1
|
Henry SG, Fang SY, Crawford AJ, Wintemute GJ, Tseregounis IE, Gasper JJ, Shev A, Cartus AR, Marshall BDL, Tancredi DJ, Cerdá M, Stewart SL. Impact of 30-day prescribed opioid dose trajectory on fatal overdose risk: A population-based, statewide cohort study. J Gen Intern Med 2024; 39:393-402. [PMID: 37794260 PMCID: PMC10897080 DOI: 10.1007/s11606-023-08419-6] [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: 03/21/2023] [Accepted: 09/07/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND Both increases and decreases in patients' prescribed daily opioid dose have been linked to increased overdose risk, but associations between 30-day dose trajectories and subsequent overdose risk have not been systematically examined. OBJECTIVE To examine the associations between 30-day prescribed opioid dose trajectories and fatal opioid overdose risk during the subsequent 15 days. DESIGN Statewide cohort study using linked prescription drug monitoring program and death certificate data. We constructed a multivariable Cox proportional hazards model that accounted for time-varying prescription-, prescriber-, and pharmacy-level factors. PARTICIPANTS All patients prescribed an opioid analgesic in California from March to December, 2013 (5,326,392 patients). MAIN MEASURES Dependent variable: fatal drug overdose involving opioids. Primary independent variable: a 16-level variable denoting all possible opioid dose trajectories using the following categories for current and 30-day previously prescribed daily dose: 0-29, 30-59, 60-89, or ≥90 milligram morphine equivalents (MME). KEY RESULTS Relative to patients prescribed a stable daily dose of 0-29 MME, large (≥2 categories) dose increases and having a previous or current dose ≥60 MME per day were associated with significantly greater 15-day overdose risk. Patients whose dose decreased from ≥90 to 0-29 MME per day had significantly greater overdose risk compared to both patients prescribed a stable daily dose of ≥90 MME (aHR 3.56, 95%CI 2.24-5.67) and to patients prescribed a stable daily dose of 0-29 MME (aHR 7.87, 95%CI 5.49-11.28). Patients prescribed benzodiazepines also had significantly greater overdose risk; being prescribed Z-drugs, carisoprodol, or psychostimulants was not associated with overdose risk. CONCLUSIONS Large (≥2 categories) 30-day dose increases and decreases were both associated with increased risk of fatal opioid overdose, particularly for patients taking ≥90 MME whose opioids were abruptly stopped. Results align with 2022 CDC guidelines that urge caution when reducing opioid doses for patients taking long-term opioid for chronic pain.
Collapse
Affiliation(s)
- Stephen G Henry
- University of California Davis Center for Healthcare Policy and Research; University of California, Davis, California, Sacramento, USA.
- Department of Internal Medicine, University of California, Davis, California, Sacramento, USA.
| | - Shao-You Fang
- University of California Davis Center for Healthcare Policy and Research; University of California, Davis, California, Sacramento, USA
| | - Andrew J Crawford
- Violence Prevention Research Program; University of California, Davis, California, Sacramento, USA
- Department of Emergency Medicine, University of California, Davis, California, Sacramento, USA
| | - Garen J Wintemute
- Violence Prevention Research Program; University of California, Davis, California, Sacramento, USA
- Department of Emergency Medicine, University of California, Davis, California, Sacramento, USA
| | - Iraklis Erik Tseregounis
- University of California Davis Center for Healthcare Policy and Research; University of California, Davis, California, Sacramento, USA
- Department of Internal Medicine, University of California, Davis, California, Sacramento, USA
| | - James J Gasper
- Department of Family and Community Medicine, University of California, San Francisco, California, San Francisco, USA
| | - Aaron Shev
- Violence Prevention Research Program; University of California, Davis, California, Sacramento, USA
- Department of Emergency Medicine, University of California, Davis, California, Sacramento, USA
| | - Abigail R Cartus
- Department of Epidemiology, Brown University School of Public Health, Rhode Island, Providence, USA
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, Rhode Island, Providence, USA
| | - Daniel J Tancredi
- University of California Davis Center for Healthcare Policy and Research; University of California, Davis, California, Sacramento, USA
- Department of Pediatrics, University of California, Davis, California, Sacramento, USA
| | - Magdalena Cerdá
- Department of Population Health, Center for Opioid Epidemiology and Policy; New York University Grossman School of Medicine, New York City, New York, USA
| | - Susan L Stewart
- Department of Public Health Sciences, University of California, Davis, California, Davis, USA
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Valdes IL, Possinger MC, Hincapie-Castillo JM, Goodin AJ, Dewar MA, Sumfest JM, Vouri SM. Changes in Prescribing by Provider Type Following a State Prescription Opioid Restriction Law. J Gen Intern Med 2022; 37:1838-1844. [PMID: 34236602 PMCID: PMC9198141 DOI: 10.1007/s11606-021-06966-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/04/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Many states have implemented opioid days' supply restriction policies, leading to reductions in opioid prescribing. Although research within certain provider types exist, no study has evaluated a restriction policy by various provider types. OBJECTIVE To evaluate changes in opioid utilization following a days' supply restriction policy stratified by provider type: surgery, emergency medicine, primary care, specialty care, and dentistry. DESIGN Interrupted time series (ITS) PARTICIPANTS: Opioid prescription claims of patients in a private health plan serving a large Florida employer from 1/1/2015 to 3/31/2019. Provider types were determined using the Healthcare Provider Taxonomy Code associated with the national provider identifier (NPI). INTERVENTIONS Florida's opioid restriction policy implemented on July 1, 2018. MAIN MEASURES Changes in mean morphine milligram equivalent (MMEs), mean days' supply, and mean number of units dispensed per opioid prescription before and after policy implementation. KEY RESULTS There were 10,583 opioid initial prescriptions dispensed. Treating providers were classified as surgery (16.4%; n = 1732), emergency care (14.3%; n = 1516), primary care (21.2%; n = 2241), specialty care (11.4%; n = 1207), and dentistry providers (23.7%; n = 2511). Significant reductions in mean days' supply were observed across most provider types ranging from 14% reduction for dentistry providers to 41% reduction for specialty care providers. Significant changes were observed for emergency care and specialty care providers with a 30% (p = 0.001)and 29% (p < 0.001) reduction in mean MME, respectively, and a 27% (p = 0.040) reduction in mean number of units dispensed in emergency care providers, after implementation. Pre-implementation trends in opioid prescribing varied by provider type impacting the effects of the opioid days' supply restriction policy. CONCLUSIONS Pre-policy opioid prescribing varied by provider type with a differential impact on mean MMEs, mean days' supply, and mean number of units dispensed per prescription following implementation.
Collapse
Affiliation(s)
- Ivelisse L Valdes
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL, USA
| | - Marie-Christin Possinger
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Juan M Hincapie-Castillo
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL, USA
- Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, USA
| | - Amie J Goodin
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL, USA
| | - Marvin A Dewar
- University of Florida Health Physicians, Gainesville, FL, USA
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Jill M Sumfest
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Scott M Vouri
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA.
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL, USA.
- University of Florida Health Physicians, Gainesville, FL, USA.
| |
Collapse
|
4
|
Rapid Discontinuation of Chronic, High-Dose Opioid Treatment for Pain: Prevalence and Associated Factors. J Gen Intern Med 2022; 37:1603-1609. [PMID: 34608565 PMCID: PMC9130349 DOI: 10.1007/s11606-021-07119-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 08/25/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To examine the prevalence of rapid discontinuation of chronic, high-dose opioid analgesic treatment, and identify associated patient, clinician, and community factors. METHODS Using 2017-2018 retail pharmacy claims data from IQVIA, we identified chronic, high-dose opioid analgesic treatment episodes discontinued during these years and determined the percent of episodes meeting criteria for rapid discontinuation. We used multivariable logistic regression to estimate the probability of rapid discontinuation, conditional on having a discontinued chronic, high-dose opioid treatment episode, as a function of patient, provider, and county characteristics. RESULTS We identified 810,120 new, chronic, high-dose opioid treatment episodes discontinued in 2017 or 2018, of which 72.0% (n=583,415) were rapidly discontinued. Rapid discontinuation was significantly more likely among Medicare (aOR 1.14, 95% CI 1.12 to 1.15) and Medicaid enrollees (aOR 1.03, 95% CI 1.02 to 1.05) compared to the commercially insured; in counties with higher fatal overdose rates (aOR 1.03, 95% CI 1.01 to 1.04) compared to counties with the lowest fatal overdose rates; and in counties with a higher percentage of non-white residents (aOR 1.21 for counties in the highest quartile relative to the lowest, 95% CI 1.19 to 1.24). Likelihood of rapid discontinuation also varied by prescriber specialty. CONCLUSIONS Most chronic, high-dose opioid treatment episodes that ended in 2017 or 2018 were discontinued more rapidly than recommended by clinical guidelines, raising concerns about adverse patient outcomes. Our findings highlight the need to understand what drives discontinuation and to inform safer opioid tapering and discontinuation practices.
Collapse
|
5
|
Heins SE, Buttorff C, Armstrong C, Pacula RL. Claims-based measures of prescription opioid utilization: A practical guide for researchers. Drug Alcohol Depend 2021; 228:109087. [PMID: 34598101 PMCID: PMC8595838 DOI: 10.1016/j.drugalcdep.2021.109087] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/14/2021] [Accepted: 08/07/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Given the increased attention to the opioid epidemic and the role of inappropriate prescribing, there has been a marked increase in the number of studies using claims data to study opioid use and policies designed to curb misuse. Our objective is to review the medical literature for recent studies that use claims data to construct opioid use measures and to develop a guide for researchers using these measures. METHODS We searched for articles relating to opioid use measured in health insurance claims data using a defined set of search terms for the years 2014-2020. Original research articles based in the United States that used claims-based measures of opioid utilization were included and information on the study population and measures of any opioid use, quantity of opioid use, new opioid use, chronic opioid use, multiple providers, and overlapping prescriptions was abstracted. RESULTS A total of 164 articles met inclusion criteria. Any opioid use was the most commonly included measure, defined by 85 studies. This was followed by quantity of opioids (68 studies), chronic opioid use (53 studies), overlapping prescriptions (28 studies), and multiple providers (8 studies). Each measure contained multiple, distinct definitions with considerable variation in how each was operationalized. CONCLUSIONS Claims-based opioid utilization measures are commonly used in research, but definitions vary significantly from study to study. Researchers should carefully consider which opioid utilization measures and definitions are most appropriate for their study and recognize how different definitions may influence study results.
Collapse
Affiliation(s)
| | | | | | - Rosalie Liccardo Pacula
- RAND Corporation, Santa Monica, CA, USA,Schaeffer Center for Health Policy & Economics, University of Southern California
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Ball SJ, Simpson K, Zhang J, Marsden J, Heidari K, Moran WP, Mauldin PD, McCauley JL. High-Risk Opioid Prescribing Trends: Prescription Drug Monitoring Program Data From 2010 to 2018. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2021; 27:379-384. [PMID: 32956292 PMCID: PMC7940459 DOI: 10.1097/phh.0000000000001203] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Deaths due to opioids have continued to increase in South Carolina, with 816 opioid-involved overdose deaths reported in 2018, a 9% increase from the prior year. The objective of the current study is to examine longitudinal trends (quarter [Q] 1 2010 through Q4 2018) of opioid prescribing volume and high-risk opioid prescribing behaviors in South Carolina using comprehensive dispensing data available in the South Carolina Prescription Drug Monitoring Program (SC PDMP). DESIGN Retrospective analyses of SC PDMP data were performed using general linear models to assess quarterly time trends and change in rate of each outcome Q1 2010 through Q4 2018. PARTICIPANTS Opioid analgesic prescription fills from SC state residents between Q1 2010 and Q4 2018. MAIN OUTCOME MEASURES High-risk prescribing behaviors included (1) opioid prescribing rate; (2) percentage of patients receiving opioids dispensed 90 or more average morphine milligram equivalents daily; (3) percentage of opioid prescribed days with overlapping opioid and benzodiazepine prescriptions; (4) rate per 100 000 residents of multiple provider episodes; and (5) percentage of patients prescribed extended release opioids who were opioid naive. RESULTS A total of 33 027 461 opioid prescriptions were filled by SC state residents within the time period of Q1 2010 through Q4 2018. A 41% decrease in the quarterly prescribing rate of opioids occurred from Q1 2010 to Q4 2018. The decrease in overall opioid prescribing was mirrored by significant decreases in all 4 high-risk prescribing behaviors. CONCLUSION PDMPs may represent the most complete data regarding the dispensing of opioid prescriptions and as such be valuable tools to inform and monitor the supply of licit opioids. Our results indicate that public health policy, legislative action, and multiple clinical interventions aimed at reducing high rates of opioid prescribing across the health care ecosystem appear to be succeeding in the state of South Carolina.
Collapse
Affiliation(s)
- Sarah J. Ball
- Division of General Internal Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Kit Simpson
- Department of Health Administration and Policy, College of Health Professions, Medical University of South Carolina, Charleston, SC, USA
| | - Jingwen Zhang
- Division of General Internal Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Justin Marsden
- Division of General Internal Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | | | - William P. Moran
- Division of General Internal Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Patrick D. Mauldin
- Division of General Internal Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Jenna L. McCauley
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| |
Collapse
|
8
|
Davis CS, Piper BJ, Gertner AK, Rotter JS. Opioid Prescribing Laws Are Not Associated with Short-term Declines in Prescription Opioid Distribution. PAIN MEDICINE 2021; 21:532-537. [PMID: 31365095 DOI: 10.1093/pm/pnz159] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To determine whether the adoption of laws that limit opioid prescribing or dispensing is associated with changes in the volume of opioids distributed in states. METHODS State-level data on total prescription opioid distribution for 2015-2017 were obtained from the US Drug Enforcement Administration. We included in our analysis states that enacted an opioid prescribing law in either 2016 or 2017. We used as control states those that did not have an opioid prescribing law during the study period. To avoid confounding, we excluded from our analysis states that enacted or modified mandates to use prescription drug monitoring programs (PDMPs) during the study period. To estimate the effect of opioid prescription laws on opioid distribution, we ran ordinary least squares models with indicators for whether an opioid prescription law was in effect in a state-quarter. We included state and quarter fixed effects to control for time trends and time-invariant differences between states. RESULTS With the exception of methadone and buprenorphine, the amount of opioids distributed in states fell during the study period. The adoption of opioid prescribing laws was not associated with additional decreases in opioids distributed. CONCLUSIONS We did not detect an association between adoption of opioid prescribing laws and opioids distributed. States may instead wish to pursue evidence-based efforts to reduce opioid-related harm, with a particular focus on treatment access and harm reduction interventions.
Collapse
Affiliation(s)
- Corey S Davis
- Network for Public Health Law, Los Angeles, California.,Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Brian J Piper
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania
| | - Alex K Gertner
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jason S Rotter
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| |
Collapse
|
9
|
Delaney L, Gunaseelan V, Rieck H, Dupree JM, Hallstrom B, Englesbe M, Brummett C, Waljee J. High-Risk Prescribing Increases Rates of New Persistent Opioid Use in Total Hip Arthroplasty Patients. J Arthroplasty 2020; 35:2472-2479.e2. [PMID: 32389404 PMCID: PMC8289485 DOI: 10.1016/j.arth.2020.04.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 04/02/2020] [Accepted: 04/07/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The association between surgeon prescribing practices and new persistent postoperative opioid use is not well understood. We examined the association between surgeon prescribing and new persistent use among total hip arthroplasty (THA) patients. METHODS A retrospective analysis of Medicare claims in Michigan was performed. The study cohort consisted of orthopedic surgeons performing THAs from 2013 to 2016 and their opioid-naïve patients, aged >65 years. High-risk prescribing included high daily doses, overlapping benzodiazepine prescriptions, concurrent opioid prescriptions, prescriptions from multiple providers, or long-acting opioid prescriptions. The occurrence of a preoperative prescription, initial prescription size, and 30-day prescription dosage were examined as individual exposures. Surgeons were categorized into quartiles by prescribing practices, and multilevel hierarchical logistic regression was used to examine associations with postoperative new persistent opioid use. RESULTS Surgeons exhibited high-risk prescribing for 66% of encounters. Patients of surgeons with the highest rates of high-risk prescribing were more likely to develop persistent use compared with patients of surgeons with the lowest rates (adjusted rates: 9.7% vs 4.6%, P = .011). Patients of surgeons with initial prescription sizes in the "high" (third) quartile (adjusted odds ratio, 2.91; 95% confidence interval, 1.53-5.51), and of surgeons in the "highest" (fourth) quartile of 30-day prescription dosage (adjusted odds ratio, 1.93; 95% confidence interval, 1.03-3.61), were more likely to develop persistent opioid use compared with patients of surgeons with low initial and 30-day prescription sizes, respectively. CONCLUSION The development of persistent opioid use after surgery is multifactorial, and surgeon prescribing patterns play an important role. Reducing prescribing and encouraging opioid alternatives could minimize postoperative persistent opioid use.
Collapse
Affiliation(s)
- Lia Delaney
- University of Michigan School of Medicine, Ann Arbor
| | - Vidhya Gunaseelan
- Department of Surgery, University of Michigan, Ann Arbor,Michigan Opioid Prescribing Engagement Network, Ann Arbor
| | - Heidi Rieck
- Department of Surgery, University of Michigan, Ann Arbor,Michigan Opioid Prescribing Engagement Network, Ann Arbor
| | | | - Brian Hallstrom
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor
| | - Mike Englesbe
- Department of Surgery, University of Michigan, Ann Arbor,Michigan Opioid Prescribing Engagement Network, Ann Arbor,Michigan Surgical Quality Collaborative, Ann Arbor
| | - Chad Brummett
- Michigan Opioid Prescribing Engagement Network, Ann Arbor,Department of Anesthesiology, University of Michigan, Ann Arbor
| | - Jennifer Waljee
- Department of Surgery, University of Michigan, Ann Arbor,Michigan Opioid Prescribing Engagement Network, Ann Arbor,Michigan Surgical Quality Collaborative, Ann Arbor
| |
Collapse
|
10
|
A Practical Approach to Acute Postoperative Pain Management in Chronic Pain Patients. J Perianesth Nurs 2020; 35:564-573. [PMID: 32660812 DOI: 10.1016/j.jopan.2020.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 02/27/2020] [Accepted: 03/02/2020] [Indexed: 01/08/2023]
Abstract
In the United States, more than 100 million people suffer from chronic pain. Among patients presenting for surgery, about one in four have chronic pain. Acute perioperative pain management in this population is challenging because many patients with chronic pain require long-term opioids for the management of this pain, which may result in tolerance, physical dependence, addiction, and opioid-induced hyperalgesia. These challenges are compounded by the ongoing opioid epidemic that has resulted in calls for a reduction in opioid use, with a concurrent increase in the number of patients with chronic opioid exposure presenting for surgery. This article aims to summarize practical considerations for acute postoperative pain management in patients with chronic pain conditions. A patient-centered acute pain management plan, including nonopioid analgesics, regional anesthesia, and careful selection of opioid medications, can lead to adequate analgesia and satisfaction with care. Also, a meticulous rotation from one opioid to another may decrease opioid requirement, increase analgesic effectiveness, and improve satisfaction with care.
Collapse
|
11
|
Heins SE. Prescription Opioids: A Continuing Contributor to the Epidemic. Am J Public Health 2019; 109:1166-1167. [PMID: 31390249 DOI: 10.2105/ajph.2019.305253] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Sara E Heins
- Sara E. Heins is with the RAND Corporation, Pittsburgh, PA
| |
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
Peahl AF, Dalton VK, Montgomery JR, Lai YL, Hu HM, Waljee JF. Rates of New Persistent Opioid Use After Vaginal or Cesarean Birth Among US Women. JAMA Netw Open 2019; 2:e197863. [PMID: 31348508 PMCID: PMC6661716 DOI: 10.1001/jamanetworkopen.2019.7863] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
IMPORTANCE Research has shown an association between opioid prescribing after major or minor procedures and new persistent opioid use. However, the association of opioid prescribing with persistent use among women after vaginal delivery or cesarean delivery is less clear. OBJECTIVE To assess the association between opioid prescribing administered for vaginal or cesarean delivery and rates of new persistent opioid use among women. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used national insurance claims data for 988 036 women from a single private payer from January 1, 2008, to December 31, 2016. Participants included reproductive age, opioid-naive women with 1 year of continuous enrollment before and after delivery. For participants with multiple births, only the first birth was included. EXPOSURES Peripartum opioid prescription (1 week before delivery to 3 days after discharge) captured by pharmacy claims, including prescription timing and size in oral morphine equivalents. Multivariable adjusted odds ratios were estimated using regression models. MAIN OUTCOMES AND MEASURES Rates of new persistent opioid use, defined as pharmacy claims for 1 or more opioid prescription 4 to 90 days after discharge and 1 or more prescription 91 to 365 days after discharge among women who filled peripartum opioid prescriptions. RESULTS In total, 308 226 deliveries were included: 195 013 (63.3%) vaginal deliveries and 113 213 (36.7%) cesarean deliveries. Participant mean (SD) age was 31.3 (5.3) years, and 70 567 (51.0%) were white patients. Peripartum opioid prescriptions were filled by 27.0% of women with vaginal deliveries and 75.7% of women with cesarean deliveries. Among them, 1.7% of those with vaginal deliveries and 2.2% with cesarean deliveries had new persistent opioid use. By contrast, among women not receiving a peripartum opioid prescription, 0.5% with vaginal delivery and 1.0% with cesarean delivery had new persistent opioid use. From 2008 to 2016, opioid prescription fills decreased for vaginal deliveries from 26.9% to 23.8% (P < .001) and for cesarean deliveries from 75.5% to 72.6% (P < .001), and fewer women had new persistent use (vaginal delivery, from 2.2% to 1.1%; P < .001; cesarean delivery, from 2.5% to 1.3%; P < .001). The strongest modifiable factor associated with new persistent opioid use after delivery was filling an opioid prescription before delivery (adjusted odds ratio, 1.40; 95% CI, 1.05-1.87). For vaginal deliveries, receiving a prescription equal to or more than 225 oral morphine equivalents was associated with new persistent opioid use (adjusted odds ratio, 1.25; 95% CI, 1.06-1.48). Women who underwent cesarean delivery and had a hysterectomy were more likely to develop persistence (AOR, 2.75; 95% CI, 1.33-5.70), although women who underwent a nonelective (AOR, 0.97; 95% CI, 0.88-1.07) or repeat cesarean (AOR, 1.45; 95% CI, 0.93-2.28) were not more likely. For cesarean deliveries, risk factors were associated with patient attributes such as tobacco use (adjusted odds ratio, 1.82; 95% CI, 1.56-2.11), psychiatric diagnoses, history of substance use (adjusted odds ratio, 1.43; 95% CI, 1.10-1.86), and pain conditions. CONCLUSIONS AND RELEVANCE The results of the present study suggested that opioid prescribing and new persistent use after vaginal delivery or cesarean delivery have decreased since 2008. However, modifiable prescribing patterns were associated with persistent opioid use for patients who underwent vaginal delivery, and risk factors following cesarean delivery mirrored those of other surgical conditions. Judicious opioid prescribing and preoperative risk screening may be opportunities to decrease new persistent opioid use after childbirth.
Collapse
Affiliation(s)
- Alex F. Peahl
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor
| | - Vanessa K. Dalton
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor
- Program on Women’s Healthcare Effectiveness Research, University of Michigan, Ann Arbor
| | | | - Yen-Ling Lai
- Michigan Opioid Prescribing Engagement Network, Department of Surgery, University of Michigan, Ann Arbor
| | - Hsou Mei Hu
- Michigan Opioid Prescribing Engagement Network, Department of Surgery, University of Michigan, Ann Arbor
| | - Jennifer F. Waljee
- Department of Surgery, University of Michigan, Ann Arbor
- Michigan Opioid Prescribing Engagement Network, Department of Surgery, University of Michigan, Ann Arbor
| |
Collapse
|