-PDMP use mandate implementation, implying that most of the avoidable prescribing likely was curtailed. The results suggest that the patient information presumably accessed from the WI PDMP interface was useful in helping prescribers to make an informed clinical decision about opioid prescribing.

Association between prescription drug monitoring programs use mandates and prescription stimulants received by Medicaid enrollees

INTRODUCTION

Prescription drug monitoring program (PDMP) use mandates are an important policy tool to curb nonmedical opioid use. However, data are scarce about their efficacy on other commonly used prescription drugs such as stimulants.

METHODS

We used 2010-2020 state-level secondary data from Medicaid State Drug Utilisation Data and quasi-experimental difference-in-differences research design to estimate the association between PDMP use mandates and population-adjusted stimulants (amphetamines and methylphenidate) prescribing outcomes: (i) number of prescriptions filled; and (ii) total amount reimbursed in US dollars. To account for heterogeneity in mandates across US states, two policy variables were considered: limited and expansive. Limited PDMP use mandates require prescribers or dispensers to check the PDMP only when prescribing/dispensing opioids or benzodiazepines, while expansive PDMP use mandates are non-specific to opioids/benzodiazepines and require prescribers or dispensers to check the PDMP when prescribing/dispensing targeted controlled substances in Drug Enforcement Agency Schedule II-V. The sample included 49 US states and the District of Columbia. Nevada was excluded since it implemented the PDMP mandate before the period of analysis.

RESULTS

The state-wide implementation of the PDMP use mandate, either limited or expansive, was not associated with the number of prescriptions filled or the total amount reimbursed in US dollars for stimulants among Medicaid enrollees.

DISCUSSION AND CONCLUSION

There was no evidence for the associations between PDMP use mandates and stimulant prescribing among Medicaid enrollees. Future works are encouraged to replicate the study in other populations and with longer post-period analysis when the impact of the mandates might be more successfully materialised.

Prescription drug monitoring programs use mandates and prescription stimulant and depressant quantities

BACKGROUND

While the mandate to check patients' prescription history in Prescription Drug Monitoring Program (PDMP) database before prescribing/dispensing controlled drugs has been shown to be an important tool to curb opioid abuse, less is known about whether the mandate can reduce the misuse of other commonly abused prescription drugs. We examined whether PDMP use mandates were associated with changes in prescription stimulant and depressant quantities.

METHODS

Using data from Automated Reports and Consolidate Ordering System (ARCOS), we employed difference-in-differences design to estimate the association between PDMP use mandates and prescription stimulant and depressant quantities in 50 U.S. states and the District of Columbia from 2006 to 2020. Limited PDMP use mandate was specific only to opioids or benzodiazepines. Expansive PDMP use mandate was non-specific to opioid or benzodiazepine and required prescribers/dispensers to check PDMP when prescribing/dispensing targeted controlled substances in Schedule II-V. The main outcomes were population-adjusted prescription stimulant (amphetamine, methylphenidate, lisdexamfetamine) and depressant (amobarbital, butalbital, pentobarbital, secobarbital) quantities in grams.

RESULTS

There was no evidence that limited PDMP use mandate was associated with a reduction in the prescription stimulant and depressant quantities. However, expansive PDMP use mandate that was non-specific to opioid or benzodiazepine and required prescribers/dispensers to check PDMP when prescribing/dispensing targeted controlled substances in Schedule II-V was associated with 6.2% (95% CI: -10.06%, -2.08%) decline in prescription amphetamine quantity.

CONCLUSION

Expansive PDMP use mandate was associated with a decline in prescription amphetamine quantity. Limited PDMP use mandate did not appear to change prescription stimulant and depressant quantities.

The association between prescription drug monitoring programs and controlled substance prescribing: a cross-sectional study using data from 2019 National Electronic Health Records Survey

OBJECTIVE

The use of controlled medications such as opioids, stimulants, anabolic steroids, depressants, and hallucinogens has led to an increase in addiction, overdose, and death. Given the high attributes of abuse and dependency, prescription drug monitoring programs (PDMPs) were introduced in the United States as a state-level intervention.

MATERIALS AND METHODS

Using cross-sectional data from the 2019 National Electronic Health Records Survey, we assessed the association between PDMP usage and reduced or eliminated controlled substance prescribing as well as the association between PDMP usage and changing a controlled substance prescription to a nonopioid pharmacologic therapy or nonpharmacologic therapy. We applied survey weights to produce physician-level estimates from the survey sample.

RESULTS

Adjusting for physician age, sex, type of medical degree, specialty, and ease of PDMP, we found that physicians who reported "often" PDMP usage had 2.34 times the odds of reducing or eliminating controlled substance prescriptions compared to physicians who reported never using the PDMP (95% confidence interval [CI] 1.12-4.90). Adjusting for physician age, sex, type of doctor, and specialty, we found that physicians who reported "often" use of the PDMP had 3.65 times the odd of changing controlled substance prescriptions to a nonopioid pharmacologic therapy or nonpharmacologic therapy (95% CI: 1.61-8.26).

DISCUSSION

These results support the continued use, investment, and expansion of PDMPs as an effective intervention for reducing controlled substance prescription and changing to nonopioid/pharmacologic therapy.

CONCLUSION

Overall, frequent usage of PDMPs was significantly associated with reducing, eliminating, or changing controlled substance prescription patterns.

The prescription drug monitoring program in a multifactorial approach to the opioid crisis: PDMP data, Pennsylvania, 2016-2020

BACKGROUND

Prescription opioids remain an important contributor to the United States opioid crisis and to the development of opioid use disorder for opioid-naïve individuals. Recent legislative actions, such as the implementation of state prescription drug monitoring programs (PDMPs), aim to reduce opioid morbidity and mortality through enhanced tracking and reporting of prescription data. The primary objective of our study was to describe the opioid prescribing trends in the state of Pennsylvania (PA) as recorded by the PA PDMP following legislative changes in reporting guidelines, and discuss the PDMP's role in a multifactorial approach to opioid harm reduction.

METHODS

State-level opioid prescription data summaries recorded by the PA PDMP for each calendar quarter from August 2016 through March 2020 were collected from the PA Department of Health. Data for oxycodone, hydrocodone, and morphine were analyzed by quarter for total prescription numbers and refills. Prescription lengths, pill quantities, and average morphine milliequivalents (MMEs) were analyzed by quarter for all 14 opioid prescription variants recorded by the PA PDMP. Linear regression was conducted for each group of variables to identify significant differences in prescribing trends.

RESULTS

For total prescriptions dispensed, the number of oxycodone, hydrocodone, and morphine prescriptions decreased by 34.4, 44.6, and 22.3% respectively (p < 0.0001). Refills fluctuated less consistently with general peaks in Q3 of 2017 and Q3 of 2018 (p = 0.2878). The rate of prescribing for all opioid prescription lengths decreased, ranging in frequency from 22 to 30 days (47.5% of prescriptions) to 31+ days of opioids (0.8% of prescriptions) (p < 0.0001). Similarly, decreased prescribing was observed for all prescription amounts, ranging in frequency from 22 to 60 pills (36.6% of prescriptions) to 60-90 pills (14.2% of prescriptions) (p < 0.0001). Overall, the average MME per opioid prescription decreased by 18.9%.

CONCLUSIONS

Per the PA PDMP database, opioid prescribing has decreased significantly in PA from 2016 to 2020. The PDMP database is an important tool for tracking opioid prescribing trends in PA, and PDMPs structured similarly in other states may enhance our ability to understand and influence the trajectory of the U.S. opioid crisis. Further research is needed to determine optimal PDMP policies and practices nationwide.

Association of prescription drug monitoring programs with benzodiazepine prescription dispensation and overdose in adolescents and young adults

INTRODUCTION

Prescription drug monitoring programs are state-run databases designed to support safe prescribing of controlled substances and reduce prescription drug misuse. We analyzed healthcare claims data to determine the association between prescription drug monitoring programs with mandated provider review and adolescent and young adult benzodiazepine prescription dispensing and overdose.

METHODS

We performed a state-level retrospective cohort study to evaluate the association between implementation of prescription drug monitoring programs with mandated provider review and benzodiazepine prescription dispensing and benzodiazepine-related overdoses among adolescents (13-18 years) and young adults (19-25 years) between 1 January 2008 and 31 December 2019. Data were obtained from a United States commercial health insurance company.

RESULTS

There were 74,539 (1.8%) adolescents and 246,760 (4.0%) young adults with at least one benzodiazepine prescription dispensed. Benzodiazepine overdoses occurred among 1,569 (0.04%) and 3,202 (0.05%) adolescents and young adults, respectively. Implementation of a prescription drug monitoring program with mandated provider review was associated with a 6.8% (95% CI, 1.6-11.8) yearly reduction in benzodiazepine prescription dispensing among adolescents and a 12.5% (95% CI, 9.3-15.5) yearly reduction among young adults. There was no decrease in benzodiazepine overdoses in either age group (-15.4% [95% CI, -21.5 to 3.0] and -8.0% [95% CI, -18.0 to 3.2] yearly change in adolescents and young adults, respectively).

DISCUSSION

Consistent with prior work, our study did not find an association between prescription drug monitoring program implementation and reduction in benzodiazepine-related overdoses among adolescents and young adults. However, the substantial reduction in benzodiazepine prescription dispensing is encouraging.

CONCLUSION

Prescription drug monitoring programs were associated with decreases in benzodiazepine prescription dispensing, but not benzodiazepine-related overdoses in this cohort of adolescents and young adults. These findings serve to inform development of further policies to address rising rates of benzodiazepine misuse and overdose in this patient population.

HealthCare educational differences in pain management, adverse childhood experiences and their relationship to substance use disorder education

Background

In order to assist the State of Ohio in the United States in addressing the opioid epidemic, the Ohio Attorney General appointed experts in a variety of academic disciplines to the Scientific Committee on Opioid Prevention and Education (SCOPE). The focus of SCOPE is the application of scientific principles in the development of prevention and educational strategies for reducing substance use disorder (SUD). One area of focus for SCOPE was SUD education of healthcare professionals. The objective of the present was to identify the content and extent to which future healthcare professionals are trained in pain management, SUD, and adverse childhood experiences (ACEs).

Methods

In December of 2019, a survey was distributed to 49 healthcare professional schools in Ohio that included the following disciplines: medicine, pharmacy, advanced practice registered nurse (APRN), physician assistant, dentistry, and optometry. The survey included four domains: initial screening of patients, training in SUD, training in care for patients at high risk for SUD, and education in evaluating patients for ACEs. Descriptive statistics were calculated.

Results

Thirty one of the forty-nine schools completed the survey. Most disciplines indicated that some form of basic training in the principles of SUD were taught in their core curriculum. The training on ethical issues surrounding SUD were not as widely covered (range 0-62.5%). Medicine, APRN, physician assistant, and pharmacy schools had a “moderate” to “great” extent of pharmacologic therapy curriculum integration. Other pain management strategies were “somewhat” to “moderately” integrated. There were variations seen in training on risk of medication misuse based on various contributors to health. At least 67.7% of medicine, APRN, physician assistant, and pharmacy programs included motivational interviewing training. The extent to which schools integrated education regarding ACEs into their curriculum varied from 0 to 66.7%.

Conclusions

The study finding suggests a need for a unified, consistent, and expanded training requirement in the foundations of pain management, SUD, and ACEs in professional healthcare education.

Characteristics of statewide prescription drug monitoring programs and potentially inappropriate opioid prescribing to patients with non-cancer chronic pain: A machine learning application

Unnecessary/unsafe opioid prescribing has become a major public health concern in the U.S. Statewide prescription drug monitoring programs (PDMPs) with varying characteristics have been implemented to improve safe prescribing practice. Yet, no studies have comprehensively evaluated the effectiveness of PDMP characteristics in reducing opioid-related potentially inappropriate prescribing (PIP) practices. The objective of the study is to apply machine learning methods to evaluate PDMP effectiveness by examining how different PDMP characteristics are associated with opioid-related PIPs for non-cancer chronic pain (NCCP) treatment. This was a retrospective observational study that included 802,926 adult patients who were diagnosed NCCP, obtained opioid prescriptions, and were continuously enrolled in plans of a major U.S. insurer for over a year. Four outcomes of opioid-related PIP practices, including dosage ≥50 MME/day and ≥90 MME/day, days supply ≥7 days, and benzodiazepine-opioid co-prescription were examined. Machine learning models were applied, including logistic regression, least absolute shrinkage and selection operation regression, classification and regression trees, random forests, and gradient boost modeling (GBM). The SHapley Additive exPlanations (SHAP) method was applied to interpret model results. The results show that among 1,886,146 NCCP opioid-related claims, 22.8% had an opioid dosage ≥50 MME/day and 8.9% ≥90 MME/day, 70.3% had days supply ≥7 days, and 10.3% were when benzodiazepine was filled ≤7 days ago. GBM had superior model performance. We identified the most salient PDMP characteristics that predict opioid-related PIPs (e.g., broader access to patient prescription history, monitoring Schedule IV controlled substances), which could be informative to the states considering the redesign of PDMPs.

The Role of Informatics in Implementing Guidelines for Chronic Opioid Therapy Risk Assessment in Primary Care: A Narrative Review Informed by the Socio-Technical Model

Approximately 2 million Americans live with opioid use disorder (OUD), most of whom also have chronic pain. The economic burden of chronic pain and prescription opioid misuse runs into billions of dollars. Patients on prescription opioids for chronic non-cancer pain (CNCP) are at increased risk for OUD and overdose. By adhering to the Center for Disease Control and Prevention (CDC) opioid prescribing guidelines, primary care providers (PCPs) have the potential to improve patient outcomes. But numerous provider, patient, and practice-specific factors challenge adherence to guidelines in primary care. Many of the barriers may be mediated by informatics interventions, but gaps in knowledge and unmet needs exist. This narrative review examines the risk assessment and harm reduction process in a socio-technical context to highlight the gaps in knowledge and unmet needs that can be mediated through informatics intervention.

Impact of Three Safety Interventions Targeting Off-Label Use of Immediate-Release Fentanyl on Prescription Trends: Interrupted Time Series Analysis

Background: The Spanish health authorities are concerned by the off-label use of immediate-release formulations of fentanyl (IRF) in noncancer pain and cancer pain in patients with no chronic pain therapy. Aim: To evaluate the impact of different interventions to improve appropriateness of IRF prescription on off-label prescription. Patients and methods: We used interrupted time series (ITS) to estimate immediate and trend changes of IRF prescription for noncancer pain (NCP) and breakthrough cancer pain (BCP) in patients with and without chronic cancer pain therapy associated with two medication reviews (I1 and I2) and the issue of a safety warning letter (I3) with data from a Spanish region with 5 million inhabitants, from 2015 to 2018. Results: The use of IRF for NCP in the region Valencia was reduced from about 1,800 prescriptions per week to around 1,400. The first medication review was followed by an immediate level change of -192.66 prescriptions per week (p < 0.001) and a downward trend change of -6.75 prescriptions/week (p < 0.001), resulting in a post-intervention trend of -1.99 (p < 0.001). I2 was associated with a trend change of -23.07 (p < 0.001) prescriptions/week. After I3, the trend changed markedly to 27.23 additional prescriptions/week, for a final post-intervention trend of 2.17 (p < 0.001). Controlled-ITS provided comparable results. For potentially inappropriate BCP use, the second medication review was followed by a downward, immediate level change of -10.10 prescriptions/week (p = 0.011) and a trend change of 2.31 additional prescriptions/week (p < 0.001) and the issue of the safety warning (I3) was followed by a downward trend change of -2.09 prescriptions/week (p = 0.007). Conclusion: Despite IRF prescription for NCP decreased, the interventions showed modest and temporary effect on off-label prescription. Our results call for a review of the design and implementation of safety interventions addressing inappropriate opioid use.

Patterns and Trends in Receipt of Opioids Among Patients Receiving Treatment for Cancer in a Large Health System

BACKGROUND

Given limited evidence on opioid prescribing among patients receiving treatment for cancer during the ongoing opioid epidemic, our objective was to assess predictors of and trends in opioid receipt during cancer treatment, including how patterns differ by type of cancer.

METHODS

Using cancer registry data, we identified patients with a first lifetime primary diagnosis of breast, colorectal, or lung cancer from 2013 to 2017 who underwent treatment within a large cancer center network. Cancer registry data were linked to electronic health record information on opioid prescriptions. We examined predictors of and trends in receipt of any opioid prescription within 12 months of cancer diagnosis.

RESULTS

The percentage of patients receiving opioids varied by cancer type: breast cancer, 35% (1,996/5,649); colorectal, 37% (776/2,083); lung, 47% (1,259/2,654). In multivariable analysis, opioid use in the year before cancer diagnosis was the factor most strongly associated with receipt of opioids after cancer diagnosis, with 4.90 (95% CI, 4.10-5.86), 5.09 (95% CI, 3.88-6.69), and 3.31 (95% CI, 2.68-4.10) higher odds for breast, colorectal, and lung cancers, respectively. We did not observe a consistent decline in opioid prescribing over time, and trends differed by cancer type.

CONCLUSIONS

Our findings suggest that prescription of opioids to patients with cancer varies by cancer type and other factors. In particular, patients are more likely to receive opioids after cancer diagnosis if they were previously exposed before diagnosis, suggesting that pain among patients with cancer may commonly include non-cancer-related pain. Heterogeneity and complexity among patients with cancer must be accounted for in developing policies and guidelines aimed at addressing pain management while minimizing the risk of opioid misuse.

Prescription Opioid Use Among a Community Sample of Older and Younger Women

Background: Women bear a heavier burden of the consequences related to prescription opioid use compared to their male counterparts; however, there has been little attention in the literature regarding prescription opioid use among women. We aimed to examine risk factors for prescription opioid use among women. Methods: Demographics, health status, and substance use data, including prescription opioid use, were collected through a community engagement program, HealthStreet, during a health needs assessment. Women older than 18 years were classified by opioid use: past 30-day, lifetime, but not past 30-day, or no lifetime prescription opioid use. Descriptive statistics and chi-square tests were calculated, and multinomial logistic regression was used to calculate adjusted odds ratios (aORs; confidence interval [CI]). Results: Among 5,549 women assessed, 15% reported past 30-day use and 41% reported lifetime use of prescription opioids. While prescription sedative use was the strongest risk factor for past 30-day use among younger women (aOR = 4.84; 95% CI, 3.59-6.51), past 6-month doctor visits was the strongest risk factor for past 30-day use among older women (aOR = 4.15; 95% CI, 2.62-6.60). Conclusions: We found higher rates of prescription opioid use in this community sample of women compared to national rates. Risk factors for recent prescription opioid use (past 30-day use) differed among older and younger women. Clinicians should be more vigilant about prescribing opioids as the medical profile for women may change through age, especially the co-prescribing of opioids and sedatives.

Mapping the research addressing prescription drug monitoring programs: A scoping review

ISSUES

Prescription drug monitoring programs are a harm minimisation intervention and clinical decision support tool that address the public health concern surrounding prescription drug misuse. Given the large number of studies published to date and the ongoing implementation of these programs, it is important to map the literature and identify areas for further research to improve practice.

APPROACH

A scoping review was undertaken to identify the research on prescription drug monitoring programs published between January 2015 and April 2021.

KEY FINDINGS

A total of 153 citations were included in this scoping review. The majority of the studies originated from the USA and were quantitative. Results on program effectiveness are mixed and mainly examine their association with opioid-related outcomes. Unintended consequences are revealed in the literature and this review also highlights barriers to program use.

IMPLICATIONS

Overall, findings are mixed despite the large number of studies published to date. Mapping the literature identifies priority areas for further research that can advise policymakers and clinicians on practice improvement.

CONCLUSION

Results on prescription drug monitoring program effectiveness are mixed and mainly examine their association with opioid-related outcomes. This review highlights barriers to prescription drug monitoring program effectiveness related to program use and system integration. Further research is needed in these areas to improve prescription drug monitoring program use and patient outcomes.

The Impact of a PDMP-EHR Data Integration Combined With Clinical Decision Support on Opioid and Benzodiazepine Prescribing Across Clinicians in a Metropolitan Area

INTRODUCTION

Despite inconclusive evidence that prescription drug monitoring programs (PDMP) reduce opioid-related mortality, guidelines recommend PDMP review with opioid prescribing. Some reported barriers to use include time-consuming processes to obtain data and workflow disruptions.

METHODS

We provided access to a PMDP-electronic health record (EHR) integrated program to 123 clinicians in one healthcare system. Remaining clinicians within the healthcare system and metropolitan area did not receive PDMP-EHR integration program access. We identified changes in opioid prescribing by linking prescription data available in the state PMDP database to individual clinicians. The primary outcome was change in receipt of high dose opioid prescriptions (>90 mg morphine equivalents) by Colorado residents before and after program integration. Secondary outcomes included changes in long-acting opioid receipt and overlapping opioid and benzodiazepine prescription days. Next, we surveyed clinicians to assess their perspectives on PDMP data acquisition before and after PDMP-EHR integration program access.

RESULTS

High-dose opioid receipt decreased significantly across all 3 clinician groups [PDMP-EHR integration program access (27.6%, to 6.9%, P < 0.001); no program access in the same healthcare system (4.8% to 2.9%, P < 0.001), and no program access across the metropolitan area (13.5% to 6.1%, P < 0.001)]. Clinicians reported improved access to PDMP data using the PDMP-EHR integrated program compared to the state PDMP website (98.6%).

CONCLUSIONS

Further study of PDMP-EHR integration programs on patient and clinician outcomes may illuminate the role of this technology in public health and in clinical practice.

Pain Management and Risks Associated With Substance Use: Practice Recommendations

Assessing and managing pain while evaluating risks associated with substance use and substance use disorders continues to be a challenge faced by health care clinicians. The American Society for Pain Management Nursing and the International Nurses Society on Addictions uphold the principle that all persons with co-occurring pain and substance use or substance use disorders have the right to be treated with dignity and respect, and receive evidence-based, high quality assessment, and management for both conditions. The American Society for Pain Management Nursing and International Nurses Society on Addictions have updated their 2012 position statement on this topic supporting an integrated, holistic, multidimensional approach, which includes nonopioid and nonpharmacological modalities. Opioid use disorder is used as an exemplar for substance use disorders and clinical recommendations are included with expanded attention to risk assessment and mitigation with interventions targeted to minimize the risk for relapse or escalation of substance use. Opioids should not be excluded for anyone when indicated for pain management. A team-based approach is critical, promotes the active involvement of the person with pain and their support systems, and includes pain and addiction specialists whenever possible. Health care systems should establish policies and procedures that facilitate and support the principles and recommendations put forth in this article.

Impacts of prescription drug monitoring program policy changes and county opioid safety coalitions on prescribing and overdose outcomes in California, 2015-2018

In 2015, California received funding to implement the Prescription Drug Overdose Prevention Initiative, a 4-year program to reduce deaths involving prescription opioids by 1) leveraging improvements to California's prescription drug monitoring program (PDMP) (i.e., mandatory PDMP registration for prescribers and pharmacists), and 2) supporting county opioid safety coalitions. We used statewide data from 2011 to 2018 to evaluate the Initiative's impact on opioid prescribing and overdose rates. Prescribing data were obtained from California's PDMP; fatal and non-fatal overdose data were obtained from the California Department of Public Health. Outcomes were monthly opioid prescribing rates and opioid overdose rates, modeled using generalized linear mixed models. Exposures were mandatory PDMP registration, presence of county coalitions, and Initiative support for county coalitions. Mandatory PDMP registration was associated with a 25% decrease (95%CI, 0.71-0.79) in opioid prescribing rates after 24 months. Having a county coalition was associated with a 2% decrease (95%CI, 0.96-0.99) in the opioid prescribing rate; receiving Initiative support was associated with an additional 2% decrease (95%CI, 0.97-0.98). Mandatory PDMP registration and county coalitions were associated with a 35% decrease (95%CI, 0.43-0.97) and a 21% decrease (95% CI, 0.70-0.90), respectively in prescription opioid overdose deaths. Both interventions were also associated with significantly fewer deaths involving any opioid but had no significant association with non-fatal overdose rates. Findings add to the knowledge available to guide policy to prevent high-risk prescribing and opioid overdoses. While further study is needed, coalitions and mandatory PDMP registration may be important components in such efforts.

How prescription drug monitoring programs influence clinical decision-making: A mixed methods systematic review and meta-analysis

BACKGROUND

Opioid prescribing, for chronic non-cancer pain, has increased substantially in the past two decades and is associated with significant harms. Various public health approaches have been adopted to address these harms including the implementation of prescription drug monitoring programs (PDMPs). This systematic review aims to identify how PDMP use influences healthcare providers' clinical decision-making.

METHODS

Six databases were searched for literature up until April 2021. Empirical studies were included, with no restrictions placed on year, location, language or study design. Thematic analysis of the identified articles was conducted and where possible, meta-analyses were conducted using a random effect model in Stata.

RESULTS

Forty-one articles related to 39 studies were included. All studies were conducted in the United States, published between 2005 and 2021 and most (n = 28) related to one state-level PDMP. PDMP utilisation influenced healthcare providers' clinical decision-making across seven broad themes: (i) the supply of controlled substances, (ii) refusal to prescribe or treat, (iii) risk mitigation strategies, (iv) communication, (v) education and counselling, (vi) referrals and care coordination and (vii) stigma.

CONCLUSIONS

PDMP use influenced healthcare providers' clinical decision-making, resulting in both intended and unintended outcomes for patients. PDMPs are a public health initiative designed to reduce harms associated with increased opioid prescribing, yet their use is associated with multiple unintended outcomes. Targeted research is needed to understand the impact of healthcare providers' clinical decision-making after PDMP utilisation, and the clinical outcomes for patients identified through these tools.

Opioid Prescribing After Implementation of Single Click Access to a State Prescription Drug Monitoring Program Database in a Health System's Electronic Health Record

OBJECTIVES

To determine the effect of one-click integration of a state's prescription drug monitoring program (PDMP) on the number of PDMP searches and opioid prescriptions, stratified by specialty.

METHODS

Our large health system worked with the state department of public health to integrate the PDMP with the electronic health record (EHR), which enabled providers to query the data with a single click inside the EHR environment. We evaluated Schedule II or III opioid prescriptions reported to the Massachusetts PDMP 6 months before (November 15, 2017-May 15, 2018) and 6 months after (May 16, 2018, to November 16, 2018) integration. Search counts, prescriptions, patients, morphine milligram equivalents, as well as prescriber specialty were compared.

RESULTS

There were 3,185 unique prescribers with a record of a Schedule II and/or III opioid prescription in both study periods that met inclusion criteria. After integration, the number of PDMP searches increased from 208,684 in the pre-integration phase to 298,478 searches in the post-integration phase (+43.0%). The number of opioid prescriptions dispensed decreased by 4.8%, the number of patients receiving a prescription decreased by 5.1%, and the mean morphine milligram equivalents (MMEs) per prescriber decreased by 5.4%. There were some notable specialty-specific differences in these measures.

CONCLUSIONS

Integration of the PDMP into the EHR markedly increased the number of searches but was associated with modest decreases in opioids prescribed and patients receiving a prescription. Single click EHR integration of the PDMP, if implemented broadly, may be a way for states to significantly increase PDMP utilization.

The impact of community-level prevention strategies on high-dose opioid dispensing rates: 2014-2019

BACKGROUND

Prescription opioids played a major role in the current opioid overdose epidemic. High rates of opioid prescribing and dispensing exposed many people to opioids, and high-dose opioid prescriptions (e.g., 90 morphine milligram equivalents [MME] per day) contributed to increases in opioid overdoses. The Centers for Disease Control and Prevention (CDC) Prevention for States (PfS) program provided funding to jurisdictions ("PfS recipients") with a high burden of opioid-involved overdoses. This paper examines associations between strategies addressing high-dose opioid prescribing and changes in high-dose opioid dispensing.

METHODS

Monthly opioid dispensing data (2014-2019) from IQVIA Xponent were analyzed using longitudinal growth models (LGM) to compare high-dose opioid dispensing rates in the 29 jurisdictions that participated in PfS with rates in non-PfS jurisdictions. Additional models examined associations between specific PfS activities and changes in high-dose dispensing among PfS recipients.

RESULTS

High-dose dispensing rates decreased significantly in both PfS and non-PfS jurisdictions from 2014 to 2019. Rates of high-dose opioid dispensing rates in PfS jurisdictions were not significantly different than those in non-PfS jurisdictions (p = 0.07). Among PfS recipients, multiple activities were associated with decreases in high-dose dispensing rates over time, including moving towards real-time prescription drug monitoring program (PDMP) reporting (p < 0.001) and implementation of opioid dispensing interventions for insurers/ health systems (p < 0.05).

CONCLUSIONS

High-dose opioid dispensing rates decreased throughout the United States from 2014-2019. As the drug epidemic continues to evolve, implementation of prevention activities by state and local partners is important. These findings highlight two potential prevention strategies and activities that jurisdictions can utilize.

A MULTIVARIATE SPATIOTEMPORAL CHANGE-POINT MODEL OF OPIOID OVERDOSE DEATHS IN OHIO

Ohio is one of the states most impacted by the opioid epidemic and experienced the second highest age-adjusted fatal drug overdose rate in 2017. Initially it was believed prescription opioids were driving the opioid crisis in Ohio. However, as the epidemic evolved, opioid overdose deaths due to fentanyl have drastically increased. In this work we develop a Bayesian multivariate spatiotemporal model for Ohio county overdose death rates from 2007 to 2018 due to different types of opioids. The log-odds are assumed to follow a spatially varying change point regression model. By assuming the regression coefficients are a multivariate conditional autoregressive process, we capture spatial dependence within each drug type and also dependence across drug types. The proposed model allows us to not only study spatiotemporal trends in overdose death rates but also to detect county-level shifts in these trends over time for various types of opioids.

Health Care Provider Utilization of Prescription Monitoring Programs: A Systematic Review and Meta-Analysis

OBJECTIVE

To synthesize the literature on the proportion of health care providers who access and use prescription monitoring program data in their practice, as well as associated barriers to the use of such data.

DESIGN

We performed a systematic review using a standard systematic review method with meta-analysis and qualitative meta-summary. We included full-published peer-reviewed reports of study data, as well as theses and dissertations.

METHODS

We identified relevant quantitative and qualitative studies. We synthesized outcomes related to prescription monitoring program data use (i.e., ever used, frequency of use). We pooled the proportion of health care providers who had ever used prescription monitoring program data by using random effects models, and we used meta-summary methodology to identify prescription monitoring program use barriers.

RESULTS

Fifty-three studies were included in our review, all from the United States. Of these, 46 reported on prescription monitoring program use and 32 reported on barriers. The pooled proportion of health care providers who had ever used prescription monitoring program data was 0.57 (95% confidence interval: 0.48-0.66). Common barriers to prescription monitoring program data use included time constraints and administrative burdens, low perceived value of prescription monitoring program data, and problems with prescription monitoring program system usability.

CONCLUSIONS

Our study found that health care providers underutilize prescription monitoring program data and that many barriers exist to prescription monitoring program data use.

How Do Clinicians of Different Specialties Perceive and Use Opioid Risk Mitigation Strategies? A Qualitative Study

BACKGROUND

In response to the opioid crisis, states and health systems are encouraging clinicians to use risk mitigation strategies aimed at assessing a patient's risk for opioid misuse or abuse: opioid agreements, prescription drug monitoring programs (PDMPs), and urine drug tests (UDT). Objective: The objective of this qualitative study was to understand how clinicians perceived and used risk mitigation strategies for opioid abuse/misuse and identify barriers to implementation. Methods: We interviewed clinicians who prescribe opioid medications in the outpatient setting from 2016-2018 and analyzed the data using Constructivist Grounded Theory methodology. Results: We interviewed 21 primary care clinicians and 12 specialists. Nearly all clinicians reported using the PDMP. Some clinicians (adopters) found the opioid agreement and UDTs to be valuable, but most (non-adopters) did not. Adopters found the agreements and UDTs helpful in treating patients equitably, setting limits, and having objective evidence of misuse; protocols and workflows facilitated the use of the strategies. Non-adopters perceived the strategies as awkward, disruptive to the clinician-patient relationship, and introducing a power differential; they also cited lack of time and resources as barriers to use. Conclusions: Our study demonstrates that clinicians in certain settings have found effective ways to implement and use the PDMP, opioid agreements, and UDT but that other clinicians are less comfortable with their use. Administrators and policymakers should ensure that the strategies are designed in a way that strengthens the clinician-patient relationship while maximizing safety for patients and that clinicians are adequately trained and supported when introducing the strategies.

The Effectiveness of Stewardship Interventions to Reduce the Prescribing of Extended-Release Opioids for Acute Pain: A Systematic Review

OBJECTIVE

To evaluate the effectiveness of stewardship interventions in reducing the prescribing of extended-release opioids for acute pain.

DESIGN

Systematic review of randomized controlled trials, pre-post intervention studies, cohort studies and case-control studies.

METHODS

A search was conducted using Medline, Scopus, Cochrane Central Register of Controlled Trials, International Pharmaceutical Abstracts, and PsycINFO from inception to March 24, 2019. Search terms included opioids, interventions, extended-release, and acute pain. Included articles were original research articles outlining the impact of stewardship interventions on reducing the prescribing of extended-release opioids for acute pain.

RESULTS

The search resulted in 1,264 articles after the removal of duplicates. Of these, 141 full texts were assessed, with three eligible for inclusion. One additional article was obtained via a manual search. Three studies explored forcing function interventions; two included prior authorization policies, which saw decreases in extended-release/long-acting scripts by 18-36%, while another evaluated order restrictions producing increased adherence to guidelines by 36%. One study explored the impact of education targeting prescribers and patients through a risk mitigation and evaluation strategy, which decreased extended-release/long-acting quarterly script volumes by 4.3%. All studies were performed at system levels. Forcing function interventions decreased extended-release/long-acting prescriptions and increased adherence to guidelines to a greater extent than less restrictive interventions such as education.

CONCLUSIONS

Forcing function interventions implemented at system levels show promise in decreasing the prescribing of extended-release opioids for acute pain. The current lack of literature warrants future research to increase understanding of the effectiveness of such interventions.

Predictors of pharmacists' likelihood to query prescription drug monitoring program databases

BACKGROUND

Low rates of enrollment and querying of the prescription drug monitoring programs (PDMPs) may be detrimental to the effectiveness of controlling prescription drug misuse. A number of individual-level, organizational, and regulatory factors may affect a community pharmacist's likelihood to query their statewide PDMP.

OBJECTIVE

To identify predictors of pharmacists' likelihood to query the PDMP.

METHODS

A self-administered survey was used to collect data from community pharmacists from a national panel. Measures were identified from previous literature assessing provider likelihood to query PDMPs. A principal components analysis of items pertaining to pharmacists' likelihood to query PDMPs was conducted as a data reduction technique to identify underlying dimensions. Multivariable linear regression was conducted to examine relationships between 5 predictor variables (state regulations, practice setting, workload, perceived barriers, and attitude) and the identified components.

RESULTS

A total of 148 completed survey responses were included for final analysis. The pharmacists'-likelihood-to-query scale comprised 2 components accounting for 71% of the total variance. The 2 components were labeled as higher-risk situations and lower-risk situations. Multivariable linear regression indicated that pharmacists' likelihood to query the PDMP for the higher-risk situations was not statistically significant for any predictor variables. For the lower-risk situations, pharmacists who had a more positive attitude toward the effectiveness of the PDMP were more likely to query it in these situations (unstandardized coefficient = 0.167; P = 0.018).

CONCLUSION

The factors affecting pharmacists' likelihood to query the PDMP may differ depending on the situations faced by the pharmacist. On the basis of the study results, it seems that pharmacists are currently aware of the importance of checking the PDMP and regularly query it. Overall, the respondent pharmacists had a positive attitude toward the effectiveness of the PDMP, which seems to have a role in their likelihood to query it in lower-risk situations.

Assessing reasons for decreased primary care access for individuals on prescribed opioids: an audit study

ABSTRACT

Many primary care clinics are resistant to accept new patients taking prescription opioids for chronic pain. It is unclear how much of this practice is specific to individuals who may be perceived to have aberrant opioid use. This study sought to determine whether clinics are more or less willing to accept and prescribe opioids to patients depending on whether their history is more or less suggestive of aberrant opioid use by conducting an audit survey of primary care clinics in 9 states from May to July 2019. Simulated patients taking opioids for chronic pain called each clinic twice, giving one of 2 scenarios for needing a new provider: their previous physician had either (1) retired or (2) stopped prescribing opioids for unspecified reasons. Clinic willingness to continue prescribing opioids and accept the patient for general primary care were assessed. Of 452 clinics responding to both scenarios (904 calls), 193 (43%) said their providers would not prescribe opioids in either scenario, 146 (32%) said their providers might prescribe in both, and 113 (25%) responded differently to each scenario. Clinics responding differently had greater odds (odds ratio = 1.83 confidence interval [1.23-2.76]) of willingness to prescribe when the previous doctor retired than when the doctor had stopped prescribing. These findings suggest that primary care access is limited for patients taking opioids for chronic pain, and differentially further reduced for patients whose histories are suggestive of aberrant use. This denial of care could lead to unintended harms such as worsened pain or conversion to illicit substances.

State-led opioid overdose prevention efforts: Challenges, solutions and lessons learned from the CDC Prevention for States Program (PfS)

Background: The Centers for Disease Control and Prevention's Prevention for States (PfS) program funded 29 state health departments to prevent opioid overdose by implementing evidence-based prevention strategies. The objectives of this analysis were to describe the scope of activities implemented across the four PfS strategies and identify implementation challenges. Methods: PfS recipients submitted annual progress reports (APRs) to state support staff at CDC from 2015 to 2017. APR data were used to calculate the number of required and optional activities implemented under each PfS strategy. APR data were qualitatively analyzed using a systematic content analysis approach to identify key implementation challenges. Results: From 2015 to 2017, PfS recipients implemented 177 activities across four strategies from 2015 to 2017. Cross-cutting implementation challenges were (1) multi-sector collaboration, (2) lack of knowledge and misperceptions about opioid used disorder (OUD) among some partners and local communities and; (3) management and access to opioid data among PfS recipients. Conclusions: PfS recipients implemented an array of prevention interventions to address the opioid overdose crisis and encountered several cross-cutting implementation challenges. Challenges and state driven solutions over the course of implementing PfS led to several lessons learned and actions that CDC enacted to continue to support and expand overdose prevention.

Assessment of gabapentin misuse using prescription drug monitoring program data

BACKGROUND

Gabapentin is an anticonvulsant medication with potential misuse reported in case reports and population studies, highlighting the need to reexamine its abuse liability. The purpose of this study was to describe gabapentin dispensing patterns and assess potential misuse. Methods: We used data from Ohio's Prescription Drug Monitoring Program (PDMP) from December 1, 2016 to March 31, 2017 and restricted the population to adults who filled at least one gabapentin prescription (N = 379,372). Gabapentin dispensing patterns are described and multiple strategies were used to assess potential misuse, including Lorenz-1 curve analysis. Supratherapeutic dosing, number of prescribers and number of pharmacies used were compared for individuals who were co-dispensed medications for opioid use disorder (MOUD) and those who were not. Results: More than one million gabapentin prescriptions were dispensed during the 4-month period, with a mean dose of 1103.8 mg. While few individuals received supratherapeutic dosing, exceptionally high doses were observed. Half of the individuals (50.9%) were co-dispensed gabapentin and opioids. The Lorenz-1 value for gabapentin (5.5%) did not exceed the threshold for misuse potential. Individuals co-dispensed MOUD were more likely to have supratherapeutic dosing; however, they had a lower Lorenz-1 value compared to individuals not co-dispensed MOUD. Conclusions: Among Ohio residents dispensed gabapentin, there was no evidence of misuse using PDMP data based on the Lorenz-1 value, yet supratherapeutic dosing of gabapentin was observed and was associated with OUD. New strategies may be needed to identify the non-medical use of gabapentin.

Best practices in benzodiazepine prescribing and management in primary care

ABSTRACT

Despite the lack of evidence on the long-term effectiveness of benzodiazepines and their potential harmful effects, prescriptions of the drug have significantly increased in the US over the past decade. This article reviews best practices regarding primary care benzodiazepine prescriptions and how providers can best prevent and treat benzodiazepine use disorder and other harmful effects.

Attending and Resident Surgeon Perspectives and Prescribing Practices of Pain Medication During the Opioid Epidemic

OBJECTIVE

Over 67,000 individuals died in the United States due to drug overdose in 2018; the majority of these deaths were secondary to opioid ingestion. Our aim was to determine surgeon perceptions on opioid abuse, the adequacy of perioperative and graduate medical education, and the role surgeons may play. We also aimed to investigate any differences in attending and resident surgeon attitudes.

DESIGN

Anonymous online survey assessing surgeons' opioid counseling practices, prescribing patterns, and perceptions on opioid abuse, adequacy of education about opioid abuse, and the role physicians play.

SETTING

Two Accreditation Council for Graduate Medical Education accredited general surgery programs at a university-based tertiary hospital and a community hospital in the Midwest.

PARTICIPANTS

Attending and resident physicians within the Departments of Surgery participated anonymously.

RESULTS

Attending surgeons were more likely than residents to discuss posoperative opioids with patients (62% vs. 33%; p < 0.05), discuss the potential of opioid abuse (31% vs. 6%; p < 0.05), and check state-specific prescription monitoring programs (15% vs. 0%; p < 0.05). Surgeons and trainees feel that surgeons have contributed to the opioid epidemic (76% attending vs. 88% resident). Overall, attending and resident surgeons disagree that there is adequate formal education (66% vs. 66%) but adequate informal education (48% vs. 61%) on opioid prescribing. However, when attending physicians were broken down into those who have practiced ≤5 years vs. those with >5 years experience, those with ≤5 years experience were more confident in recognizing opioid abuse (61% vs. 34%) and fewer young faculty disagreed that there is adequate formalized education on opioid prescribing (45% vs. 84%).

CONCLUSION AND RELEVANCE

Patient education should be improved upon in the preoperative setting and should be treated as an important component of preoperative discussions. Formalized opioid education should also be undertaken in graduate surgical education to help guide appropriate opioid use by resident and attending physicians.

Opioid Prescribing Laws Are Not Associated with Short-term Declines in Prescription Opioid Distribution

OBJECTIVE

To determine whether the adoption of laws that limit opioid prescribing or dispensing is associated with changes in the volume of opioids distributed in states.

METHODS

State-level data on total prescription opioid distribution for 2015-2017 were obtained from the US Drug Enforcement Administration. We included in our analysis states that enacted an opioid prescribing law in either 2016 or 2017. We used as control states those that did not have an opioid prescribing law during the study period. To avoid confounding, we excluded from our analysis states that enacted or modified mandates to use prescription drug monitoring programs (PDMPs) during the study period. To estimate the effect of opioid prescription laws on opioid distribution, we ran ordinary least squares models with indicators for whether an opioid prescription law was in effect in a state-quarter. We included state and quarter fixed effects to control for time trends and time-invariant differences between states.

RESULTS

With the exception of methadone and buprenorphine, the amount of opioids distributed in states fell during the study period. The adoption of opioid prescribing laws was not associated with additional decreases in opioids distributed.

CONCLUSIONS

We did not detect an association between adoption of opioid prescribing laws and opioids distributed. States may instead wish to pursue evidence-based efforts to reduce opioid-related harm, with a particular focus on treatment access and harm reduction interventions.

Factors associated with the use of the prescription monitoring program by prescribers and pharmacists in Texas

PURPOSE

To describe Texas Prescription Monitoring Program (PMP) use and identify predictors of PMP query for opioid and benzodiazepine prescriptions by prescribers and pharmacists.

METHODS

Dispensation and query records from the Texas PMP for opioid and benzodiazepine medications dispensed between October 1, 2016 and December 31, 2018 were linked using common patient identifiers. Autoregressive linear regression was used to assess trends in utilization. Hierarchical logistic models were specified to identify factors associated with provider and pharmacist query of opioid and benzodiazepine prescriptions.

RESULTS

Despite a significant increase in the total number of pharmacists (β = 169.85, p < 0.0001) and prescribers (β = 301.59, p < 0.0001) who used the PMP every month, the ratio of active to registered pharmacists (β = -0.0001, p = 0.75) and prescribers (β = -0.0015, p = 0.10) did not change. Pharmacists and prescribers were significantly more likely to query opioid and benzodiazepine prescriptions of 14 days or more, and those issued to patients new to their practice. Pharmacists were most likely to query opioid prescriptions for oxycodone (aOR = 4.51, 95%CI = 4.42-4.60) and prescribers were most likely to query prescriptions for buprenorphine (aOR = 2.24, 95%CI = 2.15-2.35) compared to codeine.

CONCLUSION

Changes in PMP utilization between October 2016 and December 2018 were driven by increasing registration, not increasing frequency of use among registered users. Use of the PMP is inconsistent and dependent upon patient characteristics thus limiting the utility of the PMP as a decision support tool. These results support the need for policy mandating PMP use in Texas and provide a useful baseline and framework to evaluate the effectiveness of mandate implementation.

The Effect of State Legislation on Opioid Prescriptions Following Arthroscopic Rotator Cuff Repair

New Jersey State Law, P.L. 2017 Chapter 28 22, C.24:21-15.2, passed in February 2017, is the most restrictive opioid legislation passed thus far in the United States. This study evaluated the effects of this legislation on the postoperative opioid prescriptions of patients undergoing arthroscopic rotator cuff repair (RCR). Opioid prescriptions were compared following arthroscopic RCR before and after implementation of the new law using the New Jersey Prescription Monitoring Program Aware Drug Database. A consecutive cohort of patients who underwent RCR during a 6-month period prior to the legislation was compared with a consecutive cohort of patients who underwent RCR during a 6-month period after the law went into effect. The primary outcome measure was prescribed postoperative milligram morphine equivalents (MME) and number of pills prescribed. There were 265 patients in the pre-law cohort and 198 patients in the post-law cohort. In the pre-law cohort, there was a median of 1250 MME (interquartile range [IQR], 900-1800 MME) and a median of 100 pills (IQR, 60-175 pills) prescribed postoperatively. In the post-law cohort, a median of 900 MME (IQR, 550-1050 MME) and a median of 60 pills (IQR, 60-90 pills) were prescribed postoperatively. A comparison of pre-law and post-law data for MME and number of pills prescribed was statistically significant (P<.001). The median opioid consumption MME and number of pills prescribed following RCR decreased significantly following the implementation of the New Jersey state law. Findings of this study indicate state regulations may play a role in reducing narcotic consumption following RCR. [Orthopedics. 2021;44(1):e80-e84.].

Changes in opioid prescribing after implementation of mandatory registration and proactive reports within California's prescription drug monitoring program

BACKGROUND

In 2016, California updated its prescription drug monitoring program (PDMP), adding two key features: automated proactive reports to prescribers and mandatory registration for prescribers and pharmacists. The effects of these changes on prescribing patterns have not yet been examined. We aimed to evaluate the joint effect of these two PDMP features on county-level prescribing practices in California.

METHODS

Using county-level quarterly data from 2012 to 2017, we estimated the absolute change associated with the implementation of these two PDMP features in seven prescribing indicators in California versus a control group comprising counties in Florida and Washington: opioid prescription rate per 1000 residents; patients' mean daily opioid dosage in milligrams of morphine equivalents[MME]; prescribers' mean daily MME prescribed; prescribers' mean number of opioid prescriptions per day; percentage of patients getting >90 MME/day; percentage of days with overlapping prescriptions for opioids and benzodiazepines; multiple opioid provider episodes per 100,000 residents.

RESULTS

Proactive reports and mandatory registration were associated with a 7.7 MME decrease in patients' mean daily opioid dose (95 %CI: -11.4, -2.9); a 1.8 decrease in the percentage of patients prescribed high-dose opioids (95 %CI: -2.3, -0.9); and a 6.3 MME decrease in prescribers' mean daily dose prescribed (95 %CI: -10.0, -1.3).

CONCLUSIONS

California's implementation of these two PDMP features was associated with decreases in the total quantity of opioid MMEs prescribed, and indicators of patients prescribed high-dose opioids compared to states that had PDMP's without these features. Rates of opioid prescribing and other high-risk prescribing patterns remained unchanged.

A Rapid Review of the Impact of Systems-Level Policies and Interventions on Population-Level Outcomes Related to the Opioid Epidemic, United States and Canada, 2014-2018

OBJECTIVES

In the United States, rising rates of overdose deaths and recent outbreaks of hepatitis C virus and HIV infection are associated with injection drug use. We updated a 2014 review of systems-level opioid policy interventions by focusing on evidence published during 2014-2018 and new and expanded opioid policies.

METHODS

We searched the MEDLINE database, consistent with the 2014 review. We included articles that provided original empirical evidence on the effects of systems-level interventions on opioid use, overdose, or death; were from the United States or Canada; had a clear comparison group; and were published from January 1, 2014, through July 19, 2018. Two raters screened articles and extracted full-text data for qualitative synthesis of consistent or contradictory findings across studies. Given the rapidly evolving field, the review was supplemented with a search of additional articles through November 17, 2019, to assess consistency of more recent findings.

RESULTS

The keyword search yielded 535 studies, 66 of which met inclusion criteria. The most studied interventions were prescription drug monitoring programs (PDMPs) (59.1%), and the least studied interventions were clinical guideline changes (7.6%). The most common outcome was opioid use (77.3%). Few articles evaluated combination interventions (18.2%). Study findings included the following: PDMP effectiveness depends on policy design, with robust PDMPs needed for impact; health insurer and pharmacy benefit management strategies, pill-mill laws, pain clinic regulations, and patient/health care provider educational interventions reduced inappropriate prescribing; and marijuana laws led to a decrease in adverse opioid-related outcomes. Naloxone distribution programs were understudied, and evidence of their effectiveness was mixed. In the evidence published after our search's 4-year window, findings on opioid guidelines and education were consistent and findings for other policies differed.

CONCLUSIONS

Although robust PDMPs and marijuana laws are promising, they do not target all outcomes, and multipronged interventions are needed. Future research should address marijuana laws, harm-reduction interventions, health insurer policies, patient/health care provider education, and the effects of simultaneous interventions on opioid-related outcomes.

Addressing the Opioid Crisis through an Interdisciplinary Task Force in Cincinnati, Ohio, USA

Opioid use has been a topic of concern in recent years in the United States, causing thousands of deaths each year. Ohio is one of the states hit hardest by the epidemic, and its state and local governments have responded with comprehensive health policies. Cincinnati, located in the southwest region of Ohio, is one of the epicenters of the state’s opioid crisis. Responding to the needs of their community, the University of Cincinnati (UC) and its affiliate health system, UC Health, have brought together leaders in research, clinical practice, and education to form the UC/UC Health Opioid Task Force. By encouraging interdisciplinary partnerships, the Task Force is pioneering new ways to understand, prevent, and treat opioid use disorder, while preparing the next generation of healthcare professionals. Additionally, collaboration across departments in UC Health has improved access to treatment and recovery resources for hundreds of patients. Leading educational events, supporting local agencies, and participating in government initiatives have further solidified UC and UC Health’s role as a stakeholder in this crisis, showcasing how academic health centers are critical to promoting public health.

Mortality Secondary to Unintentional Poisoning after Inpatient Rehabilitation among Individuals with Moderate to Severe Traumatic Brain Injury

Studies have shown reduced life expectancy following moderate-severe traumatic brain injury (TBI) with death from unintentional poisoning (UP) being 11 times higher following TBI than in the general population. The characteristics of those who die of unintentional poisoning are compared with the characteristics of those who die of other causes (OC) in a retrospective cohort who received inpatient rehabilitation following TBI and enrolled in the TBI Model Systems National Database between 1989 and 2017 (n = 15,835 cases with 2,238 deaths recorded). Seventy-eight cases (3.5%) of deaths were the result of UP, 76% were the result of OC, and 20.5% were from an unknown cause. Among the UP deaths, 90% involved drugs (of these, 67% involved narcotic drugs and 14% involved psychostimulants), and 8% involved alcohol. Age-adjusted risk for UP death was associated with: white/non-Hispanic race/ethnicity, living alone, non-institutionalization, pre- and post-injury illicit drug use and alcohol/drug problem use, any alcohol use at last follow-up, better Functional Independence Measure^TM (FIM) scores, history of arrest, moderate disability (vs. severe disability or good recovery), less supervision needed, and greater anxiety. Adults who receive inpatient rehabilitation for TBI who die from UP are distinguishable from those who die of OC. Factors such as pre-injury substance use in the context of functional independence may be regarded as targets for prevention and/or intervention to reduce substance use and substance-related mortality among survivors of moderate-severe TBI. The current findings may have implications for medical care, surveillance, prevention, and health promotion.

Assessing Patients' Risk for Opioid Use Disorder

Opioid use disorder and opioid misuse continue to increase rapidly in prevalence in North America. Nurses play a critical role in managing pain in patients who are at risk for opioid use disorder. The interplay of pain and opioid use disorder provides nurses with an opportunity to address urgent needs while treating patients across the continuum of care. This article reviews strategies for assessing risk for opioid use disorder while treating patients with pain. Implementing these approaches into daily nursing practice may improve patient care and help reduce the incidence of opioid use disorder.

Advances in prescription drug monitoring program research: a literature synthesis (June 2018 to December 2019)

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.

The Bell Tolls for Thee & Thine: Compassion Fatigue & the Overdose Epidemic

Non-fatal and fatal overdoses are traumatic events that have been increasing over the past 20 years and disproportionately impacting rural communities in the United States. The human suffering caused by the opioid epidemic is rarely described in the empirical literature. The purpose of this article is to 1) define individual- and community-level overdose-related compassion fatigue (OCF), 2) review measurement of compassion fatigue (CF) and interventions to reduce CF, 3) discuss strategies that may reduce OCF and 4) briefly discuss policy implications. OCF is distress resulting from knowledge of or exposure to overdose-related harms, which at the community-level may prohibit collaboration and adaptive agency to effectively respond. When OCF occurs at a community-level, it could have negative consequences by eroding support for evidence-based services and fueling stigma-driven policies that blame people who use drugs. Empathy underlies both OCF and vicarious resilience by allowing one to understand the suffering caused by overdose deaths and to witness the joy of addiction recovery. Using the risk environment framework, OCF at the micro- and macro-levels of the social environment, may increase rural communities' vulnerability to harm by emphasizing individual responsibility for reducing overdoses rather than community-level infrastructure and resource management. Additional research is needed to develop a measure of OCF and to confirm whether OCF is associated with increased stigma and decreased support for harm reduction in rural areas.

Opioid-induced Somatic Activation: Prevalence in a Population of Patients With Chronic Pain

Context and objective Opioids have heterogeneous side effects including a well-known effect of sedation; however, the opposing effect of stimulation, or somatic activation, has been largely ignored or overlooked. The objective of this study is to determine the prevalence of opioid-induced somatic activation (OISA). Methods We conducted a retrospective chart review of 189 patients seen by a single clinical psychiatrist/pain specialist. During the initial encounter, the clinician took a standardized history of every opioid currently or previously taken by the patients, and enquired if the patients had experienced a somatically activating or sedating effect per opioid. Results Patients recalled an average exposure to 5.1 opioids (SD: 1.9). Ninety-one patients (48.1%; mean: 1.6) reported somatic activation, while 118 (62.4%; mean: 1.7) reported sedation from at least one opioid. Fifty-eight patients (30.7%) identified at least one opioid as activating, and another as sedating. The distribution of OISA did not significantly differ by gender, race, primary pain diagnosis, or depression. The distribution of OISA by oxycodone significantly differed compared to morphine sulfate (27.3% vs 8.9%; p: 0.005), while sedation did not (29.0% vs 24.3%; p: 0.46). Conclusions In this study, we quantified the previously unstudied phenomenon of OISA. This phenomenon appears dependent on opioid type with some opioids, such as oxycodone, appearing more likely to have this effect. Given current concerns about the risks of opioids in high-risk populations, future studies are needed to study this phenomenon to arrive at an accurate determination of the potential risks and benefits of OISA.

Prescription Drug Monitoring Programs and Prescription Opioid-Related Outcomes in the United States

Prescription drug monitoring programs (PDMPs) are a crucial component of federal and state governments' response to the opioid epidemic. Evidence about the effectiveness of PDMPs in reducing prescription opioid-related adverse outcomes is mixed. We conducted a systematic review to examine whether PDMP implementation within the United States is associated with changes in 4 prescription opioid-related outcome domains: opioid prescribing behaviors, opioid diversion and supply, opioid-related morbidity and substance-use disorders, and opioid-related deaths. We searched for eligible publications in Embase, Google Scholar, MEDLINE, and Web of Science. A total of 29 studies, published between 2009 and 2019, met the inclusion criteria. Of the 16 studies examining PDMPs and prescribing behaviors, 11 found that implementing PDMPs reduced prescribing behaviors. All 3 studies on opioid diversion and supply reported reductions in the examined outcomes. In the opioid-related morbidity and substance-use disorders domain, 7 of 8 studies found associations with prescription opioid-related outcomes. Four of 8 studies in the opioid-related deaths domain reported reduced mortality rates. Despite the mixed findings, emerging evidence supports that the implementation of state PDMPs reduces opioid prescriptions, opioid diversion and supply, and opioid-related morbidity and substance-use disorder outcomes. When PDMP characteristics were examined, mandatory access provisions were associated with reductions in prescribing behaviors, diversion outcomes, hospital admissions, substance-use disorders, and mortality rates. Inconsistencies in the evidence base across outcome domains are due to analytical approaches across studies and, to some extent, heterogeneities in PDMP policies implemented across states and over time.

Self-reported sleep disturbance in ambulance attendances for suicidal ideation and attempted suicide between 2012 and 2017

BACKGROUND

Sleep disturbances are among the top-ten warning signs for suicide, however there has been limited investigation of the relationship between these variables in acute presentations, particularly community settings. We examined ambulance attendances for suicide ideation and attempt to explore the role of sleep and co-morbid factors (mental health symptoms, attendance time, and alcohol and benzodiazepine use).

METHODS

Coded clinical records from Ambulance Victoria for the period 1 January 2012 to 30 June 2017 were analysed.

RESULTS

Paramedics attended 97,198 cases of suicidal ideation or suicide attempt during the study period. Just over half (56.4%) of these were for suicidal ideation, and 43.6% were for attempted suicide. Depression symptomology-related attendances were more common than those for anxiety and despite a lower proportion of both sleep and current anxiety-related symptoms, benzodiazepine use was significantly more common in attendances for suicide attempts (25.9%) than for ideation (2.2%). Co-morbid benzodiazepine use was associated with attempted suicide (OR: 10.37 (10.04-10.72), in a hierarchical regression model.

LIMITATIONS

Data represent self-report/paramedic observation only, and do include validated measures of sleep or drug use. Sleep disturbance is likely under recorded in ambulance attendances given the primary role of paramedics is to stabilise patients, and minimise risk of harm during transport.

CONCLUSION

This study reports internationally unique data, and provides the first examination of ambulance coded clinical records for suicide ideation and attempt. Sleep disturbances had a unique role in these attendances, over and above common co-occurring factors including drug use and mental health diagnoses.

Prescription drug monitoring programs and drug overdose deaths involving benzodiazepines and prescription opioids

BACKGROUND AND AIMS

In the US, benzodiazepine overdose deaths increased at an alarming rate in the past two decades. Benzodiazepines were also the most common drugs involved in prescription opioid overdose deaths. Benzodiazepine prescribing has been monitored by Prescription Drug Monitoring Programs (PDMPs), but little was known about whether PDMPs reduced drug overdose deaths involving benzodiazepines.

DESIGN AND METHODS

This study used a difference-in-difference design with state-quarter aggregate data on drug overdose deaths. The primary data source was Mortality Multiple Cause Files in 1999-2016. Three age-adjusted rates of drug overdose deaths were examined, including those involving benzodiazepines, those involving prescription opioids, and those involving both benzodiazepines and prescription opioids. The policy variables included PDMP data access for benzodiazepines and mandatory use of PDMP data for benzodiazepines. Linear multivariable regressions were used to assess the associations of PDMP policies specific to benzodiazepines with drug overdose death rates, controlling for other state-level policy and socioeconomic factors, state and time fixed effects, and state-specific time trends.

RESULTS

No significant associations were found between PDMP data access for benzodiazepines and changes in drug overdose death rates involving benzodiazepines and/or prescription opioids. Similarly, no significant associations were found between mandatory use of PDMP data for benzodiazepines and changes in drug overdose death outcomes.

DISCUSSION AND CONCLUSIONS

This study suggested no evidence that PDMP policies specific to benzodiazepines were associated with reduction in benzodiazepine overdose death rates. Future research is warranted to examine detailed features of PDMPs and continuously monitor the impacts of PDMP policies on benzodiazepine-related consequences.

Comparing Changes in Controlled Substance Prescribing Trends by Provider Type

BACKGROUND AND OBJECTIVES

Forty-nine out of 50 states have implemented Prescription Drug Monitoring Programs (PDMPs) to monitor controlled substance (CS) prescribing. PDMPs change health care provider behavior, but few studies have examined changes in CS prescription by health care provider type.

METHODS

Aggregated yearly data, including number of CS prescriptions, doses, and doses per prescription by health care provider type (physician, advanced practice registered nurse [APRN], and dentist) for each year from 2011 to 2017 was provided by the state PDMP, Kentucky All Schedule Prescription Electronic Reporting System (KASPER). In aggregate, this data set included 64,578,307 total prescriptions and 3,982,130,994 total doses of Schedule II-V medications.

RESULTS

Physicians and dentists showed a trend of decreasing prescriptions and doses for Schedule II opioids from 2012 to 2017 (27-32% reduction in 2017 compared to 2011). APRNs showed a substantive increase in the number of doses and prescriptions (121-204% increase in 2017 compared to 2011), with increases remaining when controlling for number of providers. Physicians increased doses and prescriptions of Schedule II stimulants (37% increase for both doses and prescriptions), but by a smaller magnitude than APRN increases in stimulants (334-360% increase). Dentists showed decreases in Schedule II stimulants prescribed (69-80% reduction). Similar trends, but more modest in magnitude, were observed for Schedule III-IV.

DISCUSSION AND CONCLUSIONS

Although monitoring and continuing education requirements are similar across all providers in Kentucky, differences in prescription trends for Schedule II opioids and stimulants were noted for physicians, APRNs, and dentists.

SCIENTIFIC SIGNIFICANCE

Changes in prescribing following introduction of mandatory use of KASPER markedly differed based on provider type, with increases observed for APRNs compared with physicians and dentists. These findings advance prior research by providing a detailed examination of prescribing trends by provider type subsequent to a PDMPs mandatory use law. (Am J Addict 2019;00:00-00).

Do prescription drug monitoring programs encourage prescription - or illicit - opioid abuse?

BACKGROUND

Prescription drug monitoring programs (PDMPs) are tools that states can use to fight prescription opioid misuse within their jurisdiction. However, because PDMPs make prescription opioids more difficult to access, these programs may have the unintended consequence of increasing deaths related to illicit opioids. Methods: This study uses fixed effects models to estimate how PDMP regulatory strength is associated with both prescription opioid- and heroin-related deaths between 1999 and 2016. PDMP regulatory strength is measured by creating a score using multiple correspondence analysis (MCA). Additional models replace the MCA score with a binary indicator for the presence of one particular regulation requiring physicians to access the system before writing opioid prescriptions. Results: Results show that continuous measures of PDMP strength are not generally associated with prescription opioid- or heroin-related death rates. Yet, one model does show that PDMP scores are positively associated with the heroin-related death rate. The models using the binary mandatory access variable show a strong positive association with both prescription opioid and heroin deaths. Conclusions: This study supports the theory that more stringent state PDMPs are associated with higher rates of heroin-related deaths, potentially due to decreases in prescription opioid availability.