Trending gabapentin exposures in Kentucky after legislation requiring use of the state prescription drug monitoring program for all opioid prescriptions

Trends in dispensed prescriptions for opioids, sedatives, benzodiazepines, gabapentin, and stimulants to children by general dentists, 2012-2019

PURPOSE

Opioids, benzodiazepines and sedatives can manage dental pain, fear and anxiety but have a narrow margin of safety in children. General dentists may inappropriately prescribe gabapentin and stimulants. National evidence on dispensing rates of these high-alert medicines by dentists to children is limited.

METHODS

We utilize join-point regression to identify changes in fills for opioids, sedatives, benzodiazepines, gabapentin, and stimulants to children <18 years from 2012 to 2019 in a national dataset comprising 92% of dispensed outpatient prescriptions by dentists.

RESULTS

From 2012 to 2019, 3.8 million children filled prescriptions for high-alert drugs from general dentists. National quarterly dispensing of high-alert drugs decreased 63.1%, from 10456.0 to 3858.8 days per million. Opioids accounted for 69.4% of high-alert prescriptions. From 2012 to 2019, fills for opioids, sedatives, benzodiazepines, and stimulants decreased by 65.2% (7651.8 to 2662.7), 43.4% (810.9 to 458.7), 43.6% (785.7 to 442.7) and 89.3% (825.6 to 88.6 days per million), respectively. Gabapentin increased 8.1% (121.8 to 131.7 days per million). A significant decrease in high-alert fills occurred in 2016, (-6.0% per quarter vs. -1.6% pre-2016, P-value<0.001), especially for opioids (-7.0% vs. -1.2%, P-value<0.001). Older teenagers (15-17 years) received 42.5% of high-alert prescriptions. Low-income counties in the South were overrepresented among top-prescribing areas in 2019.

CONCLUSIONS

We found promising national decreases in fills for high-alert medicines to children by general dentists from 2012 to 2019. However, older teenagers and children in some counties continued to receive dental opioids at high rates. Future efforts should address non-evidence-based pain management in these groups.

Association of State-Imposed Restrictions on Gabapentin with Changes in Prescribing in Medicare

BACKGROUND

Between August 2016 and July 2018, three states classified gabapentin as a Schedule V drug and nine states implemented prescription drug monitoring program (PDMP) regulation for gabapentin. It is highly unusual for states to take drug regulation into their own hands. The impact of these changes on gabapentin prescribing is unclear.

OBJECTIVE

To determine the effect of state-imposed regulation on gabapentin prescribing for Medicare Part D enrollees from 2013 to 2018.

DESIGN

Population-based difference-in-difference(DID) analysis study utilizing the Medicare Part D Prescriber Public Use File.

PARTICIPANTS

All eligible Medicare Part D prescribers excluding those outside of the fifty states and the District of Columbia were included in our analysis. Prescriber data and key sociodemographic variables were organized by state and year. States with a gabapentin schedule change or PDMP regulation enacted before 2019 were included in the intervention group. For the Schedule V DID analysis, a control group of the ten highest opioid-prescribing states was used.

INTERVENTIONS

States with gabapentin schedule changes or PDMP regulation before January 1, 2019, were included and compared to control states that did not implement these policies.

MAIN MEASURES

Total days' supply of gabapentin per enrollee per year was the primary outcome variable.

KEY RESULTS

The mean total days' supply of gabapentin per enrollee increased 41% from 19.71 to 27.81 total days' supply per enrollee per year between 2013 and 2018. After adjustment, Schedule V gabapentin regulation resulted in a reduction of 8.37 total days of gabapentin prescribed per enrollee (95% confidence interval of - 10.34 to - 6.39). In contrast, PDMP regulation resulted in a reduction of 1.01 total days of gabapentin prescribed per enrollee (95% confidence interval of - 1.74 to - 0.29).

CONCLUSIONS

Classifying gabapentin as a Schedule V drug results in substantial reduction in total days prescribed whereas PDMP regulation results in modest reduction.

Risk of major adverse events associated with gabapentinoid and opioid combination therapy: A systematic review and meta-analysis

Background: The use of opioid-gabapentinoid combinations has increased, raising several safety concerns. However, meta-analysis studies focusing on this issue are limited. Objective: To evaluate the risk of central nervous system (CNS) depression, gastrointestinal (GI) adverse events, and mortality of combination therapy compared with those of opioid therapy and to explore the differences in the results according to study design and indications. Methods: Relevant studies were selected (published before 30 January 2022) by searching the MEDLINE, Embase, and CENTRAL databases. The pooled odds ratios (OR) with 95% confidence intervals (CI) of the outcomes were estimated using the Mantel-Haenszel method. Subgroup and meta-regression analyses were performed according to study characteristics. Quality assessment was conducted using the Risk of Bias 2 tool for randomized controlled trials (RCTs) and Cochrane Collaboration's Risk of Bias in non-RCTs tool for non-randomized trials. Results: Adverse events were reported in 26 RCTs and 7 non-RCTs, and mortality was reported in 10 non-RCTs. Compared to opioid therapy, dizziness, cognitive dysfunction, and respiratory depression in combination therapy significantly increased in non-RCTs (OR 3.26, 95% CI 1.82-5.85; OR 3.13, 95% CI 1.51-6.50; OR 1.71, 95% CI 1.31-2.24, respectively), and a similar trend for dizziness and cognitive dysfunction was also identified in the RCT analysis, although the difference was not significant. Combination therapy for cancer pain was associated with the highest risk of sedation in subgroup analysis. Combination therapy significantly decreased the risk of GI adverse events, including nausea, vomiting, and constipation. The mortality risk associated with combination therapy was higher than that associated with opioid therapy (OR 2.76, 95% CI 1.26-6.05). Conclusion: Opioid-gabapentinoid combination therapy could be associated with an increased risk of CNS depression and mortality, despite tolerable GI adverse events. These data suggest that combination therapy requires close monitoring of CNS depression, especially in cancer patients. Caution is needed in interpreting the clinical meanings owing to the lack of risk difference in respiratory depression in the RCT-only analysis and the absence of RCT or prospective studies investigating mortality.

Extracorporeal Treatment for Gabapentin and Pregabalin Poisoning: Systematic Review and Recommendations From the EXTRIP Workgroup

Toxicity from gabapentin and pregabalin overdose is commonly encountered. Treatment is supportive, and the use of extracorporeal treatments (ECTRs) is controversial. The EXTRIP workgroup conducted systematic reviews of the literature and summarized findings following published methods. Thirty-three articles (30 patient reports and 3 pharmacokinetic studies) met the inclusion criteria. High gabapentinoid extracorporeal clearance (>150mL/min) and short elimination half-life (<5 hours) were reported with hemodialysis. The workgroup assessed gabapentin and pregabalin as "dialyzable" for patients with decreased kidney function (quality of the evidence grade as A and B, respectively). Limited clinical data were available (24 patients with gabapentin toxicity and 7 with pregabalin toxicity received ECTR). Severe toxicity, mortality, and sequelae were rare in cases receiving ECTR and in historical controls receiving standard care alone. No clear clinical benefit from ECTR could be identified although major knowledge gaps were acknowledged, as well as costs and harms of ECTR. The EXTRIP workgroup suggests against performing ECTR in addition to standard care rather than standard care alone (weak recommendation, very low quality of evidence) for gabapentinoid poisoning in patients with normal kidney function. If decreased kidney function and coma requiring mechanical ventilation are present, the workgroup suggests performing ECTR in addition to standard care (weak recommendation, very low quality of evidence).

Day-of-Surgery Gabapentinoids and Prolonged Opioid Use: A Retrospective Cohort Study of Medicare Patients Using Electronic Health Records

BACKGROUND

While preoperative gabapentinoids are commonly used in surgical multimodal analgesia protocols, little is known regarding the effects this therapy has on prolonged postsurgical opioid use. In this observational study, we used data from a large integrated health care system to estimate the association between preoperative day-of-surgery gabapentinoids and the risk of prolonged postsurgical opioid use.

METHODS

We identified adults age ≥65 years undergoing major therapeutic surgical procedures from a large integrated health care system from 2016 to 2019. Exposure to preoperative gabapentinoids on the day of surgery was measured using inpatient medication administration records, and the outcome of prolonged opioid use was measured using outpatient medication orders. We used stabilized inverse probability of treatment-weighted log-binomial regression to estimate risk ratios and 95% confidence intervals (CIs) of prolonged opioid use, comparing patients who received preoperative gabapentinoids to those who did not and adjusting for relevant clinical factors. The main analysis was conducted in the overall surgical population, and a secondary analysis was conducted among procedures where at least 30% of all patients received a preoperative gabapentinoid.

RESULTS

Overall, 13,958 surgical patients met inclusion criteria, of whom 21.0% received preoperative gabapentinoids. The observed 90-day risk of prolonged opioid use following surgery was 0.91% (95% CI, 0.77-1.08). Preoperative gabapentinoid administration was not associated with a reduced risk of prolonged opioid use in the main analysis conducted in a broad surgical population (adjusted risk ratio [adjRR], 1.19 [95% CI, 0.67-2.12]) or in the secondary analysis conducted in patients undergoing colorectal resection, hip arthroplasty, knee arthroplasty, or hysterectomy (adjRR, 1.01 [95% CI, 0.30-3.33]).

CONCLUSIONS

In a large integrated health system, we did not find evidence that preoperative gabapentinoids were associated with reduced risk of prolonged opioid use in patients undergoing a broad range of surgeries.

Prescription History Before Opioid Overdose Death: PDMP Data and Responsible Prescribing

INTRODUCTION

As the opioid epidemic continues, state legislatures and clinicians increasingly utilize Prescription Drug Monitoring Programs (PDMPs). These programs record dates prescribed and filled for all controlled substances, attempting to identify high-risk prescribing. The aims of this study were to (i) examine data from individuals who died of accidental opioid overdose and (ii) compare differences between those with prescriptions documented in Kentucky's PDMP with individuals without recorded prescriptions.

METHODS

This was a retrospective, observational cohort study conducted in Jefferson County, Kentucky. We reviewed records for all opioid overdose death subjects from 2017 and 2018, cross-referencing with prescriptions in Kentucky's PDMP (Kentucky All Schedule Prescription Electronic Reporting System [KASPER]) back to 2014. We performed χ2 analyses for categorical variable comparisons and a separate univariate analysis for age.

RESULTS

Of the 575 individuals who died of accidental opioid overdose in Jefferson County during the study period, 379 (65.9%) had prescriptions documented in KASPER. Individuals had a high prevalence of fentanyl on postmortem toxicology. Only one individual had postmortem toxicology positive for buprenorphine, a medication for opioid use disorder (MOUD). Several subjects experienced what we termed see-saw MOUD prescribing (prescriptions alternating between MOUD and other controlled substances including full agonists), and multiple prescriptions were apparently written and/or filled for deceased subjects.

CONCLUSIONS

Review of PDMP data in deceased patients can prevent unnecessary opioid prescribing and optimize clinical practice. Buprenorphine may have a protective effect in opioid dependence, but access must be consistent. Providers should be aware of see-saw MOUD prescribing and understand the effects on patient care. In response to the prescriptions filled for deceased individuals, legislators could enact a policy such as Void All Prescriptions or VAP alerts to cancel all prescriptions for individuals who have died, reducing drug diversion. It is vital that providers routinely use PDMP data along with counseling and other treatment strategies to optimize patient care.

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

PURPOSE OF REVIEW

Nearly every U.S. state operates a prescription drug monitoring program (PDMP) to monitor dispensing of controlled substances. These programs are often considered key policy levers in the ongoing polydrug epidemic. Recent years have seen rapid growth of peer-reviewed literature examining PDMP consultation and the impacts of these programs on diverse patient populations and health outcomes. This literature synthesis presents a review of studies published from June 2018 to December 2019 and provides relevant updates from the perspective of three researchers in this field.

RECENT FINDINGS

The analyzed studies were primarily distributed across three overarching research focus areas: outcome evaluations (n = 29 studies), user surveys (n = 23), and surveillance (n = 22). Identified themes included growing awareness of the unintended consequences of PDMPs on access to opioids, effects on benzodiazepines and stimulant prescribing, challenges with workflow integration across multiple specialties, and new opportunities for applied data science.

SUMMARY

There is a critical gap in existing PDMP literature assessing how these programs have impacted psychiatrists, their prescribing behaviors, and their patients. Although PDMPs have improved population-level monitoring of controlled substances from medical sources, their role in responding to a drug epidemic shifting to illicitly manufactured drugs is under scrutiny.

Trends in Gabapentin Prescribing in a Commercially Insured U.S. Adult Population, 2009-2016

BACKGROUND

Gabapentin is prescribed for a variety of conditions and is often used off label. It is important to understand the prevalence of gabapentin prescribing and the characteristics of individuals who are prescribed gabapentin, given increasing concern regarding its potential for misuse.

OBJECTIVES

To (a) examine state- and region-level prevalence and trends in gabapentin prescribing from 2009 to 2016 and (b) characterize demographic and clinical characteristics of individuals prescribed gabapentin in a nationwide population of commercially insured adults.

METHODS

This retrospective, longitudinal study examined trends in gabapentin prescribing from 2009 to 2016. The study population included individuals aged 18-64 years who were enrolled in a commercial insurance plan at any point from 2009 to 2016. Individuals who were prescribed gabapentin were defined as beneficiaries with at least 1 gabapentin prescription claim in a calendar year (CY). A cross-sectional descriptive analysis was performed to examine differences in demographic and clinical characteristics of individuals prescribed or not prescribed gabapentin in CY 2016.

RESULTS

The prevalence of gabapentin prescribing nearly doubled from 2009 to 2016. During this time, gabapentin prescribing increased in every state (range: 44%-179%). State-specific prevalence rates in 2016 varied from 12.7 to 43.9 per 1,000 beneficiaries. Overall, 2.7% of beneficiaries filled ≥ 1 gabapentin prescription in 2016. Individuals prescribed gabapentin were more likely to fill opioid prescriptions (60.8% vs. 16.5%, P < 0.01); reside in the South (53.7% vs. 47%, P < 0.01); be female (62.5% vs. 52.3%, P < 0.01); and be aged 55-64 years (41.7% vs. 21.2%, P < 0.01) compared with the comparator. Individuals who were prescribed gabapentin also had significantly higher rates of seizure disorders, neuropathic pain, mental health disorders, substance use disorders, and diabetes.

CONCLUSIONS

The prevalence of gabapentin prescribing among a U.S. privately insured population has increased steadily in recent years. Additional research should examine coprescribing of gabapentin in the context of the opioid epidemic.

DISCLOSURES

The project described in this study was supported by the NIH National Center for Advancing Translational Sciences through grant number UL1TR001998. This study was also partially supported by grant number 2017-PM-BX-K026 (Data-Driven Responses to Prescription Drug Misuse in Kentucky) awarded by the Bureau of Justice Assistance. Viewpoints or opinions in this document are those of the authors and do not necessarily represent the official position or policies of the U.S. Department of Justice or the official views of the NIH. The authors do not have any conflicts of interest to report. Portions of this study have been previously presented in poster presentations at the 2019 Academy Health Annual Research Meeting; June 2-4, 2019; Washington, DC, and the 2019 University of Kentucky Substance Use Research Day; March 3, 2019; Lexington, KY.

Comparing Changes in Controlled Substance Prescribing Trends by Provider Type

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

DISCUSSION AND CONCLUSIONS

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

SCIENTIFIC SIGNIFICANCE

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