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Yessaillian A, Reese M, Clark RC, Becker M, Lopes K, Alving-Trinh A, Llaneras J, McPherson M, Gosman A, Reid CM. A systematic review of morphine equivalent conversions in plastic surgery: Current methods and future directions. J Plast Reconstr Aesthet Surg 2024; 95:142-151. [PMID: 38909598 DOI: 10.1016/j.bjps.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 05/16/2024] [Accepted: 06/01/2024] [Indexed: 06/25/2024]
Abstract
INTRODUCTION Protocols surrounding opioid reduction have become commonplace in plastic surgery to improve peri-operative outcomes. Within such protocols, opioid requirement is a frequently analyzed outcome. Though often examined, there is no literature standard conversion for morphine milligram equivalents (MME) at present, leading to questionable external validity. We hypothesized significant heterogeneity in MME reporting would exist within plastic surgery literature. METHODS Following the PRISMA guidelines, the authors conducted a systematic review of 16 journals. Clinical studies focused on opioid reduction within plastic surgery were identified. Primary outcomes included reporting of morphine equivalents (ME) delivery (IV/oral), operative ME, inpatient ME, outpatient ME, timeline, and method of calculation. RESULTS Among the 101 studies analyzed, 73% reported opioid requirements in the form of ME. Among those that used ME, 3% reported IV ME, 41% reported oral, 32% reported both, and 25% gave no indication of either. Operative ME were reported in 19% of studies. Furthermore, 54% of studies reported inpatient ME whereas 32% of studies reported outpatient ME. Only 19% reported the number of days opioids were consumed postoperatively. Moreover, 27% of the studies reported the actual method of ME conversion, with 17 unique methods described. Only 8 studies (8%) reported using the Center for Disease Control and Prevention guidelines for ME conversion. CONCLUSION There is significant variability among the reported ME conversion methodology within plastic surgery literature. Highlighting these discrepancies is an essential step in creating and implementing a single, standard method to mitigate opioid morbidity in plastic surgery and to optimize enhanced recovery protocols.
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Affiliation(s)
- Andrea Yessaillian
- UC San Diego School of Medicine, 9500 Gilman Dr, San Diego, CA, United States
| | - McKay Reese
- UC San Diego School of Medicine, 9500 Gilman Dr, San Diego, CA, United States
| | - Robert Craig Clark
- UC San Diego Division of Plastic Surgery, 200 W. Arbor Drive M/C 8890, San Diego, CA 92013, United States
| | - Miriam Becker
- UC San Diego School of Medicine, 9500 Gilman Dr, San Diego, CA, United States
| | - Kelli Lopes
- UC San Diego School of Medicine, 9500 Gilman Dr, San Diego, CA, United States
| | - Alexandra Alving-Trinh
- UC San Diego Division of Plastic Surgery, 200 W. Arbor Drive M/C 8890, San Diego, CA 92013, United States
| | - Jason Llaneras
- UC San Diego Division of Plastic Surgery, 200 W. Arbor Drive M/C 8890, San Diego, CA 92013, United States
| | - Mary McPherson
- University of Maryland School of Pharmacy, 20 N Pine St, Baltimore, MD 21201, United States
| | - Amanda Gosman
- UC San Diego Division of Plastic Surgery, 200 W. Arbor Drive M/C 8890, San Diego, CA 92013, United States
| | - Chris M Reid
- UC San Diego Division of Plastic Surgery, 200 W. Arbor Drive M/C 8890, San Diego, CA 92013, United States.
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Choo EK, Charlesworth CJ, Livingston CJ, Hartung DM, El Ibrahimi S, Kraynov L, McConnell KJ. Outcomes After a Statewide Policy to Improve Evidence-Based Treatment of Back Pain Among Medicaid Enrollees in Oregon. J Gen Intern Med 2024:10.1007/s11606-024-08776-w. [PMID: 38951321 DOI: 10.1007/s11606-024-08776-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 04/18/2024] [Indexed: 07/03/2024]
Abstract
BACKGROUND A novel Oregon Medicaid policy guiding back pain management combined opioid restrictions with emphasis on non-opioid and non-pharmacologic therapies. OBJECTIVE To examine the effect of the policy on prescribing, health outcomes, and health service utilization. DESIGN Using Medicaid enrollment, medical and prescription claims, prescription drug monitoring program, and vital statistics files, we analyzed the policy's association with selected outcomes using interrupted time series models. SUBJECTS Adult Medicaid patients with back pain enrolled between 2014 and 2018. INTERVENTION The Oregon Medicaid back pain policy. MAIN MEASURES Opioid and non-opioid medication prescribing, procedural care, substance use and mental health conditions, and outpatient and inpatient healthcare utilization. KEY RESULTS The policy was associated with decreases in the percentage of Medicaid enrollees with back pain receiving any opioids (- 2.68 percentage points [95% CI - 3.14, - 2.23] level, - 1.01 pp [95% CI - 1.1, - 0.92] slope), days of short-acting opioid use (- 0.4 days [95% CI - 0.53, - 0.26] slope), receipt of more than 7 days of short-acting opioids (- 2.36 pp [95% CI - 2.76, - 1.95] level, - 0.91 pp [95% CI - 1, - 0.83] slope), chronic opioid use (- 1.27 pp [95% CI - 1.59, - 0.94] level, - 0.46 [95% CI - 0.53, - 0.39 slope), and spinal surgeries and procedures. Among secondary outcomes, we found no increase in opioid overdose and a small, statistically significant trend decrease in opioid use disorders. There were small increases in non-opioid substance use and mental health diagnoses and visits but no increase in self-harm. CONCLUSIONS A state Medicaid policy emphasizing evidence-based back pain management was associated with decreases in opioid prescribing, spinal surgeries, and opioid use disorder trends, but also short-term increases in mental health encounters and an increase in non-opioid substance use disorder trends. Such policies may help reinforce evidence-based care, but must be designed with consideration of potential harms.
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Affiliation(s)
- Esther K Choo
- Center for Policy & Research in Emergency Medicine (CPR-EM), Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, USA.
| | - Christina J Charlesworth
- Center for Health Systems Effectiveness (CHSE), Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, USA
| | | | | | - Sanae El Ibrahimi
- Division of Research and Evaluation, Comagine Health, Portland, OR, USA
- School of Public Health, Department of Epidemiology and Biostatistics, University of Nevada, Las Vegas, NV, USA
| | | | - K John McConnell
- Center for Health Systems Effectiveness (CHSE), Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, USA
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Smith CJ, Payne VM. Epidemiology studies on effects of lithium salts in pregnancy are confounded by the inability to control for other potentially teratogenic factors. Hum Exp Toxicol 2024; 43:9603271241236346. [PMID: 38394684 DOI: 10.1177/09603271241236346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
INTRODUCTION In bipolar women who took lithium during pregnancy, several epidemiology studies have reported small increases in a rare fetal cardiac defect termed Ebstein's anomaly. METHODS Behavioral, environmental, and lifestyle-associated risk factors associated with bipolar disorder and health insurance status were determined from an Internet search. The search was conducted from October 1, 2023, through October 14, 2023. The search terms employed included the following: bipolar, bipolar disorder, mood disorders, pregnancy, congenital heart defects, Ebstein's anomaly, diabetes, hypertension, Medicaid, Medicaid patients, alcohol use, cigarette smoking, marijuana, cocaine, methamphetamine, narcotics, nutrition, diet, obesity, body mass index, environment, environmental exposures, poverty, socioeconomic status, divorce, unemployment, and income. No quotes, special fields, truncations, etc., were used in the searches. No filters of any kind were used in the searches. RESULTS Women who remain on lithium in the United States throughout their pregnancy are likely to be experiencing mania symptoms and/or suicidal ideation refractory to other drugs. Pregnant women administered the highest doses of lithium salts would be expected to have been insufficiently responsive to lower doses. Any small increases in the retrospectively determined risk of fetal cardiac anomalies in bipolar women taking lithium salts cannot be disentangled from potential developmental effects resulting from very high rates of cigarette smoking, poor diet, alcohol abuse, ingestion of illegal drugs like cocaine or opioids, marijuana smoking, obesity, and poverty. CONCLUSIONS The small risks in fetal cardiac abnormalities reported in the epidemiology literature do not establish a causal association for lithium salts and Ebstein's anomaly.
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Affiliation(s)
- Carr J Smith
- Department of Alzheimer's Section, Society for Brain Mapping and Therapeutics, Mobile, AL, USA
| | - Victoria M Payne
- Psychiatric Associates of North Carolina Professional Association, Raleigh, NC, USA
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Treitler P, Samples H, Hermida R, Crystal S. Association of a State Prescribing Limits Policy with Opioid Prescribing and Long-term Use: an Interrupted Time Series Analysis. J Gen Intern Med 2023; 38:1862-1870. [PMID: 36609812 PMCID: PMC10271990 DOI: 10.1007/s11606-022-07991-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 12/22/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Prescription opioids were a major initial driver of the opioid crisis. States have attempted to reduce overprescribing by enacting policies that limit opioid prescriptions, but the impacts of such policies on new prescribing and subsequent transitions to long-term use are not fully understood. OBJECTIVE To examine the association of implementation of a state prescribing limits policy with opioid prescribing and transitions to long-term opioid use. DESIGN Interrupted time series analyses assessing trends in new opioid prescriptions and long-term use before and after policy implementation. PATIENTS A total of 130,591 New Jersey Medicaid enrollees ages 18-64 who received an initial opioid prescription from January 2014 to December 2019. INTERVENTIONS New Jersey's opioid prescribing limit policy implemented in March 2017. MAIN MEASURES Total new opioid prescriptions, percentage of new prescriptions with >5 days' supply, and transition to long-term opioid use, defined as having opioid supply on day 90 after the initial prescription. KEY RESULTS Policy implementation was associated with a significant monthly increase in new opioid prescriptions of 0.86 per 10,000 enrollees, halving the pre-policy decline in the prescribing rate. Among new opioid prescriptions, the percentage with >5 days' supply decreased by about 1 percentage point (-0.76 percentage points, 95% CI -0.89, -0.62) following policy implementation. However, policy implementation was associated with a significant monthly increase in the rate of initial prescriptions with supply on day 90 (9.95 per 10,000 new prescriptions, 95% CI 4.80, 15.11) that reversed the downward pre-implementation trend. CONCLUSIONS The New Jersey policy was associated with a reduction in initial prescriptions with >5 days' supply, but not with an overall decline in new opioid prescriptions or in the rate at which initial prescriptions led to long-term use. Given their only modest benefits, policymakers and clinicians should carefully weigh potential unintended consequences of strict prescribing limits.
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Affiliation(s)
- Peter Treitler
- Institute for Health, Health Care Policy & Aging Research, Rutgers University, New Brunswick, NJ USA
- School of Social Work, Rutgers University, New Brunswick, NJ USA
| | - Hillary Samples
- Institute for Health, Health Care Policy & Aging Research, Rutgers University, New Brunswick, NJ USA
- School of Public Health, Rutgers University, Piscataway, NJ USA
| | - Richard Hermida
- Institute for Health, Health Care Policy & Aging Research, Rutgers University, New Brunswick, NJ USA
| | - Stephen Crystal
- Institute for Health, Health Care Policy & Aging Research, Rutgers University, New Brunswick, NJ USA
- School of Social Work, Rutgers University, New Brunswick, NJ USA
- School of Public Health, Rutgers University, Piscataway, NJ USA
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5
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Freeman A, Davis KG, Ying J, Lang DA, Huth JR, Liu P. Workers' compensation prescription medication patterns and associated outcomes. Am J Ind Med 2022; 65:51-58. [PMID: 34727383 DOI: 10.1002/ajim.23306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 10/20/2021] [Accepted: 10/20/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Opioid use in the treatment of musculoskeletal injuries is a complex decision where benefits must be balanced with risk. Previous research has shown an association between higher opioid doses and adverse health effects. The study's objective was to investigate whether opioid prescriptions are associated with increased costs and deaths through an injury mechanism or as a direct result of the opioid prescription. METHODS Data for 144,553 deidentified Ohio Bureau of Workers' Compensation claims from 2010 to 2014 with shoulder, knee, and low back injuries were obtained and followed until 2016. Each claim had associated prescription information. Injury claims were further classified using the allowed diagnoses by single or multiple body areas affected and injury severity ("simple" or "complex"). The outcome variables were medical and indemnity costs, lost days, MaxMED (maximum claim-prescribed daily morphine equivalent dose), and death status. Association between maximum opioid dose with deaths was determined by logistic regression analysis. RESULTS Several outcome variables, including claim medical and indemnity costs, and the likelihood of claimant death, showed significant associations with the MaxMED. In the analysis of claim deaths, these associations held for all claim types (except complex), even after adjusting for age, gender, surgery, and lost time. CONCLUSION The association between increasing opioid doses and deaths for low-severity diagnoses was disturbing given the lack of demonstrated efficacy of opioids for treatment of minor injuries. A focus on provider education, increased utilization of non-opioids, and early intervention for minor soft-tissue injuries could reduce claims costs, disability, and future deaths.
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Affiliation(s)
- Andrew Freeman
- Department of Environmental and Public Health Sciences University of Cincinnati College of Medicine Cincinnati Ohio USA
| | - Kermit G. Davis
- Department of Environmental and Public Health Sciences University of Cincinnati College of Medicine Cincinnati Ohio USA
| | - Jun Ying
- Department of Environmental and Public Health Sciences University of Cincinnati College of Medicine Cincinnati Ohio USA
| | - David A. Lang
- Department of Environmental and Public Health Sciences University of Cincinnati College of Medicine Cincinnati Ohio USA
| | | | - Peihua Liu
- Department of Environmental and Public Health Sciences University of Cincinnati College of Medicine Cincinnati Ohio USA
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Coquet J, Zammit A, Hajouji OE, Humphreys K, Asch SM, Osborne TF, Curtin CM, Hernandez-Boussard T. Changes in postoperative opioid prescribing across three diverse healthcare systems, 2010-2020. Front Digit Health 2022; 4:995497. [PMID: 36561925 PMCID: PMC9763443 DOI: 10.3389/fdgth.2022.995497] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 10/27/2022] [Indexed: 12/12/2022] Open
Abstract
Objective The opioid crisis brought scrutiny to opioid prescribing. Understanding how opioid prescribing patterns and corresponding patient outcomes changed during the epidemic is essential for future targeted policies. Many studies attempt to model trends in opioid prescriptions therefore understanding the temporal shift in opioid prescribing patterns across populations is necessary. This study characterized postoperative opioid prescribing patterns across different populations, 2010-2020. Data Source Administrative data from Veteran Health Administration (VHA), six Medicaid state programs and an Academic Medical Center (AMC). Data extraction Surgeries were identified using the Clinical Classifications Software. Study Design Trends in average daily discharge Morphine Milligram Equivalent (MME), postoperative pain and subsequent opioid prescription were compared using regression and likelihood ratio test statistics. Principal Findings The cohorts included 595,106 patients, with populations that varied considerably in demographics. Over the study period, MME decreased significantly at VHA (37.5-30.1; p = 0.002) and Medicaid (41.6-31.3; p = 0.019), and increased at AMC (36.9-41.7; p < 0.001). Persistent opioid users decreased after 2015 in VHA (p < 0.001) and Medicaid (p = 0.002) and increase at the AMC (p = 0.003), although a low rate was maintained. Average postoperative pain scores remained constant over the study period. Conclusions VHA and Medicaid programs decreased opioid prescribing over the past decade, with differing response times and rates. In 2020, these systems achieved comparable opioid prescribing patterns and outcomes despite having very different populations. Acknowledging and incorporating these temporal distribution shifts into data learning models is essential for robust and generalizable models.
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Affiliation(s)
- Jean Coquet
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Alban Zammit
- Computational & Mathematical Engineering, Stanford University, Stanford, CA, United States
| | - Oualid El Hajouji
- Computational & Mathematical Engineering, Stanford University, Stanford, CA, United States
| | - Keith Humphreys
- United States Department of Veterans Affairs, Palo Alto Healthcare System, Palo Alto, CA, United States.,Department of Psychiatry, Stanford University School of Medicine, Stanford, CA, United States
| | - Steven M Asch
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States.,United States Department of Veterans Affairs, Palo Alto Healthcare System, Palo Alto, CA, United States
| | - Thomas F Osborne
- United States Department of Veterans Affairs, Palo Alto Healthcare System, Palo Alto, CA, United States.,Department of Radiology, Stanford University School of Medicine, Stanford, CA, United States
| | - Catherine M Curtin
- Department of Surgery, VA Palo Alto Health Care System, Menlo Park, CA, United States.,Department of Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Tina Hernandez-Boussard
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States.,Department of Surgery, Stanford University School of Medicine, Stanford, CA, United States.,Department of Biomedical Data Science, Stanford University, Stanford, CA, United States
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Gewandter JS, Smith SM, Dworkin RH, Turk DC, Gan TJ, Gilron I, Hertz S, Katz NP, Markman JD, Raja SN, Rowbotham MC, Stacey BR, Strain EC, Ward DS, Farrar JT, Kroenke K, Rathmell JP, Rauck R, Brown C, Cowan P, Edwards RR, Eisenach JC, Ferguson M, Freeman R, Gray R, Giblin K, Grol-Prokopczyk H, Haythornthwaite J, Jamison RN, Martel M, McNicol E, Oshinsky M, Sandbrink F, Scholz J, Scranton R, Simon LS, Steiner D, Verburg K, Wasan AD, Wentworth K. Research approaches for evaluating opioid sparing in clinical trials of acute and chronic pain treatments: Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials recommendations. Pain 2021; 162:2669-2681. [PMID: 33863862 PMCID: PMC8497633 DOI: 10.1097/j.pain.0000000000002283] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/23/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Randomized clinical trials have demonstrated the efficacy of opioid analgesics for the treatment of acute and chronic pain conditions, and for some patients, these medications may be the only effective treatment available. Unfortunately, opioid analgesics are also associated with major risks (eg, opioid use disorder) and adverse outcomes (eg, respiratory depression and falls). The risks and adverse outcomes associated with opioid analgesics have prompted efforts to reduce their use in the treatment of both acute and chronic pain. This article presents Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) consensus recommendations for the design of opioid-sparing clinical trials. The recommendations presented in this article are based on the following definition of an opioid-sparing intervention: any intervention that (1) prevents the initiation of treatment with opioid analgesics, (2) decreases the duration of such treatment, (3) reduces the total dosages of opioids that are prescribed for or used by patients, or (4) reduces opioid-related adverse outcomes (without increasing opioid dosages), all without causing an unacceptable increase in pain. These recommendations are based on the results of a background review, presentations and discussions at an IMMPACT consensus meeting, and iterative drafts of this article modified to accommodate input from the co-authors. We discuss opioid sparing definitions, study objectives, outcome measures, the assessment of opioid-related adverse events, incorporation of adequate pain control in trial design, interpretation of research findings, and future research priorities to inform opioid-sparing trial methods. The considerations and recommendations presented in this article are meant to help guide the design, conduct, analysis, and interpretation of future trials.
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Affiliation(s)
| | | | | | | | - Tong Joo Gan
- Stony Brook School of Medicine, Stony Brook, NY, USA
| | - Ian Gilron
- Queens University, Kingston, Ontario, Canada
| | - Sharon Hertz
- (Formally) U.S. Food and Drug Administration, Silver Spring, MD, USA
| | | | | | | | | | | | | | - Denham S. Ward
- University of Rochester Medical Center, Rochester, NY, USA
| | | | - Kurt Kroenke
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - James P. Rathmell
- Brigham and Women’s Hospital / Harvard Medical School, Boston, MA, USA
| | | | | | - Penney Cowan
- American Chronic Pain Association, Rocklin, CA, USA
| | - Robert R. Edwards
- Brigham and Women’s Hospital / Harvard Medical School, Boston, MA, USA
| | | | | | - Roy Freeman
- Brigham and Women’s Hospital / Harvard Medical School, Boston, MA, USA
| | - Roy Gray
- GW Pharmaceuticals, Carlsbad, CA, USA
| | | | | | | | - Robert N. Jamison
- Brigham and Women’s Hospital / Harvard Medical School, Boston, MA, USA
| | | | | | | | - Friedhelm Sandbrink
- U.S. Department of Veterans Affairs / George Washington University, Washington, DC, USA
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Heins SE, Castillo RC. Changes in Opioid Prescribing Following the Implementation of State Policies Limiting Morphine Equivalent Daily Dose in a Commercially Insured Population. Med Care 2021; 59:801-807. [PMID: 34081679 PMCID: PMC8384656 DOI: 10.1097/mlr.0000000000001587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prescription opioid mortality doubled 2002-2016 in the United States. Given the association between high-dose opioid prescribing and opioid mortality, several states have enacted morphine equivalent daily dose (MEDD) policies to limit high-dose prescribing. The study objective is to evaluate the impact of state-level MEDD policies on opioid prescribing among the privately insured. METHODS Claims data, 2010-2015 from 9 policy states and 2 control states and a comparative interrupted time series design were utilized. Primary outcomes were any monthly opioid use and average monthly MEDD. Stratified analyses evaluated theorized weaker policies (guidelines) and theorized stronger policies (passive alert systems, legislative acts, and rules/regulations) separately. Patient groups explicitly excluded from policies (eg, individuals with cancer diagnoses or receiving hospice care) were also examined separately. Analyses adjusted for covariates, state fixed effects, and time trends. RESULTS Both guideline and strong policy implementation were both associated with 15% lower odds of any opioid use, relative to control states. However, there was no statistically significant change in the use of high-dose opioids in policy states relative to control states. There was also no difference in direction and significance of the relationship among targeted patient groups. CONCLUSIONS MEDD policies were associated with decreased use of any opioids relative to control states, but no change in high-dose prescribing was observed. While the overall policy environment in treatment states may have discouraged opioid prescribing, there was no evidence of MEDD policy impact, specifically. Further research is needed to understand the mechanisms through which MEDD policies may influence prescribing behavior.
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Affiliation(s)
- Sara E. Heins
- RAND Corporation, 4570 Fifth Ave #600, Pittsburgh, PA 15213
| | - Renan C. Castillo
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205
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Salas J, Li X, Xian H, Sullivan MD, Ballantyne JC, Lustman PJ, Grucza R, Scherrer JF. Opioid dosing among patients with 3 or more years of continuous prescription opioid use before and after the CDC opioid prescribing guideline. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 97:103308. [PMID: 34098282 DOI: 10.1016/j.drugpo.2021.103308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 05/03/2021] [Accepted: 05/13/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Opioid doses declined after the Centers for Disease Control (CDC) opioid prescribing guideline was published. However, it is unknown if dose declines occurred in patients with ≥ 3 years of continuous opioid use. METHODS Optum® de-identified integrated Electronic Health Record and claims data were used to create an adult sample (n = 400) with continuous opioid use for 18 months before and after the guideline publication. Based on the morphine milligram equivalent (MME) distribution at Month 1, patients were categorized into 1-50, 51-100, 101-200, and >200 mg baseline MME. Interrupted time series analysis using segmented mixed linear regression models stratified on baseline MME estimated average monthly changes in MME in the 18-months pre- and post-guideline, before and after adjusting for time-varying pain conditions, psychiatric disorders and benzodiazepine prescription. RESULTS Patients were 59.6 (SD±11.8) years of age, 55.8% female and 84.0% white race. For 1-50 MME, monthly dose slope was significantly (p<0.0001) flatter post-guideline (pre b = 0.34 MME/month vs. post b = 0.12 MME/month). For 51-100 MME, the pre- and post-guideline dose slopes did not significantly differ (pre b = 0.60 MME/month vs. post b = 0.27 MME/month). For 101-200 MME, post-guideline dose slope was significantly (p<0.0001) steeper and decreasing post-guideline (pre b = 0.11 MME/month vs. post b= -1.33 MME/month). Among >200 MME, dose decreased in the pre- and post-guideline periods, and post-guideline decline was significantly (p<0.0001) steeper (b= -1. 86 MME/month vs. b= -4.13 MME/month). CONCLUSIONS Among patients on multiyear opioid therapy, the CDC guideline was associated with a modest change in dosing, except for patients on very high doses. The guideline was not associated with decreasing MME among lower-dose, long-term users.
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Affiliation(s)
- Joanne Salas
- Department of Family and Community Medicine, Saint Louis University School of Medicine, 1008 S. Spring, St. Louis MO. 63110, USA; Advanced HEAlth Data (AHEAD) Research Institute, Saint Louis University School of Medicine, 1008 S. Spring, St. Louis MO. 63110, USA.
| | - Xue Li
- College of Public Health and Social Justice, Saint Louis University, 3545 Lafayette Ave, St. Louis, MO 63104, USA
| | - Hong Xian
- College of Public Health and Social Justice, Saint Louis University, 3545 Lafayette Ave, St. Louis, MO 63104, USA
| | - Mark D Sullivan
- Department of Psychiatry and Behavioral Science, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle WA. 98195, USA
| | - Jane C Ballantyne
- Department of Anesthesiology and Pain Medicine, University of Washington, 1959 NE Pacific Street, Seattle WA. 98195, USA
| | - Patrick J Lustman
- Department of Psychiatry, Washington University School of Medicine, 660 S Euclid Ave, St. Louis, MO. 63110, USA; The Bell Street Clinic Opioid Addiction Treatment Programs, VA St. Louis Healthcare System, 915 North Grand Blvd, St. Louis, MO. 63106, USA
| | - Richard Grucza
- Department of Family and Community Medicine, Saint Louis University School of Medicine, 1008 S. Spring, St. Louis MO. 63110, USA; Advanced HEAlth Data (AHEAD) Research Institute, Saint Louis University School of Medicine, 1008 S. Spring, St. Louis MO. 63110, USA
| | - Jeffrey F Scherrer
- Department of Family and Community Medicine, Saint Louis University School of Medicine, 1008 S. Spring, St. Louis MO. 63110, USA; Advanced HEAlth Data (AHEAD) Research Institute, Saint Louis University School of Medicine, 1008 S. Spring, St. Louis MO. 63110, USA
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10
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Banks J, Hill C, Chi DL. Plan Type and Opioid Prescriptions for Children in Medicaid. Med Care 2021; 59:386-392. [PMID: 33528236 PMCID: PMC8026560 DOI: 10.1097/mlr.0000000000001504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Opioids are generally an inappropriate acute pain management strategy in children, particularly because of the risk for diversion and subsequent misuse and abuse. OBJECTIVES To examine associations between Medicaid plan type [coordinated care organization (CCO), managed care (MC), fee-for-service (FFS)] and whether a child received an opioid prescription. RESEARCH DESIGN Secondary analysis of Oregon Medicaid data (January 1, 2016 to December 31, 2017). SUBJECTS Medicaid-enrolled children ages 0-17 (N=200,169). MEASURES There were 2 outcomes: whether a child received an opioid prescription from (a) any health provider or (b) from a visit to the dentist. Predictor variables included Medicaid plan type, age, sex, race, and ethnicity. RESULTS About 6.7% of children received an opioid from any health provider and 1.2% received an opioid from a dentist visit. Children in a CCO were significantly more likely than children in a MC (P<0.01) or FFS (P=0.02) plan to receive an opioid from any health provider. Children in a CCO were also significantly more likely than children in MC or FFS to receive an opioid from a dentist visit (P<0.01). CONCLUSIONS Pediatric opioid prescriptions vary by plan type. Future efforts should identify reasons why Medicaid-enrolled children in a CCO plan are more likely to be prescribed opioids.
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Affiliation(s)
- Jordan Banks
- Department of Oral Health Sciences, University of Washington, Seattle, WA
| | - Courtney Hill
- Department of Oral Health Sciences, University of Washington, Seattle, WA
| | - Donald L. Chi
- Department of Oral Health Sciences, University of Washington, Seattle, WA
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Ranapurwala SI, Ringwalt CL, Pence BW, Schiro S, Fulcher N, McCort A, DiPrete BL, Marshall SW. State Medical Board Policy and Opioid Prescribing: A Controlled Interrupted Time Series. Am J Prev Med 2021; 60:343-351. [PMID: 33309449 PMCID: PMC7902466 DOI: 10.1016/j.amepre.2020.09.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 09/10/2020] [Accepted: 09/22/2020] [Indexed: 12/25/2022]
Abstract
INTRODUCTION In March 2016, the Centers for Disease Control and Prevention issued opioid prescribing guidelines for chronic noncancer pain. In response, in April 2016, the North Carolina Medical Board launched the Safe Opioid Prescribing Initiative, an investigative program intended to limit the overprescribing of opioids. This study focuses on the association of the Safe Opioid Prescribing Initiative with immediate and sustained changes in opioid prescribing among all patients who received opioid and opioid discontinuation and tapering among patients who received high-dose (>90 milligrams of morphine equivalents), long-term (>90 days) opioid therapy. METHODS Controlled and single interrupted time series analysis of opioid prescribing outcomes before and after the implementation of Safe Opioid Prescribing Initiative was conducted using deidentified data from the North Carolina Controlled Substances Reporting System from January 2010 through March 2017. Analysis was conducted in 2019-2020. RESULTS In an average study month, 513,717 patients, including patients who received 47,842 high-dose, long-term opioid therapy, received 660,912 opioid prescriptions at 1.3 prescriptions per patient. There was a 0.52% absolute decline (95% CI= -0.87, -0.19) in patients receiving opioid prescriptions in the month after Safe Opioid Prescribing Initiative implementation. Abrupt discontinuation, rapid tapering, and gradual tapering of opioids among patients who received high-dose, long-term opioid therapy increased by 1% (95% CI= -0.22, 2.23), 2.2% (95% CI=0.91, 3.47), and 1.3% (95% CI=0.96, 1.57), respectively, in the month after Safe Opioid Prescribing Initiative implementation. CONCLUSIONS Although Safe Opioid Prescribing Initiative implementation was associated with an immediate decline in overall opioid prescribing, it was also associated with an unintended immediate increase in discontinuations and rapid tapering among patients who received high-dose, long-term opioid therapy. Better policy communication and prescriber education regarding opioid tapering best practices may help mitigate unintended consequences of statewide policies.
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Affiliation(s)
- Shabbar I Ranapurwala
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina; Injury Prevention Research Center, University of North Carolina, Chapel Hill, North Carolina.
| | - Christopher L Ringwalt
- Injury Prevention Research Center, University of North Carolina, Chapel Hill, North Carolina
| | - Brian W Pence
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina
| | - Sharon Schiro
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Naoko Fulcher
- Injury Prevention Research Center, University of North Carolina, Chapel Hill, North Carolina
| | - Agnieszka McCort
- Injury Prevention Research Center, University of North Carolina, Chapel Hill, North Carolina
| | - Bethany L DiPrete
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina
| | - Stephen W Marshall
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina; Injury Prevention Research Center, University of North Carolina, Chapel Hill, North Carolina
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Wang Y, Perri M, Young H, Abraham A, Jayawardhana J. Impact of drug utilization management policy on prescription opioid use in Georgia Medicaid. ACTA ACUST UNITED AC 2021; 12:188-193. [PMID: 33995608 DOI: 10.1093/jphsr/rmaa026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 11/13/2020] [Indexed: 01/01/2023]
Abstract
Objective To examine the effectiveness of changes in opioid prescription policies on opioid prescribing and health services utilization rates in Georgia Medicaid. Methods This study used data from the Georgia Medicaid patient enrollment, medical and pharmacy claims database from 2009 to 2014.We performed an interrupted time series analysis to examine the effect of the policy changes. Outcome measures assessed the trends in the indicators of potential inappropriate prescribing practices, including overlapping prescriptions of opioid + opioid, opioid + benzodiazepine and opioids + buprenorphine/naloxone, as well as health services utilization, including hospitalization, mean length of stay, outpatient office and emergency room visits. Key findings A total of 712 342 opioid users aged 18-64 were included in the study. The policies were associated with significant decreasing trend of opioid + opioid (-0.0011; 95% CI = -0.0020, -0.0002) and opioid + benzodiazepines (-0.001; 95% CI = -0.0022, -0.0006) overlapping while associated with a significant immediate decrease in and opioids + buprenorphine/naloxone after the implementations (-0.0014; 95% CI = -0.0025, -0.0003). Significant immediate decrease in level of office visits and ER visits were seen with the policy implementation (office visit: -0.2939; 95% CI = -0.5528, -0.0350, ER visit: -0.0740, 95% CI = -0.1294, -0.0185). The policies were not shown to be significantly associated with hospitalization and the mean length of inpatient stay. Conclusions Our analysis suggests that Georgia Medicaid opioid policies were useful to contain inappropriate opioid use.
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Affiliation(s)
- Yu Wang
- Department of Clinical and Administrative Pharmacy, College of Pharmacy, University of Georgia, Athens, GA, USA
| | - Matthew Perri
- Department of Clinical and Administrative Pharmacy, College of Pharmacy, University of Georgia, Athens, GA, USA
| | - Henry Young
- Department of Clinical and Administrative Pharmacy, College of Pharmacy, University of Georgia, Athens, GA, USA
| | - Amanda Abraham
- Department of Public Administration and Policy, School of Public & International Affairs, University of Georgia, Athens, GA, USA
| | - Jayani Jayawardhana
- Department of Clinical and Administrative Pharmacy, College of Pharmacy, University of Georgia, Athens, GA, USA
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13
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Enhanced recovery protocol for transoral robotic surgery demonstrates improved analgesia and narcotic use reduction. Am J Otolaryngol 2020; 41:102649. [PMID: 32717682 DOI: 10.1016/j.amjoto.2020.102649] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 06/30/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND No study has evaluated the impact of the Enhanced Recovery After Surgery (ERAS) protocol on opioid usage among patients undergoing transoral robotic surgery (TORS). METHODS In this retrospective study, patients undergoing TORS were enrolled in an ERAS protocol and compared to control patients. Primary outcome measures included postoperative mean morphine equivalent dose (MED), Defense and Veterans Pain Rating Scale (DVPRS) pain scores, and opioid prescriptions on discharge. RESULTS The mean MED administered postoperatively was lower in the ERAS group (17.6 mg) than in the control group (65.0 mg) (p < .001). Average postoperative DVPRS scores were 2.9 in the ERAS group vs. 4.2 in the control group (p = .042). Fewer patients in the ERAS group received opioid prescriptions on discharge (31.6%) than controls (96.2%) (p < .001). CONCLUSION The TORS ERAS protocol is associated with reduced postoperative opioid usage, lower pain scores, and reduced opioid requirements on discharge.
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14
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Sears JM, Haight JR, Fulton-Kehoe D, Wickizer TM, Mai J, Franklin GM. Changes in early high-risk opioid prescribing practices after policy interventions in Washington State. Health Serv Res 2020; 56:49-60. [PMID: 33011988 PMCID: PMC7839645 DOI: 10.1111/1475-6773.13564] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To test associations between several opioid prescribing policy interventions and changes in early (acute/subacute) high-risk opioid prescribing practices. DATA SOURCES Population-based workers' compensation pharmacy billing and claims data, Washington State Department of Labor and Industries (January 2008-June 2015). STUDY DESIGN We used interrupted time series analysis to test associations between three policy intervention timepoints and monthly proportions of population-based measures of high-risk, low-risk, and any workers' compensation-related opioid prescribing. We also tested associations between the policy intervention timepoints and five high-risk opioid prescribing indicators among workers prescribed any opioids within 3 months after injury: (a) >7 cumulative (not necessarily consecutive) days' supply of opioids during the acute phase, (b) high-dose opioids, (c) concurrent sedatives, (d) chronic opioids, and (e) a composite high-risk opioid prescribing indicator. PRINCIPAL FINDINGS Within 3 months after injury, 9 percent of workers were exposed to high-risk and 12 percent to low-risk workers' compensation-related opioid prescribing; 79 percent filled no workers' compensation-related opioid prescription. Among workers prescribed any early (acute/subacute) opioids, the indicator for >7 days' supply of opioids during the acute phase was present for 30 percent, high-dose opioids for 18 percent, concurrent sedatives for 3 percent, and chronic opioids for 2 percent. Beyond a general shift toward more infrequent and lower-risk workers' compensation-related opioid prescribing, each policy intervention timepoint was significantly associated with reductions in specific acute/subacute high-risk opioid prescribing indicators; each of the four specific high-risk opioid prescribing indicators had significant reductions associated with at least one policy. CONCLUSIONS Several state-level opioid prescribing policies were significantly associated with safer workers' compensation-related opioid prescribing practices during the first 3 months after injury (acute/subacute phase), which should in turn reduce transition to chronic opioids and associated negative health outcomes.
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Affiliation(s)
- Jeanne M Sears
- Department of Health Services, University of Washington, Seattle, Washington, USA.,Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington, USA.,Harborview Injury Prevention and Research Center, Seattle, Washington, USA.,Institute for Work and Health, Toronto, Ontario, Canada
| | - John R Haight
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington, USA.,Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Deborah Fulton-Kehoe
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington, USA
| | - Thomas M Wickizer
- Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, Ohio, USA
| | - Jaymie Mai
- Washington State Department of Labor and Industries, Tumwater, Washington, USA
| | - Gary M Franklin
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington, USA.,Washington State Department of Labor and Industries, Tumwater, Washington, USA.,Department of Neurology, University of Washington, Seattle, Washington, USA
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15
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Ansari B, Tote KM, Rosenberg ES, Martin EG. 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. Public Health Rep 2020; 135:100S-127S. [PMID: 32735190 PMCID: PMC7407056 DOI: 10.1177/0033354920922975] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2020] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Bahareh Ansari
- Department of Information Science, University at Albany–State University of New York, Albany, NY, USA
| | - Katherine M. Tote
- Department of Epidemiology and Biostatistics, University at Albany–State University of New York, Albany, NY, USA
- Center for Collaborative HIV Research in Practice and Policy, Albany, NY, USA
| | - Eli S. Rosenberg
- Department of Epidemiology and Biostatistics, University at Albany–State University of New York, Albany, NY, USA
- Center for Collaborative HIV Research in Practice and Policy, Albany, NY, USA
| | - Erika G. Martin
- Center for Collaborative HIV Research in Practice and Policy, Albany, NY, USA
- Department of Public Administration and Policy, University at Albany–State University of New York, Albany, NY, USA
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16
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Ibrahimi SE, Hallvik S, Johnston K, Leichtling G, Choo E, Hartung DM. A comparison of trends in opioid dispensing patterns between Medicaid pharmacy claims and prescription drug monitoring program data. Pharmacoepidemiol Drug Saf 2020; 29:1168-1174. [PMID: 32939909 PMCID: PMC8015255 DOI: 10.1002/pds.5097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/29/2020] [Accepted: 07/19/2020] [Indexed: 11/06/2022]
Abstract
PURPOSE Public and private payers have implemented benefit limitations to reduce high-risk opioid prescriptions. The effect of these policies on the increase of out-pocket payment is unclear. To understand this gap, we compared the discrepancies in trends between opioid prescription fills vs claims among Medicaid beneficiaries. METHODS Data from the Oregon Prescription Drug Monitoring Program (PDMP) and Oregon Medicaid administrative claims were used to identify Medicaid beneficiaries 18 years and older enrolled at least one full month from 2015 to 2017. Generalized linear models assessed the trends in the monthly rates of opioid PDMP prescription fills and pharmacy claims per 1000 eligible members. Rates by morphine equivalent dose (MED) tier (<50, 50-89, 90-120, >120 MED) and co-prescribed opioid and benzodiazepine were also assessed. RESULTS During the study period, an average of 495 355 Medicaid members had 2 797 054 opioid PDMP fills and 2 472 155 opioid Medicaid pharmacy claims. Study participants had 15.4 (95% confidence interval [CI] 13.6 to 17.0; P < .001) more prescriptions per 1000 member per month in the PDMP data (114.1 [SD 7.4]) compared with the Medicaid claims data (98.7 [SD 7.9]). Similarly, there were 1.9 more co-occurring opioid/benzodiazepine prescriptions per 1000 members per month observed in the PDMP data than the Medicaid claims data (95% CI 1.7 to 2.1; P < .001). At each MED tier, the PDMP fills were consistently higher than the claims (P < .001). CONCLUSIONS Higher rate of fills in the PDMP compared to pharmacy claims suggests that there may be an increasing trend of out-of-pocket payment among Medicaid beneficiaries.
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Affiliation(s)
- Sanae El Ibrahimi
- Department of Research and Evaluation, Comagine Health, Portland, Oregon
- Department of Epidemiology and Biostatistics, School of Public Health, University of Nevada, Las Vegas, Nevada
| | - Sara Hallvik
- Department of Research and Evaluation, Comagine Health, Portland, Oregon
| | - Kirbee Johnston
- College of Pharmacy, Oregon State University, Corvallis, Oregon
| | - Gillian Leichtling
- Department of Research and Evaluation, Comagine Health, Portland, Oregon
| | - Esther Choo
- Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland, Oregon
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17
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Kay C, Fergestrom N, Spanbauer C, Jackson JL. Opioid Dose and Benzodiazepine Use Among Commercially Insured Individuals on Chronic Opioid Therapy. PAIN MEDICINE 2020; 21:1181-1187. [PMID: 31804688 DOI: 10.1093/pm/pnz317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To examine morphine milligram equivalent (MME) trends, use of concurrent opioids and benzodiazepines, and opioid-related emergency department (ED) visits or hospitalizations in a national cohort of patients on chronic opioid therapy. DESIGN Retrospective cohort analysis of prospectively collected data from the Truven Health MarketScan Commercial Claims and Encounters database from 2009 to 2015. This includes individuals in both the Commercial Claims and Medicare Supplemental databases of MarketScan. METHODS MME comparisons of 1) patients on chronic opioids with and without opioid-related ED visits or hospitalizations, 2) patients on concurrent opioids and benzodiazepines with and without opioid-related ED visits or hospitalizations, and 3) patients on chronic opioids compared with those on concurrent opioid and benzodiazepine using the Student t test. RESULTS MME decreased from 194 mg in 2009 to 119 mg in 2015 among patients on chronic opioids. Patients on opioids and benzodiazepines had higher doses than those on opioids alone for all years (P < 0.001). Those with an opioid-related ED visit or hospitalization had a higher average MME than those without, for all years except 2009 (P < 0.05). Patients on chronic opioids or on concurrent benzodiazepine with an MME >50 had a twofold increased risk of having an opioid-related ED visit or hospitalization compared with those with an MME <50, for all years. CONCLUSIONS Although the average MME decreased over time, patients on combination opioid and benzodiazepine and those with opioid-related ED visits and hospitalizations had significantly higher doses.
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Affiliation(s)
- Cynthia Kay
- Zablocki VA Medical Center, Milwaukee, Wisconsin.,Medical College of Wisconsin, Milwaukee, Wisconsin.,Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Nicole Fergestrom
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Charles Spanbauer
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jeffrey L Jackson
- Zablocki VA Medical Center, Milwaukee, Wisconsin.,Medical College of Wisconsin, Milwaukee, Wisconsin.,Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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18
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The Impact of Morphine Equivalent Daily Dose Threshold Guidelines on Prescribed Dose in a Workers' Compensation Population. Med Care 2020; 58:241-247. [PMID: 32106166 DOI: 10.1097/mlr.0000000000001269] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Prescription opioid overdose has increased markedly and is of great concern among injured workers receiving workers' compensation insurance. Given the association between high daily dose of prescription opioids and negative health outcomes, state workers' compensation boards have disseminated Morphine Equivalent Daily Dose (MEDD) guidelines to discourage high-dose opioid prescribing. OBJECTIVE To evaluate the impact of MEDD guidelines among workers' compensation claimants on prescribed opioid dose. METHODS Workers' compensation claims data, 2010-2013 from 2 guideline states and 3 control states were utilized. The study design was an interrupted time series with comparison states and average monthly MEDD was the primary outcome. Policy variables were specified to allow for both instantaneous and gradual effects and additional stratified analyses examined evaluated the policies separately for individuals with and without acute pain, cancer, and high-dose baseline use to determine whether policies were being targeted as intended. RESULTS After adjusting for covariates, state fixed-effects, and time trends, policy implementation was associated with a 9.26 mg decrease in MEDD (95% confidence interval, -13.96 to -4.56). Decreases in MEDD also became more pronounced over time and were larger in groups targeted by the policies. CONCLUSIONS Passage of workers' compensation MEDD guidelines was associated with decreases in prescribed opioid dose among injured workers. Disseminating MEDD guidelines to doctors who treat workers' compensation cases may address an important risk factor for opioid-related mortality, while still allowing for autonomy in practice. Further research is needed to determine whether MEDD policies influence prescribing behavior and patient outcomes in other populations.
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19
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MAURI AMANDAI, TOWNSEND TARLISEN, HAFFAJEE REBECCAL. The Association of State Opioid Misuse Prevention Policies With Patient- and Provider-Related Outcomes: A Scoping Review. Milbank Q 2020; 98:57-105. [PMID: 31800142 PMCID: PMC7077777 DOI: 10.1111/1468-0009.12436] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Policy Points This scoping review reveals a growing literature on the effects of certain state opioid misuse prevention policies, but persistent gaps in evidence on other prevalent state policies remain. Policymakers interested in reducing the volume and dosage of opioids prescribed and dispensed can consider adopting robust prescription drug monitoring programs with mandatory access provisions and drug supply management policies, such as prior authorization policies for high-risk prescription opioids. Further research should concentrate on potential unintended consequences of opioid misuse prevention policies, differential policy effects across populations, interventions that have not received sufficient evaluation (eg, Good Samaritan laws, naloxone access laws), and patient-related outcomes. CONTEXT In the midst of an opioid crisis in the United States, an influx of state opioid misuse prevention policies has provided new opportunities to generate evidence of policy effectiveness that can inform policy decisions. We conducted a scoping review to synthesize the available evidence on the effectiveness of US state interventions to improve patient and provider outcomes related to opioid misuse and addiction. METHODS We searched six online databases to identify evaluations of state opioid policies. Eligible studies examined legislative and administrative policy interventions that evaluated (a) prescribing and dispensing, (b) patient behavior, or (c) patient health. FINDINGS Seventy-one articles met our inclusion criteria, including 41 studies published between 2016 and 2018. These articles evaluated nine types of state policies targeting opioid misuse. While prescription drug monitoring programs (PDMPs) have received considerable attention in the literature, far fewer studies addressed other types of state policy. Overall, evidence quality is very low for the majority of policies due to a small number of evaluations. Of interventions that have been the subject of considerable research, promising means of reducing the volume and dosages of opioids prescribed and dispensed include drug supply management policies and robust PDMPs. Due to low study number and quality, evidence is insufficient to draw conclusions regarding interventions targeting patient behavior and health outcomes, including naloxone access laws and Good Samaritan laws. CONCLUSIONS Recent research has improved the evidence base on several state interventions targeting opioid misuse. Specifically, moderate evidence suggests that drug supply management policies and robust PDMPs reduce opioid prescribing. Despite the increase in rigorous evaluations, evidence remains limited for the majority of policies, particularly those targeting patient health-related outcomes.
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Affiliation(s)
- AMANDA I. MAURI
- University of Michigan School of Public Health
- Injury Prevention CenterUniversity of Michigan Medical School
| | - TARLISE N. TOWNSEND
- University of Michigan School of Public Health
- Injury Prevention CenterUniversity of Michigan Medical School
- University of Michigan Department of Sociology
| | - REBECCA L. HAFFAJEE
- University of Michigan School of Public Health
- Injury Prevention CenterUniversity of Michigan Medical School
- RAND Corporation
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20
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Eggerstedt M, Stenson KM, Ramirez EA, Kuhar HN, Jandali DB, Vaughan D, Al-Khudari S, Smith RM, Revenaugh PC. Association of Perioperative Opioid-Sparing Multimodal Analgesia With Narcotic Use and Pain Control After Head and Neck Free Flap Reconstruction. JAMA FACIAL PLAST SU 2020; 21:446-451. [PMID: 31393513 DOI: 10.1001/jamafacial.2019.0612] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance An increase in narcotic prescription patterns has contributed to the current opioid epidemic in the United States. Opioid-sparing perioperative analgesia represents a means of mitigating the risk of opioid dependence while providing superior perioperative analgesia. Objective To assess whether multimodal analgesia (MMA) is associated with reduced narcotic use and improved pain control compared with traditional narcotic-based analgesics at discharge and in the immediate postoperative period after free flap reconstructive surgery. Design, Setting, and Participants This retrospective cohort study assessed a consecutive sample of 65 patients (28 MMA, 37 controls) undergoing free flap reconstruction of a through-and-through mucosal defect within the head and neck region at a tertiary academic referral center from June 1, 2017, to November 30, 2018. Patients and physicians were not blinded to the patients' analgesic regimen. Patients' clinical courses were followed up for 30 days postoperatively. Interventions Patients were administered a preoperative, intraoperative, and postoperative analgesia regimen consisting of scheduled and as-needed neuromodulating and anti-inflammatory medications, with narcotic medications reserved for refractory cases. Control patients were administered traditional narcotic-based analgesics as needed. Main Outcomes and Measures Narcotic doses administered during the perioperative period and at discharge were converted to morphine-equivalent doses (MEDs) for comparison. Postoperative Defense and Veterans Pain Rating Scale pain scores (ranging from 0 [no pain] to 10 [worst pain imaginable]) were collected for the first 72 hours postoperatively as a patient-reported means of analyzing effectiveness of analgesia. Results A total of 28 patients (mean [SD] age, 64.1 [12.3] years; 17 [61%] male) were included in the MMA group and 37 (mean [SD] age, 65.0 [11.0] years; 22 [59%] male) in the control group. The number of MEDs administered postoperatively was 10.0 (interquartile range [IQR], 2.7-23.1) in the MMA cohort and 89.6 (IQR, 60.0-104.5) in the control cohort (P < .001). Mean (SD) Defense and Veterans Pain Rating Scale pain scores postoperatively were 2.05 (1.41) in the MMA cohort and 3.66 (1.99) in the control cohort (P = .001). Median number of MEDs prescribed at discharge were 0 (IQR, 0-18.8) in the MMA cohort and 300.0 (IQR, 262.5-412.5) in the control cohort (P < .001). Conclusions and Relevance The findings suggest that after free flap reconstruction, MMA is associated with reduced narcotic use at discharge and in the immediate postoperative period and with superior analgesia as measured by patient-reported pain scores. Patients receiving MMA achieved improved pain control, and the number of narcotic prescriptions in circulation were reduced. Level of Evidence 3.
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Affiliation(s)
- Michael Eggerstedt
- Section of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois
| | - Kerstin M Stenson
- Section of Head and Neck Surgical Oncology, Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois
| | - Emily A Ramirez
- Section of Head and Neck Surgical Oncology, Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois
| | - Hannah N Kuhar
- Rush Medical College, Rush University Medical Center, Chicago, Illinois
| | - Danny B Jandali
- Section of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois
| | - Deborah Vaughan
- Section of Head and Neck Surgical Oncology, Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois
| | - Samer Al-Khudari
- Section of Head and Neck Surgical Oncology, Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois
| | - Ryan M Smith
- Section of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois
| | - Peter C Revenaugh
- Section of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois
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Colasanti J, Lira MC, Cheng DM, Liebschutz JM, Tsui JI, Forman LS, Sullivan M, Walley AY, Bridden C, Root C, Podolsky M, Abrams C, Outlaw K, Harris CE, Armstrong WS, Samet JH, Del Rio C. Chronic Opioid Therapy in People Living With Human Immunodeficiency Virus: Patients' Perspectives on Risks, Monitoring, and Guidelines. Clin Infect Dis 2020; 68:291-297. [PMID: 29860411 DOI: 10.1093/cid/ciy452] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 05/29/2018] [Indexed: 12/24/2022] Open
Abstract
Background Chronic opioid therapy (COT) is common in people living with human immunodeficiency virus (PLHIV), but is not well studied. We assessed opioid risk behaviors, perceptions of risk, opioid monitoring, and associated Current Opioid Misuse Measure (COMM) scores of PLHIV on COT. Methods COT was defined as ≥3 opioid prescriptions ≥21 days apart in the past 6 months. Demographics, substance use, COMM score, and perceptions of and satisfaction with COT monitoring were assessed among PLHIV on COT from 2 HIV clinics. Results Among participants (N = 165) on COT, 66% were male and 72% were black, with a median age of 55 (standard deviation, 8) years. Alcohol and drug use disorders were present in 17% and 19%, respectively. In 43%, the COMM score, a measure of potential opioid misuse, was high. Thirty percent had an opioid treatment agreement, 66% a urine drug test (UDT), and 12% a pill count. Ninety percent acknowledged opioids' addictive potential. Median (interquartile range) satisfaction levels (1-10 [10 = highest]) were 10 (7-10) for opioid treatment agreements, 9.5 (6-10) for pill counts, and 10 (8-10) for UDT. No association was found between higher COMM score and receipt of or satisfaction with COT monitoring. Conclusions Among PLHIV on COT, opioid misuse and awareness of the addictive potential of COT are common, yet COT monitoring practices were not guideline concordant. Patients who received monitoring practices reported high satisfaction. Patient attitudes suggest high acceptance of guideline concordant care for PLHIV on COT when it occurs.
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Affiliation(s)
- Jonathan Colasanti
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Marlene C Lira
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Massachusetts
| | - Debbie M Cheng
- Department of Biostatistics, Boston University School of Public Health, Massachusetts
| | - Jane M Liebschutz
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pennsylvania
| | - Judith I Tsui
- Section of General Internal Medicine, Department of Medicine, University of Washington and Harborview Medical Center, Seattle
| | - Leah S Forman
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Massachusetts
| | - Meg Sullivan
- Section of Infectious Disease, Department of Medicine, Boston University School of Medicine, Massachusetts
| | - Alexander Y Walley
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Massachusetts
| | - Carly Bridden
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Massachusetts
| | - Christin Root
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Melissa Podolsky
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Massachusetts
| | - Catherine Abrams
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Kishna Outlaw
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Catherine E Harris
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Wendy S Armstrong
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Jeffrey H Samet
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Massachusetts
| | - Carlos Del Rio
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
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Obadan-Udoh E, Lupulescu-Mann N, Charlesworth CJ, Muench U, Jura M, Kim H, Schwarz E, Mertz E, Sun BC. Opioid prescribing patterns after dental visits among beneficiaries of Medicaid in Washington state in 2014 and 2015. J Am Dent Assoc 2019; 150:259-268.e1. [PMID: 30922457 DOI: 10.1016/j.adaj.2018.12.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 12/21/2018] [Accepted: 12/25/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND Dentists contribute to the prevailing opioid epidemic in the United States. Concerning the population enrolled in Medicaid, little is known about dentists' opioid prescribing. METHODS The authors performed a retrospective cohort study of beneficiaries of Medicaid in Washington state with dental claims in 2014 and 2015. The primary outcome was the proportion of dental visits associated with an opioid prescription. The authors categorized visits as invasive or noninvasive by using procedure codes and each beneficiary as being at low or high risk by using his or her prescription history from the prescription drug monitoring program. RESULTS A total of 126,660 (10.3%) of all dental visits, most of which were invasive (66.9%), among the population enrolled in Medicaid in Washington state was associated with opioid prescriptions. However, noninvasive dental visits and visits for beneficiaries who had prior high-risk prescription use were associated with significantly higher mean days' supply and mean quantity of opioids prescribed. Results from the multivariate logistic regression showed that the probability of having an opioid-associated visit increased by 35.6 percentage points when the procedures were invasive and by 11.1 percentage points when the beneficiary had prior high-risk prescription use. CONCLUSIONS This baseline of opioid prescribing patterns after dental visits among the population enrolled in Medicaid in Washington state in 2014 and 2015 can inform future studies in which the investigators examine the effect of policies on opioid prescribing patterns and reasons for the variability in the dosage and duration of opioid prescriptions associated with noninvasive visits. PRACTICAL IMPLICATIONS Dentists must exercise caution when prescribing opioids during invasive visits and to patients with prior high-risk prescription use.
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Clark J, Fairbairn N, Nolan S, Li T, Wu A, Barrios R, Montaner J, Ti L. Prescription of High-Dose Opioids Among People Living with HIV in British Columbia, Canada. AIDS Behav 2019; 23:3331-3339. [PMID: 31286318 PMCID: PMC7062387 DOI: 10.1007/s10461-019-02589-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
People living with HIV (PLHIV) often experience pain for which opioid medications may be prescribed. Thus, these individuals are particularly vulnerable to opioid-related harms, including overdose, misuse, and addiction, particularly when prescribed at high doses. We used a comprehensive linked population-level database of PLHIV in British Columbia (BC) to identify demographic and clinical characteristics associated with being prescribed any high-dose opioid analgesic, defined as > 90 daily morphine milligram equivalents (MME/day). Among PLHIV who were prescribed opioids between 1996 and 2015 (n = 10,780), 28.2% received prescriptions of > 90 MME/day at least once during the study period. Factors positively associated with being prescribed high-dose opioid analgesics included: co-prescription of benzodiazepines (adjusted odds ratio [AOR] = 1.14; 95% confidence interval 1.11-1.17); presence of an AIDS-defining illness (ADI; AOR = 1.78; 95% CI 1.57-2.02); seen by an HIV specialist (AOR = 1.24; 95% CI 1.20-1.29); substance use disorder (AOR = 1.46; 95% CI 1.25-1.71); and more recent calendar year (AOR = 1.05; 95% CI 1.04-1.06). Given the known risks associated with high-dose opioid prescribing, future research efforts should focus on the clinical indication and outcomes associated with these prescribing practices.
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Affiliation(s)
- Jessica Clark
- Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
| | - Nadia Fairbairn
- Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
- British Columbia Centre on Substance Use, St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Seonaid Nolan
- Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
- British Columbia Centre on Substance Use, St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Tian Li
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Anthony Wu
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Rolando Barrios
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- Vancouver Coastal Health Authority, 520 West 6th Avenue, Vancouver, BC, V6Z 4H5, Canada
| | - Julio Montaner
- Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Lianping Ti
- Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada.
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
- British Columbia Centre on Substance Use, 400-1045 Howe St, Vancouver, BC, V6Z 2A9, Canada.
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Haegerich TM, Jones CM, Cote PO, Robinson A, Ross L. Evidence for state, community and systems-level prevention strategies to address the opioid crisis. Drug Alcohol Depend 2019; 204:107563. [PMID: 31585357 PMCID: PMC9286294 DOI: 10.1016/j.drugalcdep.2019.107563] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 08/07/2019] [Accepted: 08/12/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Practitioners and policy makers need evidence to facilitate the selection of effective prevention interventions that can address the ongoing opioid overdose epidemic in the United States. METHODS We conducted a systematic review of publications reporting on rigorous evaluations of systems-level interventions to address provider and patient/public behavior and prevent prescription and illicit opioid overdose. A total of 251 studies were reviewed. Interventions studied included 1) state legislation and regulation, 2) prescription drug monitoring programs (PDMPs), 3) insurance strategies, 4) clinical guideline implementation, 5) provider education, 6) health system interventions, 7) naloxone education and distribution, 8) safe storage and disposal, 9) public education, 10) community coalitions, and 11) interventions employing public safety and public health collaborations. RESULTS The quality of evidence supporting selected interventions was low to moderate. Interventions with the strongest evidence include PDMP and pain clinic legislation, insurance strategies, motivational interviewing in clinical settings, feedback to providers on opioid prescribing behavior, intensive school and family-based programs, and patient education in the clinical setting. CONCLUSIONS Although evidence is growing, further high-quality research is needed. Investigators should aim to identify strategies that can prevent overdose, as well as influence public, patient, and provider behavior. Identifying which strategies are most effective at addressing prescription compared to illicit opioid misuse and overdose could be fruitful, as well as investigating synergistic effects and unintended consequences.
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Affiliation(s)
- Tamara M. Haegerich
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA, 30341, USA,Corresponding author: (T.M. Haegerich)
| | - Christopher M. Jones
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA, 30341, USA
| | - Pierre-Olivier Cote
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA, 30341, USA.
| | - Amber Robinson
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA, 30341, USA.
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25
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Impact of Sequential Opioid Dose Reduction Interventions in a State Medicaid Program Between 2002 and 2017. THE JOURNAL OF PAIN 2019; 20:876-884. [DOI: 10.1016/j.jpain.2019.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 11/29/2018] [Accepted: 01/22/2019] [Indexed: 01/05/2023]
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26
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Sears JM, Fulton-Kehoe D, Schulman BA, Hogg-Johnson S, Franklin GM. Opioid Overdose Hospitalization Trajectories in States With and Without Opioid-Dosing Guidelines. Public Health Rep 2019; 134:567-576. [PMID: 31365317 PMCID: PMC6852059 DOI: 10.1177/0033354919864362] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES High-risk opioid-prescribing practices contribute to a national epidemic of opioid-related morbidity and mortality. The objective of this study was to determine whether the adoption of state-level opioid-prescribing guidelines that specify a high-dose threshold is associated with trends in rates of opioid overdose hospitalizations, for prescription opioids, for heroin, and for all opioids. METHODS We identified 3 guideline states (Colorado, Utah, Washington) and 5 comparator states (Arizona, California, Michigan, New Jersey, South Carolina). We used state-level opioid overdose hospitalization data from 2001-2014 for these 8 states. Data were based on the State Inpatient Databases and provided by the Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality, via HCUPnet. We used negative binomial panel regression to model trends in annual rates of opioid overdose hospitalizations. We used a multiple-baseline difference-in-differences study design to compare postguideline trends with concurrent trends for comparator states. RESULTS For each guideline state, postguideline trends in rates of prescription opioid and all opioid overdose hospitalizations decreased compared with trends in the comparator states. The mean annual relative percentage decrease ranged from 3.2%-7.5% for trends in rates of prescription opioid overdose hospitalizations and from 5.4%-8.5% for trends in rates of all opioid overdose hospitalizations. CONCLUSIONS These findings provide preliminary evidence that opioid-dosing guidelines may be an effective strategy for combating this public health crisis. Further research is needed to identify the individual effects of opioid-related interventions that occurred during the study period.
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Affiliation(s)
- Jeanne M. Sears
- Department of Health Services, University of Washington, Seattle, WA,
USA
- Department of Environmental and Occupational Health Sciences, University of
Washington, Seattle, WA, USA
- Harborview Injury Prevention and Research Center, Seattle, WA, USA
- Institute for Work and Health, Toronto, Ontario, Canada
| | - Deborah Fulton-Kehoe
- Department of Environmental and Occupational Health Sciences, University of
Washington, Seattle, WA, USA
| | - Beryl A. Schulman
- Department of Environmental and Occupational Health Sciences, University of
Washington, Seattle, WA, USA
| | - Sheilah Hogg-Johnson
- Institute for Work and Health, Toronto, Ontario, Canada
- Canadian Memorial Chiropractic College, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario,
Canada
| | - Gary M. Franklin
- Department of Health Services, University of Washington, Seattle, WA,
USA
- Department of Environmental and Occupational Health Sciences, University of
Washington, Seattle, WA, USA
- Washington State Department of Labor and Industries, Tumwater, WA, USA
- Department of Neurology, University of Washington, Seattle, WA, USA
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27
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Jandali DB, Vaughan D, Eggerstedt M, Ganti A, Scheltens H, Ramirez EA, Revenaugh PC, Al‐Khudari S, Smith RM, Stenson KM. Enhanced recovery after surgery in head and neck surgery: Reduced opioid use and length of stay. Laryngoscope 2019; 130:1227-1232. [DOI: 10.1002/lary.28191] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 06/19/2019] [Accepted: 07/02/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Danny B. Jandali
- Department of Otorhinolaryngology–Head and Neck SurgeryRush University Medical Center Chicago Illinois U.S.A
| | - Deborah Vaughan
- Department of Otorhinolaryngology–Head and Neck SurgeryRush University Medical Center Chicago Illinois U.S.A
| | - Michael Eggerstedt
- Department of Otorhinolaryngology–Head and Neck SurgeryRush University Medical Center Chicago Illinois U.S.A
| | - Ashwin Ganti
- Rush Medical CollegeRush University Medical Center Chicago Illinois U.S.A
| | - Holly Scheltens
- College of NursingRush University Medical Center Chicago Illinois U.S.A
| | - Emily A. Ramirez
- Department of Otorhinolaryngology–Head and Neck SurgeryRush University Medical Center Chicago Illinois U.S.A
| | - Peter C. Revenaugh
- Department of Otorhinolaryngology–Head and Neck SurgeryRush University Medical Center Chicago Illinois U.S.A
| | - Samer Al‐Khudari
- Department of Otorhinolaryngology–Head and Neck SurgeryRush University Medical Center Chicago Illinois U.S.A
| | - Ryan M. Smith
- Department of Otorhinolaryngology–Head and Neck SurgeryRush University Medical Center Chicago Illinois U.S.A
| | - Kerstin M. Stenson
- Department of Otorhinolaryngology–Head and Neck SurgeryRush University Medical Center Chicago Illinois U.S.A
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Zhao S, Chen F, Feng A, Han W, Zhang Y. Risk Factors and Prevention Strategies for Postoperative Opioid Abuse. Pain Res Manag 2019; 2019:7490801. [PMID: 31360271 PMCID: PMC6652031 DOI: 10.1155/2019/7490801] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 06/25/2019] [Indexed: 02/06/2023]
Abstract
Worldwide, 80% of patients who undergo surgery receive opioid analgesics as the fundamental agent for pain relief. However, the irrational use of opioids leads to excessive drug dependence and drug abuse, resulting in an increased mortality rate and huge economic loss. The crisis of opioid overuse remains a great challenge. In this review, we summarize several key factors in opioid abuse, including race, region, income, genetic factors, age and gender, smoking and alcohol abuse, history of chronic pain and analgesic drug abuse, surgery, neuropsychiatric illness, depression and antidepressant use, human factors, national policies, hospital regulations, and health insurance under treatment of pain. Furthermore, we present several prevention strategies, such as perioperative measures, opioid substitutes, treatment of the primary illness, emotional regulation, use of opioid antagonists, efforts of the state, hospitals, doctors and pharmacy benefit managers, gene therapy, and vaccines. Greater understanding and better assessment are required of the risks associated with opioid abuse to ensure the safety and analgesic effects of pain treatment after surgery.
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Affiliation(s)
- Shuai Zhao
- Department of Anesthesiology, First Hospital of Jilin University, Changchun, China
| | - Fan Chen
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, China
| | - Anqi Feng
- Department of Anesthesiology, Second Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Wei Han
- Department of Anesthesiology, First Hospital of Jilin University, Changchun, China
| | - Yuan Zhang
- Department of Anesthesiology, First Hospital of Jilin University, Changchun, China
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29
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Harrison ML, Walsh TL. The effect of a more strict 2014 DEA schedule designation for hydrocodone products on opioid prescription rates in the United States. Clin Toxicol (Phila) 2019; 57:1064-1072. [PMID: 30789065 DOI: 10.1080/15563650.2019.1574976] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: From 1999 to 2010, the annual number of US deaths due to opioid overdose increased about 400% as the number of opioids prescribed yearly also increased by approximately 400%. Over this period, hydrocodone combination products drove the opioid epidemic, as they became the most frequently prescribed medication in the United States. Our objective was to determine if the Drug Enforcement Administration's (DEA) 2014 policy change - which made it more difficult to prescribe hydrocodone combination products by moving them from Schedule III to Schedule II - reduced the total amount of opioid prescriptions as intended. Methods: We conducted a longitudinal analysis of the 10 most populous US states, beginning at the time each state began collecting data on opioid prescribing, and concluding at the end of 2016. The exposure was the DEA-mandated October 6, 2014 hydrocodone combination product schedule change. Results: After the DEA's schedule change for hydrocodone combination products, the total number of opioids prescribed each year per 100 people did not substantially change in California, Florida, Michigan, or New York. Although prescription rates dropped for hydrocodone combination products (CA: 43.2, 35.0; MI: 66.8, 55.6; NY: 20.8, 15.1), the reduction was commensurately counteracted by increased rates for tramadol (CA: 0.2, 9.9; MI: 0.1, 17.3; NY: 0.0, 7.6) and oxycodone (CA: 8.7, 9.7; MI: 10.3, 11.9; NY: 18.1, 18.8). Surprisingly, the other 6 states assessed had no viable mechanism in place for assessing state-wide opioid prescription totals, routinely expunged collected data, or only instituted a reporting mechanism toward the end of our study. Conclusion: Total opioid prescriptions were relatively unchanged following the 2014 DEA-mandated schedule change, however, physicians did change their prescribing habits by substituting tramadol for hydrocodone combination products. This substitution of similar medications for hydrocodone suggests alternative approaches are needed to reduce total US opioid prescription rates. Additionally, the current lack of standardized prescription reporting by states makes detailed opioid prescription analysis alarmingly difficult and insufficient to guide policy or monitor the impact of policy changes.
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Affiliation(s)
- Matthew L Harrison
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine, Dartmouth College , Hanover , NH , USA.,Emergency Department, Texas Health Resources - Huguley Hospital , Fort Worth , TX , USA.,Department of Emergency Medicine, The University of Texas Southwestern Medical Center , Dallas , TX , USA
| | - Thomas L Walsh
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine, Dartmouth College , Hanover , NH , USA.,Cardinal Point Healthcare Solutions , Vista , CA , USA.,Oxley College of Health Sciences, University of Tulsa , Tulsa , OK , USA
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30
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Franklin GM, Mercier M, Mai J, Tuman D, Fulton-Kehoe D, Wickizer T, Sears JM. Brief report: Population-based reversal of the adverse impact of opioids on disability in Washington State workers' compensation. Am J Ind Med 2019; 62:168-174. [PMID: 30592542 DOI: 10.1002/ajim.22937] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2018] [Indexed: 11/12/2022]
Abstract
BACKGROUND Evidence has associated opioid use initiated early in a workers' compensation claim with subsequent disability. In 2013, the Washington State Department of Labor and Industries (DLI) implemented procedures based on new regulations that require improvement in pain and function to approve opioids beyond the acute pain period. METHODS We measured opioid prescriptions between 6 and 12 weeks following injury, an indicator of persistent opioid use. Actuarial data for the association of any opioid use versus no opioid use with development of lost time payments are reported. RESULTS Prior authorization with hard stops led to a sustained drop in persistent opioid use, from nearly 5% in 2013 to less than 1% in 2017. This reduction was also associated with reversal of the increased lost work time patterns seen from 1999 to 2010. CONCLUSIONS Prior authorization targeted at preventing transition to chronic opioid use can prevent and reverse adverse time loss development that has occurred on a population basis concomitant with the opioid epidemic.
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Affiliation(s)
- Gary M. Franklin
- Washington State Department of Labor and Industries; Olympia Washington
- Department of Environmental and Occupational Health Sciences; University of Washington; Seattle Washington
- Department of Health Services; University of Washington; Seattle Washington
- Department of Neurology; University of Washington; Seattle Washington
| | - Mark Mercier
- Washington State Department of Labor and Industries; Olympia Washington
| | - Jaymie Mai
- Washington State Department of Labor and Industries; Olympia Washington
| | - Doug Tuman
- Washington State Department of Labor and Industries; Olympia Washington
| | - Deborah Fulton-Kehoe
- Department of Environmental and Occupational Health Sciences; University of Washington; Seattle Washington
| | - Thomas Wickizer
- Division of Health Services Management and Policy; The Ohio State University College of Public Health; Columbus Ohio
| | - Jeanne M. Sears
- Department of Health Services; University of Washington; Seattle Washington
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31
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Davis CS, Lieberman AJ, Hernandez-Delgado H, Suba C. Laws limiting the prescribing or dispensing of opioids for acute pain in the United States: A national systematic legal review. Drug Alcohol Depend 2019; 194:166-172. [PMID: 30445274 DOI: 10.1016/j.drugalcdep.2018.09.022] [Citation(s) in RCA: 126] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 07/31/2018] [Accepted: 09/15/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND Opioid overdose is a continuing public health crisis. In response to an increasing recognition of the negative outcomes sometimes associated with the use of opioid analgesics, states have taken a number of steps attempting to reduce inappropriate prescribing of these medications. These include the imposition of strict legal limitations on the amount or duration that opioid analgesics may be prescribed or dispensed to patients with acute pain. METHODS We conducted a systematic, multi-source legal review of state laws that impose mandatory limits on the ability of medical professionals to prescribe or dispense opioids for the treatment of acute pain. We also systematically searched for and examined publicly available documents on state legislative and regulatory bodies' websites. All relevant laws were downloaded and systematically coded. RESULTS By the end of 2017, twenty-six states had passed laws that impose mandatory limits on the prescribing or dispensing of opioids for acute pain. The oldest of these laws became effective as early as 1989, but most are much newer: approximately 65% (17/26) were passed in 2017. There is wide variation in the characteristics of these laws. CONCLUSION Just over half of all states have enacted laws that restrict the prescribing or dispensing of opioids for acute pain. To date, there is no data on whether and to what extent these laws mediate opioid-related morbidity and mortality, as well as whether they are associated with negative unintended outcomes. Research into these questions is urgently needed.
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Affiliation(s)
- Corey S Davis
- Network for Public Health Law, Los Angeles, CA, USA; Brody School of Medicine, East Carolina University, Greenville, NC, USA.
| | | | | | - Carli Suba
- Network for Public Health Law, Los Angeles, CA, USA
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32
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Hartung DM, Kim H, Ahmed SM, Middleton L, Keast S, Deyo RA, Zhang K, McConnell KJ. Effect of a high dosage opioid prior authorization policy on prescription opioid use, misuse, and overdose outcomes. Subst Abus 2018; 39:239-246. [PMID: 29016245 PMCID: PMC9926935 DOI: 10.1080/08897077.2017.1389798] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND High dosage opioid use is a risk factor for opioid-related overdose commonly cited in guidelines, recommendations, and policies. In 2012, the Oregon Medicaid program developed a prior authorization policy for opioid prescriptions above 120 mg per day morphine equivalent dose (MED). This study aimed to evaluate the effects of that policy on utilization, prescribing patterns, and health outcomes. METHODS Using administrative claims data from Oregon and a control state (Colorado) between 2011 and 2013, we used difference-in-differences analyses to examine changes in utilization, measures of high risk opioid use, and overdose after introduction of the policy. We also evaluated opioid utilization in a cohort of individuals who were high dosage opioid users before the policy. RESULTS Following implementation of Oregon's high dosage policy, the monthly probability of an opioid fill over 120 mg MED declined significantly by 1.7 percentage points (95% confidence interval [CI]; -2.0% to -1.4%), whereas it increased significantly by 1.0 percentage points (95% CI 0.4% to 1.7%) for opioid fills < 61 mg MED. Fills of medications used to treat neuropathic pain also increased by 1.2 percentage points (95% CI 0.7% to 1.8%). The monthly probability of multiple pharmacy use declined by 0.1 percentage points (-0.2% to -0.0) following the prior authorization, but there were no significant changes in ED encounters or hospitalizations for opioid overdose. Among individuals who were using a high dosage opioid before the policy, there was a 20.3 percentage point (95% CI -15.3% to -25.3%) decline in estimated probability of having a high dosage fill after the policy. CONCLUSIONS Oregon's prior authorization policy was effective at reducing high dosage opioid prescriptions. While multiple pharmacy use also declined, we found no impact on opioid overdose were observed.
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Affiliation(s)
- Daniel M. Hartung
- Oregon State University/Oregon Health & Science University, College of Pharmacy, Portland, Oregon, USA
| | - Hyunjee Kim
- Oregon Health & Science University, Center for Health Systems Effectiveness, Portland, Oregon, USA
| | - Sharia M. Ahmed
- Oregon State University/Oregon Health & Science University, College of Pharmacy, Portland, Oregon, USA
| | - Luke Middleton
- Oregon State University/Oregon Health & Science University, College of Pharmacy, Portland, Oregon, USA
| | - Shellie Keast
- University of Oklahoma College of Pharmacy, Department of Clinical and Administrative Sciences, Oklahoma City, Oklahoma, USA
| | - Richard A. Deyo
- Oregon Health & Science University, Center for Health Systems Effectiveness, Portland, Oregon, USA
| | - Kun Zhang
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - K. John McConnell
- Oregon Health & Science University, Center for Health Systems Effectiveness, Portland, Oregon, USA
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33
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Buttorff C, Trujillo AJ, Castillo R, Vecino-Ortiz AI, Anderson GF. The impact of practice guidelines on opioid utilization for injured workers. Am J Ind Med 2017; 60:1023-1030. [PMID: 28990210 DOI: 10.1002/ajim.22779] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Opioid use is rising in the US and may cause special problems in workers compensation cases, including addiction and preventing a return to work after an injury. OBJECTIVE This study evaluates a physician-level intervention to curb opioid usage. An insurer identified patients with out-of-guideline opioid utilization and called the prescribing physician to discuss the patient's treatment protocol. RESEARCH DESIGN This study uses a differences-in-differences study design with a propensity-score-matched control group. Medical and pharmaceutical claims data from 2005 to 2011 were used for analyses. RESULTS Following the intervention, the use of opioids increased for the intervention group and there is little impact on medical spending. CONCLUSIONS Counseling physicians about patients with high opioid utilization may focus more attention on their care, but did not impact short-term outcomes. More robust interventions may be needed to manage opioid use. PERSPECTIVE While the increasing use of opioids is of growing concern around the world, curbing the utilization of these powerfully addictive narcotics has proved elusive. This study examines a prescribing guidelines intervention designed to reduce the prescription of opioids following an injury. The study finds that there was little change in the opioid utilization after the intervention, suggesting interventions along other parts of the prescribing pathway may be needed.
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Affiliation(s)
| | - Antonio J. Trujillo
- Department of International Health; Johns Hopkins Bloomberg School of Public Health; Baltimore Maryland
| | - Renan Castillo
- Department of Health Policy and Management; Johns Hopkins Bloomberg School of Public Health; Baltimore Maryland
| | - Andres I. Vecino-Ortiz
- Department of International Health; Johns Hopkins Bloomberg School of Public Health; Baltimore Maryland
- Institute of Public Health; Universidad Javeriana; Bogota Colombia
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Liebschutz JM, Xuan Z, Shanahan CW, LaRochelle M, Keosaian J, Beers D, Guara G, O'Connor K, Alford DP, Parker V, Weiss RD, Samet JH, Crosson J, Cushman PA, Lasser KE. Improving Adherence to Long-term Opioid Therapy Guidelines to Reduce Opioid Misuse in Primary Care: A Cluster-Randomized Clinical Trial. JAMA Intern Med 2017; 177:1265-1272. [PMID: 28715535 PMCID: PMC5710574 DOI: 10.1001/jamainternmed.2017.2468] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
IMPORTANCE Prescription opioid misuse is a national crisis. Few interventions have improved adherence to opioid-prescribing guidelines. OBJECTIVE To determine whether a multicomponent intervention, Transforming Opioid Prescribing in Primary Care (TOPCARE; http://mytopcare.org/), improves guideline adherence while decreasing opioid misuse risk. DESIGN, SETTING, AND PARTICIPANTS Cluster-randomized clinical trial among 53 primary care clinicians (PCCs) and their 985 patients receiving long-term opioid therapy for pain. The study was conducted from January 2014 to March 2016 in 4 safety-net primary care practices. INTERVENTIONS Intervention PCCs received nurse care management, an electronic registry, 1-on-1 academic detailing, and electronic decision tools for safe opioid prescribing. Control PCCs received electronic decision tools only. MAIN OUTCOMES AND MEASURES Primary outcomes included documentation of guideline-concordant care (both a patient-PCC agreement in the electronic health record and at least 1 urine drug test [UDT]) over 12 months and 2 or more early opioid refills. Secondary outcomes included opioid dose reduction (ie, 10% decrease in morphine-equivalent daily dose [MEDD] at trial end) and opioid treatment discontinuation. Adjusted outcomes controlled for differing baseline patient characteristics: substance use diagnosis, mental health diagnoses, and language. RESULTS Of the 985 participating patients, 519 were men, and 466 were women (mean [SD] patient age, 54.7 [11.5] years). Patients received a mean (SD) MEDD of 57.8 (78.5) mg. At 1 year, intervention patients were more likely than controls to receive guideline-concordant care (65.9% vs 37.8%; P < .001; adjusted odds ratio [AOR], 6.0; 95% CI, 3.6-10.2), to have a patient-PCC agreement (of the 376 without an agreement at baseline, 53.8% vs 6.0%; P < .001; AOR, 11.9; 95% CI, 4.4-32.2), and to undergo at least 1 UDT (74.6% vs 57.9%; P < .001; AOR, 3.0; 95% CI, 1.8-5.0). There was no difference in odds of early refill receipt between groups (20.7% vs 20.1%; AOR, 1.1; 95% CI, 0.7-1.8). Intervention patients were more likely than controls to have either a 10% dose reduction or opioid treatment discontinuation (AOR, 1.6; 95% CI, 1.3-2.1; P < .001). In adjusted analyses, intervention patients had a mean (SE) MEDD 6.8 (1.6) mg lower than controls (P < .001). CONCLUSIONS AND RELEVANCE A multicomponent intervention improved guideline-concordant care but did not decrease early opioid refills. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01909076.
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Affiliation(s)
- Jane M Liebschutz
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.,Boston University School of Medicine, Boston, Massachusetts
| | - Ziming Xuan
- Boston University School of Public Health, Boston, Massachusetts
| | - Christopher W Shanahan
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.,Boston University School of Medicine, Boston, Massachusetts
| | - Marc LaRochelle
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.,Boston University School of Medicine, Boston, Massachusetts
| | - Julia Keosaian
- Boston University School of Public Health, Boston, Massachusetts
| | - Donna Beers
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts
| | - George Guara
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts
| | - Kristen O'Connor
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts
| | - Daniel P Alford
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.,Boston University School of Medicine, Boston, Massachusetts
| | - Victoria Parker
- Boston University School of Public Health, Boston, Massachusetts
| | - Roger D Weiss
- McLean Hospital, Belmont, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Jeffrey H Samet
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.,Boston University School of Medicine, Boston, Massachusetts.,Boston University School of Public Health, Boston, Massachusetts
| | - Julie Crosson
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.,Dorchester House Community Health Center, Boston, Massachusetts
| | - Phoebe A Cushman
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.,Boston University School of Medicine, Boston, Massachusetts
| | - Karen E Lasser
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.,Boston University School of Medicine, Boston, Massachusetts.,Boston University School of Public Health, Boston, Massachusetts
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35
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Han L, Allore H, Goulet J, Bathulapali H, Skanderson M, Brandt C, Haskell S, Krebs E. Opioid dosing trends over eight years among US Veterans with musculoskeletal disorders after returning from service in support of recent conflicts. Ann Epidemiol 2017; 27:563-569.e3. [PMID: 28890282 DOI: 10.1016/j.annepidem.2017.08.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 08/01/2017] [Accepted: 08/11/2017] [Indexed: 12/17/2022]
Abstract
PURPOSE To examine long-term opioid dosing trends among Veterans with chronic pain. METHODS We identified 79,015 Veterans with musculoskeletal disorders who were dispensed greater than or equal to 1 opioid prescriptions between 2002 and 2009 after returning from recent conflicts. Opioid-dosing trends were examined using a generalized estimating equation while accounting for patient characteristics, temporal and geographic confounding. RESULTS In total, 472,819 opioid prescriptions were dispensed (mean ± standard deviation: 6.0 ± 10.1 per Veteran). Both average daily morphine equivalents (MEs/d) and the proportion of high-dose prescribing (greater than 100 ME/d) increased from baseline period (2002-2004) to 2006, then remained relatively stable. Veterans with extended persistent (greater than or equal to 40 days over 1-2 episodes) and extended intermittent (greater than or equal to 40 days over greater than or equal to three episodes) dispensing patterns received more high-dose prescriptions than those dispensed prescriptions less than 40 days, with adjusted odds ratios (95% confidence interval) of 7.2 (6.0-8.8) and 3.6 (3.0-4.3), respectively. Posttraumatic stress disorder and other mental health diagnoses were associated with 30% increased odds of high-dose prescribing. CONCLUSIONS The average daily dose of opioid prescriptions and the likelihood of high-dose prescribing to these Veterans appeared to increase from 2002 to 2006, then remained relatively stable through 2009. Veterans on opioid prescriptions for extended duration or with mental health diagnoses tend to receive higher dose therapy.
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Affiliation(s)
- Ling Han
- Yale School of Medicine, Department of Internal Medicine, New Haven, CT; VA Connecticut Healthcare System, West Haven, CT.
| | - Heather Allore
- Yale School of Medicine, Department of Internal Medicine, New Haven, CT; VA Connecticut Healthcare System, West Haven, CT
| | - Joseph Goulet
- VA Connecticut Healthcare System, West Haven, CT; Yale School of Medicine, Departments of Psychiatry, Medicine and Emergency Medicine, New Haven, CT
| | | | | | - Cynthia Brandt
- VA Connecticut Healthcare System, West Haven, CT; Yale School of Medicine, Departments of Psychiatry, Medicine and Emergency Medicine, New Haven, CT
| | - Sally Haskell
- VA Connecticut Healthcare System, West Haven, CT; Yale School of Medicine, Departments of Psychiatry, Medicine and Emergency Medicine, New Haven, CT
| | - Erin Krebs
- Minneapolis VA Health Care System, Minneapolis, MN; Department of Medicine, University of Minnesota Medical School, Minneapolis
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36
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Leece P, Buchman DZ, Hamilton M, Timmings C, Shantharam Y, Moore J, Furlan AD. Improving opioid safety practices in primary care: protocol for the development and evaluation of a multifaceted, theory-informed pilot intervention for healthcare providers. BMJ Open 2017; 7:e013244. [PMID: 28446522 PMCID: PMC5719659 DOI: 10.1136/bmjopen-2016-013244] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION In North America, drug overdose deaths are reaching unprecedented levels, largely driven by increasing prescription opioid-related deaths. Despite the development of several opioid guidelines, prescribing behaviours still contribute to poor patient outcomes and societal harm. Factors at the provider and system level may hinder or facilitate the application of evidence-based guidelines; interventions designed to address such factors are needed. METHODS AND ANALYSIS Using implementation science and behaviour change theory, we have planned the development and evaluation of a comprehensive Opioid Self-Assessment Package, designed to increase adherence to the Canadian Opioid Guideline among family physicians. The intervention uses practical educational and self-assessment tools to provide prescribers with feedback on their current knowledge and practices, and resources to improve their practice. The evaluation approach uses a pretest and post-test design and includes both quantitative and qualitative methods at baseline and 6 months. We will recruit a purposive sample of approximately 10 family physicians in Ontario from diverse practice settings, who currently treat patients with long-term opioid therapy for chronic pain. Quantitative data will be analysed using basic descriptive statistics, and qualitative data will be analysed using the Framework Method. ETHICS AND DISSEMINATION The University Health Network Research Ethics Board approved this study. Dissemination plan includes publications, conference presentations and brief stakeholder reports. This evidence-informed, theory-driven intervention has implications for national application of opioid quality improvement tools in primary care settings. We are engaging experts and end users in advisory and stakeholder roles throughout our project to increase its national relevance, application and sustainability. The performance measures could be used as the basis for health system quality improvement indicators to monitor opioid prescribing. Additionally, the methods and approach used in this study could be adapted for other opioid guidelines, or applied to other areas of preventive healthcare and clinical guideline implementation processes.
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Affiliation(s)
| | - Daniel Z Buchman
- Public Health Ontario, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
- University of Toronto Joint Centre for Bioethics, Toronto, Ontario, Canada
| | - Michael Hamilton
- Institute for Safe Medication Practices Canada, Toronto, Ontario, Canada
| | - Caitlyn Timmings
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Yalnee Shantharam
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Julia Moore
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Andrea D Furlan
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Shah AC, Nair BG, Spiekerman CF, Bollag LA. Continuous intraoperative epidural infusions affect recovery room length of stay and analgesic requirements: a single-center observational study. J Anesth 2017; 31:494-501. [PMID: 28185011 DOI: 10.1007/s00540-017-2316-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 01/29/2017] [Indexed: 12/21/2022]
Abstract
PURPOSE Continuous intraoperative epidural analgesia may improve post-operative pain control and decrease opioid requirements. We investigate the effect of epidural infusion initiation before or after arrival in the post-anesthesia care unit on recovery room duration and post-operative opioid use. METHODS We performed a retrospective chart review of abdominal, thoracic and orthopedic surgeries where an epidural catheter was placed prior to surgery at the University of Washington Medical Center during a 24 month period. RESULTS Patients whose epidural infusions were started prior to PACU arrival (Group 2: n = 540) exhibited a shorter PACU length of stay (p = .004) and were less likely to receive intravenous opioids in the recovery room (34 vs. 48%; p < .001) compared to patients whose infusions were started after surgery (Group 1: n = 374). Although the highest patient-reported pain scores were lower in Group 2 (5.3 vs. 6.0; p = .030), no differences in the pain scores prior to PACU discharge were observed. CONCLUSION Intraoperative continuous epidural infusions decrease PACU LOS as discharge criteria for patient-reported NRS pain scores are met earlier.
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Affiliation(s)
- Aalap C Shah
- Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, WA, USA. .,Department of Anesthesiology, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Los Angeles, CA, 90048, USA.
| | - Bala G Nair
- Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - Charles F Spiekerman
- Institute for Translational Health Sciences (ITHS), University of Washington, Seattle, WA, USA
| | - Laurent A Bollag
- Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, WA, USA
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Zin CS, Ismail F. Co-prescription of opioids with benzodiazepine and other co-medications among opioid users: differential in opioid doses. J Pain Res 2017; 10:249-257. [PMID: 28182128 PMCID: PMC5279838 DOI: 10.2147/jpr.s122853] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose This study investigated the patterns of opioid co-prescription with benzodiazepine and other concomitant medications among opioid users. Opioid dose in each type of co-prescription was also examined. Patients and methods This cross-sectional study was conducted among opioid users receiving concomitant medications at an outpatient tertiary hospital setting in Malaysia. Opioid prescriptions (morphine, fentanyl, oxycodone, dihydrocodeine and tramadol) that were co-prescribed with other medications (opioid + benzodiazepines, opioid + antidepressants, opioid + anticonvulsants, opioid + antipsychotics and opioid + hypnotics) dispensed from January 2013 to December 2014 were identified. The number of patients, number of co-prescriptions and the individual mean opioid daily dose in each type of co-prescription were calculated. Results A total of 276 patients receiving 1059 co-prescription opioids with benzodiazepine and other co-medications were identified during the study period. Of these, 12.3% of patients received co-prescriptions of opioid + benzodiazepine, 19.3% received opioid + anticonvulsant, 6.3% received opioid + antidepressant and 10.9% received other co-prescriptions, including antipsychotics and hypnotics. The individual mean opioid dose was <100 mg/d of morphine equivalents in all types of co-prescriptions, and the dose ranged from 31 to 66 mg/d in the co-prescriptions of opioid + benzodiazepine. Conclusion Among the opioid users receiving concomitant medications, the co-prescriptions of opioid with benzodiazepine were prescribed to 12.3% of patients, and the individual opioid dose in this co-prescription was moderate. Other co-medications were also commonly used, and their opioid doses were within the recommended dose. Future studies are warranted to evaluate the adverse effect and clinical outcomes of the co-medications particularly in long-term opioid users with chronic non-cancer pain.
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Affiliation(s)
- Che Suraya Zin
- Kulliyyah of Pharmacy, International Islamic University Malaysia, Bandar Indera Mahkota, Kuantan, Pahang, Malaysia
| | - Fadhilah Ismail
- Kulliyyah of Pharmacy, International Islamic University Malaysia, Bandar Indera Mahkota, Kuantan, Pahang, Malaysia
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