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Flores MW, Sharp A, Lu F, Cook BL. Examining Racial/Ethnic Differences in Patterns of Opioid Prescribing: Results from an Urban Safety-Net Healthcare System. J Racial Ethn Health Disparities 2024; 11:719-729. [PMID: 36892815 PMCID: PMC9997438 DOI: 10.1007/s40615-023-01555-z] [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] [Received: 11/08/2022] [Revised: 02/17/2023] [Accepted: 02/23/2023] [Indexed: 03/10/2023]
Abstract
Prescription opioids still account for a large proportion of overdose deaths and contribute to opioid use dependence (OUD). Studies earlier in the epidemic suggest clinicians were less likely to prescribe opioids to racial/ethnic minorities. As OUD-related deaths have increased disproportionately amongst minority populations, it is essential to understand racial/ethnic differences in opioid prescribing patterns to inform culturally sensitive mitigation efforts. The purpose of this study is to estimate racial/ethnic differences in opioid medication use among patients prescribed opioids. Using electronic health records and a retrospective cohort study design, we estimated multivariable hazard models and generalized linear models, assessing racial/ethnic differences in OUD diagnosis, number of opioid prescriptions, receiving only one opioid prescription, and receiving ≥18 opioid prescriptions. Study population (N=22,201) consisted of adult patients (≥18years), with ≥3 primary care visits (ensuring healthcare system linkage), ≥1 opioid prescription, who did not have an OUD diagnoses prior to the first opioid prescription during the 32-month study period. Relative to racial/ethnic minority patients, White patients, in both unadjusted and adjusted analyses, had a greater number of opioid prescriptions filled, a higher proportion received ≥18 opioid prescriptions, and a greater hazard of having an OUD diagnosis subsequent to receiving an opioid prescription (all groups p<0.001). Although opioid prescribing rates have declined nationally, our findings suggest White patients still experience a high volume of opioid prescriptions and greater risk of OUD diagnosis. Racial/ethnic minorities are less likely to receive follow-up pain medications, which may signal low care quality. Identifying provider bias in pain management of racial/ethnic minorities could inform interventions seeking balance between adequate pain treatment and risk of opioid misuse/abuse.
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Affiliation(s)
- Michael William Flores
- Health Equity Research Lab, Cambridge Health Alliance, 1035 Cambridge Street, Suite 26, Cambridge, MA, 02141, USA.
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
| | - Amanda Sharp
- Health Equity Research Lab, Cambridge Health Alliance, 1035 Cambridge Street, Suite 26, Cambridge, MA, 02141, USA
- Center for Mindfulness and Compassion, Cambridge Health Alliance, Cambridge, MA, USA
| | - Frederick Lu
- Boston University School of Medicine, Boston, MA, USA
| | - Benjamin Lê Cook
- Health Equity Research Lab, Cambridge Health Alliance, 1035 Cambridge Street, Suite 26, Cambridge, MA, 02141, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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2
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Lee-Easton MJ, Magura S, Abu-Obaid R, Reed P, Allgaier B, Fish E, Maletta A, Amaratunga P, Lorenz-Lemberg B, Levitas M, Achtyes E. Direct-To-Definitive Urine and Oral Fluid Test Results for Unscreened and Rarely Screened Drugs in Individuals Applying for Methadone Treatment in 7 U.S. States. J Psychoactive Drugs 2024:1-12. [PMID: 38329134 PMCID: PMC11306407 DOI: 10.1080/02791072.2024.2314220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/22/2023] [Indexed: 02/09/2024]
Abstract
The standard protocol in addiction treatment/pain management is to conduct immunoassay screens for major drugs subject to misuse, followed by confirmatory testing of positive results. However, this may miss unscreened or rarely screened drugs that could pose risks, especially to polydrug users. We sought to determine the prevalences of unscreened/rarely screened drugs in a sample of individuals misusing drugs in 7 U.S. states, and to compare the results of urine vs. oral testing for these drugs by direct-to-definitive liquid chromatography/tandem mass spectrometry (LC-MS-MS). The five drugs with the highest prevalences were: gabapentin (16.8%), quetiapine (6.2%), chlorpheniramine (5.3%), hydroxyzine (4.9%), and ephedrine (3.5%). All have clinical significance as indicated by severity of possible side effects, interactions with other drugs, and/or misuse potential. Drugs were generally detected more frequently in oral fluid than urine, but gabapentin was more frequently detected in urine. The prevalences of the included drugs seem high enough, and their clinical significance important enough, to warrant consideration of expanding clinical drug test panels, either by direct-to-definitive testing or the addition of selected immunoassay screens when available. Oral fluid was usually more suitable than urine as the test matrix, given the higher rates of detection in oral fluid for most substances included in this study.
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Affiliation(s)
- Miranda J Lee-Easton
- Evaluation Center, The Evaluation Center at Western Michigan University, Kalamazoo, MI, United States
| | - Stephen Magura
- Evaluation Center, The Evaluation Center at Western Michigan University, Kalamazoo, MI, United States
| | - Ruqayyah Abu-Obaid
- Evaluation Center, The Evaluation Center at Western Michigan University, Kalamazoo, MI, United States
| | - Pete Reed
- Forensic Fluids Laboratories, Kalamazoo, MI, United States
| | | | - Emily Fish
- Forensic Fluids Laboratories, Kalamazoo, MI, United States
| | | | | | | | | | - EricD Achtyes
- School of Medicine, Western Michigan University, Kalamazoo, MI, United States
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3
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Lierheimer S, Beck O, Keller T, Monticelli FC, Böttcher M. Hydromorphone and codeine concentrations in oral fluid specimens from patients receiving substitution therapy with Substitol™ (morphine sulfate). Drug Test Anal 2021; 13:1743-1748. [PMID: 34250761 DOI: 10.1002/dta.3127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/30/2021] [Accepted: 07/07/2021] [Indexed: 11/07/2022]
Abstract
This study aimed to determine whether hydromorphone and codeine can be detected in oral fluid specimens following administration of Substitol™, a slow-release formulation of morphine. This is of interest for those monitoring treatment compliance using drug testing. Oral fluid specimens collected for compliance assessment in routine clinical practice or as part of a clinical trial were subjected to quantitative analysis of hydromorphone, morphine, codeine, and 6-acetylmorphine using highly sensitive mass spectrometric methods. Oral fluid was collected using a Greiner Bio-One saliva collection system. Patients undergoing substitution treatment with Substitol™, methadone, or buprenorphine were included, together with patients undergoing pain treatment with hydromorphone. Hydromorphone was detected in 642 of the 663 (97%) samples from substitol-treated patients. Concentrations were not higher in methadone- and buprenorphine-treated patients who relapsed into heroin use, or in patients on hydromorphone therapy. Codeine was detected in 29% of the samples. These concentrations were lower than those in patients who had relapsed to heroin use. Clinical administration of morphine can lead to detectable concentrations of both hydromorphone and codeine in oral fluids. This should be taken into consideration when using drug testing in oral fluid samples for compliance assessment in this patient group.
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Affiliation(s)
- Stefan Lierheimer
- Department of Toxicology, MVZ Medizinische Labore Dessau Kassel GmbH, Dessau-Roßlau, Germany
| | - Olof Beck
- Department of Clinical Neuroscience, Karolinska Institute, Solna, Sweden
| | - Thomas Keller
- Institute of Forensic Medicine, University of Salzburg, Salzburg, Austria
| | | | - Michael Böttcher
- Department of Toxicology, MVZ Medizinische Labore Dessau Kassel GmbH, Dessau-Roßlau, Germany
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Phipps WS, Bradley B, Love JE, Hoofnagle AN. Unexpected Presence of an Unusual Opioid in a Patient with Chronic Pain. Clin Chem 2021; 67:596-599. [PMID: 33788941 DOI: 10.1093/clinchem/hvaa317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 09/21/2020] [Indexed: 11/12/2022]
Affiliation(s)
- William S Phipps
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Benjamin Bradley
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Jason E Love
- Western Washington Pathology, MultiCare Tacoma General Hospital, Tacoma, WA, USA
| | - Andrew N Hoofnagle
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
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Krasowski MD. Commentary on Unexpected Presence of an Unusual Opioid in a Patient with Chronic Pain. Clin Chem 2021; 67:600-601. [PMID: 33788937 DOI: 10.1093/clinchem/hvaa320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 11/23/2020] [Indexed: 11/13/2022]
Affiliation(s)
- Matthew D Krasowski
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Approaches to drug monitoring: partnering with the clinical laboratory. Int Anesthesiol Clin 2021; 58:12-18. [PMID: 32004170 DOI: 10.1097/aia.0000000000000269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Jhamb M, Tucker L, Liebschutz J. When ESKD complicates the management of pain. Semin Dial 2020; 33:286-296. [PMID: 32367543 DOI: 10.1111/sdi.12881] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 04/08/2020] [Indexed: 12/12/2022]
Abstract
Pain is one of the most common symptoms reported by patients with end-stage kidney disease (ESKD) and negatively impacts their health-related quality of life (HRQOL), dialysis adherence, healthcare utilization, and mortality. There are a number of patient-related and health system-related barriers that make it very challenging to treat pain in these patients. Moreover, the limited availability of efficacious and safe nonopiate analgesic options has led to over-use of opioids in this population. We propose a framework for pain assessment and tailored treatment using nonpharmacological and pharmacological approaches to optimize pain management and opioid use. Additionally, we recommend system-level changes to improve care coordination and pain management in ESKD patients.
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Affiliation(s)
- Manisha Jhamb
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Laura Tucker
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jane Liebschutz
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Krasowski MD, McMillin GA, Melanson SEF, Dizon A, Magnani B, Snozek CLH. Interpretation and Utility of Drug of Abuse Screening Immunoassays: Insights From Laboratory Drug Testing Proficiency Surveys. Arch Pathol Lab Med 2019; 144:177-184. [DOI: 10.5858/arpa.2018-0562-cp] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—
Urine drug testing is frequently ordered by health care providers. Immunoassays are widely used for drug testing, yet have potential limitations, including variable cross-reactivity. The last decade has seen worsening of a prescription drug abuse epidemic.
Objective.—
To use data from a College of American Pathologists proficiency testing survey, Urine Drug Testing, Screening, to determine and summarize the characteristics, performance, and limitations of immunoassays.
Design.—
Seven years of proficiency surveys were reviewed (2011–2017).
Results.—
Rapid growth was seen in participant volumes for specific immunoassays for synthetic opioids (eg, buprenorphine, fentanyl, oxycodone) and 3,4-methylenedioxymethamphetamine (“ecstasy”). Participant volumes remained high for immunoassays targeting less commonly abused drugs such as barbiturates and phencyclidine. For opiate immunoassays, the number of laboratories using a 2000 ng/mL positive cutoff remained stable, and an increasing number adopted a 100 ng/mL cutoff. Opiate and amphetamine immunoassays showed high variability in cross-reactivity for drugs other than the assay calibrator. Assays targeting a single drug or metabolite generally performed well on drug challenges.
Conclusions.—
Survey results indicate strong clinical interest in urine drug testing and some adoption of new assays. However, urine drug testing availability does not parallel prevailing patterns of drug prescribing and abuse patterns. In particular, specific immunoassays for synthetic opioids and a lower positive cutoff for opiate immunoassays may be underused, whereas immunoassays for barbiturates, methadone, propoxyphene, and phencyclidine may be overused. Laboratories are encouraged to review their test menu, cutoffs, and assay performance and adjust their test offerings based on clinical needs and technical capabilities.
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Affiliation(s)
- Matthew D. Krasowski
- From the Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City (Dr Krasowski); the Department of Pathology, University of Utah School of Medicine, ARUP Laboratories, Salt Lake City (Dr McMillin); the Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Dr Melanson); the Proficiency Testing Division, College of American Pathol
| | - Gwendolyn A. McMillin
- From the Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City (Dr Krasowski); the Department of Pathology, University of Utah School of Medicine, ARUP Laboratories, Salt Lake City (Dr McMillin); the Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Dr Melanson); the Proficiency Testing Division, College of American Pathol
| | - Stacy E. F. Melanson
- From the Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City (Dr Krasowski); the Department of Pathology, University of Utah School of Medicine, ARUP Laboratories, Salt Lake City (Dr McMillin); the Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Dr Melanson); the Proficiency Testing Division, College of American Pathol
| | - Annabel Dizon
- From the Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City (Dr Krasowski); the Department of Pathology, University of Utah School of Medicine, ARUP Laboratories, Salt Lake City (Dr McMillin); the Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Dr Melanson); the Proficiency Testing Division, College of American Pathol
| | - Barbarajean Magnani
- From the Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City (Dr Krasowski); the Department of Pathology, University of Utah School of Medicine, ARUP Laboratories, Salt Lake City (Dr McMillin); the Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Dr Melanson); the Proficiency Testing Division, College of American Pathol
| | - Christine L. H. Snozek
- From the Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City (Dr Krasowski); the Department of Pathology, University of Utah School of Medicine, ARUP Laboratories, Salt Lake City (Dr McMillin); the Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (Dr Melanson); the Proficiency Testing Division, College of American Pathol
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Abstract
Substance use during pregnancy is common, costly and associated with maternal and newborn health consequences. Assessment of substance use should be integrated into prenatal care. Substance use identification methods include patient interview, screening instruments, and biological testing. In this review, we critically evaluate screening and testing for substance use during pregnancy, highlighting the benefits and barriers of integrated assessment into prenatal care. We also discuss the limitations and negative consequences that should be considered when implementing screening and/or testing procedures. Lastly, we provide recommendations for the ethical implementation of screening and testing for substance use in the context of prenatal care.
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